Psychiatrogenesis (Whither Psychiatry or Reform)

“It is no measure of health to be well-adjusted to a profoundly sick society”
—attributed to Jiddu Krishnamurti 

“The behaviour of any bureaucratic organisation can best be understood by assuming that it is controlled by a secret cabal of its enemies.”
—attributed to Robert Conquest

Having worked in multiple public services in the UK and Australia over the last 27 years, the constant personal struggle has been, “Am I doing more harm than good?”

Sadly, the conclusion of this reflection is that iatrogenesis is the norm from diagnosis to treatment, and doing good is the exception. Diagnoses, especially “borderline personality disorder” and “schizophrenia,” lead to a pathological, limiting view of oneself and enshrine a nocebo effect that is difficult to shrug off. Medication treatment may provide some symptom improvement, but also comes with a panoply of side effects and withdrawal symptoms.

The reason I went into psychiatry was that, unlike other medical disciplines with clear pathogenesis, clinical markers, and effective interventions, psychiatry was a much more ethereal specialty. Here, there was a balance to be made between the “is-ness” of the clinical encounter and the socio-politico-psychological cultural context in which the meeting was taking place.

There was no room for hubris or certainty; medication sometimes worked, hospitalisation may help in a crisis, self-harm may be a vitally important survival mechanism for someone. You could never get “comfortable” in the job; every day was challenging, and being an expert in psychiatry seemed oxymoronic.

But, as the years wore on, I saw a precipitous decline in deep listening, a drift to seeing people “as diagnoses” rather than “with diagnoses,” and a disconcerting faith in manualised psychotherapies and medication protocols as if you could feed each patient into the evidence-based machine and hey presto! a fully treated patient—and woe betide you if you didn’t get better, lest you be sent to the naughty chair labelled “treatment resistant.”

I see my job over the years as an anti-iatrogenic agent trying to educate my colleagues about the costs and benefits of our interventions. It is tiring, dispiriting work punctuated with short bursts of hope and optimism. To work in this way is a highly risky enterprise; at best, you may be scorned or ignored by your colleagues; at worst, you may lose your job, scapegoated as unorthodox and unscientific.

But the fight must go on to at least question why we practice the way we do, lest in our earnest attempts to do good we do in fact do bad. Too many people have died and endured ignored suffering to merely shrug one’s shoulders and say “You win some, you lose some.” Yet, in my time working with various teams, it is a rare clinician indeed who is not compassionate, thoughtful, and caring, so how does one square this circle?

Readers of this website need no introduction to the idea of how the pharmaceutical industry has warped the landscape of human distress and actually has exacerbated suffering. In my mind, however, the difficult experiences of many users of the public mental health system are not due solely to powerful vested interests, but, rather, to an emergent phenomenon borne from many recursive interactions at the personal and cultural level.

Emile Durkheim suggested that in the ideal society, there is a “collective consciousness”—a sense of shared purpose and belonging, culture and values, between the members. Durkheim criticized the burgeoning industrial society of the late 1800s and early 1900s for its fragmenting, hyper-individualising structure and “winner takes all” mentality. Durkheim coined the term “anomie” for the experience of those who are unmoored from collective belonging, becoming what he called “deranged” and purposeless. With the breakdown of collective social interaction and shared purpose, Durkheim believed, society and the individual become isolated and distressed.

I propose that into this breach of values, preying on the privatisation of distress, comes the medical-industrial complex perverting the mental health landscape, with its priorities of profit, disease-mongering, and private insurance coverage. This idea of the separated individual split off from his sociocultural milieu has been internalised by Western society and its mental health systems. In line with this, the DSM-III, emerging in 1980 as neoliberalism took hold in the West, transformed what was once a contextual discipline into an individualised, atheoretical, “objective” one. If you met the criteria and scored highly on any number of the plethora of rating scales, you had a disorder, regardless of the context.

Those models that were more expansive—psychodynamic, family therapy, systems theory—went into abeyance. Biological psychiatry was the norm. Epitomising this, President George H. W. Bush christened the 1990s “the Decade of the Brain.” Those of us in the mental health industry at the time were dazzled with images of brain scans, colourful neurotransmitter diagrams, and the pseudo-certainties of screening tools, whilst phrases like “meet the criteria” or “meets threshold” became the lingua franca of clinicians, as if we were classifying plants in nature rather than rubber-stamping a man-made abstraction.

From here, it was a short step to see the person on the other side of the desk as simply having a brain disorder in need of medical treatment—and if they refused, then they needed “psychoeducation” or maybe compulsory treatment (in their own best interests, as surely their brains must be malfunctioning if they expressed psychic pain in the idiom of suicidality)?

At this pointy end of psychiatry, when a clinician is faced with a suicidal patient, they know what is expected from them from their guild and hospital department (little matter that clinicians’ risk assessments are no better than a coin toss). They will certify. The true power dynamic of the public mental health system is revealed. It is the police who will hunt you down, use force and handcuffs if needs be, to convey you to the psychiatric department, for your own safety.

The final piece of this entangled web is the consumer herself. She is bombarded by messages on social media about if she doesn’t feel OK maybe she has an undiagnosed mental disorder. Why not fill out the questionnaire and ask your primary physician for the appropriate treatment?

How is the consumer to know that the media is saturated by the interests of an unholy alliance of government and business, and her distress (her “anomie”)—as she contends with living an atomised existence, alienated from community bonds, purposeful work, and embodied interaction with the environment—is appropriate and valid.

Maybe she thinks that for awhile, but that space is shut down by weaponised messages of resilience, happiness, and “living your best life” (and if she can’t achieve this, it is her own moral failing). Her desperation may drive her to be diagnosed and medicated in her earnest attempt to be all of those things—ironically, she may consider that idealised, unattainable neoliberal self to be more “authentic.” So many times, I have seen eloquent and articulate consumers practically demand a diagnosis and treatment.

So, what should someone struggling with their emotions do? If they have a choice, shouldn’t they surely steer well away from psychiatrists and psychiatry, behoven as they are to strictly reductionist biomedical explanations and treatments for their distress? I’d argue, though, that as Leon Eisenberg so wisely proffered, it is important to neither be brainless or mindless. Medications can make a profound difference to people’s suffering. Careful diagnoses can sometimes give people a life vest in the turbulent waters of psychic distress. But how is one to navigate the bewildering confusion of the psychiatric industry when one is already in a state of disequilibrium?

Ultimately it is psychiatry that must transform itself—not the patients who have to transform it. The patients have suffered from its yoke and clearly hold less power to manifest change. However, dissident forces like intentional peer support, Mad in America, Asylum, Surviving Antidepressants, Inner Compass, the Power Threat Meaning Framework, and Open Dialogue, all push psychiatry to its reckoning. There are groups of psychiatrists out there (eg, The Critical Psychiatry Network) who are broad thinkers who sceptically diagnose and prescribe and try to nudge change within and without the halls of academia and Royal Colleges.

What then would a fit-for-service psychiatric service look like? I suggest the following pointers:

1. Fundamentally, psychiatry should swim upstream and put community building, grassroots activism, and relationship at the heart of its mission to act as a bulwark to the overwhelming societal force to atomise, disembody, individualise, and disrupt social capital and engagement.
2. Psychiatrists should enlarge their role and use their privileged position in society to fight social injustice and inequality by advocating strongly for the marginalised to access the little funds allocated to them by the byzantine bureaucracy of government and insurance companies.
3. Psychiatric training of the future would include deconstructing the tenets of the profession as well as inculcation in alternative modes of knowing and healing (eg, body psychotherapies, shamanistic rituals, anthropological study placements in different cultures, and maybe taking the medication we prescribe our patients to get an embodied understanding of their multi-faceted effects).
4. Make central the epistemological understanding that human emotions are the result of recursive mind-body interactions and it is reductive to just treat them biologically. This approach, hopefully, will lead to a cessation of the endless specialisation in the field and build collaborative, rather than hierarchical, relationships (where the psychiatrist always has the final say) between mental health practitioners.
5. The consumer is an active collaborator, co-creating treatment rather than “being done to.”
6. Whilst the consumer may have strong views on their diagnosis and treatment, they engage with the psychiatrist because of their clinical experience and learning in a variety of fields, especially the biomedical. This particular field has a lot of tension, as it brings together the subjective reality of lived experience with the objective, outsider perspective of the practitioner. I believe it is within this force field that change and evolution can happen, perhaps mediated by peer-lead co-productions.
7. A re-orientation of services to champion peer-run spaces and a commitment to put lived experience at the heart of the design of psychiatric institutions as well as practice. This is no easy goal given the years of distrust and silencing endured by consumers in the face a psychiatric profession which in the main part took a well-meaning, patriarchal “we know what’s best for you” stance.

In the final reckoning, I believe psychiatry has a paradoxical function to perform: to rein in its hegemonic overreach into people’s lives and at the same time use the power vested in it by the state to play an active role in creating opportunities for people marginalised and scapegoated by our culture. If it is unable to do so, it will surely continue to be the unwitting handmaiden of its neoliberal overlords.