Psychiatry Under the Influence

Institutional Corruption, Social Injury, and Prescriptions for Reform

R. Whitaker, L. Cosgrove

• Publisher: Palgrave Macmillan
• Year: 2015
• ISBN:
  9781137516022
• Topic: Social Sciences
• Subtopic: Global Development Studies
• Index: Social Sciences

Psychiatry Under the Influence investigates the actions and practices of the American Psychiatric Association and academic psychiatry in the United States, and presents it as a case study of institutional corruption.

P A R T I

Seeds of Corruption

C H A P T E R O N E

A Case Study of Institutional Corruption

Institutional corruption, as a field of inquiry, does not shy away from challenging powerful institutions—from Congress and the professions to the academy itself . . . and it leads us to interrogate them in important ways.

—Jonathan H. Marks, 2012¹

In a democratic society, we hope and expect that institutions that serve a public interest will adhere to ethical and legal standards. However, in recent years, we have seen numerous institutions failing to meet that obligation. Greed on Wall Street nearly led to the collapse of our public banking system. Congress is beholden to special interests. We have seen a religious institution, the Catholic Church, systematically fail to protect children from sexual abuse. What these scandals share in common is that they cause social harm and erode the public’s faith in its institutions, and thus weaken the democratic core of society.

In this book, we put the spotlight on a medical discipline, organized psychiatry, that has transformed our society in the past 30 years.

Our society thinks of medicine as a noble pursuit, and thus it expects a medical profession to rise above financial influences that might lead it astray. The public expects that medical researchers will be objective in their design of studies and their analysis of the data; that the results will be reported in an accurate and balanced way; and that the medical profession will put the interests of patients first. However, in recent years, there has been a steady flow of reports, both in the mainstream media and in academic journals, detailing the corrupting influence that pharmaceutical money has had on modern medicine. In a 2009 essay, Daniel Wikler, a professor of ethics at Harvard School of Public Health, wrote of how this is undermining societal confidence in the medical profession:

Erosion of medical integrity is not a mere detail, but rather strikes at the heart of what it is to practice medicine. The basis for medicine’s claim to be a profession rather than a trade, exchanging a degree of self-governance and autonomy to be trusted experts, is the assurance that this trust will not be misplaced.²

Or as Giovanni Fava, editor of Psychotherapy and Psychosomatics, wrote in 2007: “The issue of conflicts of interest in medicine has brought clinical medicine to an unprecedented crisis of credibility.”³

While conflicts of interest may bedevil many medical disciplines, psychiatry is often seen at the epicenter of this “crisis of credibility.” In a 2000 editorial titled “Is Academic Medicine for Sale,” New England Journal of Medicine editor Marcia Angell told of how her journal, when it sought to find an expert to write a review of an article on the treatment of depression, “found very few who did not have financial ties to drug companies that make antidepressants.”⁴ More recently, in 2008, Senator Charles Grassley sent a letter to the American Psychiatric Association (APA), expressing his concerns about industry influence over the APA and all of organized psychiatry. The social peril is that undue industry influence may be compromising organized psychiatry’s public health mission in subtle but far-reaching ways.

Although our society today is focused on the possible corrupting influence of pharmaceutical money on medical disciplines, it is important to recognize that guild interests may also affect their behavior. As Kerianne Quanstrum, a physician at the University of Michigan, noted in a 2010 letter in the New England Journal of Medicine:

Although it is true that individual medical providers care deeply about their patients, the guild of health care professionals—including their specialty societies—has a primary responsibility to promote its members’ interests. Now, self-interest is not in itself a bad thing; indeed it is a force for productivity and efficiency in a well-functioning market. But it is a fool’s dream to expect the guild of any service industry to harness its self-interest and to act according to beneficence alone—to compete on true value when the opportunity to inflate perceived value is readily available.⁵

Like all medical specialty organizations, the APA is not immune to such ethical challenges. It may be characterized as both a professional organization and a guild, and in this latter function it is expected to further the interests of the profession and its members. Thus, it may feel a strong need to promote a societal belief in the merits of treatments prescribed by psychiatrists, even if science is raising questions about those treatments. As a result, the APA may struggle to provide unbiased information and guidance for the treatment of mental disorders. APA’s guild interests may conflict with its public health mission, providing a fertile ground for institutional corruption.

Such worries raise a profound set of questions that, given psychiatry’s pervasive influence over our society today, need to be answered. Over the past 35 years, has organized psychiatry met its societal obligation to conduct objective research? Has it disseminated fully accurate information on the efficacy and safety of psychotropic medications? Has it produced truly evidence-based diagnostic and clinical practice guidelines? And if organized psychiatry has not fully met those ethical obligations, what has been the resulting social harm?

Conceptually, we see the APA and academic psychiatry as the twin pillars of organized psychiatry in the United States, and thus jointly the “institution” we are studying. Together, they produce the diagnostic and treatment guidelines that determine psychiatric care in the United States. The psychiatric nosology that the APA produces, the Diagnostic and Statistical Manual of Mental Disorders (DSM), is often referred to as the “bible” of psychiatric disorders; the nomenclature, criteria, and standardization of psychiatric disorders codified in the DSM affect a diverse set of areas ranging from insurance claims to jurisprudence. Moreover, through its relationship to the International Classification of Diseases, the system used for classification by many countries around the world, the DSM has a global reach.

For this reason, the influence of American psychiatry extends beyond US borders. Numerous other societies—particularly in Western Europe, Canada, Australia, and New Zealand—have embraced the medical model of care promoted by American psychiatry, and this has led to a marked increase in the diagnosis of mental disorders in those societies too, and in their use of psychiatric medications. Much of the Western world has reason to inquire about the ethics of organized psychiatry.

Studying Institutional Corruption

This book arose out of a year that we, the two authors of this book, spent as fellows at the Edmond J. Safra Center for Ethics at Harvard University. The center has sought to develop an intellectual framework for identifying, investigating, and understanding institutional corruption, with the hope that this process ultimately illuminates solutions for remedying the problem. We are exploring this topic, the ethics of modern psychiatry, through that ethical lens.

First and foremost, institutional corruption is to be distinguished from individual corruption. When we speak about “corrupt behavior,” we usually think about how individuals may have acted in immoral or even illegal ways, and have done so for personal gain. That is a story of “bad people” doing “bad things.” In those instances, individuals within an institution may have behaved in a corrupt manner, but the institution itself, in its “normative” practices, may not have become corrupt. For instance, we think of Bernie Madoff as a financial manager who acted in a criminal manner, that is, outside the norm, and thus we don’t necessarily see, in his behavior, evidence of institutional corruption within the larger financial investment community.

Institutional corruption is different. The problem does not arise from a few corrupt individuals who are hurting an organization, even though the organization’s integrity remains intact. Instead, as Lawrence Lessig, director of the Edmond J. Safra Center for Ethics has observed, institutional corruption refers to the systemic and usually legal practices that cause the institution to act in ways that undermine its public mission and effectiveness, and ultimately weaken public trust in the institution. There is a “bending” of the original mission, which results from the normalization of behaviors that compromise truth-seeking. Such practices and behaviors may arise when there are financial incentives at work that encourage the members of the institution to regularly behave in ways that undermine the institution’s integrity and its capacity to fulfill its public mission. Moreover, the leaders of the organization will likely be unaware that their institution has become “corrupted,” and protest against those who have come to see their institutional behavior as being at odds with the organization’s intended mission.

Indeed, within this framework of institutional corruption, there is the assumption the individuals within the institution are “good” people. Lessig made this point in his writings on Congress: “These are not bad souls bending the public weal to private ends . . . We can presume that individuals within the institution are innocent; the economy of influence that they have allowed to evolve is not.”⁶

As can be seen, thinking of institutional corruption in this manner focuses attention on the larger social, political, and cultural factors that affect the institution. Institutions exist within a larger socio-political context. Thus, there is a need to identify the “economies of influence” that create the potential for improper dependencies to develop. Whereas individual quid pro quo corruption assumes that there is a “bad apple” problem, the framework of institutional corruption seeks to understand whether there is a “bad barrel” problem. This understanding in turn leads to a framework for identifying proposed solutions, as they must neutralize the financial influences that have corrupted the institution in a systematic way.

A Case Study of Institutional Corruption

We see this book as a case study of institutional corruption. The APA’s stated mission is to provide “humane care and effective treatment for all persons with mental disorders,” and we examine its past 35-year history to assess whether it has stayed true to that mission. First, we document how two “economies of influence” over the field—pharmaceutical funds and guild interests—arose and became entrenched. Then we look at how these influences have led to a distortion of “scientific truths” and to significant social injury. Next, having laid out this story of institutional corruption, we investigate whether organized psychiatry, on the whole, recognizes that its behavior may have undermined its public mission and led to a loss of the public’s trust. This inquiry leads us to delve into the science of “cognitive dissonance,” and how difficult it can be for a medical profession, operating under two “economies of influence,” to see itself as compromised. Finally, we explore strategies for reform and remedies for institutional corruption in organized psychiatry.

Given this focus, we are not interested in identifying instances where individuals within psychiatry may have behaved in corrupt or fraudulent ways. Instead, we presume that individuals within psychiatry want to serve their patients well, and that they seek to engage in research that will improve treatments for psychiatric disorders.

Ours is an academic inquiry. Yet, we believe it is of critical importance to American society, and, in fact, to many societies around the world. During the past 35 years, psychiatry has transformed American culture. It has changed our view of childhood and what is expected of “normal” children, so much so that more than 5 percent of school-age youth now take a psychotropic drug daily.⁷ It has changed our behavior as adults, and in particular, how we seek to cope with emotional distress and difficulties in our lives. It has changed our philosophy of being too, as we have come to see ourselves as less responsible for ourselves, and instead more under the control of brain chemicals that may or may not be in “balance.” Our use of psychiatric medic...

Table of contents

• Cover
• Title
• Part I   Seeds of Corruption
• Part II   Science Corrupted