Strange bedfellows
Psychiatric reformers are not all on a continuum
Well, goodness. I was beginning to draft a post about the New York Times Magazine article by Daniel Bergner, “The Strange Alliance Trying to Remake American Psychiatry,” when I saw that Awais Aftab not only read my mind, but supercharged it with his more comprehensive take. I never cease to be impressed by Aftab.
Bergner reported that Robert F. Kennedy Jr. and MAHA are committed to “fundamental psychiatric reform,” which apparently means “confronting overprescribing.” The article recounts a brief history of 20th century psychiatric practice that reads like a condensed version of my video on the same topic, noting the shift from psychoanalysis in the early part of the century to medications ever since. He then cites several critics of this medication focus, from Thomas Szasz “at the far edge of the movement,” to critics such as Allen Frances who are “closer to the middle.”
Without characterizing where they fall on this alleged continuum, Bergner also cites Robert Whitaker and his “Mad in America” website, and the deprescribing activist Laura Delano. He then quotes Aftab, “hardly a radical critic of his field,” who has also critiqued our field’s official medication guidelines.
The title of Bergner’s article speaks of the “strange alliance” of these critics and Kennedy/MAHA. As someone who has spoken out for years about the risks of overprescribing, my immediate reaction was to disavow any such alliance with MAHA, and with Whitaker and Delano for that matter. “Mad in America” doesn’t simply “confront overprescribing.” It’s quite clearly anti-psychiatry: opposed to the field in general.
This led me to post a quick comment on the Times website:
Re RFK Jr: Even a stopped clock is right twice a day.
This is a well researched, accurate article. I’ve argued for a more skeptical approach to medication my whole practice and teaching career. But we’re also now seeing how an entrenched psychiatric orthodoxy invites overcompensation, throwing out the baby with the bath water.
Medications are crucial in many cases, and overused in many others. Instead of being “for” meds or “against” them, we should aim to be smarter about them.
Of course, it’s not a well researched, accurate article, as Aftab noted. After all, he too doesn’t want to be lumped together with Whitaker, Delano, Joanna Moncrieff, and other “baby with the bath water” critics.
I won’t summarize Aftab’s whole post; you should go read it. I’ll just say that if I believed psychiatry was fundamentally evil or misguided, I’d leave it in a heartbeat. Certainly there are many things in the field I disagree with—enough that, unlike most American psychiatrists, I’ve never joined the American Psychiatric Association (APA), here in San Francisco this week for its big annual conference.
There is no “far edge of the movement,” nor critics “closer to the middle.” There is no continuum. As Aftab cogently writes, there are those who caricature and demonize the medical model, misrepresent it really, and in so doing dismiss psychiatry as fundamentally misguided if not plainly evil. (In reality, the medical model is a nomothetic paradigm that is always leavened, both in general medicine and psychiatry, with idiographic modifications.) Aftab also lays waste to the false dichotomy of “reactions” versus “disorders.”
Far from this dismissal of psychiatry, and not in any way on a continuum with it, are those of us who know it’s complicated, and that living with uncertainty in a young field is the only way eventually to gain more certainty. We can defend our field while endorsing “existing ideals of good psychiatric practice. More awareness of medication risks. Less reflexive prescribing in primary care. Fewer antipsychotics off-label for non-psychotic indications in children. More non-pharmacologic options. More humility about long-term maintenance.”
I’m heartened that Aftab stakes out this ground, the ground that he and I, and Allen Frances for that matter, walk on. With his usual thoughtfulness, he rejects a monolithic anti-psychiatry (or its euphemistic sibling, “critical psychiatry”) that replaces ideals of good practice with Szaszian nihilism.
Nicely said. Also much appreciated the Aftab column.