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[RUSH TRANSCRIPT BELOW] An estimated one in six American adults today are taking some form of psychiatric medication. Yet it seems mental health outcomes across America have seen no significant improvement, despite the promises of the psychopharmacology revolution.

David Cohen, professor of social welfare and associate dean at UCLA’s Luskin School of Public Affairs, argues that many of the core assumptions of modern psychiatry are flawed.

Cohen is known for his research on psychotropic drugs and coercive mental health treatment.

In our interview, we also discuss why it is that America has one of the highest involuntary mental hospitalization rates in Western countries, and what it means that suicide rates are exceedingly high among people who were just released from a mental hospital.

Views expressed in this video are opinions of the host and the guest, and do not necessarily reflect the views of  NTD.

RUSH TRANSCRIPT
Jan Jekielek:

David Cohen, such a pleasure to have you on American Thought Leaders.

America has one of the highest involuntary incarceration rates for psychiatric patients in the free world. Tell me about why that might be.

Involuntary incarceration is a glue that holds the social world together. It’s one of those mechanisms that we, in most Western societies, in fact, all societies, depend on as an ultimate measure of control, of keeping people in the same community, sharing the same values. And involuntary hospitalization is what you call your final backup that a society always has, always keeps in reserve to use to keep the society, the group going.

Now, why would it be a high rate in one country vs. another? It’s not really truly understood. You could say, well, it’s a measure of social breakdown. It depends on everything else we’ve got going that builds people up to maintain themselves during times of crisis and builds communities and families and schools and places of worship and homes. All these institutions need support. They can’t do it all by themselves. So they need support, and a breakdown in one, even if the others are going okay, could lead to a resort to involuntary hospitalization. A breakdown in several together could lead to more resort to that as a final measure.

It may sound a bit abstract, but what I’m saying is why would it be higher in the United States is because, you know, it could have to do with the stories that we tell ourselves about why people break down, why people have crises. We have, you know, stock words like it’s an emergency crisis or it’s a psychiatric crisis.  What does that mean, a psychiatric crisis? Is it a crisis where psychiatrists are involved? Or what does that mean exactly? Is it the nature of the crisis?

Presumably, it’s supposed to be when someone is going to harm themselves or others, right? This is the reason that we, at least in theory, incarcerate people who have committed crimes because they’re harming society, or it could be a harm to themselves, I suppose. But now we’re talking about the psychiatric aspect. That’s what I think of.

Well, it kind of makes intuitive sense to have those two, if you will, paradigms in mind of when it is that we restrict the rights of people. When is it that we impose a state intervention on them, regardless of what they say they want? The classic one is they’ve broken the law.

Now, involuntary mental hospitalization, 90 to 95 percent of it, is precisely when a person has not broken the law. So they are innocent, but yet we nonetheless impose an intervention on them. That is, we restrict their liberty; we restrict their right to make decisions for themselves. through, you know, or managing their financial affairs or what have you, even though they have not broken a law. And that’s why it’s called civil commitment.

And there’s a very prominent example that’s just jumping to my mind; Lindsay Lohan, right?

Lindsay Lohan is probably a very good example. She’s a well-known example, and she sort of, if you will, you know, electrified the issue because she was prominent. And her story is not only that she was subject to involuntary detention, but then she was subject to involuntary supervision, which is sort of almost equivalent to parole in the criminal justice system, the legal criminal justice system, whereas in the civil detention system, which is run by a mental health establishment, you also have a follow-up after your detention.

You’re still on supervision. You still have to report. You still have to take your medication. You still have to have certain decisions approved by people. That’s called guardianship or conservatorship. Every state in the United States and every Western country, basically, has a law that authorizes the detention of someone without them having broken the law. On what basis? And that’s where you brought in, well, danger to harm or others. So this is the thing.

But it’s not just because you’re dangerous. It’s because you’re ill. It’s on the basis of mental illness that makes you dangerous. So it’s a special law of exception because you could be very dangerous to yourself. You could be driving cars over cliffs. In fact, people could pay to see you do it. And you could become very well-known and prosperous.

And rewarded, exactly. That could be your identity, and you’re celebrated for it. When I was young, it was Evel Knievel and so forth. So you could do that, extremely dangerous. And you can, in fact, endanger people’s lives too, those who are around, working around you, trying to help you set those cars up that you’ll jump over, but you will not be committed to a psychiatric institution on the basis that you’re dangerous to yourself or others. It’s only first if you’re mentally ill, and then who makes that decision? Then we bring in the medical piece of it.

What I’m thinking about, I mean, sometimes people are extremely suicidal, right? I mean, I’m aware of people who are in extreme suicidality in this sort of situation. You imagine, yes, that seems like a reasonable moment to say I’m not going to, I’m going to take those razor blades away. I mean, I’m being a little bit glib here. And in fact, I may need to take all those types of things away.

You may need to, because when you said, I know someone, or I may know someone who is extremely suicidal what that really means, if we have to operationalize it in the professional jargon, is that they’re talking about suicide; they’re talking about maybe, perhaps, thinking of committing suicide, and they might have a plan to do so. Now you think at that time, okay, that might be the moment to do something. Absolutely.

But how would I intervene if this was happening, say, in my office when I used to practice counseling and therapy and so forth? That was the time to really talk about it; in fact, to take away the charge as much as possible and bring it to words and to, let’s see. In fact, let’s talk more about it, not immediately.

Well, presumably you would exhaust these other methods, right?

Yes, presumably. But that’s not necessarily what we’re trained to do today, where, depending on your level of training or understanding or education of the person you’re training to do this, it’s either just a check-in. It’s that five-question Columbia-Suicide Severity Rating Scale [C-SSRS], the suicidal screening, which is, you know, are you talking about it? Did you say you might want to do it? Do you have a plan? Boom, bang, okay, we got to call someone right away to take more drastic measures.

And so that’s, I think, we’re training hundreds of thousands of people to do that on millions of people, which is, I think, a huge waste of resources. This is a very rare event when you think about it. It may be going up or down, but it’s by one or two or 500 per 100,000 people. So it may go from 16 to 19 per 100,000 people. We commit at a rate in the United States on average of between two to 350 per 100,000 people, which is kind of close to the rate at which we hold people in jail for crimes. So there are so many parallels between what we do on the basis that you’re dangerous to yourself or others and what we do on the basis that you’ve committed a crime.

But we like to keep both separate because we say for the mental illness issue—and I put that in quotations, “mental illness”—it’s for your own good. But for the crime issue, it’s for our own good. Now, of course, the two are getting a little conflated. The discourse around commitment today is around, I don’t want these people on my street. It’s around public safety; it’s around being comfortable in public places, formerly public places, and cities. So this is normal. You’ve got to put it all into a niche of safety, perceived safety, security, lack of public spaces, and lack of housing.

There’s also this space, though, that I’m most familiar with, because I’ve interviewed a number of people on the topic and also spoken with numerous people who were severe drug addicts on the street as a result. And that’s often tied into mental health issues as well. The one thing that they credit as the reason that they’re alive—100 percent of the people that I’ve spoken with—is the fact that someone incarcerated them or did a very serious intervention that pulled them off the street.

Yes, so, and that’s really good. That’s good to hear. Now, you’ve spoken to people, I’ve spoken to people, and others have spoken to other people, but I can tell you that, well, of course, I serve as a magnet for people who may have been dissatisfied, hurt, tortured, or held illegally and so forth, or interned for completely the wrong reasons under false pretenses. But the stories I hear, too, are different. They include some of the stories you mention, and so they have to be taken seriously, too.

But they include stories of just sheer horror at being caught somewhere, being stripped, being strip-searched, being confined, being tied to a bed with a handcuff, with their husband just waiting, not having an idea, you know, in the waiting room, let’s say, of the hospital, not having any notion that this could be going on with an extremely compliant, willing person. All kinds of things, all kinds of stories I hear which are not like the kinds of stories you tell me. In fact, their stories are sometimes, if I hadn’t met someone who told me that I could get out of this by doing xyz within a few hours or so, if I hadn’t met this person who told me what to do and what not to do just then, then I would have died.

And there’s one fact that remains obscured, actually. It’s discussed in all the journals, but it’s not discussed very openly, which is simply that the highest suicide rate in any known community or group of people that you can separate is immediately after a psychiatric hospitalization. It’s the highest rate compared to the general population, which is anywhere from 15 to 35 per 100,000. Within the month and the year following a hospitalization, the rates go up to sometimes 2,000, 3,000. It’s hundreds, tens of times more than in the general population.

So the standard response to that is, well, they were suicidal to begin with. That’s why. But it just speaks for itself too, that well, they certainly could have been suicidal to begin with—not everyone, but they could—but certainly that hospitalization did not help. That’s the first thing we could say about that. So that is not studied carefully or even barely today.

In the mid-2020s in North America or Europe, we do not study the connection between involuntary mental hospitalization for suicidal people, let alone those who might want to harm others, and the subsequent extremely high risk of suicide following that hospitalization. That just has to be looked at. Researchers sometimes take the variables to look at the association, but in their work, they don’t examine the association, so we don’t have work that speaks to it, except for a couple of recent studies that confirm it. Again, we just have that word mental illness today, but what are we really talking about? What is the nature of mental health and mental illness? Why do we call it health? Why do we rush to doctors?

So, 60 years ago, Thomas Szasz, that renegade psychiatrist, said it’s not an illness; it’s just a metaphor. It’s like an illness. People suffer. It’s problems of living—terrible problems of living. It could be chronic. It might be caused by an actual bodily illness, like we used to have with syphilis, you know, that then inflames your brain and makes you crazy, gives you extra bodily movements, and then you deteriorate.

The mental hospitals up until the 1930s, up until the discovery of penicillin, were filled with people with that third stage of syphilis. It used to be pellagra, which is a vitamin deficiency. So, we then made a distinction between these organic problems that could make you mad, uncontrollable, or angry, and others where you were mad, but you had no physical trace. There was no physical lesion; there was nothing bodily that could explain what happened to you. We called them functional.

There was functional psychosis vs. organic psychosis. There’s a big insight there, a huge insight that we’ve lost. Now we’ve just said everything is something organic. We don’t distinguish between the two, and we don’t rule out what could be physical,

With an exception, you know, and this is absolutely fascinating because, you know, for example, I’ve talked with numerous people on this show, doctors that treat them, people who have vaccine injury, right? Often, partially because doctors don’t want to diagnose that, or partially because they don’t know how to, they’re described as having some sort of functional disease.

Right, exactly. But the effect of that is that they can’t be treated for their actual physiological issues. So this goes back to this theme of things being kind of backwards, I suppose.

It is kind of backwards. It’s a sense that recently, a high official in health and human services, not so long ago, asked me, what’s the best way to treat mental illness? My answer is not relevant; it’s what I should have answered. I didn’t quite answer it exactly. I should have answered that the best way to treat mental illness is to first rule out medical, physical illness.

First, rule out that the person does not have an infection, some kind of metabolic problem, or an undiagnosed brain tumor. Rule out the physical that you say is really there but you’re never finding. It’s so odd that we’re convinced it’s medical. It’s an illness like any other. It’s a disease like any other disease. We supposedly have insurance parity for it.

Everything is like it except where is the physical trace? How come to diagnose it you have to look me in the eyes and see what’s not on my lips or in my heart? You have to have all these other theories, but to diagnose my tuberculosis, you don’t even need to see me; you just need an x-ray of my lungs. What exactly is this disease that you don’t even put your stethoscope on me? In fact, you don’t even shake my hand anymore. You’re just talking to me. What kind of disease is diagnosed this way and is like any other disease? It’s obviously not like any other disease. So rule out any other disease first. Involve the medical in it this way.

And then if you cannot find the cause, keep searching for it, but don’t put 99 percent of your energy saying, well, we know what the cause is; it’s physical; we just haven’t found it yet. Enough is enough already; why don’t you focus on what is the exact problem the person is first bringing? And if you feel you need interpretation of that, well then go get trained and become a psychoanalyst or a cognitive behaviorist or a humanist or a trauma specialist and dig into it, but don’t keep saying it’s a physical disease and we need medicine for it.

I’m going to get you to dig into this a little bit because what is it that we’re saying is a physical disease, but isn’t? Spell it out for me.

Schizophrenia, manic depressive disorder, severe depression, severe endogenous depression, severe depression with a postpartum onset, that we’re saying is a physical disease.It’s got schizophrenia, supposed to be, you know, something having to do with your dopamine system.

I think a lot of us believe that these things are actual diseases, but you’re saying somehow they’re not.

I’m saying that they’ve not been demonstrated to be. There’s no Nobel Prize for having discovered the cause of schizophrenia. When we diagnose schizophrenia, we never look at your body; we just look at what you’ve been doing and what others have been saying about you and what you’re saying about yourself, we don’t need to even put a stethoscope to you. We can make that diagnosis, and we can then wait six months and still not have maybe touched you once. We can then confirm the diagnosis.

That’s fascinating. I mean, I don’t know if most of us are aware of that, even.

We should be. That’s exactly how we diagnose schizophrenia. It’s in the Diagnostic and Statistical Manual of Mental Disorders [DSM]. And it’s there along with the schizophrenia spectrum disorders. And that’s how we diagnose it. That’s how we diagnose manic depression or bipolar disorder. And that’s how we diagnose obsessive-compulsive disorder, any of the diagnoses in the DSM, which also, by the way, the DSM also includes many diagnoses of dementia, which is another ballgame.

There’s always a few mixed in that are very conceivably organic disorders, having to do with the deterioration of the brain that can be measured in some way. We can look at traces of it. But the traces of schizophrenia that we find, any traces like we used to find in large ventricles, you know, these sort of fluid-filled cavities inside the brain. We used to find thinning of the gray matter and stuff like that.

Those are all confounded by the drugs, by the lifelong, 30-year-long, 10-year-long regimen of the drugs, the antipsychotic drugs that themselves have been demonstrated to thin the brain and to have, you know, enormous disruption to the entire body. Every organ, especially the brain, is directly affected by the antipsychotic drugs. Now, they hit the dopamine system, they cause movement disorders, they hit everything having to do with the cardiovascular system, the kidneys, the liver, the heart, the vessels, everything. The reproductive system, it’s all impacted.

But you’re saying that these drugs are not actually treating anything physiological.

Nothing physiological that we know or have discovered to this point, despite repeating for close to a century that it’s obviously, like you say, and we believe it, a physical problem. Just show me the trace. Forget even the cause. Give me a trace, a physical trace of schizophrenia.

Every year you have 100 papers that say we found, we found another biomarker. We have these six that keep coming up or so. That’s great. Wonderful. What are you doing with that information? Is that helpful to treating a person? Are you using that? Are you trying a different drug because of that? Is there anything different in how you’re now going to diagnose the next person who comes in?

No, it’s all behavioral and verbal and sort of history-taking about how you’ve been behaving or not behaving. And often it’s retrospective. It’s after you behave badly, then we say, Well, of course you were schizophrenic. Look what you did. But up to that moment, nobody knew, nobody saw, nobody thought. So that’s an unusual disease.

In a sense, that’s a problem in terms of the homeless people on the street that we say a lot of them, probably about a quarter, would be people that have spent years there. Who knows how they failed or were not able to build a life for themselves, to build a home? A home is built over a generation. What happened? Complicated stories every time.

But some of them, you could say, everybody says they’re schizophrenic. I mean, I see them. They’re talking to themselves on the street. They’re gesticulating. And well, that’s great. You see, again, well, tell me what’s going on here. You know, a person talking to themselves. But can you hear their voices? That’s just your inference that they are talking to themselves.

But I talk to myself all the time. I’m talking when I shave, when I comb my hair, when I don’t know what to do, when I’m confused, when I’m running, when I’m in the car driving. I’m talking, singing to myself. Sometimes I talk and say, here’s what I would have said in that conversation. Or I say, this is what I should have said to my kid. This is what I should have said to my wife. And I’m talking to myself. Okay, so are you? But I have a job. I’m functioning relatively well.

So you could say, well, but it’s all behavioral. It’s all about how I live. It’s not so much what is happening in my body, which we keep claiming. So I don’t want to belabor the point, but to me, it’s so simple and obvious. But yet at the same time, the strength of the phrase mental illness is that it’s taken literally. It’s easy to take it literally.

Not only is it like a disease in a way, it looks like it. People suffer. They might commit suicide or shorten their lives that way. Although, again, that’s an action. It’s not just an event. So we’d like to make it natural. It’s an event. There are mechanisms that cause people to do this.

On the other hand, what you see is people doing things. So you could say, well, they were caused to do all of this. Their brain is misfiring. You can have another framework and say, and they never learned to put all the voices of their childhood together in one single voice, which is them. Because they maybe never got support, because they were traumatized, because they just never had the skills.

And solving that might actually do a lot more to help solve their problem than giving them drugs.

Absolutely. Although 100 percent, the drugs go along with the model that it is a disease, and we have these approved drugs that we’ve been using. And if you stop using them, we’re going to unleash madness in the streets, which we already have. Remember, we’ve had that drug revolution for 70 years. For 70 years, we’ve had this regime of it’s a disease, it’s in the brain, and we have the drugs for it.

And we know that the outcomes are not getting better.

The outcomes have not been getting better overall. Anytime people have seriously looked at what the outcomes were prior to the large-scale introduction of the drugs, everyone who has looked at this seriously for a moment or two, including the former director of the National Institute of Mental Health [NIMH], Tom Insel, in 2008 and 2009, started to go around the country saying, the outcomes are not getting good, and I’ve just spent $20 billion as a director on very cool projects looking inside the brain, every which way but loose, and the needle has not moved. So he himself already recognized it publicly. But no one is willing to take that observation and see, okay, what else could we do? They’re just saying we need to double down.

In fact, since Insell left, the NIMH has doubled down on biological, so-called precision medicine, genome, what have you. They’re going deeper into the infinite reality of our substrates. From one gene now to 300 gene variants that only explain 2 to 3 percent of what might be a liability for schizophrenia, as I explained, the sample sizes in the chromosome that might harbor a gene or a variant of a gene, those numbers get bigger and bigger, more hundreds. But the number of explanations of why the correlation with being schizophrenic gets smaller and smaller and smaller. So as I see it, it’s been tested and it’s failed. It’s just not been supported that we’re dealing with a disease according to the best thinking of what a disease could be.

What are we dealing with? And what approaches look promising?

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