ON 19 August 2005 the American Psychiatric Association published an article, in Psychiatric News, entitled ‘Big Pharma and American Psychiatry: The Good, the Bad, and the Ugly’ (see tinyurl.com/97g7j). It stated:
There is widespread concern at the over-medicalization of mental disorders and the overuse of medications. Financial incentives and managed care have contributed to the notion of a ‘quick fix’ by taking a pill and reducing the emphasis on psychotherapy and psychosocial treatments. There is much evidence that there is less psychotherapy provided by psychiatrists than 10 years ago. This is true despite the strong evidence base that many psychotherapies are effective used alone or in combination with medications… If we are seen as mere pill pushers and employees of the pharmaceutical industry, our credibility as a profession is compromised. (p.3)
ON 19 August 2005 the American Psychiatric Association published an
article, in Psychiatric News, entitled ‘Big Pharma and American
Psychiatry: The Good, the Bad, and the Ugly’ (see tinyurl.com/97g7j). It stated:
There is widespread concern at the over-medicalization of mental
disorders and the overuse of medications. Financial incentives and
managed care have contributed to the notion of a ‘quick fix’ by taking
a pill and reducing the emphasis on psychotherapy and psychosocial
treatments. There is much evidence that there is less psychotherapy
provided by psychiatrists than 10 years ago. This is true despite the
strong evidence base that many psychotherapies are effective used alone
or in combination with medications… If we are seen as mere pill pushers
and employees of the pharmaceutical industry, our credibility as a
profession is compromised. (p.3)
Printing this dissident viewpoint, directly counter to international
(particularly US) thinking for the past three decades, was a courageous
move by the APA. It reminded me of the late Loren Mosher’s magnificent
letter of resignation from the APA in 1998:
Psychiatry has been almost completely bought out by the drug companies.
The APA could not continue without the pharmaceutical company support
of meetings, journal advertising, luncheons, unrestricted educational
grants etc. Psychiatrists have become the minions of drug company
promotions… No longer do we seek to understand whole persons in their
social contexts – rather we are there to realign our patients’
What was astonishing about this revival of Mosher’s concerns was that
it was not just another rebel screaming at the indifference of his
profession before resigning – it was Steven Sharfstein, the APA
As if in response to Mosher’s call to ‘Get real about science, politics
and money. Label each for what it is,’ Sharfstein added: ‘Drug company
representatives bearing gifts are frequent visitors to psychiatrists’
offices and consulting rooms. We should have the wisdom and distance to
call these gifts what they are – kickbacks and bribes.’
The first time I attended a psychiatry conference, of the Royal
Australian and New Zealand College of Psychiatrists years ago, I was
sickened by the extent of the drug industry’s presence. Among the
endless stalls distributing ‘gifts’, perfect young bodies in skintight
bodysuits pranced around enticing psychiatrists to have ‘free’
massages. My announcing that there were more company representatives
listed as delegates than psychiatrists from the whole of New Zealand
was met with stony silence.
Last year I broke my vow never to attend such conferences again and
went to the World Psychiatric Association Congress in Florence. The
dominance of the drug companies was reflected in the ‘scientific
programme’, which contained little other than drug studies. After one
of my papers (‘The treatment of psychosis in the context of childhood
trauma’) a psychiatrist from Scotland stood up to say: ‘Calm down,
John. You are winning. We get it. Things are changing.’
But are we winning? What would winning mean? At a conference in
Vancouver last year Dr Robin Murray gave an encouraging plenary
address. He acknowledged some of the recent research about the role of
psychosocial factors influencing schizophrenia. He concluded, however,
that ‘the schizophrenia wars were over years ago’. He was referring to
the truce established under the banner of the ‘bio-psycho-social’
model, which says that schizophrenia is an interaction between a
genetically inherited predisposition and the triggering effect of
social stressors. But I think the war is far from over.
I explained that in most wars the invading power is premature in
announcing a cessation of hostilities, usually once they have reduced
the inhabitants of the invaded country to uncoordinated, sporadic
resistance. I said that many of us still feel we are living in occupied
territory. The war would end, I continued, only when simplistic
biological ideologies and technologies withdrew to the appropriate
boundary and acknowledged the damage caused by their illegitimate
In 2004, along with 23 other contributors from six countries and a
range of disciplines (including service users), I published what was
consciously intended as a coordinated counter-attack in the ‘war’. In
the opening chapter of Models of Madness: Psychological, Social and
Biological Approaches to Schizophrenia, my co-editors (Richard Bentall
and Loren Mosher) and I make our intentions quite clear. We argue that
the heightened sensitivity, unusual experiences, distress, despair,
confusion and disorganisation that are currently labelled
‘schizophrenic’ are not symptoms of a medical illness. The notion that
‘mental illness is an illness like any other’, promulgated by
biological psychiatry and the pharmaceutical industry, is not supported
by research and is extremely damaging to those with this most
stigmatising of psychiatric labels. It is responsible for unwarranted
and destructive pessimism about the chances of ‘recovery’, and has
ignored – or even actively discouraged discussion of – what is actually
going on in these people’s lives, in their families, and in the
societies in which they live.
Models of Madness brings together the body of evidence that will
increase the confidence of the majority when faced with that misguided
but powerful minority who proclaim with all the trappings of scientific
and professional expertness: ‘It’s an illness – so you must take the
drugs’, by force if necessary. I say ‘the majority’ because numerous
international surveys show that the public (like most mental health
professionals and their clients), when asked what causes schizophrenia,
cite social factors such as poverty and traumatic childhoods, far more
often than bio-
genetic factors (Read & Haslam, 2004).
Psychologists, like other academics and health professionals, tend to
be rather thoughtful and kindly folk. Most prefer not to engage in
wars, of any kind. So it is understandable that so many psychologists
have accepted the so-called bio-psycho-social model. It allows
psychologists interested in schizophrenia to study which psychosocial
factors trigger the supposed genetic predisposition, as long as they
are prepared to ignore the absence of reliability or validity for the
construct they are studying (Bentall, 2003). It permits clinical
psychologists to help ‘schizophrenics’ manage their symptoms and
prevent relapses by encouraging families to
lower their ‘expressed emotion’ (an odd euphemism for hostility and
criticism). Anyway, why bother with the tedious old nature–nurture
battle now we know everything is an interaction of the two?
Nevertheless, the supposed integration of perspectives implied by the
term ‘bio-psycho-social’ model since the 1970s is more illusion
than reality. An integral part of this has been the
‘vulnerability-stress’ idea that acknowledges a role for social
stressors but only in those who already have a supposed genetic
predisposition. Life events have been relegated to the role of
‘triggers’ of an underlying genetic time-bomb. This is not an
integration of models, it is a colonisation of the psychological and
social by the biological. The colonisation has involved the ignoring,
of research showing the role of contextual factors such as neglect,
trauma (inside and beyond the family), poverty, racism, sexism, etc. in
the etiology of madness. The colonisation even went so far as to invent
the euphemism ‘psycho-education’ for programmes promulgating the
illness ideology to individuals and families.
I admit to a barely suppressed ‘Yes!’ when I read Sharfstein’s comment
‘We must examine the fact that as a profession, we have allowed the
bio-psycho-social model to become the bio-bio-bio model’. So perhaps
things really are changing. On
a good day I can see plenty of evidence. The international
consumer/survivor movement is alive and well (Chamberlin, 2004).
British cognitive psychologists are leading a renaissance of the
involvement of psychologists in the psychosis field, an area we largely
abandoned after the introduction of antipsychotic drugs in the 1950s.
They are demonstrating not only that hallucinations and delusions are
perfectly understandable in terms of normal psychological processes
(e.g. Garety et al., 2001) but also that cognitive therapy is effective
for psychosis (e.g. Kingdon & Turkington, 2005) – with or without
medication (Morrison et al., 2004). Several other psychological
approaches have also been proven effective (Martindale et al., 2000;
Read et al., 2004).
Researchers around the world are less afraid to study psychosocial
factors, including the near taboo subject of family dysfunction (Read,
Seymour & Mosher, 2004) as causal agents in the etiology of
psychosis, rather than as mere triggers or exacerbators of an imaginary
or, at best, grossly exaggerated genetic predisposition (Joseph, 2003).
Poverty (Read, 2004), urban living (van Os et al., 2001), racism
(Karlsen & Nazroo, 2002), other forms of discrimination (Janssen et
al., 2003), child abuse (e.g. Read et al., 2003; Read et al., in press)
and having a battered mother (Whitfield et al., 2005) have all been
shown to be highly predictive of psychosis. Some even dare to speak of
schizophrenia as being preventable via universal programmes enhancing
children’s safety and quality of life (Davies & Burdett, 2004).
There are other positive signs. I have spoken to full houses at the
first two British conferences on trauma and psychosis, our book has
received positive reviews in psychiatric journals, and the
International Society for the Psychological Treatments
of the Schizophrenias and other Psychoses (www.isps.org) has grown enormously.
The true measure of progress, however, is on the front line of
practice. The emerging pockets of excellence across the UK must be
brought to the attention of managers still harbouring the
industry-sponsored notion that drugs are always the first-choice
treatment. The simple truths are that human misery is largely inflicted
by other people and that the solutions are best based on human – rather
than chemical or electrical – interventions. If mental health service
users were involved in negotiating the final truce in the
‘schizophrenia wars’, the bio-bio-bio model would be history. People
- Dr John Read is in the Psychology Department, University of Auckland, New Zealand. E-mail: email@example.com. Homepage: tinyurl.com/chwzb.
Bentall, R. (2003). Madness explained: Psychosis and human nature. London: Penguin.
Chamberlin, J. (2004). User-run services. In J. Read et al. (2004). Hove: Brunner-Routledge.
Davies, E. & Burdett, J. (2004). Preventing ‘schizophrenia’:
Creating the conditions for saner societies. In J. Read et al. (2004).
Garety, P. et al. (2001). A cognitive model of the positive symptoms of psychosis. Psychological Medicine, 31, 189–195.
Janssen, I., Hanssen, M., Bak, M. et al. (2003). Discrimination and
delusional ideation. British Journal of Psychiatry, 182, 71–76.
Joseph, J. (2003). The gene illusion. Ross-on-Wye: PCCS Books.
Karlsen, N. & Nazroo, J. (2002). Relation between racial
discrimination, social class and health among ethnic minority groups.
American Journal of Public Health, 92, 624–631.
Kingdon, D. & Turkington, D. (2005). Cognitive therapy of schizophrenia. New York: Guilford Press.
Martindale, B., Bateman, B., Crowe, M. & Margison, F. (Eds.)
(2000). Psychosis: Psychological approaches and their effectiveness.
Morrison, A.P., French, P., Walford, L. et al. (2004). Cognitive
therapy for the prevention of psychosis in people at ultra-high risk.
British Journal of Psychiatry, 185, 291–297.
Read, J. (2004). Poverty, ethnicity and gender. In J. Read et al. (2004). Hove: Brunner-Routledge.
Read, J., Agar, K., Argyle, N. & Aderhold, V. (2003). Sexual and
physical abuse during childhood and adulthood as predictors of
hallucinations, delusions and thought disorder. Psychology and
Psychotherapy: Research, Theory and Practice, 76, 11–22.
Read, J. & Haslam, N. (2004). Public opinion: Bad things happen and
can drive you crazy. In J. Read et al. (2004). Hove: Brunner-Routledge.
Read, J., Mosher, L. & Bentall, R. (2004). Models of madness. Hove: Brunner-Routledge.
Read, J., Seymour, F. & Mosher, L. (2004). Unhappy families. In J. Read et al. (2004). Hove: Brunner-Routledge.
Read, J., van Os, J., Morrison, A.P. & Ross, C.A. (in press).
Childhood trauma, psychosis and schizophrenia: A literature review with
theoretical and clinical implications. Acta Psychiatrica Scandinavica.
van Os, J., Hanssen, M., Bijl, R. & Vollebergh, W. (2001).
Prevalence of psychotic disorder and community level of psychotic
symptoms. Archives of General Psychiatry, 58, 663–668.
Whitfield, C., Dube, S., Felitti, V. & Anda, R. (2005). Adverse
childhood experiences and hallucinations. Child Abuse and Neglect, 29,