An ever-growing number of people are aware that something’s horrendously wrong with psychiatry — survivors, families, professionals, psychiatrists themselves. Of these a subsection has become actively involved in trying to bring about change. All of which is good. This notwithstanding, sincere and dedicated though almost everyone is — and it is clear that people are — only a tiny percentage of these are pressing for anything truly transformative (something beyond the humanistic correctives or additions typically called “reform”).
Without question, what people are advocating is of enormous importance. For example, for the most part reformers take seriously the deprivation of human liberty and the reductionism that characterizes psychiatry — and yet somehow they fall short of letting go of either the paradigm or the practice. What do people call for? They want less incarceration, but are not asking it be stopped. By the same token, people call for less drugging, while accepting that doctors will continue to prescribe psychiatric drugs. Most want to eliminate certain of the diagnoses, while holding tenaciously to others (e.g., Horwitz, 2002).
For obvious reasons — and who could argue with this? — the majority stipulate that there must be free and informed consent — but not for everyone and, even at that, there is little evidence that people are giving much thought to how such a thing would be possible with anything even vaguely resembling the institution as we know it. The vast majority favour a major expansion of humanistic services such as counseling and housing as well the introduction of voluntary outreach services wherein helpers turn up at people’s homes to assist with crises — good in itself, however, once again while leaving biological/institutional psychiatry relatively in tact.
What goes along with this, they want a team approach, with psychiatry only one member of that team. Albeit, of course, there are variations here and there, and some reformers go considerably further than others, here basically is the reformist position. Now I am in no way questioning the intentions or the soundness of many aspects of the position. There are a number of problems with it, however, not the least of which is the fact of leaving institutional psychiatry in tact — the elephant, as it were, in the room.
Underpinning the reformist stance, whether it is expressed or not, is the contention that psychiatry has something to offer, is worth retaining, moreover, that to do otherwise is reckless. Allen Frances (2014), by way of example, refers to antipsychiatry activists as “blind ideologues” and talks as if it were an indisputable fact that there is “good” and “bad” in psychiatry. His solution, correspondingly, is for the sensible people—the “moderates”—to join together to create the reforms needed (see Frances, 2014).
How is it that the situation gets viewed this way? Obviously there is no simple answer to this question for reformers differ from one another. Of survivors who are reformers, some are reluctant to phase out psychiatry because they feel that they themselves or people they know have benefited from the “services”. Many professionals are likewise so convinced. Professionals, including ones that courageously challenge their own profession, additionally, have vested interests that willy-nilly come into play. Then there is the more general problem: that we all us have difficulty thinking very far beyond what currently exists, never mind trusting anything substantially outside the current frame. The point here is, changes that are revolutionary inherently strike us as immoderate or to use Allen Frances’s word “extreme”. All understandable. Nonetheless, let me suggest that the reformist position begs the question.
The purpose of this article is to problematize the reformist stance and the beliefs and tendencies underpinning it. I begin by problematizing the biases surrounding the concept of moderation. I go on to theorize why something more substantial is called for. The article culminates in an investigation of some uncomfortable truths about the profession, the reality of the various industry interests, and what history has to teach us.
Thinking Beyond “Moderation”
As a species, we have a tendency to think that moderation is always and inevitably best (hence the “middle way” in Buddhism, balance in Aboriginal thought, and the golden mean in Aristotle). Without question, this bias frequently serves us well. I put it to the reader that there are times, nonetheless, when the concept is inapplicable and/or where emancipatory principles dictate a pronouncedly different course of action.
For example, would we really want to embrace a middle way between murder or rape on one hand, and respecting the bodily integrity of others on the other? And more pointedly, what would have befallen the major liberatory advances in history had visionaries bowed to the imperative to be moderate? Take the institution of slavery. We would have far more people enslaved today if we automatically assumed that the ostensibly “extreme” position — actually abolishing slavery (as opposed to, say, “humanizing” it or resorting to it less often) — was a reckless and otherwise unwise thing to do. And note, abolition did indeed look reckless to the “moderates.”
What is clear, in other words, is that what seems like “sensible moderation” seems that way from a particular vantage point and what strikes the average person as moderation, as such, is hardly unassailable. That said, the question arises: Under what circumstances is abolition a more sensible course of action than reform? While this of course is a complex issue, let me suggest that viable indicators are: 1) when the practice in question overwhelmingly harms people, and 2) when it is inherently oppressive. Auxiliary indicators — and these too can legitimately enter in and in certain cases be pivotal — are when its foundational tenets have repeatedly been demonstrated to be fallacious; also, when it is backed by a massive industry that by hook or by crook is intent in maintaining the status quo or worse. Lest readers have not as yet noticed, all of the above pertains to psychiatry.
To begin with the first two, touching quickly on the incarceral and control mission (and it is a historical accident that psychiatry is in charge of this), it is clear that substantially depriving people of freedom and control is personally hurtful, however small the numbers and whatever the rationale. Nor is the alleged ‘dangerousness” an acceptable rationale, for there is no evidence that the “mentally ill” are any more dangerous than the average person. To be clear, it goes without saying that people should be stopped from harming others, whether or not the “transgressors” are deemed “mentally ill,” that actions must have consequences, that there are moments when figuring out how to enhance an individual’s safety is far from easy.
At the same time, as peacemaking criminologists (e.g., Pepinsky and Quinney, 1991), and critical disability theorists (e.g., Ben Moishe, Chapman, and Carey, 2014) have so cogently argued, a regimen of imprisonment and control is at once injurious, of dubious value in enhancing the safety of anyone, and is morally unacceptable. To turn to the “treatments” per se, as documented by critics like Breggin (1991), the “treatments” overwhelmingly damage people. That is, they give rise to actual brain damage, result in disorders such as tardive dyskinesia, and horrific conditions such as memory and cognitive impairment.
While reformers want to make exceptions for categories like schizophrenia, suggesting that in such cases “treatment” is necessary, I would add that studies clearly establish that mainstream convictions to the contrary, “schizophrenics” never, once on the drugs, fare better in the long run than any other group of “schizophrenics” (see Harrow, 2007 and Rappaport, 1978). In other words, even when it seems as if the opposite were transpiring, everyone is being harmed.
The inherent oppressiveness of psychiatry, additionally, is common knowledge among survivors and reformers alike, though one need only look at the classical signs of oppression to realize that it permeates the industry—the daily coercion, the incarceration, the surveillance and control, the targeting of the “genderized” and the “racialized”, the us-them division, the very use of concepts like “normal” (for details on how such ruling plays out, see Burstow, 2015). Nor would moderating this element eliminate the oppressiveness at the core.
To proceed to this next indicator — and I would suggest this is pivotal — we are blatantly dealing with faulty foundations. The point is that the basic psychiatric concepts and tenets have no validity either empirically or conceptually. In this regard, as researchers like Breggin (1991) and Colbert (2001) have repeatedly demonstrated, there is no proof whatever that any of the so-called “mental illnesses” are bone fide diseases. Nor do concepts like “mental illness” hold up to scrutiny. As Szasz (1961) so adroitly put it years ago, irrespective of whether or not people are floundering, it is a category confusion to call ways of thinking and acting per se a disease.
In essence, a medical overlay is but being slipped over distressed or distressing ways of thinking and acting. This being the case, it is no accident that the treatments profoundly harm. Treat people for non-existent diseases, “correct” imbalances that exist nowhere except in psychiatric credo, and you necessarily create real imbalances and in the process do untold harm. Herein the very nature of medicine — what it is and what it does — is all-important. Note, in the vast majority of disciplines and professions, the invalidity of the basic tenets would not in and of itself necessitate abolition or even always make it desirable. It is precisely because invalidity and inevitable harm come together in psychiatry that abolition is critical.
Before I proceed to the other indicators, I would pause to touch on some of the objections likely to be posed to my points to date. The first is that there are “extreme cases” where psychiatry is needed. Let me suggest, the fact of people being in terrible straits in no way makes something medical when it otherwise is not. If there is no disease, no matter how dire the problem, treating a person as if they had a disease and thereby harming them cannot be acceptable. Equally unacceptable, I would add, is the handling of misery and conflict by resorting to incarceration, surveillance, or control.
A second commonplace type of objection is predicated on the understandable belief that a plethora of services should be available — and so why not psychiatry? — especially seeing as so many people favour the drugs. A quick response is that the state should not be involved in injuring people, irrespective of whether or not doing so is called “services.” Moreover, it is blatantly unethical to present and/or promote something as is if it were a medical treatment in the total absence of medical validity. Nor is it the case that the elimination of psychiatry would narrow the options available. In point of fact, given the amount of money spent on psychiatry and the promotion thereof, eliminate psychiatry from the picture, and — presto — there would be ample resources to make a plethora of options available. Additionally, note, abolition does not require that people be denied access to psychopharmaceutical drugs — only that they not be approached as if medical, not promoted, and not prescribed by doctors.
A final objection that I would touch on is predicated precisely on faith of how far a reform agenda can transform psychiatry. The contention here would be that in the world brought about by a reform agenda, there would be no reason to get rid of psychiatry for it would just be one of many disciplines that converge on the territory. Additionally, psychiatry would itself be reformed, with psychiatrists for the most part providing counseling or other such supportive services.
Tackling the first part of this objection brings to the fore the whole issue of power and of discourse. Hypothetically, we have a team approach now, but set foot in any hospital and it is clear that one player and one position dominates. Nor do words like “dialogue” alter the situation. The point is that even with benign intentions, dialogue can only go so far for the terms of the dialogue are already set/constrained by the psychiatric paradigm. To varying degrees, the same may be said of reform within psychiatry. What is equally fundamental, there are structural realities, vested interests, and contradictions at play that we gloss over to our peril.
A crucial factor being ignored here is that medicine is a bad fit, indeed a misfit insofar the direction sought is non-medical (nor are most medical people likely to excel at it). Correspondingly, there is a palpable danger involved in entrusting this direction, or indeed, any part of it, to psychiatry. Whatever might transpire in the short run—and of course there are individual psychiatrists who are trustworthy —why would we think that in the long run psychiatry (translation: institutional agents whose very profession is posited on emotional problems being medical) are likely to give up or even substantially qualify what, in essence, is the sole basis of their profession?
If the point being made seems confusing, look systemically at what we are dealing with here. Aside from the power attributed to it, this profession is distinguishable from others such as psychology by one sizable dimension only—the insistence on the medical. By the same token, look at what prepares psychiatrists for the tasks ahead. Psychiatrists in-the-making are people who take extensive training in medicine as if such problems in living were bone fide medical issues. Indeed, even at the residency stage, they rotate between the various medical specialties—biology, anatomy, and so forth—before they even approach “psychiatry” per se. Even were more counseling training added to the mix, the point is it remains part of the faculty of medicine, remains a “medical discipline”, and, indeed, is theorized and taught as such, with all the baggage which that entails.
That said, let us look more closely at this institution. Insupportable though the medical conceptualization is, psychiatry is “medicalized” through and through. Note, it is presided over by “doctors”; it is assisted by “nurses”; and its pivotal work happens in places called “hospitals.” Correspondingly, it specializes in the use of substances defined as medical; and its discourse is medically framed (witness, in this regard, the prevalence of terms like “pathology,” “disorder,” “symptom”). Whatever psychosocial factors are added on, being “medical” — as it were — is its defining feature. Which brings us to some key structural issues: To whit: In the long run, how could be in the interests of a medical institution to support any substantial de-medicalization — given medicine is precisely the ground on which it stands? By the same token, in the long run how could it be in psychiatry’s interests to give up what the profession has spent centuries solidifying — their command over the “madness turf”? Which is not to say that individual psychiatrists are not sincere about demedicalizing, or the profession as a whole might not be willing to entertain such directions at a moment of crisis.
What happens in a crisis and what will be supported long term, however, is a different matter altogether. Bottom line: In the long run, it simply is not in psychiatry’s interests to demedicalize, decentre itself, or stop expanding. What adds to the conundrum, while all institutions to varying degrees pursue their own interest, history teaches us that discourses about care notwithstanding—medicalization, dominance, and expansion has been overwhelmingly what the institution of the psychiatry is about. This is the profession that historically drove out all competitors—the astrologers, the women healers, for example. This is the profession that sought and gained police powers. And this is the profession/industry that has been intent on declaring ever more people “mentally ill” (for details, see Conrad and Schneider, 1984).
What relates to this, from a business point of view (and psychiatry is nothing if not a series of interrelated businesses), it is obvious that what we are dealing with is a massive industry, all parts of which have self interests. Correspondingly — and again, we lose sight of this to our peril — all of these parts are not simply incompatible with but dramatically pull in the opposite direction than the reform agenda. By way of example, the interest of the psychiatric research industry is to continue expanding on one hand and satisfying its funders on the other (that is, producing ever more research studies and research results which in some way promote the prevalent treatments and agendas). By the same token, the interest of the shock industry is the continuation and spread of ECT. Of these industries, of course, none is more formidable that the pharmaceutical industry.
Profit transparently drives the pharmaceutical industry. And significantly, reform of the type envisioned will willy-nilly hurt pharmaceutical profits, in other words, transparently conflicts with Big Pharma’s interest. (The fact that progressive psychiatrists would like to see less drugs used, I would add, is beside the point). A demedicalizing of the area doubly conflicts with psychiatry’s interest for, as demonstrated by researchers such as Whitaker (2002 and 2010), psychiatry itself is utterly dependent on pharmaceutical funding for their massive research projects, their publications, their educational endeavours. To put this another way, psychiatry needs the multinational pharmaceutical industry. Ergo, anything that hurts that industry hurts psychiatry. Indeed, at this juncture, the very existence of psychiatry is dependent on the pharmaceutical industry; and as such, as the professional elite are well aware, breaking with this industry in any substantial way would be the proverbial kiss of death. The upshot? Despite how individual psychiatrists may proceed, this is not now, and short of a new somaticizing benefactor materializing, cannot be the ultimate direction of the profession.
In short, besides that psychiatry is foundationless and by its nature harms, we cannot arrive at a better dispensation in the long run if psychiatry is included—not even a new and improved psychiatry. We cannot because it undermines the very raison d’etre of the profession. We cannot, ultimately, because it is not in psychiatry’s interest, not in the interests, that is, of the profession, the industry, or the myriad of industries surrounding it. What likewise needs to be factored in, biological psychiatry has a long history of reasserting dominance, whatever seemingly benign turns are taken in the short run, for it does not for long lose sight of where its interests lie. In this respect, we have, as it were, “been there and done that” already—and the outcome was anything but reassuring. A lesson from history:
There was a moment in “modern” psychiatric history where the relentless push to medicalize and to dominate indeed appeared to be curtailed, and beyond that, substantially reversed. This was with the spread of psychoanalysis and the concomitant rise of the talk therapies. Freudian psychoanalysis was so successful as a movement (however one may judge its tenets and practice) that throughout North America it changed the face of psychiatry, bringing the psychological as opposed to the medical to the fore. What is additionally apropos, Freud opened up psychoanalysis to non-medical therapists — which itself helped give rise to the spread of a huge variety of talk therapies and this by “lay” practitioners of various types — psychologists, social workers.
Correspondingly, increasingly, despite obvious limitations, the agenda was humanist with various new and creative way of working with people imagined. The parallels with what is being sought today are obvious. Then a huge reversal set in. While the full story is too complicated to go into here, the salient point is that demedicalization was not in the interest of psychiatry, and beyond that, what became progressively obvious to the psychiatric elite is that their interest, on the contrary, lay in medicalizing to a point beyond anything heretofore imagined.
Hence the unprecedented surge of biological psychiatry and the advent of the highly medicalized DSM-III (transparently “medical” despite the claim to being etiology-free). Hence the declaration that “mental illnesses” were “brain diseases” (e.g., Andreason, 1984). And hence the alliance between psychiatry and the drug companies and the advent of what is euphemistically called “the drug revolution.” All of which was possible, note, because institutional psychiatry had never in any way been dismantled.
Now to be clear, it is not just that the ground gained was lost. The situation which materialized was exponentially worse than what had preceded psychoanalysis, for everything became grist for biologizing agenda — even the psychoanalytical categories themselves. You can get a quick sense of how this transpired by looking at what happened with the “neurotic complaints” (originally spearheaded by the analysts). It is not that these were thrown out by biological psychiatry. Along with the various “psychoses” and the various other biological inventions, they were given a biological frame and added to the mix — with the result being an exponential growth in the number of “mental disorders” in DSM-III and, in essence, the pathologization of everyday life. (To trace this development, see Kirk and Kutchins, 1997)
Now it might be argued that what happened here arose from a unique concatenation of circumstances, and as such, liberal reform is not doomed to fail. While logically that is true, I would remind readers that a similar dynamic played out centuries earlier, after the rise of “moral management” — the one other time in history that a type of demedicalization had set in. Note, moral management involved approaching problems in living as spiritual issues. This, in essence, was the “reform” agenda of the 18th century. It being nonmedical in nature, not only the mad doctors but also lay people practiced it — the most notable being the Quakers (see Tuke, 1813/1996) — a phenomenon that was widely accepted.
What happened? The direction being pursued was hardly in psychiatry’s interest, and not coincidentally, the Quakers were considerably better at it. Accordingly, over time moral management gave way to the meteoric rise of biologically oriented psychiatry, the routing of lay people, and ultimately to the birth of the eugenics era.
In this as in a microscope, we can see the problem with non-foundational reform. It is not that there are no good tenets or good people involved. Indeed there are. Correspondingly, it is not that progressive psychiatrists have no role to play in the initial stages of a transformational process, for again, they do. However, in refusing to take seriously both the nature and the self-interestedness of the profession, reform (as opposed to revolution) leaves in tact an inherently problematic institution, legitimizes rule by “expert,” and paves the way for a return of biologism and of oppression with a vengeance.
And as such, liberal conceptualizations like “mental health reform” do not and cannot serve us well.
In ending, I would reiterate that we are currently at one of those crossroads in history. To varying degrees, people are aware that our “solutions” are backfiring. Survivors are vocal about wanting something different. The general public minimally suspects that something is horrendously wrong. “Helpers” from other disciplines are commonly in dismay. And progressively, psychiatrists are sensing that the institution is in a crisis. Indeed, with the rampant spread of iatrogenic diseases, society itself is in crisis. A terrible reality on one hand, for it bespeaks the harm being done, but a rare opportunity on the other, for crises are precisely the time when real change is possible. As a society, this is the time to be absolutely clear what we are about, for the opportunity for fundamental change does not come often; and it would be a shame to squander the moment. Do we tinker with the “mental health system”, adding more humane services, while retaining psychiatry? Or do we adopt an abolitionist agenda — that is, slowly break with psychiatry and co-construct a whole new approach to problems in living and, indeed, how we-are-with-one-another?
As you ponder this, I would invite readers to consider: What kind of world would you like to bequeath to future generations? — To your great grandchildren? To people seven generations hence? Ultimately, who should be in charge of society’s needs — the community as a whole (that is, each of us together) or stated-sanctioned “experts” and mega-industries? Who wins and who loses if psychiatric rule continues? And finally, if tempted to speak of “paradigm shift” and psychiatry in one breath, in the words of Black feminist Audre Lorde, (1984), when in social change history have we ever known the “master’s tools” to “dismantle the master’s house”?
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For this and other articles on this issue, see: http://www.bizomadness.blogspot.ca. For detailed elaboration of dimensions touched on in the article, including a visioning of services in a transformed society, see Burstow, 2015.
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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.