Wednesday, January 2, 2013

My letter to New York Times re Paul Steinberg op-ed

I rather doubt my lengthy letter to the editor will appear in the New York Times on-line edition, so I decided to print it after the comments (see below) that did appear. I have since submitted to the NYT an abridged version of my original letter. The Steinberg op-ed appears here.


The Many Unknowns of Schizophrenia     Published: January 1, 2013

To the Editor:

As a clinical psychiatrist, I found Dr. Steinberg’s article troubling. It is a common problem in our field that psychiatrists speak of schizophrenia as if it were a well-understood condition, with a clear pathology and clear, effective treatment.

In fact, our understanding of this phenomenon is evolving and unsettled. What we call schizophrenia is probably a syndrome with many causes, and with a wide range of outcomes, with and without treatment. Many people do benefit from standard treatments, but many do not — and many find these treatments objectionable because of metabolic and other toxicities.

Moreover, many people find the current system of mental health delivery to be disrespectful, coercive and violent. It would be hard to imagine forced treatment for other medical conditions, like cancer or cardiovascular disease.

It has been my experience that when people are treated in a respectful way, offering options and choices rather than dictating treatment, better outcomes occur. Similarly, when we doctors are honest about the limitations of our knowledge, and humble about the power of our proffered treatments, there is more room for the person at the center of concern to find a path of care that can be helpful and effective.

For a tiny minority of patients, with substantial histories of violence, it is appropriate that the legal system, after an adversarial process, compel patients to accept treatment against their will.

I am worried that Dr. Steinberg’s article communicates more certainty about the nature and treatment of schizophrenia than is warranted, and makes too little room for patients and their families to make informed choices about care.


Framingham, Mass., Dec. 26, 2012

The writer is a psychiatrist and an associate clinical professor of psychiatry at Harvard Medical School.

To the Editor:

Paul Steinberg makes valuable points about the dismantling of sound psychiatric care for psychotic illness. He notes that in the name of civil liberty, severely disturbed people end up undertreated, at the expense of the “rights” of the community to be safe.

People suffering the harangues of command hallucinations and terrorizing paranoid delusions cannot demand civil liberty, failing any test of the capacity for informed consent (which requires an understanding of what refusing treatment means).
More important, it is in the interest of people with acute psychotic torments to get care, to protect them from doing horrific acts and, often, committing suicide. The right to treatment has been muddled by the misguided legal impositions.

In the past, egregious overuse of electroconvulsive therapy, toxic medication and long involuntary hospitalization motivated a reasonable patient rights movement. Times have changed. Treatment is more often withheld as insurers and risk managers shrink the obligations of decent care.

Oakland, Calif., Dec. 26, 2012
The writer is a psychiatrist.

To the Editor:
Paul Steinberg says, “It takes a village to stop a rampage.” Most of the millions of Americans with schizophrenia commit no violent or nonviolent crimes. As a nation, we have no monopoly on mental illness, nor do we have the worst mental health system in the world, or the most liberal protection of civil liberties. These are not the causes of our extreme firearms violence.

Dr. Steinberg is right that some practitioners are insufficiently interested in treating serious disorders. We do need mobile early intervention teams, collaboration among community mental health professionals and police, and less reliance on medications. Our people deserve better access to known best practices, true insurance parity and affordable, accessible services.
A nation can stop rampages, but it is doubtful that a more restrictive, coercive mental health system will help achieve that goal.


Scotch Plains, N.J., Dec. 28, 2012

The writer is chairman of the department of psychiatric rehabilitation and counseling professions, University of Medicine and Dentistry of New Jersey.

To the Editor:

I am deeply offended on several levels by Paul Steinberg’s op-ed opinion, which he presents as facts. Dr. Steinberg has taken it upon himself to link schizophrenia to Adam Lanza. He seems to be the only person saying so from what I have read so far on both sides of the pond (I live in Europe). The media has variously reported autism spectrum, Aspergers, OCD, anxiety issues, but not once have I seen the word “schizophrenia.” There is nothing from what we know about Adam Lanza to date, that suggests schizophrenia to me.

But, Dr. Steinberg’s piece suggests something more troubling beyond the willingness of a psychiatrist to publically diagnose someone he has never met (which is highly unethical). He invokes his credentials as a psychiatrist to scapegoat psychiatry's perennial bogey-man, schizophrenia. Remember, the media has not speculated on schizophrenia, and it is interesting that autism bloggers and activists seem to accept that Adam Lanza had something recognizable as a form of autism, but in unanimous agreement that autism did not pull the trigger.

Propagandists know that the "big lie" has a certain emotional credibility with the public that is missing from the small lie, and that the public will more readily fall under its spell.

What does substituting schizophrenia for autism accomplish, one may ask? Well, for a start, it immediately crystallizes in the mind of the public the recent mass murders when the word “schizophrenia” actually was reported as possible diagnosis. By going for the “big lie” in a period when the public is desperate to DO SOMETHING, Dr. Steinberg skillfully shifts the debate to forced treatment, something which is not on the agenda of the autism community. The autism lobby is big, relatively strong, and child-focused. The schizophrenia community is small, diverse, and not well organized or funded. Why take on autism (and children) when you can conveniently use schizophrenia to accomplish your policy goals?

There are countless people, well-informed bloggers, and even the letters writer here, who appear to have accepted Steinberg's propaganda at face value. Perhaps this is because The New York Times gives Dr. Steinberg an authoritative platform by not allowing readers to comment directly on the piece? Why is that?

Yours sincerely,


Rossa Forbes

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