Antipsychiatry as an Analogue of Populism
Populism can be a powerful force, but it tends to be neither self-critical nor self-correcting
For background, see:
In the epilogue of the 2020 book about the history of Georgia’s state mental asylum located in Milledgeville, “Administrations of Lunacy,” Mab Segrest asks the question, “How does a culture that justified slavery, and Jim Crow, and Muscogee and Cherokee removal decide who is and is not sane?”1
This question has stayed with me and serves as a powerful reminder of the value-laden nature of judgments of pathology. Institutions such as medicine and psychology are shaped by and serve as instruments of the societies in which they exist.2 Regardless of what medicine aspires to in theory, its practice is enmeshed in the values of the broader society. We could very well ask today what sort of psychiatry exists in a country with one of the highest incarceration rates in the world, deep-rooted structural racism, homelessness, for-profit healthcare, direct-to-consumer pharmaceutical advertising, neoliberal scarcity, rampant inequality, restricted reproductive rights, political polarization, and gun violence.
I have realized over time, however, that we can ask this sort of question about the phenomenon of “antipsychiatry” as well. What sort of critique of psychiatry as a medical specialty will a culture with the MAGA movement, anti-vaccine movement, pseudoscientific “wellness” industry, COVID denialism, transphobia, QAnon, and Pizzagate produce? How does a culture that embraces “misinformation,” “alternative facts,” and “fake news” decide what is or is not a legitimate clinical and scientific discipline?
In the context of such an inquiry, it appears to me that some commonplace strands of the movement against psychiatry can be analyzed as analogues of “populism,” relying on an anti-establishment sentiment that juxtaposes the people vs the elite. I am using a superficial and crude understanding of populism here that is bound not to survive rigorous scholarly inquiry! Consequently, its application to the phenomenon of antipsychiatry is crude as well. Nonetheless, the idea of populism, vague and flexible as it is, seems useful enough as a starting point to characterize certain aspects of the antipsychiatry movement. I should also note here that populism as a political phenomenon is not by itself good or bad, although the connotations are often negative. Populism also comes in both left-wing and right-wing flavors – think Bernie Sanders and Donald Trump. We may similarly wonder about two different flavors of populist critiques of psychiatry. I’m revealing my political biases here, but the strands of psychiatric critique I’m talking about in this post are very much of the US right-wing, MAGA, and Fox News variety. (On a preliminary note, I’d put some strands of disability justice, neurodiversity, and related movements as belonging to the other populist flavor of psychiatric critique, but very little of what I say below applies to them.)
This table is my attempt at sketching out the similarities (click on the image to expand). I’m also posting the text of the table in bullet form in case the image is difficult to read for some readers.
Populism: Anti-establishment sentiment in politics
Antipsychiatry: Anti-establishment sentiment in medicine/psychiatry
Populism: “the people” vs “the elite”
Antipsychiatry: “the people” vs the psychiatric “elite”
Populism: The “elite” are presented as homogenous, corrupt, and self-serving
Antipsychiatry: The psychiatric profession is presented as homogenous, corrupt, and self-serving
Populism: The “elite” collude with the corporations
Antipsychiatry: Psychiatrists collude with Big Pharma
Populism: Led by charismatic figures who present themselves as the voice of the people
Antipsychiatry: Led by charismatic figures who present themselves as representing the real interests of the mentally ill and protecting the ordinary folks from medicalization
Populism: Demagogic politicians present overly simplistic answers to complex questions in a highly emotional manner
Antipsychiatry: Demagogic intellectuals present overly simplistic answers to complex questions in a highly emotional manner
Populism: Wealthy, powerful politicians present themselves as being on the side of the poor man and condemn academics and journalists etc. as the “elite”
Antipsychiatry: Non-clinical academics and private-practice clinicians (working with low risk, wealthy clients) condemn psychiatrists working in public sector as corrupt agents of the establishment
Populism: Vulnerable to conspiracy theories (Pizzagate, QAnon, Stop the Steal, etc.)
Antipsychiatry: Vulnerable to conspiracy theories (mental illness denialism, psychiatric medications are making you mentally ill, etc.)
Some caveats.
What I say above is somewhat of a caricature, but like many caricatures, it captures something true in an exaggerated form. I didn’t quite see this analogy between populism and antipsychiatry until I became active on Twitter a few years ago and got to observe what popular conversations were like outside my academic and clinical bubble. (Twitter is a place where seemingly intelligent people get to say outrageous things.)
The political establishment and the psychiatric establishment have many, many faults. There are good reasons for discontent and criticism! I want to fully acknowledge that.
The use of “antipsychiatry” as a pejorative label is a very psychiatry-centric judgment. The judgment is of some value to psychiatrists, but critics have no obligation to think of themselves through the lens of antipsychiatry or to accept that characterization.
I mentioned “misinformation” above. Dan Williams writes in an excellent twitter thread [edited for clarity]: “… researchers point out that even true information can be highly misleading if it is selective, stripped of context, etc. For example, explicitly partisan news outlets very rarely just fabricate things; instead, they cherry-pick, spin, frame, insinuate, and so on. However, it's difficult to see how research on misinformation, so understood, could ever be viewed as a legitimate science by a broad, diverse public. Partly this is because misleading content is pervasive, including within social science and misinformation research itself. And partly it’s because establishing what is misleading involves complex judgement calls shaped by pre-existing beliefs, values, and biases, and there is little reason to think the judgements of misinformation researchers here are much more reliable than anyone else's. To think this doesn't make one a postmodernist, or someone who thinks that Infowars is just as reliable as the BBC. Truth exists. There are better and worse ways of finding out about it. Some perspectives on reality are more reliable than, and hence superior to, others. All you have to believe is that the truth about complex issues is not self-evident; that human beings are biased and fallible; and that extremely homogeneous communities like modern misinformation researchers are subject to all sorts of epistemic pathologies.”
I am fallible with my own biases and epistemic limitations. While this doesn’t invalidate what I’ve said above, I want to be clear that it’s not entirely an objective, disinterested take.
What distinguishes “antipsychiatry” in the contemporary landscape of psychiatric critique? If I am not using “antipsychiatry” in a historical or a neutral philosophical sense (see The “Antipsychiatry” Dilemma), and if I am using the term with negative connotations, my own personal judgments are based on consideration of the following factors:
A commitment to Szaszian ideas about the non-reality of mental illness (“the myth of mental illness”)
Moralizing attitudes towards psychiatric medications (“the myth of the chemical cure”)
Hostility towards the psychiatric profession
Use of rhetoric
Someone who checks all four of these criteria—antipsychiatry par excellence!—is Philip Hickey, a blogger for Mad in America. Consider the following passage from a 2017 piece:
“Psychiatry could certainly pursue some reforms. They could sever their corrupt ties to pharma. They could stop publishing spurious, self-serving research. They could start getting honest about the adverse effects of their so-called treatments… But psychiatry can’t turn non-illnesses into illnesses. Once psychiatrists begin to acknowledge the illness falsehood — which is the underpinning of their entire structure — then their very reason for existing evaporates. As the mental illness hoax becomes increasingly exposed, it becomes commensurately clear that the psychiatric “treatment” of these non-illnesses is nothing more than drug-pushing, differing in no essential respect from the street corner variety. What psychiatrists provide is a temporary, chemically-induced feeling of comfort, control, docility, etc., at the expense of long-term damage. No psychiatric drug corrects any biological/neurological malfunction. In fact, the reverse is the case: all these drugs produce their effects by distorting, and in many cases, permanently damaging, normal functions.”
On the note of populism, here’s something Peter Zachar wrote in a commentary for Philosophy, Psychiatry, & Psychology in 2012:
“The suggestion that we all are in possession of a truth higher than the ‘derivative’ truths of the sciences is problematic because it sets up the classical ‘person-in-the street’ versus ‘overly educated egghead’ dichotomy, with the rhetorical dice being loaded in favor of the lived world of ‘real people.’ Thomas, Bracken, and Timimi are fond of the politics–science analogy, so let me give voice to my worry by following their lead. In the United States’ 2008 presidential election, one of the campaigns constructed a character named Joe the Plumber—an aspiring small businessperson who the head of the ticket suggested would be one of his economic advisors. The problem some people had with this was that ‘Joe’ had neither training in economics nor a background in government. Such populism can be powerful force in politics, but it tends to be neither self-critical nor self-correcting, and rarely builds on past achievements.3 Joe’s concerns about tax policy were politically relevant, but having concerns did not justify granting him professional authority. As in politics, we should be skeptical of the kind of epistemological populism that would make patient values and preferences into a Joe the Psychiatrist. One does not have to approve of its current state to accept that in the past 150 years psychiatry has been self-critical enough to have learned some things. I doubt that ole’ Joe would be better for society.”
Post-publication clarification:
Antipsychiatry is such a broad, fuzzy, heterogeneous phenomenon that I don’t think any single characterization is sufficient. So my view is not that antipsychiatry = populism, but that there are aspects of antipsychiatry that can be understood through that lens. That is compatible with experiences of harm being a primary source of antipsychiatric sentiment, as pointed out by Kara Slagell, or with the fact that many aspects of the phenomenon can be characterized as libertarian (a less pejorative label, with which many would self-identify), as pointed out by Thomas Reilly.
Segrest answers: “It does so flagrantly, mindless of its own contradictions. Power does not have to justify itself; its violence is its justification even as it erases its tracks in official records and buries its bodies in the woods.”
Medicine, psychiatry, and psychology are indeed instruments of social control, but they are not merely instruments of social control. A vital difference.
The subtitle for this post comes from the quote by Zachar.
I wrote that speakers had an average of 5 ties, not that every speaker had 5 ties. If Nemeroff spoke, he alone would skew the whole sample, given his galaxy wide ties to drug companies. Then again, Forbes magazine called him the most influential psychiatrist in America, which underscores the reach of the drug companies.
On a deeper level, you point out that populism does not engage in self-critique and self-reflection. I agree that there are simplistic and even vituperative tones in critiques of psychiatry. However, the profession will forever be vulnerable to them until it fully and publicly acknowledges the titanic role that corporations play in shaping it.
If history is a guide, that will not happen in my lifetime. It was only after the death of all the German psychiatrists who set up gas chambers in psychiatric hospitals, that German psychiatry finally started acknowledging its' role in the Holocaust. Eugenics was finally discredited, and that terrible virus of an idea (which was propagated by psychologists as well) was finally stopped.
But WWII had an end-date. Industry influence does not, as Johnson and Johnson's dreadful studies of esketamine and political machination to get it approved carry on to this day. I respect that you admit psychiatry has multiple flaws. But I fear that like Sisyphus, your efforts to change the profession will roll back on you as you push upward against a mountain of corporate dollars.
When each speaker at APA 2008 had financial ties with an average of 5 different drug companies, it is not a populist belief that psychiatry colludes with Big Pharma. It is an indisputable fact. The vast majority of the research is funded by Pharma, the expert guidelines are written by people with fCOI, the DSM is written by many people with fCOI, the CME is dominated by drug companies, etc. Until psychiatry grapples with that reality, and makes profound changes, everything it says and does will be viewed through that lens.