Monday, December 01, 2008

Review: Psychiatry

[Thomas Szasz. Psychiatry: The Science of Lies. Syarcuse, NY: Syracuse University Press, 2008.]

This is the third book I have read and reviewed in the last couple of weeks (first, second) by long-time right-libertarian critic of psychiatry, Thomas Szasz. Three, it turns out, is probably overkill for my purposes, but this volume is not long and it's a smooth read, so I didn't mind too much.

I am not, however, going to present a comprehensive review. The other two reviews do an adequate job of presenting my basic impressions of Szasz's analysis -- certainly I could do lots to refine what I said, but I don't think it's worth my effort. What I am going to do instead is write an abbreviated review assuming the basic groundwork layed out in those other two.

The specific focus of this book is to demonstrate how deception and lies are inherent to the psychiatric enterprise. Szasz contrasts this with real (or natural) science and its dependence on rationality, repeatability, and "truth-telling." This is a particular facet of his overall analysis of what is usually termed "mental illness" and of psychiatry, to which I have responded in a more general way before. I just want to make a few supplementary points here:

  • I would talk about it in very different ways, but I basically agree that psychiatry is not a science, at least if "science" is to designate particular practices of knowledge creation. The ways in which it is possible to generate knowledge about complex human behaviours are different from those which give natural science its credibility and authority. This is obviously true for psychoanalysis, and it is that facet of psychiatry that Szasz focuses on in making this point, but you could construct a related argument about biological psychiatry as well -- scientific paper X might identify as both "biological psychiatry" and "science," and it might do typical lab stuff about brain chemicals or what have you. The unscientific part probably comes in how those biochemical findings get related to complex human behaviours.

  • I think Szasz is far too uncritical of science itself. It is rhetorically useful to him to contrast science with psychiatry, and there are definitely legitimate reasons for doing so, but the ways in which science generates knowledge also deserve to be subjected to critical analysis. As well, there are lots of other things besides psychiatry that legitimize themselves with the authority granted to scientific ways of generating knowledge even though they do not actually operate based on knowledge generated in that way, or the knowledge generated in that way in their names is peripheral to how they are actually organized.

  • I am inclined to agree that whatever it is that gets captured by the term "mental illness," for the most part it is sufficiently dissimilar in its epistemological basis from things like, say, diabetes or pneumonia, that it makes sense to have a different vocabulary. I do not agree, though, that what usually gets called "mental illness" is nothing. A major point in this book is that the only possible options for understanding what we call "mental illness" are that it is a biologically determined disease process that preempts human agency, which Szasz argues vociferously against, or that it is a form of "malingering," which is the position he defends.

    I disagree with the "malingering" explanation for what gets called "mental illness" for a couple of reasons. It assumes that the ways in which we exist in the world -- not our circumstances, obviously, but our affect, our conduct, our manner, our practices -- are purely a result of conscious choice by the autonomous, atomized, agents of liberal theory. This is patently false. I know from my own experience that, though agency and choice are part of it, they are not a complete explanation. It also makes me think of my experiences with people who have themselves experienced significant trauma. It's not like they cease to have agency because of that -- as I've said before, I think agency is much more complicated for all of us than liberal theory allows -- but it can have a pretty profound and unchosen impact on how they exist in the world. And to understand the changes wrought on people by trauma as being purely about "malingering" is insulting and silly. (And in some of Szasz's discussions of the experiences of soldiers, he seems to be saying pretty much exactly that.)

    But beyond those arguments from felt and observed experience, which I know Szasz himself would be quite unmoved by, I would add the fact that the way he frames the argument is, like in a number of places in his writing, an unhelpful dualism. That is, he shows that "mental illness" is not, cannot be, what psychiatrists and lay psychiatric discourse claim it to be. But the way he frames the issue presents "malingering" as the only possible alternative, and perhaps it is the only alternative that is consistent with the other philosophical and analytical groundings for his work. But, given that I do not share a number of those groundings, for me brain-reductionist, agency-removing, medical disorder and malingering are hardly the only two options.

  • I would argue that there are actually phenomena with a wide range of origins captured by the term "mental illness." It is, much as Szasz says, mildly or flamboyantly unconventional behaviour that has been medicalized. How this behaviour originates is largely irrelevant to its medicalization. This behaviour certainly can be based in goal-oriented malingering, whether it is Corporal Klinger in M*A*S*H trying to get his Section 8 discharge or whether it is the somewhat more collaborative and probably (at least sometimes) only semi-conscious process that produced the displays of "hysteria" at the Salpetriere under Charcot in the late 19th century. Some is regarded by those displaying it as personal quirk that they wish the rest of the world would just leave alone, which probably we mostly should. Some is connected with unchosen anguish that may be connected with past or present experiences of trauma, with more general sorts of past individual experiences, and with the ways in which our selves are socially produced. I also feel we can't just ignore a relationship to biological phenomena, which may be relevant in some instances, though not in the ways that psychiatry tends to assume and certainly not in ways that justify coercion in the name of help (as I talked about in more detail in a previous review).

  • To put it in my own language, combining ideas that Szasz might agree with and other that he would not: The process of psychiatric diagnosis involves starting from complex human behaviours. These behaviours may have a wide range of origins, meanings, and future trajectories. Some people may be unhappy with their own behaviours, or with the experiences of anguish that underly some of these behaviours, and so might embrace the process whereby these behaviours are read into the categories understood as "psychiatric diagnoses" because it is necessary to receive access to certain kinds of supports and resources which can be attached to these diagnoses. Other people, of course, do not wish to be read into psychiatric diagnoses. Regardless of the desires of the person thus inscribed, and even given that sometimes, for some people, being read into a diagnosis provides access to things that they need, it also inevitably links them to discourses and practices that are stigmatizing, that are often coercive, that use a medical frame to appropriate certain kinds of social legitimacy, and that in many circumstances are really about ruling when they pretend to be about helping. Szasz frequently ridicules the ways in which diagnostic categories have evolved, from the huge explosion in categories from 1980 to the present, to specific categories that exist now or have existed in the past that are patently ridiculous, to the historical trajectories of categories like epilepsy (which was understood as mental illness, or at least related to mental illness, between about 1890 and 1940) and homosexuality.

  • In saying that psychiatry is not science or medicine, and that "mental illness" is a result of a variety of phenomena, some of which may be related to biology but none of which can be understood reliably by knowledge production with the same bases as somatic illness, I am not saying that there are no patterns to complex human behaviours or that we shouldn't study them. Nor am I saying there is no social obligation to create resources that people can take up and use in their own struggles with mental anguish. Diagnostic categories are categories of ruling, but that is in large part because they are institutionally grounded in relations and practices of ruling. I think we need to have writing, talking, theorizing about unchosen mental anguish that is not integrated into ruling relations -- writing, talking, and theorizing that seeks to understand how those experiences are socially produced and how they function within individuals, so that it becomes natural to see both social change and support of individuals as useful responses to the sorts of mental anguish that are but that do not have to be.

  • Further analysis of psychiatric coercion must happen as part of larger discussions. It must happen in ways that recognize the workings of power beyond just the state. It must happen in ways in which the coercive nature of these practices are named and understood as such, rather than mystifying them as helping. But they must also, unlike Szasz' discussion, be in the context of critical analysis of other kinds of coercion that receive social sanction. The most obvious of these is the prison system. In both of these instances, a key question is how to respond to various sorts of human behaviours that may actually justify coercive intervention, and how to build alternatives to empowering the state and to punitive incarceration. Szasz's answer to how to deal with removing all coercive powers from psychiatry is simply to treat psychiatrized people who commit crimes just like you treat everyone else who breaks the law, and rely on the criminal justice system. Obviously that is only an option if you do not have a radically critical analysis of law and prisons and police and so on. Given the current state of the world and the current state of North American social movements, I find such questions very difficult to deal with, but we can't ignore them.

  • I would also insist that questions of coercion, of unchosen violence, also need to look at capitalism and its role in organizing unchosen violence and suffering into people's lives.

So. Kind of disjointed, and longer than I initially intended, but that's where I think I'll leave it.

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

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