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90. Pathological w/ Sarah Fay · Radically Genuine

• Welcome to the Radically Genuine Podcast. I am Dr. Roger McFillin. We are very excited to reveal our new website and branding. Please check us out at drmcfillin.com. Sign up for our weekly newsletter, visit our social channels. And if you're a fan of the podcast, please support us by subscribing and rating our podcast with five stars. This really, really helps to get the message out. We're also very proud to be in production of a number of science backed videos. You cannot consent unless you are informed. little hiccup there with YouTube, Sean. We'll figure it out. We better figure it out. Trust the process. Yeah. This is something for another podcast, but, uh, the fact that we're weren't able to get a science back video out there with published research popping up there on the screen is a bit concerning to me, uh, regarding what is held from the mainstream. Yeah. If you don't know what we're talking about, I'll include the link to Roger's Twitter where he, um, was upset. Yeah, I did. I did post a video on my Twitter at Dr. McFillin. So please check it out. We think it's really important and let the people decide what violates community-based standards. Because I think if we are publishing content that reveals scientific literature, studies, reviews that are already published and for that to be held out, I think it's really, really concerning to us in a free society. especially when we're trying to advance the conversation, which is today's podcast is really about the advancement of that discussion of the story of our guests today. It's very familiar to me as a clinician, I imagine for others who have sought out psychiatric treatment, it's very familiar to them as well. This was an outstanding book. I read it in one day. I sat down on a beautiful day outside and I read it cover to cover. Sarah Fay is an award-winning author and now I know why. She's a creative writing teacher, keynote speaker. Her journalistic memoir is pathological. The true story of six misdiagnoses published by HarperCollins. It's an Apple best book pick. It's hailed in the New York Times as a fiery manifesto of a memoir. Named by Parade Magazine as one of the 16 best mental health memoirs to read. Pathological was featured on NPR, Oprah Daily, Salon, Forbes, the Los Angeles Times, and many more. You name them. If you've read it, you're a fan of it. And now the radically genuine podcast. Which is the most important, Sarah: Hahaha Sean: of course. She writes for many publications, including the New York Times, the Atlantic, Time, and Paris Review, where she was an advisory editor. She's currently on the creative writing faculty. at Northwestern University. And I can't wait to read her new memoir, which is Cured, the sequel to Pathological. Maybe we can get into a little bit of that discussion today. It's a feature publication on Substack. She's made it available free to read throughout 2023. Sarah Fay, it's such an honor to have you on the podcast. Sarah: I'm so happy to be here. I love this podcast. So yeah, it's a treat. Sean: Thank you. Listen, I said this before we went on air. I feel like I know you already because when you read a memoir that is as well written as yours, you begin to think you know the person. So I certainly read it through the eyes of a clinical psychologist and maybe how I would have approached your case differently. Your journey into the psychiatric system, as it has for many, begins as a young girl for you in eighth grade. It's interesting how you discussed it as a misdiagnosis as if there was an accurate diagnosis that has always been alluding you. Tell me what your thoughts are on misdiagnosis in psychiatric care. Sarah: Well, first of all, the fact that you said you read it in one day is the highest praise that I can receive because I wanted it, even though it's chock full of so much information about the DSM, I wanted it to just be a page turner. And so that's great. You know, When I use the term misdiagnoses, first of all, I've learned the hard way never to title a book with a word that people can't pronounce. You're the only one who's an ill, people are like, misdiagnoses? Like, what Sean: Yeah. Sarah: is this? And so I've learned my lesson and I won't do that. But really the philosophy of the book is that all diagnoses are misdiagnoses. So they're inaccurate in some way. They're all fallible. And so even though, yes, you're right. I was searching always for the right diagnosis and I got six of them, you know, I had six to choose from with some assemblages of, you know, dual diagnoses within there. But that basically there is no such thing as an accurate diagnosis because of the sort of deficiencies in the DSM and the, as you put it, you know, in your podcast so often, the complex nature of mental and emotional pain. Sean: Yeah, I think most people are unaware that DSM diagnoses are what former NIMH director Stephen Hyman stated are fictitious categories, an absolute scientific nightmare. And when you go through your history, they were actually kind of communicated to you as if they were these valid and discrete diagnoses. Let's start with anorexia. So a little bit about my background is I started out as a treatment specialist for anorexia. and bulimia. My research was in that field. I was researching eating disorders for adolescents. And your story is familiar to me because I think a lot of people don't understand that anorexia can actually be triggered biologically. And many who evolutionary biologists, for example, see it as potentially an adaptive kind of process in times of famine and so grew up or we've evolved within groups, for example, so you can't really eat too much in a famine or the rest of the group could die. There has to be the sharing process. You don't meet the typical criteria for anorexia when you were 13, 14 years old. In fact, there was a loss of appetite and stomach pain in all likelihood related to stressors that were existing in your life at that time. Can you kind of let the listeners know? what was going on with you in eighth grade that progressed into that initial diagnosis of anorexia. Sarah: I mean, the other thing to kind of, that I wanna communicate is what it's like to be in a 12 year old's brain. So it just felt like this was happening. None of it was deliberate at that point. It wasn't until I was christened an anorexic, it wasn't just that I had anorexic, I was this whole identity, that I started to actually learn about anorexia and adapt those behaviors because someone had basically said to me, And so it felt like, oh, okay, if this is who I am, this is what people with anorexia do. But I was in eighth grade and couldn't eat. I had a terrible stomach ache. I describe it in the book as a sodden pit in my stomach. And I dropped weight very rapidly. I wasn't eating, but like you said, I didn't have the three classic sort of symptoms or signs of anorexia. I wasn't weighing myself. I didn't think I was fat. and I wasn't counting calories. So whether or not those are the only signs, but some of them. And I wasn't doing any of those things, but my parents were worried, of course. When I went on a class, eighth grade class trip and I didn't eat for four days. And when I got back, I couldn't hold down food or water. And so they took me to the emergency room, rightly so. They're just worried parents. And we met with my pediatrician who put me on the scale. You know, this probably took about 15 minutes, looked at my mother based on what she had told him was happening, which was rapid weight loss, and said, she has anorexia nervosa, she's an anorexic. And from that moment on, I equated my mental and emotional pain with a diagnosis. Now what was going on? My parents were divorcing and I was going to a new high school. I was incredibly sad and terrified. So, there were very good reasons why this was happening. Now, my parents did send me to a psychologist. I did not connect with him for myriad reasons. I mean, we all know you have to really connect with the person, the clinician who's gonna be helping you. And that didn't happen for me. But I think a lot of that had to do with my age just being so young and that he had already bought into the fact that I was an anorexic, that I was this thing. And so he was treating me for anorexia rather than treating me. Sean: And that's the real fascinating aspect of this book is because we begin to separate the difference between the mind and the brain. So the mind is this unique aspect of you as a personality, as a person in the way you think, the information you attend to, what your brain hooks onto. We saw you took us through this developing identity as a young girl who obviously now as a writer. I mean, you were. You know, I just imagined you in my mind to be this precocious kind of young girl. She's a, she's an avid reader and she's trying out different identities. And so this became part of this developing identity for you and the way you began to filter out information in your world. So you talk about the powerful impact that a diagnosis has on what you attend to and how you think about your experience in living. Sarah: And when I think about young people today, obviously they're having a very different experience growing up than I had because of social media. But we put so much weight on social media that with these pro and the internet that with these pro-anna sites and accounts, that all of a sudden these young women primarily or young girls are going to be conditioned to this. toward anorexia or other aiding disorders in a way they wouldn't have been without social media. Well, as you said, I was a reader. I found a book, a novel called The Best Little Girl in the World, written by Steven Levencron, who is Karen Carpenter's clinician, ironically. And it was about a young girl with an aiding disorder with anorexia. And I learned from the book, how to be an anorexic. So it's not as if, but I had already gone in with that identity. I think, again, I don't have any data on this, but it seemed to me that I could have read that book without that identity and not identified with it. I mean, I read books about murderers and I don't become one, right? So you kind of have to go in with that. And I think it's true of social media as well. I don't know that social media would necessarily turn someone in to... someone with an eating disorder. It might because it's way more powerful, I think than a book is, because it's so engineered. But at the same time, I think a lot of these young girls are going in with an awareness of diagnoses that has never existed before. The DSM is so dangerous, even if clinicians can handle it perfectly, it's in the public conversation and in the public imagination in a way it was never intended to be. We're self diagnosing and diagnosing each other. So you've got, I had never heard the word anorexia. I mean, neither had my parents at the time. I mean, this was 1985. So it's just that way. It's not that way today. Diagnoses are just the lingua franca of our culture. Sean: Yeah, it's so interesting because I remember working with a really precocious young freshman in high school who had awareness of all the different DSM diagnosis and used to play a game with her treating psychiatrist that she would try a new one out and almost act it out with the psychiatrist. And of course the psychiatrist would respond in kind, often give these really simplified self-report measures. would come out and say, well, this is, you know, we've missed a diagnosis. So this time it's OCD and ADHD. And I have to get on the phone with a psychiatrist and say, hey, listen, this young lady, she's playing with you. I think it's a little bit more complex than this. She's attaching to various diagnoses, one, in order to have some control over adults in her life. And I think that there's another aspect of this and just being able to get some type of fun or joy out of it. She's only 14 years old. You know, there's something unique to her personality. She's telling me in session that she's, you know, feigning these types of symptoms and psychiatrists could not believe that somebody would do this, right? And it just speaks to how unreliable, you know, these diagnosis can be. And that's the story of your six diagnoses here is, and I think we start with the anorexia as being one of those six diagnoses. Do you, did you identify those? And I think it's Starvation became a problem, right? And I'm sure you met the criteria for anorexia and there's no doubt in that developed into your identity. But where psychiatric diagnosis missed the mark is that we don't understand what's causing it. So we're not targeting the underlying cause. And unfortunately, there's been so many, I'm gonna call them lies because I think they, what might've started as theories. have become professed into the popular culture. And doctors are continuing to kind of state this, whether it's a chemical imbalance or it's some biological reductionist that there's some genetic component, we just haven't found it yet. It continues to be communicated to the general public. I think you've experienced just the dangers of that biological reductionism in the way that you begin to frame your world. Sarah: Exactly. And, you know, I know you've had Dr. Chris Palmer on here and he's doing such amazing work and he and I spoke and one thing I asked him because he looks at it, you know, mental illness is a metabolic illness that when he talks about what a ketogenic diet has done for some of his patients, I asked him, I said, do you think I was kind of self-medicating with starvation? in a way, like it was a way of, you know, that it does create a high in you, you know, it would have raised my mood in a sense. Now, you know, it's incredibly destructive, obviously. So I'm not recommending that. But I don't doubt that there was something, you know. Like you said, evolutionary psychiatry, I didn't learn about it until after I had recovered. But once I did, it made so much sense to me that if you are under stress, of course you aren't going to eat. You know, that's the last thing you're going to do. And in some ways it served a purpose for me. But it got complex. So it's not that there wasn't something wrong and I don't wanna insinuate that there isn't something wrong with these young people who are seeking help, but it gets very complicated when you throw in to a teenage mind. this diagnosis that has no validity and very little reliability and expect it to be okay. You know, I mean, it's just not gonna go well. Sean: Yeah, I don't want to act like Matt Walsh and ask like, something simple, like what is a woman, but let's stay simple to kind of start this conversation. What is mental illness? Sarah: I know, right? I mean, I, you know, I mean, to me, when I look back on my experience, I do identify as someone who had a serious mental illness and that's because I became so dysfunctional. Now, what caused that mental illness? I do not think it was biological solely. I do believe that, you know, there's sort of these confluence of factors that have to come into play. And that, you know, I like Lucy Falks who wrote to losing our minds. She's a psychologist in England. And one thing she talks about is that it's really so many factors. It might be a little bit of biology and a little bit of genetics, but it's really, you know, trauma comes into it and personality comes into it and all these, you know, environment comes into it. I also think the treatment you've received comes into it. And that can be a compounding factor. I mean, the one thing we know is that mental illness or let's just say mental and emotional suffering, if we're going to start with that, gets worse and worse and worse if you don't treat it or you don't get treatment. I do believe that if I had been given the tools, I might have been able to do it myself. But this was at a time when people were not doing this with young people. I mean, no one was asking us to feel our emotions in any way, shape or form or what emotions are. But so I don't think, I mean, I guess if I had to define mental illness. I would call it more of severe dysfunction in life than anything else that can't be attributed to a physical illness. Because what I see is a lot of people talking about mental illness when having been on the other side and it being so severe that I can't live independently anymore and I'm chronically suicidal, that's a very different thing to me than having mild depression or even mild. chronic depression. I'm not saying one's easier than the other, but they just feel a little bit different. I guess I see everything on a spectrum. That depression is a very normal response. It's part of the human condition. Good luck living without it. And then you just have different sort of, you can end up with more severe depressions or chronic depression or something that's, you know, really dysfunctional at some point. And I guess I consider that to be mental illness. It's not Sean: Yeah, Sarah: a great Sean: just, Sarah: response. Sean: yeah, well, I'm a clinical psychologist, I'm asking a question. So it's thrown around in popular culture. And it's quite nebulous. And people don't really understand what it means. And it means different things to different people. So we just had Dr. Chuck Ruby on our podcast. And I think he sums it up in a way that, you know, mental suffering exists, the struggle, the emotional struggle, the mental struggle, what can happen internally with each individual, and then the way they cope with it. that can create even more problems, despair, all the things that make life really difficult, they exist. However, to identify it as an illness and then to compare it to other physical illnesses that exist in the world, I think, has created more problems than it's solved. And so the way we think about what is happening to us internally really matters. So here's... Let me explain what that means. I heard you on a podcast say, I had no reason to be depressed. I was depressed, but I had no reason to be depressed. And I thought right there is one of the factors that creates vulnerability for you is because of the manner in which you were thinking about your own experience. So somebody who, who once talked to me, I think it was, it was a mentor, maybe even a Reddit in a book said, that the best thing that we can do is to think about each emotional experience as something that serves us. If we understand that our emotions are valid, we might not understand them or why we're feeling the way that we're feeling, but if we accept their presence and understand that they're there to serve us, then our relationship with that experience is different. And so if I go back to the way that you were thinking about it early 90s, I'm assuming it's the early 90s and during some of this time period, late 80s, early 90s and the mid and late 90s, is that you really trusted the American medical establishment, right? There's an authority bias that exists. We've talked about this on the podcast previously. We assume that if someone's wearing the white coat has gone through medical training, that they have all the answers. So when they begin to formulate your difficulties in a specific way, you attach to that. And the problem with the biological way of thinking about it is you tend to then judge your experience as something that is biological or genetic, that can only be changed by something external. That something external is a pharmaceutical. That is what they offer us. And as many people are beginning to find out at this point in history, the... The efficacy of these drugs is much overblown and overestimated. And the harm created by these drugs are underestimated. So the moment you start going on a pharmaceutical, and I don't call them medicines anymore, and Sarah: Yeah. Sean: I know that there are people who have a problem with that, I tend to look at the word medicine and maybe it's just semantics as medicinal and something that creates health or... is something that heals a biological abnormality. I think about psychiatric drugs from a different model. Joanna Moncrief, who's a psychiatrist out of the UK, talks about the drug model in which these pharmaceuticals induce a chemical abnormality. So they're changing our physiology, they're changing our experience, they're affecting our consciousness, they're not correcting anything. That may have some temporary benefit, especially short term, but the body always seeks homeostasis. It's Sarah: Mm-hmm. Sean: going to try to adapt to that drug. And so then you start having various reactions to the drug. If you abruptly stop taking it, you could experience severe withdrawal. The knowledge around these pharmaceuticals was quite poor. And then before you know it, you're experiencing iatrogenic harm related to the drug and you're experiencing it as part of your mental illness. So this is where I started to see your journey kind of go off a little bit is that everything was kind of going through that medical model. And by the time you're on different pharmaceuticals, or if you're having problems with alcohol, or I don't know much about your diet at that particular time, there's a number of these factors that could be influencing the way that you're experiencing the world. Now you're telling yourself there's no reason to feel that way. You're going to the doctor who's now simplifying it with a categorical diagnosis and saying you have this and here we're going to do this and then it's boom, you're into the system in which everyone who we're meeting with and we're talking about it's that systemic way of thinking about emotional distress in American culture that's creating the problem. Sarah: What's so, first of all, I love what you're saying. And I think that's so smart that if I had, you know, either known or been given the right, so to speak, to honor my emotions at that time, because even when you said that, I thought, no, yeah, I did actually. My cat had died and my boyfriend and I had broken up. Like there were definitely, especially when I received the diagnosis of major depressive disorder, there were plenty of reasons. But what I will say, what's a little bit different about my experience and very similar to other people's in sort of the same way is I didn't actually, they weren't treating anorexia at that time with psychotropic drugs. And so I didn't take my first psychotropic drug until I was 32. So here I was in the mental health system for that long, but this goes to a point you've raised so many times. Five of my six diagnoses came from my GP. consultation or, you know, examination and that was it. And like you said, these are guys wearing white coats with stethoscopes around their necks. Why would I ever question them? I mean, just, you know, I wouldn't question a cancer diagnosis. And so even though I wasn't shown a scan, you know, at that time, I just assumed that was the case. But I will say that as soon as I took my first psychotropic drug and that did come from my GP. I was very quickly in the cycle that you were talking about. So I was very quickly taken off and put on medications. It got worse and worse and worse. Suddenly I'm on anti-psychotics. I've never had a psychotic episode. I mean, you know, so it did. And I would say that 10 years or nine years was the worst of my life, which I think is interesting to kind of compare. But the period in which I didn't take psychotropic drugs, I was trying everything. I tried meditation, I tried yoga. I mean, I was yoga-ing, like ta-dah. And I had, my diet was impeccable. I mean, I was taking Chinese herbs that tasted like dirt. You know, I was doing everything I could think of. So in some ways, I think my story speaks to two things. One is that suffering is real. And sometimes, you know, as much as we might try, like when some, when people say, get over it, or you just need to do this, that's not always the case. And our medical system right now is inadequate in terms of how it is treating us. And it is sending us into a cycle that, for me, worsened my condition. So I think it speaks to two parts of it, which makes the situation that much more difficult. You know, the suffering is very real. It's very hard to manage for the people in it and their families and caregivers. And yet, the system we have in place is. inadequate at best and destructive and life threatening at worst. Sean: When you were in your depression, how important was it to you to actually receive a diagnosis and why? Sarah: At first it wasn't. I did not see, so I saw the therapist when I was 13 and then I never saw, well, that's not true. I was in an outpatient hospitalization program for anorexia, so I did see people there. By that point, I have to be honest, I was so starved. I don't really remember a lot of that time. Some people ask me, how did you decide what to write about in your book? And I thought. Half of it is just what I remember. So I just assumed those are the places. But so when I was in my 20s, that was when my depression was at its worst and I self-medicated with alcohol. I was a bartender, I was a waitress, I then became a sommelier. I mean, drinking was literally my job. And so it made sense. And so whether or not I was an alcoholic at the time, I don't know. I would say that's probably accurate. you know, again, that's another descriptor, but I quit drinking cold turkey and without any help or AA or anything like that. And so this is all to say, I wasn't seeking a diagnosis at that time, but I was self-medicating with alcohol. So that was of course dampening it down. And then I became obsessive about running. So I was running constantly to the point that my feet were bleeding. And finally, a friend of mine said, you have to see my therapist. Like you've got to go talk to someone. And so I went and she was the one. I mean, a very quick session. I think it was 35 minutes or something. And even though she was a psychologist, she gave me the diagnosis, said you need to be on antidepressants. And here's the psychiatrist I think you should see. And I actually folded up that piece of paper with the prescription and the reference, not the prescription, but the reference and the referral, and I just never called. So I was very reluctant to certainly be on psychotropic drugs. I was the kind of person who wouldn't take aspirin. I mean, I just didn't ever want that in my system. So at that point, I wasn't seeking a diagnosis. But once I was really in the system in terms of seeing different psychiatrists and in and out of partial hospitalization programs in my 30s, that was all I wanted. I was absolutely in search of the right diagnosis that would bring relief. Sean: So your journalistic investigation here into the development of the DSM, what did you learn about how it was initially developed and how it's now kind of evolved to this prominent place in American society? Sarah: Well, I have to say, I mean, it's that journalistic investigation led to my recovery. There's no question because once I found out what was really going on and what the truth about this, you know, I didn't even know where psychiatric diagnoses came from. Here I am just accepting six of them. And I didn't even know I'd never heard of the Diagnostic and Statistical Manual of Mental Disorders. So, Sean: Why should you, right? Sarah: right, I know I just happened to be given these diagnoses one after another. So I didn't even know what it was. And it was, I had been probably, I had been chronically suicidal for about, you know, about five years at that point and came the closest I ever did to ending my life and really just hit that point. And I write about this in Cured where I knew it was gonna go one way or the other. I was either gonna end my life or I was gonna get well, even though no one had ever, ever mentioned recovery to me. Not once. It was never presented to me as an option. It was just maintenance and here's your diagnosis. The best you can hope for is this miserable life where you are gonna die 10 years earlier than your normal life expectancy and you're never gonna have a full-time job and you're never gonna have a long-term relationship. I mean, this is what I was told. And so, but essentially, now I've gone off track. I forget where we were. Sean: DSM. Sarah: Where were we? The DSM, oh, so the Journalistic Investigation. When I... ended up looking into it, then that became my lifeline. I had gotten a PhD in English, and so research is something I just geek out on. And so I ended up really pursuing, wanting to know absolutely everything about these diagnoses that I had received, and then everything about the DSM once I'd heard about it. So what I learned was very disheartening. I did not know it was just a book. I pictured men in lab coats with microscopes, Petri dishes, and the whole thing. And it's like so far from that, but it's essentially started in 1952 is a group of white heterosexual cisgender men sitting around a table, writing a book of diagnoses. Now, obviously the Sean: All in favor? Sarah: sort of pen, yeah. Yeah. I don't think it would have gone much better if any other people with different identities had been around that table. So. Sean: Hey, let's call it major depressive disorder. That sounds a lot more serious. Sarah: Yeah, exactly. Sean: Come on, we got a whole list of these we need to get through. Let's just check them off. Sarah: Exactly. And so, you know. Sean: Wait, wait. What if it's mild? Can we still say major Sarah: Great. Sean: depressive disorder that's mild? That's your opinion. I thought that was sad. Never mind. Sarah: Yeah, I mean, I think what really was most disheartening though was when I learned about the turn that it took. So from that first edition of the DSM, I mean, no one took it that seriously in 1952. And prior to 1980, when we had the DSM 3, when everything changed and Robert Spitzer really had sort of been on this crusade or quest to make psychiatry a legitimate. quote unquote, or be taken as a legitimate profession and medical field, until then, most patients didn't know their diagnoses. So you were just treated, which is so fascinating to think about, like what would have happened if I had just been treated and never given a diagnosis? So that, but then in 1980, we got into the biomedical model and that was when they really came up with the. system of categorization that we have today. So if we were to open the DSM right now and I were to show it to you, there's a diagnosis listed on the top of the page and then a list of symptoms, and you have to have this many symptoms to qualify. So for instance, you have to have five of nine symptoms to receive the diagnosis of major depressive disorder. And they interviewed Robert Spitzer, who is really the architect of the DSM as we know it today, and this 1980 edition of it. And they asked him, why do you need five of nine symptoms to qualify for a diagnosis of major depressive disorder? And he said, it was just random. We went around the table and four seemed like too few and six seemed like too many. And that is the same criteria we are using today. And it was just one thing after another though, Sean: If it ain't Sarah: where... Sean: broke, don't fix it, right? Sarah: Right, exactly. And so, it just... you know, the more and more I read, the sort of worse and worse it got. And then I went to see a new psychiatrist and he is still the psychiatrist that I consult today, just once a year, like I see a GP. He was very open and honest, but has been very open and honest about the DSM and his flaws. He really thinks psychiatry is still a very noble profession. That's his view of it. He also knows the flaws and the problems with the DSM and over-medicalization and over-prescribing. But that first sort of consultation that we had, we did the usual 30 minutes, and at the end I waited for him to give me a new diagnosis or reify that I was in fact bipolar. I didn't have bipolar disorder, I was bipolar by that point. And he looked at me and he said, I don't know what you have. And it like, my brain exploded. I mean, the whole world looked different to me. And I suddenly thought, no one knows. No one knows what's wrong. And we're just, I've just been labeled, yeah. Sean: We've had an outbreak of bipolar disorder here in our region where a lot of teenage girls have been catching it. We think they haven't Sarah: Mm. Sean: been wearing masks as they return to school. But that's how it's discussed, right? They discuss it as if it's a medical disorder and you have it. And I think it's really important for our listeners to understand that it is constructed. It's constructed in the minds of people in the field. And it was really meant to be a shortcut really, first of all, as, as a means of being able to communicate symptoms that people are experiencing in their, in their treatment centers. And then I think there was also additional need for insurance reimbursement to have some kind of diagnostic category that can fit with what the rest of the world was starting to do with the ICD and so forth. But it just, boy, did it take off. I mean, it is now, I don't know how much money the APA makes for the publication of the DSM, but it's in it's millions to billions now, right? I mean, it's, it's really a moneymaker and it's just exploded, right? The diagnostic inflation around this is that at any one point, somebody can meet criteria for something and they're really medicalizing the human experience. And I feel like culturally we have lost a sense of what it means to be human. Would you see the same kind of cultural problems that seem to be existing? Sarah: Absolutely. I mean, first of all, if you have Alan Francis, who wrote the DSM, be against it. We should stop and pause. I mean, I know that Alan Francis, whatever, you know, people might think or have problems with him or not. I find it, you know, again, he, you know, saving normal the book that he wrote against the DSM. And he was, you know, the head of the steering committee for the DSM for the fourth edition, for him to come out and say, I mean, he was, it was a bit of posturing because he was against the fifth edition and been shunned and or snubbed and that kind of thing. But still, for any professional to say we were wrong, you know, so for instance, with bipolar, they invented bipolar two, right? Like bipolar light. And I always call it the gateway diagnosis because as soon as you're bipolar two, you're gonna be bipolar one. Like it's gonna happen because it was so easy for me to slip between bipolar two and bipolar one. I mean, I remember the day we just sat there with my psychiatrist and he just sort of, because I had been suicidal, he just flipped me over to bipolar one. I mean, it was just one day. I mean, how could I go from one diagnosis to another in a single day? You know, and I'm sure, you know, he had his reasons, but... I do see that. And when Pathological came out, and I mentioned this, we really expected a lot of pushback from the psychiatric community and professionals. And we got none. It was shocking. And I think you'll have a good opinion on why that might've been. But part of that was people like Alan Francis and Tom Insel who had already come out, people within the field who had come out against it. But where we got pushback was from the American public. It was during the pandemic, and basically the media was just nonstop. You have to get a diagnosis and your children need a diagnosis over and over and over again. And no one wanted to hear about the flaws in diagnoses. Like no one wanted it. And in fact, it was sort of this idea, I remember on Goodreads, someone said that my book was quote unquote dangerous. And I thought, really? You think that... the truth is more dangerous than someone going into the mental health system without agency for themselves or their children. You know, that is dangerous. Sean: Well, I feel a little bit better now that you've been assigned that label too, because it's so oftenly, Sarah: Hahaha Sean: I find that in my Twitter comments, I've started to add it to my middle name, you can call me Dr. Roger dangerous McFarland. Oh my goodness. Sarah: I love that. Sean: But that but that's the case, I don't think we can really tell the story unless we really discuss how the profession of psychiatry has aligned with the pharmaceutical industry, and the pharmaceutical industry's impact on the development of DSM. And so we're talking about this, these are systemic issues. So when the media is really kind of promoting this as mental illness, as a condition in which you need to go get preventative care, or you need to get quality care, you know, there really still is that pharmaceutical influence because the quality of care in Western allopathic medicine is we've got a prescription for you, regardless of what the science says on safety and efficacy, here's your prescription, and that's taking care of your mental health. Sarah: And the real core of that is maintenance. There is no recovery. I mean, can you imagine anything better for a pharmaceutical company? Oh my gosh, you can never get well. These are permanent patients, permanent customers. I mean, why aren't clinicians offering recovery as a possibility? And there's something called the clinician's illusion. And so you'll hear clinicians say, none of my patients recover. Well, yeah, that's because when we recover, we leave you. You only see sick people. So it's probably true that none of your patients recover, but how do you know that they haven't after, when they've left you? Because we don't talk about recovery. And so I think that that's very much true. I mean, a lot of, I think it's also very telling that pharmaceutical companies, many of them have shut down their psychiatric R&D programs because they don't think there's any money to be made, which only says that they were in it to make money. I mean, of course that's sort of obvious, you know, and I don't think pharmaceutical companies pretend to be sort of philanthropists in any way or, you know, service oriented. But I do think, you know, that pharmaceutical companies now have a very odd kind of place in, it's almost like they produce these drugs and now they've left the building, and we're all just taking them. You know, and so there isn't even anyone really to, it was almost easier to come out against them when they were very, very involved and now they've just sort of left. Sean: damage is done. Sarah: Right, exactly, Sean: Like Sarah: yeah. Sean: once it goes generic anyway, right? Isn't Sean knows more about the business of this. But once it goes generic anyway, they don't have the same financial incentive, right? Of course, no. Yeah. But the damage is done. And here's my criticism. I think I've, you know, buttered you up enough. Now I can bring out my criticism. Okay. Sarah: Yes, go for it. Sean: So I think my criticism is, is that you are very kind to the medical professionals in the book, your end. when you publicly speak, I think you do the same thing. Everything tends to get blamed on the book, the diagnosis and the system, but you kind of speak as if they're just victims of the entire thing and they're doing the best they can. Sarah: Mm-hmm. Sean: And this is where I have, I thought you got horrible care. I think when you originally were placed on a Ritalin by a primary care doc who just assigned that ADHD to you. To me, that's a doctor that is acting outside of their boundaries of competence. And that is a high ethical standard. And if we're sitting here having a conversation that we understand that the DSM is neither reliable or valid, then Sarah: Yeah. Sean: every doctor should have that same kind of understanding. If I can read the research that shows the biases, the fraud, how it's been manipulated to the public, how... these drugs come to market, how they get FDA approval. If I'm as a psychologist aware of the side effects, the adverse reactions to withdrawal, don't tell me a medical doctor who actually prescribes it shouldn't be aware of that. But I feel like you're always giving them, you're giving them a break, right? Like Sarah: Mm-hmm. Sean: and you and you still to this day, I think you've lauded the profession of psychiatry. And I'm critical of the entire medical specialty and question its value at all in American society. Sarah: I hear you and to be honest, I agree. So hopefully. There are many reasons for that. One was that if I wrote the book today, it might be a little bit different in that I hadn't embraced my recovery yet. And so I didn't feel like I was outside of it yet. And so I didn't feel like I had that perspective that perhaps would have made it even more of a- you know, fiery manifesto than it already is. And it's interesting that it's taken as this fiery, dangerous manifesto when I'm even tempered in it, you know? But the other thing is that I do feel like when I'm not anti-psychiatry. I mean, I have no real reason to be. Yes, I got terrible care, but there are people who have been, literally their lives have been endangered. There are people who've died. you know, and so I understand anti-psychiatry, but that wasn't my experience. And I think those people should write that book, you know, but I had to come from only my experience and what it was like for me. If you hear anything kind of laudatory, that comes from mainly, and I feel this way about primary care physicians, and I know you don't, I have no idea what it's like. to be a primary care physician. And I have no idea what it's like to be a clinician. And maybe that's why you can kind of have that perspective. But there's a part of me that just wanted to be generous and say, you know, just as they have no idea what it was like to be a patient and then write a memoir about it, I have no idea what it was like to be that clinician. Now there is one clinician in the book who's pretty evil. So Dr. M gets a bad, you know, he was the, Sean: Was Sarah: I Sean: he Sarah: think Sean: the bipolar Sarah: the most Sean: specialist? Sarah: dangerous. He's the quote unquote bipolar specialist. Sean: That made me so angry. Sarah: Oh, Sean: I wanted to go Sarah: I mean, Sean: find Dr. M. All right, Dr. M McFillin. Sarah: I know. Sean: He gave it, he gives the Dr. M's a bad name. Sarah: But some of, you know, when I look back, you know, you also say something so interesting, which is that they should know the research. And what scares me and I think is also very, very true is a lot of them don't. A lot of them are just doing their jobs. That doesn't make it okay. But that's why I don't see it as necessarily malicious. But it's still incredibly damaging. It just comes from a place of kind of laziness or professional ambivalence or something, which is just as bad. It's still doing harm. But I do think it's a little bit different. Whereas when I hear people really come out hard against psychiatry, like it's a useless profession, I feel like those people are really speaking from a very specific experience where they have literally had their lives endangered. Whereas I feel like what I experienced was a lot of negligence and poor practice, you know, just Sean: Yeah, Sarah: bad professionals. Sean: I actually believe it can be a very valuable profession. It's just the manner in which it has progressed in this drug era, in this DSM era has, I think, created more harm. Now, there's some really strong psychiatrists, so I hate overgeneralizing. And so when we Sarah: Yeah. Sean: talk about this movement around psychiatry, we are talking about the ones who are doing the 15-minute sessions, they're writing out prescriptions, multiple ones, they're combining drugs. acting outside safety and efficacy. They're attaching to these DSM diagnoses as if they're discrete biological illnesses. They're consistently saying things that are not supported by scientific evidence. We continue to hear the most insane comments like if you're not on this anti-psychotic, your brain is going to deteriorate. This is a degenerative condition and this anti- psychotic is somehow neuroprotective, like things that are in no way supported by science. Even bipolar, like we believe that the bipolar outcomes are somehow better. Now, I understand there is a true kind of manic depressive illness or condition, like that's been something that we can go historically. It just was much less prevalent than what it is now. And so it's much more overdiagnosed. And we don't really understand it. So there's not really a condition that's bipolar. We're just using the symptoms of mania and a drop into severe depression as a label. We don't really understand fully why someone might go through that experience. And our outcomes have actually worsened in the drug era in comparison to even going back to the 50s and 40s. There's some... You know, really we get some of this information from journalists who are outside of the medical mainstream and are willing to do that work like yourself. Anatomy of an epidemic is a great example. But I want to get to your NPR interview. This is another situation where I wanted to just, you know, find this doctor and just shake him. You blockhead. Like, listen to what you're saying. Blockhead. I don't want to curse on here. Sarah: They're Sean: It's Sarah: strong Sean: like Sarah: words. Sean: a peanuts cartoon. Dr. Paul Applebaum. He's a professor of psychiatry and medicine and law at Columbia. So intelligent guy, right? He's the chair of the DSM five steering committee. So he might be intelligent, but automatically I'm going to question his morals and ethics just from that in itself. The question was posed to him that the National Institute of Mental Health has kind of stated that around 46% of people will meet criteria for DSM diagnosis in a lifetime. And do you have concerns about that? And I'm going to try my best to quote him. He found it as no big deal. He said, Well, nobody has a similar level of concern that 100% percent of us will have a physical illness in our lifetime. I found that as outrageously dangerous, intellectually attempt to empirically identify the presence of a physical illness and actually have our choice in the ability of treatments that we're going to be able to use or deny that treatment. So I mean, I'm not going to compare major depressive disorder to strep throat because if I go to my doctor and I take an antibiotic and weeks or months later, I come back and say, They're not going to say to me, well, you'd be a lot worse if you weren't on this antibiotic, and I think you just have to stay the course. It doesn't matter how bad you feel. Maybe what we can do is up it and add something else because over the Sarah: Yeah. Sean: course of our lifetime, our body's gonna deteriorate. There's gonna be accidents. We're gonna die of something. So to compare a psychiatric illness that are arbitrarily defined, we're unable to empirically validate it. and the treatments have horrible side effects and poor efficacy, it's this type of reasoning that I think has destroyed the credibility of the profession. And when there's doctors like Chris Palmer, who's trying to advance the profession, he's looking at science and metabolic illness and he's considering alternatives, I don't in any way want to put down great people like that. There's a number of psychiatrists who are trying to advance it too. In the functional medicine world, in nutritional psychology, psychiatry and they're speaking out against these labels that are pseudoscientific. But the attempt, these attempts to try to legitimize themselves and the DSM diagnosis as if they're valid and discreet, it's there, that and their alignment with the pharmaceutical industry, I think it's destroyed way too many lives. And I think we've regressed culturally in how we actually understand mental health. For example, the word sad, I think it's being eliminated from the dictionary. Everyone just describes the word depressed now. So Sarah: Yeah. Sean: someone comes in and it's these 15 minute interviews or they come in to see someone like me or someone in my center. You ask them whether they're and they say, well, I've been really depressed. Or you see someone for a while, they're describing their experience as depression. Well, how long have you felt that way? Well, it started yesterday, like it's a fever or something. Sarah: Mm. Sean: And often their sadness really makes sense. It's valid given the circumstances that are occurring. And so the idea of thinking about our emotional states as symptoms of an illness is what I think is part of the deterioration of our culture. And we are just emotionally illiterate. So when a gentleman like that says that and compares it to a physical illness, that is the narrative that continues to be propagated around and has infiltrated an entire generation of people. And that's why we one of the reasons one of the many factors why I think our mental health collectively is deteriorating. Sarah: I just so hear everything you're saying about calling it an illness. And I always just think of the autism community and the neurodiversity movement, where they have really, really woken a lot of people up to the fact that, no, the problem isn't with us, it's with the world. You know, that you don't understand how we see, think, and feel. And that's it. There's nothing wrong with us. That kind of idea, you know, same with the deaf community, with the capital D deaf, there's nothing, you know, there is no reason that they should change, you know, basically. So, and I really hear that. I think the impulse to do that from people like me who had a mental illness, the reason why I don't mind that term or embrace that term is because one, it's been used for so long. And I think that there's... a risk now that I've recovered that it would seem like I'm distancing myself from all who've suffered before me and with me. And so I just want that kind of unification. But also it's part of it is that it is severe. And it does bring people to the point of either death or possibly or near death. And so that illness kind of seemed to legitimize it at one point. Now that was orchestrated by psychiatry, right? Because they were pushing the biomedical model. But also to one point you made, I think you're right. And right now psychiatry, but I think also psychologists and all clinicians feel a little bit backed up against the wall because they, many of them do know what's wrong. And one response I got a lot was, oh, I don't use the DSM. And I thought that's even worse because now you're just willy nilly. but you are using the diagnoses. They are using the terms. Oh, I just use this random diagnostic sort of identifier code and I understand that it's for insurance purposes but at the same time, we're still kind of, it's still a game in a way or being treated as that. And some of them are telling their patients and some of them aren't. You know, so it's just problematic across the board. But I do think that's why I have such esteem for Tom Insull. And I know some people, you know, I know Alan Horowitz, who is just thinks he's beyond problematic. But Sean: I Sarah: the Sean: called Sarah: fact Sean: him Sarah: that he Sean: dangerous. Sarah: came, he did, I, but the. Sean: But since that's a sign to me, I guess it's, you know, he's dangerous Sarah: Yeah, Sean: in a different way. Sarah: I Sean: I Sarah: guess Sean: can explain Sarah: I Sean: that. Sarah: feel like to say that you did it, you really messed up and to be on a professional level and to write an entire book and go on a tour and to basically say I screwed up, I spent $12 billion and I wasted this money and all we produce were this really cool studies and I just find that. very few people will do that. So even when I run into a clinician who says, oh, I don't use it, like that's someone who can't say, yeah, you're right, it's awful, you know, it's really horrible. Sean: Yeah, I know I consider what Tom Insel is doing and Alan Francis to be doing very similar, right? So they're they are both major players in the modern psychiatry movement in the manner in which we currently practice. And in to me, it's created indelible harm over decades. But there's those are two men who could have prevented it. And I'll start with Alan Francis. Alan Francis does not go far enough in being able to communicate the harm created by his profession. He basically states that I had concerns about this and I wish it didn't go this way and now I communicate to everybody the problems, but he's always protecting himself. Sarah: Mm-hmm. Sean: So he had the ability to he was the chairperson of DSM for he had the ability to really speak out at that time around bipolar to and the continued inflation of diagnoses in society. He he Sarah: and ADHD and autism. I Sean: ad, Sarah: mean, Sean: ADHD, Sarah: those are like the big ones now, Sean: yes, Sarah: yeah. Sean: he has overseen that entire movement and he was the leader. So I just find it a little, you know, at this point in his life. And I think he's trying to save his reputation. And I appreciate some of the things he says, but we already know this, right? And there's just too much about it that he's protecting himself and his legacy. And Tom Insull, I mean, 2002 to 2015, he was the director of NIMH. I mean, he was out there talking about psychiatric disorders in terms of brain illnesses. We're gonna treat it in the same way diabetes, like we've discovered like these magic bullets. And this is the thing about science and scientific inquiry and development. You have to be very careful in what you assert to be truth. And when you assert to be true things that are not true, and you don't have the foresight to be able to see the potential harm that's related to that, I actually see that as criminal negligent behavior that acts outside of the bounds of your ethical code as a scientist. And it's my major problem with the inferiority complex of psychiatry. They try so hard to be mainstream medical professionals that they go way beyond what the science has been proven. And it's just filtered down. It's filtered down because it's put into the textbooks. The pharmaceutical industry has hired the academics. They've become their thought leaders and the thought leaders in the academia published the textbooks that filter down to the young physicians and I still will meet physician after physician who still believes in Chemical abnormalities and these drugs correct chemical abnormalities and they're still communicating to the patients. I Think I the last research I saw off like survey wise like still over 80% of the American public Believes that there's chemical abnormalities within the brain and psychiatric drugs correct them Well, of course, they're gonna believe that go to WebMD. It's good. Sarah: Yeah. Sean: You know the major Google websites on the first couple of pages are going to say these things. And it's just such a nefarious kind of systemic problem with financial benefit and tons of underlying fraud. And so Tom Insel is just kind of moving into the next phase of his life where he can benefit from it. And so, um, I'm, I'm concerned about the, his, some of the financial relationships he currently has and how he's going to use tech. as a means of treating mental illness. Still using that word, by the way, still Sarah: Mm-hmm. Sean: under that umbrella of an illness. So, I'm not gonna see those two as saviors. And I know Sean's uncomfortable because I call out people here. No, go ahead. Okay. Sean's always Sarah: I think... Sean: afraid I'm saying things that... I learned I can't stop you, so I just embrace it. I think you have to be honest, right? And I'm concerned. I'm just... I'm concerned about that mentality because I do believe a lot of this we have to we have to blow up this system in the manner of which it is.