Why does Western psychiatry continue to be dominated by the ‘illness like any other’ approach to mental health problems? And why, despite the mounting evidence of the negative physical health consequences of their long-term use, together with growing doubts about their degree of efficacy, do antipsychotic and antidepressant drugs endure as the mainstay psychiatric intervention?
Four major barriers that hinder change are proposed:
- Vested interests of drug companies and the psychiatry profession
- Collusion by other mental health professionals
- The neutralisation of alternative approaches
- Mental illness provides a convenient ‘explanation’ of problematic behaviour
It is highly likely that anyone accessing adult psychiatric services today in the Western world will receive a ‘medicate and monitor’ response to their misery and suffering. Despite the biochemical imbalance theories of the major mental health problems – the role of excess dopamine in ‘schizophrenia’ and serotonin deficiency in ‘depression’ – having been resoundingly discredited, the interventions from psychiatric professionals will broadly conform to the assumption that the recipient is afflicted with an illness or disease comparable, in its conceptualisation, to diabetes or tuberculosis. As such, the distressed patient will be diagnosed with a specific illness, prescribed medication and observed for signs of improvement that might indicate a cure.
What could be maintaining this nonsensical state of affairs? I suggest that there are four major factors that discourage change and thereby perpetuate the status quo.
1. Vested interests
Continuing to view human suffering as a bio-medical condition serves the interests of two powerful and influential groups.
The pharmaceutical industry
Between 1998 and 2010, antipsychotic and antidepressant prescribing in England accelerated each year by 5% and 10% respectively (1). In 2011, 3.1 million Americans were prescribed antipsychotics at a cost of over 18 billion dollars, the equivalent figures for antidepressants being 18.5 million and 11 billion dollars (2). Given the widespread use of these drugs, the profits reaped by the multinational drug companies are huge.
The bio-medical, ‘illness like any other’ approach to human suffering dovetails neatly with big pharma’s revenue aims. If one can maintain the illusion that mental health problems are primarily caused by biological deficits there is a rationale for, not only widespread prescribing to the multitude of distressed people, but also for long term use (often for a lifetime) to maintain ‘balance’ within the brain biochemistry.
The psychiatric profession
Psychiatrists are, by far, the most powerful and highly-paid group of practitioners within Western mental health services. Their status and remuneration primarily depend on the profession being viewed (by government, commissioners, laypeople and other mental health professionals) as a legitimate medical speciality, in essence no different from other branches of medicine such as orthopaedics and oncology. The assertion that human misery and suffering are primarily caused by an underlying biological illness – diagnosed, for example, as ‘schizophrenia’ ‘bipolar disorder’ or ‘depression’ – acts to justify their position at the top table of the medical establishment.
But while orthopaedic doctors mend broken bones, and oncologists detect and destroy cancers cells, there is no equivalent biological substrate for psychiatrists to work with; no persuasive evidence for underlying biochemical or anatomical defects in the arena of mental health problems has been found. For the psychiatric profession to acknowledge that the range of human suffering, currently categorised under dubious diagnostic labels, are not medical disorders, would be tantamount to an acceptance that the discipline has no justification for performing a central role in countering misery and distress.
Thus, these two vested interests will vehemently defend their privileged, self-serving positions. As suggested in my recent book (3), ‘the symbiotic relationship between biological psychiatry and the multinational drug companies represents one of the most pernicious collusions in peacetime history’.
2. Collusion by other professionals
Psychiatrists are not the only professionals maintaining the status quo. Many practitioners from other disciplines – clinical psychologists, psychiatric nurses, social workers, occupational therapists – collude, to varying degrees, with a bio-medical approach to human distress.
The routine use of medical language by professionals from all disciplines sustains the idea that people with mental health problems are afflicted with internal biological deficits and that any disagreement with the dominant paradigm is only superficial (4). This collusion might involve reference to diagnostic labels (‘schizophrenia’, ‘bipolar’, ‘depression’) or, more commonly, general terminology like ‘symptoms’, ‘treatments’ and ‘disorders’. The wearing of traditional nurses’ uniforms on some psychiatric inpatient units further strengthens the medicalised culture.
Perhaps based on their own inherent assumptions that mental health problems are primarily the result of biological abnormalities, the majority of service managers (and many practitioners from a variety of disciplines) perceive medical specialists to be the natural leaders of the clinical team. Consequently, the views of psychiatrists are typically given greater weight than those of their professional colleagues from other disciplines and they are routinely offered opportunities to lead service re-design initiatives. As such, psychiatrists are allowed to exercise a level of influence disproportionate to their skill set (6).
3. Skilled neutralisation of alternative approaches
Multiple critical voices have been around for over half a century, highlighting the damaging consequences of traditional psychiatric practice. Furthermore, research has demonstrated that there is no empirical basis for construing human suffering as an illness like any other. Yet despite vocal opposition, the bio-medical doctrine remains relatively intact, dominating Western mental health services. Why is this?
One potentially key factor conferring immunity to a fundamentally flawed and harmful psychiatric system concerns the way the proponents of the dominant biological paradigm respond to proposals to change the way things are done.
Neutralisation by personal attack
Suggestion regarding alternative approaches to human suffering are typically neutralised by biological psychiatrists in one of two ways (4). Proponents urging a different way of doing things can often be attacked or ridiculed. A recent example of this type of response concerns Jeffrey Lieberman (a former president of the American Psychiatric Association) dismissing Robert Whitaker as a ‘menace to society’ for his allegedly ‘preposterous’ (in fact, evidence-based) claim that unmedicated psychosis-sufferers fared better in the long term than those continuing to ingest antipsychotic medication (7). Many clinicians working within the Western psychiatric system will recognise this type of attack in response to their suggesting different ways of responding to mental health problems.
Given their power and status, personal attacks by biological psychiatrists can be effective in silencing dissenters. However, although typically vocal and hostile, the reactions of these defenders of traditional practice are easier to dismiss as their comments reflect indignation rather than persuasive argument – many antipsychiatry commentators will be aware of a cluster of these voices on Twitter and other social media.
Neutralisation by the ‘we’re doing this already’ mantra
A more difficult barrier to overcome is provided by those psychiatrists who attempt to assimilate the proposed alternative approach into existing practice; the ‘we’re broadly doing this already’ response (4). In this process, new ideas are shorn of their more radical aspects so as to strengthen the claim that change is not required as current practice is broadly consistent with the ‘innovation’.
Even psychiatrists expressing dissatisfaction with traditional practice, and urging a more socially focused form of service delivery, are sometimes guilty of assimilating new ideas while ensuring medical specialists continue to perform their clinical leadership roles. For example, in 2012 a group of psychiatrists wrote an article highlighting the limitations of traditional psychiatry and appealing for ‘a more nuanced form of medical understanding and practice’ in which ‘psychiatry has the potential to offer leadership’ (8). It seems that these emergent social psychiatrists believe they can now dispense this more sophisticated, interpersonally-nuanced brand of practice where, despite their core medical expertise no longer being central to helping people who are suffering, they remain in charge!
4. Mental illness: a convenient ‘explanation’ of problematic behaviour
Human beings tend to default to lazy explanations as a means of economising on mental effort. Biological psychiatry offers such an opportunity whereby another’s problematic behaviour and expressions of overwhelming distress can be boxed off as being caused by mental illness, a simplistic explanation that negates us having to think any further about contributors to human suffering. As such, by attributing mental health problems to some assumed biological defect within the individual sufferer, each of us – friends, relatives, communities, politicians – is absolved from feeling any direct or indirect responsibility for their emergence.
Disempowerment and marginalisation contribute significantly to the development of mental health problems (9). Childhood abuse, domestic violence, socio-economic inequality, poverty, homelessness, racism, sexism, and the experience of residing in high-criminal localities, all increase the likelihood of subsequently being labelled as mentally ill. But biological psychiatry’s stubborn assertion that human suffering of this kind is primarily the result of a brain abnormality allows Western governments to avoid responsibility for their failures to counter social and economic disadvantage.
Traditional psychiatry, with its ‘illness like any other’ assertions, lets many of us off the hook. Consequently, innovators – who typically are urging for much greater attention to past life experiences when making sense of mental health problems – are likely to meet with resistance from a variety of sources.
- Ilyas, S. & Moncrieff, J. (2012). Trends in prescriptions and costs of drugs for mental disorders in England, 1998 – 2010. British Journal of Psychiatry, 200, 393 – 98.
- IMS Institute for Healthcare Informatics (2011). The use of medicines in the United States: Review of 2010. Retrieved 22 January 2014 from, http://www.environmentalhealthnews.org/ehs/news/2013/pdf-links/IHII_Medicines_in_U.S_Report_2011-1.pdf
- Sidley, G.L. (2015). Tales from the Madhouse: An insider critique of psychiatric services, p146. PCCS Books.
- Boyle, M. (2013). The Persistence of Medicalisation: Is the presentation of alternatives part of the problem? In S. Coles, S. Keenan & B. Diamond (Eds.), Madness Contested: Power and Practice (pp 4 – 22). PCCS Books.
- Boyle, M. (2011). Making the world go away and how psychology and psychiatry benefit. In M. Rapley, J. Moncrieff & J. Dillon (Eds.) De-Medicalising Misery: Psychiatry, psychology and the human condition. Palgrave: Macmillan.
- Sidley, G.L. (2015). Tales from the Madhouse: An insider critique of psychiatric services, p69-71. PCCS Books.
- Whitaker, R. (2015). A challenge to Doctor Lieberman. Mad in America website. Retrieved on the 27th April 2015 from, http://www.madinamerica.com/2015/04/challenge-dr-lieberman/
- Bracken, P., Thomas, P., Timimi, S., Asen, E., Behr, G., Beuster, C. et al. (2012) Psychiatry beyond the current paradigm. British Journal of Psychiatry, 201, 430 –34.
- Coles, S. (2013). Meaning, Madness and Marginalisation. In S. Coles, S. Keenan & B. Diamond (Eds.), Madness Contested: Power and Practice (pp 42 – 55). PCCS Books.
Photo courtesy of Stock Images at FreeDigitalPhotos.net