Mainstream psychiatry has a long history of overpromising and underdelivering. Insulin coma therapy, psychosurgery, deinstitutionalization, psychoanalysis, and biological psychiatry are just some of the major thrusts which provided modest benefits to some while imposing widespread costs to patients and families. It’s been a struggle for the field to acknowledge this truth to itself and to those who’ve suffered as a result.
None of that is news to the critical psychiatry movement, of which MIA is a prominent component. Critical psychiatry’s members have been documenting personal stories of harms caused by mainstream psychiatry. Some see glimmers of hope in mainstream psychiatry, such as more careful decision-making around medications, increased efforts to be collaborative rather than authoritarian, and a retreat from reducing human suffering to neurotransmitters. Still, there’s a long way to go.
Critical psychiatry should continue to point out where mainstream psychiatry falls short, but it’s primarily mainstream psychiatry’s responsibility to correct itself. It’s reasonable to wonder why this is taking so long to do. I believe one major reason is that mainstream psychiatry is beset by groupthink.
Groupthink happens when conformity is too highly valued and overrides alternative views. This can happen in any group. Mainstream psychiatry is no exception. A group tells itself it has a firm grip on truth, and denies or rationalizes any information contradicting that supposed truth. It tends to minimize or negate any opposing views both from outside and—more importantly—within the group. Those with such views are either shouted down or otherwise discouraged from speaking up, and often feel intimidated and censor themselves. The need for conformity often makes the group feel morally superior. The upshot is that discussion is narrow and stifled, leading to bad decisions.
Some examples of this in history include the Bay of Pigs fiasco and the flop that was New Coke. What about mainstream psychiatry? There is a long list of ideas that mainstream psychiatry has created or adopted that it holds to be virtually unchallengeable. Many of these are so ingrained in how mainstream psychiatry is taught and practiced that it can border on sacrilege to question them. These ideas have a rigidity to them that both inhibits dissent and is often harmful to patients. Mainstream psychiatry groupthink causes it to double-down on approaches that have yielded little, wasted time and money, and shut out better ways of understanding people.
Not all psychiatrists think this way, but there are those who have felt inhibited in speaking up within the mainstream psychiatry world out of fear. Psychiatrists, like members of any group, are not monolithic in their beliefs, and more than a few have challenged the status quo.
Mainstream psychiatry ideas include, among others, the beliefs that (a) DSM entities are reliably diagnosed and reflect some brain dysfunction (even if it can’t be identified, (b) that mental suffering equals illness, (c) the benefits of psychiatric drugs usually outweigh the downsides (d) psychiatric research will surely (eventually) reveal some brain abnormalities (e) psychiatrists are the best qualified to help those with mental distress (f) psychiatrists successfully resist pressures from pharmaceutical companies, from drug-to-consumer advertising, and from others who provide mental health treatments.
Again, this is not meant to be a complete list, but these are tightly-held beliefs of mainstream psychiatry, and mainstream psychiatry resists having them scrutinized from without and, as I’m stressing here, from within.
And, predictably, mainstream psychiatry groupthink leads it to ignore what critical psychiatry has to say as well.
Groupthink is a danger for any group, and mainstream psychiatry needs to do a lot more to counter its version. It can do so by seeking out opposing or challenging views within mainstream psychiatry in its organizations’ meetings, journals and other forums. It can speak with much greater humility about what mainstream psychiatry knows and doesn’t know. It can acknowledge that the ideas I identified earlier are unproven without saying they are useless. It can acknowledge that the biological approach has crowded out social, familial, spiritual, religious, environmental, and economic factors in considering what leads to mental distress. It can be more explicitly open to critical psychiatry in a collaborative, non-patronizing way, rather than seeing critical psychiatry only as an annoyance. Leaders of psychiatric organizations have a special duty to counter groupthink.
I believe that if mainstream psychiatry were to read what I just wrote, they would likely say that they certainly agree, that they are open, that they do invite non-mainstream views, and that, perhaps, they could do more. And then I’d ask them why they think the public’s view is different from theirs.
Similar to how mainstream psychiatry often views critical psychiatry as having little merit and can’t or doesn’t “understand the full picture,” it’s also true that some within the critical psychiatry world see mainstream psychiatry as without merit, harmful, evil, greedy, and acting with no scientific or other basis for what it does. Both mainstream psychiatry and critical psychiatry are missing possible chances to find some common ground. I think excessive group loyalty tends to make it harder to find.
I’ve outlined some features of groupthink within mainstream psychiatry. Critical psychiatry is not immune, either. Although there’s no way to measure which group’s groupthink is more problematic, fairness calls for critical psychiatry to look inward if we’re going to demand that of mainstream psychiatry. Groupthink within critical psychiatry takes various forms. How powerful these forces are is open to debate, but to say they’re nonexistent would be akin to saying they don’t occur in mainstream psychiatry.
Critical psychiatry is composed in large part of those who’ve been badly hurt by mainstream psychiatry, naturally seeking support and validation. This can make it harder to see any good in mainstream psychiatry and can lead to absolute judgments about mainstream psychiatry, such as “medication is always bad,” “no diagnosis has any validity,” or “all psychiatrists are manipulated by drug companies.” It’s not that there’s no truth to this, but critical psychiatry groupthink tends to miss shades of gray in its view of mainstream psychiatry. Nuance is minimized and can be seen as disloyalty to critical psychiatry. Within critical psychiatry, there are those who have found mainstream psychiatry helpful, but it can be hard to say so when the central narrative is that mainstream psychiatry needs to be upended.
This essay is neither about fault-finding nor whether mainstream psychiatry or critical psychiatry is more hampered by groupthink. It’s about how groupthink in both gets in the way of doing right by people. Groupthink just happens and gets worse if you don’t look for it.
When it comes to concern for people in distress, mainstream psychiatry and critical psychiatry are in the same lifeboat. Neither has the full picture. Both are partially right. Both should correct each other’s excesses without invalidating everything the other believes. Research and personal stories don’t contradict each other. Science doesn’t have all the answers, but it has some. Ethics is not the sole purview of medicine.
It may be idealistic to think that mainstream psychiatry and critical psychiatry can help each other out, but groupthink can make each side want to shoot a hole in the other’s side of that lifeboat. It may feel good to shoot the other side down, but a short-term victory is not what’s needed.
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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.