Critique of Psychiatry in Rural and Remote Communities

Abstract

We criticize the collapse of psychiatry in most settings to a purely biomedical model in which strict rationalist standards are applied to thoughts and behavior leading to diagnosis and treatment with medication. The effect of this on local cultures has been to undermine acceptance of unusual behavior by community members and participation of extrafamilial agents in the recovery process of people with emotional suffering. The arrival of a biomedical model has resulted in greater stigmatization and less compassionate treatment of people with what biomedicine calls mental illness. We criticize the chief response of psychiatry being to diagnose and medicate with relative insensitivity to the social determinants of health and the specific circumstances of peoples’ lives that make them suffer. A profit-driven mental health system which exists in the United States complicates this further by its preference for short visits and medication as more profitable than longer visits and psychotherapy. Even in countries with universal coverage, however, the impetus exists to see more people in shorter time since this reduces short-term costs though arguably increasing longer-term costs. We describe the modern history of the critical psychiatry movement which has arisen in parallel with psychiatry’s increasing emphasis on mental illness arising from defective brains and its almost exclusive reliance on medication as the primary treatment model. We trace this movement from R.D. Laing and Joseph Berke, through Loren Mosher, and to Marius Romme and the Hearing Voices Movement, which is now Intervoice. We discuss Fernando’s analysis of biomedical psychiatry’s coming to Sri Lanka after their devastating tsunami and how its model of trauma undermined centuries-old ways of coping and conceptualizing loss that were grounded in the spiritualities of the region. We review Julie McGruder’s description of American psychiatry’s coming to Zanzibar and how it undermined the quality of life for those suffering from what psychiatry called schizophrenia. We conclude with a call to psychiatry to return to a more balanced biopsychosocial-spiritual model and to balance biomedical treatment with social and spiritual approaches, relying upon local community experts to be collaborative partners in a participatory democratic manner to determine what defines mental health and illness and how it should be addressed.