NAMI Paper: Psychiatry Finally Makes a Necessary “Mea Culpa”

 

As part of my process of recovering from borderline personality disorder, I’ve been reading psychiatric textbooks on its etiology, development, and treatment.  I also read NAMI’s first book written by its chief psychiatrist, Dr. Kenneth Duckworth, You Are Not Alone.  One of the heartening things I’ve learned from this reading is, psychiatry is finally offering “mea culpas” for its past mistakes—at least to other psychiatrists, and people interested in the dynamics of psychiatric treatment.  While heartening, it’s also both surprising and disheartening, because psychiatry is just not known for a public face of admitting it was wrong.  Which it has been, and so, while it is heartening to finally see psychiatry admit it’s made errors, it’s also disheartening, because its usual public face is, “Don’t worry, we know all the answers.”  Which has been the public face of psychiatry at least since the days of Freud, and maybe even all the way back to Kraft-Ebbing, the inventor of the modern case study, who was so sure that the cause of mental illness could be found—in masturbation!  Freud and later psychiatrists were also so sure the causes lay in their own often arcane theories of the unconscious mind, even though they were also so sure that competing psychiatric theories of the unconscious were so very, very wrong!  Following B.F. Skinner, the behaviorists were all so sure that we humans were basically like pigeons, and could be trained just like pigeons to modify destructive behaviors.  And so it was, and so it has been, until very recently. 

 

Of course, none of these psychiatric notions was at all noted for providing empirical evidence to back up their various claims of successful treatment.  If they relied on evidence at all, it was only anecdotally, through carefully-written case studies, or else by referring to an alleged self-consistency in their various theories.  But that is not, needless to say, how they were presented to the public at all.  What we can properly call the “psychiatric spin machine” was busy triumphing how it had found the way, or a handful of various ways, to solve the problem of mental illness, and restore its sufferers to “normality,” whatever that meant—as so much of what was touted depended on who was doing the touting.  Whether it was freed libido (for the Freudians) or modifying behavior to stay within acceptable bounds (for the behaviorists), the answer to the “unacceptability” of mental illness was now at hand.  There were even those who touted the superiority of the “mentally ill” (think Foucault, who, in his confusion, sees humane treatment of the mentally ill as depriving them of their “liberty” to be mad, and who reduces all of psychiatry except Freudian psychoanalysis to mere “positivism;” or R.D. Laing, who maintained that insanity was but a sane way to respond to a crazy society; or all those insisting that those on psychotropic medication go off such drugs immediately, and be “cured naturally”).  Freud was probably the first one to tout his particular way—psychoanalysis—as the way to cure mental illness once and for all, but he soon enough spawned psychiatric and psychoanalytic rivals to challenge his particular way.  Needless to say, all these various claims were advanced without much in the way of clinical evidence demonstrating their success, but relied more on beguiling theories that were supposedly self-consistent as evidence of efficacy.

 

Such, in a nutshell, was the history of psychiatry before the advent of the current fashionable notion (for lack of better terminology) of “evidence-based treatment,” i.e., supposedly statistically sound analyses of large groups of psychiatric patients receiving certain treatments, with comparisons to control groups not receiving such, and from such studies, assessing their effectiveness.  From such studies, it was determined that psychoanalysis did not pass the evidentiary bar, but that other therapies did—Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, certain drug and other medical treatments for schizophrenia, bipolar, depression, etc.  They passed the evidentiary bar based on measured outcomes, were thus “scientific” treatments with proven efficacy, finally making psychiatry a “real science,” a “real medicine.”

 

But even in the heyday of “unscientific” psychoanalysis, the psychiatric spin machine touted it as not only the way, but even as the only way!  So also with its chief rival, behavioral modification.  Same also for Jungian, Adlerian, Gestalt, and other approaches. Thus, each treatment had its own spin doctors, its own pitchmen and admen when it was touted before the general public, which, of course, lacked the ability to discern truth or falsehood among the various claims, and claimants.  But the psychiatric spin machine, nonetheless, was adamant: “Despite the various rival claims, we, Official Psychiatry (representing whatever claimant sounds most acceptable to you, John and Jane Public) now have all the answers.  We are the Authorities, and authoritative as such.”  Such was the marketing of Official Psychiatry: “We have all the answers you are looking for.”  And such was how psychiatry and psychiatric efficacy was sold to the general public.  “We are also Real Medicine,” touted Official Psychiatry—whether Freudian, Jungian, Gestalt, behaviorist, or whatever.   “When you are looking for Mental Health, come to us, for we have All the Answers.”

 

Now, psychiatry is admitting, at least among other psychiatrists and informed students of psychiatry, “No, we don’t have all the answers.  And a lot of the answers we had in the past have not panned out.”  Gone thus is the universal efficacy of psychoanalysis, gone also is the notion that schizophrenia results from bad parenting, gone as well is the notion that personality disorders are untreatable, and being questioned is the notion that there will come a time when there will be a pill for every psychiatric disorder, that it’s all a matter of unbalanced brain chemistry, and other nostrums within psychiatry, each one fashionable at one time, many of them now discarded, with psychiatrists themselves admitting (at least among themselves), “No, we oversold ourselves to the general public.  We simply have not produced a lot of the results we promised.  Our State of the Art isn’t so Stately after all.”

 

This was most ruefully brought home to me in my life, during my 47 years of inept and malfeasant psychiatric treatment, where I was reduced to a desperate, dependent outpatient with my life literally on hold.  I had believed in the promises of psychiatry, and as a troubled youth, I literally jumped at the chance to get psychiatric help for my troubles and depression when it was offered to me by my Resident Advisor in the dorm I occupied as a college freshman.  So began my fruitless odyssey of nearly five decades spent in university clinics and CMHCs (Community Mental Health Centers), where all I did was age, nothing more.  I found out the hard way that many of the oversold promises of psychiatric treatment simply weren’t true.  But within it I remained, feeling quite hopeless without my psychiatric “fix,” which somehow got me through to the next session without making things any better.  I felt trapped:  unable to advance within psychiatric treatment, but convinced by psychiatry itself that, without it, all would be hopeless.  So there I stood (or rather, sat) immobilized, somehow suspended between a sense of “almost (but not quite) normality” and “abject mental sickness,” with little actual life going on around or about me.  I was trapped.

 

Later, after this 47-year debacle, which went on and off (but mostly on) from 1965-2012, I did finally get the psychiatric help I needed from a private therapist, beginning in 2014.   He applied his version of Cognitive Behavioral Therapy (previous therapeutic approaches had been pretty much haphazard, directionless), which was both conversational and helpful, but most of all, he was engaged with me, and I felt it.  I felt his empathy, his compassion, his understanding, whereas with so many of the previous therapists I sensed only their indifference, their unconcern with me personally, even their boredom, their sense of “I have to put up with this to get a paycheck, so I will.”  My good therapist of now once said to me it was “unconscionable” the way the university clinics and the CMHCs had let me “fall through the cracks,” as so often I was not 100% qualified for this offering, but also not 100% qualified for that offering, so I got nothing, according to the rules set by these most bureaucratic systems.

 

I had encountered good, capable therapists in the university clinics and CMHCs, which is much of what kept me going back in anticipation, but for the most part they were either fired or quit.  It seemed only the most bureaucratic, the most merely timeserving, were the ones that survived, and I got far too many of them.  I didn’t have much contact with psychiatrists as such in the clinics and CMHCs, as my condition wasn’t deemed responsive to medication, which suited me fine, as I was all too aware of medicinal side effects from the medications psychiatrists prescribed.  However, in 1986 I was finally put on effective medication for my chronic spells of depression, which would often immobilize me in despair for days at a time, and out of which I emerged usually jobless, when I was finally prescribed lithium, later supplemented with Prozac.  I was on these antidepressants for 18 years, 1986-2004, when my CMHC suddenly abandoned me for a year because I had too “volubly” complained about the case manager messing up most ineptly my application for SSDI benefits I was entitled to, but found myself, in 2004, without my Prozac and lithium—and also, most importantly, without depression!  When this CMHC let me back in, February 2005, I saw the staff psychiatrist and told him directly I’d been off antidepressants since November 2004 and hadn’t had any depressions, so he agreed to monitor me while off antidepressant meds.  He so monitored me until December 2005, after which he said I didn’t need them anymore.  What had happened, I surmise, is that the antidepressants I’d been on did actually change my brain chemistry, my way of thinking, so I was now permanently thinking in a non-depressive mode.  I haven’t suffered from a depressive spell since 2003, 20 years ago as I write now.  So, no, my experience does say one doesn’t have to stay on medication forever; however, if one does go off meds, always be sure to be monitored off them by a psychiatrist or other medical doctor.  That I have learned.

 

I kept with my Cognitive Behavioral therapist until 2020, and shortly thereafter went to other therapists at a private clinic (both these places were exceptional among private practitioners, as opposed to public CMHCs, in that they accepted my Medicare, without which I couldn’t have afforded them).  In all, I had 69 months of effective psychiatric care, which wiped out the previous 47 years of inept care.  That, and the scientific fact that personality disorders do tend to heal themselves over time, actually made me able to feel fully recovered, and to be a “normal” person now, although I was in my early 70s when I finally had such success.  So, my own experience does not make me anti-psychiatry; however, it certainly does make me anti-bad psychiatry, which I do definitely feel is all too common.  And I do believe a lot of psychiatrists and other mental health professionals would agree with me.  Certainly that was the lesson I drew from my dismal years in the university clinics and CMHCs, which do not pay well, but which do provide perks and benefits, among them “iron rice bowl” security of employment once hired.  It should be pointedly noted, though, that I did file three written complaints against four therapists I had in the CMHCs (two of them worked together as a team, the other two saw clients alone) who had been especially pernicious in their psychiatric treatment of me, and I do wish now I’d filed complaints against several more.

 

Modern evidence-based research on treatment of personality disorders indicates that there are several effective modalities of treatment, but that it is also important for the therapist to be not only skilled, but also empathetic, considerate, and understanding.  I would generalize that to say, that applies to all therapeutic relationships.  If the so-called therapist is hostile or indifferent to his or her client (and in the university clinics and CMHCs, as I found out myself, so many are), then the whole relationship is undermined, and effectiveness of therapy is reduced to naught.

 

Sadly, even though I am a strong believer in public medicine and supporter of Medicare for All, I have to admit that CMHCs were a good idea that just had too many obstacles in the way to make them effective, which is why so many of them give only mediocre care.  Their budgets are set by politicians who are often hostile to the whole concept, and the community resources truly needed by the mentally ill are often beyond what is available.  The result too often is inadequate care, neglect, jail instead of treatment, and the proverbial “falling through the cracks.”  (By the way, I was once jailed for a week for a suicide attempt; I was placed in a cell for psychiatric observation because there were no hospital beds available!)  My own rueful experiences in CMHCs attests to this.

 

This excursion into my own mental health recovery history indicates how I went from an uncritical believer in the automatic effectiveness of psychiatric care into an informed skeptic of so much of it.  I once myself was a true believer in what the psychiatric spin machine peddled.  I learned better the hard way, though lived experience.  That is why my welcoming of the “mea culpas” psychiatry now gives (at least to itself) is so rueful.  But in our capitalist society day, so often marketing is everything, and can spin the bad or indifferent into the positive good.  Think only of cigarettes, sugary soda pop, or bottled water instead of tap water!  And in the end, I did indeed benefit from good psychiatry.  But it is necessary here to do the math, and to point out that my 69 months (5.75 years) of good psychiatry in a “career” of 52.75 years as a psychiatric outpatient (with occasional hospitalizations; from which I was often prematurely released as too “normal”!) had to overcome 47 years of bad psychiatry.  This meant that the good psychiatry came only to 11% of my time, as opposed to 89% of my time trapped in the bad!  Not a good augury, by any means.

 

But the spin continues, always trying to put a pretty face on what are not always good results.  For example, an online psychotherapy site advertises that therapy is effective for 75% of its patients.  But what of the 25% for whom it is not effective?  Too often the blame for ineffectiveness is put on the patient, going all the way back to Freud’s famous case of his patient Dora, who was blamed by Freud himself for not positively accepting his rather hairbrained suggestion that she marry the man she accused of harassing him!  She was simply dismissed as “hysteric.”  (Which was a common psychiatric diagnosis of women back in Freud’s time, the ending years of Victorian prudery, with its expectations of what was socially “proper” for women, i.e., submissive acceptance.)

 

But the history of psychiatry is often a history of fads, and what was the cutting edge of yesterday is often dismissed as wrongheaded nonsense in trendy today.  But as a former work colleague put it so well metaphorically, “Even a blind squirrel finds an acorn sometimes.”  The leading figures of psychiatry both historically and now were, and are, intelligent, educated men and women.  So there is often a kernel of truth in what they said and wrote, even if much is dismissed later.  That goes for Freud, as well as for others.  And what is considered “cutting edge” today may well be cavalierly dismissed in the future.  “State of the art” should thus be regarded as tentative, “the best as we know now,” but always, subject to later change or modification.  Same as in physics, or chemistry, or in any science.

 

But such honesty, such “This is what we know now, but that could all change,” goes against the effectiveness of marketing the product.  And, after all, psychiatry is a business, an income-generator, as much as it is a profession or science.  And a good business does not plant doubt, even informed doubt, in the minds of its prospective customers.  But if psychiatry were to be truly honest, psychiatrists and psychotherapists would admit to their prospective clients seeking help:

 

I may well be able to help you, but perhaps not.  I believe I am a skilled and able practitioner,

but perhaps I am not right for you.  Then again, although I feel I am State of the Art in what I know, we in psychiatry don’t yet know as much as we’d like to, and perhaps what problems you bring to the table may be beyond our present state of knowledge.  Having said that, it is now up to you to decide if you want to give it a go with me.

 

Needless to say, such blunt honesty could be bad for business!  Good for ethics, of course, but bad for business.   And goes against the grain of the psychiatric spin machine, with its omnipresent messaging that it has all the answers, even when it doesn’t.  As the examples given above demonstrate.   With psychiatry as with so much else, “Caveat emptor.”  Which is why, though psychiatry’s “mea culpas” are welcome, and we the public should be glad they have finally been given, there may well be more to come.  Of necessity, of course, as times change, and knowledge grows.  As the Communist Manifesto states so notably, “all that is solid melts in air….”  That holds for psychiatry as well.