Psychiatric Science

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VOLUME 2, ISSUE 6 THE INTERPSYCH NEWSLETTER JULY, 1995

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PSYCHIATRIC "SCIENCE"

Jeffrey A. Schaler, Ph.D.

The ideology of biological determinism rests, according to Lewontin (1991), on three ideas: People "differ in fundamental abilities because of innate differences...[T]hose innate differences are biologically inherited[.]...[H]uman nature guarantees the formation of a hierarchical society" (p. 23).

The psychiatric application of those ideas reads the following way: "Mentally ill" persons are different from "mentally healthy" persons because of innate differences. Those differences are biologically inherited, e.g., "schizophrenia," "manic-depression," and "alcoholism" are caused by genes. The control of "mentally ill" persons by "mentally healthy" persons is part of a natural, hierarchical order of man.

Psychiatric and psychological institutions that advance those ideas claim "to derive from sources outside of ordinary human social struggle," i.e., they are apolitical, "descend[ing] into society from a supra-human source." Their "pronouncements, rules, and results" allegedly "have a validity and a transcendent truth that goes beyond any possibility of human compromise or human error." Their "explanations" are "true in an absolute sense." They use "an esoteric language, which needs to be explained to the ordinary person by those who are especially knowledgeable and who can intervene between everyday life and mysterious sources of understanding and knowledge" (ibid., p. 7) (1). That, Lewontin tells us, is how an institution, e.g., institutional psychiatry, "legitimizes" the world and, I might add, how it justifies certain policies, i.e., committing certain acts against specific persons. In other words, it is how an institution that claims to be apolitical actually effects a political mandate, here called "right" behavior.

Lewontin explains how biological determinists, contrary to being apolitical, advance a socio- economic political agenda in the name of science.

(2) A disciplined, scientific approach in clinical psychology and psychiatry, it seems to me, must recognize the political nature of its apolitical claims. While Lewontin has done a superb job of exposing the political nature of biological determinism, Thomas Szasz has done likewise for institutional psychiatry (3).

HISTORY

The transition from societal control of the individual to the idea that society is determined by the individual coincided with the Reformation and the birth of capitalism:

Before the eighteenth century, European society placed little or no emphasis on the importance of the individual. Rather, the activity of people was determined for the most part by the societal class into which they were born...Individuals were seen not as the causes of social arrangements but as their consequence (ibid., pp.. 10-11).

After the Reformation economic prosperity was associated with godliness. Capitalism reinforced the economic power of the individual, i.e., he could determine his own economic future. A new weltanschauung coincided whereby the part--the individual--was viewed as having the power to determine the greater whole--society. Theological explanations for the world became increasingly replaced with scientific and mechanistic ones.

This atomized society is matched by a new view of nature, the reductionist view. Now it is believed that the whole is to be understood _only_ by taking it into pieces, that the individual bits and pieces, the atoms, molecules, cells, and genes, are the causes of the properties of the whole objects and must be separately studied if we are to understand complex nature (Lewontin, 1991, pp. 11-12).

The world view of an individual's relationship to the greater whole of society extends, according to Lewontin, to our philosophy of science. And our philosophy of science, what Lewontin calls "the ideology of biology," reinforces and serves a particular philosophy of how society should be.

Today, reductionism dominates the institutions of psychiatric and psychological research, practice, and public policy. "Mental illness" is called a "treatable" brain disease. Explanations and policies for dealing with persons labeled "mentally ill" are reduced to identifying and changing neurochemicals and the genes that produce them.

Yet, there is nothing scientific about those explanations and there is everything political about them. Psychiatric science is an oxymoron. Szasz's (1970) advice to examine the category mistakes of psychiatric reductionism is helpful:

[I]f our aim is to see things clearly, rather than to confirm popular beliefs and justify accepted practices, then we must sharply distinguish three related but distinct classes of phenomena: first, _events_ and _behaviors_...; second, their _explanations_ by means of religious or medical concepts...; third, their _social control_, justified by the religious or medical explanations... (p. xxi).

BEHAVIOR IS AN EVENT

In clinical psychology and psychiatry we address human behavior, be it normal or abnormal. Human behavior is an event, a "coming out." We may address that event in descriptive or prescriptive ways. Descriptive approaches imply objectivity. A factual assertion is made (Szasz, 1988).

Prescriptive approaches "describe by prescribing," i.e., one depicts "what is" by saying "what should be." To prescribe is to enjoin. That is a strategic recommendation, designed to effect a particular behavioral outcome. Prescriptions are either fair or unfair (ibid.). By confusing description with prescription existence is defined through moral commandment. A political agenda may then be actualized. The "body politic" is "treated" in name of the body human.

For example, we describe abnormal behavior when we say that behavior deviates from the norm. That is a purely statistical assessment, a factual assertion. Whether the deviant behavior is "good" or "bad" is irrelevant, for "deviant" can also describe exceptional ability as well as inability.

We prescribe abnormal behavior when we define it as maladaptive, subjective discomfort, deviation from the ideal, etc. Those are value judgments. In other words, we describe the behavior in terms of what we think it should be--but actually we are not describing it at all. We are pretending to describe it for strategic purposes in order to effect a particular mode of conduct. (4)

What is the accurate description of human behavior? Behavior is an intentional act, mode of conduct, deportment. Conduct is the expression of values through action. Herbert Fingarette (1975) differentiated between behavior and neurological reflex using the chronic drug user as an example: A pattern of conduct must be distinguished from a mere sequence of reflex-like reactions. A reflex knee jerk is not conduct. If we regard something as a pattern of conduct...we assume that it is mediated by the mind, that it reflects consideration of reasons and preferences, the election of a preferred means to the end, and the election of the end itself from among alternatives. The complex, purposeful, and often ingenious projects with which many an addict may be occupied in his daily hustlings to maintain his drug supply are examples of conduct, not automatic reflex reactions to a singly biological cause (p. 435).

Szasz (1987) agrees: [B]y behavior we mean the person's "mode of conducting himself" or his "deportment"... the name we attach to a living being's conduct in the daily pursuit of life... [B]odily movements that are the products of neurophysiological discharges or reflexes are not behavior...The point is that behavior implies action, and action implies conduct pursued by an agent seeking to attain a goal (p. 343).

The syllogism here goes like this: Human behavior is intentional conduct. "Mental illness" refers to specific behaviors. Therefore, "mental illness"-- the behaviors referred to as "schizophrenia," "addiction," "insanity," etc.--is intentional conduct. We know what a person values by paying attention to how he lives (Szasz, 1994). Since epilepsy, diabetes, cirrhosis, cancer, heart disease, etc. are not behaviors--i.e., they are diseases--we do not regard them as intentional conduct. The syllogism does not hold true for real diseases. Certain behaviors may lead to or be strongly correlated with those diseases, e.g., smoking, drinking, a high-fat diet, etc. However, a person cannot choose to have cancer, just as he cannot choose to make cancer "go away" (5).

Diagnoses of mental illness are based on observations of acts by individuals. Persons being diagnosed must move or make some claim about themselves (Sarbin, 1990). A diagnosis cannot be made if the person does not move or speak. The situation is remarkably different in the diagnosis of real disease, where movement is unnecessary.

Blood is drawn, an X-ray is taken, etc.; when the person is unconscious a proper diagnosis can still be made (T. Szasz, personal communication, April 1995). Mental illness cannot be diagnosed in such a manner, i.e., by signs. We cannot diagnose mental illness through blood analysis, EEG, CAT, MRI or PET scans. _Claiming_ that mental illness can be diagnosed through those tests is a political maneuver, not a scientific or factual assertion.

EXPLANATIONS ARE NOT CAUSES

The institutions of clinical psychology and psychiatry become politically active when explanations for events are confused with the events themselves. An explanation for an event is a theory about how or why the event occurs. We may believe that a particular event occurs because of psychological, environmental (6), unconscious (7), and/or biological factors. Freud invented the theory of the unconscious as an explanation for why a patient of his allegedly could not remember an emotional catharsis during hypnosis. He did not _discover_ the unconscious. He _invented_ it as an explanation for his patient's behavior. That invention is not a _cause_ for why people behave in certain ways. Yet people believe not only that the unconscious exists but also that it _causes_ people to act. Explanations and causes are different.

Szasz addressed the difference in 1963: There is a...difference in the theories of physicists and laymen on the subject of the flow of electricity in a copper wire. For the physicist, the theory may be a set of mathematical equations. The layman, on the other hand, may visualize electrons as little balls rolling along inside the wire. In either case, does the _theory_ of electric flow _cause_ a light bulb to glow or a radio to play?

The question is improper. It is also improper to ask if a murderer's schizophrenia caused the criminal act. An explanation or theory can never be a cause (p. 134).

Explanations of any behavior as the _result_ of interaction with others, environment, the unconscious, neurotransmitters in the brain, etc. are theoretical inventions, not empirical discoveries. (8) Moreover, those theories imply that a cause-and-effect relationship between self and internal or external entities exists, as if the two could be separated.

An explanation for a behavioral event _must_ be consistent with the definition of behavior, i.e., intentional conduct. That view is at great odds with biological explanations for behavior, explanations viewed as causes of behavior. Reductionist explanations for behavior are inconsistent with the literal meaning of behavior. They are illogical. Brains, neurotransmitters and genes do not _choose_ to act. People do!

...[T]he view that we are totally at the mercy of internal forces present within ourselves from birth is part of a deep ideological commitment that goes under the name of _reductionism_. By reductionism we mean the belief that the world is broken up into tiny bits and pieces, each of which has its own properties and which combine together to make larger things. The individual makes society, for example, and society is nothing but the manifestation of the properties of individual human beings.

Individual internal properties are the causes and properties of the social whole are the effects of those causes. Such a view about causes and effects and the autonomy of individual bits and pieces not only results in a belief that internal forces beyond our control govern what we are as individuals. It also posits an external world with its own bits and pieces, its own laws, which we as individuals confront but do not influence. Just as the genes are totally inside of us, so the environment is totally outside of us, and we as actors are at the mercy of both these internal and external worlds. This gives rise to the false dichotomy of nature and nurture (Lewontin, 1991, p. 107).

So now we have two principles with which to investigate and confront the political nature of psychiatric "science": (1) the seemingly deliberate confusion of description with prescription in identifying behavior as an event and (2) the seemingly deliberate confusion between explanations and causes for human behavior as an event.

POLICIES ARE BASED ON EXPLANATIONS

How do we know what a person values? By paying attention to what that person does. We understand something about the values psychiatrists and clinical psychologists have by examining what they do. They talk to people, give drugs, administer electric shock, commit people to prisons called "mental institutions," detain and "deinstitutionalize" "mental patients" against their will, and are often paid or empowered by government to do so. What values are those practices and policies based on?

Explanations (stories, inventions) for events can be placed in two categories: There are those explanations that are free-will oriented, i.e., the behavior is explained as existentially strategic. And there are those explanations that are deterministically oriented, i.e., the behavior is viewed as caused, which is a contradiction in terms (Szasz, 1987). The policies of psychiatrists and clinical psychologists--i.e., what they do in relation to persons, e.g., "treatment"--are based on our various explanations for events.

Contractual, i.e., voluntary, psychotherapy rests on the accurate explanation for behavior. Institutional psychiatry and clinical psychology rest on the inaccurate explanation. All involuntary "treatment" for "mental illness" is justified through explanations for abnormal behavior that confuse theory with cause, description with prescription. Involuntary treatment is at irreconcilable odds with the definition of behavior as mode of conduct executed by a moral agent. It is also based on biological determinism, e.g., "mental illness" caused by a brain disorder with genetic origins--an attempt to remove the person's intentional conduct. To view a person as "missing" intentionality in conduct is perhaps one of the most dehumanizing ways one person can relate to another. Yet this thinking is an integral part of the actions taken by institutional psychiatrists and clinical psychologists intent on diagnosing and "treating mental illness."

One can further categorize explanations for abnormal behavior into vices and crimes. Vices are acts against onself. Crimes are acts against others. If a person is physically self-destructive we may do nothing. (9) Harm to others is a jurisprudential matter (10). Confusing medical and criminal justice categories is another way a political agenda appears to be implemented in the name of a scientific/medical one (Menninger, 1968).

WHAT SHALL WE DO THEN?

In the movie "The Year of Living Dangerously," the photographer Billy, played by Linda Hunt, became exasperated when his adopted family in the Djakarta ghetto refused to follow his admonition about sewer water. Soon thereafter he realized that his hero, Sukarno, had turned out to be one more empty fraud. Flailing away at his typewriter he wailed in despair, "What shall we do?" (Luke 3:10-14),

helpless at the apparent impossibility of alleviating suffering in the world. That is the human condition. We cannot help someone unless he wants our help. As Confucius taught, we can give a starving person a fish or we can teach him how to fish (see Szasz, 1991). And he will learn to fish only when he wants to!

Yet we persist, using force to affirm the dominant ethic, now called "mental health," and to rid the world of evil, now called "mental illness," at any cost, justifying, nay legitimizing, institutional instruments of persecution, first through claims of divine communion and now, with the evolution of secular and technological society, through scientism. Theocracy died by the separation of church and state. One thing we must do is remove the engine of the state from medicine. How can that be done? (11) Exposing the proliferation of moral management masquerading as medicine and science seems necessary to achieve that goal.

The problems confronting us as therapists are human problems in living. These cannot be reduced to physiological "bits and pieces," the "environment," and/or the "unconscious." Man is a moral agent making choices in the world, and his experience as a person is an integral part of that choice that cannot be separated and "treated." We can no more change intentional conduct through chemistry and conditioning than we can do so by forcing a moral confrontation with oneself. That, to return to Lewontin's third point about biological determinism, is how the hierarchical order is maintained by institutional psychiatry and clinical psychology.

Moreover, the political nature of psychiatric reductionism is not only unscientific, it qualifies as moral indoctrination, the antithesis of autonomy and liberty in a free society. It is not enough to show and block the prescriptions masquerading as descriptions of behavior, the explanations masquerading as causes for behavior, and the illogical assault on human beings for their intentional conduct in the name of "treatment" (12, 13). Explanations for behavior and policies based on those explanations must be consistent with an accurate vision of the person and his behavior.

The concept of free action requires, ultimately, that we conceive of the person in the moment of choice as the true initiator, by that choice, of the pertinent conduct. To speak of choice as true initiation of action is to say that the content of the choice is not decisively determined by already extant conditions that are independent of the choice. This is the freedom required by the concept of the moral responsibility of the individual (Fingarette, 1991, pp. 216-217). (14)

That seems to be the basis upon which any scientific policy toward human behavior must proceed.

NOTES

(1) Foucault's (1973) "gaze," for example. "It is not as a scientist that _homo medicus_ has authority in the asylum, but as wise man" (Foucault, 1965, p. 217).

(2) "No prominent molecular biologist of my acquaintance is without a financial stake in the biotechnology business" (Lewontin, 1991, p. 74).

(3) Like Szasz, I use the term "institutional p sychiatry" to refer to all branches of psychiatry,psychology, social work and other mental health professions receiving any support from the state.

(4) Objectivity is not absolute because the focus of our attention in describing behavior is selection or preference. We choose the figure/foreground of our attention because it is meaningful to us in some way.

(5) Compassion is not the issue here. When a pathologist identifies cancer he controls his feelings and makes a factual assertion. He may well make a strategic recommendation based upon his description, but that prescription is clearly differentiated.

(6) "First, there is no 'environment' in some independent and abstract sense. Just as there is no organism without an environment, there is no environment without an organism. Organisms do not experience environments. They create them" (Lewontin, 1991, p. 109). "The definition of an organism is the definition of an organism/environment field..." (Perls et al., 1951, p. 259). "Mentality is that relationship of the organism to the situation which is mediated by sets of symbols" (Mead, 1934, p. 125). "The environment, I have said, is our environment" (ibid., p. 248).

(7) "Unconscious thought is a contradiction in terms." Attributed to Albert Bandura.

(8) Lewontin (1991) suggests that the confusion between cause and agent is an integral part of biological determinists' attempt to effect a political agenda in the name of an apolitical one. Guns, drugs, genes and environment are agents, not causes.

(9) I differentiate here between a child and an adult. I also realize that the line between childhood and adulthood is ambiguous, i.e., there are children who are more mature than some adults and vice versa. Since persons at eighteen years of age are seen as fit for military service, I prefer that as the age of demarcation into adulthood, i.e., persons at eighteen years of age should be entitled to all the privileges and responsibilities of adulthood.

(10) Harming oneself is a moral act, i.e., intentional conduct. Harming others is a criminal act. The first case is an ethical issue. Informal sanctions are the proper domain for response. The second case is a criminal justice issue. Formal sanctions are the proper domain for response (see Conrad and Schneider, 1992). Neither case seems to have anything to do with medicine, i.e., psychiatry or clinical psychology.

(11) For example: "Congress shall make no law respecting an establishment of medicine, or prohibiting the free exercise thereof..." (Szasz, 1970, p. 179)

(12) To this, I might add the confusion of homology and analogy: "There is in fact not a shred of evidence that the anatomical, physiological, and genetic basis of what is called aggression in rats has anything in common with the German invasion of Poland in 1939" (Lewontin, 1991, p. 96).

(13) Karl Menninger, in a historic letter not long before his death, seems to have yielded to many of Szasz's objections to "mental illness" and institutional psychiatry. See Menninger (1989).

(14) Fingarette continues: "On the other hand, if action is to be responsible, it is also required that the action be shaped by one's character, one's values, one's perceptions of the situation, and also in relevant ways by the actual conditions in the situation. Insofar as there is an element in one's choice that is not conditioned by _any_ of these, that element of choice, by this hypothesis, does _not_ reflect one's nature, values, or situation, and thus it cannot in that respect be _responsible_ choice." I disagree with Fingarette here because I believe that thoughts cannot "happen" to a person. Thinking that they can appears, to me, to be a form of self-deception.

REFERENCES

Conrad, P. and Schneider, J.W. (1992). Deviance and medicalization: From badness to sickness. Expanded edition, with a new afterword by the authors. Philadelphia: Temple University Press.

Fingarette, H. (1991). Comment and response. In Mary I. Bockover (Ed.) Rules, rituals, and responsibility: Essays dedicated to Herbert Fingarette. (pp. 171-220). La Salle, Ill.: Open Court.

Fingarette, H. (1975). Addiction and criminal responsibility. The Yale Law Journal, 84, 413- 444.

Foucault, m. (1973). The birth of the clinic: An archaeology of medical perception. A.M. Sheridan Smith, trans. New York: Pantheon.

Foucault, M. (1965). Madness and civilization. New York: Random House.

Lewontin, R.C. (1991). Biology as ideology: The doctrine of DNA. New York: HarperPerennial.

Mead, G.H. (1967). Mind, self, and society from the standpoint of a social behaviorist. In Charles W. Morris (Ed). Works of George Herbert Mead volume 1. Chicago: University of Chicago Press.

Menninger, K. (1989). Reading notes. Bulletin of the Menninger Clinic. 53, 350-352.

Menninger, K. (1968). The crime of punishment. New York: Viking.

Perls, F., Hefferline, R.F., and Goodman, P. (1951). Gestalt therapy: Excitement and growth in the human personality. New York: Delta.

Sarbin, T. R. (1990) Toward the obsolescence of the schizophrenia hypothesis. In David Cohen (Ed). Challenging the therapeutic state: Critical perspectives on psychiatry and the mental health system. The Journal of Mind and Behavior, 11 (Nos. 3 & 4), 259-284.

Szasz, T.S. (1994). Cruel compassion: Psychiatric control of society's unwanted. new York: John Wiley & Sons.

Szasz, T.S. (1988). Psychiatric justice. Syracuse, N.Y.: Syracuse University Press.

Szasz, T.S. (1987). Insanity: The idea and its consequences. New York: John Wiley & Sons.

Szasz, T.S. (1970) The manufacture of madness: A comparative study of the Inquisition and the mental health movement. New York: Harper.

Szasz, T.S. (1963). Law, liberty, and psychiatry: An inquiry into the social uses of mental health practices. New York: Collier Books.

Jeffrey A. Schaler, Ph.D., a psychotherapist in

private practice since 1973, received his doctorate

in human development from the University of

Maryland College Park, and lives in Silver Spring,

Md. He teaches at American and Johns Hopkins

universities and is the listowner of

NUVUPSY@sjuvm.stjohns.edu. <jschale@american.edu>

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