Rethinking Psychiatry

Societies have sacred cows. Individuals have sacred cows. There are some institutions that many esteem so highly that they do not question their existence. Even if they cause widespread harm, people endorse them.

The Mayans maintained an institution of ceremonial human sacrifice. Their priests carved out still-beating hearts with obsidian blades while the crowd cheered. The church used to round up alleged witches and burn them. The Malleus Maleficarum was their 1487 guide to witch-hunting.

These institutions lasted from decades to centuries. Few questioned their purpose or morality. Now imagine a modern equivalent—a sacred cow so ingrained that critiquing it is taboo. This cow is called psychiatry.

Most accept the diagnoses of this field without question. The notion that many suffer from mental disorders or illnesses is considered an indisputable fact. Those who push back against this sacred cow receive a label of “Scientologist” or “quack.” Their credibility is summarily revoked because to doubt any diagnosis is to doubt the system, and vice versa.

And yet, maybe your friend isn’t really “bipolar” and your sister isn’t “depressed,” but perhaps something else entirely: sad, hurting, or lonely. Possibly just misunderstood.

Perhaps people can finally muster the courage to question this field and its presumptions. Psychiatry and our attitudes toward it are long overdue for an overhaul. We must ask hard questions: Are the coercive and over-medicating aspects of psychiatry as effective as is claimed? Do they fit with our values?

In some ways, psychiatry operates as a de facto arm of the state. Psychiatrists can determine if a person is a danger to themselves or others and incarcerate them in a mental health facility based on that determination. In some instances, they can do this without the patient’s consent.

Many condone this use of coercion, arguing that it is for a person’s own good and that there is no alternative. The contention is that either society has the mentally ill involuntarily committed, or they will hurt themselves or others.

Is it ethical to lock someone up for hurting themselves? They either own themselves or they don’t. If they own themselves, then involuntarily committing people raises difficult moral questions.

And if they have not actively hurt another person, then isn’t locking them up a form of predictive policing? In Philip K. Dick’s The Minority Report, the government’s “precogs” know who is going to commit a crime before they do. Anyone who knows the story knows the “pre-crime” system has a flaw: the precogs are not always correct. Are psychiatrists a kind of deputized precog— inferring crime before any is committed, and perhaps drugging and incarcerating people based on that inference?

Technically, those who are involuntarily committed enjoy a measure of due process. In practice, however, these decisions can often be made hastily, on the word of a single psychiatrist. There is no council or possibility of bail: a patient is deemed mentally unfit and committed. Of course, there are cases in which a person truly is a danger to himself or others; yet sometimes a person who is simply struggling, and needs a little compassionate care, gets caught in this same net.

These are ethical conundrums few are foolhardy enough to discuss publicly. With greater awareness, perhaps more will speak up about psychiatry.

Psychiatry presents itself as any other medical practice: white coats, stethoscopes, clipboards, and a claim to be able to diagnose and treat medical conditions. If that claim is valid, shouldn’t some sort of objective tests be able to show definitive illnesses? A brain scan. Blood work or a cerebrospinal fluid analysis (CSF). Something should be able to reveal disease.

Many have a vague sense that mental illnesses arise because of a “chemical imbalance” or “brain differences.” When it comes to extreme psychopathology, hard science has identified some such differences. However, evidence that conclusively establishes these as causal factors in depression and other forms of mental anguish is sparse. Moreover, the long-established use of SSRIs for such conditions has recently come under strong challenge. Yet, using adept marketing, the psychiatry and pharmaceutical industries have managed to turn the notion of a “chemical imbalance” into widely accepted dogma. Painting with an overbroad brush, they peddle what Dr. Thomas Szasz called “The myth of mental illness.”

A 2012 meta-analysis titled “Why Has it Taken So Long for Biological Psychiatry to Develop Clinical Tests” highlighted Szasz’s concern. It found that 107,000 studies failed to find a biological marker for any mental illness. Without a biological marker or baseline, there are no definitive data that a brain disorder or disease exists. The study suggests that psychiatrists are, in many cases, selling a myth.

The problem deepens. Instead of objective testing, psychiatry relies on behavioral profiles for diagnosis.

When a patient enters a clinic with symptoms of hallucinations or paranoid delusions, a psychiatrist may suspect schizophrenia. Often, however, the doctor will not order a lab test. Such tests are typically only used to rule out other conditions. Schizophrenia and most mental illnesses are diagnosed using the DSM-5 (The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition).

The DSM-5 is primarily a list of behaviors and symptoms. Psychiatrists review the list and determine if a patient meets the criteria for having a “mental disorder.” However, how can a list of symptoms determine a disorder or illness? That would be akin to a doctor diagnosing an illness based solely on symptoms. Shouldn’t the underlying cause be pinpointed?

The decision to add new conditions to the DSM is primarily based on behavioral observation and group consensus. A group of psychiatrists votes on what “disorders” will appear in each new edition of the DSM.

This list of disorders changes over time and with shifting sentiments. Homosexuality, for instance, was once considered a mental disorder. If a given behavior is suddenly deemed culturally unacceptable (as homosexuality once was), it too could be labeled a mental disorder.

This voting process points up the challenges associated with the diagnosis of mental conditions, and the problematic nature of the mental health field in its current state. Imagine the outrage if physicians voted on which cancers deserved to be labeled as diagnosable medical conditions. Homosexuality is no longer considered a clinical condition, which is why it was removed from the DSM. So was its original inclusion based on data or the current zeitgeist? Can the same be asked regarding its removal?

We could analyze these problems in detail, but this article would quickly expand into a book. Instead, we can focus on solutions. How can we address mental anguish without medicalizing every psychological issue?