Emotionally focused therapy

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Emotionally focused therapy and emotion-focused therapy (EFT) are a family of related approaches to psychotherapy with individuals, couples, or families. EFT approaches include elements of experiential therapy (such as person-centered therapy and Gestalt therapy), systemic therapy, and attachment theory. EFT is usually a short-term treatment (8–20 sessions). EFT approaches are based on the premise that human emotions are connected to human needs, and therefore emotions have an innately adaptive potential that, if activated and worked through, can help people change problematic emotional states and interpersonal relationships. Emotion-focused therapy for individuals was originally known as process-experiential therapy, and it is still sometimes called by that name.

EFT should not be confused with emotion-focused coping, a category of coping proposed by some psychologists, although clinicians have used EFT to help improve clients' emotion-focused coping.

History

EFT began in the mid-1980s as an approach to helping couples. EFT was originally formulated and tested by Sue Johnson and Les Greenberg in 1985, and the first manual for emotionally focused couples therapy was published in 1988.

To develop the approach, Johnson and Greenberg began reviewing videos of sessions of couples therapy to identify, through observation and task analysis, the elements that lead to positive change. They were influenced in their observations by the humanistic experiential psychotherapies of Carl Rogers and Fritz Perls, both of whom valued (in different ways) present-moment emotional experience for its power to create meaning and guide behavior. Johnson and Greenberg saw the need to combine experiential therapy with the systems theoretical view that meaning-making and behavior cannot be considered outside of the whole situation in which they occur. In this "experiential–systemic" approach to couples therapy, as in other approaches to systemic therapy, the problem is viewed as belonging not to one partner, but rather to the cyclical reinforcing patterns of interactions between partners. Emotion is viewed not only as a within-individual phenomena, but also as part of the whole system that organizes the interactions between partners.

In 1986, Greenberg chose "to refocus his efforts on developing and studying an experiential approach to individual therapy". Greenberg and colleagues shifted their attention away from couples therapy toward individual psychotherapy. They attended to emotional experiencing and its role in individual self-organization. Building on the experiential theories of Rogers and Perls and others such as Eugene Gendlin, as well as on their own extensive work on information processing and the adaptive role of emotion in human functioning, Greenberg, Rice & Elliott (1993) created a treatment manual with numerous clearly outlined principles for what they called a process-experiential approach to psychological change. Elliott et al. (2004) and Goldman & Greenberg (2015) have further expanded the process-experiential approach, with detailed manuals of specific methods of therapeutic intervention. Goldman & Greenberg (2015) presents case formulation maps for this approach.

Johnson continued to develop EFT for couples, integrating attachment theory with systemic and humanistic approaches, and explicitly expanding attachment theory's understanding of love relationships. Johnson's model retained the original three stages and nine steps and two sets of interventions that aim to reshape the attachment bond: one set of interventions to track and restructure patterns of interaction and one to access and reprocess emotion. Johnson's goal is the creation of positive cycles of interpersonal interaction wherein individuals are able to ask for and offer comfort and support to safe others, facilitating interpersonal emotion regulation.

Greenberg & Goldman (2008) developed a variation of EFT for couples that contains some elements from Greenberg and Johnson's original formulation but adds several steps and stages. Greenberg and Goldman posit three motivational dimensions—(1) attachment, (2) identity or power, and (3) attraction or liking—that impact emotion regulation in intimate relationships.

Similar terminology, different meanings

The terms emotion-focused therapy and emotionally focused therapy have different meanings for different therapists. 

In Les Greenberg's approach the term emotion-focused is sometimes used to refer to psychotherapy approaches in general that emphasize emotion. Greenberg "decided that on the basis of the development in emotion theory that treatments such as the process experiential approach, as well as some other approaches that emphasized emotion as the target of change, were sufficiently similar to each other and different from existing approaches to merit being grouped under the general title of emotion-focused approaches." He and colleague Rhonda Goldman noted their choice to "use the more American phrasing of emotion-focused to refer to therapeutic approaches that focused on emotion, rather than the original, possibly more English term (reflecting both Greenberg's and Johnson's backgrounds) emotionally focused." Greenberg uses the term emotion-focused to suggest assimilative integration of an emotional focus into any approach to psychotherapy. He considers the focus on emotions to be a common factor among various systems of psychotherapy: "The term emotion-focused therapy will, I believe, be used in the future, in its integrative sense, to characterize all therapies that are emotion-focused, be they psychodynamic, cognitive-behavioral, systemic, or humanistic." Greenberg co-authored a chapter on the importance of research by clinicians and integration of psychotherapy approaches that stated:

In addition to these empirical findings, leaders of major orientations have voiced serious criticisms of their preferred theoretical approaches, while encouraging an open-minded attitude toward other orientations.... Furthermore, clinicians of different orientations recognized that their approaches did not provide them with the clinical repertoire sufficient to address the diversity of clients and their presenting problems.

Sue Johnson's use of the term emotionally focused therapy refers to a specific model of relationship therapy that explicitly integrates systems and experiential approaches and places prominence upon attachment theory as a theory of emotion regulation. Johnson views attachment needs as a primary motivational system for mammalian survival; her approach to EFT focuses on attachment theory as a theory of adult love wherein attachment, care giving, and sex are intertwined. Attachment theory is seen to subsume the search for personal autonomy, dependability of the other and a sense of personal and interpersonal attractiveness, lovability and desire. Johnson's approach to EFT aims to reshape attachment strategies towards optimal interdependency and emotion regulation, for resilience and physical, emotional, and relational health.

Features

Experiential focus

All EFT approaches have retained emphasis on the importance of Rogerian empathic attunement and communicated understanding. They all focus upon the value of engaging clients in emotional experiencing moment-to-moment in session. Thus, an experiential focus is prominent in all EFT approaches. All EFT theorists have expressed the view that individuals engage with others on the basis of their emotions, and construct a sense of self from the drama of repeated emotionally laden interactions.

The information-processing theory of emotion and emotional appraisal (in accordance with emotion theorists such as Magda B. Arnold, Paul Ekman, Nico Frijda, and James Gross) and the humanistic, experiential emphasis on moment-to-moment emotional expression (developing the earlier psychotherapy approaches of Carl Rogers, Fritz Perls, and Eugene Gendlin) have been strong components of all EFT approaches since their inception. EFT approaches value emotion as the target and agent of change, honoring the intersection of emotion, cognition, and behavior. EFT approaches posit that emotion is the first, often subconscious response to experience. All EFT approaches also use the framework of primary and secondary (reactive) emotion responses.

Maladaptive emotion responses and negative patterns of interaction

Greenberg and some other EFT theorists have categorized emotion responses into four types (see § Emotion response types below) to help therapists decide how to respond to a client at a particular time: primary adaptive, primary maladaptive, secondary reactive, and instrumental. Greenberg has posited six principles of emotion processing: (1) awareness of emotion or naming what one feels, (2) emotional expression, (3) regulation of emotion, (4) reflection on experience, (5) transformation of emotion by emotion, and (6) corrective experience of emotion through new lived experiences in therapy and in the world. While primary adaptive emotion responses are seen as a reliable guide for behavior in the present situation, primary maladaptive emotion responses are seen as an unreliable guide for behavior in the present situation (alongside other possible emotional difficulties such as lack of emotional awareness, emotion dysregulation, and problems in meaning-making).

Johnson rarely distinguishes between adaptive and maladaptive primary emotion responses, and rarely distinguishes emotion responses as dysfunctional or functional. Instead, primary emotional responses are usually construed as normal survival reactions in the face of what John Bowlby called "separation distress". EFT for couples, like other systemic therapies that emphasize interpersonal relationships, presumes that the patterns of interpersonal interaction are the problematic or dysfunctional element. The patterns of interaction are amenable to change after accessing the underlying primary emotion responses that are subconsciously driving the ineffective, negative reinforcing cycles of interaction. Validating reactive emotion responses and reprocessing newly accessed primary emotion responses is part of the change process.

Individual therapy

Individual therapy

Goldman & Greenberg 2015 proposed a 14-step case formulation process that regards emotion-related problems as stemming from at least four different possible causes: lack of awareness or avoidance of emotion, dysregulation of emotion, maladaptive emotion response, or a problem with making meaning of experiences. The theory features four types of emotion response, categorizes needs under "attachment" and "identity", specifies four types of emotional processing difficulties, delineates different types of empathy, has at least a dozen different task markers, relies on two interactive tracks of emotion and narrative processes as sources of information about a client, and presumes a dialectical-constructivist model of psychological development and an emotion schematic system.

The emotion schematic system is seen as the central catalyst of self-organization, often at the base of dysfunction and ultimately the road to cure. For simplicity, we use the term emotion schematic process to refer to the complex synthesis process in which a number of coactivated emotion schemes coapply, to produce a unified sense of self in relation to the world.

Techniques used in "coaching clients to work through their feelings" may include the Gestalt therapy empty chair technique, frequently used for resolving "unfinished business", and the two-chair technique, frequently used for self-critical splits.

Emotion response types

Sadness

 

Anger

 

Fear

 

Emotion-focused theorists have posited that each person's emotions are organized into idiosyncratic emotion schemes that are highly variable both between people and within the same person over time, but for practical purposes emotional responses can be classified into four broad types: primary adaptive, primary maladaptive, secondary reactive, and instrumental.

1. Primary adaptive emotion responses are initial emotional responses to a given stimulus that have a clear beneficial value in the present situation—for example, sadness at loss, anger at violation, and fear at threat. Sadness is an adaptive response when it motivates people to reconnect with someone or something important that is missing. Anger is an adaptive response when it motivates people to take assertive action to end the violation. Fear is an adaptive response when it motivates people to avoid or escape an overwhelming threat. In addition to emotions that indicate action tendencies (such as the three just mentioned), primary adaptive emotion responses include the feeling of being certain and in control or uncertain and out of control, and/or a general felt sense of emotional pain—these feelings and emotional pain do not provide immediate action tendencies but do provide adaptive information that can be symbolized and worked through in therapy. Primary adaptive emotion responses "are attended to and expressed in therapy in order to access the adaptive information and action tendency to guide problem solving."
2. Primary maladaptive emotion responses are also initial emotional responses to a given stimulus; however, they are based on emotion schemes that are no longer useful (and that may or may not have been useful in the person's past) and that were often formed through previous traumatic experiences. Examples include sadness at the joy of others, anger at the genuine caring or concern of others, fear at harmless situations, and chronic feelings of insecurity/fear or worthlessness/shame. For example, a person may respond with anger at the genuine caring or concern of others because as a child he or she was offered caring or concern that was usually followed by a violation; as a result, he or she learned to respond to caring or concern with anger even when there is no violation. The person's angry response is understandable, and needs to be met with empathy and compassion even though his or her angry response is not helpful. Primary maladaptive emotion responses are accessed in therapy with the aim of transforming the emotion scheme through new experiences.
3. Secondary reactive emotion responses are complex chain reactions where a person reacts to his or her primary adaptive or maladaptive emotional response and then replaces it with another, secondary emotional response. In other words, they are emotional responses to prior emotional responses. ("Secondary" means that a different emotion response occurred first.) They can include secondary reactions of hopelessness, helplessness, rage, or despair that occur in response to primary emotion responses that are experienced (secondarily) as painful, uncontrollable, or violating. They may be escalations of a primary emotion response, as when people are angry about being angry, afraid of their fear, or sad about their sadness. They may be defenses against a primary emotion response, such as feeling anger to avoid sadness or fear to avoid anger; this can include gender role-stereotypical responses such as expressing anger when feeling primarily afraid (stereotypical of men's gender role), or expressing sadness when primarily angry (stereotypical of women's gender role). "These are all complex, self-reflexive processes of reacting to one's emotions and transforming one emotion into another. Crying, for example, is not always true grieving that leads to relief, but rather can be the crying of secondary helplessness or frustration that results in feeling worse." Secondary reactive emotion responses are accessed and explored in therapy in order to increase awareness of them and to arrive at more primary and adaptive emotion responses.
4. Instrumental emotion responses are experienced and expressed by a person because the person has learned that the response has an effect on others, "such as getting them to pay attention to us, to go along with something we want them to do for us, to approve of us, or perhaps most often just not to disapprove of us." Instrumental emotion responses can be consciously intended or unconsciously learned (i.e., through operant conditioning). Examples include crocodile tears (instrumental sadness), bullying (instrumental anger), crying wolf (instrumental fear), and feigned embarrassment (instrumental shame). When a client responds in therapy with instrumental emotion responses, it may feel manipulative or superficial to the therapist. Instrumental emotion responses are explored in therapy in order to increase awareness of their interpersonal function and/or the associated primary and secondary gain.

The therapeutic process with different emotion responses

Emotion-focused theorists have proposed that each type of emotion response calls for a different intervention process by the therapist. Primary adaptive emotion responses need be more fully allowed and accessed for their adaptive information. Primary maladaptive emotion responses need to be accessed and explored to help the client identify core unmet needs (e.g., for validation, safety, or connection), and then regulated and transformed with new experiences and new adaptive emotions. Secondary reactive emotion responses need empathic exploration in order to discover the sequence of emotions that preceded them. Instrumental emotion responses need to be explored interpersonally in the therapeutic relationship to increase awareness of them and address how they are functioning in the client's situation. 

It is important to note that primary emotion responses are not called "primary" because they are somehow more real than the other responses; all of the responses feel real to a person, but therapists can classify them into these four types in order to help clarify the functions of the response in the client's situation and how to intervene appropriately.

Therapeutic tasks

A therapeutic task is an immediate problem that a client needs to resolve in a psychotherapy session. In the 1970s and 1980s, researchers such as Laura North Rice (a former colleague of Carl Rogers) applied task analysis to transcripts of psychotherapy sessions in an attempt to describe in more detail the process of clients' cognitive and emotional change, so that therapists might more reliably provide optimal conditions for change. This kind of psychotherapy process research eventually led to a standardized (and evolving) set of therapeutic tasks in emotion-focused therapy for individuals.

The following table summarizes the standard set of these therapeutic tasks as of 2012. The tasks are classified into five broad groups: empathy-based, relational, experiencing, reprocessing, and action. The task marker is an observable sign that a client may be ready to work on the associated task. The intervention process is a sequence of actions carried out by therapist and client in working on the task. The end state is the desired resolution of the immediate problem.

In addition to the task markers listed below, other markers and intervention processes for working with emotion and narrative have been specified: same old stories, empty stories, unstoried emotions, and broken stories.

Therapeutic tasks in emotion-focused therapy for individuals

	Task marker	Intervention process	End state
Empathy-based tasks	Problem-relevant experience (e.g., interesting, troubling, intense, puzzling)	Empathic exploration	Clear marker, or new meaning explicated
	Vulnerability (painful emotion related to self)	Empathic affirmation	Self-affirmation (feels understood, hopeful, stronger)
Relational tasks	Beginning of therapy	Alliance formation	Productive working environment
	Therapy complaint or withdrawal difficulty (questioning goals or tasks; persistent avoidance of relationship or work)	Alliance dialogue (each explores own role in difficulty)	Alliance repair (stronger therapeutic bond or investment in therapy; greater self-understanding)
Experiencing tasks	Attentional focus difficulty (e.g., confused, overwhelmed, blank)	Clearing a space	Therapeutic focus; ability to work productively with experiencing (working distance)
	Unclear feeling (vague, external or abstract)	Experiential focusing	Symbolization of felt sense; sense of easing (feeling shift); readiness to apply outside of therapy (carrying forward)
	Difficulty expressing feelings (avoiding feelings, difficulty answering feeling questions)	Allowing and expressing emotion (also experiential focusing, systematic evocative unfolding, chairwork)	Successful, appropriate expression of emotion to therapist and others
Reprocessing tasks [situational-perceptual]	Difficult/traumatic experiences (narrative pressure to tell painful life stories)	Trauma retelling	Relief, validation, restoration of narrative gaps, understanding of broader meaning
	Problematic reaction point (puzzling over-reaction to specific situation)	Systematic evocative unfolding	New view of self in-the-world-functioning
	Meaning protest (life event violates cherished belief)	Meaning creation work	Revision of cherished belief
Action tasks [action tendency]	Self-evaluative split (self-criticism, tornness)	Two-chair dialogue	Self-acceptance, integration
	Self-interruption split (blocked feelings, resignation)	Two-chair enactment	Self-expression, empowerment
	Unfinished business (lingering bad feeling regarding significant other)	Empty-chair work	Let go of resentments, unmet needs regarding other; affirm self; understand or hold other accountable
	Stuck, disregulated anguish	Compassionate self-soothing	Emotional/bodily relief, self-empowerment

Emotion-focused therapy for trauma

The interventions and the structure of emotion-focused therapy have been adapted for the specific needs of psychological trauma survivors. A manual of emotion-focused therapy for individuals with complex trauma (EFTT) has been published. For example, modifications of the traditional Gestalt empty chair technique have been developed.

Other versions of EFT for individuals

Brubacher (2017) proposed an emotionally focused approach to individual therapy that focuses on attachment, while integrating the experiential focus of empathic attunement for engaging and reprocessing emotional experience and tracking and restructuring the systemic aspects and patterns of emotion regulation. The therapist follows the attachment model by addressing deactivating and hyperactivating strategies. Individual therapy is seen as a process of developing secure connections between therapist and client, between client and past and present relationships, and within the client. Attachment principles guide therapy in the following ways: forming the collaborative therapeutic relationship, shaping the overall goal for therapy to be that of "effective dependency" (following John Bowlby) upon one or two safe others, depathologizing emotion by normalizing separation distress responses, and shaping change processes. The change processes are: identifying and strengthening patterns of emotion regulation, and creating corrective emotional experiences to transform negative patterns into secure bonds.

Couples therapy

A couple

 

A systemic perspective is important in all approaches to EFT for couples. Tracking conflictual patterns of interaction, often referred to as a "dance" in Johnson's popular literature, has been a hallmark of the first stage of Johnson and Greenberg's approach since its inception in 1985. In Goldman and Greenberg's newer approach, therapists help clients "also work toward self-change and the resolution of pain stemming from unmet childhood needs that affect the couple interaction, in addition to working on interactional change." Goldman and Greenberg justify their added emphasis on self-change by noting that not all problems in a relationship can be solved only by tracking and changing patterns of interaction:

In addition, in our observations of psychotherapeutic work with couples, we have found that problems or difficulties that can be traced to core identity concerns such as needs for validation or a sense of worth are often best healed through therapeutic methods directed toward the self rather than to the interactions. For example, if a person's core emotion is one of shame and they feel "rotten at the core" or "simply fundamentally flawed," soothing or reassuring from one's partner, while helpful, will not ultimately solve the problem, lead to structural emotional change, or alter the view of oneself.

In Greenberg and Goldman's approach to EFT for couples, although they "fully endorse" the importance of attachment, attachment is not considered to be the only interpersonal motivation of couples; instead, attachment is considered to be one of three aspects of relational functioning, along with issues of identity/power and attraction/liking. In Johnson's approach, attachment theory is considered to be the defining theory of adult love, subsuming other motivations, and it guides the therapist in processing and reprocessing emotion.

In Greenberg and Goldman's approach, the emphasis is on working with core issues related to identity (working models of self and other) and promoting both self-soothing and other-soothing for a better relationship, in addition to interactional change. In Johnson's approach, the primary goal is to reshape attachment bonds and create "effective dependency" (including secure attachment).

Stages and steps

EFT for couples features a nine-step model of restructuring the attachment bond between partners. In this approach, the aim is to reshape the attachment bond and create more effective co-regulation and "effective dependency", increasing individuals' self-regulation and resilience. In good-outcome cases, the couple is helped to respond and thereby meet each other's unmet needs and injuries from childhood. The newly shaped secure attachment bond may become the best antidote to traumatic experience from within and outside of the relationship. 

Adding to the original three-stage, nine-step EFT framework developed by Johnson and Greenberg, Greenberg and Goldman's emotion-focused therapy for couples has five stages and 14 steps. It is structured to work on identity issues and self-regulation prior to changing negative interactions. It is considered necessary, in this approach, to help partners experience and reveal their own underlying vulnerable feelings first, so they are better equipped to do the intense work of attuning to the other partner and to be open to restructuring interactions and the attachment bond.

Johnson (2008) summarizes the nine treatment steps in Johnson's model of EFT for couples: "The therapist leads the couple through these steps in a spiral fashion, as one step incorporates and leads into the other. In mildly distressed couples, partners usually work quickly through the steps at a parallel rate. In more distressed couples, the more passive or withdrawn partner is usually invited to go through the steps slightly ahead of the other."

Stage 1. Stabilization (assessment and de-escalation phase)

• Step 1: Identify the relational conflict issues between the partners
• Step 2: Identify the negative interaction cycle where these issues are expressed
• Step 3: Access attachment emotions underlying the position each partner takes in this cycle
• Step 4: Reframe the problem in terms of the cycle, unacknowledged emotions, and attachment needs

During this stage the therapist creates a comfortable and stable environment for the couple to have an open discussion about any hesitations the couples may have about the therapy, including the trustworthiness of the therapist. The therapist also gets a sense of the couple's positive and negative interactions from past and present and is able to summarize and present the negative patterns for them. Partners soon no longer view themselves as victims of their negative interaction cycle; they are now allies against it.

Stage 2. Restructuring the bond (changing interactional positions phase)

• Step 5: Access disowned or implicit needs (e.g., need for reassurance), emotions (e.g., shame), and models of self
• Step 6: Promote each partner's acceptance of the other's experience
• Step 7: Facilitate each partner's expression of needs and wants to restructure the interaction based on new understandings and create bonding events

This stage involves restructuring and widening the emotional experiences of the couple. This is done through couples recognizing their attachment needs, and then changing their interactions based on those needs. At first their new way of interacting may be strange and hard to accept, but as they become more aware and in control of their interactions they are able to stop old patterns of behavior from reemerging.

Stage 3. Integration and consolidation

• Step 8: Facilitate the formulation of new stories and new solutions to old problems
• Step 9: Consolidate new cycles of behavior

This stage focuses on reflection of new emotional experiences and self-concepts. It integrates the couple's new ways of dealing with problems within themselves and in the relationship.

Styles of attachment

Johnson & Sims (2000) described four attachment styles that affect the therapy process:

1. People who are secure and trusting perceive themselves as lovable, able to trust others and themselves within a relationship. They give clear emotional signals, and are engaged, resourceful and flexible in unclear relationships. Secure partners express feelings, articulate needs, and allow their own vulnerability to show.
2. People who have a diminished ability to articulate feelings, tend not to acknowledge their need for attachment, and struggle to name their needs in a relationship. They tend to adopt a safe position and solve problems dispassionately without understanding the effect that their safe distance has on their partners.
3. People who are psychologically reactive and who exhibit anxious attachment. They tend to demand reassurance in an aggressive way, demand their partner's attachment and tend to use blame strategies (including emotional blackmail) in order to engage their partner.
4. People who have been traumatized and have experienced little to no recovery from it vacillate between attachment and hostility.

Family therapy

A family

The emotionally focused family therapy (EFFT) of Johnson and her colleagues aims to promote secure bonds among distressed family members. It is a therapy approach consistent with the attachment-oriented experiential–systemic emotionally focused model in three stages: (1) de-escalating negative cycles of interaction that amplify conflict and insecure connections between parents and children; (2) restructuring interactions to shape positive cycles of parental accessibility and responsiveness to offer the child or adolescent a safe haven and a secure base; (3) consolidation of the new responsive cycles and secure bonds. Its primary focus is on strengthening parental responsiveness and care giving, to meet children and adolescents' attachment needs. It aims to "build stronger families through (1) recruiting and strengthening parental emotional responsiveness to children, (2) accessing and clarifying children's attachment needs, and (3) facilitating and shaping care giving interactions from parent to child". Some clinicians have integrated EFFT with play therapy.

One group of clinicians, inspired in part by Greenberg's approach to EFT, developed a treatment protocol specifically for families of individuals struggling with an eating disorder. The treatment is based on the principles and techniques of four different approaches: emotion-focused therapy, behavioral family therapy, motivational enhancement therapy, and the New Maudsley family skills-based approach. It aims to help parents "support their child in the processing of emotions, increasing their emotional self-efficacy, deepening the parent–child relationships and thereby making ED [eating disorder] symptoms unnecessary to cope with painful emotional experiences". The treatment has three main domains of intervention, four core principles, and five steps derived from Greenberg's emotion-focused approach and influenced by John Gottman: (1) attending to the child's emotional experience, (2) naming the emotions, (3) validating the emotional experience, (4) meeting the emotional need, and (5) helping the child to move through the emotional experience, problem solving if necessary.

Efficacy

Johnson, Greenberg, and many of their colleagues have spent their long careers as academic researchers publishing the results of empirical studies of various forms of EFT.

The American Psychological Association considers emotion-focused therapy for individuals to be an empirically supported treatment for depression. Studies have suggested that it is effective in the treatment of depression, interpersonal problems, trauma, and avoidant personality disorder.

Practitioners of EFT have claimed that studies have consistently shown clinically significant improvement post therapy. Studies, again mostly by EFT practitioners, have suggested that emotionally focused therapy for couples is an effective way to restructure distressed couple relationships into safe and secure bonds with long-lasting results. Johnson et al. (1999) conducted a meta-analysis of the four most rigorous outcome studies before 2000 and concluded that the original nine-step, three-stage emotionally focused therapy approach to couples therapy had a larger effect size than any other couple intervention had achieved to date, but this meta-analysis was later harshly criticized by psychologist James C. Coyne, who called it "a poor quality meta-analysis of what should have been left as pilot studies conducted by promoters of a therapy in their own lab". A study with an fMRI component suggested that emotionally focused couples therapy reduces the brain's response to threat in the presence of a romantic partner, but this study too was later harshly criticized by Coyne.

Strengths

Some of the strengths of EFT approaches can be summarized as follows:

• EFT aims to be collaborative and respectful of clients, combining experiential person-centered therapy techniques with systemic therapy interventions.
• Change strategies and interventions are specified through intensive analysis of psychotherapy process.
• EFT has been validated by 30 years of empirical research. There is also research on the change processes and predictors of success.
• EFT has been applied to different kinds of problems and populations, although more research on different populations and cultural adaptations is needed.
• EFT for couples is based on conceptualizations of marital distress and adult love that are supported by empirical research on the nature of adult interpersonal attachment.

Criticism

Psychotherapist Campbell Purton, in his 2014 book The Trouble with Psychotherapy, criticized a variety of approaches to psychotherapy, including behavior therapy, person-centered therapy, psychodynamic therapy, cognitive behavioral therapy, emotion-focused therapy, and existential therapy; he argued that these psychotherapies have accumulated excessive and/or flawed theoretical baggage that deviates too much from an everyday common-sense understanding of personal troubles. With regard to emotion-focused therapy, Purton argued that "the effectiveness of each of the 'therapeutic tasks' can be understood without the theory" and that what clients say "is not well explained in terms of the interaction of emotion schemes; it is better explained in terms of the person's situation, their response to it, and their having learned the particular language in which they articulate their response."

In 2014, psychologist James C. Coyne criticized some EFT research for lack of rigor (for example, being underpowered and having high risk of bias), but he also noted that such problems are common in the field of psychotherapy research.

In a 2015 article in Behavioral and Brain Sciences on "memory reconsolidation, emotional arousal and the process of change in psychotherapy", Richard D. Lane and colleagues summarized a common claim in the literature on emotion-focused therapy that "emotional arousal is a key ingredient in therapeutic change" and that "emotional arousal is critical to psychotherapeutic success". In a response accompanying the article, Bruce Ecker and colleagues (creators of coherence therapy) disagreed with this claim and argued that the key ingredient in therapeutic change involving memory reconsolidation is not emotional arousal but instead a perceived mismatch between an expected pattern and an experienced pattern; they wrote:

The brain clearly does not require emotional arousal per se for inducing deconsolidation. That is a fundamental point. If the target learning happens to be emotional, then its reactivation (the first of the two required elements) of course entails an experience of that emotion, but the emotion itself does not inherently play a role in the mismatch that then deconsolidates the target learning, or in the new learning that then rewrites and erases the target learning (discussed at greater length in Ecker 2015). [...] The same considerations imply that "changing emotion with emotion" (stated three times by Lane et al.) inaccurately characterizes how learned responses change through reconsolidation. Mismatch consists most fundamentally of a direct, unmistakable perception that the world functions differently from one's learned model. "Changing model with mismatch" is the core phenomenology.

Other responses to Lane et al. (2015) argued that their emotion-focused approach "would be strengthened by the inclusion of predictions regarding additional factors that might influence treatment response, predictions for improving outcomes for non-responsive patients, and a discussion of how the proposed model might explain individual differences in vulnerability for mental health problems", and that their model needed further development to account for the diversity of states called "psychopathology" and the relevant maintaining and worsening processes.

Anti-psychiatry

From Wikipedia, the free encyclopedia

Vienna's Narrenturm—German for "fools' tower"—was one of the earliest buildings specifically designed as a "madhouse". It was built in 1784.

 

Anti-psychiatry is a movement based on the view that psychiatric treatment is often more damaging than helpful to patients. It considers psychiatry a coercive instrument of oppression due to an unequal power relationship between doctor and patient and a highly subjective diagnostic process. It has been active in various forms for two centuries.

Anti-psychiatry originates in an objection to what some view as dangerous treatments. Examples include electroconvulsive therapy, insulin shock therapy, and brain lobotomy. A more recent concern is the significant increase in prescribing psychiatric drugs for children in the beginning of the 20th century. There were also concerns about mental health institutions. All modern societies permit involuntary treatment or involuntary commitment of mental patients.

In the 1960s, there were many challenges to psychoanalysis and mainstream psychiatry, where the very basis of psychiatric practice was characterized as repressive and controlling. Psychiatrists involved in this challenge included Thomas Szasz, Giorgio Antonucci, R. D. Laing, Franco Basaglia, Theodore Lidz, Silvano Arieti, and David Cooper. Others involved were L. Ron Hubbard, Michel Foucault and Erving Goffman. Cooper coined the term "anti-psychiatry" in 1967, and wrote the book Psychiatry and Anti-psychiatry in 1971. Thomas Szasz introduced the definition of mental illness as a myth in the book The Myth of Mental Illness (1961), Giorgio Antonucci introduced the definition of psychiatry as a prejudice in the book I pregiudizi e la conoscenza critica alla psichiatria (1986).

Contemporary issues of anti-psychiatry include freedom versus coercion, racial and social justice, iatrogenic effects of antipsychotic medications (unintentionally induced by medical therapy), personal liberty, social stigma, and the right to be different.

History

Precursors

The first widespread challenge to the prevailing medical approach in Western countries occurred in the late 18th century. Part of the progressive Age of Enlightenment, a "moral treatment" movement challenged the harsh, pessimistic, somatic (body-based) and restraint-based approaches that prevailed in the system of hospitals and "madhouses" for people considered mentally disturbed, who were generally seen as wild animals without reason. Alternatives were developed, led in different regions by ex-patient staff, physicians themselves in some cases, and religious and lay philanthropists. The moral treatment was seen as pioneering more humane psychological and social approaches, whether or not in medical settings; however, it also involved some use of physical restraints, threats of punishment, and personal and social methods of control. And as it became the establishment approach in the 19th century, opposition to its negative aspects also grew.

According to Michel Foucault, there was a shift in the perception of madness, whereby it came to be seen as less about delusion, i.e. disturbed judgment about the truth, than about a disorder of regular, normal behaviour or will. Foucault argued that, prior to this, doctors could often prescribe travel, rest, walking, retirement and generally engaging with nature, seen as the visible form of truth, as a means to break with artificialities of the world (and therefore delusions). Another form of treatment involved nature's opposite, the theatre, where the patient's madness was acted out for him or her in such a way that the delusion would reveal itself to the patient.

According to Foucault, the most prominent therapeutic technique instead became to confront patients with a healthy sound will and orthodox passions, ideally embodied by the physician. The cure then involved a process of opposition, of struggle and domination, of the patient's troubled will by the healthy will of the physician. It was thought the confrontation would lead not only to bring the illness into broad daylight by its resistance, but also to the victory of the sound will and the renunciation of the disturbed will. We must apply a perturbing method, to break the spasm by means of the spasm.... We must subjugate the whole character of some patients, subdue their transports, break their pride, while we must stimulate and encourage the others (Esquirol, J.E.D., 1816). Foucault also argued that the increasing internment of the "mentally ill" (the development of more and bigger asylums) had become necessary not just for diagnosis and classification but because an enclosed place became a requirement for a treatment that was now understood as primarily the contest of wills, a question of submission and victory. 

Close up of the "Horrors of Kew Asylum" featured in Lee's Pictorial Weekly Budget Police News in 1876

 

The techniques and procedures of the asylums at this time included "isolation, private or public interrogations, punishment techniques such as cold showers, moral talks (encouragements or reprimands), strict discipline, compulsory work, rewards, preferential relations between the physician and his patients, relations of vassalage, of possession, of domesticity, even of servitude between patient and physician at times". Foucault summarized these as "designed to make the medical personage the 'master of madness'" through the power the physician's will exerts on the patient. The effect of this shift then served to inflate the power of the physician relative to the patient, correlated with the rapid rise of internment (asylums and forced detention).

The Woodilee Hospital was opened in 1875 in Scotland

 

Other analyses suggest that the rise of asylums was primarily driven by industrialization and capitalism, including the breakdown of the traditional family structures. And that by the end of the 19th century, psychiatrists often had little power in the overrun asylum system, acting mainly as administrators who rarely attended to patients, in a system where therapeutic ideals had turned into mindless institutional routines. In general, critics point to negative aspects of the shift toward so-called "moral treatments", and the concurrent widespread expansion of asylums, medical power and involuntary hospitalization laws, in a way that was to play an important conceptual part in the later anti-psychiatry movement.

Internee being restrained in a bathtub

 

Internee in a restraint chair at the West Riding Pauper Lunatic Asylum

 

Various 19th-century critiques of the newly emerging field of psychiatry overlap thematically with 20th-century anti-psychiatry, for example in their questioning of the medicalization of "madness". Those critiques occurred at a time when physicians had not yet achieved hegemony through psychiatry, however, so there was no single, unified force to oppose. Nevertheless, there was increasing concern at the ease with which people could be confined, with frequent reports of abuse and illegal confinement. For example, Daniel Defoe, the author of Robinson Crusoe, had previously argued for more government oversight of "madhouses" and for due process prior to involuntary internment. He later argued that husbands used asylum hospitals to incarcerate their disobedient wives, and in a subsequent pamphlet that wives even did the same to their husbands. It was also proposed that the role of asylum keeper be separated from doctor, to discourage exploitation of patients. There was general concern that physicians were undermining personhood by medicalizing problems, by claiming they alone had the expertise to judge it, and by arguing that mental disorder was physical and hereditary. The Alleged Lunatics' Friend Society arose in England in the mid-19th century to challenge the system and campaign for rights and reforms. In the United States, Elizabeth Packard published a series of books and pamphlets describing her experiences in the Illinois insane asylum to which her husband had had her committed. 

Throughout, the class nature of mental hospitals, and their role as agencies of control, were well recognized. And the new psychiatry was partially challenged by two powerful social institutions – the church and the legal system. These trends have been thematically linked to the later 20th century anti-psychiatry movement.

As psychiatry became more professionally established during the nineteenth century (the term itself was coined in 1808 in Germany, as "Psychiatriein") and developed allegedly more invasive treatments, opposition increased. In the Southern US, black slaves and abolitionists encountered Drapetomania, a pseudo-scientific diagnosis for why slaves ran away from their masters.

There was some organized challenge to psychiatry in the late 1870s from the new speciality of neurology. Practitioners criticized mental hospitals for failure to conduct scientific research and adopt the modern therapeutic methods such as non-restraint. Together with lay reformers and social workers, neurologists formed the National Association for the Protection of the Insane and the Prevention of Insanity. However, when the lay members questioned the competence of asylum physicians to even provide proper care at all, the neurologists withdrew their support and the association floundered.

Early 1900s

It has been noted that "the most persistent critics of psychiatry have always been former mental hospital patients", but that very few were able to tell their stories publicly or to confront the psychiatric establishment openly, and those who did so were commonly considered so extreme in their charges that they could seldom gain credibility. In the early 20th century, ex-patient Clifford W. Beers campaigned to improve the plight of individuals receiving public psychiatric care, particularly those committed to state institutions, publicizing the issues in his book, A Mind that Found Itself (1908). While Beers initially condemned psychiatrists for tolerating mistreatment of patients, and envisioned more ex-patient involvement in the movement, he was influenced by Adolf Meyer and the psychiatric establishment, and toned down his hostility since he needed their support for reforms. 

His reliance on rich donors and his need for approval from experts led him to hand over to psychiatrists the organization he helped found, the National Committee for Mental Hygiene which eventually became the National Mental Health Association. In the UK, the National Society for Lunacy Law Reform was established in 1920 by angry ex-patients who sought justice for abuses committed in psychiatric custody, and were aggrieved that their complaints were patronisingly discounted by the authorities, who were seen to value the availability of medicalized internment as a 'whitewashed' extrajudicial custodial and punitive process. In 1922, ex-patient Rachel Grant-Smith added to calls for reform of the system of neglect and abuse she had suffered by publishing "The Experiences of an Asylum Patient". In the US, We Are Not Alone (WANA) was founded by a group of patients at Rockland State Hospital in New York, and continued to meet as an ex-patient group.

In the 1920s extreme hostility to psychiatrists and psychiatry was expressed by the French playwright and theater director Antonin Artaud, in particular, in his book on van Gogh. To Artaud, imagination was reality. Much influenced by the Dada and surrealist enthusiasms of the day, he considered dreams, thoughts and visions no less real than the "outside" world. To Artaud, reality appeared little more than a convenient consensus, the same kind of consensus an audience accepts when they enter a theater and, for a time, are happy to pretend what they're seeing is real.

In this era before penicillin was discovered, eugenics was popular. People believed diseases of the mind could be passed on so compulsory sterilization of the mentally ill was enacted in many countries.

Early 1930s

In the 1930s several controversial medical practices were introduced, including inducing seizures (by electroshock, insulin or other drugs) or cutting parts of the brain apart (lobotomy). In the US, between 1939 and 1951, over 50,000 lobotomy operations were performed in mental hospitals. But lobotomy was ultimately seen as too invasive and brutal.

Holocaust historians argued that the medicalization of social programs and systematic euthanasia of people in German mental institutions in the 1930s provided the institutional, procedural, and doctrinal origins of the mass murder of the 1940s. The Nazi programs were called Action T4 and Action 14f13. The Nuremberg Trials convicted a number of psychiatrists who held key positions in Nazi regimes. For instance this idea of a Swiss psychiatrist: "A not so easy question to be answered is whether it should be allowed to destroy lives objectively 'unworthy of living' without the expressed request of its bearers. (...) Even in incurable mentally ill ones suffering seriously from hallucinations and melancholic depressions and not being able to act, to a medical colleague I would ascript the right and in serious cases the duty to shorten — often for many years — the suffering" (Bleuler, Eugen, 1936: "Die naturwissenschaftliche Grundlage der Ethik". Schweizer Archiv Neurologie und Psychiatrie, Band 38, Nr.2, S. 206).

1940s and 1950s

The post-World War II decades saw an enormous growth in psychiatry; many Americans were persuaded that psychiatry and psychology, particularly psychoanalysis, were a key to happiness. Meanwhile, most hospitalized mental patients received at best decent custodial care, and at worst, abuse and neglect. 

The psychoanalyst Jacques Lacan has been identified as an influence on later anti-psychiatry theory in the UK, and as being the first, in the 1940s and 50s, to professionally challenge psychoanalysis to reexamine its concepts and to appreciate psychosis as understandable. Other influences on Lacan included poetry and the surrealist movement, including the poetic power of patients' experiences. Critics disputed this and questioned how his descriptions linked to his practical work. The names that came to be associated with the anti-psychiatry movement knew of Lacan and acknowledged his contribution even if they did not entirely agree. The psychoanalyst Erich Fromm is also said to have articulated, in the 1950s, the secular humanistic concern of the coming anti-psychiatry movement. In The Sane Society (1955), Fromm wrote ""An unhealthy society is one which creates mutual hostility [and] distrust, which transforms man into an instrument of use and exploitation for others, which deprives him of a sense of self, except inasmuch as he submits to others or becomes an automaton"..."Yet many psychiatrists and psychologists refuse to entertain the idea that society as a whole may be lacking in sanity. They hold that the problem of mental health in a society is only that of the number of 'unadjusted' individuals, and not of a possible unadjustment of the culture itself".

Graveyard attached to the Church of St. Thomas in West Yorkshire, England, where thousands of internees from Storthes Hall rest in unmarked graves

 

In the 1950s new psychiatric drugs, notably the antipsychotic chlorpromazine, slowly came into use. Although often accepted as an advance in some ways, there was opposition, partly due to serious adverse effects such as tardive dyskinesia, and partly due their "chemical straitjacket" effect and their alleged use to control and intimidate patients. Patients often opposed psychiatry and refused or stopped taking the drugs when not subject to psychiatric control. There was also increasing opposition to the large-scale use of psychiatric hospitals and institutions, and attempts were made to develop services in the community.

In 1950, Scientology was founded by L. Ron Hubbard who publicly stated a goal of "eradicating psychiatry from the face of this earth". Instead through his book Dianetics: The Modern Science of Mental Health the discredited use of introspection as treatment as well as auditing was promoted.

The Royal Earlswood Asylum for Idiots was the first hospital for people with learning disabilities, led by Lord Palmerston, Baron Rothschild and Lord Ashley in the 1850s

 

In the 1950s in the United States, a right-wing anti-mental health movement opposed psychiatry, seeing it as liberal, left-wing, subversive and anti-American or pro-Communist. There were widespread fears that it threatened individual rights and undermined moral responsibility. An early skirmish was over the Alaska Mental Health Bill, where the right wing protestors were joined by the emerging Scientology movement.

The field of psychology sometimes came into opposition with psychiatry. Behaviorists argued that mental disorder was a matter of learning not medicine; for example, Hans Eysenck argued that psychiatry "really has no role to play". The developing field of clinical psychology in particular came into close contact with psychiatry, often in opposition to its methods, theories and territories.

1960s

Coming to the fore in the 1960s, "anti-psychiatry" (a term first used by David Cooper in 1967) defined a movement that vocally challenged the fundamental claims and practices of mainstream psychiatry. While most of its elements had precedents in earlier decades and centuries, in the 1960s it took on a national and international character, with access to the mass media and incorporating a wide mixture of grassroots activist organizations and prestigious professional bodies.

Cooper was a South African psychiatrist working in Britain. A trained Marxist revolutionary, he argued that the political context of psychiatry and its patients had to be highlighted and radically challenged, and warned that the fog of individualized therapeutic language could take away people's ability to see and challenge the bigger social picture. He spoke of having a goal of "non-psychiatry" as well as anti-psychiatry.

"In the 1960s fresh voices mounted a new challenge to the pretensions of psychiatry as a science and the mental health system as a successful humanitarian enterprise. These voices included: Ernest Becker, Erving Goffman, R.D. Laing; Laing and Aaron Esterson, Thomas Scheff, and Thomas Szasz. Their writings, along with others such as articles in the journal The Radical Therapist, were given the umbrella label "antipsychiatry" despite wide divergences in philosophy. This critical literature, in concert with an activist movement, emphasized the hegemony of medical model psychiatry, its spurious sources of authority, its mystification of human problems, and the more oppressive practices of the mental health system, such as involuntary hospitalisation, drugging, and electroshock".

The psychiatrists R D Laing (from Scotland), Theodore Lidz (from America), Silvano Arieti (from Italy) and others, argued that "schizophrenia" and psychosis were understandable, and resulted from injuries to the inner self-inflicted by psychologically invasive "schizophrenogenic" parents or others. It was sometimes seen as a transformative state involving an attempt to cope with a sick society. Laing, however, partially dissociated himself from his colleague Cooper's term "anti-psychiatry". Laing had already become a media icon through bestselling books (such as The Divided Self and The Politics of Experience) discussing mental distress in an interpersonal existential context; Laing was somewhat less focused than his colleague Cooper on wider social structures and radical left wing politics, and went on to develop more romanticized or mystical views (as well as equivocating over the use of diagnosis, drugs and commitment). Although the movement originally described as anti-psychiatry became associated with the general counter-culture movement of the 1960s, Lidz and Arieti never became involved in the latter. Franco Basaglia promoted anti-psychiatry in Italy and secured reforms to mental health law there. 

Laing, through the Philadelphia Association founded with Cooper in 1965, set up over 20 therapeutic communities including Kingsley Hall, where staff and residents theoretically assumed equal status and any medication used was voluntary. Non-psychiatric Soteria houses, starting in the United States, were also developed as were various ex-patient-led services. 

Psychiatrist Thomas Szasz argued that "mental illness" is an inherently incoherent combination of a medical and a psychological concept. He opposed the use of psychiatry to forcibly detain, treat, or excuse what he saw as mere deviance from societal norms or moral conduct. As a libertarian, Szasz was concerned that such usage undermined personal rights and moral responsibility. Adherents of his views referred to "the myth of mental illness", after Szasz's controversial 1961 book of that name (based on a paper of the same name that Szasz had written in 1957 that, following repeated rejections from psychiatric journals, had been published in the American Psychologist in 1960). Although widely described as part of the main anti-psychiatry movement, Szasz actively rejected the term and its adherents; instead, in 1969, he collaborated with Scientology to form the Citizens Commission on Human Rights. It was later noted that the view that insanity was not in most or even in any instances a "medical" entity, but a moral issue, was also held by Christian Scientists and certain Protestant fundamentalists, as well as Szasz. Szasz was not a Scientologist himself and was non-religious; he commented frequently on the parallels between religion and psychiatry. 

Erving Goffman, Gilles Deleuze, Félix Guattari and others criticized the power and role of psychiatry in society, including the use of "total institutions" and the use of models and terms that were seen as stigmatizing. The French sociologist and philosopher Foucault, in his 1961 publication Madness and Civilization: A History of Insanity in the Age of Reason, analyzed how attitudes towards those deemed "insane" had changed as a result of changes in social values. He argued that psychiatry was primarily a tool of social control, based historically on a "great confinement" of the insane and physical punishment and chains, later exchanged in the moral treatment era for psychological oppression and internalized restraint. American sociologist Thomas Scheff applied labeling theory to psychiatry in 1966 in "Being Mentally Ill". Scheff argued that society views certain actions as deviant and, in order to come to terms with and understand these actions, often places the label of mental illness on those who exhibit them. Certain expectations are then placed on these individuals and, over time, they unconsciously change their behavior to fulfill them.

Observation of the abuses of psychiatry in the Soviet Union in the so-called Psikhushka hospitals also led to questioning the validity of the practice of psychiatry in the West. In particular, the diagnosis of many political dissidents with schizophrenia led some to question the general diagnosis and punitive usage of the label schizophrenia. This raised questions as to whether the schizophrenia label and resulting involuntary psychiatric treatment could not have been similarly used in the West to subdue rebellious young people during family conflicts.

Since 1970

Scientologists on an anti-psychiatry demonstration.

 

New professional approaches were developed as an alternative or reformist complement to psychiatry. The Radical Therapist, a journal begun in 1971 in North Dakota by Michael Glenn, David Bryan, Linda Bryan, Michael Galan and Sara Glenn, challenged the psychotherapy establishment in a number of ways, raising the slogan "Therapy means change, not adjustment." It contained articles that challenged the professional mediator approach, advocating instead revolutionary politics and authentic community making. Social work, humanistic or existentialist therapies, family therapy, counseling and self-help and clinical psychology developed and sometimes opposed psychiatry.

Psychoanalysis was increasingly criticized as unscientific or harmful. Contrary to the popular view, critics and biographers of Freud, such as Alice Miller, Jeffrey Masson and Louis Breger, argued that Freud did not grasp the nature of psychological trauma. Non-medical collaborative services were developed, for example therapeutic communities or Soteria houses. 

The psychoanalytically trained psychiatrist Szasz, although professing fundamental opposition to what he perceives as medicalization and oppressive or excuse-giving "diagnosis" and forced "treatment", was not opposed to other aspects of psychiatry (for example attempts to "cure-heal souls", although he also characterizes this as non-medical). Although generally considered anti-psychiatry by others, he sought to dissociate himself politically from a movement and term associated with the radical left-wing. In a 1976 publication "Anti-psychiatry: The paradigm of a plundered mind", which has been described as an overtly political condemnation of a wide sweep of people, Szasz claimed Laing, Cooper and all of anti-psychiatry consisted of "self-declared socialists, communists, or at least anti-capitalists and collectivists". While saying he shared some of their critique of the psychiatric system, Szasz compared their views on the social causes of distress/deviance to those of anti-capitalist anti-colonialists who claimed that Chilean poverty was due to plundering by American companies, a comment Szasz made not long after a CIA-backed coup had deposed the democratically elected Chilean president and replaced him with Pinochet. Szasz argued instead that distress/deviance is due to the flaws or failures of individuals in their struggles in life.

The anti-psychiatry movement was also being driven by individuals with adverse experiences of psychiatric services. This included those who felt they had been harmed by psychiatry or who felt that they could have been helped more by other approaches, including those compulsorily (including via physical force) admitted to psychiatric institutions and subjected to compulsory medication or procedures. During the 1970s, the anti-psychiatry movement was involved in promoting restraint from many practices seen as psychiatric abuses.

The gay rights movement continued to challenge the classification of homosexuality as a mental illness and in 1974, in a climate of controversy and activism, the American Psychiatric Association membership (following a unanimous vote by the trustees in 1973) voted by a small majority (58%) to remove it as an illness category from the DSM, replacing it with a category of "sexual orientation disturbance" and then "ego-dystonic homosexuality," which was deleted in 1987, although "gender identity disorder" (a widely used term for gender dysphoria) and a wide variety of "paraphilias" remain. It has been noted that gay activists at the time adopted many of Szasz's arguments against the psychiatric system, but also that Szasz had written in 1965 that: "I believe it is very likely that homosexuality is, indeed, a disease in the second sense [expression of psychosexual immaturity] and perhaps sometimes even in the stricter sense [a condition somewhat similar to ordinary organic maladies perhaps caused by genetic error or endocrine imbalance. Nevertheless, if we believe that by categorising homosexuality as a disease we have succeeded in removing it from the realm of moral judgement, we are in error."

Increased legal and professional protections, and a merging with human rights and disability rights movements, added to anti-psychiatry theory and action. 

Anti-psychiatry came to challenge a "biomedical" focus of psychiatry (defined to mean genetics, neurochemicals and pharmaceutic drugs). There was also opposition to the increasing links between psychiatry and pharmaceutical companies, which were becoming more powerful and were increasingly claimed to have excessive, unjustified and underhand influence on psychiatric research and practice. There was also opposition to the codification of, and alleged misuse of, psychiatric diagnoses into manuals, in particular the American Psychiatric Association, which publishes the Diagnostic and Statistical Manual of Mental Disorders.

Anti-psychiatry increasingly challenged alleged psychiatric pessimism and institutionalized alienation regarding those categorized as mentally ill. An emerging consumer/survivor movement often argues for full recovery, empowerment, self-management and even full liberation. Schemes were developed to challenge stigma and discrimination, often based on a social model of disability; to assist or encourage people with mental health issues to engage more fully in work and society (for example through social firms), and to involve service users in the delivery and evaluation of mental health services. However, those actively and openly challenging the fundamental ethics and efficacy of mainstream psychiatric practice remained marginalized within psychiatry, and to a lesser extent within the wider mental health community.

Three authors came to personify the movement against psychiatry, and two of these were practicising psychiatrists. The initial and most influential of these was Thomas Szasz who rose to fame with his book The Myth of Mental Illness, although Szasz himself did not identify as an anti-psychiatrist. The well-respected R D Laing wrote a series of best-selling books, including The Divided Self. Intellectual philosopher Michel Foucault challenged the very basis of psychiatric practice and cast it as repressive and controlling. The term "anti-psychiatry" was coined by David Cooper in 1967. In parallel with the theoretical production of the mentioned authors, the Italian physician Giorgio Antonucci questioned the basis themselves of psychiatry through the dismantling of the psychiatric hospitals Osservanza and Luigi Lolli and the liberation – and restitution to life – of the people there secluded.

Challenges to psychiatry

Civilization as a cause of distress

In recent years, psychotherapists David Smail and Bruce E. Levine, considered part of the anti-psychiatry movement, have written widely on how society, culture, politics and psychology intersect. They have written extensively of the "embodied nature" of the individual in society, and the unwillingness of even therapists to acknowledge the obvious part played by power and financial interest in modern Western society. They argue that feelings and emotions are not, as is commonly supposed, features of the individual, but rather responses of the individual to their situation in society. Even psychotherapy, they suggest, can only change feelings in as much as it helps a person to change the "proximal" and "distal" influences on their life, which range from family and friends, to the workplace, socio-economics, politics and culture.

R. D. Laing emphasized family nexus as a mechanism whereby individuals become victimized by those around them, and spoke about a dysfunctional society.

Inadequacy of clinical interviews used to diagnose 'diseases'

An etiology common to bipolar spectrum disorders has not been identified. Patients cannot be identified just by clinical interviews [citation needed]. A neurobiological basis of bipolar disorder has not been discovered [citation needed]. In making a bipolar spectrum disorder diagnosis based solely on a clinical interview, a false positive cannot be avoided [citation needed]. 

Psychiatrists have been trying to differentiate mental disorders based on clinical interviews since the era of Kraepelin, but now realize that their diagnostic criteria are imperfect. Tadafumi Kato writes, "We psychiatrists should be aware that we cannot identify 'diseases' only by interviews. What we are doing now is just like trying to diagnose diabetes mellitus without measuring blood sugar."

Normality and illness judgments

A madness of civilization: the American physician Samuel A. Cartwright identified what he called drapetomania, an ailment that caused slaves to be possessed by a desire for freedom and a want to escape

 

In 2013, psychiatrist Allen Frances said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests".

Reasons have been put forward to doubt the ontic status of mental disorders. Mental disorders engender ontological skepticism on three levels:

1. Mental disorders are abstract entities that cannot be directly appreciated with the human senses or indirectly, as one might with macro- or microscopic objects.
2. Mental disorders are not clearly natural processes whose detection is untarnished by the imposition of values, or human interpretation.
3. It is unclear whether they should be conceived as abstractions that exist in the world apart from the individual persons who experience them, and thus instantiate them.

In the scientific and academic literature on the definition or classification of mental disorder, one extreme argues that it is entirely a matter of value judgements (including of what is normal) while another proposes that it is or could be entirely objective and scientific (including by reference to statistical norms). Common hybrid views argue that the concept of mental disorder is objective but a "fuzzy prototype" that can never be precisely defined, or alternatively that it inevitably involves a mix of scientific facts and subjective value judgments.

One remarkable example of psychiatric diagnosis being used to reinforce cultural bias and oppress dissidence is the diagnosis of drapetomania. In the US prior to the American Civil War, physicians such as Samuel A. Cartwright diagnosed some slaves with drapetomania, a mental illness in which the slave possessed an irrational desire for freedom and a tendency to try to escape. By classifying such a dissident mental trait as abnormal and a disease, psychiatry promoted cultural bias about normality, abnormality, health, and illness. This example indicates the probability for not only cultural bias but also confirmation bias and bias blind spot in psychiatric diagnosis and psychiatric beliefs.

It has been argued by philosophers like Foucault that characterizations of "mental illness" are indeterminate and reflect the hierarchical structures of the societies from which they emerge rather than any precisely defined qualities that distinguish a "healthy" mind from a "sick" one. Furthermore, if a tendency toward self-harm is taken as an elementary symptom of mental illness, then humans, as a species, are arguably insane in that they have tended throughout recorded history to destroy their own environments, to make war with one another, etc.

Psychiatric labeling

"Psychiater Europas! Wahret Eure heiligsten Diagnosen!" ("Psychiatrists of Europe! Protect your sanctified diagnoses!"), says the inscription on the cartoon by Emil Kraepelin, who introduced the schizophrenia concept, "Bierzeitung", Heidelberg, 1896

Mental disorders were first included in the sixth revision of the International Classification of Diseases (ICD-6) in 1949. Three years later, the American Psychiatric Association created its own classification system, DSM-I. The definitions of most psychiatric diagnoses consist of combinations of phenomenological criteria, such as symptoms and signs and their course over time. Expert committees combined them in variable ways into categories of mental disorders, defined and redefined them again and again over the last half century.

The majority of these diagnostic categories are called "disorders" and are not validated by biological criteria, as most medical diseases are; although they purport to represent medical diseases and take the form of medical diagnoses. These diagnostic categories are actually embedded in top-down classifications, similar to the early botanic classifications of plants in the 17th and 18th centuries, when experts decided a priori about which classification criterion to use, for instance, whether the shape of leaves or fruiting bodies were the main criterion for classifying plants. Since the era of Kraepelin, psychiatrists have been trying to differentiate mental disorders by using clinical interviews.

Experiments admitting "healthy" individuals into psychiatric care

In 1972, psychologist David Rosenhan published the Rosenhan experiment, a study questioning the validity of psychiatric diagnoses. The study arranged for eight individuals with no history of psychopathology to attempt admission into psychiatric hospitals. The individuals included a graduate student, psychologists, an artist, a housewife, and two physicians, including one psychiatrist. All eight individuals were admitted with a diagnosis of schizophrenia or bipolar disorder. Psychiatrists then attempted to treat the individuals using psychiatric medication. All eight were discharged within 7 to 52 days. In a later part of the study, psychiatric staff were warned that pseudo-patients might be sent to their institutions, but none were actually sent. Nevertheless, a total of 83 patients out of 193 were believed by at least one staff member to be actors. The study concluded that individuals without mental disorders were indistinguishable from those suffering from mental disorders.

Critics such as Robert Spitzer placed doubt on the validity and credibility of the study, but did concede that the consistency of psychiatric diagnoses needed improvement. It is now realized that the psychiatric diagnostic criteria are not perfect. To further refine psychiatric diagnosis, according to Tadafumi Kato, the only way is to create a new classification of diseases based on the neurobiological features of each mental disorder. On the other hand, according to Heinz Katsching, neurologists are advising psychiatrists just to replace the term "mental illness" by "brain illness."

There are recognized problems regarding the diagnostic reliability and validity of mainstream psychiatric diagnoses, both in ideal and controlled circumstances and even more so in routine clinical practice (McGorry et al.. 1995). Criteria in the principal diagnostic manuals, the DSM and ICD, are inconsistent. Some psychiatrists who criticize their own profession say that comorbidity, when an individual meets criteria for two or more disorders, is the rule rather than the exception. There is much overlap and vaguely defined or changeable boundaries between what psychiatrists claim are distinct illness states.

There are also problems with using standard diagnostic criteria in different countries, cultures, genders or ethnic groups. Critics often allege that Westernized, white, male-dominated psychiatric practices and diagnoses disadvantage and misunderstand those from other groups. For example, several studies have shown that African Americans are more often diagnosed with schizophrenia than Caucasians, and men more than women. Some within the anti-psychiatry movement are critical of the use of diagnosis as it conforms with the biomedical model.

Tool of social control

Whitchurch Hospital.

 

According to Franco Basaglia, Giorgio Antonucci, Bruce E. Levine and Edmund Schönenberger whose approach pointed out the role of psychiatric institutions in the control and medicalization of deviant behaviors and social problems, psychiatry is used as the provider of scientific support for social control to the existing establishment, and the ensuing standards of deviance and normality brought about repressive views of discrete social groups. According to Mike Fitzpatrick, resistance to medicalization was a common theme of the gay liberation, anti-psychiatry, and feminist movements of the 1970s, but now there is actually no resistance to the advance of government intrusion in lifestyle if it is thought to be justified in terms of public health.

In the opinion of Mike Fitzpatrick, the pressure for medicalization also comes from society itself. As one example, Fitzpatrick claims that feminists who once opposed state intervention as oppressive and patriarchal, now demand more coercive and intrusive measures to deal with child abuse and domestic violence. According to Richard Gosden, the use of psychiatry as a tool of social control is becoming obvious in preventive medicine programs for various mental diseases. These programs are intended to identify children and young people with divergent behavioral patterns and thinking and send them to treatment before their supposed mental diseases develop. Clinical guidelines for best practice in Australia include the risk factors and signs which can be used to detect young people who are in need of prophylactic drug treatment to prevent the development of schizophrenia and other psychotic conditions.

Psychiatry and the pharmaceutical industry

Critics of psychiatry commonly express a concern that the path of diagnosis and treatment in contemporary society is primarily or overwhelmingly shaped by profit prerogatives, echoing a common criticism of general medical practice in the United States, where many of the largest psychopharmaceutical producers are based.

Psychiatric research has demonstrated varying degrees of efficacy for improving or managing a number of mental health disorders through either medications, psychotherapy, or a combination of the two. Typical psychiatric medications include stimulants, antidepressants, anxiolytics, and antipsychotics (neuroleptics). 

On the other hand, organizations such as MindFreedom International and World Network of Users and Survivors of Psychiatry maintain that psychiatrists exaggerate the evidence of medication and minimize the evidence of adverse drug reaction. They and other activists believe individuals are not given balanced information, and that current psychiatric medications do not appear to be specific to particular disorders in the way mainstream psychiatry asserts; and psychiatric drugs not only fail to correct measurable chemical imbalances in the brain, but rather induce undesirable side effects. For example, though children on Ritalin and other psycho-stimulants become more obedient to parents and teachers, critics have noted that they can also develop abnormal movements such as tics, spasms and other involuntary movements. This has not been shown to be directly related to the therapeutic use of stimulants, but to neuroleptics. The diagnosis of attention deficit hyperactivity disorder on the basis of inattention to compulsory schooling also raises critics' concerns regarding the use of psychoactive drugs as a means of unjust social control of children.

The influence of pharmaceutical companies is another major issue for the anti-psychiatry movement. As many critics from within and outside of psychiatry have argued, there are many financial and professional links between psychiatry, regulators, and pharmaceutical companies. Drug companies routinely fund much of the research conducted by psychiatrists, advertise medication in psychiatric journals and conferences, fund psychiatric and healthcare organizations and health promotion campaigns, and send representatives to lobby general physicians and politicians. Peter Breggin, Sharkey, and other investigators of the psycho-pharmaceutical industry maintain that many psychiatrists are members, shareholders or special advisors to pharmaceutical or associated regulatory organizations.

There is evidence that research findings and the prescribing of drugs are influenced as a result. A United Kingdom cross-party parliamentary inquiry into the influence of the pharmaceutical industry in 2005 concludes: "The influence of the pharmaceutical industry is such that it dominates clinical practice" and that there are serious regulatory failings resulting in "the unsafe use of drugs; and the increasing medicalization of society". The campaign organization No Free Lunch details the prevalent acceptance by medical professionals of free gifts from pharmaceutical companies and the effect on psychiatric practice. The ghostwriting of articles by pharmaceutical company officials, which are then presented by esteemed psychiatrists, has also been highlighted. Systematic reviews have found that trials of psychiatric drugs that are conducted with pharmaceutical funding are several times more likely to report positive findings than studies without such funding.

The number of psychiatric drug prescriptions have been increasing at an extremely high rate since the 1950s and show no sign of abating. In the United States antidepressants and tranquilizers are now the top selling class of prescription drugs, and neuroleptics and other psychiatric drugs also rank near the top, all with expanding sales. As a solution to the apparent conflict of interests, critics propose legislation to separate the pharmaceutical industry from the psychiatric profession.

John Read and Bruce E. Levine have advanced the idea of socioeconomic status as a significant factor in the development and prevention of mental disorders such as schizophrenia and have noted the reach of pharmaceutical companies through industry sponsored websites as promoting a more biological approach to mental disorders, rather than a comprehensive biological, psychological and social model.

Electroconvulsive therapy

A Bergonic chair "for giving general electric treatment for psychological effect, in psycho-neurotic cases", according to original photo description. World War I era.

 

Psychiatrists may advocate psychiatric drugs, psychotherapy or more controversial interventions such as electroshock or psychosurgery to treat mental illness. Electroconvulsive therapy (ECT) is administered worldwide typically for severe mental disorders. Across the globe it has been estimated that approximately 1 million patients receive ECT per year. Exact numbers of how many persons per year have ECT in the United States are unknown due to the variability of settings and treatment. Researchers' estimates generally range from 100,000 to 200,000 persons per year.

Some persons receiving ECT die during the procedure (ECT is performed under a general anaesthetic, which always carries a risk). Leonard Roy Frank writes that estimates of ECT-related death rates vary widely. The lower estimates include: 2-4 in 100,000 (from Kramer's 1994 study of 28,437 patients), 1 in 10,000 (Boodman's first entry in 1996), 1 in 1,000 (Impastato's first entry in 1957), 1 in 200, among the elderly, over 60 (Impastato's in 1957) Higher estimates include: 1 in 102 (Martin's entry in 1949), 1 in 95 (Boodman's first entry in 1996), 1 in 92 (Freeman and Kendell's entry in 1976), 1 in 89 (Sagebiel's in 1961), 1 in 69 (Gralnick's in 1946),  1 in 63, among a group undergoing intensive ECT (Perry's in 1963–1979), 1 in 38 (Ehrenberg's in 1955), 1 in 30 (Kurland's in 1959), 1 in 9 among a group undergoing intensive ECT (Weil's in 1949), 1 in 4, among the very elderly, over 80 (Kroessler and Fogel's in 1974–1986).

Political abuse of psychiatry

The psychiatric ward at Guantanamo Bay.

 

Psychiatrists around the world have been involved in the suppression of individual rights by states wherein the definitions of mental disease had been expanded to include political disobedience. Nowadays, in many countries, political prisoners are sometimes confined to mental institutions and abused therein. Psychiatry possesses a built-in capacity for abuse which is greater than in other areas of medicine. The diagnosis of mental disease can serve as proxy for the designation of social dissidents, allowing the state to hold persons against their will and to insist upon therapies that work in favour of ideological conformity and in the broader interests of society. In a monolithic state, psychiatry can be used to bypass standard legal procedures for establishing guilt or innocence and allow political incarceration without the ordinary odium attaching to such political trials.

Under the Nazi regime in the 1940s, the 'duty to care' was violated on an enormous scale. In Germany alone 300,000 individuals that had been deemed mentally ill, work-shy or feeble-minded were sterilized. An additional 200,000 were euthanized. These practices continued in territories occupied by the Nazis further afield (mainly in eastern Europe), affecting thousands more. From the 1960s up to 1986, political abuse of psychiatry was reported to be systematic in the Soviet Union, and to surface on occasion in other Eastern European countries such as Romania, Hungary, Czechoslovakia, and Yugoslavia. A "mental health genocide" reminiscent of the Nazi aberrations has been located in the history of South African oppression during the apartheid era. A continued misappropriation of the discipline was subsequently attributed to the People's Republic of China.

K. Fulford, A. Smirnov, and E. Snow state: "An important vulnerability factor, therefore, for the abuse of psychiatry, is the subjective nature of the observations on which psychiatric diagnosis currently depends." In an article published in 1994 by American psychiatrist Thomas Szasz on the Journal of Medical Ethics he stated that "the classification by slave owners and slave traders of certain individuals as Negroes was scientific, in the sense that whites were rarely classified as blacks. But that did not prevent the 'abuse' of such racial classification, because (what we call) its abuse was, in fact, its use." Szasz argued that the spectacle of the Western psychiatrists loudly condemning Soviet colleagues for their abuse of professional standards was largely an exercise in hypocrisy. Szasz states that K. Fulford, A. Smirnov, and E. Snow, who correctly emphasize the value-laden nature of psychiatric diagnoses and the subjective character of psychiatric classifications, fail to accept the role of psychiatric power. He stated that psychiatric abuse, such as people usually associated with practices in the former USSR, was connected not with the misuse of psychiatric diagnoses, but with the political power built into the social role of the psychiatrist in democratic and totalitarian societies alike. Musicologists, drama critics, art historians, and many other scholars also create their own subjective classifications; however, lacking state-legitimated power over persons, their classifications do not lead to anyone's being deprived of property, liberty, or life. For instance, plastic surgeon's classification of beauty is subjective, but the plastic surgeon cannot treat his or her patient without the patient's consent, therefore, there cannot be any political abuse of plastic surgery.

The bedrock of political medicine is coercion masquerading as medical treatment. What transforms coercion into therapy are physicians diagnosing the person's condition an "illness," declaring the intervention they impose on the victim a "treatment," and legislators and judges legitimating these categorizations as "illnesses" and "treatments." In the same way, physician-eugenicists advocated killing certain disabled or ill persons as a form of treatment for both society and patient long before the Nazis came to power.

From the commencement of his political career, Hitler put his struggle against "enemies of the state" in medical rhetoric. In 1934, addressing the Reichstag, Hitler declared, "I gave the order… to burn out down to the raw flesh the ulcers of our internal well-poisoning." The entire German nation and its National Socialist politicians learned to think and speak in such terms. Werner Best, Reinhard Heydrich’s deputy, stated that the task of the police was "to root out all symptoms of disease and germs of destruction that threatened the political health of the nation… [In addition to Jews,] most [of the germs] were weak, unpopular and marginalized groups, such as gypsies, homosexuals, beggars, 'antisocials', 'work-shy', and 'habitual criminals'."

In spite of all the evidence, people underappreciate or, more often, ignore the political implications of the therapeutic character of Nazism and of the use of medical metaphors in modern democracies. Dismissed as an "abuse of psychiatry", this practice is a touchy subject not because the story makes psychiatrists in Nazi Germany look bad, but because it highlights the dramatic similarities between pharmacratic controls in Germany under Nazism and those that have emerged in the US under the free market economy.

The Swiss lawyer Edmund Schönenberger claims that the strongholds of psychiatry have absolutely nothing to do with “care”, the law or justice – instead, they are nothing other than instruments of domination.

"Therapeutic state"

The "therapeutic state" is a phrase coined by Szasz in 1963. The collaboration between psychiatry and government leads to what Szasz calls the "therapeutic state", a system in which disapproved actions, thoughts, and emotions are repressed ("cured") through pseudomedical interventions. Thus suicide, unconventional religious beliefs, racial bigotry, unhappiness, anxiety, shyness, sexual promiscuity, shoplifting, gambling, overeating, smoking, and illegal drug use are all considered symptoms or illnesses that need to be cured. When faced with demands for measures to curtail smoking in public, binge-drinking, gambling or obesity, ministers say that "we must guard against charges of nanny statism". The "nanny state" has turned into the "therapeutic state" where nanny has given way to counselor. Nanny just told people what to do; counselors also tell them what to think and what to feel. The "nanny state" was punitive, austere, and authoritarian, the therapeutic state is touchy-feely, supportive—and even more authoritarian. According to Szasz, "the therapeutic state swallows up everything human on the seemingly rational ground that nothing falls outside the province of health and medicine, just as the theological state had swallowed up everything human on the perfectly rational ground that nothing falls outside the province of God and religion".

Faced with the problem of "madness", Western individualism proved to be ill-prepared to defend the rights of the individual: modern man has no more right to be a madman than medieval man had a right to be a heretic because if once people agree that they have identified the one true God, or Good, it brings about that they have to guard members and nonmembers of the group from the temptation to worship false gods or goods. A secularization of God and the medicalization of good resulted in the post-Enlightenment version of this view: once people agree that they have identified the one true reason, it brings about that they have to guard against the temptation to worship unreason—that is, madness.

Civil libertarians warn that the marriage of the State with psychiatry could have catastrophic consequences for civilization. In the same vein as the separation of church and state, Szasz believes that a solid wall must exist between psychiatry and the State.

"Total institution"

In his book Asylums, Erving Goffman coined the term 'total institution' for mental hospitals and similar places which took over and confined a person's whole life. Goffman placed psychiatric hospitals in the same category as concentration camps, prisons, military organizations, orphanages, and monasteries. In Asylums Goffman describes how the institutionalization process socializes people into the role of a good patient, someone 'dull, harmless and inconspicuous'; it in turn reinforces notions of chronicity in severe mental illness.

Law

While the insanity defense is the subject of controversy as a viable excuse for wrongdoing, Szasz and other critics contend that being committed in a psychiatric hospital can be worse than criminal imprisonment, since it involves the risk of compulsory medication with neuroleptics or the use of electroshock treatment. Moreover, while a criminal imprisonment has a predetermined and known time of duration, patients are typically committed to psychiatric hospitals for indefinite durations, an unjust and arguably outrageous imposition of fundamental uncertainty. It has been argued that such uncertainty risks aggravating mental instability, and that it substantially encourages a lapse into hopelessness and acceptance that precludes recovery.

Involuntary hospitalization

Critics see the use of legally sanctioned force in involuntary commitment as a violation of the fundamental principles of free or open societies. The political philosopher John Stuart Mill and others have argued that society has no right to use coercion to subdue an individual as long as he or she does not harm others. Mentally ill people are essentially no more prone to violence than sane individuals, despite Hollywood and other media portrayals to the contrary. The growing practice, in the United Kingdom and elsewhere, of Care in the Community was instituted partly in response to such concerns. Alternatives to involuntary hospitalization include the development of non-medical crisis care in the community.

In the case of people suffering from severe psychotic crises, the American Soteria project used to provide what was argued to be a more humane and compassionate alternative to coercive psychiatry. The Soteria houses closed in 1983 in the United States due to lack of financial support. However, similar establishments are presently flourishing in Europe, especially in Sweden and other North European countries.

The physician Giorgio Antonucci, during his activity as a director of the Ospedale Psichiatrico Osservanza of Imola, refused any form of coercion and any violation of the fundamental principles of freedom, questioning the basis of psychiatry itself.

Psychiatry as pseudoscience and failed enterprise

Many of the above issues lead to the claim that psychiatry is a pseudoscience. According to some philosophers of science, for a theory to qualify as science it needs to exhibit the following characteristics:

• parsimony, as straightforward as the phenomena to be explained allow;
• empirically testable and falsifiable;
• changeable, i.e. if necessary, changes may be made to the theory as new data are discovered;
• progressive, encompasses previous successful descriptions and explains and adds more;
• provisional, i.e. tentative; the theory does not attempt to assert that it is a final description or explanation.

Psychiatrist Colin A. Ross and Alvin Pam maintain that biopsychiatry does not qualify as a science on many counts.

Psychiatric researcher have been criticised on the basis of the replication crisis  and textbook errors. Questionable research practices are known to bias key sources of evidence.

Stuart A. Kirk has argued that psychiatry is a failed enterprise, as mental illness has grown, not shrunk, with about 20% of American adults diagnosable as mentally ill in 2013.

According to a 2014 meta-analysis, psychiatric treatment is no less effective for psychiatric illnesses in terms of treatment effects than treatments by practitioners of other medical specialties for physical health conditions. The analysis found that the effect sizes for psychiatric interventions are, on average, on par with other fields of medicine.

Diverse paths

Szasz has since (2008) re-emphasized his disdain for the term anti-psychiatry, arguing that its legacy has simply been a "catchall term used to delegitimize and dismiss critics of psychiatric fraud and force by labeling them 'antipsychiatrists'". He points out that the term originated in a meeting of four psychiatrists (Cooper, Laing, Berke and Redler) who never defined it yet "counter-label[ed] their discipline as anti-psychiatry", and that he considers Laing most responsible for popularizing it despite also personally distancing himself. Szasz describes the deceased (1989) Laing in vitriolic terms, accusing him of being irresponsible and equivocal on psychiatric diagnosis and use of force, and detailing his past "public behavior" as "a fit subject for moral judgment" which he gives as "a bad person and a fraud as a professional".

Daniel Burston, however, has argued that overall the published works of Szasz and Laing demonstrate far more points of convergence and intellectual kinship than Szasz admits, despite the divergence on a number of issues related to Szasz being a libertarian and Laing an existentialist; that Szasz employs a good deal of exaggeration and distortion in his criticism of Laing's personal character, and unfairly uses Laing's personal failings and family woes to discredit his work and ideas; and that Szasz's "clear-cut, crystalline ethical principles are designed to spare us the agonizing and often inconclusive reflections that many clinicians face frequently in the course of their work". Szasz has indicated that his own views came from libertarian politics held since his teens, rather than through experience in psychiatry; that in his "rare" contacts with involuntary mental patients in the past he either sought to discharge them (if they were not charged with a crime) or "assisted the prosecution in securing [their] conviction" (if they were charged with a crime and appeared to be prima facie guilty); that he is not opposed to consensual psychiatry and "does not interfere with the practice of the conventional psychiatrist", and that he provided "listening-and-talking ("psychotherapy")" for voluntary fee-paying clients from 1948 until 1996, a practice he characterizes as non-medical and not associated with his being a psychoanalytically trained psychiatrist.

The gay rights or gay liberation movement is often thought to have been part of anti-psychiatry in its efforts to challenge oppression and stigma and, specifically, to get homosexuality removed from the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders. However, a psychiatric member of APA's Gay, Lesbian, and Bisexual Issues Committee has recently sought to distance the two, arguing that they were separate in the early 70s protests at APA conventions and that APA's decision to remove homosexuality was scientific and happened to coincide with the political pressure. Reviewers have responded, however, that the founders and movements were closely aligned; that they shared core texts, proponents and slogans; and that others have stated that, for example, the gay liberation critique was "made possible by (and indeed often explicitly grounded in) traditions of antipsychiatry".

In the clinical setting, the two strands of anti-psychiatry—criticism of psychiatric knowledge and reform of its practices—were never entirely distinct. In addition, in a sense, anti-psychiatry was not so much a demand for the end of psychiatry, as it was an often self-directed demand for psychiatrists and allied professionals to question their own judgements, assumptions and practices. In some cases, the suspicion of non-psychiatric medical professionals towards the validity of psychiatry was described as anti-psychiatry, as well the criticism of "hard-headed" psychiatrists towards "soft-headed" psychiatrists. Most leading figures of anti-psychiatry were themselves psychiatrists, and equivocated over whether they were really "against psychiatry", or parts thereof. Outside the field of psychiatry, however—e.g. for activists and non-medical mental health professionals such as social workers and psychologists—'anti-psychiatry' tended to mean something more radical. The ambiguous term "anti-psychiatry" came to be associated with these more radical trends, but there was debate over whether it was a new phenomenon, whom it best described, and whether it constituted a genuinely singular movement. In order to avoid any ambiguity intrinsic to the term anti-psychiatry, a current of thought that can be defined as critique of the basis of psychiatry, radical and unambiguous, aims for the complete elimination of psychiatry. The main representative of the critique of the basis of psychiatry is an Italian physician, Giorgio Antonucci.

In the 1990s, a tendency was noted among psychiatrists to characterize and to regard the anti-psychiatric movement as part of the past, and to view its ideological history as flirtation with the polemics of radical politics at the expense of scientific thought and enquiry. It was also argued, however, that the movement contributed towards generating demand for grassroots involvement in guidelines and advocacy groups, and to the shift from large mental institutions to community services. Additionally, community centers have tended in practice to distance themselves from the psychiatric/medical model and have continued to see themselves as representing a culture of resistance or opposition to psychiatry's authority. Overall, while antipsychiatry as a movement may have become an anachronism by this period and was no longer led by eminent psychiatrists, it has been argued that it became incorporated into the mainstream practice of mental health disciplines. On the other hand, mainstream psychiatry became more biomedical, increasing the gap between professionals. 

Henry Nasrallah claims that while he believes anti-psychiatry consists of many historical exaggerations based on events and primitive conditions from a century ago, "antipsychiatry helps keep us honest and rigorous about what we do, motivating us to relentlessly seek better diagnostic models and treatment paradigms. Psychiatry is far more scientific today than it was a century ago, but misperceptions about psychiatry continue to be driven by abuses of the past. The best antidote for antipsychiatry allegations is a combination of personal integrity, scientific progress, and sound evidence-based clinical care".

A criticism was made in the 1990s that three decades of anti-psychiatry had produced a large literature critical of psychiatry, but little discussion of the deteriorating situation of the mentally troubled in American society. Anti-psychiatry crusades have thus been charged with failing to put suffering individuals first, and therefore being similarly guilty of what they blame psychiatrists for. The rise of anti-psychiatry in Italy was described by one observer as simply "a transfer of psychiatric control from those with medical knowledge to those who possessed socio-political power".

Critics of this view, however, from an anti-psychiatry perspective, are quick to point to the industrial aspects of psychiatric treatment itself as a primary causal factor in this situation that is described as "deteriorating". The numbers of people labeled "mentally ill", and in treatment, together with the severity of their conditions, have been going up primarily due to the direct efforts of the mental health movement, and mental health professionals, including psychiatrists, and not their detractors. Envisioning "mental health treatment" as violence prevention has been a big part of the problem, especially as you are dealing with a population that is not significantly more violent than any other group and, in fact, are less so than many. 

On October 7, 2016, the Ontario Institute for Studies in Education (OISE) at the University of Toronto announced that they had established a scholarship for students doing theses in the area of antipsychiatry. Called “The Bonnie Burstow Scholarship in Antipsychiatry,” it is to be awarded annually to an OISE thesis student. An unprecedented step, the scholarship should further the cause of freedom of thought and the exchange of ideas in academia. The scholarship is named in honor of Bonnie Burstow, a faculty member at the University of Toronto, a radical feminist, and an antipsychiatry activist. She is also the author of Psychiatry and the Business of Madness (2015). 

Some components of antipsychiatric theory have in recent decades been reformulated into a critique of "corporate psychiatry", heavily influenced by the pharmaceutical industry. A recent editorial about this was published in the British Journal of Psychiatry by Moncrieff, arguing that modern psychiatry has become a handmaiden to conservative political commitments. David Healy is a psychiatrist and professor in psychological medicine at Cardiff University School of Medicine, Wales. He has a special interest in the influence of the pharmaceutical industry on medicine and academia.

With the decline of industrial age psychiatric hospitals, efforts to rehabilitate them have begun, like the Traverse City State Hospital becoming the Village at Grand Traverse Commons, complete with homes, offices, and businesses, including a wine bar

 

In the meantime, members of the psychiatric consumer/survivor movement continued to campaign for reform, empowerment and alternatives, with an increasingly diverse representation of views. Groups often have been opposed and undermined, especially when they proclaim to be, or when they are labelled as being, "anti-psychiatry". However, as of the 1990s, more than 60 percent of ex-patient groups reportedly support anti-psychiatry beliefs and consider themselves to be "psychiatric survivors". Although anti-psychiatry is often attributed to a few famous figures in psychiatry or academia, it has been pointed out that consumer/survivor/ex-patient individuals and groups preceded it, drove it and carried on through it.

Criticism

A schism exists among those critical of conventional psychiatry between radical abolitionists and more moderate reformists. Laing, Cooper and others associated with the initial anti-psychiatry movement stopped short of actually advocating for the abolition of coercive psychiatry. Thomas Szasz, from near the beginning of his career, crusaded for the abolition of forced psychiatry. Today, believing that coercive psychiatry marginalizes and oppresses people with its harmful, controlling, and abusive practices, many who identify as anti-psychiatry activists are proponents of the complete abolition of non-consensual and coercive psychiatry. 

Criticism of antipsychiatry from within psychiatry itself object to the underlying principle that psychiatry is by definition harmful. Most psychiatrists accept that issues exist that need addressing, but that the abolition of psychiatry is harmful. Nimesh Desai concludes:

"To be a believer and a practitioner of multidisciplinary mental health, it is not necessary to reject the medical model as one of the basics of psychiatry." and admits "Some of the challenges and dangers to psychiatry are not so much from the avowed antipsychiatrists, but from the misplaced and misguided individuals and groups in related fields."