Ethical Human Psychology and PsychiatryThis blog post is a re-posted article from Ethical Human Psychology and Psychiatry Volume 15, Number 1, 2013.  Full sample downloads of this journal are available here.

It is evident, over the past 30 years, that there has been widespread promotion of the concept of a biological basis for psychiatric disorders and direct promotion on the belief by medical experts in media, texts, and public meetings. In developed countries, and in particular the United States, this has resulted in epidemic comparable increases in the percentage of the population that are diagnosed as having a psychiatric disorder.

The associated increases in drug-based treatments have resulted in financial benefits to pharmaceutical companies and medical experts. This relationship raises questions concerning the construction of knowledge, particularly in light of the claims promoting a proven biological/neurological basis for many psychiatric disorders that, at this point, has not been clearly established in research (Healy, 2012; Whitaker, 2010).

The claims made in the biopsychiatric discourse are supported through reference to experts’ opinions, scientific research studies, and reports in refereed journals. Linked to the research studies and journal articles are medical experts, many in esteemed positions in universities, whose power over the discourse is impenetrable even to practicing physicians, nurses, other health workers, education systems, teachers, parents, and the individuals diagnosed with a mental health disorder.

Understanding the context of the hegemonic medical model of psychiatry is critical given the rapid increases in the number of individuals diagnosed with psychiatric disorders. What is considered normal in a society varies over time and the definition of deviance can and does change in accordance with the values of a society. The increased use of psychiatric diagnoses raises questions concerning the forces in society that  have led to the acceptance of, and increasing promotion of drug regimes for an ever-increasing number of psychiatric disorders, evident in each new edition of the American Psychiatric Association’s (APA; 2011) Diagnostic and Statistical Manual of Mental Disorders (DSM). With the recent release of the DSM-5 in 2013, this issue of the journal has a focus on questioning aspects of the hegemonic psychiatric discourse.

Individual and community expectations of psychiatric medical intervention are that treatments will produce positive outcomes and result in improvements in the functioning of individuals diagnosed with a mental health problem. However, negative consequences from pharmaceutical and biopsychiatric treatments are not new or uncommon phenomena. Iatrogenic outcomes resulting from adverse drug reactions have been well documented in medicine (illustrated by the devastating consequences of thalidomide) and in biopsychiatry (illustrated by the development of tardive dyskinesia in a significant percentage of patients as a result of long-term treatment with neuroleptic drugs; Lader, 1993).

This issue of the journal concludes with an In Memoriam to Thomas Szasz. Szasz was one of the first significant critics of biopsychiatry. Szasz’s initial text The Myth of Mental Illness, first published in 1961, critiqued the biopsychiatric construct of mental illness and outlined the potentially flawed constructs of biopsychiatry. Szasz’s critical commentary was underpinned by libertarian views. He was damning of the role of psychiatry because of its coercive nature, reflected by involuntary treatment programs. Szasz’s analysis extended beyond the problems of coercion associated with psychiatric intervention, and condemned the very construct of mental illness and associated treatments (Szasz, 1976).

In Pharmacracy, published in 2001, Szasz refined his analysis, defining “pharmacracy” as a totalitarian regime of social control that uses drug therapy as the main regulating mechanism (Szasz, 2001). The agents of the regime are the health care professionals, principally psychiatrists, whose certifying role classifies, what Szasz perceived as, socially undesirable, unacceptable, or criminal behavior as diseases and results in the use of psychotropic drugs and other biopsychiatric interventions for treatment and solution. Szasz viewed the transformation of human vices, wickedness, and social problems into a socially constructed framework of biopyschiatric disorders as replacing legislative control of human behavior with a form of social control defined as pharmacracy (Szasz, 2001).

Throughout his work, Szasz dismissed biopsychiatric claims of a neurological basis for psychiatric diagnoses and suggested that if there were a neurological basis for such disorders, then the domain of treatment would lie in the field of neurology and not in psychiatry. Szasz illustrated his tenet using epilepsy as an example of a previously considered psychiatric disorder that was later discovered to be, as Szasz described, a true “brain disease” that can be diagnosed objectively (Szasz, 2001).

Szasz suggested that the vague, subjectively diagnosed “mental illnesses” were fraught with value-laden judgments combined with invalid or meaningless diagnostic procedures that allowed human behaviors, including criminal actions, to be incorrectly claimed to be the result of biologically based/neurological disorder. Szasz draws on a historical perspective to defend his analysis. Behaviors previously deemed deviant by psychiatry include homosexuality and masturbation. Szasz noted that in the past, homosexuals were incarcerated in psychiatric institutions and children were treated as deviant for exhibiting normal sexual behavior and subjected to anti-masturbation treatments (Szasz, 2001).

The discourse of experts defines the roles of agents, including government and bureaucratic organizations, to implement the discipline over the body or subjects whether indi- vidual or broader social groups (Foucault, 1979; Habermas, 1984, 1987). This process ensures that the hegemonic group maintains control and ensures that the social order is structured to meet their ends (Parton, 1994).

Foucault (1979) indicated that medical dominance is maintained by knowledge and truth claims of medical experts. The hegemonic medical view is grounded in beliefs concerning the absoluteness and infallibility of scientific method. Scientific method when applied to studies of human behavior, particularly in the area of mental health, cannot be value-free or objective in the way it is constructed in the traditional areas of science such as physics (Parton, 1994).

Habermas’s (1984, 1987) critique of Western societies led to his belief that communicative rationality in an ideal speech situation was the avenue for resolving the problems and contradictions of modern society. The process he suggested for resolution was use of open discourse concerning knowledge and truth without domination and manipulation by factional or vested interests.

Habermas (1984, 1987), in conceptualizing the ideal speech act, found its historic origins at the turn of the 20th-century German coffee house discourses that provided a forum for critiques and discussion of social change. The process of open discourse, Habermas (1984, 1987) believed, provided a medium for constructing true democratic process in contrast to a society, as he viewed it, being dominated by the hegemonic control of experts, technocrats, and bureaucrats.

With the perspective that open discourse should be encouraged, this issue of the journal is dedicated to challenging and critiquing biopsychiatry in the year of publication of the DSM-5. Characteristic of the promotion of biopsychiatric disorders through media and lobby groups has been the dismissal of counterclaims or alternative viewpoints to the hegemonic psychiatric model. Concerns or critiques are downplayed with emotional or humanitarian claims of the need to provide modern, biological, scientifically proven treatments that are necessary and essential for the improved functioning and relieve the suffering of individuals or groups labeled with a particular disorder.

According to the APA, the process setup has been the most extensive developmental process established to develop a version of the DSM. However, was the process a method of open discourse constructing true democratic practice and resolving issues without the domination and manipulation by factional or vested interests?

There appear to be some disquiet in relation to many aspects of the way the DSM-5 has been developed. In the DSM-5 Task Force Response: Letter to the American Counselling Association, the APA indicate that,

After the DSM-5 Task Force was formed in 2007 . . . APA established 13 work groups, each with 8–15 members who are leading clinicians and researchers in the field, to address the various areas for review. Since then, the 160 members of the DSM-5’s 13 work groups have sought to review nearly two decades of research published since the introduction of DSM-IV. (p. 2)

The American Counselling Association (ACA) called for an “independent, third party review” (p. 2). The APA response to that request was to indicate that review had already been established by the “work groups and the close coordination APA has with other national and international scientific groups” (p. 2). Is an APA review of its own work an independent, third party review?

There are many issues relation to the process and ideology behind the development of the DSM-5. In this issue of Ethical Human Psychology and Psychiatry (EHPP), the lead article “Psychiatry as Ideology” by McLaren (2013) challenges the basis of the hegemonic psychiatric viewpoint and reviewed the literature to conclude that none of the published biologically focused studies has proven that a psychiatric disorder is a brain/neurological disorder. In his review, McLaren critiqued the role of the U.S. National Institute of Mental Health (NIMH) in promoting a biologically bias in the field of mental health. McLaren concluded that biologically based psychiatry is an ideology and that many of the published articles promoting the biological construct of mental disorder are propaganda.

Gomory (2013) reviewed the limitations of evidence-based medicine in the field of mental health practice and concluded that the model is a pseudoscientific tool. He noted that, in synergy with McLaren’s review, that NIMH supported expert panel approaches to determine evidence-based practices effectively reduces all conclusions in the field to the lowest level of scientific proof possible, experts’ opinions.

Jacobs (2013) in his article “What’s Wrong WithPsychiatry in Plain English” deconstructs, in a personal and somewhat unorthodox style, the DSM-5 task forces approach to redefining normal and abnormal in relation to the complex bereavement process. His article reflects the lack of any real scientific basis for decisions made to determine whether a psychiatric diagnosis is included in the DSM-5. In alignment with David Jacobs’s perspective, I would assume that normal bereavement is directly related to the individual’s circumstances. For instance, the period of bereavement with the loss of a child under tragic circumstances should not be defined by time and the parents should be supported compassionately and with empathy and not viewed as having a psychiatric disorder. The passing of one’s canary may be another matter.

The last two articles in this issue focus on interventions that are not based on a biological model of psychiatric intervention but on compassion and understanding of the complex circumstances that lead or result in an individual with a mental health crisis. Both articles are written by experienced psychoanalysts with more than 100 years of practice in the field between them. Whittaker (2013) outlines psychoanalytic approaches to resolving schizophrenic thinking and Bertram Karon provides insight into psychoanalytical strategies to treat phobias (Karon & Widener, 2013).

EHPP encourages authors to submit articles reviewing or critiquing the process of development of the DSM-5 and any other aspects that are of concern.

 

REFERENCES

American Psychiatric Association. (2011). DSM-5 Task Force Response: Letter to the American Counselling Association.  http://www.dsm5.org/Documents/DOC001.pdf

Foucault, M. (1979). Discipline and punish. Harmondsworth, United Kingdom: Penguin.

Gomory, T. (2013). The limits of evidence based medicine and its application to mental health Evidence-Based Practice (Part One). Ethical Human Psychology & Psychiatry, 15(1), 18–34. Habermas, J. (1984). The theory of communicative action, Vol. 1: Reason and rationalization of society. Boston, MA: Beacon Press.

Habermas, J. (1987). The theory of communicative action, Vol. 2: Lifeworld and system: A critique of functionalist reason. Boston, MA: Beacon Press.

Healy, D. (2012). Pharmageddon. Berkeley, CA: University of California Press.

Jacobs, D. H. (2013). What’s wrong with psychiatry in plain English? Ethical Human Psychology & Psychiatry, 15(1), 35–49.

Karon, B. P., & Widener, A. J. (2013). Cognitive fears and psychoanalytic phobias. Ethical Human Psychology & Psychiatry, 15(1), 59–62.

Lader, M. (1993). Neuroleptic-induced deficit syndrome. Journal of Clinical Psychiatry, 52, 493–500. McLaren, N. (2013). Psychiatry as ideology. Ethical Human Psychology & Psychiatry, 15(1), 7–17. Parton, N. (1994). Problematics of government: Post modernity and social work. British Journal of Social Work, 24, 9–32.

Szasz, T. (1976). The myth of mental illness: Foundations of a theory of personal conduct. London, United Kingdom: Harper & Row.

Szasz, T. (2001). Pharmacracy. Westport, CT: Praeger Trade.

Whitaker, R. (2010). Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. New York, NY: Crown.

Whittaker, L. (2013). Resolving the trouble with schizophrenic thinking. Ethical Human Psychology & Psychiatry, 15(1), 50–58.