A CRITIQUE OF PSYCHIATRY AND AN INVITATION TO DIALOGUE
Ron Leifer, M.D.
This article has been published in Ethical Human Science and Services, December 27, 2000
The medical model is the dominant paradigm of psychiatry. Over the past forty years it has become the target of a rising tide of criticism. What is the medical model? Why is it the object of criticism? The medical model is not a scientific concept or theory. It cannot be confirmed or falsified by facts. A model is a conceptual-linguistic construction, a metaphor. The balsam wood model airplane is a metaphor for a real airplane. It is not a real airplane. It is a representation which highlights similarities and ignores differences. A fire in the eyes may sparkle but it doesn't burn. The medical model is a metaphor which portrays psychiatry, psychiatrists, and psychiatric patients in the language of medicine. Medicine does not need a medical model. It is the standard on which psychiatry models itself, like the real airplane is to the toy. The medical model projects the metaphors of illness on to the patient and the metaphors of medicine on to the psychiatrist.
Psychiatry is described as a medical specialty. Anyone who becomes the object of psychiatric attention, voluntarily or involuntarily, is viewed through the medical model and is subject to being labeled as mentally ill. The medical model, while based on superficial similarities between psychiatry and medicine, disguises and obscures crucial differences between them. The general and superficial similarity between medicine and psychiatry is that both are concerned with people who suffer and/or deviate from criteria of normality. The difference is that medicine deals with conditions of the body which it classifies as medical illness. Psychiatry deals with certain kinds of thinking, feeling, and acting which it classifies as mental illness. Another crucial difference is that all adult medical patients are voluntary. Their consent is required before treatment can occur. Adult psychiatric patients, by contrast, can be defined as mentally ill, involuntarily committed to a psychiatric institution, and forced to submit to drugging and electroshock. The criticisms of psychiatry are based on both the logical flaws of the medical model and the moral and political implications of its social use.
The modern critique was inaugurated in 1961 with the publication of The Myth of Mental Illness by Thomas Szasz. In this now classic work, Szasz offers a conceptual and logical critique of the medical model broadly based in philosophy, psychology, and political theory. The basic problem with the medical model is that people take it literally rather than understanding it as the metaphor it is. The medical model portrays the mind as an object. It equates mind with brain and uses this assumption to justify defining certain thoughts, feelings, and behavior as medical diseases. It is like thinking that a model plane can actually board passengers and fly, or that spring fever is a medical symptom. It is pure imagination. Szasz criticizes the view of mind as object by reminding us of the well established ontological, epistemological and linguistic differences between mind and matter. Simply stated, mind is different than matter, or body, or brain, for the obvious reason that the body is an object and the mind is not. The body is known through the methods of physics and chemistry. The mind is known through introspection, communication and interpretation. The language used to describe the body is literal. The language used to describe the mind is metaphorical. The thesis of The Myth of Mental Illness is that mental illness is a metaphor. The medical model of psychiatry is a metaphor which psychiatry, the media and, hence, the general public take literally.
A second, parallel critique of psychiatry focuses on the social uses, functions, and consequences of the medical model. It maintains that the medical model of psychiatry is an ideology which justifies covert social control. "Diagnosing" persons as mentally ill who complain of or display certain forms of undesired and undesirable thought, mood, and behavior renders them vulnerable to being managed by a ubiquitous mental health system. Involuntary confinement and forced drugging can be seen as means of social control. Indeed, the only reason not to see them as such is to hide the fact. Incredibly, this obvious fact is denied and ignored by most psychiatrists, the media and the general public in spite of the fact that people labeled mentally ill may be deprived of their freedom and coerced to take drugs without having been accused and convicted of a crime. The clearly stated purpose of commitment and forced treatment laws is to prevent suicide and harm to others. The medical model of psychiatry serves as an ideology which camouflages this covert form of social control as medical treatment.
Critics argue that mental illness is an ideology used to protect the public against persons who are judged to be dangerous or disturbing but who have not necessarily violated any law. As a covert form of social control, psychiatry violates the principle of rule of law which prohibits depriving a person of freedom without an accusatory indictment and a trial by jury governed by rules of evidence which gives a verdict of guilt for violating a specific law. This critique of psychiatry is based on the ethical and political respect for individual freedom under law which is the political foundations of this republic. Medical-coercive psychiatry violates these fundamental values. These issues invite debate in competent forums, yet they are ignored.
A third approach involves the critical evaluation of psychiatric and psycho-pharmacological research. This criticism has two prongs. First, it examines the methodology and validity of the research and the factual findings. Second, it questions the use of these facts in support of the medical model. Critics argue that the research is deeply flawed and that the flaws are ignored for social, political, and economic reasons. The premise of the medical model is that "mental illnesses" are caused by "pathological" changes in the chemistry, structure, or organization of the brain. Many eminent, non-medical neuroscientists have pointed out that the brain is far more complex than psychiatrists believe. Critics of the medical model maintain that the scientific evidence at hand does not adequately support the claim that neurochemical factors cause the behaviors which are labeled "mental illness." Nevertheless, due to a vigorous marketing program, the claim is widely believed to be true. There is a strategic disingenuousness to this critique of psychiatric research. It assumes that proper research could demonstrate a causal connection between brain function and certain kinds of thought, speech, and behavior. This is questionable and debatable since the language of brain science and the language of mind and moral behavior belong to different logical categories. One vital question which has not been addressed is: if neurochemistry can cause undesirable thoughts, feelings and actions can it also cause desirable ones? Another vital question which has never been addressed is whether neurochemical changes are the cause or effect of psychological factors. And for good reason. How can we know? How do we decide? Every behavior has a simultaneous neurophysiology. Which is cause and which is effect? Ironically, this is a rhetorical and political question not a scientific one. Biological psychiatry, to no one's surprise, prefers a theory of biological causation. Humanistic psychiatry, to no one' surprise, prefers to understand the person as a thinking, feeling, acting agent. Considering the logical gap between mind and body and the difficulty of establishing causal relations between them, it is not surprising that this research is vulnerable to technical criticism.
The fourth branch of criticism, the most heartfelt and vocal, consists of the cry of those who have been abused, harmed, coerced and drugged by medical-coercive psychiatry. Their voices are raised against medical coercive psychiatry, against involuntary confinement, against forced drugging and electroshock, against psychiatrists who only give drugs and don't talk to their patients, and against the inhumane milieu of psychiatric hospitals. Their pain, suffering, and courage add heart to the critique of medical-coercive psychiatry.
In the Spring of 1998, psychiatry was called to public account by the Foucault Tribunal: Psychiatry on Trial which was organized in Berlin by a group of psychiatric survivors and activists. Dr. Szasz was invited to represent the prosecution but excused himself for personal reasons and invited me to substitute for him. The paper he planned to present, "The Case Against Coercive Psychiatry," was translated into German and distributed at the conference. The jury consisted of psychiatric survivors and activists led by forewoman, Kate Millett. As prosecutor, I presented ten indictments against medical-coercive psychiatry, defined as that branch of psychiatry which espouses the medical model, defines human, moral problems as medical, serves as a covert agent of social control, and in that capacity confines people against their will and forces upon them unwanted drugs and other invasions. These indictments summarize the mounting criticisms of the medical model and coercive psychiatry. The indictment, like all dialectical forms, tends to elicit defenses which impede productive dialogue. The purpose of this paper is to call for a dialogue on ten serious philosophical, ethical, social and political problems raised by medical-coercive psychiatry. Our purpose is to promote critical debate in the hope of relieving human suffering. We ask for an open, constructive dialogue on these ten issues which deserve reflection and public discussion.
1. THE REPRESSION BY MEDICAL-COERCIVE PSYCHIATRY OF ITS CRITICS AND DISSENTERS: WHO CONTROLS THE DISCOURSE?
Post World War II psychiatry was split into two camps. One was the public mental hospital system. The other was psychoanalysis and psychotherapy. The discovery in the fifties and sixties of drugs which alter mind and mood changed the psychiatric climate. In its desire to appear scientific and, hence, legitimately medical, psychiatry focused attention on drugs and the brain. The mind-body pendulum, which has been swinging back and forth since philosophy began, began to swing back towards the biological-medical paradigm of human suffering. Whereas psychoanalysis heavily influenced culture and popular thought in the fourth, fifth and sixth decades of this century, the medical model and the discourse of the medical model dominates at the turn of the century.
In 1961, when Szasz published The Myth of Mental Illness, the pendulum was at midpoint. The situation at Syracuse dramatized the schism in psychiatry. The chairman of the department of psychiatry was both a psychoanalyst and the director of the Syracuse State Psychiatric Hospital. State psychiatry's response to the psychoanalyst Szasz's critique of the medical model was to restrict and repress him. He was forbidden to teach in the state hospital which was the flagship of the department of psychiatry. Serious attempts were made to remove him from his tenured appointment as professor of psychiatry.
His two main defenders at that time, Ernest Becker and myself, both of us untenured, were fired. Becker went on to posthumously win the Pulitzer Prize in 1974 for The Denial of Death. The chairman of the department at the time told me in front of the dean of the medical school that the reason for my dismissal was that he didn't want my forthcoming book, In the Name of Mental Health, to be published while I was a member of the department. The possible development of a critical, humanistic school of psychiatry at Syracuse was aborted. Szasz and other critics of psychiatry have been blackballed, repressed and oppressed by medical-coercive psychiatry and its supporters. Szasz has been a tenured professor of psychiatry at Syracuse for more than forty years. Since the attack on him by establishment psychiatry he has taught minimally and has no students or followers in that department as most academic professors do. I know of no critics of the medical model has been any academic department of psychiatry in this country. Psychiatric journals have routinely rejected articles submitted by Szasz, Becker, and myself.
Psychiatry's response to its critics has been "Todschweigen," death by silence. The time has come for dialogue.
The repression of the critics of psychiatry may seem a minor historical note but it has great potential significance. The issues here transcend the triumphs or tragedies of any individual critic. They transcend psychiatry itself. They involve nothing less than the future well being of our society. The question raised by the repression of critics of the medical model is: "Do we really have free debate on vital issues in this country, as the public assumes we do?" If one critique can be repressed other critiques can also be repressed. There is ample evidence to those who are willing to see that intellectual repression is endemic, subtle, and unnoticed in this country. If a critical discourse is repressed, the public will be unaware of it unless and until critics speak out, at great personal risk, expose what is repressed and raise public awareness.
The repression of critics of the medical model silences the long western debate on vital human issues which began in ancient Greece. Mindlessly reducing mind to brain, as medical psychiatry does, ignores the long, tortuous, historical debate on the relationship between mind and body. Accepting psychiatry as a medical discipline like any other and ignoring it's social functions is tantamount to shutting off political debate on the vital question of the balance between individual freedom and social order. Ignoring critiques of the insanity defense blinds us to the meaning of personal responsibility. These issues have broad, global significance and must be debated if humanity is to intelligently influence its fate.
A question raised by the repression of the critics of medical model is: "Who controls the discourse?" Who determines which paradigms shall be used for understanding human behavior? How we see the world shapes how we act in it. How we see people shapes how we act towards them. If we see people as machines we will fix them with physical interventions when we think they are broken. If we see people as active agents we will treat them with respect, regard them as responsible, and accept their choices. Classical sociologists recognized that knowledge is a commodity. It has (social) value, either in support of prevailing interests or against them. Paradigms arise in a social context, in relation to the interests and resistance of competing powers. Each society has its own fabric of discourses which establish and preserve its identity and functions. The critique of a prevailing discourse can rent the fabric of society and generate unsettling social change. The repression of critics serves the stability of the prevailing order. At present, there are two principle competing paradigms for understanding human behavior. the deterministic paradigm, of which the medical model is the driving example, and the moral paradigm. The deterministic paradigm explains human behavior in terms of causes. The moral paradigm refers not to any particular morality but to the person as moral agent who desires, intends, plans, acts and experiences the consequences of those actions, for better or for worse. It explains and judges human behavior in terms of desires, intentions, motives, purposes, ideals, actions, values, ethics, context, contracts, and laws. There are several versions of the causal deterministic paradigm: biological determinism explains behavior as caused by body and brain; social determinism explains behavior as caused by social conditions; and psychological determinism explains it in terms of historical events and traumas. Each of these paradigms discounts moral agency and hence, personal responsibility.
On the deterministic model, behavior cannot be free. It is contradictory to say an act is both caused and free. There is no freedom in causality and no cause of freedom. They are antithetical terms. If an individual's behavior is viewed as caused and, hence, not freely chosen, that person cannot be held responsible for his or her actions. If a person's behavior is viewed as a choice, then that person is responsible and accountable. The paradigm chosen to explain an individual's behavior thus defines that person socially. On the moral model, a person is defined as responsible and entitled to freedom under law. On the deterministic model, a person is defined as non-responsible and vulnerable to being deprived of freedom without accusation or trial.
Each paradigm has its own special discourse and discourse community. Academic, medical-coercive psychiatry and public mental health facilities use the deterministic paradigm. Private psychotherapists use the moral paradigm, whether they know it or not and whether they like it or not. Often they use both, explaining the patients suffering and symptoms as caused but assigning to the patient responsibility for change. The state and the pharmaceutical industry and their champions in the media favor the deterministic model. They control and dominate the public discourse with the result that the medical model, the causal-deterministic model of human behavior is the unquestioned dominant paradigm.
By repressing its critics, psychiatry violates one of the basic principles of the scientific method, namely free, critical inquiry and debate.
Psychiatry claims to be a science. Society regards the psychiatrist as an expert in medical science. But the hallmark of the scientific method is the "null hypothesis," the systematic effort to falsify and criticize methods, observations, and theories . In principle, any statement which is not possible to falsify, or which is not subject to critical evaluation, cannot be claimed as scientific. Psychiatry's successful efforts to silence its critics is contrary to the rules of science and refutes the psychiatric claim to psychiatric validity.
By repressing its critics, psychiatry has marked itself as intolerant and indifferent to the great debates of intellectual history and resistive to the development of new ways of understanding human behavior, including that behavior on which they designate themselves to be the final authority. As Nietzsche observed there are some truths that people don't want to see. On the other hand, it is the responsibility of the critical intellectual to open the debate, to propose new ways of understanding ourselves and the world. New ways of viewing human behavior might help us to understand vexing modern problems such as our endemic domestic aggression and violence, a spreading depression, and pervasive anxiety and stress. New paradigms for understanding human behavior might provide a new insights into the problems of people who seek professional help. It may even serve as the basis of a constructive critique of society. But the development of new ways of thinking is obstructed by those who control the discourse: psychiatry, the state, and the pharmaceutical industry. The State-Science Alliance.
2. THE MEDICAL MODEL AS IDEOLOGY.
An ideology is a set of ideas which emphasizes facts that promote certain social interests and represses facts that oppose them. The medical model, pretends to be scientific but functions as an ideology. It is an ideology because it emphasizes the similarities between medical disease and mental illness, namely, that both involve suffering and disability. And it represses their differences, namely, that the suffering and disability of medical illness is caused by demonstrable changes in the body, while the suffering and disability of mental illness have no demonstrable cause in the body and refer instead to speech, feelings, and social conduct. The skewing of the discourse on human suffering towards the brain brands the medical model of psychiatry as an ideology.
3. THE MEDICAL MODEL IS AN IDEOLOGY WHICH JUSTIFIES COVERT SOCIAL CONTROL.
The social interest served by the medical model ideology is the public mandate for a greater degree of social control than can be provided under rule of law. By labeling certain behavior as medical illness, the medical model serves, enables and justifies an extra-legal, covert form of social control. Unlike persons who are diagnosed with physical illness, whose responsibility as individuals is not usually questioned and who are not confined against their will because of their illness, persons who are "diagnosed" with serious mental illness may be defined as not responsible, be deprived of freedom without indictment or trial, and be forced to take drugs and other "treatments" against their will. Viewed through the medical model, these violations of human rights appear and are justified as medical treatment. Viewed through the moral paradigm they are seen as a covert means of social control.The medical model developed as an ideology in a historical and political context. It was "selected" by powerful social and political forces for its utility as a paradigm to describe and control certain forms of deviant behavior. The medical model developed in the context of the European Enlightenment, the rise of science and the French and American Revolutions. As the scientific view of the world replaced the religious view, jurisdiction over suffering was transferred from religion to science, and human behavior was explained in terms of cause and effect rather than in terms of virtue and sin. The political revolutions signify a historical transformation from rule of man to rule of law, from tyranny to democracy. Under rule of man, persons who were judged as acting against the interests of the state could be confined by a simple writ signed by the king or his officer. These tyrannical "lettres de cachet" were eliminated by political revolution. Under rule of law, a person cannot be deprived of freedom except after having been convicted of violating a specific law by a jury in a trial governed by rules of evidence. Rule of law is a limitation on the power of the state in the name of individual liberty. A society could not be called free that is governed by laws which are so vague and broad as to regulate ordinary speech and behavior. The medical model developed as an ideology to disguise and justify covert forms of social control. Without invoking the medical model, could we call a society free where people can be deprived of their freedom and forcibly drugged because they are homeless and disturbing to the public? For hearing or speaking to their gods? For going on spending sprees? For believing the government is after them or that they are being monitored by electronic devices? For not being able to face the difficulties of life? It happens in this country and we pretend to the world to stand for the ideal of individual freedom. The problem is that society demands a greater degree of social control than law allows. The public wants to be protected from unconventional, threatening, and dangerous behavior. There is, thus, a public mandate for a covert form of social control which supplements rule of law. Medical-coercive psychiatry, in alliance with the state, performs this function disguised as medical diagnosis and treatment.
4. PSYCHIATRIC ABUSE, COERCION, FORCE, AND FRAUD IN THE NAME OF MENTAL HEALTH.
Disguising social control as medical treatment is a deceit which conceals an abuse. Civil rights advocates have focused primarily on the physical abuse and inadequate treatment of involuntary patients in mental hospitals. This is laudable. They have sometimes failed to understand, however, that involuntary psychiatric confinement is an abuse in itself. The constitution guarantees that a person shall not be deprived of life, liberty, or property without due process. A lettre de cachet, which is what the physician's certificate of psychiatric commitment is, does not constitute due process. Nor does a judge's automatic ratification of the psychiatrist's recommendation, which is the rule. The legal justification for involuntary detention is the allegation that a person has violated mental hygiene laws which are so vague and broad that almost anyone who misbehaves is subject to arrest and transportation by the police to a mental "hospital." Only the rich, powerful, and clever can avoid it. The majority of victims are powerless, poor, young, old, or a member of a minority class. In contrast to genuine medical patients, involuntary psychiatric patients may be deprived of all their civil rights. They can be held indefinitely against their will on the word of a psychiatrist. Habeus corpus hearings, where the psychiatric "patient" petitions for freedom, are typically farcical rubber stamps of the psychiatrist's authority. Committed patient can be deprived of the right to drive, to vote, to manage money, and to communicate with their friends, relatives, and doctors. The psychiatric ward is a total institution under the absolute authority of psychiatrists and their designated agents. Inmates can be forced to take drugs against their will. They can be put in isolation. They can be forced to undergo electroshock treatment and lobotomy against their will. They are at the mercy of their "helpers."
In a society ruled by law how can deprivation of liberty without trial not be an abuse of power? Is a society free where people may be forced to submit to drugging, electroshock, or lobotomy? Many of my patients who have been involuntarily confined in a mental hospital have found the experience extremely traumatic. And while medical patients in the best hospitals might find the experience unpleasant, the unpleasantness of mental hospitalization is its inhumanity. Some former mental patients are grateful, but much in the guilt expiating way that some convicts are grateful for their imprisonment.
To deny that involuntary hospitalization is a form of covert social control seems absurd and dishonest, approaching fraud. Most psychiatrists are aware, and will admit in private, that involuntary hospitalization is a form of social control. But they deny it in public, insisting it is necessary for the medical treatment of mentally ill people. This in spite of the fact that the law in most jurisdictions stipulates that, to be deprived of freedom without trial by psychiatric confinement a person must be dangerous to him or herself, or others! Psychiatrists refuse to address the question of why medically ill persons whose diseases may be dangerous to themselves or others are not forced into confinement and treatment of their medical condition? The denial of the fact that the psychiatric "illness" is dangerousness and that the "treatment" is social control serves neither justice, fairness, honesty, integrity nor freedom under the rule of law. But society is afraid to debate this issue for fear that the consensual fraud will be exposed and the public will be deprived of an extra-legal means of maintaining domestic tranquility. Facing our problems is disturbing. Not facing them is even more disturbing.
5. THE MEDICAL MODEL IS THE BASIS OF PSYCHIATRIC IDENTITY.
Ideologies support and perpetuate social interests and, in turn, are supported and perpetuated by those interests. The medical model serves society as an ideology which justifies covert social control. It also serves the interests of psychiatrists by supporting their identity as a physicians. The personal, professional, and economic interests of psychiatrists are promoted by the medical model. No medical model, no medical psychiatry. If mental illness "exists" then they are true members of the medical fraternity. If mental illnesses do not "exist," if the term is a metaphor which uses the language of medicine to judge and describe thoughts, feelings, and behavior, then psychiatrists cannot not be viewed as "real doctors." The medical model supports the self-interest of psychiatrists and psychiatrists promote the medical model. The critics of the medical model threaten the identity of psychiatrists and, hence, are ignored, suppressed, and repressed.
6. COERCIVE-MEDICAL PSYCHIATRY MAKES AND MARKETS FALSE CLAIMS.
Psychiatrists proclaim that so called "mental illnesses," for example, schizophrenia, depression and bipolar illness, have neurochemical or genetic causes. In their journal articles and private conversations, however, they admit that the evidence is "suggestive but not conclusive." It is suggestive to them because it is in their interests to see it that way. To neutral observers, their claims are far from being scientifically verified. Critics have raised questions about psychiatric methodology, claims, and conclusions, but their voices are repressed, suppressed and ignored. For example, psychiatrists claim that depression is "caused" by low brain serotonin levels, the infamous "biochemical imbalance." The evidence for this claim is primarily based on the response to a certain class of drugs called anti-depressants. Anti-depressants are stimulants. Calling them anti-depressants is like calling a flashlight an "anti-darkness tool." Aside from the fact that the role of serotonin and other synaptic transmitters is incompletely understood, and even granting the supposition that serotonin levels are reduced in depression, the question remains: Is this cause or effect? There is ample evidence that mental events can alter brain events. Why has this issue not been debated?
The death or loss of a loved one usually involves feelings of depression, called mourning. Is the depression due to low serotonin levels or the loss? An exciting sports event may elevate the catecholamine levels of the crowd. Is the excitement due to the elevated catecholamines or to the drama of the game? An "anti-psychotic" drug may inhibit a musician's ability to play the piano as it may inhibit a "schizophrenics" unconventional thought pattern. Does that necessarily mean that the playing or the thinking was caused by neurochemicals?
As a psychiatrist in private practice I get many calls from people who say they want treatment for their "biochemical imbalance." I ask them if they have had a chemical test that demonstrated the imbalance. The answer is always no because there is no test. I ask them whether they know which chemical is imbalanced. They typically have no idea. I ask them how they know they have a chemical imbalance. They tell me either their primary physician told them, or that their aunt was told she has it, or they saw it on television. So called "biochemical imbalances" are the only illnesses I know of which are spread by word of mouth. The claim that depression is a disease is propaganda promoted by psychiatry and the state and marketed by drug companies: the State-Science Alliance.
7. COERCIVE-MEDICAL PSYCHIATRY COLLUDES WITH DRUG COMPANIES AND THE INSURANCE INDUSTRY TO BOLSTER THE MEDICAL MODEL.
The medical model serves the interests of the pharmaceutical industry by proclaiming that mental illnesses are brain diseases which can be treated with drugs the pharmaceutical industry makes, markets, and sells. The pharmaceutical industry, in turn, subsidizes research, training, education and professional journals which support the medical model. Psychiatric theories are drug driven. Psychiatric therapies are drug driven. The pharmaceutical industry grants millions of dollars to psychiatrists for research on psychiatric drugs from which the industry profits. It's advertising supports psychiatric journals which publish the positive findings of this research. It contributes money for the training of psychiatric residents and the continuing education of psychiatrists at conferences and seminars which support the use of psychiatric drugs. Pharmaceutical companies spend between eight to thirteen thousand dollars per physician in this country on gifts, meals, speaking honoraria, consulting fees, luxurious travel to conferences, and free samples of their products. In most other circumstances, the default presumption would be that money buys influence. But psychiatrists deny that money from the pharmaceutical industry influences their thought and practices.
Managed care companies also support the use of the medical model in psychiatric practice and contribute to the medicalization of human problems. The mission of managed care is to manage payment for psychiatric services. This means that every patient seen by a psychiatrist who belongs to a managed care plan must have a psychiatric diagnosis. This encourages viewing the patient's life problems as medical illnesses. Often, managed care companies will pressure the practitioner to use psychiatric drugs which they believe save time and money. Psychotherapists who avoid the medical model and who avoid psychiatric drugs in favor of encouraging the patient to experience and learn from their life problems are penalized by being excluded from insurance reimbursement.
The pharmaceutical industry and the managed care industry are powerfully linked in support of the medical model. The state, which supports the use of the medical model because it justifies covert social control is also a partner in this meeting of minds. The NIMH, which supports the medical model, is the research arm of the state. The state maintains public psychiatric hospitals which hold involuntary patients. The medicare and medicaid systems follow the official DSM of psychiatric diagnoses. It is bad enough that psychiatry, the state, and private industry are working together to patronize the medical model. It is far worse for the future of our society that this complex relationship has not been fully examined.
8. THE MEDICAL MODEL CONTRIBUTES TO THE EROSION OF PERSONAL RESPONSIBILITY.
The medical model views certain human thinking, moods, and behavior as caused. If an act is caused then it cannot also be chosen or intended. In law and ethics, intention is the key to responsibility. If an act is intentional the actor is responsible. In law, if an act is not chosen or intended, the actor cannot be held responsible and is excused, except in cases of negligence which is the failure to form proper intent. Does it not follow, then, that the increasing tendency to view human behavior through the lenses of the medical model as caused results in a erosion of the public sense of personal responsibility?
If a person who commits violence has a history of psychiatric treatment, the act is often explained as a product of mental illness. If the act is claimed to be the product of mental illness the perpetrator may not be held responsible and can plead insanity in a criminal trial. This often results in excusing the obviously guilty, as in the case of John Hinckley who was found not guilty by reason of insanity for shooting President Reagan in front of millions of witnesses on national television. Ironically, the medical model is used not only to incarcerate the innocent but to excuse the guilty.
When someone commits suicide, the most common explanation is that he or she suffered from a clinical depression caused by a biochemical imbalance. Suicide is thus, reduced from a moral problem to a medical problem. The list of caused (and excused) thoughts, moods and behaviors is long and growing rapidly. It now includes anxiety, depression, suicide, homicide, anger and aggression, phobias, obsessions, compulsions, binge eating, anorexia, sexual deviance, sexual abstinence, addictions, and various forms of withdrawal, intrusiveness, garrulousness, shyness, excitement, sloth, insomnia, somnolence, hedonism, anhedonia, egotism, self hatred, rebellion and conformity. The more we explain the spectrum of thoughts, emotions and behavior with the medical model the greater the erosion of the public sense of personal responsibility. Ironically, the more the ethic of personal responsibility is eroded, the stronger the state must be to control deviant behavior. The erosion of the sense of responsibility, thus, leads inevitably to totalitarianism.
It this age of political absurdities, it is considered politically incorrect to suggest that people are responsible for their thoughts, feelings, and actions. Nevertheless, we are responsible for our states of mind and our moods as much as for our actions. If one observes human behavior with a degree of self reflection it will be perfectly obvious that it is always possible to exert a greater degree of control over one's thoughts, feelings and actions if only one makes an effort and persists with patience. Contrary to the implications of the medical model, our intentions, choices, and deeds can make a difference. This leads to the heretical suggestion that we are responsible for our anxiety, depression, and anger, as much as for our conduct. Were this not so psychotherapy would not be possible, self-improvement would not be possible, maturity and spiritual growth could never happen.
The medical model is contrary to the concept of human agency. It does not permit of choice and responsibility. If depression is a disease, as the medical model asserts, it must viewed as caused in spite of the contradictory fact that to heal it the person must take responsibility for his or her attitudes and life choices. To suggest that depression may be better viewed as an existential or a spiritual problem rather than as a biochemical imbalance, exposes the critic to vicious attacks by medical psychiatrists and their supporters, notably, NAMI. The fact that the antidote to hopelessness, the main mark of depression, is hope, a spiritual quality, is ignored, much to the detriment of those suffering from depression who are told they need prozac rather than courage and hope.
The ideology of the medical model also serves the social function of diverting our attention away from serious social and political problems which society does not want to confront. To regard anger, aggression, and violence as symptoms of brain disease distracts us from a criticism of the social conditions and values of our anomic, consumer society in which desires run rampant and violence is recreational. By diagnosing children who disturb the classroom or do not absorb its lessons as ADD, caused by a brain defect, we do not have to examine the culture of schools which cannot capture the imagination or attention of its students. In these ways and others, the medical model serves the status quo of prevailing social interests. It is a form of social neurosis, analogous to the neurotic symptoms of the individual, which avoid, repress, and deny the awareness of conflict while constructing convenient, self serving compromises. The repressed wish is for a greater degree of social control than provided by rule of law. The super-ego, which represents the social value of individual freedom under law, opposes. Clever ego finds the neurotic solution. Social control disguised as psychiatric diagnosis, involuntary hospitalization, and forced drugging.
9. MEDICAL PSYCHIATRY CONTRIBUTES TO THE REPRESSION AND CONSTRICTION OF HUMAN CONSCIOUSNESS
Psychiatry is a house divided against itself. On the one side, represented by the medical model and the state hospital, is the function of covert social control of individual behavior and the repression of dissent. On the other side, represented by the moral model and voluntary, humanistic psychotherapy is the function of liberating the individual from self-imposed suffering and raising consciousness. By repressing its critics, medical-coercive psychiatry deceives the nation. Knowingly or unknowingly psychiatry practices social control under the rubric of medical diagnosis and treatment. Some psychiatrists know it but won't admit it. Others refuse to even consider the idea. Santayana is famously quoted for reminding us that those who forget the past are doomed to repeat it. It may be equally pertinent that those who become fixated on the past are doomed to miss the present. Historically, every new tyranny has taken an unprecedented form that those fixated on tyrannies past failed to recognize. From the historical lessons of Hitler, Stalin, Mao and the like, we expect tyranny to emanate from the head of state. The new tyranny, however, is more subtle, disguised, and diffused. It is disguised in the garb of the psychiatric helper, and it is diffused through every community, institution, organization, and industry in this country. Psychiatry contributes to the confusion and constriction of public consciousness by disguising its social functions. The American public represents its political self to itself and to the rest of the world as the defender of individual freedom under law. At the same time, it gives silent assent to the coercion, confinement, and abuse of individuals in violation of rule of law.
Psychiatry contributes to the repression and constriction of consciousness by interpreting human behavior as caused by the brain thus blinding us to the world of mind and meaning. If human thoughts, feelings, and behavior can be reduced to brain and bodily functions then what happens to the person?What happens to choice and purpose? To ambition and hope? To tragedy and comedy? To clarity and love? To law and ethics? If our thoughts, feelings and actions are no more than neurochemical eruptions, then we have lost our humanity. Our narratives are meaningless. We have forsaken the possibility of knowing ourselves. And we have lost the capacity to heal ourselves.
10. FOR ALL THE ABOVE REASONS MEDICAL COERCIVE PSYCHIATRY CONTRIBUTES TO THE DECLINE OF CIVILIZATION AND THE INCREASE OF HUMAN SUFFERING.
How shall we evaluate the contributions of medical-coercive psychiatry to the development of civilization? To answer this question we must distinguish between the persons and the acts, the people who work in the "mental health field"who follow the medical model and the social functions and practices of medical psychiatry.
We should not fail to note and pay homage to those honest and decent practitioners who follow the medical model, but eschew coercion, and display wisdom, warmth, respect, and kindness to those who come to them for help. These personal qualities are precious, vital contributions to the development of civilization. Those who suffer mental, emotional, and spiritual pain the pain of life often suffer from frustrated yearnings to be loved and respected. The maturity, wisdom, warmth, respectfulness, and kindness of a helper can be therapeutic, not in a medical sense, but in a spiritual sense it can work miracles.
We should not hesitate to add, however, that working with the medical model is a handicap in developing the virtues vital to healing and social progress. It depersonalizes and dehumanizes both the therapist and the patient. In addition, we must remember that therapists and other workers in mental health have egos too. They can be selfish and self centered, defensive and aggressive, callous and disrespectful. When the dehumanizing medical model is used by insensitive, egotistical workers the result can be, and often is, the infliction of great suffering at the hands of medical-coercive psychiatry on people who are already suffering from the difficulties of life.
The practice of coercion through involuntary hospitalization and forced drugging is a serious issue which begs for debate. On the one hand, involuntary, coercive psychiatry serves society by providing a supplemental form of social control which, because it is covert or disguised, preserves our national pride by giving us the appearance of being a nation of free individuals under law. On the other hand, when the covert is exposed it can be seen to violate the honored values on which this nation was founded. The question of the contribution of medical coercive psychiatry to civilization is a question of what balance between social order and individual freedom best serves human happiness? What balance of honesty and illusion? From the events of the past century, it is evident that totalitarian societies, which provide a high degree of social order, as well as free market capitalism, which provides a maximum of individual freedom, are both obsolete extremes. Nations, like ours, which began as free market polities, and nations like the Soviet Union, which experimented with state communism, both failed and moved towards each other. As western nations have become more socialist and closed over the past fifty years, communism has collapsed into a chaotic free market. Governments everywhere now seek to balance the mandate for social order with the mandate for individual freedom.
The fact that coercive-medical psychiatry disguises social control as medical treatment is a serious impediment to the public debate on the desirable balance between social order and individual freedom. The handicap is aggravated by psychiatry's repression of its critics. If the question whether psychiatry functions as a supplementary instrument of social control cannot be debated, then how can the question of the optimal balance between social order and individual freedom be intelligently debated? The conclusion cannot be escaped that medical-coercive psychiatry's repression of its critics does not serve the advancement of civilization because it results in the obfuscation of debate on serious ethical, social and political issues.
Whatever one's views on the desirable balance of social order and individual freedom may be, the practice of psychiatric coercion and abuse cannot possibly contribute to the development of a humane society. Depriving individuals of freedom without trial by means of involuntary confinement in a psychiatric hospital is an abuse. It violates the basic principle of individual freedom under law. When people are involuntarily confined and their keepers are undereducated and underpaid cruelty and abuse are bound to result. The voices of the oppressed and abused are rising in numbers and volume in opposition to medical-coercive psychiatry and the society which permits, even sanctions its practices.
If mental illness is a social construct rather than a bodily illness, then questions naturally arise about the use psychiatric drugs. What does it mean to prescribe a drug for a metaphorical illness? When is it proper for an individual to ingest mind altering substances? These questions bear on our national policy on drugs. If psychiatric drugs are not given to treat a genuine medical illness but to alter thought, mood and behavior, then what is the difference between legal and illegal drug use? Surprisingly, there is no consensual understanding of why people self administer psychoactive drugs. It is a mystery to the experts who rely on the medical-deterministic model. Indeed, it is a mystery to them because they rely on it. They cite early or current deprivations, peer pressure, abnormal brain chemistry, genetic predisposition, mental illness and the like as causes. Many believe that people take illegal drugs to medicate themselves for their (presumed) mental illness. But what does this explain? It is circular and illogical. It implies that if a person self administers a drug, it must be to treat a mental illness. But the taking of the drug is itself also an illness -- addiction. On the other hand, psychiatrists can legally force people to take mind and mood altering drugs for their alleged mental illness in which case the drug taking is not considered an addiction but a 'treatment." If the patient becomes addicted to the prescribed medication, the addiction is called a side effect, rather than an iatrogenic illness. The logic is baffling but unexamined and unchallenged.
To understand the deed we must look to the motive. The logic may be baffling but the motive is clear. Language is a tool, a socially useful tool. The language of the medical deterministic model facilitates social control but impedes understanding. The moral model impedes social control but facilitates understanding. The medical deterministic model cannot explain why people use drugs because the explanation of why calls for a motive, a purpose, and a context. From the moral point of view, from the point of view of the person as agent, the reason people take mind and mood altering drugs is simple, too simple for scientists to accept. People take these drugs because, in some way, they feel bad, are unhappy or dissatisfied and they want to feel good. And the drug helps them to feel good enough to suffer the risks. All one need do to confirm this as fact is to ask people. Our national failure to understand why people use drugs, in spite of a decades of war against drug users, is a symptom of the endemic repression of critical thought. We need only reframe the language of the drug discourse to understand the rationale for using mind altering drugs, legal and illegal. The majority of these drugs are either uppers, downers, pleasure enhancers, or psychedelics. If you feel down you take an upper; if you are anxious you take a downer; if you want to sleep you take a downer; if you want to stay awake you take an upper; if you want to feel sensuous you take pleasure enhancer like ecstacy or cocaine; if you are bored or curious and adventuresome you take psychedelics. The psychiatric rationale is similar, only the language differs: if the person is depressed (down) give them anti-depressants (upper); if the person is anxious or manic (up) give them an anxiolytic or a mood regulator (downers). If they suffer from their thoughts (thought disorder) give them anti-psychotics (thought suppressors.) Pleasure enhancers and psychedelics are regarded as dangerous and are prohibited.
The primary difference between the two groups of drugs is that psychiatric drugs are manufactured by pharmaceutical companies, are legal, and are prescribed by physicians, often against the patient's will. Street drugs, are usually natural substances, are illegal, and are consumed voluntarily. There are, thus, two classes of psychotropic (mentally active) drug users. One portion of the population is advised or forced to take psychiatric drugs which have similar aims and effects as the street drugs taken voluntarily by another portion of the population who are hunted, prosecuted and imprisoned for it. The people who take drugs voluntarily are regarded by medical model adherents as suffering from the disease of addiction while the people upon whom the drugs are forced are described as getting well as the result of their treatment. If we examine this situation more carefully, the conclusion is inescapable that the defining issue is social control. Psychiatric drugs are used to control people whose thoughts, feelings, or behaviors are judged out of control. The voluntary use of street drugs for mood regulation and personal pleasure is prohibited. Arguably, the social motive of drug prohibition is to keep people from dropping out of the work force or engaging in unconventional, heretical, treasonous or otherwise disturbing behavior. Thus, psychiatric drugs and drug prohibition have the same social function, to keep people in line.
One may reasonably argue that the use of any psychoactive drug is contrary to the welfare of civilization. On the other hand, every known culture has tolerated the use of intoxicants and many have endorsed the use of psychedelic sacraments. The medical model sheds no light on the question of why human beings from ancient times to the present choose to modify their mental state with natural substances. And it sheds no light on why increasing numbers of people who have been prescribed psychiatric drugs are desperately trying to withdraw from them. Something seems wrong here, and we aren't clear on what it is because debate is suppressed.
Does it contribute to the advancement of civilization that increasing numbers of people are acquiring psychiatric diagnoses as the result of innocently seeking guidance for their troubles and pain? Managed care and insurance companies require every person they reimburse for psychotherapy to be given a serious psychiatric diagnosis. Psychiatric diagnoses are forced on anyone who seeks help from a mental health professional paid for by a third party. And psychiatrists are paid to supply it. A person's diagnosis becomes part of the national data base. People are excluded from public office, from jobs, from the military, from the priesthood, from school, and even from their children based on psychiatric diagnoses acquired as a consequence of contact with psychiatry. This information is not privileged because the state, the employer, and the insurance company require the individual to give consent for its release as a condition of their approval. The unintended and unexpected result of the dominance of the medical model is the medicalization of social control and personnel management and the obfuscation of our understanding of human behavior.
Is civilization served by the deterministic view of human behavior and the designation of suffering and deviance as illness? The causal-deterministic view is amoral. The foundation of civilization is ethics, morality, and law. If behavior is viewed as caused by the brain, then the citizen, who is motivated by the desire for happiness to be virtuous and law abiding, disappears. Causes may explain the behavior of creatures but not of citizens. Behavior which is caused cannot also be intentional. If it is not intentional, it cannot be ethical, virtuous or law abiding. "Cause" and "intention" belong to different logical levels of discourse. If behavior is caused, the individual cannot be held responsible. The language of science and the medical model exclude the concept of personal responsibility. By discounting personal responsibility for thoughts, feelings, and actions, medical model psychiatry contributes to the erosion of the awareness of and the respect for individual responsibility, which is a precondition for individual freedom under law. Can anyone honestly say that this serves the advancement of civilization?
11. A CALL FOR DEBATE ON THE TEN POINTS
It is fitting to conclude these points with a simple plea to open up the intellectual milieu in this country. A blanket of fear and cynicism has suffocated the open exchange of ideas. Many intellectuals feel it. Few talk about it.
A critique of medical coercive psychiatry raises a host of moral, ethical, social, economic and political issues. The repression of critics of the medical model mutes the debate on these important issues. If the debate were opened many points of view would be heard. No one fully appreciates the scope of the problems raised. No one has the answers. We cannot even imagine the scope or the possible answers until the debate is opened, the issues are evaluated, and proposals are considered.
The repression of critics of the medical model is the tip of the iceberg. Freud wisely noted that if we leave one skeleton in the closet unexamined, then all the skeletons will hide there. The shallowness of debate in our political campaigns is a symptom of the constriction of public consciousness and discourse. The danger exists that by crippling open discourse we may blindly lead ourselves down the road to the invisible totalitarianism of the therapeutic state where coercion is disguised as help, condemnation is couched in diagnosis, social control poses as health management, responsibility evaporates into helplessness, and moral consciousness is replaced by a mechanistic view of a world ruled by the established plutocracy.
Debate is a double edged sword. On the one hand, it can threaten the establishment, which is why it is suppressed. Debate can expose flaws and injustices in the social fabric which may awaken a call for changes unfavorable to prevailing social interests. On the other hand, debate casts the light of awareness on the dark shadows of hypocrisy, injustice, insensitivity and cruelty. Debate on the ten points may stimulate the development of a society and a psychiatry which is voluntary, humane, compassionate and also respectful of scientific knowledge without reducing humans to biochemical machines.
Ron Leifer, M.D.
215 North Cayuga Street
Ithaca, New York 14850
Tel. (607) 272-7334
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