Nikolas Rose is a professor of Sociology in the Department of Global Health and Social Medicine at King’s College London. His work explores how concepts in psychiatry and neuroscience transform how we think about ourselves and govern our societies.
Initially training as a biologist, Rose found his subjects unruly: “My pigeons would not peck their keys, and my rats would not run their mazes. They preferred to starve to death.” He moved on to study psychology and sociology and has become one of the most influential figures in the social sciences as well as a formidable critic of mainstream psychiatric practice.
A prolific writer, Rose has over fifteen books to his name, including, most recently, Neuro with Joelle Abi-Rached (2013) and Our Psychiatric Future (2018), addressing the most pressing controversies in the fields of neuroscience and psychiatry. He is also a former Managing Editor of Economy and Society and Joint Editor-in-Chief of the interdisciplinary journal, BioSocieties.
Throughout his work, Rose emphasizes that one must look beyond origins, or “why something happened,” and focus instead on the conditions under which ideas and practices emerge. The answers may not be comforting or straightforward, but they can help us to avoid band-aid solutions to complex problems.
Rose builds on the work of philosopher Michel Foucault to reveal how concepts in psychiatry and psychology go beyond explanation to construct and construe how we experience ourselves and our world. Consistent with Foucault’s oft-quoted adage, “My point is not that everything is bad, but that everything is dangerous,” Rose’s work avoids simplistic explanations of why and how the mental health fields go awry and instead examines how injustices can happen without unjust people. In this way, his work often transcends critique and imagines new possibilities and ways of thinking about “mental health,” “normality,” “brains and minds,” and, ultimately, the selves we might yet become.
The transcript below has been edited for length and clarity. Listen to the audio of the interview here.
Ayurdhi Dhar: In your work, you point out that even though psychiatry and psychology (or the psy-disciplines) appear to be objective, they are actually built on societies’ “styles of thinking”—ways of thinking that no one questions. For example, in psychology, there is an underlying idea that things that happen outside of us, reach inside us. This assumption leads to research that attempts to locate trauma in brain scans and to theories about unconscious feelings or dysfunctional thoughts. How did you come to question these underlying assumptions? What led you into this area of inquiry?
Nikolas Rose: I went to Sussex University in the 1960s to read biology. We worked on fruit flies, which were the model animal for our Professor, the geneticist John Maynard Smith. This was a time when students across Europe were involved in protests questioning their universities and the associated political order. Despite my fascination with biology, and the craftwork of the laboratory, I did not think that the truth of those issues was to be found by studying fruit flies. I moved to study animal behavior, and then to human psychology
I found human psychology was a peculiar discipline. In conventional history, psychology has a long past but a short history: on the one hand it goes back to the Greeks, but on the other hand, around the end of the 19th century, psychology becomes a science when it embraced laboratory experimentation. I looked at this story, and it proved not to be the case.
One telling example was the concept of intelligence. When I started my own studies of these issues, there was a hotly contested debate about intelligence, so I started to study the history of this concept. In the late nineteenth century, the French psychologist Alfred Binet had been trying to understand human intelligence for many years. He got absolutely nowhere and felt intelligence was so difficult to pin down that one really could not have a usable concept of intelligence.
However, in the context of changes in the French schooling system, and the introduction of universal schooling, the ministry asked Binet to find a test to show which children would do well in ordinary schools and which children needed special schools. Binet invented a test aiming to identify those children who would need special education, and that became the first IQ test and the basis of what we think of as intelligence.
This is an example that the history of modern psychology does not begin in the laboratory, in philosophy, in speculative thinking, etc. It begins with very practical questions. It is not that psychology had great scientific knowledge of the mind that it was able to apply to practical questions. Rather, it seemed to be able to do a job in the practical world, and then it turned into a respectable scientific discipline.
My PhD thesis and first book The Psychological Complex showed how the psy-disciplines were not just ways of reflecting upon our world but crucial in the construction of key institutions, such as managing armies, reluctant factory workers, maladjusted children, etc. In all these practical places—the courtroom, armies, the schoolroom —the psy-disciplines were born. These practical ways of managing our lives now shape our ways of thinking in fundamental ways. We think, “Of course, some children are more intelligent than others. Of course, some children develop faster than others. Of course, some kids are more inclined to delinquent behavior than others.”
Dhar: Foucault’s work highlights that it was not simply that doctors had expert psychiatric knowledge, but instead, their stature created expertise. Similarly, it was not that asylums were healing, but because people were put in these places, they came to be seen as places of treatment.
Rose: Foucault points out that doctors gained control of the asylum not because they had great expert knowledge about madness, but because they were considered to be wise people in light of a series of scandals around the commercialization of asylums and their terrible conditions. Europe and North America began to regulate how people got into asylums and decided it was obviously through the doctors because they considered them wise trustworthy people.
Foucault also helped us question the whole idea of “origins.” Birth of the Clinic showed that the doctor’s “clinical gaze” emerges as a consequence of a whole series of contingent things that happened at that time, such as changes in French laws of assistance. When people were sick and needed free healthcare, they had to go into hospitals.
Changes in ideas of citizenship: if you went into hospital your name is written down, you now have a case history, and people observe you as your condition develops day after day, week after week. This made it appear that there was a general pattern of progression of a disorder.
When all these contingent developments came together, they created the conditions for this clinical gaze. The general lesson is that you should never look for origins, never ask ‘why’, but instead ask, “how did this occur?”
Dhar: Much of your work has to do with the writings of Michel Foucault. What was it about his work that resonated with you?
Rose: Foucault provided me with some conceptual tools to make sense of the questions I was interested in. He says somewhere, “History is not so much for knowing, as for cutting”—cutting into questions and making them intelligible.
The emergence of the psy-disciplines is about the emergence of a certain “style of thought.” Thought is not peripheral to history: systems of thought make things possible to think, to understand, and to do.
Foucault’s Madness and Civilization had a profound effect on me because it was not really a history of psychiatry; it was a prehistory showing under what conditions something like psychiatry could exist —with its asylums, its doctors, its diagnostic classifications, etc.
As a student, I entered the world of psychiatry, going to mental hospitals, seeing patients that were being demonstrated by the doctors. I wondered how some of the patients’ thoughts that seemed quite normal to me were seen as psychiatric symptoms.
I saw some treatments that were used before the huge rise of psychiatric drugs, for example, aversion therapy, which was used for homosexual men. Electrodes were attached to their genitals, and when they felt aroused after being shown stimulating images, they were whacked with electric shocks.
This was absolutely horrific, and yet the people doing it seemed to be decent, humane scientists, not concentration camp guards. How could they think and do these things and believe that it was not only legitimate but scientifically justified? That it was objective and a form of therapy grounded in scientific research?
These things made me question how these ‘styles of thought’ have come into existence and how they produce certain types of professionals—the little experts of ‘psy’ who we now see in our schools, armies, hospitals, prisons—little experts of psy everywhere.
Dhar: That’s the importance of knowing history; these methods that seem so horrific right now, were once shown to be effective in studies.
Rose: Yes. If one looks at the debates in psychiatry around World War II, there was excitement about physical psychiatry—electroconvulsive therapy, lobotomies. It seemed we had techniques that worked and that we could get into the brain and alter it. These views and hopes were shared widely among psychiatrists. The question today is: in 50 years, are we going to think the same about psycho-pharmaceuticals?
In fact, I think we are at a turning point with the drugs. More and more people are beginning to recognize that they don’t work very well and that the so-called side effects are just as damaging as those of the older tardive dyskinesia causing drugs. Brain research shows that some of the medium to long-term consequences of disorders are the consequences of taking the drugs chronically.
Schizophrenia was once thought of as a chronic degenerative condition until it became clear that degeneration was a consequence of institutionalization. Are we going to look back in 50 years and think that our obsession with these small molecules is just as bizarre as those earlier treatments? I think the jury is out on that.
We are in a paradoxical situation. More people worldwide are taking psychopharmaceuticals, in particular the SSRIs and SNRIs, yet at the same time, research is beginning to question whether they are effective and starting to reveal their adverse effects.
These drugs are given by GPs (general physicians) who think that the drugs cannot do any harm. They say, “I used to give my patients tranquilizers, Valium, etc. They were addictive. At least these drugs can’t do any harm.” We are beginning to see that this story is problematic.
Dhar: Research now suggests that antidepressants have long-lasting and severe withdrawal effects and that antipsychotics may lead to psychotic symptoms. What puzzles me is that, despite all this research, the neuro-biological position and the biomedical paradigm have not lost any vigor or power. What gives it this power?
Rose: If we put aside, for the moment, the general question of whether the drugs ‘work’, some of these drugs can, for some people, provide some short-term relief, which might enable a person to step back from an overwhelming crisis, in order to address the real issues. But the problem with all these drugs is their chronic administration and increasingly higher dosage with the assumption that if a drug stops working, add another one. So, polypharmacy is the norm.
Instead of these drugs being treated as something that, for unknown reasons, produce some short-term relief, we believe first that we know how they act on the pathway of the disorder—which has never, ever been demonstrated. Second, we believe that their effects are beneficial, so if people start getting adverse effects when they come off the drug, it is attributed to the disorder and not the consequences of withdrawal.
The tragedy is that since the 1960s, this particular paradigm has hegemonized psychiatric reason—all psychiatric disorders are about the receptors, and treatments must act on anomalies in the receptors. And these drugs work on the receptors; if it’s not dopamine or serotonin, then perhaps it’s glutamate or something else, but it’s bound to be in the receptors!
I worked with the European Commission-funded Human Brain Project, and everything that we know about the human and primate brain tells us that these are hugely distributed redundant systems —You don’t just touch one bit, and that’s it. The brain is dynamic. If you change one thing and everything changes!
We are in a very primitive state with brain interventions. As far as the drugs are concerned, in the UK at least, there is a beginning of questioning the current paradigm. There’s interest in alternative drugs such as the old psychedelics, such as LSD, which, in the history of psychopharmaceuticals, were believed to produce effects that were similar to some psychiatric disorders such as schizophrenia. Today some argue that low dosages of these drugs have considerable therapeutic efficacy. But this approach is treated in a rather hostile fashion by our government and regulators.
Dhar: You write about psychiatry’s ever-expanding diagnostic boundaries and how it has turned general discontents of life into diseases. Other authors have blamed big pharma, neoliberal capitalism, etc. but you say it is more than that. Can you elaborate?
Rose: Let me take a very contemporary example. We are in the midst of a pandemic, and newspapers are filled with stories about its mental health consequences and claims like, “There is a mental health tsunami coming, we need more psychiatrists and better access to their services!”
Of course, people are anxious as their lives are turned upside down, especially those who are already living in conditions of adversity and cannot stay off work, self-isolate, and so forth. It is understandable that people are worried and scared, but now this language of the emotions is not enough. Somehow all of this is recoded as problems of mental health.
It is now incredibly difficult to say that perhaps it is better to use the language of the emotions, that people are just fed up and miserable seeing their loved ones die. These are normal experiences and not symptoms of mental problems requiring individualized interventions by an army of psychologists.
We should step back to think about why the people most deeply affected are people from black and minority ethnic groups, living in the worst possible forms of housing, overcrowded places, who are financially vulnerable, etc. We could think of intervening on those things, but no, the language of mental health has become a way of coding our everyday discontents.
It was in the period after the Second World War that we began to see the argument that mental disorders were not confined to a small number of people in asylums but were very widespread in the population—that probably all people are affected by problematic mental health at some point in our lives and that these problems need recognition and treatment by psychiatrists.
The famous British social psychiatrist Aubrey Lewis said that there is no other profession that, when given a problem and asked if they can help, is so likely to say ‘Yes.’ You give psychiatrists problems of naughty children, reluctant workers, homeless people, and they seldom say, “that’s not our problem,” but, “yes, we can say something about that.”
They have embraced all these problems; the boundaries have spread and spread and we don’t know where to limit who is “a suitable case for treatment.” We are all pre-symptomatic and at risk of something or the other. In physical medicine, the mantra is the earlier that you detect and treat the better, so why not in psychiatry? Earlier intervention for kids, for first-episode psychosis—this is psychiatry thinking of itself as a public health vocation.
Then psychologists look outside Euro-America and think those populations are deprived access to these interventions, and we have the Movement for Global Mental Health. Psychiatrists believe that they know, they have a style of thought that has the potential to know, even if it does not fully know now, that this is the way of thinking and knowing.
They think they have treatments that work and that, even if they do not work very well, they’re on the right path to working. Because they think they know how to know, and they know how to treat you, even if neither of those is perfect at the moment, they feel that people should not be deprived of them because of the accident of their place of birth.
For me, unlike many critiques of psychiatry, I think it is important to understand why psychiatrists think the way they do and to understand the many internal arguments. We must collaborate with psychiatrists from the point of view of critical friendship to understand how they think, to question them, and the weaknesses in their evidence and arrive at alternatives. I find this more effective in helping transform psychiatry and what it does.
Dhar: Service-user groups are now thankfully beginning to be included in decisions about mental health. But we know patient advocacy groups are often taken over by pharmaceutical company interests. Do you think service-user or survivor groups, now that they are included in policy-making, will get co-opted like patient advocacy groups?
Rose: Foucault said that the rise of psychiatry cast off into the wilderness all those stammering half-formed phrases with which the dialogue between reason and unreason used to happen and the history of psychiatry is the history of that silence.
One of the changes is that the silence has been broken. Any report on the future of psychiatry, such as the Lancet commissions reports, cannot be written without reference to the lived experience of people with mental distress. Ideally involving one or two of them as authors, although exactly what power they have in shaping that narrative is uncertain.
The involvement of the patient’s voice is the most significant thing to happen in psychiatry since the invention of psychopharmaceuticals, and it has the potential to transform psychiatry, to make psychiatry answer to the demand that if it claims to be for the benefit of the people it serves, at the least it should listen to their voices —to our voices —as to what we think is good for us.
I think this is a challenge to the power of psychiatrists—not just to listen to voices as symptoms. But there is a multitude of problems—survivors being used to give legitimacy to status quo practices, the survivor being seen as just telling their story, which then has to be reframed in psychiatric terms, articulate survivors are thought to be non-representative of the others, etc.
Survivors often are not given the power to shape the research strategy, research questions, research interpretation. People in user and survivor movement in the UK are very aware of these challenges. There is a danger of co-option, but co-option is not the inevitable destiny. We are in the middle of something, and groups like Mad in America who foster survivors’ voices and survivor’s stories play a crucial role.
We must recognize that people who have experienced mental distress and the mental health care system offers not only lived experience but a different kind of knowledge, no less valid. This knowledge is worked out in collaboration with others; it is open to challenges, able to give evidence, open to question, but a knowledge of what it is like to live with these conditions and to live with the therapies for these conditions.
Like psychiatry itself, user and survivor movements are riven with conflict. For example, there are questions about whether they are dominated by the global North? Are there autonomous knowledges in the global South? Is there some virtue in traditional methods of healing? How should one relate to developments such as the Convention on the Rights of Persons with Disabilities and the idea of ‘psychosocial disabilities’? The conflicts are not a problem; contest and argument are how things develop.
Dhar: You have written about “risk-thinking.” We live in a time where measuring and identifying risks is embedded in our culture. For example, we use genetic tests to find out susceptibility and the many assessments in schools and offices. How does “risk thinking” and the psy-disciplines work together to influence how we feel about ourselves?
Rose: Canadian philosopher Ian Hacking talks about risk thinking as bringing the future into the present. This makes us feel obliged to think about these futures in the present. Then we feel obliged to do things in the present to influence this future. Imagined futures are always present to us, and so it appears irresponsible not to do something about them.
If you are told that eating hamburgers twice a day will increase your chances of having a heart attack, then it seems irresponsible to keep doing it, even if we live in an obesogenic (obesity causing) environment where hamburgers are cheap and so we can afford to feed our kids. This inducing of a sense of personal responsibility for our bodily futures has become very widespread. our responsibility is not about living a virtuous life or doing good in the world, but about managing our corporeal existence, our weight, diet, etc. in the present in the name of the future.
This is coupled with a series of technologies that claim to bring the future into the present and make it calculable to us—the scans, the genetic tests, etc. While in some cases, such as cancer, there is evidence that one can do something in the present to change the future, in others this is not so clear.
As well as these highly ethical issues, there are technical questions. Take, for example, mammograms. How many people do you need to screen to save one life? What are the consequences of the high numbers of false positives and negatives; what about the fact that many early signs that might be used to warrant early intervention would never develop into tumors. Similarly, for prostate cancer in men, there is an antigen test to pre-identify people at risk. Is the knowledge of the future and the intervention going to cause more harm than good? In the case of the prostate test, many men had surgical interventions that had major consequences for them, but most men who have prostate cancer will die with prostate cancer, not from prostate cancer.
For psychiatry, the questions become even more difficult because the markers cannot be found, and effective interventions don’t exist. You are left with the statement that someone is a high risk without specificity about what that risk indicator is, and without any interventions that are going to mitigate that risk. But what you do get is the stigma and other consequences to the individual themselves and from others thinking that someone is at risk of developing a mental disorder.
With the Psychosis Risk Syndrome argument, the vast majority of people who have one of what appears to be a psychotic episode, never go on to develop future psychosis. Even if we knew exactly what we were talking about, evidence suggests that it is a very bad move to start making those early diagnoses, because it carries all the downsides of being identified as a person at risk—thinking of yourself as a person at risk, your parents and your teachers watching for symptoms—leading to the looping effect.
‘Risk thinking’ in psychiatry leads to the idea that a diagnosed person is likely to be risky towards others, and hence is subject to all sorts of risk assessment procedures simply because they have a psychiatric condition, this can lead to serious injustices. People can be subject to long periods of involuntary detention or supervision based on rudimentary and questionable risk assessments.
There is a kind of industry of risk assessment with financial benefits for psychiatrists who are brought in as consultants. When I gave a paper on this to a psychiatric organization that shall remain nameless, I said we should stop being blackmailed by the government to make these risk assessments because we are not good at it. All the psychiatrists there knew that they were very bad at making risk assessments, but giving up the business of risk assessment meant giving up on the second car, the fees for the private schooling for their child, etc.
Of course, it is not just or mainly psychiatrists—there is a huge biotech industry seeking to promote and profit from the invention of risk assessment devices despite the many problems of indicators of risk.
Dhar: You write about psychiatry’s singular focus on the brain and how it affects how we understand ourselves. Could you talk about this concept of ‘somatic individuality’ and how the psy-disciplines alter our sense of ourselves?
Rose: Somatic individuality is the sense that our identity depends crucially on our body—its shape, its size, its fitness, its capacity, etc. So, managing our bodily existence now becomes the most virtuous thing that we can do. The slogan ‘our bodies, ourselves’ has taken on a new meaning—our selves have become very tied up with our bodies.
Brain research has made fantastic progress over the last 30 years. We know more about human brains than ever before, but the more we know, the more we realize we don’t know and understand. We understand very small-scale molecular events within the brain, but we do not how those play out across the huge complexities of multiple synapses and cortical pathways.
We do not know clearly how brains are located in the body because they are often studied in an isolated fashion in laboratories or animals like mice. In so many studies, brains are not embodied, and the bodies are not placed in an environment, and the environment is not placed in time and space. Until we can begin to think about that, we will not fully get how brains work.
There was a reductionist hope that we would start by understanding the smallest building blocks of the brain, the molecules, and synapses, and gradually work our way up to the brains of simple creatures and then humans. Going up the scale has proven to be impossible to do, let alone placing all that stuff in space and time.
We should not cast out neurobiology, but we should start with the human brain as it is, as it develops in an organism from conception onwards, always in interaction with its environment. Everything about the brain is shaped by and involved in making actions in that environment possible.
This is actually a more scientifically accurate way of researching the brain. We have come to the end of these reductionist approaches because they proved unable to answer the questions which they set themselves, and they unable to understand how you and I can be doing the weird things that we’re doing now—talking, thinking, communicating, etc.
Thus, I support the development of a new relationship between the neuro-biological and the social sciences in which we work together to understand how our social and political environment shapes who we are. To put it the other way, if people are experiencing mental distress, how can we understand that in terms of their relationship to their bodies, brains, and human existence in those environments? How can we intervene in their relationship with those environments and not just molecular structures? I think about these things in a biopsychosocial way,
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