On James Davies' "Cracked: Why Psychiatry is Doing More Harm Than Good"

I found “Cracked” by chance at Elizabeth’s second-hand bookstore in Fremantle. The writer, James Davies is psychotherapist with a phd in medical and social anthropology from the University of Oxford. He is a senior lecturer in social anthropology and psychology at the University of Roehampton, London.

Davies acknowledges that as a psychotherapist he could be seen as being biased in favour of the psychotherapeutic approach which can be considered to be in opposition to the ‘pharmaceutical’ approach of psychiatry. He makes no attempt to present a balanced account in this book—it unashamedly presents a series of arguments against psychiatry and its sugar-daddy (my words…) the pharmaceutical industry.

Overall, I think the strongest arguments presented concern depression and the inefficacy of anti-depressant drugs, and perhaps he should have narrowed his argument to focus just on depression rather than extrapolate to the whole field. Regardless, he makes a number of compelling points that portray psychiatry and the pharmaceutical industry as nothing short of despicable.

I would summarise his main points as follows:

1. psychiatric diagnostic models are more products of culture than of science.

2. the efficacy of antidepressant drugs is no better than placebo, and;

3. pharmaceutical companies engage in behaviours that present antidepressants as more effective than they really are

4. behind Western psychiatry is a variety of cultural assumptions about human nature and the role of suffering of questionable validity and utility.

5. Western practices of psychiatry may undermine successful local ways of managing distress

The DSM

Davies writes that the number of mental disorders has risen from 106 in 1952 to around 370 today. Is this because we are becoming aware of more disorders? Or is this because psychiatry is creating more disorders…

Note: In the formation of each iteration of the DSM, a team of experts gather and decide on what will go into the document. Contrary to mainstream belief—these experts “decide” not “discover what will be considered to be a disorder, and how it will be diagnosed.

Davies writes, “Many psychiatrist’s claims are no more substantiated than are the claims of religion. This is because, in so many areas…, psychiatrists do not prove things, but decide things: they decide what is disordered and what is not; they decide where to draw the threshold between normality and abnormality; they decide that biological causes and treatments are most critical in understanding and managing emotional distress. Granted, many of these decisions are informed by research, yet none of these decisions or the research on which they are often based is free from the subjective persuasions of the players involved, while much of the research is methodologically poor – DSM definitions are not fashioned in scientific laboratories but in contentious committee rooms; drug research cannot be fully impartial when it’s wedded to drug company interests; and the profession’s commitment to the biological version of our mental lives can’t be shorn from psychiatry’s historical struggle for biomedical status.”

Depression & the placebo effect

I feel like what most people want in life is to be a “bit” happier. What they want is to basically not do anything different, but to just be happier. How can I keep living the same life… but be happier? This is where drugs fit in. You just keep living the same life but with this drug added onto it and then you’ll be happy. Maybe. Because according to the data presented by Davies, the efficacy of antidepressant drugs is no better than placebo.

I think that the whole process of getting on antidepressants activates the placebo response for people. Simply making the decision to do something about your depression starts the process: going to a doctor, admitting something is wrong, talking to someone about it. Plus: the doctor is a “professional”, you can trust them. They give a prescription for “medication”. This is medicine. Given to you by a doctor. You take the drugs. They have a noticeable effect in your body. This effect tells you that the pills are working, they are doing something…

I don’t see this as much different to the ways that a witchdoctor might use ritual and ceremony to activate the placebo response in people— it’s just an incredibly refined, elaborate, and scalable (on a fucking mass scale) system to activate the placebo response.

But is it helping? Davies lists the most common impacts of these anti-depressant drugs. Most common is a feeling of a general dulling of emotional affect. A dulling down. Suppressing. While this might sound nice in the short term, surely in the long-term, this is not going to help. Maybe you should change your life? Yeah but changing your life is really, fucking hard.

Marketing

Davies argues that pharmaceutical companies present antidepressants as more effective than they really are. For example, it is common practice to only publish positive research findings and to bury negative research findings. Drug companies also “provide financial incentives for editors to publish company-sponsored research”. He argues that pharmaceutical marketing can't be relied on to report the facts unadulterated and unadorned.

“At the height of the marketing war,” writes Davies, “the [pharmaceutical] industry invested twice as much money in promoting its pills as it did researching and developing them.”

In Britain, “the pharmaceutical industry was prohibited from advertising its pills to the public, it instead had to rely on what is generally called physician-directed marketing.” Davies calls for transparency in the amounts of money that pharmaceutical companies are paying senior researchers, thought leaders, etc. He writes that, “Until we have a national online register where you can freely check what a given psychiatrist, researcher, psychiatric department or mental health organisation is getting paid and by whom, internal surveys count for very little, because the figures will continue to remain a professional secret. After all, you have a right to know whether a psychiatrist who has just prescribed you or your child a powerful drug is being paid by the company that makes that drug. You also have a right to know whether a mental health organisation that speaks favourably about antidepressants receives yearly donations from antidepressant manufacturers.”

Disease-centred vs the drug-centred models

Dr. Joanna Moncrieff, psychiatrist and senior researcher in Department of Mental Health at University College London, differentiates between the disease-centred and the drug-centred model:

• “In the disease-centred model, people are assumed to have a mental disease… and drugs are thought to be effective because they rectify or reverse that underlying brain problem in some way. This is the dominant model in psychiatry, and the one that best serves psychiatric interests.

• The drug-centred model emphasises that drugs are drugs; they are chemical substances that affect the way people think and feel. They have psychoactive properties, just like recreational drugs do, which alter they way the body functions at a physiological level.

• So the drug-centred model does not say that psychiatric drugs heal brain problems, like the disease-model claims; it rather says they alter people’s states of mind in ways that may or may not be helpful.”

The disease-centred model started to take over especially in the 90s with the new SSRI’s. Moncrieff states that, “The drug companies were trying to capture that huge market of people who once took tranquilisers… And that’s where the idea of the chemical imbalance came in—it was perfect, because it implied that these drugs actually corrected a defect in the brain. If you have a brain disorder, a chemical imbalance, and this pill is going to correct that imbalance, then obviously you take it.”

I feel that we can see a version of the “disease-model” in the psychedelic community—it’s this idea that people are broken and that a particular psychedelic will “fix” them. Mushrooms “cure” depression. Ayahuasca “cures” addiction. This is erroneous, I think. Rather, mushrooms and ayahuasca are complex plant mixtures that bring about a number of physiological and psychological effects in a person, in ways that may or may not be helpful…

Emotional suffering

Davies writes: “Once this new biological vision began to seep into popular consciousness it started to alter our understanding of the very nature of emotional suffering itself.”

This point hit for me. This is something I find so fucking despicable. We are human beings— we experience suffering. It’s a part of life. We want to end our suffering. Human suffering is an incredible marketing opportunity. Human suffering is an opportunity for companies to sell their products. There is no cure for suffering. People don’t want to hear this. People want to hear—there’s something wrong in your brain chemistry but the good news is that our drug will fix that for you. People want quick fix. Get rich quick. One simple hack. We could look to Yoga—and I don’t mean going to a yoga class twice a week. I mean the eight-fold path. Or we could take drugs to suppress this suffering. Davies writes that there are more than 50 million antidepressant prescriptions in England each year. This tells us which path is winning…

Davies writes, “the growing dominance of the bio-psychiatric myth of suffering poses many serious questions. Is this domination leading to increasing numbers of us to view our suffering in entirely negative terms, as something to be erased or anaesthetised at all costs?”

“Are we,” he asks, “replacing traditional philosophical and religious ways of managing and understanding distress, which once saw meaning and opportunity in many forms of suffering, with a starker technological view that sidesteps the bigger humanistic questions:

• cannot much suffering that is now medically managed often be a necessary call to change (and therefore a message to be heeded rather than anaesthetised),

• or the organism’s protest against harmful social conditions (therefore requiring a social or psychological rather than a chemical response),

• or a natural accompaniment of our psychological development (therefore having vital lessons to teach if managed responsibly and productively)?”

Davies asks, “is psychiatry’s essentially negative view of suffering… yet another manifestation of a wider cultural obsession with using emotional anaesthetics—pills, alcohol, retail therapy, escapist activities—as the principal consumables for managing emotional distress? And if so, in what way is the idea that we can consume our way out of psychological difficulty a myth that is economically convenient not only for psychiatry and the drug industry, but for the wider capitalist system in which we all live?”

Later, consultant psychiatrist Pat Bracken, states, “what complicates things more is that we live in a capitalist society, where there is always going to be someone trying to sell you something— whether a drug or a psychotherapeutic session… It’s a vast sociological, anthropological and almost spiritual problem for human beings. So the idea that medicine is going to come up with a neat answer is far from the truth. In fact, the belief that it can, is also behind the rise of antidepressants and other drugs. But the only people who have benefitted from that are those working in the drug companies.”

This is it right— we want a neat answer, but life is messy. We want to take a pill to fix our depression— but, the harsh truth is that it’s not simple brain chemistry that’s off, it’s a complex series of problems that stem from our very way of life. It’s our family systems, our social hierarchies, our capitalistic economic systems, even our philosophies about the nature of the mind, the human, and life itself, that are setting us up for depression and mental ill-health. These are huge problems to consider.

Fixing the cracks

In the final parts of the book Davies offers some ways to “fix the cracks” in the system. In an interview with psychiatrist, Dr. Peter Breggin, Breggin states, “The model I prefer to use is a person-centred team approach… where the prescriber and the therapist work with the family and the patient. This approach is centred around the person, and what the patient really wants, feels and needs.” For Breggin, most problems are created by the contexts in which people live and therefore require contextual not chemical solutions. Breggin says that, “People who are breaking down are often like canaries in a mineshaft… they are a sign of a severe family issue.”

This reminded my of the Internal Family Systems model which treats the mind as a family system and seeks to give voice to all members of the family and considers each part in the context of a wider-whole. This approach mentioned by Breggin calls for treating an individual as part of a wider context, a family unit, a network of individuals, as well as environmental and other external factors. Seems obvious, doesn’t it?

Cheers

Alejandro