Many readers of Mad in America are furious. The mental health system has fundamentally mistreated them—and millions of others. On that I think most, if not all, readers of Mad in America would agree. Any discussion of “reform” to at least a small number of readers is anathema. Recent comments include these:
Slaying the Dragon of Psychiatry says:
What’s the point of reforming a rotten barrel? Get rid of the thing!
Frank Blankenship says:
We don’t reform the system, we abolish it.
Tireless Fighter says:
We would know if there was reform because the mental health system and the recovery movement would no longer exist. There would be zero licensed practitioners because the government would not be allowed to issue such licenses. People would not longer be talking about healing or getting better or about recovery or rehabilitation. Instead they would be talking about the ongoing Crimes Against Humanity trials of the former mental health practitioners. We would be punishing the perpetrators, rather than further abusing the survivors.
These kinds of comments, if taken literally, seem to reflect a form of “psychiatric nihilism”—a black and white view in which psychiatry is the dark side of nothingness. No good can possibly come from it, a blot of meaninglessness that is used only to inflict harm and traumatize anyone coming into its dark web.
Maybe this view represents just a philosophical perspective and shouldn’t be taken in any literal sense other than to abolish the influence of psychiatry. And maybe it’s unfair or beside the point to ask what it would look like in the real world. But, as Tireless Fighter’s comment shows, eliminating the entire mental health system and all licensed practitioners and punishing them is a goal for some. That sounds like an attempt to change the real world to me.
Since the whole point of my blogs is to reflect on policy and practice, and because my posts almost always bring these comments, I am going to pose the question: What would it take to go about abolishing psychiatry and the mental health system? My goal is to try to shed light on whether psychiatric nihilism can actually lead anywhere. Or is it mostly something that makes people who have been so terribly harmed feel better, calmer, more self-assured?
What follows here is a description of the kinds of steps that would have to be taken to abolish psychiatry and the mental health system. They are in no way steps that I think are remotely possible. I think it will become clear that I wouldn’t advise them either. I did not put them into any kind of logical sequence. I would point out that if anyone was actually serious about taking even one of the steps, a massive planning initiative taking many years would be required. And I can assure you from my experience, no government I can imagine would ever even start on this process.
Anyone who wants to be taken seriously with the goal of abolishing psychiatry and the mental health system should share their picture of how this would be accomplished. That would be an interesting plan. Maybe I am missing something.
Here are action steps that I think would be necessary—and not even remotely feasible.
1. Close all academic training programs in psychiatry at all medical schools. This would be necessary to stop the recruitment of any new medical students into the mental health field as well as abandoning those who are currently doing residencies and fellowships. It would mean abandoning any research already underway and saving any funds left over and re-investing them in other medical school training or research programs. Neurology might be one discipline that would welcome an infusion of funding. But the reality is that closing departments of psychiatry would itself cost far more than any hoped-for savings.
2. Give termination notices to all psychiatrists employed in all community mental health programs: outpatient, resident
3. Cease operations of all psychiatric inpatient programs and discharge existing patients to the streets or to other medical units or to otherwise converted specialty units, very few of which even exist. Psychiatric patients would go back to communities which would no longer have psychiatrists—just as in all the other programs, whatever supports for short-term withdrawal would have to be assigned to other providers or peers or family members or to no one. Consideration at the state and local levels could be given to securing public funding for hundreds of Soteria House facilities and then to training staff to serve and support in this model. This would require a massive educational initiative to make state and local administrators and legislators aware of the Soteria model (a step in and of itself that would not be such a bad idea).
4. State laws would be changed to eliminate all references to psychiatrists or their current legally defined functions. This would be extremely contentious in the debate that would ensue regarding the legal issues surrounding civil and criminal court commitments. Legislators would have to be familiarized (in a way that most are not) with how people who are experiencing a mental health crisis should be handled if this process was radically altered. Decisions would have to be made around whether to abolish all civil and criminal commitment laws as well as finding alternative ways of protecting people and communities from potential harm to self or perceived threats to public safety.
5. The American Psychiatric Association and the American Academy of Community Psychiatrists would terminate themselves as organizations. Board certification procedures would be eliminated. All professional standards of care would be abolished. The Diagnostic and Statistical Manual would be abandoned along with all psychiatric diagnoses.
6. The FDA should make the prescription of psychoactive drugs (i.e., neuroleptics, “antidepressants,” “mood stabilizers,” ADHD drugs, and benzodiazepines) illegal and punishable by severe fines.
7. All academic and educational programs from undergraduate to graduate level would cease their training programs in which psychiatric treatment is any kind of a conceptual framework.
8. All psychiatric-related positions in all programs—inpatient, residential, outpatient, local jails and correctional facilities—would be terminated or otherwise restructured. Human resource departments would rewrite all position descriptions and other staff would need to be retrained to handle mental health challenges in the new non-system.
These changes are of such magnitude that a planning process, if it was taken seriously (and it would not be), would take many years and yield endless reports because this is obviously a complete re-conceptualization of how mental health challenges would be handled. It would require a complete overhaul of how any remaining supports and services would be funded, and how entirely new training programs would be created.
I can guarantee that this would bring lobbyists from every profession (not just psychiatry) and every pharmaceutical corporation out of the woodwork. No legislator would touch it with a one-hundred-foot pole.
As I stated earlier, if those who want to abolish psychiatry and the mental health system have better plans to accomplish this, I think it would be extremely interesting to see their alternatives to what I’ve outlined. In the meantime, it would seem fairly meaningless to talk about abolishing psychiatry or the mental health system. It may make some feel good in some way but fantasies of this nature have never led anywhere in the real world.
I for one will continue to seek ways to reform and not abolish the system.