Learn how social factors promote mental health, influence the onset and course of mental illness, and affect how mental illnesses are diagnosed and treated. This course explores how our understanding of mental health and illness has been influenced by social attitudes and social developments in North America and around the world. The course begins by situating our contemporary mental health practices in historical context, then looks at different aspects of mental health, mental illness and mental health services and their connections to what’s going on in our social environment.
1.4 Antipsychiatry
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來自 University of Toronto 的課程
The Social Context of Mental Health and Illness
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從本節課中
Welcome and A Brief History of Madness
We begin with a quick orientation to the course and continue with our first lecture topic: A brief history of madness.
與講師見面
Charmaine WilliamsAssociate Professor
Faculty of Social Work
Our history of psychiatry branches a bit now.
I'm going to start to talk about the anti-psychiatry movement, and I'll do
de-institutionalization next. But both of them were happening at the
same time, so these are both mid-20th century events.
The anti-psychiatry movement is usually described as emerging in the 1950's, 60s'
with major points of activity in the United States, the UK and parts of
Europe. Of course, that wasn't the first time
that there have been criticisms of psychiatry.
Essentially, since the time that psychiatry organized itself as a
profession that defined and dealt with madness, there were people that were
critical of that role. The anti-psychiatry movement was
different because it merged from within the profession itself.
The term anti-psychiatry was actually coined by a leader of the movement,
psychiatrist David Cooper. However, many of the people who are
associated with that movement really didn't embrace the term.
The anti-psychiatry movement had many different threads.
But the ideas that were most commonly associated with it were challenging the
power that psychiatrists had to, had to detain and treat people,
especially involuntarily. Challenging the use of a medical model to
explain madness. And for some, challenging the actual
existence of mental illness. The critiques of the a psychiatry were
not isolated. They were very much a part of the times,
in that they were part of general sentiments rejecting institutional power
in western society as the tool of oppression, repression, and social
control. The anti-psychiatry movement was part of
a wave of anti-establishment activism at the time.
But it was certainly bolstered by parallel developments within psychiatry,
like the development of alternatives to pharmacological treatments, like
psychoanalysis and other psychotherapies. The perception that with the advent,
with the advent of pharma, pharmacological treatments, psychiatrists
have become over reliant on them and, in fact, have really lost interest in trying
to understand their patients. And also the attention of various social theorists
we've already referred to Goffman and Foucault, who persuasively argued that
mental illness was just a label given to people who deviated from acceptable
social norms. In addition, there were some serious
problems with the way that psychiatry was being practiced.
Although the 20th century had begun with optimism about the great contributions
that would be made by the mental hygiene movement and the promise of a new
scientific era of mental health treatment,
the promises of cures for mental illness were not fulfilled.
In fact, many of the treatments of the time had turned out to be ineffective or
even harmful. Treatments like insulin shock therapy,
early versions of electroconvulsive therapy, and psychosurgeries, like
lobotomies, had caused tremendous harm and sometimes permanent damage to
patients. Even the medications of the time were
fairly blunt instruments. Patients could have severe, long-term
side effects. Until recently, it was still not uncommon
to see patients with drug-induced movement disorders that were the result
of treatment with those earlier medications.
In addition, psychiatrists have been revealed as untrustworthy.
Psychiatry was implicated in the abuse of political power in various parts of the
world. Diagnosis and institutionalization were
used to silence political dissidence. North American psychiatrists were
revealed to be participants in government experiments on unsuspecting unconsenting
patients. European psychiatrists were implicated in
the sterilization and murder of thousands of mentally ill and disabled people.
The potential for psychiatry to be harmful was appallingly clear.
Even aside from those types of extreme circumstances, psya, psychiatric
diagnoses were not seen as reliable and validated at the time.
although we had already seen the development of the Diagnostic and
Statistical Manual of Mental Disorders,, the first one is available in 1952, and
the International Classification of Diseases, which is used in much of the
world included mental disorders for the first time in 1949.
But really, what was available in those manuals wasn't based on,
on systematic research. And this was really demonstrated quite
clearly when Rosenhan did his 1973 study about faking mental illness.
If you're interested in this study and you haven't heard about it, I really
recommend taking a look on the Internet. There's lots of information about it.
But, a quick summary of it is that Rosenhan sent people into psychiatric
hospitals faking mental illness. And as soon as they were admitted, he had
instructed them to start acting as they would normally and to tell people that
they were no longer experiencing any symptoms.
What they found was that although these people were, had faked their way in, and
were now acting normally"", they were still diagnosed with major
mental illnesses, and they weren't allowed to go until they were willing to
accept the diagnosis and willing to accept treatment with anti-psychotic
medication. psychiatrists were of course, very upset
[LAUGH] by this, by this experiment, and they challenged Rosenhan to do it again
to see, to prove that they could do better a second time.
Rosenhan said he would, but he actually didn't send anybody to the hospitals. And
in this case situation, the psychiatrists ended up identifying fake patients that
were actually people who were legitimately dealing with mental health
problems. So, you can imagine that people were
really beginning to wonder if psychiatrists actually knew what they
were doing. Some of the big players associated with
the anti-psychiatry movement are probably known to you. Because part of what made
them big players was that they wrote internationally best selling books
criticizing psychiatry. R.D.
Laing, who was author of The Divided Self,, Sanity, Madness and the Family..
He suggested that what we call mental disorders, especially schizophrenia, were
actually a normal response to a mad world, sometimes a response to problems
in the family. You may note the similarity here to
earlier thinking about insanity being the response to an overwhelming world.
But an important difference here is the Laing did not see this illness as an
infirmity. In fact, he thought that madness was an
opportunity for personal growth, and that schizophrenia offered insights that many,
many of us simply were not willing to accept, so we decided to call it illness.
This was a view that was shared also by the South African psychiatrist David
Cooper. Another big player, Thomas Szasz, also a
best-selling author, wrote The Myth of Mental Illness and several other books.
His position was that disease can only be defined on the basis of some kind of
biological dysfunction, and therefore, mental illness was not a disease, what we
called mental illness was not a disease. He felt that mental illness was really a
metaphor that we use to describe misbehavior.
He was especially opposed to involuntary hospitalization for the treatment of
mental illness as he saw it as a tool of control that was used by the state and by
families to deal with behavior that they did not want to tolerate.
In the US, Szasz's critiques were further bolstered by widely-read books like Ken
Kesey's One Flew Oh, One, One Who, what is it?
One Flew Over the Cuckoo's Nest,, [LAUGH] and Irving Goffman's book about Asylums.
Both of these other books reinforced his suggestion that psychiatric institutions
were not places of healing, but instead places of great harm and, potentially,
abuse. Goffman's book further elaborated on
asylums as what he called total institutions, which created passive,
unmotivated inmates. And effectively constructed the level of
functioning that a psychiatrists then ended up calling chronic mental ill,
illness. His voice joined with others that argued
that instead of helping people, mental hospitals changed individuals into
patients that were no longer able to function in the outside world.
I also wanted to mention a European contribution to the movement as well
because I had the opportunity to visit Italy for the World Psychiatric
Association conference. And there was a protest during the
conference that really showed that the anti-psychiatry movement was alive and
well there. The work of Franco Basaglia had a huge
impact on the Italian mental health care system.
When he spent some time at an institution in the 1960's, he found deplorable
conditions. Patients in mechanical restraints, living
in filth, subjected to violence, and subjected to what he described as the
most barbaric of the treatments at the time.
In the book that he wrote about it, he asserted that psychiatric care of the
time was not based on human need, but instead on the needs of the state.
You're probably noticing a theme here. Unlike some of the others, he did not
suggest that mental illness did not exist.
But he said it was the result of social violence and social exclusion.
And he developed a theory about the cycle of poverty and mental illness that really
resonated with social critiques of the time.
He was able to stimulate quite major mental health reform in Italy that
continues to have an impact until today. Finally,
the psychiatric survivor movements were also an important component of
anti-psychiatry. So, you'll notice that I have several
different terms here and these movements have different terms as well.
Sometimes a consumer movement, a consumer survivor movement, an ex-patient
movement. Sometimes it was rolled into the
disability movement. So, a lot of different names and they
really they had a few things in common which I I can say were that they really
wanted to assert the right to self determination for people who were
diagnosed with mental illnesses. And I would also say that they probably
had in common a resistance to involuntary treatment.
But but this, the movement's range, you know, really range from conservative to
radical all the way from just wanting to have more say, in what,
what kind of treatments people received and in being able to assert their own
self-determination to again, deny that mental illness existed and just seeing
psychiatry as a tool of social control. So, what did the anti-psychiatry movement
actually, actually accomplish? I mean, a lot of people think that the
anti-psychiatry movement had a lot to do with why de-institutionalization was
going to come very soon, or at the same time.
you'll see in the next segment that it's actually a little more complicated than
that. But it certainly brought public attention
to problems with the, the mental healthcare system.
I think that one of the major contributions of the anti-psychiatry
movement and its ungoing contribution is that it, it involved the actual users of
psychiatric services in the critique of those services.
And up until that point, really psychiatric patients had not had much of
a voice. And it just was the right time that
Zeitgeist was right. And in terms of disability activism
feminism, civil rights of all kinds, that it was a time when psychiatric
patients former patients, survivors could have a voice and really be heard as part
of a larger agenda around human rights. I think that the other thing we want to
remember is that anti-psychiatry also really started to get people thinking
about the social context of mental health and mental illness as well.
So, this is something that had always been with the system.
But really looking at the possibility that part of what contributed to the
mental illness we saw was the actual environments that people were living in
was not something that was really discussed in a widespread way until,
until the anti-psychiatry movement really was out there taking that to the public.
And and then of course, the actual environment of treatment was also given a
closer look because of the work of that movement.
So, a lot of contributions. Some people are, are critical of
anti-psychiatry because they feel that it it dissuades people from seeking help who
need it. But the, the thing is if anti-psychiatry
had, had the goal of tearing down psychiatry,
it certainly wasn't successful in doing that.
In fact, in many ways, psychiatry had a tremendous growth period at the same time
that anti-psychiatry was going on. So so really, you know, it's, it's not
that it, it destroyed things.
But certainly, I think it started some conversations that maybe weren't
happening beforehand. So, let's talk about what was happening
in a parallel way in, within mental health care system that led to the thing
that we call de-institutionalization.
