Selective Pathologization: Critical Antipsychiatric Analyses of Diagnosis and Intervention in Historical and Contemporary Psychology.

by Eden Nimietz

Introduction

Psychiatric diagnoses cannot be divorced from the culture in which they preside, nor the systems they protect. The diagnostic and treatment processes are largely unsound, despite claiming to be objective. The same systems of power which control diagnostic discourse also control agendas that continue to punish and control marginalized groups such as the LGBT+ community, people of color, and those with psychiatric disabilities. The field of psychiatry seeks to preserve the status quo rather than treat supposed illness, which must be included in discussions within academia, medical practice, and in popular culture when determining a best path forward for the field and its clients. By examining the historical conditions of the field of psychiatry, we can develop a more holistically aware understanding of ‘psychiatric’ well-being which seeks to truly serve its clientele within the contextual framework of patients’ individual lived experiences.

Demons or disorders: On modern contexts within early treatment of psychiatric illness

Prior to the advent of modern psychological disciplines, clinicians attempted to understand qualities indicative of psychiatric illnesses and disorders as stemming from something wrong with the body or moral character of a person, including possession by spirits or a weak will. Disorders and proposed treatments which have all but vanished from Western, Global North psychiatric practices today were once commonplace in these same locations. Rudimentary understandings of psychiatric illnesses usually translated to diagnoses such as hysteria and various imbalances of the Four Humors. Physicians, who, though educated for the time, relied on treatments that we would now consider ineffective and perhaps even harmful. These individuals were usually the primary medical practitioners across communities (Public Broadcasting Service Online, 2012). This meant that diagnosis and treatment processes were understood according to often incorrect medical models if they were utilized at all. Techniques such as trepanation and bloodletting were effective at calming patients and disrupting symptom patterns in the moment; however, this was usually at the expense of the overall health of the individual and led to worsening of symptoms over time if the patient even survived the invasive procedure (Arani et al., 2012, PBS Online, 2012). Later treatments included forced isolation of the affected person via cruel and inhumane practices such as chaining them to walls and imprisonment alongside those deemed criminal by the state (PBS Online, 2012). Power and control have defined the medical model ever since. The imbalance of power between patient, public, and clinical practitioner continues to be grossly reinforced by the psychiatric system.

Psychiatric responses to the threat of an emerging LGBT+ community and resulting implications

The continued pathologization of gay, bisexual, and transgender individuals as disordered, immoral, and in need of correction has its roots in the very framework of psychiatric diagnosis. After WWII, efforts were made by the United States government to cover up instances of Post-Traumatic Stress Disorder and homosexuality in veterans via approximately 2,000 lobotomies (Minnesota Public Radio News, 2014). Not even fifty years ago, LGBT+ identities were pathologized and confined to the diagnosis of homosexuality, which was grouped with other so-called paraphilias, alongside modern-day diagnoses such as pedophilia (American Psychiatric Association, 1968). Unlike a diagnosis of homosexuality, however, pedophilia and similar paraphilias are, harmful to the affected person and those around them and are founded causes for concern. By declaring cisgender and heterosexual presentations as normal and associating LGBT+ orientations with the actions of legitimate predators, clinicians of the past could justify homophobic rhetoric and treatments such as conversion therapy in an apparent effort to ‘protect’ vulnerable children. Cisgender and heterosexual clinicians were seen as morally superior defenders against those with so-called sexual perversions, who were unable to function as normal members of society.

The established construct of innate normalcy and the resulting idea that deviation from the norm requires correction persists across today’s psychiatric diagnoses. Though LGBT+ people are no longer clinically pathologized for their identities (apart from the increasingly common ‘gender dysphoria’ diagnosis), popular culture still tends to view individuals belonging to the community as deviant from the norm. Some individuals believe these genders and sexualities are illnesses of the body and mind, and therefore must be corrected in any way possible. Others believe that LGBT+ people maliciously choose to reject the status quo to punish those around them. Employment of corrective methods such as conversion therapy seems appropriate to some, despite its use on minors being outlawed in twenty states and over 100 jurisdictions due to its pseudoscientific basis, elevated potential for severe mental harm to the client indicative of trauma, lack of efficacy, and incompatibility with both ethical and scientific principles (Shurka, 2021). Although conversion therapy is recognized as abuse, it is still widely practiced in other states.

Protests for gay and transgender rights beginning in the 1970s largely contributed to the removal of homosexuality from the second edition of the DSM (McCommon, 2006). Similarly, it was not until the publication of the fifth edition of the DSM in 2013 that transgender identities became less pathologized, with the substitution of terms like “transsexualism” and “gender identity disorder” for the newer, more popular term “gender dysphoria” (APA, 2013). Diagnostic criteria for inclusion of LGBT+ identities in the DSM was eventually discarded from professional clinical practice, but it once had a seemingly viable and scientific basis within psychiatry and was seen as immutable (Drescher, 2010). The shifting criteria for psychiatric diagnosis exhibited through examples such as the pathologizing of LGBT+ people exemplify how diagnoses and diagnostic entries in psychiatric literature such as the DSM are used to further the political and social agendas of those in power.

Psychiatric polarization of labels in defense of a capitalist framework

The shifting of diagnostic criteria and the shedding of old disorders in favor of newly proposed diagnoses are consistent with psychiatry’s role in upholding institutions of power under which individuals’ maladaptive traits thrive. Psychiatry is built on an unstable framework, but its faults have been overlooked by society at large as it adapts to the popular opinion of its time. Through establishing an ever-changing ‘gospel’ of what is considered psychiatrically disordered with every new edition of the DSM, those who reject the popular ideas of the time are deemed sick and in need of fixing even if their deviance has potential benefits which may be understood to propel social change and actions benefitting otherwise underrepresented voices.

Questions like, “Who controls what constitutes a valid diagnosis?” and “What image is being created about those who have been given these diagnoses?” are often brushed aside or condemned as conspiracy theories. The institution of popular psychology chooses which behaviors are disordered. This is seen in the argument as to whether dissociative identity disorder exists, whether so-called internet addictions exist, and whether or not PTSD and C-PTSD are natural behavioral responses in the face of great stress. In an individual context, psychiatric diagnoses are “scientifically meaningless” and therefore they must be decontextualized to be seen as valid (Allsopp et al., 2019).

Behaviors that are presently seen as disordered tend to be human responses to unprecedented stress, such as living under rapid industrialization and late-stage capitalism. By placing the responsibility of functioning correctly in a capitalist society on the individual and on their solitary struggle with mental health, rather than on the society which causes these difficulties, institutions of power enforce the status quo and effectively bar criticism of the field.

While people do speak out about the injustices the system enacts today—primarily against people of color, ‘psychiatrically disabled’ people, and those at the intersection of these two groups—antipsychiatry is an unpopular stance. In establishing itself as a legitimate and concrete science within capitalism despite its myriad of issues, psychiatry shields itself from everything but shallow criticism. Meaningful change cannot be achieved without condemnation of the economic system under which psychiatry posits itself as a legitimate savior: a tool to correct problems with productivity in a society ruled by capitalism.

Overdiagnosis of psychiatric disorders in people of color and its historical bases in pseudoscience

Schizophrenia and adjacent psychotic disorders are supposedly quite rare, yet they are commonly diagnosed in psychiatric patients of color, particularly Black people. Researchers discuss the issue of overdiagnosis stemming from medical racism: one study found that Black Americans are diagnosed with severe psychotic disorders at three to four times the rate of their white peers, and Latinos are diagnosed at approximately three times the rate (Schwartz & Blankenship, 2014). Other studies report similar findings. The shift in the definition and prognosis of diagnoses such as schizophrenia away from a vague affective label similar to intense depression and toward much harsher connotations of immorality, insanity, irredeemability, and violence is a racially charged deviation from established diagnostic framework. By labeling Black activists in the Civil Rights era as schizophrenics, government agencies were able to forcibly remove these activists from the front lines of protests and have a justification to perpetually institutionalize them. Whether or not the protests were violent in nature, the portrayal of Black protestors’ behavior as disordered led to both the association of Blackness with schizophrenia and the popular understanding of schizophrenia as a severe diagnosis consistent with violent, unhinged, and erratic behavior, as described in The Protest Psychosis (Metzl, 2011).

The punishment and control of Black people via weaponization of mental health diagnoses such as schizophrenia stems from the era of chattel slavery in the United States. In 1851, American psychiatrist Samuel A. Cartwright coined a diagnosis for enslaved Black people attempting to escape from those who enslaved them: drapetomania. This psychiatric diagnosis described the enslaved Black people who opposed their social conditions as being disordered and sickly because their desires contradicted social Darwinism and the so-called “natural order” of the Western racial hierarchy. Cartwright specifically described Black people who had escaped from plantation slavery as being unwell because, according to his theories, they should have been happy with their condition; this diagnostic framework was dependent on the Christian Bible for evidence supporting the justification of white supremacy. In this, the academic and popular spheres were not the distinct and separate categories of science and religion so often portrayed as rivals today, but rather, they worked in tandem to uphold white supremacy and preserve the status quo. While Carwright’s diagnostic proposal was widely ridiculed in literature in the North, Southern states frequently circulated articles written by him and the diagnosis remained included in the third edition of the once-popular text Practical Medical Dictionary as late as 1914 (Stedman, 1914).

Disparities in diagnoses and support across marginalized populations

Current diagnostic models in psychiatry still favor the mental health of white people, mainly cisgender white men, over people of color. Attention Deficit Hyperactivity Disorder and other developmental disorders are more frequently diagnosed in adolescent white males than in their peers of color. Much of the literature surrounding ADHD and adjacent disorders focuses on white boys; symptom presentation may differ in people of other genders and especially in children of color because of additional factors like trauma, systemic racism, and bias in healthcare. This discrepancy between symptom presentations contributes greatly to underdiagnosis and misdiagnosis (Nigg, 2021). Despite ADHD having the same prevalence across cultural groups (Nigg, 2020), youths of color with similar symptom sets are often misdiagnosed with conduct disorder or oppositional defiant disorder (Nigg, 2020), which are more stigmatized and weaponized. Diagnoses like these remove autonomy and opportunity from clients of color by restricting access to resources such as prescription medication and therapeutic intervention (Fadus et al., 2019). Psychiatrists who prefer to diagnose their white clients with more widely supported disorders like ADHD and autism and reserve CD and ODD for more severe cases of behavioral and emotional disturbances, yet readily diagnose their clients of color with the latter two disorders, have either not considered the nuances of neurodivergent symptom presentation across cultures or do not care to examine their own racial biases.

As Allsopp et al. (2019) describe, the DSM lists only one chapter of disorders in the full text as being indicative of trauma. This implies that other psychiatric disorders are not trauma responses and that adversities indicative of trauma, such as systemic racism, institutional ableism, and so on, bear little weight on the mental states of marginalized people. Furthermore, the behaviors of those who exhibit signs of trauma that warrant a diagnosis of PTSD or related difficulties are deemed inappropriate responses to severe and/or chronic adverse events. By labeling natural responses to great stress as disordered, clinicians blame their traumatized clients for the horrors enacted upon them. Depicting clients’ behavior as innately problematic when it is clearly borne of trauma is indicative of a system that puts on the pretense of caring for those affected by adverse events while simultaneously seeking to protect abusers.

Psychiatric abuse towards clients with schizophrenia, dissociative identity disorder, and similar “severely problematic” behavior is often dismissed by those outside psychiatrically disabled communities. Those with psychiatric disabilities may network with one another to determine which clinicians and practices are most trustworthy and safe, and therefore more worth the risks of disclosure, to avoid long-term institutionalization and medical abuse. Self-described “Mad” activists with social media presence have discussed the limitations of their advocacy as diagnosed psychotic people. Rose Parker and Mel Mallory, who respectively use the Instagram handles @psychosispsositivity and @acutepsychotic, describe the intersections between their lived experiences within mental health treatment and their professional experience in counseling and activism (Mallory, 2021, Parker, 2021). Parker describes the ways in which students with psychosis are discriminated against in higher education through formal rejection from psychology programs and mistreatment from peers and faculty (Parker, 2021).

Parker and Mallory also discuss the continued saneism faced by those with psychosis within the psychiatric and public spheres, and how antipsychotic medication is portrayed as a fix-all despite carrying an elevated risk of adverse side effects — a concern shared by others in the antipsychiatry movement, including former and current professionals within the field. Automatically medicating those who display clear signs of trauma or other serious mental health concerns with often powerful psychotropic drugs rather than turning to address structures which facilitate these “maladaptive” responses allows for the system to enforce compliance and order. The intersection of racism, ableism, and sexism within psychiatric care spheres creates a dichotomy in which psychiatrically and/or developmentally white cis men are frequently afforded the resources, accommodations, and understanding so often denied to those outside this population, especially those with multiple overlapping marginalizations such as racialization and gender through which they must navigate health systems and the world. The dichotomy resulting from the assignment of different diagnoses to members of different populations also allows for cis white men especially (but also white people as a whole) who may have the same instance of “impairments” central to a diagnosis, in terms of frequency and severity, to benefit from white supremacy in that they are afforded less severe and more accurate paper diagnoses than their peers of color by being white, which generally causes clinicians to provide more medically relevant and adequate supports instead of simply labeling them as automatically treatment-resistant (TR). The TR label is so often applied to psychiatric clients of color for the maladaptive patterns that are also found in white people, as seen with ODD/CD/ASPD/etc. with an unspoken assumption that the patient is inherently resistant to treatment due to their diagnosis, despite treatment resistance and noncompliance being an understandable and warranted reaction to misdiagnosis and repeated denial of the accommodations afforded to white individuals. Patients of color who are cautious about taking their prescribed medications or pursuing recommended therapies, which may be ineffective or irrelevant to their treatment goals in comparison to the classes of medications and other treatments prescribed to white patients, are further penalized for non-compliance and marked as distrusting and paranoid despite a wealth of evidence demonstrating there is not only a difference in levels of care, but types of care readily available to those who are marginalized on multiple axes of oppression.

Wealth over well-being: on the psychiatric medication industry

Medications like lithium and first-generation antipsychotics carry a risk of adverse effects such as tardive dyskinesia and poisoning; they were once used without regard to the willingness of the patient to take these medications, and their potential for negative effects was not adequately addressed or considered when prescribed and used (Davies, 2013). Today, the less risky second and third-generation antipsychotic medications are more commonly prescribed for psychosis, mood disorders, autism, and more, but the health risks associated with these medications remain inadequately considered by prescribing psychiatrists despite the continued elevated risk of such drugs. Potential adverse effects that stem from long-term antipsychotic use include akathisia, diabetes, seizures, low white blood cell count, hyperprolactinemia, the irreversible and progressive tardive dyskinesia, and more. Sedative-like atypical antipsychotic medications such as Abilify and Seroquel are frequently used off-label in nursing homes and hospice centers to control the behavior of elderly people affected by complex degenerative illnesses like dementia and Alzheimer’s despite the massive risks of serious side effects associated with such use, alongside the regular lack of patient consent for treatment with these drugs (Goodwin, 2014). These medications are often prescribed to foster children to control behavior deemed problematic as well, often without enactment of other less invasive and more appropriate interventions established prior to or instead of off-label prescription of antipsychotics (Lagnado, 2014). This both builds a reliance on these often-expensive medications prior to placement or aging out of foster care and allows for foster children to be further punished if they do not want to take the medication prescribed to them by branding them as “treatment non-compliant”.

Antidepressant medications like SSRIs are commonly said to work by correcting a “chemical imbalance” within the brain; however, this theory is unfounded and has been widely debunked by several experienced psychiatrists for close to ten years, if not longer (The Council for Evidence-based Psychiatry, 2014, Davies, 2013). Despite this, SSRIs efficiency is often viewed as an immutable fact (Davies, 2013). Antipsychotics are highly profitable, with over $18 billion in sales in 2011 alone, and that number is increasing yearly (Friedman, 2012). Marketing these medications as alternatives to fundamental social and economic change protects the wallets of clinicians while reinforcing capitalistic systems. The field of psychiatry has a vested interest in the income generated from harmful psychiatric interventions over more appropriate and holistic interventions which would serve as critiques of capitalist schools of thought, particularly those concerned with normalcy and productivity.

Incongruence in psychiatric methods across cultures

Western diagnostic systems are the most recognized in the world, but they are not and cannot be applicable to all cultures. When Western psychiatric diagnoses are assigned to non-Western groups, a culturally insensitive and oftentimes incorrect diagnosis (and prognosis) is formed due to the blanket application of Western values, power imbalances, and definitions of adverse life experiences onto non-Western lives. Additionally, many uniquely non-Western disorders are seen as being culture-bound, but the reverse is not necessarily held true in global psychiatric practice (Paniagua, 2013). While disorders such as Amok and Susto were/are considered culture-bound disorders informed by popular psychosocial ideas within their respective cultures until the latest edition of the DSM (and still understood as such by many clinicians even though this category is now absent from the DSM-V), this statement is not quite so readily applied to Western psychiatric disorders despite the extremely capitalist, hierarchical society most Western cultures are defined by.

Psychiatric diagnoses exist according to the temporal and spatial location of that diagnosis; not every diagnosis stays consistent in its denotation, connotation, or existence across time. Furthermore, not every diagnosis is valid outside of the culture and specific regions it exists in during times of popularity as a legitimate diagnosis (Paniagua, 2013). Some regions which practice religious ancestor-worship, for example, may treat those dealing with what would be considered schizophrenia in the West with higher regard and status (Pescosolido et al., 2015). One theory regarding the origins of schizophrenia as maladaptive and disordered proposes that psychotic symptoms manifested in ancient cultures to fill a spiritual niche upon which community could be built (McClenon, 2012). Similarly, what the West calls “disordered” and “erratic” may still prove useful in cultures which value traditional forms of spirituality, and which may also invest more in community care for those considered psychiatrically disabled in Western society. For this reason, medical diagnoses which are labeled as severe and in need of correction in capitalist societies may not formally exist in the same manner, intensity, or frequency in non-Western cultures.

In addition, psychiatry is inconsistent in the formalization of diagnoses across different cultures; culture-bound disorders such as the depression-like symptom cluster called brain fag in Ethiopia or the aforementioned disorders Amok and Susto may be pathologized as legitimate issues within popular ideas of their respective cultures, but are not given the same stigmatization as in Western cultures (Paniagua, 2013). Within the discipline, professional opinions on the standards for diagnostic processes for instances such as these remain largely divided (Ola et al., 2009). The instability of psychiatric diagnoses is exhibited through this division and polarization. Incongruency with diagnostics is extremely common across Western practices as well. The DSM is imprecise and subjective; it is constantly revised, as the current standard is the fifth edition. If a patient visits five different psychiatric doctors with the same symptom presentation, they may be diagnosed with different disorders based on their doctors’ educations, personal and professional experiences, biases, and other factors. Diagnosis therefore can function as a tool through which the enforcement of oppression is normalized.

Conclusion

Psychiatry has historic bases in faulty, unfounded practice. The present-day discipline remains a tool under which systems of oppression are reinforced. Some clinicians, however, are resisting its potential for egregious abuses and opting for a more holistic, nuanced view of individual clients’ needs. Johnstone (2017) proposes an alternative to psychiatric diagnosis called psychological formulation, a process that considers intersecting environmental and biological factors which may predispose a client to certain behaviors and perpetuate maladaptive coping mechanisms. Current anti-psychiatric stances, particularly those best articulated by seasoned prison abolitionists, discuss psychiatric institutions as extensions of the exploitative and abusive criminal justice system in the United States due to parallel structures of domination and violence, as well as their common partnership with one another (Mensah & Kaufman-Mthimkhulu, 2020). Angela Davis reports in her 2003 book Are Prisons Obsolete? that more people with mental and emotional disorders are incarcerated in prisons than institutionalized in mental health facilities (p. 108); fifteen years later, three of the largest psychiatric facilities in the US are jails (Roth, 2018). Commonly, those with psychiatric diagnoses who are subjects of criminal investigations have their diagnosis weaponized against them to support a guilty verdict and harsher punishments. In the rare instance that an insanity plea is successful, the individual is placed in a long-term psychiatric facility, usually permanently. These facilities tend to be state-run with underfunded programming and rampant abuse. The egregious abuse that incarcerated people become victims of in attempting to navigate the system which binds them only contributes to more harsh and lengthy sentences, retraumatization, and recidivism as documented again and again, with the most recent studies published in the summer of this year. The prison system and wider systems of institutionalization contribute heavily to the new onset or worsening of disorders like schizophrenia, PTSD, bipolar disorders, and more; they actively traumatize inmates and patients, cause relapses and otherwise preventable suicides, and punish those who resist rather than providing tangible and adequate resources vital to bettering the lives of these individuals and the lives of those around them, as alternative community-based justice proposes.

Numerous survivors of psychiatric abuse describe how the system has perpetuated and reinforced an array of trauma responses rather than helping psychiatric patients achieve a better quality of life (Simonson, 2019). Abuses of power increase the mental health difficulties of communities, particularly marginalized communities, by keeping individuals dependent on flawed models of intervention. Psychology professionals like community psychologists who do research alongside marginalized populations and who are mindful of the distinctions between each group have the potential to be more successful in developing an intervention process for problematic behaviors. These psychologists must listen to the community they intend to support rather than wielding power against them. It is necessary for clinicians to be aware of the power imbalances and potential for abuse they carry by working for and within a white supremacist and capitalist institution. It is vital for those same practitioners to approach their clients with mindful, informed, and beneficial treatment considerations for their individual mental health concerns while simultaneously attempting to correct the systemic issues which contribute to poor mental health. Practitioners should continue to educate themselves on issues of equity and justice while working alongside clients. These practitioners will then be able to better advocate for their clients and fundamentally transform their practices to effectively support individuals seeking professional care.

By Eden Ori (they/them). Eden is a multiply disabled interdisciplinary artist currently residing on ancestral Piscataway Conoy & Susquehannock lands. Eden graduated from the University of Maryland Baltimore County in 2022. Presently, they hold a B.A. in psychology and a minor in music, though they intend to pursue graduate studies in community psychology in the coming year. They have research interests in disability justice, chronic illness, and food sovereignty, among other subjects. In their free time, Eden writes, weaves, and takes care of their plants and pets. They are passionate about herpetological conservation, education, and husbandry and they have a membership with the Philadelphia Herpetological society. Eden is constantly exploring a variety of topics including Mad studies, performance arts, herbalism, foraging, and sustainability efforts within communities..