Psychiatry: pro and con

I write this as someone who had a career as a psychologist in the mental health system, working within the scientific/medical model of psychiatric treatment. So, I’m not writing to reject psychiatry outright, but to examine its efficacy. I’ve written about the value and limitations of models in previous posts, and about what I call the “model muddle.” Models are just maps, helpful only to the degree that they’re accurate. No one model is demonstrably superior to all other models, in all situations. Every model has its limitations.

First, I’d like to distinguish between psychology, psychiatry and psychoanalysis. Psychology is the study of human behavior, and provides the basic theoretical structure for psychotherapy. Sigmund Freud came up with the concept of “the talking cure,” the notion that dialogue with a caring professional could help to resolve symptoms and treat psychopathology. Psychiatry is a branch of medical science, based on the concept that the accurate assessment of symptoms of mental illness can lead to an accurate diagnosis, which will result in an appropriate treatment. Psychiatrists are medical doctors who specialize in the treatment of mental illness. Freud was a psychiatrist, and psychiatrists who are trained in the system of Freudian psychotherapy are called psychoanalysts.

While I believe that psychiatric (medical model) treatment has helped a lot of people with debilitating metal and emotional symptoms, like any model, it has its limitations. Since the 1960s, the efficacy of psychiatric treatment has been questioned – with good reason. A primary critic was psychiatrist Thomas Szasz, who wrote The Myth of Mental Illness. Another psychiatric rebel was R.D. Laing, and yet another psychiatrist, David Cooper, coined the term “antipsychiatry.” Critics of psychiatry argue that mental illness/madness is a social construct and not a medical condition, and that psychiatry is a process of coercive social control. This core of criticism has led to the current antipsychiatry (alt. recovery) movement.

A primary criticism of psychiatry is that psycho-diagnosis isn’t rocket science. It’s imprecise relative to the diagnostic precision for most common physical medical conditions, and can be selective and subjective in its diagnostic criteria. Unlike with physical medical conditions that can be diagnosed by tests and procedures that reveal “markers” of a specific condition (i.e. pneumonia vs. tuberculosis), there are no such markers that distinguish schizophrenia from schizoaffective disorder or bipolar disorder. I’ve known many people with chronic mental and emotional disorders who have gotten a wide range of psychiatric diagnoses, over years of treatment. Ideally in the medical model, an accurate diagnosis results in appropriate and effective treatment. This is less often the case in psychiatry, because there’s more “educated guesswork” involved.

Proponents of the antipsychiatry movement contend that psychiatric treatment is all too often more damaging than helpful to patients. Extreme treatments such as prefrontal lobotomies haven’t proven to be effective; and the negative side effects of some psychotropic medications and mood stabilizers seem to outweigh the benefits for some patients. The term “iatrogenic effects” refers to treatments that do harm.

Another valid criticism of psychiatry is that it’s over-reliant on pharmaceuticals, and that the psychiatric profession has had incestuous ties to Big Pharma. I believe that, as a culture, we’re too dependent on medications as a panacea for health problems related to bad lifestyle choices. Drug company ads suggest that we can eat whatever we want and take pills to control any gastro-intestinal symptoms that result from a poor diet.

Having said that, psychopharmacology has its place in the treatment of what we call mental illnesses. I believe that in some instances there’s no effective substitute for the right dose of the right medication at the right time. But I also believe that other interventions can mitigate the need to rely primarily on drugs as the default treatment for psychopathologies.

The concept of recovery from mental illness doesn’t necessarily mean full and permanent remission of symptoms, but suggests that psychiatric treatment isn’t the only route to symptom control or remission. There are recovery centers in cities around the country that offer alternatives to traditional psychiatric treatment, recognizing that community and peer support can be important components of treatment. Such programs don’t preclude psychiatric interventions, but don’t rely on them as the default mode.

Factors such as physical health, stress, social stigma, chemical dependency, poverty, homelessness and nutrition can all play a role in mental health and mental illness. We need to embrace a more holistic treatment model for what we call mental illness, and to provide a range of services that give people who have been labeled as mentally ill more autonomy and more options for resolving their problems.

You can find out more about the antipsychiatry movement, the recovery model, and alternatives to traditional psychiatric treatment at <>.



Who is an addict?

Who is an addict? It depends on who you ask.  To some people it’s an ugly word with negative connotations relative to, say, substance abuser. To others it’s a term with an important meaning, and recovering addict is a badge of honor, one day at a time. Addict is just a word for something real; it’s not a specific thing like a tiger or the Pope. It has no absolute meaning, but is associated with the medical model, in that it classifies addiction as a disease – specifically a chronic, progressive, relapsing disease.  Some add “fatal” to the list of adjectives, believing that if you can’t maintain recovery, your addiction will eventually kill you. To admit you’re an addict is to admit that you’ve lost control.

I’ve attended open Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings, and believe that regular attendance of 12 Step meetings is the only path to recovery for some addicts. I’ve recommended checking out 12 Step programs to many substance abusers during my career, but I disagree with anyone who claims there’s only one way – whether 12 Step programs, or Rational Recovery, or the Bible – to stay clean and sober.

My prescription for long-term recovery from substance abuse is “whatever works for you.” If believing you have a treatable life-long disease works to keep you in recovery, or believing you have an addictive personality, or believing that you have to “get right with God” to stay clean and sober, go with it. Your path to recovery is yours, but might not be what others need. It takes most people with substance abuse problems many relapses to learn what does and doesn’t work for them, as was the case with my recovery from nicotine addiction.

Not everyone has to “hit rock bottom” before getting it right. I’ve known a few people with many years in recovery who didn’t relapse once after resolving to quit. I’ve also known people in long-term recovery who initially needed to attend 12 Step meetings, but said that at some point they internalized the principals of the program and no longer had to attend meetings. Nobody has the authority to tell you that you’ll have to go to meetings for the rest of your life, in order to stay in recovery. But if you do, that’s not  a sign of weakness. It’s just part of your personal recovery plan.

Substance abuse occurs along a spectrum, and people’s definitions of abuse may differ; but being addicted generally means not being able to control your drug use once you start using mind altering chemicals. Within the recovery community it’s generally believed that if you’re addicted to whatever “drug of choice,” you also have to abstain from all other chemical highs in order to keep from relapsing on your favorite drug. I’ve known a number of chronic substance abusers who believed that substituting alcohol and/or marijuana would help them to keep from relapsing on “hard drugs” like meth or heroin or crack. (Alcohol is a hard drug, but it’s legal.) I’ve never seen it work and have concluded that you can’t solve a chemical dependency problem with chemicals.

The concept of addiction has broadened, and now a lot of people believe that sex and gambling and other non-drug-related behaviors can be addictive. The “old school” definition of addiction was characterized by three clinical phenomena: tolerance, withdrawal and physiological cravings. Tolerance means that you have to increase your dose over time to get the high you used to get from a lower dose. Withdrawal means that when you abruptly stop using an addictive drug, your body goes through distinct physiological changes – ranging from unpleasant or painful to potentially fatal – for a period of time. Physiological cravings are like hunger. Your body is telling you it needs something, and a strung-out heroin addict craves a fix the same way a starving man craves food.

Chronic marijuana use can lead to psychological dependence, but cannabis doesn’t meet the old school definition of addictive. Similarly, sex and gambling aren’t characterized by tolerance, withdrawal and physiological cravings. However, in many respects compulsive sexual activity and compulsive gambling resemble addiction, because they involve loss of control over certain activities, and some of the same neurotransmitters are involved. Like drugs, sex and gambling can predictably stimulate the brain’s “pleasure centers.” Psychological learning theory provides a good framework for understanding such compulsive activities, and I’ll elaborate in a future post.

Denial has killed millions of addicts. If drug abuse or compulsive behavior is hurting you or others, or you’re losing control of some important aspect of your life, find someone reliable and get real with them. Explore options and work on developing your personal recovery plan. Even if your plan doesn’t include active participation in a 12 Step program, it may borrow from the 12 Steps or Rational Recovery or other models. And you can’t stay in recovery without help from supportive people who understand you and don’t judge you. You need someone to share your thoughts and feelings with in recovery. We come to know ourselves better by letting others know us better, warts and all.

Identity and diagnosis

I’ve  written two prior posts on the paradox of identity, and now I want to return to the topic. I’ve run into different versions of the  following affirmation/mantra and I don’t know who to attribute it to, but it’s a good starting point for this brief examination of what identity is and isn’t: “I have a body. I am not my body. I am more than my body. I have emotions. I am not my emotions. I am more than my emotions. I have thoughts. I am not my thoughts. I am more than my thoughts. ” For people with identified mental illnesses I’d add: “I have a diagnosis. I am not my diagnosis. I am more than my diagnosis.”

Folks grappling with mental illnesses often find themselves stigmatized, treated as the modern equivalent of lepers, although they’re not contagious. Even within the mental health community individual patients are sometimes referred to by clinicians as “a schizophrenic” or “a borderline.” Mentally ill people often sense that others stereotype and define them by their mental illness. One of my great revelations early in my career (I already knew it intellectually, but not experientially) was that people with mental illnesses are, first, unique individuals – like the rest of us. Their mental illness is a feature of who they are, not a defining characteristic.

When I worked in a Dialectical Behavior Therapy (DBT) program, designed to help “borderlines,”  one of my individual therapy clients was a highly intelligent and assertive  woman. She let me know up front in our first therapy session that she wouldn’t abide being referred to as ” a borderline” by me or my colleagues. “I’m a person who meets the diagnostic criteria  for  Borderline Personality Disorder.” And that describes her better than any diagnostic label. (Years later she saw me at a mental health event and gave me one of the finest and most honest compliments I’ve ever gotten from a former client. She said that I was the second-best therapist she’d ever had.) She refused to let others define her by her diagnosis, and was her unique self. I’ve worked with a number of people diagnosed with Borderline Personality Disorder, and no two of them were alike. I’ve worked with many more who carried the diagnosis of schizophrenia, and no two were alike.

It’s easy to stereotype people we don’t understand, and whose behavior might confuse or threaten us. As with homophobia, fear of crazy people – the most common stereotype –  is rooted in the unconscious or conscious fear, “what if I were that way.” The idea of “losing your mind” is frightening to anyone who thinks about it. Les aliens is a French term for the insane. Many people with chronic mental illnesses feel internally alienated because of their symptoms, whether depression or hallucinations. But on top of that, mentally ill people are frequently treated as aliens by people who don’t understand, and therefore fear, them.

People struggling to cope with the symptoms of mental illness often find themselves judged or blamed for their symptoms. A person in a manic state may be told, “Just pull yourself together and stop acting crazy!” A person suffering from clinical depression or PTSD might hear, “What’s wrong with you, anyway? You should have gotten over that by now.”, as if they had a choice.

Psychodiagnosis is a necessary part of the medical model but, as discussed in a previous post, it’s based on decisions made by committees and applied to unique individuals. It’s not rocket science. Psychiatry puts the people it treats in the patient role, or sick role. There are both advantages and disadvantages to being conferred the sick role. It absolves you of responsibility for certain things you’d normally be held responsible for; but it prescribes what you must do as a patient, and often keeps you dependent on ongoing treatment. This makes sense for a kidney dialysis patient, but not necessarily for everyone with a psychiatric diagnosis.

In some circumstances, for mentally ill persons there’s no substitute for good psychiatric treatment. But all too often patients are told that medication is the only option, and that they’ll have to depend on medications with awful side effects for the rest of their lives. The recovery model is person-centered, not patient-centered. Centers run on the recovery model work with their clients to come up with a unique recovery plan that serves to empower them, encouraging autonomy and hope. The plan may include referrals for psychiatric treatment when it’s needed, but other options are explored. More about the recovery model soon.

The model muddle

I’ve already written posts on several therapy models (gestalt, Rogerian, Transactional Analysis, Freudian psychoanalytic), so it’s time I examine what models are: their utility, their strengths, and their limitations. First off, models are ways of organizing and framing ideas in a way that serve as a guide. A good model is like a good map: it helps you accomplish something you set out to do, to get where you wanted to go.

But the map is not the territory; it’s merely a helpful representation. I’ve known people who were so dedicated to a model that they couldn’t see its limitations, and were blind to alternative formulations, viewing everything through the lens of their fixed beliefs. No model is perfect and complete. Each one has its flaws and limitations.

I first started thinking about models as a young mental health professional, when I read Miriam Siegler and Humphrey Osmond’s Models of Madness, Models of Medicine, in which they compared the medical model to eight other models related to the care of mentally ill persons. After examining each model (moral, impaired, psychoanalytic, social,  family interaction, etc.), the authors – both MDs – conclude that psychiatry is the only way to go. Holistic, shmolistic..

Psychiatry is the medical model’s approach to treating mental illness, usually with medications. The medical model is a scientific model. In a nutshell, the model starts with the identification of symptoms, which leads to an appropriate diagnosis, which in turn leads to a specific treatment. The medical model is very good at what it’s good at, such as mending broken bones, and doing surgery, and treating many physical ailments. But its self-promotion as the only game in town for the care of the mentally ill has been challenged by many, notably Dr. Thomas Szasz and R.D. Laing.

No model is a perfect fit for all occasions, and many MDs have come around to believing in the benefits of a holistic approach to health care. Although I still believe that psychiatric treatment has its place and can be of benefit to many people with what are known as “psychiatric disorders,” like all models the medical model has its limitations. There are other valid approaches to health care that don’t rely on symptoms > diagnosis > treatment as their primary focus. The medical model is mostly focused on what to do after you exhibit symptoms, not so much on how you got there. Some medical traditions are more focused on wellness than on treating (sometimes preventable) illnesses. No model has all of the answers.

One of the limitations of the medical model as regards the care of mentally ill people is that the criteria for a differential diagnosis were determined by a committee of psychiatrists, to be applied to a unique individual. Unlike most physical disorders, there are no identifiable biological markers to distinguish what we call “schizophrenia” from “schizoaffective disorder” or “bipolar, manic.” Psycho-diagnosis is not rocket science, because mental illness isn’t precisely measurable. At best it’s educated guesses, and many people with an extensive history of psychiatric treatment have been diagnosed with – and treated for – a variety of diagnoses.

A model I’ll be writing about in a future post is the Recovery Model. A lot of mental health professionals initially scoffed at the idea of people “in recovery” from chronic psychiatric disorders. Recovery made sense as a helpful model for “recovering” chronic substance abusers, but did it apply to the chronically mentally ill? I think (hope) that many or most mental health professionals have come to recognize the merits of the recovery model, and there are now recovery centers in some cities that aren’t run on the medical model. You might want to check out <> to learn more.

Treatment models compete in the marketplace, and there’s money to be made. For instance, the Pentagon has paid millions for training in Positive Psychology. With modern marketing in the mix, we find ourselves in the midst of a model muddle. More about this down the road.