vol. 2 issue 7
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 [in science]…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, 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.
The lobbyists justify their position with scientific data derived from studies designed in favor of their interests. When there is protest against their findings, they claim that science is science, and their results are scientific.
Yes, science is indeed 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.
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 — 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.
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? 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.
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 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 Hutchin’s 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 research 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).
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. 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.
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.
During this podcast, we do not name any specific individuals, as I am not interested in blaming or fighting. I am interested in finding avenues for change. I also chose not to name the speaker, although his remarks, name, and affiliations are listed below, if you want to read what he said for yourself. 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. Whatever didn’t get addressed in this episode, I intend to address in the next.
Thanks for listening and reading.
Here are links referred to in this post:
The Future of Psychiatry by Steven Sharfstein, MD
Incoming APA president Steven Sharfstein urges reform
Here are the links referenced in the podcast. I do not endorse any of them, but offer them as a follow-up to what Dr. Caplan shared:
Website of Paula J. Caplan, PhD
The International Society for Ethical Psychology and Psychiatry
National Association for Rights Protections and Advocacy
Ending Harm from Psychiatric Diagnosis
Mad in America
Illustration: John Hain
Updated March 6, 2020 to reflect that we did not name any specific members of the field intentionally during the podcast.