DSM-5: Caught between Mental Illness Stigma and Anti-Psychiatry Prejudice
Like many psychiatrists, I have been amazed by the debates surrounding the DSM-5, the first major revision of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders in nearly twenty years, which was just released. Never before has a thick medical text of diagnostic nomenclature been the subject of so much attention. Although I was heartened to see more and more people discussing the real-world issues and challenges--for patients, families, clinicians and caregivers-within mental health care, for which the book offers an up-to-the-minute diagnostic GPS, I was also alarmed at the harsh criticism of the field of psychiatry and the APA. Consequently, I believe that as you read and watch this increased coverage, it's important to understand the difference between thoughtful, legitimate debate, and the inevitable outcry from a small group of critics --made louder by social media and support from dubious sources --who have relentlessly sought to undermine the credibility of psychiatric medicine and question the validity of mental illness.. DSM-5 has ignited a broad dialogue on mental illness and opened up a conversation about the state of psychiatry and mental healthcare in this country. Critiques have ranged in focus from the inclusion of specific disorders in DSM-5, to the concern over a lack of biological measures which define them. Some have even questioned the entire diagnostic system, urging us to look with an eye focused on the impact to patients. These are the kinds of debate that I hope will continue long after DSM-5's shiny cover becomes warn and wrinkled. Such meaningful discourse only fuels our ability to produce a manual that best serves those touched by mental illness. But there's another type of critique that does not contribute to this goal. These are the groups who are actually proud to identify themselves as "anti-psychiatry." These are real people who don't want to improve mental healthcare, unlike the dozens of psychiatrists, psychologists, social workers and patient advocates who have labored for years to revise the DSM, rigorously and responsibly. Instead, they are against the diagnosis and treatment of mental illnesses--which improves, and in some cases saves, millions of lives every year--and "against" the very idea of psychiatry, and its practices of psychotherapy and psychopharmacology. They are, to my mind, misguided and misleading ideologues and self-promoters who are spreading scientific anarchy. Being "against" psychiatry strikes me as no different than being "against" cardiology or orthopedics or gynecology--which most people, I think, would find absurd. No other medical specialty is targeted by such an "anti" movement. This relatively small "anti-psychiatry" movement fuels the much larger segment of the world that is prejudiced against people with disorders of the brain and mind and the professions that treat them. Like most prejudice, this one is largely based on ignorance or fear-no different than racism, or society's initial reactions to illnesses from leprosy to AIDS. And many people made uncomfortable by mental illness and psychiatry, don't recognize their feelings as prejudice. But that is what they are. We have, as a nation, aggressively taken on racism, sexism, homophobia and other prejudices. Perhaps the occasion of this new DSM revision (and in the aftermath of the passage of the Mental Health and Addiction Parity Act) is the right time to grapple with the prejudice against mental illness and its caretakers--which every day makes it a little harder for people suffering from mental illnesses to live their lives, and makes it harder for those of us who treat mental illnesses to do our jobs. I do understand how anti-psychiatry ideas first developed and why they have been so difficult to combat. There is historical fear of mental illness, stemming from when these diseases were viewed first as demonic possessions and later as character or moral defects, before we had any scientific understanding for the biological basis of, say, schizophrenia, bipolar disorder, autism or Alzheimer's disease. The brain is a complex organ, slow to reveal its secrets, and the effort to understand its myriad functions goes to the core of each individual's self-identity. Patients are challenged by the intimate aspects of their relationship with any doctor--a caregiver for whom you have to disrobe, and who pokes and pries. But in psychiatric treatment you "disrobe" in an even more profound way, revealing yourself psychologically. And I do not overlook the checkered history of psychiatry itself. It's a relatively new discipline which branched from neurology in the 19th century, whose early practitioners were alienists and analysts, superintendents of asylums and Freudian therapists. But, at the time, asylums were little more than humane warehouses, and Freudian theory turned out to be a brilliant fiction about personality and behavior. When psychiatry did make its first forays into medical treatment, it used crude instruments like strait jackets, cold packs, fever induction, insulin shock therapy and psycho-surgery. The underlying theories for the causes of these illnesses at the time were also wrong; it was largely about blaming the parents. However, that was then and now is now. The scientific foundation of psychiatric medicine has grown by leaps and bounds in the last fifty years. The emergence of psychopharmacology, neuroimaging, molecular genetics and biology, and the disciplines of neuroscience and cognitive psychology have launched our field into the mainstream of medicine and on a course for future growth and success. Though not everyone, including ourselves, is satisfied with the rate of our field's progress, no one can argue with one simple fact; if you or a loved one suffers from a mental illness, your ability to receive effective treatment, recover and lead a productive life is better now than ever in human history. Moreover, we have every reason to believe that there will continue to be unprecedented scientific progress, which will enhance our clinical capacity and benefit our patients. For this reason, I am especially shocked when other clinicians--psychologists, social workers, even, in some cases, primary care docs who would rather just dispense psychiatric meds themselves--side with anti-psychiatry forces without realizing these people are "against" them, too. These strange anti-mental health bedfellows include a series of contemporary psychiatrists and psychologists who have fashioned platforms for self-promotion from their critical positions on psychiatry and DSM-5. But, when it comes to medical illness, the "enemy of your enemy" is not always your friend. For all the overt anti-psychiatry we see out there, I'm also concerned about the more subtle forms of prejudice among less radicalized segments of our society. Only recently, I was at a meeting of medical school leadership at my university, where we discussed how to counsel medical students about choosing which specialty to pursue. One senior faculty member quipped "tell all students who get low scores on their board exams not to worry, they just need to change their career plans and go into psychiatry." A few months later, the same faculty member called me late one night, asking if I would see his wife, who was having a "psychiatric problem." The urgency of his request belied any awareness that the joke he made at psychiatry's expense in that meeting undermined our ability to deliver the kind of quality care that his wife now needed. But it can, and it does. Image: American Psychiatric Association
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