Noteworthy arguments that challenge the state of affairs in psychiatry.
Over the last 2 years, Psychiatric TimesTM has hosted Awais Aftab, MD’s popular series, Conversations in Critical Psychiatry, which highlights critical and conceptual issues in the mental health arena. It has featured a range of interviewees, some in fierce opposition to psychiatry and its claims to medical and scientific authority, others alarmed by overdiagnosis and medicalization of ordinary life and seeking reform, and yet others working to move the profession beyond reductionist narratives. The goal, however, was never criticism for the sake of criticism; it was to have meaningful criticisms of psychiatry and to pursue constructive alternative perspectives.
Allen Frances, MD: “I think psychiatry is among the noblest of professions, but I think that it has drifted astray from best practice. It is heartbreaking to me that 600,000 of our most severely ill patients are either in jail or homeless and that we have done so little to advocate for the community mental health centers and affordable housing that would have freed them from confinement and ended the shameless neglect. I fear that too many psychiatrists are now reduced to pill pushing, with far too little time to really know their patients well and to apply the rounded biopsychosocial model that is absolutely essential to good care.” Read more.
Anne Harrington, DPhil: “From a historian’s perspective, it only makes sense to speak of progress, or to imagine psychiatry learning from each of these eras, if it can be shown that new generations are, in fact, being taught to respect and reflect on what can be learned from projects and approaches that are now deemed overall to have largely failed. It is my impression that every time the field has decided it is in the throes of a revolution, the perspectives of rivals tend to get starved of oxygen. People become more knowledgeable about some things and more ignorant about other things. Textbooks get rewritten in ways that emphasize the new orthodoxies. Training programs get revamped. This way of engaging with the past is, of course, not inevitable.” Read more.
G. Scott Waterman, MD, with Sandra Steingard, MD: “It seems to me that the notion that a psychiatric nosology should aspire to describe and catalog every manifestation and permutation of human discomfort is unrealistic. The complexities of the brain and of the social environments within which it functions are such that the proposition that psychiatric problems should come in a tractable number of packages, each sufficiently discrete (etiologically, phenomenologically, etc) to make categorical diagnosis meaningful and useful, is likely misguided.” Read more.
Giovanni Fava, MD: “Psychiatry is going through an intellectual crisis. This crisis is shared by other areas of clinical medicine and stems from a narrow concept of science which neglects clinical practice as a source of fundamental research questions. Fewer and fewer academic psychiatrists actually assess and treat patients. Most of published research has no relevance to practice. The progress of neurosciences in the past two decades has often led to the belief that clinical problems in psychiatry were likely to be ultimately solved by this approach. Such hopes are understandable in terms of massive propaganda operated by biotechnology and pharmaceutical corporations. An increasing number of psychiatrists are wondering, however, why the cures and clinical insights that neurosciences have promised have not taken place.” Read more.
Lisa Cosgrove, PhD: “[An acontextual] symptom reduction model risks individualizing a person’s suffering and moves the focus away from the socio-political context in which “depression” is always manifest. And so I wonder, could such a model inadvertently undermine our ability as clinicians to enter fully and empathically in the other’s world? Are we missing an appreciation for the narrative content of an individual’s experience of because of an over-emphasis on a biomedical model of depression and disease-oriented outcome measures? Emotional suffering has a social, moral, and existential dimension that cannot be easily reduced to a disease category.” Read more.
Jonathan Shedler, PhD: “I long ago lost count of the number of patients I have seen with “treatment-resistant” depression who were helped by psychotherapy. Show me a patient with [treatment resistance], and the likelihood is that I will show you someone whose underlying personality dynamics were never understood or addressed in psychotherapy… Our difficulties are woven into the fabric of our lives and rooted in enduring patterns of thinking, feeling, motivation, attachment, coping, defending, and relating to others—that’s what we mean by personality. From this perspective, depression is an effect, not a cause. It cannot be treated in a vacuum, separate from the person experiencing it.” Read more.
Nev Jones, PhD: “There is collective pain, and also individual pain and distrust and anger. The tragedy here is that we have never seen the kind of dialogues and collaboration happen [between professional psychiatry and patients/service users], at least on a large scale, that this history demands. There seems to me so much potential for deep listening and systemic rethinking or redesign work. That this has not happened only further undermines trust in the system and helps seed ideological polarization.” Read more.
George Dawson, MD: “The practice environment is no longer a place of physician inclusivity and pride in the technical and humanitarian aspects of the work. It is a productivity-based model and physicians are no longer treated like knowledge workers. They are treated like replaceable production workers who can be ordered around by business administrators or their surrogates who have essentially no knowledge about patient care. The average patient has little idea about this atmosphere in which their physicians are working under when they walk into a hospital or clinic.” Read more.
Sami Timimi, MD: “The labelling of our experiences with medicalized language has spread far and wide. It entrenches a fear of, and alienation from, an appreciation of the ordinariness and understandability of a panoply of human emotional experiences. When we place our emotional experiences in a problematizing framework, we extract the everyday meanings these have and become worried that there is something wrong in us beyond our (and our meaningful others’) capacity to comprehend. Mental health education campaigns have made this dynamic worse… we have made more individuals suspicious that their experiences are a signal that there is something deeply wrong in them.” Read more.
Kathleen Flaherty, JD: “Criminalizing disability-related behavior and poverty-survival behavior is wrong. No one should go to jail or prison for being homeless. We need to provide decent, safe, affordable, and accessible housing to all. We should have an adequately funded, community-based system of voluntary services and supports. I do not believe forced psychiatry leads to anything we would call “recovery.” It causes trauma and makes it really difficult for anyone to want to engage with the system. I do not think we can use the excuse of the closing of the asylums anymore. That was decades ago. It is the choices we have made in the decades since that have led us to where we are today.” Read more.