Mad Science

Psychiatric Coercion, Diagnosis, and Drugs

Stuart A. Kirk

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351507936
• Edition: 1
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

*Winner of an honorable mention from theSociety for Social Work and ResearchforOutstanding Social Work Book AwardMad Science argues that the fundamental claims of modern American psychiatry are based on misconceived, flawed, and distorted science. The authors address multiple paradoxes in American mental health research, including the remaking of coercion into scientific psychiatric treatment, the adoption of an unscientific diagnostic system that controls the distribution of services, and how drug treatments have failed to improve the mental health outcome.When it comes to understanding and treating mental illness, distortions of research are not rare, misinterpretation of data is not isolated, and bogus claims of success are not voiced by isolated researchers seeking aggrandizement. This book's detailed analysis of coercion and community treatment, diagnosis, and psychopharmacology reveals that these characteristics are endemic, institutional, and protected in psychiatry. They are not just bad science, but mad science.This book provides an engaging and readable scientific and social critique of current mental health practices. The authors are scholars, researchers, and clinicians who have written extensively about community care, diagnosis, and psychoactive drugs. This paperback edition makes Mad Science accessible to all specialists in the field as well as to the informed public.

1
Illusions of Psychiatric Progress

Introduction

Madness poses fundamental problems for every society, past and present. The terms used to describe it–lunacy, insanity, mental disease, mental illness, nervous breakdown, emotional or psychological distress, mental disorder–carry a cargo of cultural meanings and spawn countless social reactions. Although each of these terms invokes a different understanding, the concept and the category of madness serve an essential purpose: they help those not so categorized to feel better about themselves and their presumed normalcy, while at the same time they earmark others as violating society’s expectations and deserving to be targeted by professional and state intervention.

Madness also safely subsumes and “explains” behavioral strangeness and violence that threaten social order, such as, for example, apparently unprovoked mass shootings by solitary individuals harboring deep grudges. The word madness represents some reality that triggers images for everyone, but hardly any two individuals would agree about its essence. Perhaps madness has no essence; perhaps it is only a linguistic black hole. Psychiatric historians and others, however, relying on their own personal histories and presumptions (often unacknowledged), have usually attempted to tell coherent and optimistic tales affirming the belief that medicine has virtually solved the mystery of madness and has validated it as yet another affliction of nature–a disease.

The current psychiatric establishment, exemplified by the US National Institute of Mental Health (NIMH) and the American Psychiatric Association (APA), wants the public to believe that disturbing behaviors result from brain diseases, that scientific research moves ever closer to finding causes and cures for these diseases, and that patients should be treated by approved, expertly-trained therapists applying certified, evidence-based treatments. This medical language and medicalized apparatus is a bid for authority over a long-disputed territory of distresses and misbehaviors. The language implies that errors of the past have given way to steady progress in understanding madness and treating it effectively. The claim for authority covers an immense range of human emotion, suffering, and behavior, including experiences that can severely frighten a person or those around them, such as panic, immobilizing despondency, having unusual perceptions, or acting violently in response to (possibly imagined) threats. But the bulk of the behavioral territory claimed by the modern professions addressing madness–including psychiatry, psychology, and social work–covers more common experiences, such as feeling irritable, sad, or very sensitive; having difficulty concentrating; feeling inept; working too much or too little; sleeping too much or too little; eating too much or too little; or feeling discomfort in ordinary social situations. Contemporary psychiatry claims that these diverse feelings and behaviors–from the rare and extreme to the common and mild–are symptoms of mental disorder, signs of underlying physiological dysfunction, requiring medical treatment.

In contrast, we will argue that the fundamental claims of modern American psychiatry¹ are not based on well-tested research but on science that is itself a bit mad: misconceived, flawed, erroneous, misinterpreted, and often misreported. Using the cover of scientific medicine, psychiatry has managed to become the leading legally chartered profession for the management of misery and misbehavior reframed as an illness (i.e., mental illness). We will demonstrate that the touted achievements of psychiatry in the past half century–keeping disturbed people out of psychiatric hospitals for extended periods, developing a novel and easily applied diagnostic approach embodied in the modern Diagnostic and Statistical Manual of Mental Disorders (DSM), and using “safe and effective” drugs as the first-line intervention for every ill and misfortune–are little more than a recycled mishmash of coercion of the mad and misbehaving, mystification of the process of labeling people, and medical-sounding justifications for people’s desires to use, and professionals’ desires to give, psychoactive chemicals. Obviously, then, this book questions the notion that these psychiatric achievements constitute progress. We argue that until society come to grips with the unscientific nature of the management of madness, it will perpetuate a “mental health” system that serves the interests of professional and corporate elites while it exacerbates the very problems it claims to tackle.

Mental health professionals and the public have been well apprised of the notable achievements of psychiatry this past half century: the near-closing of state asylums in order to provide “evidence-based” care in the community, the expansion of the category mental illness via the renovation of the Diagnostic Manual of Mental Disorders (especially since DSM-III), and the invention and marketing of new psychoactive drugs. These achievements have often been described as paradigm shifts that have shaped the current mental health system. Undoubtedly, their role in shaping this system cannot be taken lightly. However, we argue that these achievements constitute a trio of illusions, spawned more by the misuse than the progress of science. And, as illusions often do, they have unleashed a torrent of unanticipated adverse consequences, even as they have benefited organized psychiatry, pharmaceutical companies, and the proponents of the “mental health movement.”

As with the “unexpected” collapse of Wall Street in 2008, Americans may yet again, much to their consternation, come to realize that a huge social institution is not as sound as its best and brightest continually claim. The mental health enterprise, like some banks, is continually propped up by government, the profession, and the media because it has become too big to fail. Yet there is no question to us that it has failed and continues to fail daily. Our hope in this book is that society may yet learn to minimize psychiatric coercion and excuses, to offer help to those who need it, and to minimize the manipulation and distortion of science.

On the Language of Madness

Social scientists have to decide, every time they do research, what to call the things they study. If they choose the terms decided on by the interested and powerful parties already involved in the situations they are studying, they accept all the presuppositions built into that language.

(Becker, 2007)

As the sociologist Howard Becker reminds us in the quotation above, we should be skeptical about the rhetoric used by powerful parties and the assumptions that they may bootleg into public discourse. It is advice that we intend to follow throughout this book. Let’s begin by examining how the National Institute of Mental Health (NIMH), the federal government’s leading mental health agency, speaks of madness. Here is a typical excerpt from its website in 2008:

The mission of NIMH is to reduce the burden of mental and behavioral disorders through research on mind, brain, and behavior. Mental disorders are brain disorders and that means that achieving progress requires a deeper understanding of the brain and behavior.

Since our inception in 1946, NIMH has been the lead agency for research on mental disorders. Through our research, enormous gains have been made over the decades, including: establishing that mental disorders are complex brain diseases and demonstrating that medications and behavioral therapies can relieve suffering and improve daily functioning for many people. Recent groundbreaking discoveries from mapping of the human genome, sophisticated studies of the brain, and investigations of cognition and behavior have provided powerful new insights and approaches.

Science now provides opportunities that promise to deliver for each of these needs. Success will require an understanding of the underlying processes in brain and behavior–from neurons to neighbor-hoods–to make the discoveries that point the way to new diagnostics and interventions and, eventually to recovery, prevention, and cure. (From Strategic Planning Reports, NIMH website, 2/15/08)²

NIMH is explicit about madness: the behaviors are “brain diseases” managed by “therapies” while science moves closer to finding a “cure.” The language of biomedicine pervades today’s official views: disease, genetics, medications, behavioral therapies, rehabilitation, cure, recovery. It is as if none of these terms are contested or misleading. And yet great confusion exists at NIMH and throughout the scientific establishment about what behaviors express brain disorders, how they come about, how they should be managed, and by whom. As we will see, many experts believe that no scientific evidence exists to describe the vast array of behaviors corralled in the rubric of mental disorders as “brain diseases.” What NIMH presents as a simple equation is a political, not a scientific, pronouncement. For fifty years, the bureaucratic language about madness has contained many convoluted, vague, or tautological attempts at definition, as exemplified by the definition of “serious emotional disturbances” in children taken from the President’s New Freedom Commission on Mental Health (2002):

A serious emotional disturbance is defined as a mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified in the DSM-III-R that results in functional impairment that substantially interferes with or limits one or more major life activities in an individual up to 18 years of age. Examples of functional impairment that adversely affect educational performance include an inability to learn that cannot be explained by intellectual, sensory, or health factors; an inability to build or maintain satisfactory interpersonal relationships with peers and teachers; inappropriate types of behavior or feelings under normal circumstances; a general pervasive mood of unhappiness or depression; or a tendency to develop physical symptoms or fears associated with personal or school problems. (Retrieved 10-17-12 from: http://govinfo.library.unt.edu/mentalhealthcommission/reports/FinalReport/FullReport.htm)

The President’s Commission appears to eschew the terms brain disorder or brain disease in describing children’s behaviors. It opts to use “serious emotional disturbance” instead, admittedly a more neutral term, but its meaning is itself obscure. For example, the passage leads to confusion by defining serious emotional disturbance “as a mental, behavioral, or emotional disorder,” suggesting that three distinct types of “disorders” constitute emotional disturbance, without a wisp of explanation about the nature of the distinctions. To shore up the ambiguities, the passage borrows language from the DSM and elsewhere regarding “duration” and “functional impairment” that lead to various inabilities and inappropriate behaviors, feelings, fears, or unhappiness–plunging the reader into the depths of current psychiatric diagnostic murkiness. This type of descriptive obscurity would be unacceptable, for example, to cancer researchers trying to distinguish pathological from normal cells, suggesting that despite the official modern vocabulary of madness, we are leagues away from the logic of medicine. In fact, the more ambiguous the terms used to demarcate mental disorder from no mental disorder, or emotional disturbance from emotional stability, the more behavioral territory can be annexed under the jurisdiction of the mental health professions.

In 1980 the APA published its first serious official attempt to grapple with a definition of mental disorder, the current popular term. This occurred in the third edition and all subsequent editions of what is regularly referred to as the psychiatric Bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), readying itself for its seventh face-lift, DSM-5, scheduled for release in 2013. Admitting that “there is no satisfactory definition that specifies precise boundaries” (p. 5) for mental disorder, the DSM (APA, 1980) offered the following guidance:

In DSM each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is typically associated with either a painful symptom (distress) or impairment in one or more important areas of functioning (disability). In addition, there is an inference that there is a behavioral, psychological, or biological dysfunction, and that the disturbance is not only in the relationship between the individual and society. (When the disturbance is limited to a conflict between an individual and society, this may represent social deviance, which may or may not be commendable, but is not by itself a mental disorder.) (p. 6)

Almost every phrase in this cumbersome definition has been criticized (Kutchins & Kirk, 1997). One critic (Wakefield, 1992) noted in a widely cited article that the DSM defined disorder as a dysfunction, but without any attempt to suggest what a dysfunction is. Wakefield’s subsequent attempts to define dysfunction have, in turn, also been questioned as constituting speculative hypotheses about the functions of human evolution (Bolton, 2008; Boyle, 2002; Lilienfeld & Marino, 1995; McNally, 2011). More recently, a group of psychiatric researchers (Rounsaville et al., 2002), working under the auspices of the APA in preparation for DSM-5, concluded that mental disorder as defined in DSM is not an exact term and “is not cast in a way that allows it to be used as a criterion for deciding what is and is not a mental disorder” (p. 3), and that there is a “contentious” debate about “whether disease, illness, and disorder are scientific biomedical terms or are sociopolitical terms that necessarily involve a value judgment” (p. 3, emphasis in original). And finally, they report that the current DSM “...is based on a falsely optimistic assumption: that psychiatric disorders are discrete biomedical entities with clear . . . boundaries” (p. 8). In other words, even these prominent psychiatric researchers, trying to improve or fine-tune diagnosis of the presumed entities that make up the very subject matter of psychiatry, disagree not only with DSM but with the professed certainties of NIMH’s “brain diseases.”

The definition of madness remains in disarray. This dilemma has become abundantly clear as the American Psychiatric Association struggles to produce DSM-5, which will be discussed in greater detail in chapter 5. Particularly revealing is an article titled “What Is a Mental/Psychiatric Disorder: From DSM-IV to DSM-V,” written to guide DSM-5 (Stein et al., 2010). The authors concede the following: there are disagreements about the term mental disorder; the “clinically significant” DSM criterion for mental disorders is tautological and difficult to operationalize; the boundaries between normal and pathological are complex and contentious; and the concept of dysfunction is controversial and involves speculative theoretical assumptions about human evolution. Undeterred, the authors suggest adding additional criteria that are themselves problematic. First, “any disorder in DSM should have diagnostic validity” on the basis of a number of key validators, which they admit are variable and may not be readily available, but “in their absence . . . other evidence of diagnostic validity is helpful.” Second, any disorder in DSM “should have clinical utility,” another potentially tautological or meaningless criterion that would exclude almost no human distress, because someone somewhere can always claim that an effective treatment for it exists. Allen Frances, the chairperson of the DSM-IV Task Force (who presided over an enormous expansion of the mental disorder vocabulary and population), surprisingly summarized the definitional difficulties in the plainest terms: “There is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it” (Greenberg, 2011).

In 2007, in one of his many statements about the nature of “mental illnesses as brain di...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Preface
• 1. Illusions of Psychiatric Progress
• 2. The History and Historians of Madness
• 3. The "Therapeutic" Coercion of the Mad in the Community
• 4. And DSM Said: Let There Be Disorder
• 5. The Failure of Descriptive Diagnosis
• 6. Dancing with Drugs
• 7. From Drugs to Medications—and Back
• 8. The Structure of Mad Science
• Index