Drawing on 5090 English reviews of 486 psychiatrists working in Canada posted on ratemds.com, this study explores how mental health service users refuse to become subjectivized by psychiatric discourse and power. We interrogate how digital mediums provide mental health service users with a community of critique to regain control over settings where there are many power imbalances. We argue that websites like ratemds.com act as a digital agora in which people are afforded the ability to make the personal political. Through critiquing their own doctors, mental health service users invert the question of what is "wrong" with them to what is "wrong" with agents of the psychiatric apparatus. By regaining a say over their treatment/conditions and insisting doctors are asking the wrong questions to better control their identities, service users refuse to accept the diagnoses, pathologies, and practices imposed on them. We discuss how their transgression in this forum provides new insights into psychiatric resistance that is of special interest to scholars and service users positioned in the Mad Studies movement.
While mental health systems have come a long way since the days of 'insane asylums' and their history of cruelty and rampant abuse of people 1 under their "care", they are still plagued with controversial issues of power and control. Practices of physical or symbolic violence, degradation, infantilization (or some combination thereof) to control how people receiving psychiatric treatment and care are still rampant in mental health systems across the globe (Burstow 2015; Holmes et al. 2014; Joseph 2014; Liegghio 2013). To varying degrees, mental health service users can be subject to the administration of physical/chemical restraints while in hospital, medications that shorten life and alter reality, intensive surveillance practices, the use of involuntary incarceration in mental institutions, beatings by security officials, infantilizing punishment and reward systems, and various forms of moral judgement and stigma (Ashcraft and Anthony 2008; Johnston 2014; Johnston and Kilty 2014, 2016; Burstow 2016; Due et al. 2012; Holmes and Murray 2011; Holmes et al. 2014; Lincoln et al. 2017; Mason 2006).
Most of these instruments of power retain legislative authority in mental health acts (Federman 2012; McSherry and Weller 2010; Peay 2003; Szasz 1989), and as a result medical experts today can still forcibly incarcerate, restrain, sedate, seclude, and medicate people in hospitals as long as the doctors' decisions are not found to be punitive in nature and in the best interests of the service user (Fennell 1996). Others have questioned how the distribution of "improved" drugs to treat mental health suffering, which are supposed to reduce the side effects of older psychoactive medication, perpetuate the corporate pharmaceutical regimes that ultimately have more interest in selling drugs and controlling populations than developing (if possible) more long-term treatment plans for mental health suffering (Breggin 2008; Farber 2013; Whitaker and Cosgrove 2015).
Dynamic controversies regarding informed consent (or lack thereof) for treatment exist in psychiatry. Oftentimes, patients who seek mental health services voluntarily will report that their treatment was more effective than patients who were ordered to receive care (Alang and McAlpine 2019). Even with the recognition that individuals are autonomous and quite often can make good decisions about their care (Neilson and Chaimowitz 2015), a great deal of trust and authority is given to psychiatric experts to compulsorily treat mental health service users on the principle that their medical judgments are better than the person suffering. But this begs the question of how—if it all—can we identify an exact "threshold" after which people can no longer make decisions about their health? Additionally, what agency should service users be afforded to have their voices legitimated? By this we mean, what kind of capacities do they have to make claims about mental health and the mental health system? Tensions remain over such an ethics of care and responsibility, and continue to intersect with the person's socioeconomic status, race, gender, family support system, or broader capacities in general (Erving and Thomas 2018; Villatoro et al. 2018).
Because of the privileged knowledge of mental health professionals and suppression of other forms of knowledge on mental health suffering and distress (Cohen 2016), less is known concerning how mental health service users resist institutionalization as well as the discourses and power of the psychiatric apparatus. 2 The first author in particular has experienced involuntary psychiatric hospitalization for a psychotic disorder, and takes anti-psychotics to manage his illness. He has seen a number of psychiatrists and physicians for his mental illness. He has also taken part in psychiatric coercion, having helped restrain and chemically sedate service users during his tenure as a security officer in a psychiatric ward setting (Johnston and Kilty 2014, 2016). This experience shaped his own questions about the nature of patient-doctor relationships, and possible avenues for resistance.
This study, drawing on 5090 English reviews of 468 psychiatrists working in Canada posted on ratemds.com, examines how Canadian mental health service users enact agency and subtler forms of resistance when they are treated by doctors at the crossroads of these controversies and tensions. In doing so, we employ a post-anarchist perspective 3 in analyzing the narratives of our reviewers to discover the micropolitics of psychiatric resistance. Within this frame, anarchy is not seen as a desired Utopian end state based on the rejection of hierarchical authority and the valorization of a more fundamental level of human existence. Rather, post-anarchism takes anarchy as an ontological principle that must be adopted in any analysis of institutions of power. In this respect it is a continuation of Foucault's understanding of power as an inherently unstable relation, always susceptible to dispute, contestation, and reversal. As Newman (2016b:12) writes, post-anarchism is "a form of autonomous action, a way of acting and thinking anarchistically in the here and now". Simply, post-anarchism takes a view of politics in which essential identities are de-privileged as the point of political contestation, and one where normative categories are destabilized. Consequently, we argue that mental health service users draw on affective techniques of counter-analysis 4 to critique or appraise their doctors and the mental health system, and produce a knowledge that nuances and resists some dominant psychiatric discourses.
While much of the Mad Studies literature problematizes the functions, discourses, and practices of the psychiatric establishment (for example, see Lefrançois et al. 2013), as well as mobilizes first-person perspectives to show how service users resist and complicate its discursive power (Capponi 1992; Michener 1998), we argue our online data is unique for a number of reasons. Specifically, in micropolitical fashion, the reviews and critiques we analyze tend to focus on individual doctors rather than assert grand narratives about the psychiatric establishment, which is a unique diversion from much of the historical and current anti-psychiatry literature (see Burstow 2015; Szasz 1972, 2008, 2010). Yet interestingly, the targeted and individualist nature of our data still makes remarkable and clear links to the more macro critiques found within the realm of critical disability studies, without asserting a stable political position. We argue this online nuance is important to the future of Mad Studies, as service users in an anonymous review site can assert "distance" from the discourses and gaze of the psychiatric apparatus without necessarily committing to all of the radical political positions and divides embedded in the praxis of Mad Studies. Like other social movements in our current era (Kelly and Winlow forthcoming), Us versus Them mentalities can exclude service users' voices on the basis of the language they use or the diverging positionalities and platforms for change they invoke (Cresswell and Spandler 2016). In this sense, service users accessing online fora become included micropolitically without too much theoretical commitment, and this perspective is important to consider in the Mad Movement or any critical exegesis that is prone to becoming unproductively at odds with its own members.
Before turning to our analysis, we first flesh out the framework of this study and some of the ways in which mental health systems and psychiatric discourses have been challenged and navigated. More specifically, we overview how patient-doctor relations create tension and suffering in healthcare spaces, and how the texts upon which psychiatry draws much of its power shape experiences with pathologization and discourse resistance. We then interrogate the processes that emotions, class status, and behavioural differences play in the social construction of mentally ill people as 'deviant'. Following this discussion, we situate this research within the limited scholarship on psychiatric resistance, and then describe our online research design. We find that reviewers interrogate and disrupt discourses of pathologization, treatment, care, sexuality, and sexual function. Through these micro-political insurgencies against their doctors, reviewers re-direct clinical power dynamics in a way that demonstrates their autonomy and agency.
Mad Studies: Tensions, Problems, and Resistances in the Mental Health System
Situated under the umbrella camp of "Mad Studies," this study contributes to the body of work that places understandings of madness in the control of the authors, and often challenges the more pathologizing narratives of madness in the mental health system and their consequential impacts on service users, which sometimes work to condemn or infantilize other-minded people. There is a relatively large body of work that engages first-person narrative as a strategy to preserve and explore self-identity when illness, mental health system officials, or society in general threaten to contest or fragment it (Church 1995; McDonnell 2018; Michallat 2017; Stone 2006). Existing first-person narratives of madness confront the triggers and symptoms of madness in ways that look to rebuild, strengthen, and reinstate self-identity in the face of its disintegration (Bassman 2007; Burstow and Weitz 1988; Pembroke 2009; Russo and Sweeney 2016; Shannonhouse 2003). While what follows is a discursive map of the many theories, concepts, and empirical considerations that have shaped the critical inquiry of psychiatry, we position this work firmly within the politically diverse Mad Studies movement as a point of clarity for readers who may be unfamiliar with the porous borders of critical psychiatry scholarship.
Research suggests that mental health service users feel more dignified and safer when caregivers afford them autonomy over their treatment, making them a partner in their own care rather than a "subject" (Chambers et al. 2015; Kuivalainen et al. 2017; Lindwall et al. 2012; Quirk 2012). Others feel more powerless in settings where caregivers or security personnel misuse or abuse their power (Jacob and Holmes 2011; Johnston and Kilty 2014, 2015, 2016; Johnston 2014). Women in particular have expressed their experiences with betrayal, harm, and indifference from healthcare staff during psychiatric hospitalization (van Daalen-Smith et al. 2020). Indeed, fear of patients is a major variable influencing nurses and doctors' decisions to distance themselves from care and manage healthcare space in terms of risk and security (Jacob and Holmes 2011). Some nurses experience significant moral distress when they see other nurses and doctors refuse to talk meaningfully to in-patients, endure a hierarchal power structure of physicians, and feel like they do not have the ability to advocate for ethical change in their institution (Woktowicz et al. 2014).
There are many positions one could take in terms of how (in)effective the mental health system is at treating and helping people. However, this article is more concerned with the fact psychiatric experts have a tendency to construct service users as passive recipients of psychiatric care, perpetuating the assumption that people who suffer from serious mental illnesses are unable to comprehend their own sickness, recovery, and behaviour and therefore engage psychiatric experts about their care (Cohen 2008; Kirmayer 2000; LeFrançois et al. 2013). To people who have good experiences with doctors in the mental health system, these suppositions may be startling and troubling, but still it remains imperative to question our assumptions concerning the legitimization of mad discourses, psychiatric treatment, and who gets to advance and 'implement' such knowledge.
Doing so requires being critical of the texts upon which psychiatry draws most of its power and authority, and also because many of our reviewers problematized the processes that their doctors would engage in to diagnosis, label, and treat their condition. The third edition of the DSM in 1980 "replaced the theoretical and aetiological system of classification…with an atheoretical and purely descriptive approach to classification, which has remained the favoured methodology in subsequent editions of the DSM" (Tsou 2016:406). Psychiatry then focused on looking for indicators to classify disease rather than dig into the patient's life history to come up with a theory of why they are suffering the way they are. The DSM-III was heralded by practitioners as revolutionary for its ability to produce reliable and testable criteria for mental disorders; specifically, a cluster of various symptoms that could help explain biological, neurobiological, and molecular mechanisms occurring and interacting at multiple levels to produce unwell states of being (Clegg 2012). One limit of the DSM in a descriptive form is it has difficulty classifying and causally explaining naturally occurring disorders such as depression and schizophrenia. Though grounded in years of clinical research, another assumption is that clinicians must believe that the cumulation of descriptors and criterion are in fact a conceptually sound, uncontroversial, and valid basis for determining the existence of a disorder (Wakefield 1992).
While the DSM remains a useful text for practitioners trying to diagnose and treat people from their mental health condition or disorder, like any other discourse or narrative, the text is conceptualized and circulated through a process that is shaped by political, gendered, cultural, and socio-economic forces (Clegg 2012; Reuter 2006, 2007). For instance, the gendered disposition of psychiatric pathologization is evident by the disproportionate number of women who are prescribed psychotropic medication or diagnosed with a disorder because they express gender in ways that are deemed suitable only by men (Russell 1995). The introduction of the DSM-V, which was created in part to recognize the degrees to which culture might influence how mental health suffering is experienced and understood (Wakefield 2016), still forces patients to absorb other clinical definitions, such as depression, in order to receive attention from the mental health system. The broader shift from explanation to diagnosis and treatment results in a more volatile eruption of bottom-up forces resisting the psychiatric apparatus, especially when such definitions are too obtuse, clinical, or controlling. It is this emergence that this study intends to analyze.
In thinking more about the differences between what societies deem rationalist, sane behaviour as opposed to 'mad' and potentially sickly expressions or outbursts, Peggy Thoits (2012:201) uses the term emotional deviance to account for the "persistent, repeated, or intense violations of societal feeling or expression norms, where emotion management efforts are often ineffective". She indicates there is a perceptive (unphysical) threshold people cross when they communicate thoughts and identities that others recognize as constituting mental illness or sickness as opposed to just say, unusual forms of expression and distress. Her disconcerting yet evidentiary content analysis of the 351 Axis 1 and Axis 2 disorders located in the DSM-IV finds that 101 (30.5%) of these diagnoses are primarily established by the recognition of culturally constructed deviant feelings or emotional deviance. The labelling of mental illness begins when we lose emotional control, disturb others by expressing emotions that are unruly, disruptive, excessive, and unsightly (i.e., anger, frustration, nervousness, fear, melancholy, worry, apathy, laughter), or do not perform emotions that societies deem to be appropriate given the circumstances. She and others (Kirmayer et al. 2015) are quick to point out that the criterion that comprises definitions of mental illness as well as how it is experienced by people are heavily shaped by cultural constructions of normal behaviour and our underlying ideological orientations.
For example, patients with a lower socioeconomic status tend to get diagnosed with more severe disorders such as schizophrenia when their behaviour presents to others as unruly, confusing, irrational, or erratic (Dohrenwend 1990; Hollingshead and Redlick 1958; Kessler et al. 2005). Debate still exists as to whether socioeconomic disadvantage shapes the production and realization of psychiatric symptoms (Deleuze and Guattari 2009) or whether marginalized populations are more likely to be labeled and diagnosed with a serious mental disorder (Conrad and Bandini 2015).
Nonetheless, those whom society pits as "mad" can get taken up as a separate class of "deviants" because of how others view their behaviour. Mental illness is still not often understood well in society, but rather can be perceived and stigmatized as a dire weakness and difference, which creates a negative connotation associated with some types of behaviour (Conrad and Bandini 2015; Dobransky 2019). For instance, racial discrimination can lead to more negative mental health outcomes (Brown et al. 2019; Head and Thompson 2017; Louie 2020). Other people with more "invisible" mental illnesses, meaning sicknesses that they can conceal from others because their behavioural differences are less obvious, become obligated to perform sanity and conform to institutional behaviours so they can adequately manage the stigma, professional expectations, and vulnerabilities some may perceive as a fault (Johnston and Sanscartier 2019; Link and Phelan 2013).
While not directly related to viewpoints of psychiatrists, Lopez et al.'s (2012) study of online reviews of general physicians on ratemds.com found mostly positive results. Reviewers indicated that care extends well beyond the doctor-patient dyad, as they appraised or critiqued their doctors based on access and convenience of services, as well as their impressions of the clinic's other staff members. Negative reviews underscored the importance of good bedside manner, as doctors who were perceived to be rude were less likely to receive a positive review. In a similar study of ratemds.com, Gao et al. (2012) found that physician hierarchy influenced the results, with board certified doctors and long-term graduates tending to receive slightly higher ratings than those with malpractice claims. While both of these studies treat the reviews as their analytical object, which in turn speak to the varying functions of the medical system, we treat the psychiatrist reviews as radical tools of discourse via a post-anarchist perspective.
Psychiatric resistance in particular has manifested inside its institutions. One ethnographic study observed that male psychiatric service users problematically drew on their masculinity to emphasize their heterosexual status (Leyser 2003). They used roughhousing, touching, sexualized talk about and objectification of women as a means to resist hospital constraints that limit expressions of gender to normative enactments. Other research documents that smoking spaces found in hospital units help service users build social capital and resist institutional control, which some staff will then heavily regulate as a "protective health measure" (Wood et al. 2013). An earlier study found that ex-psychiatric service users constructed alternative forms of social organizations to oppose mainstream society and resist stigma and oppression (Herman and Musolf 1998). Some strategies involved self-labelling, selective concealment, or political activism in the forms of walkouts, sit-downs, and protest marches.
Beyond direct forms of action and activism, Montenegro (2018) recently explored how service users disengaged and distanced themselves from the psychiatric apparatus, which positioned themselves outside of the legibility, approachability, and descriptive ambitions of the mental health system. Some studies discuss the logics of professionalization (El Enany et al. 2013) and how those working in mental health are just as prone to psychiatric power and oppression as service users (Chapman et al. 2016; Tosh and Golightley 2016).
All that said, it appears that overt psychiatric resistance has only been preliminarily explored. More so, there is a gap in the literature assessing how patients engage in more subtle, anonymous techniques of psychiatric resistance, which this study seeks to explore. We are less concerned with how mental health service users engage in direct forms of resistance and action against mental health professionals, but rather are interested in how they refuse to become subjectivized by psychiatric discourse and power. We explore how digital media provide mental health service users with a community of critique to regain control over settings where there are many power imbalances. More specifically, we examine how "the online" acts as a conduit for affect, emotion, or feelings that may be considered "abnormal" under the psychiatric gaze (Thoits 2012). In other words, how does affect, which is controlled, minimized, and regulated through the normalizing forces of the medical and psychiatric apparatus, manifest online, and illustrate the discursive and emotional tactics of resistance wielded by service users? Further, (how) do these tactics serve collective functions of resistance, and create a reservoir of resistant discourse against the psy apparatus, despite the fact that posts about psychiatrists, psychotherapists, and counsellors are made by individual service users? By addressing these questions, our goal is to examine—using a post-anarchist framework—the manners by which service users establish forms of identification at a distance from psychiatric providers, destabilizing the "interpellative hail" of psychiatrists (Newman 2016b).
To explore these issues, we analyzed 5090 English reviews of 468 psychiatrists working in Canada (313 of which are male). These reviews were posted between the periods of 2007 and 2018, and collected from ten provinces and two territories, with the Northwest Territories containing no reviews. In these data, psychiatrists were primarily responsible for diagnoses and drug prescription, although they did perform secondary services of counselling/psychotherapy that were also visible in reviews to a lesser extent. Reviews of psychologists and other psy-professionals are outside the scope of this article but should be explored in future research. Names, genders, ages, and other identifying information of the doctors are not reported in this study, though they are publicly available. Last, because the focus of this research is an exploration of the micropolitics of psychiatric resistance, we are unconcerned with the quantitative aspects of the ratings, chiefly how many stars doctors were afforded.
To fully appreciate how reviewers subvert medical subjectivization through the online circulation of affective texts, an ethnographic approach is warranted as we do not aim to simply examine qualitative themes in a more or less detached, scientific manner. Online ethnography has become a popular approach in the last twenty years, serving a variety of methodological functions ranging from the digital tracking of how certain virtual communities grow and change, participant-observation in online forums, and reading online texts left by others to capture some aspect of the human experience and virtual community-building (Garde-Hansen and Gorton 2013; Gatson 2011; Hine 2008; Horst and Miller 2012; Kozinets 2015). As Pink and colleagues (2015:5) illustrate, "virtual sociologists" frequently analyze online texts to understand how "inequality is extended, reproduced, or complicated by digital media technologies", and how asymmetrical power relations manifest online textually and otherwise.
López et al. (2012:688), taking a more scientific and systematic approach to analyzing ratemds.com, developed a set of "global themes" and "specific factors" of what keeps clients happy with their doctors, notably interpersonal manners, technical competencies and administrative efficiency. While we are certainly interested in how these themes emerge from these data, we are also interested in how clients build what digital media scholar Adi Kuntsman (2012:3) calls affective fabrics, which she defines as "lived and deeply felt everyday sociality of connections, ruptures, emotions, words, politics and sensory energies, some of which can be pinned down to words or structures; others are intense yet ephemeral." Importantly, she notes, when individuals identify and discuss their feelings in online forums, they collectively create archives and communities of feelings, where "the emotionality of the everyday starts living its own life in cyberspace" (ibid: 7). Using online ethnography, then, we treat our data as indicating more than strangers simply venting on the internet about their doctors. Rather, they are "memorial talismans that carry the affective weight of the past" contained within the "digital archive" of ratemds.com (Cvetkovich 2008:120; Kuntsman, 2012:6). In sum, we want to ensure our analysis stretches beyond a scientific, cognitive function to encompass an affective one as well.
To generate a thematic scheme, the first author first read all the reviews line by line to obtain a general impression of the epistemological and theoretical connections and digressions the reviewers made about the Canadian mental health system (Creswell 2014). After getting a feel for the data, the first author then compiled a set of codes that emerged inductively and he applied these to his field notes he took during his first read-through (Chretien et al. 2015). Qualitative data were managed in a word processor program and representative quotes were highlighted for each code. Key concepts and thoughts that appeared repeatably were tracked in the word processor, which produced three sequential critical sections such as service users feeling misunderstood by their psychiatrist, counter-analyses of their doctor's behaviour, and expressions tying psychiatric practice to broader social structures like capitalism. We then coded the more positive reviews, though they were far fewer in number (18%).
Sub-categories and themes were then produced (not mutually exclusive), which included psychiatrist aggression or apathy, feelings of pressure, conflicting understandings of mental illness between service users and psychiatrics, doctor focus on sexuality, monetary corruption, and therapeutic alliance-making. Since we do not know the demographics of participants, there may be concerns over the validity of our data in terms of it being truly representative of service user opinions about the Canadian mental health system. Although we could not always code our data in terms of the reviewer's gender, race, or social class, we could determine that power (im)balances were shaping the context of the review, and thus resistance to psychiatric power remains the brunt of our analysis. Future research should continue to analyze intersections of gender, race, age, and class in service user and doctor relations.
Last, we should note that some "netnographers" might object to this kind of passive interaction with data, as we are not directly participating in the co-construction of a community of feelings (see Bengtsson 2014; Costello et al. 2017). Nonetheless, we do follow other "netnographers" in taking this kind of approach to data collection and analysis, carefully incorporating our own reflections as needed. Examples include Ferreday's (2003) earlier exploration of the "Pro-Ana" online community and Underwood's (2017) more recent online ethnography of IPED (image and performance enhancing drug) users. Finally, while there is no clearly delineated community of which to declare ourselves "consummate and acknowledged insiders" (Gatson 2011:514), we nevertheless feel like a part of this affective fabric, having experienced the psychiatric gaze ourselves. The first author's experiences with psychosis and Schizophreniform Disorder (Johnston 2020b) especially made him a real citizen of this research, and in conjunction with the reviewers' narratives, shaped his perceptions of the mental health system.
The View from the Couch: Counter-Analyses of the Doctor
Some reviewers shared concerns that their psychiatrists did not take the requisite time to get to know them or listen fully to their concerns, which they felt hindered their treatment and the psychiatrists' understandings of their illnesses. The power dynamic in patient-doctor settings can be very imbalanced, so reviewers used the ratemds forum to re-direct power relations and present valuable information about themselves that, unfortunately, often gets discredited through tight epistemological control mechanisms. In some cases, reviewers engaged in a counter analysis of the psychiatrist's behaviours, habits, and attitudes towards patients to challenge their knowledge and standards of professionalism.
Appointments include: (1) Do the rating test (2) If the results are lower than previously, add another medication. As head of psychiatry…you'd think he'd give at least 10 minutes for a conversation to really gauge a person's frame of mind…I stupidly agreed to electroconvulsive therapy. I say stupidly because he gave me no explanation about the risks or possible side effects…He never recommended talk therapy or stress management, nothing other than pills and ECT. The one time we had a discussion about me wanting to go back to work, he became verbally angry because I wanted to return to my original job…not returning there would mean a huge reduction in salary and I would have lost my home. He got very angry because he had apparently sent a note to the insurance company recently saying I shouldn't return to my job…He said agreeing to that would make him look like he couldn't make up his own mind. I said agreeing to it would show you're the type of doctor who is open to changing his mind given new information. He finally agreed to allow me to return to work but became so angry that he raised his voice loudly and angrily told me he never wanted me back in his office again.
This reviewer problematizes their doctor using a simple questionnaire as a final instrument to decide whether or not a person needs an increase in their medication, rather than learning from the service user's expressed words and feelings. The reviewer identifies time as a primary conflict preventing their psychiatrist from delving deeper into their problems of the mind, but feels that a few minutes of talk could go a long way in making the service users feel like they have some say in their treatment. Even more disconcerting is the fact that they were not given information of any potential side effects of taking electroconvulsive therapy (see Hanna et al., 2009) which is known to potentially create permanent memory loss as well as other debilitating harms (Cohen et al. 2000; Rose et al. 2003; van Daalen-Smith 2011; Watkinson 2007). When they did challenge the doctor directly over concerns about needing to go back to work, the reaction was hostile (Perry et al. 2018). In the doctor's office, this way of engaging clients might appear routine, rudimentary, and unavoidable (Cohen 2016), but in this forum the reviewer is able to debunk some of these control mechanisms and assert control over their situation and opinion of psychiatry.
The reviewer also takes issue with the fact that their psychiatrist will apply a label to the client's issues without providing any explanation of the clinical meaning for the diagnoses, nor explain how they arrived at their conclusions (see Tor and Tan 2015). The result is that the psychiatrist is unable to comprehend elements of their condition that might give him a better lens in which to view their suffering, and the client is left feeling unheard and antagonized.
One reviewer, who identified elsewhere in the review as having been diagnosed with Attention Deficit Hyperactivity Disorder, Obsessive Compulsive Disorder, Major Depressive Disorder, and Auditory Processing Disorder, used their review to debunk their psychiatrist's belief that they did not meet the legal and governmentally accepted definition of "disabled."
…Because of [Doctor's] personal beliefs I was declined for the Disability Tax Credit 5…If you have a child or are an adult living with "Chronic" ADHD and/or you believe that ADHD is a disability, then please heed my warning and DO NOT waste your time seeing [Doctor]…[Doctor]…had stated: "The chances of you getting approved is going to be rather little…In my opinion it's not a disability because a disability suggests that you can't do any job and that you would require a lot of functioning and a lot of support in order to even function without work"…"Disability" is defined by Merriam-Webster as a condition (such as an illness or an injury) that damages or limits a person's physical or mental abilities, as defined by Cambridge as a physical or mental condition that makes someone unable to act in a way that is considered usual for most people…That is EXACTLY what ADHD does to an adult, limits their mental abilities EVERY moment of EVERY day. Especially to individuals who like me are diagnosed with multiple disorders…Unfortunately due to the limitations caused by my disabilities…there would be nothing I could say to make this man understand the ignorance I heard in his opinions.
This reviewer's psychiatrist disagreed that their condition(s) impaired their functionality enough that they should be given a tax credit specific to persons with disabilities. In person, the reviewer did not feel they had the drive to continually battle their psychiatrist's definition of disability, which left them in a "catch-22" situation. They rely on the psychiatrist to prescribe them medication and continue treatment, but trying to argue amidst impairment would place the service user in a tough circumstance where they would face reprisal and potential defeat for challenging their doctor's view. So, quite intelligently, the reviewer draws on more commonly available and accessible dictionary definitions of disabilities to confront and resist their psychiatrist's understanding of their illness online – words that the doctor may have read if they surveyed their profile's reviews. They claim to experience ADHD and a conjunction of other illnesses in ways that alter their ability to think, feel, and act, and as a consequence, they warn readers about receiving treatment from this doctor if they are seeking extra help from the government.
Asking the Wrong Questions: Tensions with Sexuality
With the first author having been asked questions by mental health professionals about his sex life and traumatic details about his psychotic symptoms – details he did not always admit to due to concerns with embarrassment or fear they might assess him as dangerous – we have a deep appreciation and concern about the safety and comfort of mental health service users when they are questioned this way. On the other hand, medication side effects can be numerous, unforeseen and impact sexual functioning, which doctors have to ask about in order to understand if they are working properly. The following two reviewers drew a line in the sand about when it was necessary to probe for details about their sex life and when it was unwarranted.
I went to see him once a week for two years at a time when I was very depressed and suicidal. I will admit being there and just unloading my feelings was helpful, but I might just as well have talked to my dog. He never said a word, unless I asked him a direct question, never actually diagnosed what my "problem" was and frequently looked at me with a blank stare, as if he were taking a mental vacation. All of this for $130 for a half-hour session! He was overly fixated about my sex life and would ask me about it and want details, which really creeped me out…I was beaten and physically abused as a child, but not sexually, so his questions about my sex life were unwarranted…
I think he gets off from making people answer uncomfortable questions about their sexual lives. I get that sexual trauma or the difficulties associated with being homosexual or trans or whatever can have dramatic implications in a person's mental well being. But given that I went in to see him at age 25 as an employed professional clearly describing "I'm in a healthy relationship with a girlfriend. No I've never been with another man. And no I've never been abused." You'd think he'd at least ask some other questions. But no. The entire (five minute) consultation was about sexuality. Then I left with a diagnosis of borderline personality disorder, but medication for ADHD…I got a glimpse why someone who feels scared about their mental health and needs help would turn to suicide.
Both reviewers frame their psychiatrists as overly fixated on others' sexual lives and histories, rather than on the grounds of medical justification. The first reviewer views their doctor's eventual expulsion from medical practice as justification that the questions asked to them by the doctor should have been out of bounds. When the first reviewer "unloaded" their feelings onto the doctor, and brought up what they felt were more valid concerns related to their mental health (which had little to do with their sexuality), they describe the doctor as becoming quickly disinterested.
The second reviewer, somewhat in contrast, identifies 2SLGBTQ+ mental health issues as possibly linked to sexual trauma, and would have been more open to these lines of questioning if he did not outright identify as a straight man living in a sexually healthy relationship, with no prior history of abuse. Both reviewers felt uncomfortable and misled by their doctor's questioning, and during the sessions, there might have been little they could have done to re-direct power relations. However, through these reviews they use the forum to reassert control over their sexual identity and history, and problematize the perspectives of the doctors'.
A trans-identified reviewer also took issue with their psychiatrist's understanding of gender identity, and how to treat specific mental health issues in trans people.
On the first session he told me he wouldn't call me by my chosen name because I am not really transgender, just having an identity crisis as a result of BPD [Bipolar Disorder]…He diagnosed me with a ton of disorders I don't have. He is rude, abrupt and inattentive to my needs. He is always late. He doesn't seem to know what the pills he gives me do, and changes them every few months. He doesn't take into account the interaction the pills have with each other…On our last session he told me my gender dysphoria doesn't matter, I should put it aside and worry about my suicidal ideation instead. He told me it's not like I have large breasts. He refused to write a referral for surgery because he is worried I will regret it and kill myself…He is a transphobe and doesn't seem to know much about his practice. DO NOT SEE.
From the outset, this reviewer was appalled that their doctor would only recognize them by the gender that was assigned to them at birth, rather than their self-identified gender. The doctor overlooked the problems that come with trying to express and live their self-identified gender, and instead focused on the tidier issues he could diagnose and medicate. The reviewer sees their suicidal ideation as occurring in part from the medication (or absence of better medication) that was prescribed to them, and they raise contention with their doctor's over-pathologization of their afflictions. The issue that was important to the reviewer – getting a referral for gender transition surgery – was overlooked because the doctor felt that they might regret that decision, despite there being a low incident of regret in the extant literature (Karpel and Cordier 2013; Nelson et al. 2009). In this case, the response to transgender suffering was to diagnose and medicate without tackling the root causes of their suffering, that is, having to live in a body that does match their gender identity.
Stigmatizing Doctors in the Face of Tension
The most emotionally charged (and anti-psychiatric) reviews surfaced when reviewers expressed concerns over how their doctor's reliance on medication prescription does more damage than good for some of their conditions. Two reviewers depicted women doctors as being too hasty in their judgment to prescribe medications.
Absolute lunatic. No idea where she got her psychiatry degree but the fact that she's a doctor and can prescribe medicine is very scary and worrisome. She prescribed me Zoloft after BARELY getting to know me or the core of my issues. Pill pushing psychopath with no empathy whatsoever. After being raped she told me I was dumb and shouldn't have put myself in that situation. Please never bring your child to her.
This woman is completely inept and negligent, demonstrating a level of ignorance and distraction that would classify as dangerous if not for her staunch refusal to do anything other than point her finger and criticize. She clearly has difficulty comprehending her own computer and telephone, never mind the intricacies of pharmacology. I wouldn't trust her to brew a pot of coffee let alone 'care' for my mental health.
The first reviewer's brief encounter with their psychiatrist resulted in a quick diagnosis and prescription for medication. Considering the time constraints placed on mental health professionals to treat a plethora of disorders in their communities, it is unfortunately not uncommon for service users to receive a quick explanation and resolution for their symptoms. Many of the reviews in this study question whether psychiatric expertise can be enacted so rapidly without issue. More troubling in this review than the issues with treatment is the fact that the reviewer encountered victim blaming when she brought up her experience of being raped. The lack of empathy and sole focus on making sure the reviewer is medication-compliant led her to pathologize the doctor as psychopathic, which for a number of reasons, is problematic. By trying to subvert her doctor's intelligence and power by calling them names and stigmatizing them in an online forum, the reviewer enacts a double standard and deploys the same colonizing psychiatric language she wishes to escape. By engaging in a stigmatizing practice with little care or attention paid to its damaging consequences to others, she in turn jeopardizes her credibility as an autonomous agent of her own well being.
Rather than criticize their psychiatrist's overreliance on medications, the second reviewer voices displeasure with their doctor's lack of pharmaceutical knowledge. The reviewer observes the lack of practical skills in their doctor, such as managing their office technology, as troublesome when it is their job to prescribe highly sensitive and life-altering drugs. When such skills are absent, the reviewer becomes especially infuriated when they are forced to take criticism from their doctors. This review, like others in the study, reveals the tug of war match between service users and psychiatrists over who is at fault and who is not at fault when mental problems arise. When faced with a lack of power in clinical settings, the forum once again serves as a medium to regain the control that is lost when they reach out or become forced to seek help.
There's Still Good Doctors Out There
Not all of the reviews critically assessed the power dynamics between service users and psychiatrists. Some reviewers appraised the role their doctor played in helping them overcome their mental health issues, heal their suffering, and in some cases, save their lives.
[Doctor] is a practitioner who is committed to maintaining a standard of excellence in all areas of his practice. With extensive and ongoing education, training and experience, he is current with regard to the latest research and literature in his chosen discipline. He is human, not perfect, makes mistakes and he is not always right. As his patient, we have had some disagreements. I believe that people still view physicians of any discipline as infallible and not to be questioned. I do not…I was always honest with [Doctor] if I was uncomfortable or disagreed. We were able to discuss and compromise. For my therapy to be successful, I had to be willing to the work. It is not just meds. There are no "magic" cures. I hold [Doctor] in the highest regard. He is one of the great ones!
This reviewer was able to work through their disagreements with the doctor through ongoing discussions and compromises. Unlike the previous reviewers who described relationships of utter obedience or authoritarianism, this service user's doctor owned his mistakes and worked hard to educate himself to keep up with the changes to the profession. To recover, the reviewer also positions himself as needing to work hard on his issues, and that not all of his problems can go away simply by being treated by a psychiatrist. The psychiatrist instead was more of an instrument in recovery, and a person whose fallibility was something less to be mocked and more to look at as something that should develop and improve over time.
Another reviewer also positioned psychiatrists as works in progress who need much time to be able to trust and develop an intimate relationship with.
I believe this doctor is making a considerable effort to help his patients. He does listen and maintains a kind and friendly manner…Psychiatry is such an inexact science that you must trust the doctor to make the correct observations and diagnosis. I have been seeing this doc for about a year and am just beginning to feel somewhat comfortable with him. I am not sure that he understands how difficult it is to bare your naked soul to someone you have met just a few times. He uses statements like I have felt like that before, in an attempt to say he understands what you are trying to say. I still get the feeling this is a technique learned in training and not actually him relating to your feelings. But, as I say, he seems to be trying hard.
It is a difficult and burdensome endeavor to treat someone's mind with enough accuracy and care that they feel well again. Psychiatrists have to rely on keen observational skills and listen to a service user describe their symptoms to be able to understand what might be causing their mental health conditions or disorder. This reviewer does not see this limitation as a flaw in the science, but an inexact measurement that can be understood with more precision over time. Trust, in this reviewer's eyes, is key to honing in on a person's problems, and thus if service users are already hesitant and uncomfortable during their sessions with the doctor, and the doctors are short-tempered and unwilling to listen, it will naturally lead to mistakes. Building that kind of openness is not easy, but it can steer power relations in a direction of mutuality and curve the public's opinions of psychiatrists if such a relationship is mastered.
Discussion and Conclusion
Research has repeatably found that when mental health service users feel autonomous, they tend to praise their care (Chambers et al. 2015; Kuivalainen et al. 2017; Lindwall et al. 2012; Quirk 2012). Yet when they feel powerless, betrayed, or abused, they tend to criticize their care (van Daalen-Smith et al. 2020). Building on this literature, our findings indicate that not only do service users hold the capacity to point out the insufficiencies of psychiatric treatment through online critique, but in doing so, they turn the tables of psychiatric power and discourse unto their doctors. Sometimes their negative framing encounters tensions such as when two reviewers pathologized their doctors out of spite and anger, however, many of our reviews point to a subtler resistance not yet discussed in the budding literature on psychiatric resistance. Some patients have been known to engage in more direct forms of resistance such as sexualizing their healthcare space or walking out of their closed institution in protest (Herman and Musolf 1998; Leyser 2003), but our reviewers seem to enable the guise of anonymity to bluntly reject the practices, and more importantly, discourses of the psychiatric institution. Their reviews, which manifestly appear to be micro-political attacks on their doctors, also problematize the structures of power that enable psychiatrists to subordinate patients and restrict their sense of community because of the individualist nature of the clinical environment. We argue that communities of critiques are emerging in the online sphere that hold the potential to destabilize and disrupt the imbalanced relations permeating the psychiatric apparatus (see Burstow et al. 2014).
It has been documented that people with more "invisible" mental disabilities encounter difficulty in performing and conforming to all of the professional or societal expectations imposed on them, especially when they are problematically labeled or perceived by others as non-disabled or not disabled "enough" (Johnston and Sanscartier 2019; Lightman et al. 2009). We recognize the possibility that many of these reviewers may feel trapped in a clinical environment that, while often recognizing and treating their disability or condition, enforces obligations and norms of behaviour that do not coalesce with the service user's mad or non-realist ontology and way of being. Requiring compulsory obedience and ability, defined in this sense as an expectation that the service users work diligently to demonstrate they are sane, is a form of ableism we believe constricts relations with professionals. Johnston (2019) finds that direct confrontation with psychiatrists trying to regulate any kind of recalcitrant or "irrational" behaviour does not always yield positive benefits or meaningful negotiation. Caught in a kind of trap, it seems that the ratemds.com forum offers a space of hope and expression for service users to speak out against the psychiatric practices they find unjustifiable or concerning both to their doctor—by virtue of posting to their profile—and to a community of observers who may read such reviews. In doing so this way, reviewers anonymously escape the consequences of more direct resistance or relational engagement with "experts".
We also found that these critiques, lacking this kind of social re-direction, paves the way for uninhibited emotional expression, even at the risk of assuming a double standard, whereas other studies analyzing the person-to-person resistance demonstrate the sheer difficulty service users face when resisting psychiatric professionals whose control on the truths of the mind permeates much of the Western world and beyond (Johnston 2019; Wood et al. 2013). Unlike Montenegro's (2018) recent work that shows how service users may choose to disengage and distance themselves from the psychiatric apparatus when they no longer see the benefit in accessing psychiatry, our reviewers' words often represent a more private, subtler, but still, head-on attack on their caregivers. It could very well be that many of these reviewers decided to still engage with the doctors whom they critiqued, but nonetheless, their reviews are a powerful indicator that service users understand very well the relational dynamics and power (im)balances that govern psychiatric relationships. Not only that, our study confirms that they are willing and ready to resist in ways that are difficult to police and silence; in other words, their transgression is both perceptive and intelligent.
Grounded in years of clinical research, the Diagnostic and Statistical Manual of Mental Disorders (DSM)—a book Burstow (2016) criticizes for being a "boss text"—has become widely regarded as a legitimate tool to define encounters with mental illness and circumscribe appropriate treatment. Our reviewers who sought out treatment voluntarily, in some sense, implicitly acknowledge that they have may have some problems of the mind by virtue of seeking out a psychiatrist. However, it is the application of discourses found within the DSM that so many reviewers resist and find problematic. Reviewers tended to compete with their doctors' diagnoses by sometimes challenging the competency of their diagnosis and active listening skills, or in other cases highlighting that they are sicker than their doctor will give them credit for.
As some reviewers demonstrate through their experience, when activated by a clinician, the DSM carries with it a strong current of power, and thus the potential for abuse can be high (Tosh and Golightley 2016). Thus, this research demonstrates the need to think carefully about the ways in which we activate mental health labels. Medical professionals must understand that when they use these diagnostic tools, they should be open-minded to the possibility that these labels might change, and should be willing to negotiate with service users their applicability. This is a difficult suggestion to bear in mind since doctors may want to show their patients a sense of control and authority they have over their diagnoses, but in doing so, they run the risk of infantilizing the user to the extent that they are seen as unknowing of their own conditions (Cohen 2008; Kirmayer 2000; LeFrançois et al. 2013) – conditions that they, after all, are the ones experiencing. On the flip side, those critical of the psychiatric apparatus must accept the good work that some doctors are doing in giving meaning to those who experience mental illness, as some of our reviews astutely point to there being a social condition with doctors that can be welcomed and embraced by service users.
Another point we wish to stress is that reviewers' harsh critiques may give the impression that their psychiatrists are always acting with malice aforethought and awareness. However, as one study illustrates (Woktowicz et al. 2014), some healthcare professionals have to negotiate their own ethics in order to deliver care competently, and they too may feel like resistance within their profession is difficult to enact. Future research must study psychiatrists' perceptions of their work and the moral, ethical, and power (im)balances they must negotiate under the scrutiny of a great deal of medical responsibility.
Turning to a more theoretical direction, we would like to end this article with a brief consideration of the importance of service user feedback in any critical account of psychiatric practice. It has never been our purpose to examine whether or not such feedback is effective; these kinds of conclusions could be reached were the psychiatrists interviewed and asked whether they accessed and responded in meaningful ways to the feedback posted online, but this was not our goal. Neither has it been our goal to explain such feedback as a sort of capitalization upon the psychological suffering by the mental health industry. Though some users think it is important to "be a smart consumer" (in one unquoted review in our study), we are hesitant to explain sites such as "ratemds" as the surface effect of a more fundamental process of marketization or as yet another residual, individualizing process of a wider "neoliberal turn" (Sanscartier 2017). By counter-analyzing doctors to feel like they have a say over their treatment/conditions, insisting doctors are asking the wrong questions to better control their identities, and attempting to informally expose their doctors' ties to the pharmaceutical industries, service users refuse to simply accept the labels, diagnoses, and pathologies imposed on them. A post-anarchist framework, a view in which "essential identities and fixed normative categories are destabilised" (Newman 2016a:285) allows us to view these textual gestures as subverting medical subject-positions via discourse external to the psychiatric apparatus.
Drawing on such a framework, we do not privilege experiences of service users by granting them a status of "real" while the psychiatric apparatus is merely "ideological". To make these assumptions would to risk rendering these texts as simply another variant of identity politics, in which there is a struggle for representation/rights by a specific, marginalized group. But we understand these reviewers not as appealing to another subject-position, framing their marginalization through a lens representation or rights. Indeed, they are directly contesting their interpellation by the psychiatric apparatus, and, in doing so, refuse to adopt the technologies of the self that the latter tries to impose on them. Our examination of these texts was driven by a desire to find out more about this resistance, rather than appealing to discourses that would simply strengthen a diametrically oppositional subject-position in relation to the psychiatric apparatus, thereby reifying the latter as a repressive, totalizing mechanism.
In conclusion, we believe that websites like ratemds.com act as a digital agora in which people are afforded the ability to make the personal political. Through critiquing their own doctors, reasserting their own identities, and identifying inappropriate institutional coercions, service users invert the question of what is "wrong" with them to what is "wrong" with agents of the psychiatric apparatus (i.e. their psychiatrists). In this way, it is arguable that service users are in fact exercising a form of the sociological imagination, refusing to shoulder only individual blame for the problems they face in everyday living and instead drawing on and contributing to discourse that problematizes a system so concerned with regulating and "fixing" them. Finally, we hope this research will inspire other ways in which individuals destabilize forced subject-positions borne of trying to find help, both in the psychiatric apparatus and beyond.
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Like Boschma (2007) and Landry (2017), we are aware of the socially and culturally constructed use of the terms "mental illness," "mental disorder," and "patient". Using these terms implies knowledge that there is always cooperation between a person and their caregiver, when in reality we cannot assume that each person who experiences mental pain, anguish, and suffering accepts that they are ill, or wishes to be treated in accordance with the established psychiatric diagnoses, treatments, and discourses available. With tension remaining, we tend to refer to these people as "people" or "mental health service users".
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We use the terms 'psychiatric apparatus' and 'psy-complex' to make it clear to readers that our critique implicitly extends to the related disciplines and governing institutions that, in some way, tend to draw on, reinforce, or enforce the ideas and practices of psychiatry (i.e., psychology, social work, nursing, counselling, care, and so on). That is not to say that everyone who is employed by, or benefits from, these professions endorse psychiatric knowledge, but we recognize that psychiatric power strikes us in the most basic areas of our life, wellness, family, education, and social governance.
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Related to post-anarchism, feminist standpoint epistemology privileges situated knowledge and rejects the idea of a universal and value-free knowledge (Harding 2004). The point here is that marginalized perspectives may provide greater insight into knowledge than dominant perspectives because oppressed groups have access to the lived realities of those who experience oppression, while powerful groups often do not (Rose 2009). Revealing the experiences and perspectives of marginalized groups allows for one to invert their perspective, which can carry vast implications for policy and social relations. Post-anarchism, on the other hand, departs from this epistemology by refusing to examine whether this positionality is politically "useful" or not, in the grand sense. Instead, this praxis focuses on the micropolitical significance of resistance and what that means for practices of contestation, or even destabilization. For more on the influences of feminist epistemology in the field of Mad Studies, see Johnston (2020a).
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There are many theoretical orientations and analytic angles to the study of affect and emotions, from the psychobiological to the social, indeterminate to conscious, or corporeal to discursive. We use affect as a catchall umbrella term for what gets taken up in popular discourse and academic research as emotions, feelings, sentiments, and moods. So, our view of affect includes the in-betweenness (Muñoz 2009) that emerges amidst virtual–actual, potential–emotion, psychobiological–social, indeterminate–conscious, and corporeal–discursive responses to symbols in a digital culture (Ahmed 2014; Seigworth and Gregg 2010; Thoits 1989). We view emotions as emerging through expression, not as antecedent to expression (Campbell 1997).
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The disability tax credit (DTC) "is a non-refundable tax credit that helps persons with disabilities or their supporting persons reduce the amount of income tax they may have to pay" (Government of Canada 2018).
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