Kim Stringer and Angela Peacock don’t know each other. Stringer, 28, lives in Bucks County, Pennsylvania and once had aspirations to be an artist. Peacock, 41, lives in upstate New York and is an Iraq war veteran. Both women sought help from the mental health system. They got very different results.
Their stories reveal how people in emotional distress can be failed by psychiatry, and point to radically divergent conclusions about how to fix it. What happened to these two women embodies, more broadly, an embattled debate taking place in patient and provider communities around the world.
Stringer’s mother, Martha, said that Stringer was diagnosed with bipolar disorder in high school, and given lithium and Seroquel. Shortly after graduating, Stringer told her parents she wouldn’t be taking medication anymore, or seeing her therapist.
“We watched her steadily deteriorate,” Martha said. Martha and her husband have now spent eight years trying to get their daughter help, but as is the case in many U.S. states, Stringer cannot be involuntarily given treatment unless she poses an imminent risk to herself or others.
Martha and her husband bought Stringer a house to live in because they didn’t want her to be homeless. Though they provided her with food, Stringer would go through dumpsters to find her meals. Her apartment was filled with rotting, open food containers, and smelled of urine.
“She started pushing a shopping cart around the community and collecting trash and dead animals,” Martha said. “She got increasingly phobic around phones and technology, very fearful of computers, television, and radiation.”
After multiple encounters with the police for erratic behavior, Stringer finally met the threshold of harm, but wasn't brought to the hospital. She was arrested and put into jail at the beginning of 2020. “From there, we were denied access and denied information, told that her needs were being met when they were not,” Martha said.
Fellow inmates at Bucks County Correctional Facility contacted a local reporter about how Stringer had been “confined to a bare cell, completely naked in full view of male and female guards, with only a soiled blanket and a smock given to patients who are on suicide watch, which she rarely wears,” the reporter wrote in June. “She urinates and defecates on the floor and on herself. She has gone without a mattress at times and has no books or possessions. She is covered with bruises, and at times has hit her head or punched herself. She hasn’t had a shower in weeks.”
Martha feels her daughter’s condition has gotten so severe because she was unable to intervene. “We were not able to force her,” Martha said. “We had to sit by and watch her suffer a psychotic breakdown.” Stringer spent her 28th birthday in jail.
Peacock was a sergeant in the United States Army from 1998 to 2004. She got sick while on tour in Iraq, and was medically evacuated to Germany for treatment. The next day, one of her soldiers arrived on a gurney and told her that her convoy had hit a roadside bomb.
“At the moment, the emotions I was feeling—the fear, the stress—I could not handle it,” Peacock said. “I walked straight down the hallway to the psychiatry office because I thought that's what you do when you need help. From that moment forward, I was medicated for 13 years.”
She said she was put on 45 different medications in total, and up to 18 drugs at the same time. Nothing helped. She felt sicker, more disabled, and more emotionally distressed with each pill she went on. Every time she went back to the doctor, Peacock got new diagnoses. Finally, when a psychiatrist told her she should try lithium for her agitated depression, she said enough.
“I was doing everything they told me to do,” Peacock said. “Why am I not getting better? It's not working for me. I've been doing everything you say for 13 years and I'm not getting better. And you keep adding diagnosis and more drugs.”
She described her experience for a new documentary, Medicating Normal, which chronicles the stories of people who say they have been over-prescribed medications that ended up harming them.
“I just wanted somebody to be like, ‘No, what you're feeling is normal. You should be rattled. You just left the war zone. You're going to hear noises and think they're gunshots. But everything is okay. You're gonna be safe. We're going to take care of you. You can come in here every day if you need to talk,’” Peacock said. “There was none of that. Not even therapy was offered. It was literally, ‘Here's a prescription.’”
How could one woman be so overly medicated and diagnosed while another escaped any sort of proper care and ended up being abused in jail? Martha, influenced by her experience, has become an advocate for more medical mental health intervention, while Peacock says a medication-happy psychiatric system left her sicker than when she started. These contrasting positions are at the heart of anti-psychiatry and critical psychiatry.
One difficulty in talking about anti-psychiatry is the vagueness of the term. Many don’t like to be described as anti-psychiatrists, saying that it's a pejorative, a dismissive insult. The phrase “critical psychiatry” has emerged as an alternative—and sometimes a euphemism—but the terms denote real differences in overall philosophy. Anti-psychiatry can be considered abolitionist: It is a movement of people who feel that psychiatry is harmful and needs to be eradicated, and are against psychiatric diagnoses and medication as well as involuntary treatment. Critical psychiatry is more of a reformist movement, attempting to address psychiatry's issues while maintaining some semblance of its infrastructure.
Anti-psychiatry was originally a largely academic tendency in the 1960s and 1970s, but today lives on in various forms. Its ideas are echoed by psychiatric survivors, online communities like Mad in America, and disability rights advocates who are against legislation that would make it easier for people to be involuntarily treated. Peacock doesn’t consider herself an anti-psychiatrist, but in 2016, she said, when she found critical and anti-psychiatry articles online, “My first opinion was validation. I thought, ‘Oh my God, this is what happened to me.’”
Anti-psychiatry should not be dismissed as a fringe movement. Its views are being readily discussed and perpetuated throughout patient communities, and in many ways, it represents a reckoning over entirely real issues: Many psychiatric patients are over-medicated and can have a hard time going off of their meds; involuntarily treating someone can be a traumatic experience; and a meaningful recovery plan should address trauma and life circumstance, as well as include housing, peer support, or job support.
Yet along with these legitimate criticisms, a more extreme flavor of anti-psychiatry takes these points further, claiming that mental illnesses and diagnoses as we know them, do not exist at all; that psychiatric medication is probably harmful for everyone; and that psychiatrists believe in a solely biological model of mental illness, when most do not. These conclusions are harmful to people in emotional distress because they turn a conversation about how to make mental health care better, and more holistic, into heated debates about whether psychiatry should exist at all, leading to finger pointing and name calling between people who have experienced harm and practitioners who are defending against inaccurate generalizations about their profession.
There are also groups that have a vested interest in promoting anti-psychiatry's more extreme ideas, like the Citizens Commission on Human Rights (CCHR), established by the Church of Scientology. According to their non-profit tax documents, their total advertising and promotion expenditures exceeded $1.5 million in 2018. The Bonnie Burstow Scholarship in Antipsychiatry, currently hosted by the University of Toronto and partly funded by Burstow, who died in January, received endorsement from the CCHR.
The practice we call psychiatry can both wrong someone like Peacock and fail a person like Stringer. Perhaps the solution is neither to do away with psychiatric diagnoses and medication nor make it much simpler to treat someone against their will, but to invest more in programs that share decision making and advocate for early intervention, while also addressing issues like health insurance parity and the social determinants of mental health.
Some clues for how to do this may be found in the burgeoning early psychosis intervention programs, an approach that encourages camaraderie between clinician and patient. It recognizes the ways people's outer lives influence their health and supports trying different medications or experimenting with not being on medication at all. It uses diagnostic criteria when they are helpful, but does not hold them out as gospel. Yet it does still operate within the framework of psychiatry, and can involve involuntary treatment in some cases.
One of the biggest potential harms of getting distracted from a move to a more progressive model of mental healthcare by polarized ideas is that it could prevent people from seeking care that they may want, or invalidate the experiences of people who have been helped by psychiatry. By claiming that mental illness doesn't exist at all, anti-psychiatry could also lead us astray from much-needed reform within psychiatry, precisely because it seeks not to improve psychiatry, but to tear it down.
In 1961, psychiatrist Thomas Szasz published The Myth of Mental Illness, a text still influential within anti- and critical psychiatry circles. Szasz argued that since there was no medical basis for mental illness, there was no justified use of any psychiatric medication.
Because there was no biological test yet developed to discern mental illnesses, Szasz thought of mental disorders as metaphors. He wrote that symptoms were best understood as a means of communication—that through them, patients were trying to say something about their families or life experiences. This included symptoms like delusions or hallucinations; Szasz wrote in 1966 that "we ought to question the schizophrenic's sincerity" and that he believed "viewing the schizophrenic as a liar would advance our understanding of schizophrenia."
The context for his overall writings is important to understanding it. During the 1950s and 1960s, there were more than 600,000 Americans involuntarily committed to psychiatric facilities. Unproven, harmful, and traumatizing treatments, like lobotomies and insulin shock, were performed on people living in crowded, disgusting environments.
In part, Szasz was responding to the abuses of state psychiatric hospitals and asylums. Szasz believed that the way the mentally ill were treated was violating their civil rights, which was a fair assessment. But Szasz went far beyond responding to a system in need of reform, concluding that mental illness did not exist at all. In 1969, in a move that alienated him from many other academics, Szasz co-founded the Citizens Commission on Human Rights along with the Church of Scientology.
“Anti-psychiatry played an important role in getting us to downsize and close state hospitals, but it went too far in terms of romanticizing mental illness as a spiritual journey, which I don't believe,” said Larry Davidson, a clinical psychologist and professor of psychiatry at Yale who directs the Program for Recovery & Community Health.
When state facilities and asylums began to be shut down in the 1960s, in an initiative known as deinstitutionalization, there was a vision expressed, first by President John F. Kennedy and then by the Carter administration, of a community-centered mental health model that would step in to replace it. But funding cuts from the Reagan administration in the 1980s halted the funding and legislation dedicated to community health centers.
“[Szasz’s] influence on the humane treatment of the mentally ill forever changed the landscape of American psychiatry. But the current clinical and legal reality has reversed," wrote Allen Frances, a professor emeritus at Duke University and the chair of the DSM-IV Task Force, and Mark Ruffalo, a psychotherapist in Tampa, in Psychiatric Times. "The risks to freedom come from jails and homelessness, not from the now almost nonexistent psychiatric hospitals."
Ruffalo identified as a Szaszian psychoanalyst for years after being invigorated by his writing, and even corresponded with Szasz during graduate school. But he said that when he began to work in the emergency room, interacting with people with serious mental illnesses, he started to doubt Szasz’s claims about the metaphors of mental disorders.
“It became very hard for me to defend those beliefs when working with patients who were so disturbed and for which the only treatment that helped them was a pharmacological treatment,” Ruffalo said.
Szasz himself never worked in a hospital setting with people with serious mental illness. He refused to give medication to any patient, and one of his patients died by suicide six months after Szasz took him off of lithium.
“The vast majority of psychiatric critics have no realistic idea of what it means to provide medical care to someone who is actively psychotic, especially if they are so psychotic that they have to be hospitalized,” said Awais Aftab, a clinical assistant professor of psychiatry at Case Western Reserve University who leads an interview series for Psychiatric Times titled "Conversations in Critical Psychiatry." “These critics have no skin in the game because they are not the ones responsible for caring for these individuals; they are not the ones who have to witness the profound impairment of the psychotic individuals and the profound suffering of their families.”
Many of the criticisms presented by anti-psychiatrists influenced by Szasz are still relevant, according to Ruffalo. We do need safer and more effective drugs. We need to properly inform patients about what side effects may arise with their drugs, or what they might experience when they go off of them. Our diagnoses are based on observation, and we need better ways of delineating disorders, perhaps someday informed by biological measures. We need to recognize the social determinants of mental health, like poverty and trauma.
“I don’t disagree with that,” Ruffalo said. “But to go to the extent of saying that mental illness doesn't exist and mental illness is a metaphor, and that people are essentially doing this to themselves—I think that's way too far of a stretch for me.”
In 2010, Robert Whitaker published Anatomy of an Epidemic, a book that argues that an increase in mental health disability was caused by the long term overuse of psychiatric medication. With its success, and that of his previous book, Mad in America, Whitaker formed MadinAmerica.com in 2012—a "webzine" for summaries of research and blogs and articles that are critical of psychiatry, and a place where patients harmed by psychiatry can come for alternative views on medication and treatment. It’s probably the most active and legitimate critical psychiatry platform that exists today.
Whitaker said that Mad in America is "not an 'anti-psychiatry' website."
"If you see our mission statement, we believe that our society has organized itself around a 'false narrative' of science, and that has led to harm," he said in an email. "The site is then designed to serve as a forum for rethinking psychiatric care, with the understanding that this a societal challenge.”
But some clinicians, like Nev Jones, an assistant professor in the Department of Psychiatry at the University of South Florida, worry that the platform further polarizes the discussions around mental illness, medication, and effective treatment. Jones said that Anatomy of an Epidemic, the bedrock of Mad in America, is “just packed with misinterpreted, misunderstood studies that Whitaker uses to make claims that I think are demonstrably untrue.”
Regarding its chapter on antipsychotics, for example, Joseph Pierre, a clinical professor at the David Geffen School of Medicine at UCLA, said that Whitaker uses certain studies to suggest that people with schizophrenia who stay on antipsychotic medications do worse in the end than those who discontinue them because of the medications themselves—a misinterpretation, according to Pierre.
Whitaker cites psychologist Martin Harrow and his colleagues, who looked at how 139 people with schizophrenia fared over 20 years, with and without medication. The people who weren't taking antipsychotics long term had a greater rate of recovery. Pierre said that because the researchers didn't determine randomly who did and didn't get medication—called randomization—the findings don't necessarily mean that antipsychotics caused people to do worse. Rather than people getting sicker because of medication, the people who took medication might have been more unwell to begin with, or the course of their illness may have been more severe.
Another study published in 2013 in JAMA Psychiatry followed 257 patients with psychosis after different time periods, up to seven years, on antipsychotic medications. The patients were randomized into a group that would continue their medications, or reduce or discontinue their medication—but the dose adjustments were left up to clinicians. It too found that in the long term, people who lowered their doses ended up with better functioning than those who didn't. But as Pierre wrote in Psychology Today, most of the people in the reduced-dose group still took some level of medication, some stopped and had to start again.
Here we can see how the same study can be interpreted in different ways. While Pierre finds that it upholds clinical recommendations to use the lowest doses possible, in Whitaker's coverage of the JAMA Psychiatry study on Mad in America, he wrote that the study, along with Harrow's work, "provide convincing evidence that if psychiatry wants to promote the best possible functional outcomes, it needs to adopt protocols that will maximize the percentage of patients who are able to do fairly well off antipsychotics (or on a very low dose.)" He then continued: "But, if psychiatry doesn’t amend its protocols, and if psychiatry doesn’t sponsor new research to best reach these goals, then—and I know no other way to say this—then I think psychiatry will have to be seen, by mainstream society, as a failed medical discipline."
Whitaker sent a lengthy email response saying that all he did in his book and continues to do on the site is "look in-depth at the data," and noted that Harrow himself has updated his findings, now theorizing "the drugs, in fact, may have been causal in the worse outcomes for the medicated patients. And you’ll see there is a citation or two to me."
Pierre acknowledged that Whitaker has indeed "performed an exhaustive review" of many of the long-term studies on psychiatric medication and outcomes. But the context in which they're interpreted can skew the conclusions about medication and psychiatry one draws from them. For while it's definitely true that the Mad in America community in total is not an “anti-psychiatry” site, there are many other pieces published there—and certainly the comments in response to the articles—that could be fairly characterized as anti-psychiatry. “Readers who rely only on Mad in America will get a very distorted picture of what the state of research looks like,” Aftab said.
Alongside with more balanced critiques, it has, for instance, published an article that accused psychiatry of “edging dangerously close to eugenics." (“It’s only a matter of time until science will conclude that they know definitively which babies have genes for depression or OCD or schizophrenia … Those babies should be aborted to fix the gene pool, so we can have ‘healthy’ babies instead of diseased ones.”)
In another article, Why Is There An Anti-Psychiatry Movement?, a retired psychologist wrote that “Psychiatry’s 'treatments,' whatever transient feelings of well-being they may induce, are always destructive and damaging in the long-term."
"The pharmaceutical industry and the psychiatric establishment have a PR machine that regularly promotes research findings that support its interests," Whitaker said in an email about Mad In America's coverage. "There is no PR machine oiled to do the same for research that doesn’t support such interests. So what does Mad in America do? We have a team of science writers, who mostly are PHD students in psychology, who report on published studies that in fact do question the validity of psychiatric diagnoses, or the merits of its treatment, and which are virtually never aired in the mainstream public.”
Aftab thinks that while many psychiatrists can be quick to dismiss Mad in America as "anti-psychiatry," he doesn’t hold that view completely. “I think it does serve as a platform for certain essential perspectives, especially from consumers and survivors, that we don’t get to see elsewhere,” he said. “There are also some thoughtful critiques on the website. And sometimes their coverage of research is surprisingly insightful. But at other times I read the website and I just shake my head with disappointment.”
There are useful discussions and summaries on Mad in America. Importantly, there are also real experiences and trauma behind many of the posts that discuss the harms patients suffer from psychiatry. Not all psychiatric survivors or disability rights advocates are anti-psychiatrists—they are doing the difficult work of calling for more autonomy for people with mental illnesses, and for more holistic and compassionate care. But the more extreme anti-psychiatry articles threaten to obscure these voices with calls for the abolishment of psychiatry altogether, claiming that mental illness does not exist at all, or that all medication is toxic and causes all mental illness. This is compounded by the fact that other groups that are dedicated to proliferating these ideas, whose motives are not necessarily patient-centered, but ideological, like The Church of Scientology.
L. Ron Hubbard, the founder of Scientology, had a grudge against psychiatry. He envisioned that Scientology and its practice of Dianetics would take over mental healing, and viewed psychiatrists as one of the main enemies to that goal. Hubbard once wrote that "There is not one institutional psychiatrist alive who, by ordinary criminal law, could not be arraigned and convicted of extortion, mayhem and murder.”
Hubbard claimed that psychiatrists are ancient enemies from billions or trillions of years ago. A cover of a Scientology newspaper called Freedom depicted psychiatrists as “horned, goateed, cloven-hoofed, pointed-tailed devils performing electro-shocks and lobotomies on the peoples of the world.”
Experts may roll their eyes at a group like the CCHR, but it shouldn't be ignored. CCHR claims to be responsible for enacting more than “150 laws protecting individuals from abusive or coercive practices in the field of mental health.” Its members regularly protest psychiatric conferences and meetings.
The CCHR has held campaigns against Prozac, electroconvulsive therapy, and Ritalin. After a CCHR campaign against Prozac in 1991, sales dropped from 25 to 21 percent. In a video meant only for Scientologists obtained by a journalist for Scientology expert Tony Ortega’s website, Reverend Fred Shaw explained how he promoted CCHR's anti-psychiatry ideas covertly within NAACP and the National Action Network.
CCHR's 2018 tax documents show that they paid $416,608 to U.S. International Media LLC for advertising, $48,661 for lobbying to influence public opinion, and $145,982 on lobbying to influence legislative bodies. They spent tens of thousands of dollars on “Public Awareness,” worldwide, including $248,010 in Europe, $84,822 in East Asian and the Pacific, $18,875 in the Middle East and Africa, and $17,360 in Russia and neighboring states. In the CCHR’s headquarters in Hollywood, they maintain an anti-psychiatry exhibition, which they call Psychiatry: An Industry of Death Museum.
Meanwhile, if members of Scientology experience serious mental illness themselves, they are “treated” with something called Introspection Rundown, which is essentially solitary confinement plus vitamins. In 1995, a Scientology member, Lisa McPherson died after being subjected to Introspection Rundown.
The Bonnie Burstow Scholarship in Antipsychiatry Scholarship received at least $12,000, according to The National Post, from "parents of kids who have been hurt by psychiatry and want to see this line of research encouraged,” Burstow told the paper at the time. But the scholarship was also endorsed by CCHR, a striking example of how people with earnest motives around patient advocacy can find themselves overlapping with the radical beliefs of Scientology.
Burstow, a psychotherapist with a master’s in English, was a professor in the Ontario Institute for Studies in Education at the University of Toronto. She didn’t think that mental illness diagnoses were valid, or that medications work.
She died earlier this year, but in an email correspondence I had with her in 2018, in which I asked to hear more about the fellowship and potentially be in touch with the scholarship’s recipient, Burstow said, “The thing about anti-psychiatry is that there is no halfway. Either is true that institutional psychiatry tenets have been shown to be scientifically untenable and its 'treatments' has been shown to do way more harm than good—or it is not. And in fact, the evidence is overwhelming.”
She continued to say that she was limiting her interviews with journalists who were “truly into investigative journalism.” When I replied that I would not only be presenting psychiatry as “scientifically untenable” because I was open to the possibility that it does help some people, she replied: “Someone who takes the position off the top of their head that there is something to be said for both anti-psychiatry and psychiatry is not coming at the issue with an open mind. They already have a pre-established storyline, which is not the same as seeing where the evidence points. There were two sides too to the abolition of slavery in the US, but that does not mean that the truth of what was right lay somewhere in between.”
One of Szasz’s—and anti-psychiatry's—main arguments is that there is no biological evidence for mental illness, and it’s true we don’t have any biomarkers that can definitively diagnose a mental disorder.
There was at one time a lot of hope that brain science would provide meaningful clues about the causes and treatments for mental illness; the 1990s were designated by George W. Bush as The Decade of the Brain. Since a biology-based approach has not yet borne out, anti-psychiatry’s conclusion is that the use of medication and diagnoses should be put aside, and emotional distress should be regarded instead as understandable reactions to traumatic life circumstances.
Lucy Johnstone, a consultant clinical psychologist in the U.K. who has opposed the medical model of mental illness her whole career, wouldn’t personally identify with the term anti-psychiatry (in the U.K., the term anti-psychiatry is used as an insult, she said) though she does agree with many of the points of the critical psychiatry movement.
She believes that psychiatry is a failed paradigm. “We've had massive, extraordinary advances in what I would call legitimate branches of medicine over the last 50 to 100 years,” Johnstone said. “And we have made no comparable progress in the illegitimate branch of medicine that calls itself psychiatry.”
Johnstone doesn’t believe in the concept of serious mental illnesses as they are currently defined, nor in using the word “treatment” or “symptoms."
“Every time we use a word like 'symptom' or 'medication' or 'illness,' then we're assuming a medical model, which has never been evidenced,” Johnstone said. “Those things we might call psychosis and schizophrenia or bipolar disorder are often as linked to early and adult experiences of trauma as anything else is. People with more serious forms of distress may have clocked up more adversities."
She said there could still be a use for psychiatric medications, though she wouldn’t use the word "medication." She feels using that word implies that they are targeting a known biological target in the brain, when we’re not sure exactly how they work.
But if a biological model is not enough to explain mental illness, couldn’t it also be true that only a psychosocial model isn’t sufficient either? When I asked Johnstone about a concept called the biopsychosocial model, which incorporates life circumstance and biology, she said she doesn't deny that our bodies are involved in the experiencing of distress and trauma, as in all human experiences. “But that doesn't mean there's some disease process going on,” she said.
This is a common argument amongst critical and anti-psychiatry: that the model we work with now ignores difficult life circumstances. This resistance to a biological explanation can be why psychiatric survivors can often be against groups like the Treatment Advocacy Center, which is pushing for greater access to medicalized care.
“The thing that the Treatment Advocacy Center and those folks are not talking about is they're not talking about trauma," said Sascha Altman DuBrul, a social worker and co-founder of the Icarus Project, an activist group that takes a social justice approach to mental health. "How did people get the way that they are? So much of what we call mental health and mental illness has to do with larger societal factors and not our individual brain chemistry; our individual brain chemistry changes with the larger societal factors."
But even DuBrul can have difficulty with a hard rule against medication. DuBrul was diagnosed with bipolar disorder at 18 years old. When he first started engaging with the psychiatric survivor and advocate community he struggled, because he had decided that taking medication was helpful for him. “This was like the early 2000s, and there was a very black and white thinking around that,” he said. “People who were criticizing the mental health system were also saying that the psych drugs were poison.”
The Icarus Project resisted that black and white thinking, recognizing that while social circumstance influenced health, some people might find that they wanted to take medications.
“Sometimes antipsychotic drugs are just what you need to be able to get some sleep and to get yourself back on track,” DuBrul said. “But if we don't acknowledge that the society that we live in is really sick, if we don't acknowledge that the world we're existing in doesn't work for a whole bunch of people, and then we say,’ Oh, those people are just seriously mentally ill—what's 'ill' is the fact that we’re willing to ignore the fact that these people had a really hard time in their lives.”
DuBrul said that from what he's seen, most people accessing the public health system are still only talked to about mental illness in terms of biology. Sera Davidow, the director of the Western Mass Recovery Learning Community, agreed that the mental health system has failed to consistently provide alternatives to medication, or to be honest about what drugs will and won't do.
“I wouldn't advocate for the psych drugs being off the table for people to truly find them to be helpful,” Davidow said. “I think the question is, can this country can our providers use those drugs responsibly and not simply to control and silence people? Can they be used within the context of a system that gives true informed consent?”
DuBrul thinks it isn’t fair to conflate Whitaker, Mad in America, and the current psychiatric survivors with, say, Scientology, and that Mad in America has given marginalized people a voice, whereas otherwise they wouldn’t have one.
“My experience is that the medicalized versions have the platform about 90 percent of the time," Davidow said. "And the rest of us who are saying, 'Well, maybe that's not the whole picture' are silenced."
There are many diseases today that we don’t completely understand the biological causes of—for example, Alzheimer’s, migraines, or Lou Gehrig's disease.
“The fact that we don't have biomarkers doesn't make psychiatry irrelevant,” said Lisa Cosgrove, a clinical psychologist and professor of counseling and school psychology at University of Massachusetts Boston. “It just makes it different from other subspecialties in medicine." (Cosgrove, interestingly, is married to Robert Whitaker.)
It might even make sense that we don't have all the biological answers for psychiatry. It is, after all, an attempt to treat and assess the most complex part of our lives, our emotions, via the least understood part of the body: the brain.
Jonathan Stea, a doctoral-level clinical psychologist and adjunct assistant professor at the University of Calgary said that talking about the "chemical imbalance" hypothesis or the biological focus of psychiatry is a red herring tactic glommed onto by anti-psychiatry ideology.
“The charge that psychiatry practices from a pure 'biopsychiatry' perspective is a dishonest strawman argument that discounts the fact that in reality, modern psychiatry is an integrated biopsychosocial scientific discipline,” Stea said. “It’s therefore ironic and misguided that anti-psychiatry seeks to fault psychiatry for not pinning down an oversimplified single biological cause of mental illness, since psychiatry conceptualizes mental illness as a complex integration of biological, psychological, and social factors that interact in ways that don’t lend themselves to oversimplified and cheapened causal models.”
With the condition we call schizophrenia, for example, the reality is probably somewhere in-between: It is almost certainly neither a purely brain-based disease, nor just a normal reaction to difficult life circumstances and social oppression. Schizophrenia itself may even be a collection of similar disorders that could be arrived at by different paths.
“There is good scientific evidence to think disorders such as schizophrenia arise from a combination of multiple risk factors such as genetic risk factors, substance use, as well as psychosocial traumatic experiences,” Aftab said. “These are incredibly complex conditions and we should be wary of simple answers.”
As in any other profession, certain clinicians are more attuned to these nuances, or simply better at their jobs, than others—yet many are driven to practice from more of a biological standpoint not because of their personal views but because of the way our healthcare system is set up.
“Even people who would want to pay more attention to those psychosocial determinants, who have been trained in and who would want to engage in therapy with their clients, they're constrained in the United States, especially by our health care reimbursement system,” Cosgrove said. “So they become prescribers. To fault just one person or the discipline is under appreciating the larger picture."
“People say that daily life is being medicalized, but these same people would complain if their problem is not covered by insurance because it is not a medical disorder,” Aftab said. “People want psychotherapy for 'problems of living' but they also want insurance companies to pay for that? Our healthcare system is a mess. Psychotherapy access is a nightmare. Physicians are forced to see large volumes of patients with short appointment times and they are overwhelmed with the burden of documentation.”
And patients themselves can push their doctors for medication or think about their distress in biological ways. In his book Chemically Imbalanced, professor of sociology at the University of Virginia, Joseph Davis, found that many people explained the way they felt using terminology like "neurochemical imbalance." In national surveys about mental health, the general public also agrees more with biological causes of disorders and the use of medication than in the past. “Biogenetic language” can offer people “a way to establish their suffering as both tangible and unfeigned, and it offers a simple account and positive prognosis for their struggles,” Davis wrote in Psyche.
Critical psychiatry could be a good lens through which to challenge how biological framing has infiltrated our cultural and medical understanding of mental distress, but anti-psychiatry might not be. Anti-psychiatry risks feeding into distrust of the medical system and available treatment options completely, Aftab said, and leading people to be wary of seeking help at all. “For individuals who are on psychiatric medications, they can abruptly discontinue their medications with very serious consequences,” he said.
Stea said he's seen families reluctant to get treatment at all because of anti-psychiatry ideas they’ve read online. It makes it difficult as a person seeking out treatment or help to go online and encounter these extreme views on both sides.
“The internet is a treacherous place right now because somebody who doesn't have a background in the field and training and doesn't know how to navigate all this information,” Jones said. “It’s very easy to come across these hyper-polarized views seemingly backed by evidence because the kind of studies get misinterpreted and misused.”
Jones thinks it’s problematic and unhelpful to rigidly adopt an extreme viewpoint about psychiatry—either that everyone should try medication, or that no one should.
“Both of [those perspectives] do a kind of epistemic violence to the experiences of people who are struggling,” she said. “Medications are completely, totally unhelpful to some people, and life saving to others. And then you have everything in between."
This diversity can be found for all kinds of mental disorders, even for extreme symptoms like psychosis. Some people have one transient episode of psychosis that fully resolves, and they go on to lead healthy lives. They never need medication and never seek treatment again. And some people develop intense, chronic symptoms. They struggle to communicate, to work, to go to school, to live meaningful lives. Some people respond well to certain medications, and others don’t. Some people experience their symptoms episodically, and others are constant—day in and day out.
“That puts everybody in a difficult spot in terms of there being a lot of uncertainty,” Jones said. “If we started from this recognition, or acceptance, that we are dealing with extremely heterogeneous phenomena, causes, and risk factors, then we would start to be able to have a real meaningful conversation about how we bring about systems change.”
Early psychosis programs are one place Jones feels a change coming on: they take a more collaborative approach to patient care. While they're designed for psychosis, there could be inspiration to draw from more broadly; it's a community-based model that is trying to keep people out of hospitals and residential settings. It’s holistic in the sense that it includes things like education and employment support. “It’s a space that has encouraged and supported progressive clinicians and prescribers,” Jones said. “There’s real potential there.”
Yet Jones said that in the time she’s been involved in pushing for better mental health treatment, she has seen increasing polarization, and much of that she contributes to Whitaker and his work. She gets contacted by parents semi-regularly who have read Whitaker’s books and then refuse to let their children start or remain on anti-psychotics—even in cases where medications were working well and the young person wanted to continue with the medication. “This is not at all getting away from coercive relationships,” Jones said.
Irene Hurford, a psychiatrist recently at the University of Pennsylvania but now in private practice, started a first-episode psychosis program in Philadelphia in 2015. She said it was an opportunity to try a nuanced approach to the issues of medication and involuntary treatment.
“It was very clear to me pretty quickly, that the meds did something; it was not that the meds did nothing,” she said. “They didn’t do everything and were certainly not a cure. I see the devil's bargain with our meds all the time. They're shitty. They make people feel terrible. They make people depressed. They make people feel dead inside. They give people the awful side effects. That is all true. I also see what happens when people don't get them. I find this to be, for me, the hardest ethical dilemma of psychiatry.”
The way she describes it is that the medication can act like the foundation of a house. Without a foundation, you can’t build the rest of the house, like the walls. “You need the foundation of basic reality testing, and the meds really do help with that,” she said. “As much as I don’t like meds, I really don’t like no meds.”
But a foundation alone is not a house—it’s just a slab on the ground. Building the walls, the roof, the windows is the rest of the work: therapy, going out with friends, going back to school, getting a job.
Hurford said that she also feels that people’s delusions and hallucinations aren’t just random and false, which mainstream psychiatry can sometimes assert. Delusions are very personal and can have meaning for the people experiencing them. To just say they’re not real and try to make them go away might not be the best way forward, but neither is saying that they’re just a metaphor.
Sandra Steingard, a psychiatrist and the Chief Medical Officer at a community health center in Vermont, said it can be hard to operate from a place of nuance. She blogs for Mad in America, and is not completely against psychiatric medication. “I prescribe drugs,” she said. “I sometimes commit people to hospitals.” But when she writes about involuntary treatment, she tries to be honest about it. She doesn't make it sound pretty. It's been difficult for her to recognize that even with good intentions, she might have caused such harm in the course of her career. She thinks that that sense of humility and openness is the first step to any sort of dialogue.
“I think appreciating the harm and respecting that, making sure it weighs on me heavily, is part of how I’ve changed,” she said. “As a psychiatrist working in a critical perspective, it basically means acknowledging that you're picking between two harms. There is harm done to someone when you force them to take medication, even if you think the medication may have some benefit. That's a shift that's not going to satisfy people who think this never should be done. But it's a shift.”
Hurford said she confronts and wrestles with her desire to coerce people into treatment all the time. If a patient isn’t psychotic and they want to go off of medication because of the side effects, Hurford supports them. But someone who is fully psychotic, she contends, is not making a choice.
At some point with psychotic illness, people often lose insight, Hurford said—meaning that they stop realizing something is wrong. If forcing someone to take medication or be treated against their will is a violation of civil rights, so is psychosis, Hurford said. “They don't have their civil rights then either. It's just that it was taken away by psychosis, not us the treaters. I don't think either one is great. I don't like forcing people into care. It does not feel good to do that, no matter how ill someone might be. And I agree that I'm violating their rights. But I'm also trying my best to do no harm.”
The resolutions to these disagreements are both complicated and simple, in our grasp and yet far out of reach. It could be best to start where there is agreement. “We have known for 50 years how to provide good care for severe mental illness,” Frances wrote in Psychiatric Times. “There is nothing mysterious or complicated about it. Decent housing. Easily accessible treatment. Social clubs. Vocational rehab. Positive regard, respect, and empathy. Family support.”
Focusing only on biological mechanisms of mental illness or doling out pills to the mentally ill is not enough. Though such research into mental illness should continue, so must a re-focus on community health centers to care and support for people who need it now. Unfortunately, the current truth in this country is that many people with mental illness are not coerced into treatment long term, but put into jail, like Stringer. That doesn’t mean the answer is more institutionalization, like we did in the 1950s, but the answer isn’t to abolish psychiatry either.
Peacock now speaks to audiences all around the country about her negative experience with medication, while Martha is collaborating with The Treatment Advocacy Center to bolster a law in Pennsylvania that will make it easier for seriously mentally ill patients, like Stringer, to be medicated against their will.
Peacock still maintains that psychiatry is too focused on the brain. "We need to be focused on social change, listening, community, talking about your problems, not medicating things away," she said. "I think there's meaning in people's suffering."
But for Martha, that position is a painful one. What is the “meaning” behind why her daughter's life has deteriorated the way it has? Martha is part of a Facebook support group for parents where she sees post after post of people desperate for help for their kids, for whom contextual support wasn't enough. "I don't know that anyone could say they're happy or there's meaning in the way my schizophrenic child is able to live their life," Martha said.
It’s nearly as useless to be steadfastly pro-psychiatry as it is to be anti-psychiatry. Psychiatry is not a monolith, but an entire field and history, with some practices that are more helpful than others, and a huge range of diversity in terms of the kinds of people it treats.
This is the crucial flaw in comparing cases like Peacock and Stringer. There are completely different people with different kinds of emotional distress. Their disorders are different. We don’t know why some people develop and maintain a serious mental illness and others do not. And the attempt to tease apart biology from life circumstances—this Cartesian desire to separate mind from body, soul from biology, trauma from medical symptom— may not prove to be useful to those who need help now.
Jones would like to see deep listening and consideration on both sides, a wish rarely rarely fulfilled. When Hurford wrote about her decision to treat a psychotic patient who believed he was a prophet, she got flak from both Mad in America supporters and more biological psychiatrists. “I engaged with both of them," she said. "And I won neither battle.”
"We're bickering over these issues when if we funded the services that are needed, a strong community mental health system, we would be addressing them," Jones said. "I don't see the substantive policy proposals coming out of the Whitaker camp.”
In response to that, Whitaker said, "I would think that’s a function of policy makers, and not journalists. However, in Anatomy of an Epidemic, and in reports for our website, we have told of innovative programs that are achieving good results, and are exploring alternative 'paradigms of care.' That is the journalistic function; not to recommend, but to highlight—and make known—these efforts.”
There are countless legitimate criticisms to be made of psychiatry. But modern psychiatry does not believe that mental disorders are only the result of a chemical imbalance, or just a brain disease. Whether its practitioners have effectively communicated that to their patients, is an issue that desperately needs to be addressed. Psychiatry also operates within a medical system that doesn’t insure more holistic ways of addressing mental health, and a social system that doesn’t support people adequately from the beginning of their lives—contributing to the negative psychosocial factors that influence the rise of mental illness. All of this doesn’t mean that psychiatry should be abolished, or that mental illness does not exist, but it doesn't negate the harm it's caused along the way.
“There’s tremendous pain, and a history and weight of the exclusion and marginalization on the survivor’s side,” Jones said. “Those emotions are real and they come from somewhere very real. It’s a problem to be completely dismissive of the people who have had really negative experiences. You have to listen to that.”
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