Tuesday, July 9, 2013

We’re All Mad Here

In the early 1970’s, eight people checked themselves into psychiatric hospitals throughout the United States, complaining of hearing voices. They were all admitted, and during their hospitalizations exhibited no unusual behavior and claimed to no longer be experiencing auditory hallucinations. After stays between 7 and 52 days in the institutions, the patients were discharged and given diagnoses of either schizophrenia or bipolar disorder. None of these people had any mental illnesses, and had, in fact, falsified their symptoms as part of an experiment conducted by psychologist David Rosenhan (who was himself one of the “pseudopatients”).

The results of the study were published in a 1973 paper in Science titled “On being sane in insane places”. In the paper Rosenhan argues that it is difficult to distinguish between “normality” and “abnormality” when it comes to mental health, and that, once applied, the label of a psychiatric diagnosis can be so strong that all of an individual’s actions are viewed in light of that label, especially in a place like a psychiatric hospital where patients are assumed to be “insane”. The study was seen as an eye-opening commentary on the American mental health system and also criticized for its methodology and conclusions.1,2


The founders of The Icarus Project believe that, just like Icarus' wings, "madness" can lift people to great heights but also send them falling to their doom.
Thirty years later, the study is still cited in debates about the science and ethics of psychiatric diagnoses and treatments, often by those critical of the field. One interesting and controversial voice active in this debate is the mad pride movement.3 In my previous post, I discussed the neurodiversity movement’s views on autism. Mad pride (which has recently been discussed on this blog) takes a similar approach to issues of mental health. Like neurodiversity (and most movements and ideologies in general) mad pride encompasses a wide variety of beliefs and causes, but the primary one is to give a voice to people living with mental illness (although some in the movement dislike that term 4) in the hopes of educating the public, creating patient-run communities and support networks, and pushing for reform in mental health systems.

Psychiatric Survivor Pride Day (considered one of the first mad pride events) took place in Toronto, Canada in 1993, and was organized, in part, in response to housing discrimination against former psychiatric patients.5 The goal was to combat the stereotypes and stigma faced by current and former consumers (a neutral term commonly used by mad pride activists) of mental health services and to celebrate their contributions to culture and society. The way in which mental illness is viewed by the public (which has been explored previously on this blog) remains a key focus of the mad pride movement.

Another focus of the movement is to create communities (through, for example, group meetings and online forums and blogs) where people with various mental health issues can discuss their experiences for both educational and therapeutic reasons. Two notable examples of such communities are The Icarus Project and the National Empowerment Center. The creators of these communities believe that talking with others who have had similar experiences and being able to describe their own unique situations (which are more complex and specific than the broad diagnostic labels applied to them) are good ways for people to improve their mental health, especially if they feel marginalized and misunderstood in their day-to-day lives. 


Many mad pride organizations also advocate for changes in the field of psychiatry and the mental health system. Just as they fight for a voice in society, they fight for a voice in their treatment, arguing that, like the Rosenhan study seemed to show, those diagnosed with mental illnesses are often patronized and not taken seriously by doctors and therapists when, in fact, they need to be heard both out of respect for them as people and because it is beneficial to their treatment.

Advocating for giving patients a greater voice also extends to supporting self-determination and choice when it comes to psychiatric treatment. Mad pride and patient advocacy groups, like the Law Project for Psychiatric Rights and MindFreedom International, campaign against involuntary treatment and involuntary institutionalization, seeing these actions as human rights violations. Some take this argument further, casting suspicion on mainstream psychiatry and arguing that the medical model of mental health is not the only legitimate approach. To them, conditions labeled as psychiatric disorders (particularly mood disorders like depression and bipolar disorder) might in fact be extreme forms of the non-pathological emotions and mental states we all experience and which, while they can be unpleasant and even dangerous, can be controlled and managed in ways other than medication or traditional psychotherapy. While they do not oppose the use of psychiatric drugs by those who choose to do so, their rejection of what they see as a healthy/sick duality leads them to also support the freedom to reject treatment or to explore alternative therapies.6 

A MindFreedom protest against the American Psychiatric Association
These critiques of psychiatric treatment (both compulsory and otherwise) and the support for non-traditional therapies are where the controversy lies. I am personally very uneasy with the concept of involuntary institutionalization; ideally all medical treatments should be purely consensual. But when a person’s thoughts are possibly compromised, the concepts of self-determination and autonomy obviously get murkier, especially when the debilitating nature of some of these disorders and the risk of suicide is taken into account.

Many of the outspoken critics of psychiatry in the mad pride movement are current or former psychiatric patients whose opinions were formed through their own experiences with involuntary treatment and abuses in the system. But many of them were patients in the 1960s and 70s (or earlier)7 when the state of the field was much different than it is now. Involuntary commitments were more common and harmful and painful procedures were performed (like insulin shock therapy and electroconvulsive therapy done without anesthesia) that are no longer used.8 I know that these activists are aware of such changes in psychiatry and most likely are more familiar with the current state of the mental health system than most people, but in making their arguments they sometimes seem to present it as it was decades ago.

The rejection of the medical model among some mad pride advocates enters into anti-psychiatry (a different, but related movement that opposes the foundations and activities of the medical field of psychiatry), blurring the lines between the two movements. The opponents of psychiatry claim that there is not enough evidence to support purely biological models of mental illness and the use of psychiatric drugs.While the effectiveness of such drugs and the accuracy of such models are being questioned in the medical and scientific communities9,10 (including the controversy surrounding the newly released DSM-511), anti-psychiatry takes those criticisms further and is (not surprisingly) denounced by psychiatrists.12 And those who are skeptical of psychiatric medication don’t apply the same standards to their own claims since there is even less evidence to support the alternative therapies they advocate. Though the alternatives usually include diet, exercise, meditation and social support, which are supported by medical professionals, just not as replacements for psychiatric help.  


Is the serotonin hypothesis of depression correct?
In addition, the rejection of the medical model of mental illness might actually put some mad pride activists at odds with other mental health activists. Mad pride advocates dislike portraying psychiatric conditions as illnesses or diseases because they think that it increases the stigma around them, making people see those diagnosed with such conditions as diseased and abnormal. But some mental health professionals and patients encourage the medical view of mental health, hoping that it will reduce stigma because such disorders will seen as medical conditions (just like physical illnesses) rather than character flaws or moral failings on the part of the patient (for example, seeing a depressed person as being lazy) or their families (believing that all mental health problems are the result of an abusive household).13,14

Still, the most visible and active elements of the mad pride movement are working for the rights of those diagnosed with mental illnesses both in society and in the psychiatric systems. Reducing stigma and giving patients a greater voice in their treatment will only improve the current state of psychiatry, and should be accepted by everyone, no matter where they stand in this debate. Whether you see those with psychiatric conditions as people who are sick and need help or as people whose emotions and mental states are more extreme than usual, they are still people who deserve the same rights and respect as everyone else.

References
1. Spitzer, Robert L. On pseudoscience in science, logic in remission, and psychiatric diagnosis: A critique of Rosenhan's "On being sane in insane places". Journal of Abnormal Psychology, 1975, 84(5): 442-452.
2.  “Rosenhan Experiment,” the Psychology Wiki.
3. Gabrielle Glaser. ‘Mad Pride’ Fights a Stigma. The New York Times, 2008.
4. David Oaks. Let’s stop saying ‘Mental Illness”! MindFreedom International.
5. Consumer/Survivor Information Resource Centre of Toronto. July 15, 2008 bulletin.
6.  David Davis. Losing the Mind. Los Angeles Times, 2003.
7. MindFreedom International: Personal Stories.
8. Eisenberg, L. and Guttmacher, L. B. Were we all asleep at the switch? A personal reminiscence of psychiatry from 1940 to 2010. Acta Psychiatrica Scandinavica, 2010, 122: 89–102.
9. Lacasse JR, Leo J.  Serotonin and Depression: A Disconnect between the Advertisements and the Scientific Literature. PLoS Med, 2005, 2(12): e392.
10. Moncrieff J, Cohen D. Do Antidepressants Cure or Create Abnormal Brain States? PLoS Med, 2006, 3(7): e240.
11. Thomas Insel. Director’s Blog: Transforming Diagnosis.
12. Nasrallah, Henry. The antipsychiatry movement: Who and Why. Current Psychiatry, 2011, 10(12).
13. “Overcoming The Stigma of Depression.” Healing From Depression.
14. Jennifer Welsh. Blood Test may Reduce Stigma of Depression. Live Science, 2012.


Want to cite this post?
Queen, J. (2013). We’re All Mad Here. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2013/07/were-all-mad-here.html.

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