Chapter 6 Open to abuse Controversies in psychiatric practice

   

  The very nature of psychiatric practice lays it open to potential misuse and abuse. It involves a highly unequal power relationship with very dependent and vulnerable patients whose opinions and complaints can so easily be dismissed as ‘part of the illness’. Add to this the subjective nature of a diagnostic process which relies on psychiatrists’ assessments of the patient’s motives and mental state with no visible markers for diseases. The history of psychiatry doesn’t inspire that much confidence either. There have been shameful episodes of political abuse, some hare-brained theories, and treatments that appear to us both dangerous and barbaric. The very visibility of modern-day psychiatry (out from behind the institutions’ walls), plus a well informed public and a willingness to admit if things go wrong, is probably the greatest safeguard against such abuses. Psychiatry is also, thankfully, fully engaged in the worldwide movement of scientific, evidence-based medicine – facts and figures take precedence over authority and opinion. So while we focus in this chapter on what it can get wrong, let’s not forget that it more often gets it right and that progress has been substantial.

  In the public imagination the greatest risk of psychiatric abuse comes from its immense power. The evil psychiatrist is portrayed in films manipulating the minds of his victim for his own ends, taking pleasure in subjugating the distressed and suggestible. Hannibal Lecter in Silence of the Lambs is one such – immensely skilled at reading his victim’s mind and using that power to trap and exploit them. In other films psychiatrists develop megalomaniacal delusions of using their power to rule the world.

  There have been cases where this has happened on a small scale–where psychiatrists, convinced of their own infallibility, have wreaked havoc. Experiments with altering gender identity to confirm that it was socially determined is an extreme example, the mutilation of hundreds of individuals in a craze to remove sources of infection in teeth and bowels that were deemed the cause of mental illness and the wholesale use of lobotomy in the 1940s and early 1950s are others. However most of psychiatry’s excesses have stemmed from the very opposite, from psychiatrists’ sense of impotence and frustration turning to ever more desperate interventions to help tormented patients.

  This dynamic is changing. Professions are no longer so powerful and independent. Deference and respect for authority are under global attack. The current risks in psychiatric practice may come less from professional isolation and arrogance than from social compliance. Monitoring psychiatrists may be only half of the job – we need to keep a wary eye on the other powerful players (multinational drug companies, governments, pressure groups) who can manipulate psychiatry. This is a diffuse and changing subject so what follows is just indicative.