Today, a wide variety of treatment strategies are used in psychiatry, to combat many different psychological disorders. Psychiatry may involve physiological or psychological treatment, or a combination of the two. Physiological treatment generally involves the use of drugs influencing neurotransmitter functions in the brain, or electroconvulsive treatment (see electroconvulsive therapy). Psychiatrists are licensed physicians, specially trained to treat patients with mental disorders and to prescribe drugs. In recent years, psychological difficulties have lost much of the stigma they once had, and many people have sought psychiatric help who might have been reluctant to do so in the past.
See C. M. McGovern, Masters of Madness: Social Origins of the American Psychiatric Profession (1985); C. Thompson, ed., The Origins of Modern Psychiatry (1987); L. Robins and D. Regier, ed., Psychiatric Disorders in America (1991); R. Michaels, ed., Psychiatry (1992); H. Kaplan and B. Sadock, Comprehensive Textbook of Psychiatry (2 vol., rev. ed. 1993); T. M. Luhrmann, Of Two Minds: The Growing Disorder in American Psychiatry (2000).
Anti-psychiatry refers to a post-1960s configuration of groups and theoretical constructs hostile to most of the fundamental assumptions and practices of psychiatry. Its igniting influences were Michel Foucault, R.D.Laing and Thomas Szasz.
The word "psychiatry" was invented by Johann Christian Reil in 1808. Two central contentions of the anti-psychiatry movement are that:
Other 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 psychiatry uses a system of categorical diagnoses (e.g., Diagnostic and Statistical Manual of Mental Disorders or DSM) which is scientifically or clinically ill-founded, and which stigmatizes patients; further: that its attitude to patients is too often experienced as simply demeaning and controlling.
Individual mental health professionals as well as academics profess anti-psychiatry views, as do a certain proportion of current or former users of psychiatric services. Some critics focus on the now prevalent form of biological psychiatry. Despite the movement's name, however, some tendencies in reality, it's alleged, merely promote a form of psychiatry that happens to be contrary to the dominant theories and methods of the day. Some "anti-psychiatrists," indeed, are concerned to dissociate themselves from the term and its sometimes pejorative associations.
What much later became known as the anti-psychiatry movement had its earliest origins in concerns that arose from the alleged application of psychiatric techniques for purposes of social control. Daniel Defoe, best known as the author of Robinson Crusoe, reported as far back as the eighteenth century that some husbands were using madhouses to incarcerate their disobedient though sane wives.
Psychiatry became more professionally established as the nineteenth century progressed. As more invasive forms of treatment evolved so too, in some quarters, did opposition rise. Some disputes concerned custodial rights over those seen as mad, particularly if unfortunate enough to end up in one of the multiplying lunatic asylums.
In the 1800s the American physician Samuel A. Cartwright had stumbled upon drapetomania, the explanation for why slaves would on occasion display an alarming tendency to run away from their masters. A further disorder afflicting slaves and, by extension, their owners was dysaethesia aethiopica, a disease "affecting both mind and body." This explained the apparent lack of a proper work ethic among slaves. Found exclusively among blacks, dysaethesia aethiopica — "called by overseers 'rascality'" — was characterized by partial insensitivity of the skin and "so great a hebetude of the intellectual faculties, as to be like a person half asleep."
In the latter part of the nineteenth century Emil Kraepelin became an eminent deviser of novel categories of mental illness, which duly entered psychiatric usage despite their origin in extrapolation from observed behavior, rather than in clinical pathology or etiology in any strict sense. The Soviet state in the twentieth century devised suitable psychiatric diagnoses for any who opposed its will with sufficiently persistent vigor but who, whether by dint of ingenuity or mere social eminence, proved difficult to criminalize. They were duly hospitalized instead.
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. The Radical Therapist, a journal begun in 1971 in North Dakota by Michael Glenn, David Bryan, Linda Bryan, Michael Galan and Sara Glenn, challenged the psychotherapy establishment in a number of ways, raising the slogan "Therapy means change, not adjustment." It contained articles that challenged the professional mediator approach, advocating instead revolutionary politics and authentic community making. Social work, humanistic or existentialist therapies, family therapy, 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 pharmaceutic 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.
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 argues 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.
One prominent example of a psychiatric diagnosis being used to reinforce cultural bias and oppress dissidence is the diagnosis of drapetomania. In the United States of America, prior to the American Civil War, psychiatrists, such as Samuel A. Cartwright, 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 mental trait as abnormal and a disease, psychiatry promoted cultural bias about normality, abnormality, health, and unhealth. This example indicates the probability for not only cultural bias but also confirmation bias and bias blind spot in psychiatric diagnosis and psychiatric beliefs.
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. 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". However, an antipsychiatric viewpoint is not found in nearly all of those advocating acceptance for autists or other "outsiders".
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.
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, hypnotic minor 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.
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, 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.
Some persons receiving ECT die from the procedure. Frank cites approximately 400 deaths mentioned in psychiatric journals.
Psychiatry critics particularly hold this procedure in low repute. John Breeding, a controversial social 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.
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.
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 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.
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 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." Although Szasz appears in some CCHR's keynote addresses, he 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 that psychiatry was responsible for World War I, the rise of Hitler and Stalin, the decline in education standards in the United States, the wars in Bosnia and Kosovo, the September 11 attacks. Secular critics of psychiatry do not share these positions.
Scientology doctrine, further, holds that psychiatrists caused the decline in this universe billions of years ago, while Scientologists are religiously committed never to take psychiatric drugs and reject psychology outright.
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 magick.