I have not read Stastny and Lehmann's book, so I will refrain from judging its claims. However, I find myself quite puzzled by Mr. Hammersley's review. Perhaps in the U.K., psychiatry is, indeed, characterized by the "absolute dominance of the medical/biological model of psychiatry, a situation that has persisted for the last thirty years." According to Mr. Hammersley, this "one sided promotion of a disease model of serious mental illness, with medication as the only possible 'cure' has seen the exclusion of more holistic and humanistic approaches." My goodness--England must be quite an unpleasant place to practice psychiatry!
As a psychiatrist, professor, researcher, and clinician for over 25 years, I have never seen this one-sided model promulgated in the U.S. In my residency program, back in the 80s, we were exposed as much to Otto Kernberg and Tom Szasz as we were to psychopharmacology. In all my academic years, I have never once heard any responsible psychiatrist say anything remotely as silly as the views Mr. Hammersley attributes to "the medical/biological model of psychiatry."
There have always been psychiatrists (including myself) urging us to consider psychosocial, cultural, and even spiritual factors in the genesis of what is called "mental illness" (for my views on the term "disease" and how it applies to psychiatric nosology, readers are referred to my chapter in Dr. Jeff Schaler's book, Szasz Under Fire; and to my recent piece on schizophrenia at http://www.psychiatrymmc.com/psychiatric-diagnosis-and-the-pathologist%e2%80%99s-view-of-schizophrenia/).
I have never once heard any well-respected psychiatrist in the U.S. claim that psychotropic medication was a "cure" for anything, much less the "only possible" cure for mental illness!
Psychiatry in the U.S. is indeed under great pressure to reduce its emphasis on psychotherapy, especially during residency training, and there are undoubtedly powerful market-driven forces working toward this unfortunate end. But U.S. psychiatry, in my view, has never been absolutely dominated by a purely "biological" understanding of disease.
So--I wonder: is the bogeyman behind Mr. Hammersley's caricature of psychiatry a real creature, or merely a politically expedient fiction for those who prefer to denigrate and marginalize psychiatry?
At a minimum, it would be very helpful to learn the names of those psychiatrists who propound the sort of simplistic views Mr. Hammersley imputes to the entire profession of psychiatry, as well as the journal articles or lectures in which these views are stated. --Ronald Pies MD, Professor of Psychiatry, SUNY Upstate Medical University, Syracuse NY; Clinical Professor of Psychiatry, Tufts U. School of Medicine, Boston.
Competing interests
Dr. Pies reports no competing interests.
Reflections in the mirror
Brian Langshaw, Liverpool John Moores University
3 September 2008
I write with concerns relating to the comments returned by Dr Pies in connection to the book review by Paul Hammersley. I am concerned with the relative lack of insight afforded to the problems of pathology and mental illness both in the UK and USA. Unpleasant as it may be to Dr Pies, Psychiatry is dominated by a medical perspective of mental illness with a definite need to address this imbalance from a research, treatment and humanity perspective. If we are to move to a holistic view of care/treatment of individuals with mental illness, we need to first address the aetiological dominance of biological sciences on our understanding of these conditions and repair this breach with a more balanced and realistic view of these problems, with a greater emphasis on the individuals environments as influencing factors affecting the onset, outcome and recovery potential. Dr Pies need to first take a closer look in the mirror and reflect on his current understanding of what he means by psychosocial approaches to mental health treatments and only then can he can realise that the bogeyman is the face of psychiatry he does not want to acknowledge.
Competing interests
None
I'd prefer to be an anonymous service user, but...
Jennifer Spackman, Retired
5 September 2008
In reference to comments on Paul Hammersley's review of "Alternatives Beyond Psychiatry" by Peter Stastny and Peter Lehmann, Dr Pies might well surmise that "England must be quite an unpleasant place to practise psychiatry". The compassionate and forgiving among surviving service users, of whom I believe there must be more than me, might well agree. I haven't yet read the book in question, but I look forward to doing so. Now nearly seventy years old, I have experienced over thirty-seven years of the stigmatising effects of several different diagnoses originating from a post-natal state of extreme fear, distress, confusion and bewilderment. Labelling this a psychosis did nothing to promote a cure, help or understanding. In a few subsequent periods of illness, nothing was the same, and I had, amongst other periods of well-being, about fifteen trouble-free years at work in one interval. No-one ever spoke of cure in all that time. I am heartened to have met in the past two years a few truly caring and forward-thinking professionals. These excellent people understand their human field and can think "out of the box" of a patient-damaging and punitive past practice, and dare to look and hope for cures. We should all have learned by now that stigmatising labels can be, and are, used to infringe human rights. Psychiatry seems to be the only so-called science which has progressed little since the 'Sixties, and legislation based on such an anachronism can only be retrogressive. The time for rethinking is well overdue. Abroad, people with disabilities are sometimes called "special little people", or as suffering from culture-shock. I have found no fear, ignorance, suspicion or prejudice in the most unexpected places, but rather, friendship and care. Please let us have more of such alternative science books and some real advances in humanistic research aimed at cures!
Competing interests
None declared
authors reply
paul Hammersley, University of Lancaster
5 September 2008
I would like to thank Professor Pies for his comments and would also urge him to read Peter Stastny and Peter Lehmanns book.
Perhaps I do see 'Bogeymen,' possibly because
I dont view the world through rose tinted spectacles.
The unholy (and unhelpful) alliance between large parts of mainstream psychiatry and the multi-billion dollar pharmaceutical industry is a scandal, and the denial of proven effective alternative treatments to many can no longer be justified.
I am not alone in this belief as the following quote illustrates
"There is a widespread concern at the over- medicalization of mental disordersand the overuse of medications. Financial incentives and managed care have contributed to the notion of a 'quick fix' by taking a pill and reducing the emphasis on psychological and psychosocial treatments. There is much evidence that there is less psychotherapy provided by psychiatrists than ten years ago.
This is true despite the strong evidence base that many psychotherapies are effective alone or in combination with medications ... If we are seen as mere pill pushers and employees of the pharmaceutical industry, our credibility as a profession is compromised."
Strong words indeed, but the above qoute is not from an idealistic radical, it is in fact from Steven Sharfstein the then head of the American Psychiatric Association in August 2005.
Are we to assume that his opinion was also a 'caricature'
Things are changing, very slowly, but in the right direction.
Allowing service users and consumers to recover through genunie attempts to understand the reality of their lived experience is legitimate, as is the appropriate use of medications.
Balance is all we ask
Paul Hammersley
Spectrum centre
University of Lancaster
UK
Ref - Read.J 2005. The bio, bio, bio model of madness. The Psychologist, Vol 17, no 12.
Competing interests
None declared
A Point of View and a Review from Germany
Karl Koehler, University Professor Emeritus of Psychiatry, Bonn
8 September 2008
It cannot be gainsayed that the history of psychiatry has seen a number of attempts at reductionism in the face of the immense complexity of mental disturbance. Indeed, the paradigm that was more or less dominant in American psychiatry at the start of the 1970s during my residency happened to be the psychoanalytical model. But during the past 25 years or so, the winds have shifted again, with the dominant position this time having been taken over by the biomedical model, especially in research centers and university clinics.
Of course, there is also a teaching and discussion of other etiological and therapeutic points of view, with a knowledge – at least theoretically - of these latter perspectives usually being a prerequisite to qualify. Many psychiatrists certainly try to apply some of this in their everyday work – as Professor Pies points out - not blindly seeing everything in terms of the dominant biomedical model. Yet the fact remains that “true power” – especially with respect to fostering or not fostering the careers of those under them - is presently wielded by those holding key positions in psychiatric research centers or university clinics; and of these the majority no doubt are enthusiastic adherents of the biomedical model.
Although this is not “absolute domination” – an expression with which Professor Pies seems to take umbrage – it is a form of domination no less, and a most unhealthy one. But let’s not talk so much about the dominance of the biomedical model. Let’s be more concrete and talk more about the pharmaceutical industy, in whose best interest it is that this biomedical model should become even more dominant. And in this connection let’s talk about “treatment” instead of “cure” - another term to which Professor Pies rightly takes exception – since it has been part of the drug industry’s aggressive marketing strategy to promote its treatments by forming an alliance with many of those in psychiatry in positions of power.
But all this, or course, is nothing new, for in recent years several inspired polemics by physicians, all of them straightforward indictments of the pharmaceutical industry and its for-profit webs, have appeared, so that a pychiatrist not aware of the problematic tangle of moral compromise involved, must have been keeping his head in the sand. Indeed, it is not just a case of a few rotten apples in the barrel. The complex and often invisible bonds between psychiatry – indeed medicine in general - and the drug industry are now so blatant that they are - as Howard Brody, a medical ethicist and physician, who has brought his discipline’s tools to the issue, puts it - dependent on each other as any addicts are on their substance of choice.
How bad things have gotten may perhaps best be anecdotally exemplified by the following taken from Brody’s book, in which a drug company president is quoted as saying: “If we put horse manure in a capsule, we could sell it to 95% of these doctors."
For those who still remain unconvinced, as a starter I strongly recommend a two-page Royal College of Psychiatry publication: “Psychiatry and the Pharmaceutical Industry: Who Pays the Piper?” in Psychiatric Bulletin (2005) 29: 84-85, which is easily accessible under the link http://www.critpsynet.freeuk.com/PsychiatricBulletin.htm
In spite of the appalling collusion of a large segment of those wielding psychiatry’s “true power” with the pharma industry, common sense has been leading many ordinary people to doubt what the so-called experts have been telling them. Indeed, it is a fact that most American and European adults now use alternative or complementary therapies for their medical problems, with the numbers continuing to grow, for reasons that have much to do with an increasing distrust of mainstream medicine. People are looking around and feel that the conventional system doesn’t measure up, and that something deeper about their well-being is not being addressed. The time when they would listen to their doctor and do whatever he told them, that time is long gone. From here it is only a small step to begin doubting medical science, with many concluding that, if Western medicine is imperfect and sometimes corrupt, then mainstream doctors may not be the best judge of treatments after all. People’s actual experience and the personal testimony of friends and family then feels more truthful.
In other words, when trust in doctors erodes, other treatments fill the void.
It is no wonder then that the movement of (ex-) users and survivors of psychiatry has gained such momentum. That alone is a compelling reason why “Alternatives Beyond Psychiatry” is a most welcome book, one that psychiatrists cannot afford to overlook. I totally agree with Hammersley that this is not a balanced book, that it is refreshingly one-sided, and that it will delight some and infuriate others. Moreover, psychiatrists even have something to learn from those contributions to the book that they might be tempted all too smugly to categorize as being too naïve, idealistic, impractical or radical.
One will not agree with everything in this text – I certainly did not – but I believe that in the light of the parlous state of psychiatry in the public’s perception, it behooves its practitioners to have at least some awareness and respect for the issues raised in this book.
What now follows is my own review of Stastny’s and Lehmann’s book, which first appeared 2007, and is also posted on the INTERVOICE site.
It seems, as if countries that have adopted the modern drug-based paradigm of psychiatric care have, in the past 50 years, experienced a great surge in the number of people disabled by mental disorders. Accordingly, it would appear that we desperately need to reflect on alternatives to this failed paradigm of care. Although in its present form issues dealing with values, meanings, relationships and power are not ignored, these always seem to be secondary to the more important technical aspects of mental health. Indeed, it only tends to underscore the centrality of "experts." In spite of the fact that service (ex-) users and survivors might be consulted and invited to comment on the interventions and the research connected with the reigning paradigm of care, they are nonetheless always recipients of expertise generated elsewhere.
In contrast, the recovery agenda, as Pat Bracken puts it in a paper in this book, presents a radical challenge, since it reorients our thinking about mental health completely. It foregrounds issues that have to do with power and relationships, contexts and meanings, values and priorities, which now become primary. Although such an agenda does not reject or deny the reigning role of therapy, services, research and, in some instances, even drugs, it does work to render them all secondary. Indeed, its most radical implication is the fact that when it comes to issues having to do with values, meanings and relationships, it is the (ex-) users or survivors themselves, who are the most knowledgeable and informed. In other words, when it comes to the recovery agenda, they are the real experts.
This then is the basic theme of this fascinating new book.
After a very short first part on why psychiatry hurts more than it helps - containing a personal report by the 91 year old activist Dorothea Buck-Zerchin, who describes her experience of what she calls 70 years of coercion in psychiatric institutions, as well as a paper by Kate Millett, which focuses on the question of legal rights and the mental health system - the long second part takes up approximately half the book in its discussion of present-day actual alternatives to psychiatry.
Its first section describes the concrete strategies of individual (ex-) users and survivors, with or without professional support, and demonstrates that the individual paths taken in order to manage mental crises without ending up in a psychiatrist's office are extremely varied. All fourteen personal reports presented here are deliberately positive, since it is meant to show that it is possible - at least for some - to recover their mental equilibrium using the personal resources at hand and uniquely tackling their problems with at times rather simple and reasonable methods.
The second section, which deals with concrete examples of organized (ex-) user and survivor self-help, leads off with Wilma Boevink's paper on the TREE program in the Netherlands, whose underlying principle is that an important element in recovery from long-term mental distress is to develop and pass on narratives. In other words, developing one's own narrative and comparing it with the narratives of other (ex-) users and survivors of psychiatry is the beginning of building experiential knowledge.
Of most interest to this reader in this section, however, were the reports on the Hearing Voices movement. Hannelore Klafki's paper on how voices accompanied her throughout her life and how she managed to cope with them to lead a normal life was quite moving. Following up, Romme and Escher describe INTERVOICE, the international network, the basic assumption of which is that accepting and making sense of voices is a much more helpful alternative for recovering from the distress associated with voice hearing.
Hearing voices in itself, they point out, is not a sign of mental illness, but it is quite possible to become ill and a psychiatric patient, when one cannot cope with them and the problems laying at their roots. Persons who hear voices and have become ill tend to show a different relationship with their voices than do persons who hear voices and do not become psychiatric patients. Accepting the voices means realizing that the experience of voice hearing is real, and making sense of them suggests that the voices are not something crazy, but have a purpose in helping to learn to cope with life's problems.
In another paper, Rufus May, after describing his own struggle with mental crises, discusses the unusual beliefs movement. For example, he reports on the Beyond Belief Network, which aims to help people to cope with unusual beliefs that might be termed delusions by mental health professionals. There are many people, he says, who have beliefs that meet the criteria for delusions, yet who are living successful lives with no contact with psychiatry. The difference between them and those who receive mental health services is whether the individuals involved can cope with their beliefs, and whether they are distressed or preoccupied by them. This way of thinking about unusual beliefs, then, follows from the main concept of the Hearing Voices movement, which states that each person should be able to choose how best to understand his or her own reality and that acceptance, as already mentioned, is an important stage in gaining back the power to manage one's experiences.
The third section then goes on to report on alternative models of professional support. In it, the editors Stastny and Lehmann's long paper on Soteria - the treatment model introduced by Loren Mosher in the early 1970s - was to me one of the most informative in the book. After describing Mosher's original model in detail, they discuss the dissemination and replicability of the Soteria approach, list the catalogue of crucial elements that must be in place before a program can call itself Soteria, and soberly give a current assessment and outlook with respect to the model's future, stating there is a risk that Soteria development might come to a complete halt, or even gradually recede.
In this section there are also papers on a user-controlled house, the Hotel Magnus Stenbock in Sweden; the Windhorse Project in Boulder, Colorado, Nova Scotia and Vienna, based on Podvoll's working model of psychosis; the Crisis Hostel Project in Ithaca, New York; the Berlin Runaway House; the Second Opinion Society in the Yukon; Trauma-informed Peer Run Crisis Alternatives; La Cura in Sicily; and the Open Dialogue in Finland
The third part focuses on general and specific beneficiaries of alternative approaches, that is, on certain subgroups of people with mental health problems. For example, Philip Thomas and Salma Yasmeen's paper presents a conceptual critique of mental health theory and practice to help understand the problems that Western psychiatry poses for people from non-Western cultures or for those in the black and minority ethnic communities. Bruce Levine's paper on managing troubled children and teens without using psychiatric drugs analyses the ten most common sense causes and solutions and is most interesting. In another article, Erich Schützendorf considers the development of a person with dementia not as a pathological alteration, but rather as an expression of individualistic behavior, which makes a respectful encounter possible, offering many concrete examples to prove his point.
Psychiatric (ex-) users and survivors, as is known, have been highly skeptical of family involvement in the recovery movement, and have often felt both the controlling and paternalistic experience of not only their own families, but also those of large family advocacy organizations. Dealing with this issue, Karyn Baker contributes a paper on the Family Outreach and Response Program (FOR) in Toronto, which is based on the belief that families can be exceedingly helpful in their relative's recovery when given proper education, support and skills based on a critical recovery perspective. Finally, this section also contains a paper by Guy Holmes and Geoff Hardy on the means of breaking what the authors call the shame cycle, especially in homosexual men.
Part four, which this reviewer particularly enjoyed, examines the problem of realizing the alternatives and the humane forms of treatment discussed earlier. It centers on the potential strategies for promoting and disseminating such alternatives and for achieving human rights for mental patients. It is stressed, however, that implementation remains a most difficult undertaking, because the pharmaceutical industry, the health insurance companies, the hospitals and other institutions of authority - banded together with the psychiatric profession - have more or less succeeded in keeping effective alternative projects deprived of funding opportunities.
Three articles in this part (as well as one earlier by Miriam Krücke) treat of the manner in which psychiatric patients can legally protect themselves and/or fight for their rights. Two of these focus on the issue of the advance directive, which can be used to assert and sustain self-determination in situations, where people are no longer able to express their will, or are deemed to be lacking the capacity to express their free will. This, then, is a legal instrument designed to preserve the rights of competent individuals to choose or refuse health care. One of these papers, from the American perspective, by Laura Ziegler, is of great interest, especially since she concretely and extensively reports on six cases of varied legal complexity from the USA, showing how patients had to fight to have their psychiatric advance directives accepted by the courts.
Of the two other articles that deal with the issue of the legal rights of patients in this part, the one by James Gottstein is a must read. It highlights the work of PsychRights in the USA, which aims at mounting a coordinated litigation campaign in order to substantially reduce forced psychiatric treatment and to create non-coercive, non-medical model alternatives. After some interesting theoretical considerations, Gottstein presents extensive concrete detail on just how a PsychRights campaign works, drawing upon a legal action in Alaska as his primary example. The other paper by Peter Rippmann describes the work of PSYCHEX in Switzerland, which also has taken up the legal fight to free patients incarcerated against their will.
David Oaks's paper on MindFreedom International is another high point of the book, in which he calls for a non-violent revolution of freedom, equality, truth and human rights throughout the entire mental health system, the unfair influence of the psychiatric drug industry adding to these human rights violations. He points out that drug corporations use fraud, force and fear to violate the human rights of clients, that they have manipulated the media, advertising and research to convince the public and mental health professionals that those with mental health problems have a chemical imbalance, and that they also use fraud by routinely covering up any information that their products might be harmful and can even kill.
Forced drugging is growing, Oaks insists, and psychiatric drug companies fund organizations that lobby the government to make it easier to force the products they manufacture into customers. Moreover, fear is used to show that there is no alternative to force and drugs. In light of this, there ought to be a full range of voluntary, humane, safe options and alternatives offered to all who choose to use them. This Western style mental health system, he says, is often called a "medical model," but more accurately ought to be called the "domination model", since its main effect is to squeeze out all other options from mental health care.
Another paper in this section by Ahern et al reports on INTAR, the International Network Toward Alternatives and Recovery, founded in 2003, which is dedicated to advancing the knowledge and availability of alternative approaches for individuals experiencing severe mental distress. Quite characteristic of many alternatives, they point out, is that they often remain the sole example of their generally quite successful approach, but with INTAR there is the possibility that such individual efforts will cross-fertilize and these positive results will become disseminated to a wider audience.
In their paper Peter Lehmann and Maths Jesperson describe how (ex-) users and survivors of psychiatry are presently organized and how they cooperate internationally, with a particular emphasis on the role that the internet plays in reaching their goals. Rounding out this part of the book, there are articles on the system of the personal ombudsman in Skane, Sweden; on user-led research, which emphasizes the value of personal experience in knowledge creation in order to develop an evidence base for alternative approaches; and on the Distress Awareness Training Agency (DATA), which prepares people for (ex-) user or survivor involvement work in England.
Part five, the last in the book, takes up the issue of why alternatives to psychiatry are needed. It starts off with Marc Rufer's long article on various aspects of present-day psychiatry's "reductionist vision of humanity", a hard-hitting critique aimed at its diagnostic methods, its therapies and the power that it thereby wields. And then there is Pat Bracken's short, but incisive, analysis of the radical interpretation of recovery, alluded to at the outset.
In the last paper, the editors Stastny and Lehmann sum up their position. They believe that a non-medical alternative to psychiatry is possible either within the psychiatric system or outside. Basically, however, they harbor no hope that the psychosocial system will change of its own accord, since it does not support in any substantial manner the organizations of (ex-) users and survivors of psychiatry, the cooperation with other human rights or self-help groups, or promote forms of living with mental problems outside of institutional settings. Psychiatry, they feel, still tends to turn a cold shoulder to the movement of (ex-) users and survivors of psychiatry and its supporters, and to scorn its proposals for reform along with all the important knowledge it has generated.
Hopefully this book will help the (ex-) user and survivor movement, not only by introducing a wider public in and out of psychiatry to its very many real accomplishments, its vital importance and its future goals, but also by strengthening the international ties of those directly involved in the movement itself. I can only wish that this book be read by all psychiatrists, especially younger psychiatrists in training, since I am quite certain that they will find much food for thought in its pages.
Competing interests
None declared.
Paradigms Lost?
Ronald Pies, SUNY Upstate Medical University/Tufts USM
9 September 2008
I appreciate the comments from Mr. Langshaw, Ms. Spackman, Mr. Hammersley, and Professor Koehler. Though I disagree with many aspects of their remarks, I believe that our positions and beliefs are not as far apart as might first seem the case. However, the issues raised in their remarks are far too complex to answer in a casual “blog.” Moreover, the stakes of the debate are far too high. It is not just the stature and reputation of my profession that are on the line—it is the well-being of those my profession strives to help. The following, then, is merely an interim statement, signaling the direction I will take in my full response (which I expect to post in some form on PEHM). Please understand that I will probably not respond in a “piecemeal” fashion to subsequent comments; rather, I will offer a unified and fully-referenced response within the next few weeks. The following is but a very short sketch of what I will argue:
The claim that the fundamental paradigms of so-called “mainstream psychiatry” are narrow, “reductionistic” or predominantly focused on “biomedical” explanations and treatments is vastly oversimplified, and, in many respects, erroneous. As demonstrated in numerous textbooks and position papers, “mainstream” psychiatry—at least in the U.S.—has been and remains a broad-based, pluralistic, and philosophically sophisticated science. There has been no “one-sided promotion of a disease model in mainstream psychiatry” nor has there been any concerted attempt to suppress pluralism or “alternative” approaches to the care of those who suffer with serious mental illness. (The existence of the PEHM website—edited and founded by two psychiatrists—bears witness to this claim). On the contrary, recent trends in the U.S. show a willingness on the part of the psychiatric profession to integrate alternative and complementary approaches into our model of care.
The stigmatization of those with mental illness is all too real. But the notion that psychiatric diagnosis is, by itself, the cause of stigma; or that a clinician’s conscientiously arriving at a psychiatric diagnosis is inherently stigmatizing, must be rejected. The very real stigma surrounding psychiatric illness is a function of society’s ignorance and prejudice, as regards the “mentally ill”, not a result of having received a diagnosis per se. Mental health clinicians are themselves the objects of stigmatization, and cynical allusions to “psychiatric survivors” only increase public animus against psychiatrists and other mental health professionals. There are, of course, many cases of misguided treatment in psychiatry, as in other areas of health care; but this must not serve as an excuse to stigmatize an entire profession. There are, indeed, good grounds for patients to feel that “…the conventional system doesn’t measure up, and that something deeper about their well-being is not being addressed” as Prof. Koehler rightly notes. But this dissatisfaction—at least in the U.S.—stems largely from deficiencies and inequities in the health care system, not from fundamental flaws in the underlying “paradigms” of mainstream psychiatry. The traditional psychiatric model of care has been grotesquely distorted in the U.S., owing to the pressures of so-called “managed care”, which limits not only access to good treatment, but also the time and attention that conscientious psychiatrists fervently wish to provide. And, as Prof. Koehler rightly notes, the baneful effects of “Big Pharma” on medical practice patterns—in all medical specialties-- must be addressed and counteracted.
Although I will not provide a full review of the book by Stastny and Lehmann, I will argue that the claims of the journalist, Robert Whitaker, prominently stated in the preface of the book, are deeply flawed and largely erroneous. In particular, the notion that there has been a great upsurge in disabling mental illness or psychiatric disorders in the past 50 years is not supported by well-designed epidemiological studies. There is also no convincing epidemiological data to support the claim that “countries that have adopted the modern drug-based paradigm of psychiatric care have, in the past 50 years, experienced a great surge in the number of people disabled by mental disorders.” The underlying premise that one can reach inferences regarding the incidence or prevalence of mental illness using data from Social Security disability determinations—a major source of Whitaker’s data—is fundamentally fallacious. Because the fundamental premise of burgeoning rates of mental illness is false, the notion that “we desperately need to reflect on alternatives to this failed paradigm of [psychiatric] care” is also fallacious. This is not to say that refinements and improvement in psychiatric care are not sorely needed—they most certainly are. Our present treatments (both pharmacological and psychosocial) are far from ideal and may sometimes impose considerable burdens (e.g., medication side effects) upon patients. But the fundamental theories and paradigms of “mainstream” psychiatry are not impugned by increasing rates of administrative determinations of mental “disability”.
The most rigorous epidemiological data generally do not provide any consistent evidence of a greatly increased incidence of schizophrenia or bipolar disorder, on a world-wide basis; nor is there clear evidence that rates of these diseases have markedly increased in the post-neuroleptic era (since 1954). Rates of major depression are more complicated to assess, as there is some evidence of a “birth cohort” effect since World War II; i.e., some data indicate rising rates of depression in birth cohorts born after WWII. But it would be fallacious and simplistic to attribute this solely to psychiatric or medical interventions. There are numerous economic, social, environmental and cultural factors that may be at work here. Moreover, the rising prevalence of major depression may be largely confined to certain subgroups, such as middle-aged women, and may not apply to the general population. There are good epidemiological studies (such as the recent Baltimore ECA follow-up study by Eaton et al—see Acta Psychiatr Scand. 2007 Sep;116(3):182-8) that point to a reduction in incidence (number of new cases in a specified interval) of depression, even as prevalence (the accumulated or total number of cases) among middle-aged females may be increasing. This hardly supports claims that we are witnessing an “epidemic” of depression, or that there has been a generalized failure of the fundamental paradigms of psychiatry. Many other factors, such as a break- down in the social support system for women, may be at work. However, these data do tell psychiatrists that we must re-evaluate our treatment efforts in some populations. Epidemiological data must be carefully examined to clarify these issues, and the promiscuous use of anecdotal case vignettes to support claims of a “failed paradigm” in psychiatry is indefensible.
By means of research studies, I will show that—notwithstanding some inexcusable cases of poor psychiatric treatment--many, and perhaps most, recipients of psychiatric care in the U.S. are largely satisfied with it. I will argue that psychiatry as a profession continues to be a positive and constructive force in addressing the needs of those who suffer with severe--and often life-threatening--afflictions.
Finally, like most psychiatrists, I share Mr. Hammersley’s quest for “balance” in approaching the diagnosis and treatment of those who suffer with psychiatric illnesses. But balance requires a fair-minded and accurate appraisal of the field one seeks to reform. “Balance” is not well-served by polemical attacks founded on anecdotal or shoddy research, such as those contained in the preface to the book by Stastny and Lehmann.
Competing interests
Dr. Pies reports no conflicts of interest with respect to the material posted. He is Editor-in-Chief of the Psychiatric Times, a monthly, peer-reviewed journal [www.psychiatrictimes.com].
Another - and Last - Point of View from Germany
Karl Koehler, University Professor Emeritus of Psychiatry, Bonn
22 September 2008
In his last comment, Prof. Pies states the claim that the fundamental paradigms of "mainstream" psychiatry are narrow, "reductionistic," or predominantly focused on "biomedical" explanations is vastly oversimplified, and in many respects, erroneous.
How, then, to explain why in his presidential address in 2005, Steven Scharfstein, the newly elected president of the APA, claimed that psychiatry had "let the biopsychosocial model (BPS) become the bio-bio-model." And then go on to lay much of the blame for this at the feet of the drug industry, because of their pushing biological paradigms so as to sell their products.
Does this mean that American psychiatrists have all become Samuel –"Biological Psychiatry: Is There Any Other Kind? – Guze clones?
Of course not, for biological psychiatrists, although most commonly affirming a biopsychosocial eclecticism, nonetheless focus more on the biological aspects of mental illness. With the result that a marked asymmetry in research and practice has occurred in the past two decades: far more funding, publication, and practice are given to biological, especially pharmacological, than to psychosocial approaches – with "alternative" paradigms, like those offered by the user movement, for the most part, tending to be ignored or marginalized.
Although Prof. Pies feels that the recipients of psychiatric care in the US are largely satisfied with it, I hope this may not be wishful thinking – notwithstanding the "evidence" he intends to present for this view. Perhaps what Shooter, the president of the RCP, had to say in an editorial in 2005, might be more realistic – maybe, I would suspect, even be applicable to the States: "the level of mistrust in press and public is now so deep that the jobbing clinician will have difficulty in persuading the patient that the advice being given about medication is open and honest."
There are certainly many in the user movement, who share such a negative opinion of psychiatry. Since the movement is by no means monolithic, the views of some of its sub-groups are inacceptable - and perhaps even a danger in replacing science, properly understood in all its limitations with some form of 1970s-like antipsychiatric ideology. Although I am not an antipsychiatrist – a slippery term, if ever there was one – I still am convinced that some of the pragmatic "antipsychiatric solutions" featured in "Alternatives Beyond Psychiatry" offer something positive in opposing the biological reductionism and capitalist ethos of much of "mainstream" Western psychiatry.
It is naive to think that professional research, undertaken by hordes of resaerachers is always of high quality and free of bias. I have experienced too many young residents, still green behind the ears, who were tucked into a drug study, although still utterly devoid of any deeper psychopathological sense or interest – since their co-ordinators probably lacked it too – dutifully checking off symptoms and dropping patients into some Procrustes bed DSM-III/IV diagnosis, and then mechanically checking off their rating scales.
Is this only a caricature?
Not for me it isn't. This surreal situation was part of my psychiatric Damascus experience – as well as that of many other colleagues not part of the power broker psychiatric structure "cooperating" with the drug industry - during the so-called decade of the brain. In particular, I better came to understand how the sponsoring of drug studies could vitally and negatively impinge upon routine, everyday clinical decision making in an institution, studies that would later be added to the growing mass of evidence based medicine (EBM).
I thus welcome Prof. Pies's intention to present a more detailed EBM-oriented critique of the "Alternatives Beyond Psychiatry." Although he does not intend to review the book as a whole, he does plan on zeroing in on Whitaker's preface, indicating he would present details why the evidence presented there is based on inadequate research.
Why not do the same with all the articles in the book? On doing so he would see they are almost all descriptive or opinion pieces, and those containing some data are hardly of a caliber to satisfy the EBM mind.
Why then did I so strongly praise the book, without pointing out its weak points? Indeed, there were many, and I must admit that I was quite irritated by some statements made about psychiatrists and psychiatry. Indeed, some remarks struck me as being downright disrespectful of – and even paranoid toward - our profession.
Notwithstanding that, however, there was much that I liked.
For the sake of argument, let us accept that Prof. Pies has completely demolished Whitaker's argument in the preface with the best that such research has to offer. It is my contention that he can go further, and offer all the EBM research he can muster against all the arguments contained in the rest of the book – or as he puts it, against the "polemical attacks founded on anecdotal or shoddy research."
Unfortunately, he will still be fighting windmills and missing the point of the book.
And the point, I contend, is this: the user movement has never really been taken seriously, has perhaps been marginalized, has been a voice crying in the wilderness, without any real power and influence. But now, finally, through the changes wrought by the internet, it has the possibility of more easily organizing world-wide opposition and bringing more public and political pressure to bear, this book being a milestone in this development.
As the Service User Research Enterprise (SURE) at the Institute of Psychiatry in London, for example, has demonstrated, the emerging field of responsible collaborative research between clinical academics and service users in the field of mental health seems to be a feasible future undertaking. Indeed, user-led research would involve service users controlling all stages of the research process: design, recruitment, ethics, data collection, data analysis, writing up and dissemination. In other words, psychiatrists need to support not only EBM, but also embrace the importance of other forms of knowledge
Sound too radical?
I don't think so. Users come to the research endeavour with a different perspective than professionals and are able to elucidate how services and treatments feel to service users ‘from the inside’. They can provide fresh insights, and so responsible, serious research done from this point of view could lead to services that are more acceptable to consumers than many find them today. Indeed, it is time for greater openness between the profession and service users, in our academic departments, journals and scientific meetings.
Indeed, as Prof. Pies has so correctly pointed out, the issues raised are quite complex, and the stakes of the debate enormously high.
Competing interests
None declared
Antipsychiatry's striking lack of data and alternatives
Peter Lepping, Cardiff University, North Wales NHS Trust
8 November 2008
I have a number of serious objections to the statements made in the book review. It does not surprise me that the book takes the slant it takes considering Peter Lehmann’s previous work. I do agree with their notion that psychiatry has been subject to political influences and that some of psychiatric decision making has been influenced by the political persuasions of the time. I also do not deny that psychiatry has been abused to harm people that society deemed undesirable and that psychiatrists were party to this. Whilst this is a shameful part of the history of psychiatry it has to be said that eugenics and other similar movements were by no means exclusive to psychiatry and effected all of medicine equally.
I have to say though that I very much disagree with the notion that orthodox psychiatry a) exists and b) is entirely biological and that the medical or biological model of psychiatry has prevailed throughout the decades. Quite on the contrary, I think that psychiatry has always been driven between the two extreme poles of biological and social. Peter Lehmann is of course at the extreme end of social psychiatry where the existence of psychiatric illness is denied entirely. He argues that psychiatric illness is a social construct that hinders the development of people who are not conforming with the establishment’s view of how they should conform. This is, in my opinion, an unacceptable mockery of the suffering of the mentally ill.
Coming back to the point of the two poles of biological and social psychiatry: ever since the 1920’s when work therapy was developed in earnest and since the advent of antipsychotic medication in the late 1950’s there have been developments that moved psychiatry more into one direction or another. It is certainly true that the 1990’s were more dominated by biological psychiatry but it seems wrong to suggest that that was to the complete exclusion of social psychiatry. Since the turn of the century social psychiatry has clearly gained more and more ground. It is unfortunate that this dichotomy remains when in fact most psychiatrists would accept that a bio-psycho-social model is the only way to holistically look at patients’ difficulties.
It has been really interesting to witness a demystifying of some of the second generation antipsychotics, which promised much more than they could keep, with studies that were independently funded such as CATIE. I feel that professionals have at least as much contributed to this demystification than mental health care consumers, not all of whom believe that psychiatry has failed them. What the author of the review finds refreshing is not new to psychiatrists in Germany where Peter Lehmann works, and where anti-psychiatry has remained a powerful force in politics since the 1970’s, influencing political decision-making and making some decisions on psychiatric services extremely difficult. It would be impossible for Peter Lehmann to claim that he would write a balanced book on antipsychotics given his track record so I am not surprised that he does not claim it.
Their argument that psychiatry does not work because the number of people with mental illness has not gone down is completely unscientific because it would assume that we only measure success by absolute cure rates. If that were the case no anti-anginal tablet would be deemed a success because they do not actually cure ischemic heart disease but merely try to improve quality of life. However, to what extent medication is useful to an individual is something that we have to discuss openly and honestly and there are individuals where medication is clearly not useful.
I believe that at the end of his review the reviewer puts his finger into the wound that always remains wide open when anti-psychiatrists write such books, which is the absence of data. Whilst they are very good at pointing out individual patient’s stories where psychiatry has clearly not been of much help to that particular patient they completely lack any supportive data to suggest that their suggestions are more successful or that without psychiatric input the life of the mentally ill would be much better than it is now.
I have always maintained that we ought to treat patients with a bio-psycho-social approach. I have also been extremely grateful for the CATIE Team who have revolutionised the way we see second generation antipsychotics and who have made it possible for other researchers to publish data that has shown the limitations as well as the benefits of second generation antipsychotics. However, we should also be careful not to throw the baby out with the bath water pretending that all would be well if only those "nasty" mental health professionals would never be able to treat a patient.
"Medical Model" or Bogeyman?
11 August 2008
I have not read Stastny and Lehmann's book, so I will refrain from judging its claims. However, I find myself quite puzzled by Mr. Hammersley's review. Perhaps in the U.K., psychiatry is, indeed, characterized by the "absolute dominance of the medical/biological model of psychiatry, a situation that has persisted for the last thirty years." According to Mr. Hammersley, this "one sided promotion of a disease model of serious mental illness, with medication as the only possible 'cure' has seen the exclusion of more holistic and humanistic approaches." My goodness--England must be quite an unpleasant place to practice psychiatry!
As a psychiatrist, professor, researcher, and clinician for over 25 years, I have never seen this one-sided model promulgated in the U.S. In my residency program, back in the 80s, we were exposed as much to Otto Kernberg and Tom Szasz as we were to psychopharmacology. In all my academic years, I have never once heard any responsible psychiatrist say anything remotely as silly as the views Mr. Hammersley attributes to "the medical/biological model of psychiatry."
There have always been psychiatrists (including myself) urging us to consider psychosocial, cultural, and even spiritual factors in the genesis of what is called "mental illness" (for my views on the term "disease" and how it applies to psychiatric nosology, readers are referred to my chapter in Dr. Jeff Schaler's book, Szasz Under Fire; and to my recent piece on schizophrenia at http://www.psychiatrymmc.com/psychiatric-diagnosis-and-the-pathologist%e2%80%99s-view-of-schizophrenia/).
I have never once heard any well-respected psychiatrist in the U.S. claim that psychotropic medication was a "cure" for anything, much less the "only possible" cure for mental illness!
Psychiatry in the U.S. is indeed under great pressure to reduce its emphasis on psychotherapy, especially during residency training, and there are undoubtedly powerful market-driven forces working toward this unfortunate end. But U.S. psychiatry, in my view, has never been absolutely dominated by a purely "biological" understanding of disease.
So--I wonder: is the bogeyman behind Mr. Hammersley's caricature of psychiatry a real creature, or merely a politically expedient fiction for those who prefer to denigrate and marginalize psychiatry?
At a minimum, it would be very helpful to learn the names of those psychiatrists who propound the sort of simplistic views Mr. Hammersley imputes to the entire profession of psychiatry, as well as the journal articles or lectures in which these views are stated. --Ronald Pies MD, Professor of Psychiatry, SUNY Upstate Medical University, Syracuse NY; Clinical Professor of Psychiatry, Tufts U. School of Medicine, Boston.
Competing interests
Dr. Pies reports no competing interests.
Reflections in the mirror
3 September 2008
I write with concerns relating to the comments returned by Dr Pies in connection to the book review by Paul Hammersley. I am concerned with the relative lack of insight afforded to the problems of pathology and mental illness both in the UK and USA. Unpleasant as it may be to Dr Pies, Psychiatry is dominated by a medical perspective of mental illness with a definite need to address this imbalance from a research, treatment and humanity perspective. If we are to move to a holistic view of care/treatment of individuals with mental illness, we need to first address the aetiological dominance of biological sciences on our understanding of these conditions and repair this breach with a more balanced and realistic view of these problems, with a greater emphasis on the individuals environments as influencing factors affecting the onset, outcome and recovery potential. Dr Pies need to first take a closer look in the mirror and reflect on his current understanding of what he means by psychosocial approaches to mental health treatments and only then can he can realise that the bogeyman is the face of psychiatry he does not want to acknowledge.
Competing interests
None
I'd prefer to be an anonymous service user, but...
5 September 2008
In reference to comments on Paul Hammersley's review of "Alternatives Beyond Psychiatry" by Peter Stastny and Peter Lehmann, Dr Pies might well surmise that "England must be quite an unpleasant place to practise psychiatry". The compassionate and forgiving among surviving service users, of whom I believe there must be more than me, might well agree. I haven't yet read the book in question, but I look forward to doing so. Now nearly seventy years old, I have experienced over thirty-seven years of the stigmatising effects of several different diagnoses originating from a post-natal state of extreme fear, distress, confusion and bewilderment. Labelling this a psychosis did nothing to promote a cure, help or understanding. In a few subsequent periods of illness, nothing was the same, and I had, amongst other periods of well-being, about fifteen trouble-free years at work in one interval. No-one ever spoke of cure in all that time. I am heartened to have met in the past two years a few truly caring and forward-thinking professionals. These excellent people understand their human field and can think "out of the box" of a patient-damaging and punitive past practice, and dare to look and hope for cures. We should all have learned by now that stigmatising labels can be, and are, used to infringe human rights. Psychiatry seems to be the only so-called science which has progressed little since the 'Sixties, and legislation based on such an anachronism can only be retrogressive. The time for rethinking is well overdue. Abroad, people with disabilities are sometimes called "special little people", or as suffering from culture-shock. I have found no fear, ignorance, suspicion or prejudice in the most unexpected places, but rather, friendship and care. Please let us have more of such alternative science books and some real advances in humanistic research aimed at cures!
Competing interests
None declared
authors reply
5 September 2008
I would like to thank Professor Pies for his comments and would also urge him to read Peter Stastny and Peter Lehmanns book.
Perhaps I do see 'Bogeymen,' possibly because
I dont view the world through rose tinted spectacles.
The unholy (and unhelpful) alliance between large parts of mainstream psychiatry and the multi-billion dollar pharmaceutical industry is a scandal, and the denial of proven effective alternative treatments to many can no longer be justified.
I am not alone in this belief as the following quote illustrates
"There is a widespread concern at the over- medicalization of mental disordersand the overuse of medications. Financial incentives and managed care have contributed to the notion of a 'quick fix' by taking a pill and reducing the emphasis on psychological and psychosocial treatments. There is much evidence that there is less psychotherapy provided by psychiatrists than ten years ago.
This is true despite the strong evidence base that many psychotherapies are effective alone or in combination with medications ... If we are seen as mere pill pushers and employees of the pharmaceutical industry, our credibility as a profession is compromised."
Strong words indeed, but the above qoute is not from an idealistic radical, it is in fact from Steven Sharfstein the then head of the American Psychiatric Association in August 2005.
Are we to assume that his opinion was also a 'caricature'
Things are changing, very slowly, but in the right direction.
Allowing service users and consumers to recover through genunie attempts to understand the reality of their lived experience is legitimate, as is the appropriate use of medications.
Balance is all we ask
Paul Hammersley
Spectrum centre
University of Lancaster
UK
Ref - Read.J 2005. The bio, bio, bio model of madness. The Psychologist, Vol 17, no 12.
Competing interests
None declared
A Point of View and a Review from Germany
8 September 2008
It cannot be gainsayed that the history of psychiatry has seen a number of attempts at reductionism in the face of the immense complexity of mental disturbance. Indeed, the paradigm that was more or less dominant in American psychiatry at the start of the 1970s during my residency happened to be the psychoanalytical model. But during the past 25 years or so, the winds have shifted again, with the dominant position this time having been taken over by the biomedical model, especially in research centers and university clinics.
Of course, there is also a teaching and discussion of other etiological and therapeutic points of view, with a knowledge – at least theoretically - of these latter perspectives usually being a prerequisite to qualify. Many psychiatrists certainly try to apply some of this in their everyday work – as Professor Pies points out - not blindly seeing everything in terms of the dominant biomedical model. Yet the fact remains that “true power” – especially with respect to fostering or not fostering the careers of those under them - is presently wielded by those holding key positions in psychiatric research centers or university clinics; and of these the majority no doubt are enthusiastic adherents of the biomedical model.
Although this is not “absolute domination” – an expression with which Professor Pies seems to take umbrage – it is a form of domination no less, and a most unhealthy one. But let’s not talk so much about the dominance of the biomedical model. Let’s be more concrete and talk more about the pharmaceutical industy, in whose best interest it is that this biomedical model should become even more dominant. And in this connection let’s talk about “treatment” instead of “cure” - another term to which Professor Pies rightly takes exception – since it has been part of the drug industry’s aggressive marketing strategy to promote its treatments by forming an alliance with many of those in psychiatry in positions of power.
But all this, or course, is nothing new, for in recent years several inspired polemics by physicians, all of them straightforward indictments of the pharmaceutical industry and its for-profit webs, have appeared, so that a pychiatrist not aware of the problematic tangle of moral compromise involved, must have been keeping his head in the sand. Indeed, it is not just a case of a few rotten apples in the barrel. The complex and often invisible bonds between psychiatry – indeed medicine in general - and the drug industry are now so blatant that they are - as Howard Brody, a medical ethicist and physician, who has brought his discipline’s tools to the issue, puts it - dependent on each other as any addicts are on their substance of choice.
How bad things have gotten may perhaps best be anecdotally exemplified by the following taken from Brody’s book, in which a drug company president is quoted as saying: “If we put horse manure in a capsule, we could sell it to 95% of these doctors."
For those who still remain unconvinced, as a starter I strongly recommend a two-page Royal College of Psychiatry publication: “Psychiatry and the Pharmaceutical Industry: Who Pays the Piper?” in Psychiatric Bulletin (2005) 29: 84-85, which is easily accessible under the link http://www.critpsynet.freeuk.com/PsychiatricBulletin.htm
In spite of the appalling collusion of a large segment of those wielding psychiatry’s “true power” with the pharma industry, common sense has been leading many ordinary people to doubt what the so-called experts have been telling them. Indeed, it is a fact that most American and European adults now use alternative or complementary therapies for their medical problems, with the numbers continuing to grow, for reasons that have much to do with an increasing distrust of mainstream medicine. People are looking around and feel that the conventional system doesn’t measure up, and that something deeper about their well-being is not being addressed. The time when they would listen to their doctor and do whatever he told them, that time is long gone. From here it is only a small step to begin doubting medical science, with many concluding that, if Western medicine is imperfect and sometimes corrupt, then mainstream doctors may not be the best judge of treatments after all. People’s actual experience and the personal testimony of friends and family then feels more truthful.
In other words, when trust in doctors erodes, other treatments fill the void.
It is no wonder then that the movement of (ex-) users and survivors of psychiatry has gained such momentum. That alone is a compelling reason why “Alternatives Beyond Psychiatry” is a most welcome book, one that psychiatrists cannot afford to overlook. I totally agree with Hammersley that this is not a balanced book, that it is refreshingly one-sided, and that it will delight some and infuriate others. Moreover, psychiatrists even have something to learn from those contributions to the book that they might be tempted all too smugly to categorize as being too naïve, idealistic, impractical or radical.
One will not agree with everything in this text – I certainly did not – but I believe that in the light of the parlous state of psychiatry in the public’s perception, it behooves its practitioners to have at least some awareness and respect for the issues raised in this book.
What now follows is my own review of Stastny’s and Lehmann’s book, which first appeared 2007, and is also posted on the INTERVOICE site.
It seems, as if countries that have adopted the modern drug-based paradigm of psychiatric care have, in the past 50 years, experienced a great surge in the number of people disabled by mental disorders. Accordingly, it would appear that we desperately need to reflect on alternatives to this failed paradigm of care. Although in its present form issues dealing with values, meanings, relationships and power are not ignored, these always seem to be secondary to the more important technical aspects of mental health. Indeed, it only tends to underscore the centrality of "experts." In spite of the fact that service (ex-) users and survivors might be consulted and invited to comment on the interventions and the research connected with the reigning paradigm of care, they are nonetheless always recipients of expertise generated elsewhere.
In contrast, the recovery agenda, as Pat Bracken puts it in a paper in this book, presents a radical challenge, since it reorients our thinking about mental health completely. It foregrounds issues that have to do with power and relationships, contexts and meanings, values and priorities, which now become primary. Although such an agenda does not reject or deny the reigning role of therapy, services, research and, in some instances, even drugs, it does work to render them all secondary. Indeed, its most radical implication is the fact that when it comes to issues having to do with values, meanings and relationships, it is the (ex-) users or survivors themselves, who are the most knowledgeable and informed. In other words, when it comes to the recovery agenda, they are the real experts.
This then is the basic theme of this fascinating new book.
After a very short first part on why psychiatry hurts more than it helps - containing a personal report by the 91 year old activist Dorothea Buck-Zerchin, who describes her experience of what she calls 70 years of coercion in psychiatric institutions, as well as a paper by Kate Millett, which focuses on the question of legal rights and the mental health system - the long second part takes up approximately half the book in its discussion of present-day actual alternatives to psychiatry.
Its first section describes the concrete strategies of individual (ex-) users and survivors, with or without professional support, and demonstrates that the individual paths taken in order to manage mental crises without ending up in a psychiatrist's office are extremely varied. All fourteen personal reports presented here are deliberately positive, since it is meant to show that it is possible - at least for some - to recover their mental equilibrium using the personal resources at hand and uniquely tackling their problems with at times rather simple and reasonable methods.
The second section, which deals with concrete examples of organized (ex-) user and survivor self-help, leads off with Wilma Boevink's paper on the TREE program in the Netherlands, whose underlying principle is that an important element in recovery from long-term mental distress is to develop and pass on narratives. In other words, developing one's own narrative and comparing it with the narratives of other (ex-) users and survivors of psychiatry is the beginning of building experiential knowledge.
Of most interest to this reader in this section, however, were the reports on the Hearing Voices movement. Hannelore Klafki's paper on how voices accompanied her throughout her life and how she managed to cope with them to lead a normal life was quite moving. Following up, Romme and Escher describe INTERVOICE, the international network, the basic assumption of which is that accepting and making sense of voices is a much more helpful alternative for recovering from the distress associated with voice hearing.
Hearing voices in itself, they point out, is not a sign of mental illness, but it is quite possible to become ill and a psychiatric patient, when one cannot cope with them and the problems laying at their roots. Persons who hear voices and have become ill tend to show a different relationship with their voices than do persons who hear voices and do not become psychiatric patients. Accepting the voices means realizing that the experience of voice hearing is real, and making sense of them suggests that the voices are not something crazy, but have a purpose in helping to learn to cope with life's problems.
In another paper, Rufus May, after describing his own struggle with mental crises, discusses the unusual beliefs movement. For example, he reports on the Beyond Belief Network, which aims to help people to cope with unusual beliefs that might be termed delusions by mental health professionals. There are many people, he says, who have beliefs that meet the criteria for delusions, yet who are living successful lives with no contact with psychiatry. The difference between them and those who receive mental health services is whether the individuals involved can cope with their beliefs, and whether they are distressed or preoccupied by them. This way of thinking about unusual beliefs, then, follows from the main concept of the Hearing Voices movement, which states that each person should be able to choose how best to understand his or her own reality and that acceptance, as already mentioned, is an important stage in gaining back the power to manage one's experiences.
The third section then goes on to report on alternative models of professional support. In it, the editors Stastny and Lehmann's long paper on Soteria - the treatment model introduced by Loren Mosher in the early 1970s - was to me one of the most informative in the book. After describing Mosher's original model in detail, they discuss the dissemination and replicability of the Soteria approach, list the catalogue of crucial elements that must be in place before a program can call itself Soteria, and soberly give a current assessment and outlook with respect to the model's future, stating there is a risk that Soteria development might come to a complete halt, or even gradually recede.
In this section there are also papers on a user-controlled house, the Hotel Magnus Stenbock in Sweden; the Windhorse Project in Boulder, Colorado, Nova Scotia and Vienna, based on Podvoll's working model of psychosis; the Crisis Hostel Project in Ithaca, New York; the Berlin Runaway House; the Second Opinion Society in the Yukon; Trauma-informed Peer Run Crisis Alternatives; La Cura in Sicily; and the Open Dialogue in Finland
The third part focuses on general and specific beneficiaries of alternative approaches, that is, on certain subgroups of people with mental health problems. For example, Philip Thomas and Salma Yasmeen's paper presents a conceptual critique of mental health theory and practice to help understand the problems that Western psychiatry poses for people from non-Western cultures or for those in the black and minority ethnic communities. Bruce Levine's paper on managing troubled children and teens without using psychiatric drugs analyses the ten most common sense causes and solutions and is most interesting. In another article, Erich Schützendorf considers the development of a person with dementia not as a pathological alteration, but rather as an expression of individualistic behavior, which makes a respectful encounter possible, offering many concrete examples to prove his point.
Psychiatric (ex-) users and survivors, as is known, have been highly skeptical of family involvement in the recovery movement, and have often felt both the controlling and paternalistic experience of not only their own families, but also those of large family advocacy organizations. Dealing with this issue, Karyn Baker contributes a paper on the Family Outreach and Response Program (FOR) in Toronto, which is based on the belief that families can be exceedingly helpful in their relative's recovery when given proper education, support and skills based on a critical recovery perspective. Finally, this section also contains a paper by Guy Holmes and Geoff Hardy on the means of breaking what the authors call the shame cycle, especially in homosexual men.
Part four, which this reviewer particularly enjoyed, examines the problem of realizing the alternatives and the humane forms of treatment discussed earlier. It centers on the potential strategies for promoting and disseminating such alternatives and for achieving human rights for mental patients. It is stressed, however, that implementation remains a most difficult undertaking, because the pharmaceutical industry, the health insurance companies, the hospitals and other institutions of authority - banded together with the psychiatric profession - have more or less succeeded in keeping effective alternative projects deprived of funding opportunities.
Three articles in this part (as well as one earlier by Miriam Krücke) treat of the manner in which psychiatric patients can legally protect themselves and/or fight for their rights. Two of these focus on the issue of the advance directive, which can be used to assert and sustain self-determination in situations, where people are no longer able to express their will, or are deemed to be lacking the capacity to express their free will. This, then, is a legal instrument designed to preserve the rights of competent individuals to choose or refuse health care. One of these papers, from the American perspective, by Laura Ziegler, is of great interest, especially since she concretely and extensively reports on six cases of varied legal complexity from the USA, showing how patients had to fight to have their psychiatric advance directives accepted by the courts.
Of the two other articles that deal with the issue of the legal rights of patients in this part, the one by James Gottstein is a must read. It highlights the work of PsychRights in the USA, which aims at mounting a coordinated litigation campaign in order to substantially reduce forced psychiatric treatment and to create non-coercive, non-medical model alternatives. After some interesting theoretical considerations, Gottstein presents extensive concrete detail on just how a PsychRights campaign works, drawing upon a legal action in Alaska as his primary example. The other paper by Peter Rippmann describes the work of PSYCHEX in Switzerland, which also has taken up the legal fight to free patients incarcerated against their will.
David Oaks's paper on MindFreedom International is another high point of the book, in which he calls for a non-violent revolution of freedom, equality, truth and human rights throughout the entire mental health system, the unfair influence of the psychiatric drug industry adding to these human rights violations. He points out that drug corporations use fraud, force and fear to violate the human rights of clients, that they have manipulated the media, advertising and research to convince the public and mental health professionals that those with mental health problems have a chemical imbalance, and that they also use fraud by routinely covering up any information that their products might be harmful and can even kill.
Forced drugging is growing, Oaks insists, and psychiatric drug companies fund organizations that lobby the government to make it easier to force the products they manufacture into customers. Moreover, fear is used to show that there is no alternative to force and drugs. In light of this, there ought to be a full range of voluntary, humane, safe options and alternatives offered to all who choose to use them. This Western style mental health system, he says, is often called a "medical model," but more accurately ought to be called the "domination model", since its main effect is to squeeze out all other options from mental health care.
Another paper in this section by Ahern et al reports on INTAR, the International Network Toward Alternatives and Recovery, founded in 2003, which is dedicated to advancing the knowledge and availability of alternative approaches for individuals experiencing severe mental distress. Quite characteristic of many alternatives, they point out, is that they often remain the sole example of their generally quite successful approach, but with INTAR there is the possibility that such individual efforts will cross-fertilize and these positive results will become disseminated to a wider audience.
In their paper Peter Lehmann and Maths Jesperson describe how (ex-) users and survivors of psychiatry are presently organized and how they cooperate internationally, with a particular emphasis on the role that the internet plays in reaching their goals. Rounding out this part of the book, there are articles on the system of the personal ombudsman in Skane, Sweden; on user-led research, which emphasizes the value of personal experience in knowledge creation in order to develop an evidence base for alternative approaches; and on the Distress Awareness Training Agency (DATA), which prepares people for (ex-) user or survivor involvement work in England.
Part five, the last in the book, takes up the issue of why alternatives to psychiatry are needed. It starts off with Marc Rufer's long article on various aspects of present-day psychiatry's "reductionist vision of humanity", a hard-hitting critique aimed at its diagnostic methods, its therapies and the power that it thereby wields. And then there is Pat Bracken's short, but incisive, analysis of the radical interpretation of recovery, alluded to at the outset.
In the last paper, the editors Stastny and Lehmann sum up their position. They believe that a non-medical alternative to psychiatry is possible either within the psychiatric system or outside. Basically, however, they harbor no hope that the psychosocial system will change of its own accord, since it does not support in any substantial manner the organizations of (ex-) users and survivors of psychiatry, the cooperation with other human rights or self-help groups, or promote forms of living with mental problems outside of institutional settings. Psychiatry, they feel, still tends to turn a cold shoulder to the movement of (ex-) users and survivors of psychiatry and its supporters, and to scorn its proposals for reform along with all the important knowledge it has generated.
Hopefully this book will help the (ex-) user and survivor movement, not only by introducing a wider public in and out of psychiatry to its very many real accomplishments, its vital importance and its future goals, but also by strengthening the international ties of those directly involved in the movement itself. I can only wish that this book be read by all psychiatrists, especially younger psychiatrists in training, since I am quite certain that they will find much food for thought in its pages.
Competing interests
None declared.
Paradigms Lost?
9 September 2008
I appreciate the comments from Mr. Langshaw, Ms. Spackman, Mr. Hammersley, and Professor Koehler. Though I disagree with many aspects of their remarks, I believe that our positions and beliefs are not as far apart as might first seem the case. However, the issues raised in their remarks are far too complex to answer in a casual “blog.” Moreover, the stakes of the debate are far too high. It is not just the stature and reputation of my profession that are on the line—it is the well-being of those my profession strives to help. The following, then, is merely an interim statement, signaling the direction I will take in my full response (which I expect to post in some form on PEHM). Please understand that I will probably not respond in a “piecemeal” fashion to subsequent comments; rather, I will offer a unified and fully-referenced response within the next few weeks. The following is but a very short sketch of what I will argue:
The claim that the fundamental paradigms of so-called “mainstream psychiatry” are narrow, “reductionistic” or predominantly focused on “biomedical” explanations and treatments is vastly oversimplified, and, in many respects, erroneous. As demonstrated in numerous textbooks and position papers, “mainstream” psychiatry—at least in the U.S.—has been and remains a broad-based, pluralistic, and philosophically sophisticated science. There has been no “one-sided promotion of a disease model in mainstream psychiatry” nor has there been any concerted attempt to suppress pluralism or “alternative” approaches to the care of those who suffer with serious mental illness. (The existence of the PEHM website—edited and founded by two psychiatrists—bears witness to this claim). On the contrary, recent trends in the U.S. show a willingness on the part of the psychiatric profession to integrate alternative and complementary approaches into our model of care.
The stigmatization of those with mental illness is all too real. But the notion that psychiatric diagnosis is, by itself, the cause of stigma; or that a clinician’s conscientiously arriving at a psychiatric diagnosis is inherently stigmatizing, must be rejected. The very real stigma surrounding psychiatric illness is a function of society’s ignorance and prejudice, as regards the “mentally ill”, not a result of having received a diagnosis per se. Mental health clinicians are themselves the objects of stigmatization, and cynical allusions to “psychiatric survivors” only increase public animus against psychiatrists and other mental health professionals. There are, of course, many cases of misguided treatment in psychiatry, as in other areas of health care; but this must not serve as an excuse to stigmatize an entire profession. There are, indeed, good grounds for patients to feel that “…the conventional system doesn’t measure up, and that something deeper about their well-being is not being addressed” as Prof. Koehler rightly notes. But this dissatisfaction—at least in the U.S.—stems largely from deficiencies and inequities in the health care system, not from fundamental flaws in the underlying “paradigms” of mainstream psychiatry. The traditional psychiatric model of care has been grotesquely distorted in the U.S., owing to the pressures of so-called “managed care”, which limits not only access to good treatment, but also the time and attention that conscientious psychiatrists fervently wish to provide. And, as Prof. Koehler rightly notes, the baneful effects of “Big Pharma” on medical practice patterns—in all medical specialties-- must be addressed and counteracted.
Although I will not provide a full review of the book by Stastny and Lehmann, I will argue that the claims of the journalist, Robert Whitaker, prominently stated in the preface of the book, are deeply flawed and largely erroneous. In particular, the notion that there has been a great upsurge in disabling mental illness or psychiatric disorders in the past 50 years is not supported by well-designed epidemiological studies. There is also no convincing epidemiological data to support the claim that “countries that have adopted the modern drug-based paradigm of psychiatric care have, in the past 50 years, experienced a great surge in the number of people disabled by mental disorders.” The underlying premise that one can reach inferences regarding the incidence or prevalence of mental illness using data from Social Security disability determinations—a major source of Whitaker’s data—is fundamentally fallacious. Because the fundamental premise of burgeoning rates of mental illness is false, the notion that “we desperately need to reflect on alternatives to this failed paradigm of [psychiatric] care” is also fallacious. This is not to say that refinements and improvement in psychiatric care are not sorely needed—they most certainly are. Our present treatments (both pharmacological and psychosocial) are far from ideal and may sometimes impose considerable burdens (e.g., medication side effects) upon patients. But the fundamental theories and paradigms of “mainstream” psychiatry are not impugned by increasing rates of administrative determinations of mental “disability”.
The most rigorous epidemiological data generally do not provide any consistent evidence of a greatly increased incidence of schizophrenia or bipolar disorder, on a world-wide basis; nor is there clear evidence that rates of these diseases have markedly increased in the post-neuroleptic era (since 1954). Rates of major depression are more complicated to assess, as there is some evidence of a “birth cohort” effect since World War II; i.e., some data indicate rising rates of depression in birth cohorts born after WWII. But it would be fallacious and simplistic to attribute this solely to psychiatric or medical interventions. There are numerous economic, social, environmental and cultural factors that may be at work here. Moreover, the rising prevalence of major depression may be largely confined to certain subgroups, such as middle-aged women, and may not apply to the general population. There are good epidemiological studies (such as the recent Baltimore ECA follow-up study by Eaton et al—see Acta Psychiatr Scand. 2007 Sep;116(3):182-8) that point to a reduction in incidence (number of new cases in a specified interval) of depression, even as prevalence (the accumulated or total number of cases) among middle-aged females may be increasing. This hardly supports claims that we are witnessing an “epidemic” of depression, or that there has been a generalized failure of the fundamental paradigms of psychiatry. Many other factors, such as a break- down in the social support system for women, may be at work. However, these data do tell psychiatrists that we must re-evaluate our treatment efforts in some populations. Epidemiological data must be carefully examined to clarify these issues, and the promiscuous use of anecdotal case vignettes to support claims of a “failed paradigm” in psychiatry is indefensible.
By means of research studies, I will show that—notwithstanding some inexcusable cases of poor psychiatric treatment--many, and perhaps most, recipients of psychiatric care in the U.S. are largely satisfied with it. I will argue that psychiatry as a profession continues to be a positive and constructive force in addressing the needs of those who suffer with severe--and often life-threatening--afflictions.
Finally, like most psychiatrists, I share Mr. Hammersley’s quest for “balance” in approaching the diagnosis and treatment of those who suffer with psychiatric illnesses. But balance requires a fair-minded and accurate appraisal of the field one seeks to reform. “Balance” is not well-served by polemical attacks founded on anecdotal or shoddy research, such as those contained in the preface to the book by Stastny and Lehmann.
Competing interests
Dr. Pies reports no conflicts of interest with respect to the material posted. He is Editor-in-Chief of the Psychiatric Times, a monthly, peer-reviewed journal [www.psychiatrictimes.com].
Another - and Last - Point of View from Germany
22 September 2008
In his last comment, Prof. Pies states the claim that the fundamental paradigms of "mainstream" psychiatry are narrow, "reductionistic," or predominantly focused on "biomedical" explanations is vastly oversimplified, and in many respects, erroneous.
How, then, to explain why in his presidential address in 2005, Steven Scharfstein, the newly elected president of the APA, claimed that psychiatry had "let the biopsychosocial model (BPS) become the bio-bio-model." And then go on to lay much of the blame for this at the feet of the drug industry, because of their pushing biological paradigms so as to sell their products.
Does this mean that American psychiatrists have all become Samuel –"Biological Psychiatry: Is There Any Other Kind? – Guze clones?
Of course not, for biological psychiatrists, although most commonly affirming a biopsychosocial eclecticism, nonetheless focus more on the biological aspects of mental illness. With the result that a marked asymmetry in research and practice has occurred in the past two decades: far more funding, publication, and practice are given to biological, especially pharmacological, than to psychosocial approaches – with "alternative" paradigms, like those offered by the user movement, for the most part, tending to be ignored or marginalized.
Although Prof. Pies feels that the recipients of psychiatric care in the US are largely satisfied with it, I hope this may not be wishful thinking – notwithstanding the "evidence" he intends to present for this view. Perhaps what Shooter, the president of the RCP, had to say in an editorial in 2005, might be more realistic – maybe, I would suspect, even be applicable to the States: "the level of mistrust in press and public is now so deep that the jobbing clinician will have difficulty in persuading the patient that the advice being given about medication is open and honest."
There are certainly many in the user movement, who share such a negative opinion of psychiatry. Since the movement is by no means monolithic, the views of some of its sub-groups are inacceptable - and perhaps even a danger in replacing science, properly understood in all its limitations with some form of 1970s-like antipsychiatric ideology. Although I am not an antipsychiatrist – a slippery term, if ever there was one – I still am convinced that some of the pragmatic "antipsychiatric solutions" featured in "Alternatives Beyond Psychiatry" offer something positive in opposing the biological reductionism and capitalist ethos of much of "mainstream" Western psychiatry.
It is naive to think that professional research, undertaken by hordes of resaerachers is always of high quality and free of bias. I have experienced too many young residents, still green behind the ears, who were tucked into a drug study, although still utterly devoid of any deeper psychopathological sense or interest – since their co-ordinators probably lacked it too – dutifully checking off symptoms and dropping patients into some Procrustes bed DSM-III/IV diagnosis, and then mechanically checking off their rating scales.
Is this only a caricature?
Not for me it isn't. This surreal situation was part of my psychiatric Damascus experience – as well as that of many other colleagues not part of the power broker psychiatric structure "cooperating" with the drug industry - during the so-called decade of the brain. In particular, I better came to understand how the sponsoring of drug studies could vitally and negatively impinge upon routine, everyday clinical decision making in an institution, studies that would later be added to the growing mass of evidence based medicine (EBM).
I thus welcome Prof. Pies's intention to present a more detailed EBM-oriented critique of the "Alternatives Beyond Psychiatry." Although he does not intend to review the book as a whole, he does plan on zeroing in on Whitaker's preface, indicating he would present details why the evidence presented there is based on inadequate research.
Why not do the same with all the articles in the book? On doing so he would see they are almost all descriptive or opinion pieces, and those containing some data are hardly of a caliber to satisfy the EBM mind.
Why then did I so strongly praise the book, without pointing out its weak points? Indeed, there were many, and I must admit that I was quite irritated by some statements made about psychiatrists and psychiatry. Indeed, some remarks struck me as being downright disrespectful of – and even paranoid toward - our profession.
Notwithstanding that, however, there was much that I liked.
For the sake of argument, let us accept that Prof. Pies has completely demolished Whitaker's argument in the preface with the best that such research has to offer. It is my contention that he can go further, and offer all the EBM research he can muster against all the arguments contained in the rest of the book – or as he puts it, against the "polemical attacks founded on anecdotal or shoddy research."
Unfortunately, he will still be fighting windmills and missing the point of the book.
And the point, I contend, is this: the user movement has never really been taken seriously, has perhaps been marginalized, has been a voice crying in the wilderness, without any real power and influence. But now, finally, through the changes wrought by the internet, it has the possibility of more easily organizing world-wide opposition and bringing more public and political pressure to bear, this book being a milestone in this development.
As the Service User Research Enterprise (SURE) at the Institute of Psychiatry in London, for example, has demonstrated, the emerging field of responsible collaborative research between clinical academics and service users in the field of mental health seems to be a feasible future undertaking. Indeed, user-led research would involve service users controlling all stages of the research process: design, recruitment, ethics, data collection, data analysis, writing up and dissemination. In other words, psychiatrists need to support not only EBM, but also embrace the importance of other forms of knowledge
Sound too radical?
I don't think so. Users come to the research endeavour with a different perspective than professionals and are able to elucidate how services and treatments feel to service users ‘from the inside’. They can provide fresh insights, and so responsible, serious research done from this point of view could lead to services that are more acceptable to consumers than many find them today. Indeed, it is time for greater openness between the profession and service users, in our academic departments, journals and scientific meetings.
Indeed, as Prof. Pies has so correctly pointed out, the issues raised are quite complex, and the stakes of the debate enormously high.
Competing interests
None declared
Antipsychiatry's striking lack of data and alternatives
8 November 2008
I have a number of serious objections to the statements made in the book review. It does not surprise me that the book takes the slant it takes considering Peter Lehmann’s previous work. I do agree with their notion that psychiatry has been subject to political influences and that some of psychiatric decision making has been influenced by the political persuasions of the time. I also do not deny that psychiatry has been abused to harm people that society deemed undesirable and that psychiatrists were party to this. Whilst this is a shameful part of the history of psychiatry it has to be said that eugenics and other similar movements were by no means exclusive to psychiatry and effected all of medicine equally.
I have to say though that I very much disagree with the notion that orthodox psychiatry a) exists and b) is entirely biological and that the medical or biological model of psychiatry has prevailed throughout the decades. Quite on the contrary, I think that psychiatry has always been driven between the two extreme poles of biological and social. Peter Lehmann is of course at the extreme end of social psychiatry where the existence of psychiatric illness is denied entirely. He argues that psychiatric illness is a social construct that hinders the development of people who are not conforming with the establishment’s view of how they should conform. This is, in my opinion, an unacceptable mockery of the suffering of the mentally ill.
Coming back to the point of the two poles of biological and social psychiatry: ever since the 1920’s when work therapy was developed in earnest and since the advent of antipsychotic medication in the late 1950’s there have been developments that moved psychiatry more into one direction or another. It is certainly true that the 1990’s were more dominated by biological psychiatry but it seems wrong to suggest that that was to the complete exclusion of social psychiatry. Since the turn of the century social psychiatry has clearly gained more and more ground. It is unfortunate that this dichotomy remains when in fact most psychiatrists would accept that a bio-psycho-social model is the only way to holistically look at patients’ difficulties.
It has been really interesting to witness a demystifying of some of the second generation antipsychotics, which promised much more than they could keep, with studies that were independently funded such as CATIE. I feel that professionals have at least as much contributed to this demystification than mental health care consumers, not all of whom believe that psychiatry has failed them. What the author of the review finds refreshing is not new to psychiatrists in Germany where Peter Lehmann works, and where anti-psychiatry has remained a powerful force in politics since the 1970’s, influencing political decision-making and making some decisions on psychiatric services extremely difficult. It would be impossible for Peter Lehmann to claim that he would write a balanced book on antipsychotics given his track record so I am not surprised that he does not claim it.
Their argument that psychiatry does not work because the number of people with mental illness has not gone down is completely unscientific because it would assume that we only measure success by absolute cure rates. If that were the case no anti-anginal tablet would be deemed a success because they do not actually cure ischemic heart disease but merely try to improve quality of life. However, to what extent medication is useful to an individual is something that we have to discuss openly and honestly and there are individuals where medication is clearly not useful.
I believe that at the end of his review the reviewer puts his finger into the wound that always remains wide open when anti-psychiatrists write such books, which is the absence of data. Whilst they are very good at pointing out individual patient’s stories where psychiatry has clearly not been of much help to that particular patient they completely lack any supportive data to suggest that their suggestions are more successful or that without psychiatric input the life of the mentally ill would be much better than it is now.
I have always maintained that we ought to treat patients with a bio-psycho-social approach. I have also been extremely grateful for the CATIE Team who have revolutionised the way we see second generation antipsychotics and who have made it possible for other researchers to publish data that has shown the limitations as well as the benefits of second generation antipsychotics. However, we should also be careful not to throw the baby out with the bath water pretending that all would be well if only those "nasty" mental health professionals would never be able to treat a patient.
Competing interests
none