Modern psychiatry has given us a new way to think of ourselves, and in this short, fascinating book, The Medicalization of Psychiatric Suffering, Fernando Ferreira Pinto de Freitas and Paulo Amarante make the case that it gives us an impoverished sense of self. They detail too how psychiatry's current paradigm of care is built upon “falsehoods.” They close with a look at promising alternative therapies, and as such, their book makes a strong case for fundamentally rethinking psychiatric care.
While The Medicalization of Psychiatric Suffering can be described as a new addition to the growing international library of “critical psychiatry” books, it is notable that, in this instance, both of the authors have positions of leadership within the mental health establishment. This gives their critique of “biological” psychiatry an extra punch and legitimacy.
Paulo Amarante, a psychiatrist, is well known for his decades of work reforming psychiatric care in Brazil. In the late 1980s, after having studied with Franco Basaglia and other Italian psychiatrists who developed community care in that county, he championed and wrote the mental health legislation that led to deinstitutionalizion in Brazil. Today he is honorary president of the Brazilian Association of Mental Health, and a professor and researcher at the Oswaldo Cruz Foundation (Fiocruz), which is attached to the Brazilian Ministry of Health.
Fernando Freitas, a psychologist, was a director of the Brazilian Association of Mental Health, and, like Amarante, a professor and researcher at Fiocruz.
The beauty of their book begins to become apparent in the first chapter, as they provide a larger philosophical context for understanding what modern biological psychiatry has wrought. They write of the “medicalization” of modern life, and the consequences that has for us as individuals. This is a phenomenon that arose in the aftermath of World War II, and while medical advances – such as the discovery of antibiotics – helped tame many illnesses, the growth of the medical industry encouraged the modern citizen to view the self through a medical lens of “what is wrong with me.” That is particularly true in psychiatry.
In this way, Freitas and Amarante remind readers what is at stake. Medicalization can become a means social control, with the individual encouraged to adopt the “sick role,” which leads to a loss of individual autonomy. We are encouraged to think that it is “abnormal” to suffer, or to experience pain in our lives, when, of course, as any reading of literature will remind us, that to suffer is to be human.
When it comes to the medicalization of our emotional lives, this has been fostered by an “unholy alliance”– as the authors point out – between academic psychiatry and the pharmaceutical industry that formed in the United States in the 1980s. The pharmaceutical companies hired psychiatrists from prestigious U.S. medical schools to serve as their consultants, advisors, and speakers, and together this alliance told the public a narrative of great scientific advance. Researchers had discovered that mental disorders were “brain diseases” caused by “chemical imbalances” in the brain, which could then be fixed by a new generation of psychiatric drugs. With his narrative being peddled to the public, the consumption of psychiatric drugs in the United States exploded, and soon this “unholy alliance” exported this narrative to Brazil and other developed countries around the world.
Freitas and Amarante provide a succinct deconstruction of that narrative, starting with the existential crisis that ultimately prompted the American Psychiatric Association to adopt its “disease model” narrative. In the United States, as was true in many other countries, psychiatrists in the 1960s were often not seen as “real doctors.” Then, in the early 1970s, Stanford University psychologist David Rosenhan published a study that publicly humiliated the profession.
Rosenhan and seven other “normal” volunteers presented themselves at psychiatric hospitals, claiming that they heard a voice that said “hollow” or some other simple word. All were admitted and diagnosed as “schizophrenic,” and even though they behaved normally once in the hospital, none of the hospital staff – including the psychiatrists – identified them as imposters. In contrast, the other patients in the hospital did recognize them as such. It seemed that the “mad” in the hospital were much more discerning than the professionals.
This humiliation – and other societal challenges to its legitimacy – prompted the American Psychiatric Association to redo its Diagnostic and Statistical Manual. The profession needed to present psychiatrists to the public as “real doctors,” and in 1980, it published DSM III, which it touted as a great scientific advance, for this was now a manual of real “diseases” and “disorders” that could be reliably diagnosed. But as Freitas and Amarante write, the DSM – which became global psychiatry's “Bible” – is not grounded in science. The diagnoses are “constructs” with symptom criteria arbitrarily set; thirty-five years of research has failed to validate any of them as discrete diseases.
With DSM III in hand, American psychiatry then peddled the notion that depression, anxiety, psychosis, and other mental disorders were due to chemical imbalances in the brain. This narrative told of brain illnesses that could be successfully treated with drugs. But as the authors explain, the chemical hypothesis could be said to have been put to rest in 1996, when Stephen Hyman, director of the National Institute of Mental Health in the United States, wrote a paper on how psychiatric drugs “perturb” normal brain function, rather than correct a chemical imbalance. Psychiatric medications, Freitas and Amarante correctly explain, cause your “brain to function abnormally.”
In this way, Freitas and Amarante deconstruct the “myth” of modern psychiatry step by step. Next, they review the outcomes literature for antispychotics and antidepressants. This section might seem particularly surprising to lay readers. A close look at the research reveals that the drugs do not provide a particularly pronounced benefit over placebo even in the short term, and that over the long term, patients off medication – and this is true even for those diagnosed with schiozophrenia – have better outcomes.
So what is to be done? If Brazil and other societies have organized their care around a false narrative, what new ways can be found for helping those who struggle with their minds? In their closing chapter, Freitas and Amarante describe a way forward. They discuss various therapeutic programs, past and present, that have focused on providing psychosocial care while making limited – or no – use of medications, that have proven quite successful. In particular, they tell of the “Open Dialogue” approach employed in northern Finland, which has produced remarkably good long-term results for people diagnosed with psychotic disorders.
In sum, the two authors envision a new paradigm of care, one that would “provide psychiatric care” outside the asylum and not create chronic patients. In other words, they envision a paradigm of care that would help people who struggle with their mind to truly recover and get on with their lives.
Publication Dates
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Publication in this collection
05 Jan 2017 -
Date of issue
Jan-Apr 2017
