Volume 46 Number 22 page 4-4
American Psychiatric Association
From the President (now the former president)
Psychotherapy in a Changing World
John Oldham, M.D.
an excerpt:
First off, the American Psychiatric Association needs to clean up their own side of the psychiatric diagnosis and treatment street. After that, share with the world just how this was done. Tell the public what safeguards the APA has implemented which will hold unethical psychiatrists accountable. Tell the world how the APA will help prosecute psychiatists whose criminal prescription practices harms and kills their patients; including those who submit fraudulent claims and defraud the American people through Medicaid and Medicare. Tell the world the APA will no longer protect the individual psychiatrists whose unethical "care" standards and treatment protocols are without scientific support. Psychiatric care standards are in effect, marketing tools, not ethical medical care standards---which is why the standards harm, disable and kill psychiatric patients; calling them "standard practices" distorts the meaning of "standard practice."
Psychiatry has in effect, redefined what the term "standard practice" signifies. In psychiatry, a standard practice is legal mechanism to protect psychiatrists; traditionally, standards of care were developed in medicine to protect the patients from unethical professionals. Being "experts" who are practicing a sub-specialty of medicine, psychiatrists have implemented unethical standards of care which the APA and the AACAP have codified by taking a vote, i.e. consensus. The standards are theoretically validated by evidence in clinical research and practice, i.e. the evidence base. Standards of care with little to no foundation in accurately reported research or carefully reported clinical care experience, are not ethical standards of care, consenus based standards are merely an affirmative defense for medical malpratice for the iatrogenic injuries recklessly inflicted as a direct result of using unethical treatment standards.
Psychiatry's standards of care cause a significant percentage of people who become psychiatric patients to be permanently disabled and die preciptiously from numerous iatrogenic diseases and injuries. Many die from drug-induced or iatrogenically induced homicide, the deaths are classified as "natural" which is despicable, criminal really... With these common real world outcomes, calling what psychiatry does an "ethical medical specialty" is insulting to one's intelligence. In effect, a standard practice, has become a way to hang psychiatric patients in distress out to dry, in order to protect unethical psychiatrists who use unethical standards of care with impunity. Claiming the treatment is in a patient's best interest and iatrogenic injuries are "tolerable side effects" while simultaneously refusing to acknowledge or address the harm done to patients is bullying; not an ethical medical practice. The prolific use of teratogenic drugs is a standard that is supported by consensus, a political process, not a scientific finding of safety and effectiveness of the recommended treatments. Using treatment algorithms and protocols that are not supported by evidence is shameful and indefensible, consensus is no substitute for relying on sound scientific principles, relevant data, and ethical medical principles. It is human experimentation that psychiatry has codified as the psychiatric "standard of care" used in clinical practice.
Psychiatry developed standards of care to legitimize psychiatry as a medical specialty, and prevent psychiatrists from being held legally liable for damage done to iatrogenically injured patients. In effect, psychiatry's standards of care are primarily an affirmative defense to protect professionals. Psychiatrists have only to demonstrate they followed a "standard clinical practice," to refute malpractice claims---that the standard has no evidence-base and is unethical, apparently doesn't "legally"matter ... The original purpose of having (ethical) standards of care is to protect patients; psychiatry's standards--(or lack therof) serve to protect psychiatrists.
Obviously, abusing authority, using manipulation, misinformation and coercion as treatment tools, is unethical. The nature of the acts involved in the abuse of power and authority and weilding power to control vulnerable people and while depriving them of the means of defending themselves, is not made innocuous, or transformed into a therapeutic practice just because it is being done by doctors in standard clinical proactice. In reality, the fact that it is doctors doing these things make the crimes praticularly heinous because they are being carried out under the guise of medical beneficence. The fact that these unethical behaviors and standards of care are being vehemently defended instead of focusing on how to improve the validity of the diagnostic and patient care standards and thereby improve the real world outcomes of psychiatric patients, is the most troubling aspect of the ongoing crisis of conscience in psychiatry.
As long as the APA has "leaders" in it's hierarchy who exhibit or condone the bad behavior of it's members, and fails to censure unethical academians, e.g. the ego-driven professionals who are PHarma's whores; the APA will lack the trust that only comes from exhibiting ethical conduct and using ethical scientific principles in the practice of medicine. The APA consistently refuses to discredit individual psychiatrist who sell their professional opinions to the highest bidder; the APA continues to publish conflict-ridden op-eds and ghost-written research articles in it's "peer-reviewed" professional journals, and uses textbooks based on fraudulent or sub-standard research data. These facts make past and present APA presidents proclamations, editorial opinions and criticisms, nearly if not entirely, worthless. To realistically be considered a credible requires a consistent record for having exercising ethically sound medical judgement, and a consistent record of using standard ethical scientific research methods and principles. Psychiatry as a profession has not demonstrated that it values either of these ethical principles with any consistency. Without a record for ethical integrity, attempting to critique other mental health professionals, appear to be nothing more than juvenile attempts to divert the public's attention away from the APA's serious ethical failures, which is where the focus belongs.
"In a recent TIME Healthland blog, Alan Kazdin responded to questions in a posting with the unfortunate title "Q&A: A Yale Psychologist Calls for the End of Individual Psychotherapy." I found the title puzzling and misleading, since Kazdin acknowledged, in a thoughtful article referred to in the blog, that there is strong evidence of the effectiveness of psychotherapy to treat many psychiatric conditions. Kazdin's concern was that the percentage of people who really need this treatment and actually receive it is extremely low. He urged us to develop new and different ways to provide treatment to reach more people, and I agree. The challenge is substantial, however, and he says that "the poor public has no chance. You go to the bookstore or look online, and 99 percent of what you get is someone winging it." It's hard to argue with most of that.
"Psychiatrists and behavioral health clinicians have been studying the effectiveness of psychotherapy for years. Published randomized, controlled trials are piling up demonstrating the effectiveness of many types of therapy, from cognitive to behavioral to psychodynamic and more, for conditions ranging from mood and anxiety disorders to personality disorders. Yet far at the other end of the spectrum, often under the same heading of "therapy," untested strategies are proliferating. While some of these offerings may help some who are suffering, others may be frankly ineffective, unethical, or the psychological equivalent of snake oil." (emphasis mine)
Oldham then asks, "What to do?" I am more than a little disgusted by members of the APA who focus on what others are doing wrong; there's plenty of the APA's own wrong-doing for the APA to focus on.
"Psychiatrists and behavioral health clinicians have been studying the effectiveness of psychotherapy for years. Published randomized, controlled trials are piling up demonstrating the effectiveness of many types of therapy, from cognitive to behavioral to psychodynamic and more, for conditions ranging from mood and anxiety disorders to personality disorders. Yet far at the other end of the spectrum, often under the same heading of "therapy," untested strategies are proliferating. While some of these offerings may help some who are suffering, others may be frankly ineffective, unethical, or the psychological equivalent of snake oil." (emphasis mine)
Oldham then asks, "What to do?" I am more than a little disgusted by members of the APA who focus on what others are doing wrong; there's plenty of the APA's own wrong-doing for the APA to focus on.
For instance, the "diagnosis and medical treatment" provided by psychiatrists...Psychiatric diagnoses are based on subjective observations and perceptions, i.e. personal opinions; without using diagnostic testing. Psychiatric diagnoses have been defintively declared by the APA to be neurobiological conditions, caused by brain diseases and genetic defects. The APA's declaration is "validated" with a vote among APA members... Declaring diagnoses to be "chemical imbalances," "brain diseases," and "genetic defects" then claiming the diagnoses are incurable, but require life-long "medical treatment" without ever supporting either the declaration, or the claim with any evidence that conforms to any ethical scientific or medical standards is at best, suspect; at worst, it is simply fraudulent. Psychiatrists use teratogenic drugs which are prescribed singularly, and in combinations which are minimally effective. For some people, the drugs are not at all effective; but virtually all the drugs have significant risks for causing chronic impairments, i.e. iatrogenic harm. Some psychiatrists justify using this unethical standard of care with the excuse, "it's ALL we have." examples: Schizophrenia, and PTSD
I'm not a psychiatrist, I'm a MadMother.
I have a challenge for the American Psychiatric Association.
Psychiatry has in effect, redefined what the term "standard practice" signifies. In psychiatry, a standard practice is legal mechanism to protect psychiatrists; traditionally, standards of care were developed in medicine to protect the patients from unethical professionals. Being "experts" who are practicing a sub-specialty of medicine, psychiatrists have implemented unethical standards of care which the APA and the AACAP have codified by taking a vote, i.e. consensus. The standards are theoretically validated by evidence in clinical research and practice, i.e. the evidence base. Standards of care with little to no foundation in accurately reported research or carefully reported clinical care experience, are not ethical standards of care, consenus based standards are merely an affirmative defense for medical malpratice for the iatrogenic injuries recklessly inflicted as a direct result of using unethical treatment standards.
Psychiatry's standards of care cause a significant percentage of people who become psychiatric patients to be permanently disabled and die preciptiously from numerous iatrogenic diseases and injuries. Many die from drug-induced or iatrogenically induced homicide, the deaths are classified as "natural" which is despicable, criminal really... With these common real world outcomes, calling what psychiatry does an "ethical medical specialty" is insulting to one's intelligence. In effect, a standard practice, has become a way to hang psychiatric patients in distress out to dry, in order to protect unethical psychiatrists who use unethical standards of care with impunity. Claiming the treatment is in a patient's best interest and iatrogenic injuries are "tolerable side effects" while simultaneously refusing to acknowledge or address the harm done to patients is bullying; not an ethical medical practice. The prolific use of teratogenic drugs is a standard that is supported by consensus, a political process, not a scientific finding of safety and effectiveness of the recommended treatments. Using treatment algorithms and protocols that are not supported by evidence is shameful and indefensible, consensus is no substitute for relying on sound scientific principles, relevant data, and ethical medical principles. It is human experimentation that psychiatry has codified as the psychiatric "standard of care" used in clinical practice.
It is not ethical.
It is not "medicine."
Psychiatry developed standards of care to legitimize psychiatry as a medical specialty, and prevent psychiatrists from being held legally liable for damage done to iatrogenically injured patients. In effect, psychiatry's standards of care are primarily an affirmative defense to protect professionals. Psychiatrists have only to demonstrate they followed a "standard clinical practice," to refute malpractice claims---that the standard has no evidence-base and is unethical, apparently doesn't "legally"matter ... The original purpose of having (ethical) standards of care is to protect patients; psychiatry's standards--(or lack therof) serve to protect psychiatrists.
The APA needs to tell the world what it will do to prevent unethical researchers from disseminating fraudulent data about psychiatric diagnoses and recommended treatments; and prevent these unethical psychiatrists from providing "professional advice and training" to others...
How will the APA will ensure psychiatrists practice as if
their primary purpose is to serve the patient's best interests?
Obviously, abusing authority, using manipulation, misinformation and coercion as treatment tools, is unethical. The nature of the acts involved in the abuse of power and authority and weilding power to control vulnerable people and while depriving them of the means of defending themselves, is not made innocuous, or transformed into a therapeutic practice just because it is being done by doctors in standard clinical proactice. In reality, the fact that it is doctors doing these things make the crimes praticularly heinous because they are being carried out under the guise of medical beneficence. The fact that these unethical behaviors and standards of care are being vehemently defended instead of focusing on how to improve the validity of the diagnostic and patient care standards and thereby improve the real world outcomes of psychiatric patients, is the most troubling aspect of the ongoing crisis of conscience in psychiatry.
As long as the APA has "leaders" in it's hierarchy who exhibit or condone the bad behavior of it's members, and fails to censure unethical academians, e.g. the ego-driven professionals who are PHarma's whores; the APA will lack the trust that only comes from exhibiting ethical conduct and using ethical scientific principles in the practice of medicine. The APA consistently refuses to discredit individual psychiatrist who sell their professional opinions to the highest bidder; the APA continues to publish conflict-ridden op-eds and ghost-written research articles in it's "peer-reviewed" professional journals, and uses textbooks based on fraudulent or sub-standard research data. These facts make past and present APA presidents proclamations, editorial opinions and criticisms, nearly if not entirely, worthless. To realistically be considered a credible requires a consistent record for having exercising ethically sound medical judgement, and a consistent record of using standard ethical scientific research methods and principles. Psychiatry as a profession has not demonstrated that it values either of these ethical principles with any consistency. Without a record for ethical integrity, attempting to critique other mental health professionals, appear to be nothing more than juvenile attempts to divert the public's attention away from the APA's serious ethical failures, which is where the focus belongs.
Using a juvenile defense tactic serves only to further tarnish
the APA's already sullied reputation.
the APA's already sullied reputation.
To summarize, I believe it is apropos to paraphrase Dr. Oldman:
"While some of psychiatry's offerings may help some who are suffering, others are frankly ineffective, unethical, and the medical equivalent of snake oil."
Psychotherapy in a Changing World in it's entirety:
Not long ago I received an unsolicited e-mail promoting a new book. The author of this work holds a doctorate in "transpersonal psychology" and the book describes the author's work with "transmundo beings," described as "nonearth entities that arise in regression therapy."
Well, OK, I think most of us would agree that this particular "therapy" is pretty far out and is unlikely to show up in published research on evidence-based psychotherapies. But coincidentally, a few days later, a colleague at the Menninger Clinic gave me a few printouts from Web sites offering online counseling or "chats," and these samples barely skimmed the surface of the pages and pages that a Google search serves up about this fast growing industry.
For example, one company offers "private online chats" (by appointment, through an online appointment system, $95 for one 60-minute chat, $888 for 10 one-hour chats, paid through Paypal), or "therapy sessions" (response guaranteed within two days, $39.95 for one e-mail session, $349 for 10 e-mail sessions, paid through Paypal). Therapists' photos, credentials, and profiles are provided, and all online therapists are billed as "licensed or board certified in their states, have at least 10 years' experience, and are carefully selected. . . ."
Another example: a self-described "premier online therapy service" advertises that one can "get live help for depression, stress, relationship issues, mental health issues" for clients who "live in rural areas, are homebound, will not go to therapy in person, want convenient, discreet access." Therapists are "licensed counselors" and "e-mmediate care" is provided. When I accessed this site, however, the "e-mmediate care" page said, "All therapists are currently with clients. Please try again."
And yet one more example: "Get professional online counseling advice now." Photos of the therapists are shown, along with profiles. Rates are shown as well, usually $3 a minute (except for one pricey guy who charges $3.25 a minute).
You get the picture. Yet while this may sound outlandish, if you think about it, it's not really new. Doctors and clinicians charge for services rendered, or by the hour. It's just that once we're on the Web or using other new media, it feels (and is) unregulated. There are more and more "celebrity" therapists whose faces become familiar on network or cable shows, where the temptation to slide close to or over the ethical edge is very real. Diagnose a famous person based on secondhand information or hearsay. Give a sound-bite opinion that may sound wise but may be misunderstood by or even harmful to those who are desperate. I recently came across the Web site of a well-trained, credentialed psychiatrist who offers "street therapy," with video samples of his curbside consultations to strangers on city streets, cameras rolling.
In a recent TIME Healthland blog, Alan Kazdin responded to questions in a posting with the unfortunate title "Q&A: A Yale Psychologist Calls for the End of Individual Psychotherapy." I found the title puzzling and misleading, since Kazdin acknowledged, in a thoughtful article referred to in the blog, that there is strong evidence of the effectiveness of psychotherapy to treat many psychiatric conditions. Kazdin's concern was that the percentage of people who really need this treatment and actually receive it is extremely low. He urged us to develop new and different ways to provide treatment to reach more people, and I agree. The challenge is substantial, however, and he says that "the poor public has no chance. You go to the bookstore or look online, and 99 percent of what you get is someone winging it." It's hard to argue with most of that.
Psychiatrists and behavioral health clinicians have been studying the effectiveness of psychotherapy for years. Published randomized, controlled trials are piling up demonstrating the effectiveness of many types of therapy, from cognitive to behavioral to psychodynamic and more, for conditions ranging from mood and anxiety disorders to personality disorders. Yet far at the other end of the spectrum, often under the same heading of "therapy," untested strategies are proliferating. While some of these offerings may help some who are suffering, others may be frankly ineffective, unethical, or the psychological equivalent of snake oil.
What to do? The world is changing very fast, and the Internet is a main engine of change. The development of Web-based therapy was inevitable, and new video-link technology makes "face-to-face" treatment available to remote areas where in-person resources are scarce. APA endorses in-person, face-to-face psychotherapy as an evidence-based, effective treatment for many conditions, spelled out in detail in our practice guidelines. But we need to get on board with the technology of tomorrow, taking an active role to harness its potential, so that more people who need help can get valid, legitimate help in new and nontraditional ways.
One organization doing just that is the American Association for Technology in Psychiatry, in which many APA members are part of a team dedicated to promoting "the use of information technology to improve the quality and availability of psychiatry and mental health care." In addition to establishing a new ECP/MIT Work Group on New Technology, which will focus on improving communication within APA, I am putting the topic of "e-therapy" on the agenda for discussion at the Board of Trustees meeting.
Meantime, while we're exploring new horizons, let's keep teaching each other about the psychotherapy of today. One great opportunity to do just that is already confirmed for our annual meeting in Philadelphia in May 2012. At the Opening Session on Sunday, May 6, a special presentation is planned titled "Cognitive Therapy and Psychodynamic Therapy: More Alike Than Different? A Conversation Between Aaron Beck and Glen Gabbard." I'll be moderating this session, and I'm delighted to be able to share the stage with these uncontested leaders in the world of psychotherapy. Mark your calendars! here
Not long ago I received an unsolicited e-mail promoting a new book. The author of this work holds a doctorate in "transpersonal psychology" and the book describes the author's work with "transmundo beings," described as "nonearth entities that arise in regression therapy."
Well, OK, I think most of us would agree that this particular "therapy" is pretty far out and is unlikely to show up in published research on evidence-based psychotherapies. But coincidentally, a few days later, a colleague at the Menninger Clinic gave me a few printouts from Web sites offering online counseling or "chats," and these samples barely skimmed the surface of the pages and pages that a Google search serves up about this fast growing industry.
For example, one company offers "private online chats" (by appointment, through an online appointment system, $95 for one 60-minute chat, $888 for 10 one-hour chats, paid through Paypal), or "therapy sessions" (response guaranteed within two days, $39.95 for one e-mail session, $349 for 10 e-mail sessions, paid through Paypal). Therapists' photos, credentials, and profiles are provided, and all online therapists are billed as "licensed or board certified in their states, have at least 10 years' experience, and are carefully selected. . . ."
Another example: a self-described "premier online therapy service" advertises that one can "get live help for depression, stress, relationship issues, mental health issues" for clients who "live in rural areas, are homebound, will not go to therapy in person, want convenient, discreet access." Therapists are "licensed counselors" and "e-mmediate care" is provided. When I accessed this site, however, the "e-mmediate care" page said, "All therapists are currently with clients. Please try again."
And yet one more example: "Get professional online counseling advice now." Photos of the therapists are shown, along with profiles. Rates are shown as well, usually $3 a minute (except for one pricey guy who charges $3.25 a minute).
You get the picture. Yet while this may sound outlandish, if you think about it, it's not really new. Doctors and clinicians charge for services rendered, or by the hour. It's just that once we're on the Web or using other new media, it feels (and is) unregulated. There are more and more "celebrity" therapists whose faces become familiar on network or cable shows, where the temptation to slide close to or over the ethical edge is very real. Diagnose a famous person based on secondhand information or hearsay. Give a sound-bite opinion that may sound wise but may be misunderstood by or even harmful to those who are desperate. I recently came across the Web site of a well-trained, credentialed psychiatrist who offers "street therapy," with video samples of his curbside consultations to strangers on city streets, cameras rolling.
In a recent TIME Healthland blog, Alan Kazdin responded to questions in a posting with the unfortunate title "Q&A: A Yale Psychologist Calls for the End of Individual Psychotherapy." I found the title puzzling and misleading, since Kazdin acknowledged, in a thoughtful article referred to in the blog, that there is strong evidence of the effectiveness of psychotherapy to treat many psychiatric conditions. Kazdin's concern was that the percentage of people who really need this treatment and actually receive it is extremely low. He urged us to develop new and different ways to provide treatment to reach more people, and I agree. The challenge is substantial, however, and he says that "the poor public has no chance. You go to the bookstore or look online, and 99 percent of what you get is someone winging it." It's hard to argue with most of that.
Psychiatrists and behavioral health clinicians have been studying the effectiveness of psychotherapy for years. Published randomized, controlled trials are piling up demonstrating the effectiveness of many types of therapy, from cognitive to behavioral to psychodynamic and more, for conditions ranging from mood and anxiety disorders to personality disorders. Yet far at the other end of the spectrum, often under the same heading of "therapy," untested strategies are proliferating. While some of these offerings may help some who are suffering, others may be frankly ineffective, unethical, or the psychological equivalent of snake oil.
What to do? The world is changing very fast, and the Internet is a main engine of change. The development of Web-based therapy was inevitable, and new video-link technology makes "face-to-face" treatment available to remote areas where in-person resources are scarce. APA endorses in-person, face-to-face psychotherapy as an evidence-based, effective treatment for many conditions, spelled out in detail in our practice guidelines. But we need to get on board with the technology of tomorrow, taking an active role to harness its potential, so that more people who need help can get valid, legitimate help in new and nontraditional ways.
One organization doing just that is the American Association for Technology in Psychiatry, in which many APA members are part of a team dedicated to promoting "the use of information technology to improve the quality and availability of psychiatry and mental health care." In addition to establishing a new ECP/MIT Work Group on New Technology, which will focus on improving communication within APA, I am putting the topic of "e-therapy" on the agenda for discussion at the Board of Trustees meeting.
Meantime, while we're exploring new horizons, let's keep teaching each other about the psychotherapy of today. One great opportunity to do just that is already confirmed for our annual meeting in Philadelphia in May 2012. At the Opening Session on Sunday, May 6, a special presentation is planned titled "Cognitive Therapy and Psychodynamic Therapy: More Alike Than Different? A Conversation Between Aaron Beck and Glen Gabbard." I'll be moderating this session, and I'm delighted to be able to share the stage with these uncontested leaders in the world of psychotherapy. Mark your calendars! here
photo from http://www.justducks.co.uk/
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