Sunday, July 10, 2011
Much heat has been expended debating the relative merits of psychoanalytic work versus other approaches, especially CBT. While research and theory is of undoubted importance in better defining quality and success in psychotherapy, the more enduring threat to independent practice of psychoanalysis and psychoanalytic psychotherapy does not come from CBT practitioners, or even CBT researchers, however dearly we may resent their current hegemony in academia. I submit it that any successful practicing clinician, regardless of orientation, works with resistance, transference, unconscious processes, dissociated affect, repressed memories, as well as habits, symptoms, cognitive distortions and so on, regardless of what labels describe these concepts. Working psychotherapists often have far more in common in their understanding and approach than research would suggest.
For the average clinician struggling to survive financially in the marketplace, the issues they face are quite different than deciding the relative efficacy of EFPP, DBT, EMDR, LTPP or any of the many “brands” of psychotherapy. The first barrier for all psychotherapists is the o’erweening influence of Big Pharma promoting the unthinking assumption on the part of the general public that emotional problems are best treated with medications. The second barrier is the pernicious ascendance of managed care restrictions on treatment with its wholesale insistence on defining mental health as a service treating only the “severely mentally ill” with medications and, perhaps, ultra short-term therapy. The result of this emphasis has been to provide incentives to overpathologize our patients (to obtain reimbursements) and to underplay our commitment to meaning and truth in working with our patients (to appear compliant with reviewers). The false assumption that CBT treatment is super-fast provides the cover for managed care to continually ratchet down care and results in a false competition among psychotherapists in a perverse version of “Name that Tune:” “I can treat that person in three sessions!”
These two obstacles to psychotherapy practice have a common root in the decision of the psychiatric profession to become “respectable” (and prosperous) by insisting that all psychological and emotional ills are merely manifestations of physical disorders, brain malfunction, misfiring neurotransmitters, etc., that can be treated scientifically without recourse to such ephemera as the patient’s life struggles, his failed social support systems, her resilience and motivation to change, and so on. The manifest failure of psychiatry to succeed in this endeavor to become a “real” science of brain disorders has had little or no impact on its undoubted success in transforming mental health treatment into drug treatment as first, last and only approach.
It was not always thus. It is not so very long ago psychiatry and psychiatric diagnosis was under withering attack by many, from Thomas Szasz, to R.D. Laing, to Michel Foucault, who from varying perspectives condemned psychiatric diagnosis as nothing more than either moralizing about behaviors we disliked, labeling nonconforming individuals as “sick” (rather than annoying), or injecting the power of the state to regulate intimate and personal aspects of our lives, and so on. In movies (King of Hearts), novels (One Flew Over the Cuckoo’s Nest) and Broadway musicals (Anyone Can Whistle), the notion that there was any significant difference between the sane and the insane was pilloried. Perhaps the high water mark was the decision of the American Psychiatric Association in 1974 to strike out homosexuality as a mental illness. For the first time, an established mental illness was voted out of existence! Who knew such a thing could happen? But whatever happened, it did not last long and soon psychiatry was riding high, higher than ever before.
Psychiatry’s success came about through its alliance with a pharmaceutical industry ever eager to expand the use of its drugs in treating as wide a variety of illnesses as possible. Drugs developed to treat physical illness proved remarkably adaptable in addressing psychiatric ills. With the development of the DSM, especially its recent incarnations, psychiatry was able to gain a monopoly over diagnosis of mental problems, insulating itself from the rising tide of other mental health professions that emerged in the 60s and 70s, imposing upon those professions a concept of mental health and illness that was alien to their traditions (however eager they were to use the DSM to obtain insurance reimbursement!). The date of introduction of Prozac (1987) is perhaps the best marker for the consolidating alliance with Big Pharma. This was also a boon to managed care as it developed, allowing insurance companies to play the two-pronged game of sequestering off mental health care as “behavioral treatment” but rarely paying unless treatment included medication as well for a presumed brain disorder.
So maybe Pogo was wrong and there really is an enemy other than “us” that has been able to convince the public, policymakers and the great mass of physicians that emotional difficulties, drug addiction, marital conflicts, etc., are nothing more that examples of “drug deficiency” easily enough treated with the right kind and combination of medications. The fact that psychotherapy works, that psychotherapy not only addresses symptoms but also provides for increased quality of living, has been obscured by the successful alliance of psychiatry with the pharmaceutical industry. The fact that the so-called brain disorders remain undiscovered has not flagged both the researchers and the public’s enthusiasm for the “next big thing.”
While waiting for the day when the incestuous relationship between professional psychiatry and the pharmaceutical industry finally stirs the legal system to substantive action, we can take solace in the recent revelations that Harvard University has imposed sanctions on the eminent child psychiatrist Joseph Biederman and two colleagues. As reported in the Boston Globe, the three psychiatrists admitted to unspecified violations of institutional policies and are barred from receiving remuneration for any industry-sponsored activity for one year and will remain “under review” for another two years. Although Biederman’s links to Big Pharma have been know for years and prompted a public dressing-down before a congressional committee in 2008 by Sen. Charles Grassley, this is the most significant consequence he has had to endure to date.
This revelation was particularly gratifying to me because I had suffered three days of indoctrination at a Harvard workshop years ago on the benefits of drug treatment for children and adolescents. In addition to such compelling encouragement offered by Dr. Biederman to simply ignore the “black box” warnings on use of stimulants and antidepressants, there was an appalling paucity of thoughtfulness throughout the sessions. Speakers referred almost solely to the symptom lists offered by the DSM-IV in determining diagnoses, sadly shaking their heads at times as they noted the alarming rise of psychiatric illness among children and adolescents, and asking for our commiseration with their “discovery” of an equally astonishing rise in comorbidity. Every speaker described drugs as the main form of treatment with occasional nods to CBT and “family work” as having some benefit. The speaker discussing eating disorders ruefully noted that neither drugs nor CBT have been found effective in treating anorexia and bulimia and that long-term psychoanalytic psychotherapy, while effective, was not offered due to limitations imposed by managed care.
The fact that researchers at one of the most prestigious university and teaching hospital in the country would spout such unrelieved nonsense was profoundly depressing. My discovery that many of these same researchers had their hands in the till of the pharmaceutical industry to the tune of million of dollars came later; and I have patiently waited for these revelations to merit more than New York Times editorials and congressional scoldings. I have eagerly hoped that the “perp walk” would begin and fervently desired that Dr. Biederman would be among the first. Imagine my dismay that the actions that have been taken in this case is that he and his colleagues have gotten little more than a wrist slap, with their institution rallying round them and intoning piously that violations of conflict-of-interest rules will henceforth be strictly enforced . . in the future.
There has been a lot of information out there in the last ten years or so concerning the absolute corrupting relationship between organized psychiatry and Big Pharma. It is commonplace to observe that universities want to keep psychiatric researchers happy; drug companies want successful outcomes for their research trials, and pharmaceutical representatives would be happy to announce that Prozac (or Abilify, or Seroquel) have also been found to cure Asperger’s, Alzheimer’s or Alcoholism on the basis of solid anecdotal evidence. And in may ways it is hardly surprising that institutions tend to rally round their own in the face of criticism, and money talks and power corrupts, and on and on. What has been less well publicized is the utter vacuity of thought within psychiatry to the point that the bizarre notion of “chemical imbalance” as cause for depression (and everything else) and the prospect that almost everyone suffers from some sort of mental illness has become a substitute for any reasoned exploration of what ails our patients and ourselves. Public credulity has been a reliable ally in the promotion of one psychiatric syndrome into prominence for a few years before giving place to the “next new thing,” such that ADHD is far less fashionable to have than the newly minted Asperger’s Syndrome. And it is de rigueur for bipolar disorders to have just a little psychotic disorder on the side.
In a series of articles recently published in the New York Review of Books, Marcia Angell reviews the state of mental illness in this country and the overwhelming involvement of the pharmaceutical industry allied with psychiatry to discover ever-new forms of mental illness in conjunction with ever-new drug treatments. In the first article she describes the astonishing rise in diagnosis of mental illness over the last twenty years and links this increase to the widespread availability of medications designed to treat these problems beginning 50 years ago with the introduction of Thorazine, but taking off 30 years ago as “new” antidepressants, anti-psychotics and so on, came on the market. Drugs that were found to partially alleviate symptoms of depression and psychosis have led to the largely unquestioned assertion that drugs that affect serotonin and dopamine levels in the brain are only correcting a “chemical imbalance” that was the cause of the disorder in the first place, although by this logic headaches are caused by aspirin deficiency!
She reviews the work of Irving Kirsch in detailing the failure of researchers to find the elusive “chemical imbalance” after many attempts and the increasing discovery that the effects of antidepressant medication are largely due to placebo effects. This remarkable discovery has been increasingly replicated in double blind studies. These studies have found that the beneficial effects of antidepressant medication, while statistically significant, are not clinically any better than those achieved by use of placebos. Moreover, when the placebo used in drug research mimics the same side effects of antidepressants, the differences in effectiveness trend toward zero.
While one possible implication of these studies is a kind of “no harm, no foul” outcome (after all, if patients report improvements, what’s the problem?), Robert Whitaker explores the darker side of the use of psychoactive medications. In Anatomy of an Illness, Whitaker notes that the long-term use of these medications does have significant, long-term and deleterious effects, including shrinkage of the prefrontal cortex, an area of the brain that we would sort of like to retain for as long as possible. While psychiatric science has failed to find the chemical imbalance that causes mental illness, Whitaker points out that psychoactive drugs to indeed cause “chemical imbalance” as the body tries to adjust to these medications, sometimes to three or four medications, each one “chasing” the side effects of the others. So, the diagnosis of Attention Deficit Hyperactivity Disorder gives way in time to the emergence of Bipolar Disorder with solemn assurance that it was “there” all along, without any consideration that stimulants impact sleep (especially when used “as needed”) and that disturbed sleep tends to lead to depression and anger, merging imperceptibly into bipolar illness..
In the second article, Angell focuses on the development of the DSM in it’s various iterations and the ongoing revision that threatens to vastly increase the number of psychiatric conditions available, expanding the reach of diagnoses to include such categories as “psychotic risk syndrome,” and with a range of “spectrum” disorders to allow diagnosis below the threshold of actual symptoms. Children may be discovered to have “temper dysregulation disorder” in the new DSM-V, presumably allowing all children to be found to suffer from mental illness.
Angell addresses the perverse incentive parents, especially poor parents, face when financial benefits flow from having a child with a mental illness and therefore eligible to receive SSI benefits, including Medicaid. Curiously, she does not address the perquisites of diagnosis that benefit the middle and upper classes, so that a child with ADHD may be assured to “accommodations” well into college and beyond. Additionally, she does not address the financial benefits to psychiatrists in being able to diagnose, and be reimbursed for, an expanding list of new disorders. After all, the DSM was originally developed as a way for psychiatrists to justify insurance reimbursement and the success of the first DSM has not been lost on generations of psychiatrists. Daniel Carlat exemplifies the psychiatric profession, with its own perverse incentives to see patients for 15-20 minutes, prescribing solely on the basis of symptoms and reported symptom relief, all of which allows him to make at least twice as much as a psychotherapist.
Angell comes to a final conclusion,
The books by Irving Kirsch, Robert Whitaker and Daniel Carlat are powerful indictments of the way psychiatry is now practiced . . At the very least, we need to stop thinking of psychoactive drugs as the best, and often the only, treatment for mental illness or emotional distress. Both psychotherapy and exercise have been shown to be as effective as drugs for depression, and their effects are longer lasting, but unfortunately, there is no industry to push these alternatives and Americans have come to believe that pills must be more potent.
Her conclusions seem woefully incomplete and there is a great deal more to be said about those treatments and interventions, including psychoanalytic psychotherapy, that work and have sustained and enduring benefits. While this was not the purpose of her review, it remains an important task for us all educate the public. For at least the last 30 years, the pharmaceutical industry has been on an unremitting and largely successful campaign to convince Americans that their depression, anxiety, blue moods, and shyness are illnesses that can be alleviated with a simple pill. The realities that Angell reviews (and Kirsch and Whitaker have documented), will not have any impact on the public without a sustained campaign to educate Americans to the shortcomings and dangers of drug treatments and the benefits of alternatives.
We can and must do better to address this unholy alliance of psychiatry, Big Pharma, and managed care. It is not sufficient that we know that drug treatment for emotional problems, however useful in the short term, does not address the underlying problems of living that our patients struggle with. The reality is that drug companies and the insurance industry have far greater clout with policymakers and far greater resources to indoctrinate the public (and truth be told, Americans have always sought the “quick fix” in many areas) than any of our organizations. Even combined we cannot compete on a level playing field; but we can begin to address what is essentially an illusion that medication cures emotional distress and that psychotherapy in whatever iteration is essentially an adjunctive approach to ensure patient compliance with medications.
One of the goals of Division 39 has been for our Council Representatives to forge closer connections with the other practice divisions and our new Committee for Professional Affairs will also have collaboration with the Practice Directorate as well as the practice divisions as a major goal. Finally, the Psychoanalytic Consortium has agreed to address the issue of public relations for psychoanalysis and psychoanalytic psychotherapy at every meeting. Psychotherapists of whatever orientation need to stand together to protect a patient’s right to choice, privacy, access, and quality in mental health and substance abuse care. Make you voice heard within Division 39 and APA by attending the APA Annual Convention in August and learning more about ways to promote and protect psychoanalytic psychology as theory, research paradigm and, especially, treatment.
 This newspaper article came to me from Kenneth S. Pope’s e-mail list kspope.com. Thanks to Ken Pope for distributing such a wide range of information relevant to psychology and psychotherapy.
 In fairness, psychiatry is not alone in being in bed with Big Pharma and, as documented by the investigative organization, Pro Publica, universities have routinely failed to enforce their own conflict of interest policies and have only been goaded into doing so by investigations such as Pro Publica’s. See http://www.propublica.org/article/medical-schools-plug-holes-in-conflict-of-interest-policies and thanks again to Ken Pope for bringing this to our attention.
 Marcia, A (June 23, 2011). The epidemic of mental illness, New York review of books, available online at http://www.nybooks.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/?pagination=false
 Kirsch, I. (2010). The emperor’s new drugs: Exploding the antidepressant myth, New York: Basic Books.
 Whitaker, R. (2010). Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America, New York: Crown.
 and Marcia, A. (July 14, 2011). The illusions of psychiatry, New York Review of Books, available at http://www.nybooks.com/articles/archives/2011/jul/14/illusions-of-psychiatry/
 Carlat, D. (2011). Unhinged: The trouble with psychiatry—A doctor’s revelations about a profession in crisis, New York: Free Press.