Cui bono?

I haven’t blogged about meta psychiatry much.  If you are following the unfolding DSM debacle, you may well see the demise of extant US psychiatry (take it away, 1 boring old man). As I responded to Steve Balt’s weasel words excuse-filled post, I believe that psychiatry has broken the social contract. UPDATE: Steve deleted my response and apparently banned me from commenting. In a perverse way, I’m pleased because it validates what I am writing here.)  It deserves to have limits placed on it via licensure restrictions and practice proscriptions. It should be demoted to technician helper status, and it should no longer be viewed as having the right to call itself a medical specialty.  Indeed, psychiatrists should be mandated to practice as physician’s assistants – under the direct supervision and accountability by a physician.

US psychiatry is having a Flexner Report (pdf, but well worth the hassle) moment, and here’s hoping that a modern day Flexner – or committee – will appear, free of conflicts of interest (snort), and raring to delve into every psychiatry department of every medical school, academic medical center and private and public psychiatric facility.

The key question here is who benefits?  In the case of the licensed helping professions, the underlying ethic historically has been that the patient’s interests are first and foremost, and that the helping relationship is one of beneficence.

Well, let’s see:

Are there clear standards of practice and care in psychiatry?

Beyond that of assessment of “symptoms” and socially defined unacceptable and undesirable behaviors (dangerousness, aggression, agitation), and establishing a therapeutic alliance, no there are not.  You will not find any Cochrane meta analyses of psychiatric care demonstrating efficacy, patient cure or higher quality of life, effective palliation or patient satisfaction. There are no medical diagnoses which fall under psychiatry.  Bunches of symptoms labelled arbitrarily with “disorder”, but no biologically-based pathophysiology.  That falls under neurology, or as manifestations of symptoms of endocrine, cardiac and infectious diseases.

What are the drivers of psychiatry?

Sources of reimbursement demand patient diagnoses, even if there is no “disorder” present.  The absence of a pathologic diagnosis means that the psychiatrist will not be paid by a third party.  Ergo, the patient becomes the means to the psychiatrist’s ends. Stigma?  What the hell do they care? Well, actually, distress from stigma is a source of their business.

Practice and professional autonomy.  No one can tell the psychiatrist how to practice.  Indeed, the literature is filled with admonitions for psychiatrists to use their “informed intuition” and “professional judgment.”  There is no difference between this and the practice of quackery.  None.  It’s based on nothing scientific, reproducible and ethical.  Moreover, in using intentionally flowery and obscure terms such as psychoeducation and psychopharmacology, psychiatrists try to make patient education and medication prescription something mysterious, specialized and requiring advanced knowledge and practice. That is deceptive, inaccurate and serves only the psychiatrist’s interests in perpetuating a sham specialty.

How does extant US psychiatry practice benefit patients?

It doesn’t. Patients present seeking help for distressing symptoms – feelings, emotions, perceptions, thinking and behavior which interferes with their perceived quality of life. Alternatively, they present involuntarily when law enforcement becomes involved.

The therapeutic alliance is a dishonest relationship which is presented as one of equals, partnering to address distressing symptoms.  In reality, it is a sham cover for the psychiatrist to retain control and power and to coerce the patient into compliance with the psychiatrist’s ordered treatment.  Many, if not most, medications used by psychiatrists cause iatrogenic harm – up to and including death.  Patients are not routinely warned about these, and so cannot and do not make informed decisions about taking them.  The adverse effects of them are the most common reasons that patients stop taking them, which is entirely their right.

Psychiatric hospital facilities are prisons.  There is no therapeutic benefit to patients.  The routines used in them are designed to maintain power and control over patients by staff, to facilitate custodial functions (eating, hygiene, activity), and to intrusively observe patients/inmates.  Most deny inmates access to fresh air, direct sunlight and nature.  Diets are non-nutritive. Patients are denied visitors, their dignity, and their civil rights.

Most of all, the psychiatrist/patient relationship is judgmental, dehumanizing and designed to keep the patient under the psychiatrist’s “care” on a chronic basis.  The emphasis is on continuity, not cure.

Everything about this is unethical, unprofessional and wrong.

Why write about it here?

People who suffer with suicidality need a place of absolute safety to discuss their feelings of unbearable distress.  They need to be able to speak with someone who is knowledgeable about the distressors and their causes, tolerates having someone else share this distress, and has the capability and professional experience to support and coach them to lower their level of distress to the point that they can then address alleviating the underlying causes.

Patients need to be equal partners in the relationship, and their needs, wants, desires and functional goals should be paramount within the constraints of civil society. (Psychiatry is alone in hosting a forensic subspecialty and working for law enforcement agencies [prisons and jails] as well as serving as for-profit expert witnesses in court trials.)  There should never be a threat of law enforcement involvement as a condition of care.  There should be no threat of involuntary incarceration – forget about calling it hospitalization – it’s no such thing.

In the Reading List, I’ve included some programs and interventions which do this.  But to date, I’ve not found a single licensed provider of any sort who has the above skill set and practices by the stated objectives. And while support groups can be helpful in long term coping and adaptation, I think that acutely distressed people deserve to have competent, capable and non-coercive, humane care.

That care is decidedly not to be found within extant US psychiatry.


9 thoughts on “Cui bono?

  1. aek,

    Hi, I just found this post thanks to a mention on Twitter. I’m sorry, but I didn’t get any comments from you (aek) on my April 1 post. Please note that while I do moderate my comments, I don’t censor anything unless it’s (a) an advertisement, or (b) a personal attack. And you’ve never done either of those. I’ve also never “banned” anyone from commenting.

    Please submit your comment again and I’ll approve it. I’ve always appreciated your contributions.

    • Consider this post an extended version of my comment (although I didn’t include the weasel words phrase in the original.) My comment querying where the first disappeared to also was not published at all. The first appeared, so I don’t know at what point it entered the ether. At any rate, the Flexner Report is a good read – surprisingly brisk, too.

  2. You wrote:
    “People who suffer with suicidality need a place of absolute safety to discuss their feelings of unbearable distress. They need to be able to speak with someone who is knowledgeable about the distressors and their causes, tolerates having someone else share this distress, and has the capability and professional experience to support and coach them to lower their level of distress to the point that they can then address alleviating the underlying causes.

    Patients need to be equal partners in the relationship, and their needs, wants, desires and functional goals should be paramount within the constraints of civil society… There should be no threat of involuntary incarceration – forget about calling it hospitalization – it’s no such thing.”

    I agree with you – 100% – however, I would extend (as you did in the 2nd paragraph) the category of folks who need a ‘place of absolute safety to discuss their feelings of unbearable distress’ to all who seek help and by extension, a form of ‘comfort,’ from helping professionals, notably psychiatrists. It is, I would imagine, more than some can bear to carry to a sense of moral obligation to intervene, or fear of legal liability on some level, around with them that accompanies learning about someone’s talking about committing suicide. I experienced this first hand, from my own doctor, because of comments I made. I was not going to commit suicide, however, the comments were enough to trigger a very forceful response, which taught me what not to say at the psychiatrist’s office, if you don’t want to end up in a hospital.

    In your second paragraph, you say patients need to be ‘equal partners in the relationship…’ Yet a doctor / patient relationship (or, for that matter, any relationship involving professionals and those seeking their services) is by nature an unequal one. I go to doctors for their expertise, and want to be cared for by them, not by someone who does not possess that expertise. Folks go to lawyers, and others, for the same reasons. That doesn’t mean that the patient / consumer does not have a right to be treated as an adult, which is how I am reading “equal’ here. My ‘ideal’ is of two adults, discussing a situation, and together arriving at the right solution for the patient / consumer.

    While some professionals try to approach that ideal, in my experience, there is usually at least one “I’m the doctor – that’s why” moment in most of my interactions with them. Sometimes, I’ll go with that – after all, I am seeking their expertise. However, if I perceive that they are just pulling rank, I am learning now to assert myself, remembering I’m not a child who can be coerced with the ‘threat’ of hospitalization, or disapproval but instead, an adult, seeking assistance. Unsurprisingly, this is much harder for me to do with the psychiatrist than with other types of doctors, because of the special vulnerability you experience, as a psychiatric patient.

    As a professional person myself, I have been guilty of pulling rank at times with clients who tell me how to practice law, who try to dictate what I will do or say in their cases. I make clear to them that they have the final say – but I set out the legal strategy. It is for them, after careful consideration, to reject if they wish to. However, If their rejection is such that I can’t, in good conscience, continue to provide zealous counsel, I must so advise them, and seek to be relieved. However, that does not happen unless there has been a very full discussion of why I advocate a certain strategy and why they don’t want to follow it, and even then, only if alternatiaves to the strategy proposed are not available.

    In sum, psychiatrists should discuss strategies for help, including non-med strategies – in a collaborative way, without the spoken or unspoken ‘threat’ of hospitalization. You’re so right,
    aek, a safe place is indeed needed. I have long fantasized about their being a place I could go to when I am alone and suffering, where I would just be near caring people who would know how to help, quietly and in a comforting way, without it being coercive or involuntary (or costly, for that matter.)

    Keep advocating for such places – maybe some day they will exist. At minimum, I see a book here.

    • Annalaw, I’ve never acknowledged your comments, and for that I deeply apologize. They are cogent, insightful and they are moving. I appreciate your reading and contributing, as I know this isn’t a “top 10” subject area!
      If you’d like to author pieces here, say the word, and I’ll add you to the admin access.
      As to safe places, the words, sanctuary and spa, come to mind. However, I have no notion as to how to make such entities appear where needed on the scale needed and with the essential services provided by competent and compassionate people.
      Also, a society based on the classic virtues and that values the health, well-being and happiness of all its members is fundamental and totally lacking. That may be the place to start.

  3. Thanks, aek, for your response, and for the offer to write on your blog. For now, I am fine with just popping in and posting when something moves me to do so. I do hope, however, that your blog gets a wide readership, despite that the subject of suicide, and seeking safe, comforting alternatives to traditional psychiatric treatment might not be ‘top 10’ subject areas, as they are important issues. As a ‘lay’ person, not a nurse, doctor or mental health worker, I also hope that this venue becomes a place – assuming you want it to be – where patients (or ‘consumers’ as we’re sometimes called) and others who are interested, could engage in an honest conversation with psychiatrists, doctors, nurses, and others who work in the mental health field, either in response to the main posts or prehaps in a forum or separate area. Because these folks need to know how they affect those they aim to help. It may not be evident when one is in a doctor’s office, but as your blog attests, the effects of such ‘care’ are far reaching and long-lasting.

    As for physical safe places, it’s a pipedream – but at least there is a blog like this one. I note you mentioned the Flexner Report above – have not read it yet but plan to as it looks interesting and given what I did see, yeah, psychiatry could do with an overhaul. It would be nice if the place I went to was such a space but it isn’t. The therapist I see does provide some of the elements for such a space. I can speak freely, and i am comfortable there, but it is only because of the lengthy relationship we have that I can do so. When I go to the psychiatrist, I “behave myself,” and get in, get meds, and get out.

    As for a society that values ‘the health, well-being, and happiness of all its members,’ I don’t see that forming any time soon, in a country where a law offering health care coverage for ‘all,’ needs to be approved by the Supreme Court, despite its previous legal passage. I wish you well w/ this blog, and do hope that more folks find it and contribute. And that they see it as a safe space in which to do so.

    • One thing I’m not is original. Here’s my muse:

      “The care of human life and happiness and not their destruction is the first and only legitimate object of good government.” –Thomas Jefferson to Maryland Republicans, 1809. ME 16:359

      I guess I should throw a link on the Reading List to the most excellent Yale online repository called The Avalon Project.
      This is where I read about American history from the makers, themselves.

      I hoped for dialogue here, too. But so far, nothing. I think the topics of suicide and ostracism hit a limbic fear and repulsion response. It may well be a fundamental reason that so many care providers are so inept and callous – they are literally protecting their sense of self.

  4. Maybe such topics hit too close to home – people may think if they give voice to such ideas, they make them more real. I was given a psychological test today and asked to rate whether I felt like committing suicide, or harmng myself. I laughed, and told the psychologist that even if I DID feel that way I would never check it off on his test – and proceeded to put “Not at all” down as my response. I didn’t want to think about what would happen if I said I read about it online or something. I am not a scientist and do not follow some of what I read on these blogs, but do think these issues deserve much wider play so folks won’t be afraid to address their real feelings about it. Perhaps over time, more folks, including average joes and josephines like me, will find the site and may be encouraged to weigh in. ( l like your muse.)

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