Wednesday, June 20, 2012

Why psychiatry is an important skeptical and social justice issue

Just as the Irish government’s policy review has created openings for radical critique of psychiatric practice, ongoing debates about priorities in the skeptical-atheist community are providing opportunities to bring new issues and challenges to the table. The more I learn about the subject, the more astonished I am that psychiatry isn’t a central issue of concern to skeptical and social justice movements. I want to summarize here several arguments for why this should change. (I’ll include a few links, but won’t litter this post with them; I’ll provide a list of recommendations in my next post.)

The first reason is corporate involvement with the scientific research and the dissemination of psychiatric ideas. It’s difficult to think of any area of knowledge in which corporations exert more power than they do in psychiatry. They sponsor drug trials, they market the drugs and the model on a massive scale, they lavish vast sums on influential psychiatrists and academic research centers and sponsor professional bodies and advocacy groups, they put their spin on textbooks, they shape which results are published and which are not, they control access to knowledge about drug research, they influence media coverage,…

Related to this, the corporations lie. Beyond all manner of research and publication chicanery, they have lied about research outcomes. They’ve been taken to court and paid billions in fines, which of course are but a small fraction of the profits they’ve made on the drugs in question. And they’re organized. PhRMA is a union of these organizations, all of which, despite competition amongst them, have a strong interest in perpetuating the disease model and the story about the drugs’ effectiveness.

Despite this, and of course very significant in terms of skepticism, the evidence that the model is baseless and wrong and that drugs are ineffective and harmful continues to mount, coming from many sources (including the companies’ own clinical trials and the admissions of even the drug advocates). Called to answer demands from various groups and organizations to show that the biopsychiatric model is supported by evidence and that the drugs that are being administered to people – often coercively – are effective and safe, the corporations and the psychiatric community have repeatedly demurred. Many people have even gone so far as to suggest that a scientific approach isn’t needed in this case - that anecdotes and judgments based on clinical experience are sufficient. The corporations have wisely decided that, in general, ignoring scientific criticisms and calls for evidence is the best response, and that’s worked well for them. But skeptics should be hammering them on this.

Challenges to psychiatry are frequently greeted with the sorts of responses that are rejected when they’re made by CAM supporters or, more apt in this case, religious defenders. This is a thorny issue because people really are suffering and struggling with problems, many people believe the drugs have helped or could help them or their loved ones biochemically (I’ll talk more about this in a later post), and the large placebo effect shown in research on antidepressants complicates matters. But skeptics can’t accept such anecdotes as the basis for evaluating a drug’s effectiveness or risks, and should be very suspicious of any alleged treatment for which clinical or anecdotal experience is a preferred defense against evidence-based challenges.

Another aspect of psychiatry that opens it up to challenges from skeptics and justice advocates is its history. Examining the institutional, social, and political history of psychiatric beliefs and treatments is essential to understanding psychiatry today. The more we understand about changes over time in how the behaviors and experiences viewed today as mental illnesses/disorders/diseases have been seen and the twisting paths by which they’ve come to be portrayed in the way they have, the more contingent and constructed the current batch of diagnoses and the “symptoms” used to define them show themselves to be. More generally, this context helps us to appreciate the brain-disease model as a historically bound product of its time, and to appreciate its similarities with previous models of mental problems and the similar confidence with which previous treatments were promoted.

In fact, it’s been quite frequent in the history of psychiatry that new alleged treatments have been developed and propagated, models of the “illness” have been developed to fit with whatever the treatment affects, and a widespread belief that a powerful understanding and cure have been found has emerged. An attitude of extreme arrogance and repeated lapses in scientific humility characterize the history of the psychiatric profession, its models, and its treatments, and in light of this history and contemporary scientific challenges the claim that the dark days of false models and ineffective and harmful treatments are well in the past looks highly dubious.

We should recognize that the acceptance of the biomedical model and drug-based approach are themselves the result of a social movement within and beyond the psychiatric profession. What distinguishes this model and form of treatment from earlier ones, driving its cultural acceptance, is the increased weight of corporations and their sophisticated propaganda in recent decades. This is even more apparent when this history is understood cross-culturally. With this broader field of vision, we can recognize the diversity of understandings of and responses to psychological distress across cultures. When we look at the spread of the biopsychiatric model around the world, we see how other understandings of mental suffering are being pushed out as giant corporations and doctors connected to powerful governments impose their reductionistic model of human distress. It’s an aspect of cultural imperialism that goes beyond consumerism, shaping how people understand themselves, their relationships, and their suffering.

Not only outside the West but in some of the richest Western nations, these corporations and the health professionals who support this model wield a great deal of power, including the power to influence government choices about what to treat and how,* to influence legal systems, and to coercively administer the drugs to people in vulnerable groups (including children, young people in group homes, military personnel, people in need of government aid, and old people in facilities, amongst others). Nonvoluntary drugging, especially of children, is a key issue for psych and human rights groups. Corporations and psychiatric researchers also have great power in research settings – over both humans and nonhuman animals – and psychiatric drug research has a terrible history of abuses.

Given that we live in a hierarchical world, this model hasn’t been applied with perfect evenness or equally harmful to all social categories. The history of psychiatric “science” is replete with racism, sexism, homophobia, transphobia, and classism. This is true of the nature of the diagnoses at any given moment, of the way these diagnoses are applied, and of the treatments used. In this sense, psychiatry has conformed with and perpetuated unjust social systems.

In light of the notion of mental distress reflecting a biological abnormality or disease, in some cases argued to be genetic, psychiatry’s (ever-changing) diagnostic labels have proven, with a few limited and ambiguous exceptions, to be stigmatizing. There’s been a global campaign for many years to destigmatize “mental illness,” well-meaning on the part of most advocacy groups and more cynical on the part of the drug companies who want more people to accept the labels as this would make them more open to taking the drugs themselves or drugging their children. This contributes to the problem, though, in that it encourages the acceptance of a model of mental experiences and problems that is both unfounded and itself inherently stigmatizing. So even with a parallel – and largely ineffective - campaign for “acceptance,” the stigmatizing nature of the model remains. (It isn’t the case, as some claim, that in terms of stigma it constitutes a relative improvement over all other understandings; quite the contrary, in fact.) And the drug manufacturers, moreover, continue to medicalize all sorts of problems and experiences, leading people to view as abnormal or pathological what was previously seen as normal, unproblematic, or even positive.

Also of great importance are the negative political-economic effects of this model. Historically, psychiatry has often participated in oppression, and not only in Communist regimes where dissidents were labeled insane, confined, and forcibly drugged. Intersecting with other axes of oppression and marginalization, the mental illness axis has served to control, stigmatize, and devalue resistance, criticism, and activism. More broadly, the brain disease model doesn’t just reflect a hyper-individual culture; it profoundly depoliticizes mental suffering. In Fromm’s terms, of course, this would be an example of psychiatry’s setting aside humanistic values to serve the status quo. In a general sense, it encourages people to view their and others’ distress not in terms of a response to (and possibly critique of) their social world but as an individual sickness or flaw – that is, in the best terms for capitalist society and the need for people to “function” within it.

In this post, I’ve tried to make a case for why psychiatry and psychiatric drugs should be a priority for skeptics and social justice advocates. I’ve noted the nonexistence of a solid scientific basis for the mental illness brain-disease model and the evidence against it, the poor performance of the drugs (and certainly the failure to demonstrate a positive risk profile), and the role of pharmaceutical companies in distorting science and misleading the public. I’ve pointed to the historical and cross-cultural contexts which reveal this model to be another culturally-specific set of beliefs and practices spreading globally by way of a movement backed by powerful Western interests. I’ve discussed the social and legal power of corporations and the psychiatric profession, especially with regard to vulnerable populations, and the history of abuses in treatment and in research. I’ve also raised the issues of how this model has stigmatized people, reflected and reinforced inequalities, and served the political and economic status quo. I believe this all points to why contemporary psychiatry should be regarded as suspect and also why there’s a pressing social need for the application of skepticism to psychiatric practice.

I’ll note that in addition to the direct and indirect harm they cause to people, the actions of these companies and the psychiatrists who push the biomedical model do very real harm to the scientific-epistemic movement and to medicine. We as skeptics have the responsibility to not take it on authority that what’s sold as solid science really is and to investigate each claim in light of all of the relevant evidence. Promoting and defending this model and form of treatment as equivalent to models of diseases that are well understood and demonstrably effective treatments will only compromise the reputation of science and medicine, and of skepticism, in the long run.

*At great public expense. Further, the more people and governments buy into this expensive, drug-dominated model, the more corporate power in every sense is enhanced.

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