François Ferrero: Inquiry of the Geneva 1980s’ Psychiatry Crisis
Barry Blackwell’s comments on Edward Shorter’s comments and François Ferrero’s reply to it
Attempts to treat the mind and the best way to do so (psychiatry) often evoke opposition (anti-psychiatry). Such debates date from the mid-17th century when Descartes’s launched an unprejudiced philosophical search for the truth concerning what influenced functions of the mind and distinguished between the senses (psychological). the environment (social) and processing by the brain itself (biological).
Now, as then, this topic can arouse not only scientific controversy but religious and political opposition as well. Inevitably the innovative and productive pioneer period in psychopharmacology (1949-1980) ushered in a worldwide spate of anti-psychiatry movements in the 1960’s and 1970’s. In my previous comment on the Geneva situation (Blackwell 2018) I attempted to create an international framework distinguishing events within psychiatry concerning the relative value of psychological social or biological paradigms contrasted with aspects of the biopsychosocial model competing with totalitarian regimes and ideologies (Fascist, Communist or Military).
I cited examples of such conflicts including Jean Delay in France (Blackwell 2013); Jose Delgado in America (Blackwell 2014b); Insulin coma (Sharma 2015); and also electroconvulsive Therapy (ECT) (Kellner 2011), both provoked anti-psychiatry sentiment world-wide. But I neglected to include less dramatic examples including Heinz Lehmann, (Blackwell 2015), Enoch Calloway (Blackwell 2014a) and Karl Rickels (Blackwell 2014c). Now we must add Geneva and, possibly in the future, South America. I thought initially that these comparisons might yield interesting data about what components influenced the virulence and duration of anti-psychiatric sentiment and the efficacy of opposition to it.
Perhaps the most clear cut and consistently favorable factors associated with brevity and mild disruption were a firm conviction in a biopsychosocial frame of reference and absence of political or ideologic influences. This applies to Rickels, Lehmann and Calloway, and was also a characteristic of virtually all the pioneers beginning with Joel Elkes (Blackwell 2015; Ayd and Blackwell 1970) and long before George Engel restated its virtues in 1977 (Engel 1977). Severe or prolonged disruptions were associated with political involvement or widespread public disapproval. Examples of the former were Jean Delay and Jose Delgado. Electroconvulsive therapy met the most persistent public disapproval while insulin coma therapy met with public and professional concerns reinforced by the discovery of chlorpromazine, leading to its demise.
These generalizations fall short in two instances: events in Geneva and the current situation in America. This is due to difficulty of separating clinical and scientific facts from socio-political features. The concerns raised by Ned Shorter are emblematic.. It is clear that in Geneva among psychiatrists political influence trumped any strong conviction in a biopsychosocial model based on scientific evidence. Political correctness and public sentiment dictated outpatient versus inpatient treatment (“sectorisation”) and avoidance of classical biological treatments including ECT. Ned considers this “a flagrant violation of the moral obligation to provide effective treatment.” Whether or not Ned is accurate in describing this as “The Swiss shooting themselves in the foot” is debatable. A Google search revealed a portmanteau derivation of these time-worn mottos: “Making a situation worse while not intending to do so” or “Cowardice in warfare to avoid fighting.” Perusing François Ferraro’s catalogue of clinical and political events, but without citing examples (to avoid rubbing salt in the wounds), I suspect they illustrate both meanings - averting the gaze and looking askance at scientific truth.
Like Geneva, the situation in America today is troubled and muddied. It is well described in the best-selling book Unhinged (Carlat 2010). Daniel Carlat, a psychiatrist in private practice, followed his father into the profession and trained at Harvard Medical School, then began as a resident at Massachusetts General Hospital in 1992. In just over two decades not only had psychoanalysis almost disappeared from training programs but so had any concerted effort to teach or inculcate psychological mindedness in patient management. Daniel was mainly trained to perform “med checks” and patients who needed therapy were referred elsewhere, mostly to mental health providers in other disciplines. The DSM system and its flaws became a tool to invent new disorders and further inflate prescribing.
This coincided with my own experience and the information in 10 books I reviewed by distinguished clinicians and investigative journalists painting a picture of the increasing medicalization of psychiatric practice in the first two decades of the 21st century (Blackwell 2017). The fallacy of post hoc, propter hoc reasoning during the pioneer epoch destroyed the myth that drug efficacy in given diagnostic categories was linked to specific biochemical pathways in the brain. Faced with this fact and the realization that drug development was mired in “me-too” products industry decided to divert resources from new drug development to sophisticated and seductive marketing, a strategy that yielded large increases in prescribing of psychotropic drugs, yielding enormous profits,
Faced with the same reality the NIMH closed the federally funded Early Clinical Drug Evaluation Units in the mid-1970s and switched their research priorities from drugs to genetics. A few years later1980 ushered in an eight-year period of Republican rule under President Reagan. Congress was mobbed by more than 600 drug industry lobbyists leading to legislation that mandated knowledge transfer from academic programs to industry co-incident with a weakened FDA.
Starved of government research support clinical psychopharmacologists and their parent academic programs were quickly co-opted into becoming acolytes of industry, bribed and corrupted from its lavish profits. Conflict of interest proliferated largely unchecked by failure of institutions and professional organizations to develop or implement policies and sanctions to constrain wayward overzealous members.
Added to these political and clinical changes has been a social climate of income disparity, greed and addiction to money. Large health care corporations, allegedly “not for profit,” and insurance company gate keepers focused on profit margins and bottom lines, discriminating against folks with mental illness, and were reluctant to approve psycho-social treatments they considered more expensive, rejecting “pre-existing conditions” that are ubiquitous due to the early onset of most severe and persistent mental illness in adolescence and early adult life.
Finally, the 21st century has seen medicine evolve from a profession committed to oaths that protect the patient’s economic well-being to a business like any other in a “buyer beware” economy with a delusion that the costs of health can be constrained by market competition when even the most devout believer is not eager to exchange earth for heaven. Big Pharma reckons people will pay almost any price, even bankruptcy, to delay death.
In my city (Milwaukee) there is a severe shortage of psychiatrists which leads to long waiting times, stretching to months. Citizens with Medicaid insurance and some with Medicare may find it impossible to find a psychiatrist willing to accept them.
It is sad to note how this combination of cultural, clinical, economic and political forces in the Zeitgeist can unravel the ties of philosophy, history and best practices that bind together integrative biopsychosocial care which people coping with mental illness need and deserve.
While not all segments of our specialty have been affected equally by this inhospitable environment, psychopharmacologists, the most likely to practice a biopsychosocial model of care, are a dying breed, close to extinction. The American College of Neuropsychopharmacology recently announced plans to change its name and by-laws to become the American College of Neuroscience and Psychiatry.
References:
Ayd F, Blackwell B. (editors) Discoveries in Biological Psychiatry. Philadelphia, Lippincott, 1970.
Blackwell B. A distinguished but controversial career. inhn.org.biographies. May 30, 2013.
Blackwell B. Enoch Calloway. Asylum a mid-century madhouse and lessons about mental illness today. inhn.org.biographies. April 10, 2014a.
Blackwell B. A serendipitous life. From German POW to American psychiatrist. inhn.org.biographies. May 29, 2014b.
Blackwell B. A biography of Jean Delay. inhn.org.biographies. February 27, 2014c.
Blackwell B. Joel Elkes. An integrative life. inhn.org.biographies. October 20, 2015.
Blackwell B. Corporate corruption in the psychopharmaceutical industry. inhn.org.controversies. March 16, 2017
Carlat DJ. Unhinged. New York, Toronto, Free Press, 2010.
Engel G. The need for a new medical model: a challenge for biomedicine. Science 1977; Apr 8;196(4286):129-36.
Kellner CH. Electroconvulsive Therapy: The Second Most Controversial Medical Procedure. Psychiatric Times 2011; 28(1).
Sharma S. Insulin coma treatment, facts and controversies. inhn.org.controversies. November 19, 2015.
July 11, 2019