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Illness as Metaphor

Catching up on my reading while “sheltering at home” in Chicago, Susan Sontag’s (1933 – 2004) book length essay, “Illness as Metaphor” (1977) is especially timely in view of the psychological dynamics around the Covid-19 pandemic.

The message of “Illness as Metaphor” is that human beings make things mean things. The

The look: Mayor Lightfoot clears the beaches and parks in Chicago

The look: Mayor Lightfoot clears the beaches and parks in Chicago

talent for doing this is metaphor. This means that – this is that.. That is sometimes called “art,” but other times, less inspirationally, it is called “magical thinking.” (“Magical thinking” is when not bringing my umbrella casues it to rain and vice versa.)

For example: Cancer is a death sentence. Tuberculosis (TB) is a source of genius. AIDS (acquired immune deficiency syndrome) is punishment from God. People who get sick have made a mistake – done something wrong, broken a taboo, committed a transgression against morality or community or both. Seems like problem, yes?

Any disease that is not well understood shows up as “The Plague!” and marks the person who has it. It is a stigma – literally, a mark – on the victim. Thus, the tendency of human beings to take a bad situation – and make it worse.

If Sontag were alive today, she would no doubt have something to contribute to the conversation about Covid-19 as another example of illness as metaphor.

Citing examples from literature, Sontag’s commitment is to drain the meaning from illness as a metaphor so that the patient can get treatment entirely independently of magical thinking about “what did I do to deserve this?” Even the victim blames the victim: “What did I do wrong?” Nothing in particular – follow doctor’s orders – take the treatment (if there is any).

Sontag collects diverse and entertaining literary anecdotes about the meaning of illness for the people impacted by it prior to the antibiotics that cure TB or the admittedly rougher chemo- and immuno-interventions that [often] cure cancer – that is, send it into long-term remission.

For example, TB was regarded and written about as the creative artist’s disease, an enhancement of identity. The disease itself becomes the mark of a creative personality. The disease is the source of creative genius. The list is long but Schiller, Chopin, Keats, Shelley, and Kafka top the list of artists whose lives and productivity were shortened by TB. Unlike such disorders as manic-depression where the boundary between productive creativity and uncontrolled acting out can vary problematically (and some of those on the list may have had some of that too), TB is just bad news. But it is not treated that way.

The tubercular character is both passionate and repressed. Literature is filled with romantic characters whose suffering from TB enhances their beauty when they are women – see Mimi in La Bohéme – or their intellectual vitality when they are men – see Hans Castrop in Thomas Mann’s Magic Mountain.

In contrast, according to Sontag, cancer is the metaphor for what is most ferociously energetic (p. 68). The uncontrolled multiplication of cells run riot. There are fewer narrative engagements in literature – see Tolstoy’s The Death of Ivan Illych as a notable exception – but the stigmatization is no less metaphorical. In Mann’s late novel The Black Swan the aging heroine, engaged in a romantic relationship, initially mistakes bleeding as the return of her menses whereas it is a hemorrhage due to cancer.

The link between moral disease and the underlying character is supposedly illustrated by Freud, who communicated brilliantly but was brought low by cancer of the mouth, chomping on his ever-present cigar long before the carcinogens in tobacco were understood. Wittgenstein was a carefully closeted gay person (in the UK where homosexuality was illegal at the time) and died when his prostate cancer spread.

This leads to the discussion of plague literature beginning with the setting for Boccaccio’s Decameron in the pestilence struck Florence of 1348. Thomas Mann’s “The Death in Venice” (1912) has its aging, celebrity hero, Gustav von Aschenbach, metaphorically plagued by an infatuation with a pubertal boy, who looks like Donatello’s statue of David.

The love affair unfolds across ninety pages without the lovers so much as doing more than exchanging an occasional remote glance on the beach across a distance of ten meters, but the animal magnetism on the part of Aschenbach is palpable, the references to Dionysius and Nietzsche compelling, and the ending unpredictable. Aschenbach eats the strawberries, and catches a version of the cholera epidemic that kills him before he so much as feels the slightest need to go to the bathroom. Hmmm. Might not have been cholera. Old age? A broken heart? An unscheduled cerebral event due to a hypertensive crisis brought on by stress?

Fast forward some ten years, in real life, and Sontag is herself a cancer survivor. She was realistic, did not romanticize her illness, did not mistakenly believe that aromatherapy, talk therapy or yoga would cure her cancer. She engaged with the chemotherapy, and lived to fight another day.

In 1989 Sontag updates her work in a separate essay entitled “AIDS and Its Metaphors.” Ten years on (roughly 1987) the AIDS (acquired immune deficiency syndrome) epidemic is in getting going and would continue accelerating until 1995. Antiretroviral treatments would start emerging in 1996 that ultimately would substantially reduce AIDS-related mortality.

Here the stigma of being gay loomed large as the Reagan administration and Evangelical Christians led the way in blaming the victims. Drug addicts who used infected needles also formed a marginalized population that, according to the some versions of the Christian right, did not deserve treatment, never mind the sayings of Jesus of Nazareth about what one does to the least of the brethren one also does to Him.

Never was it truer that we are all related – and the least of the brethren eventually and unwittingly started infecting the heterosexual population. Indeed even the credible threat of such infection was game changing, along with the gay rights growing protests, political power, and the participation of fellow travellers of integrity of diverse persuasions.

What Sontag may not have appreciated as much as we do today (Q1 2020) is that it is a cognitive design defect of human thinking to take responsibility for things for which we have responsibility as well as no responsibility, because it is adaptive to do so from the point of view of survival in the face of the unknown. This “taking responsibility” is “making it mean that I did something = x to cause this.” In turn, this “x” is often “I did something wrong.” Not necessarily – unless you consider “being born” to have been a mistake.

When the solution [or cure] is known one has to shift the responsibility and just take the medicine or when there is no medicine just follow evidence-based doctor’s orders. Thus, Sontag’s self-described mission is to treat disease as disease – not as a curse, embarrassment, punishment, or stigma. “Without meaning.”

It is a design defect of human cognition that in the face of the unknown causes of TB, cancer, AIDS, Ebola, or Covid-19, people’s imaginations ran riot with meaning-making about the causes, expressive value, symbolic portend, possible treatments and cures, and outcome of illness.

The lesson? As Sontag surely appreciated, Psychology 101 teaches us that the most fearsome thing is – the unknown. The unknown is a source of meaning generation as one tries to comprehend it, structure it, control or at least manage it. But meaning making itself has its own risks and break downs.

As of this writing (Q1 2020) we do not know if or how readily the Covid-19 virus can be aerosolized – hang in the air and be contagious – twenty minutes (not so bad?) – twenty hours (no so good!). The rapid spread of the community contagion suggests the coronavirus is more contagious than was at first suspected. Bad news. Yet it is the unknown takes one’s power away and unworkably leaves one with the thought, “Maybe I should hold my breath.”

You know how in the vintage back 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 (CDC), frequently updated as we learn more and more about what to do or not do.

I hasten to add that “following doctor’s orders” does not mean abandoning critical thinking. It means following the light, but it does not mean following the light off a cliff. How to know the difference?

Medical “science” makes mistakes. George Washington got a fever, and bleeding him to reduce the imagined excess of blood contributed to his untimely death. In the 1960s, thalidomide was a horrific episode that lead to the strengthening of the Food and Drug Administration’s (FDA) requirements for validating the uses of medications. Yet in the face of political pressure to “do something” even the FDA bows to the bully pulpit to approve an unproven treatment against malaria for use against Covid-19. Well, at least it doesn’t cause birth defects – we think, we hope.

Sontag does not touch the fraught matter of psychiatric treatments, and some psychiatric treatments that have been applied in certain places and times are indistinguishable from human rights violations, especially seen with the benefit of 20-20 hindsight. For example, the prefrontal lobotomy destroys the personality, rending the acting-out patient compliant and docile – and sometimes incontinent. While some patients have benefited from electro shock therapy (ECT), its use remains controversial, and it has not always been used (as it should be) as a treatment of last resort. (For example, at a time when ECT was the first line treatment because it was arguably the only treatment, see Marsha Linehan’s memoir Building a Life Worth Living of the damage it did to her.)

Medical science makes mistakes. But medical science still makes fewer mistakes than do politicians appearing on TV and pretending to be doctors, touting unproven anecdotal remedies.  Alternative facts, half truths, and dangerous nonsense are readily projected onto the unknown.

Thus Albert Camus writes in his novel The Plague (translation by Stuart Gilbert 1947/1948): “The evil that is in the world always comes of ignorance, and good intentions may do as much harm as malevolence, if they lack understanding. On the whole, men are more good than bad; that, however, isn’t the real point. But they are more or less ignorant, and it is this that we call vice or virtue; the most incorrigible vice being that of an ignorance that fancies it knows everything”

The management and overcoming of epidemics is difficult under the best of circumstances. As well as deep medical and public health expertise, it requires leadership, communication, and political skills. Not for the faint of heart.

For example, Albert Camus’s The Plague provides the paradigm structure of an epidemic. The epidemic is a social drama is three acts. The first act contains hints that all is not right. Most of the tourists pack up and leave. No one dares say the word “cholera” or “plague.” The commercial class of businesses and shop-keepers are in denial out of a combination of economic interests and outright fear for their own health and well-being. Then a rising number of illnesses and deaths requires people to confront the fact.

The second act consists in the search for causes. When science does not have the answer (or as in medieval times science is not quite what we mean by “science”), people substitute value judgments for causal accounts. In medieval times, Jewish people and practices were blamed. In our own time with Covid-19, some are pointing a finger at Chinese people, projecting their fears. I hasten to add there are Covid-19 lessons to be learned in the breakdown of the early warning system for disease under diverse political and economic stressors not further analyzed here.

At this point in the drama, act three, the social and political strengths and weaknesses of the community are exposed. The poor suffer disproportionately whereas the rich leverage their access to resources to survive. The ultimate voter suppression opportunity? The ruling class uses the opportunity to thin the ranks of the opposition; though to be sure, the disease is a great equalizer, arbitrarily carrying away rich and poor, indiscriminately.

Other individuals and groups – first responders – step up and perform heroic acts of self-sacrifice for the good of the community. The latter also exposes the weaknesses of the response of the authorities as people are asked to “step up” without adequate personal protective equipment and systems.

Finally, the disease runs its course when it runs out victims susceptible to its action and intervention by the authorities – medical and social – succeeds in stemming its tide.

Sontag is clear. Disease is the result of pathogens such as bacteria, viruses or toxic chemicals such as tobacco and arsenic, so follow doctor’s orders, take the medicine (if available), in our own current predicament, maintain social (physical) distance, shelter in place, and live to fight another day.

By 1977 tuberculosis (TB) had long been curable. Innovative chemo- and immuno-therapies for cancer were supplementing radiation therapy. So cancer no longer equaled a death sentence. But the inertia of thinking, judging, moralizing, politicking is such that TB and cancer were rich sources of metaphor – commentary, comparison, and expressive discourse about relationships, community, and politics. In literature and historical narrative illness is not mere disease, it is metaphor. Illness gathers together, activates, and occasions meaning making about life, death, morality, merit, transgression, finitude, and mortality.

Sontag’s method is based on her breakthrough approach in “Against Interpretation” (1964), which is directed against the accumulations of meaning that stick to modern art. Her recommendation? Instead of trying to figure out what it means, let it be what it is.

This is the existentialist moment in Sontag. Disease is a reminder of human finitude – mortality. That is one of the few things that can be said to be the truth with a capital “T” – no one gets out of this thing – that is, life – alive. Everyone dies – but the manner of coming and going is highly diverse. We humans work mightily to negotiate and postpone the exit – that is called modern medicine. Go back to the top of this post and substitute “modern medicine” for “illness”; and, while that does not change the guidance, it puts in perspective just how much trouble we really are today.



David S. Jones, MD PhD History in Perspective – Lessons for Covid-19


March 12, 2020: March 12, 2020
DOI: 10.1056/NEJMp2004361

Megan Molteni, (3/4/2020), Everything you needed to know about a coronavirus vaccine:


Politico: Coronavirus Will Change the World Permanently. Here’s How (03/19/2020): https://www.politico.com/news/magazine/2020/03/19/coronavirus-effect-economy-life-society-analysis-covid-135579

Note this material is highly time sensitive. All the usual disclaimers apply.

© Lou Agosta, PhD and the Chicago Empathy Project


Alternative facts, dangerous half truths, and complete nonsense

Granted, medical science may sometimes mistakes. But medical science still makes many, many fewer mistakes than do politicians appearing on TV and pretending to be doctors, touting unproven anecdotal remedies.  Alternative facts, half truths, and dangerous nonsense are readily projected onto the unknown.

The management and overcoming of a pandemic is difficult under the best of circumstances. Along with deep medical and public health expertise, it requires leadership, communication, and political skills. Not for the faint of heart.

A single fact is worth a thousand opinions. Here is a fact from Emily Landon, MD, Executive Director Infection Prevention and Control, University of Chicago Medical Center (for the complete text see the URL at the end of this post):

“Two cities in America made different choices [in 1918] about how to proceed and when only a few patients were affected. St. Louis shut itself down and sheltered in place. But Philadelphia went ahead with a huge parade to celebrate those going off to war.

“A week later, Philadelphia hospitals were overrun. And thousands were dead, many more than in St. Louis. This is a cautionary tale for our time. Things are already tough in Illinois hospitals, including mine. There is no vaccine or readily available antiviral to help stem the tide.

“Our health care system doesn’t have any slack. There are no empty wards waiting for patients or nurses waiting in the wings. We barely even have enough masks for the nurses that we have. Looking back to the last time, we were–limited tools and having a dangerous infection spread quickly was the beginning of the 1918 pandemic.

“All we have to slow the spread is social distance. And if we let every single patient with this infection infect three more people and then each of them infect two or three more people, there won’t be a hospital bed when my mother can’t breathe very well or when yours is coughing too much.”

[March 20, 2020: https://www.uchicagomedicine.org/forefront/coronavirus-disease-covid-19/emily-landon-speaks-about-covid-19-at-illinois-governors-press-conference ]

The genie seems to be out of the bottle (in this case, not a friendly genie) and to get it back in we need to “shelter in place” and stay home except for necessary trips for groceries, medicine, elder care, nuclear plant maintenance, and a small set of related activities.

Psychologically the most anxiety and fear inspiring thing is the unknown – that one can be infected without realizing it, and, thus, spread the infection without realizing it.

The lesson? My behavior affects you and your behavior affects me. We are all related in community. That’s the empathic moment.

Relatedness creates responsibilities to conduct ourselves in such ways as not to harm others. A lot of innocent activities – going to a restaurant, the theatre, a sporting event, playing cards (?!) – that involve congregating in groups seem less innocent this week than they did last week.

Yet another anxiety-inspiring unknown is that we do not know when we will be engaging in these activities again, though we surely will be doing so. I feel like the little kid who fifteen minutes into a three-day road trip to Florida starts asking, “Are we there yet?” The matter is serious, but we also need to enjoy a lighter moment. Chill, dude!

I am going to keep it short today; and for the to-be-determined weeks ahead – follow Dr Landon’s guidance – follow doctor’s orders – stay home.

See the complete blog post of which this is an update: Empathy in the age of the coronavirus: https://wp.me/pXkOk-aq


I acknowledge the title of Jeffry Pfeffer and Robert Sutton’s excellent business book, not directly related to this post, which I own and enjoyed reading, Hard Facts, Dangerous Half Truths, and Total Nonsense: Profiting from Evidence-based Management (2006).

Also relevant is a first hand account of the symptoms (March 27, 2020) [once again, not for the faint of heart]:

(c) Lou Agosta, PhD, and the Chicago Empathy Project

Empathy in the age of the coronavirus

What does empathy in the age of coronavirus look like? Two words to get started: social distancing.

Social distancing makes sense and is necessary; but social distancing has a cost and an impact.

No hugs allowed. No shaking hands. Bumping elbows? Questionable. “Hug therapy”? There is such an innovation, as the right kind of hug seems to release endorphins – but it is on the ropes. Not good news, though perhaps only a temporary – months long? – setback.

Do not overlook the obvious good news. Some jobs can be performed remotely using

Follow medical doctor's orders - keep calm - and wash your hands!

Follow medical doctor’s orders – keep calm – and wash your hands!

online methods and Skype-like facilities such as Zoom or Signal. Many businesses already operate secure virtual  private networks. Many kinds of consulting, coaching, guidance, and talk therapy can occur via telecomm, and, though aspects of empathic relatedness may be lost or stretched thin, good enough results can be attained to make it worthwhile to try. Other situations are more problematic.

The social distancing recommendation is strained to the breaking point when it comes to first responders such as doctors and nurses (police, fire, ambulance drives, and others).

Yes, one can take a throat and nose swab without too much interaction, but it is not going to happen from six feet away. Moreover, one does not know what is the cause of the patient’s symptoms so further “laying on of hands” is often required. Thus, the risk. I acknowledge that it is deeply cynical, but I have to note: “Just because we have a germ phobia does not mean we cannot get sick.” We can – and do.

Here the empathy lesson is that empathy is a two way street and the first responders may require reasonable accommodation – and empathy from the community including the patients. So if the doctor shows up in a HAZMAT [hazardous materials] suit, it is not for lack of empathy, it is due to needing to screen dozens of people and stay healthy to screen even more. See above on the cost of social distancing.

What to do when there are no masks and gowns, or MDs and nurses are asked to wear yesterday’s contaminated stuff, are the tough questions. Some hospitals (and families), who have fabrication (including sewing) skills, are making their own. Others are calling the media and blowing the whistle on this appalling situation of first responders at unnecessary risk. All are madly rushing about trying to close the barn door now that the horses [of the apocalypse?!] have escaped. [Update: paragraph added: 03/21/2020.]

Once again, empathy is about community and responsibility. Here is the empathic moment according to celebrity MD, Sanjay Gupta:

“How I behave affects your health. How you behave affects my health,” Gupta said on the air with CNN. “Never, I think, have we been so dependent on each other, at least not in my lifetime, and we should rise to that occasion.” [Kate Shepard and Allison Chiu reporting The Morning Mix March 18, 2020: ‘I’ve never seen Dr. Sanjay Gupta like this’: Strollers, joggers in locked down San Francisco spark anger on CNN: https://www.washingtonpost.com/nation/2020/03/18/coronavirus-cnn-sanjay-gupta/ ]

UPDATE: March 22, 2020:

University of Chicago Medicine infectious diseases expert Dr. Emily Landon spoke during the Illinois governor’s COVID-19 press conference on March 20, 2020. Hear her explain why the statewide order to stay at home is crucial to protecting everyone.

“Our health care system doesn’t have any slack. There are no empty wards waiting for patients or nurses waiting in the wings. We barely even have enough masks for the nurses that we have. Looking back to the last time, we were– limited tools and having a dangerous infection spread quickly was the beginning of the 1918 pandemic.

“Two cities in America made different choices about how to proceed and when only a few patients were affected. St. Louis shut itself down and sheltered in place. But Philadelphia went ahead with a huge parade to celebrate those going off to war.

“A week later, Philadelphia hospitals were overrun. And thousands were dead, many more than in St. Louis. This is a cautionary tale for our time. Things are already tough in Illinois hospitals, including mine. There is no vaccine or readily available antiviral to help stem the tide.

“All we have to slow the spread is social distance. And if we let every single patient with this infection infect three more people and then each of them infect two or three more people, there won’t be a hospital bed when my mother can’t breathe very well or when yours is coughing too much.” Do your part – follow Dr Landon’s guidance. Meanwhile –

You have got to get the black humor here. The situation in Washington DC (and on CNN) is serious but not hopeless; the situation in Milan, Italy, is hopeless but not serious – people under lock down as the death toll rises are going out onto their balconies and singing.

The mother of an eight grader in New Rochelle, New York, who comes home with a fever, is leaving trays of food outside his bedroom door and everyone is eating off of paper plates. This is what empathy looks like in the age of the coronavirus.

This is not a Saturday Night Live (SNL) skit. Six guys in HAZMAT [hazardous materials] suits descend on the family in New Rochelle and make them sign an agreement to stay home for two weeks. They signed. It could be worse. This too shall pass, and presumably the kid (whose fever is going down) will have enhanced (if not unconditional) immunity and can himself serve as a first responder once he grows up.  [See Jason Riley’s Report from New York’s Containment Zone March 17, 2020: https://www.wsj.com/articles/report-from-new-yorks-containment-zone-11584485597?cx_testId=3&cx_testVariant=cx_2&cx_artPos=3#cxrecs_s.%5D

Well and good, except where’s the empathy?

Empathy is all about boundaries and crossing boundaries with understanding, receptivity, responsiveness, respect, dignity, courtesy, humor (when appropriate), affection, affinity, and, at the risk of circular reasoning, empathic relatedness.

So what are the proper boundaries in a coronavirus epidemic? Empathy lessons 101 teach us that the most fearsome thing is the unknown – the Hold that thought. The unknown is stressful. The unknown leaves one feeling isolated. The unknown inspires anxiety. The unknown creates an opening for alternative facts, half truths, and total nonsense.

As noted in this blog previously, you know how in the vintage black and white monster movies, once the audience actually sees the Swamp Thing, which is obviously a guy in a lizard suit, 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.

Doubtful this is the Zombie Apocalypse, but it puts me in mind of that U2 classic “Mysterious Ways”: “We’ll be living underground. Eating from a can. Runnin’ away from what you don’t understand. Love.” [Insert dramatic base line here.]

All right, so we are not yet ready for the Zombie Apocalypse, but some people are acting like it – like Zombies, that is. Especially unfortunate is that a few of them hold high public office or are media personalities. But we have got to work with what we’ve got for the time being. Other people are totally “business as usual.” Both extremes need to cut that out! Instead think! Think:  community and responsibility.

I am inspired in this thought – community and responsibility – by Jason Bridges. From a practical point of view, Jason Bridges, a professor of philosophy of mind and of Ludwig Wittgenstein (University of Chicago), writes eloquently in an unpublished but widely circulating email of community and responsibility in the time of coronavirus:

“Crises like this lay bare what is always anyway true: we are all members of community. To belong to a community is to be responsible for it” (Unpublished email 2020).

Though Bridges does not use the word “empathy,” this is the empathic moment. Those of us who are not at an especially high risk may usefully ask: “Is doing this responsible?” (“This” being many forms of in-person social contact we have taken for granted.)

The issue – and conflict – is that empathy is supposed to bring us closer –emotionally and spiritually. However, given the kind of physical embodied creatures that we humans are, emotional and spiritual closeness are often mediated by physical, bodily closeness (though crucially not always). (See above – back to “hug therapy.”)

We seem intrinsically to be a species that likes to congregate and get close to one another, at least on many occasions. Some cultures – Italian, Spanish, French, Southern (?) – seem to do this more so than others – Scandinavian, German, Northern (?). America, China, and Russia are vast and include some of each.

Thus, we return to the crucial issue of social distancing and its impact – and cost – with an illness spreading through community contagion.

By cancelling in person events at church, work, school, sports, theatre, and so on, in order to save lives, one is doing exactly the thing predicted to expand loneliness, isolation, detachment, and risking irrational behavior such as hording and opportunistic price increases. You solve one problem; create another. That’s another reason this is a crisis – the dominoes are still falling.

You see the dilemma? Going to church is not usually regarded as an intrinsically empathic activity, but lots of people do it because the experience of community addresses their need for empathy, to be acknowledged as a whole person, to feel included. Same idea with other community events.

Research shows that loneliness can be as bad for one’s health as smoking cigarettes or obesity (see John Cacioppo, (2008), Loneliness, Human Nature, and the Need for Social Connection, New York: W. W. Norton). Loneliness causes stress, reducing the immune system response, and triggering inflammation. Fear also causes such an immune response decline; and, heaven knows, the unknown – including aspects of the COVID-19 situation – is the most fearsome thing. So here is the rock and here is the hard place – what is one to do?

Just doing some brain storming here. The line at the polling station during the March 17, 2020 election had people waiting six feet apart. The frozen custard shop was reconfiguring its service line with markers on the ground at six-foot intervals. Given that the store is often jammed with children pushing forward, it is going to be interesting to see how that works.

Tips and techniques for maintaining and expanding social contact include: pick up the phone and talk to someone. Do not merely text, but have a conversation. Same idea using video conferencing such as Skype, Zoom, or Signal. Talk with one or two friends a day –once again, talk, not text. Do something for someone. It does not have to be volunteering to get the first coronavirus vaccination human trials, and dealing with the uncertainty whether it will cause your children to be born with tails. Do something small. Make a trip to the store for the senior couple next door. Help with chores, homework, or whatever you can contribute.

Although exercise and mindfulness do not usually require talking with others, they can be done in such a way that social distancing is maintained – for example, running outdoors or sitting indoors in a spacious room. These reduce loneliness and related stress.

I will not further comment on the detailed recommendation as numerous resources are available from WHO and the CDC (other relevant local authorities should be included here), frequently updated as we learn more and more about what to do or not to do. I accept the guidance and so should you, dear reader.

Now I agree events need to be cancelled due to the risk of community contagion. What I am asking is whether, for the time being, people can get their head around sitting two sneezes distance apart (in accordance with present CDC guidelines) and the pastor holds two services – one for seniors and one for those less at risk. More work? Yes, but perhaps doable just the same. (Okay, “two sneezes” means the six

Seems like the right idea to me for so many reason. Artistic activity boosts the immune system? Might be worth a try, though tragically the local Italian newspapers are crowded with obituaries. The hypothesis is that the warm, affectionate, cultural practices of getting in close for conversation and food and Catholic mass and so on, did not work well, rapidly spreading a highly contagious pathogen. No good deed goes unpunished!? Yet good deeds in abundance are many and even more are needed.

So, once again, what does empathy in the time of coronavirus look like?

As noted, it also looks like the Italian people, who are suffering severe fatalities in the pandemic, getting out on their balconies and singing – serenading the neighborhood.

It looks like maintaining a healthy routine of exercise, diet, communicating at arms lengths and with electronic media, keeping calming and carrying on – I mean – washing your hands.

It also looks like young healthy people making grocery shopping runs for senior citizens who are still healthy but reluctant to venture out. It looks like shoppers buying two cartons of eggs and two packages of toilet paper instead of two dozen.(What were these people thinking? Right, they were not thinking – that is the point – as Hannah Arendt noted long ago, not thinking can provide an opening for evil to get a foothold.)

It also looks like employers keeping staff on the payroll even though business is in a downturn.

It looks like insurers forgoing their monopoly rents and agreeing to reimburse first responders for their services in treating all potential patients without condition or qualification.

It also looks like government support for big pharma, which has a chance to shine [for a change!], in developing a vaccine (and anti-viral treatments) on a crash, moon-shot-style basis, which vaccine, in turn, has to be given-away to the planet.

Paraphrasing Jason Bridges, crises like this lay bear the weakness and strengths of the community. It puts me in mind of the kid’s game “The Cooties.” Some seven-year-old yells “You’ve got the cooties!” It is the game of tag. The kids all runs around like crazy playing tag – the opposite of social distancing, yet a transformation of it – because you cannot get close or you might be “tagged.” Fortunately, no one dies of the cooties, unlike COVID-19. Thus the breakdowns of empathy of the community are exposed – hoarding, stigmatizing, opportunistic behavior, boundary violations, beggar thy neighbor behavior.

Never was it truer that good fences (not walls!) make good neighbors; but there is a gate in the fence and over the gate is inscribed the word “Empathy.” Every breakdown, when handled with empathy, has the possibility of a breakthrough – a breakthrough in sustaining and crossing boundaries with expanded understanding, generosity, humor (as appropriate and inappropriate), responsiveness, receptivity, respect, random acts of kindness, dignity, and our shared humanity.

© Lou Agosta, PhD and the Chicago Empathy Project


Online therapy now. This is the time.

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

Cover art: Theory and Practice of Online Therapy, eds., Weinberg and Rolnick

Cover art: Theory and Practice of Online Therapy, eds., Weinberg and Rolnick

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!

Meanwhile –

Meanwhile –

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: Psychiatry Under the Influence by Whitaker and Cosgrove – Follow the Money

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

Psychicatry Under the Influence by Whitaker and Cosgrove (Cover Art)

Psychicatry Under the Influence by Whitaker and Cosgrove (Cover Art)

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