Controversy surrounding psychiatry

Freeing the mad from chains

"The Extraction of the Stone of Madness". Art between 1488 and 1516

Pieter Huys: A surgeon extracting the stone of folly

Pieter Jansz. Quast,
Die Steinoperation, ca 1630

Controversy has often surrounded psychiatry. Psychiatry's history involves what may now be seen as dangerous treatments, such as electroconvulsive therapy and lobotomy. The term anti-psychiatry was coined by psychiatrist David Cooper in 1967 and is understood in current psychiatry to mean opposition to psychiatry's perceived role in: (1) medicalizing madness, (2) drastic measures such as lobotomies used to control mental illness, (3) physical or pharmacological restraints applied to suicidal inpatients, (4) disabling or intolerable side effects of medications, (5) the diagnosis of slaves as being mentally ill for wanting to escape from their masters, (6) regarding psychoanalysis as unscientific or harmful, (7) treating homosexuality as a mental illness, and (8) diagnostic practices not based on objective scientific evidence. The general anti-psychiatry view is that psychiatric treatments are ineffective, unnecessary, or unsafe, and that ultimately psychiatric treatment is not helpful to patients. Some ex-patient groups, referring to themselves as "survivors", have become anti-psychiatric, while others are critical of anti-psychiatry as well as psychiatry.

Power imbalance

Too often it is felt institutions have too much power, concerns of patients or their relatives are ignored. Psychiatric nurses impose decisions, are reluctant to share information and feel they know best. Only a minority of staff involve patients in decision making. Client empowerment can improve power imbalance. Psychiatrically ill patients are at risk of abuse and discrimination in the mental health system and also the primary care sector. Studies are needed to determine whether power imbalance leads to abuse. Some degree of power imbalance appears inevitable since some patients lack decision making capacity but even then patients benefit from being impowered within their limits. For example, a patient felt lethargic in mornings due to medication she was required to take. She was allowed to stay in bed and miss breakfast as she wanted. Multidisciplinary teams benefit patients to the extent that professionals with a range of different expertise are caring for them. There is also a problem because patients who complain about the way they are treated face a group rather than one individual opposing them.

Mental illness myth

Vienna's Narrenturm — German for "fools' tower" — was one of the earliest buildings specifically designed as a "madhouse". It was built in 1784.

Since the 1960s there have been many challenges to the concept of mental illness itself. Thomas Szasz wrote The Myth of Mental Illness (1960) which said that mental illnesses are not real in the sense that cancers are real. Except for a few identifiable brain diseases, such as Alzheimer’s disease, there are "neither biological or chemical tests nor biopsy or necropsy findings" for verifying or falsifying psychiatric diagnoses. There are no objective methods for detecting the presence or absence of mental disease. Szasz argued that mental illness was a myth used to disguise moral conflicts. He has said "serious persons ought not to take psychiatry seriously -- except as a threat to reason, responsibility and liberty".

Sociologists such as Erving Goffman and Thomas Scheff said that mental illness was merely another example of how society labels and controls non-conformists; behavioural psychologists challenged psychiatry's fundamental reliance on unobservable phenomena; and gay rights activists criticised the APA's listing of homosexuality as a mental disorder. A widely publicised study by Rosenhan in Science was viewed as an attack on the efficacy of psychiatric diagnosis.

These critiques targeted the heart of psychiatry:

They suggested that psychiatry's core concepts were myths, that psychiatry's relationship to medical science had only historical connections, that psychiatry was more aptly characterised as a vast system of coercive social management, and that its paradigmatic practice methods (the talking cure and psychiatric confinement) were ineffective or worse.

Medicalization of normality

For many years, some psychiatrists (such as David Rosenhan, Peter Breggin, Paula Caplan, Thomas Szasz) and outside critics (such as Stuart A. Kirk) have "been accusing psychiatry of engaging in the systematic medicalization of normality". More recently these concerns have come from insiders who have worked for and promoted the APA (e.g., Robert Spitzer, Allen Frances). In 2013, Allen Frances said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests".

Medicalization of deviance

See also: Medicalization

The concept of medicalization is created by sociologists and used for explaining how medical knowledge is applied to a series of behaviors, over which medicine exerts control, although those behaviors are not self-evidently medical or biological. According to Kittrie, a number of phenomena considered "deviant", such as alcoholism, drug addiction and mental illness, were originally considered as moral, then legal, and now medical problems. As a result of these perceptions, peculiar deviants were subjected to moral, then legal, and now medical modes of social control. Similarly, Conrad and Schneider concluded their review of the medicalization of deviance by supposing that three major paradigms may be identified that have reigned over deviance designations in different historical periods: deviance as sin; deviance as crime; and deviance as sickness. According to Franco Basaglia and his followers, whose approach pointed out the role of psychiatric institutions in the control and medicalization of deviant behaviors and social problems, psychiatry is used as the provider of scientific support for social control to the existing establishment, and the ensuing standards of deviance and normality brought about repressive views of discrete social groups. As scholars have long argued, governmental and medical institutions code menaces to authority as mental diseases during political disturbances.

Political abuse

Main article: Political abuse of psychiatry

Psychiatrists have been involved in human rights abuses in states across the world when the definitions of mental disease were expanded to include political disobedience. As scholars have long argued, governmental and medical institutions code menaces to authority as mental diseases during political disturbances. Nowadays, in many countries, political prisoners are sometimes confined and abused in mental institutions. Psychiatric confinement of sane people is a particularly pernicious form of repression.

Psychiatry possesses a built-in capacity for abuse that is greater than in other areas of medicine. The diagnosis of mental disease allows the state to hold persons against their will and insist upon therapy in their interest and in the broader interests of society. In addition, receiving a psychiatric diagnosis can in itself be regarded as oppressive. In a monolithic state, psychiatry can be used to bypass standard legal procedures for establishing guilt or innocence and allow political incarceration without the ordinary odium attaching to such political trials. The use of hospitals instead of jails prevents the victims from receiving legal aid before the courts, makes indefinite incarceration possible, discredits the individuals and their ideas. In that manner, whenever open trials are undesirable, they are avoided.

Examples of political abuse of the power, entrusted in physicians and particularly psychiatrists, are abundant in history and seen during the Nazi era and the Soviet rule when political dissenters were labeled as “mentally ill” and subjected to inhumane “treatments.” In the period from the 1960s up to 1986, abuse of psychiatry for political purposes was reported to be systematic in the Soviet Union, and occasional in other Eastern European countries such as Romania, Hungary, Czechoslovakia, and Yugoslavia. The practice of incarceration of political dissidents in mental hospitals in Eastern Europe and the former USSR damaged the credibility of psychiatric practice in these states and entailed strong condemnation from the international community. Political abuse of psychiatry also takes place in the People's Republic of China and in Russia. Psychiatric diagnoses such as the diagnosis of ‘sluggish schizophrenia’ in political dissidents in the USSR were used for political purposes.

Electroconvulsive therapy

Electroconvulsive therapy (ECT) was one treatment that the anti-psychiatry movement wanted eliminated. Their arguments were that ECT damages the brain, and was used as punishment or as a threat to keep the patients "in line". Since then, ECT has improved considerably, and is performed under general anaesthetic in a medically supervised environment.

The National Institute for Health and Care Excellence recommends ECT for the short term treatment of severe, treatment-resistant depression, and advises against its use in schizophrenia. According to the Canadian Network for Mood and Anxiety Treatments, ECT is more efficacious for the treatment of depression than antidepressants, with a response rate of 90% in first line treatment and 50-60% in treatment-resistant patients. On the other hand, a 2010 literature review concluded that ECT had minimal benefits for people with depression and schizophrenia.

The most common side effects include headache, muscle soreness, confusion, and temporary loss of recent memory. There is no credible evidence supporting claims that ECT causes structural damage to the brain.

Deinstitutionalisation

The prevalence of psychiatric medication helped initiate deinstitutionalization, the process of discharging patients from psychiatric hospitals to the community. The pressure from the anti-psychiatry movements and the ideology of community treatment from the medical arena helped sustain deinstitutionalization. Thirty-three years after deinstitutionalization started in the United States, only 19% of the patients in state hospitals remained. Mental health professionals envisioned a process wherein patients would be discharged into communities where they could participate in a normal life while living in a therapeutic atmosphere. Psychiatrists were criticized, however, for failing to develop community-based support and treatment. Community-based facilities were not available because of the political infighting between in-patient and community-based social services, and an unwillingness by social services to dispense funding to provide adequately for patients to be discharged into community-based facilities.

In a study of 82 deinstitutionalized schizophrenia patients, 68% were found to have no symptoms of schizophrenia at the time of the study, 32 years later.

Pharmaceutical industry ties

Psychiatry has greatly benefitted by advances in pharmacotherapy. However, the close relationship between those prescribing psychiatric medication and pharmaceutical companies, and the risk of a conflict of interest, is also a source of concern. This marketing by the pharmaceutical industry has an influence on practicing psychiatrists, which affects prescription. Child psychiatry is one of the areas in which prescription has grown massively. In the past, it was rare, but nowadays child psychiatrists on a regular basis prescribe psychotropic drugs for children, for instance Ritalin.

Several prominent academic psychiatrists have refused to disclose financial conflicts of interest, which further undermines public trust in psychiatry. Charles Grassley led a 2008 Congressional Investigation which found that well-known university psychiatrists (such as Joseph Biederman, Charles Nemeroff, and Alan Schatzberg), who had promoted psychoactive drugs, had violated federal and university regulations by secretly receiving large sums of money from the pharmaceutical companies which made the drugs.

In an effort to reduce the potential for hidden conflicts of interest between researchers and pharmaceutical companies, the US Government issued a mandate in 2012 requiring that drug manufacturers receiving funds under the Medicare and Medicaid programs collect data, and make public, all gifts to doctors and hospitals.

Prisoner experimentation

Main article: Experimentation on prisoners

Prisoners in psychiatric hospitals have been the subjects of experiments involving new medications. Vladimir Khailo of the USSR was an individual exposed to such treatment in the 1980s. However, the involuntary treatment of prisoners by use of psychiatric drugs has not been limited to Khailo, nor the USSR.

Anti-psychiatry

Main article: Anti-psychiatry

Controversy has often surrounded psychiatry, and the anti-psychiatry message is that psychiatric treatments are ultimately more damaging than helpful to patients. Psychiatry is often thought to be a benign medical practice, but at times is seen by some as a coercive instrument of oppression. Psychiatry is seen to involve an unequal power relationship between doctor and patient, and advocates of anti-psychiatry claim a subjective diagnostic process, leaving much room for opinions and interpretations. Every society, including liberal Western society, permits compulsory treatment of mental patients. The World Health Organization (WHO) recognizes that "poor quality services and human rights violations in mental health and social care facilities are still an everyday occurrence in many places", but has recently taken steps to improve the situation globally.

Psychiatry's history involves what some view as dangerous treatments. Electroconvulsive therapy is one of these, which was used widely between the 1930s and 1960s and is still in use today. The brain surgery procedure lobotomy is another practice that was ultimately seen as too invasive and brutal. In the US, between 1939 and 1951, over 50,000 lobotomy operations were performed in mental hospitals. Valium and other sedatives have arguably been over-prescribed, leading to a claimed epidemic of dependence. Concerns also exist for the significant increase in prescription of psychiatric drugs to children.

Three authors have come to personify the movement against psychiatry, of which two are or have been practicing psychiatrists. The most influential was R.D. Laing, who wrote a series of best-selling books, including; The Divided Self. Thomas Szasz rose to fame with the book The Myth of Mental Illness. Michael Foucault challenged the very basis of psychiatric practice and cast it as repressive and controlling. The term "anti-psychiatry" itself was coined by David Cooper in 1967.

Divergence within psychiatry generated the anti-psychiatry movement in the 1960s and 1970s, and is still present. Issues remaining relevant in contemporary psychiatry are questions of; freedom versus coercion, mind versus brain, nature versus nurture, and the right to be different.

Psychiatric survivors movement

See also: Outline of the psychiatric survivors movement

The psychiatric survivors movement arose out of the civil rights ferment of the late 1960s and early 1970s and the personal histories of psychiatric abuse experienced by some ex-patients rather than the intradisciplinary discourse of antipsychiatry. The key text in the intellectual development of the survivor movement, at least in the USA, was Judi Chamberlin's 1978 text, On Our Own: Patient Controlled Alternatives to the Mental Health System. Chamberlin was an ex-patient and co-founder of the Mental Patients' Liberation Front. Coalescing around the ex-patient newsletter Dendron, in late 1988 leaders from several of the main national and grassroots psychiatric survivor groups felt that an independent, human rights coalition focused on problems in the mental health system was needed. That year the Support Coalition International (SCI) was formed. SCI's first public action was to stage a counter-conference and protest in New York City, in May, 1990, at the same time as (and directly outside of) the American Psychiatric Association's annual meeting. In 2005 the SCI changed its name to Mind Freedom International with David W. Oaks as its director.

References

Cited texts