What does psychiatry have in common with the US Congress? "Institutional corruption," concludes Psychiatry Under the Influence (Palgrave Macmillan, 2015), which investigates how drug company money and psychiatry's own guild interests have corrupted psychiatry during the past 35 years.
Coauthored by investigative reporter Robert Whitaker and psychologist Lisa Cosgrove, the foreword for Psychiatry Under the Influence is written by Harvard Law School professor Lawrence Lessig, who helped create Harvard's Edmond J. Safra Center for Ethics' lab on institutional corruption (where both Whitaker and Cosgrove served as fellows).
Whitaker and Cosgrove - as does Lessig - distinguish between "individual" versus "institutional" corruption, between a "bad apple" versus a "bad barrel." In individual corruption, a politician takes an illegal bribe. But in institutional corruption, nothing illegal may be occurring when, for example, politicians raise campaign money via special interest political action committees (PACS). And just as elected officials develop dependency on special interests and become beholden to these funders instead of the citizenry, Whitaker and Cosgrove conclude, the same thing has occurred in psychiatry, which has had its social mission subverted by drug companies as well as by the psychiatry guild's self-preservation and expansionism needs.
Both authors responded to questions that I had about their recently published book.
Bruce Levine: The corruption of psychiatry by pharmaceutical companies has been widely known since the 2008 Congressional investigation of psychiatry, reported by the mainstream media including The New York Times; and this corruption has been bemoaned by major figures in medicine such as Marcia Angell, former editor-in-chief of The New England Journal of Medicine. But what you are saying is that there is a second corrupting "economy of influence" that is not as well recognized by the public but which is even more problematic. Can you speak about that?
Robert Whitaker: There has indeed been much public attention on the corrupting influence of pharmaceutical money on American psychiatry. But the public's focus on pharmaceutical companies as the main problem distracts attention from the larger corrupting influence, and that is psychiatry's own guild interests.
In 1980, when the APA [American Psychiatric Association] published the third edition of its Diagnostic and Statistical Manual [DSM III], it adopted a "medical model" for diagnosing and treating mental disorders. The APA then launched a public relations effort to sell this new model to the public, which meant informing the public that psychiatric disorders are real "diseases" of the brain; that they are under-recognized and undertreated; and that psychiatric drugs are very effective - and disease-specific-treatments - for these disorders. The APA has relentlessly promoted that message to the public for 35 years.
This is a narrative that has served the psychiatry guild's interests well. Pharma money flowed to the APA and to academic psychiatrists and their medical schools; psychiatry's influence in society dramatically increased; and psychiatry was able to present itself, to the public and to itself, as a medical specialty that treated diseases of the brain. Money, power, a boost in psychiatry's public image - that is a powerful mix of rewards from a narrative.
The problem is that mainstream psychiatric research was not showing it to be true. Research failed to validate the disorders in psychiatry's DSM; the chemical imbalance hypothesis fell apart long ago; and clinical studies of the drugs, including studies funded by the NIMH [National Institute of Mental Health], have shown that their short-term efficacy is of a very modest sort and that they may do more harm than good over the long-term.
But the APA and academic psychiatry haven't told the public that story of science, and that is because it runs counter to their guild interests. And, of course, the public relies on the medical specialty - as opposed to pharmaceutical companies - to be a reliable provider of information, which is why this corruption due to guild interests is so problematic.
Lisa Cosgrove: I would add to what Bob said that there was a clear scientific impulse to the APA's creation of DSM III. As we wrote in our book, the APA set out to redo its diagnostic manual in order to address issues of reliability. Spitzer, the chair of the DSM III task force, did have the public's interest at heart. He wanted to have a more scientific, empirically based taxonomy.It also should be noted, as part of this discussion, that no medical specialty or professional organization is immune to guild interests.
Psychiatry Under the Influence attempts to understand psychiatry's denial and refusal to accept blame for its failures. So, for example, Ronald Pies, editor-in-chief of Psychiatric Times, refuses to blame psychiatry for the dissemination of the disproven chemical imbalance theory of mental illness (which fueled the dramatic rise of antidepressant use). Pies claims that the chemical imbalance theory "was always a kind of urban legend - never seriously propounded by well-informed psychiatrists," and he blames Americans' widespread belief in it on drug companies. You attribute much of psychiatry's denial and evasion of responsibility to "cognitive dissonance theory" - can you speak about this?
Robert Whitaker: Again, this is part of the "institutional corruption" lens we were using to study the institution of psychiatry and its behavior. The assumption is that individuals within the institution can't see that their behavior has been corrupted by "economies of influence." And so, when those outside the institution begin pointing out the corruption in it, those within it may construct a narrative that protects their self-image. In this case, psychiatrists need to protect their image as honest researchers and as physicians who put the interests of their patients first. Cognitive dissonance theory reveals that there are a myriad of ways that people protect themselves in this manner.
We can see that cognitive dissonance quite clearly in Ronald Pies' claim that the "chemical imbalance" theory was always a kind of urban legend. The fact that psychiatrists, for a long period of time, regularly told patients that the drugs fix chemical imbalances in the brain represented a fundamental betrayal of those patients. So once the chemical imbalance story fell apart publicly, what does Pies do? Does he admit, even in his own mind, that psychiatrists told this false story to patients for decades? No, he says well-informed psychiatrists never said it and places the blame on the pharmaceutical companies for telling that false story. Pies makes this argument even though it is easy to document that the leaders of the APA often told this chemical imbalance story to the public, and that, even today, many prominent psychiatrists serve on advisory boards of patient advocacy groups that continue to tell it to the public.
Lisa Cosgrove: One of my favorite quotes is by Carol Tavris: "Mistakes were made, but not by me." None of us are immune to cognitive dissonance. It is part of the human condition to have implicit biases and remain blissfully ignorant of them.
You talk about the "social injury" caused by psychiatry's institutional corruption, and I sense that you both are especially troubled by the injury incurred by young people, especially foster kids. Can you elaborate?
Robert Whitaker: This is one of the reasons that the institutional corruption framework can prove so useful. It requires an examination of the social injury resulting from the corruption, and when you do that in this case, you see how vast it is. We, as a society, have organized ourselves - both individually and as a society - around a false narrative of science. And what has been the resulting social injury? It has led to the pathologizing of millions of children, which is doing extraordinary harm; it has given us an impoverished philosophy of being, with its ever-narrowing boundaries of what is deemed normal; and it prevents us, as a society, from trying to create a more just society, since problems are located within the brain of the individual, rather than in poverty, poor schools and so forth. Society gets a free ride with this model.
The injury done to children in foster care illuminates, with great clarity, this larger societal injury. ... The children may be neglected, abused and so forth - they in essence drew a short straw in the lottery of life. But what do we do in the post DSM III era? We don't ask what happened to these children and try to create nurturing environments for them. Instead, we regularly diagnose them with a psychiatric disorder and medicate them. Of course the drugs - and this is particularly true of the antipsychotics - make it more difficult for the child to think and to experience emotion. And thus the social injury from this corruption: We as a society think we are providing medication to fix a disease the child has, while the child is now burdened with the stigma of a diagnosis and the burden of the medications.
Lisa Cosgrove: In order to fully address this social injury in marginalized populations, such as foster care children, we also need to understand that the way our health-care system is structured deincentivizes prescribing providers from taking a more contextual approach. If you talk to clinicians on the ground, that is what they want to do, but they are incentivized to prescribe.
You describe institutional corruption as a problem of "good people" doing "bad things" because of a corrupted environment. I personally know a young politician who genuinely sought to do public good but quickly grasped the reality that candidates with the most money win elections, and he was compelled to either focus on raising money or not run at all. Is psychiatry really in that same situation? Psychiatry is not facing a big-spending opponent, and it has had every opportunity as the "incumbent" to gain public confidence by simply being honest and effective. And individual psychiatrists can reject drug company incentives and still make a good living, at least compared to most Americans - and some dissident psychiatrists do reject those incentives. Are you being too easy on psychiatry?
Robert Whitaker: Perhaps, but that too is part of the of the institutional corruption framework: Any path to reform must start with a generosity of spirit, which avoids condemnation of individuals - regardless of whether some individuals within the institution deserve such condemnation - and instead focuses on how "economies of influence" have created an environment where "corrupt" behavior has become normalized and unrecognized. The point is that the framework seeks "understanding" rather than "condemnation," with the thought that such understanding will have two effects. First, in the absence of condemnation, leaders in the institution may be better able to see how the economies of influence have corrupted their behavior. Second, it will focus public attention on how to neutralize the economies of influence as a solution to the corruption, as opposed to stirring public anger toward individuals within the institution.
Lisa Cosgrove: I think this question points to a problem with the societal discussion we have been having. To me, this question of whether we were too easy on psychiatry is close to asking, are you "anti-psychiatry" or "pro-psychiatry?" And I think when we pose questions or answers as dichotomies, we undermine the potential for solutions. I am not anti-psychiatry; I am not pro-psychiatry. I hope that our book provides data that enables people to think critically about these issues. In my work as a researcher, I try to do empirical work that fosters such critical thinking, and helps people make more informed decisions about their mental health issues.
In your subsection on "Psychiatry's Self-Image," you had quotes from the 12 past American Psychiatric Association presidents who address psychiatry's low professional self-esteem, upset that psychiatrists are not seen as real doctors and suffer demeaning jokes in medical school - and exalting APA members to "change the way the world thinks of psychiatry and the way we think of ourselves as psychiatrists" (Jeffrey Lieberman, APA president through 2014). In addition to trying to pump up psychiatrists' self-esteem, a major role of the APA president is apparently to attack psychiatry's critics - as Lieberman recently called you, Bob, "a menace to society." Is there any hope of reforming American psychiatry?
Robert Whitaker: This is the bottom-line question, and unfortunately, when you apply this institutional framework to psychiatry, the answer becomes clear: American psychiatry, as an institution, is not going to reform itself. The guild influence is too strong; so too the cognitive dissonance. Lieberman is an example of this: He called me a "menace to society," but what had I done? I had written and spoken about research that reported better long-term outcomes for unmedicated psychiatric patients, compared to those taking medication. But Lieberman can't acknowledge that this could be the case, and so he needs to kill the messenger to protect his profession and to protect his own beliefs. That is precisely why psychiatry can't be expected to reform itself. The field, as a whole, is too invested in a narrative born of guild interests, and it has shown little sign of the introspection, as an institution, that could lead it to seriously reform its ways.
So what is a possible solution? It must come from an informed public that will see the need to strip psychiatry of its authority over this domain of our lives and instead demand that the authority be vested in a multidisciplinary group of professionals, philosophers and "users" of psychiatric care. Psychiatry could be a part of this multidisciplinary group, but not the ruler of it. But can this really happen? I am rather pessimistic, and yet, at the same time, the public is increasingly becoming aware that our society has organized itself around a false narrative and that this is doing great harm, and so perhaps this will lead to society putting its trust in a more diverse, multidisciplinary group. I hope so, because this is a case of institutional corruption that is doing great harm to our society.
Lisa Cosgrove: What we were trying to highlight in our book is the harm that can be done when norms and incentive structures develop that undermine reflexivity and critical thinking. Although it is easy to vilify a few people, to effect real change, members of that organization will need to be willing to address the ways in which their guild interests took precedence over their public health mission.
In addition, the framework of institutional corruptions gives us tools to identify solutions and to think big. If we want to effect change, we need to change our current health-care system. We have a society that thinks there is a pill for every ill and a system that incentivizes the prescribing of pills. So there needs to be a paradigm shift, as well as public policy initiatives, that will foster an appreciation of the socio-political grounding of emotional distress.