Psychiatry is a branch of medicine. As such, psychiatrists apply the medical model to problems of emotion, thought, behavior, human relations, and living. This narrow gaze of the biomedical on problems that seem to transcend disease and disorder, brain and biology, has brought the field under severe criticism both from external commentators and from within its own ranks. Thomas Szasz, the libertarian psychiatrist, went as far as to argue that mental illness was in fact a “myth.”1 In contrast, the narrative of the history of medicine is one of technical triumphalism, with the historian Roy Porter titling his treatise on the topic The Greatest Benefit to Mankind.2
Many critics of psychiatry engage in “splitting.” They see psychiatry as an “all bad” object, mired by pseudoscience, pathologizing all of mental life, peddling quack treatments, often under coercion or control. So-called “real medicine” is idealized as the product of scientific advancement, with diagnoses and treatment precise, its diseases and treatments not influenced by sociopolitical, or economic fancy, and its practitioners portrayed as healers rather than agents of social control. Psychiatry aspires to be like the rest of medicine. Given that the problems that beleaguer psychiatry in particular, are true of medicine in general, it is a mistake to criticize psychiatry alone, and not locate it within a medical-industrial complex in need of dire reform.
Illness, Disease, and Slippery Syndromes
Many critics of psychiatry object to the use of the term ‘mental illness.’ These critics argue either that because the mind is a metaphor, it cannot be diseased (and thus conflate disease with illness), or wrongly believe the term implies such problems are biomedical in origin and warrant medical intervention.1 Illness is the subjective experience of being unwell, does not imply the existence of underlying disease, and labeling problems as illness never has led the majority of people to seek medical consultation. Medical sociologists have noted there exists an ‘illness iceberg’ whereby the majority of people in the community who identify as experiencing illness do not seek medical attention, and if they were the system would be completely overwhelmed.3 Instead, most people tend to consult a ‘lay referral system,’ seeking explanation and remedy of their problems from friends, family, and informal experts within their community, before seeking medical attention.4 Even with the creeping medicalization of everyday life and professionalization of helping, it is still the case that the majority of those who may identify as ill, ‘mental’ or otherwise, do not seek medical attention. Thus it is incorrect to state that ‘illness’ implies medicalization when it is a subjective experience that may or may not correspond with disease. Many of the individuals I see endure immense suffering and understandably see themselves as sick. I think it would be incredibly invalidating of me to say they are not ‘ill’ though they do not have disease.
The actual definition of disease is one of contention. I refer to the term disease to describe a clinical syndrome for which there is a well-described underlying pathology or pathogen. In this definition, schizophrenia, bipolar disorder, or major depression are not diseases. Alzheimer’s, vascular dementia, and frontal lobe syndrome due to traumatic brain injury do fall under this definition of disease. In other areas of medicine, it is clear that physicians cannot reach a consensus outside of infectious disease, which problems should be classified as ‘disease.’5 Epilepsy for example, in my definition could not be considered a disease. There also appear to be differences in definitions of disease between general practitioners, non-medical academics, medical academics and high school students.6
Psychiatry has rightly been criticized for the ever-expanding definition of mental illness, with the boundaries between mental health and mental illness (arbitrary as they are) becoming increasingly blurred. However this is true of medicine as well, where asthma is now diagnosed in children with minor wheezing and breathlessness, and diabetes expanded with a lower threshold of glucose level needed for the diagnosis. There is now even ‘pre-diabetes,’ a harbinger state of full-blown disease recognized as a condition.
With the increasing transparency of the body we are recognizing disease in those who are not ill. CT scans will routinely pick up lung nodules of unknown significance or early cancers in people who have no symptoms at all. These individuals are not ‘ill’ (they do not subjectively feel unwell) but through the medical gaze they do have disease, disease for which the significance may be entirely unknown and treatment cause more harm than good.
‘The medical establishment has become a threat to health.’ So begins Ivan Illich, social scientist and priest, in his book Medical Nemesis: The Expropriation of Health.7 He noted that with the professionalization of medicine, doctors had come to transform problems that were previously seen as social, moral or spiritual in nature into medical ones. In the process, physicians had created a new disease killing many: iatrogenesis. As such, medicine was doing more harm than good with the ill-conceived notion of treating problems that physicians had no business treating.
Psychiatry has particularly come under attack for transforming grief, shyness, hyperactivity, worry, and social suffering into mental disorders requiring professional intervention and quite rightly so. Given that extreme states of despair lie on a nebulous continuum with emotional states we all experience on a daily basis, it is no surprise that the mental health industry in particular has been particularly successful in increasing the range of human misery falling under its province. But it is a mistake to think that psychiatry alone is guilty of making us sick.
The menopause, once part of the normal reproductive trajectory of a woman’s life has been transformed into a sickness needing medical intervention.8 These interventions have now been shown to increase the risk of blood clots, strokes, and breast cancer. The urge to moves one’s legs about is now an increasingly diagnosed as restless leg syndrome9, and treated with drugs that can cause confusion, psychosis, dependency, or compulsive gambling. Pfizer has been successful in redefining the quality of an erection, leading many men to seek Viagra as a lifestyle pill, with the risk of blindness, deafness, and priapism.10 The American Medical Association last year voted to classify obesity as a disease, despite the evidence showing doing so is harmful by de-emphasizing the role of behavior and lifestyle in weight control. It is not by coincidence the emergence of obesity as a ‘disease’ occurred just as two new drugs for obesity appeared on the market.11 The pharmaceutical industry’s co-option of medicine neither begins nor ends with psychiatry.
Although obstetrics, a field once known as “man-midwifery” was denounced by the rest of the medical profession, today pregnancy is so entrenched in the medical model and so profitable, that the American College of Obstetrics and Gynecology continues to promote obstetric involvement in normal labor, despite the evidence that home births or midwife-led deliveries are better for uncomplicated pregnancies.12 In the same way, the American Psychiatric Association will never renounce any practice that would affect the earning of its members, regardless of the evidence base for those practices, no other professional organization in medicine or beyond would do so. Professional organizations by their very nature are self-serving. You do not bite the hand that feeds you. The profit motive has corrupted medicine and transformed it into a multi-billion dollar business – psychiatry is not the exception but the rule.
The Myth of ‘Objectivity’ in Medicine
Psychiatry by its very nature deals with subjectivity. Patients present with experiences; experiences that I can never know, nor ever see.13 The field has come under criticism for lacking objectivity, and not having blood tests or imaging or other confirmatory markers for the existence of illness or disorder. In a misguided attempt to look more scientific and objective, psychiatry has turned to the ridiculous task of looking for blood tests or biomarkers for depression and other such mental states. Quite apart from just how absurd it would be to ‘diagnose’ someone with depression or psychosis from a blood test or brain scan, the reliance on so-called objective indicators of disease is a hermeneutical nightmare. The technologization of medicine has led to spiraling healthcare costs, the devaluing of relationships and narratives, and the deskilling of doctors.14
Take the example of hypertension. This is a risk factor rather than a disease, but it is ‘objectively’ measured and thus the point at which blood pressure is considered hypertension in need of treatment should be uniform based on the scientific evidence. Yet if you live in the US and had uncomplicated hypertension, you would be treated when your blood pressure is above 150/90mmHg.15 In the UK, you would be treated if your blood pressure is above 160/100mmHg.16 What constitutes hypertension in need of treatment cannot then be based on science alone. It is constrained by interpretation, an act which itself is constrained by the surrounding social, political, and economic space.
Turning to cancer, which most people would consider a diagnosis made through objective means, the story is even more frightening. One test that has been used in the US until recently to screen for prostate cancer is the prostatic specific antigen (PSA). Screening identifies cancers in people who are not ill, do not need or benefit from diagnosis and are ultimately harmed by treatment. Overdiagnosis of prostate cancer is as high as 50% in those diagnosed with prostate cancer. In one of the largest studies of its kind involved 182000 men, 1410 men had to bee screened and 48 unnecessarily treated in order to prevent one death.17 Complications of treatment of prostate cancer routinely include impotence, urinary incontinence, and radiation proctitis. The largest study of its kind to review the effects of mammography for breast cancer found that over a 30 year period 1.3 million women were unnecessarily diagnosed and treated for breast cancer, with 70 000 women in 2008 alone unnecessarily diagnosed with breast cancer.18 Mammography routinely identifies disease in those who would never become ill (have symptoms), or where the cancer would never pose a threat to life. The use of objective tests in medicine is rife with their own problems because they need interpretation. Where there is interpretation, there is error.
Diagnostic tests in the majority of cases were never meant to ‘make’ a diagnosis but to support a diagnosis, which is made from carefully listening to the history of the illness and through physical examination. As medical practice has become more litigious and we have become more reliant on tests to make diagnoses, doctors spend less time listening to their patients, and no longer trust their clinical skills. I went into psychiatry because of the focus on subjectivity, narrative, meaning and relationships. Because these are no longer valued in medicine, they are also less valued in psychiatry.
Coercion and Control
One of the biggest criticisms of psychiatry is that ‘treatment’ often involves coercion and that psychiatrists are agents of social control. I don’t believe any meaningful treatment can occur within a coercive setting, and find it troubling how often force is used, and how comfortable psychiatrists seem to feel with its use. As a lowly intern, I found myself accused of “insubordination” for refusing to write an order for compelling intramuscular neuroleptics for a patient. Involuntary ‘treatment’ and drugging occurs far too often and is often avoidable. For almost 60 years, we have known that the organization of psychiatric units which foster an “us” and “them” mentality between patients and staff leads to inappropriate use of force and can be re-organized for the better.19 Non-hospital residential alternatives to hospitalization such as Soteria House have also successfully shown than in the majority of cases, violent behavior can be managed without recourse to coercive practices.20 Unfortunately, there do not appear to be models of care that have successfully avoided coercive practices in those who are actively dangerous to themselves or others altogether.
Some critics of coercion in psychiatry seem to ignore the reality that coercive practices occur in all of medicine, and in many occasions more often. In the institutions where I have worked, mechanical and chemical restraint of patients overwhelmingly occurs in the emergency room or medical wards, with no psychiatric involvement. Although there have been some recent studies exploring use of restraints in the medical (as opposed to psychiatric) setting, including identifying racial biases21, the use of coercion in these settings comes under far less scrutiny or study than in psychiatric settings, despite these patients not being involuntarily detained.
Similarly, physicians in all fields are agents of social control. In addition to caring for patients, physicians have the sometimes conflicting task of protecting the public. This includes determining safety to drive, fitness to care for children, and control of infectious diseases. Those who refuse treatment for TB can be detained against their will and forced to have treatment against their will or face legal repercussions.21 In the recent Ebola panic, Kaci Hicox was inappropriately quarantined in a misguided attempt to protect the public from a disease she did not have.23 In the case of the HPV vaccine for schoolgirls, Rick Perry as governor of Texas tried to force all school girls to have the vaccine, which appears to have been motivated from kickbacks he received from Merck, the makers of the vaccine.24
In the United States the overwhelming majority of psychiatrists are not involved in civil commitment or forcibly drugging their patients. For many, this facet of psychiatric practice is extremely uncomfortable. However, it is misguided to pretend that coercion does not occur in the rest of medicine, when it routinely does with less accountability than in psychiatry. We need to critically examine the use of control and coercion in all areas of medicine so that it is truly a rare occurrence and always of last resort.
The mental health industry has a lot to answer for. The psychologization of everyday life has eroded the range of human experience seen as normal, disempowered people to manage their own life challenges, professionalized helping relationships and undermined the already decaying support structures through which people found meaning and connection, stigmatized people through psychiatric labeling, led to iatrogenic misery from harmful treatments and traumatized already vulnerable individuals through excessively coercive practices. It is not because psychiatry is distinct from the rest of medicine that it has done so much damage. Rather it is precisely because it is a part of medicine and aspires to the medical model, a model that outside all but the most acute problems has been an abject failure, that it has done so. If our approach to problems of emotion, thought, behavior, human relations, and living is to be radically altered, we must take a closer look at what is wrong with medicine as a whole.
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- Szasz T. The myth of mental illness. American Psychologist 1960; 15:113-118
- Porter R. The Greatest Benefit to Mankind: A Medical History of Humanity from Antiquity to the Present. London: Fontana Press, 1999
- Hannay DR. The ‘iceberg’ of illness and ‘trivial’ consultations. Journal of the Royal College of General Practitioners 1980; 30:551-554
- Friedson E. Client control and medical practice. American Journal of Sociology 1960 65:374-382
- Smith R. In search of “non-disease”. British Medical Journal 2002; 324:883-885
- EJM Cambpell, Scadding JG, Roberts RS. The concept of disease. British Medical Journal 1979; 2:757-762
- Ilich I. Medical Nemesis: The Expropriation of Heath. London: Caldar & Boyars, 1975
- Moynihan R, Cassels A. Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All Into Patients. New York: Nation Books, 2006
- Woloshin S, Schwartz LM. Giving Legs to Restless Legs: A Case Study of How the Media Helps Make People Sick. PLoS Medicine 2006; 3: e170. doi:10.1371/journal.pmed.0030170
- Lexchin J. Bigger and Better: How Pfizer Redefined Erectile Dysfunction. PLoS Medicine 3: e132. doi:10.1371/journal.pmed.0030132
- Pollack A. A.M.A. recognizes obesity as a disease. New York Times, June 19th 2013, B1 http://www.nytimes.com/2013/06/19/business/ama-recognizes-obesity-as-a-disease.html
- Bennhold K, Saint Louis C. British Regulator Urges Home Births Over Hospitals for Uncomplicated Pregnancies New York Times, December 4th 2014, A6 http://www.nytimes.com/2014/12/04/world/british-regulator-urges-home-births-over-hospitals-for-uncomplicated-pregnancies.html?_r=0
- Laing RD. The Politics of Experience. Harmondsworth: Penguin Books, 1967
- Kleinman A. The Illness Narratives: Suffering, Healing and the Human Condition. Cambridge: Basis Books, 1988
- National Institute for Health and Clinical Excellence. Hypertension: Clinical Management of Hypertension in Adults. London: NICE, 2011
- James PA, Oparil S, Carter BL et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Reprot from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). Journal of the American Medical Association 2014; 311:507-520
- Schröder FH, Hugosson J, Roobol MJ et al. Screening and prostate-cancer mortality in a randomized European study. New England Journal of Medicine 2009; 360:1320-1328
- Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. New England Journal of Medicine 2012; 367:1998-2005
- Cameron JL, Laing RD, McGhie A. Patient and nurse; effects of environmental changes in the care of chronic schizophrenics. Lancet 1955; 269:1384-1386
- Mosher LR, Menn AZ, Vallone R, Fort D. Treatment at Soteria House: A manual for the practice of interpersonal phenomenology. 1992, unpublished monograph.
- Zun LS. A prospective study of the complication rate of use of patient restraint in the emergency department. The Journal of Emergency Medicine 2003; 24:119-124
- Centers for Disease Control and Prevention. Module 9: patient adherence to tuberculosis treatment reading material. http://www.cdc.gov/tb/education/ssmodules/module9/ss9reading6.htm (accessed 12/20/14)
- Hartcollis A, Fitzsimmons EG. Tested negative for Ebola, nurse criticizes her quarantine. New York Times, October 26th 2014, A1 http://www.nytimes.com/2014/10/26/nyregion/nurse-in-newark-tests-negative-for-ebola.html
- Colgrove J, Abiola S, Mello MM. HPV vaccination mandates – lawmaking amid political and scientific controversy. New England Journal of Medicine 2010; 363:785-791