Editor’s note: this post was first published on Mad In America on August 3rd 2024
The harm caused by the medical profession is called iatrogenesis, and in 1975, Ivan Illich (1926-2002) published Medical Nemesis (republished titled Limits to Medicine) in which he discussed the clinical, social, and cultural iatrogenesis of modern medicine. Illich was a philosopher and social critic of monopolistic institutions and bureaucracies in Western society that undermine self-sufficiency, community, freedom, and dignity.
For Illich, the iatrogenesis of modern medicine is clinical when harm to individuals results specifically from medical treatment. Iatrogenesis is social when medicine as an institution and a bureaucracy creates ill-health by increasing stress; by subverting autonomy and community support; and by depoliticizing sources of illness. And medicine’s iatrogenesis is cultural when its ideology undermines the values that allow individuals to cope with life’s trials and tribulations.
Illich does not discount the beneficial effects of modern medicine. He is clear that, for example, through blood transfusions, surgical techniques, and other treatments, many people who have suffered traumatic physical injuries survive who would not otherwise have survived. However, viewing modern medicine in its clinical-social-cultural entirety, Illich concluded that, on balance, its dehumanizing negative effects outweigh its positive ones.
In narrowing the scope of Illich’s analysis to psychiatry, the iatrogenic balance sheet is far worse. Psychiatry’s clinical iatrogenesis—the physical and psychological harm caused by psychiatric treatment—has been directly experienced by many Mad in America readers, and the social and cultural iatrogenic effects of psychiatry are even more glaring than in the rest of medicine. What follows begins with psychiatry’s clinical iatrogenesis and then covers its social and cultural iatrogenesis.
Clinical Iatrogenesis
In medicine, clinical iatrogenesis comprises all conditions for which physicians and other medical professionals, hospitals and other medical facilities, and their treatments are the causes of various types of harm, including death. This includes not only malpractice, but also includes treatments not considered as violations of medical codes of competence even though the treatment consequences result in damage. In 2000, JAMA reported the US yearly estimated iatrogenic deaths: 12,000 caused by unnecessary surgeries; 27,000 caused by medication errors and other errors in hospitals; 80,000 hospital/healthcare facility acquired infections; and 106,000 “non-error” adverse effects of medication. This totals to 225,000 iatrogenic deaths per year, making it the third leading cause of US death (behind heart disease and cancer); and this 225,000 annual death total does not include iatrogenic non-death injuries.
Still, given modern medicine’s benefits, some of which are life-saving, the clinical effects of non-psychiatry medicine are a mixed bag of positives and negative outcomes. In contrast, psychiatry can point to no treatment that is effective in a scientific sense (in other words, compared to a placebo control or the passage of time). Historically, from bloodletting to contemporary antidepressant drugs, there have always been claims by psychiatry, and even some patients, of treatment effectiveness. However, in all of psychiatry’s bio-chemical-electrical treatments, there is little scientific evidence that any of these treatments are superior to a placebo or the passage of time. Furthermore, all of psychiatry’s bio-chemical-electrical treatments result in serious adverse effects—this even acknowledged by establishment psychiatry.
Antidepressants? In April 2002, JAMA published a randomized controlled trial (RCT) in which the placebo worked better than both the herb St. John’s wort and SSRI Zoloft (a positive “full response” occurred in 32% of the placebo-treated patients, 25% of the Zoloft-treated patients, and 24% of the St. John’s wort-treated patients). Also, in 2002, Irving Kirsch, a leading researcher in the placebo effect, examined 47 drug company studies on various antidepressants (published and unpublished trials), and he discovered that in the majority of the trials, antidepressants failed to outperform placebos; and Kirsch reported that “all antidepressants, including the well-known SSRIs . . . had no clinically significant benefit over a placebo.” Long-term, Psychotherapy and Somatics reported in 2017 (“Poorer Long-Term Outcomes among Persons with Major Depressive Disorder Treated with Medication”) that even after controlling for baseline depression severity, at a nine-year follow-up, antidepressant users had significantly more severe symptoms than those individuals not using antidepressants.
The natural course of depression without any medication? A 2006 National Institute of Mental Health (NIMH) study, “The Naturalistic Course of Major Depression in the Absence of Somatic Therapy,” examined depressed patients who had recovered from an initial episode of depression, then relapsed but did not take any medication following their relapse. One year later, the recovery rate of these non-medicated depressed patients was 85%, which is far higher than the one-year effectiveness for antidepressants.
While antidepressants lack scientific evidence of effectiveness, the iatrogenic effects of SSRIs and other antidepressants are uncontroversial. When trying to reduce or come off antidepressants, 56% of individuals experience withdrawal effects, and approximately one in four people will experience severe withdrawal symptoms. The percentage of sexual dysfunction for SSRI antidepressants runs from 25%–73%, according to a 2010 examination of several studies (in one study of 344 patients who had a history of normal sexual function before SSRI treatments, there was an overall incidence of 58% sexual dysfunction). Furthermore, post-SSRI sexual dysfunction (PSSD), in which sexual dysfunction exists even after discontinuation of the SSRI, was first reported to regulators in 1991. Withdrawal misery, sexual dysfunction, and PSSD are now acknowledged by psychiatry, and antidepressants have also been shown to increase the rate of suicide and violence.
This same negative balance sheet of poor outcomes and serious iatrogenic effects is seen for patients diagnosed with psychosis and treated with antipsychotic drugs. In an NIMH-funded study, Martin Harrow and Thomas Jobe reported in 2007 that at the end of fifteen years, among those patients who had stopped taking antipsychotic drugs, 40% were judged to be in recovery, compared to only 5% in recovery among those who had remained on antipsychotic drugs; and at twenty years, they reported: “While antipsychotics reduce or eliminate flagrant psychosis for most patients with schizophrenia at acute hospitalizations, four years later and continually until the twenty-year follow-ups, patients with schizophrenia not prescribed antipsychotics had significantly better work functioning.” Similar results were found in an RCT done by Lex Wunderink, reported in 2013 in JAMA Psychiatry.
The severe short-term and long-term iatrogenic adverse effects of antipsychotic drugs are uncontroversial. Many Mad in America readers are well acquainted with these adverse effects: from Parkinsonian symptoms of muscle dystonias and akathisia; to large weight gains and diabetes; to neuronal supersensitivity causing psychotic reactions; to brain-structural abnormalities; to reduced life span.
The same negative balance sheets of scientific ineffectiveness and uncontroversial serious short-term and long-term adverse effects exist for all of psychiatry’s bio-chemical-electrical treatments.
Social Iatrogenesis
For Illich, “Medicine undermines health not only through direct aggression against individuals but also through the impact of its social organization on the total milieu.”
Social iatrogenesis includes a medical bureaucracy that renders patients and their families helpless and thereby increases stress, which itself is a prime source of ill-health. Iatrogenesis is social when the institution of medicine subverts autonomy and social supports. Social iatrogenesis also includes depoliticizing sources of sickness, pacifying people so as to not fight against unhealthy societal conditions.
In my clinical practice, the ordeal of medical bureaucracy is one of the top stresses reported. Among these stresses routinely reported are: false-positive diagnostic tests that create extremely stressful anxiety, sometimes for weeks before the bureaucratic machinery provides the correct result; impersonal interactions with medical professionals lacking time and patience; patients feeling captive to uncaring bureaucracies owing to the need for a necessary medication prescription (such as a blood pressure medication); exhausting battles with health insurance carriers; unwanted and coerced treatments; and lost confidence with medical professionals who themselves report to patients being coerced by their bureaucracies to employ diagnostic procedures and treatments that these professionals would not otherwise employ.
It is stressful for all involved in modern medicine. Patients and professionals are dehumanized to become machine cogs to meet the needs of machine medicine, which itself needs be an efficient machine to accommodate the larger societal structure—called the “megamachine” by social critic Lewis Mumford. Patients are dehumanized to become mere broken machines, and physicians, beginning in their sleep-deprived dehumanizing residencies, are socialized to be machine-cog mechanics rather than practitioners of the art of healing. Patients and physicians are made to fit into the machine, alienating them from their humanity. This alienation is of course quite stressful and a source of ill-health.
Modern medicine also depoliticizes sources of illness and thereby pacifies people so as to not fight against unhealthy conditions. Take one issue—the increase in cancer among young people. In 2023, BMJ Oncology reported, “Global incidence of early-onset cancer increased by 79.1% and the number of early-onset cancer deaths increased by 27.7% between 1990 and 2019.” However, rather than people becoming enraged and politically engaged to change carcinogenic environments, an extremely powerful medical-pharmaceutical industrial complex has controlled the societal narrative to focus—not on eliminating environmental-societal causes of cancer—but on expensive cancer treatments. Illich notes:
“People would rebel against such an environment if medicine did not explain their biological disorientation as a defect in their health, rather than as a defect in the way of life which is imposed on them or which they impose on themselves. The assurance of personal political innocence that a diagnosis offers the patient serves as a hygienic mask that justifies further subjection to production and consumption.”
While modern medicine has become increasingly impersonal, bureaucratized, and socially iatrogenic, the essence of psychiatry has long been one of social iatrogenesis.
Psychiatry’s diagnostic manual, the scientifically invalid and unreliable DSM, is an instrument of social iatrogenesis. The DSM manufactures illness from normal human reactions by some individuals in response to some environments. Labeling as medically ill those individuals who are reacting to a dysfunctional family, school, workplace, and societal environment subverts sociopolitical challenges to alienating and dehumanizing environments. DSM diagnoses are also used to categorize individuals as medically ill who themselves are not in distress, but only causing discomfort in others—resulting in those with power in families and society to coerce those without power to submit to treatment.
So, children are labeled with some type of “disruptive behavior disorder,” such as oppositional defiant disorder (ODD), because they refuse to comply with the demands of their school or family; and their rebellion causes discomfort for school and family authorities—resulting in these children being drugged. Illich notes: “Industrial parents, forced to procreate manpower for a world into which nobody fits who has not been crushed and molded by sixteen years of formal education, feel impotent to care personally for their offspring and, in despair, shower them with medicine.”
Similarly, adults experiencing altered states, who themselves may not be in emotional distress but are causing distress for others, are labeled with schizophrenia and other psychoses—and drugged. And among individuals who actually are in emotional distress, psychiatry’s illness categorizations subvert an inquiry into the family, school, workplace, and other societal sources of normal human reactions to alienation and dehumanization—and these individuals are instead simply drugged. Illich notes that social iatrogenesis occurs when an institution:
“. . . serves to legitimize social arrangements into which many people do not fit. It labels the handicapped as unfit and breeds ever new categories of patients. People who are angered, sickened, and impaired by their industrial labor and leisure can escape only into a life under medical supervision and are thereby seduced or disqualified from political struggle for a healthier world.”
Psychiatric diagnoses can be as seductive, addictive, but ultimately as disempowering as heroin. Initially, many individuals report “good feelings” of relief upon hearing an explanation for their malaise (albeit a pseudoscientific explanation), of hope for misery reduction (albeit false hope), and of compassion from others (albeit short-lived). However, these individuals routinely discover that these good feelings are transitory. Illich notes that such diagnostic labels “may protect the patient from punishment only to submit him to interminable instruction, treatment, and discrimination, which are inflicted on him for his professionally presumed benefit.”
Powerlessness and stigma are two such social iatrogenic effects of psychiatry’s diagnostic labels and its biological-genetic explanations. In 2006, Acta Psychiatrica Scandinavica published “Prejudice and Schizophrenia: A Review of the ‘Mental Illness is an Illness Like Any Other’ Approach,” a research review of several studies that compared societal attitudes to labeling someone with a medical illness such as “schizophrenia” versus describing them non-medically as “in crisis.” The researchers found that a belief in biological causality was associated with a more pessimistic view about recovery, and the authors state: “Biogenetic beliefs are related to perceptions of dangerousness and unpredictability, to fear, and to desire for social distance.” Similarly, “Myth: Reframing Mental Illness as a ‘Brain Disease’ Reduces Stigma” (2012), the Canadian Health Services Research Foundation (CHSRF) concluded: “Biological explanations can also instill an ‘us vs. them’ attitude, defining individuals with mental illness as fundamentally different.”
Moreover, if one believes that these conditions are genetically passed on, these diagnoses can stigmatize not only patients but family members, as Illich notes that “. . . diagnosis can defame the patient, and sometimes his children, for life. By attaching irreversible degradation to a person’s identity, it brands him forever with a permanent stigma.”
People who are experiencing emotional and behavioral crises can be helped by others who have patience, curiosity, compassion, and respect—all of which require no special professional training. By medicalizing people’s emotional suffering and behavioral disturbances so that only professionals in a professional environment are sanctioned to treat them, suffering people are deprived of a healing community. And when community members abdicate their helper possibilities, all in the community are deprived of opportunities for growth and bonding.
Cultural Iatrogenesis
Illich explains cultural iatrogenesis:
“It sets in when the medical enterprise saps the will of people to suffer their reality…. Professionally organized medicine has come to function as a domineering moral enterprise that advertises industrial expansion as a war against all suffering. It has thereby undermined the ability of individuals to face their reality, to express their own values, and to accept inevitable and often irremediable pain and impairment, decline and death.”
For Illich, modern medicalization destroys traditional ways of dealing with suffering, sickness, and death, and he saw great cultural harm in which individuals lose their autonomous coping skills, and their communities are weakened.
In the mid-twentieth century, in addition to Illich, there were other prominent thinkers such as Erich Fromm and Lewis Mumford concerned that an increasingly technological, institutionalized, machine-like society was resulting in loss of our humanity. For Mumford, there was a “bribe” occurring in technology-worshipping modernity: for our surrender to an impersonal megamachine, we receive some comforts, conveniences, and even some luxuries, but we lose autonomy, individuality, dignity, community, and love. In a 2021 article, “The Magnificent Bribe,” social critic Zachary Loeb explained: “In denouncing the bribe, Mumford was not simply blasting this or that particular machine. He was questioning the ways that particular machines were used to incorporate people into a much larger technical system.” Mumford was worried that such an incorporation would necessitate people having to become machines at the expense of their humanity.
In non-psychiatry medicine, in return for our acceptance of the idea that sick humans are nothing but broken machines to be fixed by an impersonal mechanic, some patients, at least sometimes, do receive a treatment that extends their lives or actually cures an illness. And so depending on one’s value system, the bribe may be a good deal.
In contrast, in psychiatry, patients receive nothing of scientific value—and often greater suffering in the long-term. Bupkis is the Yiddish word that means absolutely nothing (including nothing of value); and one could title a book about the history of psychiatry as “Bribed with Bupkis.”
How did Illich become a critic of what he would call “cosmopolitan medicine”? He grew up in Europe, and in his twenties came to New York City where he worked for five years as a parish priest in an Irish-Puerto Rican neighborhood; but he became critical of the Roman Catholic Church’s position on several issues, and after being rebuked by the Vatican, he renounced active priesthood. He then lived in Puerto Rico, and traveled widely throughout South America on foot and by bus. He eventually settled in Cuernavaca, Mexico, founding the Centro Intercultural de Documentación, which he called “a center for de-Yankeefication,” aimed at educating clergy and development workers about the negative effects of the imposition of Western values and institutional bureaucracies on traditional communities.
For Illich, modern medicalization destroys traditional ways of dealing with suffering, sickness, and death. Advanced industrial societies and cosmopolitan medicine have redefined “good health.” In traditional societies, Illich observed, good health means enjoying success coping with reality, to be able to feel alive in pleasure and in pain, and to cherish survival but also to risk it. In contrast, “medical civilization” turned “pain into a technical matter, thereby depriving suffering of its inherent personal meanings.” For Illich:
“Traditional cultures confront pain, impairment, and death by interpreting them as challenges soliciting a response from the individual under stress; medical civilization turns them into demands made by individuals on the economy, into problems that can be managed or produced out of existences. Cultures are systems of meanings, cosmopolitan civilization a system of techniques. Culture makes pain tolerable by integrating it into a meaningful setting; cosmopolitan civilization detaches pain from any subjective or intersubjective context in order to annihilate it. Culture makes pain tolerable by interpreting its necessity.”
Through psychiatry’s social iatrogenesis, normal human reactions to individuals’ environment are transformed into illnesses, and through psychiatry’s cultural iatrogenesis, emotional reactions are stripped of meaning, and people are deprived of their autonomous coping skills and supports; and family and community are socialized to believe they lack the training and credentials to be helpful.
Take the example of anxiety, which in cosmopolitan medicalized society is a “symptom” of “mental illness” that requires “treatment” by mental health professionals. In traditional cultures, anxiety has meaning, while psychiatry detaches anxiety from its context in order to annihilate it. In traditional cultures, anxiety is seen as a challenge to an individual’s coping ability, while medicalized civilization turns anxiety into a consumer demand made on the economy for a professional to eliminate. Traditional culture makes anxiety tolerable by interpreting its necessity, while psychiatry actually makes anxiety more intolerable by viewing it as merely a defect to be repaired.
Illich observed that traditional cultures see suffering and death as inevitable; and so to enable these to be borne with dignity, traditional cultures highly value patience, courage, resignation, self-control, perseverance, duty, fascination, compassion, and love. In contrast, in cosmopolitan medicine and cosmopolitan civilization, pain has ceased to be conceived as “natural” and instead:
“It is a social curse, and to stop the ‘masses’ from cursing society when they are pain-stricken, the industrial system delivers them medical pain-killers. Pain thus turns into a demand for more drugs, hospitals, medical services, and other outputs of corporate, impersonal care and into political support for further corporate growth no matter what its human, social, or economic cost. Pain has become a political issue which gives rise to a snowballing demand on the part of anesthesia consumers for artificially induced insensibility, unawareness, and even unconsciousness.”
Seriously depressed moods, suicidality, ego collapses, and bizarre behaviors can often be painful to experience and to observe, but traditional societies, unlike modern cosmopolitan civilization, are not so frightened by these pains that they need to anesthetize them and strip them of meaning. For thinkers such as Illich, Mumford, and Fromm, it is important for us to understand the general context of modern civilization in which psychiatry exists, a context which Illich describes:
“In this context it now seems rational to flee pain rather than to face it, even at the cost of giving up intense aliveness. It seems reasonable to eliminate pain, even at the cost of losing independence. It seems enlightened to deny legitimacy to all nontechnical issues that pain raises, even if this means turning patients into pets. With rising levels of induced insensitivity to pain, the capacity to experience the simple joys and pleasures of life has equally declined. Increasingly stronger stimuli are needed to provide people in an anesthetic society with any sense of being alive. Drugs, violence, and horror turn into increasingly powerful stimuli that can still elicit an experience of self. Widespread anesthesia increases the demand for excitation by noise, speed, violence—no matter how destructive.”
In 1950s through the 1970s, in addition to Illich, Fromm, and Mumford, there were other prominent critics of a bureaucratic societal structure that was not meeting human needs and forcing people to become dehumanized cogs in a machine. In such an era when the megamachine was being seriously challenged, Illich was frustrated by the manner in which some psychiatry critics diverted society from the more fundamental problems of cosmopolitan medicine and the megamachine. Illich believed that psychiatry critics, such as Thomas Szasz, who emphasized the contrast between “unreal” mental illness and “real” physical disease, rendered it more difficult to raise questions about medicalized society in general. Illich concluded that the emphasis of Szasz came at the expense of a more fundamental critique of cosmopolitan medicine and the megamachine societal structure. While Illich agreed with psychiatry critics such as Szasz about the use of “mental illness” for political purposes, for Illich, ideology and politics were at work not only in psychiatry but across the entire field of cosmopolitan medicine.
There is a distinction between psychiatry and non-psychiatry medicine that, with knowledge of treatment outcomes, appears undeniable. The distinction is the nature of the bribe deal. Specifically, in all of the megamachine’s cosmopolitan medicine, we are made to accept the idea that we are machines that get broken and need to be fixed by an impersonal mechanic, and in this “machinizing-dehumanizing,” we lose autonomy, individuality, dignity, community, and love. For our acceptance of our machine-cog role, non-psychiatry medicine provides a mixed-bag clinical return, while from psychiatry, we are bribed with bupkis.