Anti-psychiatry

Overview
Anti-psychiatry refers to a collection of movements that challenge the fundamental theories and practices of (mainstream) psychiatry. Common criticisms include: that psychiatry applies medical concepts and tools inappropriately to the mind and society; that it too often treats patients against their will; that it inappropriately excludes other approaches to mental distress/disorder; that its medical and ethical integrity is compromised by financial and professional links with pharmaceutical companies and insurance companies; that it uses a system of categorical diagnoses (e.g., Diagnostic and Statistical Manual of Mental Disorders) that stigmatizes and is poorly founded scientifically or clinically; and that the psychiatric system is experienced by too many of its patients as demeaning and controlling.

Some mental health professionals and academics profess anti-psychiatry views. A proportion of users or ex-users of psychiatric services do as well. Some critics now focus on the predominant biological psychiatry. Despite its name, some parts of the movement promote a form of psychiatry which is merely contrary to current mainstream theories and methods. Some so-called "anti-psychiatrists" are keen to dissociate themselves from the term and the pejorative associations it has attracted.

Origins of anti-psychiatry
Daniel Defoe, the author of Robinson Crusoe, revealed, in the 18th century, that husbands used asylum hospitals to incarcerate their disobedient but sane wives. As psychiatry became more professionally established during the 19th century and they developed more invasive treatments, opposition increased. Other disputes concerned custodial rights over those seen as "mad," including in the expanding lunatic asylums, and divergent theoretical interpretations of mental problems. Emil Kraepelin introduced new medical categories of mental illness, which eventually came into psychiatric usage despite their basis in behavior rather than medical pathology or etiology.

In the 1800s abolitionists first encountered Drapetomania, a pseudo-scientific rationale for why slaves ran away from their masters.

In the 1920s surrealist opposition to psychiatry was expressed in a number of surrealist publications.

In the 1930s several controversial medical practices were introduced including inducing seizures (by electroshock, insulin or other drugs) or cutting parts of the brain apart (leucotomy or lobotomy). Both came into widespread use by psychiatry, but there were grave concerns and much opposition on grounds of morality, harmful effects, or misuse. In the 1950s new psychiatric drugs, notably the antipsychotic chlorpromazine, were designed in laboratories and slowly came into preferred use. Although often accepted as an advance in some ways, there was some opposition, partly due to serious adverse effects such as tardive dyskinesia. Patients often opposed psychiatry and refused or stopped taking the drugs when not subject to psychiatric control. There was also increasing opposition to the large-scale use of psychiatric hospitals and institutions, and attempts were made to base services in the community.

Coming to the fore in the 1960s, "anti-psychiatry" (a term first used by David Cooper in 1967) defined a movement that vocally challenged the fundamental claims and practices of mainstream psychiatry. Psychiatrists R.D. Laing, Theodore Lidz, Silvano Arieti and others argued that schizophrenia could be understood as an injury to the inner self inflicted by psychologically invasive "schizophrenogenic" parents, or as a healthy attempt to cope with a sick society. Psychiatrist Thomas Szasz argues that "mental illness" is an inherently incoherent combination of a medical and a psychological concept, but popular because it legitimizes the use of psychiatric force to control and limit deviance from societal norms. Adherents of this view referred to "the myth of mental illness" after Szasz's controversial book of that name. (Even though the movement originally described as anti-psychiatry became associated with the general counter-culture movement of the 1960s, Szasz, Lidz and Arieti never became involved in that movement.) Michel Foucault, Erving Goffman, Deleuze and Guatarri, and others criticized the power and role of psychiatry in society, including the use of "total institutions," "labeling" and stigmatizing.

Foucault argued that the concepts of sanity and insanity were social constructs that did not reflect quantifiable patterns of human behavior, and which, rather, were indicative only of the power of the "sane" over the "insane". The novel One Flew Over the Cuckoo's Nest became a bestseller, resonating with public concern about involuntary medication, lobotomy and electroshock procedures used to control patients.

In addition, Holocaust documenters argued that the medicalization of social problems and systematic euthanasia of people in German mental institutions in the 1930s provided the institutional, procedural, and doctrinal origins of the mass murder of the 1940s. The Nuremberg Trials convicted a number of psychiatrists who held key positions in Nazi regimes. Observation of the abuses of psychiatry in the Soviet Union in the so-called Psikhushka hospitals also led to questioning the validity of the practice of psychiatry in the West. In particular, the diagnosis of many political dissidents with schizophrenia led some to question the general diagnosis and punitive usage of the label schizophrenia. This raised questions as to whether the schizophrenia label and resulting involuntary psychiatric treatment could not have been similarly used in the West to subdue rebellious young people during family conflicts.

New professional approaches were developed as an alternative or reformist complement to psychiatry. At least one network, epitomized by Jerome Agel's Rough Change: Therapy Means Change Not Adjustment (1974?), challenged this professional mediator approach, giving as alternatives authentic community making. Social work, humanistic or existentialist therapies, counseling and self-help and clinical psychology developed and sometimes opposed psychiatry. Psychoanalysis was increasingly criticized as unscientific or harmful. Contrary to the popular view, critics and biographers of Freud, such as Alice Miller, Jeffrey Masson and Louis Breger, argued that Freud did not grasp the nature of psychological trauma. Non-medical collaborative services were developed, for example therapeutic communities or Soteria houses.

The anti-psychiatry movement was also being driven by individuals with adverse experiences of psychiatric services. This included those who felt they had been harmed by psychiatry or who felt that they could have been helped more by other approaches, including those compulsorily (including via physical force) admitted to psychiatric institutions and subjected to compulsory medication or procedures. During the 1970s, the anti-psychiatry movement was involved in promoting restraint from many practices seen as psychiatric abuses. The gay rights movement challenged the classification of homosexuality as a mental illness and, in a climate of controversy and activism, in 1974 the American Psychiatric Association membership (following a unanimous vote by the trustees in 1973) voted by a small majority (58%) to remove it as an illness category from the DSM, replacing it with a category of "sexual orientation disturbance" and then "ego-dystonic homosexuality," which was deleted in 1987, although "gender identity disorder" and a wide variety of "paraphilias" remain. Increased legal and professional protections, and merging with human rights and disability rights movements, added to anti-psychiatry theory and action.

Anti-psychiatry came to challenge a "biomedical" focus of psychiatry (defined to mean genetics, neurochemicals and drugs). There was also opposition to the increasing links between psychiatry and pharmaceutical companies, which were becoming more powerful and were increasingly claimed to have excessive, unjustified and underhand influence on psychiatric research and practice. There was also opposition to the codification of, and alleged misuse of, psychiatric diagnoses into manuals, in particular the American Psychiatric Association, which publishes the Diagnostic and Statistical Manual of Mental Disorders.

Anti-psychiatry increasingly challenged alleged psychiatric pessimism and institutionalized alienation regarding those categorized as mentally ill. An emerging Consumer/Survivor Movement often argues for full recovery, empowerment, self-management and even full liberation. Schemes were developed to challenge stigma and discrimination, often based on a social model of disability; to assist or encourage people with mental health issues to engage more fully in work and society (for example through social firms), and to involve service users in the delivery and evaluation of mental health services. However, those actively and openly challenging the fundamental ethics and efficacy of mainstream psychiatric practice remained marginalized within psychiatry, and to a lesser extent within the wider mental health community.

Civilization as a cause of distress
In Civilization and Its Discontents, Freud, in later life, wrote of the conflict between man's instinctive nature and the demands of society (a view rejected by some of Freud's later epigones as the cause of mental problems). Many others, before and after him, have written in similar vein, and some, such as George Miller Beard have pointed to an epidemic of "neurasthenia" (a condition no longer recognized as an illness) at the start of the twentieth century as indicative of the breakdown of a section of society under the increasing stresses of modern life. R. D. Laing emphasized family nexus as a mechanism whereby individuals become victimized by those around them.

In recent years, David Smail, a psychotherapist considered part of the anti-psychiatry movement, has written extensively of the "embodied nature" of the individual in society, and the unwillingness of even therapists to acknowledge the obvious part played by power and interest in modern Western society. He emphasizes the fact that feelings and emotions are not, as is commonly supposed, features of the individual, but rather responses of the individual to his situation in society. Even psychotherapy, he suggests, can only change feelings inasmuch as it helps a person to change the "proximal" and "distal" influences on his life, which range from family and friends, to politics and work.

Normality and illness judgments
Critics of psychiatry generally do not dispute the notion that some people have emotional or psychological problems, or that some psychotherapies do not work for a given problem. They do usually disagree with psychiatry on the source of these problems; the appropriateness of characterizing these problems as illness; and on what the proper management options are. For instance, a primary concern of anti-psychiatry is that an individual's degree of adherence to communally, or majority, held values may be used to determine that person's level of mental health. Using this logic they argue that in a communal display of violence like a public stoning, a person who abstains from violence could be diagnosed mentally ill and should, subsequently, be treated. Furthermore, if disagreement with the majority in a society constitutes delusion, then anyone whose statements are considered by that majority to be incorrect is delusional, regardless of the actual correctness of his or her ideas; or, alternately, the criteria by which a belief is deemed to be a delusion must necessarily fluctuate with the majority's opinion. Under this definition, critics of psychiatry argue, early proponents of heliocentrism, such as Galileo, would have been rightly characterized as delusional since their ideas were widely held to be incorrect when they were originally formulated; it is only because the majority currently backs a heliocentric model of the solar system that an opposing belief might now be considered a "delusion".

One prominent example of a psychiatric diagnosis being used to oppress dissidence is the diagnosis of drapetomania. In the United States of America, prior to the American Civil War, psychiatrists diagnosed some slaves with drapetomania, a mental illness in which the slave possessed an irrational desire for freedom and a tendency to try to escape slavery. By classifying such a dissident tendency as abnormal and a disease, psychiatry promoted cultural biases about normality, abnormality, health, and unhealth.

In addition, many feel that they are being pathologized for simply being different. Some people diagnosed with Asperger's Syndrome or autism hold this position (see Autism rights movement). While many parents of children diagnosed autistic support the efforts of autistic activists, there are some who say they value the uniqueness of their children and do not desire a "cure" for their autism. The autistic community has coined a number of terms that would appear to form the basis for a new branch of identity politics; terms such as "neurodiversity" and "neurotypical". It has been argued by philosophers like Foucault that characterizations of "mental illness" are indeterminate and reflect the hierarchical structures of the societies from which they emerge rather than any precisely-defined qualities which distinguish a "healthy" mind from a "sick" one. Furthermore, if a tendency toward self-harm is taken as an elementary symptom of mental illness, then humans, as a species, are arguably insane in that they have tended throughout recorded history to destroy their own environments, to make war with one another, etc.

Psychiatric labeling
There are recognized problems regarding the diagnostic reliability and validity of mainstream psychiatric diagnoses, both in ideal controlled circumstances and even more so in routine clinical practice (McGorry et al. 1995). Criteria in the principal diagnostic manuals, the DSM and ICD, are inconsistent. Some psychiatrists who criticize their own profession say that comorbidity, when an individual meets criteria for two or more disorders, is the rule rather than the exception. There is much overlap and vaguely-defined or changeable boundaries between what psychiatrists claim are distinct illness states. There are also problems with using standard diagnostic criteria in different countries, cultures, genders or ethnic groups. Critics often allege that Westernized, white, male-dominated psychiatric practices and diagnoses disadvantage and misunderstand those from other groups. For example, several studies have shown that African Americans are more often diagnosed with schizophrenia than Caucasians, and women more than men. Some within the anti-psychiatry movement are critical of the use of diagnosis as it conforms with the medical biopsychiatry model. The late Kevin F. McCready, founder of San Joaquin Psychotherapy Center, was critical of the use of diagnosis for people suffering from psychological and emotional overwhelm. He opened a day treatment program in Fresno, California, utilizing an integrative milieu model of psychotherapy without the use of diagnosis or psychiatric drugs. This center has served clients from all over the world who have sought this type of specialized treatment where they could gradually titrate off of their psychiatric drugs. Today there are a number of centers open around the United States based on this model.

Psychiatry and the pharmaceutical industry
Stern concerns about how disease is managed in large populations for financial purposes alone appear constantly in the literature critical of the medical profession and the industry. Psychiatrists prescribe drugs for adults and children. Administration of the drugs can be undertaken voluntarily or, in certain situations, involuntarily. Psychiatrists claim that a number of medications have a proven efficacy for improving or managing a number of mental health disorders. This includes ranges of different drugs referred to as stimulants, antidepressants, tranquilizers and neuroleptics (antipsychotics).

On the other hand, organizations such as MindFreedom International and World Network of Users and Survivors of Psychiatry maintain that psychiatrists exaggerate the evidence of medication and minimize the evidence of adverse drug reaction. They and other activists also complain that individuals are not given sufficient balanced information or truly informed consent, that current psychiatric medications do not appear to be specific to particular disorders in the way mainstream psychiatry asserts; and psychiatric drugs not only don't correct measurable chemical imbalances in the brain, but also induce undesirable side effects. For example, though children on Ritalin and other psycho-stimulants become more obedient to parents and teachers, critics have noted that they can also develop abnormal movements such as tics, spasms and other involuntary movements This has not been shown to be directly related to the therapeutic use of stimulants, but to neuroleptics. The diagnosis of Attention Deficit Hyperactivity Disorder on the basis of inattention to compulsory schooling also raises critics' concerns regarding the use of psychoactive drugs as a means of unjust social control of children.

The influence of pharmaceutical companies is another major issue for the antipsychiatry movement. The pharmaceutical industry is one of the most profitable and powerful in existence, and as Joe Sharkey has argued, there are many financial and professional links between psychiatry, regulators, and pharmaceutical companies. Drug companies routinely fund much of the research conducted by psychiatrists, advertise medication in psychiatric journals and conferences, fund psychiatric and healthcare organizations and health promotion campaigns, and send representatives to lobby general physicians and politicians. Peter Breggin, Sharkey, and other investigators of the psycho-pharmaceutical industry maintain that many psychiatrists are members, shareholders or special advisors to pharmaceutical or associated regulatory organizations. There is evidence that research findings and the prescribing of drugs are influenced as a result. A United Kingdom cross-party parliamentary inquiry into the influence of the pharmaceutical industry in 2005 concludes: "The influence of the pharmaceutical industry is such that it dominates clinical practice" and that there are serious regulatory failings resulting in "the unsafe use of drugs; and the increasing medicalization of society". The campaign organization No Free Lunch details the prevalent acceptance by medical professionals of free gifts from pharmaceutical companies and the effect on psychiatric practice. The ghost-writing of articles by pharmaceutical company officials, which are then presented by esteemed psychiatrists, has also been highlighted. Systematic reviews have found that trials of psychiatric drugs that are conducted with pharmaceutical funding are several times more likely to report positive findings than studies without such funding.

The number of psychiatric drug prescriptions have been increasing at an extremely high rate since the 1950s and show no sign of abating. In the United States antidepressants and tranquilizers are now the top selling class of prescription drugs, and neuroleptics and other psychiatric drugs also rank near the top, all with expanding sales. As a solution of this alleged conflict of interests, critics propose legislation to separate the pharmaceutical industry from the psychiatric profession.

Electroconvulsive therapy
Psychiatrists may advocate psychiatric drugs, psychotherapy or more controversial interventions such as electroshock or psychosurgery to treat mental illness. The use of electroconvulsive therapy (ECT) is administered worldwide typically for severe mental disorders such as severe depression, sometimes involuntarily. Across the globe it has been estimated that approximately 1 million patients receive ECT per year. Exact numbers of how many persons per year have ECT in the United States are unknown due to the variability of settings and treatment. Researchers' estimates generally range from 100,000 to 200,000 persons per year. Anti-psychiatry critics particularly hold this procedure in low repute. John Breeding, a vocal critic of psychiatric practices, believes that "Electroshock always causes brain damage". On the other hand, a 2003 systematic review concluded that, despite these risks, ECT "is an effective short-term treatment for depression". It is used most often in situations of life-threatening, i.e., suicidal, depression.

Psychiatry and the law
The United States Supreme Court ruled in 1975 that it is a violation of civil rights to medicate, treat, or hospitalize a person against their will.

While the insanity defense is the subject of controversy as a viable excuse for wrong-doing, Szasz and other critics contend that being committed in a psychiatric hospital can be worse than criminal imprisonment, since it involves the risk of compulsory medication with neuroleptics or the use of electroshock treatment. Moreover, while a criminal imprisonment has a predetermined time of end that could be anticipated, patients are typically committed to psychiatric hospitals for indefinite durations.

Involuntary hospitalization
Critics see involuntary committal's use of legally-sanctioned force as counter to one of the pillars of open or free societies: John Stuart Mill's principles. Mill argues that society should never use coercion to subdue an individual as long as he (or she) does not harm others. In contrast to the Hollywood portrait of schizophrenics, disturbed people are usually no more prone to violence than sane individuals. The growing practice, in the United Kingdom and elsewhere, of care in the community was instituted partly in response to such concerns. Alternatives to involuntary hospitalization include the development of non-medical crisis care in the community.

In the case of people suffering from severe psychotic crises, the American Soteria project used to provide, critics of psychiatry contend, a more humane and compassionate alternative to coercive psychiatry. The Soteria houses closed in 1983 in the United States due to lack of financial support. However, Soteria-like houses are presently flourishing in Europe, especially in Sweden and other North European countries.

The "Therapeutic State"
The "Therapeutic State" is a phrase coined by American psychiatrist Thomas Szasz in 1963.

The collaboration between government and psychiatry results in what Szasz calls the "therapeutic state," a system in which disapproved thoughts, emotions, and actions are repressed ("cured") through pseudomedical interventions.

Civil libertarians warn that the marriage of the State with psychiatry could have catastrophic consequences for civilization. In the same vein as the separation of church and state, Szasz believes that a solid wall must exist between psychiatry and the State.

CCHR: A parallel and collaborative movement in antipsychiatry
Scientology has also challenged psychiatric theory or practice. L. Ron Hubbard, the founder of Scientology, became increasingly at odds with psychiatry and in 1969 cofounded the Citizens Commission on Human Rights (CCHR), with Thomas Szasz. CCHR was formed as an advocacy group focused on what it calls psychiatry's "human rights crimes". In 1986, the Special Rapporteur of the United Nations submitted a report that was published and distributed by the United Nations. In this report the CCHR was credited for the introduction and passage many pieces of legislation to improve the rights of individuals with regard to psychiatric treatment.

In the keynote address at the 25th anniversary of CCHR, Szasz stated: "We should all honor CCHR because it is really the organization that for the first time in human history has organized a politically, socially, internationally significant voice to combat psychiatry. This has never been done in human history before." Szasz continues to make content for Scientology, nonetheless, Szasz has never been a Scientologist, instead self-identifying as a secular humanist.

However, the delineation between the viewpoints of the critics associated with Scientology, and those within anti-psychiatry is not absolute, especially with regards to mental illness, psychiatry, and psychiatric drugs. For example, the CCHR hosts content about these subjects by noted anti-psychiatry critics like Szasz, Gary Null and Fred Baughman.

Despite sharing notable antipsychiatrists' views on some issues, Scientology doctrine differs in some respects. Scientology has promoted psychiatry-related conspiracy theories, including the 9/11 terrorist attack and that psychiatrists caused the universe's havoc billions of years ago. Scientologists are religiously committed never to take psychiatric drugs and to reject psychology outright. Few secular critics of psychiatry share these positions.

The socio-political roots of the movements also differ. Classic anti-psychiatrists such as David Cooper and Ronald Laing had ties with the political left of the 1960s; Szasz, with the civil libertarians of the right. On the other hand, Jon Atack considered the sources of Scientology to be a mixture of Freud's abreaction therapy, science fiction, Buddhist ideas, and Aleister Crowley's magic.