An ever growing number of people are aware
that something’s horrendously wrong with psychiatry—survivors, families, professionals,
psychiatrists themselves. Of these a subsection has become actively involved in
trying to bring about change. All of which is good. This notwithstanding, sincere
and dedicated though almost everyone is—and it is clear that people are—only a
tiny percentage of these are pressing for anything truly transformative (something
beyond the humanistic correctives or additions typically called “reform”). Without
question, what people are advocating is of enormous importance. For example, for
the most part reformers take seriously the deprivation of human liberty and the
reductionism that characterizes psychiatry—and yet somehow they fall short of
letting go of either the paradigm or the practice. What do people call for? They
want less incarceration, but are not asking it be stopped. By the same token, people
call for less drugging, while accepting that doctors will continue to prescribe
psychiatric drugs. Most want to eliminate certain of the diagnoses, while holding
tenaciously to others (e.g., Horwitz, 2002). For obvious reasons—and who could
argue with this?—the majority stipulate that there must be free and informed consent—but
not for everyone, and even at that, there is little evidence that people are
giving much thought to how such a thing would be possible with anything even
vaguely resembling the institution as we know it. And the vast majority favour
a major expansion of humanistic services such as counseling and housing as well
the introduction of voluntary outreach services wherein helpers turn up at
people’s homes to assist with crises—good in itself, however, once again while
leaving biological/institutional psychiatry relatively in tact. What goes along
with this, they want a team approach, with psychiatry only one member of that
team. Albeit, of course, there are variations here and there, and some
reformers go considerably further than others, here basically is the reformist
position. Now I am in no way questioning the intentions or the soundness of many
aspects of the position. There are a number of problems with it, however, not the
least of which is the fact of leaving institutional psychiatry in tact—the
elephant, as it were, in the room.
Underpinning the reformist stance, whether
it is expressed or not, is the contention that psychiatry has something to
offer, is worth retaining, moreover, that to do otherwise is reckless. Allen Frances
(2014), by way of example, refers to antipsychiatry activists as “blind
ideologues” and talks as if it were an indisputable fact that there is “good”
and “bad” in psychiatry. His solution, correspondingly, is for the sensible people—the
“moderates”—to join together to create the reforms needed (see Frances, 2014).
How is it that the situation gets viewed
this way? Obviously there is no simple answer to this question for reformers
differ from one another. Of survivors who are reformers, some are reluctant to phase
out psychiatry because they feel that they themselves or people they know have
benefited from the “services”. Many professionals are likewise so convinced. Professionals,
including ones that courageously challenge their own profession, additionally,
have vested interests that willy-nilly come into play. Then there is the more
general problem: that we all us have difficulty thinking very far beyond what
currently exists, never mind trusting anything substantially outside the current
frame. The point here is, changes that are revolutionary inherently strike us
as immoderate or to use Allen Frances’s word “extreme”. All understandable.
Nonetheless, let me suggest that the reformist position begs the question.
The purpose of this article is to
problematize the reformist stance and the beliefs and tendencies underpinning
it. I begin by problematizing the biases surrounding the concept of moderation.
I go on to theorize why something more substantial is called for. The article culminates
in an investigation of some uncomfortable truths about the profession, the
reality of the various industry interests, and what history has to teach us.
Thinking
Beyond “Moderation”
As a species, we have a tendency to think
that moderation is always and inevitably best (hence the “middle way” in
Buddhism, balance in Aboriginal thought, and the golden mean in Aristotle). Without
question, this bias frequently serves us well. I put it to the reader that there
are times, nonetheless, when the concept is inapplicable and/or where emancipatory
principles dictate a pronouncedly different course of action. For example, would
we really want to embrace a middle way between murder or rape on one hand, and respecting
the bodily integrity of others on the other? And more pointedly, what would have
befallen the major liberatory advances in history had visionaries bowed to the
imperative to be moderate? Take the institution of slavery. We would have far
more people enslaved today if we automatically assumed that the ostensibly “extreme”
position—actually abolishing slavery (as opposed to, say, “humanizing” it or
resorting to it less often)—was a reckless and otherwise unwise thing to do.
And note, abolition did indeed look reckless to the “moderates”. What is clear,
in other words, is that what seems like “sensible moderation” seems that way
from a particular vantage point and what strikes the average person as moderation,
as such, is hardly unassailable. That said, the question arises: Under what
circumstances is abolition a more sensible course of action than reform? While
this of course is a complex issue, let me suggest that viable indicators are:
1) when the practice in question overwhelmingly harms people and 2) when it is
inherently oppressive. Auxiliary indicators—and these too can legitimately
enter in and in certain cases be pivotal—are when its foundational tenets have
repeatedly been demonstrated to be fallacious, also, when it is backed by a
massive industry that by hook or by crook is intent in maintaining the status
quo or worse. Lest readers have not as yet noticed, all of the above pertains
to psychiatry.
To begin with the first two, touching
quickly on the incarceral and control mission (and it is a historical accident
that psychiatry is in charge of this), it is clear that substantially depriving
people of freedom and control is personally hurtful, however small the numbers and
whatever the rationale. Nor is the alleged ‘dangerousness” an acceptable rationale,
for there is no evidence that the “mentally ill” are any more dangerous than
the average person. To be clear, it goes without saying that people should be
stopped from harming others, whether or not the “transgressors” are deemed
“mentally ill”, that actions must have consequences, that there are moments
when figuring out how to enhance an individual’s safety is far from easy. At
the same time, as peacemaking criminologists (e.g., Pepinsky and Quinney,
1991), and critical disability theorists (e.g., Ben Moishe, Chapman, and Carey,
2014) have so cogently argued, a regimen of imprisonment and control is at once
injurious, of dubious value in enhancing the safety of anyone, and is morally unacceptable.
To turn to the “treatments” per se, as documented by critics like Breggin (1991),
the “treatments” overwhelmingly damage people. That is, they give rise to
actual brain damage, result in disorders such as tardive dyskinesia, horrific
conditions such as memory and cognitive impairment. While reformers want to
make exceptions for categories like schizophrenia, suggesting that in such
cases “treatment” is necessary, I would add, studies clearly establish that mainstream
convictions to the contrary, “schizophrenics” never once on the drugs fare
better in the long run than any other group of “schizophrenics” (see Harrow,
2007 and Rappaport, 1978). In other words, even when it seems as if the
opposite were transpiring, everyone is being harmed. The inherent
oppressiveness of psychiatry, additionally, is common knowledge among survivors
and reformers alike, though one need only look at the classical signs of
oppression to realize that it permeates the industry—the daily coercion, the incarceration,
the surveillance and control, the targeting of the “genderized” and the “racialized”,
the us-them division, the very use of concepts like “normal” (for details on
how such ruling plays out, see Burstow, 2015). Nor would moderating this element
eliminate the oppressiveness at the core.
To proceed to this next indicator—and I
would suggest this is pivotal—we are blatantly dealing with faulty foundations.
The point is that the basic psychiatric concepts and tenets have no validity
either empirically or conceptually. In this regard, as researchers like Breggin
(1991) and Colbert (2001) have repeatedly demonstrated, there is no proof
whatever that any of the so-called “mental illnesses” are bone fide diseases. Nor
do concepts like “mental illness” hold up to scrutiny. As Szasz (1961) so adroitly
put it years ago, irrespective of whether or not people are floundering, it is
a category confusion to call ways of thinking and acting per se a disease. In
essence, a medical overlay is but being slipped over distressed or distressing ways
of thinking and acting. This being the case, it is no accident that the
treatments profoundly harm. Treat people for non-existent diseases, “correct”
imbalances that exist nowhere except in psychiatric credo, and you necessarily
create real imbalances and in the process do untold harm. Herein the very
nature of medicine—what it is and what it does—is all important. Note, in the vast majority of disciplines and
professions, the invalidity of the basic tenets would not in and of itself necessitate
abolition or even always make it desirable. It is precisely because invalidity
and inevitable harm come together in psychiatry that abolition is critical.
Before I proceed to the other indicators, I
would pause to touch on some of the objections likely to be posed to my points
to date. The first is that there are “extreme cases” where psychiatry is
needed. Let me suggest, the fact of people being in terrible straits in no
makes something medical when it otherwise is not. If there is no disease, no matter how dire the
problem, treating a person as if they had a disease and thereby harming them
cannot be acceptable. Equally unacceptable, I would add, is the handling of
misery and conflict by resorting to incarceration, surveillance, or control.
A second common place type of objection is
predicated on the understandable belief that a plethora of services should be
available—and so why not psychiatry?—especially seeing as so many people favour
the drugs. A quick response is that the state should not be involved in
injuring people, irrespective of whether or not doing so is called “services”.
Moreover, it is blatantly unethical to present and/or promote something as is
if it were a medical treatment in the total absence of medical validity. Nor is
it the case that the elimination of psychiatry would narrow the options
available. In point of fact, given the amount of money spent on psychiatry and
the promotion thereof, eliminate psychiatry from the picture, and—presto—there
would be ample resources to make a plethora of options available. Additionally,
note, abolition does not require that people be denied access to
psychopharmaceutical drugs—only that they not be approached as if medical, not
promoted, and not prescribed by doctors.
A final objection that I would touch on is
predicated precisely on faith of how far a reform agenda can transform psychiatry.
The contention here would be that in the world brought about by a reform
agenda, there would be no reason to get rid of psychiatry for it would just be
one of many disciplines that converge on the territory. Additionally, psychiatry
would itself be reformed, with psychiatrists for the most part providing
counseling or other such supportive services.
Tackling the first part of this objection
brings to the fore the whole issue of
power and of discourse. Hypothetically, we have a team approach now, but
set foot in any hospital and it is clear that one player and one position
dominates. Nor do words like “dialogue” alter the situation. The point is that
even with benign intentions, dialogue can only go so far for the terms of the
dialogue are already set/constrained by the psychiatric paradigm. To varying
degrees, the same may be said of reform within
psychiatry. What is equally fundamental, there are structural realities, vested
interests, and contradictions at play that we gloss over to our peril.
A crucial factor being ignored here is that
medicine is a bad fit, indeed a misfit insofar the direction sought is
non-medical (nor are most medical people likely to excel at it).
Correspondingly, there is a palpable danger involved in entrusting this
direction, or indeed, any part of it, to psychiatry. Whatever might transpire
in the short run—and of course there are individual psychiatrists who are
trustworthy —why would we think that in the long run psychiatry (translation: institutional
agents whose very profession is posited on emotional problems being medical)
are likely to give up or even substantially qualify what, in essence, is the sole
basis of their profession? If the point
being made seems confusing, look systemically at what we are dealing with here.
Aside from the power attributed to it, this profession is distinguishable from
others such as psychology by one
sizable dimension only—the insistence on the medical. By the same token, look
at what prepares psychiatrists for the tasks ahead. Psychiatrists in-the-making
are people who take extensive training in medicine as if such problems in
living were bone fide medical issues. Indeed, even at the residency stage, they
rotate between the various medical specialties—biology, anatomy, and so forth—before
they even approach “psychiatry” per se. Even were more counseling training added
to the mix, the point is it remains part of the faculty of medicine, remains a
“medical discipline”, and, indeed, is theorized and taught as such, with all the
baggage which that entails.
That said, let us look more closely at this
institution. Insupportable though the medical conceptualization is, psychiatry
is “medicalized” through and through. Note, it is presided over by “doctors”; it is assisted by
“nurses”; and its pivotal work happens in places called “hospitals”. Correspondingly,
it specializes in the use of substances defined as medical; and its discourse
is medically framed (witness, in this regard, the prevalence of terms like “pathology”,
“disorder”, “symptom”). Whatever psychosocial factors are added on, being “medical”—as
it were—is its defining feature. Which brings us to some key structural issues:
To whit: In the long run, how could be in the interests of a medical
institution to support any substantial de-medicalization—given medicine is precisely
the ground on which it stands? By the same token, in the long run how could it
be in psychiatry’s interests to give up what the profession has spent centuries
solidifying—their command over the “madness turf”? Which is not to say that
individual psychiatrists are not sincere about demedicalizing, or the
profession as a whole might not be willing to entertain such directions at a
moment of crisis. What happens in a crisis and what will be supported long
term, however, is a different matter altogether. Bottom line: In the long run,
it simply is not in psychiatry’s interests to demedicalize, decentre itself, or
stop expanding. What adds to the conundrum, while all institutions to varying
degrees pursue their own interest, history teaches us that discourses about
care notwithstanding—medicalization, dominance, and expansion has been overwhelmingly
what the institution of the psychiatry is about. This is the profession that historically
drove out all competitors—the astrologers, the women healers, for example. This
is the profession that sought and gained police powers. And this is the
profession/industry that has been intent on declaring ever more people
“mentally ill” (for details, see Conrad and Schneider, 1984).
What relates to this, from a business point
of view (and psychiatry is nothing if not a series of interrelated businesses),
it is obvious that what we are dealing with is a massive industry, all parts of
which have self interests. Correspondingly—and again, we lose sight of this to
our peril—all of these parts are not
simply incompatible with but dramatically
pull in the opposite direction than the reform agenda. By way of example,
the interest of the psychiatric research industry is to continue expanding on
one hand and satisfying its funders on the other (that is, producing ever more research
studies and research results which in some way promote the prevalent treatments
and agendas). By the same token, the interest of the shock industry is the
continuation and spread of ECT. Of these
industries, of course, none is more formidable that the pharmaceutical industry.
Profit transparently drives the pharmaceutical
industry. And significantly, reform of the type envisioned will willy-nilly hurt
pharmaceutical profits, in other words, transparently conflicts with Big
Pharma’s interest. (The fact that progressive psychiatrists would like to see
less drugs used, I would add, is beside the point). A demedicalizing of the
area doubly conflicts with psychiatry’s
interest for, as demonstrated by researchers such as Whitaker (2002 and 2010),
psychiatry itself is utterly dependent on pharmaceutical funding for their massive
research projects, their publications, their educational endeavours. To put
this another way, psychiatry needs the multinational pharmaceutical industry. Ergo,
anything that hurts that industry hurts psychiatry. Indeed, at this juncture, the
very existence of psychiatry is dependent on the pharmaceutical industry; and
as such, as the professional elite are well aware, breaking with this industry
in any substantial way would be the proverbial kiss of death. The upshot?
Despite how individual psychiatrists may proceed, this is not now, and short of
a new somaticizing benefactor materializing, cannot be the ultimate direction
of the profession.
In short, besides that psychiatry is
foundationless and by its nature harms, we cannot arrive at a better dispensation
in the long run if psychiatry is included—not even a new and improved
psychiatry. We cannot because it undermines the very raison d’etre of the
profession. We cannot, ultimately, because it is not in psychiatry’s interest,
not in the interests, that is, of the profession, the industry, or the myriad
of industries surrounding it. What
likewise needs to be factored in, biological psychiatry has a long history of
reasserting dominance, whatever seemingly benign turns are taken in the short
run, for it does not for long lose sight of where its interests lie. In this
respect, we have, as it were, “been there and done that” already—and the
outcome was anything but reassuring. A lesson from history:
There was a moment in “modern” psychiatric
history where the relentless push to medicalize and to dominate indeed appeared
to be curtailed, and beyond that, substantially reversed. This was with the
spread of psychoanalysis and the concomitant rise of the talk therapies.
Freudian psychoanalysis was so successful as a movement (however one may judge
its tenets and practice) that throughout North America it changed the face of
psychiatry, bringing the psychological as opposed to the medical to the fore. What
is additionally apropos, Freud opened up psychoanalysis to non-medical
therapists—which itself helped give rise to the spread of a huge variety of
talk therapies and this by “lay” practitioners of various types—psychologists,
social workers. Corresponding, increasingly, despite obvious limitations, the
agenda was humanist with various new and creative way of working with people
imagined. The parallels with what is being sought today are obvious. Then a
huge reversal set in. While the full story is too complicated to go into here, the
salient point is that demedicalization was not in the interest of psychiatry,
and beyond that, what became progressively obvious to the psychiatric elite is that
their interest, on the contrary, lay in medicalizing to a point beyond anything
heretofore imagined. Hence the unprecedented surge of biological psychiatry and
the advent of the highly medicalized DSM-III (transparently “medical” despite
the claim to being etiology-free). Hence the declaration that “mental
illnesses” were “brain diseases” (e.g., Andreason, 1984). And hence the
alliance between psychiatry and the drug companies and the advent of what is
euphemistically called “the drug revolution”. All of which was possible, note, because
institutional psychiatry had never in any way been dismantled. Now to be clear,
it is not just that the ground gained was lost. The situation which
materialized was exponentially worse than what had preceded psychoanalysis, for
everything became grist for biologizing agenda—even the psychoanalytical
categories themselves. You can get a quick sense of how this transpired by
looking at what happened with the “neurotic complaints” (originally spearheaded
by the analysts). It is not that these were thrown out by biological psychiatry.
Along with the various “psychoses” and the various other biological inventions,
they were given a biological frame and added to the mix—with the result being
an exponential growth in the number of “mental disorders” in DSM-III, and, in
essence, the pathologization of every day life (to trace this development, see
Kirk and Kutchins, 1997).
Now it might be argued that what happened
here arose from a unique concatenation of circumstances, and as such, liberal reform
is not doomed to fail. While logically that is true, I would remind readers
that a similar dynamic played out centuries earlier, after the rise of “moral
management”—the one other time in history
that a type of demedicalization had set
in. Note, moral management involved approaching problems in living as
spiritual issues. This, in essence, was the “reform” agenda of the 18th
century. It being nonmedical in nature, not only the mad doctors but also lay people
practiced it—the most notable being the Quakers (see Tuke, 1813/1996)—a
phenomenon that was widely accepted. What happened? The direction being pursued
was hardly in psychiatry’s interest, and not coincidentally, the Quakers were
considerably better at it. Accordingly, over time moral management gave way to the
meteoric rise of biologically oriented psychiatry, the routing of lay people, and
ultimately to the birth of the eugenics era.
In this as in a microscope, we can see the
problem with non-foundational reform. It is not that there are no good tenets
or good people involved. Indeed there are. Correspondingly, it is not that
progressive psychiatrists have no role to play in the initial stages of a
transformational process, for again, they do. However, in refusing to take
seriously both the nature and the self-interestedness of the profession, reform
(as opposed to revolution) leaves in tact an inherently problematic institution,
legitimizes rule by “expert”, and paves the way for a return of biologism and
of oppression with a vengeance.
And as such, liberal conceptualizations
like “mental health reform” do not and cannot serve us well.
Concluding
Remarks
In ending, I would reiterate that we are
currently at one of those crossroads in history. To varying degrees, people are
aware that our “solutions” are backfiring. Survivors are vocal about wanting
something different. The general public minimally suspects that something is horrendously
wrong. “Helpers” from other disciplines are commonly in dismay. And progressively,
psychiatrists are sensing that the institution is in a crisis. Indeed, with the
rampant spread of iatrogenic diseases, society itself is in crisis. A terrible
reality on one hand, for it bespeaks the harm being done, but a rare
opportunity on the other, for crises are precisely the time when real change is
possible. As a society, this is the time to be absolutely clear what we are about,
for the opportunity for fundamental change does not come often; and it would be
a shame to squander the moment. Do we tinker with the “mental health system”,
adding more humane services, while retaining psychiatry? Or do we adopt an abolitionist agenda—that is,
slowly break with psychiatry and co-construct a whole new approach to problems
in living and, indeed, how we-are-with-one-another?
As you ponder this, I would invite readers to
consider: What kind of world would you like to bequeath to future generations?—To
your great grandchildren? To people seven generations hence? Ultimately, who
should be in charge of society’s needs—the community as a whole (that is, each
of us together) or stated-sanctioned “experts” and mega-industries? Who wins and
who loses if psychiatric rule continues? And finally, if tempted to speak of “paradigm
shift” and psychiatry in one breath, in the words of Black feminist Audre
Lorde, (1984), when in social change history have we ever known the “master’s
tools” to “dismantle the master’s house”?
(For
this and other articles on this issue, see: http://www.bizomadness.blogspot.ca.
For detailed elaboration of dimensions touched on in the article, including a
visioning of services in a transformed society, see Burstow, 2015).
References
Andreasen, N. (1984). The
broken brain. New York: Harper and Row.
Breggin, P (1991). Toxic
psychiatry. New York: Springer.
Ben-Moshe, L., Chapman, D, and Carey, A (Eds.). (2014). Disability Incarcerated: Imprisonment and
Disability in the United States and Canada. New York: Palgrave Macmillan,
Burstow, Bonnie (2015). Psychiatry
and the business of madness: An ethical and epistemological accounting. New
York: Palgrave Macmillan.
Colbert, T. (2001). Rape of
the soul. Tiscam: Kevco.
Conrad, P. & Schneider, J. (1980). Deviance and medicalization: From badness to sickness. St. Louis:
The C.V. Mosby Company
Frances, A. (2014). Finding a middle ground between psychiatry and
anti-psychiatry. Retrieved from http://www.madinamerica.com/2014/10/between-psychiatry-and-anti-psychiatry-mad-in-america-opens-a-dialogue/.
Harrow, M. (2007). Factors in outcome and recovery in schizophrenic
patients not on antipsychotic medications. The
Journal of Mental and Nervous Disease, 195,
406-414.
Horwitz, A. (2002). Creating
mental illness. Chicago: University of Chicago Press.
Kirk, S. & Kutchins, H. (1997). Making us crazy: DSM: The psychiatric bible and the creation of mental
disorders. New York: The Free Press.
Lorde, A. (1984). Sister
outsider. New York: Crossing Press.
Pepinsky, H. & Quinney, R. (1991) (Eds.). Criminology as peacemaking. Bloomington: Indiana University Press.
Rappaport, M. (1978). Are there schizophrenics for whom drugs may be
unnecessary or contradindicated? International
Pharmacopsychiatry, 13, 100-111.
Szasz, T. (1961). The myth of
mental illness. New York: Paul B. Hoeber.
Tuke, S. (1813/1996). Description of the retreat. New York: Process Press.
Whitaker, R. (2002). Mad in
America. New York: Perseus Books.
Whitaker, R. (2010). Anatomy
of an epidemic. New York: Broadway Paperbacks.
No comments:
Post a Comment