The Iatrogenic Gaze: How We Forgot That Psychiatry Could Be Harmful

Michel Foucault begins his work on the history of modern medicine, The Birth of the Clinic, with this enigmatic statement: “This book is about space, about language, and about death; it is about the act of seeing, the gaze.” Here, he coined a term which has become commonplace in the sociological study of medicine: “the medical gaze”. For Foucault, clinical observation—the way in which a doctor examines a patient—is not scientifically impartial. It is conceptual, invoking a latent theoretical grid which narrows potential interpretation. It is a kind of language, with an often cumbersome grammar. Nor is it socially impartial. The gaze surveils us. It contorts our lives into its awkward categories, often injuring us in the process. Foucault writes: “To look in order to know, to show in order to teach, is not this a tacit form of violence, all the more abusive for its silence, upon a sick body that demands to be comforted, not displayed?”  I’ve attempted here to write my own essay about this gaze—about this language and its violence.

As a 20-year-old nurse, Rosie Tilli developed mild depressive symptoms amidst her city’s strict covid lockdown. Her GP prescribed Lexapro and immediately she suffered severe emotional numbness. She was reassured that the numbness was a benign reaction to a new antidepressant. Begrudgingly she continued with Lexapro and was even recommended a dose increase. She went on to develop disconcerting symptoms like visual snow, tinnitus, and complete genital anesthesia. These symptoms continued for months after stopping the medication. Rosie was understandably panicked. She was calling her mother constantly, asking if she would be okay. Although her parents fully support her now, they were originally skeptical. Is this kind of injury really possible?

Rosie explains: “My cousin is a pharmacist and she’s telling us ‘oh, it can’t do that. I’ve taken Lexapro before and that doesn’t happen'”. Alarmed by Rosie’s distress, her family set up a group meeting with Rosie and her psychiatrist. The psychiatrist reiterated “it’s not possible. Side effects [like this]—that doesn’t happen”. The doctor diagnosed her with a delusional disorder. Her medical records state: “Firm fixed delusional belief about medications causing side effects… Impression: delusional disorder with significant health anxiety and OCD with comorbid depressive symptoms.” Rosie was then committed against her will to a psychiatric facility and forced to take medication for her “delusions”. Four years later, Rosie still suffers the same symptoms.

Although her doctors were ignorant, the problems Rosie suffered are actually well-known amongst patient advocacy groups. Rxisk.org, a drug safety compendium founded by psychiatrist David Healy, explains: “Post-SSRI sexual dysfunction (PSSD) is an iatrogenic condition in which sexual function does not return to normal after the discontinuation of serotonin reuptake inhibiting antidepressants… Most people who take an SSRI, SNRI, or related medication, will feel some degree of genital numbing, often within 30 minutes of taking the first dose. In PSSD, this genital numbing and other sexual side effects remain or do not resolve completely when the drug is stopped… Non-sexual symptoms that may accompany PSSD include emotional numbing, sensory problems, and cognitive impairment… It has been suggested that based on the available data, PSSD may be quite common.” Although sexual dysfunction is labeled as a “side effect”, numerous patients report issues far persisting withdrawal. The term “drug injury” is more appropriate here.

Drug Injuries are a piece of a wider problem known as iatrogenesis (doctor-made illness). Although drug injuries are virtually absent from public discourse, available research considers them a leading health risk. A 2018 paper examined FDA data on adverse drug events (ADEs) and found a rate of over 100,000 serious injuries per year. That rate has been increasing rapidly: “From 2006 to 2014, the number of serious ADEs reported to the FDA increased 2-fold… A previously published study… found that from 1998 to 2005, there was a 2.6-fold increase in the reports of serious ADEs and a 2.7-fold increase in the reports of fatal ADEs”. It seems that the rate of serious drug injury is doubling per decade. Moreover, the study grouped ADEs into categories of severity and determined the top 10 contributors for each. The “death” category contained one psychiatric drug. The “disability” category contained four—three of which were SSRIs, the class of medication that injured Rosie.

For most of my life, I knew nothing about this problem. I had some vague awareness that patients occasionally had a “bad reaction” to a pill, but I assumed that these reactions were one in a million and it never crossed my mind that something like permanent genital numbness could occur. I only came to understand it when it happened to me personally. I don’t feel comfortable telling my whole story right now, but the outline parallels Rosie’s. I had a mental health episode and was prescribed ostensibly “mild” medication. I developed anhedonia and mild akathisia which persists nine years later. After my injury, I suffered severe health anxiety which was diagnosed as “obsessive compulsive disorder” (OCD). I started panicking about things like “how much water am I drinking” and “does my apartment have a secret mold infestation”—things that I had never previously considered threats. My therapist was baffled, but for me the cause was quite obvious. After medicine had betrayed me so badly, I became terrified that I couldn’t trust anything to keep me safe. Like Rosie, I became so distressed that my father had me involuntarily committed to a psychiatric hospital.

I spent a long time in OCD therapy and learned a lot about the field. I really believed in it for a while, but I have a very negative opinion now. I find the field’s thinking quite frustrating because it omits any discussion of iatrogenesis. This ignorance is particularly troubling because OCD patients are heavily medicated (often with doses surpassing the FDA recommended maximum) and are therefore at an elevated risk of injury. While in treatment, I met five OCD patients who suffered this ordeal—severe “health anxiety” following an iatrogenic injury; and numerous others who I suspect had such an injury. One developed tinnitus after an SSRI and was worried that the noise would ruin his life. Another suffered memory problems after withdrawing from an SSRI, provoking constant panic about failing to recall details of her day. Three all underwent ECT (electroconvulsive therapy) and developed daily distress over reported cognitive impairment.

As far I am aware, there is zero mention of iatrogenesis in the OCD literature. Not only have I never met an OCD therapist who believes in PSSD, I have never met an OCD therapist who has heard of PSSD. In fact, OCD patients are encouraged to view reluctance towards medication as “obsessive anxiety” and are recommended “exposure therapy”. This entails playing at taking medication (holding medication in hand, taking a vitamin instead of medication etc.) in order to desensitize to the “irrational” fear that medication might be harmful. This is the advice I got from my therapist (a published expert in the field). I described how my health anxiety started after a drug injury. He said “maybe the best exposure would be to ask your psychiatrist for ‘the dirtiest med’ [his exact words], the one with the most side effects and the worst evidence-base, and take that as an exposure to overcome your fear”.

An acknowledgment of the OCD community’s awkward reticence motivates two research questions: 1) How often do OCD patients develop an iatrogenic injury resulting from psychiatric treatment? 2) How often do patients develop “health anxiety” only subsequent to an iatrogenic injury? My hypothesis is that the rates for both are substantial. Moreover, I hypothesize that the absence of such questions from OCD literature is not an academic accident, but rather the effect of an institutionalized ignorance.

How Did Medicine Go Blind?

In his book Pharmageddon, David Healy writes: “Drug-induced injuries are now the fourth leading cause of death in hospital settings. They are possibly the greatest single source of disability in the developed world… If we turn to the evidence base to care for and ideally cure this new disorder afflicting us, we find there is none—no guidelines, no studies, but instead close to a blanket dismissal of any evidence that things could be going wrong”.

Healy notes that this “blanket dismissal” is a recent development. “Good medical care once firmly embraced the idea that every remedy was a potential poison that inevitably produced side effects—the trick lay in knowing how and to whom to administer this poison… [But] in the era of evidence-based medicine, the marketing barrage of the pharmaceutical companies and the promise of statistical significance have led doctors into a world in which they regard treatments more as fertilizers or vitamins that can only do good if applied widely”. I believe this has been a ubiquitous experience for the victims of psychiatric iatrogenesis: assuming that you are ingesting a vitamin, only to later realize that you have been ingesting a poison.

I interpret this eerie ignorance as a kind of false seeing; a reconfiguration of Foucault’s “medical gaze”, thus inspiring the name “the iatrogenic gaze”. In its violence against the patient, this gaze has both a positive and a negative task. The positive task is to misinterpret human suffering (particularly madness) as medical illness in need of prescription. The negative task is to dissimulate any injury caused by these prescriptions, misinterpreting it as a new symptom of the original diagnosis.

Foucault described his philosophical method as an “archaeology”. This entails collecting a bulk of historical records in order to trace the origins of a concept; but in clarifying the origins, he also hoped to destabilize the concept, showing it to be contingent and dubious—or at least showing that something worthwhile in an old style of thinking had been forgotten. I would like to explore the iatrogenic gaze with an abbreviated attempt at such an archaeology. I will focus on the two aforementioned works: Foucault’s The Birth of the Clinic and Healy’s Pharmageddon. Both examine changes in medical theory (Foucault studies French medicine from 1750 to 1850, Healy studies American medicine throughout the 20th century) and challenge the assumption that such changes are unequivocally progressive.

Let’s start by clarifying Foucault’s concept of “the medical gaze”. Foucault rebukes the common perspective that modern medicine arose simply out of scientific objectivity. Rather than characterizing premodern medicine as “superstitious” and modern medicine as “objective”, Foucault suggests that the eras employed two different conceptual frameworks: what he calls “the botanical model” and “the anatomo-clinical model”. The botanical model entailed visiting a patient’s home and classifying his story into a thematic species (similar to how a botanist classifies plants). The anatomo-clinical model entailed admitting a patient to a clinic and interpreting disease as aberration in a particular part of the body (relying heavily on autopsy for research and confirmation of such aberrations). The change altered the very way a doctor “sees”. When examining a patient, a doctor has an overwhelming amount of information presented to him. Inevitably, he will have to focus on some information and ignore other information. Therefore, when the doctor “sees” the patient, he is selectively looking for predetermined concepts. He sees with a language. The vocabulary of signs, symptoms, and diagnoses forms “a theoretical grid”. He gazes through this grid and matches diagnoses only to pre-established options. This process of seeing through a grid is what Foucault means by “the medical gaze” and he was fascinated by how greatly a new grid could change medical practice.

Foucault concedes that the anatomo-clinical grid is preferable, but reminds us that it also carries limitations: “That which is not on the scale of the gaze falls outside the domain of possible knowledge. Hence the rejection of a number of scientific techniques that were nonetheless used by doctors in earlier years. Bichat even refused to use the microscope… Still more significant is the rejection of chemistry… In eighteenth-century medicine… when one wanted to know what inflammatory fever consisted of, one carried out blood analyses… At the beginning of the nineteenth century, this experimental apparatus disappeared, and the only remaining technical problem was to know whether the opening up of the corpse of the patient affected by inflammatory fever would or would not reveal visible alterations”. Medicine became so fixated on autopsy that microscopy and blood sampling were strangely rejected.

Healy describes a similar change by contrasting two influential American doctors: Alfred Worcester and Richard Cabot. Worcester represents the old style of doctor-patient relationship and intuitive care. Cabot represents the new style of biological analysis and scientific rigor. Ideally, there would be a synthesis: a patient-first medicine outsourcing to high-tech interventions only when necessary; but the opposite seemed to occur. Not only did Cabot’s scientific austerity win out, but it degenerated into a parody of itself. Doctors became hypnotized by the appearance of “science”, even if the literature they consulted was essentially pharmaceutical advertising. They prescribed medications which were useless if not harmful, for conditions that debatably even existed. When medications did cause harm, the doctors were completely blind to it. We can understand this change as a new medical gaze and use Healy’s extensive research as grounds for an archaeology.

The early 20th century saw “[the] astonishing development of truly novel and extremely effective agents, from the antibiotics and cortisone to the diuretics, antihypertensives, hypoglycemics, and psychotropic drugs, as well as the first chemotherapy for cancer. It seemed [medicine was] set on a course in which genuine developments would succeed each other for years to come”. Such optimism would be disappointed by dwindling pharmaceutical progress in the later half of the century. Nevertheless, the optimistic attitude became second nature and doctors viewed new drugs, even ones barely outperforming placebo, with the same exuberance with which they viewed penicillin. Early success in a field is often misinterpreted as a generalized template for future science, ignoring limitations of the research. Antibiotics and insulin were genuine scientific breakthroughs. However, a culture developed which viewed pharmaceuticals as inherently revolutionary and assumed future research could only provide more breakthroughs. Doctors developed an automatic disbelief of emergent findings showing new pharmaceuticals to have limited benefits and substantial risks.

Pharmaceutical disappointment was more easily acknowledged by industry executives who realized that dwindling progress would undermine profits. Industry pivoted to a focus on regulatory capture—hijacking the academic process to promote dubious new drugs. This move “transformed pharmaceutical outfits into companies who market drugs rather than companies who manufacture drugs for the market.” A crucial factor enabling the change was the delegation of drug safety testing, formerly conducted by impartial public sector academics, to the private sector. We see the emergence of “Clinical Research Organizations” (CROs) which deliver clinical testing as a service. A lack of oversight allows the CROs to massage trial data in favor of industry objectives.

Healy writes: “Where once a professor might have analyzed the data from a trial, now personnel from the CRO collect the records from each center and assemble them back at base. The events in a patient’s medical records or the results of investigations are then coded under agreed-upon headings from dictionaries listing side effects… If later asked at an academic meeting what happened to patients on the drug, this is what they will cite. In this way the blind lead the blind—giving a whole new meaning to the idea of a double-blind study. For instance, academics presenting the results of clinical trials of Paxil for depression or anxiety in children wrote about or showed slides containing rates of emotional lability on Paxil and placebo. The presentations were relatively glib, and there is no record of any member of any audience being concerned by higher rates of emotional lability on Paxil, probably because none of those involved realized that emotional lability is a coding term that covers suicidality; in fact, had they had the raw records in front of them clinicians would have realized there was a statistically significant increase in rates of suicidal acts following commencement of treatment with Paxil.”

Control over clinical trials allows the pharmaceutical industry to formulate medical guidelines opportunistically. Although guidelines are established by independent committees, they often use only the glib summaries that industry provides. The presentation of strategic summaries can exploitatively bend guidelines so their recommendation conveniently endorses the prescription of the newest drug that industry is trying to market. The guidelines thus formed shape how doctors are trained and how they practice. There can even be a legal dimension in which a doctor is held culpable if he contravenes a guideline. As such, the guidelines reconfigure the medical gaze. They become its language—its theoretical grid. Doctors see only the illnesses listed in guidelines and become blind to the treatment risks that aren’t mentioned in the guidelines. I once spoke to a psychiatrist about PSSD and he agreed to watch a video about it. The next time I saw him, he shook his head glumly and said “I’m studying for recertification and there’s nothing about PSSD in our training”.

Guidelines are all the more powerful in a medical culture that has become increasingly standardized. The medicine of Worcester’s time was more “botanical”, focusing on a patient’s story and only outsourcing to biological testing when investigating an hypothesis. The modern era is instead inundated with routine testing. We have measurements of blood pressure and weight, blood tests for sugars and cholesterol, imaging such as bone scans and mammograms, and psychiatric screenings for depression and anxiety—just to name a handful. Healy laments the tendency of doctors to rigidly follow guidelines for these tests, often recommending unnecessary treatments just to get the numbers right.

Conversely, overreliance on testing blinds doctors to problems which are not currently testable. Psychiatric iatrogenesis is neurological and neuroscience is in its infancy. Traumatic brain injury is easily recognizable on an MRI, but most neurological damage (even most concussions) lacks reliable biomarkers. When a patient develops genital numbness there is no way to examine his nervous system and confirm the damage. The new gaze can only see with empirical testing and, as Foucault understood, “that which is not on the scale of the gaze falls outside the domain of possible knowledge”. If a patient starts an antidepressant and immediately develops genital numbness, Worcester would see an obvious drug injury; but the standardized doctor, lacking any testing protocol for genital numbness, is blind.

But how does this blindness spread outside of the medical field? In The Birth of the Clinic, Foucault is not only interested in the academic changes accompanying a new medicine, but also the cultural changes it fosters. The impetus to reform medicine was catalyzed by the French revolution. Its culture despised entrenched traditionalism, particularly that of the Catholic church. The revolutionaries suggested that government funding once provisioned to the church should be reallocated to medical practice, thus creating a modernized religion. The culture was enchanted by “the myth of a nationalized medical profession, organized like the clergy, and invested, at the level of man’s bodily health, with powers similar to those exercised by the clergy over men’s souls”; We see the construction of the “doctor-magistrate… In addition to his role as a technician of medicine, [the doctor] would play an economic role in the distribution of help, and a moral, quasi-judicial role in its attribution; he would become ‘the guardian of public morals and public health alike’”. The iatrogenic gaze is then internalized as a pseudo-religious practice. Hyper-medicalized man scrutinizes himself for deviance from medical guidelines in the same sense that Christianized man scrutinizes himself for deviance from Church doctrine. We are all mini-psychiatrists now, self-screening for depression and anxiety, ready and eager to follow the prescription guidelines; and, as psychiatrists, it never crosses our minds that these guidelines might be harmful.

Drug Injuries Are Hidden Behind “Health Anxiety”

Now we can understand the iatrogenic gaze as forming from outdated pharmaceutical optimism, predatory publication mechanisms, and early neuroscientific ignorance. We can also see how this gaze is made ubiquitous by its transformation into a public morality. This gaze has a catastrophic effect on psychiatric practice. Common drug injuries are inevitably misinterpreted as psychiatric illness. For the modern psychiatrist, Healy observes: “it is depression that gives rise to suicidality in patients on antidepressants, not the drugs… it is schizophrenia that gives rise to a disfiguring neurological condition, tardive dyskinesia, rather than treatment with antipsychotics”. Ex-patients lament the frustrating contradiction in which, despite having numerous friends who were harmed by psych meds, any doctor they speak to simply responds “I’ve never seen that before”; but from a Foucauldian perspective, the doctor’s ignorance makes perfect sense. The doctor, examining his patient only through his theoretical grid, genuinely cannot “see” PSSD because he doesn’t have a word for it. In the narrow language of hospital codes, his best translation is “health anxiety”.

And here we reach a troubling question. Is “health anxiety” just a rhetorical trick to hide iatrogenesis? I do not wish to make the argument that all (or even most) cases of health anxiety are actually iatrogenic injuries. People have always worried about their health and will always worry about their health. Rather, I suspect that “health anxiety”, as a diagnosis, has a secondary usage. It is too uncomfortable for our medicine-worshiping culture to admit that its proud institution might actually be harmful. The “health anxiety” diagnosis therefore allows us to avert this painful truth by misattributing it to a psychiatric disorder.

In his essay Mental Illness and Psychology, Foucault writes: “Our society does not wish to recognize itself in the ill individual whom it rejects or locks up; as it diagnoses the illness, it excludes the patient. The analyses of our psychologists and sociologists, which turn the patient into a deviant and which seek the origin of the morbid in the abnormal, are, therefore, above all a projection of cultural themes”. He then references the Freudian concept of “infantile regression” (the tendency for the madman to resume childlike behavior).

Foucault believed this concept is faulty because it ignores its cultural background—namely, the construction of an institutionalized education system. “If regression to childhood is manifested in neuroses, it is so merely as an effect… The whole development of contemporary education, with its irreproachable aim of preserving the child from adult conflicts, accentuates the distance that separates, for a man, his life as a child and his life as an adult. That is to say, by sparing the child conflicts, it exposes him to a major conflict, to the contradiction between his childhood and his real life… Neuroses of regression do not reveal the neurotic nature of childhood, but they denounce the archaizing [infantilizing] character of the institutions concerned with childhood”.

For Foucault, infantile regression is not an innate characteristic of madness; rather, it is a stylized expression of madness stemming from a culture whose education system has become infantilizing. The education system has become an artificial incubation chamber in which a child is sequestered from outside life. It is only because of this institutional bubble that “childhood-mode” is considered a refuge to return to in times of despair. As the psychiatric concept of “infantile regression” ignores this context, it serves to mask the failures of the education system.

Similarly, we can understand the psychiatric concept of “health-anxiety” as a mask for the failures of the medical field. Medicine harms us physically by promoting dangerous treatments. It harms us mentally by converting health-care into an overbearing morality. In many cases, this is the obvious cause of a patient’s distress. Yet, the medical field can never acknowledge this because doing so would mar its reputation. Perhaps Healy’s most damning criticism is his characterization of the modern provider as a “factor doctor”. “Doctors increasingly resemble the employees of the occupational health department of a factory that in the course of business exposes its workers to disability-inducing aerosols. These are doctors who are all too aware that their ongoing employment depends first on keeping mum about problems the workers may be having and second on being willing to recommend laying off workers at the first signs of any ill health—having persuaded them that they aren’t fit for the job rather than conceding that job conditions might be the problem.”

In a similar sense, the psychiatrist persuades Rosie that her illness is causing delusions about medication, rather than conceding that medication might be causing her illness. I do not mean that providers are intentionally covering-up iatrogenesis (although this does sometimes happen). I believe that the OCD providers I met with were well-meaning, albeit quite naive. Instead, I suspect that the masking happens on a subconscious and paradigmatic level. To acknowledge iatrogenesis, the doctor must first entertain iatrogenesis as an hypothesis. He must consider the possibility that he has caused harm and that psychiatry causes harm somewhat often. Such a theory is unsettling, so it is typically ignored (perhaps in the same way that we ignore red flags in an otherwise attractive romantic partner).

My guess is that this avoidance forms a negative feedback loop, particularly in academia. Researchers don’t consider iatrogenesis, so there is no research on iatrogenesis, which makes future researchers even less likely to consider iatrogenesis. Instead, they research “health anxiety”. I believe that this negative feedback loop, founded in a squeamishness around iatrogenesis, is the primary reason for the omission of iatrogenesis from the OCD literature. Until the OCD community comes to acknowledge the extent to which the medical gaze has become iatrogenic, they will fail to understand their patients and often proceed to harm them further; and until the medical gaze learns to turn inward and see its own pathologies, we will continue to suffer its violence.