Introduction: The Medical Model as the Ideology
of the Therapeutic State
Ronald Leifer, Ithaca, New York
The Journal of Mind and Behavior , Summer 1990, Vol. 11, No. 3, Pages 247 -258 , ISSN 0271-0137, ISBN 0-930195-05-1
The modern, therapeutic state came into existence as a result of the political transformation from Rule of Man to Rule of Law. This transformation carries with it an internal contradiction: while people value individual freedom under Rule of Law, they wish for a greater degree of social control than is provided by law. Under the ideology of the medical model, psychiatry provides this extra-legal social control. Politically, this model justifies the involuntary incarceration of those people not found guilty of crimes but regarded as strange, threatening or dangerous. This justification rests on switching from the moral model of behavior, which implies choice and responsibility, to a causal-determinist model which implies no choice and non-responsibility. This socially useful deception blinds us to ourselves and to the nature of our personal and public problems, while rendering us less capable of intelligently discussing and dealing with these problems.
Requests for reprints should be sent to Ronald Leifer, M.D., 115 DeWitt Park Apartments, Ithaca, New York 14805.
Toward the Obsolescence of the Schizophrenia
Theodore R. Sarbin, University of California, Santa Cruz
The Journal of Mind and Behavior , Summer 1990, Vol. 11, No. 3, Pages 259 -284 , ISSN 0271-0137, ISBN 0-930195-05-1
The disease construction of schizophrenia is no longer tenable. That construction originated during a period of rapid growth of biological science based on mechanistic principles. Crude diagnostis measures failed to differentiate absurd, unwanted conduct due to biological conditions from atypical conduct directed to solving existential or identity problems. The construction was communicated - in the absence of solid evidence - by medical practitioners by means of symbolic, rhetorical, and organizational acts. The patient came to be regarded as an object without agency or goals. In spite of enormous research funding, no biological or psychological marker has been discovered that would differentiate diagnosed schizophrenics from normals without creating unacceptable proportions of false positives and false negatives. Employing a moral category, "unwanted conduct," as a criterion, and tacitly transforming moral judgments to the medical category, schizophrenia, leads to the use of schizophrenia/nonschizophrenia as the independent variable in research designs. The failure of eight decades of research to produce a reliable marker leads to the conclusion that schizophrenia is an obsolescent hypothesis and should be abandoned.
Requests for reprints should be sent to Theodore R. Sarbin, Ph.D., Adlai E. Stevenson College, University of California, Santa Cruz, California 95064.
Institutional Mental Health and Social Control:
The Ravages of Epistemological Hubris
Seth Farber, Network Against Coercive Psychiatry
The Journal of Mind and Behavior , Summer 1990, Vol. 11, No. 3, Pages 285 -300 , ISSN 0271-0137, ISBN 0-930195-05-1
I argue in this essay that the phenomena we classify as "mental illness" result largely from the refusal of socially authorized "experts" to recognize - and thus to constitute - the Other (the developing person, the social deviant) as a subject. I suggest that Institutional Mental Health refuses to do this not merely because it seeks to aggrandize its own power but also because it fears to acknowledge that we are all participants in a process of historical development. It denies this because it is historically conditioned by its own moment of origin in the project of the Enlightenment, It is conseqently wed to an ethos of rationalized order that does not accomodate, much less support, the unpredictable creative power of the Other (the individual) and that sustains instead the project of mastery, of domination, of disovering eternal laws that will (supposedly) enable Reason to master history and to master the Other. For this reason Institutional Mental Health and its diverse ideologies, ranging from the pyschoanalytic to genetic defect models, constitute a major obstacle to the evolution of humanity.
Requests for reprints should be sent to Seth Farber, Ph.D., 172 West 79th Street, Apt 2E, New York, New York 10024.
Deinstitutionalization: Cycles of Despair
Andrew Scull, University of California, San Diego
The Journal of Mind and Behavior , Summer 1990, Vol. 11, No. 3, Pages 301 -312 , ISSN 0271-0137, ISBN 0-930195-05-1
Examining the period from the rise of the asylum in the nineteenth century through the current debates about the failures of deinstituionalization, this paper provides a critical perspective on the history of Anglo-American responses to chronic mental disability. It concludes with a pessimistic assessment of the prospects for the future evolution of public policy in this area.
Requests for reprints shouls be sent to Andrew Scull, Ph.D., Department of Sociology, C-002, University of California at San Diego, La Jolla, California, 92093.
Twenty Years Since Women and Madness:
Toward a Feminist Institute of Mental Health and Healing
Phyllis Chesler, College of Staten Island, CUNY
The Journal of Mind and Behavior , Summer 1990, Vol. 11, No. 3, Pages 313 -322 , ISSN 0271-0137, ISBN 0-930195-05-1
This article reviews the development of a feminist analysis of female and male psychology from 1970 to 1990; the acceptance, rejection or indifference to feminist theory and practice by women in general and by female patients and mental health practitioners in specific. The article describes what feminist therapy ideally is and discusses the need for a Feminist Institute of Mental Health.
Requests for reprints should be sent to Phyllis Chesler, Ph.D., College of Staten Island, CUNY, 715 Ocean Terrace, Staten Island, New York 10301.
The Ex-Patients' Movement: Where We've Been and
Where We're Going
Judi Chamberlin, Ruby Rogers Advocacy and Drop-In Center
The Journal of Mind and Behavior , Summer 1990, Vol. 11, No. 3, Pages 323 -336 , ISSN 0271-0137, ISBN 0-930195-05-1
The mental patients' liberation movement, which started in the early 1970s, is a political movement comprised of people who have experienced psychiatric treatment and hospitalization. Its two main goals are developing self-help alternatives to medically-based psychiatric treatment and securing full citizenship rights for people labeled "mentally ill." The movement questions the medical model of "mental illness," and insists that people who have been labeled as "mentally ill" speak on their own behalf and not be represented by others who claim to speak "for" them. The movement has developed its own philosophy, and operates a variety of self-help and mutual support programs in which ex-patients themselves control the services that are offered. Despite obstacles, the movement continues to grow and develop.
Requests for reprints should be sent to Judi Chamberlin, Ruby Rogers Advocacy and Drop-In Center, 2336 Massachusetts Avenue, Cambridge, Massachusetts 02140.
AIDS and the Psycho-Social Diciplines: The Social
Control of "Dangerous" Behavior
Mark S. Kaplan, University of Illinois at Urbana-Champaign
The Journal of Mind and Behavior , Summer 1990, Vol. 11, No. 3, Pages 337 -352 , ISSN 0271-0137, ISBN 0-930195-05-1
AIDS provides society an opportunity to expand and rationliza control over a broad range of psychological phenomena. Social control today is panoptical, involving dispersed centers and agents of surveillance and discipline throughout the whole community (as exemplified by workplace drug testing). The control of persons perceived as "dangerous" is effected partly through public psycho-social discourse on AIDS. This reproduces earlier encounters with frightening diseases, most notably the nineteenth-century cholera epidemic, and reveals a morally-laden ideology behind modern efforts at public hygiene.
Requests for reprints should be sent to Mark S. Kaplan, Dr.P.H., School of Social Work, University of Illinois at Urbana-Champaign, 1207 West Organ Street, Urbana, Illinois 61801.
Therapeutic Professions and the Diffusion of
Kenneth J. Gergen, Swarthmore College
The Journal of Mind and Behavior , Summer 1990, Vol. 11, No. 3, Pages 353 -368 , ISSN 0271-0137, ISBN 0-930195-05-1
The mental health professions operate largely so as to objectify a language of mental deficit. In spite of their humane intentions, by constructing a reality of mental deficit the professions contribute to hierarchies of privilege, reduce natural interdependencies within the culture, and lend themselves to self-enfeeblement. This infirming of the culture is progressive, such that when common actions are translated into a professionalized language of mental deficit, and this language is disseminated, the culture comes to construct itself in these terms. This leads to an enhanced dependency on the professions and these are forced, in turn, to invent additional terms of mental deficit. Thus, concepts of infirmity have spiraled across the century, and virtually all remaining patterns of action stand vulnerable to deficit translation. Required within the professions are new linguistic formulations that create a reality of relationships without evaluative fulcrum.
Requests for reprints should be sent to Kenneth J. Gergen, Ph.D., Department of Psychology, Swarthmore College, Swarthmore, Pennsylvania 19081.
The Futility of Psychotherapy
George W. Albee, University of Vermont
The Journal of Mind and Behavior , Summer 1990, Vol. 11, No. 3, Pages 369 -384 , ISSN 0271-0137, ISBN 0-930195-05-1
While psychotherapy is helpful to individual clients, the slim cadre of therapists and the vast number of disturbed people precludes any hope that more than a relative few will receive help. Nowhere is the futility of psycotherapy as obvious as among the poor and powerless whose suffering, crowding, and dispair will yield only to social and political solutions. In the United States the expansion of the number of psychiatric diagnoses and the demographic changes in populations will only make larger the gap in numbers between therapists and clients. Psychotherapy is an expensive oddity to the poor, but their taxes will help the affluent obtain prepaid care. Psychotherapy does reveal some of the social and economic factors, like bad parenting, homelessness and unemployment, that cause emotional disturbances. But one-to-one treatment, medical or psychological, does not, and cannot, affect incidence. The rightward movement of American psychiatry, supported by political conservatives and by activist parent-groups, espouses an organic explanatory model for all mental disorders and for a wide range of human problems. Only effective primary prevention leading to social change will reduce future incidence.
Requests for reprints should be sent to George W. Albee, Department of Psychology, University of Vermont, Burlington, Vermont 05405.
The Name Game: Toward a Sociology of Diagnosis
Phil Brown, Brown University and Harvard Medical School
The Journal of Mind and Behavior , Autumn 1990, Vol. 11, No. 4, Pages 385 -406 , ISSN 0271-0137, ISBN 0-930195-05-1
Although diagnosis is integral to the theory and practice of psychiatry, social scientists have not developed a comprehensive approach to diagnosis. This paper presents a preliminary outline of the issues which a sociology of diagnosis should integrate. These include bias and social control in psychiatric diagnosis, diagnosis as part of a new extension of the biopsychiatric medical model, and flaws in contemporary diagnostic categorization. These issues are then viewed in terms of professional practice styles, diagnostic biases, psychiatry's professional dominance over the mental health field, and psychiatric hegemony over the clinical interaction with patients.
Requests for reprints should be sent to Phil Brown, Ph.D., Department of Sociology, Brown University, Box 1916, Providence, Rhode Island 02912.
Subjective Boundaries and Combinations in Psychiatric
John Mirowsky, University of Illinois at Urbana-Champaign
The Journal of Mind and Behavior , Autumn 1990, Vol. 11, No. 4, Pages 407 -424 , ISSN 0271-0137, ISBN 0-930195-05-1
This distinctions embodied in official psychiatric diagnoses represent arbitrary and subjective views of patients' problems. Historically, individual psychiatrists were free to superimpose their own distinctions and categories. In recent decades, a uniform set of concepts has been negotiated, promoted, and enforced. The uniform diagnoses improve descriptive communication and meet administrative needs. However, they remain arbitrary. This essay argues that a descriptive theory of psychiatric problems should distinguish the objective pattern of correlation among the thoughts, feelings, and behaviors in question from the subjective view of them embodied in diagnoses. A map of correlations among psychiatric symptoms reveals a graded circular spectrum, analogous to a color wheel. The psychiatric types are not empirical islands in correlational space. They are subjective points of reference on a circular continuum. Problems that appear to be of one type shade into those that appear to be of another. Salient locations on the circle correspond to the following labels, in the following order: schizophrenia, alcoholism, autonomic arousal, sleep problems, emotional distress, fear and panic, paranoia, and back to schizophrenia.
Requests for reprints should be sent to John Mirowsky, Ph.D., Department of Sociology, University of Illinois, 326 Lincoln Hall, 702 South Wright Street, Urbana, Illinois 61801.
Brain Damage, Dementia and Persistent Cognitive
Dysfunction Associated With Neuroleptic Drugs: Evidence, Etiology, Implications
Peter R. Breggin, Center for the Study of Psychiatry and George Mason University
The Journal of Mind and Behavior , Autumn 1990, Vol. 11, No. 4, Pages 425 -464 , ISSN 0271-0137, ISBN 0-930195-05-1
Several million people are treated with neuroleptic medications (major tranqulizers or antipsychotics) in North America each year. A large percentage of these patients develop a chronic neurologic disorder-tardive dyskinesia-characterized by abnormal movements of the voluntary muscles. Most cases are permanent and there is no known treatment. Evidence has been accumulating that the neuroleptics also cause damage to the highest centers of the brain, producing chronic mental dysfunction, tardive dementia and tardive psychosis. These drug effects may be considered a mental equivalent of tardive dyskinesia. Relevant data are derived from human autopsies, brain imaging (CT, MRI and PET scans), neurophysical tests, and clinical research. That the neuroleptics can damage higher brain centers is confirmed by their known neurotoxicity and neurophysiological impact, animal autopsies, and a comparison to diseases that mimic neuroleptic effects, such as Huntington's chorea and lethargic encephalitis. Patients and the public should be informed of the danger of both tardive dyskinesia and tardive dementia. The mental health professions should severely limit the use of neuroleptics and develop safer and better alternatives to these dangerous substances.
Requests for reprints should be sent to Peter R. Breggin, M.D., Center for the Study of Psychiatry, 4628 Chestnut Street, Bethesda, Maryland 20814.
The Political Economy of Tardive Dyskinesia:
Asymmetries in Power and Responsibility
David Cohen, Universite de Montreal and Michael McCubbin, York University
The Journal of Mind and Behavior , Autumn 1990. Vol. 11, No. 4, Pages 465 -488 , ISSN 0271-0137, ISBN 0-930195-05-1
Tardive dyskinesia is a serious, well publicized adverse effect resulting from long-term neuroleptic drug use. However, little progress has been made during the last two decades in ensuring that these drugs are prescribed with necessary caution. Incentives and constraints operating on the major participants (patients, families, physicians, institutions, drug companies, society) in the decision-making process leading to the prescription of neuroleptics increase the likelihood that the benefits of drugs will be exaggerated and their adverse effects minimized. When combined with imbalances of power, these factors ensure that persons having little power and information to make the decision to prescribe will bear most costs of that decision. This points to the operation of an ineffective system which can be expected to yield sub-optimal results. We suggest ways to make the decision process more efficient by more closely aligning responsibility with cost. If those who hold power in the decision process are held accountable for the unwanted risks they impose upon others, both the use of neuroleptics and its inevitable iatrogenesis would probably be reduced.
Requests for reprints should be sent to David Cohen, Ph.D., Ecole de service social, Universite de Montreal, C.P. 6128, succursale A, Montreal, Quebec, Canada H3C 3J7.
Electroshock: Death, Brain damage, Memory Loss,
Leonard Roy Frank, San Francisco, California
The Journal of Mind and Behavior , Autumn 1990. Vol. 11, No. 4, Pages 498 -512 , ISSN 0271-0137, ISBN 0-930195-05-1
Since its introduction in 1938, electroshock, or electroconvulsion therapy (ECT), has been one of psychiatry's most controversial procedures. Approximately 100,000 people in the United States undergo ECT yearly, and recent media reports indicate a resurgence of its use. Proponents claim that changes in the technology of ECT administration have greatly reduced the fears and risk formely associated with the procedure. I charge, however that ECT as routinely used today is at least as harmful overall as it was before these changes were instituted. I recount my own experience with combined insulin coma - elcetroshock during the early 1960s and the story of the first electroshock "treatment." I report on who now is being electroshocked, at what cost, where, and for what reasons. I discuss ECT technique modifications and describe how ECT is currently administered. I examine assertions and evidence concerning ECT's effectivness and ECT-related deaths, brain damage, and memory loss. Finally I describe "depatterning treatment," a brainwashing technique developed in Canada during the 1950s, drawing a parallel between electroshock and brainwashing.
Requests for reprints should be sent to Leonard Roy Frank, 2300 Webster Street, San Francisco, California 94115.
Behavior in a Vacuum: Social-Psychological Theories
of Addiction That Deny the Social and Psychological Meanings of Behavior
Stanton Peele, Mathematica Policy Research
The Journal of Mind and Behavior , Autumn 1990. Vol. 11, No. 4, Pages 513 -530 , ISSN 0271-0137, ISBN 0-930195-05-1
Social psychologists have been in the forefront of the development of modern theories of cigarette smoking and obesity. These theories are reductionist: they account for behavior in purely physiological terms and regard cognitive, value, personality, and social class factors as secondary or irrelevant. Yet, from their beginnings, these theories have failed to account for major aspects of the behaviors under investigation, aspects apparently related to personal intention and social background. While it may seem suprising that work by social psychologists denies social and psychological reality, the theories discussed here actually reflect broader trends in social psychology, trends with rather large implications for our ideas about individual and social efforts at change.
Requests for reprints should be sent to Stanton Peele, Mathematica Policy Research, Inc., P.O. Box 2393, Princeton, New Jersey 08543-2393.
The Conceptual Bind in Defining the Volitional
Component of Alcoholism: Consequences for Public Policy and Scientific Research
Richard E. Vatz, Towson State University and Lee S. Weinberg, University of Pittsburg
The Journal of Mind and Behavior , Autumn 1990. Vol. 11, No. 4, Pages 531 -544 , ISSN 0271-0137, ISBN 0-930195-05-1
An essential element in both lay and professional definitions of alcoholism is the a priori claim that afflicted individuals lack control over their drinking and/or over their behavior while drinking. The social, legal and scientific consequences of accepting this claim are examined. Based on specific evidence drawn from recent journal articles, we argue that alcohol researchers fail to adequately engage the issue of volition and that their research designs and findings are thereby flawed.
Requests for reprints should be sent to Richard E. Vatz, Ph.D., Department of Communication, Towson State University, Baltimore, Maryland 212204.
False Accusations of Sexual Abuse: Psychiatry's
Latest Reign of Error
Lee Coleman, Berkely, California
The Journal of Mind and Behavior , Autumn 1990. Vol. 11, No. 4, Pages 545 -556 , ISSN 0271-0137, ISBN 0-930195-05-1
The problem of false accusations of child sexual abuse requires explanation. Investigators uncritically accepted theories and techniques from mental health authorities because of our society's traditional faith in such "experts." The history of this development is reviewed, illustrating the confusion resulting from a blending of investigative and therapeutic roles. Similarly hasty acceptance of unsupported medical interpretations are also reviewed. Recommendatons for reform stress a separation of investigators from mental health ideology, as well as more responsible investigative techniques.
Requests for reprints should be sent to Lee Coleman, M.D., 1889 Yosemite Road, Berkeley, California 94707.
Law and Psychiatry: The Problems That Will Not
Thomas Szasz, State University of New York
The Journal of Mind and Behavior , Autumn 1990. Vol. 11, No. 4, Pages 557 -564 , ISSN 0271-0137, ISBN 0-930195-05-1
The practice of psychiatry rests on two pillars: mental illness and involuntary mental hospitalization. Each of these elements justifies and reinforces the other. Traditionally, psychiatric coercion was unidirectional, consisting of the forcible incarceration of the individual in an insane asylum. Today, it is bidirectional, the forcible eviction of the individual from the mental hospital (which becomes the home) supplementing his or her prior forcible incarceration in it. So intimate are the connections between psychiatry and coercion that noncoercive psychiatry, like noncoercive slavery, is an oxymoron.
Requests for reprints should be sent to Thomas Szasz, M.D., Department of Psychiatry, State University of New York, Health Science Center, 750 East Adams Street, Syracuse, New York 13210.