Sunday, November 16, 2008

Review: The Medicalization of Everyday Life

[Thomas Szasz. The Medicalization of Everyday Life: Selected Essays. Syarcuse, NY: Syracuse University Press, 2007.]

As I noted in a recent review, it is difficult but commonplace to have strongly mixed reactions to political writing. In reading this book, to my initial open-minded curiosity I added firm but bounded regard for some of its critical insights, deep misgivings about some of its assumptions, and, by the end, a fairly intense political dislike for the author for all that I value some of what he has to say.

Thomas Szasz is a Hungarian-born academic who has lived most of his life in the United States. Though he is a professor of psychiatry, he has been one of the most prolific and consistent U.S. critics of psychiatry since the publication of The Myth of Mental Illness in 1961, and he is still publishing at 88 years old.

This book is a collection of essays that were originally published in a wide range of venues between 1972 and 2006. The first batch in the book deal with the boundaries between disease and nondisease, a major interest for Szasz, and the rest are about the various ways medicine has responded to "disturbing behaviour," and why those responses are problems. This includes a brief look at the history of psychiatry, a presentation of Szasz's framework for understanding what is usually labelled "mental illness," a number of interventions in legal and medical-ethical issues, and some broader political analysis.

Some of Szasz's core criticisms of psychiatry, medicine, and the state are useful efforts to analyze real phenomena that have huge impacts on people's lives and that are usually erased or dismissed in mainstream ways of talking about the world. Though I think much of what he has to say is worth listening to in a narrow sense and important to take up and work with, some of his underlying assumptions about the world and his broader political analysis are very much at odds with my own.

Szasz, you see, is a libertarian, in the U.S. sense of the term rather than the European sense. His political ancestors seem largely to be 19th century classical liberals. So, for instance, he is very critical of the state, from his opposition to state interference in our authority over our own bodies to his recognition that state-based approaches to meeting needs have serious problems. It also means he is able to be unrelenting in his attacks on psychiatric coercion. But as sympathetic as I am to anti-state politics and politics opposed to coercive interventions in people's lives, this grounding in a classical liberal/libertarian view of the world also means his analysis includes elements that for me range from troubling to odious. Many of these elements boil down, I think, to the unrealistic and abstract classical liberal conception of the person, and to the ever-frustrating liberal tendency to treat entire vast areas of human experience and political questioning as inadmissable, invisible, insoluble, or uninteresting.

One of Szasz's central contentions is that mental illness does not exist. He is often assumed to mean that it is entirely made up, a figment of imagination and deception, but that isn't quite what he is saying. Disease, he argues, is classically understood as a malfunctioning of some physically identifiable aspect of the body. Without a physical (anatomical, physiological, cellular, biochemical, genetic, etc.) problem, there is no disease. Of the broad and heterogeneous range of phenomena that get labelled "mental illness," a small proportion are related to physical problems with the brian, and these are properly understood as medical problems that are not psychiatric but neurological. The majority of "mental illness" has no physical basis and therefore they are not really diseases in the same sense as strep throat, lung cancer, or arthritis. Whatever might be going on with a person's mind (which he understands as an abstraction that is quite distinct from the physical brain), to speak of it as a "disease" is to speak not literally but metaphorically. Failing to recognize the metaphorical nature of this usage opens up significant areas of human life that are nonmedical to interventions that, by framing themselves as medical when they are not, can illegitimately wield the authority that we tend to grant medicine. This means that all sorts of interventions in our lives that are nonmedical (and often not really scientific) and coercive get a free ride because they can so easily borrow the authority of science and medicine. In this way, medicine (understood broadly) has inherited religion's former power to govern our lives in the secular West. To reclaim our liberty from this encroachment, he argues, we must recognize the nonmedical nature of psychiatry and we must completely divorce medicine from the state. That way, people will be free to govern their own bodies -- to take drugs to self-medicate, to commit suicide if they choose, and to seek help for both medical problems and nonmedical mind-based distress in a free market without fear of coercion. If we don't like the behaviour of someone we currently see as "mentally ill" we should just refuse to associate with them. If they commit crimes, they should be arrested just like anyone else, and "mental illness" should not be understood as either grounds from judging someone not legally competent (i.e. no insanity defense) or a basis for extrajudicial incarceration. That is, for instance, that Szasz believes that because millions of people who have been labelled "schizophrenic" can function in ways that may discomfit or annoy but not harm their neighbours, then "schizophrenia" is neither a basis for justifying involuntary committal nor for excusing harmful behaviour.

So. There's a lot in there, including plenty of hidden nuance that can't be captured by a brief summary, but that's the basic gist of it. "Disturbing behaviours," Szasz argues, are communicative acts and can certainly be a response to genuine experiences of distress, but treating that as medical in nature is usually incorrect and invariably leads to awful, liberty-removing social consequences.

Sorting out the bits of that which I agree with from the bits which I don't is a bit tricky. For instance, I think the insight that our understandings of physical illnesses and "mental illness" have different epistemological bases is really important, and I think I agree that as a consequence it is probably better to have explicitly distinct vocabularies when talking about these two things. Nonetheless, I see only assumption and no argument to go from there to concluding that we shouldn't have some sort of language of damage, dysfunction, hurt, disorder, or whatever that is explicitly not medical but is nonetheless grounded in efforts to support in noncoercive ways people experiencing the sorts of anguish we currently call "mental illness". There are places where it seems Szasz would be fine with that as well, but other places where he seems quite hostile to the idea.

Of course, any effort to create such a vocabulary with accompanying practices has to start from recognizing the importance of many of the criticisms made by Szasz and others of the coercive nature of psychiatry. There is lots of difference of opinion about the details, but there is plenty of evidence that psychiatry, from its founding in the early 19th century up to today, often has more interest in managing behaviours that are considered to be "abnormal" than providing support to people on their own terms. I've commented before how, in my own inexpert way, I often find material that is grounded in one or another approach to "mind-doctoring" to be full of generalizations and assumptions about how human beings work that seem implausible to me, even when I have some political sympathy for the work otherwise. So exactly how to construct practices of support for people who are experiencing some sort of mental anguish, and what to take from existing practices and what to abandon, is a huge, important question that, at least in this volume, Szasz ignores.

I also have concerns about the ways in which psychiatric discourse can be used to cast individuals out of humanity -- that is, if you behave in certain ways, the procedures for depriving you of liberty are much less subject to due process than for most other people. But I also am very uncomfortable with Szasz's seeming insistence (though he doesn't quite use this language) that the only legitimate way to talk about human subjects is the human subject of 19th century classical liberalism. He concedes that we need to understand how different people make choices under different constraints, but that unitary selves subjected to a formal, abstract equality is the only just way to evaluate and respond to human behaviour. And I just don't believe that. Yes, we must never lose sight of the importance of respecting the individual human subject, but the ways in which human subjects are produced and experience the world are so much more complicated than that. We are much more complicated, divided, and produced in ways that are integrated from the level of parts-of-self on up through massively social. Reifying the liberal subject is a key tool to erase so much that I consider to be politically and analytically important. And on a more personal basis, it just isn't how I experience myself.

Which isn't to defend the current ways in which the legal system and popular discourse deal with questions of responsibility, causality, and "mental illness." I'm not sure I have any immediate proposals about how to do it better, but I'm no more fond of the status quo than Szasz. However, his enthusiasm for dealing with the choices of human subjects only and always with a frame of morality and individual responsibility is not an improvement if you ask me. Our world is more complicated than that. And the way that the legal system factors in what is currently called "mental illness," with the tight relationship between coercive psychiatry and the law as it now stands, is a serious problem, but I think it would be no better to completely disallow any consideration of the sorts of genuine mental anguish experienced by many people currently labelled as "mentally ill."

I also agree with Szasz's assessment that practices and discourse labelled "medical" and "psychiatric" have also been thoroughly integrated into (to use my preferred language rather than his) practices of ruling. Some of my earliest (unpublished) musings about the world, as an undergraduate biochemistry student on a work-term with a drug regulatory agency of the federal government, were related to this. I reflected on the ways in which scientific authority coming from a particular approach to creating knowledge was, by individual scientists and by capital and the state, appropriated to legitimize all sorts of things that were not themselves a result of that same approach to knowledge production. For instance, regulatory standards for drugs or pollutants get presented as a product of science in the same sense as, say, a determination of the strength of gravity at the surface of the Earth. This hides how those regulatory standards are inevitably based on guesses, assumptions, and political decisions about how to think about risk and how to relate to the capitalist imperative to extract profit from everything.

Science and medicine, that is, give cover to all sorts of decisions, discourse, and practices in ways that obscure their political origins. Yet in discussing this, rather than recognizing the ways in which knowledge production is always political and always a terrain of struggle, Szasz's position seems to be a sort of return to purity, whereby clear definitions, a commitment to "objectivity," and disentangling medicine from the state, will get all that nasty political stuff out of knowledge production. In terms of the delivery of health care, he seems to think that the same sort of purity and justice can be obtained by ending any and all state regulation or funding related to health, whether it is liscencing of doctors, regulation of drugs, public health interventions, or socialized health care. This is a typical liberal/libertarian refusal to critically examining the actual causes and consequences of what they refer to in mystifying language as the "free market." In the final essay of the book, Szasz takes this to ridiculous extremes in his discussion of Nazi Germany. He makes some very important points about how state interventions justified by ideology claiming to be medical resulted in the Nazi state getting away with some pretty awful things, in ways that are substantially analogous to the ways in which the modern U.S. state uses ideology claiming to be medical to do some pretty awful things. But he examines only certain kinds of harms and certain aspects of the overall social relations, which allows him to conclude that all that is nasty that currently emanates from the U.S. state is because of its "socialist" -- he does not appear to be laughing when he says this -- approach to health. To make this even vaguely plausible he has to refuse to consider most other elements that go into making state relations and social relations more broadly what they are. I agree there are serious issues that result from healthcare being so wrapped up in state relations, but I don't think that "social" has to mean "state", and I think that attending to the dangers this poses to liberty and autonomy does not have to mean, as it does for Szasz, dismissing concerns for social justice. And I find it laughable that turning health exclusively over to for-profit tyrannies rather than not-for-profit tyrannies is somehow going to make the dangers to liberty disappear.

Another area where the pattern is similar is his take on public heath initiatives. For him, the only proper focus for public health initiatives is narrow efforts to prevent things like outbreaks of infection due to poor sanitation. He is adamantly opposed to public health interventions into individual choices for living that might be unhealthy, and, it seems, into responding to social causes of poor health outcomes, though in this volume he kind of avoids addressing this head-on. He argues that both excuse state incursions into individual liberty. I agree to a certain extent -- for instance, I think public health excuses for punitive drug laws are very much an example of using medical discourse to disguise the political nature of a decision. But many interventions into individual living choices stop at public education campaigns that often strike me as being a bit insulting and perhaps foolish but not really harmful. I definitely dislike the way that such an emphasis on individual lifestyle factors ends up blaming individuals for poor health outcomes that are largely socially produced. The thing is, he doesn't want us to look at social determinants of health, either, and mostly does not consider them. There are better and worse ways to respond to the ways in which ill-health is socially produced and distributed, and probably most public health officials, by the constraints of their mandates and their personal inclinations, lean towards approaches to addressing them that do not empower and that paper over the social contradictions that actually cause the problems. But that doesn't mean we should ignore how ill-health is socially produced. To the extent that he doesn't just avoid this side of the issue, Szasz's rebuttal to this sort of analysis of social health amounts to citing some strange and offensive stuff about how any mechanism for allotting wealth but the capitalist market encourages "pauperism" and how the only real way of dealing with poverty in either the global north or in the global south is the so-called "free market." In other words, though he is open to seeing how the state can encroach on individual lives, he refuses to consider the ways in which social relations more broadly force ill-health on people.

I am a little concerned because I have two more books on my shelf by the same author, waiting to be read and reviewed. They will take a certain amount of energy to read, I'm afraid. But I will certainly learn, and it will certainly spur me to refine my own thoughts on these issues.

[For a list of all book reviews on this site, click here.]


thwap said...

Ack! Two more books! Sounds like you've got your work cut out for you.

I've said it before and I'll say it again, ... never trust victims of Soviet Communism on the subject of economics.

Waitaminnit: Did he come from Hungary in the 1950s? Or is he just of Hungarian descent?

Scott said...

Yes...I'm reading some really interesting feminist history of psychiatry right now, but I think after that I need to turn back to Szasz and get those other two books out of the way. Like I said, I'm sure I'll learn from them.

From what I gather, he was born in 1920 and moved to the United States in 1938 with his family. They were secular Jews who had realized that Europe was not a great place for them to be at that juncture in history, and who were able to get into the U.S.

Scott said...

(Comment spam deleted.)