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.
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