And Still the Battle Rages…
by Siegfried Othmer | January 4th, 2006With the onset of the new year, I wanted to turn the page and start off on a new topic. However, the question of professional boundaries continues to occupy some of the lists. If discussions of this issue are intended to bring parties together, rather the opposite is happening. Arguments are being refined; lines of demarcation are being more firmly drawn; and the bulwarks are going up.
In my own observation of this field, there has been considerably more effort put into defending turf than in building the field in the first place. The number of lawsuits per capita must exceed that for any field of comparable size, and the money put into such law suits, patents, and patent defenses probably exceeds the cash invested in actual instrumentation development. It has availed essentially nothing for those who sought to restrict others. The patents succeeded at most in slowing down progress, or forcing developments underground, and at the same time the patents are most likely indefensible.
In my previous newsletter, where I discussed the issue of whether licensure actually serves to protect the public rather than the professions, I failed to raise an obvious point. If the public is at risk from a proposed new technique, then the risk to the public is surely greater if the technique is entirely fraudulent than if it is effective but may simply be poorly administered. If a technique is entirely fraudulent, then it injures by diverting an ostensibly gullible public from more effective remedies. If the public interest were truly at issue, then the promotion of an entirely fraudulent technique to the public should be of greater concern to the caring professions than the haphazard, sub-optimal administration of an effective one. In actual fact, we see the concern about the public welfare raised substantively only when it finally dawns on the professions that there is actually something here worth fighting over. The claim that this has anything at all to do with the public interest is the rankest hypocrisy.
Ironically, a parallel situation prevails in the matter of fake medicines. According to an article in the current issue of The American Prospect, the problem of fake malaria medication runs rampant in Africa, with bulk shipments from China leading the way. In each of these cases, it is the products of the major pharmaceutical companies that are being faked. Alternatively, their contents may be diluted. The result is a life-and-death issue for millions, with tens of thousands having died annually. Additionally, there is the long-term risk that the use of diluted drugs incubates drug resistance. Curiously, the companies are keeping silent on this issue, on the callous calculation that alerting the public (and the medical community) on this issue would cause a greater loss of sales of a particular drug than the ongoing loss from fake drugs in the distribution pipeline. This is obviously a close call, and the fact that things tilt the way they do proves that the public interest does not factor into the decision.
Much is made of the point that it is the prerogative of the licensed professions to “treat” medical diagnoses. As it happens, two articles bearing on this point appeared on the Los Angeles Times editorial page this past Sunday. The first is by Irwin Savodnik, psychiatrist at UCLA, who laments the fact that his profession is in the business of selling mental illness, and this enterprise has some of the qualities of a growth industry. Nowhere else in medicine is the unearthing of new diseases bearing such abundant fruit. Psychiatric diagnostic categories are metastasizing on an exponential growth curve (in one of the rare correct usages of the term in current reportage). Even the verbiage of infectious diseases is being adopted, with people warned of “coming down with,” “developing,” or even “contracting” one or another species of depressive illness.
With things like shyness and a lack of sexual interest among elderly women moving through the process of canonization into status as formal disorders even psychiatrists themselves observe that matters are out of control. The process is reminiscent of the staking of mining claims on public land. As soon as miners place the stakes, all mining rights are subsequently theirs. But the public health is at issue here, and the public is in a position to talk back even if the land cannot. I see no reason why we should allow sole mining claims to be established on our psyches.
The process of speciation in mental health would not be succeeding without challenge if it weren’t for the fact that it has the aura of scientific validity about it. But Savodnik points out that it is far more a matter of ideology than of science. “The ‘diagnosis’ of ‘pathological behavior’ is based on social, political or aesthetic values.” We have, as a case in point, the former designation of homosexuality as a mental illness.
Says Savodnik: “It’s a natural step from using social and political standards to create a psychiatric diagnosis to using them to influence public policy.” Witness the evolution of the insanity defense. Consider “Teen-Screen.”
Savodnik’s concern is the pathologizing of much of the range of normal human behavior. Even while Peter Kramer was singing the praises of Prozac he was mindful of the problem of overreach into the penumbra of mental disorders, of the use of Prozac as “anti-wallflower compound.” Since that time it has become clear that the real pay dirt for the SSRIs lies in that shadowy region where diagnostic criteria are not met for serious mental disorders. Prozac is not the remedy of choice for major depression.
But Savodnik’s real concern goes beyond that into the cultural realm: “The erosion of personal responsibility is, arguably, the most pernicious effect of the expansive role psychiatry has come to play in American life.” Ultimately all of human behavior will have its reflection in some transient blush on an fMRI scan, and can then be reclassified as subject to the purview of medical professionals. Moral agency can never show up on a brainscan. Hence it can never become part of the medical model of human behavior.
So here we are. Is there any burden on our part to acquiesce to such a self-serving classification of the idiosyncrasies, quirks and follies our brains are heir to? Or are we instead dealing with a highly specialized interest group that has energized itself into vast overreach, with the enthusiastic collusion of the pharmacological enterprise? Just how have things come to such a point? On this question I am informed by a book that is now more than twenty years old but still seems relevant: It is “The Social Transformation of American Medicine,” by Paul Starr.
The ascendancy of medicine is a fairly recent phenomenon, it turns out. It has by no means been the state of affairs throughout most of our country’s history. Early on there were two pillars in the edifice, the practicing docs and the apothecaries. And whereas the docs had the advantage of being present on the scene and comforting the patient, it was the apothecaries that offered the goods that were available in those days. So in the social hierarchy of the time, the apothecaries actually ranked higher than the practicing docs. What Starr could not have anticipated back in 1982, when his book was published, was the re-emergence of the dominance of the apothecaries, on this occasion in the form of Big PhRMA.
When it is suggested that we acquiesce to the dictates of medicine in matters of mental health, it is largely to Big PhRMA that we are yielding our autonomy. It is Big PhRMA that has imposed a pharmacological monoculture on the universities, on the NIH, and on the clinical journals. And in Big PhRMA we are dealing with one of the most corrupt enterprises on the planet. On top of everything else, they are in a position to strong-arm Congress, with more than one lobbyist-minder per Congressman. The suggestion that the public interest is driving their agenda is completely absurd.
Let us please understand where the real threat to our enterprise comes from: It comes from the top, where Big PhRMA is in a position to harass us to delirium with their unbounded resources. The threat does not come from the bottom, from the continued contribution to our field of a small number of unlicensed practitioners. Once the field attracts mainstream professionals in great numbers, the unlicensed professionals will cease to be an issue. They will either be absorbed into the larger practitioner community that will emerge; they will be embraced through the well-established process of grand-fathering; or they will fall by the wayside, unable to compete. And if they can compete by appealing to the non-medical market, more power to them. Even the law that gave the FDA the power of regulation over medical instruments had to take things the way they were back in 1976. Regulation functioned prospectively, not retrospectively.
The appeal to “protection of the public interest” that we have been hearing in connection with the defense of the professions does have one virtue. It is the recognition that the ultimate repository of rights lies with the public, and that any professional privileges derive their validity from that bedrock of public rights. But that may not count for much after all. Even Robert Mugabe and Russian President Putin profess to be acting in the interest of their respective publics as rights are being trampled all around. In our land, the public has the right at any time to revisit the question of whether the privileges that have been delegated still serve its interest.
There is yet another major entity that needs to be discussed in this connection: the insurance companies. Aetna says on its website: “Aetna Clinical Policy Bulletins are developed to assist in administering plan benefits and do not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members.” This disclaimer is a mere fig leaf over the reality that insurance companies make treatment decisions all the time that overrule the “treating provider.” And the decisions flow from largely non-medical personnel who have no contact with, or responsibility for, the patient at risk. What happened to the chain of ethical responsibility in such cases? The question is strictly rhetorical, as the same companies dominate any appeal process that may be provided for in law.
So on the one hand we have the most predatory of major industrial enterprises, the drug companies; a self-serving professional organization (psychiatry) that operates on the basis of science-by-committee; and a self-interested insurance industry. Yet we are asked to believe that their combined work product serves the public interest to the point where they should be allowed to stake unique mining claims on our states of mental function. How preposterous. But this does bring us to the final pole in the tent, which is the role of a government that lends the force of law to such aggrandizement. The three major interest groups have simply succeeded in making the instrumentalities of government subservient to their interests. The public need not acquiesce to such machinations.
The second Op-Ed piece in the Sunday LA Times was an article by Steve Salerno lamenting the damage done in this country by an overly enthusiastic self-help movement. His main targets were the empowerment movement, the drive to mobilize self-esteem as an entity separable from any objective basis, and the raw power of disembodied optimism. Self-help healthcare also met with his disapproval:
“Consider healthcare, where vague notions of personal empowerment are a key factor in the startling American exodus from traditional medicine. A comprehensive study reported in the medical journal JAMA pegged the number of patient visits to alternative-medicine practitioners at 629 million a year, easily eclipsing the 386 million visits to conventional MDs. In theory, these defections represent a desire for “self-empowered healing” that will “put people in charge of their healthcare destiny,” to quote one holistic health website. In practice, the trend puts hordes of Americans at the mercy of quacks who shrewdly position themselves at the nexus of mind and body. It behooves us to remember that feeling better about a health problem is not the same as doing better.”
Ouch. I don’t need to address the substance of this complaint to the readership of this newsletter. Obviously we believe we have something that takes us beyond Tony Robbins, something that can put meat on the bones of Martin Seligman’s positive psychology movement and provide the needed tangible basis for enhanced self-esteem. My point is rather to call attention to the fact that the ground of contention for both Salerno and Savodnik is the terrain beyond classical mental disorders. This is really the natural turf for neurofeedback, one currently claimed inappropriately by psychiatry on the one hand, and by an undisciplined, vacuous empowerment movement on the other. The answer for us lies in “rendering unto Caesar what is Caesar’s,”as I have suggested before, and to construct something new that does not require us to take up quarter in the already occupied edifice around the formal mental disorders.
It is with respect to the psychiatric overreach alluded to above that we must begin to construct an alternative model. Here we are on the most solid ground. The “soft failures” of disregulation are our natural terrain. Meanwhile, the cost-benefit ratio of the major drugs progressively ceases to pencil out in application to such minor disregulations. We do not need to make extraordinary claims to succeed at what we do. We don’t need to fight for a larger share of the reimbursement pie. Shaping neurofeedback to qualify systematically for reimbursement, to define it as a routinely reimbursable “procedure,” would be an unnatural, contortionist act that would leave the major promise of neurofeedback unfulfilled. Further, the field would from then on be shaped by forces that are not heading our way and are not congenial to our worldview.