The evolution of modern psychiatry has at times been fraught, but the discipline has adapted and survived through periods of controversy. As with any scientific endeavor, self-criticism and self-correction are intentional built-in features required for growth that move us closer to truth. Disciplines that lack rigorous mechanisms for such interrogation, such as the peer-review process, are at risk of crossing the fuzzy boundary from science into pseudoscience. Medical disciplines that do not confront their tarnished pasts -- as all disciplines must -- will never grow to be better versions of human healing. Scientific criticism of psychiatry is therefore both necessary and healthy to the benefit of people who experience mental health concerns.
But beyond scientific critique, psychiatry has long been a target of criticism that has been moralistic and ideological as well. Dating back to at least the 1960s, the so-called "anti-psychiatry" movement began as an understandable reaction to various missteps of psychiatry, such as the over-medicalization of mental health, the inhumane management of asylum care, and the inappropriate pathologizing of minority groups. In the early days of the movement, it might be said that "anti-psychiatry" helped psychiatry to self-correct in a way that moved the discipline towards a more scientific endeavor reliant on empiric evidence, while maintaining a sharp focus on the interaction between biological, psychological, and social contributions to mental health and illness.
More recently, however, the anti-psychiatry movement has lost its way. It has transformed from a predominantly academic and political movement to one of consumer groups, akin to the anti-vaccine saga. In its current form, anti-psychiatry exists as a disorganized entity outside of mainstream medicine, largely propagated on social media and in non-peer-reviewed sources like newspaper opinion articles, books, and blogs that evade scientific dialogue and critique.
Modern anti-psychiatry is not a monolith, yet there are common themes that could be harmful to patients. Different from helpful scientific criticism, it often takes the dangerous form of disinformation that aims to tear down the discipline and deter treatment-seeking. Those who espouse anti-psychiatry ideology often lay charges against the very existence of psychiatric disorders and the wholescale efficacy of psychiatric medication. While the late psychiatrists Thomas Szasz and R.D. Laing remain heroes of the movement, academic critics of psychiatry today are often psychologists with limited experience treating severe mental illness, involvement in medication management, or collaborating with psychiatrists.
A tragedy of anti-psychiatry is that its merit is lost in its extremism. Topics that warrant amplification -- such as the importance of risk-benefit in full informed consent of medications and patient autonomy -- are drowned out by sentiments that position psychiatry as the enemy where only harm stories count and taking a pill is viewed as a morally weak and reckless act that destroys lives.
Ironically, most anti-psychiatry positions now wish to take choices away from patients (for example, the ability to choose a medication instead of therapy) and chastise diagnoses and interventions that many people with lived experience have found helpful and beneficial. On social media, a person with a positive response to medication is often admonished as "lucky," followed by a warning that "these meds are poisonous." A person who identifies with a nuanced explanation of mental disorders -- like borderline personality disorder or even schizophrenia -- are told that these disorders do not exist.
There are common tropes of anti-psychiatry that, in the age of social media, continue to sprout up each day as if they are new, unrefuted issues (see the eight points below). Though debunking these tropes is easy enough, the recurrence of these claims and the personal manner in which they are defended often degenerates into an all-too-familiar pattern of social media name-calling. As one psychiatrist colleague wrote during a discussion about informed consent, "I want to step in and say something, but I don't want to be attacked and harassed online like you all are."
Refuting Common Tropes of Anti-Psychiatry
- "Psychiatry still promotes the 'chemical imbalance' hypothesis to explain mental illness." Not really. The "chemical imbalance" explanation was an early and incorrect way to make sense of the effectiveness of medications that alter neurotransmitters like dopamine or serotonin in the brain, whereas in reality the biochemical mechanisms of mental illness and how treatments work are still being researched.
- "It is not ethical to use a medication if one doesn't know the mechanism of action." This has never been a principle of medicine. Efficacy and safety are routinely established long before full mechanisms are understood and they guide future understanding of pathophysiology.
- "Psychiatric medications are harmful." All medical interventions can cause harm, including surgery, medications, psychotherapy, and recommendations to exercise. In medicine, interventions must be understood and explained to patients in terms of "risk-benefit" relative to prognosis without treatment. This is the foundation of informed consent.
- "Psychiatric medications don't work." There are a range of different psychiatric medications used to treat different conditions, each with varying levels of efficacy compared to placebo.
- "Psychiatric diagnoses are made by checklist." Sound diagnosis requires thorough investigation, interview, collateral history, objective examination, and sometimes "ruling out" medical disorders and other psychiatric issues. Bonus side trope debunking: the DSM (Diagnostic and Statistical Manual of Mental Disorders) is not the "Bible" of psychiatry -- it is more of an imperfect "rough guide" that continues to be revised.
- "Psychiatrists practice 'biological psychiatry.'" Modern psychiatry is a medicine subspecialty that seeks to understand mental illness based on the integration of biological, psychological, and social aspects of one's life. In this respect, psychiatry was ahead of most medical fields in understanding the impact of psychology and social factors on health.
- "Psychiatrists seek to 'medicalize normal.'" The boundary between health and disease is "fuzzy" across all of medicine, where the treatment of disease overlaps with health promotion. Generally speaking, psychiatry focuses on emotional suffering and impairments to functioning, whether it is an "expected reaction" or not.
- "Mental illness doesn't exist." The definitions and boundaries of particular mental disorders fluctuate over time, reflecting our shifting understanding of the biological, psychological, and social phenomena that account for them. Mental disorders can best be understood as symptom clusters that co-occur in patterns that can be recognized and identified with good "inter-rater reliability" in order to guide evidence-based treatment approaches.
Unfortunately, debunking anti-psychiatry claims outside of a therapeutic relationship is an ethical duty that can feel like a personal attack to those with lived experience who identify as being harmed by psychiatry. Indeed many, but not all, who campaign against psychiatry are former or active patients that report experiencing harm firsthand. On the one hand, medical side effects are real and patients sometimes feel too uncomfortable to speak up with or feel otherwise unheard by their treating clinicians. The internet provides a useful outlet to vent feelings of anger and resentment and to seek camaraderie from people with similar experiences. But on the other hand, just as anti-psychiatry is not a monolith, neither is psychiatry or patient experience. Generalizing criticism from one medication or one interaction to all of psychiatry invalidates the benefits that many people derive from psychiatric care and that psychiatrists witness in clinical practice.
Like many debates today, seemingly irreconcilable differences in perspective about psychiatric treatment often boil down to disputes over epistemology and the evidential basis of knowledge or facts; in other words, differences in belief about how we come to acquire knowledge. While human beings tend to see subjective, lived experience as an irrefutable reality as well as a source of great meaning, psychiatrists -- perhaps more than anyone -- know that subjective perceptions are biased and often wrong. The scientific method is an antidote to that bias, with truth being determined by repeated, objective, and controlled observations and experiments. The inherent tension between objective assessment and subjective experience risks invalidating lived experience unless negotiated carefully and compassionately outside of a therapeutic relationship. Unfortunately, some patients who identify with being harmed by psychiatry have given up on finding that kind of relationship and instead attempt to find meaning in identity as an injured party.
It might be said that the Achilles' heel of modern anti-psychiatry lies in its inevitable conflation of scientific scrutiny with moralistic criticism. This is no doubt an unfortunate result of many within the anti-psychiatry movement feeling excluded from the "inner circle" of scientific self-scrutiny, so that moralistic criticism seems like the only option. In a similar and all-too-familiar way these days, the lay public also conflates scientific research with online "research" (as the author Dan Brown warned, "Google is not a synonym for research") where the often quasi-scientific claims of those who post on blogs and social media escape careful peer review. It is easy to be a critic, especially when one has a bone to pick.
Anti-psychiatry rhetoric distracts from legitimate criticisms of psychiatry: over-diagnosis related to insurance reimbursement, over-prescribing to the exclusion of psychosocial therapies, and the profit-driven influence of "Big Pharma." In fact, such perils are healthcare system issues that most psychiatrists would love to see change. But independent of those issues, ethical psychiatric care helps people. Well-trained psychiatrists remain vigilant about over-diagnosis and over-treatment; they are patient-centered and evidence-based; they practice conservative prescribing and de-prescribing when appropriate; and they constantly preach "skills over pills"! Unethical care, out-of-date diagnostic considerations, and poorly informed, consented, and followed-up medication use are quite certainly the common enemies of psychiatry and anti-psychiatry, and there could be common ground shared in the volatile space that separates them.
Ultimately, the under-recognized harm of anti-psychiatry rhetoric is the stigmatization of people who experience psychiatric disorders and its treatment, which can translate to compromised patient care. All too often, those within the anti-psychiatry movement actively seek to steer others away from appropriate psychiatric treatment altogether. Psychiatry is far from a perfect science and must continue to evolve and improve over time and in response to criticism. But the wholescale assault on psychiatry as a profession invalidates the many positive treatment experiences people have had and robs others from the chance to benefit from much-needed, evidence-based care.
Jonathan N. Stea, PhD, RPsych, is a registered and practicing clinical psychologist and adjunct assistant professor at the University of Calgary. Clinically, he specializes in the assessment and treatment of concurrent addictive and psychiatric disorders. Follow him on Twitter: @jonathanstea
Tyler R. Black, MD, FRCPC, is a child and adolescent psychiatrist and the medical director of the Child and Adolescent Psychiatric Emergency Department at BC Children's Hospital. He is also a clinical instructor in the Department of Psychiatry at the University of British Columbia. Follow him on Twitter: @tylerblack32
Joseph M. Pierre, MD, is a health sciences clinical professor in the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA. His clinical work focuses on the treatment of individuals with severe mental disorders, including schizophrenia, bipolar disorder, major depression, and co-occurring substance use disorders. Follow him on Twitter: @psychunseen
Disclosures
The authors reported no conflicts of interest.