Why Psychiatry is Outdated

Psychiatry’s roots in paternalism: why the field has not kept up with contemporary thinking, an article by Juli Lawrence of ect.org:

At its core, the field of medicine has always been paternalistic: doctor knows best. Even the Hippocratic Oath included a line that encouraged physicians to perpetuate the imbalance of power between doctor and patient: “I will prescribe regimen for the good of my patients according to my ability and my judgment.”

But while patients’ rights activists have provoked change in this power struggle, the field of psychiatry maintains roots deeply planted in paternalism and patriarchy. This imbalance of power is evident in the privacy of the doctor’s office, among colleagues, in hospitals, and even in the courtroom.

The very nature of psychiatry seeks to modify emotions and behavior, whether through therapy, medications, electroshock and other methods, and the doctor-
patient relationship revolves around a paternalistic imbalance of power. Psychiatrists label their patients as compliant or noncompliant to characterize whether or not the psychiatrist’s power has been accepted.

The doctrine of informed consent theoretically gives a patient information about a treatment, and the right to refuse treatment for any reason. But the doctrine hinges on the patient’s competence, and in psychiatry, the concept of competence is often used to reassert the psychiatrist’s power.

In many states, a person’s competence can be decided by the views of one psychiatrist. Some states require a second opinion, though it’s rare that in a simple competency hearing one doctor will disagree with another. In the court system, psychiatrists are given even more power and it would take a unique judge to listen to a patient - particularly a psychiatric patient - over a doctor.

Consider a case of forced electroshock involving an elderly woman in St. Louis, Missouri in August, 2000.

Kathleen Garrett was a woman in her 60s, recently widowed and undergoing treatment for breast cancer, as well as enduring a recent estrangement from one of her sons. Most women in such circumstances would find themselves with feelings of grief, if not downright depressed. Mrs. Garrett, with a lifelong history of episodic depression, did become depressed. Her psychiatrist adjusted her medications, but the depression remained. He then told her she needed to have electroconvulsive therapy, or electroshock. Mrs. Garrett refused, and immediately transformed into a “noncompliant patient.”

Instead of spending time discussing other options or why she didn’t want electroshock, her psychiatrist rushed into court, told the judge that he knew best, and that Mrs. Garrett was not competent to make such a decision. He didn’t mention that until the moment she said no, he considered her competent to make the decision.

Mrs. Garrett had very little time to put together a legal defense, and her Social Security income limited her access to an experienced attorney. The judge quickly ruled against her, ordering the doctor to begin electroshock treatments against her will. Mrs. Garrett would have been just another silent victim of the abuse of psychiatric power, but a loud and angry e-mail campaign against the doctor and hospital focused negative attention on her plight, and she was released from the hospital before completing the full series of treatments against her will.

Psychiatric patients often find themselves labeled noncompliant if they dare to speak back to their doctors, challenge his authority, or even ask questions. If a prescribed treatment, such as medication, is unsuccessful, the patient is again labeled noncompliant, with the psychiatrist just assuming that the patient has not followed directions. Psychiatric patients are at a distinct disadvantage because of the psychiatrists’ ability to use force to maintain the power structure.

Certainly “noncompliance” is a term used in other medical specialties, and doctors complain that patients with high blood pressure, diabetes, and other diseases sometimes do not take medications as directed. However, despite a potential life-threatening outcome, a person with high blood pressure won’t find herself plunged into a courtroom drama to force compliance. A woman with diabetes who skips an insulin injection, or decides she’s tired of the routine, will not open her door to a nurse with a hypodermic in hand.

Psychiatric patients often face scenarios like this once they threaten a psychiatrist’s power, and states are enacting laws making it easier to force “compliance,” such as Illinois SB0198, currently undergoing Senate review. As it went through the Rules Committee, the proposed bill has had its language changed from “cause serious harm to self or others” to “engage in dangerous conduct.” Past experience has shown that dangerous conduct could be anything from eating unhealthy foods to disagreeing with a psychiatrists’ order to take medications despite having caused dangerous side effects in the patient’s past. Or dangerous conduct, more often, would simply be a “noncompliant patient.”

A mental health rights activist once said that if someone prepares a buffet of delicious, healthy food, people will come. But if that buffet serves food that makes people feel sick, they won’t return. It is an excellent analogy, and one that needs attention in the world of psychiatry. Too often, patients who tell their psychiatrists that the medications make them feel worse than their original symptoms made them feel are quickly tossed into the basket of “noncompliant patients.” The atmosphere quickly shifts from the psychiatrist’s comfortable balance of “Doctor says, patient obeys,” to one of “I am the expert, you must do as I say.” It can easily disintegrate into the psychiatrist labeling the patient incompetent, because she did not submit to his power and authority.

Experienced patients quickly learn they have a choice: they can submit and follow orders, or they can play “the game.” Most psychiatric patients fully understand that the game involves pretending to do exactly as ordered, and to put on an air of gratefulness. Unfortunately, this also means that the patient no longer confides in the psychiatrist with regard to symptoms, and their emotional disorders may grow worse. Alternately, the symptoms may abate on their own, as is common with psychiatric disorders. In the end, the doctor proclaims his methods are successful, he asserts his superiority, and the power game goes on. But under the surface of cooperative relationship, the truth reveals a relationship based on distrust and deception.

Psychiatrist Sally Satel, author of “PC, M.D.: How Political Correctness Is Corrupting Medicine,” has written extensively about the need to maintain the status quo of doctor over patient. Her writings reveal her anger that women are trying to take control of their healthcare, particularly with regard to mental healthcare.

“But it is wrongheaded to confuse the need to know more - an imperative that will always be with us - with the unwarranted and poisonous notion that women are somehow second-class subjects in the world of medicine,” she writes.

She chastises health activists for interfering with “effective diagnosis and doctoring.”

Psychiatric patients are fighting back, however.

A growing movement of patients and ex-patients is demanding change in the system, and asking that patients be given a long-overdue voice and control of their healthcare choices. Not surprisingly, activists are not generally well-
received by psychiatrists. But psychiatrists still have their secret weapon, and it’s a weapon that the general public accepts without question: the issue of competence. To discredit an activist’s words, simply declare she is suffering from mental illness, and doesn’t know what’s best. Reassert psychiatry’s authority, and you have an effective method of discrediting just about anything.

The courts buy into it, because psychiatry has been given special status in the court system. The public buys into it, because they don’t have the experience to understand how paternalistic psychiatry is. And of course the medical industry buys into it because paternalism fits in with their views to “help” anyone who needs help, even when the help is intrusive, inappropriate and unwanted. The doctor knows best.

Psychiatry has a long way to go in moving into modern times. Psychiatrists want so badly to be taken seriously as medical doctors and legitimate scientists, but until they confront a history that is full of abuses, and a method that continues today to abuse authority, psychiatry will remain mired in an atmosphere of paternalism, controversy and resentment.