Unveiling mental health patient perspectives in online psychiatry reviews

In the world of psychiatry it is unfortunately common for some patients to express discontent. There are multiple legitimate reasons for this dissatisfaction – abuse, abuse of power, misdiagnosis, lack of adequate consent, and forced treatment, to name a few.

A recent study by Canadian researchers Matthew S. Johnston, Matthew D. Sanscartier and Rhys Steckle shifts the focus to patients’ voices, capturing their candid experiences with psychiatrists via online reviews.

Those considered by society to be insane may be taken as a separate class of deviants because of how others view their behavior. Mental illness is often not yet well understood in society, but rather can be perceived and stigmatized as a terrible weakness and difference, which creates a negative connotation associated with certain types of behavior. For example, racial discrimination may lead to more negative mental health outcomes, the researchers write.

Other people with more invisible mental illnesses—that is, illnesses they can hide from others because their behavioral differences are less obvious—become compelled to maintain sanity and conform to institutional behaviors so they can adequately manage stigma, professional expectations, and vulnerabilities that some may perceive as guilt.

Researchers analyzed 5,090 English-language reviews of 468 practicing psychiatrists in Canada, posted on www.ratemds.com between 2007 and 2018. They sought to understand how patients spoke and potentially challenged their treatment. The study was limited to psychiatrists, with a suggestion for future research to include psychologists and other mental health professionals.

The researchers used a post-anarchist lens for their study, aiming to disrupt traditional power dynamics and uncover knowledge within patient reviews that challenge conventional psychiatric narratives. Their work is rooted in an ethnographic or netnographic research methodology, which searches for themes in both cognition and emotion.

The study’s uniqueness lies in its focus on individual voices rather than macro critiques of the psychiatric system. That said, they argue, the focused and individualistic nature of our data still makes for striking and clear links to the more macro criticisms. They further explain:

This article is more concerned with the fact that psychiatric experts have a tendency to construct service users as passive recipients of psychiatric care, perpetuating the assumption that people with severe mental illness are unable to understand their illness, healing and behavior and then engaging psychiatric experts on their care.

The authors identified four major themes from their qualitative analysis, excluding the 5-star quantitative rating system rating.

The look from the sofa: the doctor’s counter-analysis

First, it is not surprising that some reviewers felt they were not given enough time or attention in their psychiatric consultations. Anecdotally, this is a common phenomenon, spawning their own jokes about psychiatrists who rarely even glance at service users as they ask a series of prescribed survey questions.

A user of the service explains:

As head of psychiatry you would think he would give at least 10 minutes for a conversation to really gauge a person’s state of mind. I foolishly accepted electroconvulsive therapy. I say stupidly because he didn’t explain the risks or possible side effects to me. He never recommended talk therapy or stress management, anything but pills and ECT.

As the authors note, in cases such as these, there may be a de-emphasis on learning from the words and feelings expressed by service users.

The same reviewer was dissatisfied with psychiatrists arriving at a diagnosis with no explanation of the meaning of the diagnosis, much less the thought process that led to that diagnosis.

A different reviewer, though probably in a similarly recognizable situation, felt that if he disagreed or reacted to the psychiatrist’s recommendation, he risked jeopardizing treatment or facing reprisals, given the inherent power imbalance and the dependence on the psychiatrist for the continuation of the drugs.

Asking the Wrong Questions: Tensions with Sexuality

A second theme concerned invasive questions about sexuality. While it’s not unreasonable for psychiatrists to ask basic questions about sex when certain medications can affect libido, several reviewers found the conversation uncomfortable and beyond the scope of necessity.

One reviewer stated:

He was overly fixated on my sex life and would ask me about it and want details, which really freaked me out. I was beaten and physically abused as a child, but not sexually, so his questions about my sex life were unwarranted.

This accusation of being overly fixated on the sexual history and sex life of service users when seemingly irrelevant has appeared in multiple reviews.

Disturbingly, a psychiatrist refused to call a trans service user by their chosen name, claiming they weren’t really transgender, just having an identity crisis due to BPD [Bipolar Disorder] He diagnosed me with a lot of ailments that I don’t have.

Stigmatize doctors in the face of tension

The most emotionally charged reviews came from users of the service who felt that psychiatrists’ over-reliance on drugs was hurting them and were too hasty to prescribe:

An absolute madman. I have no idea where he got his psychiatry degree but the fact that he is a doctor and he can prescribe medicine is very scary and worrying. He prescribed me Zoloft after barely knowing me or the core of my problems. Pill pushing a psychopath without any empathy. After being raped she told me I was stupid and that I shouldn’t put myself in that situation. Please never take your child to her.

As the authors point out, this rapid assessment and revolving door mentality is common in mental health services. This is a point worth looking into on a systemic level, as some well-meaning suppliers may find it difficult to keep up with demand. However, as the authors rightly point out, victim blaming is unforgivable and indicates serious ethical problems.

There are still good doctors out there

Not all reviews of psychiatrists were negative. Several reviewers praised their psychiatrist for helping them overcome their mental health issues, heal their suffering and, in some cases, save their lives.

A key issue here was the mutual willingness on the part of the service user and psychiatrist to cultivate an honest and compromised dialogue relationship, as explained by one reviewer:

As his patient, we’ve had some disagreements. I believe people still regard doctors of any discipline as infallible and not to be questioned. I haven’t always been honest with myself [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 work. It’s not just medicines. There are no magical cures. i hold [Doctor] in the utmost consideration. He is one of the greats!

Another reviewer noted that psychiatry is such an inexact science and didn’t blame their psychiatrist for their shortcomings, concluding with but like I said they seem to be trying very hard.

A constantly recurring theme in this article, as the authors write, is that of autonomy. When people feel that their voice and point of view matter, they are more likely to value assistance highly. On the other side of things: however, when they feel powerless, betrayed or abused, they tend to criticize their care.

While these statements may seem obvious, it is also evident that psychiatry continues suffer from many of the problems discussed by the reviewers during this analysis.

On a closing note, the authors value this digital space where service users can engage in a form of politics that allows them to reclaim part of their voice and offer counter-narratives and resistance to the psychiatric establishment:

By cross-analyzing doctors to feel they have a say in their treatment/conditions, by insisting doctors ask the wrong questions to better vet their identities, and by attempting to informally expose their doctors’ ties to the pharmaceutical industries, service users simply refuse to accept the labels, diagnoses and pathologies imposed on them.

A post-anarchist framework, a vision in which essential identities and fixed normative categories are destabilized allows us to see these textual gestures as subversion of the positions of the medical subject through discourse external to the psychiatric apparatus.

Addressing the limitations of the study, the authors admit that overt psychiatric resistance has only been explored tentatively. They are interested in how individuals refuse to be subjectified by psychiatric discourse and power. More research is needed on these forms of resistance and pushing for counter-narratives against the establishment.

There is a plethora of research, both academic and personal, on the issues addressed by this paper. From the harms of coercive and involuntary confinement/treatment and overprescribing of pharmacological drugs to the continuing power imbalances in psychiatry recognized by the United Nations, the fight for equal treatment and, indeed, autonomy for service users is long and arduous.

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Johnston, MS, Sanscartier, MD & Steckle, R. (2023). Patient resistance to psychiatric discourse and power. Disability Studies Quarterly, 42(3-4). (Connection)