What Whitaker wants us to know about Mad in America

Robert Whitaker, the founder of Mad in America, has responded to my blog about MIA’s reporting of a JAMA Psychiatry viewpoint with a long-winded article in defense of MIA’s mission. Now Whitaker could’ve responded to my blog in a number of ways. He could’ve ignored it. He could’ve said, “This report was an outlier; it doesn’t represent who we are.” He could’ve said, “This report was overly zealous in its interpretation; we will do better in the future.” Instead, Whitaker has chosen to double down in the defense of the report, and by doing so, he has basically signaled: This report is not an anomaly or an aberration; this report represents exactly what MIA sets out to do and is in complete alignment with its mission. Very well. If this report represents what MIA is about, we will judge MIA based on it.

Whitaker asks the question: “Is it Mad in America that misleads the public? Or is it psychiatry, as an institution, that is guilty of this sin?”

There is no reason why this should be an either-or scenario. From my perspective, psychiatry as an institution and MIA can both very well be guilty of misleading the public. Whatever the sins and shortcomings of psychiatry as a profession, and there are many no doubt, they don’t absolve MIA of its sins and shortcomings.

A big chunk of the response article is about Whitaker revisiting his own journalistic path to MIA. From my perspective, Whitaker is a smart, intelligent, detail-oriented, well-intentioned journalist, who held some rather naïve ideas about psychiatry in the 1990s through no fault of his own (such ideas were in wide social circulation at the time, and often promoted by sections of the psychiatric and medical professions as well). When he confronted the scientific literature, instead of recognizing that the science was a lot more complex than he had been led to believe, he was shocked and radicalized. He noticed some interesting patterns in longitudinal studies and population data pertaining to the use of psychotropic medications, and fleshed out the provocative hypothesis that psychiatric medications are actually making psychiatric patients worse, causing an epidemic of psychiatric disability. His thinking entered the stage of “trapped priors.”¹ When his views were ignored and rejected by the mainstream scientific community, he rapidly developed the anti-epistemology necessary to protect his thesis, according to which the psychiatric community was not receptive to his criticisms because of their sheer corruption and professional insecurity. Spurned by the scientific community, Whitaker made it his mission to directly convince the public—and basically anyone with an axe to grind against psychiatry—of the validity of his views.

Whitaker says that I am “seeking to protect psychiatry’s narrative of progress—a narrative that arises from psychiatry’s guild interests, and not a faithful record of its own research literature.” Whitaker and others at MIA constantly conflate ordinary assertions about progress with the fallacious “progress narrative” that is much derided by historians. The Panglossian narratives of scientific progress are indeed fallacious and not uncommon (Lieberman & Ogas’s 2015 book Shrinks comes to mind as a prominent, recent example), but the nihilistic narratives of “no progress at all” are equally fallacious and problematic. The progress I point towards is the complicated, messy, multi-faceted, all-too-human progress that characterizes all medicine and science, where things get better, but things also get worse, where moments of breakthroughs may very well coincide with historic failures, where the impact of effective interventions may be nullified by societal forces, and where outcomes of trajectories may be heterogeneous and subject to massive disparities, etc.

The historian Jonathan Sadowsky writes in his review of Whooley’s book for Isis:

“None of psychiatry’s treatments are perfect. The physical treatments have adverse effects—as do many treatments in other medical specialties. The psychotherapies only help small numbers of the most severely ill (and are increasingly used more by other mental health workers, anyway). No treatments work in all patients, and permanent cures are rare, but these limits are found in many areas of medicine. Taken together, psychiatry’s treatments comprise a repertoire that offers hope to people who, for example, develop morbid delusions or devastating mood problems. Psychiatry may not be able to account well for why the treatments work. It may not be able to define the conditions it treats with the precision we would like. It may not even be able to show exactly why those conditions merit the label of “illnesses.” It would be better if it could. It still matters that treatments work… Psychiatry continues to present philosophical problems that elude resolution. It is still, for most people with access to treatment, better to have a major mental disorder now than it was 150 years ago. We know this.”

We know this! This is not hard to admit—unless you are wedded to the myth of “no progress at all.” It is tragic that this is the current state of popular critical discourse around psychiatry. In this particular moment in psychiatry when even a framework such as RDoC is emphasizing environmental context and developmental processes, when the president of the American Psychiatric Association publicly says: “Rather than exclusively seeking more biological cures for downstream psychiatric illness that are socially driven, patients and the public may benefit from less prescribing and more listening to the desperate voices that can be heard if one pays attention,” and when the former director of the NIMH writes a popular book arguing for the path of healing to be built upon the foundation of “people, place, and purpose,” Mad in America cannot bring itself to say that maybe something good has come out of psychiatry’s evolution over the last 200 years after all. That maybe some people have found relief from suffering in ways that weren’t even conceivable in the 18^th century. And that even some lives have been saved thanks to psychiatry—lives of those suffering from catatonia, delirious mania, melancholic depression, agitated psychosis, postpartum psychosis, severe obsessive compulsive disorder, etc. (And yes, I have no qualms acknowledging that some lives have also been lost, from iatrogenic states such as akathisia, protracted withdrawal, PSSD, or cardiometabolic complications.)

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Two items particularly standout in what Whitaker describes as MIA’s reporting philosophy and template:

1) Research coverage at MIA is selective by design

“We founded Mad in America in January of 2012, and our science coverage was meant to continue the reporting that was present in those two books: we would provide a running account of studies that belie the common wisdom but are never promoted by psychiatry for that reason.”

“Our mission statement tells of a failed paradigm of care, with that failure documented in the scientific and medical literature. This is an assertion that psychiatry cannot let stand.”

Research coverage at MIA is intentionally selective. MIA is interested in research that expands on Whitaker’s own work and that supports the idea that psychiatry is a failed paradigm of care. If the research doesn’t tell the story of a failed paradigm, if it portrays psychiatry in a positive light, MIA isn’t interested.

As anyone with a basic understanding of epistemic echo chambers knows, such selective coverage is a recipe for confirmation bias and ideological radicalization.²

2) MIA is committed to interpreting and reporting research findings through the lens of Whitaker’s work

“In sum, our reporting on science isn’t meant to serve simply as a collection of reports on individual studies. We provide reviews that help readers see the “bigger picture” that exists in the research literature, and yet isn’t generally known.”

And since the de facto bigger picture for MIA is the “anatomy of an epidemic” and “failed paradigm” worldview, MIA is committed to interpreting and reporting research findings through this lens. This is why Whitaker sees no problem at all in reporting “we should measure success rates over time” as “no evidence that psychiatric treatments produce successful outcomes.” They are only nudging the readers towards the “bigger picture”!

As far as systematic ideological biases go, this is a big red flag. We have to assume that what we read at MIA is explicitly and implicitly colored by the commitment to portray psychiatry as a failed discipline. This means that mental health professionals, trainees, journalists, researchers, historians, basically anyone who finds their way to MIA and is seeking a more neutral perspective on psychiatry, has to take this agenda into account. They have to treat it as an ideological conflict of interest, and they have to correct for it as much as possible.

Whitaker shares a lot of data and graphs in the post to make his case. I won’t go into the specifics of that right now—unpacking it is going to require a lot more time and effort—but the relevant point here is that none of this is new. Whitaker has been making this case for more than a decade, and folks within the psychiatric communities who are active in these debates and specialize in these areas are well aware of it, but they don’t interpret this data in the same manner as Whitaker and they remain unpersuaded. Psychiatry is not a centralized institution. We are talking about individuals, departments, agencies, journals, and associations across the world. The only way Whitaker can make sense of this cold reception is: “I do agree that within the psychiatric community, this research is mostly derided, ignored, and kept from the public. The reason is that this research, which is their research and voluminous in kind, belies the narrative of progress that psychiatry has told to itself and to the public, and in order to maintain that narrative, it has to keep such research hidden from the public, or to dismiss it as insignificant.”

So multiple independent organizations, such as the American Psychiatric Association, the National Institute of Mental Health (and other related institutes within the National Institute of Health), the Centers for Disease Control and Prevention, the Office of the Surgeon General of the United States, the American Academy of Child and Adolescent Psychiatry (and other US psychiatry sub-specialty organizations who produce practice recommendations), the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the Canadian Network for Mood and Anxiety Treatments, the Royal College of Psychiatrists, the National Institute for Health and Care Excellence, the Royal Australian and New Zealand College of Psychiatrists, and academic psychiatry departments, and journal editorial boards across the world, etc. etc. are all in on some sort of agenda to keep this research hidden from the public and to dismiss it?

What about me? I read Anatomy of an Epidemic many years ago, and I have followed Whitaker’s work on MIA. I found a lot of it to be brilliant and provocative. I spent a long time engaging with the research studies and discussing them with colleagues, and I found the process rewarding because I gained a new appreciation of the iatrogenic aspect of psychiatric medications, but ultimately, I found the central thesis to be untenable. The methodological problems with this literature (lack of randomization, lack of appropriate controls, multiple confounders, etc.) do not allow for the conclusions to be asserted with the certainty that Whitaker maintains, and the emphasis on medications ignores the massive contributions from social determinants and neoliberal welfare policies.

In fact, in his book Healing (2022), Thomas Insel, the former director of the NIMH, ponders a very similar question to the one asked by Whitaker, and arrives at a very different—and much more plausible—answer:

“In the United States, we have treatments that work, but our system fails at every stage to deliver care well… Quality of care varies widely, and much of the field lacks accountability. We focus on drug therapies for symptom reduction rather than on plans for long-term recovery. Care is often unaffordable and unavailable, particularly for those who need it most and are homeless or incarcerated… Mental illnesses are medical problems, but… the cures for the crisis are not just medical, but social.”

Insel’s assessment of Whitaker is particularly scathing:

“Some critics, such as science journalist Robert Whitaker, have blamed the mental health crisis on the treatments. Noting the temporal correlation of increased disability with increased medication use, Whitaker argues that antidepressants and antipsychotics create a “supersensitivity” that makes patients dependent and chronically disabled. With claims that long-term outcomes were better before the “psychopharmacology revolution,” he writes that the psychiatric establishment, in collaboration with the pharmaceutical industry, has conspired to overmedicate and overtreat children and adults with disastrous results.

Not everyone buys this conspiracy theory.” – Thomas Insel, Healing (pp. 19-20).

My own assessment is less harsh. I have found engagement with Whitaker’s work to be generally rewarding, although I disagree with him. I also think phenomena such as dopamine supersensitivity are likely clinically relevant to a subset of patients and are woefully understudied, but I am not convinced that dopamine supersensitivity has much to do with the poor outcomes we see at the population level.

One gets the sense that Whitaker is unable to consider the prospect of informed and reasonable disagreement. The fact that the vast majority of clinicians and researchers in the profession disagree with him must be because they are corrupt, insecure, and threatened!

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I think MIA holds a lot of promise. It is a valuable platform, and it has done a lot of good by highlighting critical issues that were otherwise neglected. I know many wonderful people who have written for or worked for MIA. I have no black-and-white assessment of it. I think MIA can and ought to do better. There is a genuine need for healthy critical spaces in mental healthcare. But there is a dogma at the heart of MIA, and until MIA is willing to critically examine its own foundations, it will continue on its current trajectory. This is a pivotal moment for MIA to decide what its future relationship with its critics is going to be. As someone who encourages psychiatric colleagues to be less defensive about psychiatric criticisms, I offer the same encouragement now to my critical colleagues.

I think MIA holds a lot of promise. It is a valuable platform, and it has done a lot of good by highlighting critical issues that were otherwise neglected… But there is a dogma at the heart of MIA, and until MIA is willing to critically examine its own foundations, it will continue on its current trajectory. This is a pivotal moment for MIA to decide what its future relationship with its critics is going to be.

And in case readers are wondering, yes, I do have an “agenda” as well, one that I have been open about. I shared it in my very first post on this newsletter, and I have repeated it subsequently as well. I see myself as engaged in a two-fold mission:

i) To promote a philosophically-informed and scientific practice of psychiatry that robustly engages with the metaphysical, relational, and phenomenological dimensions of psychiatric problems

ii) To contextualize psychiatry within a broader pluralistic domain of mental healthcare and psy-disciplines, taking into account that it is only one disciplinary approach among many other approaches that remain essential.

And yes, this agenda explicitly and implicitly colors everything you read in this newsletter.

1. A state where people hold on to their beliefs so rigidly that “they start out wrong, and each new fact they learn, each unit of effort they put into becoming more scientifically educated, just makes them wronger.” Scott Alexander

2. “Of the fifty-odd biases discovered by Kahneman, Tversky, and their successors, forty-nine are cute quirks, and one is destroying civilization. This last one is confirmation bias - our tendency to interpret evidence as confirming our pre-existing beliefs instead of changing our minds.” Scott Alexander