It’s Time for Us to Realize We Are All on the Same Side

According to 1 doctor, we all need to communicate the legitimacy of psychiatry as a medical specialty.

In his response, “It’s Time for Us to Stop Being So Defensive about Psychiatry,” I believe that Awais Aftab, MD, has almost entirely mistaken the overall thrust of my article. In fact, the article did not attempt to excuse psychiatrists by tone policing critics, or to deny psychiatrists’ responsibility for the problems of psychiatry. Do these sound like fighting words? I assure you they are not. The fault for such a misunderstanding is my own. By pressing in on the ambiguities of my article, “It’s Time for Us to Stop Waffling About Psychiatry,” Aftab has given me a precious opportunity to clarify its purpose.

Before I explain, I would like to extend more than the usual thanks to Dr Aftab for his willingness to deeply engage with my thoughts about public perceptions of psychiatry. We clearly share a passion not only for our profession, but for the patients we attempt to serve. And, in the interest of full disclosure, I should note that I am a big fan of Aftab and grateful for his many articles that have appeared in the pages of Psychiatric TimesTM. I am delighted that he cared enough about my article to refute it.

My article was intentionally provocative. I believe that I and many of my colleagues need a call to arms during a time of great opportunity for mental health in our culture. We need to emphatically defend and affirm the ethical, practical, and scientific legitimacy of what we do as psychiatrists. I hope that many people found the article energizing, whether or not they agreed with my many assertions. It is time for our profession to speak out in a new way.

Nevertheless, the article was—in 1 way—confusing from the very beginning. Its original title was, “It’s Time for Psychiatrists to Stop Waffling About Psychiatry” (italics added), which had to be shortened in the editorial process. Thus, my article was in no sense an attack on the critics of psychiatry. It was not addressed to the critics of psychiatry. It was not addressed to the public at large. The article was addressed solely to psychiatrists—more specifically, all psychiatrists who go about practicing as if psychiatric illness were legitimate medical illness. It called on psychiatrists to energetically address distorted impressions and assertions about our field whenever and wherever they arise.

But, contra Aftab, I was not calling on critics to pipe down—rather, I was calling on psychiatrists to speak up. I was not attempting to squelch critics; I was attempting to get psychiatrists to join the debate. I was not hoping that the public would stop hearing about problems with psychiatry; I was hoping that the public would start consistently hearing about the medical legitimacy of psychiatry.

Pro-Psychiatry vs Anti-Criticism

Contrary to appearances, I am not especially worried about the critics of psychiatry. If I had the power to cancel what they have said, I would not cancel a single word. In particular, I have found Aftab’s series of critical articles fascinating and enlightening. With decade upon decade of sustained critique, critics like him have forced our profession to examine and reexamine our assumptions, teachings, diagnoses, and treatments. They have contributed mightily to the improvement of psychiatry. Yet the prominance of such critics, coupled with the relative lack of positive public education about psychiatry, has inadvertently and seriously harmed our patients (as I shall explain below). There is too much criticism in the public ear and not enough education.

It is more than understandable that many people took my stance as being against the critics of psychiatry. After all, I was energetically asserting a pro-psychiatric position and attempting to dispell some of the pervasive myths of psychiatry’s extreme critics. But being pro-psychiatry is not, in fact, the same as being anti-criticism. I myself agree with most of the common criticisms of psychiatry, including the pervasive influence of drug companies in shaping our research and practice, the problematic use of the DSM, the underappreciated risks of some of our biological treatments, and the tendency to pathologize and anesthetize normal human suffering.

What is my problem with critics of psychiatry? I have no problem with them. My problem is with the grossly distorted imbalance in our public discussions of mental illness—a balance that is grossly distorted in favor of anti-psychiatry and against psychiatry. As documented in my article, it is not difficult to find a host of critical and negative articles and books both within and outside of psychiatry, while on the other hand, prominent defenders and explainers of psychiatry are far more rare. Where are our Sigmund and Anna Freuds, Carl Jungs, Karen Horneys, and Karl Menningers of today? Where are the bestsellers explaining psychiatry to the public? Where are the articles in prominent journals and magazines explaining and defending our practices? The critics regularly appear in all of these forums, as well as on YouTube and other internet outlets. Where are the educators and the defenders of psychiatry?

What is my solution to this problem? My solution is not to take away criticisms of psychiatry, but to add to the knowledge and appreciation of psychiatry as a true medical specialty. My solution is not to paper over criticisms, but to help give the public a wider grounding and more realistic context in which these criticisms can be accurately understood.

Patients vs Doctors

Regardless of which “side” gets more press, people outside our field are left in a state of confusion by this vigorous debate. Regardless of whether they hear accurately, members of the general public hear that psychiatry is both hopelessly corrupt and unassaillably good, haplessly inept and unimaginably sophisticated. And it leaves millions in a state of paralysis and irresolvable ambivalence. This state of paralysis and ambivalence is demonstrable from research and almost certainly—in my mind—has had catastrophic consequences.

This is why I painted critics of psychiatry with a broad brush. On one hand, Aftab is right that I was falsely equating careful and thoughtful critics such as himself and Allen Frances with extremists such as Szasz and Scientology. One group wants to improve medical psychiatry, while the other wishes to abolish it. But on the other hand, I lumped psychiatry’s critics together in this article for 1 specific reason: because I perceive that the various criticisms are lumped together in our confused public perceptions of psychiatric illness and treatment.

What I mean is this: Those of us who are practicing psychiatrists have a deep knowledge, born of both study and experience, that the following assertions are unshakably true:

Psychiatric illness is legitimate medical illness.

Psychiatric treatment is legitimate medical treatment.

Aftab himself endorses such statements in his article. Because we psychiatrists understand these truths, we are neither alarmed nor confused when we encounter critiques of psychiatry. We are not worried that the whole basis for psychiatry is going to be overturned. We are not worried that all psychiatrists are going to be proven quacks or charlatans. We already know better. But the general public, as a whole, does not know better. In fact, even our nonspecialist intelligentsia do not know better. They are likely to be confused and disconcerted by such unanswered criticisms.

When members of the public hear critiques of psychiatry, they do not have a wider and deeper intellectual context in which to receive them. As a result, they may hear accurate critiques in a distorted way. The public is likely to believe either that extreme critiques are true or that moderate critiques are actually supporting extreme points of view. In my opinion, it is most likely that the critiques of psychiatry simply get lumped together into 1 vague, inchoate, and negative impression, which is as much emotional and symbolic as it is articulated and intellectual (Table).

I am not asserting that the public is overwhelmingly negative about psychiatry. Instead, I am noting that the public is both highly positive and highly suspicious about psychiatry, and this leads to a state in which half of people with mental illness receive no treatment for it (in any given year),1 and half of those who do receive treatment fail to adhere to or continue with it.2,3 This state of affairs also leads government bodies to both affirm the necessity of psychiatric care and fail to adequately defend or fund it, while insurance companies claim to cover mental health treatment, but refuse to do so at every opportunity.

Allow me to offer 2 brief case vignettes to illustrate our cultural problem.

Vignette #1

“Rob” is a 20-year-old college student who has suffered from depression as long as he can remember. He is ashamed of himself for needing to “depend on a pill,” but reluctantly accepted a prescription for an antidepression from his primary care physician. Rob’s parents do not believe in mental illness and tell him regularly that he just needs to have a better attitude and quit feeling sorry for himself. While hesitating to begin the antidepressant, Rob comes across a news article on a random internet site: “New Study: Antidepressants No Better than Placebo.” He reads the headline, slams the bottle of medications into the wall, and stalks out of his dorm room, leaving the medicines behind.

Vignette #2

“Dr Jones” is a psychiatrist who is familiar with the medical literature on major depression and has successfully treated scores of patients with the illness. She also happens to have major depression herself, which has been successfully treated with an SSRI antidepressant. While enjoying her morning coffee, Dr Jones comes across an online news story: “New Study: Antidepressants No Better than Placebo.” She smiles to herself, takes her morning medication, and goes about her day.

Discussion

Obviously, “Rob” and “Dr Jones” represent the extremes of knowledge about psychiatric illness and treatment—but I do not think either is unrealistic or atypical. The 2 of them illustrate that criticisms of psychiatry have a very different effect on laypersons than on psychiatrists like ourselves. To laypersons who are ambivalent about their ongoing treatment, such public critiques can be deeply unsettling, worrisome, and even undermining of their treatment. To those who suffer psychiatric illness and are hesitating to seek treatment, such critiques can further delay or even prevent treatment from ever occurring. For those in positions of influence with governments and insurance companies, such critiques can weaken their resolve and ability to decisively end unjust and prejudicial practices against those with mental illness.

Once again, I am not opposing criticism. I am not saying that criticism in and of itself has these harmful effects. Rather, it is critique in the absence of context and affirmation that proves so harmful to our patients and the wider public. The fault of this does not lie with those who are critical of psychiatry. The fault lies with myself and other psychiatrists who have been quiet and interested observers in the debate rather than vocal advocates for our field.

All Together Now

Because of all this, I would like to call on Aftab and other psychiatrists who have been critical of psychiatry to accept the complementary task of affirming and defending a basic understanding of psychiatry with the general public, including nonpsychiatric intellectuals such as journalists and academics. Some of our most brilliant and energetic psychiatrists in recent decades have been those who challenged our field in fundamental ways. I do not want such psychiatrists to stop challenging our field. But I do say that we badly need them to help us communicate the legitimacy of psychiatry as a medical specialty to those outside our field. They can do both. All of us can do both. And perhaps all of us can agree that it is time to begin this task in a new way.

Allow me to end with 2 quotes, which illustrate that Aftab and I are on the same side. Such statements can also remind us that both critics and defenders of psychiatry are on the same side: the side of those who suffer from mental illness. Critics want to protect patients from the flaws of psychiatry, while defenders want to protect patients from the ravages of mental illness. All of us should endorse both of those goals.

First, Aftab: “Dr Morehead and I agree about a lot of things: the fundamental legitimacy of psychiatry as a branch of medicine; the essential role psychiatry has to play in the treatment of mental health problems; that a defense of psychiatry is warranted against egregious and misplaced criticisms; and that the value of psychiatry must be conveyed to legislators, insurers, and the general public.”4

Second, I shall ungraciously quote myself from a previously published book: “On a deeper level, I am grateful to these critics of psychiatry, and thank them for their work. They care, and they should care. They see problems in our system, and then want to address those problems. They say that this is a matter of life and death, and they are right.”5

The way our culture regards mental health is indeed a matter of life and death. It is not something that we as psychiatrists should just passively observe. I am grateful to Aftab and everyone else who cares enough to do something to address this critical issue.

Dr Morehead is a psychiatrist and director of training for the General Psychiatry Residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health, and is author of Science Over Stigma: Education and Advocacy for Mental Health, published by the American Psychiatric Association. He can be reached at dmorehead@tuftsmedicalcenter.org.

The author wishes to thank Awais Aftab, Ron Pies, and Mark Ruffalo for their review and comments on an earlier draft of this article.

References

1.Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53). Center for Behavioral Health Statistics and Quality. 2018. Accessed January 11, 2022. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHFFR2017/NSDUHFFR2017.pdf

2. Dufort A, Zipursky RB. Understanding and managing treatment adherence in schizophrenia. Clin Schizophr Relat Psychoses. January 3, 2019. Online ahead of print.

3. Sawada N, Uchida H, Suzuki T, et al. Persistence and compliance to antidepressant treatment in patients with depression: a chart review. BMC Psychiatry. 2009;9(1):38.

4. Aftab A. It’s time for us to stop being so defensive about criticisms of psychiatry. Psychiatric Times. January 6, 2022. https://www.psychiatrictimes.com/view/its-time-for-us-to-stop-being-so-defensive-about-criticisms-of-psychiatry

5. Morehead D. Science Over Stigma: Education and Advocacy for Mental Health. American Psychiatric Association Publishing; 2021:67.