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A recent article in Vice, “The Movement Against Psychiatry,” wrestled with the ongoing debate between mainstream, institutional psychiatry and what has been called “anti-psychiatry” or critical psychiatry. The subtitle to the article was “The contentious debate of whether to fix—or completely overthrow—the way we treat mental illness.” Around the same time Mad in America highlighted an article published in the American Journal of Physical Anthropology, “Mental health is biological health.” The authors noted that while the biomedical sciences have rapidly reduced the global burden of infectious disease, mental disorders are emerging as major contributors to the global burden of disease. However, “the causes of most mental disorders … remain a mystery, and there has been little progress in reducing the prevalence of any of them.”
You get a condensed, but ultimately biased, picture of the debate, and are introduced to several of the individuals and institutions associated with anti-psychiatry in “The Movement Against Psychiatry,” whose author said anti-psychiatry should not be dismissed as a fringe movement. Issues like over-medication, and problems tapering off of meds are being seriously discussed within mainstream psychiatry. An interview series published in Psychiatric Times called “Conversations in Critical Psychiatry” seeks to engage “prominent individuals who have made meaningful criticisms of psychiatry and have offered constructive alternatives.” Awais Aftab, the author and interviewer for “Conversations in Critical Psychiatry”has interviewed several of the same individuals quoted and referred to in “The Movement Against Psychiatry”: Allen Frances, Sandra Steingard, Lisa Cosgrove, and Lucy Johnstone. Other individuals interviewed for “Conversations in Critical Psychiatry” include Joanna Moncrieff, Giovanni Fava, and Ronald Pies—names I recognized from my own journey and reading articles for and against “anti-psychiatry.”
In “Mental health is biological health,” you find a persuasive argument for a “re-thinking” of psychiatry from the ground up, including psychopharmacology and diagnosis. The authors said scientists understand little about the etiology of mental disorders and noted popular treatments like antidepressants and antipsychotics “have only moderate-to-weak efficacy in treating symptoms” and do not target biological systems that correspond to discrete psychiatric syndromes. The track record of biological psychiatry was said to be poor. “So far, there are no diagnostic tests, and treatments have limited efficacy.” Many critics believe this is due to fundamental flaws in the DSM classification system and that it is impeding research.
Unlike the natural classifications of plants, animals, infectious diseases, and inorganic substances, which all played key roles in the discovery of underlying causal principles, such as the theory of evolution, the atomic theory of matter, and the germ theory of disease, the various classifications of mental disorders have failed, so far, to uncover their underlying causes. The current system has little claim to be a “natural” classification, and is instead deeply contingent on the specific history of psychiatry.
Both articles are long, but worth reading and digesting, if you are interested in the topic. But first let’s push through some of the rhetoric. “The Movement Against Psychiatry” made a distinction between “anti-psychiatry” and “critical psychiatry” seeing anti-psychiatry as having more of an abolitionist sense—a movement of people who feel psychiatry is harmful and needs to be eradicated. Critical psychiatry may be a good lens to see how a biological paradigm has captured our cultural and medical understanding of mental distress. Lucy Johnstone said she agrees with many of the points made by critical psychiatry and opposes what she sees as the medical model of mental illness. She added the term anti-psychiatry is used in the U.K. as an insult.
Challenging the medical model of mental illness seems to be at the heart of the current debate over “anti-psychiatry.” Psychiatrists see their position as a medical specialty being attacked by so-called “anti-psychiatrists.” Aftab, who is a psychiatrist, warned that anti-psychiatry positions run the risk of encouraging distrust of the medical system and available treatment options. This leads people to be wary of seeking help. “For individuals who are on psychiatric medications, they can abruptly discontinue their medications with very serious consequences.”
On the other hand, “Critical psychiatry is more of a reformist movement, attempting to address psychiatry’s issues while maintaining some semblance of its infrastructure.” Lisa Cosgrove, a clinical psychologist and professor at the University of Massachusetts Boston, has a more nuanced view of psychiatry as a medical discipline. She said the fact that we don’t have biomarkers does not make psychiatry irrelevant as a medical discipline. “It just makes it different from other subspecialties in medicine.”
The failure to identify biomarkers for psychiatric illnesses under the auspicious of the medical model of mental illness, despite decades of research and millions of research dollars, stands in direct contrast to the progress with other medical specialties over the past 150 years. Psychiatry seems to feel uncomfortable or self-conscious of this difference.
In her article “Does ‘Mental Illness’ Exist?”, Lucy Johnstone said it obviously does exist, but the idea that the experiences subsumed under the term ‘mental illness’ are best explained as medical disorders “has never had any evidence to support it.” She said that despite decades of research, no so-called symptoms have been causally linked to established patterns of chemical imbalances, genetic flaws or other bodily malfunctions. “Any science – in this case medicine – needs to be able to demonstrate that it is based on a reliable and valid classification system, in order to develop testable hypotheses and hence the general laws that constitute a body of scientific knowledge.” If this cannot be established, she said the whole model breaks down and all psychiatry’s functions are fundamentally undermined. “In the words of Peter Breggin, psychiatry would then become ‘something that is very hard to justify or defend – a medical specialty that does not treat medical illnesses.’”
Johnstone said a psychiatric diagnosis turns ‘people with problems’ into ‘patients with illnesses.’ Psychiatry itself is a failed paradigm. While we have made extraordinary advances in what she called legitimate branches of medicine, “we have made no comparable progress in the illegitimate branch of medicine that calls itself psychiatry.” Her suggested starting point for understanding these problems was ‘formulation,’ the process in psychology of making sense of a person’s difficulties in the context of their social circumstances and life events. “The professional contributes their clinical experience and their knowledge of the evidence—for example, about the impact of trauma. The client or service user brings their personal experience and the sense they have made of it.”
In “Moving Beyond Psychiatric Diagnosis,” Awais Aftab interviewed Lucy Johnstone for his series, “Conversations in Critical Psychiatry.” He said he was intrigued by her envisioning formulation as an alternative to psychiatric diagnosis. He thought most people in psychiatry and psychology don’t see diagnosis and formulation as mutually exclusive, but rather as complementary and synergistic. “In fact, many would argue good diagnostic practice requires diagnosis to be made in the context of a formulation. Why should we see diagnosis and formulation as competitors rather than allies?” Johnstone replied:
The argument for psychological formulation—or formulation as an alternative to diagnosis—is simple. A formulation is a hypothesis, drawing on the best evidence, and tailored for the particular client. If you have a reasonably complete hypothesis, based on someone’s life experiences and the sense they have made of them, about why they are having mood swings or feeling suicidal or self-injuring, then you don’t need another, competing hypothesis that says, “And it is also because you have bipolar disorder/clinical depression/borderline personality disorder.” Even if we think these are valid categories, the diagnosis is now redundant.
Aftab disagreed that a diagnosis could be conceived as a causal hypothesis. He later asked her if she advocated for the abolition of psychiatric diagnosis. Johnstone said she did not think “abolition” was the right word. She believed they should use concepts that were evidence-based and jettison those that weren’t. Aftab responded by saying he thought it was disingenuous to argue that psychiatric diagnoses were not valid with respect to a certain scientific standard and then not apply the same standard to psychological formulations. But Johnstone was not distracted from her point.
She replied that in science, it was understood that constructs routinely had to be revised and then abandoned in favor of more accurate ones. She noted that in Biblical times, people believed madness was caused by evil spirits. No one could see them, but everyone was certain they existed. Diagnoses like schizophrenia were based on the same logic. “There are no bodily signs to confirm or disconfirm their presence, but we are convinced we’ll find them someday. This is purely a matter of faith, and it flies in the face of the mountain of evidence for psychosocial causal factors in all forms of mental distress.”
We may be able to come up with all kinds of cleverly nuanced perspectives on how we, as professionals and philosophers, understand psychiatric diagnosis, but the fact remains that people are being told they have mental illnesses and disorders, with all the usual connotations of those terms in Western societies. Moreover, they are heavily encouraged to take on the particular narrow understanding that you refer to—we are all bombarded with messages about “mental illness” being “as real as a broken arm”, and needing to be managed by drugs “just like diabetes.” Even the dubious compromise that is the “biopsychosocial” model—a way of acknowledging some role for psychosocial factors while at the same time instantly relegating them to “triggers” of a disease process—is not much in evidence on the ground. And furthermore, the biomedical message is reinforced by the fact that these labels are applied by doctors and nurses, working in hospitals and clinics, who use not just the labels themselves but the whole medicalized discourse of symptom, patient, prognosis, treatment, relapse, and so. The “stereotypical biomedical understanding of diagnosis” as you put it, is absolutely everywhere.
Aftab said clearly there was a lot wrong with the popular perception of what a diagnosis entails and he thought they needed tremendous effort to counter that. But he thought she was engaging in a certain sense with a strawman—a widespread stereotype of psychiatric diagnosis. If she was only trying to convince the public or professionals who did not have a nuanced understanding, her arguments worked well. But if her goal was to engage with thoughtful psychiatrists and psychologists, they were not sufficient.
Johnstone replied that her primary goal was to work towards a non-medical understanding of emotional suffering, which was what “mental illness” actually meant. She and her colleagues decided this was necessary because “there is not and never has been” any hard evidence that experiences that are now called “mental illness/disorder” were best understood in that way. There is an overwhelming amount of evidence that they arise from within the person and can be understood as a response to psychosocial adversities. “The dominance of the diagnostic viewpoint blinds us to the extent to which non-medical alternatives are already flourishing.”
In summary, it doesn’t matter whether you think I am putting forward a caricature of diagnosis. Diagnosis—however we choose to understand it—has no place in this field, and nor does the diagnostic thinking that it supports and perpetuates. All human experience has biological aspects, but not all forms of suffering are medical illnesses. We are dealing with people with problems, not patients with illnesses, and the whole paradigm—the “DSM mindset” as clinical psychologist Mary Boyle puts it—needs to change.
Notice another piece of rhetoric here: diagnosis itself is a medical term. So, the critique of psychiatric diagnosis has a medical nuance from the start.
Returning to “The Movement Against Psychiatry,” I agree that whether we are pro-psychiatry or anti-psychiatry resolving disagreements over the medicalization of ‘problems in living’ is complicated. After millions of dollars in research funding, biological psychiatry still finds the human brain to be an enigma. As Allen Frances said, “The human brain is the most complicated thing in the known universe and keeps its secrets well hidden.” Yet he thought the next right thing in care for the severely mentally ill was simple: decent housing; easily accessible treatment; social clubs; vocational rehab. The top priority was to get people out of prison and off the streets; and provide them with proper community housing and care. “How can it be that the richest country in the world is most neglectful of its most vulnerable citizens?”
It’s nearly as useless to be steadfastly pro-psychiatry as it is to be anti-psychiatry. Psychiatry is not a monolith, but an entire field and history, with some practices that are more helpful than others, and a huge range of diversity in terms of the kinds of people it treats.
Can’t we start with a critical psychiatry approach and see where it leads us? Calling for the abolition of psychiatry or diagnosis only results in the further entrenchment of psychiatry and supporters of the medical model with no real change to the existing system. Attempts at dialogue, as with Dr. Aftab’s interviews for “Conversations in Critical Psychiatry” and the formation of groups like CEP, Council for Evidence-Based Psychiatry, and the Critical Psychiatry Network are a good start.