Lock the doors: Today, we’re taking on the psychiatry establishment. Here are excerpts of our conversation.
Alaina Mabaso: I wanted to ask you about something in your book that you touch on a little bit. I was just interested because of some of the crossover with my own experience. You mentioned your own sojourn in inpatient care at Johns Hopkins Hospital. I also was a patient at Johns Hopkins earlier this year for depression. It was not a good experience. Given your view of depression as an evolutionary mood system that we should try listening to and approaching in interdisciplinary ways, what do you think about inpatient or hospital stays for people who are depressed?
Jonathan Rottenberg: No-one normally hospitalizes anyone these days because of the difficulty of paying for it, so it really is, in our current system, an absolute last resort, and I think in my case [several years ago], it was still pretty hard to get admitted.
It was sort of an admission of defeat that all these other therapies hadn’t helped me…and the hospital offered a break… It didn’t really make a big difference for me, but was really very frightening: the idea of going to a hospital for a psychiatric problem. I think in certain cases it can be helpful; if someone’s environment is really chaotic and is interfering with any hope of stabilizing the person.
I’m just saying more generally that I would agree that mainstream psychiatry and even pretty good psychiatry isn’t that good. I just don’t think depression is like having diabetes, which is one of the main metaphors that’s typically used in really any sense, but really even in a treatment sense, where you can find out to what extent your therapy for diabetes is making a difference on the targets that you’re interested in; you can draw blood, you get different measures of people’s reactions to sugar, but you can’t do that with depression. There’s no biological test that would tell you whether or not your treatment is working, and so that’s pretty horrible [as an analogy that] breaks down as soon as you look at it.
It’s true that insults to the body can cause depression. It’s really not a shock from the evolutionary perspective either, that if you sustain a head trauma, or are sick with cancer, that that can have profound effects on your mood…but fundamentally I don’t think that’s the right approach for most people.
AM: My experience with many psychiatrists is a refusal to look at my underlying physical issues. The thing that landed me in inpatient care is I have an extremely painful chronic illness that nobody can cure; I grew very, very depressed and expressed that I wanted to die, because I was in so much pain, and I was locked up. There was this disconnect: the idea that my body being extremely painful and debilitated was not a valid reason to be feeling bad, and I needed to be locked up and put under guard.
JR: Did they address what your reactions were to the pain? Were they simply saying that having depression in this context was maladaptive and we were going to treat the depression? Did they give you any tools for thinking about the pain and reacting to it differently or anything like that?
AM: No, it was a short stay. They forced me onto a couple different drugs, and after my release, required me to see an outpatient psychiatrist who specializes in pain management. He essentially ignored the chronic pain history, and diagnosed me with a personality disorder, based partly on the fact that in his opinion, I write too much: my devotion to writing is pathological, therefore I have a mental illness. And for me, that connects with what you write in your book about part of what you think the key to overcoming depression is: a sense of purpose in your life, a sense of passion about something that you like to do. What happens when there’s this disconnect in a medical scenario, and your doctor sees something that’s your passion, and calls it a symptom of a disease?
JR: In any field, there are people who don’t know what they’re doing…psychiatry maybe more than some other fields of medicine where it’s a lot easier to quantify the outcomes… If someone’s replacing knees, I think they can grade difficult and easy cases, and look at success rates, but I think in psychiatry that’s a lot harder to do.
There are people who were trained a long time ago and didn’t keep up [or] people who are just intellectually not very strong, and they’re left in a position of incredible power. [Patients] are trained to defer to [psychiatrists’] expertise. I think that in addition to purpose, I’d argue it’s really important for people to take control of their treatment, if they’re in treatment (which I don’t think is a bad thing).
We’re better consumers of things like toasters and what airline to fly on than something as important as mental health. There’s amazingly poor data for the consumer. It’s a huge issue. If you want to buy a toaster, you can go to underwriters’ laboratories and consumer reports and find out about all these toasters you can buy, and all their features… With psychiatry or other areas of mental health, there’s very little reputational information you can get, and people can do things that are borderline unethical, and it’s very difficult to sue. But if your toaster doesn’t toast the toast, you can take it back and get your money back.
AM: When I was at Hopkins, part of the problem that landed me there was my physical illness. I have to stick to a very strict diet because of it, but the doctors and practitioners on the ward would not accommodate my diet… To me, it seemed like this extremely basic disconnect from care and human dignity, like here you’re claiming to cure my psychiatric illness, and you’re failing to even give me food that I can eat. And this is supposedly one of the top hospitals in the country, so how does this reflect on psychiatric care in general? It’s scary to me.
JR: I want my book to be more than just anti-psychiatry — I feel like that’s kind of too easy. I agree with everything you’re saying, and that a lot of that is pretty shameful and we need to do better. There are some good psychiatrists out there. There are even a lot of psychiatrists who share these same kinds of critiques.
Psychiatrists have a tough job in the sense that [they’re dealing] with the most difficult patients that haven’t gotten better on their own, or with the help of their families…I think the thing that would kill me if I were doing that job is just that there’s a certain intellectual fraudulence to it, especially when prescribing the drugs.
Therapy’s another matter; that’s a real art form. Some people are probably magicians and can have some pretty remarkable results (of course a lot of terrible ones too), but [with] drug treatment, I just think you have to tell the patient a series of white lies about what’s going on…the whole thing is shrouded in mystery: how you’ll get better and when you’ll know that there’s any benefit.
AM: When I was in Hopkins, and I was in a conference with my psychiatrists, forced onto a [psychotropic] medication that I didn’t want to take and that had disastrous consequences for me, I asked the doctor, “Why are you putting me on this medication versus another one?” And she said, “it’s more anti-cholinergic.” And I’m like, here I am, a psych patient, a layperson, and you’re just going to tell me that as the answer for why you’re making me swallow this pill?
JR: Well, they don’t know. There’s no rational basis for…prescribing a drug [based on its side-effects]… If someone is potentially dying of cancer, you would not prescribe medicine based on whether it’s more sedating or less sedating. [But psychiatrists] prescribe medicine to people who are wanting to kill themselves, [a] life-threatening problem, on the basis of things like side-effects.
It’s all just completely seat-of-the-pants type decisions, and that’s why I’m saying that I would find it hard if I were in psychiatry; that it’s kind of an intellectual fraud. It’s intellectually weak.
[There may be more progress in other types of medicine like imaging and diagnostics]…but in psychiatry it seems like it’s been pretty much a steady state, no progress, and yet more and more market share and mind share. That’s really ugly.
I had a similar experience in the system, that I was a smart person being told a bunch of stupid things by smart people who should have known better. I just felt that they weren’t sufficiently humble.
AM: that’s one way to put it.
JR: A critique of where we are now has got to be the place to start…the current dominant approach is really part of why we’re in such a bad place.
AM: I remember being on the ward, and they’re serving dinner to the patients, and my attending psychiatrist comes up, and begins to talk to me about my medication dosage, in the middle of the kitchen, in earshot of all the other patients and guards and nurses. How dehumanizing is this? You would not do that in any other field of medicine: discuss someone’s most intimate problems and medication regime in front of thirty other people you don’t know.
JR: Yeah, that’s a good point. I think that on some level, there is a view that if you’re having these sorts of problems, you’re a very compromised human being. If you’re in a psychiatric hospital, even if you’ve consented…I think it is hard to accord the same status, the same respect, that you would [otherwise get].
I think that again, in terms of really changing things, a first position is to say that people who have problems with depression are people who are just about as flawed as people who don’t have depression, and just say, ok, they’re not fundamentally flawed, they’re flawed like everyone else is flawed.
I don’t think it means that you’re superior or that you’re inferior, it means that your mood is not within bounds that you would like, and that’s important to know, and could be a real challenge to get in better bounds, but the thing is, when people are overtaken by these moods, the moods themselves cry out these kind of judgments, so it’s very easy for the culture to act on and say, well, [the patients] say that they’re no good, so they must be no good.
In part III of our interview with Jonathan Rottenberg, we discuss treating depression versus learning to thrive, and society’s role in ending the epidemic. Comment below, scroll down to the bottom of the page to subscribe, and stay tuned. Miss part I? Read it here.
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