L'antipsichiatria vista da uno psichiatra americano

 da currentpsychiatry (via Doppiamente)

L'antipsichiatria vista da uno psichiatra americano

Notare la sciatteria e le falsità a buon mercato di questo personaggio quando parla di Basaglia

The antipsychiatry movement: Who and why

Although irritating, antipsychiatry helps keep us honest and rigorous about what we do

Henry A. Nasrallah, MD 

Psychiatry is the only medical specialty with a longtime nemesis; it’s called “antipsychiatry,” and it has been active for almost 2 centuries. Although psychiatry has evolved into a major scientific and medical discipline, the century-old primitive stage of psychiatric treatments instigated an antagonism toward psychiatry that persists to the present day.

A recent flurry of books critical of psychiatry is evidence of how the antipsychiatry movement is being propagated by journalists and critics whose views of psychiatry are unflattering despite the abundance of scientific advances that are gradually elucidating the causes and treatments of serious mental disorders.

What are the “wrongdoings” of psychiatry that generate the long-standing protests and assaults? The original “sin” of psychiatry appears to be locking up and “abusing” mentally ill patients in asylums, which 2 centuries ago was considered a humane advance to save seriously disabled patients from homelessness, persecution, neglect, victimization, or imprisonment. The deteriorating conditions of “lunatic” asylums in the 19^th and 20^th centuries were blamed on psychiatry, not the poor funding of such institutions in an era of almost complete ignorance about the medical basis of mental illness. Other perceived misdeeds of psychiatry include:

• Medicalizing madness (contradicting the archaic notion that psychosis is a type of behavior, not an illness)
• Drastic measures to control severe mental illness in the pre-pharmacotherapy era, including excessive use of electroconvulsive therapy (ECT), performing lobotomies, or resecting various body parts
• Use of physical and/or chemical restraints for violent or actively suicidal patients
• Serious or intolerable side effects of some antipsychotic medications
• Labeling slaves’ healthy desire to escape from their masters in the 19^th century as an illness (“drapetomania”)
• Regarding psychoanalysis as unscientific and even harmful
• Labeling homosexuality as a mental disorder until American Psychiatric Association members voted it out of DSM-II in 1973
• The arbitrariness of psychiatric diagnoses based on committee-consensus criteria rather than valid and objective scientific evidence and the lack of biomarkers (this is a legitimate complaint but many physiological tests are being developed)
• Psychoactive drugs allegedly are used to control children (antipsychiatry tends to minimize the existence of serious mental illness among children, although childhood physical diseases are readily accepted)
• Psychiatry is a pseudoscience that pathologizes normal variations of human behaviors, thoughts, or emotions
• Psychiatrists are complicit with drug companies and employ drugs of dubious efficacy (eg, antidepressants) or safety (eg, antipsychotics).

Most of the above reasons are exaggerations or attributed to psychiatry during an era of primitive understanding of psychiatric brain disorders. Harmful interventions such as frontal lobotomy—for which its neurosurgeon inventor received the 1949 Nobel Prize in Medicine—were a product of a desperate time when no effective and safe treatments were available. Although regarded as an effective treatment for mood disorders, ECT certainly was abused many decades ago when it was used (without anesthesia) in patients who were unlikely to benefit from it.

David Cooper¹ coined the term “antipsychiatry” in 1967. Years before him, Michel Foucault propagated a paradigm shift that regarded delusions not as madness or illness, but as a behavioral variant or an “anomaly of judgment.”² That antimedicalization movement was supported by the First Church of Christ, Scientist, the legal system, and even the then-new specialty of neurology, plus social workers and “reformers” who criticized mental hospitals for failing to conduct scientific investigations.³

Formerly institutionalized patients such as Clifford Beers⁴ demanded improvements in shabby state hospital conditions more than a century ago and generated antipsychiatry sentiments in other formerly institutionalized persons. Such antipathy was exacerbated by bizarre psychiatrists such as Henry Cotton at Trenton State Hospital in New Jersey, who advocated that removing various body parts (killing or disfiguring patients) improved mental health.⁵

Other ardent antipsychiatrists included French playwright and former asylum patient Antonin Artaud in the 1920s and psychoanalysts Jacques Lacan and Erich Fromm, who authored antipsychiatry writings from a “secular-humanistic” viewpoint. ECT use in the 1930s and frontal leucotomy in the 1940s understandably intensified fear toward psychiatric therapies. When antipsychotic medications were discovered in the 1950s (eventually helping to shut down most asylums), these medications’ neurologic side effects (dystonia, akathisia, parkinsonism, and tardive dyskinesia) prompted another outcry by antipsychiatry groups, although there was no better alternative to control psychosis.

In the 1950s, a right-wing antipsychiatry movement regarded psychiatry as “subversive, left-wing, anti-American, and communist” because it deprived individuals of their rights. Psychologist Hans Eysenck rejected psychiatric medical approaches in favor of errors in learning as a cause of mental illness (as if learning is not a neurobiologic event).

The 1960s witnessed a surge of antipsychiatry activities by various groups, including prominent psychiatrists such as R.D. Laing, Theodore Lidz, and Silvano Arieti, all of whom argued that psychosis is “understandable” as a method of coping with a “sick society” or due to “schizophrenogenic parents” who inflict damage on their offspring. Thomas Szasz is a prominent psychiatrist who proclaimed mental illness is a myth.⁶ I recall shuddering when he spoke at the University of Rochester during my residency, declaring schizophrenia a myth when I had admitted 3 patients with severe, disabling psychosis earlier that day. I summoned the chutzpah to tell him that in my experience haloperidol surely reduced the symptoms of the so-called “myth”! Szasz collaborated with the Church of Scientology to form the Citizens Commission on Human Rights. Interestingly, Christian Scientists and some fundamental Protestants³ agreed with Szasz’s contention that insanity is a moral, not a medical, issue.

A major impact of the antipsychiatry movement is evident in Italy due to the efforts of Franco Basaglia, an influential “psychiatrist-reformer.” Basaglia was so outraged with the dilapidated and prison-like conditions of mental institutions that he convinced the Italian Parliament to pass a law in 1978⁷ that abruptly dismantled and closed all mental hospitals in Italy. Because of uncontrolled psychosis or mania, many patients who were released ended up in prisons, which had similar or worse repressive conditions as the dismantled asylums. Many chronically hospitalized patients died because of self-neglect or victimization within a few months of their abrupt discharge.

Finally, the antipsychiatry movement aggressively criticizes the pharmaceutical industry’s research, tactics, and influence on psychiatry. Also included in the attacks are academic psychiatrists who conduct FDA clinical trials for new drugs and educate practitioners about the efficacy/safety and indications of new FDA-approved drugs. Although industry research grants are deposited at the investigators’ universities, critics mistakenly assume these psychiatrists personally benefit. The content of all educational programs about psychiatric drugs is strictly restricted to the FDA-approved product label, but critics assume that expert speakers, who are compensated for their time and effort, are promoting the drug rather than educating practitioners about the efficacy, safety, tolerability, and proper use of new medications. Part of the motive for attacking this collaboration is the tenet held by many in the antipsychiatry movement that medications are ineffective, unnecessary, or even dangerous. I wish antipsychiatrists would spend a week on an acute psychiatric unit to witness the need for and benefit from psychotropic medications for psychotic, manic, or depressed patients. Although psychiatric patients experience side effects, they are no worse than those experienced by cancer, arthritis, or diabetes patients.

The antipsychiatry movement is regarded by some as “intellectual halitosis” and by others as a thorn in the side of mainstream psychiatry; most believe that many of its claims are unfair exaggerations based on events and primitive conditions of more than a century ago. However, although irritating and often unfair, antipsychiatry helps keep us honest and rigorous about what we do, motivating us to relentlessly seek better diagnostic models and treatment paradigms. Psychiatry is far more scientific today than it was a century ago, but misperceptions about psychiatry continue to be driven by abuses of the past. The best antidote for antipsychiatry allegations is a combination of personal integrity, scientific progress, and sound evidence-based clinical care.

References

1. Cooper DG. Psychiatry and antipsychiatry.London, United Kingdom: Tavistock Publications; 1967.
2. Rabinow P, ed. Psychiatric power. In: Foucault M. Ethics, subjectivity, and truth.New York, NY: The New Press; 1997.
3. Dain N. Critics and dissenters: reflection on “anti-psychiatry” in the United States. J Hist Behav Sci. 1989; 25(1):3–25.
4. Beers CW. A mind that found itself.Pittsburgh, PA: University of Pittsburgh Press; 1981.
5. Freckelton I. Madhouse: a tragic tale of megalomania and modern medicine (Book review). Psychiatry, Psychology, and Law. 2005;12:435–438.
6. Szasz T. The myth of mental illness. American Psychologist. 1960;15:113–118.
7. Palermo GB. The 1978 Italian mental health law—a personal evaluation: a review. J R Soc Med. 1991;84(2):99–102.