Worldwide, there have been consistently high or even rising incidences of people classified
as mentally ill (Bloom et al., 2011; World Health Organization, 2019), paired with
increasing mental healthcare service utilization over the last decades (Lipson et
al., 2019; Olfson et al., 2019). While psychiatric institutions have been successively
expanding, psychiatric knowledge has become increasingly dispersed and globalized,
making psychiatric vocabularies and classificatory systems widely available, shaping
increasing areas of life, creating powerful markets for therapeutic services of all
kinds, and impacting how we understand ourselves and others. This process can be described
as the psychiatrization of society (Beeker et al., 2021). Psychiatrization is highly
complex, diverse, and global, although it takes different forms in different contexts,
involves various actors with largely diverging motives, and is part of a wider assemblage
of the psy-disciplines.
The effects of psychiatrization are vast and varied. Individuals or groups might well
benefit from aspects of psychiatrization, as the growing mental healthcare system
can also increase accessibility of services that are subjectively helpful (Lancet
Global Mental Health Group et al., 2007; Thornicroft et al., 2017). In this context,
psychiatric diagnosis may essentially determine which quality and quantity of support
is available for people in distress. Yet psychiatrization can be potentially harmful
to individuals and to public healthcare, e.g., through overdiagnosis and overtreatment
(Moynihan et al., 2012), the psychological burden of being labeled (Livingston and
Boyd, 2010), the epistemic injustice inherent in not valuing the knowledge of those
with lived experience (Leblanc and Kinsella, 2016), and, in the Global North, exploding
costs to meet the needs of the “worried well” (Wang et al., 2007). From a societal
perspective, psychiatrization may further narrow down what is perceived as normal,
diverse attention from the structural determinants of mental health and boost medical
interventions which incite individual coping instead of encouraging long-term political
solutions (Davies, 2017). In the Global South, where biomedical psychiatric practice
is to a large degree exerted by trained non-specialists, psychiatrization could lead
to excessive diagnosis and prescription of medication with little monitoring (Mills,
2014) while the expansion of westernized, colonially informed psychiatry risks undermining
local support systems (Davar, 2014).
Given the rich body of research on medicalization (Zola, 1972; Illich, 1974; Conrad,
1992, 2005) with seminal publications going back to the 1970s, the question is legitimate
why a whole Research Topic should be dedicated to psychiatrization, which might be
perceived as just one special branch of medicalization among many others. It seems
safe to say that there are more than enough medical specialties in which overdiagnosis
and overtreatment are posing significant problems to patients, clinicians and public
finance. So why should we speak of psychiatrization but not, for example, of an “urologization”
of society to criticize the widespread overdiagnosis of prostate cancer (Vickers et
al., 2023)?
The above listed effects of psychiatrization already indicate the reason: There might
be much more at stake than harm through sub-optimal treatment decisions and the irresponsible
use of taxpayers' money. As several contributions to this Research Topic compellingly
show, psychiatry has the power to shape large parts of modern societies and is increasingly
used to handle its discontents. By defining, for example, which kinds of human suffering
should be understood as individual pathologies, psychiatric diagnosis ultimately becomes
an important terrain of negotiation for fundamental questions such as how we expect
ourselves and other people to be or in which kind of society we want to live. And
in an ironic contrast to the scope of potential consequences of psychiatric diagnosis,
there might be no other medical branch where it is so easy to invent new disease entities
or to expand criteria for diagnosis, due to the notorious lack of objective correlates
of psychiatric disorders, which pushes the doors wide open for the inflationary use
of psychiatric concepts and treatments.
Apart from the more obvious large-scale impacts that are mentioned above, psychiatrization
may become tangible in a multitude of more subtle phenomena, for instance in science
publishing: when we set up this Research Topic, our aim was to motivate scientific
contributions from a broad array of fields, following our understanding of psychiatrization
as being an interdisciplinary phenomenon. Clearly, we wished for academic psychiatry
to play a main role among the contributing disciplines. However, when we asked Frontiers
in Psychiatry to co-host our Research Topic with Frontiers in Sociology, which is
actually a very common design in the Frontiers' universe, our query was denied with
the brief notice that “psychiatrization of society” as a topic was not of interest
for the journal because it would not fit well with its aims. But when mainstream psychiatry
fails to understand that debates on its role in society are relevant to its very nature,
this seems to be a highly problematic self-conception. It also begs the question of
how psychiatry as a practical and scientific discipline can possibly be trusted to
responsibly manage its various and often controversial impacts on society, when it
does not acknowledge its situatedness within the realm of the social. Adding to that,
a scientific discourse that becomes hermetic toward the perspectives from other disciplines
risks to lose the essential openness that characterizes every true scientific endeavor.
However, we were very happy to receive many valuable contributions. In their totality,
they may help to shed a light on how psychiatrization can be conceptualized, how it
manifests in different terrains, its effects on individuals and societies, and strategies
to counter psychiatrization. Despite that, any kind of heuristics risks falling short
of their variety and complexity, the articles are presented in chapters that reflect
the theoretical, practical, and political dimensions of psychiatrization, with a special
emphasis on the lively debate about the psychiatrization of childhood (Beeker et al.,
2020).
Theorizing psychiatrization
In Beeker et al., the authors present a working definition of psychiatrization as
a “complex process of interaction between individuals, society, and psychiatry through
which psychiatric institutions, knowledge, and practices affect an increasing number
of people, shape more and more areas of life, and further psychiatry's importance
in society as a whole”. As a starting point for further research, the authors suggest
a basic model of psychiatrization. This model takes into account that psychiatrization
is not exclusively caused in a top-down-way by organized psychiatrists or the pharmaceutical
industry, but quite frequently co-produced by top-down and bottom-up-interactions.
The latter may originate from a demand for support, recognition or explanations by
patients, consumers and ordinary citizens without professional ties to the healthcare
system.
In direct reply, Haslam et al. compare psychiatrization with their seminal idea of
“concept creep” that was first described by Haslam in 2016 (Haslam, 2016). Concept
creep refers to the gradual expansion of harm-related concepts such as addiction,
prejudice, or bullying, that were semantically re-shaped over the last decades to
include an increasingly wide range of phenomena. The authors show that their original
conception of “vertical” vs. “horizontal creep” can be applied fittingly to diagnostic
inflation in its twofold meaning of relaxation of diagnostic criteria respectively
creation of new diagnostic entities. They suggest considering that psychiatrization
may be embedded in the same cultural dynamics as concept creep, which is a growing
sensitivity to harm with a tendency to its amplification. Thus, concept creep and
psychiatrization may have similar ambivalent effects by drawing attention to neglected
harms or illnesses but inflating also minor harms in a problematic way at the same
time.
Demke provides a close critical reading of the influential vulnerability-stress-model,
finding that while the model appears to integrate social dimensions of mental health,
it also perpetuates a medicalised view of faulty individuals. The author questions
the very idea of inherent vulnerability—with its potential to divert “attention from
the gravity of actual wounds, which would have to be taken seriously in order to open
up empowering avenues such as fighting for one's rights and against discrimination,
victimization and other grievances that are known to make people unwell”. She situates
the model, as it emerged in the 1970s, during a period of fundamental critique of
psychiatric theory and practice, showing how such critique can be integrated into
psychiatry while “allowing for a continued reliance on core elements of the medical
model such as the focus on the inherently deficient individual and mandatory pharmaceutical
intervention”.
Topor et al. describe how “recovery” evolved from a radical concept questioning the
core of psychiatric practice and knowledge to an idea that has become increasingly
psychiatrized itself. Starting as a concept that emphasized the social character of
mental health and promoting hope for individuals that the use of psychiatric services
could be left behind once and for all, the concept of recovery underwent a transition
during which it became gradually individualized and detached from the social. This
streamlined notion of recovery finally became even integrated into the psychiatric
services, where it did not mean much more than a never-ending personal journey. In
contrast to such a shallow, de-socialized view, the authors advocate the reappropriation
of the concept of recovery as a “deeply social, unique, and shared process in which
our living conditions, material surroundings, social relations and sense of self evolve”.
Russo shifts the focus of this volume by urging researchers concerned with the concept
of psychiatrization to clearly define their position in relation to their field of
study. She poses a critical question on how to prevent the (re)psychiatrization of
our own research work. The author argues from a mad studies' perspective that psychiatrization
is not something separate from us as researchers; rather, it is an integral part of
the knowledge production on mental health and distress in which we are actively involved.
The author encourages us to examine our perspectives, research ethics, and the manner
in which we communicate our findings. Her text can be interpreted as both a manifesto
and a call for a candid debate about the potential for enacting transformative research
within the existing structures of knowledge production. When viewed as a personal
issue, a political matter, and a strategy for de-psychiatrizing our own research,
it delves into the epistemological and ethical foundations that underlie the social
production of knowledge. Specifically, the author advocates for a radical shift toward
de-psychiatrization in our work and invites us to actively participate in this crucial
endeavor.
The psychiatrization of childhood
Witeska-Młynarczyk suggests examining the adoption practices in contemporary Poland
as a part of larger processes of psychiatrization. She provides an ethnographic account
of what she calls “the advancing psychiatrization of kinning”. This phenomenon occurs
at the intersection of family and social policies as the medicalization, and psychologization
of familial relationships. Taking a diachronic perspective, the author offers a portrayal
of the adoption network and its functioning. She perceives it as facilitating the
“privatization of the social problem” and working toward individualizing the responsibility
for its resolution. To describe the ways in which the network of public institutions,
relying on psy-knowledge, assesses children and prospective parents for adoption,
as well as educates future parents about the therapeutic role their future family
should play, Witeska-Młynarczyk employs the concept of “biopolitical bureaucracy”
(Nissen and Bech Risør, 2018). She also introduces the notion of “invisible disabilities”
(Blum, 2015) to discuss the range of anxieties, self-doubts, and intense emotions
generated within this context set in motion by the state. Once adoption is legalized,
the new family is compelled to embark on a solitary “diagnostic journey”, bearing
the full financial and emotional responsibility while completely absolving the state
of its role. This is coupled with a growing interest of psychiatry in mental health
of adopted young people, as well as in adoptive family as such.
Batstra et al. argue that to avoid unnecessary psychiatrization, schools potentially
need to be a primary target as teachers are often the first to instigate a psychiatric
classification. However, reification is a pervasive problem. Reification refers to
the process of presenting behavioral descriptions from the DSM, like ADHD, as disease
entities. A major driver of reification is for instance the widely made “ecological
fallacy” which means that very small average differences like slower brain maturation
in groups with an ADHD classification are presented as if everyone with a classification
displays such a pattern of brain growth. Reification is at odds with the goal of inclusive
education, because the perception of unwanted behaviors as caused by medical entities
entails the (psychiatric) adjustment of children to make them fit in. The authors
contrast this with a more community-based view of disability that holds the position
that it is not disabilities but barriers in society that cause exclusion. The authors
argue that for such a community-based approach to be successful however, a small but
pervasive perceptual shift might be necessary. Rather than singling out children as
having special needs to be addressed, the focus can instead be placed on teachers
who -as an inherent part of the professionalized socialization- will always need some
degree of special needs to do their work. Hence, we should no longer be speaking about
children with special needs but about teachers with special needs.
However, the many challenges that need to be faced when moving away from an individualized
narrative become clear in the study by Honkasilta and Koutsoklenis. The authors debunk
the feeble scientific basis of a classification like ADHD, for instance by looking
at the ambiguous, overlapping, and rather arbitrary criteria, obviously informed by
contemporary norms and societal values and changing from one version of the DSM to
the next, without any real scientific rationale. However, despite the weak scientific
base, the authors reveal how deeply engrained classifications like ADHD have become.
They may serve as legal entities, deciding who gets additional services and goods
but a classification may also provide a moral excuse for misbehavior and may even
exempt from legal liability. Likewise, classifications can be instrumental for parents
and children themselves as tools to evoke understanding and compassion. Some may feel
empowered by classification such as ADHD in an attempt to embrace their alleged “differently
wired brains”. At the same, classifications can remove agency, helped by the DSM discourse
suggesting children are “unable” rather than unwilling to perform certain behaviors.
Eventually, the pseudo-scientific discourse surrounding classification seems to create
a reality rather than describe it, and unfortunately a reality that might severely
restrain ways of being normal or even ways of being in general.
Psychiatrization and medical practice
van Dijk et al. present a qualitative study on how general practitioners (GPs) in
the Netherlands dealt with sadness complaints of young adults. Based on 13 interviews,
a typology of GPs was developed. GPs who tended to a fast referral to specialist care
were usually motivated by personal concern for their patients, by pragmatical reasons
or by feelings of incompetence when confronted with seemingly psychiatric conditions.
Sadness complaints, thus, were transferred quite easily into a medical condition.
GPs who felt well prepared to recognize and treat psychiatric disorders themselves
also tended to low-threshold diagnosis and pharmaceutical treatment in primary care.
Only GPs who acknowledged that their responsibility may often transcend pure medical
problems and, in consequence, saw themselves as partners to discuss the more or less
existential questions of life, were inclined to non-psychiatrizing interventions such
as watchful waiting. This result emphasizes that only those practitioners who are
willing to set the biomedical framework aside in favor of true human encounter may
be able to offer support in a non-psychiatrizing way.
In a similar vein, Beeker explores how psychiatrization may emerge from mental healthcare
settings. The author focusses on the micro-level by analyzing two prototypical cases
of patients coming to the emergency department of a general hospital to receive help
in an initially undefined situation. The cases illustrate why decisions whether to
label and treat a certain condition as a “mental disorder” or not, can be highly difficult
for practitioners, especially in cases where the (health) concerns are rather moderate,
and clearly associated with common life problems. However, psychiatrist's decisions
may be largely biased in favor of psychiatrization by a wide array of top-down-drivers
on the one hand, among which clinical routines, the vagueness of classificatory systems,
the necessity of diagnosis for reimbursement of any kind of support and professionals'
striving for the reduction of legal risks. On the other hand, also bottom-up mechanisms
such as help-seekers' expectations and understandings of their own problems, that
may be shaped by soft cultural factors or prior treatment-experiences of friends and
family, may play a crucial role when negotiating the accurate interpretation of a
situation of crisis.
Baumgardt and Weinmann forward the use of Crisis Theory as a less pathologizing and
more normalizing approach to provide help in situations such as those witnessed by
the emergency department. The authors discuss Crisis Theory against the background
of the widely adopted but severely flawed medical nosology of the DSM and go on to
discuss the stress-vulnerability model that was successively introduced to counter
some of the limitations of the biomedical approach. Unfortunately, misapplication
of the model again placed biological factors at the centerfold. Crisis Theory offers
an alternative heuristic approach for understanding the nature and development of
mental distress but is seldom explored to its full capacity. The authors discuss several
misconceptions and problems that may hamper the adoption of Crisis Theory like it's
supposed unsuitability to tackle more severe problems of people with an alleged biological
disposition for mental illness–which psychiatry assumes to be different from those
who experience a psychological, stress-related crisis. However, the authors clarify
how, regardless of the alleged biological or stress-related nature of the problems,
Crisis Theory can bring many improvements to the status quo, particularly by combining
it with a system-oriented approach.
von Peter et al. explore if Open Dialogue (OD) has the potential to offer psychosocial
support in a significantly less or even non-psychiatrizing way. OD was initially developed
in Finland in the 1980 for patients with acute psychosis and from then on applied
in more than 30 countries. Being essentially a kind of home-treatment with systemic
background, it offers multi-professional, and needs-oriented support, nowadays also
for users with various kinds of mental distress. As a core element, regular network
meetings with the service users and their private or professional environments provide
an opportunity to develop a shared understanding of the current crisis, and to make
joint decisions for the further course of action. While previous research has shown
that OD can limit the use of neuroleptics and decrease the use of psychiatric services,
the authors explore the inner logic of OD for further potential for de-psychiatrization.
They suggest that OD's tendency to encourage the use of everyday terms instead of
the psychiatric idiom, together with a dialogical, polyphonic process of meaning making
can be “breaking the interpretative sovereignty of psychiatric language” and concepts.
In this polyphonic process, psychiatrists and other health professionals become only
individual voices among many others. Instead of communicating psy-knowledge in a top-down
way, their new role is to facilitate the dialogical quest for a mutual understanding
and for adequate, by far not only medical help. In sum, OD could be a promising means
to offer a different, less-psychiatrizing kind of support, shifting the emphasis from
individualizing medical thinking toward a more social model of crisis and help.
Politics of psychiatrization
Logan and Karter analyze psychiatrization as a kind of “ontological politics”, that
imposes narrow interpretative limits on states of difference and distress and tends
to exclude other possible meanings. By doing so, psychiatrization may function as
a tool of disciplinary control of any kind of resistance against hegemonic norms and
institutions of gendered or racialized oppression in domestic or international contexts.
The authors exemplify their hypothesis with a close look on consumer/survivor/ex-patient
and psychosocial disability movements in the Global South. They demonstrate how psychiatrization
may thwart activists' original aims of transforming both the mental healthcare system
and the political weight of mental distress, and advocate for understanding at least
some mental suffering as a materialization of discontent with oppressive political
or socioeconomic conditions.
In a thorough Marxist analysis of the mental health system, Moncrieff argues that
the concept of mental illness (understood as an individual medical problem) plays
a strategic role in contemporary societies. Specifically, it works to obscure the
failings of the neoliberal economic system. The author takes the United Kingdom as
a case study to explain how the public mental health system has evolved alongside
capitalism, catering to the regulatory needs of the labor market. Adopting a synchronic
approach, she unravels trends typical of the capitalist system in general, with a
particular focus on the neoliberal system. In this context, large segments of the
post-industrial population are marginalized and categorized as mental patients. Indicators
of the changing structure of capitalism include the widespread consumption of antidepressants
and the increasing psychiatric diagnoses. The author does not limit herself to a critical
analysis but also emphasizes the need for political change based on a radical rejection
of the medicalization of “so-called” mental health problems.
Schumann et al. discuss Psychiatry's relation to right-wing extremism which they view
as an example of undue top-down psychiatrization. For instance, they criticize the
superficial tendency to focus on psychological vulnerabilities and social risk factors
such as bad peer influence leading up to right-wing extremism. The authors argue that
this narrow focus may lead to a predominantly individualized psychiatric gaze on right
wing beliefs that are often better understood as a response of more complex factors
such as societal conflict, economic uncertainty and societal processes of individualization
and anomie. Furthermore, due to this narrow focus other areas of interests may be
overlooked. For example, more conceptual understanding of the complex interplay between
individual and social factors is needed, as well as a more practical orientation on
the challenges that patients and staff may face when working with patients with right-wing
tendencies.
Conclusion: the way ahead
The heterogeneity of the papers included in this collection demonstrates once more
the complexity of psychiatrization as a field of research and gives a glimpse into
the many different ways that psychiatric knowledge and practices may be engrained
into contemporary societies. Further studies following different epistemologies and
using different methodologies still seem necessary to get a clearer view on the scope,
the origins, the mechanisms and the various impacts of psychiatrization—including
its influence on the researchers themselves. However, despite the magnitude of this
endeavor, a dash of optimism appears legitimate: as this collection shows, a critical
interdisciplinary analysis of psychiatrization seems to be possible and worthwhile,
especially when research is conceptualized as dialogical and multi-perspective.
Nevertheless, research alone cannot be an end in itself. The negative effects of psychiatrization
are ubiquitous and significant, as constantly voiced by the user-/survivor-movement
and underlined by this collection. Many creative ideas will be needed to build up
measures of psychosocial support that are not psychiatrizing, but provide effective
and sustainable help in situations of crisis. The articles of this Research Topic
may offer valuable inspirations for winding back some of the harms of psychiatrization
and to start doing what will most likely be inevitable on the long run: to move away
from the individualized, medical perspective with its narrow confines toward a broader
view that dares to re-contextualize and re-politicize human suffering.
Author contributions
TB: Conceptualization, Writing—original draft, Writing—review and editing. AW-M: Writing—original
draft, Writing—review and editing. SM: Writing—original draft, Writing—review and
editing. CM: Writing—original draft, Writing—review and editing.