Sunday, December 27, 2009

To Medicate or not to Medicate, that is the Question 2

In short, my argument in general is that both medication and psychotherapy work hand-in-hand and are complementary. Both/and, not either/or as I have argued above. Okay, there are some cases where psychotherapy alone will work, but for more complex cases and deeper suffering a combination of drug and talk therapy is needed. There probably are extreme cases also where no talk therapy could ever be used as the patient is too disturbed. But that is surely the exception.

What has brought all of the above to my mind? Well, I have been listening to an old broadcast, a podcast of an interview by one of my favourite broadcasters, Andy O'Mahony with Dr Daniel Burston, Associate Professor of Psychology at Duquesne University, Pittsburg, USA. The tenor of their discussions centred around the influence of these three great psychoanalysts: Erich Fromm, Erik Erikson and the famous Scot R.D. Laing on psychiatry in general and psychotherapy in particular. Erik Erikson (1902–1994) was a Danish-German-American developmental psychologist and psychoanalyst known for his theory on social development of human beings. Erich Seligmann Fromm (1900–1980) was an internationally renowned social psychologist, psychoanalyst, humanistic philosopher, and democratic socialist. Of R.D. Laing the WIKI has this to say:
Ronald David Laing (7 October 1927 – 23 August 1989), was a Scottish psychiatrist who wrote extensively on mental illness – in particular, the experience of psychosis. Laing's views on the causes and treatment of serious mental dysfunction, greatly influenced by existential philosophy, ran counter to the psychiatric orthodoxy of the day by taking the expressed feelings of the individual patient or client as valid descriptions of lived experience rather than simply as symptoms of some separate or underlying disorder. Often associated with the anti-psychiatry movement, he himself rejected the label as such, as did certain others critical of conventional psychiatry at the time. (see this link: Laing )
However, these three "greats" could be seen as viewing the client from a very wide model of therapy, not from a narrow pharmacopsychological one. O'Mahony and his guest began their discussions with the present reality or nature of teaching at third level, with both lamenting a certain deterioration of standards that have resulted in too high a level of grades being given out. Sadly, both also felt that there was a consumerist approach to education today, just as there is a consumerist approach to health in all its incarnations whether mental or physical. They then discussed Erich Fromm's marvellous division of the nature of authority into three types, viz., (i) Rational, (ii) Irrational and (iii) Anonymous.

The first of these three types, Rational Authority, teaches by example. It's an accountable authority which is transparent, never secretive or mystifying or confusing. In short it is a freeing and empowering authority that is not based on coersion. The second of these types, Irrational Authority thrives on secrecy and deception, and eventually perpetuates or continues conditions of inequality. Here, the lecturer or master is remote and superior and always remains so. I only experienced a little of this type of leccturing with a few individuals in UCd in the early 1980s. Thankfully, they were a rarity, though where they did occur, they left us students mystified and confused. Rational Authority, on the other hand, brings student and teacher onto an equal footing. (It's interesting that Fromm was talking with the Nazi or German Fascist Movement in mind.) The last of the three types, namely Anonymous Authority depends on the vagaries of the market. Here people are conformist in attitudes, opinions and actions. Also one gets such reactions as the fear of rejection, of not belonging in this type of authority as, in short, it is based on the principle of the herd mentality. Quite obviously, counselling or psychoanalysis would use a rational approach to authority, if it were to use any.

Erik Erickson was against the over-medicalisation of psychiatry. In this regard, Daniel Burston, laments a similar type of over-medicalisation in what he calls Polypharmacy. This is where a psychiatrist writes multiple prescriptions for a child. If the first drug they use does not work, these psychiatrists add another without withdrawing the first. They, then, Burston argues, keep going in this manner until the child is stable. Such use of "polypharmacy" is patently wrong. Now, the long term effect of these drugs on children is sketchy to say the least. Burston also feels that psychiatrists rush to diagnosis far too quickly with children. He believes that many psychiatric problems in children are more social or psycho-social, that is they result from bad parenting, break-ups of relationships and so on. A quick chemical fix is often the easy way out for everyone. That's why I expressed my fear in relation to one of my SEN pupils in the previous post. Perhaps in his case, the medical fix is the easy way out. However, I'm not 100% convinced either way, though I will remain open to the ideas and suggestions of other experts, both educational and medical.

Then they discussed the views of Dr. Joseph Biederman, who is Chief of the Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD at the Massachusetts General Hospital, and Professor of Psychiatry at the Harvard Medical School. Dr. Biederman is Board Certified in General and Child Psychiatry. Burston referred to the New York Times' declaration that Dr Biederman was/is in collusion with certain drug companies and that he had recommended the use or over-use of drugs for child/pediatric bipolar disorder (PBD). The discussion then ranged as far as a worrying modern tendency to tranquillize children "in utero." One gets the scent of the sulphur of some Huxleyan Brave New World here, does one not? See this link here: PharmaGossip . Then I read the following at

Home / News / Local / Mass. Senator broadens inquiry into psychiatrist Suggests MGH doctor was biased in research By Liz Kowalczyk Globe Staff / March 21, 2009 Email Print Single Page Yahoo! Buzz ShareThisText size – + Senator Chuck Grassley of Iowa has widened his investigation into well-known Harvard child psychiatrist Dr. Joseph Biederman, questioning whether Biederman promised pharmaceutical giant Johnson & Johnson that his research into the company's drugs would yield positive results before beginning the studies. Dr. Joseph Biederman last year was also accused of failing to make timely disclosures of drug company payments. Embattled psychiatrist The expanded inquiry is based in part on slide presentations that summarize projects at the Johnson & Johnson Center for Pediatric Psychopathology Research, a center at Massachusetts General Hospital that was funded by Johnson & Johnson and headed by Biederman from 2002 to 2005. (See this link )

So it seems O'Mahony's guest, Dr. Burston, is not too far from the truth. One can only heartily declare with O'Mahony and guest that psychopharmacological interventions are very important indeed, but they must be ethically as well as scientifically controlled. We need to always direct our efforts, medical and psychotherapeutic, to getting at the root causes always, and that while medical interventions may control the symptoms, we do indeed need to dig deeper. Burston and O'Mahony are at one that the neglect of the ideas of the likes of the three great psychoanalysts alluded to in this and the previous post has indeed led to the phenomenon of OVERMEDICALISATION of our mental health problems in modern society.

I am also at one with both Burston and O'Mahony in their contention that R.D Laing was fundamentally correct , when in the tradition of Dr. Harry Stack and others, that if we are to help heal the psychoses of others, the healers themselves must be in touch with their own "psychotic side," not that they themselves should be going through a psychotic episode at the time obviously!

During this learned and deep interview there were also lovely throw-away remarks like: "We are all a little bit madder than we think, and also a little bit saner." Lovely! I also loved Laing's comment on schizophrenia: "There but for the grace of God go I," that is, we all share to some little or perhaps some greater extent in a common ground with our clients and patients, be they psychotic or neurotic. That's what I loved about R.D. Laing: he did sincerely believe in and sincerely did achieve in practice what he preached, namely that the psychiatrist, psychotherapist or psychoanalyst can communicate in a human manner with their patient. He really believed thoroughly in what Rogers called the healing or therapeutic relationship between doctor and patient or therapist and client.

I also loved Burston's insight into what so-called "normality" really is. He describes it in this interview as "just an assumption merely", "a cultural congruence" and a "statistical average" and that we must never forget that. We can then ask as to whether such "normality" is really set in stone for all time. Surely it can change also. And then, does normality change from society to society? And will it change with whims or fashions? The questions are legion, but highly important annd necessary. Such appeals to "normality", Burston contends, do not of themselves, "confer the benefits of robust mental health." With both O'Mahony and Burston, I, too, lament the demise of psychoanalytic psychiatry as practised in the 1950s and 60s. I, too, lament the fact that psycholanalysis has lost its place in the Social Sciences and that it has now migrated into the Humanities where it has become most eclectic indeed. However, I also share their interest in the work of the modern psychoanalysts like Jacques Lacan and Michel Foucault who both belong to the antipsychiatric pantheon.

In short, there is much wisdom to be gained and many insights to be had by listening to Andy O'Mahony's wonderful radio programme called Dialogue.

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