Anti-psychiatry

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This article is an expansion of sections within the main articles: Psychiatry and Biological psychiatry

Anti-psychiatry refers to approaches (sometimes seen as a coherent movement) which fundamentally challenge the theory or practice of mainstream psychiatry in general, and biological psychiatry in particular. Common criticisms include that psychiatry: uses medical concepts and tools inappropriately; treats patients against their will or is over dominant compared to other approaches; is compromised by financial and professional links with pharmaceutical companies; uses a system of categorical diagnosis that is stigmatizing (the Diagnostic and Statistical Manual of Mental Disorders) and is perceived by too many of its 'patients' as demeaning and controlling.

A significant minority of mental health professionals and academics profess anti-psychiatry views, and even some non biological psychiatrists hold such views in regard to mainstream (biological) psychiatry [1] [2]. Psychiatrists generally view anti-psychiatry as a fringe movement with little or no scientific validity, although it is difficult to quantify the proportion of the general public or professionals involved, or the range of views held.

Despite its name, the movement is often seen as promoting a type of psychiatry itself, albeit one that is in stark contrast to current mainstream thinking. Thus many so-called 'anti-psychiatrists', including psychiatrists with non-mainstream beliefs, are keen to dissociate themselves from the term and the pejorative associations it has attracted [3].

Origins of anti-psychiatry

There was opposition to psychiatry from its origins and as it became more professionally established during the 19th century. Disputes often concerned custodial rights over those seen as 'mad', including in the expanding lunatic asylums, and divergent theoretical interpretations of mental problems. Emil Kraepelin introduced new medical categories of mental illness, which eventually came into psychiatric usage despite their basis in behavior rather than pathology or etiology.

In the 1920s surrealist opposition to psychiatry was expressed in a number of surrealist publications.

In the 1930s several controversial medical practices were introduced including inducing seizures (by electroshock, insulin or other drugs) or cutting parts of the brain apart (leucotomy or lobotomy). Both came into widespread use by psychiatry, but there were grave concerns and much opposition on grounds of basic morality, harmful effects, or misuse. In the 1950s new psychiatric drugs, notably the antipsychotic chlorpromazine, were designed in laboratories and slowly came into preferred use. Although often accepted as an advance in some ways, there was some opposition, due to serious adverse effects such as tardive dyskinesia. Patients often opposed psychiatry and refused or stopped taking the drugs when not subject to psychiatric control. There was also increasing opposition to the use of psychiatric hospitals, and attempts to move people back into the community on a collaborative user-led group approach ('therapeutic communities') not controlled by psychiatry.

Coming to the fore in the 1960s, anti-psychiatry (a term first used by David Cooper in 1967) defined a movement that vocally challenged the fundamental claims and practices of mainstream psychiatry. Non biological psychiatrists R.D. Laing, Theodore Lidz, Silvano Arieti and others argued that schizophrenia could be understood as an injury to the inner self inflicted by psychologically invasive, “schizophrenogenic” parents. Arieti won the American National Book Award in the field of science for his work “Interpretation of Schizophrenia” [4], in which he rejects the medical model of schizophrenia and advances instead a psychological approach to the disorder. Psychiatrist Thomas Szasz argued that 'mental illness' is an inherently incoherent combination of a medical and a psychological concept, but popular because it legitimises the use of psychiatric force to control and limit deviance from societal norms. Adherents of this view referred to "the myth of mental illness" after Szasz's controversial book of that name. (Even though the movement originally described as anti-psychiatry became associated with the general counter-culture movement of the 1960s, Szasz, Lidz and Arieti never became involved in that movement.) Michel Foucault, Erving Goffman and others criticised the power and role of psychiatry in society, including the use of 'total institutions', 'labelling' and stigmatizing [5] (pdf). The novel One Flew Over the Cuckoo's Nest became a bestseller, resonating with public concern about forced medication, lobotomy and electroshock procedures used to control patients.

In addition, Holocaust documenters argued that the medicalization of social problems and systematic euthanasia of people in German mental institutions in the 1930s provided the institutional, procedural, and doctrinal origins of the mass murder of the 1940s. The Nuremberg Trials convicted a number of psychiatrists who held key positions in Nazi regimes. Observation of the abuses of psychiatry in the Soviet Union also led to questioning the validity of the practice of psychiatry in the West [6]. In particular, the diagnosis of many political dissidents with schizophrenia led some to question the general diagnosis and punitive usage of the label schizophrenia. This raised questions as to whether the schizophrenia label and resulting involuntary psychiatric treatment could not have been similarly used in the West to subdue rebellious, though basically sane, young people during family conflicts.

New professional approaches were developed as an alternative, or complement, to psychiatry. Social work, humanistic or existentialist therapies, counselling and self-help developed and often opposed psychiatry. Psychoanalysis was increasingly criticised as unscientific [7]. Contrary to the popular view, critics and biographers of Freud, such as Jeffrey Masson and Louis Breger, argue that Freud did not grasp the nature of psychological trauma. Conversely, proponents of psychohistory advanced theories to understand mental disorders in a way that closely resembled the models of the professionals who do indeed work in the traumatogenic-mode of parenting [8].

The anti-psychiatry movement was also being driven by individuals with adverse experience of psychiatric care. This included those who felt they had been harmed by psychiatry or who felt that they could have been helped more by other approaches, including those compulsorily (including via physical force) admitted to psychiatric institutions and subjected to compulsory medication or procedures. During the 1970s, the anti-psychiatry movement was involved in promoting restraint from many practices seen as psychiatric abuses. The gay rights movement challenged the classification of homosexuality as a mental illness, and in a climate of controversy and activism in 1973/1974 the American Psychiatric Association decided by a small majority (58%) to remove it as an illness category, although "ego-dystonic homosexuality" remained until 1987. Increased legal and professional protections, and merging with human rights and disability rights movements, added to anti-psychiatry theory and action.

Additionally, and largely separately, some contemporary cults or new religious movements, most notably Scientology, began challenging aspects of psychiatric theory or practice.

Anti-psychiatry came to challenge a 'biomedical' focus of psychiatry (defined to mean genetics, neurochemicals and drugs). There was also opposition to the increasing links between psychiatry and pharmaceutical companies, who were becoming more powerful and were increasingly claimed to have excessive, unjustified and underhand influence on psychiatric research and practice. There was also opposition to the codification of, and alleged misuse of, psychiatric diagnoses into manuals, in particular the American Psychiatric Association, which publishes the Diagnostic and Statistical Manual of Mental Disorders.

Anti-psychiatry increasingly challenged alleged psychiatric pessimism regarding those categorized as mentally ill. Mental health users argued for full recovery, empowerment and self-management. Schemes were developed to challenge stigma and discrimination; to assist or encourage people with mental health issues to more fully engage in work and society, and to involve service users in the delivery and evaluation of mental health services. However, those actively and openly challenging the fundamental ethics and efficacy of mainstream psychiatric practice remained marginalised within psychiatry, and to a lesser extent within the wider mental health community.

Scientific criticisms

Modern psychiatric practice strives to create and use explicit diagnostic criteria for mental illness, such as the Diagnostic and Statistical Manual of Mental Disorders or DSM. This method of practice is often called neo-Kraepelinian, after Emil Kraepelin, an early psychiatrist who advocated such an approach.

One of the paradigms of the DSM manual, the concept of schizophrenia, has been challenged from various perspectives. Critics say despite media publicity it has yet to be proven that schizophrenia is a bio-medical condition [9]. More significantly, the traumatogenic etiology of some types of schizophrenia has been considered by some as a revolutionary approach in the mental health field [10] [11].

The fourth edition of the DSM is a list of 374 disorders. Only two of them, “Post-traumatic stress disorder” and “Dissociative identity disorder” are thought to be psychogenic or caused by traumatic experiences. Biological psychiatrists maintain that the other 372 disorders are biomedical entities of unknown etiology. For example, in a statement released in September 2003 the American Psychiatric Association, that represents 36,000 physician leaders in mental health, conceded that “brain science has not advanced to the point where scientists or clinicians can point to readily discernible pathologic lesions or genetic abnormalities that in and of themselves serve as reliable or predictive biomarkers of a given mental disorder or mental disorders as a group […]. Mental disorders will likely be proven to represent disorders of intracellular communication; or of disrupted neural circuitry” [12].

Critics of psychiatry often complain about the futuristic stance (“will likely be proven...”) in this field that claims to be a branch of medicine. In the psychiatric profession, people labeled with a DSM disorder are usually treated with psychiatric drugs or electroshock. Since in some cases these various treatments are administered involuntarily, the lack of biological markers in the profession has been an issue of great concern among the critics.

Similarly, the fact that millions of children are being treated with methylphenidate (Ritalin) or other psychiatric drugs [13] has also been an issue of concern and even open censure and condemnation among the critics.

Unjustified focus on biochemical factors

The focus on biochemical investigations of mental distress is seen by critics as unjustified. Many mainstream psychiatrists believe that the balance of neurotransmitters in the brain is the major biological regulator of mental health, yet neurobiologists would point out that neurotransmitters are the primary signalling agents used by neurons and that as such they are produced in response to brain activity. While a general build-up of neurotransmitters outside the synapse can 'modulate' brain activity in a given region, this is a secondary effect. That unusual brain activity results in unusual neurotransmitter accumulation should not surprise us. The theory that emotions within a 'normal' spectrum reflect a proper balance of neurochemicals, but abnormally extreme emotions, such as clinical depression, reflect an imbalance cannot therefore be taken to mean that chemical imbalance is the cause of extreme emotions.

Psychiatrists claim that medications regulate neurotransmitters and also claim they treat abnormal personalities by removing a neurochemical excess or replenishing a deficit. However current drugs, especially the neuroleptics, popularly known as “antipsychotics”, lack specificity, leading to counterclaims that they function as "chemical strait-jackets" [14] [15]. Critics also claim that the broad biochemical assertions and assumptions of mainstream psychiatry are not supported by evidence and are partly value judgements [16]. Some also believe that the media has distorted information promoting the idea that autism is a physical disorder. Leo Kanner views autism as a psychological disorder resulting from bad parenting. Psychiatrists who do not accept the medical model of mental disorders, such as Peter Breggin, maintain that the labeling of children inflicts additional humiliation and injury to the self-esteem of an already traumatized child.

Unjustified focus on genetic factors

According to mainstream psychiatry, genetic and environmental factors both appear to be of vital importance in determining mental state and therefore certain genetic factors can predispose people to particular mental illnesses [17]. To date - and in contrast to diseases affecting almost every other human organ but the brain - only a few genetic lesions have been proposed to be mechanistically responsible for psychiatric conditions [18], though there are reports of significant associations between specific genomic regions and psychiatric disorders [19] [20]. The reasons offered for the relative lack of genetic understanding is because the links between genes and mental states defined as abnormal appear highly complex, involve extensive environmental influences and can be mediated in numerous different ways, for example by personality, temperament or life events. Therefore while twin studies and other research suggests that personality is heritable to some extent, the genetic basis for particular personality or temperament traits, and their links to mental health problems, is currently unclear [21].

Anti-psychiatrists often argue that biological psychiatrists use genetic terminology in an unscientific way to reinforce their approach, for example by referring to findings of the genetic basis for illnesses and weaknesses, rather than the role of genetic factors in traits which may make some problems more likely in some environments and societies. Some propose that the biochemical differences observed in some mental illnesses are not the genetic cause, but rather the effect of a condition caused solely by psychological trauma [22]. Others argue that there is no significant genetic component involved at all, suggesting instead that observed patterns of family transmission are neutral with respect to genetic versus environmental etiology [23]. Some critics also claim psychiatrists disproportionately focus on understanding the genetics of those individuals with mental health problems at the expense of addressing the problems of the living in the environments of some extremely abusive families or societies [24].

Normality and illness judgements

Critics generally do not dispute the notion that some people have emotional or psychological problems, or that some psychotherapies do not work for a given problem. They do usually disagree with psychiatry on the source of these problems; the appropriateness of characterizing these problems as illness; and on what the proper management options are. For instance, a primary concern of anti-psychiatry is that an individual's degree of adherence to communally, or majority, held values may be used to determine that person's level of mental health. Using this logic they argue that in a communal display of violence like a public stoning, a person who abstains from violence could be diagnosed mentally ill and should, subsequently, be treated.

In addition, many feel that they are being pathologised for simply being different. Some people diagnosed with Asperger's Syndrome or autism hold this position (see autism rights movement). While many parents of children diagnosed autistic oppose the efforts of autistic activists, there are some who say they value the uniqueness of their children and do not desire a 'cure' for their autism. The autistic community has coined a number of terms that would appear to form the basis for a new branch of identity politics; terms such as "neurodiversity", "neurotypical" and "neurodivergent".

Psychiatry as a pseudo-science

Many of the above issues, and others, lead to the common claim within the anti-psychiatry movement that psychiatry is a pseudo-science.

According to the generally-accepted philosophy of science, for a theory to qualify as hard science it needs to exhibit the following characteristics:

parsimony, as simple as the phenomena to be explained allow (see Occam's Razor);
empirically testable and falsifiable (see Falsifiability);
changeable, i.e. if necessary, changes may be made to the theory as new data are discovered;
progressive, encompasses previous successful descriptions and explains and adds more;
provisional, i.e. tentative; the theory does not attempt to assert that it is a final description or explanation.

Critics maintain that psychiatry does not qualify as a science on many of these counts, and that presently, most biological hypotheses in psychiatry are untestable and thus unfalsifiable. [25]

Challenges and alternatives to psychiatric practice

Psychiatric labeling

There are recognized problems regarding the diagnostic reliability and validity of mainstream psychiatric diagnoses, both in ideal controlled circumstances (Williams et al. 1992) and even more so in routine clinical practice (McGorry et al. 1995). Criteria in the principal diagnostic manuals, the DSM and ICD, are inconsistent (van Os et al. 1999). Some psychiatrists who criticize their own profession say that comorbidity, when an individual meets criteria for two or more disorders, is the rule rather than the exception. There is much overlap and vaguely-defined or changeable boundaries between what psychiatrists claim are distinct illness states [26].

There are also problems with using standard diagnostic criteria in different countries, cultures, genders or ethnic groups. Critics often allege that Westernized, white, male-dominated psychiatric practices and diagnoses disadvantage and misunderstand those from other groups. For example, several studies have shown that African Americans are more often diagnosed with schizophrenia than Caucasians [27].

Psychiatry and the pharmaceutical industry

Biological psychiatrists prescribe drugs for adults and children. The administration of the drugs can be voluntarily or, in certain situations, involuntarily. Psychiatrists claim that a number of medications have a proven efficacy for improving or managing a number of mental health disorders. This includes ranges of different drugs referred to as antidepressants, tranquilizers and neuroleptics.

On the other hand, non biological psychiatrists maintain that their colleagues exaggerate the evidence of medication and minimize the evidence for adverse drug reaction [28]. Critics also complain that individuals are not given sufficient balanced information or truly informed consent; that current psychiatric medications do not appear to be specific to particular disorders in the way mainstream psychiatry asserts [29]; and that psychiatric drugs do not fix chemical imbalances in the brain but induce instead undesirable side effects. For example, though children on Ritalin and other psycho-stimulants become more obedient to parents and teachers, critics have noted that they also develop abnormal movements such as tics, spasms and other involuntary movements [30] (pdf). For those with some training in General Semantics and understanding of the social construction of social reality it should be obvious that to an excellent first approximation there can be no such thing as Attention Deficit/Hyperactivity Disorder as long as you are coercing someone's attendance. If adults were to leave some public performance or lecture in droves -- either because of disgust or boredom -- then that would generally be considered an adverse judgment on the performance, not the attendees.

The influence of pharmaceutical companies is another major issue for the antipsychiatry movement. The pharmaceutical industry is one of the most profitable and powerful in existence, and as Joe Sharkey has argued there are many financial and professional links between psychiatry, regulators and pharmaceutical companies. Drug companies routinely fund much of the research conducted by psychiatrists; routinely advertise medication in psychiatric journals and conferences; routinely fund psychiatric and healthcare organizations and health promotion campaigns; and routinely send representatives to lobby general physicians and politicians. Sharkey and other investigators of the psycho-pharmaceutical industry maintain that many psychiatrists are members, shareholders or special advisors to pharmaceutical or associated regulatory organizations.

There is evidence that research findings and the prescribing of drugs are influenced as a result. A United Kingdom cross-party parliamentary inquiry into the influence of the pharmaceutical industry in 2005 [31] (pdf) concludes: "The influence of the pharmaceutical industry is such that it dominates clinical practice" (page 100) and that there are serious regulatory failings resulting in "the unsafe use of drugs; and the increasing medicalisation of society" (page 101). The campaign organization No Free Lunch details the prevalent acceptance by medical professionals of free gifts from pharmaceutical companies and the effect on psychiatric practice [32]. The ghost-writing of articles by pharmaceutical company officials, which are then presented by esteemed psychiatrists, has also been highlighted [33]. Systematic reviews have found that trials of psychiatric drugs that are conducted with pharmaceutical funding are several times more likely to report positive findings than studies without such funding [34] (pdf).

The number of psychiatric drug prescriptions have been increasing at an extremely high rate since the 1950s and show no sign of abating. In the United States antidepressants and tranquilizers are now the top selling class of prescription drugs, and neuroleptics and other psychiatric drugs also rank near the top, all with expanding sales [35] (pdf).

As a solution of this alleged conflict of interests, critics propose legislation to separate the pharmaceutical industry from the psychiatric profession.

Electroshock

In contrast to other mental health professionals who advocate psychotherapy for emotional distress and mental disorders, bio-psychiatrists may advocate psychiatric drugs or more controversial interventions such as electroshock or lobotomy (presently called psychosurgery within psychiatry).

Despite potential adverse effects, mainly memory loss, the use of electroshock (also called electroconvulsive therapy or ECT) is administered worldwide for a wide range of mental illnesses [36]. By 1978, as many as 200,000 patients every year were being treated by ECT [37]. However, according to health activist, Vernon Coleman, the practice is now more limited: "In the United States, 92% of psychiatrists do not use ECT. And the 'therapy' is used by a minority of psychiatrists in other countries" [38].

Coleman is among a growing number of critics who believe ECT to be a "disgrace to psychiatry and to the medical profession as a whole" (ibid). Max Fink, a biological psychiatrist, stated in the 1978 January/February issue of Comprehensive Psychiatry that "the principal complications of ECT are death, brain damage, memory impairment and spontaneous seizures" though he also believes that it "has saved many lives" [39]. In Clinical Psychiatric News, March 1983, Sidney Samant, M.D., stated: “Electroconvulsive therapy in effect may be defined as a controlled type of brain damage produced by electrical means”. However, a 2003 systematic review concluded that, despite these risks, ECT "is an effective short-term treatment for depression" [40], though this interpretation is disputed [41].

Psychiatry and the law

Psychiatrists often give testimony as to whether an individual is mentally fit to face trial, the so-called insanity defense. Some non biological psychiatrists dispute the right of bio-psychiatrists and the judicial system to do this or the way in which they do it. Since the 1960s Szasz has being arguing that, because mental illness is an incoherent concept, the insanity defense should be abolished. Most of his colleagues do not accept this view.

While the insanity defense is the subject of controversy as a possible excuse for wrong-doing, other critics contend that being committed in a psychiatric hospital is often much worse than criminal prisons, since it involves the risk of compulsory drugging with neuroleptics or electroshock treatment [42].

Involuntary hospitalization

Psychiatry is at the forefront of the practice of mental health care in hospital wards, or other medical settings, using legally-sanctioned force to admit individuals against their will. Critics point out that this practice runs against one of the pillars of open or free societies: John Stuart Mill’s principles, as advanced in his foundational work of the concept of liberty. Mill argues that society should never use coercion to subdue an individual as long as he (or she) does not harm others. Involuntary psychiatric hospitalization, critics contend, violates this principle. (In contrast to the Hollywood portrait of schizophrenics, disturbed people are usually no more prone to violence than sane individuals.) The growing practice, in the United Kingdom and elsewhere, of "care in the community" was instituted partly in response to such concerns. Alternatives to involuntary hospitalization include the development of non-medical crisis care in the community.

In the case of people suffering from severe psychotic crises, the American Soteria project used to provide, critics of bio-psychiatry contend, a more humane and compassionate alternative to coercive psychiatry. The Soteria houses closed in 1983 in the United States due to lack of financial support. However, Soteria-like houses are presently flourishing in Europe, especially in Sweden and other North European countries [43].

Toward a Therapeutic State?

The 'Therapeutic State' is a phrase coined by American psychiatrist Thomas Szasz in 1963. The United States under the presidency of George W. Bush is currently planning to implement a nation-wide screening program, the New Freedom Commission on Mental Health, which will seek to diagnose purported psychiatric disorders throughout the entire U.S. [44]. If approved by the Congress and implemented, the Act will have significant pharmaceutical company influence. Civil libertarians warn that the marriage of the State with psychiatry could have catastrophic consequences for civilization [45]. Szasz believes that a solid wall must exist between psychiatry and the State [46].

Civilisation as a cause of distress

In Civilisation and Its Discontents Freud, in later life, wrote of the conflict between man's instinctive nature and the demands of society. Many others, before and after him, have written in similar vein, and some, such as George Miller Beard have pointed to an epidemic of 'neurasthenia' (a condition no longer recognised as an illness) at the start of the twentieth century as indicative of the breakdown of a section of society under the increasing stresses of modern life. R. D. Laing emphasised family nexus as a mechanism whereby individuals become victimised by those around them, often under pressure to keep a family secret.

In recent years, David Smail, a psychotherapist considered part of the anti-psychiatry movement, has written extensively of the 'embodied nature' of the individual in society, and the unwillingness of even therapists to acknowledge the obvious part played by power and interest in modern Western society. He emphasises the fact that feelings and emotions are not, as is commonly supposed, features of the individual, but rather responses to the individual in his situation in society. Even psychotherapy, he suggests, can only change feelings inasmuch as it helps a person to change the 'proximal' and 'distal' influences on his life, which range from family and friends, to politics and work.

Anti-psychiatry quotes

"Labeling a child as mentally ill is stigmatization, not diagnosis. Giving a child a psychiatric drug is poisoning, not treatment." - Thomas Szasz
"Human salvation lies in the hands of the creatively maladjusted." - Martin Luther King, Jr
"I`d rather be alone / with a schizophrenic / than a psychiatrist" - Carol Batton

See also

External links

Articles

Oikos.org - The Dark Side of Psychiatry

Sites of Non biological psychiatrists

Rossinst.com - Home page of Colin A. Ross Institute for Psychological Trauma
Breggin.com - Homepage of Peter Breggin
LaingSociety.org - The Society for Laingian Studies, R.D. Laing (1927-1989)
Mosher Soteria - Loren Mosher, MD, (1933-2004)
Szasz.com - The Thomas S. Szasz, MD, Cybercenter for Liberty and Responsibility

Organizations critical of psychiatry

ICSPP.org - International Center for the Study of Psychiatry and Psychology
MindFreedom.org - Support Coalition International (a coalition of groups supporting "United Action for Human Rights in Mental Health")
PsychRights.org - Law Project for Psychiatric Rights
CCHR.org - Citizens Commission on Human Rights

References

Caplan, Paula J., They say you're crazy: how the world's most powerful psychiatrists decide who's normal, Addison-Wesley, 1995. An inside look at the politics of the DSM from a former consultant.

McGorry PD, Mihalopoulos C, Henry L et al (1995) Spurious precision: procedural validity of diagnostic assessment in psychiatric disorders. American Journal of Psychiatry 152 (2) 220-223

van Os J, Gilvarry C, Bale R et al (1999) A comparison of the utility of dimensional and categorical representations of psychosis. Psychological Medicine 29 (3) 595-606

Williams, J.B., Gibbon, M., First, M., Spitzer, R., Davies, M., Borus, J., Howes, M., Kane, J., Pope, H., Rounsaville, B., and Wittchen, H. (1992). The structured clinical interview for DSM-III-R (SCID) II: Multi-site test-retest reliability. Archives of General Psychiatry, 49, 630-636.de:Antipsychiatrie

et:Antipsühhiaatria es:Antipsiquiatría fr:Antipsychiatrie he:אנטי פסיכיאטריה nl:Antipsychiatrie pl:Antypsychiatria sv:Antipsykiatri

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Categories: Anti-psychiatry | Ethics | Psychiatry

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