The Controversial Nature of Psychiatry

By and large, we have assigned the twin tasks of understanding and responding to mental suffering to psychiatrists. If not the most scientifically primitive area of modern Western medicine, psychiatry is easily the most polarizing. A study of psychiatry’s history will present bewilderingly divergent depictions of the profession. In its two-hundred-year history, psychiatry has undergone many periods of crisis and reinvention — and, with each transformation, new paradigms, evidentiary standards, and research methods emerge.

Whether one is a proponent or critic of the discipline, the ever-shifting identity of psychiatry poses a significant challenge to anyone trying to weave a coherent narrative of its institutional and intellectual history. Advocates contend that psychiatrists are stubborn idealists or beleaguered soldiers of medical science. The field’s high-profile scandals, failed reforms, grand pronouncements, and public defeats are all stages along the familiar scientific path of incremental progress.

Critics, on the other hand, depict the discipline’s history as rife with startling violence. From this view, psychiatry is characterized by repression and conspiracy — psychiatrists are calculating agents who both benefit from and contribute to the punishment of those who threaten bourgeois morality and routine orderliness. And yet across these deep schisms of disagreement, one finds a fragile consensus connecting psychiatry’s apologists and many of its critics: madness continues to evade our basic comprehension.

Critics of the status quo approach to mental suffering have offered valuable objections to our most cherished assumptions about what constitutes mental illness. More importantly, they have drawn crucial attention to serious issues of moral and scientific integrity in the field.

On the Left, common criticisms seek to explain how psychiatry can inadvertently medicalize injustice. These criticisms highlight the incriminating relationship of interdependence between psychiatry and the pharmaceutical industry and the ways in which psychiatry can be used to legitimize violence and social oppression. Critics such as Michel Foucault, R. D. Laing, and David Cooper have brought an invaluable political lens to bear on issues of diagnosis, treatment, and detention. They have, however, also given succor to the view that further interventions that target mental suffering are either misguided, futile, or inhumane.

Capitalism Is the Disorder, Mental Illness Is the Symptom

The intimate links between social inequality and mental suffering are well documented, and understood by liberals and leftists alike. The New York Times, the Financial Times, and Canada’s Globe and Mail have linked rising rates of depression, anxiety, and “deaths of despair” to defective social safety nets and woefully underfunded or severely inaccessible health care systems. Leftists, on the other hand, have long highlighted the structural tension between social welfare programs and the basic functioning of capitalism. The systematic privileging of accumulation over human need ensures that nothing — including care work — can take precedence over the imperatives of commodification and profit.

If poverty, exploitation, and alienation are inherent features of capitalism, the degradation of physical and mental health is inevitable as long as we continue to live under the domination of the market. For some, both episodic and chronic feelings of sadness, anxiety, and stress are best understood as logical responses to the structural forces at play in everyday life under capitalism.

Psychiatric medicine can function to legitimize and enforce the interests of the ruling elite either by default or design. As the late great Mark Fisher once wrote: “The current ruling ontology denies any possibility of a social causation of mental illness. The chemico-biologization of mental illness is of course strictly commensurate with its de-politicization.” This view, it must be said, is held by some psychiatrists and clinical mental health professionals themselves. Regardless, the general sentiment behind it is right: when political suffering is medicalized as personal dysfunction, our sense of social solidarity and collective political power also suffers.

In The Sane Society, the Marxist philosopher Erich Fromm attempts to offer a corrective formulation to the mainstream medical paradigm of mental health and illness. For Fromm, mental health is defined not by how well an individual can adapt to their society but by how well society adjusts to the needs of its people. A healthy society is one in which people have the means, freedom, and security to flourish as individuals while feeling solidarity and belonging as part of a greater whole. The corrosive ethos of competition and atomization of life under capitalism gnaws at our collective psyche and no one, not even the ruling class, is spared from its production of existential misery.

Efforts to expose the socioeconomic foundations of mental suffering typically take as their case studies mental states where the lines between health and illness are not easily differentiated. Depression, anxiety, existential dread — or “mood and anxiety disorders” — are as prevalent as they are different in degree. The near impossibility of drawing causal connections between concrete social phenomena and ill-defined mood and anxiety disorders is one of the limitations of socioeconomic explanations of mental illness.

It’s doubtful that all forms of mental suffering and disorganization — like psychosis — can be equally and satisfactorily explained by the miseries of life under capitalism (though one can easily see how they might be made worse). Discussions of the degree to which socialism could be a panacea for depression, anxiety, and trauma — especially those that are more chronic and severe — are mostly speculative. It seems more reasonable to presume that just as sorrow would exist in a postrevolutionary world, so, too, would mental illness.

Popular discussions of psychiatry often attribute to the profession an unnuanced understanding of our psychic life. One can certainly find neurobiological zealotry in the pharmaceutical industry and certain corners of the field. However, over the last two decades, the “biopsychosocial model” has emerged as the mainstream paradigm of contemporary psychiatry. It represents a significant shift in how the complex interplay between social factors, psychological development, and genes are taken into account by mental health clinicians.

Nevertheless, there are important criticisms regarding the applicability and coherence of the biopsychosocial model. Chief among these is that the model has no systematic framework for prioritizing between biological, psychological, and social factors. This leaves ample room for clinicians to ignore or overstate the importance of particular determinants and, in so doing, significantly impact care delivery.

As an example, consider the hypothetical case of someone who is experiencing extreme distress due to their belief that powerful and malevolent spirits are trying to take control of their body. When interpreted through a narrow biological lens, their suffering might be attributed to poorly treated schizophrenia — it follows that finding a more effective antipsychotic medication would be the best course of action. A different physician, however, exploring this patient’s developmental history, might find a history of childhood abuse at the hands of a respected member of the patient’s faith community. Insofar as the patient’s current experience is rooted in psychological trauma, a psychotherapeutic intervention might be prioritized over medication trials. Yet another physician might explore both biological and psychological elements, but give further consideration to the patient’s social environment. If, for example, this patient resides in a dingy, violent, and chaotic boarding home, clinicians are far less likely to address the barriers that prevent them from pursuing psychotherapy, remembering to take their medication, and building trusting relationships.

Clinical case formulation is one of many areas in which a political analysis, guided by social and economic justice, is still sorely needed to avoid the kind of psychiatrization of daily life with which Fisher, Fromm, members of the Critical Psychiatry Network, and many others are rightly concerned. However, advancing a critique of the overreliance of psychiatry on chemical explanations of human suffering should not close off the possibility of investigating its biological causes.

Major Repressive Disorder: Madness and Social Control

Mental illness has assumed many different names, meanings, and definitions throughout history. Descriptions of “lunacy” and “melancholy” date back to antiquity. Because understandings of “madness” appear to be historically contingent, the very concept of mental illness is contentious.

Few thinkers have been as influential in constructing a theoretical scaffolding for madness as Michel Foucault. Madness and Civilization (1988), Foucault’s historico-philosophical analyses, traces the emergence of “madness” as a subject of scientific study and as a social phenomenon requiring state intervention and control. In his account, developing a “mental science” of madness — i.e., psychiatry — had nothing to do with deepening our understanding of human nature, and everything to do with new modes of governance. On this view, sciences of the mind are themselves structures of control — a “monologue of reason” drowning out all voices that threaten ruling-class authority or the social order.

Foucault’s theory that rulers in the early modern and industrial periods viewed the mad as threats to the social order is dubious at best. Historians have found virtually no evidence to substantiate this idea, which we should view as conjecture. Nonetheless, Foucault’s account still has merit. His careful treatment of the political and cultural values associated with madness has extended welcome theoretical tools to “mad activists” and anti-psychiatry groups. His work also inspired generations of scholars and clinicians to question what we deem normal and why, and how deviant behaviors are turned into disorders that need fixing.

These are useful questions. History is rich with examples of how psychiatry has pathologized political resistance, dismissing acts of opposition as cases of mental disorder. To cite two examples: drapetomania, or “the disease causing slaves to run away,” is an appalling instance of diagnosis giving cover to egregious social practice, and oppositional defiant disorder (ODD, presently included in the fifth edition of the Diagnostic and Statistical Manual) is a diagnosis typically applied to children and adolescents who appear unusually hostile and are insufficiently obedient or deferential to adults in positions of authority. As many critics have pointed out, ODD is a value-laden and poorly defined diagnosis that risks medicalizing the environmental and contextual factors that shape childhood development and behavior. Yet another of psychiatry’s failings, as LGBTQ campaigns and movements have shown, is the way in which sexual orientation and nonnormative expressions of gender have been targeted by medical pathology in unspeakably harmful ways.

However, arguments that equate psychiatry with almost dictatorial social control present a reductive understanding of the profession and credit psychiatrists with far more power than is warranted. Absent in these narratives is a vision of patients as recipients of care rather than victims. How then are we to make sense of present and former patients who report positive and, in some cases, life-changing outcomes following psychiatric treatment? Not only does the victimhood and survivorship view discount some people’s experiences of healing — it also suggests that people need only be freed from the vice grip of psychiatry to flourish.

Taken to their logical end point, social control theories — those that are broadly termed “anti-psychiatry” — argue that mental illness is a myth. This is a deeply contentious proposition, especially for boots-on-the-ground mental health workers, or anyone who’s ever experienced or observed someone struggle with debilitatingly obsessive behavior, incomprehensibly horrific visual and auditory disturbances, or radically out-of-character and dangerous decisions in the throes of a manic state.

For the most intransigent members of the anti-psychiatry movement, the myth of mental illness is an attempt by oppressive social strictures to foreclose on the revolutionary power of desire and deviance. The concept of the schizophrenic, for some French thinkers writing in the wake of the Paris uprising of May 1968, was a lodestar for the libidinal power that could remake society. Revolutionaries, according to this school of thought, could dismantle structures of hierarchy and oppression by embracing madness and desire. While the liberatory force of the mad or deviant individual may have failed to achieve revolutionary social change, the architects of neoliberalism deployed an ethos of radical individualism to considerable success. Ronald Reagan and Margaret Thatcher were only too happy to give emphasis to a social order premised on self-interest and self-gratification.

Historically, those who deny the existence of mental illness have found strange bedfellows in right-wing politicians. The Right, eager to justify the abdication of responsibility for publicly funded and humane mental health supports, is only too happy to trade on psychiatry’s manifest wrongs. In Canada and the UK, deinstitutionalization — the historic process of dismantling the asylum system toward community-based care — unfolded with the explicit aim of reducing health care expenditures.

Over recent decades, community-based mental health services and supports have developed through a process of path dependency, without coherent plan or vision. The feeble networks of private, charity-based, and government services that now form the basis of community care across much of the United States and Canada are unable to provide continuous care to many people struggling with severe mental illness. The lives of those suffering from mental illness are often marked by violence, poverty, homelessness, and incarceration. Anti-psychiatry activists characterize psychiatry as a component part of this domination to claim that it does more harm than good, thereby advocating the eschewal of treatment. At what point does the struggle against social control align with a politics of social neglect?

The Pharmaceutical-Industrial Complex

The influence of the pharmaceutical industry over medical education, clinical research, and clinical practice is not unique to psychiatry. However, it is true that psychiatry’s role in impeding a thorough understanding of the very conditions the pharmaceutical industry’s drugs purport to treat is disturbing. Pharmaceutical companies exert a troubling degree of power and authority in defining mental disorders, conducting research into the causes of mental suffering, and determining how it can best be addressed.

In the mid-twentieth century, as psychiatry became increasingly reliant on pharmaceutical interventions, the pharmaceutical industry recognized how profitable an alliance could be, and a relationship of disquieting dependency was born. In Anatomy of an Epidemic (2010), Robert Whitaker traces psychiatry’s struggle for legitimacy alongside the interests of the pharmaceutical industry to expose the deep links of dependency between them. This relationship, following the emergence of “breakthrough” psychoactive drugs in the 1950s, is clearly illustrated by the transition from talk therapy as the dominant method of treatment toward pharmaceutically driven therapy.

Though initially developed to treat infections, drugs like Thorazine and meprobamate were found, rather serendipitously, to be helpful in altering mental states and blunting the presence of acute symptoms of psychosis, anxiety, and depression. Even though nobody knew how they worked, they rapidly gained widespread use in mental hospitals and outpatient settings.

Over time, researchers were able to observe that psychoactive drugs affected the balance of various chemical messengers (neurotransmitters) in the brain, and reasoned that the drugs must be correcting for chemical imbalances. For example, because Thorazine blocks dopamine receptors in the brain — the effect of which reduces aggression and psychotic symptoms such as hallucinations — it was postulated that psychoses must be caused by an excess of dopamine. From these kinds of observations, the infamous “chemical imbalance” theory of mental illness was born.

The following decades of research into the physiology of psychotic illnesses opened important lines of inquiry for understanding the neurobiological elements involved in mental distress and disturbance. The trouble with all this research, however, is the same problem inhibiting most psychiatric groundwork and experimentation — it is largely controlled by pharmaceutical interests. Working within the matrix of market incentives, pharmaceutical companies make bold pronouncements and reductive claims about the causes of mental illness. The chemical imbalance theory was peddled to patients and the public because it was a convenient marketing tool. But its promise of chemical cures was greatly exaggerated.

Pharmaceutical companies have explicit means of selling their products — such as direct-to-consumer advertising — and more covert strategies. Industry lobbying has a significant impact on public health and drug policy, and corporate financing of academic activities and clinical research seriously biases medical education and clinical practice guidelines. By and large, psychiatry rests on a knowledge base that has been compromised by industry involvement, but this fact alone does not explain legitimate concerns over psychiatric overreach. Family physicians — who are responsible for the majority of psychopharmaceutical medications available to outpatient populations — receive far less training in psychotherapy than they ought to. Their good-faith efforts to help people are often compromised by an overreliance on the prescription pad.

As prescribers continue to make use of crude psychopharmacological tools, research and development for novel psychopharmaceutical interventions has ground to a virtual halt. It’s far more profitable for companies to tweak, re-patent, and rebrand existing medications than it is to engage in the much riskier business of creating novel theories and treatments. This explains, in part, why pharmaceutical companies spend far more money on marketing than research and design.

Those who defend and promote psychopharmacology do so largely because its drugs, though imperfect, are generally effective. However, difficulties arise when appraising the truthfulness of the pharmaceutical company’s claims. The inordinate amount of pharmaceutical industry money involved in medical studies severely compromises the quality and trustworthiness of the information it makes public. The fact that studies with pharmaceutical industry funding are far more likely to report positive findings has been well documented. Furthermore, the drug approval processes of the US Federal Drug Administration and Health Canada — which generally follows decisions made in the United States — are dramatically skewed to the benefit of pharmaceutical companies.

In order to take a drug to market, drug companies must submit all the clinical trials they have sponsored (they are not obliged to submit independent reviews of their products). Although drug companies can run as many trials as they like, they only must produce two trials showing that a drug is more effective than a placebo for it to be approved. Negative trials rarely see the light of day, while the positive studies are promoted at conferences and published in medical journals. The public, and to some extent the physicians who treat us, are left largely in the dark.

Toward a Left Politics of Mental Care

It’s easy to cherry-pick from psychiatry’s conspicuous abuses in order to cast the entire field — past, present, and future — in a negative light. It should be noted, however, that defenders of psychiatry have also been able to produce their own selective histories that cast a far less negative light on their discipline. A more evenhanded approach would be to maintain our criticisms of psychiatric medicine while recognizing the profoundly difficult task of responding to mental suffering.

Prominent figures in the field like Leon Eisenberg and Allen Frances have offered very public appraisals of psychiatry’s chronically limited capacities and its many failures. In 1982, amid the frenzied promises of a “neurobiological revolution” in psychiatry, Roberto Mangabeira Unger highlighted the discipline’s challenges in a stirring address to the American Psychiatry Association:

Nothing harms science more than the denial or the trivialization of enigma. By holding the explanatory failures of psychiatric science squarely before our eyes, we are also able to discover the element of valid insight in even the most extreme and least careful attacks on contemporary psychiatry: to make even his most confused and unforgiving critics into sources of inspiration is a scientist’s dream.

Science is far from politically neutral, but the Left can and must employ its methods to advance emancipatory and transformative political ends.

There are several dimensions to the politics of mental suffering. We know that people are enduring significant mental distress that can be reduced or resolved. However, we lack satisfying sociological, psychological, and biological explanations for the diverse forms of mental distress and disturbance that people can experience. Psychiatrists do not have a monopoly over this state of ignorance — we all share it. But we have ceded significant authority and power to physician researchers and pharmaceutical companies to advance our public understanding over matters of great concern and complexity. Further study must be held to higher standards of transparency and democratic accountability.

Care work is an important part of the broader fight to win universal social and economic freedoms. The public provision of thoughtfully designed social and therapeutic programs — such as clubhouses, peer groups, supportive housing, case management, and truly accessible psychological and medical therapies — are desperately needed to support people to live safely and well.

Wresting power from the corporations and institutions currently profiting off their monopoly over mental suffering is neither easy nor straightforward. The road to democratizing scientific research is sure to be an uphill battle. Nevertheless, it is critical that we move beyond censure and wholesale rejection of psychiatry toward a more active engagement with these issues. This begins with humility and a nuanced appreciation of the epistemological and political challenges we face.

A left politics of mental care must call for publicly funded and democratic inquiry into the nature of mental suffering and possible treatments, ongoing assessments of what is important to people who suffer, and a commitment to provision of treatment and solicitude in care. Societal responses to mental illness have long been characterized by extremes of paternalism or neglect. The Left has much to contribute to forging a new path.