The answer: We need to address what’s happening inside the office as well as stigma.
During the creation of the documentary Going Sane I interviewed Cindy Bulik. She is perhaps the most important researcher on anorexia today. She lives between UNC where she is a distinguished Professor of Eating Disorders and Sweden where she is a professor at the Karolinska Institute. Her current research is exploring genetic influences on anorexia and by the end of our interview she asked if my entire family would be willing to give a sample of blood for the study.
She is not the single-minded professor oblivious to social customs that is often portrayed in movies — quite the opposite. She is terribly charismatic and careful in her word placement. If she doesn’t like how she said something, she will try again until she feels she has communicated just what she means. And it is with that charming and careful exactness that she told me the American mental health system was “practically third world.”
If you were there, you would have expect her to pause and reconsider her words — to add a disclaimer. I would not have been surprised if she had retracted the statement entirely. But she did not. She had said just what she wanted to say, and the purpose of this post is to explain what I believe she meant by it.
Attributes of a Third World System
The history of medicine up until the last century is almost entirely the history of placebo. The word placebo comes from Latin and is actually used in the Bible. It means to please as in “I shall please the Lord.” The religious connotations seem particularly appropriate because when we think of third-world healthcare, we think of societies that can’t separate religion from medicine. We think of shaman and witchdoctors. While I believe there is value in religious approaches to healing, it is clear that our medical interventions improved rapidly after our society was willing to put treatments to the test.
But the placebo effect is complicated. It is very hard to know if treatments are doing more for the body than the body can do for itself. The ability to recognize and identify the placebo effect is one of the greatest steps in modern medicine. Conversely, the inability to discriminate is perhaps the basic identifier of a third-world healthcare system.
When we imagine third-world treatments we think of leeches and bloodletting and think of a time very long ago, much longer ago than we should. The placebo effect was not demonstrated until one year before 1800 when John Haygarth tested a treatment for inflammation, headaches, and rheumatism. The treatment had been invented in the United States by a doctor who claimed that metal rods made from a specific alloy would “draw of the noxious electrical fluid that lay at the root of the suffering.”
Haygarth tested the mental rods against plain wooden rods and found that the recovery rate was no different. His conclusion was that the expensive metal alloy had no special ability to dispel “electrical fluid.” That was precisely what Haygarth had expected — not particularly interesting. But it led to a question that was much more interesting and continues to be relevant today: why do doctors and patients come to believe that ineffective treatments actually work?
Repairing the Medical Field
Identifying the placebo effect was just the first step in a battle to overcome it. While researchers began to run tests that could accurately identify which treatments were effective and which treatments were simply palliative, the research did not necessarily dictate what treatments doctors actually prescribed. In the 1960s Alvin R Feinstein realized that American doctors were choosing treatments based on their own observations rather than by consulting the latest research. As a result, doctors were again being fooled by the placebo effect: Doctor gives medication to sick individual; person gets better after taking medicine; the medicine worked. It seems so obvious.
Researchers began to realize that even trained doctors can’t see past placebo. They almost always overestimated the positive effect of their treatments and forget to account for other variables: patients want to get better, and if they’re spending a lot of money for treatments then they really want to get better; over time bodies heal; extreme states tend to normalize. And so to a doctor, almost every treatment will seem to work most of the time. The exceptions are on the occasion when the variables align in a different way: when treatments don’t work and the body cannot heal itself. Then people die.
This was an American reality until the medical field created what came to be known as evidence-based practice (EBP). EBP is a method to help mental health professionals select optimal treatments for their patients by avoiding personal biases. Rather than allowing doctors to select the treatments that they have seen work, doctors were asked to consult research, research which had been specifically designed to avoid biases.
This research method is known as randomized controlled trials. The whole point of this research is to combat the hydra-like presence of the placebo effect. Think of that: it took thousands of years to identify the placebo effect and then another one hundred and sixty years to create a research and dissemination system that could combat it.
But while the medical field began its long transition into evidence-based practice, the mental health field continued business as usual.
The Problem with the Mental Health Field
Many of the issues we saw in the medical field, we see again in the mental health industry.
The problem is that today mental illnesses are rising. A profession that used to only treat extreme psychedelic cases could conceivably be treating one fifth of the American population. Mental health care is mainstream. If it is going to provide treatments, if insurance is going to pay for treatments, it’s got to become more scientific. It’s got to do what the medical field did a half century ago: admit that therapists are not very good at deciding if their treatments work.
Today, mental health practitioners claim that psychology is a science (with good reason), but most remain unwilling to be scientific. While there will always be elements of therapy and mental health that alludes science and research, there is one aspect that is observable: how effective is treatment? How does a treatment measure against a placebo? A lot of this research has already been done. In many cases, we know which treatments work and which do not.
What’s shocking, though perhaps we should expect it by now, is that even with persuasive evidence about which treatments actually work, therapists consistently assign the wrong treatments. Most therapies are little better than placebo and some do more damage than they do good. That’s what third-world medication looks like. That’s why I believe Cindy Bulik said what she said.
It took the medical field thousands of years to figure out how to avoid being fooled by placebo. Let’s hope the mental health field can be a little quicker. This time we have compelling evidence and a powerful example to move us forward.
The example, of course, is what has taken place in the medical field over the last half century since they adopted EBP. Since then, death rates for medical conditions have plummeted. The death rate of leukemia has decreased by 85%. Death rates of heart disease, AIDS, and stroke have all dramatically decreased. But suicide, the main killer in mental illness, has shown no appreciable decline. Here’s one fact we can’t ignore: Over the last fifty years, we have not gotten any better at stopping people from dying of mental illness.
There’s a lot of nitty-gritty once you get into the specific of health-care regulation, but that’s not what this article or the documentary I’ve been working on is about. This is about two stories of healthcare. One story is a success story, the other is a tragedy. Whether you believe in the currently validated treatments or not, it doesn’t really matter. EBP is a way forward. Of course, we don’t know everything we need to know about mental illness. We don’t know everything we need to know about cancer, either. But at least cancer treatments are getting better every year. That’s the key. Until things start getting better, mental health care will remain a third-world industry full of doctors who believe, like millions before them, they won’t be fooled by placebo.
If this is an issue you care about, if the fact that over 70% of therapists are assigning the wrong treatments disturbs you, then watch Going Sane to understand what you can do to help transform mental health care in America.