Dangerous Debates

I like a good public debate, especially when it comes to mental health. I’ve been to a fair few, like the Maudsley Debate on CBT for psychosis, and even spoken at one myself, on the value of diagnosis in psychiatry.

Debates are often called for, much anticipated, and generally held up to be an uncontaminated source of truth and progress in heated times.

I wonder though, whether they’re the universal answer that they’re cracked up to be. I’d never argue against issues being discussed informally on smaller platforms like Twitter, but hosting an official and well publicised event on a grand stage seems to hold quite a propensity to make the issue at hand even less clear.

Firstly, the motion sometimes isn’t fair. I was rather piqued to read the introduction to a debate due to happen in November at the Royal Geographic Society, at which speakers will argue for and against the motion that ‘Psychiatrists and the Pharmaceutical Industry are to Blame for the Current ‘Epidemic’ of Mental Disorders’. It’s a straw man – the assumption has been made that there is an epidemic of psychiatric diagnosing (when in fact, mental health services are too busy to see even the sickest patients enough and are being cut further) and someone is to blame.

The rest of the blurb is obnoxiously biased too, for example ‘Drug pushers. We tend to associate them with the bleak underworld of criminality. But some would argue that there’s another class of drug pushers, just as unscrupulous, who work in the highly respectable fields of psychiatry and the pharmaceutical industry.’

Sir Simon Wessely, speaking against the motion, is one of the best public orators I’ve ever seen but he’s starting from a phenomenally biased position. Unless the motion and backdrop are fair and balanced, a debate can turn into a pointless inquisition and show trial serving only to reinforce the skewed presumptions of the people who set the motion.

Secondly, I just don’t think that some topics are suitable for public debate, either because of the nature of the question or the state of the current answer to that question.

Public debates are not objective. They are rhetorical sniping contests won not by people with the best and most useful answers but by the people who convince the audience, who are themselves hugely biased already, using charisma, ethos, selective information and verbal trickery. The recent demand in a broadsheet newspaper by the so-called ‘Council for Evidence Based Psychiatry’ for a public debate on the harms of psychiatric medication was in my view completely ridiculous – there is no way a complex, lengthy and highly statistical issue like that should be thrown to a few angry academics in front of microphones.

In some cases too, simply having the debate lends credence to one side of the argument that it doesn’t deserve. We wouldn’t have a public debate on vaccination and autism, because we know well enough already what the answer is and we don’t want to give the other side more credit than it deserves. I suppose you could call it meta-debate. Far be it from me to ascribe that to any topic in mental health, but Nick Clegg didn’t seem to fair too well against Nigel Farage. It was over before it even started – Farage had proven that his views were apparently worthy of airtime. The fact he outdid Clegg with panache too was an added bonus for him. The sensible, grown up politicians steered clear of the no-win situation.

To finish, we shouldn’t mistake the result of a debate for closure on an issue either, which seems to be a nagging recent trend. If we can’t make our minds up about an issue after decades of research then there’s no way we’ll get there in one evening.

At the end of the day we just need to remember what a public debate is – a few highly biased people talking in a highly biased way to a highly biased audience about an often highly biased motion. They can be fun, exciting and stimulating, but they run the risk of distorting an argument even further and they certainly aren’t an absolute truth.

About Alex Langford
I am a psychiatrist (now an SpR) based in Oxford after 3 years working in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology. I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights. Don't mention cricket unless you've got the next fortnight free to discuss it.

34 Responses to Dangerous Debates

  1. pm says:

    When Psychiatrists routinely prescribe dangerous medications for chemical deficiencies that they NEVER test for, how is that not a grounds for legitimate fact based criticism ? They have NEVER cured anyone with this protocol and they don’t see the need for change. There is nothing to debate regarding this point. Psychiatry is merely a money making fraud.

  2. elvis jones says:

    I don’t think you can take Lucy Johnstone, clinical psychologist, twitter and others with similar views literally, but only as a kind of opposition to the dominance of evidence based medicine. Some of the claims they make are hilarious and I really enjoyed wathching the spat with keith laws on twitter. The points Johnstone and co make are small but significant.
    However, there is a risk that some people might take their comments at face value (anti-drugs, diagnosis and ECT) rather than as a type of game. Power should always be questioned and perhaps disrupted, but clients/patients/service users might get caught up in the tactical crossfire.
    I mean I don’t think it likely that there is a conspiracy among psychiatrists to harm patients using drugs and ECT.
    Patients rarely are capable of informed consent for any medical proceedure. What are you going to do, study medicine for six years?

    • >.Patients rarely are capable of informed consent for any medical proceedure.>> Really? Glad my medical team think otherwise and that you are not involved in my treatment. How obnoxious. I have complex medical difficulties and am fully involved in discussions abut treatment with all my consultants many are high level Professors. Unbelievable. BTW Procedure has one e.

      • elvis jones says:

        If patients knew as much as doctors then we wouldn’t need them. I could treat myself or someone else. How many patients know how to conduct clinical trials, work out complex statistics, analyze evidence, read complex scientific evidence, understand physical science. A small minority do. I don’t. Most don’t. You might, but then you might be a doctor. When I sign a consent form I do so in good faith, but not as a specialist. Most do. I don’t think i’m being obnoxious somehow, just using common sense. You however, are emoting. Quite frankly I don’t give damn about your medical problems; the world doesn’t revolve around you. Try basing your opinions on common sense.

      • I’m making a point that lay people can have
        Informed consent. True most don’t have in depth
        Knowledge but some do and that is helpful.
        I am not a doctor but a researcher and
        A lot was self taught although a basic Uni grounding
        Helpful and many other non
        Scientists have in depth self taught
        Knowledge. I do work with clients who
        Struggle at times to trust psychiatrists re
        Medication issues more than other medics and
        This has been a major global problem
        With psych patients for years. Despite advances
        The scepticism grows and all debate is healthy
        But sadly will not restore the trust in
        Psychiatrists by the anti med SU movement

      • pm says:

        What do Psychiatrists know? Do they know that their patient has a Chemical imbalance in their brain by means of a test of their brain chemistry before making such a diagnosis? No, they don’t do any tests beyond cracking open theirDSM5. They merely prescribe one or more SSRI drugs recommended by their pharmaceutical rep. based upon research conducted by pharma corps. If their patients get sicker, as they are guaranteed to do (look at research of side effects), they just prescribe more (and more) SSRI drugs. Patients never get cured and must take these meds forever just to prevent severe withdrawal reactions & events. You don’t need to go to medical school to be an unscrupulous drug pusher, but it sure gives you card blanche cover, impunity and respectability.

      • elvis jones says:

        I think informed consent is a legal term rather than being knowledgeable about medicine. Informed in the sense of risks, but not knowledgeable about the procedure per se. It’s a bit confusing because by suggesting the procedure they -the doctors-have kind of hinted what would be best, and then they are asking for consent from the (generally) non-expert patient. A bit of a double-bind. Hence the logic behind my statement ‘patients are rarely capable of giving informed consent.’ It is even more difficult to establish informed consent if the patient has a severe mental disorder: precisely the situation in which ECT might be suggested. In reality, then, can the patient ever give informed consent to ECT and what does it actually mean to do so?
        So does this mean I am obnoxious for pointing this paradox out? No, I don’t think so. This is the problem with mental health generally that people are in such a rush that they never bother to read things carefully, resulting in carnage later. If you are writing about informed consent on a mental health blog, there is only so many things it could be about, and it is probable either you or someone you know is suffering from a mental health problem. So it is concerning, to say the least, that someone would call you obnoxious and pick up on their (presumed) lack of education, promote and give advice by virtue of the hyperlink on their name, and not countenance the possibility inherent in the initial comment that that person themselves may have faced that precise dilemma by extention of their having severe depression.
        It is disturbing that someone seeking to garner clients for psychotherapy would not see the context of the comment. Does that reflect on the quality of the psychotherapy itself? Is it just a spelling lesson with a bit of death?

  3. elvis jones says:

    I think antidepressants are extremely useful, Ive taken them myself for years, and don’t have any issues with medication WHATSOEVER.
    I don’t give advice either. I AM NOT PART OF ANY ANTI MED SERVICE USER MOVEMENT!!!!!!
    I would much rather take treatment advice from keith laws than lucy johnstone!!!!!!!!! This is based as much on intuition as anything!!!! Johnstone vs. Laws is an academic spat.
    I just see Johnstone as a safety mechanism, like in the houses of parlaiment, where you need some opposition. But take her lot as a government? Dont be RIDICULOUS!!!

    • pm says:

      I’m not against pharmaceutical drugs per se. What i am against is the prescription of these drugs without any diagnostic proof that they are needed. Psychiatrists do no medical testing to determine this or whether you have some physical illness which might be relevant to your psychological issue.

      By contrast Naturopathic physicians do a variety of tests to determine nutritional deficiencies and pathological states in the body; and based upon this they prescribe natural remedies that do no harm.

  4. elvis jones says:

    If there is a organised criminal conspiracy involving pharmaceutical companies and psychiatrists you need: a) motive, b) opportunity and c) proof.

    Just because pharmaceutical companies make large profits and try to influence doctors is not PROOF that doctors are prescribing harmful drugs unnecessarily.

    Secondly, why become a psychiatrist if you are primarily interested in money? There must be easier, less stressful ways.

    Thirdly, psychiatrists work with other doctors. If there was a conspiracy, I think other doctors would spot it.

    • pm says:

      The following article by Dr. David Healy explains perfectly the problem that exists in psychiatry today: Sense about Science: Follow the Patient http://davidhealy.org/sense-about-science-follow-the-patient/

      • elvis jones says:

        Not being medically or legally trained, I can’t review this evidence, sorry.

        You could, in theory, apply the same arguments to the anti-psychiatrists.
        A). Motive…feeling aggreived by life circumstances. Wanting to hit out against authority figures. Wanting justice for abuse some times. Wanting to make a living by selling books or giving talks.

        B) Opportunity…using theorists like Michel Foucault, Derrida, Heidegger, R D Laing all of whom can be very confusing kicking up doubts and a ‘fog’ and casting insinuations. Sometimes making nuanced, valuable contributions.

        C). Proof. Why have the anti psychiatrists not been able to bring a legal case against the NHS? (Apologies if they have.)

  5. Claire says:

    Pharmaceutical Industry are to Blame for the Current ‘Epidemic’ of Mental Disorders’ – I think the answer to this is “Yes.” There have been many, many cases in the U.S. where the pharma companies have been faced criminal charges do to illegal promotion of antipsychotics and other psychiatric meds for off label use. This move was quite lucrative for the drug companies as the proceeds from their illegal activities was greater than the fines imposed. While I think the vast majority of psychiatrists are ethical people, if they are basing their treatment decisions on corrupt drug studies I wonder about the impact of this on patients. We have had an explosion of bipolar diagnoses in children in the U.S. Either there is something in the water here, or people are vastly over diagnosing this illness. I don’t know how this compares to what is occurring in other countries but it is a huge problem here. There is a lot of clean up that needs to occur with psychiatric research.

  6. Claire says:

    I meant, “due” to illegal promotion…

  7. Claire says:

    I think another part of the problem with the epidemic of mental illness in the U.S. is due to pharma’s direct marketing to patients. We cannot turn on the television or open a magazine without being shown a woman looking a little sad and being told the answer is Abilify. People actually come in asking their doctor for Abilify not even realizing they are asking for an antipsychotic. The U.S. needs to outlaw the direct marketing of drugs to patients.

  8. elvis jones says:

    When people want to obliterate their critics I want no part in that. Fenella lemonsky is right also of course. ‘One often disagrees because someone’s tone is unsympathetic’.(nietzsche ish). Then truth suffers. Who to choose to believe? Beneath the struggles for Absolute Truth between profs clients will rebuild their own lives amongst the ruins. “Truth” liberates and enslaves: a paradox fitting for this debate.

  9. elvis jones says:

    1).A question pertaining to antidepressants: Expecting science to be impartial in a slave wage economy on the question whether workers wages should be increased by decreasing profit is as fooloishly niave as asking whether capitalists profit should be decreased to provide this. (After lenin.) Does the biomedical perspective collude with capitalists, when depression is known to be caused by stress resultant from low income?

    2). An attack on one psychiatrist is an attack on the profession. How many service users are able to mobilize a small army? Why does the president of the Royal College of Psychiatrists misrepresent the profession as underdogs in the debate?

  10. Elvis please can I apologise for using that
    Obnoxious word. I think I had in mind that you
    We’re saying that patients can’t be capable of
    iC. Rather than not generally! I agree oh and
    I am not a qualified therapist. Interesting
    Points you make. Thanks.

  11. elvis jones says:

    Dangerous debates:
    How should society be best organised? Marxist – leninist ideological domination perhaps produced Thomas Szaz, who wanted to prevent communism gaining a back door foothold in America via a human science (which marxism claimed to be) like psychiatry, hence his violence towards it.
    Genetic basis to disease, because of the eugenics programmes and T4 killing programme; because the genetic search for schizophrenia may be an example of ‘promisary science’, that is science making a claim that it will know something in the future that it does not know now. Science can only falsify, not prove theory correct.

    Imagine how useful it would have been for communists, nazi’s and other enemies of open society to prevent debate. But are peoples aversions more like anaphylactic shock? Inappropriately triggered?

  12. elvis jones says:

    If history had taken a different course then there would be no need for drugs or interventions. This seems to be the position taken by phil hickey. (Behaviourism and mental health.) Is this position testable? No. Is it protean? Yes. Is it like building a haystack and saying theres a needle in it somewhere? Yes.
    People need practical support. His position is not provocative but something else beginning with p: pointless.

    No one can say I didn’t make a serious effort to understand, was reasonable and judicious but when you hear people say no one should ever take antidepressants you wonder if they are not really mad and dangerous. Sick revenge politics.

  13. thealienist says:

    I’ve had the argument with commenters on my blog. It seems that most of the argument is based on equivocation. They say that psychiatrists have never “cured” anyone. They base this on their particular definition of “cure.” Using their definition, no one has ever been cured of diabetes either, though they don’t complain about diabetes care. They also complain that psychiatrists do not have laboratory tests to confirm their diagnoses. I’ll admit that this is a frustration — it would be seriously cool to be able to measure mania titres — but this overlooks the fact that many of the illness treated by a variety of kinds of medical doctors are diagnosed and treated based on characteristic symptom patterns, not laboratory tests.

    The fact is that psychiatrists do alleviate suffering in many, but not all, patients. We can argue about what we do that works and how it works. We can (and do) argue about how best to understand the conditions we treat. It seems presumptuous to me, however, for anyone to argue that all psychiatrists are drug pushers, that no one is helped by medications, and that the absence of laboratory tests renders mental illness diagnosis untrue.

    • pm says:

      If you are looking for a cure in the allopathic establishment medicine, then you will not find any for diabetes — or any degenerative disease for the a matter. Their medical paradigm calls for only treating symptoms with toxic synthetic drugs, which cause side effects for which more toxic drugs are prescribed. They are told by pharma corp research that cures are impossible and only option is palliative drug therapy. http://www.youtube.com/watch?v=UIm8fHxqUAM

      Naturopathic/holistic physicians cure diabetes quite regularly because they address the causes of the disease and prescribe remedies in diet and vitamin/mineral supplementation that cause no harm and are very inexpensive.

      Psychiatrists operate on the exact same “business” model of the allopathic MDs. They treat symptoms with toxic drugs that suppress the illness by reducing mental function. For side effects or worsening of a problem, more SSRIs are prescribed. This protocol guarentees profits for the doctor and pharma corps. It also guarentees patient a lifetime of misery.

      • thealienist says:

        Funny. Your description of what a psychiatrist does doesn’t sound at all like what I do, nor does it reflect my motives and the motives of many of my colleagues. It also doesn’t sound at all like what my patients experience in the course of their treatment. Perhaps you have a convenient straw man to argue against.

      • pm says:

        So what is it that you do? Any testing or do you just look through your DSM5 and prescribe some SSRI drugs?

      • thealienist says:

        Just like other physicians, I look for patterns of symptoms that indicate recognized syndromes. Most are described in DSM-V, but others are best described in terms of medical illnesses. I order tests when tests are likely to to be helpful in differentiating between competing diagnoses or choosing between different treatments.

        Many of my patients take SSRI’s for mood and anxiety problems. Most of them tolerate the medications very well and choose to stay on them to prevent relapse. Some have side effects that lead to changes in medications or changes to primarily psychotherapy. Other patients may be treated with psychotherapy alone or with appropriate medications from other classes.

        The vast majority of my patients are treated with at least psychodynamic-based supportive psychotherapy. If needed, behavioral and cognitive-behavioral therapy is added to whatever other treatment they are receiving. Most of the BT or CBT is done by psychologists sharing responsibility for the treatment, but I do some.

        It’s a pretty rewarding practice, and my patients seem satisfied with the service they receive. I let them know at the beginning of treatment that if they find a provider that they would prefer to see or a treatment that they would prefer to try, that they are free to pursue it without any resistance from me. I have not yet noticed that I am losing many patients to naturopaths.

      • pm says:

        So the DSM5 is your primary guide in diagnosing mental illness and you do no testing of brain chemistry to determine composition or deficiency before prescribing SSRIs?

        Do you fully inform you patients of all the documented risks and outcomes of SSRI drugs? Most do not and also do not permit refusal of treatment — and not just in cases of involuntary commitment.

      • pm says:

        Allopathic Gastroenterologists operate the same way as psychiatrists. If you go to them for GERD or Acid reflux they will assume that your stomach is producing too much acid and prescribe a proton pump inhibitor. How do they know that this is true? They solely take account of your symptoms which the pharma corp research say indicates too little stomach acid. No actual test of your stomach acids or digestive enzymes is done.

        Naturopaths actually test for the PH of your stomach with the Heldelberg Test and accordingly have learned that in 99% of cases involving GERD and acid reflux , too little stomach acid is the cause. I know because I take HCL supplement with meals now and am cured. Proton pump inhibitors quell symptoms, which is why they are popular, but make the digestion of food properly impossible. Overtime this leads to other degenerative diseases, most notably osteoporosis. Pharma corps know this and profit from sales of more drugs to treat symptoms of bone fragility.

      • thealienist says:

        PM, I’m not very sure that you know as much as you think you do about psychiatry. Somehow you claim to know what proportion of psychiatrists inform their patients about side effects of medication and that they do not allow refusal of treatment. Remarkable.

        I’m sure that I don’t inform people as well as you would like. I inform them up to a “reasonable person” standard. In addition, there is no way I could force my outpatients to take a medication if they did not want to. The vast majority take the medications voluntarily or they don’t take it at all.

        As far as testing brain chemistry, no I don’t. There is no evidence yet that testing brain chemistry is predictive of treatment outcome. I use pharmacotherapy empirically. The medications have been tested in double-blind, placebo-controlled experiments and found to be effective. I do not tell my patients that their illness is due to any chemical imbalance in their brain nor that any improvement in their condition is due to a correction of an imbalance.

      • pm says:

        I know I wasn’t given information about the SSRI I was given and I know for certain that 100% of those in the military aren’t given any information. 8,000 soldiers a year commit suicide because these drugs. http://www.cchr.org/documentaries/the-hidden-enemy.html I also know its not standard practice for psychiatrists to fully inform their patients because there are so many testimonials of lives ruined. Coercion and deceit are not uncommon tactics. http://beyondmeds.com/2013/02/02/coercion-rule-in-psychiatry/

        You need to have your head examined to see a psychiatrist. seriously. They do no testing of your brain chemistry because then they would be forced to realize what honest physicians, researchers and patients already know: that SSRI drugs deleteriously affect your brain chemistry. http://www.drugawareness.org/ssri-facts/ssri-meds/ http://www.cchrint.org/psychiatric-drugs/antipsychoticsideeffects/ http://www.cchrint.org/psychiatric-drugs/antidepressantsideeffects/ http://www.cchrint.org/psychiatric-drugs/antianxietysideeffects/ http://www.cchrint.org/psychiatric-drugs/stimulantsideeffects/
        And to make things worse, their entire medical justification of why and how these drugs are prescribed rests on research conducted by the Pharmaceutical corps that sell them. You blithely admit this yourself. http://www.cchrint.org/2013/04/08/be-skeptical-of-pharmaceutical-company-claims/ Anyone with a pulse and no scruples can be a psychiatrist given this modality of treatment.

      • thealienist says:

        Well, pm, I guess we have reached the end of our conversation. I have tried to engage you in informative conversation, but you want to paint the entire psychiatric profession with your assumptions and stories about bad practice. I don’t deny that all professions have members who do not live up to the standard they should, but I do deny that the statements you make apply to all (or even most) psychiatrists. I also deny that most people who seek care from psychiatrists are adversely affected by the medications prescribed.

        I also deny that the people who agree with you are all “honest physicians, researchers and patients” and that psychiatrists are “anyone with a pulse and no scruples.” Your resort to ad hominem attacks shows that your arguments are more fueled by emotion than information (I don’t count anything by the Citizens Commission on Human Rights as reliable information).

        I had hoped that this conversation would be done with mutual respect, but it seems that your antipsychiatry stance is simply too strong to set aside.

      • pm says:

        You haven’t responded to any of the documented information I’ve given links to with anything but vacuous flippant dismissal. Typical of psychiatrists is the arrogance to assume that their credentialed fiat is good enough. Well it isn’t, not when people are suffering and dying. That you don’t like CCHR makes perfect sense since they provide factual documented proof that your profession is harming and killing people with their pharmaceutical drug protocol.

        I will end my part in this discussion with one last reason not to take SSRI drugs: if taken long enough they cause dementia and alzheimer’s http://beyondmeds.com/2014/09/10/drug-induced-dementia-2/ Now that’s certainly something to look forward to during your drug induced impairment.

  14. Thank you thealienist. Those like PM project negative iages of psychiatry that do not help those in acute distress. Psychiatrists assess people through a clinical structured interview. Admittedly some better than others in how thorough they are. However it is not just about DSM V it is about your life situation and how you live and socioecon factors, environmental such as housing issues and have you access to green grass like a park. Unless very unwell no psychiatrist will enforce any medication. The evidence base for many medicines is clear. There s a role for naturopaths – for those who have money to waste. Want advice on good diet and supplements see a dietician,

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