Challenging “The Great Disconnect”: The History and Changing Role of Psychiatry in Drug Use

(Editors Note: This post was written by Dr. Lucas Richert, a lecturer at the University of Saskatchewan.)

In recent years, the modification of marijuana laws in the United States, multiple doping scandals in professional sports (from Lance Armstrong to A-Rod), and the right-to-die debate have helped focus the public’s attention on drugs. At the same time, academia, policy-makers and interest groups all have a need for superior information about the complex role that recreational drugs and pharmaceutical products play in our lives.

According to Alan Leshner, “There is a unique disconnect between the scientific facts and the public’s perception about drug abuse and addiction. If we are going to make any progress, we need to overcome the ‘great disconnect.’”

Progress, whatever that meant for Leshner, will certainly be accompanied by a public discussion. And psychiatrists will continue to play a major role in shaping our understanding of drugs.

supplementsFor the uninitiated, it is all too easy to characterize the average psychiatrist as having been an agent of the medico-industrial complex. In recent years, such well-respected authors as Daniel Carlat, David Healy and Allen Frances, among others, have leveled devastating accounts of the failures in psychiatry and suggested that the profession has had far too much influence on Americans’ lives. And, indeed, the link between the psychiatric profession and the titanic rise of the pharmaceutical industry is undeniable.

Yet psychiatrists have also long challenged preconceived notions of certain recreational drugs, seeking to recast them as valuable tools in the therapeutic armamentarium.

This is happening right now in the cases of LSD, mescaline and ketamine (known as Special K on the street), as well as with other drugs. Special K, as I have written elsewhere, is now driving a significant debate in mental health circles because a growing number of psychiatrists in the United States and elsewhere are using it to combat depression. LSD, similarly, has arguably matured and psychiatrists and researchers are using it for a variety of health issues.

In other words, psychiatrists in the United States have and continue to recast the popular views on drugs in mainstream medical practice, and in society more broadly. Take a step back, though, and one can see that the profession was never uniform in its perception about recreational drugs or drugs as therapy.

During the late 1960s, psychiatry in the United States began to reflect the turbulence of society at large. Just as widespread APAsocial movements across the country focused on the Vietnam War, civil rights, and the advancement of feminism, there was also unrest within the American Psychiatric Association.

A Radical Caucus was formed in the APA and its members contributed to debates about recreational drugs as well as the newly emerging biomedical paradigm in which drugs created in the laboratory helped define the parameters of mental health and psychopathology. For a select group of radical psychiatrists, it was crucial to engage with the American public on the topics of drugs, which involved “freedom, health, and human behavior,” and thereby helped with the development of evidence-based drug policy.

At the same time, radical psychiatrists sought to move beyond the outdated notion of “neutral” psychiatry. In articulating one of the dilemmas of 1960s psychiatry, the radicals contended that electroshock and drugs were used to suppress symptoms, and thus the psychiatrist was “telling his patient in effect that he must adapt himself to whatever environment exists, however oppressive.”

Modern pharmaceuticals were, in short, part of the problem and the radical psychiatrists were anything but co-conspirators with Big Pharma.

In another example, by the 1980s, psychiatrists and others in the mental health field became embroiled in a protracted struggle with the Drug Enforcement Administration over the scheduling of MDMA under the Controlled Substances Act and, ultimately, its use as a tool in psychotherapy.

Psychiatrists and psychologists argued that the Alexander Shulgin’s Ecstasy was necessary. And, in 1985, a group of prominent professionals in mental health, including Harvard’s Lester Grinspoon, sued the DEA for its ban of MDMA.

ReaganIn a tense back-and-forth before Congress and within the judicial system, MDMA was, like LSD before it, found to be an unsuitable agent in the treatment of mental illness and other counseling. In 1988, at the height of the Reagan administration’s War on Drugs, MDMA was placed in Schedule I, meaning it had no “accepted medical use.”

While this was far from the end of the story surrounding MDMA’s use, it signaled that the medical community, including psychiatrists, was contributing alternative views on how MDMA ought to regulated and employed in American society.

Anyone familiar with Rick Doblin and the Multidisciplinary Association for Psychedelic Studies will recognize that the debate over MDMA in the 1980s formed part of a longer chain that has contributed to the reemergence of LSD as an object of study in the field of mental health.

Patterns and cycles typify the history of drugs. And psychiatrists continue to play vital roles in the evolving stories of such drugs as LSD, MDMA, ketamine, and others.

American psychiatry, for its part, is in a fascinating period of flux. Such authors as Hannah Decker, Lawrence Samuel, Edward Shorter and Deborah Weinstein investigate specific diagnoses and illnesses (depression), societal units (the family), and broader structures (DSM-III), while others are taking an unapologetically cultural approach to the history of psychiatry.

In the introduction of Edward Shorter’s influential 1997 book, A History of Psychiatry, he writes that his subject was a “minefield.” In his view, both revisionists and neoapologists (as he described himself) were in perilous terrain, because their interpretations risked being “blown up” by new evidence. Even as he rejected the revisionist orthodoxy in psychiatric scholarship, Shorter noted, “many surprises may lie in store for us all.”

Closer attention to the history of drugs and alcohol will surely help produce some shocks, if not massive detonations, in the years ahead. But the need for superior information remains strong, even as the great disconnect between public perception and facts continues to shift.