Table of contents
- Service User
This essay is going to evaluate the statement, ‘psychiatry does more harm than good’. This essay will define psychiatry to provide context, then will use examples to explore and discuss the history of psychiatry and how this history helps evaluate the grounds for this claim. Specifically, this essay will look at the role of asylums, diagnosis and the service user movement.
Psychiatry can be defined as “a word used as shorthand for the development of a set of ideas and practices that deal with what came to be defined as ‘mental illness’” (Jones, 2020). The emergence of psychiatry was largely led by those who proclaimed themselves as working within a medical specialty. However, many other interest groups and forces have contributed to the development of the institutions and practices surrounding the area of mental health. There are two contrasting claims about the history of psychiatry: care and concern, versus power and control. The first view considers care and concern when specializing treatments for ‘mental health’. The second more critical view is the anti-psychiatry perspective. This view suggested that psychiatry and the surrounding notions of ‘mental illness’ were developed as fundamental tools of a culture that had sought to interact with and control those individuals whose behavior deviates from the norm and might pose a threat to social order (Jones, 2020).
In 1845 the Lunacy and Asylum Act was brought into force, mandating local authorities to build asylums to serve the needs of ‘pauper lunatics’ in their area. Asylums themselves were shaped by conflicting forces and ideas; products both of anxiety about disorder but also of the desire to care. Their initial purpose was to confine the insane however, through development, their purpose became providing a cure through the provision of moral treatment. These developments were important in establishing the new medical specialty of psychiatry. Although there were positives to asylums there were also negatives.
There was an aspect of control in asylums as they were taking people out of society’s care. They often featured overcrowding, harsh treatment and strict regimes, as well as a potential for institutionalization. Other negative aspects included that they were not regulated, loss of identity, treatment used, understaffed and underfunded. Limited space, no privacy beds in very close proximity to each other. No personal possessions that could be used to maintain a sense of identity. Cold, imposing environment.
Psychiatric diagnosis involves the application of a medical framework to problems in living. By looking at people’s problems against the criteria found in diagnostic manuals like the DSM, a closest matching diagnostic category or categories can be identified.
Benefits of diagnosis were that they can inform treatment and support, can give people a sense of relief, give a framework for understanding and sharing good practice, and also help enable research. Categorizing the types of problems, a person has can provide access to other kinds of support and aid the planning of health services. In some cases, a diagnosis can provide clarity and a framework of understanding. Opposing that optimistic view are those who argue that the development of professional expertise in this area is not helpful at all. Drawbacks of diagnosis include a tendency towards labelling and stigma, based often on non-observable symptoms. Restricting the ability to explore contextual and individual factors can result in overly broad diagnostic categories, can lead to the prescription of unnecessary medication, and can reduce the validity of diagnosis, particularly as new disorders might be proposed for experiences not previously regarded as mental health problems (Harper, 2020). If diagnostic categories are overly broad and use definitions that leave lots of room for subjective judgement, then some clinicians may apply a given diagnosis more than other clinicians. Perhaps all those psychiatrists and psychologists are really part of a system that is trying to enforce particular kinds of normality (Jones, 2020).
DSM was established in 1952: publication of the first edition of the Diagnostic and Statistical Manual by the American Psychiatric Association. DSM is a system of classification, and one of the most highly influential breakthroughs in the field of psychiatry. DSM is based on the premise that mental health concerns can be medicalized. Pre DSM a number of different diagnostic systems were used, often obsessed with gathering basic statistics about patients in asylums and predominately focused on psychosis (Harper, 2020).
Although there are advantages to DSM there are also drawbacks. One of the repeated criticisms of DSM has been that it leads to an increasing medicalization of problems in living. Medicalization, in its broadest sense, occurs when phenomena are viewed through a medical lens (Harper, 2020). There are both positive and negative aspects to this. For example, in relation to PTSD, the condition was welcomed by activists for Vietnam veterans. However gay and lesbian activists campaigned to de-medicalize homosexuality, and feminists have criticized the inclusion of PMDD in DSM (Harper, 202).
Such opposing views continue to exist, with some service users finding diagnosis helpful and some finding it unhelpful (Harper, 2020). Jo Lomani clearly expresses this when she is talking about her experience of being diagnosed with unstable personality disorder as an inpatient in hospital. She says receiving the diagnosis made her feel badly treated and labelled. Put on contract to agree not to self-harm, she states that for herself harm was a coping mechanism. Because she broke that contract she was subsequently discharged from the hospital because self-harm often accompanies the UPD diagnosis and if self-harm occurs its viewed as something that needs to be punished (The Open University, 2020).
Diagnosis often contributed to feelings of stigma and oppression (The Open University, 2020). Patients often felt oppressed and as though their experiences were invalidated, their identity was threatened and stigmatized, and even that their experiences equated to bullying. Stories of harm from survivors of asylums center on diagnosis, forced treatment, electric convulsive treatment, detainment, coercion and restraint, drug treatment, chronic neglect and other overt abuses of power (Lomani, 2020). The service-user movement began in opposition to the visibly oppressive treatment of patients within a medico-psychiatric system. Years later the patients were joined by prominent radical psychiatrists who were discontented with conventional psychiatry. They began what is now termed the ‘anti-psychiatry movement’. Academics and psychiatrists such as Ronald Laing and Thomas Szaz challenged and undermined the legitimacy of psychiatry, highlighting the subjective nature of psychiatric diagnosis. Service users have fought for the right to receive humane treatment, to access adequate housing and welfare provisions, to expect reasonable workplace adjustments and sometimes simply to remain free from psychiatric detainment (Lomani, 2020).
Patients can also be harmed by various interventions including psychological and psychotherapeutic ones. Jo Lomani (2020) states that in her experience as a service user, the psychologist who wrote an incorrect and non-collaborative formulation of her problems was just as harmful as the psychiatric nurse who forcibly injected and traumatized her as a non-consenting patient.
Healthcare professionals, such as psychologists, therapists and counsellors, may hold problematic beliefs that negatively impact on mental health users. For example, Bartlett, Smith and King (2009), cited by Lomani (2020), conducted a survey of over 1300 mental health professionals and found that more than 200 had offered some form of LGBTQ+ conversion therapy (an oppressive practice whereby a mental health professional believes that sexual orientation or gender identity is something that can be ‘cured’ and attempts to provide therapy towards meeting that aim). In fact, there remains a widespread (incorrect) belief among healthcare staff that identifying as LBGTQ+ is a mental disorder (Stonewall, 2015; cited by Lomani, 2020).
People with mental health difficulties are frequently disadvantaged by the lack of adjustments and understanding within the workplace. Despite the protections offered under the Equality Act (2010), people with mental health problems remain heavily stigmatized in the workplace. She goes onto say that opportunities are restricted with part time and temporary contracts, resulting in exclusion from more stable opportunities due to stigma and the episodic nature of mental distress.
The involvement and consultation of service users in mental health services has brought an array of difficulties. Despite the requirement to involve service users, there is no standardized way of doing this. Most mental health research will not receive funding unless researchers provide a clear strategy for mental health engagement. However, despite this policy requirement, collaboration is “patchy and slow, and often concentrated at the lowest levels of involvement” (Ocloo and Matthews, 2016; cited by Lomani, 2020).
Although the movement began through collectively resisting oppressive psychiatric practices it has since evolved into something much broader. This includes the legitimization of survivor knowledge as a distinctive epistemology, not merely in opposition to dominant discourses of psychiatry but as a unique discipline (Lomani, 2020).
An understanding of history shows us that psychiatry does more harm than good. Public and media responses to mental health problems have formed a very significant force that shaped psychiatry. Arguably, there is no other area of medicine and perhaps social policy that has been so heavily debated and fought out in the public sphere. It would only be fair to conclude that psychiatry has been shaped by anxieties about the threat to social order potentially posed by people who were viewed as different and thus something that should be ‘remedied’ by their confinement and treatment in order to ‘normalize’ their behavior.