Psychiatry's Death Grip

Steve Fuller argues controversially that the customer is always right when it comes to psychiatry.

Steve Fuller is an American philosopher and sociologist, and an expert in the field of science and technology studies. Born in New York City, Fuller has written over 18 books, including the highly acclaimed Kuhn vs. Popper and Science vs. Religion? Since 2011, Fuller has been the holder of the Auguste Comte Chair in Social Epistemology at the University of Warwick.

We spoke to him about the power of psychiatry.

How can sociology help us understand psychiatry?

Sociology can provide insight into the source and nature of the authority that psychiatry exerts, despite the highly contested character of its knowledge claims. This character is periodically in open display with each new edition of the Diagnostic and Statistical Manual of Mental Disorders, as happened in May of this year, when the fifth edition was published. The DSM is often dubbed the Bible of psychiatry, which is apt not because its knowledge claims are inviolate but because, as the "sacred text", many interested parties seek legitimacy in its pages.

Are psychiatrists ignoring social causes of mental illness?

Not really. Given the hybrid nature of their profession (part scientist, part practitioner), psychiatrists are fairly open-minded in terms of diagnosing mental disorders, so they are unlikely to neglect social causes. The real question is how they translate those causes into a prescription for the patient. After all, a psychiatrist may correctly realise that the patient’s suffering is a result of social deprivation related to her class position. But many different prescriptions remain possible: (a) take a drug; (b) remain in therapy; (c) engage in politics; (d) try harder to reform your life.

How does the shape of psychiatry relate to societal norms and ideals?

Psychiatry is problematic because of the enormous discretionary power it has over people’s lives. At the risk of sounding cynical, it should be obvious that psychiatrists would have very little to do if we did not think that many of us are on the verge of mental disorder. (Put another way, if we placed more trust in the legal system, we might just let people be as they are and when they break the law, they are simply tried for their specific offence.) Freud may be credited (or blamed?) with having created this indefinitely extensive market for psychiatry by speaking of "normalcy" as an idealised absence of neurosis.

Another Freudian neologism, "coping", captures the prospect that a mental disorder is never properly cured but one learns somehow to live with it. The most recent edition of the DSM, though hardly Freudian in content, deepens this death grip of psychiatry over patients by stressing the potential genetic bases for mental disorders that have yet to be manifested. I can easily imagine some psychiatry zealot calling for people’s genomes to be scanned so that their mental disorders can be pre-empted, as in the "pre-crime" policy of the Steven Spielberg film, Minority Report.

What is the power balance between psychiatrists and their clients and what ought it to be?

First of all, we should take the idea of the client seriously! In the 1960s, Carl Rogers popularised the idea of "client-centred therapy", in which the term "client" – as opposed to "patient" – signified a level playing field with the therapist, who was dealt with face-to-face as a notional equal (i.e. not in the oblique manner of Freudian therapy, where the patient did most of the talking in a dark room, lying down, with minimal input from the therapist, who in the end delivered a diagnosis). A client pays for therapy just as long as it makes sense for her, no more and no less. Moreover, while the client is paying for advice from the therapist, she is under no obligation to accept that advice. Of course, "clients" may end up making more mistakes than "patients" who might have acted more cautiously as self-understood "mentally disordered" people. But if we claim to live in a truly "modern" society that values Enlightenment ideals of autonomy, then we should afford to live with such mistakes.

But despite ideals of autonomy, isn’t an asymmetry of power reasonable between the psychiatrist and his client, if the client is suffering from severe mental illness?

I believe that a much sharper legal distinction needs to be drawn within the category of "mental illness". A client-centred relationship by definition is one in which, so to speak, "the customer is always right". This means that, however much the client may be suffering, she is granted autonomy to respond as she wishes to the psychiatric encounter and accept the consequences. I admit that perhaps not everyone who engages the services of a psychiatrist is in such a mental state, but then perhaps those people should not be allowed to see psychiatrists. Instead the radical asymmetrical relationship between doctor and patient may need to be legally enforced, which harks back to the early 19th century hospitals and asylums. While the two extreme alternatives that I am suggesting here – "liberal" and "carceral" understandings of mental illness – may seem harsh, I believe that they send much clearer signals to society about the status of the "mentally ill", a category whose current vagueness will otherwise continue to contaminate public life and interpersonal relations.

Where do you see psychiatry going in the future? Will it continue to expand its domain in the way you hinted at?

If the psychiatric profession gets its way, based on the latest edition of the DSM, the Curse of Freud will continue in full swing. Surface normality will remain the hunting ground for arrested neuroses. The difference now, of course, is that diagnoses based on genetic predispositions will be increasingly part of the mix. The genome opens up a new way to identify disorders that might otherwise elude one’s medical history. However, the exact implications for treatment are unclear, but I doubt that they will be overtly authoritarian. My best guess that we are not far from a time when the sort of genetically-linked checks that insurance companies try to do when setting premiums will become something that people will be encouraged, if not obliged, to conduct for themselves. In that respect, we will be made to own our genetic makeup – and whatever virtues or liabilities come with it. Thus, in the future, you may be deemed guilty of "self-negligence" for not attending to a genetically linked trait that you should have known about and hence taken measures to prevent it from having any adverse social consequences.


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Mike Johnson 13 December 2013

No confidence in the author. DNA will be collected at birth if not before for data analysis for all varieties of disorders. Ultimately your treatment will be based to some degree on indications drawn from your genome.
Whether you participate or not is of no interest to anyone but the client.
One might investigate iterated embryonic selection to get some idea of where technology is today.