For those who have not read my original article, it traces the social functions of the mental health system and its relationship to Capitalism. It suggests the principal functions of this system consist of the public provision of care for those who cannot care for themselves, and the control of socially disruptive behaviour on behalf of society. It looks at how these functions relate to the capitalist organisation of work and also covers the way that medicalising feelings and behaviour contributes to the hegemony of the capitalist system. I conclude:
‘The concept of mental illness has a strategic role in modern societies, therefore, enabling certain contentious social activities by obscuring their political nature, and diverting attention from the failings of the underlying economic system’
Thank you for responding to my article. You make some excellent points, and it is exciting to have a debate of this sort. I will respond to what I see as the three main issues you raise: the scientific and the political; medicalisation and coercion.
By the way, there is no unified UK ‘critical psychiatry’ position. I am giving my own specific view on the nature and problems of psychiatry, and many in the UK critical psychiatry movement would view the issues differently, particularly in relation to the views of Thomas Szasz, for example.
Politics and science
On the issue of politics and science, I was not trying to say that we should replace a political system with a scientific one- almost quite the opposite. I am saying we should replace the current pseudo-scientific mental health system, which is a system that claims to be based on science but is not, with a transparently political system, one that acknowledges that it is political and can therefore be subjected to democratic control and scrutiny.
I agree that any social system, whether it is general medicine, laboratory science or whatever is necessarily political in some sense. But although all social systems may be political, the activity of doing science aims, at least, to be apolitical or objective. Therefore it is difficult to question the content of scientific knowledge, even if you can question and debate the social system that produces it, the priorities it follows etc. If we acknowledge that mental disorder is not a question of what is going on in someone’s brain, but a question of what behaviour society deems to be normal and acceptable, then it is quite clear that how we define and respond to this needs wide public debate.
Calling something scientific has the result of closing off debate on it- just witness how often critics of psychiatry are accused of being ‘subjective’ or unscientific.
I am also not suggesting that simply doing away with the medical view of mental disorder will make everything rosy. I agree that a non-medical narrative and system would not necessarily be more responsive to people’s needs or more humane. It could well be more punitive. This is why it needs democratic control and scrutiny. Doing away with medicalisation opens up a difficult debate about controversial issues – and this is one of the reasons why, in my view, medicalisation has survived for so long.
You also mention how some individuals welcome a medical understanding of their problems, how they may embrace the chemical imbalance model, for example. You describe how this may enable people to avoid unbearable emotional pain. I would add that the assumptions behind the medical view can bring relief by exonerating people from blame or shame for their behaviour, sometimes enabling people to become unstuck and move on. Forcing people to see their problems differently is not often helpful, I agree. However, the medical paradigm has many drawbacks too. It can disempower people and persuade them they are biologically flawed and permanently impaired. By offering a false hope of a quick biological fix, it can set people off on a lifetime of chronic dependency and misery that might have been avoided.
My article was looking at the issues from the point of view of society, however, not of the individual, and at a social level, regarding people’s experiential suffering as a disease rooted in their brains lets society off the hook. It enables us to ignore the root causes of suffering and to turn away from the things we could do to address these.
But regardless of the benefits and harms of the medicalisation of mental distress for individuals or society, it surely cannot be right to accept an idea – namely the idea that mental disorder is a brain disease – that is not justified; that is not based in reality. Building a system on such a basis prevents it from being challenged and debated. It renders it impervious to change.
You argue that the problem of the mental health system is not really medicalisation but social control and coercion, and maybe this is where we diverge most. Your aim to do away with social control is laudable, and I agree that we should try negotiation and compromise before we incarcerate people. One of my concerns about medicalisation is that it makes the justification of coercion too easy. However, I also think that there are circumstances in which coercion of some sorts is justified. There have always been people who behave in ways that are disruptive, unpredictable and sometimes threating and dangerous, and I believe every society needs a fair and balanced system to manage these situations.
So maybe we both agree and disagree here. I agree that the issue of coercion is at the heart of the debate about the mental health system. In my view, what we need is a system that minimises the use of coercion, by fairly balancing the interests of the individual to live their life as they want to live it with those of family members, neighbours and others in the community to be free of disturbance, fear and danger. I know this is not a fashionable point to make in critical psychiatry circles, but I believe it is a fact that society will devise some mechanism of control. In my view what is important is that that system is as fair as possible, and in order to be fair, it has to be transparent.
The system cannot be transparent, however, if it is disguised as a medical activity. If we (that is society) call behaviour we do not like ‘illness’ then we give ourselves a licence to do whatever we want to the individual, because who can argue that it is not a good thing to treat an illness, and if that illness affects the brain, then we do not need to respect the autonomy of the individual either. This is the point that Thomas Szasz has made, of course. Cloaked in the apparently benign language and rituals of medicine, we can subject people to almost anything. ‘The road to hell is paved with good intentions’ as they say!