Is There a Professional Turf War in the Mental Health Field?

By Marvin Ross – First published in the Huffington Post on March 9, 2015

One of my pet peeves is the use of the term “mental health problems and issues” to reflect mental illness. Some have told me that if we imply that people are mentally ill then we are stigmatizing them because we are saying that there is something wrong with their brain. Well, there is, and so what? With cancer, we don’t say someone has cell problems and issues but rather they have cancer and we are usually pretty specific because there are so many different forms of cancer each with its own unique outcomes.

And the same goes for mental illness. But, someone recently pointed out to me that the reason we use the vague term “mental health problems and issues” is that what we are seeing is a turf war amongst professionals. And I think that person is right.

When we think of an illness, we think medical doctor. When you are ill, you see an MD who uses diagnostic skills, tests, imaging — a methodology developed over time, to determine what the problem is. Once determined, the MD decides on a course of action (with the patient) which may include referral to another more appropriate health professional (dietitian, counsellor, medical specialist, hospitalization) or medication. The MD is at the apex of the pyramid and the gatekeeper for others.

Now as my cynical friend stated, there is only one relatively finite pot of money for services for the mentally ill and, if we call it an illness, then the medical docs are going to get most of it. Other professionals will get the crumbs. However, if we don’t call it an illness but a problem, then it becomes more appropriate for other professionals like psychologists, social workers and others to be the first line of assessment and treatment.

Last year, one of my blogs upset the Canadian Psychological Association because I pointed out that in 2006, they were concerned that the newly formed Mental Health Commission of Canada would focus on mental illness to the exclusion of mental disorders and behavioural health. That generated a reply from Karen Cohen, the CEO of the CPA.

In November of last year, the British Psychological Society issued a report called Understanding Psychosis and Schizophrenia where they conclude that “psychosis can be understood and treated in the same way as other psychological problems such as anxiety or shyness.” And that “Hearing voices or feeling paranoid are common experiences which can often be a reaction to trauma, abuse or deprivation. Calling them symptoms of mental illness, psychosis or schizophrenia is only one way of thinking about them, with advantages and disadvantages.” And they conclude that “Psychological therapies — talking treatments such as Cognitive Behaviour Therapy (CBT) — are very helpful for many people.”

What they have done is to trivialize schizophrenia and suggest that its treatment be shifted to themselves and that they can uncover the underlying trauma that is the cause over the course of many talk sessions and help.

To be fair, before they had any effective treatments, psychiatrists tried this as well, and it did not work.

First out of the gate to criticize this report were three bloggers on theMental Elf. Keith Laws, a Professor of Cognitive Neuropsychology, analyzed their claim on the efficacy of CBT and found that the research does not support the statement that it is as effective a treatment as medication. Alex Langford, a psychiatry trainee who also studied psychology, challenged their conclusions on medication and pointed out that there is “solid evidence for elevated presynaptic dopamine levels being a key abnormality in psychosis, and there is copious evidence that inhibiting the action of this excess dopamine using antipsychotics leads to clinical improvement in psychosis.” Samei Huda, a Consultant Psychiatrist, points out that the “reduction of psychosis to just hallucinations and delusions is flawed.” He points out that “Cognitive impairment and negative symptoms (depression, lack of enjoyment, lethargy) are important as they often have a bigger effect on social functioning than hallucinations or delusions.”

James Coyne, a psychologist himself and one who is very critical of his colleagues, pointed out that:

Key stakeholders were simply excluded — primary care physicians, social workers, psychiatrists, police and corrections personnel who must make decisions about how to deal with disturbed behavior, and — most importantly — the family members of persons with severe disturbance. There was no check on the psychologists simply slanting the document to conform to their own narrow professional self-interests, which we are asked to accept as ‘expertise’.

He goes on to say that this paper is not evidence based and that “quotes are carefully selected to support the psychologists opinions expressed before the document was prepared — like 15 years ago in their Recent Advances in Understanding Mental Illness and Psychotic Experiences. ”

Dr Ronald Pies, a psychiatrist, writes that what is missing from the report “is any deep understanding of the psychic suffering occasioned by severe and enduring psychotic states, including but not limited to schizophrenia.” The psychologists see psychosis and schizophrenia simply as hearing voices that others do not and/or having fears or beliefs that those around us do not share. Pies points out that this is a shallow and superficial description of the psychotic experience and does scant justice to the nightmarish reality of severe psychotic states.

In fact, he finds that the psychologists responsible for this report do nothing but trivialize the profound suffering that is psychosis and schizophrenia.

It is well to remember that the prime directive for any physician, including psychiatrists, is not to “be clever”; not to “define abnormal,” not even “to diagnose,” but to reduce suffering.

And while the psychologists lobby for a greater piece of the treatment pie or, as Coyne says slanting to there own “narrow professional self-interests,” and debate with other professionals, the suffering of those with the most serious of mental health problems and issues — real illnesses — continues.

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12 thoughts on “Is There a Professional Turf War in the Mental Health Field?

  1. I am glad you are re-circulating this blog, Marvin, because it’s message really resonates with me as a mother. To me, the most helpful activity for me to adequately support my son is to speak directly with the psychiatrist. There is actually a “doctor-family model” that has come from China,in the last few years, describing the positive outcomes of this approach.

    When I expressed this sentiment at a meeting at the local hospital, my remarks were not welcome. I was relaying how happy the parents at the SSO “Strengthening Families Together” session, that I co-facilitated, had been when a CAMH psychiatrist came and spent the better part of two hours answering their questions directly. In the hospital meeting, I was informed by the program manager (a social worker) that it is not only psychiatrists that can talk about psychotic illness. Perhaps this could be interpreted as a reflection of the Turf War you speak about in your blog. Well I am also a social worker and I did not receive training in psychotic illnesses or on the medications that are prescribed to treat these illnesses, so I would still prefer to speak with a psychiatrist.

    Family caregivers have that unique perspective of seeing the patient in his/her natural setting usually on a 24/7 basis. So in the doctor-family model it is a “win-win” arrangement where the expertise of the family combines with the expertise of the psychiatrist to produce the most effective treatment. This approach also makes sense because most mentally ill people live with their families because of the housing crisis.

    This approach would probably save the system significant financial resources too, as it would help cut down the useless bureaucracy generated to support the current ineffectual system.

    The money saved could be re-directed into developing supportive housing and also into research of serious mental illness.

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  2. As much as I admire Dr. Ross’ experience and expertise, and although I agree that the UK psychologists’ report was faulty, I think he missed the broader problem: personal and professional greed and self-aggrandizement. The history of psychiatry, and indeed most of scientific exploration, contains outrageous examples of extreme theories and practices, all claiming miraculous insights and cures. Different “schools” of Freudian vs. biological, Szaz vs. asylums, neurological vs. metabolic, etc., ad naseum, are the legacies WITHIN the guild of psychiatry.
    So the problem is not just professional turf, it’s human turf. The solution is not to prove which profession is right and which should be the boss. The solution is to focus on the human condition called mental illness, a vast spectrum of different severity and complexity, and the different specific solutions matched with specific problems. No we/they, right/wrong, psychiatry/nonpsychiatry, all or nothing mentality.

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  3. I am also a mother of a son with schizophrenia and his suffering is mostly due to lack of friends and finding a place in this world in his everyday life. He doesn’t think he has this illness or any really, yet he gets his monthly injections. This is after many hospitalizations and years of struggle as a family to try to have him comply with his medication schedule If I thought CBT would help him I would get him this help immediately .. Everyone has tried to help my son with some type of talk therapy. His odd and delusional thinking is the way he sees the world and he will not see many other issues any other way than his own. He wanders from day to day trying to fit into our world and that is his true suffering . I am insulted to think their are psychiatrists out there today writing about a simple answer to this extremely complex illness. It’s an extremely heartbreaking illness for parents, siblings and all those around these precious human beings

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    1. I would agree with you Vivian that psychotic illnesses are complex. Families are in the unique position of observing this. My own doctor actually said to me that many psychiatrists and family doctors do not understand Schizophrenia. If there were more realization about the complexity of psychotic illness, then perhaps there may be more motivation to fund research. Then perhaps I am only dreaming.

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  4. Re; the turf war;Another issue is the attempt to normalize brain-based, pathological symptoms and this is at the forefront of the anti-psychiatry agenda. This group aims to eliminate all of psychiatry due to their position that psychiatry is unscientific, harmful and there is no point to reform….it simply has to be abolished. These anti psychiatry groups are similar to scientology in their positions- they are people who say that they have been harmed by psychiatrists and they have long histories of hospitalizations and complaints. Please let me know how to get in contact with you and your organization; I initially wrote articles for one of these groups until I fully understood their agenda. I attempted to open their minds to the benefits of medication and to the destructive nature of their views in general. They are not receptive to any diverse points of view.Thank youM. Altman (semi-retired LCSW)

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  5. The “evidence” which purports to “prove” “brain disease” myth of Madness is riddled with several embarrassingly obvious shortcomings.

    1) Doctors don’t study the people who quit psychiatry and thrive.

    2) Clinicians don’t even try to measure the physical and psychological damage of psychotherapy, medication, and shock therapy.

    3) Even if the iatrogenic illnesses of psychiatry *were* being measured, the results would be invalid because people are now being psychiatrized very early in their lives. The natural developmental vulnerabilities of youth are no match for toxic body-and-mind-control narcotics. Additionally, the biographical disruption of toxic psychiatry, to borrow a phrase from the great Peter Breggin, on the lives of Mad youth is preempting clinicians and laypeople from comparing how people are living pre-psychiatry as opposed to post-psychiatry.

    4) Society has not yet developed and implemented any quality-control systems that prevent schizophrenogenic families from working their evil. Beef, batteries, and booze are regulated more than families are.

    5) “Families of the mentally ill” and their lackeys in the field of psychiatry have seized the “final” word on Mad people’s worth as social agents and on the “etiological” and “prognostic” aspects of their “biologically based illnesses”

    5) Sanism (prejudice against Mad people) and courtesy sanism (prejudice against people who choose to have close and long-lasting personal and professional relationships with Mad people) both foreclose the recognition, and even the very concept, of Mad people, like myself, enjoying happy, healing, and mutually satisfying relationships with anybody. When Mad people are meaningfully included in other people’s lives, we are always seen as somehow “stealing” these people’s favor by “splitting” them, “mooching” off of them, and “warping” their minds. Likewise, the friends, family members, coworkers, etc. of Mad people are accused of “enabling” us being “in denial” about the repellent nature of our “illnesses”, and suffering from pathological impulses to be our sycophants.

    Once this psychiatrization of age-old human interactions commences, it concludes the study of Madness as a condition that is caused SOLELY by human beings. Mad people may be more productive and less “symptomatic” or even “asymptomatic” around the people who love, support, and admire us for enriching their lives. However, neither psychiatry nor our sanist civilization can survive if the public draws a causal link from Mad people’s improved health and functioning to their healthy and functional social ecosystems. Therefore, Mad people and everybody in our social circles are contemptuously trivialized as being a sick bunch of losers by sanists like Mr. Ross. That way, Mad people can be seen as “passing as sane” or “in remission” instead of as people who were misdiagnosed or healthy all along.

    Calling Madness a “brain disease” is stigmatizing because this “great white hope” of the “families of the mentally ill” has no scientific basis and no regard for the human rights and capacities of Mad people. You’ve built a straw-man argument by claiming that Mad people are attributing undeserved stigma to diseases of the brain. We aren’t. We’re attributing stigma to the lies and dehumanization that people like you insist on clobbering us with.

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  6. I would like to thank Mr. Ross for the “call out” to my work on this issue, but more important, for calling attention to the painful reality and immense suffering that often attends psychotic illnesses–particularly, schizophrenia. Academic debates as to the nature and “reality” of psychiatric illnesses–and simplistic attempts to “normalize” psychosis–fail to appreciate the pain and disability these disorders bring to patients and their families. We need not take a stance on whether schizophrenia and related illnesses are “brain” diseases, “mind” diseases, or–as I believe–pathological conditions that radically undermine “personhood” itself. We simply need to recognize that persons diagnosed with conditions like schizophrenia need our understanding, compassion, respect, and, yes–comprehensive and holistic treatment.

    Ronald W. Pies MD

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    1. Dr. Pies, I am NOT less of a person. YOU are less of a person for dehumanizing Mad people. My greatest suffering has never come from my Madness. My greatest suffering has come from quacks like you and sanists like Mr. Ross. You have no help to offer Mad people. Anti-psychiatry exists because quacks like you have, to some extent, succeeded in turning sanism into medicine.

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      1. Sorry, we seem to forget that drooling and rocking in extreme autism is merely a choice of how to respond to the wide world. We forget that even infants can make this choice. We fail to understand that a trainpusher’s murderous act is as much a part of a flowering civilization as riding the train like cattle to “good jobs.” and we’re so mean we slmost hope the behaviorists beat the mean docs who dont do guilt like the anti medical mad fiddler. Those liberationists will tell you theres no disease in you. Like a new bride youll swoon. The next morning youll be shamed for malingering in bed. Better grow up and learn about bread and how its buttered,and by whom,
        not how its gonna be replaced by cake for all.

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  7. from Ronald Pies, MD:

    I would like to clarify my comment that serious illnesses like schizophrenia undermine “personhood.” This certainly doesn’t mean that someone who suffers from, e.g., schizophrenia is “less of a person” in the sense of having less worth or dignity or the right to be loved, respected and befriended. By “undermining personhood”, I have in mind the ways in which schizophrenia interferes with thinking, feeling, decision-making, perception, and the ability to achieve one’s goals. To get a more concrete sense of this, I am pasting in a personal account from a hospitalized patient with schizophrenia, quoted in Dr. Silvano Arieti’s book, Interpretation of Schizophrenia (1974).

    Respectfully,
    Ronald Pies MD

    “The inmates, here, hate me extremely because I am sane…By the power of their imagination and daily and continuously, they create extreme pain my head, brain, eyes, heart, stomach and in every part of my body. …they lift my heart and stomach and they pull my heart, and they stop it, move it, twist it and shake it and pull its muscles and tissues. ..By their imagination and their bodily mouvents [sic], they scare me continuously and by their imagination, they move the blood violently in every part of my body…they force me to sleep and awake as many times as they desire and they create my dreams…I am suffering daily, extremely, and without cessation, day and night, because they are continuously creating extreme pain in my eyes, brain, heart, and in every part of my body.” [2, pp. 404-405]

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