If ever there was a time for online (tele/cyber) talk therapy, this is it.
In case you were trekking through Tibet or living in a cave with Buddhist monks, allow me to clarify why. Key term: social distancing.
It is not that anyone who is sick or symptomatic would knowingly go to an in-person
therapy session anyway, nor does one have to avoid mass transit or public taxis or garage attendants (who may park one’s auto while coughing on the steering wheel). Reasonable accommodation works well. Yet just because you have a germ phobia or are getting clinically paranoid does not mean you cannot get physically ill!
Therefore, keep calm – and carry on – I mean: wash your hands!
Okay, this is not funny. The lesson? Psychotherapy 101 teaches us that the most fearsome thing is – the unknown.
You know how in the vintage black and white monster movies, once you actually see the guy dressed up as Swamp Thing, it is a lot less scary? The creature may still be disgusting, but it is no longer nearly as scary? The scary part is when the heroine is innocently combing her hair and the swamp thing (which is “off camera” and the audience cannot yet see) is silently sneaking up behind her.
You know that scenario? Well, that’s what we’ve got here with the World Health’s Declaration of a pandemic. I will not further comment on the details as numerous resources are available from WHO and the Center for Disease Controls, frequently updated as we learn more and more about what to do or not do.
Just as many businesses, schools, colleges, universities are working remotely – that is, online – for example, delivering a webcast online, clients and therapist may leverage the convenience and social distancing of online therapy for their therapy sessions. One can also apply the lessons of social distancing in an in-person office setting, but it has to be a reasonably large office (which I do have) about the distance of two sneezes across. However, that is not what I am talking about here. What am I talking about? Download a video telecommunication application (function) such as Zoom (this is just an example, not a product endorsement), which reportedly uses encryption. Then review the instructions or call the Help Desk (which I am not operating for purpose of this post).
I cut to the chase. Here are two lessons learned since I originally published this post about online (cyber) therapy in September 13, 2019.
First, an online session presents new opportunities for the equivalent of slips of the tongue. There was one individual with whom the occurrence of the word “mother” was inevitably followed by the Internet connection freezing up, requiring a restart. You can’t make this stuff up. After I called it out, he stopped messing with the volume controls, which seemed to have occasioned pressing the wrong button. Therefore, in an empathic space of acceptance and toleration, the therapist may reasonably provide understanding, accommodation, and some extra time to reinforce and support relatedness.
Next, I can see many psychiatrists, psychologists, and clinical social workers with contracts with insurance companies getting stressed because insurers generally resist paying [will not pay] for tele-consultation (or will do so only (say) in Alaska where there is no other provider within 200 miles).
That is definitely an issue; and it will not be solved here. It may require an act of Congress to curb expanding monopoly rents on the part of insurers during a national crisis, and I would be in favor of such action. It is true (as far as I know) that one cannot take someone’s blood pressure over Skype, though I would not rule out some innovator coming up with an attachment that connects to the computer’s USB. In any case, I am not holding my breath, and I am continuing to expand my online empathy consulting practice, since – how shall I put it delicately? – my relationship with insurers is actually more than a distance of two sneezes across and, in many cases, breaks down in that an empathy deficiency is not [properly speaking] a medical diagnosis.
Update: March 17, 2020: This just in from The Washington Post: “Medicare expands telemedicine to allow seniors to get virtual care at home” [https://www.washingtonpost.com/world/2020/03/17/coronavirus-latest-news/#link-FAF2A2J73BDH3FH6GUHMGM5OSE] This is progress – and it is about time!
The following was published on September 13, 2019 and is repeated here as highly relevant to our current wellness challenges.
The genie is out of the bottle. The day that the first therapist invited his one-on-one client (who had an urgent need for a conversation but an inability to get to the office) to put down the phone and dial into Skype, the genie escaped from the bottle.
The reader will recall that in the 1001 Arabian Nights the Genie was very powerful but a trickster and nearly impossible to control. Making wishes is tricky, and if one is not careful, the sausages end up stuck to one’s nose and one must waste the last wish to get them off. In this case, the Genie is Internet technology such as Skype and Google Groups and the emerging conveniences, affordances, complexities, entanglements, and even resistances that it offers.
In the Arabian Nights, the hero, Aladdin, had to trick the Genie to getting back in the bottle by appealing to his narcissism. “You are not all powerful,” Aladdin said. “A large creature like you could not possibly fit in that small bottle!” The Genie’s wounded narcissism caused him to prove that he can indeed fit back in the bottle. Aladdin puts the stopper back on – trapped! However, in the case of the Internet and online communication tools, do not look to be able to turn back the clock.
But there is good news. The human face is an emotional hot spot. It is rich in micro-expressions many of which are available and visible even though the “real estate” on the screen in less rich in detail than an in-person experience. Indeed it is not even clear that the face as presented online is “less rich.” It is the only thing being displayed, and the viewer is led to concentrate on it in detail. But here the trade-off of bodily presence versus the imaginary comes into the foreground.
The criticism fails that the online conversation between persons lacks the reality of the in-person encounter. But this criticism fails, in a surprising way. The criticism fails not because the online media is so real. Rather the criticism fails because the in-person psychotherapy encounter is shot through-and-through with the imaginary, with symbolism, the imaginary and irreality. The “irreal” includes the symbolic, the imagined, the fictional, the part of reality which is distinct from the real but includes the past and the future and the imaginary, which are not really present yet influence reality.
In psychotherapy, the in-person encounter is precisely about the symbolic and the imagined – the transference. The basic definition of “transference” is that the person relives emotionally the relationship to objects (persons) from the past, persons who are not physically present in the room (or in the virtual space online).
What we are calling the “virtuality” of the technology media adds an additional dimension of irreality to the symbolic and imagined transference relationship. Yes, the media is the message (as Marshall McLuhan famously wrote), but with the arrival of online therapy the media is first and foremost the transference. The message now occurs with a strike-through, message.The online technology itself becomes a source and target of transference.
The one thing that immediately occurred to me: Psychotherapy invokes a virtual reality all of its own – even without cyber space. This is especially the case with dynamic psychotherapy that activates forms of transference in which one relates to the therapist “as if” in conversation with a past or future person or reality, the latter not physical present. Indeed, with the exception of being careful not to step in front of a bus while crossing the street on the way to therapy, we are usually over-confident that we know the reality of how our relationships work or what people mean by their communications. This is less the case with certain forms of narrowly focused behavioral therapies, which are nevertheless still more ambiguous than is commonly recognized. Never was it truer that meaning – and emotions such as fear – are generated in the mind of the beholder.
While virtual reality (VR) goggles as such are not a part of any online therapy group process, VR goggles are currently being used in individual psychotherapy with clients who are dealing with phobias and related individual issues.
[See www.psious.com– an engaging start up which is promoting the VR goggles for psychotherapists. The author (Lou Agosta) reports: I have no financial relationship with this company, and I wrote a blog post in 2016: “A Rumor of Empathy at Psious”: https://tinyurl.com/jyuxedq]
For example, it is much easier for someone with a fear of flying to put on a set of VR goggles in the therapist’s office and take a virtual trip to the airport, board an airplane (in VR), and be taxing down the run away (in VR), than it is to do this in the real world. The next step in a group process is to create an avatar that resembles one’s individual physical self, warts and all, and to join the other avatars in an online virtual reality group session. New possibilities are opened up by this form of therapy for dealing with all kinds of emotional and mental issues that are beyond the scope of this article.
Here the point is just to look at how virtual reality (“virtuality”) already lives in the in-person psychotherapy session even as it might have been conducted in 1905. There is a strong sense in which the conversation between a client and a psychodynamic therapist already engages a virtual reality, even when the only “technology” being used is a conversation is English or other natural language.
For example, when Sigmund Freud’s celebrated client, Little Hans, developed a phobia of horses, Freud’s interpretation to Hans’ father was that this symbolized Hans’ fear of the father’s dangerous masculinity in the face of Hans’ unacknowledged competitive hostility towards his much loved father. The open expression of hostility was unacceptable for so many reasons – Hans was dependent on his father to take care of him; Hans loved his father (though he “hated” him, too, in a way as a competitive for his mother’s affection); and Hans was afraid of being punished by his father for being naughty. So Hans’ hostility was displaced onto a symbolic object, the horse. Hans’ symptoms (themselves a kind of indirect, “virtual reality” expression of suffering) actually gave Hans power, since the whole family was then literally running around trying to help him and consulting “The Professor” (Freud) about what was going on. In short, the virtual reality – now remove the quotes – made present in the case is that the horse is not only the horse but is a virtual stand-in for the father and aspects of the latter’s powerful masculinity.
So add one virtual reality of an imagined symbolic relatedness onto another virtual reality of a simulated visual reality (VR) scenario, the latter contained in a headset and a smart phone. Long before VR technology, therapists of all kinds, including behaviorists, used VR by activating the client’s imagination by asking him or her to imagine the getting on the feared airplane. One may try to escape virtual reality by not going online, but the virtuality follows as long as human beings continue to be symbolizing, imagining creatures.
This blog post is an excerpt from: Lou Agosta’s article “Empathy in Cyberspace: The Genie is Out of the Bottle” in Theory and Practice of Online Therapy: Internet-delivered Interventions for Individuals, Groups, Families, and Organizations edited by Haim Weinberg and Arnon Rolnick. London and New York: Routledge: To order the complete book, click here: Theory and Practice of Online Therapy [https://tinyurl.com/yyyp84zc]
(c) Lou Agosta, PhD and the Chicago Empathy Project
The Theory and Practice of Online Therapy: Internet-delivered Interventions for Individuals, Groups, Families, and Organizations, eds., Haim Weinberg and Arnon Rolnick, published by Routledge:
Table of Contents
Introduction to the book Haim Weinberg and Arnon Rolnick
Section 1 General considerations for online therapy edited by Haim Weinberg and Arnon Rolnick
Chapter 1 Introduction to the general consideration section: principles of internet-based treatment Arnon Rolnick
Chapter 2 Interview with Lewis Aron and Galit Atlas
Chapter 3 Empathy in Cyberspace: the genie is out of the bottle Lou Agosta
Chapter 4 Sensorimotor psychotherapy from a distance: engaging the body, creating presence, and building relationship in videoconferencing Pat Ogden and Bonnie Goldstein
Chapter 5 The clinic offers no advantage over the screen, for relationship is everything: video psychotherapy and its dynamic Gily Agar
Chapter 6 Cybersupervision in psychotherapy Michael Pennington, Rikki Patton and Heather Katafiasz
Chapter 7 Practical considerations for online individual therapy Haim Weinberg and Arnon Rolnick
Secion 2 Online couple and family therapy edited by Shoshana Hellman and Arnon Rolnick
Chapter 8 Introduction to the online couple and family therapy section Shoshana Hellman and Arnon Rolnick
Chapter 9 Interview with Julie and John Gottman
Chapter 10 Internet-delivered therapy in couple and family work Katherine M. Hertlein and Ryan M. Earl
Chapter 11 Digital dialectics: navigating technology’s paradoxes in online treatment Leora Trub and Danielle Magaldi
Chapter 12 Practical considerations for online couple and family therapy Arnon Rolnick and Shoshana Hellman
Section 3 Online group therapy edited by Haim Weinberg
Chapter 13 Introduction to the online group therapy section Haim Weinberg
Chapter 14 Interview with Molyn Leszcz
Chapter 15 Online group therapy: in search of a new theory? Haim Weinberg
Chapter 16 Transformations through the technological mirror Raúl Vaimberg and Lara Vaimberg
Chapter 17 Practical considerations for online group therapy Haim Weinberg
Section 4 Online organizational consultancy edited by Rakefet Keret-Karavani and Arnon Rolnick
Chapter 18 Introduction to the online organizational consultancy section Rakefet Keret-Karavani and Arnon Rolnick
Chapter 19 Interview with Ichak Kalderon Adizes
Chapter 20 All together, now: videoconferencing in organizational work Ivan Jensen and Donna Dennis
Chapter 21 A reflexive account: group consultation via video conference Nuala Dent
Chapter 22 Practical considerations for online organizational consultancy Rakefet Keret-Karavani and Arnon Rolnick
Epilogue Arnon Rolnick and Haim Weinberg
Book Review: Robert Whitaker and Lisa Cosgrove. (2015). Psychiatry Under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform. New York and the UK: Palgrave Macmillan. 241 pp. [$33.81 – less if digital]
This is an important book that deserves to be better know, since the consequences of the
self-dealing and conflicts of interest that it documents have not been reversed. This book points powerfully to a post-psychiatry future for individual psychiatric practitioners of integrity, navigating a way carefully between anti-psychiatry and a problematic institutional framework which has failed patients and most providers alike. The authors, Robert Whitaker and Lisa Cosgrove, spent a year at the Harvard Edmund J. Safra Center for Ethics. This work on the American Psychiatric Association (APA) is the result.
Though psychiatric “thought leaders,” principal investigators, researchers, and fellow travellers are now required to disclose the financial fees they receive from pharmaceutical corporations as the result of reforms, the consequences of several decades of self-dealing and conflicts of interests have been embedded in clinical practice guidelines (CPG). Fast forward the five years since this book was originally published and, not withstanding enhanced transparency, the band plays on.
As of this writing (Q1 2020), the APA is still going forward with significant momentum and merely modestly diminished revenues – and, therefore, merely modestly diminished economics of influence and conflicts of interest. The lack of action on the part of health care consumers, insurers, governmental regulators and legislators, indicates that Whitaker and Cosgrove are either being not believed or simply ignored.
My take on it? Whitaker and Cosgrove have a good chance of being prophets like Cassandra, the Trojan visionary and seer. Remember Cassandra was the seer whose curse was to always see and tell the truth but not be believed. Her partners threw a spear against the side of the Trojan Horse – a gift from the Greeks – and it rang hollow – thump – because the bad guys were hiding inside the hollow horse. Cassandra tried to warn her countrymen about Greeks bearing “gifts,” but Cassandra was not believed; and, in the story, a large snake ate her partners [I’m not making this up], so the trick of the Trojan Horse worked; the Greeks breached the impregnable walls of Troy; and Troy was burned to the ground.
I find it hard to accept that anyone who reads Whitaker and Cosgrove’s book would not be persuaded by the detailed marshaling of facts and figures. Therefore, the suspicion is that it is not being read. It is being overlooked. It is not too late to turn that situation around. Hence, this review.
If one were to summarize Whitaker and Cosgrove’s work in a single sentence, it would be: Whitaker and Cosgrove document institutional self-dealing in the form of conflicts of interest and the influence of big money from big pharma, which have decisively and irreversibly compromise the ability of the American Psychiatric Association (APA) to support and promote the health and well-being of patients. (Not to put to fine a point on it, the self-dealing and conflicts of interest are the definition of “corruption.”)
Whitaker and Cosgrove emphasize contextual and systematic explanations rather than bad actors, bad characters, or bad guys. As they say, it is not a matter of bad apples, but the barrel itself has gone bad.
I have searched to see if any of the targets of institutional corruption have tried to answer the charges, which, frankly, I found well-documented, compelling, a source of indignation, and, upon reflection, deeply distressing.
I found only one attempt to answer Whitaker and Cosgrove from D. J. Jaffe who claims the defects of the DSM-5 are widely known and discounted, the errors of the past have been (or are being) corrected, and Whitaker and Cosgrove are distorting and sensationalizing: “For example, the authors spend multiple pages examining the efficacy of a particular class of depression medicines, SSRIs, and find them wanting. But buried in the text is the line it “was only for severely depressed patients…that the SSRIs had provided a benefit.’” (For Jaffe’s review see: https://tinyurl.com/u7jvrmm.)
The quotation Whitaker and Cosgrove is accurate as far as it goes, but Jaffe is not accurate on the use of this data point. It is not ”buried”; but called out multiple times. Nor are the other defects and errors of the past been reversed, though they have been called out a number of times. The ineffectiveness of such denunciations and the anti-psychiatry movement leads Whitaker and Cosgrove to suspect that the problem is not one of a few (or even many) “bad apples.” The problem is an institutional one and must be addressed at that level.
Whitaker and Cosgrove’s point (contra Jaffe) is that the APA, Big Pharma, and selected researchers consulting to them have undertaken a largely successful marketing campaign: the science of medicine now knows the cause of depression (and other mental illnesses) and has a cure.
Most patients still comes in saying, “I feel depressed – I think I have a chemical imbalance – help me.” The doctor is, of course, helpful – with her or his prescription pad. Yet one theory after another has been exposed as “not proven” – the caricature of the Freudian unconscious, inflammatory cytokines, and the chemical imbalance theory.
The prescription for an antidepressant, mood stabilizer, antipsychotic, or anxiolytic, is going to work in far fewer instances – see below about major mental illness – than patients, front line MDs, and most residents in psychiatry have been led to believe. And this is 5 years after the publication. People are not reading this book, though, I submit, they may usefully do so.
The APA – and those who align with the educational (i.e., marketing) program – are not just “over sold.” They are engaging in ethically problematic practices. It is not just a bad apple, the barrel itself has a problem – the barrel itself is bad. After Whitaker and Cosgrove work, the debate is not about whether institutional corruption has occurred – the documentation is both boring and overwhelming – the debate is about what to do about it. No easy answers here.
When Whitaker and Cosgrove write about the “guild interests” of the American Psychiatric Association (APA), I was taken aback. Are the authors making matters sound like the Teamster’s back in the day when Jimmie Hoffa was running the organization? Hmmm. Whitaker and Cosgrove are surgically austere in their citing of facts and figures – which principal psychiatric investigators were also “thought leaders” working for Big Pharma.
Though Whitaker and Cosgrove are not explicit about this, an argument can be made that the APA gives the Teamsters a bad name. The latter has been required to “clean up its act,” thanks to criminal investigations by large governmental organizations. In contrast, most health care consumer remains relatively uninformed (excepts for this book (and a few others like it)) that the APA would expand diagnostic boundaries in a way that served commercial interests. This is called the APA’s “guild interest,” making money for psychiatrists independent of conflicts with the commitment unconditionally to promote patient health and well-being.
This is a particularly tangled issue in the case of psychiatry – as opposed to other medical specialties – in that psychiatry does not have biological markers such as blood tests (and so on) to identify the diseases and disorders it treats.
“In most other medical specialties, diagnoses are bounded by biological markers, and thus outcomes can be more easily quantified. Does a treatment reduce the size of a tumor? Lower blood pressure? Reduce cholesterol? Reduce or eliminate a virus? And so forth. However, in psychiatry, there are no biological markers that separate a patient with a “disease” from someone without, which renders psychiatry more vulnerable to bias, since it relies more heavily on subjective judgments for making diagnoses and assessing symptoms” (p. 139).
This leaves psychiatry vulnerable to commercial influences when making decisions about diagnoses, treatments, and professional relations (p. 115).
Yes, there is a molecular process hypothesized to exist for every disease entity, we just have no determinate, firm scientific idea what it is in the case of schizophrenia, depression, substance abuse, obsession, personality disorders, and so on. Yes, science is expanding our knowledge of brain processes, endocrinology, and biochemistry at an encouraging rate. But we know the cause of diabetes – lack of insulin. We know the cause of tuberculosis – the specific pathogen. Not so with mental illness, though a biological component looms large along with adverse childhood experiences, trauma, issues of poverty, social justice, domestic violence, access (or lack thereof) to education, jobs, housing, and recreation.
Science speculates and hypothesizes that depression (and so on) is determined in important ways by an imbalance of certain neurotransmitters such as serotonin, dopamine, and norepinephrine. Chemicals up, chemicals down – the influence on behavior, symptoms, and reports of human suffering are such that we are still trying to connect the dots. Human beings have different ways of expressing their suffering the symptoms of which have been collected in the Diagnostic and Statistically Manual, now in its 5th edition. That leaves a lot of wiggle room for human beings to be human beings and game the system.
The example I find most telling – and use with my third year medical students – is as follows: medical treatment can cure person if they have pneumonia and are unconscious in a coma; but that is not the case with substance abuse disorder. “Curing” substance abuse is a matter of body and mind. The patient must be conscious and participate like a commitment in the process. (For those who may have been living in a cave, substance abuse is now considered a disease, thus eliminating the stigma of a moral failing and opening the way to an unbiased, evidence-based approach to treatment.)
Another data point that was eye opening and needs to be better known:
“The NIMH [National Institute for Mental Health] also funded a trial that compared Zoloft to Zoloft plus exercise and to exercise alone, and at the end of ten months, 70 percent in the exercise-alone group were well, compared to fewer than 50 percent in either of the groups treated with Zoloft.19 At least in this study, Zoloft appeared to detract from the benefits of exercise” (p. 122).
Gone are the days when, if I feel the need to work out, I will lie down until it passes.
All of the psychiatrists that I know – and I know quite a few because of my empathy consulting – are dedicated, committed and hard working. No exceptions. The challenge arises when the marketing myth that mental illness is caused by a chemical imbalance gets embedded in the clinical practice guidelines (CPG).
Even though many psychiatrists are properly skeptical from an evidence-based perspective about the universality of this narrative, there are perceived medical risks in deviating from the CPG if treatment goes off the rails for unrelated reasons. It is truly a rock and a hard place scenario.
In addition, marginally informed prospective patients come in and say, “Hey, give me the medicine.” They have a sufficiently compelling narrative, sometimes gleaned from searching the diagnostic criteria on Google to validate the checklist. Rarely do they say, “I want to do the hard work it takes to change my life step-by-step, one conversation at a time, one bullet on my resume at a time, one relationship at a time.” It is deeply cynical and elitist but trending, “Show the people the light, and they will follow it anywhere!”
Here “the light” looks like: “It is just a chemical imbalance.” Millions of dollars, heck, maybe billions when the indirect expenses are included, were invested by the APA, Big Pharma, and their fellow travellers, to embed the idea: “It is just a chemical imbalance.”
One cannot just reduce ties with Big Pharma by rules about disclosing financial payments (which still occur) and expect the idea of mental illness as a chemical imbalance spontaneously to evaporate from the community at large where it is well-entrenched.
One needs a equally extensive educational program to challenge, root out, and transform the inaccuracies – but this time actual education, not marketing – to inform people of the complexity, nuances, and values involved. I see no such program in the offing, though it would be useful to require one perhaps as tobacco companies were required to advertise the consequence of smoking. The black box warning on Paxil (paroxetine) and selected other medications that it may induce suicidal ideation in children under 18 years of age is a start, but hardly a solution to the institutional issues documented here.
In section after section, I come away saying the medical literature, press releases, and marketing collateral are just flat out making stuff up. It is fake news before fake news was invented or at least became a top of mind consideration. It was marketing, not science. A sample is useful:
“[…][T]he FDA has assessed the merits of 31 studies for these four drugs [Celexa, Paxil, Prozac, and Zoloft], and even with the FDA’s charitable standards for determining that a study was ‘positive’ – it would often allow the company to sort through the data in a post-hoc analysis, to find a positive outcome – only 14 were positive. There were 14 others that were negative, and three more that were questionable. However, the published literature related to those 31 studies told of 19 positive outcomes and two negative ones” (p. 76)
“The medical literature simply didn’t reflect, in any meaningful way, what clinical trials had revealed about the efficacy of the four drugs, and this was just the tip of the iceberg. Ghostwritten papers from post-marketing studies also filled psychiatric journals, with these repots regularly telling of the drug’s efficacy, and this ghostwriting practice became so accepted that SmithKline Meacham, as it marketed Paxil, organized a campaign called “Case-Study Publications for Peer Review,” which it wittily dubbed CASPPER, mindful of television’s friendly ghost” (p. 76).
Once again, great marketing, but more than a tad short of scientific validity.
The authors go through a similar drill for other classes of medicines – attention deficit medicine, mood stabilizers, and antipsychotics. Though the details are different, the bottom line is similar.
The assessment of the authors? “Within the conceptual framework of institutional corruption, the pharmaceutical industry could be said to have ‘captured’ academic psychiatry and the APA as it tested and marketed the SSI antidepressants” (p. 77).
What was supposed to have been the Gold Standard in determining the efficacy of antidepressant medications produced disappointing results. But these sometimes negative results got embedded in complex statistical tables without explanations. A favorable spin was put on the outcomes using data mining and 20-20 hindsight.
Since this was a National Institute of Mental Health the STAR-D (Sequenced Treatment of Alternatives to Relieve Depression, psychologist Ed Pigott was able to file a “freedom of information” request to get the raw data. Some in the profession suggest this is widely known, but most consumers of psychiatric services do not know it, nor are they informed by their medical doctors (many of whom also do not know it). The results were different than those emphasized in the publications:
“[…] [I]f the protocol had been followed, 38 percent (1,192 out of 3,110) would habe been reported as remitted [free of symptoms] during this acute phase of the study (after all four rounds of treatment) [….] [A]nd if the readers got out their calculators they could discover that 568 of the 1,518 patients who entered the follow-up phase in remission had relapsed. This indicated that 950 patients – or 63 percent – had remained well” (p. 126)
Now we can debate how these data are sliced and diced, but nothing like a 6.3 % long term “cure” rate is EVERdiscussed with patients by providers contemplating SSRIs when quoting this study. That is not because providers are withholding data; it is because the providers do not know about it. It is buried.
John Rush, MD, psychiatrist at Texas Southwestern Medical Center in Dallas, reported his results: “Only 26 percent of the real-world patients responded to the antidepressant during the first year of treatment (meaning their symptoms decreased by at lest 50 percent on a rating scale), and only half of that group had a “sustained response.” Even more dispiriting, only 6 percent of the patients saw their depression fully remit and stay away during the year-long study. These ‘findings reveal remarkably low response and remission rates,’ Rush concluded” (p. 122).
Whitaker and Cosgrove make the case that the APA has been demonstrably unable to self-regulate – “police” itself – over the past three decades. The conclusion is that, therefore, others will have to provide the external regulation that has been missing internally.
The APA is not suddenly going to see the light and start urging its members to clear the schedule and engage in talk therapy with their light or moderately depressed patients instead of summarily reaching for the prescription pad as the default and acting in the face of evidence-based research, the opposite of which, however, has been built into “evidence-based” practices – this time in scare quotes – thanks to an intricate tangle of self-dealing and conflicts of interest spanning decades. It boggles my mind how this mess was created; and it is hard to see any way out, much less an easy one, which is precisely what the APA is counting on.
Thus, I believe that Whitaker and Cosgrove have “given up” on institutional psychiatry (the APA) and with cause:
“[…][T]he APA is already taking steps to ‘re-engage with pharma,’ and is doing so with little apparent appreciation that psychiatry was compromised in a significant way by its close ties to industry. Nor is there any evidence that the APA and academic psychiatry are aware that guild influence have proven to be so corrupting” (p. 199).
Here “guild influences” refer to commitment to expanding the population of diagnosable people – shyness is now “social anxiety,” boisterous kids being kids have “attention deficit,” normal sadness due to life setbacks is “major depression,” more forgetful senior citizens dealing with “mild” neurocognitive disorder, having a diagnosis for every medicine and a medicine for every diagnosis. These issues are supposedly well-know and are being addressed. I have not seen any evidence that is so. It is “baked into” the clinical practice guidelines to offer medications as first line treatments.
Since this is not a softball review, you see the issue. This stuff is dry as dirt and it takes significant effort to disentangle the details. Of course, Whitaker and Cosgrove do that, but it raises the bar on engaging the average health care consumer to expect her or him to follow the argument.
Whitaker’s earlier debunking was equally well documented in its time (see Mad in America), but criticized for being sensational. It was. But it was also accurate. I hasten to add that “sensational” is different than “sensationalism.” Here the conclusions are sensational, too, and they are well-argued, thoroughly documented, and, therefore, all the more dramatic for being understated.
Here the writing is toned-down and befits the neutral, mostly emotionless language of a scientific journal – or the Harvard Edmund J. Safra Center for Ethics. And so the authors get “dinked” with being “boring.” It is truly a case of “no good deed goes unpunished.”
No individual psychiatrist can fix this mess. Having psychiatrists transparently declaring their financial ties to funding organizations as the APA has agreed to do just does not fix the problem, though it does make clear the depth of the influences. Why not? People (and psychiatrists are people) have blind spots and conclude that most other people have a conflict of interest, but the money does not bias me (the psychiatrist in question). Cognitive dissonance causes the individual to make exceptions for themselves.
This is highly ironic because psychiatry was the discipline that promoted the notion in the 1950s through 1980s of the Freudian unconscious as a motivated blind spot. Indeed, even today, if a person takes an implicit bias test as required by many corporate diversity and inclusion programs, virtually everyone is found to have biases – biases against smokers, overweight people, bald people, old people, young people, poor people, rich people, political people, as well as more stereotypical racial and ethnic prejudices. Blind spots are pervasive among human beings as a species. Yet psychiatrists do not have blind spots when it comes to favoring funders who give them money? Hmmm.
Whitaker and Cosgrove conclude that individuals within organized psychiatry are in principle unaware that their behavior has been ethically compromised because such behaviors have become normative – required – within the institution.
Still, there is one instance in which disclosure does work: if it provides the individuals with incentive to free themselves from such ties because of the perceived devaluing cost to one’s societal and professional standing. Don’t hold your breath.
The postpsychiatry future moves beyond the psychiatry versus anti-psychiatry debate. The future belongs to postpsychiatry. Whitaker and Cosgrove conclude that a paradigm shift is required. Take seriously the bio-psycho-social model of the mind and body. Physicians have an important role to play, since biology is involved. We are neurons “all the way down.” However, the neurons then generate consciousness, language, and community.
It is also necessary to include in the team psychologists, social workers, philosophers of mind, and ethicists, that address the kind of life issues that drive people crazy. It is not a conclusion that a medical doctor would be in charge of such a team, outside the biological component of such a group. And that is the conclusion likely to raise hackles and not only at the APA. Ultimately the individual consumer of services is in charge of her- or his own life and well-being. The informed consumer of services – whether medical services, life transformational services, emotional guidance, and so on – needs to be in charge of the team. But in the meantime, as philosopher kings are still in short supply, any adult able to provide grown up supervision will do.
(c) Lou Agosta, PhD and the Chicago Empathy Project