A critical attitude needs for its raw material, as it were, theories or beliefs which are held more or less dogmatically. Thus science must begin with myths, and with the criticism of myths, neither with the collection of observations, nor with the invention of experiments, but with critical discussion of myths and of magical techniques and practices.
Karl Popper, Conjectures and Refutations, p. 50.
In this book we have, indeed, taken a critical attitude toward the conventional understandings and treatments of madness over the last fifty years in America. We sought to examine the three major psychiatric “revolutions” that scholars often use to define and characterize the mental health system. These revolutions are often proclaimed to be the results of enlightenment, humanitarianism, and scientific progress. For each revolution we found that the particular rhetoric used by the psychiatric establishment to claim progress in the management of madness was and is pseudoscientific. It does not describe a science based on independent inquiry, transparency, objectivity, or the skeptical scrutiny of assumptions and evidence, but a distorted science, a make-believe science, one used to advance a welter of particular institutional agendas and cultural schemes. Instead of a science of madness, we documented a mad science.
As scholars and researchers, we recognize that our personal unexamined assumptions affected how we shaped this book. As we indict the self-interest of countless actors in the mad science enterprise, our own self-interest must be scrutinized. Indeed, each of us has not only written critically about these issues for decades but has built an academic career on critical writings, especially ones challenging the disease model of distress and misbehavior and practices based on this model. We think that we have accurately communicated the recognized absence of biological verification of the Western scientific model of disease—disease as cellular or molecular pathology—applied to distress and misbehavior. Nonetheless, perhaps we bring a presumptive bias against disease as a first-line explanation for any complex, negatively perceived human behavior.
Still, our book does not privilege our own data but rather our serious effort to assess what psychiatry itself has presented as its best evidence for the disease model of distress and misbehavior. We have looked at the disease model and found the scientific evidence wanting. In drawing our conclusions, we did not seek out obscure studies conducted by outsiders. Rather, we analyzed what psychiatry has promoted as its best evidence, the most notable studies published in the leading journals of medicine and psychiatry, what psychiatric leaders and promoters in government and elsewhere have stated and written publicly. Although many critical books about psychiatry and the disease model have been published, especially recently,1 we think our book is the first to examine systematically the links among three major arenas that typify psychiatric practice and thinking today: coercion in institutional and community settings, DSM diagnoses, and drugs. We are not aware of any important, substantive, independent studies that we have overlooked.
Perhaps we hold psychiatry to unreasonable expectations of scientific rigor, when some merely claim psychiatry to be a clinical art that tries to use science. For example, when Louis Menand in The New Yorker (March 1, 2010) raised the question, “Can psychiatry be a science?” the APA’s president at the time, Alan Schatzberg, responded (March 22, 2010) by stating that no medical specialty, including psychiatry, is a science. “Psychiatry,” Schatzberg wrote, “rests on a foundation of scientific findings . . . but must employ both clinical judgment and their empathic skills in diagnosing and treating patients.” Revealingly, Schatzberg omitted to mention involuntary hospitalization and treatment—which no other medical specialty but psychiatry uses. Although his depiction of some psychiatric practices as art makes sense to us and could benefit patients and society were it taken literally, it is definitely not the depiction that psychiatry itself promotes and presents. We think that, here again, we have not misrepresented psychiatric sources. Self-servingly, when trying to explain failure to deliver on promises of factual understandings, novel treatments and improved outcomes, individual psychiatrists might claim occasionally to be only practicing an art—or an art mixed with guesswork, placebos, and something else. But, beyond any doubt the profession’s consistent message has been that its accomplishments rest on the best scientific thinking. Furthermore, it is by claiming psychiatry as a medical science that authorities justify funding its activities and enforcing the coercive recommendations of its practitioners.
Although our story of the last fifty years of the mental health movement is not a tale of progress—if such is possible in the realm of human affairs—we have not argued in this book that the mental health system is monolithic. We are too steeped in systems thinking to ignore that social systems (open systems by definition) change over time, sometimes radically and unpredictably. Moreover, although we observe that groupthink and herd behavior characterize much of what passes as mental health practice, the fact is that the mental health institutional infrastructure manages to accommodate critics like ourselves, who have been funded by governmental institutions such as public state universities and federal research institutes as well as private foundations. Realistically, we believe this accommodation is extremely small, but it does suggest a potential for change. Of course, as this book demonstrates, change in and of itself may not represent progress in the eyes of different stakeholders. But we do confess to worrying about the increased efficacy of institutions that rely on control by coercion and use mystification to expand their jurisdiction and power. Is it unwarranted to be anxious about that sort of progress—the possibility of a nightmarish therapeutic state in which all misbehavior or ineptitude is defined by presumed defective physiology and managed by empowered quasi-medical bureaucrats? This is no fantasy. America and its legal, political, and mental health authorities have previously come together to handle human “defectives” by legitimating involuntary sterilization of innocent citizens. As late as 1927, during a time ironically called the Progressive Era, one of America’s most famous Supreme Court justices, Oliver Wendell Holmes Jr., wrote the opinion for a court majority (that included Justice Louis Brandeis and the chief justice, former president William Howard Taft) to uphold the right of a state to sterilize mental defectives. By 1941, about 36,000 men and women had been sterilized or castrated (Black, 2003, p. 121–123).
One final potential bias to consider is that we are social workers, not psychiatrists or other medical doctors. We think that this bias, really our professional training as social workers, shows in our consistent attention to interactions and transactions between individuals and their environments over time. Having said this, we think, first, that being social workers gives us pertinent inside knowledge of the field of mental health services, treatment, and research, if only because more social workers are involved in delivering mental health services in the United States than any other profession. Second, while we have no expertise in treating patients for their physical illnesses, each of us has been professionally trained to work and has worked as a clinical social worker with people who are very distressed, who misbehave badly, or both, which we’ve argued throughout this book is the real stuff of madness—if madness can be said to be made up of any thing. Also, together we’ve amassed over seventy-five years of teaching mental health courses in graduate schools of social work to thousands of students and practitioners (and learning from them), and as academics we’ve published scores of articles in journals of all of the mental health disciplines. In sum, we are not exactly outsiders to the madness enterprise.
Any assessment of the psychiatric enterprise over the last fifty years depends primarily on assessing the success of deinstitutionalization and community treatment, descriptive diagnosis, and the prescription of psychoactive drugs.
Our analysis of the psychiatric state of affairs past and present is a linguistic attempt at persuasion, an argument by three individuals, each with his own fallible nature, earnestness, background, experiences, knowledge, and biases regarding the book’s subject matter. “Authoritative” historians of madness are not that different from us; they are as earnest, conscientious, and flawed. They may fail to recognize where they imply (absent any demonstrations) that madness is self-evidently a medical problem by using medically tainted language. As we described, despite their differences (see Scull, 1985), virtually all infuse their texts with medicalized terms such as mental illness, disorder, or disease, as analogs for madness, even when they recognize the inability of these concepts to capture the range of heterogeneous behavioral content that is subsumed under the disjunctive category of madness. Their message to their readers is therefore likely to be: you are reading an account of the laborious journey to the scientific discovery of the true nature of madness as medical illness amenable to medical supervision.
However, an alternative vision of madness recurs throughout history. It accepts of course the mental and behavioral consequences of well-defined diseases such as pellagra, neurosyphilis, Alzheimer’s dementia, or alcohol poisoning resulting in delirium tremens. It portrays madness not as a medical issue (disease/illness) or a phenomenon of nature as much as a human locus for a wide variety of existential struggles and deviant human actions. That conception requires a willingness to see the vast majority of mad persons, those whose behavior has not been scientifically linked to pathological processes, as poorly, sometimes very poorly, prepared actors (or sometimes evil actors) in a complex world, who try their best to deal with problems in living, sometimes very grave ones. We suggest throughout this book that this conception remains a wholly valid contender, despite its old-fashioned appearance, because, after more than ten decades of determined research and the expenditure of untold sums, no one can verify that madness is a medical disease. But even were we to accept psychiatry’s basic premises about madness, we would be forced to conclude that its approaches to the mad are steeped in coercion (by which we mean deliberately and forcefully interfering in their lives), mystification (by which we mean propagating false or unverifiable statements about their problems and their solutions), and intoxication (which means according to standard dictionary definitions, “stupefaction or excitement by the action of a chemical substance,” and “poisoning by a toxic substance”). These have extremely little connection with scientific inquiry or medical treatment.
Language is a human construction. Words do not necessarily represent a tangible reality and often rest on “perceptual metaphors,” all the while giving listeners directions for response. The use of disease in reference to madness suggests that we should respond to many disparate behaviors as if they were diseases (e.g., schizophrenia) or the personal and social harm caused by diseases (e.g., suicide caused by post-psychotic depression). These words instruct their speakers to view some actors in the drama of life as nonvolitional and to excuse them from responsibility for behaviors that otherwise would be considered vexing or inept but motivated. Simultaneously, these words instruct their speakers to view other actors as healers motivated only by the desire to help, surely an absurd proposition. The language of disease permeates all aspects of the psychiatric enterprise and distorts how we think about deviance, distress, and suffering, and about responding to these.
That is why psychiatric language has been essential to that profession’s economic and political success. For psychiatrists and all the allied mental health professionals, the mere application of the language of disease has managed to give madness a scientific verity, because the language’s abstractions were easily treated as if they had a concrete existence. This was accomplished through the simple substitution of one metaphor for another, with people attributing more material reality to each new expression. Perhaps it went something like this: From about the late Middle Ages (circa 1350 CE) we have had useful if murky terms in the English language such as madness, lunacy, and craziness (Merriam-Webster.com, 2011) for troubling or troubled behavior. When the social order expected more formal codification to enforce the organized control of persons who could not resist their labeling by these terms, the terms were changed to the legal and perhaps more definitive-sounding insanity. Later, under the control of medical managers of the insane, that term was changed to our contemporary terms, mental disease, illness, and disorder. No change ever involved demonstrating the material referent of the words, but each change deeply shaped—while also reflecting—society’s understandings and responses to human travails. So it was with the change to illness and to medical conceptions of madness, which has beguiled even historians perhaps because we are all still steeped in it. It is difficult for anyone to disentangle the embedded assumptions in the language from the story that is told. And to complicate matters further, the stories serve professional, institutional purposes.
The metaphor of disease is extremely seductive, not only because it distances a person from volition and responsibility while absolving “helpers” of political fallout when they take sides in interpersonal conflicts, but because it refers to something immediately recognizable. Without comment we ask our readers to reflect on the following few words and how they are viscerally experienced simply when reading them: illness, brain disease, research, doctor, patient, diagnosis, prescription, treatment, therapy, evidence-based, medication, safe, effective, hospitalization. We think this vocabulary transforms the awesome threat of madness—confusion and bewilderment—into the still challenging but more understandable and controllable threat of disease. It is as if these words (just like the words marketing firms employ to claim laundry detergents can, impossibly, clean “whiter than white”) do much of their work just by being intoned regularly.
Coercing the mad into madhouses to separate and detain them occurred long before physicians were authorized to manage that enterprise, and coercion continues to distinguish “scientific” psychiatry to our day. Though many people might know that madmen and madwomen used to be confined, beaten, tied, shocked, or whirled into submission, fewer might realize that the physical control of “dangerous” mental patients remains today a central if not the only function of the public mental health system, with more people being coerced now than ever.
About half a million people were involuntary residents of state and county asylums and mental hospitals by the mid-1950s. Today, about three times that many experience shorter periods of involuntary detention in psychiatric wards and other mental health facilities for examination and evaluation of their dangerousness to self or others. They are part of the approximately four million people who experience coercive measures from mental health workers, including those treated involuntarily in the community, the place once proffered as the obviously more humane alternative to long-term hospitalization of the mad. Coercion runs deep and wide throughout psychiatry and the mental health system, creating an unavoidable yet strangely silent climate of intimidation and acquiescence among clients and professionals and the media, whose job used to be to alert us to human rights abuses and scrutinize the functioning of the state.
Beginning slowly in the 1950s and extending throughout several decades, with encouragement from federal and state governments, the inmates of state mental hospitals were forcefully discharged to communities, even when they wished to remain institutionalized. The ostensible rationale was to remove them from coercive and inhumane total institutions and usher them into more therapeutically effective community-based programs. Assertive community treatment, one of the best-known such programs, was developed by a few mental health professionals steeped in the use of force on psychiatric inmates in one particular Wisconsin institution for the mad between the 1950s and 1970s. However, the only consistent outcome for patients uncovered by ACT proponents then and now is that of reduced hospital stays. This was not achieved by improving patients’ functioning or reducing their distress and misbehavior but by forcing ACT patients to stay in the community while allowing comparison patients to be hospitalized. Understandably, “reduction in hospital stays” made policy makers, agency administrators, and government funders happy because it appeared to save money. It also allowed ACT promoters to enjoy continued authority because uncritical observers implicitly assumed that ACT accomplished other objectives, such as providing humane, noncoercive, effective interventions. Yet no consistent improvement in autonomous motivated behavior regarding education, vocation, or “symptoms” can be attributed to ACT, nor can it be distinguished from other less expensive and less coercive community programs used nationwide (reduced hospital stays disappeared when ACT programs did not force patients to stay in the community for treatment). Needless to say, ACT has been anointed as an evidence-based treatment.
Extremely few authors today discuss openly the extent of psychiatric coercion in America (Oaks, 2011). The first recorded involuntary confinement in an American mad hospital occurred in 1752. Two hundred and fifty-five years later, psychiatrist Robert Drake explained that the majority of the severely mentally ill opt out of mental health care because “They’re afraid of the coerciveness of the system” (cited in Wiencke, 2007, p. 4). Today, coercion has been reinvented and institutionalized as a scientifically valid therapeutic approach for managing madness and as a proper subject for scientific investigation by psychiatric clinicians. Coercion might be presented as an unpleasant but necessary extra push to make patients use the range of available effective treatments for their mental illnesses. Our analysis, however, leads us to conclude that outside coercion, public psychiatry has no effective approaches to handle the existential difficulties of those who don’t ask for help with their travails but whom nevertheless psychiatry claims under its jurisdiction. Coercion is the only intervention to have endured since the birth of psychiatry. We suggest that coercion (sometimes verbally airbrushed into the term leverage) and the threat of coercion persist because coercion is all there is for those who are behaviorally disobedient or wish to be left alone.
Once an acknowledged ethical and legal problem in psychiatry given its use against the helpless, the hopeless, or the legally innocent (Szasz, 2007), coercion is now a therapeutic tool, and discussions of coercion increasingly focus on the technical strength and effectiveness of its leverage effects (Monahan, 2008) and whether those who are coerced might not necessarily perceive it as such. Further, as we discussed in chapter three, some psychiatric authorities are beginning to argue that no medical justification is really needed for what psychiatric coercers do since this is identical to what other state sanctioned coercers, such as the police, do to maintain civil order. The police maintain that they catch and punish lawbreakers. However, psychiatry has originally and consistently maintained that it coerces not to punish but to treat, because it deals with problems constituting a special subset of medical disease that impairs its victims’ ability to judge and discern rationally, thus requiring coercion when all else fails.
Coercion directly affects the freedom of mental health professionals. To receive payments from government programs and insurance companies, practitioners must generate DSM diagnoses, constraining the reluctant or skeptical to conform even though the diagnostic system—now openly recognized as deeply flawed, even caricatural—does arguably little to help their work. Designating some interventions as “evidence based” through a nonscientific, consensus-authority based arrangement also restricts professionals to use only these, if they want to keep their professional credibility. This would be especially the case in slow-to-change agencies dependent on public funds. Other interventions that are not yet anointed as acceptable by experts but which may prove to be or are useful to particular clients are discouraged. Few professionals will risk employing such interventions or risk sanctions by some supervisory agency. If the attitude prevails that “we already know what works best,” innovation becomes even less probable, unless it promises to accommodate to or take a subsidiary position toward dominant interventions (inevitably, drugs).
More importantly, the recognition in public psychiatric practice that coercion is always at hand if persuasion fails creates an atmosphere of surveillance and expected compliance, making it difficult for a professional and a client to develop a meaningful working alliance. Deeply troubled persons will be careful to censor their thoughts and feelings, even if expressing them might be essential to their well-being, because they fear involuntary measures that could lead to psychiatric detention, involuntary drugging, and occasionally involuntary electroshock (Snyders, 2009). As stated earlier, involuntary measures keep many of the mad from seeking help in the first place (Hahm and Segal, 2010).
Instructed by tradition and by law, mental health professionals, too, will be hypervigilant for any sign from the patient of thoughts of suicide or harm in order to safeguard the patient’s existence. Despite the fact that most state statutes concerning civil commitment are discretionary rather than mandatory (that is, professionals are not automatically required to take measures in response to perceived dangerousness), in our experience, extremely few mental health professionals actually know the letter of these laws.2
We see no legitimate role for coercion in the helping enterprise. It is obvious that societies must use coercion and force in particular circumstances. Our police and military have the authority to maintain civil order and defend against threats to our survival, while our legal and political systems are charged with supervising its appropriate use. We question why psychiatry, under the guise that it is a medical discipline, persists in using coercion in the mental health system and why other medical disciplines, who reject coercion in their own practice, turn a blind eye to it in psychiatry. Before homosexuality’s sudden redefinition from feared condition and mental disorder to merely a variant of normal sexual preference, was it proper to coerce homosexuals to change their sexual behavior?
Compared to the historical uncertainties about the nature of madness, the disease model of madness offered the rubric of medicine to classify, understand, and control various misbehaviors as one would do with symptoms of brain diseases. To mimic research and practice of physical medicine, psychiatry needed a method of identifying and categorizing types of mental illnesses. The initial invention and subsequent attempted refinements of the DSM embodies this effort to name and classify.
The first edition of the DSM was ignored, the second scorned, and by the 1970s the DSM had become a battleground of contending interest groups and ideologies. A subgroup of biologically oriented research psychiatrists wrestled control of the DSM from the dominant psychoanalytic faction, claiming that diagnosis must become more scientific (as they understood the term) if psychiatry as a profession was to endure and thrive. This new leadership cadre emphasized making the classification system more reliable (i.e., consistent), conveniently ignoring the far more important criterion of validity (i.e., establishing the reality of the disorders). They created “descriptive diagnosis,” exemplified by the 1980 DSM-III and its subsequent editions. It simply assumed that mental disorders existed and focused on getting clinicians to agree on who fit into which DSM diagnosis. For thirty years, the leaders of the APA claimed that descriptive diagnosis succeeded in making the DSM more scientific. They convinced policy makers and the public to trust their claims. The medical model of madness became further institutionalized, supported, and promoted by NIMH, mental health professionals, Big Pharma, insurance companies, and virtually everyone else.
Yet, as the unfolding controversies over the DSM-5 illustrate, descriptive diagnosis has been an utter scientific failure. It led neither to more reliable or valid diagnoses, nor to any sort of scientific breakthrough in identifying hoped-for biomarkers of the elusive disorders that would begin to validate the medical model of madness. Moreover, in an effort to ape medical reasoning, by removing contextual clues about person’s situations and circumstances to produce neutral- and objective-sounding “diagnostic criteria sets,” understanding living persons became a quaint and irrelevant enterprise in the new psychiatry, where studying contrived DSM diagnoses substituted for studying persons and the possible functions of their disturbing behaviors. Much of this failure has remained hidden behind hopeful promises that the causes and cures for madness are just around the next biomedical corner. More deleteriously, descriptive diagnosis has allowed for widespread financial conflicts of interest among the APA, government, mental health practitioners, and leading researchers. By making it exceedingly easy to name new disorders and expand the scope of existing ones, the latter editions of the DSMs have manufactured an epidemic of mental illness and a huge expansion in the uses of lucrative but questionably useful psychochemicals. Improving the psychiatric diagnostic system was supposed to bring accuracy to psychiatric judgments, and for a while it was a public relations triumph. But instead of serving as a scientific cornerstone for research and practice, the DSM has become a mainstay of mad science, in which professional interests and power regarding diagnosis trump logic and scientific evidence.
The modern prescribed psychoactive drugs are associated with nearly identical outcomes as all biological psychiatric treatments have always been. At best, about 30 percent of people diagnosed with the major clinical madnesses of our time (persistent depressed mood, called Major Depressive Disorder, persistent depressed mood punctuated by euphoric mood, called Bipolar Disorder, and extremes of despair and deviance, called Schizophrenic Disorder) appear to show sustained improvement while taking these treatments. This proportion is very similar to that obtained today and in the past in observational or controlled studies by placebos, by seclusion and restraints, by excision of various bodily organs, by prolonged barbiturate-induced comas, by lengthy baths and showers, by surgical mutilations of the brain, by epileptic seizures induced by chemical or electrical shocks, by conversation, by seemingly irrelevant activities, or by the mere passage of time. The latest drug treatments—the SSRI antidepressants, the mood stabilizers, and the second-and third-generation antipsychotics administered under whatever conditions and in whatever combinations their adherents have proposed—have had no additional positive impact whatsoever on any measurable indices of pain and burden associated with madness and may have had negative impacts.3
This total failure has been the dirty little secret of psychiatric drug treatment for decades, but starting in 2005 with publications from the largest drug trials using real-world patients, doctors, and outcomes, funded by the NIMH and conducted by the drug industry-soaked clinical and research elite of American psychopharmacology, it could no longer remain shrouded. Some leaders of the mental health movement professed surprise at the findings, and some admitted that prescribers had accepted exaggerated claims of drugs’ effectiveness in the absence of evidence. But the findings came as no surprise whatsoever to careful observers of the drug treatment scene. The disconnect between findings from reasonably well-conducted studies and lay and professional claims about the powers of the latest psychotropic medications suggests that much prescribed psychoactive drug use is today as it has always been: fundamentally ceremonial, fulfilling deep social needs, and needing no scientific justification whatsoever (Szasz, 1974).
The history of psychoactive substance use throughout time and throughout the world highlights the elemental fact that some users appreciate the effects of a drug, some users don’t, and still more users have no particular responses. Instead of building upon this observation, drug experts and authorities invented artificial divides between “approved medications” and “dangerous drugs.” Not only were the same drugs separated linguistically, they were made unequal politically. Authorities then justified desires for approved drugs by postulating that these drugs corrected chemical imbalances in their users, thereby ameliorating mental illnesses and enhancing population health—and should be prescribed by duly licensed physicians. As for the unapproved drugs, experts warned that these caused chemical imbalances, thereby creating mental illnesses and disrupting the fabric of society—and should be proscribed by any reasonable person. No genuine science, medicine, or public health could ensue from such a ridiculous dichotomy.
To maintain the dichotomy, a scientific and administrative apparatus was established, within which psychiatry was offered a retainer. The apparatus included the procedures and experiments testing psychoactive drugs’ effectiveness in treating DSM-defined madnesses, all of them modeled to duplicate procedures used to evaluate conventional medical treatments for medical diseases. The Food and Drug Administration promised to verify the integrity of these procedures to ensure “safe and effective” prescribed psychoactive drugs, while the Drug Enforcement Agency promised to wage war on those who persisted on using unapproved psychoactive drugs. The puzzling fact that unapproved drugs could cross over into approved territory, or vice versa, or occupy both spaces simultaneously, seemed to puzzle no one.
Already blinded by unquestioned assumptions of madness as disease, experts confused the effects of stupefying drugs producing quiet on oppressive asylum wards with a revolutionary new medical understanding of psychosis. They confused dazzling images of our living brains with discoveries of the physiological substrates of the specific mental illnesses served up by new editions of the DSM. They took doctored reports of drugs’ effectiveness as scientific validations of the guesses or marketing slogans proposed to explain the (presumed) drug effectiveness. They chose not to see how drug industry largesse made them indentured servants. Finally, because most of them had given up engaging in disciplined conversation with distressed persons (but could not fathom abandoning coercion), they lost the ability to conceive of psychiatric practice and research as anything other than prescribing drugs and waiting for new drugs. In these ways, American biological psychiatry became a state- and corporate-funded cult of psychoactive drug use.
That people might find psychoactive drugs helpful to them is obvious and cannot be contested. Nonetheless, and incredibly so, much of this power of psychoactive drug use went completely unnoticed and unmentioned—let us say, repressed—in the prodigious psychopharmacological research effort. By definition, psychoactive drugs change people’s thoughts, feelings, and behavior. Yet, psychopharmacology continually assumed that if the bearer of a psychiatric diagnosis reacted positively to a drug, this confirmed the presence of disease. That psychoactive drugs sedate, calm, tranquilize, desensitize, stupefy, awaken, arouse, or excite people who take them, and thereby may help some people temporarily or permanently to traverse daunting circumstances, disappeared from the official psychiatric understanding of psychiatric medications. As a result, this official understanding also neglected the rigorous detection of drug-induced harm in psychiatric practice.
In the academic literature on any complex subject, careful readers can find examples of the misinterpretation of data, conclusions only partially supported by the evidence, and inadequate methodologies. Occasionally, someone uncovers deliberate falsification of data or unscrupulous behavior by a researcher, although recently there has been an alarming increase in reports of such behavior (Zimmer, 2012). These discoveries usually make newspaper headlines. Names are noted, careers are ruined, institutions are tainted, and the truth-seeking of science is reaffirmed.
This is not the story we have told in this book. When it comes to the understanding and treatment of madness, the distortions of research are not rare, misinterpretation of data are not isolated, and bogus claims of success are not voiced by isolated researchers seeking aggrandizement. In our detailed analyses of community treatment, diagnosis, and drugs, these characteristics of bad science are endemic, institutional, and protected. They are what we have labeled “mad science.” Here are some of its major ingredients and the institutional arrangements that promote it.
The mental health field displays an uncanny tendency to sweep under the carpet vexing issues that threaten the status quo, only to treat them as novel problems once they resurface. We have discussed, for example, how by the early 1980s the architects of DSM-III had managed to deflect the scientific gaze off the central problem in psychiatric diagnosis—the lack of validity—onto the more manageable, less threatening problem of lack of reliability. By 2010, however, no less than the chair of the DSM-IV task force could lament that the DSM’s imperialism had created “false epidemics” of childhood disorders and could assert that the very definition of the key concept in the DSM, and arguably in all of psychiatry—mental disorder—was “bullshit” (Greenberg, 2011). We have cited the informed director of the NIMH professing surprise that the best conducted trials of optimally administered drug treatments had shown that these had reduced neither symptoms nor impairment. Yet such results characterized the longer-term fate of every major biological psychiatric treatment in the last hundred years. We have seen that coercion as the key mechanism ensuring compliance with treatments for the seriously disturbed has continually been downplayed publicly or rendered benign through verbal anesthesia and promoted as another helpful mental health technique called leverage, while its widespread employment never wavered.
Psychiatry via the APA and NIMH has continuously proclaimed that, despite conflicting evidence, great scientific strides were made in community treatment, diagnosis, and drug treatments. These claims would have no shelf life without their acceptance and repetition by the mental health professional organizations and practicing clinicians. This acceptance rests on a few factors.
The first is the sheer power and prestige of the medical enterprise in the United States. Psychiatry used its links to medicine to capitalize on the technical breakthroughs and successes of this powerful social institution. Everyone has at least some vague appreciation of brain imaging, microsurgery, and other impressive technical advances in physiological medicine. The medical imprimatur stamped on psychiatric coercion, misdiagnosis, and ineffective drugs as the latest technological advances for helping the mad goes a long way in producing uncritical acceptance.
Second, psychiatric claims are not easily verified by other scholars, clinicians, or the public. Both the methods of scientific studies and the complex and arcane statistical analyses of data that fill the medical and psychiatric journals are a challenge to comprehend, even for the best-trained professionals, as articles in The Economist (2012) and elsewhere recently noted (Zimmer, 2012). Only a handful of psychiatrists, psychologists, social workers, or other mental health clinicians have the time, skills, or motivation to scrutinize the deluge of claims published weekly. Most rely only on popular media sources for soundbites of progress.4 And when the media broadcast “advances,” why should the clinicians be skeptical? In fact, they have seemed quick to become boosters, exploiting their membership in an enterprise that appears to be advancing.
Finally, professionals and the public are not simply gullible to shaky claims but have found many ways to benefit from them. The mental illness metaphor, whatever its possible uses for thinking, speaking, and coercing, is accepted as a statement of fact. But even if it is not, clients and professionals widely use it to justify insurance reimbursement from third parties, to get services to those who they think need help, and to earn a living. They collude with psychiatry to do something that the rest of medicine cannot do: to diagnose as an illness “behavior that society doesn’t like,” allowing assumed pathology to replace morality. The public, confounded and discomfited by these behaviors, goes along with the ruse, relinquishing or outsourcing responsibility for one’s behavior to experts. Irwin Savodnik, a UCLA psychiatrist and philosopher, has written that “the erosion of personal responsibility is, arguably, the most pernicious effect of the expansive role psychiatry has come to play in American life” (Savodnik, 2006, p M3).
As we have described, many psychiatric studies take on the trappings and the appearance of scientific investigations, even when they are seriously flawed or interpreted much more positively than justified. Concerning diagnosis, it is the very rare study that actually tests average clinicians’ agreement on DSM diagnoses for the same patients. Instead, the reliability literature is awash with tests of structured scales and checklists of presumed mental illnesses. Moreover, the vast majority of these studies are conducted among groups of clients or in narrowly focused research settings where it is expected that the problem being studied will be the chief presenting complaint (i.e., where there are likely to be high base rates of behaviors that are the diagnostic criteria of a particular disorder category). These studies are the equivalent of shooting fish in a barrel. Finally, without valid methods to verify the existence of “mental disorders,” what exact purpose besides conformity or indoctrination is served by teaching clinicians to agree with published diagnostic criteria sets?
The durations of clinical drug trials are truncated to avoid showing that the drugs are ineffective over more than a couple of months of use. Double-blind procedures are rarely tested. Inconvenient subjects who respond to placebo early on are dropped. Only inert placebos, never active placebos known to evoke more powerful responses, are used as comparisons to drugs with sometimes stupefying behavioral effects. Adverse effects are investigated and reported with approximately one-tenth the energy devoted to assess hoped-for beneficial effects. It is a rare study that compares a drug treatment with a well-administered psychosocial alternative. The methodologically sound use of no treatment comparison groups is considered to be unethical in psychiatric research, and such groups are never used in experiments. But if one is attempting to determine whether a treatment is effective, than it would be crucial to know if that treatment (which typically produces some toxic adverse effects) is better than doing nothing at all (recalling medicine’s commitment to “First, do no harm”). Finally, when results are unacceptable or deemed too financially threatening to sponsors, results have been doctored or suppressed.
We have illustrated throughout the book how even studies that are repeatedly cited to confirm claims of scientific progress are seriously flawed. Of course, all studies, no matter how meticulously conducted, have limits. Still, studies with profoundly serious flaws are presented as highly credible breakthroughs, sponsored by NIMH, authored by esteemed scientists at prestigious universities, and supported by the research community. That community praises the findings and exaggerates their significance: reliability is greatly improved; community treatment is effective and noncoercive; medications are safe and effective. The psychiatric lobbyists insert these conclusions into repositories of “evidence-based practices,” “practice guidelines,” or “best practices,” thereby institutionalizing some of the weakest science (Medical Guesswork, 2006).
The exaggerated claims today are often about neuroscience. The public and professionals appear to suspend judgment in the face of “the seductive allure of neuroscience explanations” (Weisberg, Keil, Goodstein, Rawson, & Gray, 2008). About five hundred brain-imaging studies are published each year, and researchers for thirty years have been promising that “snapshots of the living brain” will unlock the mysteries of madness and will be used for diagnosing mental disorders (Carey, 2005). Although many of these studies may help scientists to understand more about brain functioning, to date, no standardized brain imaging tools exist for diagnosis or treatment in psychiatry. (No biomarker appears as a diagnostic criterion for any primary mental disorder in the DSM.) Harvard psychiatrist and former director of NIMH, Steven Hyman, admits that “the community of scientists was excessively optimistic about how quickly imaging would have an impact on psychiatry . . . people forget that the human brain is the most complex object in the history of human inquiry” (cited in Carey, 2005). The writer Diane Ackerman, in An Alchemy of Mind, captured this strange optimism well while offering an apt analogy for what brain imaging offers the understanding of persons:
. . . we may lift the lid off the brain with PET, MRI, fMRI, or MEG and peer inside, but that still leaves us voyeurs, distant viewers. . . . We measure its blood flow, hunger for glucose and oxygen, its radioactivity or magnetism. Regions light up and offer us some illumination. But the porch light can be on without telling you who is at home. When it comes to brain mapping “our knowledge is akin to looking out of the window of an airplane,” neuroscientist William Newsome, of Stanford University, explains. “We can see patches of light from cities and towns scattered across the landscape, we know that roads, railways, and telephone wires connect those cities, but we gain little sense of the social, political, and economic interactions within and between cities that define a functioning society.” (Ackerman, 2004, p. 251)
Jonathan Cole, a prominent Columbia University sociologist and former provost, resigned in protest from the National Research Council’s committee charged with evaluating PhD programs in the United States, just before the committee’s final report (sponsored by the National Academy of Sciences) was due to be published in 2010, after seven years of committee effort. Cole (2011) concluded that it “was not worthy of publication” and had succumbed to “faulty assumptions, poor analysis, political pressure from the academy, and unexamined preconceptions.” Cole’s protest highlights an all-too-common disappointment with large scientific undertakings. The members of the committee, Cole believes, were unwilling to acknowledge that their study had failed (recall Donald Campbell and Karl Popper’s methodological urgings):
There are many examples . . . of large studies thought too big to fail, despite insufficient data. One can find such failures, which lead to policy changes based on poor data, in medical experiments about drugs, public-health studies, and a variety of assessments of health risks . . . A crowd psychology emerges within committees where individuals don’t want to be perceived as spoilers. Discussion of why a study has failed is truncated—to the detriment of learning from our mistakes. An attitude has developed in American society, and it plagues research efforts as well.
The mantra is, “It’s better than nothing. But is it?” (p. B12)
Has psychiatry simply become better than nothing? Is it too big to fail? Consider the size and character of psychiatric research. Nearly all studies published in the major psychiatric journals are big studies, involving sizeable teams of researchers at multiple clinics and hospitals across the nation, funded by big sponsors such as the pharmaceutical industry, the NIH, and foundations, and recruiting very large samples of patients. Like the NRC study described by Cole, the studies take years of planning and years of data collection. Decision making is done by teams and committees, which are carefully selected and supervised by the study directors and by the funding bodies. This is Big Science in psychiatry, and many institutions and individuals have a significant and personal stake in making it a success.
Big Science, however, is an insider’s game. The leading players move easily among positions in the major arenas or psychiatric power. Top university scientists have their research funded by NIMH, are later appointed to review panels at NIH, are selected to serve on important APA committees such as the DSM task force, all the while earning increasing amounts of money serving as consultants or speakers for multiple pharmaceutical companies. Universities thrive on the large grants from NIH, foundations, and Big Pharma, as does the APA and other organizations such as NAMI. These individuals and institutions, woven tightly together by personnel, money, and self-interest have an additional shared goal, namely to consistently portray the vast enterprise as a scientific success and to ensure that it doesn’t fail, no matter what.
The insiders’ preferred world view is, of course, the biomedical model of madness: mental disorders are prevalent and spreading, caused by soon-to-be-discovered brain defects (themselves caused by soon-to-be-discovered genetic variations); palliation, prevention, and cures are just around the corner or already available but used by too few; and all that is needed to eradicate madness is more money, more time, and fewer critics. All evidence to the contrary, this worldview has been a runaway success.
The success results partly from the ways Big Science can annihilate potential opposition. By controlling almost all sources of funding, no rival scientific efforts gain traction. Funded and published studies are too big to replicate except by the insiders themselves. Outsiders, especially if they have no clinical appointments within medical institutions, may have a very difficult time conducting outcome studies on patients. This is especially so for studies on controversial topics, such as evaluating the outcomes of electroconvulsive treatment or involuntary commitment (McCubbin, Dallaire, Cohen, & Morin, 1999). The power-elite insiders control appointments to decision-making committees, to grants review panels, and to what gets published in the main journals. Academic enthusiasts of assertive community treatment, for example, receive federal and state funding to create ACT programs, and they also implement them and design the training manuals and tools to ensure that replications cohere to the ACT model. Then these same individuals evaluate the programs for effectiveness. Because of all of these ACT-related activities, these insiders become the experts. Thus they sit on the consensus committees that “objectively” validate their own treatments as evidence-based practices. All this allows them to buttress the status quo, reinforcing the view that they are promoting the “correct” view of madness and its management, reassuring the public that the experts have it under control and brushing off outcroppings of dissent.
As we write these lines one example occurs in the latest data brief from the US Centers for Disease Control and Prevention (CDC) bearing on usage of antidepressants in the United States (Pratt, Brody, & Gu, 2011). The report documents an increase from 1988–1994 to 2005–2008 of approximately 400 percent in the use of antidepressants in the general population, finding use in one in six women and one in sixteen men over the age of twelve years. The increase is observed in both genders, all age groups, and in the major races and ethnicities (though white users largely predominate). We have made many sorts of comments on these trends in this book. The authors of the CDC brief, however, chose to make a single comment, and it bears on their subfinding that “only” one-third of individuals with severe depressive symptoms were using antidepressants:
According to American Psychiatric Association guidelines, medications are the preferred treatment for moderate to severe depressive symptomatology. The public health importance of increasing treatment rates for depression is reflected in Healthy People 2020, which includes national objectives to increase treatment for depression in adults and treatment for mental health problems in children. (p. 5, references omitted).
The authors of this brief ignore the mountain of data on the near-equivalence of antidepressants (i.e., the numerous different substances gathered under that inappropriate moniker) to placebos in addressing feelings of depression. They ignore concerns that led the FDA to place black box warnings on antidepressants’ labels starting in 2004 warning of agitation, agressivity, and suicidal ideation, especially in children. They cite guidelines produced by the most interest-conflicted professional organization in the United States on the subject of whether people ought to take antidepressants for what ails them. And for the final seal of approval to get even more people on antidepressants, they cite an official government policy. For sheer errancy or inanity, it would be hard to top this Big Science comment under the imprimatur of the CDC.
Has mainstream psychiatric thinking permeated all agencies devoted to protecting us from disease? Are there no countervailing sources of dissent within the established madness institutions? Psychiatry, unfortunately, may not be an only child in the medicine family to be harmed by the central planning of the biomedical industrial complex in this regard. The journalist Gary Taube (2007) conducted an exhaustive review of the research literature on nutrition and health and questions whether the research is deemed worthy of being called science.
The institutionalized vigilance . . . is nowhere to be found in the study of nutrition, chronic disease and obesity, and it hasn’t been for decades. For this reason, it is difficult to use the term “scientist” to describe those individuals who work in these disciplines, and indeed, I have actively avoided doing so in this book. It’s simply debatable, at best, whether what these individuals have practiced for the past fifty years, and whether the culture they have created, as a result, can reasonably be described as science, as most working scientists or philosophers of science would typically characterize it. . . . Practical considerations . . . have consistently been allowed to take precedence over the dispassionate, critical evaluation of evidence and the rigorous and meticulous experimentation that are required to establish reliable knowledge. . . . The urge to simplify a complex scientific situation . . . has taken precedence over the scientific obligation of presenting the evidence with relentless honesty. (p. 451)
The leaders of the bureaucracies in which many scientists work are not accustomed to honesty when it might reveal weaknesses and cause trouble, nor are they good at promoting innovation. Their organizations are much more adept at protecting their flanks by the control of information. The few signs of countervailing influences come not from contending organizations but from the relatively uncontrollable Internet. Communities of dissent now have direct access to the public. These include networks of former psychiatric patients, blogs offering pointed criticisms of establishment thought, broadly distributed critical e-mails from whistleblowers and insiders, and websites brimming with detailed personal reviews of medications. Of course, the Internet is also itself an arena for battles between established sources and upstarts, especially as concerns “health information” (Hughes & Cohen, 2011).
But Big Science in psychiatry is trying hard to be absorbed into neuroscience, largely abandoning sociology and psychology, drawing the wagons around a biomedical fortress at NIMH. Thomas Insel, the director of NIMH, (as reported by Kaplan, 2011), explained that the new direction seeks to identify biomarkers of individual responses to drugs in order to develop “preemptive treatments . . . to prevent disability.” He is following guidance provided by a report of a high-level National Mental Health Advisory Council, From Discovery to Cure: Accelerating the Development of New and Personalized Interventions for Mental Illness. The co-chair of that council, John March from Duke Clinical Research Institute, describes the report as advancing the “transformative neurodevelopment research in mental illness.” In the report all mental illnesses are considered brain disorders and virtually all are called “developmental disorders.” March wants the NIMH to invest in “translational neuroscience” based on drugs being developed by NIH, as Big Pharma has signaled its withdrawal from psychiatric drugs since most lucrative patents from the 1990s are expiring or have expired. March describes this new direction as “incredibly exciting.” He states that the report “points the field toward the molecular origins of mental illness in early development” and he adds, “it becomes possible for the first time to envision preemptive treatments, a world without mental illness. How wonderful is that?” (cited by Kaplan, 2011).
There is now a broad recognition that psychiatry and psychiatric research—the heart of mad science—is awash in money that distorts honest inquiry. In medicine, in general, it is estimated that 25 percent of practitioners take cash payments from drug and medical device companies, and nearly 66 percent receive routine “gifts” from them (Pear, 2012). Among psychiatric leaders and researchers, the proportion is probably greater. The federal government has enacted regulations mandating as of 2012 drug companies receiving funds under Medicare and Medicaid programs to collect data on all payments and gifts to doctors and hospitals and to make this information publicly available. The research enterprise should be an arena that prizes free and open inquiry, independence of thought, and unbiased research. Instead, as we and many others have described, psychiatry has become engulfed in a thicket of distortions. On Big Pharma’s payroll are most prominent psychiatrists as speakers, consultants, researchers, and marketeers in every state. It funds the APA and its major conferences; shapes the research agendas of scientists; censors what data may be published and when; manipulates studies to ensure positive results; pays for ghostwritten articles; hides its sponsorship of spokespersons and events; forges corrupting ties with universities; attacks critics; floods the professional and public media with ads for drugs; constrains and manipulates the FDA; and ensures that expensive but ineffective drugs remain the dominant treatment in psychiatry as they are sought by millions of people. At the cost of dozens of billions of dollars, Big Pharma and its allies in the biomedical industrial complex finance mad science and own a profession.
The entanglement of researchers and clinicians in financial conflicts of interest means that the interests and welfare of consumers and the public are ignored. Senator Charles Grassley’s recent congressional investigations of the madness establishment were a welcomed exposé of the corruption of science.
Big Pharma and Big Science are supported by a much larger entity: Big Government. The federal government’s size, power, and influence make it the number-one funder of mad science and buyer of Big Pharma’s products. For instance, the federal Medicare and Medicaid programs for older adults, the disabled, and poor purchase more than $100 billion a year of drugs and devices (Pear, 2012). With regard to the biomedicalization of human distress and suffering, the pharmaceutical industry and the federal government function as corporate partners in supporting the therapeutic state.
The federal government collaborates with the APA on many fronts, serves as patron of institutional psychiatry via the NIMH, and utilizes the myth-enhancing DSM in its proclamations. Moreover, through regulation and funding of medical and social services in conjunction with the states and through its “public health” policies identifying “mental health” goals, it has institutionalized, sanctioned, and legitimized the disease model of madness. Through policies governing health care, Medicaid, Supplemental Security Income (SSI), and Social Security Disability Insurance (SSDI), and making both public and private health insurance programs offer “parity” coverage for the mentally ill, the federal government has provided enormous financial incentives to states, hospitals, clinics, and providers of mental health services to interpret human distress as symptoms of brain disease. The boom in rates of mental disability for adults and children are striking. Angell (2011) notes an increase of 250 percent for adults between 1987 and 2007, and a thirty-five-fold increase for children. The offer of insurance coverage for psychiatric help and cash supplements for those in poverty if they are “disabled” is seductive and exploited by all players in the system. Robert Samuelson in the Washington Post calls Social Security’s disability program a budget-busting, expensive “political quagmire” (Samuelson, 2012). The mechanisms for creating these huge increases in mental disability are the focus of many of our chapters: confusing the illness metaphor with reality, accepting brain disease as the ultimate cause of misery sans evidence, reifying arbitrary DSM categories, and creating the illusion that safe and effective medications are available. The government has become a full partner with psychiatry in medicalizing human problems.
The problem is this: people who need assistance are labeled as mentally ill in order to receive income supports, health care, and social services. Why do so many people need assistance? The economy is stalled or spiraling down, fewer unskilled jobs are available and unemployment has increased, inflation-adjusted wages for the average middle-class family have not increased in two generations, record numbers of families have lost their homes, and services from nonprofits and local and state governments have been sharply cut in the Great Recession. Millions of adults and children, normally living in relatively precarious circumstances, are now under enormous social stress. This stress does not result from the increasing incidence of brain defects, but from economic and policy defects. These people need opportunities and assistance, and social workers and mental health clinicians would like to help them with some of their problems so that they might seize opportunities or bear discomfort more constructively until circumstances improve. But to help an increasing number of these individuals today can only be done after fulfilling one enormously silly requirement: diagnose them with some form of mental disability or mental disorder. As one psychiatric blogger noted (thelastpsychiatrist.com, 2011):
If, however, you abolish SSI then you will reduce psychiatry to the size of neonatal endocrinology [very small]. If you uncouple social services from “medical disability”—not abolish them, just find some other, better, more logical way to distribute them—you’ll change America forever. . . . Psychiatry serves at the pleasure of the government.
Change of all kinds prompts resistance. The familiar, even if uncomfortable, often trumps the unknown; uncertainty causes understandable feelings of anxiety. Institutions as well as people are suspicious and defensive of calls for reform, even when they can expect the change to be beneficial. They might lie and confabulate to keep things the same. None of this is surprising. Even scientists trained in critical thinking, as Thomas Kuhn (1962) argued in his famous book, The Structure of Scientific Revolutions, resist findings suggesting that their theories are inadequate.
This is certainly the case in trying to suggest an alternative to the medical and public health model of madness. Biomedicine is a great success story. Epidemics of infectious disease were averted or prevented, fatal afflictions became treatable or were eradicated, infant mortality was reduced and life-span accordingly increased. Science has triumphed over nature by producing knowledge that has greatly improved the quality of life for billions of individuals. There is no question about this. Thus, we understand why it is so alluring to view madness as a brain disease that awaits a miraculous cure.
But the available empirical research literature, corroborated by even the most enthusiastic supporters of the notion that disturbances of behavior are diseases, provides no convincing evidence that this is so. Yet the public is as quick as NIMH and the APA to nourish this illusion. The seduction is easy to appreciate. The medical explanation of human travails provides comfort, solace, and hope. It suggests that personal distress, inadequacy, and failure are really due to internal neurological defects that once fixed will eradicate these failings, much as antibiotics cure bacterial infections. It promises that people will not be held responsible for their failings. It promises John March’s happy myth of “a world without mental illness.” This illusion also helps all the institutions and bureaucracies that must count and categorize people and their troubles in the process of trying to help and support them. Even invalid classifications grounded in myth can ease the work of organizations, particularly once they become dependent on them to rationalize their operation. There is also a dark side to using mental illness as the focus of scientific efforts, and that is to scapegoat those who are called mentally ill. In the second debate of the candidates in the 2012 US presidential campaign, President Barack Obama actually mentioned the “mentally ill” on three occasions, surely an unusual occurrence in such a forum. Twice, he proposed keeping guns out of the hands of “the mentally ill.”5 Although, as we have cited earlier, the APA claims that 25 percent of the US population in any given year, and 50 percent over their lifetime, will be mentally ill, we suspect that the president was not slyly introducing a new gun control strategy.
Despite the described difficulties of mad science and how its results have become institutionalized in mental health policy and practice, there are alternative ways of thinking about and reimagining the provision of services for people in need. Some of these alternatives already exist, although at the margins of mental health practice. We offer here a few suggestions for a different roadmap for charting a more reasonable and humane future for those in the current mental health system.
Individuals and families in distress have always turned to others for advice, explanations, and solutions. Historically, help was sought from members of the extended family, neighbors, village elders, spiritual healers, witchdoctors, and priests. The assistance provided by these traditional sources of help was sometimes effective and gratefully received. At other times, the effects were illusive, questionable, or harmful. Faith in the healer, good fortune, and placebo effects undoubtedly aided helping efforts. By the late twentieth century, however, such traditional sources of help were devalued, as the biomedical industries encouraged people to turn first to medical professionals. Assistance with personal and family problems was moved under the jurisdiction of the new mental health professions and the medical establishment. Interpersonal supports were transformed into medical interventions, talismans into pharmaceuticals.
During this cultural transformation, the definition of normal was narrowed, and the perimeter of pathology was expanded. In the old normal, one recognized that existence is a struggle, an effort to be engaged with the world. Everyone’s life had its ups and downs; people had strengths and weaknesses; and all experienced times of loss, disorientation and restoration, failure and resilience. Some dealt better than others with these challenges. This was viewed as part of the textured variation and diversity of human life. But, as we have described in this book, much of this diversity of life, some of it quite troublesome, has been redefined as an ominous sign of incipient brain disease. To a great extent, the public accepts this medicalized view that traumas, fears, dilemmas, conflicts, and misbehaviors are not inevitable parts of the human comedy but expugnable illnesses. The new implicit definition of a normal or “healthy” person is someone who will harbor no serious worries or animosities, no undue sadness over losses or failed ambitions, no failures or disabilities, no serious disappointments with children or spouses, no doubts about themselves or conflicts with others, and certainly no strange ideas or behaviors. Those who fall short of these lofty expectations become candidates for psychiatric labeling. By reframing personal troubles or differences, especially serious ones, as psychiatric illness, as expressions of brain disease, people can be released from individual responsibility for imperfections of mood and behavior. They are given a temporary pass. Unusual behavior is a result of disease; foul moods the outcome of chemical imbalances.
It is incontrovertible that many, if not all, people face distress of many types and from diverse sources. People try to cope with distress in many different ways, some by seeking professional help. This is natural and prudent, because many may benefit from such professional help and support. Nothing we have argued in this book is an attempt to ignore or deny these elemental facts. Seeking professional help, especially voluntarily and in an informed manner, can be a positive method of coping. Psychotherapy (structured conversations or activities focused on the client) with caring, capable, and committed helpers of all stripes, even nonprofessionals, can be extremely helpful. Psychoactive drugs may be perfectly effective, if informed and willing clients choose them based on clearly announced profiles of effects.
The fact is, however, that assistance for those who need and want it can be offered without using the DSM’s list of contrived mental disorders. A fidgety boy or an adult who thinks the devil is out to kill him does not need to be labeled as suffering from a brain disease called Hyperactivity Disorder or Delusional Disorder. They are more usefully and honestly called . . . a fidgety boy and a person with incredible, scary beliefs. People who are distressed or misbehaving can be helped without inferring some, as yet undiscovered, neurological defects. Exhibiting an arbitrary number of ambiguous “symptoms” from a DSM checklist and, thereby, qualifying for a mental disorder label and insurance reimbursement, is neither necessary nor perhaps the best way to allocate assistance. Our current system has many drawbacks. First, labels of mental disorder imply that the needed help is “medical,” which currently results overwhelmingly in a prescription for one or more medications written quickly by physicians who are not paid to investigate realistically what is the matter with the patient (Carlat, 2010; Greenberg, 2010; Harris, 2011). Second, the labels incorrectly imply that a specific medication can be effectively used with all people having the same label (Moncrieff & Cohen, 2005). Third, it disregards the vastly different skills and personal resources that each person may have that bear directly on their capacities to contend with their own weaknesses and fears (Saleeby, 1992). Forcing those who are most socially vulnerable—the poor, the uninsured, the marginal, or inept—to submit to becoming officially mentally ill in order to receive financial assistance, health care, social services, educational services, and other forms of assistance is medically and socially improper and unnecessary. This sorting may be bureaucratically useful and politically safe, but both scientifically and as a matter of social policy it is deeply flawed. We realize that changing that entrenched system, with so many stakeholders gripping firmly to the illusion that human suffering is merely a matter of disease, is a tall order. But the only possible way that Dr. March’s wish for a world without “mental illness” will be achieved is by abandoning that very term.
The alternative view is that the array of misbehaviors, mistaken and disturbing feelings experienced by those now labeled with brain disorders are better viewed as normal human experiences in all their varieties, as described by scholars in sociology, psychology, anthropology, history, philosophy, and other disciplines that study the human condition, than by neuroscience. We realize that this view is not as seductive, comforting, or immediately useful, even if it is more accurate. Such an expanded view does not dismiss human agency or personal responsibility. It recognizes that individuals are inextricably rooted in and influenced by the social environments in which they struggle and flourish. It acknowledges the power of cultural and social learning and accepts the imperfections of the human condition. It also embraces the power of individuals and communities to provide compassionate assistance to others when needed. There are no silver bullets for the human condition, only collective and personal striving to cope.
As a result we think that psychiatry must abandon one of the two foundational roles allocated to it. First, the two professional roles that have been sanctioned by society for psychiatry must be decoupled: the pseudomedical coercive police or social management of behavioral deviance (involuntary treatment and involuntary hospitalization)6 from the therapeutic or helping role for people seeking to ameliorate their minor and serious problems in living (voluntary treatment). This would put psychiatry on par with all other medical and helping professions, who are judged as providing help, or not, by the recipients of their services.
Because the scientific evidence for the reality of mental diseases is nonexistent, no rationale for such entities causing harm to others should be advanced, and so psychiatry’s police and social management role must be integrated back into the already-existing legal system, where bad behavior toward others beyond a certain level of intensity is deemed either a civil or criminal offense subject to penalties ranging from probation to community service to fines to imprisonment and, ultimately in American society at present, to death. This approach makes clear to all that bad behavior deemed directly harmful to others has consequences and that outside of the legal (not psychiatric) finding that the individual lacks mens rea (a guilty mind) and therefore is not responsible, the proper penalty is imposed. This in no way should prevent someone who wishes voluntarily to be helped to change behaviors that might have caused the harm from seeking and receiving help either during or after their punishment.
With regard to individuals who are at risk of harming themselves or threatening suicide, which is understandably deeply frightening to others, helping professionals should continue to reach out vigorously and offer help but not engage in forced treatment. With adults7 there are ethical concerns about whether professionals should act solely on their own assessment of an identified self harmer, without full knowledge of why that person chooses to self harm. This is particularly the case since the extensive research literature on suicide suggests that involuntary treatment in any form can neither predict when or if someone will kill themselves, nor prevent a committed person from the act of suicide (Sher, 2004). Involuntary treatment may, of course, delay that act. We think that mental health professionals should offer only voluntary help, free of coercion (since coercive “help” does not work). Only in this way can helper and client honestly confront what is known and unknown about volitional human behavior, and only in this way can troubled human beings seek self-understanding and realistic options to deal with the complexities of existence.
The regulation of psychoactive drugs could also use some bold rethinking. It’s obvious that medical practitioners do not engage in any sort of sophisticated biomedical reasoning when they prescribe these drugs to distressed people and may actually engage in illogical reasoning. Further, the collective judgment of psychiatric practitioners has been hijacked by the drug industry, and little exists to ensure that individual prescribers’ decisions aim to protect individual patients’ best interests. Prescribers, it seems, are the very last players to catch on to knowledge about the ill effects of the drugs they prescribe. With polypharmacy becoming the norm and any class of drugs being prescribed for any presenting problem, the question is raised why a psychiatric diagnostician stands between a patient and a drug. Whatever diagnosis-treatment pairings do exist (e.g., antipsychotics initially for psychosis, antidepressants initially for depression, etc.) can be easily memorized by the average junior high school student. Moreover, with direct-to-consumer ads now ubiquitous, prescription drugs have fully become consumer products. Finally, the Internet has already revolutionized access to and dissemination of information about medications and can revolutionize how prescribers and users can minimize unintended harm to users (Healy, 2012). This means that knowledge about drugs—about taking, continuing to take, or ceasing to take them—is now distributed and being constructed far beyond the offices or authority of traditional medical experts.
For these and other reasons, one of the principal arrangements for providing access to psychoactive medications to people has not served them well. In fact, granting physicians a monopoly on prescribing drugs is probably causing excess harm and needs to be seriously challenged. Our own preference is to abolish prescription privileges. We don’t think they should be merely redistributed, say, to clinical psychologists, who have lobbied their state legislatures since the 1990s to obtain them. We cannot justify that any profession should possess a state-enforced monopoly to grant or deny people permission to use psychoactive drugs. Overall, prescription privileges have hindered the discovery of psychoactive drugs’ potential benefits by hindering personally creative ways to employ drugs (self-medication). Prescription privileges also help to perpetuate patients’ exposure to toxic effects and excessive drug combinations that patients otherwise would probably never attempt on their own. Although we guess that medical prescription privileges are widely seen as a “natural” arrangement for which no alternatives could possibly exist, the facts are that an explicit argument for the existence of this arrangement cannot be found, and the notion that they comprehensively “protect the public” has never, ever been critically tested (Cohen, 2008). Thomas Szasz and David Healy are two psychiatrists who differ fundamentally on their understanding of madness and the proper spheres of psychiatry as a profession. However, it happens that both have analyzed—the first from a libertarian perspective and the second from a public health perspective—the prescription psychoactive drug system. Both have proposed abolishing prescription privileges (Healy, 1997, 2012; Szasz, 1992).
Regardless of who is licensed to prescribe drugs, safety should be the primary formal concern of the FDA, and perhaps its only concern. The 1962 Kefauver amendments mandated the FDA to establish both efficacy and safety of drugs before their approval for marketing. We think the FDA has failed miserably in its mandate to establish the efficacy of psychiatric drugs currently on the market. From the perspective of a potential or actual user of these drugs, establishing their efficacy via randomized clinical trials has been a colossal waste of money and resources. Worse, clinical trials have radically restricted the understanding of psychoactive drugs as substances with psychoactive (and other) effects and created the absurd impression that every psychoactive drug that someone might find useful must fit to a “disease.” And all this occurred despite the “efficacy” established by the drug’s premarketing investigation having practically no bearing on how the drug will be prescribed once it’s on the market. “Efficacy” is to clinical trials as “protecting the public” is to prescription privileges—a ruse.
If people were allowed to determine for themselves how to use chemical aids for the vicissitudes of life—with all the guidance, advice, and recommendations that experts and authorities wish to provide them and should be able to provide them—any genuine psychological benefits deriving from drug use are more likely to be discovered and then nurtured by users. Without the arbitrary obstacles and barriers erected to benefit pharmaceutical companies that have been documented in this book, information about drugs, their uses, their effects, their advantages, and their disadvantages should flow more freely. Individual consumer preferences, rather than clinical or regulatory commercial prerogatives or strategies, should determine the value of a psychoactive drug. Adverse effects—so defined by whoever would wish to so define them, rather than by industry-sponsored researchers and bureaucracies aided and abetted by the FDA—should be immediately publicized. This would reduce use of bad drugs, just as investors recoil from a bad stock if the system isn’t manipulated to withhold or suppress information about the genuine value of stocks. In sum, no one would need to take a useless or harmful drug merely because only an overwhelmed and disinformation-vulnerable doctor controlled access to pharmaceuticals.
So-called clinical trials could be broadened to include many other ways to evaluate the impact of drugs ingested for long periods of time on complex biopsychosocial beings. This would help to establish safety as the genuine central concern of a drug regulatory system. As to ascertaining benefits of drugs, clinical trials would have to define these benefits from users’ perspectives rather than employ contrived outcome measures of short-term “symptomatic improvements” decided upon by psychiatric investigators. The range of tested drugs would, of course, have to encompass more than just the chemicals that drug companies can patent, to include the countless psychoactive drugs that may have important benefits for people experiencing psychological distress. Of course, this proposal is not nearly as practical as it is logical, as it comes up against the century-old wall of drug prohibition. As Szasz (2004) aptly reminds,
In the absence of a free market competition between legal and illegal psychoactive drugs—say, lithium and opium—the benefits of psychiatric drugs, as the patient defines benefit, will remain unknown and unknowable. (p. 178)
If one were interested in conducting genuine real-world trials of psychotropic drugs, one should compare realistic options, including drugs with other forms of help, tailored to broad groups of individuals with varying preferences. To accomplish this, different stakeholders (the federal and state government, insurance companies, Consumer Reports, family lobbies, independent or charitable foundations) must get involved in funding clinical trials—especially since establishing so-called efficacy for a “disorder” would not drive the entire process of bringing a drug to market. Moreover, as former British Medical Journal editor Richard Smith (2005) has already suggested, medical journals should agree not to publish company-funded clinical trials, only critical reviews of such trials, and only if their data are publicly available for reanalysis. Such reforms would help to free disciplined psychoactive drug use (i.e., drug use as therapy) from its current pseudoscientific pretensions, its disease justifications, and its medico-legal guardians. Enhanced by a rapidly developing technological matrix, it’s possible that a truly consumer-oriented “cosmetic psychopharmacology” would bloom. Though we think cosmetic psychopharmacology remains a mythical, hopeless pursuit, society might have an easier time to regard it as such. The availability of psychoactive drugs by prescription is a monopolistic arrangement that remains extraordinarily sheltered from critical examination. Perhaps this is so because the arrangement sweeps—under the veneer of medical experts directing diseased people toward efficacious treatments too dangerous to understand by anyone but the self-styled experts—a mountain of painful, exceedingly complex personal and social ethical and practical choices. Our society is hesitant to tackle these choices forthrightly because they rest on ill-clarified values concerning the availability of chemical performance enhancement in education, working, and sports.8
Despite all of our concerns just expressed about the difficulties ahead for alternate ways to handle madness, we still remain optimistic. As far as we can tell mad science has failed: it informs us that madness has grown, not shrunk, with about one in five American adults diagnosable as mentally ill today. We don’t know much more—and perhaps less—about madness after the famed decade of the brain than we did before. Medications must obviously be beneficial for some people who take them, but that is not saying much, given the extent of iatrogenic harm and the baseline level of appreciation of any and all psychoactive substances by their users.
We think, keeping in mind our conviction that all forms of psychiatric coercion must be disavowed and disallowed, the first step is to get this information out to the population at large. Some of this has already begun and is accelerating, and unsurprisingly it is being led by some mainstream psychiatric insiders who provide a steady flow of articles and books about much that is wrong with psychiatry and the way it handles its charges. This expands public awareness, fueling further debates, which in turn encourage further critical examinations. We believe that this cycle cannot but be self-reinforcing (as previous cycles of reform that we have criticized have been). We can imagine a future time when a forward-thinking foundation or a Silicon Valley billionaire funds a series of well-crafted commercials adeptly communicating to ordinary people the scientific and moral emptiness of the mental health enterprise in our society.
When the information and the wasteful expenditure of public funds are more broadly disseminated, we believe that both mad and “normal” citizens will be energized. The so-called grassroots mental health recovery movement is the first sign that mad people can take care of themselves if they so desire. The surgeon general’s report on mental health (US Department of Health and Human Services, 1999) recognized that the recovery movement is helping the mad to have “a more optimistic view of the possibility of recovering.” Official recognition of this movement by psychiatric authorities has likely resulted from “the contemporary wave of writings [with] their critical mass, organizational backing, and freedom of expression from outside the institution” (pp. 97–98). This, together with the massive failure of institutional psychiatry to successfully deal with the problem of madness, triggered a lobby powerful enough to gain the attention of experts and authorities. We believe, however, that the official recognition of the recovery movement occurred also because its main spokespersons did not directly question the reality of mental illness and only mildly challenged the medical management of mental patients. So, as long as the foundational belief in madness as mental disease is apparently assented to by this movement, institutional psychiatry can appear gracious to recognize some of its tenets, that mad individuals can be helped to “build full meaningful, and productive lives . . . [by] a focus on life goals, consumer involvement, a diversity of treatment options, an emphasis upon consumer choice, and individually tailored services” (Kidd et al., 2010, p. 343). Again, we think that this agenda ultimately must be met with the absence of coercion and without superfluous diagnoses (unless helpers and their contracting clients wish to use “diagnoses” they agree upon).
We are also impressed by the fact that knowledge that was once the prerogative of medical professionals is now discussed with a high level of intelligence and wisdom by ordinary consumers who are seeking to acquire information and to share information with others. We’ve briefly reviewed in an earlier chapter how the aggregate, first-person reviews of prescribed psychoactive medications by consumers may resemble much of what official and “authoritative” medical accounts disseminate, with the useful added dimension of providing contextual clues and insights to people trying to make treatment decisions. As technological progress increases the ability to use these freely available databases and to allow even more focused and individualized contributions from laypersons, many pseudoscientific pretensions of clinical psychopharmacology might be laid bare.
We believe that these cracks in the fortress of the medical model can be used to engage both the mad and their families to move further away from the current system. This is absolutely essential, because the system will not be changed entirely from within. Power is not voluntarily relinquished, but those in power respond when the formerly powerless coalesce around critical issues that cannot be ignored. If the extent of the failure of psychiatric practice is made clear to the mad, their families, and friends, the critical dialogue may become more earnest. There is, of course, the unpredictable but remote possibility that the psychiatric system produces its “Gorbachev,” a widely acknowledged leader and spokesperson who says plainly and loudly that the emperor has no clothes, that while many people could use help for their distress or have their disturbance contained to preserve our peace of mind, there is no mental illness.
The current worldwide economic crisis and the related serious debates about health-care costs will directly affect the issues of change in the mental health system. Since most mental health costs are paid for by public monies, the system appears unlikely to sustain the current infrastructure based on the medical model, although societies have in the past and in our time pursued wrongheaded policies that nearly ruined them. If our analysis is correct, moving toward an increasingly demedicalized, voluntary approach could reorient the services needed (even a moderate reduction in involuntary hospitalizations will reduce expenditures by billions of dollars, though it could increase expenditures by other social control systems).
Our suggestions may seem radical, but we think that both ethics and science are on our side. There can be no cutting-edge science in this field as long it rests on the unverified but reified concept of mental disease or mental disorder. Society’s response to personal distress and misbehavior should be guided by the ideals of compassion, justice, tolerance, education—and yes, protection of society. Human existence, the struggle for survival and for fulfillment, entails an effort to improve the troubled and fallible world of human beings. That effort must be tempered by the oft-confirmed realization that solutions lead rarely to their intended consequences. And even then, they entail other, unimagined consequences that must be resolved, creating other new problems . . . ad infinitum. In place of gleaming but illusory promises of medical cures for madness, we would all be better served by recognizing the inevitable precariousness of the human condition. To move society forward in the service of others who request help, the best that human beings are capable of is taking courageous steps based on honest critical analysis and debate, and constant scrutiny to minimize harm and monitor unintended consequences.
1.Some of these books include the following: Psychiatry: The Science of Lies (Szasz, 2010), Unhinged: The Trouble with Psychiatry—A Doctor’s Revelations about a Profession in Crisis (Carlat, 2010), Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America (Whitaker, 2010), The Emperor’s New Drugs: Exploding the Antidepressant Myth (Kirsch, 2010), Pharmageddon (Healy, 2012), Manufacturing Depression: The Secret of a Modern Disease (Greenberg, 2010), and The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment (Moncrieff, 2009).
2.State laws vary, but jurisprudence has established that professionals’ actions do not depend directly or entirely on the patient’s behavior. Rather, they depend on a variety of factors, including: the duration of the relationship established with the patient; the implicit and explicit promises professionals have made; the type of consent provided by patients; the usual responsibilities of the setting in which the relationship occurs; and other factors. A competent technical description of one large state’s commitment laws is found in Behnke et al., 2000. A first-person account by a practicing psychiatrist of coercion and commitment in the psychiatric emergency room is found in Linde, 2010.
3.In a remarkably thorough and well-documented book, Robert Whitaker (2010) argues that the modern psychiatric drug treatments have created an enormous swell of iatrogenic injury in the form of neurobiological dysfunctions. Thus, the antipsychotics have damaged the dopaminergic systems, and SSRI antidepressants have damaged the serotonergic and monoaminergic systems, of people who take them for long periods of time. Whitaker also argues that these neurological dysfunctions explain the increase in counts of what he calls mental illness, principally as inferred from the number of people receiving social security funds for mental or behavioral disability in the United States since the widespread use of these drugs. We think that Whitaker’s arguments concerning iatrogenic damage are persuasive, but we question calling drug-induced injury “mental illness.”
4.French researchers from University of Bordeaux and one of the authors of this book (DC) teamed up to analyze how the media echoed scientific findings. They identified the ten scientific studies on ADHD most-often echoed by English-language newspapers during the decade of the 1990s, as well as sixty-seven subsequent scientific studies that investigated the same questions until 2011. While 223 newspaper articles covered the first 10 studies, only 57 articles covered the subsequent related studies. More important, the authors found that the findings in eight of the top ten studies were either refuted or strongly attenuated in the subsequent studies. This fact, however, was acknowledged in only a single of the fifty-seven newspaper articles covering these subsequent studies. The authors conclude: “Because newspapers preferentially echo initial ADHD findings appearing in prominent journals, they report on uncertain findings that are often refuted or attenuated by subsequent studies. If this media reporting bias generalizes to health sciences, it represents a major cause of distortion in health science communication” (Gonon et al., 2012).
5.According to the transcript of the October 16, 2012 debate, published by the Commission on Presidential Debates, President Obama’s three mentions were the following: 1) “So my belief is that, (A), we have to enforce the laws we’ve already got, make sure that we’re keeping guns out of the hands of criminals, those who are mentally ill;” 2) “And so what I want is a—is a comprehensive strategy. Part of it is seeing if we can get automatic weapons that kill folks in amazing numbers out of the hands of criminals and the mentally ill;” 3) “We’re not going to eliminate everybody who is mentally disturbed, and we’ve got to make sure they don’t get weapons.” (Retrieved from http://www.debates.org/index.php?page=october-1-2012-the-second-obama-romney-presidential-debate)
6.This would necessitate abandoning all statutory authority for involuntary hospitalization and treatment.
7.Children, the largest coerced minority in the world, have exceedingly few rights to make autonomous decisions. Regarding their self-harming behaviors or actions, like any of their other actions, children should continue to be subjected to parental authority and “treated” according to that authority’s best judgment, except where that authority is deemed judicially not to operate in the child’s best interest, in which case the standard legal procedures as exist today would be applied.
8.Perhaps this critical examination might be triggered by what we think are three important and extremely unusual newspaper publications, all appearing in late 2012 in the New York Times and the Washington Post. The first is a series of six brief position papers arguing the pros and cons of having various prescription medications available to patients over the counter, without a doctor’s prescription. The position statements appeared in the Times’ Room for Debate forum on September 16, 2012, under the title “Getting Your Prescriptions, Without A Prescription,” and thoughtful reader comments were appended (Available from http://www.nytimes.com/roomfordebate/2012/09/16/getting-your-prescriptions-without-a-prescription). The second Times article, written by reporter Alan Schwartz, appeared on October 9, 2012, with the title “Attention Disorder or Not, Pills to Help in School” (Available from http://www.nytimes.com/2012/10/09/health/attention-disorder-or-not-children-prescribed-pills-to-help-in-school.html?pagewanted=all). This article laid bare, for the first time as far as we know in a major media outlet, the reality that both psychiatric diagnoses and medical prescription for drugs are merely convenient pretexts for making various psychoactive drugs available to users for their own ends. Over seven hundred reader comments were quickly appended to that article. The third, an opinion piece by Brad Allenby, a professor of ethics and engineering at Arizona State University, appeared in the Post on October 26, 2012, under the title “Lance Armstrong’s Fall: A Case for Allowing Performance Enhancement” (available, along with nearly eight hundred reader comments, from http://www.washingtonpost.com/opinions/lance-armstrongs-fall-a-case-for-allowing-performance-enhancement/2012/10/26/6f7cccf0-1d41-11e2-b647-bb1668e64058_story_1.html).
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