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In my last column (October) I discussed the concept of medicalization and its role in modern societies. In this column I propose to ask and answer the question: How are we to understand the contemporary confusion about what counts as a disease?
Medical classification -- the linguistic-conceptual ordering of
phenomena we call "diseases" and of the interventions we call
"treatments" -- is a human activity, governed by human interests.
In the United States today, the forces of medicalization rule
virtually unopposed, indeed unrecognized for the economic, moral,
and political interests that they represent. Our drug policies
are illustrative. For millennia, the regulation of drug use was
a matter of self-control, custom, religion, and law. In part,
this is still the case. More importantly, however, drug use is
regulated by laws and ostensibly scientific "facts," exemplified
by a broadly based drug prohibition consisting of prescription
laws and criminalization of the trade in many drugs, such as opiates,
cocaine, and marijuana. This is drug medicalization from above.
Drug medicalization from below is pursued no less zealously by
individuals who, while ostensibly opposed to our drug laws, promote
so-called medical marijuana initiatives, physician-assisted suicide,
and similar schemes. The result is loss of self-ownership and
the right to self-medication -- the classical liberal/libertarian
perspective on drug use.
Because the mind is not an object like the body, it is a mistake
to apply the predicate disease to it. Hence, as I asserted half
a century ago, the "diseased mind" is a metaphor, a mistake, a
myth.
Actually, this idea is not as novel as it might seem. Emil Kraepelin
(1856-1927), the creator of the first modern psychiatric nosology,
acknowledged the fundamental analytic truth that there are no
mental illnesses. In his classic, Lectures on Clinical Psychiatry
(1901), he stated: "The subject of the following course of lectures
will be the Science of Psychiatry, which, as its name [Seelenheilkunde]
implies, is that of the treatment of mental disease. It is true
that, in the strictest terms, we cannot speak of the mind as becoming
diseased [Allerdings kann mann, streng genommen, nicht von Erkrankungen
der Seele sprechen]." Half a century earlier, the Viennese psychiatrist
Ernst von Feuchtersleben (1806-1848) explicitly emphasized the
analogical-metaphorical character of mental illnesses: "The maladies
of the spirit [die Leiden des Geistes) alone, in abstracto, that
is, error and sin, can be called diseases of the mind only per
analogiam. They come not within the jurisdiction of the physician,
but that of the teacher or clergyman, who again are called physicians
of the mind / soul (Seelenärzte) only per analogiam".
The transformation of religious explanations and controls into
medical explanations and controls of behavior is one of the momentous
consequences of the Enlightenment. The waning power of religion
and the Church and the waxing power of science and the State is
manifested, among other things, by the political control of medical
practice and the drug laws that deny access to lay person to drugs
(except those classified as over-the-counter). To legally obtain
or possess a "prescription drug," the lay person must establish
a professional relationship with a licensed physician and receive
a diagnosis for an illness: that is, he must be a patient who
suffers from a proven or putative illness. For example, to receive
a sleeping pill, the person must "suffer from insomnia." This
charade contributes mightily to the medicalization rampant in
our society. In turn, medicalization is mindlessly equated, especially
by the cognoscenti, with scientific, moral, and social progress,
and contributes further to its popularity.
Although medicalization encompasses more than psychiatry, we must
be clear about one thing: Psychiatry is medicalization, through
and through. Whatever aspect of psychiatry psychiatrists claim
is not medicalization, is not medicalization only if it deals
with proven disease, in which case it belongs to neurology, neuroanatomy,
neurophysiology, neurochemistry, neuropharmacology, or neurosurgery,
not psychiatry.
Psychoanalysis is medicalization squared. It is important, in
this connection, not to be fooled by lay analysis, clinical psychology,
or social work. These and other non-medical mental health and
counseling "professions" are medicalization cubed: as if to compensate
for their lack of medical knowledge and qualifications, nonmedical
mental health "professionals" are even more deeply committed than
psychiatrists to their claim of special expertise in the diagnosis
and treatment of mental illnesses.
Freud's Contribution
By the time Sigmund Freud (1856-1939) appeared on the historical
stage, medicalization was in full swing. The birth of psychoanalysis
is, in fact, a manifestation of the increasing popularity of this
trend at the end of the nineteenth century as well as a cause
of its explosive growth during the twentieth century. The gist
of Freud's thesis was that the symptoms of mental illnesses are
the "products" of the same "mental processes" that are responsible
for the thoughts and actions of normal persons. In other words,
Freud rediscovered that "there is method in madness," or as he
preferred to put, that sane and insane behaviors are subject to
the same "psychological laws." To create his special brand of
pseudoscience, he titled his book The Psychopathology of Everyday
Life. He could just as well have titled it The Everyday Normality
of Psychopathological Life. There would, of course, have been
neither fame nor fortune in that. Instead, he fanned the flames
of medicalization and transformed a smoldering fire into an all-consuming
conflagration. At the same time, because he knew better, Freud's
attitude toward medicalization was ambivalent and opportunistic.
The public's memory is short. Towards the end of nineteenth century,
doctors transformed diverse human sexual appetites and practices
into a Latin dictionary of diseases. A hundred years later, they
transformed many of those diseases -- for example, masturbation,
pornography, and prostitution -- into "sex therapy."
People do not have to be told that malaria and melanoma are diseases.
They know they are. But people have to be told, and are told over
and over again, that alcoholism and depression are diseases. Why?
Because people know that they are not diseases: that mental illnesses
are not "like other illnesses," that mental hospitals are not
like other hospitals, that the business of psychiatry is control
and coercion, not care or cure. Accordingly, medicalizers engage
in a never-ending task of "educating" people that non-diseases
are diseases.
Formerly, people felt depressed or were depressed. Now they have
depression. Formerly, some depressed persons killed themselves,
but most did not. Now people do not kill themselves, depression
kills them, and (virtually) everyone who kills himself is said
to have been depressed. And just as people can have cancer and
not know it, so they may have depression and not know it, and
hence need to be tested for it, lest "it" kill them. On its web
site, the Depression is Real Coalition emphasizes: "Indisputable
scientific evidence shows depression to be a biologically-based
disease that destroys the connections between brain cells."
Cui bono? The peddlers of psychiatric snake oil who are unfailingly
silent about two important risks inherent in every professional
contact between an individual and a psychiatrist, namely, stigmatization
by psychiatric diagnosis and loss of liberty by psychiatric incarceration.
Why do the promoters of psychiatric slavery regularly fail to
mention the potential downside of "mental health services"? Because
they self-servingly define psychiatric oppression of the patient
as beneficial for him, much as the promoters of chattel slavery
regarded oppression of the slave as beneficial for him. Lincoln's
answer to this outrage remains relevant: "But, slavery is good
for some people! As a good thing, slavery is strikingly peculiar,
in this, that it is the only good thing which no man ever seeks
the good of, for himself." In short, medicalization is neither
medicine nor science; it is a semantic-social strategy that benefits
some persons and harms others.
"[T]he medical treatment of [mental] patients began with the infringement of their personal freedom," warned Karl Wernicke (1848-1905), the pioneer German neuropathologist. It still begins with the infringement of their personal freedom. |