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In the United States today everyone considers himself an expert on psychiatry, especially in the aftermath of a mass murder by a "deranged madman." Yet, academically and legally qualified experts in the field keep telling us that they cannot even define psychiatry.
In
1886, Emil Kraepelin, the undisputed founder of modern psychiatry
as a medical specialty and science, declared: "Our science has
not arrived at a consensus on even its most fundamental principles,
let alone on appropriate ends or even on the means to those
ends." Eighty years later, the encyclopedic American Handbook
of Psychiatry opened with this statement: "Perhaps no other
field of human endeavor is so ... difficult to define as that
of psychiatry." Andrew Lakoff, a professor of sociology at the
University of California in San Diego, airily opines: "Two centuries
after its invention, psychiatry's illnesses have neither known
causes nor definitive treatments." This did not prevent him
from writing a book about the diagnosis and treatment of a particular
mental disease, "bipolar illness," in a particular country,
Argentina.
Perhaps
even more dramatic is the recent comment by Nancy Andreasen,
professor of psychiatry at the University of Iowa and a former
editor of the American Journal of Psychiatry, about American
psychiatry's sacred symbol, schizophrenia.
Concerns
about the American Psychiatric Associations "Diagnostic and
Statistical Manual of Mental Disorders (DSM)," she writes, "led
the author to write several editorials for the American Journal
of Psychiatry about the current problems that have been created
by DSM. ... Europeans can save American science by helping us
figure out who really has schizophrenia or what schizophrenia
really is." One wonders how Andreasen reconciles her uncertainty
about "who really has schizophrenia" or "what schizophrenia
really is" with the standard legal-psychiatric practice of using
the diagnosis to deprive innocent persons of liberty and excuse
guilty persons of crimes, and deprive them, too, of liberty,
often for a much longer period than they would have been had
been sentenced to prison.
Actually, it is easy to define psychiatry. The problem is that
doing so -- acknowledging its self-evident ends and the means
used to achieve them -- is socially unacceptable and professionally
suicidal. The law, social expectation, and psychiatric tradition
and practice point to coercion as the profession's paradigmatic
characteristic. Accordingly, I define psychiatry as the theory
and practice of coercion, rationalized as the diagnosis of mental
illness and justified as medical treatment aimed at protecting
the patient from himself and society from the patient. It is
impolite and impolitic to take this truism and its consequences
seriously.
Non-acknowledgment
of the fact that coercion is a characteristic and potentially
ever-present element of so-called psychiatric treatments is
intrinsic to the standard dictionary definitions of psychiatry.
According to the Unabridged Webster's, psychiatry is "A branch
of medicine that deals with the science and practice of treating
mental, emotional, and behavioral disorders."
Plainly,
voluntary psychiatric relations differ from involuntary psychiatric
interventions the same way as, say, sexual relations between
consenting adults differ from the sexual assaults we call "rape."
Sometimes, to be sure, psychiatrists deal with voluntary patients.
As I have shown elsewhere, it is necessary therefore not merely
to distinguish between coerced and consensual psychiatric relations,
but to contrast them. The term "psychiatry" ought to be applied
to one or the other, but not both. As long as psychiatrists
and society refuse to recognize this, there can be no real psychiatric
historiography nor any popular understanding of the varied practices
called "psychiatric treatments."
Consider
the parallels between coercive psychiatry and missionary Christianity.
The heathen savage does not suffer from lack of insight into
the divinity of Jesus, does not lack theological help, and does
not seek the services of missionaries. Similarly, the psychotic
does not suffer from lack of insight into being mentally ill,
does not lack psychiatric treatment, and does not seek the services
of psychiatrists. This is why the missionary tends to have contempt
for the heathen, why the psychiatrist tends to have contempt
for the psychotic, and why both conceal their true sentiments
behind a facade of caring and compassion. Each meddler believes
that he is in possession of the "truth," each harbors a passionate
desire to improve the Other, each feels a deep sense of entitlement
to intrude into the life of the Other, and each bitterly resents
those who dismiss his precious insights and benevolent interventions
as worthless and harmful.
The
writings of historians, physicians, journalists, and others
addressing the history of psychiatry rest on three erroneous
premises: that so-called mental diseases exist, that they are
diseases of the brain, and that the incarceration of "dangerous"
mental patients is medically rational and morally just. The
problems so created are then compounded by failure -- purposeful
or inadvertent -- to distinguish between two radically different
kinds of psychiatric practices, consensual and coerced, voluntarily
sought and forcibly imposed.
In
free societies, ordinary social relations between adults are
consensual. Such relations -- in business, medicine, religion,
and psychiatry -- pose no special legal or political problems.
By contrast, coercive relations -- one person authorized by
the state to forcibly compel another person to do or abstain
from actions of his choice -- are inherently political in nature
and are always morally problematic.
Mental
disease is fictitious disease. Psychiatric diagnosis is disguised
disdain. Psychiatric treatment is coercion concealed as care,
typically carried out in prisons called "hospitals." Formerly,
the social function of psychiatry was more apparent than it
is now. The asylum inmate was incarcerated against his will.
Insanity was synonymous with unfitness for liberty. Toward the
end of the nineteenth century, a new type of psychiatric relationship
entered the medical scene: persons experiencing so-called "nervous
symptoms" began to seek medical help, typically from the family
physician or a specialist in "nervous disorders." This led psychiatrists
to distinguish between two kinds of mental diseases, neuroses
and psychoses. Persons who complained of their own behavior
were classified as neurotic, whereas persons about whose behavior
others complained were classified as psychotic. The legal, medical,
psychiatric, and social denial of this simple distinction and
its far-reaching implications undergirds the house of cards
that is modern psychiatry.
Fashionable Clichés
Psychiatry and society face a paradox. The more progress scientific
psychiatry allegedly makes, the more intolerable becomes the
idea that mental illness is a myth and that the effort to treat
it a will-o'-the-wisp. The more progress scientific medicine
actually makes, the more undeniable it becomes that "chemical
imbalances" and "hard wiring" are fashionable clichés, not evidence
that problems in living are medical diseases justifiably "treated"
without patient consent. And the more often psychiatrists play
the roles of juries, judges, and prison guards, the more uncomfortable
they feel about being in fact pseudomedical coercers -- society's
well-paid patsies. The whole conundrum is too horrible to face.
Better to continue calling unwanted behaviors "diseases" and
disturbing persons "sick," and compel them to submit to psychiatric
"care."
It
is easy to see, then, why the right-thinking person considers
it inconceivable that there might be no such thing as mental
health or mental illness. Where would that leave the history
of psychiatry portrayed as the drama of heroic physicians combating
horrible diseases? Where would it leave psychiatrists, the law,
and the public that depend on the myriad social institutions
that rest on the mendacious premises that the phenomena we call
"mental illnesses" are illnesses, and that "mental illnesses
are like other illnesses"?
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