Why The Antipsychiatrists Have It All Wrong

Twitter is an odd place to read about antipsychiatry.  There are apparently some academics in the UK who are keeping it alive and well. I sent this Tweet about the continued mischaracterization of psychiatry by various antipsychiatry factions. Those factions certainly are varied ranging from cults to academics - but they all seem to have an agenda that they are promoting. I certainly don't hope to correct their various rants and obvious conflicts of interest - only to set the record straight from this psychiatrist's perspective.

In a previous post, I pointed out how some of the more famous antipsychiatrists characterize psychiatry as monolithic and fail to appreciate both the diversity in the field and the complexity of the field.  Examples of those errors abound and I included them in previous posts about the monolithic mischaracterization and another rhetorical attack on the DSM-5.

It comes down to power and that argument is a gross distortion of reality. Before I proceed, let me say that I am talking about the time frame that encompasses my training and clinical practice. At this time that is the last 32 years post residency. During that time I have lived and breathed psychiatry and know what really happens in the field.  I came in to this field with my eyes wide open since I had a family member with severe bipolar disorder who was treated for years by primary care physicians with benzodiazepines and antidepressants so that by the time she was able to see psychiatrists - she could be partially stabilized but continued to have significant comorbidity. That family member was my mother.  As her son, I experienced first hand the lack of concern and care by any responsible entity in the community.  When she was extremely agitated and ill to the point that the police were being called repeatedly, I know what it is like when you are a kid and an angry cop says to you: "Do you want us to lock her up like a chicken in a chicken coop?" The cop of course knew nothing about severe mental illness and just wanted to leave and not have to deal with my mother's illness and her 5 young kids (my father was deceased).  In addition to my mother's illness, I witnessed first hand the toll that psychiatric illness had on the neighborhood as I walked to school every day. My point here is that I am not the only kid who had these problems.  In fact, I am certain the general view that psychiatric illnesses and addictions are diseases begins with this experience.

As a clinical psychiatrist with a solid medical orientation, my method has always been one that tries to engage the patient in a detailed analysis and solution to their problem.  Like many physicians, as a resident there is always an emphasis on what you are doing to solve the person's problem, but it was fairly evident that medical interventions themselves were risky and that higher risk interventions should be reserved for high risk conditions. It was also obvious that medical treatment depended on informed consent.  In other words provide the information to the patient and they either consent or don't consent to treatment.  It is really no different than seeing any other physician.

Since antipsychiatrists are a diverse group, they advance diverse rhetoric to advance their agendas.  That typically includes making money or seeking to elevate their status over psychiatry.  I will focus on a single common agenda and that is power.  The last time I actually studied power it was in a physics class.  It certainly never came up in medical school.  Studying psychiatry was an identical process to studying medicine and surgery.  Recognize the problems, diagnose, and treat them.

Somewhere along the line I realized that people were using rhetoric based on Foucault and whatever Szasz adapted from that to suggest that psychiatry had a hidden agenda.  It is so well hidden that it is unknown to psychiatrists.  It is more or less of a conspiracy theory that psychiatry wants to medicalize the treatment of all human behaviors and treat those behaviors as an illness.  Of course along the way, psychiatrists will enrich themselves and inflict untold suffering on the people they misdiagnose and treat.  Take a look at this argument that the DSM-5 was supposed to be a manual about how to live as an example. Their supporting arguments range from the non-existence of all mental illness to the fact that there are no tests that prove there is such a thing as mental illness.  The underlying antipsychiatry theories are predominately from the 1960s and 1970s and they have been classified by philosophers (1).  There has been little change since then - just a long series of repetitive recycled arguments.  The rhetoric can range from the recycled arguments of Szasz to overt threats.  One uniform feature of antipsychiatrists is that they believe they are above any sort of criticism.

The table below contains some of the common rhetoric used by antipsychiatrists. It is not exhaustive, but it is a good example of the rhetoric I referred to in my Tweet.

Here is why their power arguments and all of the associated rhetoric are irrelevant. The reality is that psychiatrists represent only 5% of mental health providers in the US.  Primary care physicians and now nurse practitioners and physician assistants prescribe far more medications than psychiatrists do and they have for some time.  Even though psychiatrists are a little slow in picking up on it – health plans are replacing physicians with non-physician prescribers and that is also true of psychiatry.  In fact, in most cases if you are trying to see a psychiatrist about medications you will end up seeing a nurse practitioner. Does that sound like an all-powerful profession?

The second point that the detractors seem oblivious to is that physicians in general have not run the field of medicine for the past 35 years. Nobody cares what a psychiatrist or for that matter any physician has to say.  Businessmen and politicians determine who patients see, for how long, and what those physicians are paid.  The only exception is specialty groups (Radiology, Orthopedics, Neurology, Urology, Ophthalmology) that can avoid employment relationships with healthcare organizations.  Does that sound like an all powerful profession? Strange that the antipsychiatrists with guild issues don't get that since they are under the same constraints from these monopolies.  

More to the point – if you see any physician in the USA and you don’t like what you are hearing – you are free to walk away and see somebody else.  It is not a question of being a victim of medical or psychiatric treatment.  In fact, psychiatric treatment is just as straightforward as I have portrayed it.  Come in, sit down and we will talk about your problems. My job is to give you the best possible scientifically based advice.  Your job is to decide whether to take it or not.  There is no medical treatment known that does not involve some risk.  Accepting treatment involves risk. If you accept that risk and are injured that does not mean that you were intentionally victimized by that physician or the profession.  In fact, only antipsychiatrists seem to routinely use that argument. 

Consider an example very familiar to me. Let’s say you are diagnosed with a hormone secreting pituitary adenoma.  The neurosurgeon you are seeing recommends removal but also says there is a chance that the carotid artery may be cut and the result would be catastrophic and irreparable.  Your choices are an experimental procedure with an uncertain outcome that may lead to surgery or radiation therapy (gamma knife) or doing nothing and trying to manage symptoms that will lead to your eventual death by congestive heart failure.  The risks are clear and significant, but the majority of people who I have met who have had this conversation decided on surgery. Antipsychiatrists will say it is not the equivalent to a suicidal person deciding to take an antidepressant.  I would say the risk of no treatment is equivalent, but the actual risk of psychiatric treatment is much less.  I have not seen a catastrophic, irreversible event from taking antidepressants as prescribed.  As far as the power dynamic – there is no comparision.  Being unconscious under general anesthesia for hours while an ENT surgeon and a neurosurgeon drill through your sphenoid bone into your pituitary fossa doesn’t compare to consciously talking to a psychiatrist for an hour, picking up a prescription, and then deciding on a day to day basis to keep taking an antidepressant pill.  There is really no comparison at all.

The point of this example is not that patient injuries do not occur during patient care. The point is that they do occur but that is the risk people generally have to take to get well.  The notion that psychiatrists are somehow more likely to cause these injuries and that the entire profession should be blamed as a significant cause of injuries compared with other specialists is a dubious argument at best.   

Antipsychiatry rhetoric has really not changed much over the years.  There is just a question of how much distortion, overt paranoia, or conflict of interest it contains.  In the 50 years that the antipsychiatrists have been hard at work, they have had more than ample time to come up with an alternate way to help people with severe mental illness.  To my knowledge they have not come up with a single treatment for mental illness. Of course that is no problem if you don't believe mental illness exists or that there is any way to diagnose or treat it.

That would also mean that the antipsychiatrists would have to do something positive instead of just blaming psychiatrists.  I am not holding my breath for that day to come.

George Dawson, MD, DFAPA




References:


1:  Fulford KWM, Thornton T, Graham G.  Oxford Textbook of Philosophy and Psychiatry.  Oxford University Press, Oxford, 2006: 17.



Graphic Credit:

Samei Huda contributed 3 points on the graphic.