‘Psychiatric prejudice’ is a term being bandied about these days, mainly by aggrieved psychiatrists who feel that psychiatry is not being given equal status with other medical specialities. Ordinary people, other doctors and medical students are all prejudiced because they do not appreciate that psychiatry is a proper medical activity, and critics of psychiatry are prejudiced because their analyses undermine this medical point of view (1).
Obviously no one can afford to be labelled as prejudiced, so whether it is conscious or not, this looks like an attempt to silence criticism and shut down debate . If successful it will deny people access to many valid criticisms of psychiatric diagnoses and treatments and to hearing other views about how to respond to mental health problems.
Some of the recent accusations of psychiatric prejudice were made in response to articles in the British press by Danish doctor, Peter Gøtzsche, a leading member of the highly respected organisation for analysing medical evidence, the Cochrane Collaboration (2). Gøtzsche argued that evidence for the benefits of psychiatric drugs, like antidepressants, was so weak and flawed, and adverse effects so often under-rated or ignored, that the widespread use of these drugs was likely to be doing more harm than good. Other people have made similar claims, including Peter Breggin, Irving Kirsch and Robert Whitaker, but coming from the heart of medicine itself, this attack may have been more painful than others.
In a direct response to Gøtzsche’s article, five leading psychiatrists accused those who criticised psychiatric drug treatment as demonstrating ‘deep-seated stigma’ against mental health, insulting psychiatry and ‘reinforcing stigma against mental illnesses and the people who have them’ (3). In another article in the Times, psychiatrist Simon Wessely, newly elected president of the Royal College of Psychiatrists, complained that other doctors were prejudiced against mental health, and look down on psychiatry. Although acknowledging widespread overmedicalisation and overprescription, Wessely too asserted that psychiatric drugs treat real disorders and that it is ‘nonsense’ to suggest that antidepressants don’t work (4).
The job of psychiatrists, according to Wessely, is to identify these real ‘disorders’, and to make sure that the people who have them get the drugs, but others don’t. This position assumes that psychiatry is basically the same sort of activity as physical medicine, as if you could easily distinguish those who have ‘real,’ clinical or major depression from those who are just sad or discontent, and once identified prescribe a treatment that targets the origin of the problem.
But, of course, you can’t. No blood test, X-ray or brain scan can reveal depression, schizophrenia or any other ‘mental disorder’. There is no underlying psychological process either that can somehow be separated off from an individual’s feelings and behaviour and designated as ‘the disorder’. Psychiatric diagnoses are based on judgements made by patients, doctors, relatives and other people (such as the police) about someone’s behaviour and whether it conforms to what is expected in any given society and situation. Think about depression for a moment. It is when someone stops functioning as usual- when they start to have difficulties fulfilling their roles – going to work, looking after family – that they seek help and are diagnosed. Until feelings affect someone’s behaviour, it is rare that they would come to psychiatric attention, or be considered severe enough to require intervention.
Apart from its conceptual incoherence and lack of empirical support, the problem with the concept of ‘mental illness’ is that it assumes that what psychiatrists are treating is not a person with problems and difficulties, but a disease- or its pseudonym, a ‘disorder’. This is why so many people accuse psychiatry of being dehumanising.
Despite decades of propaganda from the pharmaceutical industry and sections of the medical profession, much of the public and many doctors and medical students are not convinced that mental illnesses are illnesses, ‘just like any other’. Many people remain inclined to view the difficulties we label as mental disorders as understandable reactions to adverse life events or circumstances and importantly, evidence suggests that people who think in this way are more tolerant of such situations. Contrary to what some psychiatrists are now saying, viewing mental disorder as a brain diseases leads to less tolerant attitudes- in other words more prejudice (5).
Psychiatrists’ complaints only betray their continuing insecurity about their status as ‘proper’ doctors. But helping people with mental health problems does not have to be regarded as second class just because it is not the same sort of activity as other medical specialisms. Education and social work are different from medicine, but no one suggests they are not important. In my view, there is a role for medical expertise in helping people with mental health problems, but that does not mean we have to call those problems illnesses. As I have suggested in other blogs and articles, drug treatment can help to modify unwanted thoughts and behaviours or subdue overwhelming emotions in some situations, and people who prescribe and recommend drugs should have a thorough knowledge of all their effects and the body’s likely response to them. Although I think drugs should usually be a last resort, it takes more knowledge and expertise, not less, to use them sparingly and selectively.
Nevertheless, psychiatry is different from the rest of medicine. When its differences are not acknowledged, and psychiatrists behave as if they were treating chest infections, people are objectified into diagnoses. It is then a short step to subjecting them to all sorts of physical intrusions in the name of treating the disease. Criticism and debate are essential to enable mental health services to develop their own distinctive ethos and practice.
- http://www.wpanet.org/detail.php?section_id=7&content_id=922 (I am grateful to Phil Hickey to alerting me to the WPA’s position: http://www.behaviorismandmentalhealth.com/2014/06/19/psychiatrys-response-attack-and-pr/)
- Read J, Haslam N, Sayce L, Davies E (2006) Prejudice and schizophrenia: a review of the ‘mental illness is an illness like any other’ approach. Acta Psychiatr Scand, 114, 303-318