Anti-psychiatry is a loose social movement that first emerged in the 1960s in Europe and the US, and it began as an ideological response to the treatment of mental illness in asylums at the time. Those supporting the movement were concerned about the poor conditions of many of these asylums, as well as the abusive and inhumane treatment that patients were subject to. In addition, anti-psychiatry proponents believed that the process of institutionalising patients in asylums, in general, would not aid their recovery but frustrate it. Those opposed to psychiatry also argued that conditions like schizophrenia could not be real diseases because they did not involve any obvious brain changes, nor could they be detected by a physical test (although, we now know that schizophrenia is associated with various structural brain changes). Then there was the issue of the psychiatric profession classifying homosexuality as a mental illness, which entrailed attempts to ‘cure’ gay people.
The anti-psychiatry movement was therefore based on a deep-seated dissatisfaction with both the assumptions and treatments central to psychiatry. But the movement today is significantly different from the movement in the 60s; after all, conventional psychiatric treatments and hospitals have dramatically changed, as have many of the models that psychiatrists use to think about mental illness. However, much of the foundational beliefs of anti-psychiatry remain, namely, that psychiatric treatment is often more harmful than helpful to patients; psychiatry is oppressive, due to the unequal power dynamic between doctor and patient; and diagnosis is subjective (and not objective in the way that psychiatrists make it out to be). Advocates of anti-psychiatry also question whether so-called mental illnesses are actually ‘illnesses’, arguing that many reactions and behaviours that doctors pathologise are actually a normal part of the human condition. This medicalisation of normal behaviour, members of the movement contend, has led to over-medicating among psychiatrists.
The extreme brand of anti-psychiatry calls for the abolition of psychiatry, based on the harm that psychiatry causes patients. Truth be told, many patients have routinely suffered abuse at psychiatric hospitals, despite the improvements in psychiatric care over the decades. Indeed, according to one survey conducted in the UK, only one-third of patients detained under the Mental Health Act felt they had been treated with dignity and respect. Many ex-patients, based on the trauma and harm they suffered as a result of compulsory institutionalisation and treatment, will refer to themselves as ‘psychiatric survivors’, with some subscribing to anti-psychiatry beliefs. The label ‘survivor’ and the tendency towards anti-psychiatry makes sense when you consider what the lived experience of these ex-patients was like. If you were regularly dehumanised while in a highly vulnerable state, and by people who were meant to take care of you, what would be your lasting impression of psychiatry?
I do want to emphasise, however, that ex-patient organisations often distance themselves from the anti-psychiatry movement. The National Empowerment Center, for instance, describes the movement as “largely an intellectual exercise of academics and dissident mental health professionals”, adding that “[t]here has been little attempt within anti-psychiatry to reach out to struggling ex-patients or to include their perspective.” The journalist Shayla Love underlines in a piece for Vice that “[n]ot 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.” This is an important point, as the label ‘anti-psychiatry’ may be confounded with the psychiatric survivors movement in order to up to paint it as extreme. Many ex-patients do not wish to abolish psychiatry; they simply want to see unethical doctors and practices removed from the profession.
The anti-psychiatry movement, like the psychiatric survivors movement, also brings attention to the dangers of psychiatric medication, as many of these can be iatrogenic (meaning that harmful complications or symptoms result from medical treatment). For instance, it’s not just various unpleasant side effects of medications that are common but more serious effects, such as dependence, addiction, and withdrawals (which is a particular risk with benzodiazepines, often prescribed for anxiety disorders). In psychiatry, iatrogenesis can also occur as a result of medical error, adverse drug reactions, malpractice, and negligence.
Psychiatric iatrogenesis can manifest as both physical and psychological symptoms (indeed, psychiatric medications can sometimes worsen the mental health of people or cause psychological symptoms to arise that were absent before treatment). Akathisia, a movement disorder characterised by restlessness, is a common side effect of antipsychotic drugs (and an occasional side effect of SSRI antidepressants). The condition can be extremely distressing. And this distress has been associated with suicidality (increasing the risk of both suicidal ideation and suicide attempts). In addition, brain damage can result from the long-term use of antipsychotics, antidepressants, and benzodiazepines, while post-SSRI sexual dysfunction (PSSD) can occur following the cessation of serotonergic antidepressants.
While it’s crucial to take seriously all of the concerns raised by exponents of anti-psychiatry, we should question whether malpractices (which may be far too prevalent) justify complete opposition towards psychiatry. Many patients, for instance, have mixed opinions about psychiatric treatment, rather than an entirely negative one, whereas other patients speak of their psychiatrist, hospitalisation, and treatment in a highly favourable way, maintaining that psychiatry not only kept them well but that it perhaps saved their life. For this reason, we should ask: Could the anti-psychiatry movement – through its wholesale rejection of psychiatry and calls for its abolition – actually be harmful in its own way? Many psychiatrists strongly believe that this is the case. I now wish to describe and analyse their arguments.
The clinical psychologist Jonathan N. Stea, in an interview for Psychology Today, is clear about his anti-anti-psychiatry stance:
I consider modern anti-psychiatry to be a potentially dangerous disinformation campaign that aims to tear down the discipline and deter treatment-seeking. Those who espouse anti-psychiatry ideology often lay charges against the very existence of psychiatric disorders and the wholescale efficacy of psychiatric medications. In this way, anti-psychiatry differs from helpful scientific scrutiny—instead, it attempts to offer moralistic and ideological criticism.
While the definition itself hasn’t changed much over time, I would argue that the early days of the movement actually helped psychiatry to appropriately self-correct towards the more humane and scientific discipline that it is today…
Stea is keen to point out that modern anti-psychiatry is more unorganised and loose compared to when it first arose. Anti-psychiatry advocates today can be divided in their opinions. You have those who believe all of psychiatry is misguided and harmful (which the Church of Scientology believes), and then you have less extreme views, which mainly oppose involuntary hospitalisation and coercive treatment, which often amount to human rights abuses. Yet while modern anti-psychiatry is not clear-cut, Stea argues that homogeneous beliefs among proponents of anti-psychiatry often converge on common themes “that could be harmful to patients”. He adds:
The often seen extremism of anti-psychiatry is tragic because it undermines legitimate issues that warrant attention, such as patient autonomy, over-diagnosis, over-treatment, and the importance of risk-benefit in full informed consent of medications. Instead, what is often seen, for example on social media, is that these important topics are often lost in positions of extremism where psychiatry is inaccurately marked and tarnished as more harmful than helpful, and any voiced benefits derived from psychiatric conceptualizations and medications are chastised.
Stea feels that if those belonging to the anti-psychiatry movement had more experience with the treatment of severe psychiatric disorders (like psychosis and schizophrenia), then they might not be so quick to dismiss psychiatry. Indeed, there are those – like Darius Galasiński, professor of Discourse and Culture at the University of Wolverhampton – who shake off their anti-psychiatry beliefs after having this experience. When Galasiński interned at one of the best psychiatric hospitals in Poland, the psychiatry clinic of the Collegium Medicum of the Jagiellonian University, he witnessed unsettling heights of misery – people going through acute states of distress, the likes of which he had never seen before.
But he also saw, first-hand, psychiatrists who genuinely cared for these patients, psychiatrists who attentively listened to them and who were humble and critical of their profession, agreeing with much of what the anti-psychiatry literature had said. In relation to one psychiatrist that he spent some time with, Galasiński remarks, “I hate to admit it, but what I saw was a human being experiencing uncomfortable dilemmas, not an oppressor waiting to exercise his Foucauldian and physical power [over] his patients.” He acknowledges that this quality of psychiatric care is perhaps “rare and unique”, but his lasting impression is still that “it was real psychiatry, really helping real people.” The kindness and thoughtfulness of the psychiatrists were undeniable and he has no doubt that many others practise psychiatry with these sorts of virtues.
Many supporters of the anti-psychiatry movement, on the other hand, do not campaign for better psychiatric treatment; instead, they call for more talking-based therapies, including for debilitating conditions like schizophrenia. According to a study published in the journal Schizophrenia Research, 30% of patients with schizophrenia can manage without the use of antipsychotic medication, even after 10 years since their diagnosis. This is a large minority, of course, but it does still mean that most schizophrenic patients often need antipsychotic medication to manage their symptoms. Improved non-drug treatments may allow even more patients to cope without the need for medication; but, as it stands (and as it may stand long into the future), the use of medication can be critical.
As Stea states: “At the severe end of psychopathology, the use of psychiatric medications can be life-saving, and withholding their use based on misguided ideology is a life-threateningly terrible idea.” It’s not just schizophrenic patients who feel grateful for the existence of antipsychotic medication, patients with depression, too, feel this way about antidepressants. In spite of anti-psychiatry claims that antidepressants work no better than placebo, a meta-analysis of 21 different antidepressants found that they all – in differing degrees – are more efficacious than placebo (although it’s worth noting that the mean difference between all antidepressants and placebo is slight, and most studies included were funded by pharmaceutical companies, which can lead to biased results).
It is still unclear whether antidepressants are, in fact, more efficacious than placebo – yet for a lot of people struggling with depression, medication is still seen as immensely valuable. Meanwhile, meta-analyses demonstrate that various antipsychotic medications are effective in the treatment of schizophrenia – and they are significantly more efficacious than placebo (concerns about funding and biases should be kept in mind, of course). Schizophrenia is not a condition that responds well to novel, non-conventional drug treatments like psilocybin and ketamine in the way that depression does; in fact, these drugs can provoke psychotic symptoms in patients with schizophrenia.
In the second part of the interview, Stea points out that in his day job, he has “witnessed the reluctance of family members to participate in treatment as a result of anti-psychiatry sentiments that they read online.” The anti-psychiatry movement can also feed into conspiracy theories about the medical and pharmaceutical industries at large. Its adherents may view psychiatry as a malignant force in society, hell-bent on medicating the general population and dulling their minds for the sake of control, power, and profit. Stea is unsurprised to find that anti-psychiatry ideology shares features with ideologies like anti-vaccine ideology, including the elevation of anecdote, the rejection of evidence, conspiracy theory, preferences for alternative medicine, and distrust of scientific authority.
On the other hand, it is understandable for people to be sceptical of evidence and scientific authority – after all, a great deal of psychiatric drug research is biased. In his book, Cracked: Why Psychiatry is Doing More Harm Than Good, the social anthropologist and psychotherapist James Davies illustrates how common this bias is: we see this bias in the manipulation of research to produce a positive result and in the fact that negative drug trials go unpublished. He claims psychiatrists have been creating more disorders and prescribing more pills as a result of financial incentives from pharmaceutical companies, and explains how all of these scientific and treatment flaws have been concealed by clever marketing tactics.
In an op-ed for Medical News Today, Stea, and the psychiatrists Tyler Black and Joseph Pierre, attempt to refute the common tropes of anti-psychiatry. For instance, some anti-psychiatry advocates may claim that psychiatry currently promotes the ‘chemical imbalance’ hypothesis to explain mental illness, although the authors emphasise this hypothesis was an early and incorrect one in psychiatry, noting that the biochemical mechanisms of mental illness are still being critically researched. Nonetheless, the American Psychiatric Association (APA) still tells the public that “[d]ifferences in certain chemicals in the brain may contribute to symptoms of depression.”
There is then the related misconception that psychiatrists practise biological psychiatry (or biopsychiatry), which aims to understand mental illness in terms of the biology of the brain. Modern psychiatry, however, conventionally adheres to a biopsychosocial model, which, while subject to criticism, certainly includes non-biological factors in its analysis of mental illness. Moreover, Stea et al. say it is a myth that all psychiatrists are prone to overdiagnosis and overprescription. They stress that many practitioners are vigilant about this issue. One should, nevertheless, consider whether this is truly a myth, given that antidepressant prescriptions continue to rise (having increased by 35% over the last six years in England). A lot of understandable distress, as a response to personal, relational, political, and economic conditions, could very well be mislabeled as some type of disorder, thereby leading to both overdiagnosis and overprescription.
Stea believes that the anti-psychiatry movement derails good-faith attempts to critically examine the problems with psychiatry, with the aim of improving it, so that outcomes look better for patients. He notes: “Anti-psychiatry ideology seeks not to improve psychiatry but to tear it down. Psychiatry itself is a scientific discipline, and therefore criticism is a built-in feature with a view towards improved biopsychosocial patient care.” Calling psychiatry a purely ‘scientific’ discipline may be somewhat misleading, though, given that psychiatric diagnoses are unscientific in nature. Having said that, many professionals do practise evidence-based psychiatry, which means treating patients in accordance with the most up-to-date and robust scientific research.
The problem is not that psychiatry is somehow inherently corrupt or useless. But there are definitely widespread issues with psychiatry that do need to be addressed – and we should be wary of anyone’s attempt to attach the label ‘anti-psychiatry’ to valid criticisms of psychiatry, as this can end up denying the very real and very serious harms suffered by patients. At the same time, the harms of psychiatry do not justify the more extreme side of anti-psychiatry. For example, desiring the abolition of psychiatry does seem to discount the ethical integrity and compassion that is common in psychiatric care.
Allen J. Frances, a well-known critic of psychiatry, is keen to highlight that psychiatrists want to deliver high-quality care but they often find themselves struggling to do. This is because they are often working in a mental health system that is underfunded, understaffed, and mismanaged. Due to these systemic issues, psychiatrists will spend their limited time with patients discussing symptoms, adjusting medication, and determining side effects. There will be little time left to really get to know the patient, provide emotional support, and teach skills through psychotherapy. Resolving the systemic problems in providing mental health care could redeem at least some aspects of psychiatry.
Furthermore, there are some reasons to be hopeful about the future of psychiatry. With the re-emergence of psychedelics in psychiatry, we are finding that psychedelic compounds like psilocybin do not carry the risk of iatrogenic harm associated with many psychiatric medications. Psilocybin also seems to be highly effective in the treatment of major depression, offering patients relief when conventional treatments failed to do so. By promoting safer and more effective treatments, and improving the doctor-patient relationship, psychiatry can be reformed (or revolutionised, depending on how you look at it). An abolitionist approach, meanwhile, implies that there is no hope left for psychiatry.
Undeniably, those living with mental illness, active patients, and ex-patients may be wary about seeing a psychiatrist, sometimes due to anti-psychiatry sentiments, but these worries can be abated by finding a respectable psychiatrist to work with. There are flaws with psychiatry, no doubt, and plenty of incompetent practitioners, but the extreme claims made by some people in the anti-psychiatry movement can end up causing a whole different set of harms. Critical psychiatry, unlike anti-psychiatry, does not call for the abolition of psychiatry but instead offers constructive criticism of psychiatric diagnosis and treatment. Both psychiatry and anti-psychiatry have the potential to be dangerous. For this reason, prioritising critical perspectives over abolitionist ones may be the more balanced and fruitful route to take.
A balanced and educational approach to this disturbing controversy.