prepared for and distributed at ICSPP meeting, Oct.2004
The insanity epidemic
-and how psychiatry aggravates it
Nathaniel S. Lehrman, M.D.
Former Clinical Director, Kingsboro Psychiatric Center, Brooklyn NY
An immense increase in all
forms of mental illness, especially insanity (psychosis, disabling mental
disorder), has occurred in this country over the past 50 years. The percentage
of Americans said to be mentally ill has nearly tripled since 1955. The total
number of "patient care episodes" for disabling mental disorder (such as
schizophrenia) has, on a per capita basis, quadrupled since 1955.
Similarly, per capita
outpatient admissions to ambulatory mental health programs - dealing with milder
disorders rather than disability - have increased 250% since 1969. This
increase in mental symptomatology is real; only a small fraction of it is due to
changes in diagnosis, such as the lowering of diagnostic thresholds.
The increase in both
treatment and disability
Although one might expect that all this treatment would reduce psychiatric
disability, the exact opposite has occurred: the more that psychiatric treatment
has been provided, the more has disability increased. Over the past 15 years -
between 1987 and 2002 - the number of people disabled by mental illness, and
therefore receiving either a social security welfare or disability benefit, has
almost doubled: from 3.5 million to 5.8 million. The expenditure on
psychotropic drugs has risen from $1 billion in 1987, the year Prozac,
psychiatry's first so-called "wonder drug," was introduced, to $23 billion
fifteen years later. These medications are the heart of treating the disabled,
and important in treating the ambulatory. During this same period, psychiatric
residency programs have reduced or eliminated training in
counseling/psychotherapy - always psychiatry's key therapeutic tool - and
replaced it with education in psychopharmacology.
Harmful changes in
The simplest explanation for these figures is that psychiatric treatment
increasingly harms its patients. This was demonstrated by Dr. M.V. Pinheiro's
description of the changes in treatment methods he found on returning to this
country after a fifteen year absence.
Although "American psychiatry
considers itself more scientific" than it had been earlier, he wrote, it has
actually "changed for the worse in terms of patient care" by returning "to the
unfortunate attitudes of pre-Freudian days. A whole new generation of
psychiatrists, coming from the best medical schools, ... are unable to pay
attention to their patients' subjective worlds. They have been trained to look
at people's outsides: behavior is what counts... Psychosocial factors, once so
popular, now seem almost forgotten."
Instead, the current "emphasis
on the brain... is being used defensively by patients, families and
professionals alike. One patient recently said to me, 'I am upset today because
of my brain chemistry. Would you please adjust my medication?' A mother
recently said to me about her schizophrenic son, 'we just hope that someday you
doctors will find a way to fix his brain chemistry.'" The notion that treatment
helps patients become more responsible for themselves seems to have disappeared.
Major changes imposed on
psychiatric practice from above or outside have also been harmful, Pinheiro
points out. Third parties, including "government advisory groups and insurance
companies, are now determining what constitutes good clinical practice although
their major interest, dictated by economic concerns, is not always related to
the patient's well being. Available funds are now the main determinants of
treatment...., with patients being shipped from program to program in order to
comply with funding."
The relative importance of
patients and paper - the subordination of patients' needs to those of
administrators - was indicated by the colleague who told Pinheiro, "in this
hospital, if you lose a patient, that is bad. But if you lose a patient's
records, you must be prepared to leave town."
He wrote this in 1989. Since
then, the situation has worsened markedly.
Why treatment harms the disabled/insane
As implied by Pinheiro's report, psychiatric treatment increasingly harms
its most seriously ill patients by
1) its destruction of the
psychiatrist-patient relationship - always the most important part of
psychiatric treatment and the foundation for creating patient self-understanding
and volitional change,
2) its almost total reliance
on medication as the heart of treatment,
3) its deprofessionalization
of patient counseling, once carried out within the psychiatrist-patient
relationship, then by social workers and psychologists, and now by relatively
untrained "case managers," whose primary task is often to ensure that patients
take their medications.
The importance of this relationship cannot be overemphasized. Dr. Kerr S.
White, former deputy director of research at the Rockefeller Foundation,
maintains that the relationship itself is responsible for about half of any
physician's total therapeutic impact upon his patient.
In psychiatry, the impact of
this relationship is greater than in any other branch of medicine. In the
hospital, it is best established by having the psychiatrist see the newly
admitted patient regularly and often in order to take a detailed history, and
then continuing these regular meetings to help the patient examine, understand
and change his maladaptive attitudes and behavior.
That was how treatment was
once carried out. Now, however, the doctor-patient relationship in psychiatry
has been more systematically and successfully destroyed than in any other
Continuity of care
doctor-patient relationship is most therapeutic when continuity of care exists -
having the same knowledgeable professional (formerly the psychiatrist) caring
for a patient from admission to hospital as disturbed to discharge from office
or clinic as recovered. I first recognized continuity's importance in 1978,
when, after retiring as Clinical Director at a large New York state Psychiatric
Center, I visited Cambridge, England. The deputy director of the state mental
hospital there, a friend, showed me their remarkably successful system: the same
skilled psychiatrist (aided, when necessary, by a social worker) took care of a
patient both in and after hospital. This system was effective, satisfying and
inexpensive; chronicity and incapacity were relatively rare, and Cambridge's
costs were less than half of New York State's.
After my return, I took a
part-time aftercare clinic position at another state psychiatric center where I
made continuity a key aspect of my work - by visiting in hospital all my
rehospitalized patients, even though I was not assigned there. Since the ward
psychiatrists did not know the patients and I did, they were delighted with the
help which my coming provided. And when the patients were released, I resumed
formal responsibility for them. My 1982 paper, "Effective Psychotherapy of
Chronic Schizophrenia," describes my successful, albeit incomplete, efforts with
over a hundred such patients.
Over-reliance on medication
The first modern, drug-company-endorsed psychotropic drug - thorazine
(chlorpromazine) - was originally promoted as an aid to psychotherapy with
schizophrenic patients - psychiatrically the most seriously ill. But after this
drug and its many new cousins were accepted, the notion of psychotherapy with
these patients, and the significance of the doctor-patient relationship itself,
were gradually eclipsed. Drugs, especially the newer ones - supposedly
constantly improved and increasingly expensive - have become the heart of
treating serious mental illness.
When the drugs may be
The anti-psychotic drugs reduce explosiveness - often a desirable short-term
goal for out-of-control patients - but they also impair the ability to think and
feel. Reliance on them has caused us to forget how much patients' agitation can
be eased by just talking calmly and respectfully with them. The psychiatrist's
compassionate reaching out to the disturbed patient can reduce the amount of
medication needed, and may even make medication unnecessary.
After the patient's initial
disturbance has subsided, his medications should therefore be reduced or
eliminated as soon as possible. Maintaining them, today's standard practice,
continues their interference with his capacity to think and function.
How long should medication
The indefinite continuation of psychiatric drugs for once-hospitalized
patients is a major reason for the large increase in the number of
psychiatrically disabled people. Efforts purporting to rehabilitate heavily
drugged patients to normal living can therefore be compared to sending a boxer
into the prize ring with one hand tied behind his back.
Various rationales exist for
endless medication, such as equating schizophrenia patients' alleged need for
drugs to diabetics' real need for insulin, and seeing mental illness as really
"brain disease," which is never completely reversible and therefore needs
medication forever. Another reason for indefinite continuation of medication is
that the fragmentation of public mental health services makes dosage reduction
and discontinuation almost impossible.
Since each dosage reduction may re-evoke some of the patient's original
symptoms, reducing his medication, and its ultimate elimination, require close
collaboration and trust between him and his psychiatrist; the latter must know
the former well. But this relationship has been greatly attenuated by
psychiatry's abandonment of psychotherapy/counseling. Psychiatrists' consequent
lack of knowledge of their patients as people undermines the collaboration which
dosage reduction requires.
The fragmented structure of
mental health care also interferes with the possibility of reducing medication.
After having medication throughout his hospital stay, a patient is transferred
to a new agency, psychiatrist, treatment team - and often medication.
Sometimes, as Pineiro says, "in order to comply with funding," additional
subsequent transfers occur. Dosage reduction cannot even be considered until
psychiatrist and patient have gotten to know each other.
Orienting initial release toward recovery
A patient's first mental hospital discharge is difficult. He will usually
return to where he lived earlier, and again encounter those with whom he may
have interacted negatively. The more medication he is receiving, the more
impaired he will be in facing these problems.
The transition's difficulties will be minimized if "continuity of care" exists.
If, however, as is customary nowadays, another psychiatrist and treatment team
(and perhaps even another agency !!!) take over responsibility for the patient,
the difficulties of establishing relationships with this new treatment team will
be added to those of the transition itself, thus significantly reducing the
likelihood of recovery.
One of a psychiatrist's central obligations is to provide hope and courage to
her patient, especially when he seems to be losing them. Having a familiar,
respected care-taker (preferably a professional), who is available for comfort
and support, can help prevent the demoralization and loss of hope patients so
often experience upon release from hospital.
When should discharge occur?
The purpose of hospitalization is (1) to begin correcting the behavior and
thinking which made the patient unable to cope with his external world, and (2)
significant restoration of his ability to do so. The time needed in hospital
for this varies greatly from one patient to another. It is a totally individual
matter, about which psychiatrist and patient must reach a decision together. and
unrelated to formal diagnosis. Home visits before release may help determine a
patient's readiness to leave, and a brief day hospital stay can ease the
transition if necessary.
Releasing the patient too soon will increase the likelihood of his failure to
readjust, while over-retention can produce passivity and overdependence, which
also impair his ability to function. Both help lead to chronicity.
Orienting initial release toward chronicity
Demoralization and hopelessness are the key adversaries of improvement. If
patients trust their initial care-takers, their then being transferred to other
settings with new care-takers will undermine both that trust and the hopes it
evokes. After several such transfers, and especially if impaired by medication,
they often give up trust and hope altogether, and try instead merely to survive,
sometimes without significant human relationships.
Reliance on medication as the primary treatment modality, exclusion of the
psychiatrist as central treatment agent while retaining her as drug-prescriber,
the yo-yo-ing of hope and trust (which are evoked by each new treatment
relationship and destroyed by each transfer), and the absence of a competent
professional whom the patient trusts and with whom he makes important treatment
decisions, all help create chronicity.
Where the path to chronicity diverges
Chronicity begins when patients lose hope after repeated failures and
transfers, including hospital readmission and discharge. While those who
recover from disabling mental illness can return to previous homes, work or
schools, those becoming chronic need assistance with many or all of these
aspects of living.
Places for chronic mental patients to live, and for them to spend their days,
and counselors helping with lost abilities in daily living, are all costly, and
large bureaucracies have been created to supply them. The danger exists that
these bureauracies, in order to maintain themselves, will foster patients'
dependency and consequent chronicity. And when ensuring that patients take
their psychotopic medications is defined as a counselor's main or primary task,
chronicity becomes increasingly irreversible. And that's why the number of
psychiatrically disabled individuals keeps rising.
The vast increase in the number of mentally disabled - insane - Americans
during the past fifteen years represents a veritable epidemic. While the
comparably huge increase in psychiatric services during this period would be
expected to reduce these numbers, it has not. Unlike the more effective
psychiatric services of years past, those provided today often harm patients and
This new harm is caused by (1) psychiatry's almost total reliance on medication
as the heart of treatment, (2) the resultant destruction of the doctor-patient
relationship - always a central part of medical practice in general and of
psychiatry in particular, (3) the deprofessionalization of patient counseling,
once carried out within the psychiatrist-patient relationship in order to evoke
patient self-undestanding and volitional change, but now often limited to
ensuring that patients take their medications.
Some new programs
Two new programs for the
mentally disabled warrant examination in the light of the creation of chronicity
by overmedicating and under-counseling. Both see medication as the core of
treatment - presumably endless because of the difficulties of dosage reduction.
The Texas Medication Algorithm Project, a creation of the drug companies,
placed large numbers of mentally disabled patients on the newest, and therefore
most expensive, drugs. Apparently in response to the high costs, the state
dissolved its existing mental health department, transferred mental health
centers to the state health department, and directed them to focus on "disease
management" - "a managed care concept that helps to care more effectively for
people with chronic diseases like major mental illness."
Although the new system offers several levels of benefit
package based on patient functioning, the first item on the lowest level - and
therefore involving all patients - is medication: perhaps "five hours of
medication management per year," which includes "20 minutes with a psychiatrist
every 90 days," according to the chief operating officer of a local public
mental health center.
While claiming that "mental illness is finally being treated as a brain
disease," the C.O.O. maintains that "the emphasis is on treating the whole
person," and that "the client will [therefore] be more involved in their own
treatment, giving them a better opportunity for recovery."
The brain disease concept of mental illness, and the "disease management" model
of its treatment, represent a self-fulfilling prophecy - that mental illness is
necessarily chronic and irreversible. Definng the new system's sole role as
providing permanent, long-term care ignores how treatment creates chronicity,
and ignores or abandons those efforts toward full recovery which are most likely
to succeed: those made before chronicity develops
In New York, the primary purpose of its new "Personalized Recovery Oriented
Services" (PROS) is to get Medicaid (i.e. 50% federal) funding for existing
rehabilitation programs, such as day hospitals and drop-in clubs. A very
complicated reporting system has therefore been set up - evoking memory of
Pinheiro's comment about losing a patient's records being worse than losing the
Like the Texas program, New York's has different "service components" "to assist
individuals in managing their illness and restoring the skills and supports
necessary for living successfully in the community," and to assist "in attaining
specific goals such as a higher level of education, secure housing and
employment." Despite its recovery rhetoric, however, it is also based on the
indefinite continuation of drug treatment.
To train the people relating directly to patients in this and similar programs,
a nationwide Certified Psychiatric Rehabilitation Practitioner (CPRP) program
has been set up. Admission to the certification examination requires a minimum
of high school or equivalent; psychosocial rehabilitation (PSR) experience of 6
months to 2 years, depending on education level; and additional approved
training in PSR (60 hours for most applicants). Whether called CPRP's or case
managers, these are relatively untrained people taking primary responsibility
for chronic patients. To what extent they will serve primarily as state-paid
baby-sitters, whose first task is ensuring that patients continue taking their
medications, remains to be seen.