November 15, 2023
Source: Encyclopedia
Photo Source: Unsplash,
During the holidays it behooves us to remember how such abuses can find their way into our homes during the holidays and how abuses are typically built on lies and sinister motives.
Abuse of psychiatry conjures up a situation in which a psychiatrist acts improperly, causing a patient to experience some sort of harm. The concept is more complex than it appears to be at first sight. This article examines psychiatric abuse in an effort to determine its accurate meaning so that steps can be taken to eliminate or prevent it.
Historical Background Evidence has emerged of such practices as the abuse of psychiatry for political purposes in the former Soviet Union (Bloch and Reddaway, 1977, 1984), a similar pattern in Cuba designed to suppress political dissent (Brown and Lago), the deployment of psychiatric knowledge in torture and interrogation in Northern Ireland in 1971 (Bloch, 1990), and pursuit of financial profit as a priority in Japanese private psychiatric hospitals (Harding). The tragic perversion of psychiatry during the Nazi era, in which tens of thousands of chronic psychiatric and mentally retarded patients were gassed to death, and similar numbers were sterilized, is the most gross instance of abuse (Burleigh; Müller-Hill).
Commentary on psychiatric abuse has also referred to its prevalence elsewhere particularly in the United States and South Africa. But, as will become evident in the section on definition, care must be taken to distinguish between intentional misapplication of psychiatric knowledge, skills, and technology and inadequate or negligent practice.
In the South African case, the policy of apartheid involved massive inequity in the provision of mental health services, with blacks allocated substantially lesser resources compared with whites despite equivalent need. On the other hand, the allegation of the misuse of psychiatry to squelch black political activism never had any basis (Bloch, 1984).
In the United States, discriminatory practices have also occurred but due to economic rather than explicitly political forces. With millions of Americans unable to afford health insurance and inadequate budgets for public psychiatric services, the result has been substandard care in state mental hospitals, particularly for minority groups and the poor (frequently the same population) (Green and Bloch; Torrey).
The abuse of psychiatry for political or other purposes in the United States has been sporadic, the examples of the poet Ezra Pound (1885–1972) and General Edwin Walker (1909–1993) being especially well known. In the case of Pound, psychiatry was recruited to deal with a politically sensitive situation. A celebrated poet, indicted for treason following his pro-Axis broadcasts in Italy during World War II, Pound faced possible execution.
Although the evidence was equivocal, Pound was judged incompetent to stand trial on grounds of insanity and transferred to St. Elizabeth's Psychiatric Hospital where he spent the next thirteen years. The indictment was later dismissed and Pound released. Whether psychiatry was misused to extricate the U.S. government from a quandary or Pound was deluded and this accounted for his wartime behavior remains a baffling issue. Suffice to say, the case demonstrates the vulnerability of psychiatry to political exploitation. Similar factors prevailed in the case of Edwin Walker, a decorated major general in the American army who adopted an extreme right-wing position during the civil rights campaigns of the 1950s and the 1960s. His competence became a matter of dispute after he had been charged with offenses related to his activism. Although declared competent to stand trial (the case was later dismissed for technical reasons), the possibility of the government's recourse to psychiatry to deal more conveniently with a troublemaker cannot be ruled out (Stone). A final comment in this brief historical context concerns criticism of psychiatry for its patronizing attitude toward women. The dramatic case of Mrs. E. P. W. Packard in 1860 illustrates how prejudice may undermine clinical judgment. Upon the insistence of her husband, a fundamentalist clergyman, that she harbored dangerous religious beliefs, Mrs. Packard was committed to a mental hospital, where she remained confined for three years. Upon her release, she launched a campaign against the expression of opinions as a basis for psychiatric detention (Musto). Over a century later in 1972, Phyllis Chesler was among the first to argue that psychiatry's view of women was so distorted as to impair its objectivity. Other feminist perspectives followed (e.g., Showalter; Luepnitz). According to this view, a male-dominated profession too readily regards women not conforming to stereotypic roles as psychologically suspect, even disturbed. Freud's contribution to gender psychology has no doubt been influential in the maintenance of such attitudes. Definitions Psychiatric abuse can be defined according to specified criteria and differentiated from other undesirable activities, which are best termed malpractice. Abuse refers to the intentional, improper application of the knowledge, skills, and technology of psychiatry for a purpose other than serving the patient's interests or to harm, in diverse ways, people who do not warrant psychiatric status in the first instance. Abuse is invariably perpetrated by psychiatrists (and other mental health professionals) in collaboration with other persons or agencies, such as a state security service or political authority and, then, usually as part of a totalitarian system. Such institutional abuse is always unethical in that the protagonist intentionally carries out an act in the knowledge that the act is intrinsically wrong (whether or not it turns out to harm), explicitly violating professional ethics. A psychiatrist who acts in this way, claiming that he is obliged to follow the orders of superiors and in that sense is heteronymous, is inexcusably rejecting a responsibility to ensure that regulations serve good, not bad, professional goals. In these circumstances, even if psychiatrists covertly seek to ameliorate the welfare of the patient, claiming that this is the sole means to maintain an ethical stance, their behavior, by virtue of colluding in an abusive practice, becomes an inherent part of the abuse. Reference to institutional abuse, on which this article focuses, does not negate the possibility of individual psychiatrists abusing one or more of their own patients. A similar ethical violation takes place in both cases, psychiatrists in the latter exploiting patients to meet their personal needs on the pretext that the practice applied is clinically indicated. A clear-cut example is sexual involvement, but other forms of abuse of power intrinsic to the psychiatrist–patient relationship, such as financial and religious, are relevant here. This sort of abuse may mar any doctor–patient relationship, but the not uncommon situation in psychiatric treatment of an excessively vulnerable patient seeking comfort from an ostensibly all-caring professional is arguably more conducive to its occurrence than in other medical spheres.
Abuse can also be perpetrated by a psychiatrist in conjunction with, or acceding to, attempts by lay people to exploit the discipline for nonmedical purposes. Consider this example: A husband who knows that his wife is not mentally ill, but is determined to gain custody over their children in an impending legal tussle, persuades a psychiatrist to commit her to a mental hospital. His interests are other than the welfare of his wife; he desires to wield power over her for his own purposes and recruits the psychiatrist as an accessory (Robitscher). Malpractice is distinguishable from abuse with respect to intent. Although the term is used in diverse ways, an alternative remains elusive; inadequate practice comes closest in meaning. A psychiatrist who does not set out to use knowledge, skills, or technology improperly but who deploys these in an unskilled fashion is engaging in malpractice. An example is prescribing psychotropic drugs for patients upon the request of nursing staff, who claim they are otherwise unable to manage "difficult behavior," in cases where patients do not need such medication. Psychiatrists do not pervert their science in these circumstances but fail to adhere to a standard of practice that requires the application of drugs only when clinically indicated. Malpractice should be differentiated from "errors in clinical judgment" when that judgment has been made in good faith. Psychiatrists, like any other professionals, are prone to err on occasion. Although the consequences may simulate the effects of malpractice, malpractice is not actually carried out.
The Vulnerability of Psychiatry to Abuse Abuse is more common in psychiatry than elsewhere in medicine, probably because it is inherently more vulnerable to it in at least three respects: (1) its boundaries remain illdefined; (2) diagnosis is often made in the absence of objective criteria; and (3) the psychiatrist is granted immense power by society to determine the fate of other people, even to the extent of detaining them in hospital or imposing treatment on them. The lack of a well-demarcated conceptual boundary in psychiatry leads to a correspondingly ill-defined role for its practitioners. Debate has long continued among psychiatrists themselves, and in the wider community, as to what constitutes their legitimate role (Dyer). Attitudes vary considerably, even to the point of contradiction. The following views, expressed by former presidents of the American Psychiatric Association, reflect this diversity. In 1969 Ewald Busse argued for a limited role whereby psychiatrists restrict their focus to the suffering patient, and services are accordingly confined to reducing pain and discomfort. In 1970 his colleague Raymond Waggoner had a much wider perspective, calling upon the profession to pursue "fundamental social goals," and for psychiatrists to be visionaries.
Definitions of health and ill health are pertinent to the above positions. Thus, a visionary outlook brings psychiatrists into the domain of social policy. Their potential participation in a context beyond hospital and clinic is boundless, leading to professional judgements, ostensibly derived from expertise, on social issues like unemployment, racism, poverty, torture, religious cults, child-rearing practices, sexual expression, and indigenous rights. Psychiatrists may assume roles, including those of social commentator, political activist and lobbyist, that extend well beyond the traditional role of clinician. Whatever the role adopted, psychiatrists are buffeted by the demands of multiple loyalties. They are caught ineluctably between responsibilities to patients and to society, the latter potentially including, among others, a patient's family, an employer, the courts, prison officials, and military authorities. In these circumstances they have to weigh the interests of patients against those of social agencies. In so doing, they may be subject to such intense pressure as to subordinate themselves to social forces, and so neglect their obligation to patients.
Psychiatry's role is more clear-cut when limited to an exclusively medical function. But this depends on the psychiatrist's ability to conduct diagnostic assessments that are relatively objective and value-free—for example, in the case of a person with a brain disorder like Alzheimer's Disease. This brings us to the second feature of psychiatry that contributes to its vulnerability to abuse, lack of objective criteria in clinical evaluation.
Although psychiatry has evolved as a scientific discipline for over a century and a half, including progress in classification, the discipline still faces the key question of what constitutes mental illness (Fulford, 1989). No satisfactory criteria exist to define precisely many of the conditions with which psychiatry deals. Compared with those in other medical fields, many currently used psychiatric diagnoses derive from clinical observation alone, and lack identifiable pathophysiological correlates. Objective tests to confirm the presence of a psychiatric condition are rare. Moreover, in the diagnostic task psychiatrists rely in uncomfortably large measure on social criteria and value judgments. As the British sociologist Kathleen Jones reminds us, society would not be able to determine what was normal if it failed to designate certain acts and certain people as abnormal or antisocial. William Fulford and Walter Reich have contributed handsomely to the question of what constitutes a mental disorder by dissecting the complex process psychiatrists use to determine whether a diagnosis should be applied to a specific constellation of mental or behavioral features. Fulford (1999) stresses the place of values in clinical practice overall, positing that diagnoses in both physical and psychological medicine are an admixture of the factual and the evaluative. For him the concept of mental illness is on the same logical platform as the concept of physical illness. Reich makes explicit the vulnerability of the diagnostic process in psychiatry to error given its reliance on subjective criteria, the intrusion of bias and prejudice and shifting criteria leading to inconsistency and frequent change. Consider the illustrative diagnostic controversies which buttress Reich's contentions: the deletion of homosexuality as a condition following a poll of members of the American Psychiatric Association in 1973; intense debates over whether a concept like attention-deficit hyperactivity in children or in adults is valid; and the question of whether antisocial personality disorder is a valid disorder of personality functioning or mere social deviance (and therefore belongs within the sphere of crime and delinquency). Many more examples could be added to this list. In the context of an ill-defined professional framework and the vague criteria for diagnosis, the psychiatrist is sanctioned by law to manage the situation in which a person suffers or is suspected of suffering from mental illness that may require enforced hospitalization and/or treatment to protect a person's welfare or that of others (Peele and Chodoff). This is an awesome responsibility in that a person may be deprived of his liberty, lose basic civil rights, and be subject to a range of legal regulations.
Although commitment statutes in many jurisdictions, particularly those pertaining to determining the risk of dangerousness to self-and/or others, have been rigorously scrutinized, a disconcerting uncertainty persists as to what constitute relevant criteria. Psychiatrists are caught in a dilemma of having to arrive at a judgment about a person's clinical needs and protecting her civil rights at the same time. The civil libertarian would insist that an inalienable right to liberty should be guaranteed above all other considerations whereas those with a paternalistic outlook would aver that society, through its legally sanctioned agents, has an obligation periodically to take measures, undesirable as they may be, to protect patient, society, or both from harm.
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