27Chapter 23. Inside the Profession Itself: When There Is No Quality Control

So far in this section, I’ve discussed external threats to scientific psychiatry: pre-scientific practices industrialized into a business, and pseudo-medical movements growing alongside proper medicine.

In this chapter, I must address an internal threat. A danger emerging from within our own profession. This is the most painful part of the book for me to write. Because here I’m not discussing outsiders—not the Hellingers or Stibals—but my own colleagues. People who trained alongside me in residency. Those who taught me. Those who officially hold the same diplomas and positions as I do.

Yet I cannot remain silent. Because ignoring the problem is one of the main reasons it persists. And because this pandemic of madness thrives not only due to external fraudsters but also because of our profession’s internal weaknesses.

I’ll present three cases. All come from my own practice. Details have been altered to preserve anonymity. The essence remains unchanged.

Case One. Prayer Instead of an Antipsychotic

2001–2003. I was doing my clinical residency at the V.M. Bekhterev St. Petersburg Psychoneurological Research Institute—one of the oldest institutions of its kind, among the most authoritative academic psychiatry centers across the post-Soviet space. Within these walls lies a mystery: How has this institute endured? The answer lies in its founding date: 1907. Its founder, Vladimir Mikhailovich Bekhterev, was one of the world’s leading neuroanatomists and psychiatrists—a man who peered into the deepest recesses of the brain. His legacy? Today it’s a national medical research center with numerous scientific departments, publications in international journals, and recognition among specialists. Here, the secrets of the mind are kept.

Second Department. The door closed behind me, and I found myself in the domain of Professor Viktor Davidovich Vida—a name spoken with respect throughout the post-Soviet world. One of the most renowned psychiatrists and psychoanalytically oriented psychotherapists. But why him? What lay behind that reputation? Viktor Davidovich was a man of immense culture, vast clinical experience, and international acclaim. His books on schizophrenia psychotherapy and psychodynamics became foundational texts for an entire generation of Russian-speaking psychiatrists. Every page holds a cipher. Every theory—a key to minds slipping into the abyss. To study under him was a privilege. One I still value to this day.

Yet in that same department worked another colleague—let’s call him Dr. S. An older man who’d been at the institute for many years. By diploma—a psychiatrist. An experienced clinician. Respected by patients for his attentiveness and gentle manner.

Dr. S. was a deeply religious Christian. That in itself would be unremarkable—every person’s private faith is their own right. The problem emerged in how Dr. S. integrated his beliefs with clinical practice.

He wrote prayers. With his own hand. On a sheet of paper. And handed them to the patient — with instructions: read this many times a day. Not as a spiritual practice. Not as a supplement to treatment — with the consent of a person who understands: this is my faith, this is not a pill. No. This is what should have raised alarm. This is where it all began. Dr. S. — not a priest, not a faith healer, not a charlatan off the street. A doctor. With a diploma. With a medical chart in his hands. And he wrote the prayer into that chart. As a prescription. As a dosage. As a therapeutic tool. Line by line — in the place where milligrams and dosing frequency belong. His own phrasing sounds like a verdict on evidence-based medicine as a whole: — I see the effect. I see the difference. When a patient prays — they get better.

This happened at one of the leading academic institutions. In 2002. In the schizophrenia ward. With patients diagnosed with psychotic disorders.

I was a young resident. I didn’t know what to do about it. I watched and said nothing.

He didn’t violate a single clause. Not one. Open up post-Soviet ethics codes — not a word about prohibiting prayer. Not a line about banning “prayer therapy.” Nothing. Full stop. Twenty-five years of difference. A quarter century of clinical experience against my theory. His intuition — wiser. That’s how it was supposed to be. That’s what’s carved into the hindbrain of anyone who ever saw him at a patient’s bedside: these hands, remembering more than any book. And what if it works? What if patients really do leave the ward different — through placebo, through supportive engagement, through whatever — what then? Where’s the error? Where’s the violation? There’s the question. There’s the puzzle. Three dry “technically”s — and not a single answer.

The problem is this.

When a psychiatrist places prayer on the same footing as an antipsychotic, he undermines the very status of scientific medicine. He tells the patient: “Taking haloperidol is one intervention, and prayer is another. Both work.” The patient receives the message: science and religious practice have equal therapeutic status. And from there unfolds the logic the patient inevitably develops on his own: if prayer helps — maybe it’s enough on its own? If I pray fervently — maybe I won’t need the medication?

We are talking about patients with schizophrenia. About people who, if you don’t treat them with antipsychotics in the acute phase, face progressive deterioration, social maladjustment, loss of contact with reality, and s••••e. Any message that weakens their connection to evidence-based pharmacotherapy is a message that ultimately leads to death.

But there was something worse. Dr. S. was being watched by young colleagues: interns, residents, graduate students. For them, Bekhterev was becoming their first real clinical experience. The price of mistakes here was someone else’s psyche. And here they saw it: a professorial colleague practicing “prayer therapy” right in the clinic. No one stopped him. No one grabbed his hand. What does that mean to a novice? Is this normal? Is it normal — to mix scientific medicine with spiritual practices? Is it normal — to consider your own subjective religious intuition equivalent to neuroscience? Decades of clinical research? Burn it. Throw it out. Ignore it. Because the main thing is to “see the effect” with your own eyes.

I believe that Dr. S. was replicating the structure of a pandemic of madness within its very adversary, within academic psychiatry. This is a form of internal betrayal of scientific medicine. Not malicious—he was a kind man. But no less harmful because of it.

And the most alarming part isn’t that there was one such doctor. It’s that there were many—in Bekhterev’s clinic and in other institutions across the post-Soviet space. Some wrote prayers, some recommended “visiting a priest,” some applied “bioenergetic” methods, some chanted mantras to patients, and some referred them to “specialists in ancestral memory” (!). None of this was an exception. It happened within the bounds of what was considered normal by a segment of post-Soviet psychiatry.

That’s why I consider the topic of this chapter no less important than the issue of pseudomystical healers on social media. If there’s a leak within the very citadel of scientific psychiatry, no fight against pseudoscience outside its walls will help.

Case Two. Thirteen Years of OCD and “Sex Therapy”

A thirty-three-year-old woman came to see me. Let’s call her Leila. She had a higher education, a steady job, and financial independence. She had never been married. She came from a religious family but wasn’t strictly observant herself.

Her problems began at sixteen. Obsessive-compulsive disorder. Compulsive fears of contamination. Hours spent washing her hands. Compulsively checking whether the stove was off or the doors were locked. Exhausting obsessive thoughts she couldn’t shake. Constant anxiety. Sleep—four to five hours a night. A feeling that her life was spent in a battle with her own brain.

Thirteen years before we met—from sixteen to twenty-nine—Leila sought help from specialists. First, psychiatrists in her hometown. Then, in Moscow. Then, in Istanbul, where her parents took her to see “the best doctor.”

Thirteen years. A full thirteen years—and what did she get in return? Almost nothing. Just a handful of pills. The first psychiatrist. Fluoxetine. A low dose. She felt better for six months. Then everything returned. The darkness closed in again. The second. Paroxetine. A replacement. The third added quetiapine. For the anxiety. The fourth prescribed clonazepam. To sleep. The fifth—risperidone. Low doses. By the time she was twenty-eight, Leila was taking four medications at once: an antidepressant, an atypical antipsychotic, a benzodiazepine, and a sleeping pill. Four chemical keys, each locking a different cage in her exhausted body. Every one of these drugs had been prescribed to her at some point. Each helped for a short time. Each stopped working—or caused side effects. And then it was ruthlessly swapped for the next.

Not one of these psychiatrists offered her psychotherapy.

It would have been shocking—if it weren’t, alas, so typical.

International guidelines for treating OCD—issued by the American Psychiatric Association, NICE (UK), and the World Health Organization—agree on one thing: the first-line therapy for OCD is exposure and response prevention (ERP), a specialized form of cognitive-behavioral therapy. The effectiveness of this therapy is approximately 80% in terms of significant improvement for patients who receive it correctly. Medications can complement the therapy; for moderate severity, SSRI monotherapy without CBT may sometimes suffice; but treating OCD solely with medication, without psychotherapy, violates the standard of care.

So why, over thirteen years, did Leila never receive psychotherapy?

The reasons intertwine into a suffocating bouquet. The first—across the post-Soviet region, genuine CBT with ERP is virtually inaccessible. There are only a handful of specialists in each major city who have undergone proper training and practice according to global standards. What do the rest call “cognitive-behavioral therapy”? Anything and everything—from generic advice like “think positively” to outright eclecticism flavored with esotericism. A counterfeit instead of salvation. The second reason is even more glaring: psychiatrists themselves often aren’t aware of the actual effectiveness of ERP. They’re firmly locked into the biomedical paradigm, where the only answer is to prescribe a pill. Write a prescription. Suppress the symptom. The third reason delivers a gut punch—pure economics. A psychiatrist’s appointment is covered by insurance. A psychotherapist’s? Not at all. Or a pittance. A psychiatrist sees a patient for fifteen minutes. A psychotherapist must work for an hour. Weekly. For several long months. Economics ruthlessly pushes for a pharmacological solution. The system grinds people down in the mills of pills.

For thirteen years, Leila went along. Took the medications. Waited. “Maybe this drug will work.” It didn’t. Or it worked for two or three months, then faded.

And then—here begins the heaviest part of her story—one of her treating psychiatrists, seeing that the medications weren’t helping, decided to suggest something else. In this doctor’s words, it was called “sex therapy.”

The essence of the proposal was this: “You’re in your thirties. You’ve never had sexual relations. Freud showed that most neuroses are tied to repressed sexuality. If you engage in sexual relations—your OCD will go away.” The psychiatrist then offered himself as a partner—“not as entertainment, but specifically as part of the therapeutic process.” He explained that this was precisely why “sex therapy” should be conducted by a trusted professional, not a random individual.

Leila agreed.

Let’s pause. Why did she agree?

She wasn’t foolish. She wasn’t frivolous. She was worn down by thirteen years of futile treatment. She trusted the doctor—this wasn’t her first psychiatrist, and she had been working with this particular one for several months. She was desperate. She was offered a last-ditch solution by someone she considered a professional. Her ethnic and religious beliefs were firmly against premarital relations, but her desperate need to escape her illness outweighed them. She agreed, overcoming her inner resistance, the way one consents to surgery.

The outcome was exactly what one might expect. Leila entered into an intimate relationship with this psychiatrist—first once, then again. Her OCD didn’t go away. After a few encounters, the psychiatrist lost interest and returned to the standard medication regimen for her condition. Her sense of dignity, her religious identity, her trust in medicine—all of it was shattered.

And after a few months, she realized what had happened. This wasn’t “therapeutic treatment.” It was a crime disguised as healing.

Let’s now examine this case through the lens of international ethics.

Madrid, 1996. The document we’ve already discussed—the Madrid Declaration—reveals a chilling formula. Read it slowly. Read between the lines. Why is the patient’s consent here not a defense but a condemnation? Because the declaration lays bare the monstrous anatomy of power. Knowledge. The knowledge a psychiatrist holds about a patient is inherently corrupt—even before any physical contact occurs. And the power differential? It grants the doctor exceptional control over another’s will and body. Under these circumstances, consent ceases to be consent. It becomes exploitation. Pure. Relentless. And then the declaration strikes hard. Under no circumstances—do you hear me?—under no circumstances should a psychiatrist engage in any form of sexual behavior with a patient. None. It doesn’t matter who made the first move. It doesn’t matter whether the patient or the therapist initiated it. The boundary is sealed.

The phrase “it doesn’t matter who initiated it” is key. It becomes a hammer, shattering conventional logic. It uproots the classic excuses of offenders: “she agreed,” “she made the first move,” “they were both adults.” Strike. Strike again. Psychiatric ethical codes expose the harsh truth: the power asymmetry in therapeutic relationships renders genuine consent impossible. Picture this: a prison guard offers an inmate “voluntary” sex in exchange for leniency. Formally, consent is possible. In reality, it’s rape. Why? Refusal comes with severe consequences for the inmate. In therapeutic relationships, the structure is the same.

In most U.S. states, sexual relations between a psychiatrist and patient are criminal offenses. The same holds true in many European countries. When professional associations learn of such incidents, they revoke the doctor’s license irrevocably.

Azerbaijan. Russia. Dozens more former Soviet states. Not a single sanction was enforced. Not one. That psychiatrist still sits in his office today. He sees patients. Writes prescriptions. Signs his name—that same sweeping, confident signature. His name has never surfaced in any disciplinary case. Not once. In all these years. And Leyla? Leyla keeps silent. Her family doesn’t know. Not her mother, not her father, not her brother—no one. And she’ll do everything to keep it that way. Her faith forbids her to speak. Faith—stronger than anger, stronger than pain, stronger than what remained of her after that office. And the healthcare system? After that episode? Her trust in it stands at zero.

She came to me by referral. A woman I’d treated for a year—classic CBT for a similar disorder—gave her my number. Leyla was thirty-three. Thirty-three years—and not one correct diagnosis. Not one adequate treatment. Eighteen months. Standard cognitive behavioral therapy. Exposure. Response prevention. Milligram by gradual milligram—reducing medication. The daily rituals, the compulsions stealing hours—gone. The obsessive thoughts that had gripped her brain for years receded to a level that simply allowed her to live. To live normally. She lowered her dosages. Then discontinued most. At thirty-three, Leyla finally received proper treatment for her disorder.

A year after the active therapy phase ended, Leyla made a difficult decision. She left the country. Not for economic reasons—she had a good job—but because she could no longer live among people in her hometown who knew her “treatment” history. She started anew in another country with a different culture, and today—to the best of my knowledge—is happy.

Case Three. Pharmacological Routine Without Psychotherapy

The third case I’ll outline briefly, as it structurally mirrors the previous one—minus the sexual component.

A forty-two-year-old woman. Let’s call her Mehri. Moderate depressive disorder, first episode at thirty-two after divorce. Since then—ten years of continuous medication. Over that decade, she sequentially took: mirtazapine, sertraline, venlafaxine, escitalopram, duloxetine, vortioxetine, bupropion. Seven antidepressants total. Additional drugs cycled in periodically: quetiapine “for sleep,” lithium “to boost effects,” modafinil “for alertness.”

Did it work? Temporarily. Each new drug brought improvement for a few months, then the symptoms came crashing back. The psychiatrists interpreted this as treatment-resistant depression and looked for yet another combination.

Psychotherapy — not a single session in ten years. No CBT, no interpersonal therapy, no behavioral activation — none of the evidence-based treatments for depression. Not even a serious discussion of what was actually driving her condition: the circumstances of her divorce, the loss of motherhood (her daughter lived with her ex-husband), the loneliness, the end of her professional career.

She came to me in a state of chronic depression with feelings of hopelessness. Not an acute phase — just a long, flat, unrelenting bad. Functioning, but without pleasure. Alive, but disengaged.

We began the work. The first two months — gradually tapering off the unnecessary medications (keeping one antidepressant at an adequate dose), alongside weekly CBT sessions with behavioral activation. The focus was on her specific cognitions, her real relationships, her daily planning, her social connections.

A year later — remission. Full remission. Two years later — she came off the last antidepressant as well. Three years later — she returned to her profession, found a new partner, and rebuilt her relationship with her daughter.

Ten years of her life on the medication carousel — that’s not just her lost years. It’s a question for the entire system in which such ten years are possible.

What do these three cases have in common?

All three cases reveal one common systemic defect in contemporary psychiatry across the post-Soviet space and in a number of other regions of the world.

That defect is the absence of a quality-control mechanism.

When a patient comes to a psychiatrist and receives treatment that hasn’t worked for years, no mechanism kicks in to raise the question: is this treatment correct? Does it meet current standards? Why isn’t it producing results?

When a fellow psychiatrist at an academic institution practices non-rational methods, mixing them with medical ones, no mechanism kicks in to correct or stop him.

When a board-certified psychiatrist commits a gross ethical violation bordering on a criminal offense, no mechanism kicks in to hold him accountable.

This is a failure of the quality-assurance system. And it operates on many levels.

The first level is educational. Psychiatrists and clinical psychologists in post-Soviet countries are often trained far more in the use of pharmacotherapy than in psychotherapy. Training in evidence-based psychotherapeutic methods — ERP, CBT, DBT, interpersonal therapy, trauma-focused therapy — is often limited to lectures; actual supervision and long-term training are rarely provided and are usually paid for by the specialists themselves.

The second level is regulatory. A psychiatrist’s license is issued once and is essentially indefinite. Requirements for continuing medical education are formalities. Mechanisms for revoking a license function poorly — even for gross ethical violations.

The third level is professional associations. Unlike the American APA or Britain’s Royal College of Psychiatrists, post-Soviet professional psychiatric associations have no real ethics committees capable of hearing complaints and imposing sanctions. When a patient files a complaint against a doctor, it is usually forwarded to the Ministry of Health, where it drowns in bureaucracy.

The fourth level is the patient. A patient who receives poor-quality care often doesn’t know their rights and has no tools to defend them. Unlike buying a defective product—where consumer protection law applies, along with experts, courts, and clear procedures—a patient dealing with poor medical care finds themselves alone against a system in which they are, by definition, the weaker party.

The fifth level is social. A complaint against a doctor. Especially a psychiatrist. Especially for delicate reasons. All of it is stigmatized. A patient who dares to speak up is instantly labeled: “He has mental problems, that’s why he’s complaining.” The system forms a perfect trap. A conspiracy of silence takes hold. English-language medical ethics has a precise term for it—conspiracy of silence. The v••••••s have been struck dumb with horror. And so the abusers keep practicing. Because their v••••••s are afraid to speak.

Connection to the Book’s Main Theme

Now—why this chapter is no accident in a book about the pandemic of madness.

Every patient who receives poor care within the official psychiatric system inevitably becomes prey for the market of pseudo-healers. Thirteen years. Thirteen years a person swallows pills, and the OCD doesn’t budge an inch. Disillusionment with medicine hits like a punch to the gut. Or another case: an academic institution, advanced degrees—and then a psychiatrist performs a prayer alongside the prescriptions. Where does science end? Where does esotericism begin? The line is blurred. Third. A psychiatrist who sexually exploited a patient. The body remembers someone else’s hands beneath the white coat. No more doctors. Ever.

All these people are a ready-made audience for advertisements for ThetaHealing, Hellinger constellations, regressive hypnosis. Dissatisfied, disillusioned, desperate—the perfect target group for those selling a “quick answer.” And some of them will indeed go there—not because they’re stupid, but because the official system betrayed them.

The pandemic of madness feeds not only on gaps in care, but on the direct failures of the care that exists. And until scientific psychiatry puts its own house in order, it will keep pushing patients into the arms of frauds.

The profession’s self-cleansing is necessary. It requires several things.

First. Real ethics committees with the power to investigate and impose sanctions.

Second. Mandatory continuing medical education with exams that can cost you your license if you fail.

Third. Public physician registries listing every confirmed disciplinary action.

Fourth. Secure channels for patients to file complaints, with guaranteed anonymity and protection from retaliation.

Fifth. A cultural shift within the profession — an end to closing ranks around those who break the rules, and recognition that protecting the profession’s reputation requires transparency and accountability, not covering up its problems.

None of these demands is impossible. A number of Western countries have implemented them to one degree or another. In the post-Soviet world, they exist only as declarations of intent.

Until they are put into practice, the epidemic of madness will keep spreading. Within the profession. Around it. Everywhere.