Deconstructing Antipsychiatry: Psychiatry has Much to Critique

Antipsychiatry writings, pretty much by definition, contain a lot of examples of harmful, abusive practices and behaviours in psychiatry. Sometimes these examples are exaggerated or even made up, but quite frankly there’s little reason to do so given the myriad of verifiable, well-documented examples. PBM documents many of these, most of which can be backed up by a variety of sources.

In this section, I’ll very briefly highlight just a few of what I feel are the legitimate concerns raised by PBM and similar writings.

The Past

I’ll restrict myself to issues that I feel are still relevant to present day psychiatry (the last decade or so), well after the “purge” of patients from asylums into the community that occurred in the 60’s and 70’s. This is not to ignore the past, and certainly not to deny the horrific nature of practice. Don’t worry, I’m not going to pull any kind of “yes the past was bad, but it’s all butterflies and sunshine now.” Let’s all just for the sake of argument agree that the period in the past was equivalent to the “dark ages,” and argue instead about whether that period continues to the current day or not.

Scientific Foundations

In terms of the underlying science, psychiatry trails far back of other areas of medicine. Given the complexity of the brain and its various mechanisms, it’s not too hard to imagine why. That leaves a lot more that’s unknown in psychiatry. My wife told me once about a cardiologist who addressed her medical school class. He told them that if they were interested in research and innovations that they should go into psychiatry, as that’s where all the opportunities will be.

Despite its limitations, psychiatry has too often adopted terminology implying a definitive understanding of underlying mechanisms of illness. Doctors may be at the top of the status and power ladder in clinical settings, but amongst doctors, psychiatrists have lower status than for example surgeons. Whether due to insecurity, competition, etc., they too quickly emulated practices and language of other medical disciplines to better fit in. PBM provides many examples of this. Similarly, while there have been incremental advances in the science, they are too often portrayed as more significant. We’ve been hearing for a long time that the big breakthrough will be coming “any day now.”

This is, alas, unfortunately common not only in psychiatry and neurosciences, but across medicine and in fact science as a whole. Science is, and has always been, a highly political endeavour, where what is important at a given time is based as much on personality and power as specific evidence. Intimately tied up in this dynamic are issues of career advancement, tenure, competition for grant money, etc. The defunding of basic research by governments, leaving the private sector to fill the void, has exacerbated this problem.

Unlike PBM, I don’t believe that psychiatry’s incomplete understanding of the underlying etiology of illness is a fatal flaw, and does not invalidate either lower-level or outcome-based research. Over-selling and under-delivering, however, is rarely a formula to engender much trust.

The DSM

As PBM suggests, and none but the most idealistic psychiatrist would dispute, the Diagnostic and Statistical Manual of Mental Disorders (DSM), which defines a precise taxonomy of mental illnesses, is very much influenced by political and organizational considerations and laden with conflicts of interest. The evolution of this tome is not guided by disinterested parties, and many “school of thought” differences play out with each revision. Having your particular slant on how we categorize certain illnesses “blessed” by its inclusion in the DSM can come with great influence, prestige, grant money, career advancement, and all the other things mentioned previously.

The involvement of pharmaceutical companies is more troubling, in that they can twist the definition of an illness a certain way (or create other illnesses) and get their products approved for its treatment. Particularly in the USA, insurance companies are more likely to pay out for drugs approved to treat a given condition, rather than pay for drugs being used “off-label.” Thus what does and does not count as a particular illness matters a great deal to them.

For someone seeking mental health treatment, while changing criteria may result in a different diagnosis, as I’ll discuss later, it’s not likely to change things very much in terms of actual treatment.

Involuntary admission and treatment

When it comes to the rights of people being admitted or treated against their will, the law has improved significantly over time. Some jurisdictions in Canada, notably British Columbia, lag behind other provinces who updated their Mental Health Acts over the last ten or so years. Notably, in BC if someone is involuntarily admitted, no further justification is needed if a psychiatrist feels it necessary to treat them against their will. Elsewhere, the issue of capacity to consent to treatment is separate from admission. A challenge currently (2016) before the courts will likely fix this.

Practice unfortunately often lags behind the law. Truly informed consent (vs. signing a form) is an issue throughout all of medicine, but more so in psychiatry. Too many inpatients feel belittled and disrespected by doctors and nurses, coerced to accept treatment, or feel treated like prisoners. Mechanisms to ensure appeals exist but often have no resources behind them, making them ineffective in practice.

While the situation is slowly improving, and such abuses of patients are far from universal in today’s ER’s and psych wards, they are distressingly not uncommon either. The system does not yet have the safeguards or culture that would prevent it from being so open to abuse. We’ll discuss the impact of this on mental health patients in general later as well.

Limited and varied psychiatric resources

Suffice it to say, PBM does not call for an increase in psychiatric treatment resources, but I feel this is a big concern in today’s system. The supply of psychiatrists does not begin to meet the demand for their services, leading to long waiting lists, and an inability to get appropriate treatment in a timely manner.

Some of the secondary effects are picked up on in PBM. For example, practitioners pushed by a mental health system to see more and more patients can lead to all-too-short one-off consultations, with premature diagnosis based on the scantiest of evidence. For new patients especially, who may not know what to expect, being suddenly faced with blunt, machine-gun questioning about the most personal aspects of their life does not normally promote forthcoming responses.

The quality of psychiatrists varies greatly, it seems more so than in other areas of medicine. Overt paternalism remains widespread. Opportunities for oversight and accountability are few, given the lack of choice and often-onerous process to lodge a complaint through the provincial medical colleges.

Summary

I’ve touched on some of the areas where I feel significant improvement is warranted.

There’s more than enough in these issues to argue for a major overhaul to how psychiatry is practiced, or at the very least fight to get in place more effective safeguards.

But that isn’t what antipsychiatry is arguing for. They want nothing less than the complete elimination of psychiatry and all its trappings. This goes way beyond even the most grandiose improvements. We’re left to answer two questions: how are they going to accomplish this, and perhaps more importantly, why?