I write this as a psychiatrist of two minds. But, first, the Drop the Disorder!…
This book is a collection of essays inspired by the event – and eventually series of events – called "A Disorder for Everyone!" (AD4E) hosted by authors Jo Watson (book editor) and Dr. Lucy Johnstone in the United Kingdom. The introduction of the book explains these events as having 2 primary goals: 1) challenging the culture of diagnosing psychiatric problems as disorders and 2) reinterpreting mental health symptoms as distress embedded in social context. The book itself is an expression of what is characterized as a "struggle to 'drop the disorder!'" as well as a call for activists, survivors, and professionals to join this mission. Twenty chapters written by twenty-four different contributors follow the introduction; a brief review of the subject index shows common themes of the writings to include abuse, borderline personality disorder, diagnoses, disability, and language.
Threaded throughout the chapters is the fundamental critique of medicalization of mental health symptoms. The inherent question is what benefits – if any – pathologizing distress has. There is a deep inquiry into its potential harms, which is seen as centered on tying persons to biomedical labels and services. Paula J. Caplan's foreword details some of the potential harm of psychiatric diagnoses: "…loss of self-confidence to loss of physical health, employment, child custody, and the right to make decisions about one's medical and legal affairs – even to loss of life."
Sally Fox calls psychiatry a dangerous raft, while Dolly Sen says that there is something "deeply wrong" with the field; Guilaine Kinouani characterizes diagnoses as performing epistemic violence. Psychiatry is characterized as Big Business, more interested in itself than its patients, and rooted in an uncritical, often false, biomedical context. Examples include its reliance on the Diagnostic and Statistical Manual of Mental Disorders, support of chemical imbalance theories, ties to the pharmaceutical industry, and frank insistence on being a field of medicine on par with others.
The book certainly adds important voices and arguments to the extant literature about psychiatry. It serves to give people with lived experience support in reflecting on their symptoms and choosing labels and supports that are meaningful to themselves. When this book is at its best, it supports people with mental distress having the opportunity to make choices: informed choice, Jo Watson; genuine choice, Lucy Johnstone; their own choices, Jo Watson. It also calls attention to structural aspects of racism (Gillaine Kinouani) and calls for feminist liberation (Emmy van Deurzen). Jo Watson lays out a wonderful map to "offer accurate information" on psychiatric diagnosis, give "access to all the relevant information on which to base" decisions about prescribed drugs, witness individual stories, and "work with honesty and integrity and be equipped with evidence based information to ensure that we do not collude unknowingly with the misinformation that surrounds us all."
At its core, this book is an anti-establishment resistance piece. To frame my review, it is important to know that, yes, I am a psychiatrist, but the spirit of the book resonates with me. I teach a class called "Alternatives to Psychiatry" to 4th year psychiatry residents – peppered with lyrics by Crass and The Exploited – aiming for such learning objectives as: to unlearn; to criticize, be critical; to make familiar with our lack of familiarity; to understand trends in etiology, diagnosis, and treatment; to understand some critical aspects of lived experience; to be aware of alternate paradigms of understanding and support. I think the contributors of Drop the Disorder! might agree.
But reading the book still leaves me feeling a bit defensive at times, wanting to put forth both rebuttals and hope. Yes! Mental health labels can come with stigma and its harms, but at times they also bring benefits. People seek them. In the United States, access to income, housing, legal defenses, and even support animals can be tied to having a psychiatric diagnosis. When resources are limited, distribution requires some elements of differentiation amongst potential recipients, and when psychiatry is beneficial, it can aid in this allocation. In a broken system, it can help. The DSM is not a bible (as referred to by Lucy Johnstone, Sally Fox, John Read, Lorenza Magliano, Terry Lynch, and many of the included references), but for many of us a tool of communication – often to bridge gaps with entities that bring the profession distress, too…billers, coders, administration, insurance companies, executives, et al.
I hope that psychiatrists could read Drop the Disorder! with an open mind and that, one day, the activists of AD4E can work alongside professionals in improving the system. This book is a step in that direction. Lisa Thompson and Becky Willetts ask professionals "to pay attention to power dynamics, consent, control, choice, equality and the expertise of people with lived experience." I will continue to strive to do so. In return, I also offer some hope for the future, as psychiatric trainees immerse themselves in courses on recovery, social psychiatry, trauma-informed care, ethics, structural competency, and more. While many chapters in the book reference psychiatry's focus on compliance (Pete Sanders, Sally Fox, Akima Thomas) and the inherent dynamics implied by using such words (emphasized by Clare Shaw, Gary Sidley, Chris Coombs, and Jacqui Dillon) chapters, just this week a 1st year resident asked me how to avoid using the term noncompliant in charting, adding that nonadherent just didn't seem good enough either…
In reading this book, and in teaching, I have hope for psychiatry and with that comes a respect for the resilience of those with lived experience, too.
© 2019 Michelle Joy
Michelle Joy, MD, Philadelphia