Paradigms of Psychiatry: Eclecticism and Its Discontents

Seyyed Nassir Ghaemi

Disclosures

Curr Opin Psychiatry. 2006;19(6):619-624. 

In This Article

Reactions Against Biology: Postmodernist, Antipsychiatry, Libertarian, Anticapitalist, and Recovery-oriented Views

Postmodernist interpretations of psychiatry have focused on the power structures that underlie the practice of psychiatry. The most famous of these interpretations can be found in the work of Foucault.[18] Other predecessors, often grouped in the term 'antipsychiatry', include Laing[19] and Szasz.[20] While not overtly rejecting the concept of mental illness, as does Szasz,[20] many of the views of the antipsychiatry movement have been reformulated by contemporary critics. Recent works in this vein have included the writings of Healy[21,22*] who has argued that a 'corporate psychiatry' has developed, heavily influenced by the pharmaceutical industry. A recent editorial along these lines was published in the British Journal of Psychiatry by Moncrieff,[23**] arguing that modern psychiatry has become a handmaiden to conservative (or 'neoliberal' in the British context) political commitments. Treating the unhappiness of the masses, which derives from poverty and racism and other socio-political causes, as if they are biological entities, not only diverts the masses from the real causes of their discontent but also enriches capitalist entities directly (i.e., the pharmaceutical and insurance companies). A particularly influential paper[24] in the UK rephrased this movement in the concept of 'postpsychiatry', with a consequent rise in a group of psychiatrists formed around a 'Critical Psychiatry' Web site (http://www.critpsynet.freeuk.com ). A recent book[25*] seeks to extend this perspective to American psychiatry.

While 'critical psychiatry' represents the reaction of some psychiatrists to the failures of biopsychosocial eclecticism, the patient advocacy movement has begun to coalesce around the 'recovery' movement, deriving from the 12-step approach to behavior.[26**] In this perspective, the goal is full recovery: a complete return to normal mental and physical states, whereby one relinquishes the role of being a patient and resumes simply being a person. The medical model of simply alleviating symptoms is not enough. Recovery requires the active involvement of the person with the illness and not simply passively receiving medical care from professionals. The recovery movement has implied that the psychiatric profession has not appreciated, and thus not sufficiently abetted, the ability of persons with mental illness to get well. Though implicitly critical of mainstream psychiatry, this approach has garnered support from many community psychiatrists,[27**] as well as the leadership of the American Psychiatric Association.[28*] It has also appealed to many in less medically based professions, such as social work, as well as groups generally critical of psychiatry. Ironically, it also received a stamp of approval from the George W. Bush administration's New Freedom Commission on Mental Health (www.mentalhealthcommission.gov ). Apparently, a libertarian philosophy of self-help and thus less need for provision of medical care appealed to American political conservatives. American conservatives and British left-oriented critics appear to agree on a critique of the biological paradigm in psychiatry and on a need for more individual liberties in relation to mental healthcare. This alliance of extremes is surprising and powerful, putting biological paradigms in psychiatry on the defensive. Yet it is not unprecedented; in fact, as recent historical scholarship has shown, antipsychiatry movements have existed for at least 100 years, beginning in Germany in the late 19th century.[29] At that time, too, critiques of mainstream psychiatry came from both left-wing and right-wing perspectives. This observation suggests that it is not political ideology per se that drives these critiques of psychiatry, but rather other factors.

The fact that power, economics, and politics permeates society is as old as Aristotle and as recent as Marx. Hence, these aspects of the postmodernist/semi-socialist critique are, in my view, relatively valid. The reduction of mental illness entirely to social constructs, however, is another matter. To be fair, not all of these critics (e.g. Healy) engage in this kind of postmodernist dogmatism but many do. As McHugh[12**] once wrote, it is sufficient to interview and treat a person with schizophrenia over time to realize that postmodernist dogmas are one-sided. E. O. Wilson, pointing out the nihilism of postmodern extremism, commented: 'Scientists, being held responsible for what they say, have not found postmodernism useful'.[30] Nonetheless, ideas have consequences, and postmodernist critiques likely have had both positive and negative consequences: positive in opposing the biological reductionism and capitalist ethos of much of the mainstream psychiatry, and negative in providing, at times, a simplistic alternative that probably adds to the suffering of many people. Clearly there are limitations to science, and science is influenced by socio-political factors; yet this does not invalidate science. Dennett[30] draws this distinction: 'The irony is that these fruits of scientific reflection, showing us the ineliminable smudges of imperfection, are sometimes used by those who are suspicious of science as their grounds for denying it a privileged status in the truth-seeking department - as if the institutions and practices they see competing with it were no worse off in these regards. But where are the examples of religious orthodoxy being simply abandoned in the face of irresistible evidence? Again and again in science, yesterday's heresies have become today's new orthodoxies. No religion exhibits that pattern in its history'. A major danger exists in replacing science, properly understood in all its limitations, with any ideology - be it postmodern, postpsychiatry, antipsychiatry, recovery-oriented, libertarian, anticapitalist, or procapitalist. My own perspective is that any kind of dogmatism, or belief that one perspective has a monopoly on knowledge, is bound to fail in psychiatry, and that dogmatisms of left and right are similar. The problem is how to reject dogmatism while also avoiding the pitfall of eclecticism.

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