Antipsychiatry

I debated whether to call this post "antipsychiatry" or "critical psychiatry". Hardly anyone label themselves "antipsychiatrist", at least not these days. It's mostly a term very conservative psychiatrists and psychologists use to smear everyone who disagrees with them. But "critical psychiatry", which is something people do use about their own work, seems a bit too broad. We can think of "criticism" as existing on a scale from those who see systematic problems in psychiatry and the need for some reforms, over those who see the need for very extensive reforms, to those who basically want to tear the whole system down and can properly be called "anti". I want to look at those who are more towards the "anti" end of the scale in this post.

Psychiatry needs criticizing

1. Bad doctors 

Psychiatry absolutely needs criticizing, and there are absolutely systematic problems in the field that cannot be explained away as isolated incidents. I've met some wonderful doctors both as a patient and as a scholar, but there are also many who treat their patients badly, not just "a few bad apples" here and there. 
There are psychiatrists who think that there's no need to listen to their patients or take seriously what they say since they're crazy anyway. Some may have an okay attitude to some patient groups, while being horribly dismissive to, e.g., BPD patients and people with schizo diagnoses. Many psychiatrists serving in mental health tribunals believe that any patient who disagrees in any way whatsoever with their doctor thereby exhibits "lack of insight" (Susanna Radovic has done research on this). Psychiatrists can be very dismissive of patient complaints about medication side effects, even when these cause terrible suffering. Patients may get more and more diagnoses and more and more meds prescribed until they're basically zombies.

The last problem - loads of diagnoses, loads of meds - need not stem from dismissive attitudes towards patients, but an honest desire to help. A psychiatrist once told me that he suspected something like this often goes on: the psychiatrist tries one treatment after the other for the initial diagnosis, but none helps. Both doctor and patient feel frustrated and desperate. When the doctor tells the patient "hey, I think the problem might be that you actually have X in addition to Y! I'm gonna prescribe you a medication for X too!" both of them feel better and more hopeful. But after a while, when the patient still hasn't improved, they feel frustrated and desperate again ... until the doctor once again goes "hey, I think the problem might be that you actually have Z in addition to X and Y!" and they feel momentarily better. And so the vicious circle continues.
Moreover, present-day diagnostic manuals stress what's most unique about each diagnosis, rather than what's most typical. (Mads Henriksen held an interesting presentation about this at a conference I attended earlier this summer.) It is, for instance, very common and typical for schizophrenia patients to suffer from anxiety. But anxiety is hardly unique for schizophrenia - diagnostic criteria instead stress more unusual symptoms like hallucinations. Therefore, psychiatrists might think that a schizophrenia patient who suffers from anxiety has an additional condition - an anxiety disorder - which requires additional medication. Similarly, it's very common and typical for schizophrenia patients to have difficulties with focus and motivation. But psychiatrists may think this means that the patient also has ADHD, and should get ADHD meds on top of the antipsychotics (that is, a medication designed to increase dopamine flow in the brain in addition to a medication designed to block dopamine flow ...). 

There are also common problems with how psychiatry is depicted in mainstream media and social media. 

2. The modern humor theory

There is legit research on how various psychiatric symptoms may be connected to various brain phenomena and brain events involving various neurotransmitters, but it's all very complicated. However, in popular media and social media, we often encounter a kind of updated humor theory of mental disorders.
In antiquity and the middle ages, people believed that the body has four primary fluids or humors - blood, phlegm, black bile and yellow bile. When these are properly balanced, you're healthy, but imbalances lead to both physical and mental problems. Today, people talk about serotonin, dopamine, perhaps oxytocin and adrenaline too. They must be balanced - if they're imbalanced, mental problems result. The role of the psychiatrist is presumably to prescribe medications that rebalance the different neurotransmitters in the brain. Related to this is the bullshit analogy between diabetes and depression, and insulin and antidepressants.
Many psychiatric patients (perhaps mostly depression patients and people who take meds for ADHD) embrace and spread this modern humor theory because they've been told that they're just lazy and should pull themselves together - saying that they have a chemical imbalance in their brains which is comparable to diabetes is their way of pushing back against the laziness accusations. However, people who believe this theory and believe that psychotropic drugs are like insulin for diabetes will also believe that everyone with a psychiatric diagnosis must be on meds, that it's self-destructive not to. This isn't great either. Especially psychosis patients are often pushed to take meds even if the meds don't work, or even if it makes them all-things-considered worse off, and dismissed as too crazy to understand their own good if they object. I'm not saying that people never quit their meds for stupid and ill-considered reasons - in the past, I have myself quit antipsychotics on a number of occassions because tralalala, I feel so good now, I must be cured! But people also quit them for rational reasons, like I did five years ago, after carefully considering the pros and cons and my whole life situation.

The modern humor theory is compatible with all kinds of explanations of what causes them to go imbalanced in the first place. However, there's a widespread tendency to think that if your brain humors are imbalanced, that's really just a quirk of your brain. Perhaps environmental factors may play some small role, but it's mostly just about what's inside your skull, not about your environment. This is both very problematic and very unscientific - personal trauma, family dysfunction, abuse, poverty, job stress, being PoC in a racist society, etc., are all important causes of psychiatric problems. There's plenty of research on this, but popular media and social media tend to focus on humors and genes. 

3. Just get help

People often say that those who suffer and struggle should just "seek help", with the implicit assumption that everyone can be helped and get better if only they choose to. But even if you find a wonderful psychiatrist, the meds might not work, you might be a so-called "non-responder", you might be unable to recover because of shitty life circumstances that you and your psychiatrist are equally helpless to do anything about, and so on. And there is absolutely no guarantee that you manage to find a wonderful or even descent psychiatrist - a shitty one might be worse than having no professional mental health care at all.
The assumption that people who continue to struggle and struggle basically have themselves to blame for not "seeking help" - like, don't they know that there is help to get - is harmful.

To sum up: There's plenty to criticize. But.

BUT

1. Antipsychiatry and the problematic contrast between psychiatry and somatic medicine

Antipsychiatrists like to argue that psychiatry is radically unlike all somatic medicine. Whereas all somatic medicine is super scientific and objective, with reliable diagnostic methods, obvious borders between "healthy" and "sick", not value-laden at all, psychiatry is unscentific, subjective, unreliable, and all about society's values.
Robert Chapman has published at length about this, but here goes the short version: No. Somatic medicine is not all that antipsychiatry cracks it up to be. Psychiatry needs criticism, but somatic medicine does too!

"Somatic medicine" has many subfields and deals with many different kinds of conditions. Some areas might fit the description antipsychiatrists give better than others - for instance, if someone has a bacterial infection we might be able to determine exactly which bacteria it is and which antibiotics will kill them. We might be able to draw a definite line between those who suffer from this infection and those who don't. But grey areas between healthy and ill are everywhere. When is a hairline fracture in a bone an actual medical problem? When does a little menstrual pain turn into a medical issue? Debilitating back pain is one of the most common physical medical problems, and also one that we can't reliably diagnose except by talking to the patient about their problems. There are some weak correlations between debilitating back pain and stuff you can see on a spinal X-ray, but only weak ones - just like you can see some weak correlations between certain detectable brain events and psychiatric problems.
Generally, anyone who says that there's a clear-cut, objective and non-value-laden difference between what's healthy and what's pathological in somatic medicine thereby shits on the entire field of disability studies. 

2. Anti-psychiatry and dismissing people's lived experience

People have very different experiences with psychiatry, ranging from terrible and in itself traumatizing to positive, helpful, even life-changing. However, just like painting all of psychiatry as great and helpful dismisses many people's negative experiences, painting all of it as shitty dismisses positive experiences. 

I'm not saying that people can't be mistaken about their own experiences, that they can't be caught up in "false consciousness", that they can't fail to see that some system they're deeply caught up in actually oppresses and hurts them. What I am saying is this: The burden of proof should be placed on the person who wants to dismiss people's own narratives as mistaken. 

This goes for medication too. People can be mistaken about the effect a certain medication has on them, that's why we do double-blind randomized trials. But once again, the burden of proof should be on the person who claims the pill-taker is mistaken about the effects of the pill. If I believe in homeopathy and insists that sugar pills have a dramatic effect on my health because of water memory, I think it's fine to dismiss my story based on science in general. But if I take a pill that we know does stuff to the brain, the burden of proof should be on the person who insists that I'm wrong about how it affects me mentally.

I was on antipsychotics for many years. We know that their effects vary a lot from person to person (unfortunately for both doctors and patients, since it's tough to go through lengthy trial-and-error periods looking for a medication that does its job without intolerable side effects). I'm sure there's a sizeable portion of the psychotic population for whom all antipsychotics do is numb them down, but I'm also pretty sure that's not everyone.
When Haldol lost its desired effect on me, I desperately compensated by taking more and more Xanax. Xanax, a benzodiazepine, does numb me down. It extingiushes all my worries, and if I took enough, I wasn't scared of my demons anymore. But Haldol, for quite a lot of years, took the demons away with only a little numbing. Actually, I used to think that it didn't bring me down at all, but after I quit them, I realized that wasn't true. I became more energetic, more creative, more fast-thinking, off Haldol than I was on them. Nevertheless, they were very different from Xanax in their effect on me. I could work full-time on Haldol with no demons - whereas getting rid of the demons, or at least the demon fear, with Xanax, required getting pretty damn drugged.
Now, an antipsychiatrist who claims that I am deeply mistaken - actually, Haldol did nothing but numb me as well, anything in addition must be pure placebo effect - should have the burden of proof on their side. If I and others like me, who do experience a different effect from antipsychotics than benzo, couldn't tell the difference between antipsychotics and benzo in a blinded trial, that would be proof. But in the absence of such studies, we should accept patient testimony. For some, antipsychotics only numb them, for others, it has a more targeted effect.

3. Antipsychiatry and the claim that psychiatry "pathologizes" this or that group

Antipsychiatrists can also move far too quickly from "this demographic receives more psychiatric diagnoses than the population at large" to "this demographic is unduly pathologized". This is a bad move. Yes, sometimes groups are unduly pathologized. The often cited example of "draeptomania" - an alleged mental illness that caused nineteenth century American slaves to run away from the plantations - isn't actually illustrative, because even at the time, most doctors thought this was preposterous. But more recent, actual examples include diagnosing political dissidents with schizophrenia in the Soviet Union and afro-Americans fighting for civili rights with paranoia and psychosis in 1970's USA. However, being oppressed and marginalized can actually make people sick too, physically as well as mentally.
For instance, being black in a predominantly white society increases the risk that one will be diagnosed with paranoid schizophrenia, and being black in a predominantly white neighbourhood increases the risk even further (even though it's unlikely that doctors would have more racist prejudice against black people who live in white neighbourhoods than against those who live in mostly black areas). Psychologist Richard Bentall and others have written about this research, and suggests that people who frequently suffers from real racism might have a higher risk of eventually breaking down and becoming clinically paranoid (Bentall thinks there's also an increased risk if you've been bullied, or just generally persecuted in some manner in real life). I don't think this is surprising - but we miss out on how much marginalization and discrimination hurt people if we dismiss any increased frequency of psychiatric diagnoses as due to "pathologization". 

Comparison: Shift workers have an increased risk of cardiovascular problems. Imagine how problematic it would be if we argued that this is only because medicine has a "day job norm", and therefore considers the softer, more open arteries and rythmical heart beats of day workers "normal", whereas the stiffer, closed-up arteries and irregular hearts of shift workers are "pathologized". 

4. Antipsychiatry and being cool

Finally - antipsychiatrists frequently insist that there's no such thing as "psychosis", there's only "trauma". We shouldn't say, according to these people, that trauma can cause psychosis, because that's already wrong and mystifying. Traumatized people are traumatized, that's all there is. There are no psychotics, only trauma victims. 

Well. If someone thinks they've been misdiagnosied as psychotic, when really they were only traumatized, I say we should listen to them - see above on the importance of taking people's own narratives and stories seriously. But don't push that narrative on me!

I may be tragic in some ways. (Or were tragic in some ways, I'm actually quite well off nowadays!) But I'm also kinda cool, I think. Even my most terrifying psychotic experiences have been much more interesting than just "it's trauma" can convey. (Demons! Alternate realities!) I mean, I have experienced plenty of altered states of consciousness without the aid of drugs. That's kinda cool!
So fuck off to anyone who insists that no, you're not cool, you're only tragic and traumatized.