Whither critical psychiatry?

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1 1 Whithercriticalpsychiatry? Professor,SchoolofSocialWork,FloridaInternationalUniversity,Miami,USA Keynoteaddress,June22,2009,CriticalPsychiatryNetworkConference,Norwich,UK IwishtothanktheCriticalPsychiatryNetworkforinvitingmeandsupportingmetoaddressthis conference,andaffordingmethepleasuretorenewmyconnectionswithsomeofitsmembersand forgenewconnections. It sanhonorformetospeakhere,ontheoccasionofthetenthanniversaryoftheonlynetworkby thatnameintheworld.forwhatit sworth,iappreciatethatthebritishseemmorereceptivethanthe Americanstocriticalviewsaboutpsychiatry,asillustratedbythefactthatyourmedicaland psychologicaljournalsstilloccasionallypublisharticlesbythomasszasz,theoriginalcriticalpsychiatrist ofthe20 th century,whoisnowinhis89 th yearandstillkicking,whereasheappearstohavebeen shunnedbyamericanmentalhealthjournals.also,idaresaythatthejournaloftheamericanmedical Associationhasneverpublishedanythingwiththephrase criticalpsychiatry init,whereasthebritish MedicalJournalhas,atleastadozentimes(althoughinmostcasesthephrasereferstothisnetwork). Istillthinkthereisstillaneedtodefinejustwhatcriticalpsychiatryis.Ihopewecanallagreethat theterm anti psychiatry, originallycoinedbydavidcooper(1967)isnotsuitablebecauseitimplies beingagainstanythingpsychiatric.yetitmaybeusefultorecallthatdavidcooperenunciatedhis originalconcernaboutpsychiatryasfollows: Aboveall,Ihavebeenconcernedwiththequestionof violenceinpsychiatryandhaveconcludedthatperhapsthemoststrikingformofviolenceinpsychiatry isnothinglessthantheviolenceofpsychiatry... (1967,p.12).Cooperhadinmind thesubtle,tortuous violence ofsocietythatpsychiatry choosestorefractandcondenseontoitsidentifiedpatients (p. 29),regardlessofthesincerityanddevotiontothepatientofpsychiatristsandotherswhomCooper called the saneones (p.29).bythishemeantthatthesaneonesdeniedthatothersmight experienceintheirbodiesandconsciousnessthecontradictionsandconflictscreatedbylivingin advancedcapitalistsocieties.itwasan everyday sortofviolence,thoughonethatcooperfeltcouldbe mostintenseandoverwhelming. There sanothersortofviolencethatpsychiatristsandsaneonesinflictonpeoplewhodisturb families,communities,thesocialorder,andthatistheviolenceofinvoluntarycommitmentand treatmentjustifiedbythemythofmentalillness,whichcooperdidn tquitedenounceordiscuss extensivelyassuch.thisisthemainissuewhichiwouldliketodiscusstoday. AbrieflookattheWikipediasiteundertheentry antipsychiatry revealsalistofworthyactivities andpositionsofcriticalpsychiatrists,includingacritiqueoftheuseofthemedicalmodel,ofabusesof powerinpsychiatry,oftheuseofdrugsinpsychiatricpractice,oftheinfluenceofthepharmaceutical industryonpsychiatricresearchandpractice.it sclearalsothatcriticalpsychiatryisnolongerthe provinceofpsychiatristsandmentalhealthprofessionals.itsideas,thoughusuallyindilutedform,are nowspreadfarandwideamongex patients,philosophers,andespeciallynowadays,journalists.some journalistsandbloggers,suchas,intheunitedstates,martharosenberg,margarethealy,philipdawdy, andevelynpringle,seemtobemorecriticallyinformed,andseemtofulfillmoreofthedutiesofpublic intellectuals,thanvirtuallyanypsychiatristalivetoday.theirexposesofthefadsandfolliesof psychiatricpractices especiallyasconcernsthesymbiosiswithbigpharma,whichisimpossibleto ignoreassoonasyoufollowthemoney aremoreenlighteningthananyothermentalhealthreading bythatname. Butforseriouscriticalthinking,wemustgoelsewherethanthemedia.Today sjournalismrequires everyparagraphofanarticletohavenomorethanoneortwosentencesandtostandaloneforeasy digestionandscanning.everyideaisthuschoppedtoitslowestcommondenominator.thissortof

2 baserhetoric doeslittletohelppeoplethinkortobringpeopletothemselves.butthemainreasonfor themedia sincapacitytobecriticalaboutpsychiatricmattersisthatit sonethingtocrusadeagainstbig Pharma,it sanotherthingentirelytochallengeeverydayassumptions,thegluethatbindsrespectable peopleandgroupstogether.asthomasszasz(2007)pointsout, Facedwithvexingpersonalproblems, the truth peoplecraveisasimple,fashionablefalsehood (p.xv). ThetwoissuesthatIbelievejournalistsandmostcriticalpsychiatristsnever,evertackledirectlyare (1)themetaphoricalnatureofthetermmentalillnessand(2)thedistinctiveuseofoutright,legal coercionbypsychiatry.letmesuggestthatwherecriticalpsychiatrygoeswillbedeterminedbyits stanceonthesetwoissues,thatindeed,nootherstanceispossibleforagenuinelycriticalpsychiatrist thancategoricallyrejectingthemythofmentalillnessandthepracticeofpsychiatriccoercion. Everythingelseisjustcommentary. Thesetwoissuesareprobablyneveraddresseddirectlybytheswarmofnouveau psychiatriccritics ofthelasttwodecadesbecauseexpressingthemtodaycomesascloseaspossibletoexpressinga delusioninrespectablecompany.it sakintoexpressingablasphemyinreligiouscompany.todiscuss psychiatriccoercionplainlyandsquarelywouldleadtoamostdifficultquandary,andthespeakerwould immediatelyfeelthestigma.speakingaboutitplainlyandopenlymightmakeusfeelthatweshoulddo somethingaboutit,anddoingsomethingaboutitmightputusinthepositionofpushingoffthevery cornerstoneoftheentirepsychiatricedifice. Coercionsupportsthefalsepsychiatrictheoriesthatspeakershavediscussedandwilldiscusshere today.withoutcoercion,noneofthistheorizingwouldmatterexceptasmerelyacademicissues. Coercionbypsychiatryofourunwantedandisturbedallowssociety andallowspsychiatry,ofcourse tocloseitseyesasthesillinessandunfalsifiabilityofitstheories,chiefamongthembeingtheideathat (mis)behaviorisillness.absentpsychiatriccoercion,thetheoriesandtheir evidencebase wouldneed tofendforthemselves,anditseemsobviousthattheycouldnotwithstandacriticalassaultfromthe humanandthesocialsciences,letalonethemedicalsciences.(thepracticesrestingonthetheories wouldofcoursealsoneedtowithstandcriticalassaultfromthehumanserviceandotherhelping professionals,andheretooit sdifficulttoimaginehowpsychiatrycouldsurviveinitspresentform.) Thusit squitedifficulttoimaginewhomightbeinterestedinplayingwiththiscornerstoneofthe psychiatricedifice,exceptthosewhohavenoneedtoremainwithinthepsychiatricorbit.forthoseof uswhomakealivingbythegracesofthepsychiatricestablishment,orthementalhealthestablishment, orthestate andthat smostofuseheretodayiassume theoptionsarefewandfarbetween.i recognizethatfully.it saquestionofkeepingourjobs,earningoursalaries,payingourbills.byand large,becauseofeconomicself interest,wesubmittothecorepsychiatricorthodoxyandtinkeratthe edgesofthesystemwherewegenerate critical ideas,andpsychiatricorthodoxyrecognizesthatitcan recycleourcriticalideasasithasrecycledeverychallengeeverthrownitswaythatdidnot fundamentallyquestionitsraison d être.thosechallengesthatdid theszaszianassaultonthemythof mentalillnessandonpsychiatriccoercion weredeniedandtheirpersistentproponentsfully marginalized.predictably,whatfollowedthedenialwasaveritableorgyofcreatingnewmentalillnesses andrenewinginterestinso called therapeuticcoercion. Forothersamonguswhocherishmedicalidentity,whowishtobegenuinemedicalhealers,the optionissimple:topracticerealmedicine.thereisprobablysomeroominmedicineandmedical research inneurology,perhapsendocrinology forpsychiatristswhowishtopracticerealmedicine withrealpatients.butremember:thelawexpresslyforbidscoercedmedicaltreatment. Twofoundersofthisnetwork,PatBrackenandPhilThomas(nodate),madeaconstructive suggestionafewyearsago:theyproposed,asafirststep, toremovedoctorsfromtheassessment processesthatleadtocompulsoryadmission,relinquishingtootherprofessionalswhomightwishit, thepowertocommit.thisisaconstructivesuggestion:itdoesnotrequiredenouncingtheimmoralityof involuntarycommitment,itrecognizesthat society actsasitwill butitremindsusofthechoicethat 2

3 professionalsmakewhentheyparticipateornotincoercivesocialcontrol(andwhentheyaffirmthat coercivesocialcontrolisabranchofmedicalscience).brackenandthomasbelievedthatsuchafirst step willnotinitselfreducethepowerofpsychiatry,asthisisconstitutedlargelythroughthedomain ofitsknowledge. MuchasIrespectBrackenandThomas proposal,theirviewofpsychiatricknowledge asprocuringpsychiatrypowershouldbeinverted,andextended:itispsychiatry ssociallyaccepted powerthatlegitimizespsychiatricknowledge,andthisknowledgeispsychiatry sweakestfoundation. Szasz(2007)commentedthatIdaMacalpineandherson,RichardHunter,bothpsychiatrists, observed,intheirmonumentalthreehundredyearsofpsychiatry, : Therecanasyetbeno definitivehistoryofthesubjectsincepsychiatryisstilltoolittledifferentiatedfromitspast (p.ix).szasz askedwhattheymeant,andanswereditviaanotheroftheirquotesfromaroyporter(1994)volume: Ratherthanachronicleoffeats,facts,anddiscoveries,thehistoryofpsychiatrypresentsarecordof perennialproblems,recurrentideas,disputes,andtreatments,trailinginthewakeofmedicineand exhibiting...amixtureofasmanyfalsefactsasfalsetheories (p.87).the progressofneuroscience thatisallegedtodaytounderlieadvancesinthediagnosisandtreatmentofmentalillness what preciselydoesitamountto?dennischarneyandcolleagues(2002),theveryproponentsof a neuroscienceresearchagendafordsm V anda pathophysiologicallybasedclassificationsystem, concluded thatthefieldofpsychiatryhasthusfarfailedtoidentifyasingleneurobiologicalphenotypic markerorgenethatisusefulinmakingadiagnosisofamajorpsychiatricdisorderorforpredicting responsetopsychopharmacologictreatment (p.33).butmytaskisnottoengageinadeconstruction ofbiologicalpsychiatry,whichisfairlyeasytodo. Ourtaskascriticalpsychiatristsandmentalhealthprofessionalsisfirstandforemosttodayonthe definitionalfront:notmerelytodecrytheencroachmentofmedicalizedthinkingonanever growing sphereoflife,buttochallengetheverypurposeofmedicalization.thatpurposefindsitsjustificationin thecategory mentalillness (or mentaldisorder ).Backtofundamentalprinciples:behavioriswhat youdo.illnessiswhatyouhave.andneverthetwainshallmeet exceptofcourseinthecategoryerror ofpsychiatry,wheretheynotonlymeet,butmergecompletely. Becausetacklingthementalillnessmythdirectlyissorarelydonenowadays, reformist critiques aretakenforcriticalorradicalcritiques.mosteveryonetakesforgrantedthata core ofgenuine mentalillness schizophrenia, forexample,anextremeofdespair,deviance,anddisturbance truly exists,andonlytheflat earthersandthedeludedwouldpretendotherwise.onethereforeneedonly debatewhich treatment ismosteffectiveforthiscore.thiserroneousviewalsoleadstothestance thatgiventheproperpublichealthmeasures,theproblemsthatpsychiatryfaces( mentalillnesses ) canactuallybemadetodisappear.butpainandtragedydisappearonlyinutopianvisions.thisnaïve andmisguidedviewleadsustoundertakeabsurd,nightmarishendeavorsundertheguiseofpublic health. Thelatestexampleofsuchanendeavoristhesoon to bereleasedreportfromtheu.s.national AcademiesofScience,entitledPreventingMental,Emotional,andBehavioralDisordersAmongYoung People(O Connelletal.,2009).Ablue ribbonpanelofpublichealthscientistsurgesystematicscreening ofchildrenandadolescentsforanxietydisorders,mooddisorders,attention deficithyperactivity disorders,andschizophrenia.thisisthesecondmajorusgovernmentpaneltourgemassscreeningof thepopulationtodetectandtreatmentalillnesses.(thefirstwasfrompresidentgeorgebush snew FreedomCommission).Theimageryinthereportisasfollows:humanswalktheearth,andmental diseasesstrikethemfromnowhereandinsidiouslytakehold.there snowaybiologicalwaytodetect thediseases,butwecandiagnosethemusingthedsm IV,and,thankheaven,wecantreatthemwith moderneffectivetreatments.whywaittopreventthem? Ourfailuretokeepthedefinitionalissue(therearenomentalillnesses,thereareonlyproblemsof living)frontandcenterinthemindsofthepublicledofcoursetodsm III.PsychologistDavidJacobs pointsoutthateventhoughthedsmrequiresdiagnosticianstodistinguishbetweenontheonehand, 3

4 so calledreactionstoculturally sanctionedandexpectablestressors,andontheotherhand, mental disorders, thedsmdoesn tleavemuchroomoratallfortheformer.jacobs(2009)writes: Ithinkthe coreethic/tenetofcontemporaryamericanbiopsychiatryistobefoundbaldlystatedunderadjustment Disorder[APA/DSM IV TR,2000,p.679]: areactiontoastressorthatmightbeconsiderednormaland expectablecanstillqualifyforadiagnosisofadjustmentdisorderifthereactionissufficientlysevereto causesignificant[social]impairment. Inshort,withtheexceptionofbereavementforatwomonth period,noonecanbeexcusedfromfailingtoperformasexpected inoneormoreimportantareasof [social]functioning foranyreasonorsetofcircumstanceswithoutthejudgmentofmentaldisorderand whateversocialand/orlegalconsequencesmayflowfromthat. Thisistheofficialpositionofthe AmericanPsychiatricAssociation. Onceabehavior,howeverrareorseriouslyimpaired,becomesmentalillness,thereisnostopping anythingandeverythingfrombecomingmentalillness.andthisofcoursehasnothingtodowith whetherthosewhoparticipateondsmtaskforceshavefinancialtieswithdrugcompaniesornot: psychiatricdiagnosislongprecededdrugtreatment.ifdrugcompaniesexertednoinfluence,psychiatric diagnosticjudgmentswouldbenomore objective thantheyaretoday. Whenwelookatreligiousextremistsandfanatics,whomightpronounceadeathsentenceon someonebecausetheirideasaredifferent,wemightfeelsmugandsuperior.soweshouldweask ourselves,asszasz(1993)does: Whatargumentdoweregardasatoncesoimportantandsotruethat itsrejectionjustifiescoercingpersonswhohavenotdeprivedanyoneoflife,liberty,orproperty? For him,theanswerwasobvious: WeseektruthinwhatScience tellsus, muchasourforebearssought truthinwhatgod toldthem. Webelieveinmentalillnessandpsychiatrictreatment,muchasour forebearsbelievedinpossessionandexorcism. (p.102).buthealsoremindsusthat Asmere abstractions,religionandsciencearesimplyblankchecks;inactuality,eachiswhatwe,fallibleand fallenhumanbeings,makeofthem (p.103). InFlorida,populationabout18.7millionpeople,83,629peoplewere Baker acted in2007,which meanstheyunderwentatleast1officiallyrecordedinvoluntarypsychiatricexamination(~123,000 examinationsinall)(christy,2008).asistypicalforsuchinvoluntarypsychiatricproceduresworldwide (incontrastwithinvoluntarycriminaljusticeprocedures),thequalityofthefloridadatadoesn tallow knowinghowmanywereactuallyincarceratedasinpatients.butthefiguresindicatethatfor2/3of these83,629,thereasonwaslistedas harm, andfortwothirdsofthislastgroup,itwasharmtoself (threatofsuicide).ifwecanextrapolatefromthesefigures,wecanconcludethatpsychiatrists main legaldutytodayistocoercepeoplewhospeakaboutorthreatentokillthemselves. Naturally,psychiatriccoercionisnotlinguisticallytransparent:itisalwaysjustifiedbyappealto mentalillness.suicidalpeoplearenotmerelysuicidal,humiliatedandoverwhelmedbydisappointment, disruptivetothesocialorderorunfeelingabouttheirfamilies theyaredisplayingsymptomsofillness anddoctorstreatillness.thatiswhypsychiatriccoercionisjustifiedbythemythofmentalillness,and doingawaywithonemustmean,inevitably,inexorably,doingawaywithboth.anduntilbotharedone awaywith, criticalpsychiatry willremain,ifyouallowmetheanalogy,afringeguerillatactic,an annoyingformofharassmentthatdoesnotfundamentallyengagewiththeenemy,andonethatislikely toperpetuatethesameregimeevenifitaccedestopower. LetmeconcludebystatingthatthereisofcoursenothingoriginalinwhatIamadvancing,Iam merelytryingtoremindourselvesofwhatibelievearethefundamentalissuesforacriticalpsychiatry, andthatweareindebtedtoszaszforfirststatingthem,nearly50yearsago.soit sfittingtoconclude withaquotefromhis2007book,coercionascure: Theinstitutionofpsychiatry,liketheinstitutionof slavery,consistsofasociallysanctionedrelationshipbetweenaclassofsuperiorscoercivelycontrolling aclassofinferiors.thesystemrestsontheideaofmentalillness,itssemanticclones,andtheirlegal implications;itisdestinedtoengenderdisdainontheoneside,anddefianceontheother.the juxtapositionofpersuasionandcoercionliesattheheartofmankind sgreatmoralconflicts relations 4

5 betweenmenandwomen,leadersandfollowers,capitalandlabor,expertandlayperson.thetrue healerofthesoulisa doctor ofpersuasion,notcoercion.psychiatricpeaceandtoleranceare contingentontherecognitionthat mentalillness isamisleadingmetaphorandontherejectionof psychiatriccoercionasacrimeagainsthumanity (p.227). Thankyou. References Bracken,Pat,andThomas,Phil.(nodate).Mentalhealthlegislation:Timeforarealchange.Available from: Charney,DenisS.,Barlow,DavidH.,Botteron,K.,Cohen,J.D.,Goldman,D.,Gur,RaquelE.,etal.(2002). Neuroscienceresearchagendatoguidedevelopmentofapathophysiologicallybasedclassification system.in,d.j.kupfer,m.b.first,&d.a.regier(eds.),aresearchagendafordsm V(pp.31 84). Washington,DC:AmericanPsychiatricAssociation. Christy,Annette.(2008).TheFloridaMentalHealthAct(BakerAct)2007AnnualReport.Preparedforthe FloridaAgencyforHealthCareAdministration.LouisdelaParteFloridaMentalHealthInstitute, UniversityofSouthFlorida. Cooper,David.[1967](1970).Psychiatryandanti psychiatry.frogmore,uk:paladin. Hunter,Richard,andMacalpine,Ida.(1963).Threehundredyearsofpsychiatry, :Ahistory presentedinselectedenglishtexts.london:oxforduniversitypress. Jacobs,David.(2009).Thechoice: Mentaldisorder (reification)or ArgumentWithoutEnd. Unpublishedpaper. O Connell,MaryEllen,Boat,Thomas,andWarner,KennethE.(Eds.).(2009).Preventingmental, emotional,andbehavioraldisordersamongyoungpeople:progressandpossibilities.committee onthepreventionofmentaldisordersandsubstanceabuseamongchildren,youth,andyoung Adults:ResearchAdvancesandPromisingInterventions.NationalResearchCouncilandInstitute ofmedicine.washington,dc:thenationalacademiespress. Porter,Roy.(1994).IdaMacalpineandRichardHunter:Historybetweenpsychoanalysisandpsychiatry. InM.S.MicaleandR.Porter(eds.),Discoveringthehistoryofpsychiatry(pp.83 94),p.87.New York:OxfordUniversityPress. Szasz,Thomas.(1993).Alexiconoflunacy:Metaphoricmalady,moralresponsibility,andpsychiatry.New Brunwick,NJ:TransactionPublishers. Szasz,Thomas.(2007).Coercionascure:Acriticalhistoryofpsychiatry.NewBrunswick,NJandLondon: TransactionPublishers. 5