Psychiatry as a colonial power.

Back in the Dark Ages, when I was at school, history was largely the story of Great White Men carrying the Light of Civilisation to relieve the misery of the deprived people who lived far from the centre of the world. That's the story: the real reason was so they could rush around and clobber a lot of the locals to grab whatever they had and make off with it. We simply don't know the true history of colonialism, history is written by the victors so all the bad bits are overlooked until they're forgotten. For example, in Grade 5, we learned about the Indian Mutiny and the iniquitous Black Hole of Calcutta. We were not told of the Amritsar Massacre in 1919, in which perhaps ten times as many people attending a peaceful protest meeting were machine-gunned by troops under British General Dyer.

We always need to be careful that what we're being told is factually correct and not just a narrative that suits the winners. And at the moment, the dominant force in psychiatry, biology, is rewriting history so that where we used to think "OK, that's a bit wierd but it's not my problem," we now automatically think "Yes, that's clearly a case of a sick brain that needs treatment." Where the European colonial empires were built using cannon and gunboats, biological psychiatry simply marches out and announces: "From now on, this is our territory so everybody keep away." This is politely called "medicalisation," the process of converting into a matter of medicine something that was previously considered normal, or quirky, naughty, boring, dangerous or just plain stupid.

Whereas previously we could talk in moral terms ("You shouldn't do that") or eccentricity ("You do what? How peculiar") or a normal process of life ("Don't worry, it's the same for all of us. You'll be right"), we are now required to talk about it in terms of health and illness: "Actually, the problem is that you're sick, you've got a genetic disease of the brain and you need to take tablets for the rest of your life." There are actually two processes going on here: first, granting physicians jurisdiction over a part of human behaviour, and second, offering an explanation in medical terms. The difference is real: the fact that something has never been explained in medical terms is no longer enough to prevent medical interference.

This concept of medicalisation has attracted attention from sociologists, although remarkably little from the medical profession. Different authors give different definitions [1] but they all amount to the same thing: there is a creeping colonisation of various aspects of human behaviour by medical authorities who, with the active connivance of the civil authorities, determine that they and they alone are entitled to make all relevant decisions about that behaviour. Their justification is that the particular behaviour is unquestionably biologically-determined and therefore nobody else has the knowledge or skills to deal with it. A whole lot of things flow from this, but the main one is that it imposes a moral duty on everybody else to stand back, to stop passing damaging judgements and to leave it to the experts. Unpacking this, as they now say, would take a book but the essential features are clear:

1. There is wide agreement that some behaviour or other is, for some reason, undesirable. It may be seen as wicked, or damaging for educational or employment prospects, or a sign of weak will, or rebelliousness, whatever. The behaviour is deviant, but only in the sense that it deviates from the statistical norm as most kids/people don't show it;

2. Beyond wilful perversity, there is no formal explanation for it;

3. The behaviour bothers somebody and they want it suppressed for some reason. Perhaps they are angered by it, or embarrassed, or it is inconvenient, it doesn't matter. They have an explanation but very often they won't say other than "That's disgusting, it shouldn't be allowed" or "I need my space too";

4. The medical fraternity either move in on the basis that they alone can deal with it or they are told that nobody else wants it so they can have it. On the basis of information exclusive to the medical profession that nobody else is qualified to judge, physicians claim that their generic theory of all deviant behaviour means they have the full scientific explanation of the behaviour;

5. Everybody is delighted to hand the problem to them and joins in singing their praises. Sometimes the subjects are happy with this and join in the chorus, sometimes they're not, but nobody takes any notice of them anyway.

The only time morality intrudes on this comfortable scenario would be if people didn't allow the unfortunate access to the necessary treatment. That is, the doctors only have to say "This behaviour belongs to us," and everybody has to back off. Parents have to listen, schools and universities, courts, legislatures, even the military have to listen to the latest medical pronouncements. We will go through each of these features in turn.

Pt 1: Deviant behaviour. Yes, it exists. Because behaviour can vary from person to person and from one day to the next, it is statistically to be expected that some will lie close to the centre of the graph and some will be a long way off. As they say, there's no accounting for taste. Why would anybody choose to fight the Church as Martin Luther did? These days, he'd be arrested for causing damage to the door and then pronounced psychotic because he believed the bishops were creaming off a fortune in a vast conspiracy. They were. In fact, his only problem was a highly developed sense of right and wrong. The question is not whether statistically deviant behaviour exists - by definition, it does - but whether it is up to society to judge and condemn, and then to pretend it isn't a moral judgement. And so often, of course, the most judgemental people are guilty of worse offences themselves.

Pt 2: Can't be adequately explained. That's mainly because either people don't ask or don't want to hear, or the subject is too embarrassed/frightened to say. Behaviour always has an explanation, all you have to do is find it. Trouble is, all too often the people with the power don't like the explanation.

Pt 3: Somebody gets wound up over it. Behaviour which is seen as perfectly normal in one context can be unacceptable in another but, as society becomes increasingly regulated and governed by clocks, lawyers and bean counters, the range of normality is rapidly shrinking. But ... Nobody wants to be blamed for the newly deviant behaviour - it's not the parents' fault, it's not the church's fault, not society or capitalism - so they look around for a scapegoat. The ideal scapegoat is somebody who can't push back, somebody who is isolated with no friends in high places to call on. That's why the medieval witch hunts burned old women, not mighty princes - the princes could do what they liked, and usually did. People want something done about the behaviour; these days they can't beat the offender to a pulp, so they do the next best thing, they hand the problem to somebody else. Enter the...

Pt 4: ... Medical profession. Peter Conrad, one of the first and most influential of the sociology writers, commented: "The medical profession may not have entirely sought this role, but its members have been, in general, disturbingly unconcerned and unquestioning in their acceptance of it" [2, p20]. Remember we are talking about behaviour here, not the difference between believing malaria is due to breathing bad swamp air and discovering it is due to a parasite. General medicine has worked very hard within the positivist tradition to build its credibility as a disciplined body of knowledge, and deserves it. I'm not suggesting medicine is without fault but the difference is that psychiatry is trying to ride to glory on medicine's coat tails. Has anybody ever shown that what works for kidneys must necessarily work for the full complexity of the human being? No, they have not [3]. The belief that behaviour is fully contained by the language of the neurosciences laboratory [4] is wholly an ideological assumption.

Pt 5: Anybody who isn't happy with the white knight riding to the rescue is obviously sick and needs more of the blue pills.

I've talked about positivism before, and will do so again, but in simple terms, it is the belief that the only reliable knowledge is knowledge that can be seen and counted. If it can't be seen, the early positivists said, we can't talk about it. It may appeal to poets and philosophers but, as scientists, we can't go there. This has worked very well. Every aspect of science and technology today is based in this disarmingly simple philosophy, except people have carried it to extremes. Over the past hundred years, the core of positivism has morphed, from "If we can't see it, we can't talk about it," (i.e. can't take it into account, can't have any opinions about it) to "If we can't see it, it doesn't exist."

So for psychiatry to escape the mess it had become by about 1970, there was only one path: join mainstream medicine. That is, give up all pretence of being able to say something meaningful about the mind and stick to what can be seen and measured. Biology can be seen and measured, therefore we will build a biological psychiatry. In the process, emotions changed from saying something significant about the patient, from expressing something meaningful about that person as a human, to data points on a questionnaire which give a score which yields a diagnosis which indicates a treatment, here's your script, pay as you go out. Of course, the process of turning psychiatry into a "clinical neuroscience" [4, again] was greatly aided by the thoughts of the torrents of drug company money that would flow from it, and by so many other social factors which we can talk about another day.

But medicalisation, the process of psychiatry colonising normal or various unwanted behaviours and claiming it as its own, cannot now be stopped. Since they replaced "Can't see it, so can't talk about it" with "Can't see it, so doesn't exist," there is nothing in the positivist movement that says "Enough. Stop there, go no further. You biologists have nothing to say about non-biological matters." What started as a limited attempt to avoid the wild excesses of a mentalist-type psychiatry (say, psychoanalysis) has turned into a free-for-all in which anybody with a bee in his bonnet can stake out a claim on an aspect of human behaviour, run up the biological flag and say "This is ours. Forever. Only we can deal with this." And it doesn't stop.

In fact, it can't stop. The process of psychiatry claiming authority over ever-increasing fields of behaviour is driven by many different social forces but there is nothing in the philosophy of positivism to draw a line in the sand. In formal terms, there is no demarcation criterion between "... normal, or quirky, naughty, boring, dangerous or just plain stupid ..." behaviour, and genuinely pathological.

Some of the forces include the vast fortunes that drug companies make from "new illnesses," which they then spread around (in the US between 2000-2020, drug companies handed some$340million to psychiatrists in return for publicity); the urgent need for academic psychiatrists to make a name by discovering a "new disease"; the need for parents to find some excuse for the difficult/awful/infuriating behaviour of their offspring rather than shoulder the blame themselves; the fact that schools have never developed proper behavioural methods of control; maybe the fact that the one-size-fits-all school was devised for the convenience of teachers, not kids; and the need for governments to shift responsibility for failings from the society they are running to the individual.

Books have been written on these topics but I feel they all miss the point that medicalisation is a process driven by a false account of the human being, one that ratchets up, never down again.

Once psychiatry builds a clinic for some condition or other, they never disband it.

It's going to get worse before it gets better.

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The formal definition of medicalisation is this:

Medicalisation is the act of reclassifying an observation or event as a medical matter, where medicine is a positivist endeavour directed at giving self-contained reductionist explanations of such events etc. within the physicalist ontology, and thereby opening the possibility of a physical intervention. Note that, in practice, this is an incomplete reductionist account of the human condition as medicalisation only applies to undesirable observations or events. Even if a full reductionist account of human life were available, not all behaviours or observations would be considered as matters suitable for attempted rectification by physicians. This allows the intrusion of what, within positivism, would otherwise be a prohibited moral element, leading to legitimate or illegitimate medicalisation.

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I had intended to continue the question of detention and involuntary treatment this week but it was covered on ABC Four Corners. This is the premier investigative program for the national broadcaster, similar to BBC Panorama or PBS Frontline. It covers only forensic detention, which is a small part of the much larger problem: https://iview.abc.net.au/show/four-corners

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References:

1. Busfield J (2017). The concept of medicalisation reassessed. Sociology of Health & Illness 39:759-774. doi: 10.1111/1467-9566.12538

2. Conrad, P. (1975) The discovery of hyperkinesis. Social Problems, 12:12–21.

3. McLaren N (2013). Psychiatry as Ideology. Ethical Human Psychology and Psychiatry 15: 7-18.

doi: 10.1891/1559-4343.15.1.7

4. Insel TR (2009). Disruptive insights in psychiatry: transforming a clinical discipline. J. of Clinical Investigations. 119:700-05