Letter of Resignation from the American Psychiatric Association
4 December 1998
Loren R. Mosher, M.D. to Rodrigo Munoz, M.D., President of the American Psychiatric Association (APA)
After nearly three decades as a member it is with a mixture of pleasure and disappointment that I submit this letter of resignation from the American Psychiatric Association. The major reason for this action is my belief that I am actually resigning from the American Psychopharmacological Association. Luckily, the organization's true identity requires no change in the acronym.
Unfortunately, APA reflects, and reinforces, in word and deed, our drug dependent society. Yet it helps wage war on "drugs". "Dual diagnosis" clients are a major problem for the field but not because of the "good" drugs we prescribe. "Bad" ones are those that are obtained mostly without a prescription. A Marxist would observe that being a good capitalist organization, APA likes only those drugs from which it can derive a profit -- directly or indirectly. This is not a group for me. At this point in history, in my view, psychiatry has been almost completely bought out by the drug companies. The APA could not continue without the pharmaceutical company support of meetings, symposia, workshops, journal advertising, grand rounds luncheons, unrestricted educational grants etc. etc. Psychiatrists have become the minions of drug company promotions. APA, of course, maintains that its independence and autonomy are not compromised in this enmeshed situation. Anyone with the least bit of common sense attending the annual meeting would observe how the drug company exhibits and "industry sponsored symposia" draw crowds with their various enticements, while the serious scientific sessions are barely attended. Psychiatric training reflects their influence as well: the most important part of a resident's curriculum is the art and quasi-science of dealing drugs, i.e., prescription writing.
These psychopharmacological limitations on our abilities to be complete physicians also limit our intellectual horizons. No longer do we seek to understand whole persons in their social contexts -- rather we are there to realign our patients' neurotransmitters. The problem is that it is very difficult to have a relationship with a neurotransmitter -- whatever its configuration. So, our guild organization provides a rationale, by its neurobiological tunnel vision, for keeping our distance from the molecule conglomerates we have come to define as patients. We condone and promote the widespread use and misuse of toxic chemicals that we know have serious long term effects -- tardive dyskinesia, tardive dementia and serious withdrawal syndromes. So, do I want to be a drug company patsy who treats molecules with their formulary? No, thank you very much. It saddens me that after 35 years as a psychiatrist I look forward to being dissociated from such an organization. In no way does it represent my interests. It is not within my capacities to buy into the current biomedical-reductionistic model heralded by the psychiatric leadership as once again marrying us to somatic medicine. This is a matter of fashion, politics and, like the pharmaceutical house connection, money.
In addition, APA has entered into an unholy alliance with NAMI (I don't remember the members being asked if they supported such an association) such that the two organizations have adopted similar public belief systems about the nature of madness. While professing itself the "champion of their clients" the APA is supporting non-clients, the parents, in their wishes to be in control, via legally enforced dependency, of their mad/bad offspring: NAMI with tacit APA approval, has set out a pro-neuroleptic drug and easy commitment-institutionalization agenda that violates the civil rights of their offspring. For the most part we stand by and allow this fascistic agenda to move forward. Their psychiatric god, Dr. E. Fuller Torrey, is allowed to diagnose and recommend treatment to those in the NAMI organization with whom he disagrees. Clearly, a violation of medical ethics. Does APA protest? Of course not, because he is speaking what APA agrees with, but can't explicitly espouse. He is allowed to be a foil; after all - he is no longer a member of APA. (Slick work APA!) The shortsightedness of this marriage of convenience between APA, NAMI, and the drug companies (who gleefully support both groups because of their shared pro-drug stance) is an abomination. I want no part of a psychiatry of oppression and social control.
"Biologically based brain diseases" are certainly convenient for families and practitioners alike. It is no-fault insurance against personal responsibility. We are all just helplessly caught up in a swirl of brain pathology for which no one, except DNA, is responsible. Now, to begin with, anything that has an anatomically defined specific brain pathology becomes the province of neurology (syphilis is an excellent example). So, to be consistent with this "brain disease" view, all the major psychiatric disorders would become the territory of our neurologic colleagues. Without having surveyed them I believe they would eschew responsibility for these problematic individuals. However, consistency would demand our giving over "biologic brain diseases" to them. The fact that there is no evidence confirming the brain disease attribution is, at this point, irrelevant. What we are dealing with here is fashion, politics and money. This level of intellectual /scientific dishonesty is just too egregious for me to continue to support by my membership.
I view with no surprise that psychiatric training is being systematically disavowed by American medical school graduates. This must give us cause for concern about the state of today's psychiatry. It must mean -- at least in part that they view psychiatry as being very limited and unchallenging. To me it seems clear that we are headed toward a situation in which, except for academics, most psychiatric practitioners will have no real, relationships -- so vital to the healing process -- with the disturbed and disturbing persons they treat. Their sole role will be that of prescription writers -- ciphers in the guise of being "helpers".
Finally, why must the APA pretend to know more than it does? DSM IV is the fabrication upon which psychiatry seeks acceptance by medicine in general. Insiders know it is more a political than scientific document. To its credit it says so -- although its brief apologia is rarely noted. DSM IV has become a bible and a money making best seller -- its major failings notwithstanding. It confines and defines practice, some take it seriously, others more realistically. It is the way to get paid. Diagnostic reliability is easy to attain for research projects. The issue is what do the categories tell us? Do they in fact accurately represent the person with a problem? They don't, and can't, because there are no external validating criteria for psychiatric diagnoses. There is neither a blood test nor specific anatomic lesions for any major psychiatric disorder. So, where are we? APA as an organization has implicitly (sometimes explicitly as well) bought into a theoretical hoax. Is psychiatry a hoax -- as practiced today? Unfortunately, the answer is mostly yes.
What do I recommend to the organization upon leaving after experiencing three decades of its history?
1. To begin with, let us be ourselves. Stop taking on unholy alliances without the members' permission.
2. Get real about science, politics and money. Label each for what it is -- that is, be honest.
3.Get out of bed with NAMI and the drug companies. APA should align itself, if one believes its rhetoric, with the true consumer groups, i.e., the ex-patients, psychiatric survivors etc.
4.Talk to the membership -- I can't be alone in my views.
We seem to have forgotten a basic principle -- the need to be patient/client/consumer satisfaction oriented. I always remember Manfred Bleuler's wisdom: "Loren, you must never forget that you are your patient's employee." In the end they will determine whether or not psychiatry survives in the service marketplace.