Psychiatry has always been associated with controversies. Psychiatric diagnoses are often vulnerable to public and scientific criticism and studies that are frequently cited to claim success in resolving the reliability problem are often themselves flawed, incompletely reported and inconsistent. The interpretation of data has also been found to be often partially misleading. These factors have combined to create various controversies in psychiatry. To resolve the problem of reliability, the late 20th century saw the publication of the Diagnostic and Statistical Manual of Mental Disorders, written by the American Psychiatric Association. The first edition (DSM-I), published in 1952, was a pamphlet that listed a mere 60 disorders. However, the most recent edition DSM-IV, published in 1994 has 886 pages and this dramatic increase in the number of disorders seems to suggest that ordinary human troubles are today being reclassified as disorders (Cohen, 2005). Hence one of the major controversies in psychiatry is that psychiatry tends to pathologize everyday life and whether a person” is happy or sad, neat or messy, chaste or promiscuous, bumptious or withdrawn, fat or thin, drunk or sober” (Cohen, 2005, 30), he will have the symptoms of a mental disorder and he can always be considered ill or if he is a criminal, he always has an alibi. Thus psychiatry is and always has been a field of controversies ranging from diagnosis, interpretation, treatment, and post-treatment labeling.
Some critics such as Szasz and Foucault have accused psychiatrists of labeling individual differences as signs of pathology (Cohen, 2003) to maintain the existing social order. Thomas Szasz (1970) held that the very construct of mental illness is a myth. He said, “instead of calling attention to conflicting human needs, aspirations and values, the concept of mental illness provides an amoral and impersonal “thing” – an ‘illness’ – as an explanation for problems in living” (Szasz, 1970, 20). His statement shakes the very foundation of psychiatry. He further said that belief in mental illness is only similar to belief in demonology and witchcraft (Szasz, 1970). It is amazing to find that this concept of Szasz has wide support even in recent times. According to a recent survey, 71% of the U.S. population views mental illness as a state caused by emotional weakness, 65% think it is the outcome of bad parenting, 45% believe that it is the victim’s fault, 43% believe that it is incurable and 35% view it as punishment for “sinful behavior”. Only 10% of the population believes that mental illness has a biological basis or involves the brain (Cohen, 2003, 8). Szasz did not accept that the government had any kind of role to play in the problems of mental suffering. According to Szasz, those who are named mentally ill suffer from problems in living, an inability to live by the expectations of society. Instead of ‘institutional psychiatry’ with its custodial approach to the mentally ill, Szasz suggested ‘contractual psychiatry’ where the affected people will be legally empowered to seek help on a personal basis.
The controversy as to whether biological psychiatry is real science or not has been further fueled by the ideas of critics such as Michel Foucault in “Madness and Civilization” (1961). Foucault viewed madness as a state of “wisdom, non-being, freedom, communicating what is deepest in man” (Bowers, 2000, 103). Foucault relied on the history of madness to arrive at this conclusion. He cites the fact that before the seventeenth century madness was viewed as the liberation of the animal within an individual (Bowers, 2000). Foucault’s objective may be defined as a return to that ‘zero points in the course of madness at which madness is an undifferentiated experience’ (Smart, 2002, 22). In his book “Madness and Civilization” Foucault begins with references to the existence of leprosariums across the entire continent of Europe during the Middle Ages, where lepers were kept in confinement. This notion of treating people through exclusion and confinement later spread in Western culture to treat socially unacceptable classes of people such as the poor, the criminals and the mentally ‘deranged” (Smart, 2002, 22). Foucault argued that confinement of mad people in the name of hospitalization was a kind of moral exploitation, and social control, where the confined people were subject to a regime of forced labor. Thus Foucault viewed the medicalization of madness not as a sign of progress but as an outcome of the slow evolution of man’s nature to exhibit social control by confining people who were different.
Michel Foucault is one of the leading experts in the study of social control and his greatest contribution lies in his interpretation of social control, not as the product of an evil central authority of repression, but as a product of a complex interplay of forces within the making of social order. In the 1960s and the 1970s social control was equated with sovereign power or the State. Michel Foucault was able to develop a critique of the psychiatric institution, medical justice, and how society disciplines differences in individuals (Ariggo, 2002). Foucault was concerned about deviance and how the way it was perceived was manipulated by society. He felt that any institution can be seen as a site of discipline, control and ultimately punishment by persons who consider themselves the authorities. For Foucault even the consideration of homosexuality as a deviant act by self-appointed sexologists was a form of social control that produced a standard against which normal behavior could be judged (Barth et al, 2005). In his book, “Madness and Civilization (1965) and Discipline and Punish (1977) he explained the roles institutions assume in society. He traced the growth of social control in the context of disciplinary practices in society. He opined that law, psychiatry and confinement are all instruments of social control. Foucault (1990: 134) states: “if psychiatry became so important in the nineteenth century, it was not simply because it applied a new medical rationality to mental or behavioral disorders; it was also because it functioned as a sort of public hygiene” (Foucault, 1990, 134). The gap between the medical function of psychiatry and the management function of police helped create a new form of repression, namely, cleansing public morality. The true vocation of psychiatry became that of moral policing and public hygiene (Arrigo, 2002). Psychiatry also claimed to possess privileged knowledge regarding criminal behavior and social control extended to the area of law and order when psychiatry was used to explain crime and the attention shifted from the crime to the criminal. The insanity that motivates a person to do a crime is hidden, according to Foucault and it represents a danger that he is not aware of. This latent criminality in the form of insanity was considered a threat to society and hence crazy people were regarded as criminals for having that quality hidden in them. The intervention of psychiatry into law legitimized the causal link between insanity and crime and the concept of dangerousness still governs the way society addresses mental illness. As it is the social custom to confine dangerous people, insane people are also confined and psychiatry thus becomes a social control force. Thus, psychiatry has evolved, not to liberate or help the mentally ill but to regulate the citizens and their differences. It serves as an instrument of social control.
Laing was one of the principal figures of the counter-culture of the 1960s; Laing (1965) viewed madness as a voyage of self-discovery and personal growth (Bowers, 2000). In “The Politics of Experience” (1967) Laing argued that the ‘mad’ was sometimes saner
than the ‘normal’ and believed that psychotic experiences may have a healing dimension. Laing, particularly in his later works maintained that there is a positivity to the state of madness and it is not “what we need to be cured of, but that it is itself a natural way of healing our appalling state of alienation called normality” (Rigney, 1980, 74). Normality, for Laing is the negative and truly insane state because it meant clinging on to uncertain certainties and dependence on a reality that is not truly real. To go mad in a positive sense is to give up all certainty and enter into a state of mind far saner than that understood by the normal world (Rigney, 1980). In the Politics of Experience, Laing claims: “There is no such condition as “schizophrenia, but the label is a social fact. the person labeled is inaugurated not only into a role, but into a career of the patient, by the concerted action of a coalition of family, G.P., mental health officer, psychiatrists, nurses, psychiatric social workers, and often fellow mental patients” ( Laing, 1967, 100). While The Politics of Experience brought Laing name and fame, it also divided public opinion (Kotowicz, 1997). The roots of the controversy generated by Szasz, Foucault and Laing are best explained in the words of Szasz: “As the Communists seek to raise the poor above the rich, so the anti-psychiatrists seek to raise the ‘insane’ above the ‘sane’” (Szasz,1976, 2).
Most of the psychiatric definitions and treatments are based on a universal approach – assuming that people from all kinds of societies have similar problems that can be treated similarly. But it must be noted that psychiatry is the study of abnormal behavior and abnormality can only be defined relative to normality. A study of cultures indicates that the normal can be defined only in terms of cultural norms. Any
person who is considered normal in the society he belongs to might be considered abnormal in another society. This implies that psychiatry cannot view normality or abnormality universally. It is important that cultural elements are considered before making a clinical judgment of the pathology or deviation from normality of an act. Deviations from normality can happen as a symptom, as a syndrome and as a specific psychiatric disorder and culture as a variable has varying levels of influences in these cases. Symptomatically, the content of delusions or auditory hallucinations is subject to the environmental context in which the pathology is manifested. Moreover, when a person suffers from guilt based depression, the emphasis on guilt or shame depends on the society and its culture. The effect of cultural factors on deviations from normality or psychopathology can affect the syndrome as a whole. For example, Chinese in Hong Kong with Anorexia nervosa are rarely concerned with being physically overweight. Culture can also lead to the development of a unique psychopathology that is observed only in a certain cultural environment (Tseng and Streltzer, 1997). This is known as culture-related specific psychiatric disorder. For example, “Koro is an intense anxiety associated with the fear that the penis will shrink into the abdomen resulting in death” (Tseng and Streltzer, 1997, 11). This condition is a unique psychopathology that is dependent on the South Asian culture and hence found mainly in the South Asia regions. There are four ways to distinguish normality from pathology: by agreement of experts, by deviation from the mean, by assessment of function and by social judgment. Culture plays a huge role in the fourth approach, which utilizes judgment in deciding whether behavior is normal or pathological. For example, to walk naked in a public area maybe seen as normal behavior in one society, unusual in another and obscene in a third depending on how each country defines the nature of such behavior and the cultural tolerance for that action. Normality is a cultural relic and hence abnormality or psychopathology which refers to deviation from normality is also culture based (Tseng and Streltzer, 1997).
Psychiatry has its measures of controversies in the realm of treatment options as well. Electroshock or Electroconvulsive therapy is one of the most controversial treatments in psychiatry. During electroshock the generalized electrical stimulation of the brain during which an electrical current of less than a second’s duration is passed from one side of the head to the other. Electroshock also known as Electroconvulsive therapy (ECT) is widely used in psychiatry for the treatment of severe depression. It was first tested in 1938 by Cerletti on a Milanese man and after he responded well, ECT spread to European hospitals and by 1940 arrived in the United States (Shorter and Healy, 2007). ECT proved to be a great treatment method as it did not have side-effects such as vomiting nor did it cause psychological trauma (Shorter and Healy, 2007). However, patients suffered from the painful effects of muscular convulsions and sometimes as they thrashed around on the treatment table many patients bit their tongues and cheeks. In addition, patients suffered memory loss. ECT was also overused and abused by some doctors. Milledgeville State Hospital, in Georgia used it to punish uncooperative patients terming it as the “Georgia Power Cocktail” (Shorter and Healy, 2007, 93). The publicized experiences of famous patients treated privately with ECT created a public perception that ECT was a brutal and inhumane method of treatment. As a result ECT disappeared in the 1970s with the advent of the psychiatric drugs and sophisticated neuro-imaging techniques. However, the psychiatrists felt these new methods were not as efficient as ECT and hence set out to modernize ECT. By modernizing ECT devices, administering fast-acting anesthesia and muscle relaxants, ECT has become safer and more exact. Though it remains controversial, ECT is selectively used for patients with mutual consent by psychiatrists (Shorter and Healy, 2007). Recent studies show that ECT is effective in the treatment of a range of mental illnesses, from depression to some forms of schizophrenia and catatonia. It has even been found to cure chronic sneezers and stammerers. Despite the increasing popularity of ECT, stigma towards ECT continues to remain as people are given a bleak picture of ECT by “activists who push for prohibitive legislation, a few former ECT patients, some dissenting psychiatrists and the Church of Scientology” (Smith, 2001, 70).
Like electroconvulsive therapy, psychosurgery is another controversial psychiatric treatment method. Psychosurgery refers to the “surgical alteration of brain tissue” for reasons of behavior control and it is the “most invasive, irreversible and destructive” of psychiatric procedures and one that is opposed by many people (Brown, 1985, 162). It is used as a last resort to treat behavior, personality and obsessive compulsive and bipolar disorders and severe depression. The modern practice of psychosurgery began in the 1930s when two Portuguese neurologists Ega Moniz and Almeida Lima began severing connections to and from the frontal lobes in people with ‘psychoneuroses’. By 1936, this procedure became popular and was called the prefrontal leucotomy or lobotomy. Initially the procedure was very crude as the neurosurgeons were unable to accurately estimate where to lesion the brain (Bennett, 2006, 82). However, it became more and more precise with advancing technology and between 1935 and 1950 some 20,000 American psychiatric patients were subjected to lobotomies, or “psychosurgery” (Barber, 2008). There are four major psychosurgical procedures – “anterior cingulotomy, subcaudate tractotomy, limibic leukotomy and capsulotomy” (Thompson, 2007, 66). In the UK, between 1936 ad 1961, over 10000 people received psychosurgical treatment and “of these an estimated 20% with schizoprenia and about 50% with depression benefitted. But 4% died from the surgery, 4% developed severe loss of motivation and up to 60% developed troublesome personality changes while 15% developed epilepsy” (Bennett, 2006, 82). It has also been found that a number of people commit suicide following psychosurgery (Bennett, 2006, 83). Because of the huge risk factors involved, this approach has been considered highly controversial and rates of psychosurgery have fallen dramatically since the availability of drugs to treat psychiatric problems. In fact, psychosurgery is even banned by law in countries such as Germany and in some US states. But it must be noted that as a result of new advanced technology, mortality and rate of post operative epilepsy have dropped. In addition it has been found that there is no negative impact on intelligence or personality following the psychosurgery. But how psychosurgery works has not yet been explained by the neurosurgeons. This lack of understanding of what is being done raises concerns regarding the nature and use of psychosurgery (Bennett, 2006, 83). Moreover due to the risks associated with brain surgery and the potential side effects, psychosurgery continues to remain controversial and is reserved for sever intractable cases of OCD (Weynandt, 2006).
The most common psychiatric intervention, namely psychiatric medications is one that has become increasingly controversial in recent times. Psych meds or psychiatric medications refer to psychotropic drugs that are prescribed in the treatment of psychiatric disorders. In fact the advent of these drugs helped stop the abuse of potentially dangerous treatments such as ECT and psychosurgery. Psych meds act by controlling symptoms though they do not cure mental illness. Drugs like chlorpromazine can turn off the “voices” heard by some people with psychosis and help them to see reality more clearly. And antidepressants can lift the dark, heavy moods of depression. However, the level of efficacy depends on the individual and the disorder being treated. Psychotropic medications are prescribed only on the major assumption that psychiatric disorders have a biological etiology – neuropathological, neurochemical, or genetic explanation (Kendler, 2005). But there are no valid tests to know whether a psychiatric disorder listed in the DSM-IV has a physiological base or not. And when there a disease process or genetic flaw identified in any of the disorders listed in DSM-IV-TR , the treatment for the disorder will come under the purview of neurology and not psychiatry (Murray Jr., 2006). Despite the lack of clear evidence for neuropathological, neurochemical, or genetic explanations for psychiatric disorders, more and more drugs are being prescribed and marketed extensively for the patients by the psychopharmacologists and physiological psychiatrists. This has generated a controversy in recent times as to the ethics of prescribing drugs that may not be beneficial and sometimes may be harmful to the patient. While psychiatrists feel that psych meds can be effective in the treatment of psychiatric disorders and have minimal side effects, statistics show otherwise. For example, only 30% to 50% of clients on antipsychotic medications experience any level of remission of psychotic symptoms (Jackson, 2005), and up to 74% of clients discontinue their medication within 18 months (Lieberman et al., 2005). According to a study conducted by the World Health Organization (WHO) it was found that schizophrenics in developing countries experienced a higher rate of recovery from schizophrenia than those in developed countries and this was attributed to the differences in psychiatric treatment. In the developing countries, only 16% of clients were maintained on antipsychotic medication versus 61% of clients maintained on these medications in the developed countries (Whitaker, 2004). The success of psych meds depends on its ability to prevent relapse. But, studies show that neuroleptics may actually worsen the symptoms and increase the chances of relapse (Irwin, 2004, 1). The most commonly used antidepressants for children are the SSRIs (selective serotonin reuptake inhibitors) such as Prozac (fluoxetine), Paxil (paroxetine), Celexa (citalopram), Zoloft (sertraline) etc. Timothy E. Wilens claims that these medicines do help in treating depression in youth over 12 years of age. But there is a great deal of controversy over SSRI use and the potential for SSRIs to induce suicide mentality in children (Wilens, 2008). Mendelson and Nemeroff (2007) hold that psychiatric medications are particularly prone to cause disturbances in appetite, weight gain, changes in serum glucose and in some cases can cause morbidity and death. Of all anticonvulsant mood stabilizers, the most adverse effects are seen with valproic acid: weight gain, insulin resistance, hypertriglyceridemia, etc.(Mendelson and Nemeroff, 2007). Despite these frightening side effects, increased prescription of psych meds is mainly due to greater acceptance among physicians and the public of psychotropic drugs, the advent of new medications with fewer side effects, increased screening for mental health disorders, and patient demand for such drugs.
In a study titled ‘On being sane in insane places’, Rosenhan (1973) explored the extent to which psychiatric findings can be considered valid. In this study, 8 sane pseudopatients (including Rosenhan) got themselves admitted to 12 different psychiatric hospitals with complaints of hearing voices saying ’empty’, ‘hollow’ and ‘thud’ (Cave, 2002). Apart from this single falsehood, they gave true information about themselves to admissions staff, and asked to be admitted to the hospital. After admission, they behaved normally, with a view to being discharged as soon as possible. All of them but one were admitted with a diagnosis of schizophrenia, and spent 7-52 days in hospital (Cave, 2002). From the standpoint of nurses and some of the patients they showed no signs of abnormality. However case notes prepared for some of the patients, as well as interpretations of current behaviors, showed that even behaviors that might be considered ‘normal’ were now interpreted in the light of their diagnosis. When they paced the corridor out of boredom, the patients were interpreted to show nervousness and waiting for the canteen to open was interpreted as oral-acquisitive behavior. The staff failed to respond to their questions when the pseudo patients tried to contact them. Thus the pseudopatients were pushed to a state of powerlessness and depersonalization after the application of a psychiatric label. They were finally discharged with a diagnosis of ‘schizophrenia in remission’ showing how difficult it is to be removed of psychiatric labeling (Cave, 2002). Rosenhan was also interested in whether the insane might be judged sane. Staff at a teaching hospital, were told to expect a pseudopatient to arrive at the hospital during a 3-month period and the staff were asked to rate every patient on a 10-point scale to indicate the likelihood that she or he was a pseudopatient (Cave, 2002). All the 193 patients were in reality genuine. Yet, due to prior notice, 23 were suspected of being pseudopatients by at least one psychiatrist and 41 by at least one staff member. This finding challenges the idea that clinicians use clear-cut, objective criteria as the basis for diagnosis and has generated a controversy regarding the validity of psychiatric diagnosis. It also emphasizes that patients diagnosed with psychiatric disorders find it difficult to shake off the label and are often discriminated against.
These are some of the controversies that have plagued psychiatry ever since it emerged as a field of medicine.
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