Because of psychiatry’s power to coerce, society gives psychiatric theories a free pass.
Both Michel Foucault and Thomas Szasz dated the beginnings of a distinct European institutional response to madness to the late 1500s-early 1600s. For Foucault it started in France with the creation of the public “hôpital général” for the poor insane. For Szasz it began in England with for-profit madhouses where upper class families shut away inconvenient relatives.
Despite their different ideas on the beginnings of anything resembling a mental health system, both authors agreed that it was characterized by the coercive incarceration of a specially labeled group.
Since its origins, the psychiatric system has coerced its lunatics and madmen and madwomen in madhouses, its inmates and patients in mental hospitals, its consumers and users in the community. (Yes, for a brief moment in the 1800s, British asylum superintendent John Connolly started a movement to ban all physical restraints within his establishment, but it didn’t last long.) The coercive element of psychiatry has persisted despite all changes in treatments, despite all changes in places for treatments. This is the invariant part of psychiatry.
My colleagues Tomi Gomory and Stuart Kirk and I argue in Mad Science: Psychiatric Coercion, Diagnosis, and Drugs that the only constant in psychiatry has been coercion. We also argue that no other treatment can compete with coercion — nothing. According to some psychiatric discourse and doctrine, for those who “need treatment the most,” only coercion makes the administration of a treatment possible. Not to mention that coercion itself has often been called a treatment.
I venture to suggest that most practicing psychiatrists, if pressed, would choose to replace or discard any existing treatment or intervention save one: the power to impose a treatment or intervention.
It seems to me that this coercive function is what society and most people actually appreciate most about psychiatry. That families and other people in crisis can call upon the police to restrain someone acting in a seemingly incomprehensible or dangerous way and have that person taken by force to a place run by psychiatrists is truly where psychiatry as a profession distinguishes itself. It’s the distinguishing service it offers or function it meets as a helping profession (aside, today, for the prescription of psychoactives).
(I hasten to add here that coercion is probably necessary for the survival of a social group, as we discuss in Mad Science, following the insights of author Morse Peckham. The questions are when is it used in a disagreement between parties, and by whom.)
In my view, society’s appreciation — its gratitude — for psychiatric coercion, for psychiatry’s extra- and intra-legal police function, has a largely unappreciated consequence: it supports the so-called knowledge base of that discipline.
That means that without the shock and awe of a coercive medical discipline, the flimsy theories and continually-refuted hypotheses of physiological defects as causes of distress and misbehavior would have to truly fend off on their own in the marketplace of ideas about what ails people, what makes them tick, and how to help them overcome their problems. Psychiatric theories would have to compete squarely against other theories and schools of thought, and it’s doubtful to me that they could do so successfully.
Society’s appreciation for psychiatric coercion subtly, but radically, imbalances the playing field. Because of psychiatric coercion, society gives psychiatric theories a free pass. These theories never need to pass any rigorously devised tests (as we expect other important scientific theories to pass), they only need to be asserted.
Here I am turning on its head the often-expressed idea that society supports psychiatric interventions because people believe that psychiatric theories are valid. And since “evidence” fails to support these theories and the hypotheses derived from them, so the belief goes, one therefore needs to debunk the theories by critical analysis of the evidence and the continual stream of findings.
But it’s the opposite in my view. The knowledge is not supporting the power. The power to coerce is what excuses the lack of valid knowledge.
I’m not discounting the influence of the biomedical-industrial complex, like a fish might discount water. But after decades of engaging in critical analysis of the psychiatric and other evidence, I conclude that there has never been good evidence to support psychiatric theories. Psychiatry has never ever needed scientific evidence to spread its ideas and practices, and possibly never will. Indeed, its top experts can state today that they have found no biomarkers of expertly diagnosed mental disorders and falsely promised the American public for decades that biomarkers were just around the corner.
Let’s face it: No one cares that psychiatric research of the past 50 years failed to turn up one finding of use for a scientific clinical psychiatry. The business of psychiatry continues with barely a pause.
In order to prosper, all psychiatry (and, increasingly, other mental health professions whose formerly distinctive training and theories are slowly blurring into one psychiatrized whole) needs is the social support for its coercive practices.
If so, removing formal coercion from the helping enterprise should be an investment that will yield the greatest actual return in terms of debunking the “psychiatric knowledge base.” Limiting mental health professionals’ option to coerce their patients and clients will open up the “mental health system” to a multiplicity of choices and interventions based on diverse schools of thought.
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Note: Adapted from a talk given at Mad in America’s International Film Festival in Arlington, VA, October 12, 2014.
Beyond Health and Illness: David Cohen, a researcher, author, professor of social welfare at UCLA and practicing clinical social worker for over 30 years, writes about social and cultural constructions of reality.