Allen J Frances M.D.

Saving Normal


Reconciling Recovery and Psychiatry: Response to Open Letter

Finding the right balance

Posted Sep 15, 2013

This conversation began a few weeks ago when the editors at Huffington Post asked me to comment on Eleanor Longden's wonderful Ted talk 'Learning From The Voices In My Head' and also on her commentary -'Why I Thank The Voices In My Head'

It is not surprising that hundreds of thousands of people have been deeply touched by Ms Longdon's vivid memoir describing how she was badly harmed by mental health treatment and then saved by her own efforts to find meaning in her voices.

I too felt touched by Ms Longden's courage and intelligence in pursuing her own personal road to recovery, but was also concerned that her message might be taken as a blanket condemnation of all psychiatric treatment.

Ms Longden's decision to go off medicine worked wonderfully well for her, but is not suitable for everyone who hears voices and sometimes leads to disaster.

I titled my response- 'Psychiatry and Recovery: Finding Common Ground and Joining Forces'- and tried to locate a balance between those who focus only the harms of psychiatry and those who praise only its benefits. In my view, it doesn't make any sense to be either completely for psychiatry or completely against it. When psychiatry is done well and for the right indications, it is essential. When psychiatry is done poorly or unnecessarily, it can be quite harmful.

The dialogue has now been usefully furthered by an 'An Open Letter to Allen Frances' posted by Intervoice and signed by more than 140 people.

Supporters of the useful Hearing Voices initiative suggest that I have over stated the case for staying on psychiatric medicine in a way that might caste their approach in an unfavourable light.

I may be missing something, but don't think there is that much difference of opinion. Like Hearing Voices, I am strongly against over diagnosis and over treatment- having written hundreds of blogs, dozens of editorials, and two books warning of the dangers . I have frequently and explicitly attacked Big Pharma and the physicians who over prescribe. My concern about these issues goes back more than forty years- first published in a 1972 Archives of General Psychiatry paper called 'No Treatment As The Treatment of Choice'.

I have met with many people in the survivors movement and fully understand its value and successes. One chapter in my book 'Saving Normal' is devoted to personal memoirs describing all that can go wrong when psychiatric treatment is done badly. You can read a sample 'Two Flew Over the Cuckoo's Nest'- coauthored with Mindy Lewis, herself a survivor of bad psychiatric care.

But there are at least two sides to every story and we all have biases depending on our experiences. I have known hundreds of patients harmed by psychiatric treatment, but have also known thousands helped by it. And I have seen dozens of lives irrevocably ruined by going off medication that was desperately needed.

The signers of the open letter write from a very different experience- lives harmed by psychiatric treatment and helped by finding an alternative way to recovery.

My point in responding to Eleanor Longden's inspirational story was that it didn't cover the waterfront of possibilities and could not possibly serve as a model for everyone who hears voices. There is no one size fits all. What worked for her would not work for everyone.

The experience of having voices takes many different forms. About 5-10% of the general population hears occasional and benign voices that have absolutely no clinical significance and require no treatment. Voices, usually transient, are part of a variety of psychiatric disorders (eg depression, mania, PTSD, and brief psychotic disorder). The most severe,chronic, and problematic voices accompany the other symptoms that define schizophrenia- delusions, disorganised thought, and disturbed emotions and behaviour.

When voices occur as part of schizophrenia, they are often chronic and debilitating, and sometimes dangerous. I have seen dozens of patients who made suicide attempts in response to a voice commanding that they do so.

Ms Longden succeeded in understanding and taming her voices where traditional treatments had failed and done her grave harm. And so have many others. But for most people suffering from the symptoms of schizophrenia, treatment is necessary, even essential. I am concerned that trying to follow Ms Longden's path might help some, but may harm others.

The signers of the open letter are concerned about excessive psychiatric treatment, excessive dosing, careless polypharmacy, and unnecessary hospitalizations. And so am I.

But I am equally concerned about inadequate funding of mental health care and lack of access to treatment for people who need it. How scandalous that one million people with mental illness are now locked away in US prisons for nuisance crimes that could have been avoided had they received prompt care and decent housing in the community.

My hope in writing the blog was to help promote a balanced, cooperative, non-adversarial relationship between recovery and psychiatry. People with troubling thoughts, feelings, and relationships need all the help they can get from whatever source works best. We all want to help them and there is no one right way. So we should join forces to provide the most effective safety net. The goal is to find what works is best for each person.

One last bit of common ground. The signers of the open letter believe that voices have psychological meaning. And so of course do I. The content, tone, and type of voice can usually shed great and valuable light on the person's fears, impulses, conflicts, perceptions, and attitudes,

Understanding the meaning of the voices and treating them with medication can, and often should, go hand in hand.