What are the underlying reasons why some psychiatrists cause more harm than good?

Why do some psychiatrists do more harm than good? One response is that they do not, that they do a perfect job and that there is absolutely no room for improvement in the service that they offer across the entire profession. If you believe that, there is no need to read on.

If, on the other hand, you think that there could be some scope for improvement in the profession of psychiatry, then where are the areas for improvement? In my last blog I suggested that underlying financial incentives may cause some psychiatrists to do more harm than good. This blog builds on that rather simplistic idea, and provides some alternative perspectives as to why, under the current system, some psychiatrists may be doing more harm than good.

The financial incentives are pretty blatant and are well understood. James Davies does an excellent job of describing the symbiotic relationship between the drugs companies and psychiatry in his book, Cracked. In short, over the last seventy years psychiatrists have largely dropped the role of analyst, a role which has been filled by therapists, and have instead focused on extracting maximum value from the power that their ability to diagnose and prescribe provides them. In some cases, there may be direct or indirect remuneration or enticements from pharmaceutical companies. In others, psychiatrists may collude with the pharmaceutical companies to bring drugs to market which have been tested over only short periods of time, and which are intended for long term or lifetime usage.

The power issues are, I believe, more subtle. The system in the UK and US is autocratic. The psychiatrist is generally the sole decision maker regarding diagnosis and prescription of psychiatric drugs. This provides one individual with an extraordinary level of power. No two psychiatrists seem to agree about diagnoses, and other service providers (such as therapists), who spend more time with the client and arguably know them better are not consulted, neither are family members, friends or carers. The decisions are made by the psychiatrist, with no discussion with anyone, and communicated behind closed doors to the client. There is generally no power sharing in the relationship between doctor and client, and the diagnoses are imposed. Some argue that there is a bias, and that doctors diagnose according to their specialities. This is something that I have witnessed. The psychiatrist it seems must be in a position of autocratic ruler, not even willing to discuss his decisions. It is mainly the psychiatrist who is qualified to have an opinion on this part of the job, and in my experience at least, they appear to be unwilling to share that power. Could that be because, after all, that is how they extract financial value for their qualification. If a nurse, or a therapist were to share decision making, what would that mean for the psychiatrists’ money and power?

This is all well and good and need not concern the client as long as the diagnoses are accurate and the prescriptions proportionate. The problem, however, could be that as a result of monopolising the power to diagnose and prescribe the doctor is also monopolising responsibility for the client’s wellbeing. In a profession where suicide is a realistic fear in many cases, this may well lead doctors to be over-cautious in their decisions regarding diagnoses and medication. This over caution could lead to unnecessary diagnoses, over-medication and unnecessary treatment plans.

The situation in the UK and the US contrasts markedly with the open dialogue approach in Finland. Under this approach decision making about the treatment plan is undertaken in an open and democratic manner, with all participants (professionals as well as those individuals the client has selected to support her recovery) able to ask questions and have a say. Through this transparent process the responsibility is shared among all participants. One result of this is that psychiatric drugs are used in only a minority of cases, with significantly better outcomes. The psychiatrists on the team still earn more than other professionals, in recognition of their training and expertise. Not so much more, however, as to create a power dynamic that risks harming the clients.

Apart from money and power, what other factors could influence a psychiatrist such that they do more harm than good? One thing that springs to mind is legacy and reputation. Let us imagine for a moment that a doctor has spent a career diagnosing and prescribing, without ever looking to the real underlying issues of a client’s distress. Let us imagine that a doctor has not recognised the side effects of the drugs that they have been prescribing as being iatrogenic, and instead has blamed the client, and blamed them as being in relapse. Let us imagine that the doctor has been routinely over-medicating, causing serious side and withdrawal effects to their clients. Let us imagine that they have been using treatment methods such as ECT, which has caused brain damage to a number of his clients, which he is reluctant to take responsibility for, or has suffered a number of suicides in his practice which could be a result of his practices. It is said that science advances one funeral at a time. It seems perfectly clear to me that a doctor in that position might very well be in a lot of denial about the harms that he had caused through his career, might prefer to think that he had done everything in his power to keep the suicide rate among his clients down to an absolute minimum, and might prefer that not too much light be shed on the cases where clients were claiming that harms had been caused.

What about training? Could it be the case that psychiatrists do more harm than good because they stick to outdated methods that they are taught at school, and their education is not updated sufficiently? Are new methods being reviewed as part of a continuing professional development process, or is any such process more of a box ticking exercise? My impression, from my own experience as a user of psychiatry, is that the intellectual property is largely static. My experience to date has been that I have brought innovations to my psychiatrist’s attention, rather than the other way around.

Could there also be institutional factors at play? Could it also be the case that psychiatrists collude with each other in various ways to support the power structure that supports their wages and prestige, and seek to grow their market by complicating and medicalising human distress? Friedrich Nietzsche memorably said that “In individuals, insanity is rare; but in groups, parties, nations, and epochs it is the rule.” Could that also be true in the case of psychiatrists? Much could be said here about the way that psychiatry has manufactured mental illness, in partnership with the pharmaceutical industry. Together they have sold a story about these illnesses, which have been promoted from social constructs, drafted by committee, to real life mental ills. Is that something which could cause more harm than good?

I have looked at money, power, reputation, training, and institutional factors as ways in which psychiatrists may be doing more harm than good to their clients. I do not for a moment believe that psychiatrists are harming their clients consciously or willingly, however there are growing communities of psychiatric survivors forming on the internet, and telling their stories, which often include aspects of iatrogenic harm. Could any of the factors listed here be underlying this dynamic? Are there other ways can you think of, or other factors that could explain the growth in vocal dissatisfaction which is evidenced by the growth in withdrawal communities and support groups on the internet? Please let me know what you think.

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Jim Miller

Father, writer, psychotherapist, sailor and value investor. Living in Barbados. 😎