Psychiatry's Poor Image: Reflecting on Psychiatrists' "Apologias"

Those of us who critique psychiatry were recently treated to an interesting phenomenon—the publicly available part of the January 2015 issues of Acta Psychiatrica Scandinavica, which contains multiple articles devoted to the question of psychiatry’s “poor image”—how to understand it, how to assess it, what to do about it (see http://onlinelibrary.wiley.com/doi/10.1111/acps.2014.131.issue-1/issuetoc). The release of this issue is hardly the first occasion where articles have appeared in which psychiatrists have speculated on outsiders’ negative image of the profession. Indeed, more and more, we are seeing such articles together with other evidence that the professionals are concerned (e.g., Bhugra and Moran, 2014; and Oxtoby, 2008). What makes this issue special is that there is a sizable number of commentators; moreover, they include such leading figures as Gaebel, current President of the European Psychiatric Association, Wasserman, former President of the European Psychiatric Association, and Bhugra, President of the World Psychiatric Association. Could it be that the upper echelons of psychiatry, whether they admit or not, are becoming alarmed? Regardless, these psychiatric reflections are themselves a source of data—hence this article.

This article probes the collection in question for themes, positions, framing. Questions explored include: What positions are being taken? How valid are they? Insofar as constructions are never “innocent” but invariably have a function, what functions are being served? What do these articles tell us about psychiatrists? About the state of psychiatry?  How successful are the proffered solutions likely to be in resuscitating the “image of psychiatry”? And what should we be wary of here? 

The Special Issue in a Nutshell

The majority of the special issue is tightly focused on the image question. At the centre of the issue is a piece/study by Stuart et al. (2015). Counting the study and the two editorials, there are 10 pieces focused on this question in all.

The Stuart et al. article is in essence the write-up of a study conducted on non-psychiatric medical faculty’s opinions of psychiatry. 1057 faculty members were sampled. The major findings? The majority hold a very negative view of psychiatry, of psychiatrists, and as well as of their “patients”. Ninety per cent thought that psychiatrists were poor role models. One in five thought that psychiatrists have too much power over “their patients”.  Many questioned the efficacy of the treatments. Additionally, many saw psychiatrists as having poor medical skills and deemed psychiatrists to be illogical. Correspondingly, “the majority felt that students in their medical school were not interested in pursuing a psychiatric specialization” (p. 24), with over a third opining that “their colleagues generally do not speak well of psychiatry.” (p. 24). By way of commentary, the authors of the study note that there is no clear way to distinguish how much of the poor image may be attributed to being part of a “stigmatized group” and how much is attributable to accurate perception. Correspondingly, they link these perceptions to the low number of medical students choosing psychiatry as their specialty.

In the related pieces, authors comment not only on this article but more generally on psychiatry’s image— overall, whether it is indeed bad or not, and insofar as there is a problem, who is at fault and what to do about it.

The Most Important Question Never Emerges

Before I proceed further, I would point out that there is a conspicuous void in this collection. While all authors in their own different ways address what might be done to improve psychiatry’s image, significantly, not a single psychiatrist thinks to ask what by humanistic standards would appear to be the compulsory question: Insofar as any of the bad image is deserved, exactly how are the “patients” being ill served and what is owed them? With one exception only —and we will shortly see why he is an exception—nor does anyone seem to take in that in all likelihood, in dialoguing with each other, they are talking to the wrong people. The point is, insofar as this poor image in any way merited and in any way relates to practice—and it is arguably arrogant just to assume otherwise—it is not so much their colleagues with whom they most need to be in dialogue but the people whose situations they appear to badly misunderstand. What relates to this and is similarly worrisome, “patients” are discussed only insofar as psychiatrists speculate that part of the image problem arises from “stigma” against the “patients” being transferred to the psychiatrists. Nor is improving care per se a major theme. All of which suggest that advancing the profession is taking precedence over the welfare of the people “served”.

What the Focal Piece and the Introductions Set Up

There is somewhat more objectivity in the focal piece by Stuart et al. and in the two editorials than in most of the related psychiatric pieces. This notwithstanding, each constructs the inquiry and the issue in such a way that prejudice on the part of others appears as potentially the single most important factor in accounting for the poor image—and as such, they are hardly neutral. What is apropos here, the study itself was conceptualized in the context of trying to address “stigma” against psychiatrists—hardly a legitimate way to theorize critiques of a profession whose views are hegemonic and which is endowed with huge resources and massive power (not that I am ruling out the possibility of non-psychiatric doctors being unfair to psychiatrists). More particularly, it was “conducted as part of the scientific activities of the World Psychiatric Association’s Stigma and Mental Health Scientific Section.” (Stuart et al., p. 21) The bias inherent in this framing is reinforced by including in this study about negatives attitudes toward psychiatrists an investigation into negative attitudes toward “psychiatric patients”. Holding the two together in this way constructs the attitudes toward these very different constituencies as “of a piece”. The function served is that psychiatry appears as a victim, with all negative evaluations of it set up to be seen as examples of “stigma”. Other ways in which bias enters in? In the first editorial, the author states unequivocally (albeit without proof) that with the advent of molecular biology, the image of psychiatry is improving. Correspondingly, on a personal note, he writes, “This author represents the generation of young academics, with a background in psychiatric genetics. From my perspective, the view of our profession among medical students and doctors has improved significantly since I completed medical school.” (Tesli, 2015, p. 1) And the second editorial actually announces a victory right in the title—“Psychiatry Generating Comparative Respect”, thereby prompting us to view the forthcoming articles in a way favourable to psychiatry (see Munk-Jorgensen and Christiansen, 2015, p. 2-3).

The path is thereby set for evasion on the part of the other psychiatrists in this collection to appear as honest inquiry and for anything unfavourable to appear outdated. 

Emergent Themes/Claims

In this section, I am limiting myself to the pieces penned by the medical doctors (the vast majority of whom are psychiatrists). Most of these responses can be divided into several categories, and all entail some level of evasion. Emergent themes or claims in this regard include: 1) The evidence that psychiatry has a bad image is either not credible or is limited and as such, claims based on it are misleading; 2) Insofar as psychiatry and psychiatrists have a bad image, it is not primarily psychiatry’s fault but the fault of others; 3) The bad image is not exactly anyone’s fault—it goes with the territory; 4) While psychiatry is partially to blame, it is only one or two things psychiatry is doing wrong—none of which are substantive.

The “this is not credible or misleading” line of reasoning is evident to varying degrees in most of the commentators. The most cogent of these is Hartley (2015, pp. 10-11). He points out that the survey itself was conducted in a biased manner, for colleagues were asked to respond only to negative statements about psychiatry—a totally valid point. This notwithstanding, the critique is not as cogent as first appears for it ignores how dramatic the negativity was, also that there were other biases in the construction that pull in the opposite direction.  It likewise ignores the fact that the low enrollment in the psychiatric specialty in an abundance of medical schools itself serves as confirmation. That said, more obviously evasive are other variations on the theme. Note, in this regard, some, including Hartley, object that studies in Australia have had different results, thereby erroneously making it look as if outreach was limited, whereas in point of fact 15 different countries were surveyed. Likewise suggested is an “old-young” divide. The argument here (e.g., Kristiansen et al., 2015) is that being younger and so more keenly aware of how advanced psychiatry now is, medical students have a very positive image of it. It is only medical faculty that do not, and as the old are replaced by the young, the problem will disappear. What is wrong with this construction is that while psychiatry may well enjoy greater popularity among medical students in Australia and Denmark (there is a positive piece by medical students from Denmark in this collection), there is little indication of this other places; correspondingly, were young medical students really excited by psychiatry generally, the percentage of them signing up to study psychiatry would not be so low (for more representative figures, see, for example, Read 2015).

More pronounced and more blatantly evasive is the response/claim, “While psychiatry has a bad image, others are to blame for this.” Herein we see the disingenuous claim of stigma discussed earlier. In this regard, Gaebel et al. (2015, p. 5 ff.) call their article “Overcoming Stigmatizing Attitudes toward Psychiatrists and Psychiatry”.  Correspondingly, they dismiss the critiques by the medical colleagues in question offhand with words like “bad mouthing” and “psychiatry-bashing”. All of this, note, without evidence or even a thought to what evidence in support of such a contention might entail. Ironically, what surprises most of us who are aware of psychiatry’s baselessness, is not how critical other doctors are of psychiatrists but how silent they are about the fraudulence of the medical claims—at least as a big a dynamic as the putative unfairness. The evasion evident here is in turn reinforced by linking the so-called “stigma against psychiatrists”  to the stigma against “mental patients”. Now indeed, it may well be, as these authors claim, that stigma against “mental patients” can impact negatively on people’s perceptions of psychiatrists. Nonetheless, trying to get around the problem like this begs the question. That is, it totally bypasses the central question of whether or not the critiques are accurate. Also it is hard to imagine how “transferred stigma” could translate into such critiques as “psychiatrists exercise too much power over their patients.” Since when do people operating out of “prejudice” against a population want less control—as opposed to more—exercised over said population? Correspondingly, this construction functions to create a false solidarity between psychiatrists and “patients” when psychiatry itself is one of the principle causes of stigma against “mental patients”.  

The primary purpose of the construction of course is to absolve psychiatry by transferring blame onto others. The various people blamed throughout this collection include: other medical teaching faculty; funders (who allegedly are not  providing sufficient resources to make psychiatry attractive to enter (see, for example Bhugra, 2015), and finally, the media.  Note in this last regard, Bhugra’s curious reference to the “antipsychiatry media coverage”. This of course is ironic given the enormous complicity of the press in furthering psychiatry (see Whitaker, 2002). Moreover, as those of who organize against psychiatry but receive negligible coverage are well aware, if there is antipsychiatry press out there, it is keeping itself well hidden. Which brings us to the next claim.

Mostly the people who take the position that the bad image comes with the territory are nonetheless likewise suggesting that stigma is an issue (see, for example Bhugra, 2015).  There is one author that does not and he is the one psychiatrist in this collection who appears to be thinking—and indeed, he can be credited with having a point. In this regard, Kapezinski and Passos (2015) distinguish between what they call “wet minds” (the science of the brain) and “dry minds” (our mental processes) and they state that psychiatry runs into trouble when it tries to simply ascribe “the issues of the mind to brain tissue.” (p.7) This is undoubtedly true and important. Where the authors err is not not going far enough. They recommend that psychiatrists focus their work on scientific explanations and leave it to others to develop explanatory models for human behavior.  The question remains: What about the issue of power?  And insofar as there is any science here that has both validity and relevance, would it not be better handled by credible scientists like neurologists?

Finally, comes the very common contention that while psychiatry is wonderful and amazingly successful (and all the psychiatrists more or less concur on this point), it is in fact doing but one or two things wrong, none of which are substantial, albeit they facilitate the “stigma”. Generally, the deficits identified relate to not having a game plan for fighting back and not properly communicating (e.g., what we are being asked to believe is that despite the enormity of the funds spent on promulgating its message—see this regard, Whitaker, 2002—psychiatry is failing to communicate how very scientific and advanced it is—hence the “misperceptions”—an example of this position being Wasserman’s piece, which largely assumes this is the case, then proceeds to offer suggestions). Given the decades of disaster and the enormity of the evidence that psychiatry’s basic tenets will not hold (see, for example, Whitaker, 2002 and Burstow, 2015), herein lies the ultimate evasion. Correspondingly, it is blatantly clear what purpose is served by such a construction. It is at once an evasion and an argument for pumping ever more resources into what is in essence medical model propaganda. That said, while there is a more general acknowledgement that psychiatrists need to learn how to communicate better, valid though that may be, that acknowledgment in no way touches the heart of the matter. As such, it is but another obfuscation.

The Lone Voice in the Wildness

The lone voice in the wilderness is critic John Read (2015). Read acknowledges the poor image, validating it with reference to statistics and narratives, and he lays the blame for the poor image squarely at the door of psychiatry. He identifies the underlying problem as a “rigid adherence to a narrow biogenetic ideology combined with arrogant dismissal of those with broader perspectives.” (p. 11) One need go no further than the various apologias in this issue to see what he is talking about—a source of confirmation in its own right. While I do not contend that no psychiatrist could have written this, I would add, it is hardly coincidental that what likewise distinguishes Read is that he is not a medical doctor, never mind a psychiatrist. Solutions which Read advocates include: Psychiatrists should start listening to their patients. They should not automatically head all “mental health” teams. And they should restrict themselves to providing scientific information, in the process, limiting themselves to what is “evidence-based”.

Read is a breath of fresh air, and much of what he recommends has validity. Who could argue against listening more to others—in particular, to the people whom one is hypothetically attempting to serve? And yes, something is very wrong with the assumption that psychiatrists should head all “mental health” teams. That said, there are a few questions that I would invite readers to ponder when looking at Read’s other solutions: Why do we need psychiatrists on these teams at all? Could not scientific data, insofar as relevant, be better provided by figures like neurologists? Why are we assuming that teams of professionals should be in charge of others’ emotional well being? Why should we be placing this degree of trust in evidence-based research? Was not the fetishization of evidence-based research part of what landed us in this current predicament (for a hard hitting critique of evidence-research, see Burstow, 2015; see also forthcoming articles). And finally, while Read is suggesting ways to “save psychiatry from itself”—is there in fact any cogent reason to save it?   

The Solutions Proffered by the Psychiatrists: A Further Reflection

The solutions offered by the psychiatrists, not surprisingly, match their positions as articulated above. Insofar as more or less everyone agrees that stigma against psychiatry is involved (again an all-too-convenient confabulation), anti-stigma campaigns are advocated, with one of the authors, Gaebel, additionally inviting his colleagues to address what he sees as the problem of “self stigma” (more commonly known as pangs of conscience). People are urged to come up with road maps. To facilitate the “needed communication”, correspondingly, the use of professional bodies is recommended as well as individual training in communications skills, with authors such as Wasserman (2015, p. 13), for example, writing, “To promote the destigmatization of psychiatry and change the negative attitudes toward psychiatrists, a road map of action is needed along side professional training in communication skills.”  And beyond that, there is encouragement and general agreement to proceed further and further along the road of biological psychiatry, for it here where psychiatry’s credibility allegedly lies.  In others words, a continuation and intensification of the status quo.

That these “solutions” will hardly get rid of psychiatry’s fundamental deficits is clear. How can you get rid of shortcomings by putting all your energy into attempting to persuade everyone that they don’t exist?  How can you deal with the problem of a faulty paradigm by further entrenching oneself in that paradigm? But, of course, addressing actual deficits is not the point of the exercise. Now whether or not increased efforts in the direction identified will help psychiatry improve its image—demonstrably, the overriding goal—is hard to say. This is exactly how psychiatry improved its image in the 70s, though, when its credibility was at an all-time low (for details, see Burstow, 2015), and, alas, it worked—and so there is always the possibility that it will work again. That is the “bad news”. The “good news”? At this point in time there is an unprecedented amount of evidence that the claims are untenable –even fraudulent—moreover, more and more people are aware of that—and as such, there is an excellent chance that it will backfire. 

Closing Thoughts

In ending, I would draw attention to our need as critics and activists to be ready to address what appears to be in the “offing”—a renewed propaganda push by psychiatry, whatever form that propaganda take (whether it be “explaining” alleged medical advances or laying claim to being uniquely holistic, whether it calls its model “biological” or “biopsychosocial”, whether it is presented as just providing “information” or as an “anti-stigma” campaign). I would also alert readers to attempts to lure survivors and their allies into taking a common stand against stigma (now being discussed almost as if it were shared). What is significant in this regard, besides that the very concept of stigma against psychiatry is a non sequitur, psychiatry’s constructions themselves are arguably the number one cause of the “stigma” faced by survivors. Also, while like everything else, psychiatry may at times be the object of unfair evaluations; overwhelmingly, it is given a high credibility that it in no way deserves. Correspondingly, given that psychiatrists stand in a relationship of oppressor to survivors, however it may appear or be made to appear, ultimately, neither structurally nor practically do psychiatric survivors have common cause with psychiatrists.

References

Bhugra, D. (2015). To be or not to be a psychiatrist-what is the question? Acta Psychiatrica Scandinavica, 131, 4-5.

Bhugra, D. and Moran, P. (2014). The alienation of the alienist: Psychiatry on the ropes? Journal of the Royal Society of Medicine, 107, 224-227.

Burstow, B. (2015).  Psychiatry and the Business of Madness: An ethical and epistemological accounting. New York: Palgrave Macmillan.

Gaebel, W. et al. (2015). Overcoming stigmatizing attitudes toward psychiatrists and psychiatry. Acta Psychiatrica Scandinavica, 131, 5-6.

Hartley, L. P. (2015). The past is a foreign country: They do things differently there. Acta Psychiatrica Scandinavica, 131, 10-11.

Kapezinski and Passos (2015). Wet Minds, dry minds, and the future of psychiatry as a science. Acta Psychiatrica Scandinavica, 131, 8-9.

Kristiansen et al. (2015). Future perspectives on psychiatry. Acta Psychiatrica Scandinavica, 131, 8-9.

Munk-Jorgensen, P. and Christiansen, B. (2015). Psychiatry generating comparative respect. Acta Psychiatrica Scandinavica, 131, 2-3.

Oxtoby, K (2008). Psychiatry in crisis. BMJ Careers (http://careers.bmj.com/careers/advice/view-article.html?id=3050).

Read, J. (2015).  Saving psychiatry from itself. Acta Psychiatrica Scandinavica, 131, 11-12. 

Stuart, H. et al. (2015). Images of psychiatry and psychiatrists. Acta Psychiatrica Scandinavica, 131, 21-28.

Tesli, M. (2015). Acta Scandinavica—this issue. Acta Psychiatrica Scandinavica, 131, 1. 

Wasserman, D. (2015). Some thoughts on how to improve the image of psychiatry. Acta Psychiatrica Scandinavica, 131, 13-14.

Whitaker, R. (2002). Mad in America. New York: Perseus Books.