Anti-psychiatry

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This article is an expansion of the section within the main article: Psychiatry. The debate of psychiatry’s theoretical basis is discussed in Biopsychiatry controversy

Anti-psychiatry refers to approaches which fundamentally challenge the theory or practice of mainstream psychiatry. Some proponents focus on biological psychiatry in particular. Anti-psychiatric criticisms of mainstream psychiatry include that it applies medical concepts and tools inappropriately to the mind, that it treats patients against their will (unnecessarily, or at all), that it inappropriately dominates and excludes other approaches to mental distress and disorder, that its medical and ethical integrity are compromised by its financial and professional links with pharmaceutical companies and insurance companies, that it uses a system of categorical diagnosis (the Diagnostic and Statistical Manual of Mental Disorders) that is stigmatizing and poorly founded scientifically or clinically, and that the psychiatric system is experienced by too many of its patients as demeaning and controlling.

A significant minority of mental health professionals and academics profess anti-psychiatry views, as does a significant proportion of users or ex-users of psychiatric services, and even some psychiatrists hold such views in regard to mainstream (currently biological) psychiatry[1]. Psychiatrists often 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, some parts of the movement can be 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.[2]

Contents

[edit] 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 medical 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, partly 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 large-scale use of psychiatric hospitals and institutions, and attempts were made to base services in the community.

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. 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, or as a healthy attempt to cope with a sick society. Psychiatrist Thomas Szasz argued that "mental illness" is an inherently incoherent combination of a medical and a psychological concept, but popular because it legitimizes 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 criticized the power and role of psychiatry in society, including the use of "total institutions", "labeling" and stigmatizing. [3] Foucault argued that the concepts of sanity and insanity were social constructs that did not reflect quantifiable patterns of human behavior, and which, rather, were indicative only of the power of the "sane" over the "insane". 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 in the so-called Psikhushka hospitals also led to questioning the validity of the practice of psychiatry in the West. [4] 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, counseling and self-help and clinical psychology developed and often opposed psychiatry. Psychoanalysis was increasingly criticized as unscientific or harmful. [5] Contrary to the popular view, critics and biographers of Freud, such as Alice Miller, Jeffrey Masson and Louis Breger, argued that Freud did not grasp the nature of psychological trauma. Non-medical collaborative services were developed, for example therapeutic communities or Soteria houses.

The anti-psychiatry movement was also being driven by individuals with adverse experiences of psychiatric services. 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, which 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. An emerging Consumer/Survivor Movement often argued for full recovery, empowerment and self-management. Schemes were developed to challenge stigma and discrimination, often based on a social model of disability; to assist or encourage people with mental health issues to more fully engage in work and society (for example through social firms), 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 marginalized within psychiatry, and to a lesser extent within the wider mental health community.

[edit] Challenges and alternatives to psychiatric practice

[edit] Civilization as a cause of distress

In Civilization and Its Discontents, Freud, in later life, wrote of the conflict between man's instinctive nature and the demands of society (a view rejected by some of Freud’s later epigones as the cause of mental problems). 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 recognized 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 emphasized family nexus as a mechanism whereby individuals become victimized by those around them.

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 emphasizes the fact that feelings and emotions are not, as is commonly supposed, features of the individual, but rather responses of the individual to 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.

[edit] Normality and illness judgments

Critics of psychiatry 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. Furthermore, if disagreement with the majority in a society constitutes delusion, then anyone whose statements are considered by that majority to be incorrect is delusional, regardless of the actual correctness of his or her ideas; or, alternately, the criteria by which a belief is deemed to be a delusion must necessarily fluctuate with the majority's opinion. Under this definition, critics of psychiatry argue, early proponents of heliocentrism, such as Galileo, would have been rightly characterized as delusional since their ideas were widely held to be incorrect when they were originally formulated; it is only because the majority currently backs a heliocentric model of the solar system that an opposing belief might now be considered a "delusion".

In addition, many feel that they are being pathologized 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" and "neurotypical".[citation needed]

It has been argued by philosophers like Foucault that characterizations of "mental illness" are indeterminate and reflect the hierarchical structures of the societies from which they emerge rather than any precisely-defined qualities which distinguish a "healthy" mind from a "sick" one. Furthermore, if a tendency toward self-harm is taken as an elementary symptom of mental illness, then humans, as a species, are arguably insane in that they have tended throughout recorded history to destroy their own environments, to make war with one another, etc.

[edit] 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).[6] 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.[7] 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, [8] and women more than men. Some within the anti-psychiatry movement are critical of the use of diagnosis as it conforms with the medical biopsychiatry model. The late Kevin F. McCready, founder of San Joaquin Psychotherapy Center, was critical of the use of diagnosis for people suffering from psychological and emotional overwhelm. He opened a day treatment program in Fresno, California, utilizing an integrative milieu model of psychotherapy without the use of diagnosis or psychiatric drugs. This center has served clients from all over the world who have sought this type of specialized treatment where they could gradually titrate off of their psychiatric drugs. Today there are a number of centers open around the United States based on this model.[9]

[edit] Psychiatry and the pharmaceutical industry

Stern concerns about how disease is managed in large populations for financial purposes alone appear constantly in the literature critical of the medical profession and the industry.[10]

Psychiatrists prescribe drugs for adults and children. Administration of the drugs can be undertaken 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 (antipsychotics).

On the other hand, organizations with thousands of members such as MindFreedom International and World Network of Users and Survivors of Psychiatry maintain that psychiatrists exaggerate the evidence of medication and minimize the evidence of adverse drug reaction. They and other activists 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;[11] and psychiatric drugs not only don't correct measurable chemical imbalances in the brain, but also induce 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.[12] The diagnosis of Attention Deficit Hyperactivity Disorder on the basis of inattention to compulsory schooling also raises critics' concerns regarding the use of psychoactive drugs as a means of unjust social control of children. 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, advertise medication in psychiatric journals and conferences, fund psychiatric and healthcare organizations and health promotion campaigns, and send representatives to lobby general physicians and politicians. Peter Breggin, 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.[13] 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 concludes: "The influence of the pharmaceutical industry is such that it dominates clinical practice"[14] and that there are serious regulatory failings resulting in "the unsafe use of drugs; and the increasing medicalization of society".[14] 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.[15] The ghost-writing of articles by pharmaceutical company officials, which are then presented by esteemed psychiatrists, has also been highlighted.[16] 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. [17]

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

[edit] Electroconvulsive therapy

In contrast to other mental health professionals who advocate psychotherapy for emotional distress and mental disorders, psychiatrists may advocate psychiatric drugs or more controversial interventions such as electroshock or psychosurgery.

Despite potential adverse effects, mainly memory loss, the use of electroconvulsive therapy (ECT) is administered worldwide for a wide range of mental illnesses.[19] By 1978, as many as 200,000 patients every year were being treated by ECT.[20] 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".[21]

Coleman is among a number of critics who believe ECT to be a "disgrace to psychiatry and to the medical profession as a whole".[21] Max Fink, a 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".[22] 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", [23] though this interpretation is disputed. [24]

[edit] Psychiatry and the law

Psychiatrists often give testimony in competence hearings. These hearings seek to determine whether an individual is mentally fit to face trial. They also often testify in trials in which the insanity defense is used. Some mental health professionals dispute the right of psychiatrists and the judicial system to do this or the way in which they do it. Since the 1960s Szasz has agued that, because mental illness is an incoherent concept, the insanity defense should be abolished. Most experts in the field do not accept this view.

While the insanity defense is the subject of controversy as a viable excuse for wrong-doing, other critics contend that being committed in a psychiatric hospital is often much worse than criminal imprisonment, since it involves the risk of compulsory medication with neuroleptics or the use of electroshock treatment.[25]

[edit] 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 regarding 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 (Monahan 1992). 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 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.[26]

[edit] 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. [27] 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. [28] Szasz believes that a solid wall must exist between psychiatry and the State. [29]


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[edit] See also

[edit] External links

[edit] Information

National Mental Health Consumers' Self-Help Clearinghouse

[edit] Articles

  • PLoS Medicine - Why Most Published Research Findings Are False, by John P. A. Ioannidis. Vol. 2, No. 8, DOI:10.1371/journal.pmed.0020124.Last accessed 16 June 2006
  • PLoS Medicine - Medical Journals Are an Extension of the Marketing Arm of Pharmaceutical Companies, by Richard Smith, Vol.2, No.5, e138 DOI:10.1371/journal.pmed.0020138. Last accessed 16 June 2006
  • British Medical Journal - Commercial influence and the content of medical journals, by Joel Lexchin, associate professor1, Donald W Light, professor2, BMJ 2006;332:1444-1447 (17 June),doi:10.1136/bmj.332.7555.1444; Last accessed 16 June 2006
  • PLoS Medicine - The Latest Mania: Selling Bipolar Disorder, by David Healy, Vol.3, No.4, DOI: 10.1371/journal.pmed.0030185; Last accessed 16 June 2006

[edit] Organizations critical of psychiatry

[edit] Notes

  1. ^ http://www.springerpub.com/journal.aspx?jid=1523-150X
  2. ^ http://www.uea.ac.uk/~wp276/define.htm
  3. ^ http://www.jrsm.org/cgi/reprint/94/3/148.pdf?ijkey=07b5d6fed040a1f4c99d9e0fe381f33314e70145
  4. ^ http://www.aaas.org/news/releases/2003/1212reich.shtml
  5. ^ http://www.jeffreymasson.com/freud.html
  6. ^ PD McGorry; C Mihalopoulos, L Henry, J Dakis, HJ Jackson, M Flaum, S Harrigan, D McKenzie, J Kulkarni and R Karoly (1995). Spurious precision: procedural validity of diagnostic assessment in psychotic disorders. Am J Psychiatry 1995; 152:220-223. American Psychiatric Association. Retrieved on 2006-07-02.
  7. ^ http://www.rossinst.com/trauma.htm
  8. ^ http://www.psychjourney.com/Schizophrenia%20Among%20Blacks.htm
  9. ^ http://www.medsfree.com
  10. ^ Moynihan, Ray and Alan Cassels (2006). Selling Sickness: How the World's Biggest Pharmaceutical Companies are Turning Us All Into Patients, Nation Books.
  11. ^ http://content.karger.com/ProdukteDB/produkte.asp?doi=83999
  12. ^ http://breggin.com/Newstimulants.pdf
  13. ^ http://heall.com/holistic_psychology/toxic_psychiatry.html
  14. ^ a b http://www.publications.parliament.uk/pa/cm200405/cmselect/cmhealth/42/42.pdf
  15. ^ http://www.nofreelunch.org
  16. ^ http://observer.guardian.co.uk/uk_news/story/0,6903,1101680,00.html
  17. ^ http://www.nihcm.org/finalweb/spending2001.pdf
  18. ^ http://www.nihcm.org/finalweb/spending2001.pdf
  19. ^ http://www.camhindia.org/campaign_against_direct_ect.html
  20. ^ http://www.ect.org/sitemap/sitemap.html
  21. ^ a b http://www.vernoncoleman.com/ect12.htm
  22. ^ http://www.ect.org/news/newsday7_22.html
  23. ^ http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12642045&query_hl=6&itool=pubmed_docsum
  24. ^ http://www.healthyplace.com/Communities/Depression/ect/news/newyork/franktest.asp
  25. ^ http://www.stopshrinks.org/yoder/index.htm
  26. ^ http://ahrp.org/infomail/04/07/13.php
  27. ^ http://www.mentalhealthcommission.gov/mission.html
  28. ^ http://www.fff.org/freedom/fd0411b.asp
  29. ^ http://www.independent.org/pdf/tir/tir_05_4_szasz.pdf
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