Critique of psychiatric practice is a long tradition that has led to significant improvements in the field. Antipsychiatry, however, is a more radical movement, that does not seek to improve psychiatry, but to destroy it. Through carefully selected examples, it spins a one-sided tale, trying to persuade us that mental illness isn’t real, psychiatric drugs cannot work, and that all treatment is coercive and damaging. This is all for the benefit of corrupt pharmaceutical giants and governments.
This article examines the arguments advanced in Burstow’s 2015 book Psychiatry and the Business of Madness, a wide-ranging analysis that exemplifies the antipsychiatry genre. Beneath a carefully constructed veneer of credibility, we will find a series of ill-constructed “proofs” that have their basis in trickery and logical fallacy. Yet, far from engaging intellectually with a wider audience, antipsychiatry’s “good vs. evil” narrative aims primarily to recruit devotees to their cause.
Antipsychiatry raises fear, uncertainty, and doubt among those at their most vulnerable. Yet it offers no practical alternatives to those who are suffering, only ideology.
If you’re reading this, you likely already have some idea what antipsychiatry is about. You may be currently under the care of a psychiatrist, or considering whether to take medications to help with some mental health difficulties, or you may have had a bad experience with the mental health system, or know someone else who has.
You may have read some persuasive antipsychiatry writings that introduce you to many troubling aspects of psychiatry. Perhaps you have a nagging feeling that, while you believe a lot of what you read, you’re not being told the entire truth. Or perhaps you’re here to defend antipsychiatry from another Big Pharma funded smear campaign trying to cover up the truth so as to ensure continued profits.
Most of all, you probably want to do the right thing to help yourself, a family member, or friend. You’ve probably got plenty of questions about what that right thing is, and not a lot of good answers.
You’re not going to find passionate cheerleading on behalf of psychiatry here. Psychiatry is far from perfect, and anyone who tells you otherwise is either delusional or trying to deliberately manipulate you. But the picture that antipsychiatrists paint goes to the other extreme.
To misappropriate the quote about democracy and government often attributed to Winston Churchill:
No one pretends that psychiatry is perfect or all-wise. Indeed, it has been said that psychiatry is the worst practice for dealing with significant mental health concerns except all those other forms that have been tried from time to time.
Those who have courageously shared their stories and experiences have helped bring to light issues that could have too easily remained hidden. I greatly support those who want to engage in serious discussions about psychiatry’s strengths and weaknesses, flaws and fixes, with the goal of making things better for people suffering from mental health issues.
But that isn’t what antipsychiatry is about. Antipsychiatry is a position that psychiatry is 100% flawed, has no redeeming features, is built on a stack of lies, necessarily does harm to all who encounter it, and must be abolished in its entirety. Moreover, the real proponents of antipsychiatry do not want to seriously engage in discussion with the broader community. They are not interested in critique, or divergent opinions, but only discouraging those seeking treatment, and attracting new followers to their movement.
To me, this all sounds a bit extreme. And while I’d seen some antipsychiatry Internet trolls with pretty extreme viewpoints, I was more surprised to see this from some fairly intelligent people, including a few journalists and university professors. That seemed odd to me, because someone saying “X is 100% flawed, false, and is of no benefit to anyone,” where “X” is any large, complex practice (e.g. capitalism, socialism, democracy, or as here, psychiatry) doesn’t seem the sort of thing intelligent people say, or at least not on a regular and consistent basis.
I was curious to know more. I’m sympathetic to people who may have criticisms of psychiatry, but this “all or nothing” stuff seemed way over the top. What was behind that? What were they really telling people? What kind of arguments were they trying to use to justify such an extreme perspective? And why?
Psychiatry and the Business of Madness
One of the people who’s published frequently in the area of antipsychiatry is Dr. Bonnie Burstow (BB), who has for the last 20+ years been working at the Ontario Institute for Studies in Education (OISE), part of the University of Toronto (UofT) in Canada; she’s currently an associate professor.
I first came across her work via a blog she writes for a left-wing website I frequent (rabble.ca). She’s written a number of substantial articles and books on antipsychiatry. As she’s in Canada, her work includes a good amount of material based on mental health in the Canadian system, which I’m more familiar with than the American one.
The impetus for starting this article came when I read about a new antipsychiatry scholarship at OISE. I was somewhat astonished that a generally respectable university was supporting an antipsychiatry scholarship. Again, it’s not the critique of psychiatry I find objectionable. Antipsychiatry appeared to me to reject critique of its own work, which seems out of place for a secular, Canadian university. To get a flavour of this, check out the comments, many by her students, to this article.
When I tried to ask more about aspects of her perspective, she suggested reading her recent book, whose full title is “Psychiatry and the Business of Madness: An Ethical and Epistemological Accounting” (PBM). This certainly sounds like a quite serious academic title, and at 300 pages, quite weighty (no comment on the latter, as I bought the ebook).
Like many such tomes in the antipsychiatry genre, it goes into considerable detail, providing well-referenced evidence and logical arguments, all making the case that psychiatry is in its entirety a lie, conspiracy, threat, and must be replaced. Sounds like some good light reading.
I would add that while to me PBM appears to be a good representative of antipsychiatry writings, contains many arguments and references commonly seen in such writings, and covers a broader range of topics than most, it doesn’t have any special status within the community (it’s not a “Boss text,” as BB would say).
Who am I and Why am I doing this?
To start with, I’m not a psychiatrist, nor do I play one on the internet. Nor do I work for Big Psychiatry, Big Pharma, or Big Government, nor are any of them (or anyone else) paying me to do this. I have no special qualifications or insider status here (beyond, as will surely be pointed out, white male privilege).
My interest in psychiatry is twofold. First, I’ve had ongoing, mild-moderate problems with depression, and have been on psychiatric medications (via family doctors) for around 15 years. Second, my wife is a psychiatrist, and we’ve been together since she was in medical school, through her psychiatry residency, and about a dozen years of practicing in various clinical settings in Ontario, Alberta and BC. I’ve also helped her out with the administrative side of a couple of private practices she’s had, getting to know a lot of her patients, etc.
As a frequent internet user, I’ve read and commented on many things related to this interest in psychiatry and mental health. I’ve seen the good (and some bad) that psychiatry can do. I believe that antipsychiatrists denying mental illness exists, denying that psychiatry can in any way help, etc. and trying to scare people away from getting medical help for mental health problems is not only misdirected but incredibly dangerous.
I’m generally sympathetic to non-extreme activist movements, including those associated with environmental, human rights, and social justice causes. Yet, I think that social activists (or for that matter, practitioners of science) that eschew logic or evidence (from all perspectives) can be dangerous, crossing the line from activism to extremism.
Alice Dreger, a science historian writes eloquently about this in her book “Galileo’s Middle Finger: Heretics, Activists, and the Search for Justice in Science.” It chronicles the vicious repercussions that can come when confronting either a highly invested scientific establishment or an intransigent activist group (a cautionary tale as I write this article!). One quote:
Science and social justice require each other to be healthy, and both are critically important to human freedom… I have come to understand that the pursuit of evidence is probably the most pressing moral imperative of our time. All of our work as scholars, activists, and citizens of democracy depends on it.
So yes, I’m coming into this with a distinct bias and point of view, which I think is important for readers to recognize. BB also is very open in PBM about her antipsychiatry activism, and extensive work with people who have had extremely negative experiences with psychiatry. She doesn’t try to pretend she’s going into her investigations as a neutral observer.
I’ll also add that I’m not big on conspiracy theories. I generally assume that most people within the antipsychiatry movement are doing what they’re doing because they truly think it’s the right thing to do to help people (or prevent further hurt). If overt persuasion is being consciously used, it’s in their minds to serve that larger purpose.
My academic background is actually in computer science, which beyond some foundational material in logic and proofs doesn’t seem to give me a whole lot of credibility when it comes to writing about this topic. As noted, I’m no expert when it comes to psychiatry, psychology or neurosciences.
Only slightly more relevant is that my undergrad minor was in philosophy (ethics, epistemology, existentialism, etc.) and my work in grad school was in a field that had techies intermix quite a lot with sociologists and anthropologists working on ethnographic studies of work practices. These are areas where I’ve continued to read “for fun” (my Kindle library is a bit eclectic), and also happen to be some of the methodological and intellectual foundations used by PBM.
I’ve also written and reviewed enough academic papers to know the difference between a sound and convincing argument and someone trying to pull a fast one.
There have been a number of critical responses and refutations of many antipsychiatry works, including of PBM. Most take the form of relatively short blog posts or book reviews. To be honest, most practitioners are too busy to devote time to even reading 300 pages from what they perceive as a lunatic fringe.
I wasn’t aware of anyone that had more thoroughly deconstructed the arguments and fallacies used in a substantial work of modern antipsychiatry. And I also still didn’t fully appreciate why antipsychiatry was so completely uncompromising in its stance.
So why take this on? It sounded like something intellectually interesting to work on, that I hope may actually help people. I hope it highlights the difference between constructive critique and extremism. I hope it encourages some people to think about psychiatry from multiple perspectives. And I hope it dulls some of the scaremongering that discourages too many people from considering helpful treatments.
Topics to be Addressed
This article is not going to be a review of every argument used by antipsychiatry, or every argument in PBM. For one thing, this is an unpaid side project and I definitely don’t have the time for a more comprehensive review or critique.
For another, I don’t have enough knowledge and familiarity with certain practices in psychiatry to be able to intelligently comment on them. So I will try to restrict myself to topics that I feel confident to be able to address. This includes both arguments from PBM that I feel are flawed, but also deficiencies in psychiatry, many raised in PBM, that appear to me to need serious improvement.
I will, however, be addressing some of the key arguments used in PBM to claim that psychiatry is 100% flawed. So while this will be far from complete, I think it touches on some (but not all) of the major, overarching issues.
Moving forward in this article, I’ll start by enumerating many of the topics in PBM that I agree with (and a few others). I think the work that psychiatric survivors and other movements have done in terms of bringing critical flaws and abuses in psychiatry to light is incredibly valuable. It is also a viewpoint that I wish was better integrated into a more honest, open discussion with psychiatry practitioners. This appears to be a point of departure with antipsychiatry.
The next section will argue that despite its rigorous, academic appearance, PBM is written with the primary goal of persuading, and not informing the reader. The form, style and content of the writing is designed to remove any doubts from the minds of readers about its claims. The overpowering use of selective, one-sided references primes the reader so that they are more likely to believe the more error-prone and hyperbolic arguments. And attracting fervent believers is exactly what this book is trying to accomplish.
The next several sections tackle a number of the key arguments, used in PBM to discredit psychiatry in its entirety. These include arguments about mental illness having no basis in reality and being arbitrarily created, that psychotropic medications are necessarily harmful, and the exaggerated reductionism expressed as biological psychiatry. I will outline the arguments used, and explain the errors and misrepresentations inherent in them. I will also delve briefly into the practical concerns around involuntary commitment and treatment and how it does (or does not) affect people today.
I will then turn to the preliminary solution to the psychiatry problem that PBM proposes. A lack of alternative solutions has long been a criticism of antipsychiatry, so it is notable that PBM offers one. However, as we explore the proposal, we will see that while explicitly utopian in nature, it rests on problematic and highly unlikely foundations. We will understand better, however, the reasoning behind antipsychiatry’s “all or nothing” approach.
An Invitation to the Reader
Unlike those in the antipsychiatry community, I would explicitly welcome comments, suggestions, corrections and criticisms of this article. I see it now as being in a preliminary form, and expect to revise it over time with your feedback.
As I do hope to incorporate your ideas and suggestions into future versions, before sending any comments etc. to me, I’d ask you to please carefully read the information on commenting, so that we can agree on if and how you might be willing to share your thoughts with others.
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.
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.
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.
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.
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?
Persuasion or Information?
PBM makes a very long, detailed and strong-sounding case about the dangers of psychiatry and the necessity of its dissolution.
Were the purpose of the book to critique psychiatric practice for the purposes of improving it, lobbying for safeguards, different standards, etc. a series of carefully documented anecdotes, thematically joined, would suffice.
Yet, the goal is far more audacious—to logically prove that psychiatry is fundamentally and irrevocably flawed. This is a tall order, impossible perhaps. Why take that step? The only conclusion I can draw is that it’s less about the noble pursuit of truth, and more about gaining converts to the antipsychiatry movement. The more the better, and especially those who are the most militant in their convictions that psychiatry is inherently wrong and must be defeated. People reading a mountain of evidence may be persuaded, yet open to the idea that there might be another side to things. But if it’s logically proven—well, there’s no room for doubt!
Let me highlight four manipulative techniques that are used to great persuasive effect in PBM: veneer of credibility, suppressed evidence, appeal to conspiracy theories, and obscuring logical fallacies within volumes of examples.
Veneer of credibility
PBM is a large academic book. It adopts a generally appropriate academic tone, though the neutral stance is frequently supplanted by the unmistakeable passionate activist trying to restrain herself. It strings together what appear at first glance to be logical and coherent arguments. There are lots and lots of references.
The investigation into psychiatry proceeds via a formal mechanism, the institutional ethnography (and who could criticize the work if they are not familiar with that methodology?) that separates observations from bias. It relies on multiple other theories drawn from feminism, political science, social justice, phenomenology, discourse analysis, indigenous and environmental schools of thought, etc. Jargon from these disciplines is sprinkled liberally throughout.
Odd choices for a book that’s designed to appeal to the masses. But really, just the existence of the book, having the form of serious academic research, is enough. After all, if you’re reading a book or paper, do you really follow up and read the references, to see what they actually say? They sound credible; good enough.
There are a lot of references, but almost all to the same group of works and authors you’ll find in many antipsychiatry books. Despite the dozens if not hundreds of mental health and neuroscience journals with hundreds of articles each, thousands of books, etc., you will find very few references to them here. The supporting material is specifically selected to reinforce the author’s viewpoint.
That’s not necessarily a bad thing if you’re building up a set of examples to advocate for change in a discipline. But if you’re looking to eradicate an entire discipline, a higher standard, and certainly greater attention to alternative points of view, would be in order.
Cherry-picking references in this matter, from the antipsychiatry “echo chamber” provides a nicely encapsulated, closed circle of information that appeals to the intended readers’ confirmation biases (i.e. they think psychiatry is bad, and this just confirms it). It’s one sided, and it’s used to persuade, and to remove the possibility of doubt, not to inform.
Critics are neutralized and dismissed in a pro forma manner. Practitioners are automatons so enmeshed within the dominant system that they cannot see beyond the next drug company kickback in front of them. Patients who claim they have received benefit from medications have simply been “subdued” by their medications.
This, from a book that identifies its specific contribution is that “it elucidates and ‘maps’ the institution as a whole” [italics added].
Appeal to conspiracy theories
A reasonable argument can be made (and at times is made) for various biases of psychiatrists, researchers, pharmaceutical companies. There are documented examples where psychiatry has been used as a means of punishment or coercion by state or other actors. Yet, the extent to which this appears to actually occur according to PBM is truly breathtaking (again, using specific examples, but lacking evidence of the extent to which it occurs). The terminology throughout, e.g. “regime,” or “madness industry,” only emphasizes this.
When most actors are assumed to be motivated by malicious and nefarious reasons, we’ve gone past a healthy concern for bias and into the realm of serious broad-based conspiracy theories, which of course appeals to those who are most fanatical and tend to traffic in conspiracy theories. It also weakens any doubt or resistance in terms of accepting arguments and evidence that are presented.
It’s hyperbole at best, blatant manipulation at worst. What it certainly is not is a massive all-encompassing government and/or Big Pharma conspiracy.
Logical fallacies, obscured by examples
The most obvious evidence of departure from rigorous academic work is the blatant reliance on logical fallacies to “prove” the rather more extreme positions. Or to put it another way, key arguments, intended to show the inherent flaws of psychiatry as an entire discipline, are completely bogus.
Suppressed evidence is one example of a type of fallacy carried throughout the book. The fallacies of composition and overgeneralization (i.e. one part is bad so the whole thing is bad) are frequently encountered as well, including with respect to conspiracy theories. Several rather incongruous definitions of terms form the foundation for other arguments. There are a multitude of others. The next sections will detail the flaws and fallacies of several of the key arguments, highlighting the ways in which arguments are incorrectly constructed.
It’s not surprising of course to find significant logical fallacies at the heart of claims that an entire discipline is logically flawed.
If these logical flaws stood alone, they would perhaps be more obvious. They are, however, presented in a way that is intended to obscure their simplicity. First, the incorrect logical argument is made, as a “preliminary” step, though the full intended conclusion is already contained. Then, a large number of examples, references, and explanations are appended, thematically related to the argument, to highlight the horrible practices, abuses, biases, violations, and so on (and yes, the Nazi comparison’s come quickly).
While the examples do not provide additional logical support to the argument already made, they do their best to portray psychiatry and its practitioners as horrible people committing horrible acts, to the point that the reader would believe there is no level they would not stoop to, and so have no doubts as to the veracity of the earlier argument.
Yet, painting psychiatry as “the bad guy” via a seemingly endless stream of selective examples (in effect, “induction by attrition”) does not meet the standard of logical proof that PBM has inexplicably set for itself.
If PBM, and antipsychiatry writing in general, were merely meant to inform the public about abuses and violations, it could do so without resort to the manipulative techniques I’ve outlined here. In fact, there are legitimate critics of psychiatry who stick to actual facts, do not overstate their conclusions, and are open to differing arguments, opinions, and evidence. These reasonable voices contribute to a valuable and important conversation. But that is not the antipsychiatry movement.
That such an activist movement as antipsychiatry exists I can understand, and though I disagree with it and feel it is very harmful, they have the right to express their opinions, unless they descend into e.g. hate speech. I can even (at times) understand such a movement that would not consider authentically engaging with any of its critics.
What I have great difficulty with is the notion that an extreme activist movement, spewing grandiose arguments that would embarrass a first year philosophy student, apparently unwilling to entertain open dialog and criticism, appears to have pockets well-entrenched within serious academia. That such poor scholarship (in my opinion) might gain credibility from the stature of an environment known for openness and reason is truly disappointing.
With that said, let’s move on to look at some of the arguments in detail.
Mental Illness Isn’t Real
One of the core arguments in PBM is that mental illness isn’t a real illness, because it has no observable physical pathology. Or in other words, if you can’t point to something physical, it’s not an illness, and thus outside the scope of medicine.
This claim is used to bootstrap further arguments, e.g. if it’s not an illness, all these things you’re putting in the DSM are meaningless, and given that medications are designed to correct something physical, and by definition there’s nothing physical going on in mental not-really-an-illness, these medications are by definition not addressing any illness. And so on.
The base argument is most pointedly made in Chapter 2 of PBM, in the section “Medical Advances, Professionalization, and the State,” in discussing the evolution of medicine at the point in the late 1800’s where studying of corpses allowed for a better understanding of human anatomy and disease. If I may quote extensively from PBM:
Continuing to study anatomy and inventing more and more instruments to extend its observation, it [medicine] further progressed as a science. What was particularly important—and the significance of this cannot be overstated—as Szasz (1976/1988) points out, it progressively conceptualized like a science. Most especially it put aside impressionistic concepts of what constituted a disease, adopting in their stead concrete criteria based on observation. Instrumental in this regard was physician Rudolf Virchow, who introduced a standard henceforth embraced by the medical community.
According to this new understanding, pain or discomfort per se no longer sufficed for something to qualify as a disease. Real lesion, real cellular pathology observable directly or by tests was to be the standard. While disease might be hypothesized and temporarily entertained in the absence of pathology, to be clear, it was discoveries of pathology alone which confirmed them. With Virchow criterion, medicine had essentially crossed the science threshold and found its “gold standard.”
The end of that passage concludes with a footnote reading “For highly informed commentary on the Virchow criterion and its significance, see Ackerknecht (1953) and Szasz (1976/1988).”
A lot seems to reside on that definition of “disease” and by implication whether the scope of medicine (and hence psychiatry) is determined by “disease” or not. And is “illness” the same thing as “disease”? And does medicine deal with illness or just disease? But isn’t illness something we all understand, and… well, the above thing about lesions and such sounds reasonable, and if that is the gold standard…
In the quoted passage, BB makes two claims supporting her position, “a standard henceforth embraced by the medical community” and “crossed the science threshold and found it’s ‘gold standard’.” These are her words.
These claims that Virchow’s ‘physical’ standard was then and continues to be the definition of disease, and that presence or absence of disease defines what is or is not medicine, is supported by references to “highly informed commentary” by Szasz, an early pioneer of psychiatric criticism referenced by most antipsychiatry works, but nothing else (selective reference).
Virchow was a pioneer for his time, though some of his positions didn’t work out so well over time (he was anti-evolution and did not believe in the germ theory of disease). How did this standard hold out?
Not well either unfortunately. In both medical practice and common usage, there is a lot of overlap between the terms “disease” and “illness,” sometimes used interchangeably. Some medical texts simply define “illness” as “disease.” Many dictionaries define illness as “being unhealthy in body or mind.”
The actual definition of “illness” has been an occasional matter of debate to this date. There were a lot of short back-and-forth letters and articles during the 80’s in the Canadian Medical Association Journal (CMAJ), including the ones by Szasz. The definitional debates continue more sporadically to this day in various professional medical journals, including CMAJ.
The Gold Standard?
Even taking “mental illness” out of the equation, does medicine today deal with illnesses or diseases that would not be identified by “real lesion, real cellular pathology”?
Has medicine evolved since the late 1800’s?
Our understanding today of germs, viruses and bacteria go beyond what Virchow proposed. Think of all the illnesses and diseases associated with those.
There have been thousands of medical discoveries between then and now which identified causes and treatments for various illnesses. Before the discoveries, were they not illnesses, managed or treated by doctors, even though the cause, physical or otherwise, was unknown? Absolutely.
Are there illnesses today, treated by doctors, for which we do not know the cause? Here are a few:
- irritable bowel syndrome
- Sjogren’s syndrome
- Bell’s palsy
- interstitial cystitis
I could go on. But nobody would dispute that these illnesses are within the purview of medicine. Medicine even has a term for these: diseases (or illnesses, or ailments) of “unknown etiology.”
The bottom line is that medical doctors treat many illnesses and diseases in terms of their symptoms, as a regular and standard part of their practice. And to experts and the public alike, it’s not a question of whether they are real or not.
Defining a concept in a particular, narrow way is a common technique used in debating circles. Choosing a definition (“illnesses have physical causes”) that is so close to the conclusion you want to draw (“mental illnesses have no known physical causes so are not real illnesses”), is an example of a logical fallacy called “begging the question.”
The use of only selective references here, showcases an “appeal to improper/biased authority” fallacy. Yes, Virchow and Szasz have important contributions to make with regards to medicine and psychiatry. Yet, while the claims attributed to them carry some weight, they are not generally accepted in common practice today.
For this argument to work, you need to agree to a particular definition of a term that is at best controversial and at worse false in light of common practice.
A large chunk of the remainder of that chapter in PBM is dedicated to examples where psychiatry has assumed causes and adopted terminology suggestive of specific etiologies, without proper evidence of such. As suggested in a previous section, I agree with BB that psychiatry did itself no favours here.
The flawed notion that mental illnesses have no known etiology and therefore aren’t real illnesses is a foundation on which several other major arguments in PBM rest. We will also see the same attempts to persuade the reader to a false conclusion in other arguments shortly.
But really, if at some point in the future, a definitive underlying physical/biological cause for mental illness was discovered, do you really think the antipsychiatry community would admit that mental illness is real?
DSM Creates Phony Illness
Chapter 4 of PBM, “Probing the Boss Text: The DSM—What? Whither? How? Which?” is devoted to discrediting the DSM, in terms of the process used to create it, allusions to scientific foundations that are sketchy at best, various political and financial conflicts of interests attached to its creators, and more questioning about the “validity” of mental illness as a whole.
As I have discussed previously, I agree there are serious flaws in the DSM along the lines which BB suggests, leaving the question of how exactly “mental illness” is carved up into these individual disorders somewhat sketchy.
Starting with the section “Activating the Text,” BB then proceeds to make the case that diagnosis is the primary, if not sole, driver of all that follows in the psychiatric system. You see a psychiatrist, you get a diagnosis, you are necessarily treated, which is done solely on the basis of that diagnosis, etc.
If the initial diagnosis (from the flawed DSM) is meaningless, the argument would go, all that follows is flawed.
Again, sounds logical enough. Let’s probe deeper.
The Necessity of Diagnosis
To quote from PBM:
While hypothetically, the practitioner separates those allegedly with “mental disorders” from those without, in point of fact, that is neither what happens nor what the system mandates. The practitioner rather is tasked with the job of assigning a diagnosis… A veritable diagnostic imperative is at work… The question then is not whether or not someone seeing a psychiatrist or psychologist will be assigned a “disorder.” The question is which disorder.
It’s true in one sense that if you see a psychiatrist, there will be a diagnosis assigned. For doctors to get paid by insurance companies (e.g. HMO’s etc. in the USA, provincial government health insurance plans in Canada) they need to provide along with your personal identifying information a “procedure code” (i.e. what they did for you) and a diagnosis code. This is incidentally true for all types of doctors, and all types of illnesses. It’s not restricted to mental disorders or psychiatrists.
Is the sole goal of an interview to arrive at diagnosis? Again, quoting from PBM:
[Tools like the Structured Clinical Interview for DSM perform] the all-important function of helping practitioners fill the empty shell of one the criteria sets with details of the patient’s life. The purpose of clinical interview per se is to arrive at the diagnosis… While the patient telling his story may be under the impression that a normal or quasi-normal conversation is going on, essentially behind his back a complex text-act sequence is under way.
While a diagnosis will indeed be found in every psychiatric assessment/consultation report, these multi-page reports also include far more information than what is strictly required to arrive at a diagnosis. More on this shortly.
So far we’ve agreed with BB that a diagnosis will exist, even for pro forma reasons, e.g. billing.
But BB would like to distract us from the fact that diagnostic criteria require a certain threshold to be met, essentially that the behaviour/problem/stressor has to be clinically significant. The DSM makes some attempt at codifying this, and the five years of psychiatry training every psychiatrist receives provides further positive and negative examples of meeting criteria. There are grey areas and some amount of subjectivity to be certain, but overall there is general agreement about what it means to meet each criteria.
But an important criterion for being diagnosed with any mental illness is the following:
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Again, clinically significant is not as flimsy as BB would have the reader believe. Moreover, if you ask most people seeking help for mental health problems if their symptoms are getting in the way of different aspects of their life, they would be able to provide an answer.
So yes, your doctor may bill your insurance saying you have a catch-all diagnosis like “Mood Disorder Not Otherwise Specified,” but that is far different from saying you have an actual mental health diagnosis that is significantly impairing your life.
The Treatment Imperative
Which in turn brings us to the next point. The argument in PBM implies that you receive a diagnosis, and on the sole basis of that diagnosis necessarily receive treatment. This is patently false.
While a diagnosis might suggest what treatment options might be appropriate for people with that disorder who are seeking treatment, it does not determine if and how you are treated. This is determined by your individual symptoms and their severity, and in almost all cases, your own choices.
If I sprain my ankle, would I automatically get it treated? For a mild sprain that isn’t affecting me much, it’s very unlikely, and I doubt I’d even go to a doctor. For something a bit more severe, I might see the doctor, who might well tell me to just give it a rest, i.e. not treat. Or they might propose some noninvasive treatment such as a support or brace of various sorts, or something more invasive like surgery. Am I compelled to agree? No.
In all these cases, both my doctor and I would be weighing the costs and benefits of the treatment against the costs and benefits of leaving it untreated. Severity of the illness is a definite factor in this process, not just the actual diagnosis. Mental illness is no different.
For a reinforcement of this discussion, I’d refer you to an excellent blog post by Natasha Tracy entitled Mental Illness is Only a Problem When Mental Illness is a Problem.
Some other smaller arguments are made to discredit the construction of diagnoses in the DSM.
I’d mentioned previously the “Not Otherwise Specified” notion, which PBM ridicules:
[NOS]… undermines the very concept of “criteria.” By these maneuvers, note, something qualifies as a disorder either if it meets or fails to meet stated criteria.
As noted previously, one “use” for such diagnoses is purely for billing purposes, where the physician doesn’t think the patient actually has a mental illness. Someone will see a physician because they are concerned about their mood. After hearing their story, the physician will conclude that what they are experiencing is a normal emotion, part of normal human experience, and that they don’t have an illness. This happens quite often, despite BB’s claims to the contrary.
Alternatively, while the arbitrariness of the criteria (and for example, needing five of seven symptoms to meet criteria) is criticized, “Not Otherwise Specified” is also used to specify an illness that may not fit into one of the standard boxes, yet is still severe enough that it is causing “clinically significant distress or impairment” to the patient. In other words, patients won’t need to be left to suffer with severe illness just because the categorization doesn’t quite fit.
Another criticism of the DSM is that mental illnesses are classified in such a way that:
… it is possible for two people who have no symptoms in common to receive the diagnosis of [a specific mental illness]
Again, we’d find that many “medical” illnesses exhibit similar patterns (Crohn’s disease, which can present in a multitude of different ways in different people, springs to mind).
Reconceptualizing the DSM
With the above in mind, let us reconsider the role of the DSM in actual practice.
Does it create illnesses ex nihilo (Latin for “out of nothing”; doesn’t fancy terminology give me credibility and make my argument stronger?) which are then necessarily applied to all patients, who then automatically proceed forward to treatment based on their diagnosis alone? Plainly, the answer is no.
The illness already exists in the patient, as a set of symptoms, severities, and impacts on their life. What the DSM does is take that illness and attempts to classify it. This is for several reasons. First are for mundane, administrative purposes such as billing.
Second, this serves (imperfectly) as a means to suggest treatments. As noted in an earlier section, it is for this purpose that the DSM is most-often abused by those with vested interests in applying particular treatments to as large a range of patients as possible.
Finally, as all classification tools provide, it serves as a way to decompose a larger problem (“mental illness”) into something more manageable so as to more easily conceptualize, understand and problem solve. This property also allows it to more effectively serve as a communications tool between different practitioners, a shorthand or placeholder (but not a replacement) for describing a whole range of symptoms, behaviours and effects.
Oddly, BB’s rigorous institutional ethnography did not reveal to us this common and important use of the DSM in actual practice.
From this new vantage point, the multiple iterations, changing perspectives, and differing conceptualizations of illnesses between versions can be seen not in terms of a changing understanding of some underlying physical process, but as (ideally) improvements in their effectiveness for allowing clinicians to conceptualize and communicate about mental illness.
Mental illness exists. It’s not the (at times arbitrary, or politically influenced) divisions in the DSM that make it exist.
Drugs Cause Abnormal Brain Changes
Chapter 7 of PBM is entitled “Marching to ‘Pharmageddon’: Psychopharmacy Unmasked” and argues that psychiatric drugs, the “kingpin itself,” are inherently dangerous, and can only damage, not help.
We’ll pass over the sections describing the flaws in the drug creation and approval process (selectively referenced of course) and proceed to the primary argument intended to demonize psychiatric medications en masse.
Here we’re going to be relying on the idea that mental illness has to do with imbalances (too much, too little) of several different neurotransmitters. To summarize, again from PBM:
… these substances alter brain chemistry, and given that the people being treated for “mental illnesses” in point of fact have “normal” brain chemistry, it stands to reason that these substances themselves create imbalances. [italics in original]
Sounds logical enough, leading us to the next question of whether or not people being treated for mental illnesses do have “normal” brain chemistry.
To address that, PBM leads us through an exceedingly lengthy description of neurotransmitters, how larger or smaller amounts of each can affect us behaviourally (e.g. stimulating, relaxing). The main point that she makes with respect to the argument in question is that the brain has mechanisms which automatically adjust the level of neurotransmitters to bring things back into equilibrium, to correct levels when things are too off-balance.
Because the brain does that as a normal part of its functioning, this is normal brain chemistry.
Anything that alters it is therefore abnormal brain chemistry. The drugs alter this normal functioning of the brain and its chemistry, ergo they are creating abnormal brain chemistry.
Stated that way, a lot seems to rest on this “normal” vs. “abnormal” distinction. If you’re getting a sense of deja vu, you should be, because as with the argument “mental illness has no known physical cause so it’s not real”, you have to buy the validity of this particular definition of “normal” for the argument to work.
Can we look at this another way, that is perhaps, more person-centered?
Assume that without medications, our neurotransmitters do their thing as “normal”, and our brain’s corrective mechanisms do their “normal” thing to keep everything in equilibrium. Yet oddly, for no apparent reason we’re still curled up in the fetal position on the floor in a dark room, crying and screaming 18 hours a day, like we’ve been doing for the last week.
Our spouse drags us to the doctor, who suggests a medication trial. Some psychotropic medications are added, which disrupt our brain’s “normal” way of balancing out all the neurotransmitters. We are making an “abnormal” change. Yet, we’re now able to rise, speak, eat, think, communicate with our friends and family, feel positive and negative emotions, and participate in life.
If that’s what “normal” and “abnormal” were to look like for me, sign me up.
Again, relying on a dubious definition, even when surrounding it with as many examples as you’d like of bad things that psychiatric medications have done, does not make for a convincing argument.
A slight variation of the argument is also used, namely that psychotropics are inherently flawed because there is no underlying cause for mental illness, and as such there is nothing for them to work on. We’ve addressed the physical cause issue in the “Mental Illness Isn’t Real” section already.
I will just add at this point that there are hundreds if not thousands of diseases in other areas of medicine that are treated partially, primarily or solely via treating the symptoms, and not an underlying physical pathology. Those diseases with no known etiology are just a tiny fraction of that.
Are they effective?
Once we dismiss this notion that the drugs are inherently damaging, we can discuss whether or not they are effective, cause problems, how often this occurs, etc.
PBM provides all kinds of studies and examples, many from patients directly, where harms were caused (or allegedly caused, depending on the example).
The psychiatry community can bring studies and examples, many from patients directly, where the medications were helpful to them.
This is a great situation! Let’s all actually look at all the evidence, and judge it on its strengths and weaknesses. Where we’re missing evidence, or the evidence we have isn’t compelling, let’s get more. Let’s actually address this issue through evidence.
The alternative is throwing up our hands, dismissing everything as hopelessly biased as a result of the government-pharmaceutical-industrial complex, and tossing around conspiracy theories and “logical” arguments based on ridiculous premises.
A quick note on the whole idea of chemical imbalances as a theory for how psychotropic medications work. While the idea of “too much serotonin” or what not may have been at one time suggested by some overzealous academic looking for tenure, it’s a gross oversimplification of our current understanding of neurobiology.
It is, however, useful as a fairly easy to comprehend model for explaining the basic idea to people. It’s the same way that we’ll still refer to Newtonian mechanics and think about things through that lens, even though we know that quantum mechanics is a more accurate depiction of physics. So don’t get too caught up in arguments resting on the existence of chemical imbalances.
Having dispatched with the ridiculous notion that all psychiatric medications are inherently flawed as a concept, we are left being able to think of them as we would other medications. What are the benefits and risks, and how do they compare with the benefits and risks of either other treatments, or doing nothing?
For most people who choose to use them, psychiatric medications represent the “least bad alternative.” Just like medications for other illnesses. They may be overused in certain circumstances for all kinds of reasons (e.g., cost, “quick fix”), but are either highly recommended, or an option that should be seriously considered, in many situations for many people.
As you read through PBM, you’re left with the impression that psychiatry consists of extracting a diagnosis from a patient, and based on that diagnosis, psychotropic medications are then prescribed, or if they’re feeling particularly nasty, ECT is delivered. This is the model that is implied through repeated, disparaging use of the phrase “biological psychiatry.”
If you buy this conception of what psychiatrists do, and you believe that mental illness isn’t real, diagnoses are a sham, and psychiatric medications are by definition harmful, it seems pretty obvious that giving psychiatry the boot is a logical and necessary step.
We’ve addressed the latter three issues previously. Let’s consider how accurate “biological psychiatry” and all that it implies actually takes into account theory, training and practice.
The Psychiatric Perspective
One word you will find exactly once in the entirety of PBM is “biopsychosocial.”
It’s an interesting omission, as the biopsychosocial model is the fundamental approach taken in modern psychiatry. It tells us that our health (in this case, mental health) is based on a wide range of different factors that interact in various ways. These factors include biological ones (which includes genetics, other illnesses, nutritional or other deficiencies, and the behaviour of neurotransmitters), psychological ones (broadly speaking, the coping styles you’ve learned to think about and deal with stressors), and social ones (including such things as family issues, community pressures, socioeconomic status).
This sounds like it encompasses a lot more than just diagnosing and prescribing, but what does it all really mean?
It means that when we talk about assigning a diagnosis, it’s rarely about diagnosing one particular disorder, and effectively saying “you patient are XYZ disorder.” That would fit the reductive antipsychiatry narrative of “biological psychiatry” but is inaccurate.
Instead, when asked to assess a patient, a psychiatric diagnosis is more likely to look something like this (until recently; more on that shortly):
Axis I: Major Depressive Disorder, moderate Generalized Anxiety Disorder rule-out Social Anxiety Disorder Axis II: Obsessive-Compulsive Personality Disorder Axis III: iron deficiency Coronary Artery Disease Axis IV: financial strain limited supports Axis V: GAF 60
Each “axis” consists of one or more diagnoses or factors that are impacting the patient’s mental health. Axis I is what we’ll tongue-in-cheek refer to as the “chemical imbalance” disorders. Axis II is the “personality disorders” (more on this shortly). Axis III includes other non-psychiatric medical issues. Axis IV is factors in their social situation affecting their illness. Axis V consists of something called a Global Assessment of Functioning (GAF) which is a rough measure of in general how well a person is doing in their daily life. If there are no relevant problems on a particular axis, it is labelled as “non-contributory,” while if it hasn’t really been examined yet, it is marked as “deferred.” Particular factors to be considered later are noted as “rule-out”.
That is a lot more than just pushing pills. Let’s elaborate further.
What Psychiatrists Actually Do
Let’s start with the biological side of things (Axis I and III).
A big part is certainly what is implied by the term “biological psychiatry.” That is, determining if the patient meets diagnostic criteria for one of the mental illnesses in the DSM where medications can play a role. When it comes to suggesting medications, a psychiatrist is more likely to look at symptoms rather than a particular diagnosis. This is because, as we described earlier, certain symptoms tend to be influenced by certain neurotransmitters.
Psychiatrists also look for a range of physical health problems that can be affecting a patient’s mental health, and have nothing to do with neurotransmitters. The sorts of things that are considered are based on the patient’s physical and family health history as well as mental health symptoms. For example, an iron deficiency can present as poor concentration, low energy, and memory problems. So psychiatrists order and review a wide range of blood tests (e.g. looking at vitamin deficiencies, hormone levels, electrolytes, etc.) as these can all pay a role in mental health.
They may also, again based on physical history and symptoms, order more complex tests like EEG’s (electroencephalograms, which can pick up types of epilepsy) or CT scans (which might pick up a tumour or other brain lesion). It’s not uncommon for behaviour changes to be the first indication of some of these illnesses. Psychiatrists, as medical doctors, are particularly trained at recognizing the signs of different physical health disorders that can appear as mental illnesses. Even if patients intend to seek treatment elsewhere, seeing a psychiatrist to rule-out some of these physical causes can be valuable. Brain tumours and vitamin deficiencies don’t generally respond well to psychotherapy.
So contrary to the reductive suggestions sprinkled throughout PBM, a crucial aspect of psychiatry is being aware of the impact of physical illnesses on mental health.
On the psychological side, psychiatrists are mostly dealing with Axis II, the “personality disorders.” To grossly over-simplify, we all learn to cope with stressors in different ways. An unhealthy coping strategy is one that causes you a lot of difficulties, or doesn’t deal very well with the stress. Someone who feels no control in their life may cope by trying to take strict control of the few things they can control, and spend hours each day devoted to this; this would be an example of Obsessive-Compulsive Personality Disorder. Personality disorders are not about passing judgment on “right” ways to deal with things, but if a coping style is causing significant distress to you, the framework of personality disorders helps to better understand what isn’t working for you.
On the treatment side, addressing personality disorders usually involves psychotherapy of some sort. This is a normal part of psychiatric practice, to varying degrees (some people, usually in private practice, do more). Often psychotherapy is delegated to psychologists or other professionals, but is part of the required skill set of any psychiatrist. When my wife was doing her psychiatry residency, she was required to learn the theory of over a dozen therapeutic modalities, as well as use each one over a number of weeks with a particular patient, while being supervised by someone expert in that modality.
On the social side (Axis IV), psychiatrists are more likely to defer handling of many issues to social workers or other professionals, but issues raised certainly affect treatment decisions. As an obvious example, if they prescribe a particular medication, will the patient be able to afford it?
So, it seems psychiatrists do a bit more than just pushing pills.
A Retreat to Biology?
You may hear various things about the biopsychosocial model no longer being used, or falling out of favour. Does this mean the critics are right, and psychiatry is admitting it is really just about biology (and specifically neurotransmitters)?
Not at all. What’s actually happening is that everyone recognizes that all the different biological, psychological and social factors overlap and interact with other in complicated ways. By separating things out too much (e.g. putting things on a different axis), things felt too compartmentalized and simplistic, and didn’t take into account this complexity.
So the “end” of biopsychosocial is really just the end of assigning each illness to a category and thinking of each category as a separate type of thing, e.g. that an Axis I disorder was very different from an Axis II disorder. In fact, the latest version of the DSM, DSM-5, dispenses with the whole “Axis” form of diagnoses altogether.
Incidentally, that one mention of “biopsychosocial”? It’s used to summarily dismiss it—without evidence, mind you—as “essentially the biological model with add-ons.” The way the text is written also implies that the biopsychosocial model is a component of the Canadian Mental Health Association (CMHA), as opposed to a fundamental part of psychiatry as a whole. For readers not in Canada, the CMHA is a voluntary organization that “promotes the mental health of all and supports the resilience and recovery of people experiencing mental illness.” Or as BB puts it, the CMHA is one of the “seemingly more benign organizations … [that] receive huge funding from the state to do its bidding, and as such, constitute an integral part of the ruling regime.”
For what it’s worth, I was expecting “biopsychosocial” to not appear in PBM at all.
PBM, and antipsychiatry in general, chooses to focus most of its energy on involuntary (“forced”) inpatient psychiatric commitment and treatment, and how psychiatry is empowered by the state to lock up those who are “different.”
What they omit, however, is situating that mode of psychiatric care within the context of psychiatric care in general. Given the goal of discrediting psychiatry as a whole, it seems a curious oversight if they were trying to provide an accurate portrayal.
Acknowledging that this omission is actually being used for persuasive purposes, I assume that PBM is trying to leave the impression that most psychiatric care is (or will necessarily become, after you’ve been diagnosed) involuntary. The argument is made that everything associated with involuntary commitment and treatment is bad, though as we’ve seen elsewhere, what is actually backed up by evidence is the existence of multiple negative examples.
Even if it were true (which it isn’t), does that mean that psychiatry as a whole bears the sins of involuntary treatment? Logically it does not; that would be an example of the fallacy of composition.
How about in practice? For how many people today will involuntary commitment be an issue at all? It’s hard to find good data here, but let’s try to break things down a bit. We know that the vast majority of psychiatric care (in the neighbourhood of 80%) is provided by family physicians, with somewhere between 30–70% of people never seeing anyone except their family doctor. So clearly, admission of any kind isn’t an issue for them.
Similarly, most people who go to an ER for mental health reasons aren’t admitted. And for a good proportion of people who see a psychiatrist at all, it will be for a one-time consult or a few short visits. Most psychiatric care is provided on a (voluntary) outpatient basis, rather than inpatient. And in terms of inpatient admissions, somewhere between 25-40% are involuntary.
In terms of involuntary admissions, they’re most prevalent for people with psychotic disorders (e.g. schizophrenia) or bipolar disorder (during either an acute manic or acute suicidal phase), much less so for unipolar depression (acute suicidality), and fairly rare for anxiety, personality disorders, etc.
Keep in mind also that the number of inpatient psychiatric beds continues to shrink (starting with the whole deinstitutionalization movement, but still continuing). We know that its more difficult for a patient to arrange a voluntary admission due to bed shortage; they typically need to be acutely suicidal. Similarly, people are discharged earlier than they have been previously (hence the “revolving door”).
For any given person then who seeks mental health care, what are the odds they will ever in their lifetime be involuntarily admitted and mistreated? Without the data, it’s hard to say, but based on the above rough analysis, for the vast majority of people who tend to be primarily diagnosed with a form of depression or anxiety, not very high.
Having said all that, one person who has their rights violated is one too many. But to imply that it’s almost a virtual certainty is plainly ridiculous.
Pathologizing the Atypical
Is the real goal of “inventing” mental illness, as PBM and antipsychiatrists often claim, to identify and punish societally unacceptable behaviour, to discourage the dissident or free-thinker?
It is certainly true that in the past, asylums were a convenient place for wealthy and powerful families to permanently relocate their more “embarrassing” relatives. Those days are, along with most of the asylums, long gone.
As just noted, involuntary treatment is one relatively small (but important) piece of psychiatry today. Being “different” or just having a psychiatric diagnosis, does not meet the threshold.
For the majority of people who are seen or treated, it is on a voluntary basis. As we’ve already discussed, to receive a diagnosis in the first place, it is not enough to be “different,” but that the symptoms demonstrate “clinically significant distress or impairment.”
And even if a diagnosis is given, the decision to agree to treatment (often choosing among several offered) is a matter of individual choice. As is the decision to later terminate treatment. Many people receive a diagnosis, yet decide the likely negative consequences of the treatment outweighs the likely benefits. Yet others will choose to look for non-pharmacological treatments, both those that might be recommended by psychiatrists (e.g. therapy, exercise, nutrition, meditation) and those that would not be (e.g. homeopathy). These are all rational decisions that most individuals are free to pursue.
For others, some perhaps who have tried some alternatives, realize the terrible cost that their symptoms are putting on their life, and feel that this outweighs the potential negative consequences of treatment. These are rational decisions, freely made.
Exploring an Antipsychiatry ‘End Game’
Having addressed the veracity of some of the key arguments, we probably have a healthy skepticism of this claim at the start of PBM’s last chapter, “Dusting Ourselves Off and Starting Anew”:
One conclusion that has already been reached is that the institution of psychiatry must go.
Again, while many critics of psychiatry propose what PBM calls “tinkering,” this notion here, as is typical with antipsychiatry, is rejected wholesale.
A frequent criticism of the movement is that no viable solution is offered to replace what we are throwing out, the theory being that at least removing all this harm is a massive improvement over the current situation.
PBM differs in that it offers us a solution, admittedly preliminary in nature.
Here’s the starting point:
One obvious direction that has surfaced is freeing ourselves from our frightening over-belief in and fetishization of science-the privileging of positivism, evidence-based research, and instrumental reason. What goes along with this and is likewise pivotal, we need to free ourselves from rule by “experts.”
It shortly continues:
That noted, cutting back on experts hardly suffices. Nor is insertion of peer workers into the current system. Such measures cannot simply by add-ons to an inherently injurious system. Moreover, even if we rid ourselves of psychiatry and even if we dispensed with mental health services as now know them—indeed, even if we drastically reduced our reliance on all associated workers—we would not have gone far enough.
The point is, you cannot simply separate out a part of a gestalt, part of a discourse—and our entire society is penetrated/constructed by regimes of ruling.
What follows is a remarkable vision of a society, a “eutopia” (“a good place”) that in its very structure provides a less competitive, more communal vision for how we all live with each other. Specifically related to mental distress, it posits a realm that values and thrives on diversity, peer support, local decisions that better respect autonomy and differences, without the centralized power structures that exist today. Some of it actually sounds quite lovely in many respects, though may be a bit too close to a “socialist paradise” for the comfort of many.
This eutopia would necessitate a few changes. In particular, it requires overturning every single cultural, legal, social, political, environmental, artistic, communal and economic foundation of our current society.
I therefore feel on safe footing if I take issue with the second part of this statement:
This chapter is necessarily both highly visionary and highly practical
From here to there
This sort of visioning exercise has its place in thinking about what kind of society would we ideally want, if we were able to start from scratch. Typically you’ll see this in university classes on political philosophy. Fresh from studying Rousseau, Locke, and Hobbes, our eager students imagine the creation of a new society, arising from a “state of nature” where life is “solitary, poor, nasty, brutish, and short.”
Yet, given that we’re rather further down the road in a different direction already, how do we make it happen?
Acknowledging that due to vested interests, big government nor big business will make these changes, this can only be accomplished by working outside the system.
There are some concrete suggestions for specific groups, mostly involving talking and starting to think about things a little bit differently, which sounds slow, incremental and unreliable. Mind you, PBM explicitly condemns incremental approaches as ineffectual and insufficient.
Perhaps greater hopes are pinned on a Kuhn-ian paradigm shift, where a rising tide of ideas finally overwhelms and replaces our existing systems and institutions en masse. This would be spurred on by activist movements akin to what we’ve seen during the antiglobalization protests, the environmental movement, or Idle No More. (The reader is presumably being asked to suspend disbelief that any such movement would be capable of coming to any shared understanding on even matters of terminology, let alone multiple substantive, highly-interconnected, complex organizational systems, and to say nothing of an implementation plan).
I’ve remarked since the beginning of this article that a concerted effort to logically “disprove,” at a fundamental level, an entire discipline seems distinctly like overkill. If the goal was to shed light on negative practices, to argue for substantial changes to practice, this could proceed without heavily relying on deeply flawed arguments. An openness to engage with critics and practitioners would presumably be warranted, rather than eschewed.
The deceptive cloak of objective scholarship and academia notwithstanding, the movement’s writings appear designed to persuade the reader, not inform them. To what end?
In light of the proposed “solution” suggested above, we perhaps gain new insight into the extremist “all or nothing” nature of the antipsychiatry movement.
The movement appears to literally be looking to recruit activists, the more engaged the better. Effective activist discourse is inherently one-sided, and often (as here) with a goal of not influencing the status quo, but overpowering and replacing it. The best chance to achieve a radical new vision of society, with a complete reconceptualization of mental health, can only possibly proceed through the mobilization of a vast army of unquestioning supporters.
Evidence, discussion, collaboration and compromise all lessen the chances of that happening. Black and white, good and evil, and not shades of grey must carry the day. As we have seen public discourse elsewhere fracture into “us vs. them,” “you’re with us or against us,” etc., the true message for antipsychiatry, despite the high-sounding rhetoric, is good humanity vs. evil psychiatry.
The worst thing that can happen for antipsychiatrists is legitimate progress continues to be made in psychiatry—in science, law, practice and culture. The opposite, an uptick in verifiable human suffering and abuses, though likely to be taken advantage of by the movement, is wisely left unstated.
And just as they have accused the “madness industry” itself of doing, they are preying on the weak and vulnerable, at times when they are most in need of real help.
To be clear, antipsychiatrists feel the best hope of replacing psychiatry, to improve the lives of people suffering from great anguish and distress, lies not in improving what we have. It is proposed instead that we replace almost every aspect of our entire society within a short time period, most likely to be accomplished by a (successful) activist revolution and mass uprising on a scale never before seen.
As the introduction of PBM so clearly states, “much like a lawyer in a courtroom, this book in essence ‘makes a case’.” But for those sincerely seeking to learn the truth, PBM cannot stand on its own. To carry forward the analogy, we need to add, at a minimum, opposing council, rebuttal, and a judge or jury to weigh the testimony.
Patients who have been victimized or harmed in the past by psychiatric practice, whether rooted in malice, manipulation, ignorance or bad luck, have done an invaluable service and have helped overturn unjust and abusive practices of the past. Those courageous people who continue to do so to this day constantly remind us that we are still too far away from where we want to be.
Patients, families, advocates, journalists, and others who have brought these stories forward, identified structural flaws and promoted changes, who critically but openly have engaged with the broader mental health community, have similarly helped move practice forward, to open the eyes of those who need them opened, and have thereby improved the lives of other patients. As have those who have told other stories about mental health and treatment, the impact on their lives of these very real illnesses, how their lives have sometimes been improved, sometimes imperfectly, with treatment. As have those who have fought to reduce stigma, make it easier for people to come forward, and to raise the level of public conversation on this topic to unprecedented levels.
Those in the antipsychiatry movement are not to be counted amongst those who have helped. They seek not to improve psychiatric practice, but destroy it. They deny the very nature of mental illness, dissuading people from coming forward and obtaining treatment that could improve their lives. They do not engage with the broader community, but reject criticism, and retreat within an echo chamber of their own making, recycling the same examples and arguments ad nauseum.
In PBM, we have a holistic, broadly-based representative of the antipsychiatry genre. It carries the trappings of rigorous knowledge: the language, references, methodologies, and ostensible blessing of an esteemed university. Yet beneath this carefully constructed façade lies a one-sided, overzealous polemic.
Not content to advocate for change, more oversight, etc., PBM takes the audacious step of claiming with absolute logical certainty that psychiatry is without any redeeming quality and must be annihilated. The ludicrousness of this overreaching attempt is revealed in its reliance on numerous overly-simplistic and fallacious arguments.
Yet, irresponsibly but predictably, no viable alternative, no concrete solution, nothing with the slightest chance of actually happening is offered instead. We are left only with a simplistic “good vs. evil” paradigm intended only to deliver recruits to an extremist movement.