Taking a Critical Look at Critical Psychiatry

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This is the second part of a series on anti-psychiatry—a.k.a. critical psychiatry—taken from an interview I did with Shayla Love for her Vice article, "The Movement Against Psychiatry." The interview has been edited and updated with expanded answers.

I spoke with one psychologist who found that working with very mentally ill people, like those with psychosis, challenged his notion of anti-psychiatry. Do you relate to this? How does antipsychiatry explain these severe conditions, like schizophrenia?

It has been noted that the anti-psychiatrist Thomas Szasz never really worked in a hospital setting with patients with severe mental illness, which colored his views about mental illness and civil commitment. Likewise, I think that some anti-psychiatry views—like the claim that “schizophrenia doesn’t exist”—are rooted in errors of conflating the “softer” end of the mental illness-mental health continuum with the “harder” end. In other words, if more people saw severe mental illness up close, there might be less anti-psychiatry sentiment along the lines of "mental illness doesn't exist." In fact, when the general public sees severe mental illness in front of them, in their neighborhoods, or on the street corner, what we often hear is people clamoring for more civil commitment and involuntary psychiatric treatment. Compared to that perspective, it's often psychiatrists who are the ones advocating to preserve a patient’s rights and autonomy.

On the subject of "undiagnosing" people—how do you think this plays into the whole anti-psychiatry conversation? Has people getting undiagnosed bolstered the ideas of anti-psychiatry? How so? What criticisms of psychiatry do you think incorrect diagnoses raise, and how do you think it should be addressed, outside of deciding that psychiatry is fundamentally flawed?

The reality is that diagnoses change all the time, as they should, based on new information that relates to the clinical course or clarifications about the causes of symptoms such as drug use. So, diagnostic revision and “undiagnosing” is a routine part of clinical practice.

Categorical boundaries by their nature are attempts to “carve nature at its joints” as they say, but they’re often imperfect. When I wrote about this with Allen Frances and others some years ago, in response to him posing a question about the best “umpire” style in psychiatric diagnosis, I cited the analogous example of Pluto… Is it a planet? Is not? If it is, should other non-planets be given the label? If the answer is fuzzy, does that mean that astronomy is fundamentally flawed and that planets don’t exist?¹

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is intentionally vague in order to leave room for clinical judgment. Different clinicians might have different thresholds of diagnosis, just as different patients have different thresholds of stress tolerance that might lead them to seek, or for that matter to avoid, help. That reflects the messiness of real life.

Used in the context of antipsychiatry, I think the term “undiagnosed” is more often used to mean that diagnoses were inappropriately applied in the first place based on the argument that “nothing is actually wrong” with the patient or that, echoing R.D. Laing, the problem is with society and not the individual in question. I’m less sympathetic to that claim when I see a patient who is help-seeking. It’s more common that in “undiagnosing” someone, I’m actually “re-diagnosing” someone rather than telling them, “there’s nothing wrong with you… you don't need any help.” Of course, part of the diagnostic challenge here and across all of medicine is that insurance reimbursement requires that DSM be used as a billing manual. That unfortunately incentivizes diagnosis on the more severe side of the diagnostic continuum.

What do anti-psychiatrists propose as treatment instead of psychiatry?

There’s a wide range of touted alternatives that includes no treatment (including a kind of “pull yourself up by your bootstraps” approach), psychotherapy (instead of medications, as if psychiatry is only about prescribing), and "lifestyle alternatives” including things like exercise, dietary changes or herbal supplements, or other less conventional approaches like Reiki (or even Scientology's Dianetics).

But it’s important to remind ourselves that many of the anti-psychiatry criticisms that are directed at psychiatry can apply to these alternatives as well. For one thing, all of them have potential harms. That’s certainly true of doing nothing to treat mental illness and even true of psychotherapy that's a core part of psychiatric care. For another, many of these alternative approaches—especially the kind we see promoted within the “wellness movement” today—also represent for-profit industries where conflicts of interest can be significant. Many who promote anti-psychiatry rhetoric are trying to sell people on something else.

Do the tenets of anti-psychiatry threaten to harm some mentally ill patients? How?

The biggest potential harm of anti-psychiatry ideology is that it can prevent people from seeking care and can invalidate the experiences of people who have been helped by psychiatric treatment. Mental illness stigma is a significant obstacle to mental health, so the last thing we need is another way to disincentivize people from reaching out for professional help.

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Does anti-psychiatry feed into conspiracy theories about the medical industry at large, big pharma, etc?

Certainly part of the antipsychiatry narrative is that “psychiatry” is in bed with “Big Pharma,” with individual psychiatrists hopelessly biased by its advertising propaganda. There’s no doubt that some egregious examples of such conflicts of interest have unfortunately occurred. Like other sectors of industry within a capitalistic society, psychiatry has to take better care to maintain its focus on quality patient care, steering clear of for-profit industry influences.

With regard to conspiracy theories more generally, there’s evidence that people who tend to believe in them are often attracted to other conspiracy theory narratives, even when they’re logically incompatible. So yes, I suspect that antipsychiatry views have some overlap with critical and conspiratorial attitudes towards medicine and science. As someone interested in why people hold false beliefs, I've followed the “anti-vaccination” movement closely and have seen many parallels with anti-psychiatry, with claims about vaccine side effects based largely on anecdotal evidence that isn't reflected in objective studies. And yet, I’ve been somewhat surprised that I haven't seen evidence of anti-psychiatry and anti-vaxxers being actual bedfellows and on the contrary, anti-psychiatrists often seem to loathe being compared to anti-vaxxers.

But the parallel is there nonetheless. Both anti-psychiatrists and anti-vaxxers are fundamentally opposed to medical interventions that they see as ineffective and harmful. Both rely primarily on the subjective anecdotal experiences of those that have claimed “harm” and “damage," whereas that harm is, for the most part, not reflected in the clinical experience of physicians, research studies, or in FDA reporting databases. Of course, vaccines and psychiatric treatment alike do have potentially serious side effects, but claims like developing autism from vaccines, having permanent “brain damage” from ECT, or being bedridden for years from short-term medication side effects like antidepressant withdrawal or akathisia raise legitimate questions about validity and causality.

This fundamental disconnect between the subjective experience of patients and doctors and between patient reports and objective data is at the heart of the divide between psychiatry and anti-psychiatry. For psychiatrists, it's hard to accept such claims at face value outside of a therapeutic relationship. For patients who identify as being harmed, the counter-claims of doctors and research data are in turn rejected as unreliable, deceitful, and corrupted by influences like Big Pharma. Evil Pharma, corrupt doctors, and harmful medications are all-too-convenient conspiratorial tropes, but they exist because there have been some real-life examples and because they reflect mistrust of actual entities of power. In the end, this mistrust means that some have given up any hope of treatment in favor of seeking support and validation elsewhere, often on the internet where there are ample testimonials indicting psychiatric interventions.

That to me is the real challenge of finding common ground with anti-psychiatry. On the one hand, patients insist they’ve been irreparably harmed by psychiatric interventions. On the other, the psychiatric establishment is skeptical about some of those claims. How do we bridge that divide? Through better research investigating the risks and benefits of psychiatric interventions? Absolutely. But on the individual level, my undying refrain is that this is best addressed between a patient and their psychiatrist or some other qualified mental health professional. Unfortunately, anti-psychiatry ideology and mistrust—whether earned or not—can prevent that collaboration from happening.

How do you respond to anti-psychiatry claims coming from academia and other mental health professionals?

I want to be clear that some aspects of psychiatry deserve criticism and that psychiatry, as a profession, should be open to it. Certainly, there are legitimate examples of serious missteps in the history of psychiatry and there's plenty of room for middle ground between psychiatrists and anti-psychiatrists today. At the same time, those doing the criticism shouldn't be immune from critique themselves. For all the claims of corruption and conflicts of interest in medicine and psychiatry, there have been few attempts to shine a light back on potential conflicts of interest within academic anti-psychiatry.

Criticizing psychiatry is potentially big business. Within the anti-psychiatry movement, the “academics” are often psychologists, especially in the UK, along with a few psychiatrists and other mental health professionals, and some science writers. Many of them have built careers and professional identities based on their anti-psychiatry stances. Some have made substantial sums of money as expert witnesses testifying against drug companies. Many have written books about anti-psychiatry or about cognitive behavioral therapy (CBT) while touting it as a better alternative to medications—even for psychosis, with little acknowledgment of studies that have failed to support the efficacy of CBT in schizophrenia² or that some patients with severe psychosis or other mental disorders are too ill to be able to participate in talk therapy. Details like these support the idea that there’s a “guild war” element to anti-psychiatry, much more so in the UK than here in the US, though the pitting of psychiatry against psychology wrongly suggests that medication management and psychotherapy is an either-or. But that's not the case at all—both treatment modalities are important parts of psychiatric care and many psychiatric disorders are best managed with a combination of both. And needless to say, psychiatrists and psychologists often work collaboratively side by side here in the US and Canada without any conflict.

Do you know anything about the Bonnie Burstow Anti-Psychiatry Fellowship at the University of Toronto? What do you make of including anti-psychiatry ideas into the education and training of young people?

I had not heard of this fellowship, but thinking critically about psychiatry is part of the scientific process. Psychiatric training should including teaching on where the discipline has gone wrong historically and where there are still areas of controversy now.

But that’s different than “teaching anti-psychiatry.” Of course, what constitutes legitimate and illegitimate controversy is central to the distinction, but also a matter of perspective and ideology. By way of analogy, some believe that creationism should be taught as an alternative to evolution. Others believe that we should be teaching about the “other side” of the climate change debate, as if there isn’t a 97% consensus of climate change scientists on the matter. Scientists and psychiatrists alike should avoid the trap of overly dogmatic thinking, but that’s not the same as supporting the false equivalence issue of “both sides” that seems common today. I think that applies here to “anti-psychiatry.”

Do you have any recommendations for people I could talk to who are "anti-psychiatrists" but hold nuanced opinions?

You might try Dr. Awais Aftab—not an "anti-psychiatrist," but a psychiatrist who moderates the Conversations in Critical Psychiatry column in the Psychiatric Times. His recent interview with Ken Kendler addresses some nuanced issues related to psychiatric diagnosis and the series in general has featured an impressive range of critical perspectives.

To read more about the anti-psychiatry movement:

• What is Anti-Psychiatry?
• Answering Antipsychiatry
• Why Anti-Psychiatry Now Fails and Harms