Comments and Controversies
Not ’antipsychiatry’; Defending Dr. Szasz; Perpetrators of abuse
Dr. Nasrallah misrepresents Drs. Jacques Lacan, Erich Fromm, Theodore Lidz, and others in his December 2011 editorial (“The antipsychiatry movement: Who and why,” From the Editor, Current Psychiatry, December 2011, p. 4-6, 53). They were not antipsychiatry, nor am I.
I am “anti” the sort of concrete biological reductionism espoused by Dr. Nasrallah. The psychiatrist nattily dressed in a white jacket and a neat suit and tie looks like a real doctor, but the so-called rigorous objective medical practice he does ignores a huge domain that psychiatry used to be concerned about. In effect, under the leadership of those such as Dr. Nasrallah, psychiatry has “lost its mind.” The disorders we treat are real disorders, but getting rid of the mental dimension and reducing all to “brain disorders” reduces our effectiveness in helping patients, is not humane, and flees from the truth. Psychiatry needs to re-find its mind.
Ronald Abramson, MD, DLFAPA
Associate Clinical Professor of Psychiatry
Tufts University School of Medicine
Defending Dr. Szasz
Dr. Nasrallah’s editorial (“The antipsychiatry movement: Who and why,” From the Editor, Current Psychiatry, December 2011, p. 4-6, 53) on the antipsychiatry movement was an excellent historical overview. It also was right on target in its conclusion, namely, that antipsychiatry can help keep psychiatry honest and rigorous.
However, the portrayal of Dr. Thomas Szasz as an antipsychiatrist is not wholly correct. For decades, Dr. Szasz has severely criticized both psychiatry and the antipsychiatry movement. Like antipsychiatrists, he is critical of psychiatry, but unlike antipsychiatrists, Dr. Szasz steadfastly has defended the right of consenting individuals to engage in treatment, as long as their participation is voluntary. It is this libertarian streak, the idea that people are free to choose any treatment arrangement they desire—including psychiatry—that distinguishes Dr. Szasz from antipsychiatrists such as Drs. Theodore Lidz, R.D. Laing, and others.
Thomas Rosko, MD
Los Angeles, CA
Perpetrators of abuse
Dr. Nasrallah appears to be deliberately avoiding some of the real abuses perpetrated by modern-day psychiatry (“The antipsychiatry movement: Who and why,” From the Editor, Current Psychiatry, December 2011, p. 4-6, 53), including deliberately misdiagnosing alcoholics and drug abusers as bipolar in order to give them mood stabilizers, often while they are actively abusing substances.
It seems unfathomable for a physician to document a history of depressive episodes, let alone manic episodes, in someone who has been either intoxicated or in early withdrawal constantly over the years, yet this is done routinely. The abuser is happy to play along, as long as the psychiatrist prescribes benzodiazepines along with valproic acid, lithium, or lamotrigine for the patient’s persistent panic attacks and chronic insomnia.
This psychiatric version of “when you have a hammer, everything is a nail” extends to the treatment of uncomplicated grief with antidepressants, additionally labeling oppositional defiant adolescents as bipolar to give them mood stabilizers, and, of course, treating large-portion junk food eaters for “bulimia,” placing them into eating disorder programs, and prescribing psychotropics.
Dr. Nasrallah’s examples of old abuses are a “straw man” argument and unfortunately divert attention from the legitimate concerns about “scientific” modern psychiatry.
Ronald Cann, MD
San Diego, CA
Dr. Nasrallah responds
I appreciate the letters from Drs. Abramson, Rosko, and Cann. I particularly liked their “healthy skepticism” about parts of my editorial about antipsychiatry.
My clinical training was heavily “mind-oriented” with intensive psychodynamic as well as behavioral psychotherapy (not cognitive-behavioral therapy), and my National Institute of Mental Health research training was heavily “brain oriented” with a neuroscience focus. I integrated both brain (hardware) and mind (software) in my work with each patient and it worked spectacularly well for both of us! George Engel, the father of the biopsychosocial model, was one of my residency supervisors at the University of Rochester, so I was “inoculated” by his mentorship against the hazards of biological reductionism, to which Dr. Abramson assumes I subscribe.
Dr. Thomas Szasz certainly was more of a libertarian than an antipsychiatrist and did a great injustice to patients with severe brain disorders, such as schizophrenia, by asserting that they are competent enough to choose or deny treatment, possibly because of the early state of neurobiology research 50 years ago when the neurotoxic effects of psychosis were still undiscovered. Unlike persons with healthy brains and prefrontal executive functions that enable sound decision-making, schizophrenia patients have anosognosia—the neurologic term for lack of insight and self-monitoring—severe cognitive deficits in processing information and decision-making, and reality distortion, and they lack the capacity to determine that they urgently need treatment. Witness the death of thousands of schizophrenia patients who were abruptly released from Italy’s asylums in the 1980s because they lacked the basic brain functions needed to survive. It was a tragic mistake to leave them to their own devices in the name of freedom, conceptualized by lay legislators who had no idea how impaired the brain is in many schizophrenia patients.
Finally, Dr. Szasz practiced long before research demonstrated that the longer psychosis went untreated, the worse the deterioration and functional outcome. Thus, his stance to let patients with psychosis refuse medications significantly harmed those patients, worsened their symptoms, and reduced their chance for remission.
Dr. Cann’s allegations of the “real abuses” of modern day psychiatry are to the best of my knowledge just that–allegations. I have never seen valid documentation of the large-scale abuses he cites, although an occasional deviation occurs in any profession. The practice guidelines for various psychiatric disorders never recommend what Dr. Cann claims is happening with diagnostic distortions and ulterior motives.
Psychiatry still is evolving as a medical discipline and there are comorbidities that confound the primary diagnosis—such as anxiety or heavy drinking in bipolar disorder—but research is actively seeking a biopsychosocial explanation. The Epidemiological Catchment Area study,1 published 20 years ago before any of the current medications were introduced, is upheld as the best estimate of the prevalence of psychiatric disorders in the United States—approximately 25% lifetime risk, which means approximately 75 million children, adolescents, and adults have a diagnosable psychiatric disorder. Some of them receive good evidence-based treatments and some do not, but many more never receive any treatment and suffer in quiet desperation.
Henry A. Nasrallah, MD