Harm from psychiatric diagnosis? A second look

Backfilling some gaps in understanding

vol. 2 issue 8

Greetings,

In my most recent podcast, my guest, clinical and research psychologist Paula Caplan, PhD, currently at the Harvard Hutchins Center, laid out a strong case for why psychiatric diagnosis is the root of suffering for those seeking help within the mental health system in this country.

My own perspective is that naming something is not inherently harmful. My commentary accompanying the podcast was intended to illustrate my opinion that while diagnosis might be at the nexus of harm, it is not necessarily the genesis of harm. The harm comes when diagnosis becomes a tool that restricts our individual and our practitioners’ freedom. This happens when diagnosis is used as the justification for policies that serve business and not individual patient interests.

Dr. Caplan does not agree with my take on this point, seeing diagnosis instead as the justification for psychiatry as a type of industry unto itself. There are other points with which Dr. Caplan and I differ, including my decision to not call attention to the name of the American Psychiatric Association president who was critical of his peers. She also asserts that I am too in the thrall of psychiatry to see its potentials for harm, but I maintain that I have seen people become happier and more at peace after using psychotropic medications. And yet, I also know of those for whom doing so was indeed harmful.

That is why I maintain what we need is less restrictive policies that enrich industry at the individual’s expense. We need freedom to choose.

Dr. Caplan sent me a detailed response to my commentary which I offered to publish unedited with the exception of two items I added in brackets for clarity.

Here are Dr. Caplan’s comments in bold, embedded in my original piece:

Greetings,

It was 2017. I was in a posh conference room at a five star hotel in Scottsdale, Arizona. An elder statesman of the psychiatric community who’d recently stepped down from his post as leader of one of the nation’s oldest and most venerated mental health hospitals and research facilities, was giving an honorary address. The room was filled with esteemed psychiatrists. I was there to report.

Among the man’s many startling claims was that psychiatry was broken, and was likely to get worse before it got better, especially if the field continued to view patients as pathways to profits instead of persons in need of succor. I had never heard anyone in the profession take such a public stand before. One psychiatrist in attendance, not unsympathetic to what the speaker was saying, nonetheless referred to it in conversation with me later as a “fever dream”.

Most intriguing of all was the speaker’s assertion that by 2067:

“Most physicians will be employees of one out of four major health care nonprofit corporations that are vertically or horizontally integrated systems of care…managed care will be perceived as a regrettable experiment of the late 20th century ending in the first part of the 21st century. With the enactment of a universal single payer system of care, the high-cost intrusive middle management of carve-out behavioral health care companies will become moot… [Further,] significant advances …will make the prior 200 years of psychiatric care seem crude, quaint, and absurd.”

More than a decade before this, the psychiatrist and noted humanitarian, as president of the American Psychiatric Association,

Paula J Caplan: Precisely BECAUSE this man said something so radical and daring, given that he was APA President, I think it is very important to name him. But by the way, my dealings with Dr. [Steven] Sharfstein by no means reflected what you describe him as saying here. He was in fact a staunch defender of what the APA was doing.

had chastised his colleagues for allowing a dissolution of their professional values, and thus a loss of credibility in the eyes of the public. In particular, he’d called out the need to reverse the influence of the pharmaceutical industry the field, and declared war on his fellow psychiatrists’ reluctance to fight for the rights of their patients across many fronts. He also called out the lax standards of scientific inquiry in the field.

As the speaker re-iterated in an interview with me later, he was deeply disappointed in his colleagues for not sharing his alarm over the drop in psychiatry’s professionalism. What struck me then and stays with me now is the sense that the speaker was genuinely broken hearted over what he had seen his beloved profession become.

I thought about his sorrow as I was editing this podcast episode of docu-mental. It occurred to me that whether or not he realized it, what he was describing was the erosion of freedom in psychiatry.

Freedom’s erosion looks like this:

It is the insurance industry with their need to deliver shareholder profits, not psychiatrists with their clinical judgement, that has ultimate say over the treatment algorithms, the time spent with patients, and the length of time for treatment. With help from the pharmaceutical industry, insurance got and keeps that power to determine treatment through policies held in place by legislators. Why do they put such restrictions in place? Because too often, as I have also seen firsthand, the legislators don’t really understand what they are agreeing to, and take at face value what the lobbyists tell them makes sense.

Paula J. Caplan: You rightly call out the insurance industry and Big Pharma, but you miss the crucial point (which I made in the podcast and in the video I sent you ahead of time, so it is demoralizing that you missed this point, because I don't know how I could make it more clearly and strongly, and given how smart you are, if you missed it, how can I ever hope that others will get it?) that without Big Diagnosis, i.e., the Diagnostic and Statistical Manual of Mental Disorders and its publisher and recipient of its vast profits, the American Psychiatric Association, none of this would be happening, because ALL OF THE HARM IN THE MENTAL HEALTH SYSTEM starts with and is rooted in these diagnostic labels. I wonder why you totally left them out. I think that because you have known one or two or maybe more psychiatrists you considered humane (though Sharfstein certainly was not consistently so), it is hard for you to hold the DSM people and APA accountable. Also, the latter have done a brilliant job of making people believe that the categories are scientifically validated and helpful, but this is totally untrue. Furthermore, they so often ruin people's lives.

The lobbyists justify their position with scientific data derived from studies designed in favor of their interests.

Paula J. Caplan: You are right. And not only are these studies DESIGNED in favor of their interests, but also their findings are routinely distorted and even lied about. And when in the above sentence you say "lobbyists," remember that the APA is officially and legally a registered lobby group. Readers of what you wrote would not know this, because you seem to refer only to the insurance industry and Big Pharma. For the edification of your readers and listeners, I think it is crucial to point out the foundational role, the sine qua non, of Big Diagnosis. After all, if they don’t diagnose you, they are not supposed to “treat” you, but once they give you any psychiatric label, they can do frighteningly close to anything in the name of “treatment,” and because psychiatric diagnosis is totally unregulated, and for other reasons, those who are thereby harmed have little or no redress.

When there is protest against their findings, they claim that science is science, and their results are scientific.

Yes, science is indeed science,

Paula J. Caplan: This is not true. Bad science is not good science!!!!

but there are many ways to occlude the whole of the scientific findings. One is that when outcomes aren’t favorable, too often they are kept quiet, never to be seen by the public, despite calls to publish them in a public database.

The result is drugs that are marketable, in part because their efficacy can be proven in some cases (if not all), which results in treatment that is quicker and often cheaper than less metric-laden methods, which helps insurance tighten the noose even more on the necks of psychiatrists who know that other methods also work, even if they take far more time but are ultimately more enduring if the end point is a reduction in anxiety and depression, a will to live and connect.

Paula J. Caplan: But none of this would be possible without the foundational role of the diagnoses themselves. You give the impression that the only distortion of science is by Pharma, but it all begins with the DSM Task Force's ignoring, distorting, or lying about the research in order to try to justify their creation and use of psych categories.I wrote about this extensively in They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal.

Why aren’t those other methods studied? Some will say they are too difficult to measure. But that is a half truth. Measurement, while important, is too often tied to money, and the power of so-called “interventions” and “treatments” like listening, connecting, and empathy are immeasurable, and so offer no profit margin. In healthcare now, money matters more, no matter how often we hear the protests that is not true.

I’ve heard those protests from (mostly) men with their academic and industry affiliated credientials, standing at those podiums in those posh five star hotels in glamorous locations, paid for in part by sponsorships from drug companies. The story coming from the men and women standing at the podiums in the less luxurious conference rooms where meetings of community psychiatrists — the ones you and I might ask to help us if we can gain access to them — is that there is a lack of resources being made available for people in crisis, and they, the mental health professionals trying to help them, are starting to feel pain themselves because they feel helpless to do so.

That is a loss of freedom.

All that money, they argue, such as the National Institutes of Mental Health’s 4.5 billion spent to study things like whether schizophrenia has a specific genetic code — something we will not know for years, if we ever know —

Paula J. Caplan: Actually, if you would read Jeffrey Poland's brilliant and thorough chapter about the research on what gets called "schizophrenia," in the book called Bias in Psychiatric Diagnosis, you would see that there is NO research to support a genetic basis for "schizophrenia," and I wish you would at least think about the fact that there is no solid scientific basis even for creating the concept of "schizophrenia." I think you maybe missed hearing what I said in the podcast about this, which came from one of the top experts and which was that he had concluded after long being considered an expert on “schizophrenia” that unfortunately it is a wastebasket term. This does not mean that no one has hallucinations or delusions, but those are specific experiences, not psychiatric categories, and there are ways to try to help people if their hallucinations or delusions bother or frighten them (please see the Hearing Voices Network’s excellent work on this) rather than by saying, “This makes you crazy. You have schizophrenia, and you need to take this heavy-duty medication.” The meds usually given people who get this diagnosis have extremely dangerous effects and literally shrink the brain and shorten the lifespan, as Dr. Phillip Seaman in Toronto and others have shown. There are so many ways to be helpful to people who have these kinds of problems, but the diagnosis tends to get in the way, as Jeffrey Poland explains in the above mentioned chapter.  I beg you to read that chapter, because you are in a position to do so much good, and you are already doing so much good in so many ways.

could be put to better use now, in this moment, to help ease the pain and suffering of so many patients with schizophrenia made worse by the lack of basic safety net provisions for them once in place in this country, such as housing, food, basic healthcare.

Paula J. Caplan: In the above, you reify the totally in-valid construct of "schizophrenia," treating it as though it were scientifically validated and helpful, and I assume you are unaware of how much harm the use of that term has caused to people. This is precisely the kind of harm that I know you want to see diminished, so that people can be treated in more humane ways.

This causes moral injury to the psychiatrists who are forced to act not in the best interests of their patients, but of The System.

What actually is The System?

Paula J. Caplan: Well, again, it all starts with psych diagnosis. It is the sine qua non of everything that ever happens in the mental health system.

I don’t have a fancy definition for it. I just see it and have experienced it as the collected mass of agency and power we give over as individuals when we don’t ask good enough questions about how our assent to something that enriches some now will rob us later. That mass becomes too solid for us to push against as individuals. To break it down will take the force of enough of us waking up to our lost power and pushing against that mass all at once until it disintegrates, at least enough to break through, reclaim the good, and rebuild.

There was a time before psychiatry was so subsumed by the blob that is The System. It was the time before the discovery and industrial manufacture of psychotropic drugs, a time when there was less at stake financially for clinical psychiatric researchers. That was the time the speaker that day in that fancy conference room came of age in the field. He was describing not a distant utopia, but his non-fevered dream of the potential the field once had to help people not just heal their pain but grow and become more humane.

Like any field of study or industry, at a certain point, when the system becomes The System where “everybody does it”, whatever “it” is, then resistance becomes, if not futile, then nearly so. In medicine, this places psychiatrists and other clinicians in a situation where it is hard to uphold their oath to do no harm. This erodes freedom.

Paula J. Caplan: And the "everybody does it" has even affected you, though I think you don't see that yet. But it is reflected in this essay and in what you said in the podcast, through the way you protect the creators and purveyors of psych diagnosis. By the way, those folks profit HUGELY from the DSM. The APA earned more than $100 million from DSM-IV.

This intersection of the American notion of freedom and how mental healthcare is delivered is of keen interest to me. I see a national cognitive dissonance when we are told by our leaders that America is a free country, when held at the mercy of monopolistic entities such as

Paula J. Caplan: the creators of psychiatric categories!!! and...

insurance, pharmaceutical companies, and also policymakers, we clearly are not.

I believe there is a way to reverse this conundrum. It begins with waking up to what has happened, to how we’ve outsourced ourselves to The System. That’s when we can ask better questions, find better pathways.

In this episode of docu-mental, I speak with Paula J. Caplan, PhD, a clinical and research psychologist at Harvard University’s Hutchins Center, and the author of several books including They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal. Dr. Caplan is also the recipient of the International Society for Ethical Psychology and Psychiatry’s 2019 Lifetime Achievement Award, among numerous other accolades. As a clinical andresearch psychologist, Dr. Caplan also was a committee member involved in creating the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), before she resigned in protest (the DSM is now in its 5th edition)

Paula J. Caplan: …about the way that good scientific research was ignored, distorted, or lied about and the way that junk science was presented as though it were good science, all in the service of creating psychiatric diagnostic categories.

Dr. Caplan takes a bold stance against psychiatry. She believes that the field causes more harm than good, and that the harm begins with diagnosis. I find some of Dr. Caplan’s claims problematic, and I do not believe psychiatry as a field is inherently harmful, as you will hear me explain in this episode.

Paula J. Caplan: Well, maybe the Catholic Church is not inherently harmful, but that does not justify defending the priests who abused so many children. I hope you can see the parallel here.

And despite my misgivings about the pharmaceutical industry overall, I also have seen where drug interventions are positive, life saving even, which is why, unlike Dr. Caplan, while I do not believe drugs should be in the ascendant, I do think they are important treatment options.

Paula J Caplan: The above is extremely important to correct in as public and strong a way as you possibly can. I have NEVER said that ANYTHING should be ruled out as an option for reducing human suffering! Where in the world did you get that? I always say -- and I cite the brilliant Robert Whitaker's books to support this -- that each psych drug has been proven to help some people sometimes at least for awhile but harms far more people. (Please read Whitaker’s earlier book, Mad In America, and his more recent classic, Anatomy of an Epidemic.) And something I was about to say when you interrupted me in the podcast was this, which I always say every chance I get: ANY PROFESSIONAL EVER recommending anything to help reduce a person's suffering has the moral, ethical, and legal obligation to meet two criteria, and almost no one ever meets them. They are: (1)When recommending approach or treatment or drug X, to tell the person, "I am going to tell you everything I have been able to learn about both the potential benefits and potential kinds of harm from X, but if it is a drug, in all honesty, I have to inform you that the drug companies have been proven repeatedly to produce falsely positive information about it and to conceal even very serious harms about it, so I cannot claim that I learned everything that could be known about it, and (2)Although I am recommending X, I am now going to tell you about the vast range of other kinds of things that have been helpful to people who are going through what you are going through. (And that MUST include NOT just drugs and therapy but also the many nonpathologizing approaches that entail little or no risk, some -- but not all -- of which you can find at http://www.youtube.com/playlist?list=PL51E99E866B9D735E(this was from a conference I organized for veterans, but these approaches are good for anyone)

Still, Dr. Caplan is utterly correct to say that the problems which do exist in psychiatry will not be adequately addressed from the inside, as the speaker that day hoped, but by lay people such as you and me. Change will begin when we educate ourselves and ask better questions about just how much power we give up once we enter the mental health system at any point, not just through the door of psychiatry.  

I asked Dr. Caplan to please not name specific individuals with whom she has issues, as I am not interested in blaming or fighting.

Paula J. Caplan: I don't recall your asking me that. It is in fact important to hold people accountable and not to evade that by alleging that it would be about "blaming or fighting." I expect to be held accountable for what I say. Why absolve others of that responsibility?

[WMF: I do have audio that confirms I asked we not discuss a particular psychiatrist, as I did not want to focus on the inter-personal aspect to this discussion. Before printing this, I reminded Dr. Caplan about that portion of our discussion, but since I agreed to print her comments in full, I am leaving this portion here.]

I am interested in finding avenues for change. That is why I don’t name the speaker, although his remarks, name, and affiliations are listed below, if you want to read what he said for yourself.

Paula J. Caplan: You say you don't name the speaker and then say you name him below, as in fact you do. [WMF: I included references to his printed speeches.]

Just as he urged psychiatrists from the inside to stop playing the game, I suggest you can, too. See your part in the madness. Ask questions. Reclaim your freedom.

Dr. Caplan shared many resources where you can begin to do just that. They also are listed below.

Next month’s episode of docu-mental will feature an interview with a former head of research at the NIMH, a psychiatrist now in private practice specializing in treating persons with psychosis and schizophrenia.

Paula J. Caplan: Here again, you reify the often harmful and totally unscientific "category" of "schizophrenia. If at least you would use terms like "persons who have been given the label 'schizophrenia,'" you would thereby encourage people to start asking critical, crucial questions.

Also, please add to the list of references Robert Whitaker's classic, scrupulously researched book, Anatomy of an Epidemic.

THANK YOU!!!!!!

Paula 


That’s it for this week, folks, unless something astounding happens around COVID-19 and I feel as though I might be able to offer some insight.

Meanwhile, thanks for reading and for subscribing. If you think a friend would like to read along, too, please share this with them and even encourage them to subscribe.

In health,

Whitney

Photo: Gerd Altmann

Update: March 19, 2020. The headline of this piece as revised to reflect more nuance in the content.