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Biopsychiatry Illuminated
THE CANDLELIGHT PROJECT
by Bob Collier
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22 September 2003 Issue 60 In Issue 58 of Parental Intelligence, I included a quote from a letter of resignation written to the American Psychiatric Association by a Dr. Loren Mosher, then an official with the National Institute of Mental Health. There was another reference to that letter of resignation in last week's article by Dr. Richard Shulman, 'The Surgeon General's New Clothes'. I am now able to bring you the complete text of Dr. Mosher's letter, published here with the permission of the author. Letter of Resignation from the American Psychiatric Association 4 December 1998 Loren R. Mosher, M.D. to Rodrigo Munoz, M.D., President of the American Psychiatric Association (APA) Dear Rod, After nearly three decades as a member it is with a mixture of pleasure and disappointment that I submit this letter of resignation from the American Psychiatric Association. The major reason for this action is my belief that I am actually resigning from the American Psychopharmacological Association. Luckily, the organization's true identity requires no change in the acronym. Unfortunately, APA reflects, and reinforces, in word and deed, our drug dependent society. Yet it helps wage war on "drugs". "Dual diagnosis" clients are a major problem for the field but not because of the "good" drugs we prescribe. "Bad" ones are those that are obtained mostly without a prescription. A Marxist would observe that being a good capitalist organization, APA likes only those drugs from which it can derive a profit -- directly or indirectly. This is not a group for me. At this point in history, in my view, psychiatry has been almost completely bought out by the drug companies. The APA could not continue without the pharmaceutical company support of meetings, symposia, workshops, journal advertising, grand rounds luncheons, unrestricted educational grants etc. etc. Psychiatrists have become the minions of drug company promotions. APA, of course, maintains that its independence and autonomy are not compromised in this enmeshed situation. Anyone with the least bit of common sense attending the annual meeting would observe how the drug company exhibits and "industry sponsored symposia" draw crowds with their various enticements, while the serious scientific sessions are barely attended. Psychiatric training reflects their influence as well: the most important part of a resident's curriculum is the art and quasi-science of dealing drugs, i.e., prescription writing. These psychopharmacological limitations on our abilities to be complete physicians also limit our intellectual horizons. No longer do we seek to understand whole persons in their social contexts -- rather we are there to realign our patients' neurotransmitters. The problem is that it is very difficult to have a relationship with a neurotransmitter - whatever its configuration. So, our guild organization provides a rationale, by its neurobiological tunnel vision, for keeping our distance from the molecule conglomerates we have come to define as patients. We condone and promote the widespread use and misuse of toxic chemicals that we know have serious long term effects -- tardive dyskinesia, tardive dementia and serious withdrawal syndromes. So, do I want to be a drug company patsy who treats molecules with their formulary? No, thank you very much. It saddens me that after 35 years as a psychiatrist I look forward to being dissociated from such an organization. In no way does it represent my interests. It is not within my capacities to buy into the current biomedical-reductionistic model heralded by the psychiatric leadership as once again marrying us to somatic medicine. This is a matter of fashion, politics and, like the pharmaceutical house connection, money. In addition, APA has entered into an unholy alliance with NAMI (I don't remember the members being asked if they supported such an association) such that the two organizations have adopted similar public belief systems about the nature of madness. While professing itself the "champion of their clients" the APA is supporting non- clients, the parents, in their wishes to be in control, via legally enforced dependency, of their mad/bad offspring: NAMI with tacit APA approval, has set out a pro-neuroleptic drug and easy commitment-institutionalization agenda that violates the civil rights of their offspring. For the most part we stand by and allow this fascistic agenda to move forward. Their psychiatric god, Dr. E. Fuller Torrey, is allowed to diagnose and recommend treatment to those in the NAMI organization with whom he disagrees. Clearly, a violation of medical ethics. Does APA protest? Of course not, because he is speaking what APA agrees with, but can't explicitly espouse. He is allowed to be a foil; after all - he is no longer a member of APA. (Slick work APA!) The shortsightedness of this marriage of convenience between APA, NAMI, and the drug companies (who gleefully support both groups because of their shared pro-drug stance) is an abomination. I want no part of a psychiatry of oppression and social control. "Biologically based brain diseases" are certainly convenient for families and practitioners alike. It is no-fault insurance against personal responsibility. We are all just helplessly caught up in a swirl of brain pathology for which no one, except DNA, is responsible. Now, to begin with, anything that has an anatomically defined specific brain pathology becomes the province of neurology (syphilis is an excellent example). So, to be consistent with this "brain disease" view, all the major psychiatric disorders would become the territory of our neurologic colleagues. Without having surveyed them I believe they would eschew responsibility for these problematic individuals. However, consistency would demand our giving over "biologic brain diseases" to them. The fact that there is no evidence confirming the brain disease attribution is, at this point, irrelevant. What we are dealing with here is fashion, politics and money. This level of intellectual /scientific dishonesty is just too egregious for me to continue to support by my membership. I view with no surprise that psychiatric training is being systematically disavowed by American medical school graduates. This must give us cause for concern about the state of today's psychiatry. It must mean -- at least in part -- that they view psychiatry as being very limited and unchallenging. To me it seems clear that we are headed toward a situation in which, except for academics, most psychiatric practitioners will have no real relationships -- so vital to the healing process -- with the disturbed and disturbing persons they treat. Their sole role will be that of prescription writers -- ciphers in the guise of being "helpers". Finally, why must the APA pretend to know more than it does? DSM IV is the fabrication upon which psychiatry seeks acceptance by medicine in general. Insiders know it is more a political than scientific document. To its credit it says so -- although its brief apologia is rarely noted. DSM IV has become a bible and a money making best seller -- its major failings notwithstanding. It confines and defines practice, some take it seriously, others more realistically. It is the way to get paid. Diagnostic reliability is easy to attain for research projects. The issue is what do the categories tell us? Do they in fact accurately represent the person with a problem? They don't, and can't, because there are no external validating criteria for psychiatric diagnoses. There is neither a blood test nor specific anatomic lesions for any major psychiatric disorder. So, where are we? APA as an organization has implicitly (sometimes explicitly as well) bought into a theoretical hoax. Is psychiatry a hoax -- as practiced today? Unfortunately, the answer is mostly yes. What do I recommend to the organization upon leaving after experiencing three decades of its history? 1. To begin with, let us be ourselves. Stop taking on unholy alliances without the members' permission. 2. Get real about science, politics and money. Label each for what it is -- that is, be honest. 3. Get out of bed with NAMI and the drug companies. APA should align itself, if one believes its rhetoric, with the true consumer groups, i.e., the ex-patients, psychiatric survivors etc. 4. Talk to the membership -- I can't be alone in my views. We seem to have forgotten a basic principle -- the need to be patient/client/consumer satisfaction oriented. I always remember Manfred Bleuler's wisdom: "Loren, you must never forget that you are your patient's employee." In the end they will determine whether or not psychiatry survives in the service marketplace. Copyright © Loren R. Mosher, MD About Dr. Loren Mosher Born and raised in California, Dr. Mosher received his B.A. from Stanford University and M.D., with honors, from Harvard Medical School in 1961, where he also subsequently took his psychiatric training. He was Clinical Director of Mental Health Services for San Diego, California from 7/96 to 11/98 and remains a Clinical Professor of Psychiatry at the School of Medicine, University of California at San Diego. One of his principal tasks in San Diego was the implementation of a managed care system for public sector adult clients. From 1988-96 he was Chief Medical Director of Montgomery County Marylands Department of Addiction, Victim and Mental Health Services and a Clinical Professor of Psychiatry at the Uniformed Services University of the Health Sciences, F. Edward Herbert School of Medicine. In his role in Montgomery County, he helped establish a number of innovative programs, including a consumer owned and operated computer company and a new residential alternative to psychiatric hospitalization for persons in crisis. His professional training and experience is both extensive and wide-ranging. He received research training at the National Institute of Mental Health (NIMH) Intramural Research Program in Bethesda, Maryland and at the Tavistock Clinic in London. From 1968-80 he was the first Chief of NIMH's Center for Studies of Schizophrenia. While with the NIMH he founded and served as first Editor-in-Chief of the Schizophrenia Bulletin. From 1970 to 1992 he was a collaborating investigator, then Research Director, of the Soteria Project - Community Alternatives for the Treatment of Schizophrenia. In this role, he was instrumental in developing and researching an innovative, non-drug, non-hospital, home-like, residential treatment facility for acutely psychotic persons. The many publications from this experiment demonstrate both the feasibility and cost-effectiveness of its non-traditional approach to the treatment of persons newly identified as having schizophrenia. Continuing his career long interest in clinical research Dr. Mosher more recently (1990 - 1996) has been the Principal Investigator of a Center for Mental Health Services(CMHS) research/demonstration grant for the first study to compare clinical outcomes and costs of long term seriously mentally ill public-sector clients("frequent flyers" randomly assigned (with no psychopathology based exclusion criteria) to a residential alternative to hospitalization or the psychiatric ward of a local general hospital (the McPath project). Its findings, comparable clinical effectiveness with a 40% cost saving favoring the alternative, have important acute care implications. In 1980, while based at the University of Verona Medical School, Dr. Mosher conducted an in-depth study of Italy's revolutionary new mental health system. He documented that a new National Health Service supported system of catchmented community care could stop admissions to large state hospitals enabling them to be phased down and eventually closed. He also showed that where the mandated community system was implemented properly there were no adverse consequences for patients or the community. In his legal/psychiatric work Dr. Mosher was expert witness for the plaintiffs in two successful class action suites related to forced medication of psychiatric patients (N.J.; Renie vs. Klein, 1978; CA; Jamison vs. Farribee 1983). He is currently expert witness for the plaintiffs in four class action suites (MD, VA, DC &AZ) against Psychiatric Institutes of America(PIA) and National Medical Enterprises (NME) for medical malpractice and insurance fraud (1994-present). As a clinician, Dr. Mosher specializes in family and adolescent treatment, community psychiatry program consultation, and staff training. As a teacher, he is an acknowledged expert at conveying the essential and critical aspects of the interviewing process to students at all levels. In addition to over 100 articles and reviews, Dr. Mosher has edited books on the Psychotherapy of Schizophrenia and on Milieu Treatment. His book, Community Mental Health: Principles and Practice, written with his Italian colleague, Dr. Lorenzo Burti, was published by W.W. Norton in 1989. A revised, updated, abridged paperback version, Community Mental Health: A Practical Guide, appeared in 1994. It has been translated into five languages. Most recently he has founded his own consulting company, Soteria Associates, to provide individual, family and system consultation using the breadth of experience described above. For consultation please call, fax or e-mail Dr. Mosher at his home. ADDRESSES: Office and Home: 2616 Angell Avenue, San Diego, CA 92122 Phone: (858) 550-0312 Fax: (858) 558-0854 E-Mail: 102754-@compuserve.com Dr. Mosher's website is at: http://www.moshersoteria.com/ |
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