Why Is Psychiatry So Defensive About Criticism?

INTRODUCTION

On January 6, 2022, Awais Aftab, MD, a psychiatrist and clinical professor at Case Western, published a piece in Psychiatric Times.  The title is It’s Time for Us to Stop Being So Defensive About Criticisms of Psychiatry.

Dr. Aftab’s paper is essentially a response to another paper, published also in Psychiatric Times.  This latter paper is titled It’s Time For Us To Stop Waffling About Psychiatry, by Daniel Morehead, MD, director of training for the general psychiatry residency at Tufts.  Dr. Morehead acknowledged the generous assistance he received from Ronald Pies, MD, in the writing of the article.

This is all a bit complicated.  But the gist is this:  Dr. Morehead wrote a piece condemning psychiatry’s critics.  Dr. Aftab responds by suggesting a more moderate approach, and expressing the opinion that “…we need to reconceptualize psychiatry’s relationship with critique in a more productive manner.”

And although Dr. Aftab’s call for moderation sounds positive and conciliatory, and he certainly avoids the overt vituperation of Dr. Morehead’s piece, he also clings to an image of psychiatry that is not, in my experience, in line with the theoretical and practical realities that actually underpin and drive modern psychiatry, with its profusion of profound failures and ongoing errors.

SO LET’S TAKE A LOOK

Here are some quotes from Dr. Aftab’s paper, interspersed with my observations and opinions.

“Dr Morehead and I agree about a lot of things: the fundamental legitimacy of psychiatry as a branch of medicine; the essential role psychiatry has to play in the treatment of mental health problems; that a defense of psychiatry is warranted against egregious and misplaced criticisms; and that the value of psychiatry must be conveyed to legislators, insurers, and the general public.”

Dr. Aftab’s contentions in this quote are essentially unproven – and probably unprovable – platitudes.  He is apparently expressing some of his own core beliefs on these matters.

For instance, he asserts “the fundamental legitimacy of psychiatry as a branch of medicine”.  If by this statement he means that the various psychiatry schools have been granted the appropriate state charters and have passed the various inspections for quality of teaching, etc., then of course, he’s correct.  But that’s not what critics have in mind when they challenge psychiatry on this particular issue.  What’s at stake here is not the successful completion of various bureaucratic expectations, but rather whether the subject matter of psychiatry is sufficiently tangible, coherent and valid to constitute a reliably definable and teachable body of thought, and whether this body of thought has been demonstrated effective in the amelioration of real illnesses.  Academic and professional legitimacy are not things that can be conjured up by committees to fit the mood of the moment or to obscure deep-seated societal problems, such as poverty, inequality, discrimination, unemployment, racism, substandard housing, child abuse/neglect, etc.

He also mentions “the essential role that psychiatry has to play in the treatment of mental health problems”.  What’s particularly interesting here is that Dr. Aftab apparently can’t even imagine a world without psychiatry (“the essential role that psychiatry has to play”), and seems entirely unmoved by the fact that many of psychiatry’s critics can.

Dr. Aftab also contends that “a defense of psychiatry is warranted against egregious and misplaced criticisms”.  This assertion is largely tautologous, in that the adjectives “egregious” and “misplaced” entail the notion that the criticisms should be challenged.

So we are left with his notion that “the value of psychiatry must be conveyed to legislators, insurers, and the general public” which of course, begs the question why?  If psychiatry had genuine value, wouldn’t these individuals be aware of this, and wouldn’t targeting them in the manner mentioned be a waste of time?  On the other hand, if legislators, insurers, and the general public are not persuaded on the value of psychiatry, doesn’t this suggest that psychiatry has some deep-rooted problems?  After all, there are no other medical professions (and with regards to psychiatry, I use the term loosely) about which legislators, insurers, and the general public entertain these kinds of misgivings, at least not to the best of my knowledge.

. . . . . . . . . . . . . . . .

“Psychiatry is a profession with a rich intellectual history…” 

This history, incidentally, includes the Bethlehem hospital in London, where townfolk were encouraged to visit the facility for the price of a few pence, and be “entertained” by the antics of the “lunatics” who were housed there in appalling conditions.  Other “treatments” used in psychiatry’s “rich intellectual history” include:  fever therapy, including malaria therapy; insulin coma therapy; the tranquilizing chair; the Utica crib; lobotomy; deep sleep therapy; rotational therapy; hydrotherapy, including ice baths; mesmerism; chemically induced seizures; high voltage electric shocks to the brain, etc..

“… that exemplifies some of the best of what medicine has to offer.”

To which I can only shake my head and wonder where in the world Dr. Aftab has been spending his time.

Is Dr. Aftab not aware that unlike real medical specialists, who painstakingly, and through years of study, discover their illnesses in nature, psychiatry dispenses with this tiresome formality, and simply makes them up to fit the fashions of the hour?  All that’s needed is a vote of the APA’s DSM committee, as if nature has the slightest interest in majority rule.  And besides, I know of no psychiatric breakthrough that can hold a candle to smallpox vaccination, the discovery of penicillin, or the successful transplantation of a kidney or liver.

. . . . . . . . . . . . . . . .

“There are understandable reasons psychiatry is scrutinized way more than other medical specialties. It, for instance, exercises social control over the lives of individuals under its care to a degree exercised by no other specialty; it is subject to more value disagreements; it has to work across multiple disciplines and perspectives that are difficult to integrate; it has a tumultuous historical legacy; the state of scientific development is still comparatively rudimentary; and it deals with conditions that are stigmatized and poorly understood, etc.”   

Let’s open up this paragraph.

“It [psychiatry]…exercises social control over the lives of individuals under its care to a degree exercised by no other specialty;”

This is indeed true.  Hearings for civil commitments to mental hospitals are largely rubber-stamp formalities, sometimes held within the “hospital” itself.  “Patients” are assigned a lawyer whom they typically meet for just a few minutes before the hearing.  Many patients agree to sign in voluntarily because the odds of them prevailing in the legal arena are miniscule.  But in many jurisdictions, once committed, they can’t revoke their voluntary agreement.  They can only be released when and if the hospital authorities declare them fit to be released.  As a legal process, it is a farce.  But what’s particularly important here is that psychiatry was never forced to assume this role.  Rather, they willingly embraced it and considered it an integral part of the management of the asylums, and of psychiatric “treatment”.

“…it [psychiatry] has a tumultuous historical legacy;”

I would say that psychiatry’s historical legacy has not been particularly tumultuous.  I would describe it as cruel, unusual, and designed to break people’s spirits.  The old asylums were little more than torture chambers in which the welfare of the “patients” was often subordinated to the ambitions, whims and prejudices of their keepers.  Apart from those institutions that embraced moral treatment philosophy and practice, the asylums could claim little in the way of efficacy or even the very basic regard for human rights.

“…and it [psychiatry] deals with conditions that are stigmatized and poorly understood, etc.”

This assertion is difficult to reconcile with the glowing self-promotion that one finds on websites of prominent psychiatric institutions and other pro-psychiatry groups, which convey the impression that the root causes of “mental illnesses” are well understood, and that any stigma associated with these “illnesses” is a function of the reckless claims from the anti-psychiatry movement.  This notion is pushed hard within the context of psychiatry’s “rich intellectual history”, even though the evidence has long indicated that it is the avid promotion of mental illnesses as neurochemical imbalances that has been the major source of stigma. [Angermeyer, MC, et al (2018); Lee, AA, et al (2013); Read J, et al 2006; Deacon, BJ (2013)]

. . . . . . . . . . . . . . . .

“These and other factors ensure that psychiatry will be under the spotlight (just as we can expect that the police force will almost always be more scrutinized than the postal service). This additional scrutiny intersects with disorder within psychiatry’s own house, giving critics plenty of flammable material to work with. Even problems that are pervasive across all of medicine—such as industry influence and corruption of evidence-based medicine—become more noticeable in the context of psychiatry thanks to the additional scrutiny.³ There are also too many ‘unhappy customers’ when it comes to psychiatry, so to speak: recipients of psychiatric care who have been left traumatized, disenchanted, even devastated by their experiences. There has been [a] tendency within the profession to not take such individuals seriously, at least not without being forced to do so.”

So, Dr. Aftab tells us, there is “disorder” within psychiatry, which gives critics plenty of “flammable material to work with”.  This is nice imagery, of course, but when reduced to plain prose, it simply means that there are problems within psychiatric practice which provide critics with ample opportunity and legitimate incentive to criticize.  If there is “disorder” in a medical profession, then it is right and proper that this should be identified and corrected.  But Dr. Aftab’s imagery subtly shifts the blame for this to the critics, who are portrayed as mischievous searchers for “flammable material to work with”.

It is a fairly common experience in society that individuals who don’t clean up their own acts will, sooner or later, have someone come along and clean them up for them.  And this is exactly what’s happening to psychiatry.  For decades they have wallowed in spurious science and corruption, and have blatantly lied to their customers concerning the nature of their problems, and the efficacy of the treatments.  There were, and still are, occasional dissenters, but the majority of psychiatrists went along with the illness ruse, the routine 15-minute med-checks, and the pill-for-every-ill that collectively came to constitute established psychiatric practice.  And now the anti-psychiatry movement is calling them out, demanding proofs of efficacy, exposing conflicts of interest, exposing the ill effects of psychiatry’s treatments, etc.  These are things that need to be said, and need to be said repeatedly and convincingly, yet Dr. Aftab likens us to arsonists looking for easy targets.

. . . . . . . . . . . . . . . .

“There are also too many ‘unhappy customers’ when it comes to psychiatry, so to speak: recipients of psychiatric care who have been left traumatized, disenchanted, even devastated by their experiences. There has been [a] tendency within the profession to not take such individuals seriously, at least not without being forced to do so.”

And this comes from a psychiatrist who earlier affirmed unambiguously “the fundamental legitimacy of psychiatry as a branch of medicine;” “the essential role psychiatry has to play in the treatment of mental health problems;”  that psychiatry should defend itself “against egregious and misplaced criticisms;” “that the value of psychiatry must be conveyed to legislators, insurers, and the general public”; and that “Psychiatry is a profession with a rich intellectual history that exemplifies some of the best of what medicine has to offer.”

But now he acknowledges that psychiatry has too many “unhappy customers”.  And these are:  “recipients of psychiatric care who have been left traumatized, disenchanted, even devastated by their experiences.”  The fact is that psychiatry needs to be held accountable for the unhappy customers who have been traumatized, disenchanted, and devastated by their experiences.  And if psychiatry’s leaders aren’t willing or prepared to hold the culprits accountable, can anyone blame the anti-psychiatry movement for stepping into this breach?  It is also worth asking what exactly psychiatrists are doing that leaves “too many” of their customers traumatized, disenchanted, and devastated by their experiences?

And then:

“There has been [a] tendency within the profession to not take such individuals seriously, at least not without being forced to do so.”

There are indeed “understandable reasons psychiatry is scrutinized way more than other medical specialties.”  These reasons are:  because they systematically lie to their customers concerning the source and causes of their woes; they administer dangerous drugs and shocks without explaining the potential for damage and even death; they routinely induce a sense of dependency, powerlessness, and unworthiness in their customers; and then tend to not take these individuals seriously unless and until they are forced to do so.

. . . . . . . . . . . . . . . .

“Psychiatry has been vulnerable to diagnostic fads. The profession has allowed itself to be exploited by pharmaceutical companies. Psychiatric theory has been vulnerable to ‘single-message mythologies’ and zealous reductionism.⁴ Its leaders have neglected structural determinants of health. The state of science is what it is; we can make conditions conducive to scientific research, but discoveries and breakthroughs cannot be rushed or forced. While acknowledging the state of psychiatric science should lead to an attitude of humility, many psychiatrists in positions of power and influence have often made grandiose claims—and at times have displayed stunning arrogance.”

In the above paragraph, Dr. Aftab asserts that psychiatry “has allowed itself to be exploited by pharmaceutical companies.”  So, we have these highly educated physicians (10 years of university training) being “exploited” by …what?  Well-dressed sales reps who bring free samples?  Pharma ads?  Slick presentations?  Payments for pushing drug presentations to colleagues?  And these highly educated physicians actually fall for this tawdry schmoozing.  Poor lambs!  Were they just born naïve, or is there some nepenthe doled out to psychiatry trainees that causes them to forget the basics of science, and to mindlessly swallow the self-congratulatory pablum that passes for professional education in psychiatry schools?

Psychiatrists have not allowed themselves to be exploited by pharma; rather they have actively and willingly embraced a hand-in-glove relationship with pharma for their own ends.  This has been happening at the academic and practice levels for decades.  To characterize this as exploitation is to miss the point.

. . . . . . . . . . . . . . . . .

“…but discoveries and breakthroughs cannot be rushed or forced.” 

Yet that is precisely what psychiatry has been doing with the chemical imbalance theory, that claims that depression is not caused by adverse events or abiding adverse circumstances, but rather by neurochemical imbalances.  This spurious notion has been promoted by psychiatry for several decades, has been reinforced by the cause neutrality statements in successive DSM editions, and has induced millions of people worldwide, who would not otherwise have done so, to take psychiatric drugs to which many of them are now addicted.

“While acknowledging the state of psychiatric science should lead to an attitude of humility, many psychiatrists in positions of power and influence have often made grandiose claims—and at times have displayed stunning arrogance.”

I would say that a good majority of psychiatrists fall in this latter group.  In my experience, grandiosity, arrogance, and self-serving fabrications are pretty much the norm in psychiatric circles.

“This is not to say that psychiatry does not face unfair criticisms. There is rampant hostility, misinformation, misguided arguments, etc, exemplified well by Scientology, Szasz, and other actors. It is right to be wary of them and to push back against them, but at the same time, many psychiatrists have been too trigger-happy with allegations of ‘antipsychiatry’ and have lumped all sorts of critics under the same banner.⁵“

So, Dr. Aftab tells us “There is rampant hostility, misinformation, misguided arguments, etc, exemplified well by Scientology, Szasz, and other actors.”  It seems to me that the various flaws in psychiatric theory and practice, that Dr. Aftab himself has conceded, justify a generous measure of hostility, rampant or otherwise.  As to whether Scientology, Thomas Szasz, and other actors also promote “misinformation, misguided arguments, etc.” depends on one’s perspective.  I would respond that anyone who asserts the “fundamental legitimacy of psychiatry as a branch of medicine” and promotes the notion that psychiatry is “a profession with a rich intellectual history”, while at the same time and in the same paper, acknowledges that many psychiatrists in positions of power and influence “have often made grandiose claims – and at times have displayed stunning arrogance”, and that “recipients of psychiatric care have often been left traumatized, disenchanted, even devastated by their experience” is not being entirely consistent.  Dr. Aftab correctly describes a truly dreadful state of affairs, but berates certain selected members of the anti-psychiatry movement on the grounds that their hostility to psychiatry is “rampant” and that in Dr. Aftab’s opinion their assertions constitute “misinformation” and “misguided arguments”.

Perhaps if he were to set out precisely which arguments of Scientology, Thomas Szasz, and the unspecified “other actors”, constitute misinformation, we could form our own judgments as to who is misguided or misinformed.  Or is Dr. Aftab suggesting that we should just leave these thorny questions for him to decide, and pass on to the rest of us the results of his superior knowledge and wisdom?

Note, incidentally, that Dr. Aftab uses the phrase “allegations of ‘antipsychiatry'” as if being anti-psychiatry were some sort of a crime, and that only critiques approved by Dr. Aftab have genuine validity.  Is this an instance of the “stunning arrogance” that he earlier attributed to “many psychiatrists in positions of power and influence”?

. . . . . . . . . . . . . . . .

“As I have mentioned, based on the social role that psychiatry currently occupies, excessive scrutiny is inevitable.”

Note the implied assertion that the scrutiny is inevitable and excessive, and stems from psychiatry’s “social role”.  In response to this assertion from Dr. Aftab, I contend that based on the quasi law-enforcement role that psychiatry has willingly embraced and continues to willingly embrace, and on the harm done to their customers in these and other contexts, a high level of scrutiny, and indeed condemnation, is not only inevitable, but warranted.

. . . . . . . . . . . . . . . .

“Morehead references the 2012 paper by Phillips et al on conceptual and definitional issues in psychiatric diagnosis.²⁰ This article highlights some of the most prominent names in philosophy of psychiatry and reveals the philosophical difficulties that surround the notion of mental illness and the elusiveness of a satisfactory definition. This has been a topic of interest to me for many years, and my own philosophical work in this area reflects the conceptual inadequacies of our notion of mental illness.^21″

This is the core issue in the entire debate.  But the notion of mental illness is not elusive; in fact, it is crystal clear.  It is an error – but it is not elusive in any ordinary sense of the term.

. . . . . . . . . . . . . . . .

This post, however, is becoming lengthy.  I will return to this theme in my next post.

I should also mention in passing that although I disagree with much of Dr. Aftab’s article, it is, nevertheless, a courageous piece of writing.  He calls out many of psychiatry’s contradictions and errors, and the primary question in my mind is why he doesn’t switch specialties to something more valid and helpful, and leave the inane rantings of psychiatry to its inane ranters, of whom there is no shortage.