“It’s a fair cop. But society is to blame.” — Monty Python
For the last forty years, psychiatry has been comprehensively critiqued from a myriad of disciplines including sociology, psychology, and the user movement.
But how do these criticisms hold up from the perspective of a psychiatrist working in the public system? Is there anything that can be salvaged from the psychiatry project? Indeed, would it be better, as many have argued, if psychiatrists were voted off the island altogether so other practitioners can more effectively help those with broken minds?
I propose that critiquing biological psychiatry is a straw man — albeit reinforced with concrete — as it is but one player in the crowded mental health industrial complex that involves culture, economics, government bureaucracy, the pharmaceutical industry and patients.
But first it is necessary to understand the niche psychiatry occupies in the medical establishment, which is underwhelming to say the least. Other medical specialists tend to see psychiatry as wooly, unscientific, “not proper medicine” and, most perniciously, an easy way out from the more arduous and exacting training of other specialties.
This leads to at least two reactions in psychiatrists. The first is to go on the front foot, proclaim the speciality as a subfield of neurology and be preoccupied by genetics, neurotransmitters and medication. The second group embrace this stigmatised role as an echo of the outsider status of psychiatric patients and take a more psycho-social stance around treatment.
It is important to note that both approaches accept, prima facie, the reality of ‘mental illness’.
Pulling back further, we can see that diagnoses, far from being “objective” or “carved at the joints of nature,” in fact follow socio-cultural changes. How else can we explain the ballooning of the American DSM classification of mental illnesses from 24 in 1978 to 265 currently? Alas, this increase is not the result of new discoveries of candidate genes or biomarkers. More likely it is the marketplace haggling between key opinion leaders, patient advocate groups, pharmaceutical and insurance companies and the cultural tides of the day. We are all now familiar with chronic pain, fibromyalgia, gender dysphoria, and social anxiety, yet these entities did not exist in the early 1980s. If we go further back we notice the complete disappearance of common disorders in their time. One would be hard-pressed to find a case of hysteria now — the diagnosis de jour in the late 19th century — or perhaps neurasthenia, the condition of indolence and lethargy that afflicted the middle classes in the last century. Lest those examples seem too obscure, how about homosexuality which only exited as a psychiatric diagnosis in 1987?
Far from being universal and objective, psychiatric diagnoses are cultural products moulded by the societal forces at the time. To take one final example: unlike the DSM, the ICD is a committee with representatives from 55 countries. In the most recent version of their classification, they found no evidence for the inclusion of narcissistic personality disorder which by stark contrast is firmly accepted as a common clinical entity in the Western world.
So if cultural mores affect psychiatric diagnoses, what about macro-economics? Is it a coincidence that the neoliberal project which started flowering particularly in the US and UK in the 1980s also saw the spectacular rise of psychiatric diagnoses? One could see that this emphasis on the individual as a discrete self-interested actor in the marketplace could have caused an epistemological shift in people where the seismic shifts in unemployment, government spending and income inequality were transmuted into private concerns, and the agony of anomie recast as disorders of the brain. Systemic, group and family therapies were jettisoned in favour of individualised, time-limited, data-driven (insurance approved!) manualised psychological treatments like CBT, solution-focussed therapy and positive psychology. Medications were matched to individual diagnoses, marketing slogans developed (“chemical balance”) and unscientific “screening” questionnaires distributed to general practitioners.
Voila — the mental health epidemic!
Does this mean mental illnesses don’t exist? Surely this isn’t a tired rehash of iconoclasts from the 60s like Szasz, Laing, Foucault, et al? Are you saying that people aren’t suffering?
Now we are on treacherous territory and I have to tread carefully. When I trained in the 1990s, schizophrenia, manic depression (reclassified as bipolar affective disorder) and severe depression were rare conditions that needed extended hospitalisation. But now the incidence of these diagnoses are rising exponentially in only a couple of decades, which rules out biological causes as genetic change moves at a far more glacial pace. By having de-contextualised checklist diagnoses, the boundaries have loosened appreciably.
Lethargic and feeling hopeless after you were retrenched when your company relocated? That’s major depression! Feeling inexplicably angry and at other times anxious because of your zero hours contract? Don’t worry, it’s bipolar disorder! Feeling like you need to stay at home and avoid people as the government subjects you to humiliating disability assessments and sends private investigators to check if you are not faking? Not a problem — a clear case of social anxiety disorder!
But not everyone gets a prize in the Psychiatric Kingdom. Those unfortunate enough to have addictions or personality disorders are chucked outside the castle gates, the stigmatised of the stigmatised; unwilling scapegoats of a system that needs to have some boundaries lest everyone have a disorder.
But surely the government can ensure there is no skullduggery as it is not, in theory, beholden to vested interests. The state is, however, preoccupied by risk and it delegates the management of this to the criminal justice system and, increasingly, psychiatry. That is why, should you have the misfortune to attend a psychiatric emergency department, you will be subjected to a lengthy risk assessment. Never mind that violent and suicidal acts are rare (incidence rate of suicide is 0.01%) and the predictive power of a psychiatrist’s risk assessment is the same as a member of the public. But, and this is a big but, should a patient harm someone or kill themselves after assessment, the psychiatrist will face serious professional and personal jeopardy; he will have to write a report, be subject to a chastening internal investigation and if relatives are aggrieved be cross-examined in a Coroners’ Court. To avoid this terrible fate, many psychiatrists will section a patient who says they are suicidal. In this scenario the patient is subject to a traumatic incarceration, all in the service of this bureaucratic shadow play.
The mental illness landscape, to a large extent, has had a hostile takeover from Big Pharma. They own the peer-reviewed academic journals, they own the key opinion leaders, they sponsor conferences and sweeten GPs and psychiatrists with sandwiches and gaudy ballpoint pens. They manage to get their drugs through regulatory bodies despite trials lasting often no more than four weeks and no long-term data on adverse effects. Read any of the established psychiatric journals now and you will notice a plethora of brain imaging and neurochemical research which reinforces the dominant on-brand message about treating mental illness with medication. Shamefully, for a psychiatrist to truly know how a drug is affecting his patient he needs to consult patient websites like Inner Compass or Surviving Antidepressants. It is the bottom-up advocacy groups that have alerted doctors and public alike to the manifold dangers of psychotropics.
And finally, on to the patient, user, survivor, client. Surprisingly, perhaps, the caricature of the disempowered patient kowtowing to a prescription-pad-wielding authoritarian expert psychiatrist is only a partial picture. Far away from the eloquent critiques of Mad in America, one is as likely to have a patient requesting to be diagnosed or to start a new medication. The matrix has done its job. Often a patient feels bitterly disappointed if he has left the psychiatrist’s office without a diagnosis or prescription. Solitary misery is painful, and wouldn’t you want your pain assuaged by society’s legal drug dealer?
So how would a psychiatrist practice ethically in such a nefarious environment?
Firstly, I believe she should realise that the psychiatric gods have feet of clay and the mental health industry serves the mores of the current socio-cultural-economic structures rather than the individual. Fundamentally, the abiding principle should be to do no harm. This is manifestly complex and involves many judgments about best interests, patient autonomy and the right of a person to make both wise and unwise decisions. For example, is it right to withhold a numbing addictive medication for someone who is in deep despair and wanting something to be done? Should the psychiatrist write the supporting letter for a disability pension acknowledging that the patient is not fit to take part in the circus to find ever more vanishing jobs, but at the same time risking that the patient sees himself as defective and existing outside of mainstream society?
And so, in the final analysis, a solution of sorts is to keep questioning in the spirit of not-knowing — crucially, in collaboration with the patient and his family.
It may be true that the house always wins, but that only applies if you choose to cross the threshold and enter the casino.