Stigma and Psychiatry

I ran across an article written by a columnist for the New York Times a couple of days ago about what the columnist felt was psychiatry’s “overreaching” (saying that some people who are bereaved may also have a major depression). The article made reference to Michel Foucault’s view that psychiatry is essentially all about making moral judgments on behalf of society.

It was interesting to read the article because as a young person all of what the writer had to say would have made complete sense  to me. I was very concerned at the time that psychiatry was really a way of labeling people as “bad” or defective rather than trying to understand them. .

Now many years later I found myself thinking that the author of this piece had really fundamentally misunderstood my specialty.

As a psychiatrist, I know that our specialty has many flaws, but among them is really not any tendency to judge people’s behavior on moral grounds. If anything one could argue that psychiatry tends to take a position that ignores morality.

The controversy within our field about Scott Peck’s books on good and evil rather neatly illustrates the fact that we have a profound antipathy towards mixing morality and mental health.

As a field psychiatry is not about what is good or bad, it is about what works.  The field’s view is that what works is what leads to relatively productive and happy lives. Now there is a morality embedded in this, of course, but it’s not the same morality as the author of this opinion piece suggests.

The author of this article was writing about the controversy surrounding the decision to include grief and brereavement as conditions that may be associated with major depression (previously being recently bereaved was considered an exclusion criteria for the diagnosis on the grounds that many of the symptoms of depression were normal reactions to bereavement).

He was suggesting that psychiatrists wanted to try to pathologize grief and brereavement, but I think that really, the struggle within our field is of not wanting to leave those people whose grief becomes overwhelmingly painful and destructive without any resources. The fact of the matter is, without a diagnosis, insurance companies won’t pay for treatment, and I imagine many of us know people whose grief was so unmanageable that it led to significant harm, harm that might perhaps has been reduced or minimized with psychological or psychiatric intervention.

None of this is about labeling grief, which almost all of us have experienced, as “abnormal” or “bad”.

In fact, after thinking about this for the better part of one day, it occurred to me that this article could really be seen as an example of the logical fallacy of post hoc propter hoc – 

1. Psychiatric diagnosis labels or stigmatizes people

2. Psychiatrists want to apply a diagnosis to more people

If we start with the notion that psychiatric diagnosis is not stigmatizing, then the discussion about whether or not someone who just lost a partner can be depressed does not seem nearly so ominous. It is about making sure that everyone who needs help gets it.