History of anti-psychiatry

Anti-psychiatry is a movement and a diverse set of theories and practices, that challenges and stands in contrast to the fundamental theories and practices of psychiatry. Psychiatry is the field of medicine concerned with diagnosing, treating and managing what it classes as mental illness or disorder. The history of anti-psychiatry extends back to the 1960s and beyond.

Precursors

Towards the end of the 18th century, a "moral treatment" movement developed that challenged the harsh, pessimistic, somatic- and restraint-based approaches that prevailed in the system of hospitals and "madhouses" for people considered mentally disturbed. In the context of the Age of Enlightenment, the movement was led in different areas by ex-patient staff, physicians themselves in some cases, and religious and lay philanthropists. It pioneered more humane psychological and social approaches, whether or not in medical settings. However, it also involved some use of physical restraints, threats of punishment, and personal and social methods of control. Later critiques of the negative aspects of moral treatment, or the concurrent widespread expansion of asylums, medical power and involuntary hospitalization laws, was to play a conceptual part in the later antipsychiatry movement.Nick Crossley [http://cat.inist.fr/?aModele=afficheN&cpsidt=2352280 R. D. Laing and the British anti-psychiatry movement: a socio–historical analysis] Social Science & Medicine Volume 47, Issue 7, 1 October 1998, Pages 877-889]

Various 19th century critiques of the newly-emerging field of psychiatry overlap thematically with 20th century anti-psychiatry, for example in their questioning of the medicalisation of "madness". Those critiques are said to have occurred at a time when physicians had not yet achieved hegemony through psychiatry, however, and so there was not such a single unified force to be "anti-". Nevertheless, there was increasing concern at the ease with which people could be confined, with frequent reports of abuse and illegal confinement (for example, Daniel Defoe, the author of "Robinson Crusoe", had previously argued that husbands used asylum hospitals to incarcerate their disobedient wives. [Defoe, D. "Demand for public control of madhouses"] ) There was general concern that physicians were undermining personhood by medicalizing problems, by claiming they alone had the expertise to judge it, and by arguing that mental disorder was physical and hereditary. The Alleged Lunatics' Friend Society arose in England in the mid-18th century to challenge the system and campaign for rights and reforms.N Hervey (1986) [http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=1139650&pageindex=1#page Advocacy or folly: the Alleged Lunatics' Friend Society, 1845-63.] Med Hist. 1986 July; 30(3): 245–275.] In the United States, Elizabeth Packard published a series of books and pamphlets describing her experiences in the Illinois insane asylum to which her husband had had her committed. Throughout, the class nature of mental hospitals and their role as agencies of control were well recognized. The new psychiatry was also partially challenged by two powerful social institutions-the church and the legal system. These trends have been thematically linked to the later 20th century antipsychiatry movement.Dain, N. (1989) [http://www3.interscience.wiley.com/journal/112416171/abstract Critics and dissenters: Reflections on anti-psychiatry in the United States] Journal of the History of the Behavioral Sciences Volume 25 Issue 1, Pages 3 - 25]

As psychiatry became more professionally established during the nineteenth century and developed allegedly more invasive treatments, opposition increased. [cite book | last =Kleinman | first =Arthur | title = Rethinking Psychiatry: From Cultural Category to Personal Experience | publisher = Collier Macmillan| date = 1988 | location = | pages = | ISBN = 0029174422] In the Southern US, black slaves and Abolitionists encountered Drapetomania, a pseudo-scientific diagnosis for why slaves ran away from their masters. [ [http://www.ferris.edu/jimcrow/question/nov05.htm Question of the Month - Jim Crow Museum at Ferris State University] ]

There was some organized challenge to psychiatry in the late 1870s from the new speciality of neurology. Practitioners criticized mental hospitals for failure to conduct scientific research and adopt the modern therapeutic methods such as nonrestraint. Together with lay reformers and social workers, neurologists formed the National Association for the Protection of the Insane and the Prevention of Insanity. However, when the lay members questioned the competence of asylum physicians to even provide proper care at all, the neurologists withdrew their support and the association floundered.

Early 20th century

Emil Kraepelin introduced new medical categories of mental illness, which eventually came into psychiatric usage despite their basis in behavior rather than medical pathology or etiology.

The Soviets invented a diagnosis for persons who oppose the will of the state, as an excuse for hospitalizing them.

In the 1920s surrealist opposition to psychiatry was expressed by Antonin Artaud in his book on van Gogh.

The post-World War I1 decades saw an enormous growth in psychiatry; many Americans were persuaded that psychiatry and psychology, particularly psychoanalysis, were a key to happiness. Meanwhile, most hospitalized mental patients received at best decent custodial care and at worst they were abused and neglected. From the 1930s several controversial medical practices were introduced including inducing seizures (by electroshock, insulin shock therapy or other drugs) or cutting parts of the brain apart (leucotomy or lobotomy).cite book | last = Whitaker| first = Robert| title = Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill | publisher =Basic Books | date= 2004 | id = ISBN 0-7382-0799-3 ] Both came into widespread use by psychiatry, and labotomies began to practiced in outpatient clinics with minimal care, but there were grave concerns and much opposition on grounds of morality, harmful effects, or misuse.

In the 1950s new psychiatric drugs, notably the antipsychotic chlorpromazine, slowly came into use. Although often accepted as an advance in some ways, there was opposition, partly due to serious adverse effects such as tardive dyskinesia, and partly due their "chemical straightjacket" effect and their alleged use to control and intimidate patients. Patients often opposed psychiatry and refused or stopped taking the drugs when not subject to psychiatric control. There was also increasing opposition to the large-scale use of psychiatric hospitals and institutions, and attempts were made to develop services in the community.

It has been noted that "the most persistent critics of psychiatry have always been former mental hospital patients", but that very few were able to tell their stories publiclyor to openly confront the psychiatric establishment, and those who did so were commonly considered so extreme in their charges that they could seldom gain credibility. In the early 20th century, ex-patient Clifford W. Beers campaigned to improve the plight of individuals receiving public psychiatric care, particularly those committed to state institutions, publicizing the issues in his book, "A Mind that Found Itself" (1908) [Clifford Beers, "A Mind That Found Itself," Pittsburgh and London: University of Pittsburgh Press, 1981 ISBN 0822953242] While Beers initially damned psychiatrists for tolerating mistreatment of patients, and envisioned more ex-patient involvement in the movement, he was influenced by Adolf Meyer and the psychiatric establishment, and toned down his hostility as he needed their support for reforms. His reliance on rich donors and his need for approval from experts led him to hand over to psychiatrists the organization he helped found, the National Committee for Mental Hygiene which eventually became the National Mental Health Association. In the UK meanwhile, the National Society for Lunacy Law Reform was established in 1920 by angry ex-patients sick of their experiences and complaints being patronisingly discounted by the authorities who were using medical "window dressing" for essentially custodial and punitive practices.Phil Fennell (1996) [http://books.google.com/books?id=XqlBoZ_Vm7UC Treatment Without Consent: Law, Psychiatry and the Treatment of Mentally Disordered People Since 1845] Routledge, 1996 ISBN 0415077877 pg108] In 1922, ex-patient Rachel Grant-Smith added to calls for reform of the system of neglect and abuse she had suffered by publishing "The Experiences of an Asylum Patient". [Rachel Grant-Smith (1922) [http://mcgovern.library.tmc.edu/data/www/html/texascoll/Psych/EAP/EAPContents.htm The Experiences of an Asylum Patient] John P. McGovern Historical Collections and Research Center] In the US, We Are Not Alone (WANA) was founded by a group of patients at Rockland State Hospital in New York, and continued to meet as an ex-patient group.Reaume G. (2002) Lunatic to patient to person: nomenclature in psychiatric history and the influence of patients' activism in North America. Int J Law Psychiatry. Jul-Aug;25(4):405-26. PMID 12613052 doi:10.1016/S0160-2527(02)00130-9]

The psychoanalyst Lacan has been identified as an influence on later antipsychiatry theory in the UK, and as being the first, in the 1940s and 50s, to professionally challenge psychoanalysis to rexamine its concepts and to appreciate psychosis as understandable. Other influences on Lacan included poetry and the surrealist movement, including the poetic power of patients' experiences. Critics disputed this and questioned how his descriptions linked to his practical work. The names that came to be associated with the antipsychiatry movement knew of Lacan and acknowledged his contribution even if they did not entirely agree.Mervat Nasser [http://pb.rcpsych.org/cgi/content/abstract/19/12/743 The rise and fall of anti-psychiatry] Psychiatric Bulletin (1995). 19, 743-746] The psychoanalyst Erich Fromm is also said to have articulated, in the 1950s, the secular humanistic concern of the coming antipsychiatry movement. In The Sane Society (1955), Fromm wrote ""An unhealthy society is one which creates mutual hostility [and] distrust, which transforms man into an instrument of use and exploitation for others, which deprives him of a sense of self, except inasmuch as he submits to others or becomes an automaton"..."Yet many psychiatrists and psychologists refuse to entertain the idea that society as a whole may be lacking in sanity. They hold that the problem of mental health in a society is only that of the number of 'unadjusted' individuals, and not of a possible unadjustment of the culture itself" [Levine, B. (2008) [http://www.huffingtonpost.com/bruce-e-levine/thinking-critically-about_b_125019.html Thinking Critically About Scientology, Psychiatry, and Their Feud] The Huffington Post, September 10]

1960s

Coming to the fore in the 1960s, "anti-psychiatry" (a term first used by David Cooper in 1967) defined a movement that vocally challenged the fundamental claims and practices of mainstream psychiatry. Psychiatrists R.D. Laing, Theodore Lidz, Silvano Arieti and others argued that schizophrenia could be understood as an injury to the inner self inflicted by psychologically invasive "schizophrenogenic" parents, or as a healthy attempt to cope with a sick society. Psychiatrist Thomas Szasz argues that "mental illness" is an inherently incoherent combination of a medical and a psychological concept, but popular because it legitimizes the use of psychiatric force to control and limit deviance from societal norms.

Adherents of this view referred to "the myth of mental illness" after Szasz's controversial book of that name. (Even though the movement originally described as anti-psychiatry became associated with the general counter-culture movement of the 1960s, Szasz, Lidz and Arieti never became involved in that movement.) Michel Foucault, Erving Goffman, Deleuze and Guatarri, and others criticized the power and role of psychiatry in society, including the use of "total institutions," "labeling" and stigmatizing. [ [http://www.jrsm.org/cgi/reprint/94/3/148.pdf?ijkey=07b5d6fed040a1f4c99d9e0fe381f33314e70145 Does psychiatry stigmatize?] ]

Foucault argued that the concepts of sanity and insanity were social constructs that did not reflect quantifiable patterns of human behavior, and which, rather, were indicative only of the power of the "sane" over the "insane". The novel "One Flew Over the Cuckoo's Nest" became a bestseller, resonating with public concern about involuntary medication, lobotomy and electroshock procedures used to control patients.

In addition, Holocaust documenters argued that the medicalization of social problems and systematic euthanasia of people in German mental institutions in the 1930s provided the institutional, procedural, and doctrinal origins of the mass murder of the 1940s. [cite book | last = Lapon| first = Lenny| title = Mass Murderers in White Coats : Psychiatric Genocide in Nazi Germany and the United States | Psychiatric Genocide Research Inst | date= 1986 | id = ISBN 0961496193 ] [ [http://home.iprimus.com.au/burgess1/breggin.html The Psychiatric Holocaust - excerpts] ] The Nuremberg Trials convicted a number of psychiatrists who held key positions in Nazi regimes.

Observation of the abuses of psychiatry in the Soviet Union in the so-called Psikhushka hospitals also led to questioning the validity of the practice of psychiatry in the West. [ [http://www.aaas.org/news/releases/2003/1212reich.shtml AAAS - AAAS News Release] ] In particular, the diagnosis of many political dissidents with schizophrenia led some to question the general diagnosis and punitive usage of the label schizophrenia. This raised questions as to whether the schizophrenia label and resulting involuntary psychiatric treatment could not have been similarly used in the West to subdue rebellious young people during family conflicts. [ [http://www.antipsychiatry.org/kendra-c.htm Why Outpatient Commitment Laws Change (Almost) Nothing] ]

1970s

New professional approaches were developed as an alternative or reformist complement to psychiatry. "The Radical Therapist", a journal begun in 1971 in North Dakota by Michael Glenn, David Bryan, Linda Bryan, Michael Galan and Sara Glenn, challenged the psychotherapy establishment in a number of ways, raising the slogan "Therapy means change, not adjustment." It contained articles that challenged the professional mediator approach, advocating instead revolutionary politics and authentic community making. Social work, humanistic or existentialist therapies, family therapy, counseling and self-help and clinical psychology developed and sometimes opposed psychiatry.

Psychoanalysis was increasingly criticized as unscientific or harmful. [Adolf Grünbaum's "The Foundations of Psychoanalysis: A Philosophical Critique". Berkeley (University of California Press, 1984); "Validation in the Clinical Theory of Psychoanalysis: A Study in the Philosophy of Psychoanalysis". (International Universities Press, 1993).] Contrary to the popular view, critics and biographers of Freud, such as Alice Miller, Jeffrey Masson and Louis Breger, argued that Freud did not grasp the nature of psychological trauma. Non-medical collaborative services were developed, for example therapeutic communities or Soteria houses.

The anti-psychiatry movement was also being driven by individuals with adverse experiences of psychiatric services. This included those who felt they had been harmed by psychiatry or who felt that they could have been helped more by other approaches, including those compulsorily (including via physical force) admitted to psychiatric institutions and subjected to compulsory medication or procedures. During the 1970s, the anti-psychiatry movement was involved in promoting restraint from many practices seen as psychiatric abuses.

The gay rights movement challenged the classification of homosexuality as a mental illness and, in a climate of controversy and activism, in 1974 the American Psychiatric Association membership (following a unanimous vote by the trustees in 1973) voted by a small majority (58%) to remove it as an illness category from the DSM, replacing it with a category of "sexual orientation disturbance" and then "ego-dystonic homosexuality," which was deleted in 1987, although "gender identity disorder" and a wide variety of "paraphilias" remain. Increased legal and professional protections, and merging with human rights and disability rights movements, added to anti-psychiatry theory and action.

Anti-psychiatry came to challenge a "biomedical" focus of psychiatry (defined to mean genetics, neurochemicals and pharmaceutic drugs). There was also opposition to the increasing links between psychiatry and pharmaceutical companies, which were becoming more powerful and were increasingly claimed to have excessive, unjustified and underhand influence on psychiatric research and practice. There was also opposition to the codification of, and alleged misuse of, psychiatric diagnoses into manuals, in particular the American Psychiatric Association, which publishes the "Diagnostic and Statistical Manual of Mental Disorders".

Anti-psychiatry increasingly challenged alleged psychiatric pessimism and institutionalized alienation regarding those categorized as mentally ill. An emerging Consumer/Survivor Movement often argues for full recovery, empowerment, self-management and even full liberation. Schemes were developed to challenge stigma and discrimination, often based on a social model of disability; to assist or encourage people with mental health issues to engage more fully in work and society (for example through social firms), and to involve service users in the delivery and evaluation of mental health services. However, those actively and openly challenging the fundamental ethics and efficacy of mainstream psychiatric practice remained marginalized within psychiatry, and to a lesser extent within the wider mental health community.

Diverse paths

Although often lumped together, those associated with antipsychiatry have held widely divergent views and backgrounds.

The psychoanalytically-trained psychiatrist Szasz, although professing fundamental opposition to what he perceives as medicalization and oppressive or excuse-giving "diagnosis" and forced "treatment", has not opposed other aspects of psychiatry (for example attempts to "cure-heal souls", although he also characterizes this as non-medical). Although generally considered anti-psychiatry by others, he has long sought to dissociate himself politically from a movement and term associated with the radical left-wing. In a 1976 publication "Anti-psychiatry: The paradigm of a plundered mind", which has been described as an overtly political condemnation of a wide sweep of people, Szasz claimed Laing, Cooper and all of antipsychiatry consisted of "self-declared socialists, communists, or at least anti-capitalists and collectivists". While saying he shared some of their critique of the psychiatric system, Szasz compared their views on the social causes of distress/deviance to those of anti-capitalist anti-colonialists who claimed that Chilean poverty was due to plundering by American companies, a comment made not long after a CIA-backed coup had deposed the democratically elected Chilean president and replaced him with Pinochet. Szasz argued instead that distress/deviance is due to the flaws or failures of individuals in their struggles in life. [Kotowicz, Z. (1997) [http://books.google.com/books?id=EHTEEMQ2INUC R.D. Laing and the Paths of Anti-Psychiatry] Routledge ISBN 0415116112 pg90]

Szasz later further emphasized his disdain for the movement, arguing in 2008 that its legacy has been the creation of a "catchall term used to delegitimize and dismiss critics of psychiatric fraud and force by labeling them "antipsychiatrists". Szasz points out that the term originated in a meeting of four psychiatrists (Cooper, Laing, Berke and Redler) who never defined it yet "counter-label [ed] their discipline as anti-psychiatry", and that Laing was considered most responsible for popularizing it despite also personally distancing himself. Szasz describes the deceased Laing in vitriolic terms, accusing him of being irresponsible and equivocal on psychiatric diagnosis and use of force, and detailing his "public behavior" as "a fit subject for moral judgment" which he gives as "a bad person and a fraud as a professional". Szasz clarifies that his own views on psychiatry come from libertarian politics held since his teens, rather than through experience in the area; that in his rare contacts with involuntary mental patients he either sought to discharge them (if they were not charged with a crime) or "assisted the prosecution in securing [their] conviction" (if they were charged with a crime and appeared to be prima facie guilty); and that he is not opposed to any form of consensual psychiatry and has himself practiced "listening-and-talking ("psychotherapy")" from 1948 until 1996, which he characterizes as non-medical and not associated with his being a psychoanalytically-trained psychiatrist. [Szasz (2008) [http://www.springerlink.com/content/5181704176g65265/ Debunking Antipsychiatry: Laing, Law, and Largactil] Current Psychology, Volume 27, Number 2 / June Pages 79-101 DOI 10.1007/s12144-008-9024-z]

The gay rights or gay liberation movement is often thought to have been been part of antipsychiatry in its efforts to challenge oppression and stigma and, specifically, to get homosexuality removed from the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders. However, a psychiatric member of APA's Gay, Lesbian, and Bisexual Issues Committee has recently sought to distance the two, arguing that they were separate in the early 70s protests at APA conventions and that APA's decision to remove homosexuality was scientific and happened to coincide with the political pressure. Reviewers have responded, however, that the founders and movements were closely aligned; that they shared core texts, proponents and slogans; and that others have stated that, for example, the gay liberation critique was "made possible by (and indeed often explicitly grounded in) traditions of antipsychiatry." [McCommon, B. (2006) [http://psychservices.psychiatryonline.org/cgi/content/full/57/12/1809 Antipsychiatry and the Gay Rights Movement] Psychiatr Serv 57:1809, December doi 10.1176/appi.ps.57.12.1809] [Rissmiller, DJ, D.O., Rissmiller, J. (2006) [http://www.ps.psychiatryonline.org/cgi/content/full/57/12/1809-a Letter in reply] Psychiatr Serv 57:1809-a-1810, December 2006 doi 10.1176/appi.ps.57.12.1809-a] It has been noted that gay activists adopted many of Szasz's arguments against the psychiatric system, but that he had also said in 1965 "I believe it is very likely that homosexuality is, indeed, a disease in the second sense [expression of psychosexual immaturity] and perhaps sometimes even in the stricter sense [a condition somewhat similar to ordinatry organic maladies] [Wright, RH, Cummings, NA. (2005) [http://books.google.com/books?id=OY05uZUCaTsC Destructive Trends in Mental Health: The Well-intentioned Path to Harm] Routledge ISBN 0415950864 pg 67]

In the clinical setting, the two strands of antipsychiatry—criticism of psychiatric knowledge and reform of its practices—were never entirely distinct. In addition, in a sense, antipsychiatry was not so much a demand for the end of psychiatry, as it was psychiatrists and allied professionals questioning their own judgements and practices. In some cases, the suspicion of non-psychiatric medical professionals towards the validity of psychiatry was described as anti-psychiatry, as well the criticism of "tough headed" psychiatrists towards "soft head" psychiatrists. Even the leading figures of antipsychiatry were within psychiatry and equivocated over whether they were really against psychiatry, or which parts. Outside psychiatry however, for example student and lay activists and paraprofessionals such as social workers and psychologists, antipsychiatry tended to mean something more uniformly radical. The ambiguous term "antipsychiatry" came to be associated with the stronger forms, but there was debate over whether it was a new phenomena, who "owned" it, and whether it even constituted a genuinely singular movement. [Paul Laffey [http://www.historycooperative.org/journals/hah/5.2/laffey.pdf Antipsychiatry in Australia:Sources for a Social and Intellectual History] Health & History, 2003. 5/2: 17–36] In the 1990s, a tendency was noted among psychiatrists to regard the anti-psychatric movement as having entered the annals of history, and to look back on its ideology as an attempt to flirt with polemics at the expense of scientific thought and enquiry. However, it was argued that the movement contributed towards generating demand for grassroots involvement in guidelines and advocacy groups, and to the shift from large mental institutions to community services. In addition, in reality, community centers tended to distance themselves from the psychiatric medical model, and continued to see themselves as representing a culture of resistence or opposition to psychiary's power. On the other hand, mainstream psychiatry became more biomedical, increasing the gap between professionls. As a result, while antipsychiatry may have fallen from grace and was no longer be led by eminent psychiatrists, it was argued that it had in fact only been handed over to the team.

In the meantime, the Consumer/Survivor/Ex-Patient Movement carried on campaigning for reform, empowerment and alternatives, with an increasingly diverse representation of views. Groups have often been opposed and undermined, especially when they proclaim to be, or when they are labelled as being, anti-psychiatry.McLean, A. (2003) [http://www.psychosocial.com/IJPR_8/Recovering1-McLean.html Recovering Consumers and a Broken Mental Health System in the United States: Ongoing Challenges for Consumers/ Survivors and the New Freedom Commission on Mental Health. Part II: Impact of Managed Care and Continuing Challenges] International Journal of Psychosocial Rehabilitation. 8, 58-70.] However, as of the 1990s, more than 60 percent of ex-patient groups reportedly support anti-psychiatry beliefs and consider themselves to be "psychiatric survivors." [ [http://www.umaine.edu/JMB/archives/volume15/15_1-2_1994winterspring.html#abstract4 Everett B (1994)] Something is happening: the contemporary consumer and psychiatric survivor movement in historical context. "Journal of Mind and Behavior", 15:55–7] Although antipsychiatry is often attributed to a select few psychiatric or academic figures, it has been pointed out that consumer/survivor/ex-patient individuals and groups preceded it, drove it and carried on through it. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16754765&dopt=Abstract Rissmiller DJ & Rissmiller JH (2006)] Evolution of the antipsychiatry movement into mental health consumerism. "Psychiatric Services", Jun;57(6):863-6.] [ [http://psychservices.psychiatryonline.org/cgi/content/full/57/8/1212 Oaks, D. (2006)] The Evolution of the Consumer Movement, "Psychiatric Services" 57:1212]

Notes