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In the 19th century, Matthew Arnold famously wrote of the ‘melancholy long withdrawing roar of the sea of faith’.1 This referred to the decline of Christian belief and the influence of Christian institutions in the day-to-day life of European societies. Such a decline was predicted by the enlightenment, which promised the triumph of rational science over religious superstition.2 Predictions of the demise of religion have been somewhat validated by the course of history. Fewer people are attending religious services, religious institutions have lost much of their influence on the masses, and religious views are frequently mocked and vilified as archaic delusions more suited to a dark and distant past.3,4 GK Chesterton famously remarked that when people stop believing in God, they start believing in anything. This begs a simple question – is there a lay replacement for religion in contemporary societies? Is there any comparable system of beliefs, behaviours and attitudes that stands as a binding doctrine held ‘true’ by the populace at large? Is there any such comparable system marked by a proselytizing zeal and enthusiastic sense of mission? In this essay, I argue that psychiatry, and its handmaiden, clinical psychology, now constitutes an amorphous system of beliefs, behaviors and attitudes whose functions and doctrines are unsettlingly similar to those held by conventional religions. Are psychiatrists the new priests? Are clinics the new confessionals? Are pills the new prayer? Read on to learn that now may be the time to proudly add ‘psychiatry’ to the pantheon of world religions.
Mainstream religions have often demarcated the populace into two neatly distinct categories that could be crudely labeled as believers and non-believers. Much effort was expanded on ensuring that believers are kept within the fold while non-believers are recruited into the faith's welcoming arms. This involved mission work at home and abroad. Such activity is the fodder of Victorian novels, perhaps best encapsulated in the risible figure of Dickens's Mrs Jellyby.
It could be argued that psychiatry and clinical psychology are characterized by a somewhat similar Manichean attitude, as both endeavors involve large amounts of ‘outreach’ work to people not currently encompassed within its loving embrace. Like religious mission, this occurs at home and abroad.5 This is often conceptualized in the language of ‘untreated illness’ or ‘unmet need’.6,7 Large campaigns are organized to make people aware that they or their loved ones may need to consult psychiatrists.8 Literature is distributed, advertisements are put in the media, seminars are held.9 People may even be contacted unannounced and asked to discuss psychiatry, in the same manner that some of the oft-ridiculed religious missionaries will ‘doorstep’ people to discuss matters theological.10 These efforts often attempt to persuade the uninitiated heathen to believe in the central doctrines of psychiatry.
Such activity is implicitly supported by large epidemiological surveys suggesting that there are thousands (if not millions) of people who need to see psychiatrists and psychologists.11 Like the more zealous religions in times past, the idea that some of the uninitiated may actually be enjoying quite satisfactory lives is rarely entertained. That said, one significant large-scale study roundly stated ‘the majority of those who receive no treatment felt that they did not have an emotional problem requiring treatment’.12 This raises the question of whose ‘need’ is being met in talk of ‘unmet need’ in psychiatry.
Kleinman13 argued that there is no such thing as an untreated illness (though there are untreated diseases) in that individuals and their social networks respond to any suffering and distress with multifarious action, even if they do not see ‘professionals’. It has been argued that ardent adherents of the medical model often disparage such ‘non-professional’ management of the suffering and distress inherent in the human condition.14 This is similar to the way that indigenous belief systems in times past were disdained and ‘colonised’ by the more established religions. A corollary of this is that some devotees to psychiatry/clinical psychology believe that only ‘real’ professionals in ‘real’ clinics can conduct ‘real’ treatment. Such belief is somewhat similar to those who believe in the ‘one true church’ (or variants thereof). Psychiatric belief in ‘the one true system’ remains strong, and indeed may get stronger as the growing influence of ‘evidence-based medicine’ leads to a focused distinction between what is ‘true’ and what is ‘false’.
That said, it should be noted that psychiatry is a broad church (pun intended). Many who fall under its crucible are skeptical of some of its rigid doctrinal statements and more dogmatic precepts. Indeed ongoing struggles between social psychiatrists and biological psychiatrists may be considered analogous to struggles between liberal and traditional wings of established religions. For example, the traditional Christian theology of original sin posits that man is born defective and only God's grace can save him. More Pelagian proponents of Christianity rail against this view as archaic and dehumanizing. Popular psychiatric theory posits that man is born defective (in that genetic factors are posited as strongly responsible for psychiatric illness) and only psychiatric intervention can help. Other psychiatrists inveigh against such theories arguing that situational factors determine suffering and distress, and that changing these circumstances will be of more benefit to the individual.
It may sound bizarre to suggest that those working in psychiatry are somewhat akin to missionaries, but anyone with access to an Internet search engine will soon discover that this is indeed a common self-conceptualization. For example, prominent psychiatric journals, service providers and academic departments all have ‘mission statements’. Missions cannot occur without missionaries. Thus psychiatry (and clinical psychology), it can be concluded, is ‘on a mission’.
All mainstream religions make a distinction between the priesthood and laity. The priesthood leads, the laity follows. The priesthood goes through years of abstruse training; the laity does not. The priesthood has reserved esoteric powers including administering sacraments; the laity does not. Acting collectively, the priesthood can ex-communicate internal dissidents; the laity is expected to abide and support such decisions. The priesthood may be wedded to concepts such as Cartesian dualism; the laity may not understand these concepts but should unquestionably accept them. Does something sound familiar here? Can such a pattern be seen in the relationship between psychiatry/clinical psychology and the contemporary public? Certainly, psychiatrists go through arcane training which sets them apart from the general public. Psychiatrists have reserved powers to administer medication and can even coerce treatment and compulsory detention. Like many religious denominations, loyalty and conformity are prized virtues within mainstream psychiatry. This can be witnessed in the peer treatment of figures who have deviated from the orthodoxy of their day, whether it be Ronnie Laing, Thomas Szasz, Peter Breggin and more latterly David Healy.15 Job offers have been rescinded, books have been ignored, careers have been ruined. Psychiatry also operates on a presumption of Cartesian dualism and is very concerned (often not explicitly) with the ‘ghost in the machine’.16 Indeed it could be argued that its topic matter, ‘the mental’ or ‘the mind’ is as ephemeral and nebulous as notions of ‘soul’, which underpin religion and theological inquiry. Like priests, psychiatrists are struggling with a topic matter that is often unfathomable to the general public. One final point of comparison – priests generally consider it part of their vocation to offer care for those not already in the flock, though contemporary mission is more often about community outreach work and development projects rather than ‘Bible bashing’. Likewise, psychiatrists and psychologists often consider those outside of their immediate care to be in need of their attention, which is manifested by the increasing penetration of self-help books and media psychologists. Many postwar households, from 23 Railway Cuttings to Rigsby's dilapidated lodging house, used to fear the knock on the door from the local vicar, who would usually descend upon them during rambunctious moments. Door-knocking may be passé, but the public can rest assured that almost every TV channel, magazine, newspaper and the like, will have its friendly mental health expert offering their words of wisdom on life's travails.
All religions have their canonical texts. The Koran, the Tanakh and the Christian Bible serve the three great monotheistic religions. These texts have been in existence for millennia, serving as guiding lights for proponents and adherents of the said religion. They are used to determine appropriate attitudes and behaviours to the slings and arrows of outrageous fortune. Psychiatry also has texts which are often referred to in reverential and canonical tones – these are DSM-IV17 and ICD-10, specifically the mental and behavioral disorders section V.18 These texts, in existence for decades, guide both psychiatrists, and to a lesser extent the lay public, in thought and deed. Like more overtly religious texts, these are organized into chapter and verse (i.e. codes) that can be quoted and debated between professionals and interested public.
Sacred texts inspire priests and laity to write devotional literature that interprets the greater power behind (and expressed in) the text in order to help people face quotidian vicissitudes. Likewise, psychiatry and psychology have spawned many books (often labelled self-help) that interpret psychiatric beliefs to the general public, helping them journey through this vale of tears. Indeed, most reputable bookstores now have shelves devoted to psychological self-help, often outweighing those devoted to religious interpretation. Where once stood CS Lewis, now stands Dr Phil.
Most religions encourage attendance at a house of worship at least once a week. Rituals and practices occur therein, which should be repeated in one's own homes. This includes, for example, regular prayer, confession of sins and sacramental participation. An aim of these practices is to maintain or restore the supplicant's equanimity and wellbeing, allowing them to bear the mortal coil with strength and courage. Though the content may be different, in terms of form these hallmarks of religion are somewhat shared in the clinical encounter with a psychiatrist/psychologist. As religious leaders encourage weekly visits to their house of worship, some psychiatrists and psychologists encourage weekly visits from their patients. Therein, patients are expected to reveal intimate details of their day-to-day life to the clinician. The clinician may refer to their text or training to dispense advice that may be behavioral and/or moral in nature. This advice often has unnerving similarities to religious ritual. For example, Christian ministers may advise a supplicant to engage in Holy Communion. In theological terms, this is a transformative experience that involves the sacred consumption of a small white host, in whose substance God is deemed to be (symbolically or literally) present. Psychiatrists may advise their patients to engage in another somewhat ritualistic behaviour, that is the consumption of a small white tablet in whose substance efficacious agents of change are deemed to be present. Evidence supporting the intrinsic efficacy of both these behaviors is equivocal, though the transformative value of their ritualistic aspects should not be overlooked.19,20
My comparison of Holy Communion with consumption of psychotropic medication may be questioned, given that some psychiatric medications have shown significant therapeutic effects through randomized controlled trials (RCT), whereas religious attendance and sacramental participation have not been subject to RCT. This may be true, and this evidence for efficacy should not be lightly dismissed. That said, churches, synagogues and mosques (and the world-view espoused therein) could be deemed efficacious in terms of their enduring attraction to millions of people for millennia. Whatever, if Karl Marx resurfaced today, he may be more circumspect in concluding that religion is the ‘opium of the people’. He may decide there is no need for clever metaphorical poetics in describing the people's penchant for diminishing the pain, distress and suffering concomitant with the human condition. Today, psychiatry, and its panoply of psychotropic medication, may be the literal ‘opium of the people’.
Competing interests None declared
Ethical approval Not applicable
Contributorship RW is the sole contributor