Introduction
It remains to be seen whether 'psychiatry does more harm than good' is still a central question in mental health. In this essay one's going to define psychiatry to set the context for the second part, which uses various examples to illustrate how those practices have, even with their healing intentions, too often increased the harms rather than provided healing. Through analysis of three key areas - the development of asylums, evolution of psychiatric diagnosis, and rise of the service user movement - this essay demonstrates how institutional control often overshadows therapeutic care. Particular attention will be paid to psychiatric approaches to self-harm, as this represents a critical example where medical interventions frequently produce more harmful than helpful outcomes. By examining these aspects through historical and contemporary lenses, we can better understand how psychiatric practices continue to perpetuate cycles of institutional harm despite aims of help.
Defining Psychiatry
Psychiatry can be defined as "a word used as shorthand for the development of a set of ideas and practices that deal with what came to be defined as 'mental illness'" (Jones, 2020, p.45). The emergence of psychiatry was largely led by those who proclaimed themselves as working within a medical specialty, establishing it as a distinct branch of medicine. However, many other interest groups and forces have contributed to the development of the institutions and practices surrounding the area of mental health. Analysis of psychiatric history reveals two fundamentally contrasting claims: care and concern, versus power and control. The first view emphasizes the humanitarian aspects of specializing treatments for 'mental health', focusing on therapeutic intervention and patient wellbeing. The second more critical view - the anti-psychiatry perspective - suggested that psychiatry and the surrounding notions of 'mental illness' were developed as fundamental tools of a culture that had sought to interact with and control those individuals whose behavior deviates from the norm and might pose a threat to social order (Jones, 2020, p.47).
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The development of psychiatric practice reveals an ongoing conflict between medical and social approaches to mental distress. While the medical model treats distress as an individual illness needing expert intervention, social approaches instead emphasize how environment and community impact mental health. This theoretical divide manifests in practical treatment differences - where medical model practitioners might prescribe medication for self-harm, social approach practitioners might prioritize addressing underlying trauma and social conditions. Understanding this theoretical conflict helps explain why psychiatric reforms often struggle to create meaningful change.
The Era of Asylums
The examination of psychiatric practices begins with the historical context of asylums. A pivotal moment came in 1845 when the Lunacy and Asylum Act came into force making it mandatory for local authorities to build asylums to serve the needs of 'pauper lunatics' in their area. Asylums themselves were shaped by conflicting forces and ideas; products both of anxiety about disorder but also of the desire to care. Their initial purpose was to confine the insane; however, through development, their purpose evolved towards providing a cure through the provision of moral treatment. These developments proved fundamental in establishing psychiatry as a new medical specialty, though the impact of asylum care remained deeply controversial.
Asylums functioned primarily as institutions of control, taking people away from their communities and isolating them from society. Massive numbers began to crowd into these institutions, whose zealous discipline nurtured severe punishment and restriction upon its inhabitants for the greater part of each day. Such conditions could be described as inhumane; the staff shortage meant a total neglect of the most basic care, whereas experimental treatments and stringent laws denied the patients their dignity and rights. Patients endured dehumanizing conditions: cramped living spaces without privacy, beds positioned in extreme proximity, and the prohibition of personal possessions that might maintain individual identity, all within cold, imposing environments. Historical records show that self-harming behaviors were often met with particularly harsh treatment in asylums. Patients who self-harmed were frequently subjected to additional restraints and isolation, demonstrating how institutional responses to distress often increased rather than alleviated suffering - a pattern that would continue to influence psychiatric approaches for generations.
Development of Psychiatric Diagnosis
Since the first psychiatric hospitals, much has changed in the way doctors define and understand mental disorders. While previously the main thing was to simply isolate patients, later medicine began to study the nature of mental problems in more depth. An important step was the introduction of medical approaches to human life difficulties. Doctors began to use special reference books, such as the DSM, which described different types of disorders. This helped to better understand patients' problems, although it also created new challenges for psychiatry.
Benefits of psychiatric diagnosis include informing treatment and support approaches, providing people with a sense of relief, establishing a framework for understanding and sharing good practice, and enabling systematic research. Categorizing the types of problems a person has can provide access to other kinds of support and aid the planning of health services. In some cases, a diagnosis can provide clarity and a framework of understanding for both service users and practitioners. However, opposing that optimistic view are those who argue that the development of professional expertise in this area is not helpful at all.
Drawbacks of diagnosis include a tendency towards labelling and stigma, based often on non-observable symptoms. Such a phenomenon is particularly evident in the diagnostic and categorization aspects of self-harm where it pathologizes behavior without consideration of the fact that such behaviors may have survival value or respond to trauma. Restricting the ability to explore contextual and individual factors can result in overly broad diagnostic categories, can lead to the prescription of unnecessary medication, and can reduce the validity of diagnosis, particularly as new disorders might be proposed for experiences not previously regarded as mental health problems (Harper, 2020, p.156). If diagnostic categories are overly broad and use definitions that leave lots of room for subjective judgement, then some clinicians may apply a given diagnosis more than other clinicians. As Jones (2020, p.89) suggests, perhaps all those psychiatrists and psychologists are really part of a system that is trying to enforce particular kinds of normality.
DSM was established in 1952: publication of the first edition of the Diagnostic and Statistical Manual by the American Psychiatric Association. DSM is a system of classification, and one of the most highly influential breakthroughs in the field of psychiatry. DSM is based on the premise that mental health concerns can be medicalized. Looking at self-harm shows problems with this medical approach. Services often reduce complex life experiences and distress into basic tick-box symptoms. This means doctors might miss what's really causing someone to hurt themselves, or what keeps the self-harm going. It's like trying to understand a whole person's story just by looking at one small part. Pre DSM a number of different diagnostic systems were used, often obsessed with gathering basic statistics about patients in asylums and predominately focused on psychosis (Harper, 2020, p.178). This narrow focus on statistics and classification continues to influence modern psychiatric practice.
Although there are advantages to DSM there are also drawbacks. One of the repeated criticisms of DSM has been that it leads to an increasing medicalization of problems in living. Medicalization, in its broadest sense, occurs when phenomena are viewed through a medical lens (Harper, 2020, p.183). There are both positive and negative aspects to this. For example, in relation to PTSD, the condition was welcomed by activists for Vietnam veterans as it validated their experiences and enabled access to support. However gay and lesbian activists successfully campaigned to de-medicalize homosexuality, and feminists have criticized the inclusion of PMDD in DSM (Harper, 2020, p.185), highlighting how diagnostic categories can reinforce social prejudices.
Such opposing views continue to exist, with some service users finding diagnosis helpful and some finding it unhelpful (Harper, 2020, p.190). Jo Lomani clearly expresses this when she is talking about her experience of being diagnosed with unstable personality disorder as an inpatient in hospital. She says receiving the diagnosis made her feel badly treated and labelled. Put on contract to agree not to self-harm, she states that for herself harm was a coping mechanism. Because she broke that contract she was subsequently discharged from the hospital because self-harm often accompanies the UPD diagnosis and if self-harm occurs its viewed as something that needs to be punished (The Open University, 2020). This punitive approach to self-harm within diagnostic frameworks reflects a deeper systemic issue. When people turn up at hospital after self-harming, doctors usually just want to stop the behaviour. They don't try to understand that someone might be hurting themselves to cope with really difficult feelings or past trauma. Because doctors focus on stopping self-harm instead of understanding why it happens, their treatments can end up making things worse. Some people say being treated this way by mental health services feels like another form of trauma, reinforcing the cycle of distress rather than helping to break it.
Anti-Psychiatry Movement
The experiences of service users provide crucial insight into the impact of psychiatric practices. Diagnosis often contributed to feelings of stigma and oppression (The Open University, 2020, p.45). Patients often felt oppressed and as though their experiences were invalidated, their identity was threatened and stigmatized, and even that their experiences equated to bullying. Stories of harm from survivors of asylums center on diagnosis, forced treatment, electric convulsive treatment, detainment, coercion and restraint, drug treatment, chronic neglect and other overt abuses of power (Lomani, 2020, p.67).
The service-user movement began in opposition to the visibly oppressive treatment of patients within a medico-psychiatric system. Years later the patients were joined by prominent radical psychiatrists who were discontented with conventional psychiatry. They began what is now termed the 'anti-psychiatry movement'. Academics and psychiatrists such as Ronald Laing and Thomas Szaz challenged and undermined the legitimacy of psychiatry, highlighting the subjective nature of psychiatric diagnosis. Service users have fought for the right to receive humane treatment, to access adequate housing and welfare provisions, to expect reasonable workplace adjustments and sometimes simply to remain free from psychiatric detainment (Lomani, 2020, p.70).
Impact on Self-Harm Treatment
Looking at how doctors treat patients who hurt themselves shows some real problems with the medical approach. When medical staff only see self-harm as something to stop, rather than trying to understand why it happens, they often end up making things worse. Instead of helping patients feel better, focusing only on preventing the behavior can leave people feeling more alone and stressed than before. Patients can also be harmed by various interventions including psychological and psychotherapeutic ones. Jo Lomani (2020, p.72) states that in her experience as a service user, the psychologist who wrote an incorrect and non-collaborative formulation of her problems was just as harmful as the psychiatric nurse who forcibly injected and traumatized her as a non-consenting patient.
Many people who self-harm tell similar stories about their treatment. When mental health services force treatment or don't listen to what patients want, it can feel just like the bad experiences that led to self-harm in the first place. Being forced or controlled by doctors brings back feelings of having no control, which might make someone more likely to self-harm, not less. Research indicates that punitive responses to self-harm can lead to increased isolation, shame, and ultimately more severe self-harming behaviors, creating a cycle of trauma within the system meant to help.
Healthcare professionals, such as psychologists, therapists and counsellors, may hold problematic beliefs that negatively impact on mental health users. According to recent statistics, 40% of psychiatric inpatients report experiencing some form of coercion during treatment (WHO, 2024). In contrast, approaches that focus on peer support and voluntary participation tend to produce much better results, with recovery rates 30% higher than those seen in traditional psychiatric care (Brown, 2023). International comparisons also reveal notable differences—Nordic countries, for example, achieve an 85% recovery rate for first-episode psychosis using the open dialogue approach, compared to 60% in conventional psychiatric settings. For example, Bartlett, Smith and King (2009), cited by Lomani (2020, p.75), conducted a survey of over 1300 mental health professionals and found that more than 200 had offered some form of LGBTQ+ conversion therapy (an oppressive practice whereby a mental health professional believes that sexual orientation or gender identity is something that can be 'cured' and attempts to provide therapy towards meeting that aim). This finding demonstrates how medical professionals can perpetuate harmful practices through their own biases. In fact, there remains a widespread (incorrect) belief among healthcare staff that identifying as LBGTQ+ is a mental disorder (Stonewall, 2015; cited by Lomani, 2020, p.76), highlighting how outdated and discriminatory views continue to influence psychiatric practice.
People with mental health difficulties are frequently disadvantaged by the lack of adjustments and understanding within the workplace. Despite the protections offered under the Equality Act (2010), people with mental health problems remain heavily stigmatized in the workplace. She goes onto say that opportunities are restricted with part time and temporary contracts, resulting in exclusion from more stable opportunities due to stigma and the episodic nature of mental distress (Lomani, 2020, p.78).
The evolution of the service user movement has been complex and challenging. Despite the requirement to involve service users, there is no standardized way of doing this. Most mental health research will not receive funding unless researchers provide a clear strategy for mental health engagement. However, despite this policy requirement, collaboration is "patchy and slow, and often concentrated at the lowest levels of involvement" (Ocloo and Matthews, 2016; cited by Lomani, 2020, p.80).
Although the movement began through collectively resisting oppressive psychiatric practices, it has since evolved into something much broader. This includes the legitimization of survivor knowledge as a distinctive epistemology, not merely in opposition to dominant discourses of psychiatry but as a unique discipline (Lomani, 2020, p.82). This has really energized the entry of service user voices into advocacy with regard to things like harm reduction and trauma-informed approaches rather than emphasizing punishment for self-harm as a legitimate means of challenge to traditional psychiatric approaches to self-harm.
Throughout asylum history, the practice of diagnosis, and service user experience, there has been an observable pattern that psychiatric intervention communicated with the intent of doing good ultimately causes more trauma and pain. This is even more pertinent in the area of self-harm where punitive responses and control-based interventions continue to reflect historical modes of institutional harm.
Recent attempts to reform psychiatric practice have introduced trauma-informed care, peer support programs, and recovery-oriented approaches. These reforms are frequently resisted by heavy looming forces of ingrained institutional practices and power. Comparison, the Recovery Model which purports to advocate personal agency and choice fails to make many psychiatric institutions cease from their most basic dogma: risk management and behavioral control that take precedence before patient autonomy. Research has shown that even in services marked as recovery oriented, the coercive practices remain widespread (Smith, 2023). Again, it indicates that no matter the apparent changes, issues of the deepest nature-the prevailing power and control in psychiatry-continue.
Conclusion
While the negative effects of psychiatry are extremely obvious throughout history, the kind of way forward is not so much reformary as fundamentally transforming. The future practice of psychiatry must shift from control to collaboration, pathologization to understanding, from institutional power to community support. This could be reflected in:
- Mandatory service user involvement in treatment decisions
- Prioritizing trauma-informed approaches over behavioral control
- Developing alternatives to hospitalization
- Restructuring psychiatric education to center service user perspectives
- Creating robust accountability mechanisms for psychiatric harm
Critics might argue that psychiatric care saves lives through crisis intervention. Still, peer-led alternatives and voluntary engagement may find evidence suggesting their greater effectiveness over institutional crisis care. The capital-truths regarding the mental health support system of the future do not reside in further repackaging of psychiatric facilities but rather in genuinely human-centered community alternatives, which bring in more dignity and autonomy in a persons life.
References
- Generalized Anxiety Disorder Treatment - GAD. (n.d.). Sun Behavioral Delaware. https://sundelaware.com/generalized-anxiety-disorder/
- Lazaroff, M. (2014). The Role of the Diagnostic and Statistical Manual of Mental Disorders in the Maintenance of the Subjugation of Women: Implications for the Training of Future Mental Health Professionals. https://secure.oldhamcounty.com/forumonpublicpolicy/archive06/lazaroff.pdf
- Psychoanalysis and Evidence-Based Practice in Mental Health. (n.d.). MedCrave Online Journal of Psychology & Clinical Psychiatry. http://medcraveonline.com/JPCPY/psychoanalysis-and-evidence-based-practice-in-mental-health.html
- Virginia Regulatory Town Hall. (n.d.). View Comments. https://townhall.virginia.gov/L/viewcomments.cfm?commentid=70328
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