Making Sense of Antipsychiatry for the 21st Century

Nassir Ghaemi, MD, MPH


June 15, 2021

As part of this year's annual meeting of the American Psychiatric Association, which was held virtually, I organized and chaired a session that, among other things, gathered experts to discuss the past and future of the antipsychiatry movement, which shows no signs of slowing down.

I co-chaired and co-presented this symposium with Awais Aftab, MD. Dr Aftab presented on "the historical evolution of antipsychiatry," a term he noted is often used as pejorative criticism in itself. Instead, he recommended that the term be used only descriptively for those who have made central critiques of psychiatry, but that it is not itself proof of the invalidity of those views.

In fact, many of the critiques of our field of medicine that can get labeled as "antipsychiatry" are made by psychiatrists. Dr Aftab noted that two major founders of the modern antipsychiatry perspective were both psychiatrists, Thomas Szasz and R. D. Laing, although they came to their critiques from different viewpoints.

Current groups that might be seen in the overall antipsychiatry camp include the Critical Psychiatry Network in the United Kingdom, many of whom are "practising psychiatrists keen to grapple with the intellectual and practical challenges that confront them"; the "psychiatric survivors movement," a group of "mental health consumers" who feel that they have been harmed by psychiatric treatments and medications; Scientology, a religion that rejects psychiatry completely and even criminalizes the profession; and the "neurodiversity and mad pride" movement, which values the experiences that psychiatry pathologizes.

Dr Aftab urged clinicians not to be defensive in the face of such criticisms of psychiatry, nor to use the term "antipsychiatry" as a pejorative means of rejection of those criticisms. Instead, we should try to understand the experiences and conceptual claims behind them.

He then spoke on "philosophical responses to antipsychiatry." He noted that one response is "pragmatic" (or as I would say, postmodernist, but more on this shortly). It is the view expressed by the leaders of the previous edition of the DSM, who argued that there is no truth, but that psychiatrists are the best judges of matters related to mental illness (like a baseball umpire calling balls and strikes). A second response is "naturalist," which argues that there are truths about mental illness that science will establish. A third response is "normativist," which holds that psychiatry is about values and ethics, which require a consensus.

The psychologist Derek Bolton was cited for his "skepticism of the gentle variety," which accepts many of the critiques made against psychiatry, in that perhaps no clear "mental disorders" can be shown to exist in nature, but nonetheless people have experiences of mental distress that take them to caregivers. These experiences are real, and caregivers can try to attend to the suffering they entail.

Postmodern Psychiatry and Scientific Skepticism

I presented on "psychiatry and antipsychiatry in the postmodern age." My central thesis was that antipsychiatry is based on a postmodernist ideology, but so is modern psychiatry. As a result, despite the apparent conflict, they actually agree with each other conceptually. The problem is that they do not realize that they both share postmodernist beliefs, and thus they argue past each other.

What is postmodernism? It's our contemporary cultural ethos. Historically, it is labeled "post" because it began after the modern era, which roughly corresponds to the Renaissance and Enlightenment period until the world wars of the 20th century. In that era, Reason and Science replaced God as the sources of Truth. I write these purposefully in capital letters to emphasize the value placed on these concepts.

Before the modern era, God and religion were the main sources of truth. After the modern era, God was proclaimed dead by Nietzsche; and later postmodernists of the 20th century, like Michel Foucault and Martin Heidegger, also tried to kill Reason and Science.

Scientific knowledge was not seen as more valuable than any other kind of knowledge, such as religion. All were "social constructions," creations of human beings based on cultural consensus — not something related to the real world in any kind of absolute sense. There is no Truth; all claims to truths are relative to social preferences and norms.

Foucault famously made this critique first and foremost against the profession of psychiatry and claims about mental illness. He viewed psychiatrists as essentially medical policemen, serving a function of social control over those who are deviant but can't be labeled criminals. I held that the basic critiques of psychiatry made by many antipsychiatry groups are based on these postmodernist ideas, which are relativistic and highly skeptical about science.

The paradoxical problem is that the mainstream leadership of modern psychiatry is also postmodernist. DSM leaders admit that the primary criteria for making and changing DSM diagnoses are not scientific criteria but "pragmatic" ones, based on the preferences of the psychiatric profession. These include economic (billing and insurance), legal (forensic), and cultural (clinician preferences) factors. This approach is social construction and thus not different from the critique leveled by Foucault.

I concluded that mainstream psychiatry is unable to respond to the critiques of antipsychiatry effectively, given its own nonscientific social constructionist assumptions. I argued for a return to scientific realism, meaning accepting the limitations of science and the postmodernist critiques of scientific work, while at the same time holding that when conducted correctly, legitimate scientific attitudes can reveal truths that are not relative to human beings but actually reflect the realities of nature.

Nassir Ghaemi, MD, MPH, is a professor of psychiatry at Tufts Medical Center and a lecturer in psychiatry at Harvard Medical School. He is the author of several general-interest books on psychiatry. He is employed currently at Novartis Institutes for Biomedical Research in Cambridge, Massachusetts. The views expressed here are his own and do not reflect those of his employers.

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