Just Because We Do Not Know Everything Does Not Mean We Do Not Know Anything
In this new series, explore how to approach the criticisms of psychiatry.
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AFFIRMING PSYCHIATRY
It is all too easy to be negative. It is far easier to criticize than contribute—easier to tear down than to build up. Positivity fades, but negativity seems to build on itself.1 “Friends come and go; enemies accumulate,” as Mark Twain put it.
It is easy to be negative because it is natural to be negative. As human beings—indeed as mammals—our nervous systems give more weight, more attention, and more energy to negative and threatening experiences than to positive ones.1 So at a time when many medical and scientific authorities are viewed with suspicion, negativity about psychiatry is hardly shocking. Even vaccines have become a hard sell in our polarized and angry public culture.
Psychiatry has always been subject to more criticism and abuse than any other medical specialty. Dating back to the publication of Thomas Szasz’s The Myth of Mental Illness,2 negativity about psychiatry has been a constant refrain longer than any of us have been psychiatrists, so much so that most of us hardly notice it. It is the elevator music of our professional pursuits—something that only registers when a particularly good or bad tune warbles in the background. Negativity about psychiatry has become a long-running and tacitly accepted tradition, both inside and outside psychiatry.
At least the narrative is consistent, rarely straying over the decades from Szasz’s powerful indictment: Psychiatry is unscientific. Contemporary critics assert that psychiatrists make diagnoses on the basis of a pseudoscientific and self-serving DSM, and that we go about treatment through the use of dangerous and unjustified overprescribing. Because we lack a firm scientific grounding (they say), self-interest runs rampant. As psychiatrists, our arbitrary definitions of mental illness expand to include more and more “patients,” while drug companies push treatments for newer and more expansive “disorders.”3,4
None of this affects us much as practicing psychiatrists. But, when these criticisms are left unanswered, it is deeply distorting and injurious to people outside of our field who suffer from mental illnesses. It also influences the journalists, professors, and public intellectuals who shape public opinion. All of these, in turn, affect those who make life-and-death decisions about mental health in hospital corporations, governments, and insurance companies.
Psychiatric illness is not treated the same as other medical illnesses. This tragic state of affairs persists in spite of the fact that parity has been the law of the land since 2008 (and again in 2016). Stigmatizing stories of tragedy and violence dominate news media coverage of mental illness, not positive stories of healing and recovery.5 The majority of individuals with mental illness do not get treatment (in any given year), and the situation is little better for those with severe mental illness.6,7
Negativity about psychiatry is a major impediment to the mental health of this country. What do we do? We do not oppose negativity with more negativity. Our world has grown weary of flame wars. Instead, we oppose negativity with positivity. We oppose distortion with clarity. We do not deny the problems of psychiatry; we demonstrate its strengths. We accept legitimate criticisms of psychiatry, but place them in a wider and more affirmative context. In short, we show why psychiatric illness is medically real and psychiatric treatment is medically legitimate.
As psychiatrists, the fundamentally benign nature of what we do has been too obvious for words. Few of us have wasted time debating it amongst ourselves. Instead, when we have spoken of psychiatry in the abstract, we have routinely spoken of its problems and limitations. Now, for the sake of the rest of the world, we need to habituate ourselves to explaining and affirming our field. We need to articulate a basic sense of what we are doing with each other, our patients, and the wider communities of which we are a part.
I hope that this series of articles will contribute in a small way to this project. In the coming months, I hope to offer a positive take on many of the topics that lie at the root of deep skepticism about psychiatry:
-Is the DSM a Fraud?
-Is Mental Illness Medical?
-The History of Psychiatry: A History of Failure?
-Is Psychiatry Inferior to Other Specialties?
-Psychiatric Medicines: More Harm than Good?
I believe we can answer the questions that dog psychiatry in a way that is honest, satisfying, and relatable to the public. I believe it is time for psychiatry to find its voice in a new way. We have nothing to hide and no need to patronize. We need not deal in denial, rationalization, or intellectualization. The truth will do nicely for our interests and for those we serve. We are psychiatrists, after all.
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.
References
1. Rozin P, Royzman EB. Negativity bias, negativity dominance, and contagion. Pers Soc Psychol Rev. 2001;5(4):296-320.
2. Szasz TS. The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. Harper & Row; 1961.
3. Greenberg G. The Book of Woe: The DSM and the Unmaking of Psychiatry. Plume; 2014.
4. Whitaker R. Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. Broadway Books; 2010.
5.McGinty EE, Kennedy-Hendricks A, Choksy S, Barry CL. Trends in news media coverage of mental illness in the United States: 1995–2014. Health Affairs. 2016;35(6):1121-1129.
6. Park-Lee E, Lipari RN, Hedden SL, et al. Receipt of services for substance use and mental health issues among adults: results from the 2016 National Survey on Drug Use and Health. CBHSQ Data Review. 2017.
7. Treatment Advocacy Center. Severe mental illness and treatment prevalence. May 2017. Accessed February 8, 2022. https://www.treatmentadvocacycenter.org/key-issues/anosognosia/3638-serious-mental-illness-and-treatment-prevalence
