by Chuck Ruby, Ph.D.

An interesting exchange has taken place between psychiatrist and Psychiatric Times author Awais Aftab, M.D. and journalist Robert Whitaker of Mad in America (MIA). The initial trigger was MIA’s March 27th review of a JAMA Psychiatry article that reported how psychiatry has failed to publicize data about treatment success rates over time.

A day after MIA's review, Aftab responded on his "Psychiatry at the Margins" blog, claiming that the MIA review was worded in a way that misrepresented the JAMA Psychiatry article. The title, and essence, of MIA's review was that psychiatry had "no evidence that psychiatric treatments produce 'successful outcomes,'" when the JAMA Psychiatry article actually said:

...success rate trends are rarely reported in psychiatric journals or in other mental health or behavioral medicine journals. This makes it difficult to determine whether psychiatric treatment outcomes are improving over time, stagnating, or perhaps even regressing.

The MIA review language, whether intended or not, does seem to imply that a lack of psychiatric treatment success rates over time is the same as there being no evidence of treatment success. This is contrary to the "absence of evidence is not evidence of absence" idea.

However, absence of evidence regarding this matter is astounding. In science, those who make a claim (such as the often-advertised assertion that psychiatric treatment is increasingly effective and safe over time) are obligated to provide the evidence to support that claim. As the JAMA Psychiatry article confirms, psychiatry has failed to do so. This doesn't mean the evidence isn't "out there" somewhere. But it is a flaw of reasoning, and a threat to consumers' rights and safety, to assume it is.

MIA was on spot in challenging why psychiatry hasn't established these success rates like other medical specialties have. Psychiatry is not exactly a new specialty, having existed for over two centuries, and since its foundation, it has steadily increased its impact and control over millions of lives with chemical, electrical, and surgical treatments for illnesses that it has a very hard time defining or even finding. 

In response to Aftab, Whitaker replied on April 6th, clarifying MIA’s original purpose and mission and further detailing the reasoning used in the MIA review and how important it was to address the problem that psychiatry has not provided trend data about treatment success. As part of his reply, Whitaker cited a litany of psychiatric research to date as a backdrop, which at the least, makes one seriously question the effectiveness and safety of psychiatric treatments, and why trend data is missing.

Aftab again replied to Whitaker on April 9th. But this time, his comments redirected away from the issue of psychiatry's lack of success rate trend data and, instead, he unfortunately seemed to go to lengths to belittle Whitaker and MIA.

He first described Whitaker's thoughtful and comprehensive reply of April 6th as “long-winded” and a “double down in the defense of” the original MIA review. He further suggested it would have been better if, instead of replying to Aftab’s March 28th blog, Whitaker just remained quiet, distanced MIA from the review, or reacted with contrition. This is a familiar reaction by mainstream psychiatry; they seem to only respect criticism that doesn’t seriously attack its foundations.

After this initial disparaging salvo, Aftab then launched into a false equivalency, claiming that both the institution of psychiatry and MIA are guilty of the sin of misleading the public. He pushed even further and resorted to the political red herring ploy of attacking the accuser, saying whatever the institution of psychiatry is guilty of, it doesn’t “absolve MIA of its sins and shortcomings.” This turning of the tables and pointing the finger back at Whitaker and MIA avoids the challenge of the March 27th review, which was about psychiatry’s empirical shortcomings of its widely claimed treatment successes over time. Challenge sidestepped.

Aftab further tries to marginalize Whitaker, condescendingly declaring that he “held some rather naïve ideas about psychiatry in the 1990s through no fault of his own.” Aftab is making the incredulous claim that Whitaker, an award-winning investigative journalist and part of a Pulitzer Prize finalist team, who has covered medicine and science for over 30 years, just doesn’t understand the complexities of psychiatric research. This is another ploy by mainstream psychiatry - when serious criticism comes, just discount it as naïveté. Aftab tops it all off by casting Whitaker and MIA aside with the charge of having “anti-epistemology” blinders.

Aftab spends considerable time (“long-winded”?) exploring questionable charges that Whitaker’s and MIA’s work (and presumably everyone else that challenges psychiatry’s orthodox standing) is contaminated with “trapped priors,” ideas of “progress narratives,” “epistemic echo chambers,” “intentionally selective” research coverage, and “ideological conflicts of interest.” It is ironic that these are the very things that have corrupted institutional psychiatry. Eventually, Aftab punctuates his mocking of Whitaker and MIA by insinuating they are conspiracy theorists.

Institutional psychiatry at its essence, not just its research and practice, is fundamentally flawed. It makes the assumption that emotional distress, suffering, difficult behaviors, and unusual thoughts are its proper target. Given that over 200 years of efforts have produced no evidence that these problems are the result of brain/body pathology that can be medically assessed and treated, it is not surprising that psychiatry cannot present medical success rate trend data. 

In quoting a previous blog of mine:

...research that conforms to proper design, methodology, and analysis to tease out confounding variables of effect and increase confidence in the results, has shown that traditional psychiatric treatment is either ineffective, only marginally effective, only temporarily effective, is "treatment that works," or is "efficacious in reducing symptoms." The latter two outcomes are examples of the ubiquitous medicalese commonly used by the mainstream to portray psychiatry's work as medical science. But in the case of prescribed drugs and ECT, the medicalese merely describes the psychoactive effects of chemicals and electricity and how they can act as tranquilizing (or energizing) agents, pushing someone to the point of not being as troubled by real life problems and, thus, not complaining about those problems, giving the false impression of some type of resolution.

Furthermore, those “successes” are presented in isolation, without the context of the longer term harm brought on by repeated treatment of that sort, just like what happens with long term illicit and recreational drug use. A quick snort of cocaine can rejuvenate an exhausted soul, a stiff drink can settle one's angst after a grueling week, and LSD can open up new possibilities. But daily lines of cocaine, stiff drinks, and acid trips can ruin lives, while they do little to address the important human challenges that we all face.

In order to correct this flaw, one of two things must happen. On one hand, psychiatry can abandon the role of the moral arbiter that anoints certain behaviors and experiences as abnormal, sick, inappropriate, but still medical matters, along with attempts to “treat” these transgressions. It can then stick with problems that are due to bodily pathology.

On the other hand, psychiatry can openly announce that it wants to be that moral arbiter, expanding medicine’s role to the extent that the Church did centuries ago in applying a religious model to human suffering. Until psychiatry makes this choice, it will continue to dance the psychiatry two-step, switching from one foot to the other, as it tries to obscure its failures that result from this fundamental flaw, yet continuing to claim professional standing without the evidence.

Again, to quote my previous blog entry, psychiatry is:

…a presumed medical specialty that has no reputable theory about the alleged internal dysfunction that causes mental illness, that has no biomarkers with which to diagnose those illnesses, that has no treatments that correct deficiencies of bodily systems responsible for those illnesses, yet that has a long history of coercing people to act, think, and feel in accordance with an ill-defined and ever-changing set of moral standards.

Chuck Ruby, Ph.D., is a psychologist who has been in private practice for the past 25 years, after a 20-year career with the U.S. Air Force. You can read more about him at his personal website. He is the author of Smoke and Mirrors: How You Are Being Fooled About Mental Illness - An Insider's Warning to Consumers. Dr. Ruby is the past Chairperson of the Board for ISEPP and has been the Executive Director since 2015.