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Psychiatry s Poor Image: Reflecting on Psychiatrists Apologias

Those of us who critique psychiatry were recently treated to an interestingphenomenon—the publically available part of the January 2015 issues ofActaPsychiatrica Scandinavica, which contains multiple articles devoted to the question ofpsychiatry’s “poor image”—how to understand it, how to assess it, what to do about it(see ip://onlineiibrary.wi1ey.comIdoi/i 0.111 1/ac201 4.131 .issue-1/issuetoc). Therelease of this issue is hardly the first occasion where articles have appeared in whichpsychiatrists have speculated on outsiders’ negative image of the profession. Indeed,more and more, we are seeing such articles together with other evidence that theprofessionals are concerned (e.g., Bhugra and Moran, 2014; and Oxtoby, 2008). Whatmakes this issue special is that there is a sizable number of commentators; moreover, theyinclude such leading figures as Gaebel, current President of the European PsychiatricAssociation, Wasserman, former President of the European Psychiatric Association, andBhugra, President of the World Psychiatric Association. Could it be that the upperechelons of psychiatry, whether they admit or not, are becoming alarmed? Regardless,these psychiatric reflections are themselves a source of data—hence this article.

This article probes the collection in question for themes, positions, framing. Questionsexplored include: What positions are being taken? How valid are they? Insofar asconstructions are never “innocent” but invariably have a function, what functions arebeing served? What do these articles tell us about psychiatrists? About the state ofpsychiatry? How successful are the proffered solutions likely to be in resuscitating the“image of psychiatry”? And what should we be wary of here?

The Special Issue in a Nutshell

The majority of the special issue is tightly focused on the image question. At the centre ofthe issue is a piece/study by Stuart et a!. (2015). Counting the study and the twoeditorials, there are 10 pieces focused on this question in all.

The Stuart et al. article is in essence the write-up of a study conducted on non-psychiatricmedical faculty’s opinions of psychiatry. 1057 faculty members were sampled. The majorfindings? The majority hold a very negative view of psychiatry, of psychiatrists, and aswell as of their “patients”. Ninety per cent thought that psychiatrists were poor rolemodels. One in five thought that psychiatrists have too much power over “their patients”.Many questioned the efficacy of the treatments. Additionally, many saw psychiatrists ashaving poor medical skills and deemed psychiatrists to be illogical. Correspondingly, “themajority felt that students in their medical school were not interested in pursuing apsychiatric specialization” (p. 24), with over a third opining that “their colleaguesgenerally do not speak well of psychiatry.” (p. 24). By way of commentary, the authors ofthe study note that there is no clear way to distinguish how much of the poor image maybe attributed to being part of a “stigmatized group” and how much is attributable toaccurate perception. Correspondingly, they link these perceptions to the low number ofmedical students choosing psychiatry as their specialty.

In the related pieces, authors comment not only on this article but more generally onpsychiatry’s image— overall, whether it is indeed bad or not, and insofar as there is aproblem, who is at fault and what to do about it.

The Most Important Question Never Emerges

Before I proceed further, I would point out that there is a conspicuous void in thiscollection. While all authors in their own different ways address what might be done toimprove psychiatry’s image, significantly, not a single psychiatrist thinks to ask what byhumanistic standards would appear to be the compulsory question: Insofar as any of thebad image is deserved, exactly how are the “patients” being ill served and what is owedthem? With one exception only —and we will shortly see why he is an exception—nordoes anyone seem to take in that in all likelihood, in dialoguing with each other, they aretalking to the wrong people. The point is, insofar as this poor image in any way meritedand in any way relates to practice—and it is arguably arrogant just to assume otherwise—it is not so much their colleagues with whom they most need to be in dialogue but thepeople whose situations they appear to badly misunderstand. What relates to this and issimilarly worrisome, “patients” are discussed only insofar as psychiatrists speculate thatpart of the image problem arises from “stigma” against the “patients” being transferred tothe psychiatrists. Nor is improving care per se a major theme. All of which suggest thatadvancing the profession is taking precedence over the welfare of the people “served”.

What the Focal Piece and the Introductions Set U

There is somewhat more objectivity in the focal piece by Stuart et al. and in the twoeditorials than in most of the related psychiatric pieces. This notwithstanding, eachconstructs the inquiry and the issue in such a way that prejudice on the part of othersappears as potentially the single most important factor in accounting for the poor image—and as such, they are hardly neutral. What is apropos here, the study itselfwasconceptualized in the context of trying to address “stigma” against psychiatrists—hardlya legitimate way to theorize critiques of a profession whose views are hegemonic andwhich is endowed with huge resources and massive power (not that I am ruling out thepossibility of non-psychiatric doctors being unfair to psychiatrists). More particularly, itwas “conducted as part of the scientific activities of the World Psychiatric Association’sStigma and Mental Health Scientific Section.” (Stuart et al., p. 21) The bias inherent inthis framing is reinforced by including in this study about negatives attitudes towardpsychiatrists an investigation into negative attitudes toward “psychiatric patients”.Holding the two together in this way constructs the attitudes toward these very differentconstituencies as “of a piece”. The function served is that psychiatry appears as a victim,with all negative evaluations of it set up to be seen as examples of “stigma”. Other waysin which bias enters in? In the first editorial, the author states unequivocally (albeitwithout proof) that with the advent ofmolecular biology, the image of psychiatry isimproving. Correspondingly, on a personal note, he writes, “This author represents thegeneration of young academics, with a background in psychiatric genetics. From myperspective, the view of our profession among medical students and doctors has improvedsignificantly since I completed medical school.” (Tesli, 2015, p. 1) And the second

editorial actually announces a victory right in the title—’Psychiatry GeneratingComparative Respect”, thereby prompting us to view the forthcoming articles in a wayfavourable to psychiatry (see Munk-Jorgensen and Christiansen, 2015, p. 2-3).

The path is thereby set for evasion on the part of the other psychiatrists in this collectionto appear as honest inquiry and for anything unfavourable to appear outdated.

Emergent Themes/Claims

In this section, I am limiting myself to the pieces penned by the medical doctors (the vastmajority of whom are psychiatrists). Most of these responses can be divided into severalcategories, and all entail some level of evasion. Emergent themes or claims in this regardinclude: 1) The evidence that psychiatry has a bad image is either not credible or islimited and as such, claims based on it are misleading; 2) Insofar as psychiatry andpsychiatrists have a bad image, it is not primarily psychiatry’s fault but the fault ofothers; 3) The bad image is not exactly anyone ‘s fault—it goes with the territory; 4)While psychiatry is partially to blame, it is only one or two things psychiatry is doingwrong—none of which are substantive.

The “this is not credible or misleading” line of reasoning is evident to varying degrees inmost of the commentators. The most cogent of these is Hartley (2015, pp. 10-11). Hepoints out that the survey itself was conducted in a biased manner, for colleagues wereasked to respond only to negative statements about psychiatry—a totally valid point. Thisnotwithstanding, the critique is not as cogent as first appears for it ignores how dramaticthe negativity was, also that there were other biases in the construction that pull in theopposite direction. It likewise ignores the fact that the low enrollment in the psychiatricspecialty in an abundance of medical schools itself serves as confirmation. That said,more obviously evasive are other variations on the theme. Note, in this regard, some,including Hartley, object that studies in Australia have had different results, therebyerroneously making it look as if outreach was limited, whereas in point of fact 15different countries were surveyed. Likewise suggested is an “old-young” divide. Theargument here (e.g., Kristiansen Ct al., 2015) is that being younger and so more keenlyaware of how advanced psychiatry now is, medical students have a very positive image ofit. It is only medicalfaculty that do not, and as the old are replaced by the young, theproblem will disappear. What is wrong with this construction is that while psychiatrymay well enjoy greater popularity among medical students in Australia and Denmark(there is a positive piece by medical students from Denmark in this collection), there islittle indication of this other places; correspondingly, were young medical students reallyexcited by psychiatry generally, the percentage of them signing up to study psychiatrywould not be so low (for more representative figures, see, for example, Read 2015).

More pronounced and more blatantly evasive is the response/claim, “While psychiatryhas a bad image, others are to blame for this.” Herein we see the disingenuous claim ofstigma discussed earlier. In this regard, Gaebel et al. (2015, p. 5 ff.) call their article“Overcoming Stigmatizing Attitudes toward Psychiatrists and Psychiatry”.Correspondingly, they dismiss the critiques by the medical colleagues in question offhand

with words like “bad mouthing” and “psychiatry-bashing”. All of this, note, withoutevidence or even a thought to what evidence in support of such a contention might entail.Ironically, what surprises most of us who are aware of psychiatry’s baselessness, is nothow critical other doctors are ofpsychiatrists but how silent they are about thefraudulence of the medical claims—at least as a big a dynamic as the putative unfairness.The evasion evident here is in turn reinforced by linking the so-called “stigma againstpsychiatrists” to the stigma against “mental patients”. Now indeed, it may well be, asthese authors claim, that stigma against “mental patients” can impact negatively onpeople’s perceptions of psychiatrists. Nonetheless, trying to get around the problem likethis begs the question. That is, it totally bypasses the central question of whether or notthe critiques are accurate. Also it is hard to imagine how “transferred stigma” couldtranslate into such critiques as “psychiatrists exercise too much power over theirpatients.” Since when do people operating out of “prejudice” against a population wantless control—as opposed to more—exercised over said population? Correspondingly, thisconstruction functions to create a false solidarity between psychiatrists and “patients”when psychiatry itself is one of the principle causes of stigma against “mental patients”.

The primary purpose of the construction of course is to absolve psychiatry by transferringblame onto others. The various people blamed throughout this collection include: othermedical teaching faculty; funders (who allegedly are not providing sufficient resourcesto make psychiatry attractive to enter (see, for example Bhugra, 2015), and finally, themedia. Note in this last regard, Bhugra’s curious reference to the “antipsychiatry mediacoverage”. This of course is ironic given the enormous complicity of the press infurthering psychiatry (see Whitaker, 2002). Moreover, as those of who organize againstpsychiatry but receive negligible coverage are well aware, if there is antipsychiatry pressout there, it is keeping itself well hidden. Which brings us to the next claim.

Mostly the people who take the position that the bad image comes with the territory arenonetheless likewise suggesting that stigma is an issue (see, for example Bhugra, 2015).There is one author that does not and he is the one psychiatrist in this collection whoappears to be thinking—and indeed, he can be credited with having a point. In thisregard, Kapezinski and Passos (2015) distinguish between what they call “wet minds”(the science of the brain) and “dry minds” (our mental processes) and they state thatpsychiatry runs into trouble when it tries to simply ascribe “the issues of the mind tobrain tissue.” (p.’7) This is undoubtedly true and important. Where the authors err is notnot going far enough. They recommend that psychiatrists focus their work on scientificexplanations and leave it to others to develop explanatory models for human behavior.The question remains: What about the issue of power? And insofar as there is anyscience here that has both validity and relevance, would it not be better handled bycredible scientists like neurologists?

Finally, comes the very common contention that while psychiatry is wonderful andamazingly successful (and all the psychiatrists more or less concur on this point), it is infact doing but one or two things wrong, none of which are substantial, albeit theyfacilitate the “stigma”. Generally, the deficits identified relate to not having a game planfor fighting back and not properly communicating (e.g., what we are being asked to

believe is that despite the enormity of the funds spent on promulgating its message—seethis regard, Whitaker, 2002—psychiatry is failing to communicate how very scientificand advanced it is—hence the “misperceptions”—an example of this position beingWasserman’s piece, which largely assumes this is the case, then proceeds to offersuggestions). Given the decades of disaster and the enormity of the evidence thatpsychiatry’s basic tenets will not hold (see, for example, Whitaker, 2002 and Burstow,2015), herein lies the ultimate evasion. Correspondingly, it is blatantly clear what purposeis served by such a construction. It is at once an evasion and an argument for pumpingever more resources into what is in essence medical model propaganda. That said, whilethere is a more general acknowledgement that psychiatrists need to learn how tocommunicate better, valid though that may be, that acknowledgment in no way touchesthe heart of the matter. As such, it is but another obfuscation.

The Lone Voice in the Wildness

The lone voice in the wilderness is critic John Read (2015). Read acknowledges the poorimage, validating it with reference to statistics and narratives, and he lays the blame forthe poor image squarely at the door of psychiatry. He identifies the underlying problem asa “rigid adherence to a narrow biogenetic ideology combined with arrogant dismissal ofthose with broader perspectives.” (p. 11) One need go no further than the variousapologias in this issue to see what he is talking about—a source of confirmation in itsown right. While I do not contend that no psychiatrist could have written this, I wouldadd, it is hardly coincidental that what likewise distinguishes Read is that he is not amedical doctor, never mind a psychiatrist. Solutions which Read advocates include:Psychiatrists should start listening to their patients. They should not automatically headall “mental health” teams. And they should restrict themselves to providing scientificinformation, in the process, limiting themselves to what is “evidence-based”.

Read is a breath of fresh air, and much of what he recommends has validity. Who couldargue against listening more to others—in particular, to the people whom one ishypothetically attempting to serve? And yes, something is very wrong with theassumption that psychiatrists should head all “mental health” teams. That said, there are afew questions that I would invite readers to ponder when looking at Read’s othersolutions: Why do we need psychiatrists on these teams at all? Could not scientific data,insofar as relevant, be better provided by figures like neurologists? Why are we assumingthat teams of professionals should be in charge of others’ emotional well being? Whyshould we be placing this degree of trust in evidence-based research? Was not thefetishization of evidence-based research part of what landed us in this currentpredicament (for a hard hitting critique of evidence-research, see Burstow, 2015; see alsoforthcoming articles). And finally, while Read is suggesting ways to “save psychiatryfrom itself’—is there in fact any cogent reason to save it?

The Solutions Proffered by the Psychiatrists: A Further Reflection

The solutions offered by the psychiatrists, not surprisingly, match their positions asarticulated above. Insofar as more or less everyone agrees that stigma against psychiatry

is involved (again an all-too-convenient confabulation), anti-stigma campaigns areadvocated, with one of the authors, Gaebel, additionally inviting his colleagues to addresswhat he sees as the problem of “self stigma” (more commonly known as pangs ofconscience). People are urged to come up with road maps. To facilitate the “neededcommunication”, correspondingly, the use of professional bodies is recommended as wellas individual training in communications skills, with authors such as Wasserman (2015,p. 13), for example, writing, “To promote the destigmatization of psychiatry and changethe negative attitudes toward psychiatrists, a road map of action is needed along sideprofessional training in communication skills.” And beyond that, there is encouragementand general agreement to proceed further and further along the road of biologicalpsychiatry, for it here where psychiatry’s credibility allegedly lies. In others words, acontinuation and intensification of the status quo.

That these “solutions” will hardly get rid of psychiatry’s fundamental deficits is clear.How can you get rid of shortcomings by putting all your energy into attempting topersuade everyone that they don’t exist? How can you deal with the problem of a faultyparadigm by further entrenching oneself in that paradigm? But, of course, addressingactual deficits is not the point of the exercise. Now whether or not increased efforts in thedirection identified will help psychiatry improve its image—demonstrably, the overridinggoal—is hard to say. This is exactly how psychiatry improved its image in the 70s,though, when its credibility was at an all-time low (for details, see Burstow, 2015), and,alas, it worked—and so there is always the possibility that it will work again. That is the“bad news”. The “good news”? At this point in time there is an unprecedented amount ofevidence that the claims are untenable —even fraudulent—moreover, more and morepeople are aware of that—and as such, there is an excellent chance that it will backfire.

Closing Thoughts

In ending, I would draw attention to our need as critics and activists to be ready toaddress what appears to be in the “offing”—a renewed propaganda push by psychiatry,whatever form that propaganda take (whether it be “explaining” alleged medicaladvances or laying claim to being uniquely holistic, whether it calls its model“biological” or “biopsychosocial”, whether it is presented as just providing “information”or as an “anti-stigma” campaign). I would also alert readers to attempts to lure survivorsand their allies into taking a common stand against stigma (now being discussed almostas if it were shared). What is significant in this regard, besides that the very concept ofstigma against psychiatry is a non sequitur, psychiatry’s constructions themselves arearguably the number one cause of the “stigma” faced by survivors. Also, while likeeverything else, psychiatry may at times be the object of unfair evaluations;overwhelmingly, it is given a high credibility that it in no way deserves. Correspondingly,given that psychiatrists stand in a relationship of oppressor to survivors, however it mayappear or be made to appear, ultimately, neither structurally nor practically do psychiatricsurvivors have common cause with psychiatrists.

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References

Bhugra, D. (2015). To be or not to be a psychiatrist-what is the question? ActaPsychiatrica Scandinavica, 131, 4-5.

Bhugra, D. and Moran, P. (2014). The alienation of the alienist: Psychiatry on the ropes?Journal ofthe Royal Society ofMedicine, 107, 224-227.

Burstow, B. (2015). Psychiatry and the Business ofMadness: An ethical andepistemological accounting. New York: Palgrave Macmillan.

Gaebel, W. et al. (2015). Overcoming stigmatizing attitudes toward psychiatrists andpsychiatry. Acta Psychiatrica Scandinavica, 131, 5-6.

Hartley, L. P. (2015). The past is a foreign country: They do things differently there. ActaPsychiatrica Scandinavica, 131, 10-11.

Kapezinski and Passos (2015). Wet Minds, dry minds, and the future of psychiatry as ascience. Acta Psychiatrica Scandinavica, 131, 8-9.

Kristiansen et al. (2015). Future perspectives on psychiatry. Acta PsychiatricaScandinavica, 131, 8-9.

Munk-Jorgensen, P. and Christiansen, B. (2015). Psychiatry generating comparativerespect. Acta Psychiatrica Scandinavica, 131, 2-3.

Oxtoby, K (2008). Psychiatry in crisis. BMJ Careers(tt://arecrs.bnij.com/careers/advce/view-artic1e.html?id3 050).

Read, J. (2015). Saving psychiatry from itself. Acta Psychiatrica Scandinavica, 131, 11-12.

Stuart, H. et al. (2015). Images of psychiatry and psychiatrists. Acta PsychiatricaScandinavica, 131, 21-28.

Tesli, M. (2015). Acta Scandinavica—this issue. Acta Psychiatrica Scandinavica, 131, 1.

Wasserman, D. (2015). Some thoughts on how to improve the image of psychiatry. ActaPsychiatrica Scandinavica, 131, 13-14.

Whitaker, R. (2002). Mad in America. New York: Perseus Books.