In my October column I discussed the concept of medicalization and its role in modern societies. In this column I propose to answer the question: How are we to understand the contemporary confusion about what counts as a disease?
Medical classification—the linguistic-conceptual ordering of phenomena we call “diseases” and of the interventions we call “treatments”—is a human activity, governed by human interests. In the United States today, the forces of medicalization rule virtually unopposed, indeed unrecognized for the economic, moral, and political interests they represent. Our drug policies are illustrative. For millennia, the regulation of drug use was a matter of self-control, custom, religion, and law. In part, this is still the case. More importantly, however, drug use is regulated by laws and ostensibly scientific “facts,” exemplified by a broadly based drug prohibition consisting of prescription laws and criminalization of the trade in many drugs, such as opiates, cocaine, and marijuana. This is drug medicalization from above. Drug medicalization from below is pursued no less zealously by individuals who, while ostensibly opposed to our drug laws, promote so-called medical-marijuana initiatives, physician-assisted suicide, and similar schemes. The result is loss of self-ownership and the right to self-medication—the classical liberal/libertarian perspective on drug use.
Because the mind is not an object like the body, it is a mistake to apply the predicate disease to it. Hence, as I asserted half a century ago, the “diseased mind” is a metaphor, a mistake, a myth.
Actually, this idea is not as novel as it might seem. Emil Kraepelin (1856–1926), the creator of the first modern psychiatric nosology, acknowledged the fundamental analytic truth that there are no mental illnesses. In his classic, Lectures on Clinical Psychiatry (1901), he stated: “The subject of the following course of lectures will be the Science of Psychiatry, which, as its name [Seelenheilkunde] implies, is that of the treatment of mental disease. It is true that, in the strictest terms, we cannot speak of the mind as becoming diseased.” Half a century earlier, the Viennese psychiatrist Ernst von Feuchters-leben (1806–1849) explicitly emphasized the analogical-metaphorical character of mental illnesses: “The maladies of the spirit alone, in abstracto, that is, error and sin, can be called diseases of the mind only per analogiam. They come not within the jurisdiction of the physician, but that of the teacher or clergyman, who again are called physicians of the mind/soul only per analogiam.”
The transformation of religious explanations and controls of behavior into medical explanations and controls of behavior is one of the momentous consequences of the Enlightenment. The waning power of religion and the Church and the waxing power of science and the State are manifested, among other things, by the political control of medical practice and the drug laws that deny access to the layperson to drugs (except those classified as over-the-counter). To legally obtain or possess a “prescription drug,” the layperson must establish a professional relationship with a licensed physician and receive a diagnosis for an illness; that is, he must be a patient who suffers from a proven or putative illness. For example, to receive a sleeping pill, the person must “suffer from insomnia.” This charade contributes mightily to the medicalization rampant in our society. In turn, medicalization is mindlessly equated, especially by the cognoscenti, with scientific, moral, and social progress, and contributes further to its popularity.
Although medicalization encompasses more than psychiatry, we must be clear about one thing: Psychiatry is medicalization through and through. Whatever aspect of psychiatry psychiatrists claim is not medicalization, is not medicalization only if it deals with proven disease, in which case it belongs to neurology, neuroanatomy, neurophysiology, neurochemistry, neuropharmacology, or neurosurgery, not psychiatry.
Psychoanalysis is medicalization squared. It is important, in this connection, not to be fooled by lay analysis, clinical psychology, or social work. These and other nonmedical mental-health and counseling “professions” are medicalization cubed: as if to compensate for their lack of medical knowledge and qualifications, nonmedical mental-health “professionals” are even more deeply committed than psychiatrists to their claim of special expertise in the diagnosis and treatment of mental illnesses.
By the time Sigmund Freud (1856–1939) appeared on the historical stage, medicalization was in full swing. The birth of psychoanalysis is, in fact, a manifestation of the increasing popularity of this trend at the end of the nineteenth century as well as a cause of its explosive growth during the twentieth century. The gist of Freud’s thesis was that the symptoms of mental illnesses are the “products” of the same “mental processes” that are responsible for the thoughts and actions of normal persons. In other words, Freud rediscovered that “there is method in madness,” or as he preferred to put it, that sane and insane behaviors are subject to the same “psychological laws.” To create his special brand of pseudoscience, he titled his book The Psychopathology of Everyday Life. He could just as well have titled it The Everyday Normality of Psychopathological Life. There would, of course, have been neither fame nor fortune in that. Instead, he fanned the flames of medicalization and transformed a smoldering fire into an all-consuming conflagration. At the same time, because he knew better, Freud’s attitude toward medicalization was ambivalent and opportunistic.
People do not have to be told that malaria and melanoma are diseases. They know they are. But people have to be told, and are told over and over again, that alcoholism and depression are diseases. Why? Because people know that they are not diseases, that mental illnesses are not “like other illnesses,” that mental hospitals are not like other hospitals, that the business of psychiatry is control and coercion, not care or cure. Accordingly, medicalizers engage in a never-ending task of “educating” people that nondiseases are diseases.
Formerly, people felt depressed or were depressed. Now they have depression. Formerly, some depressed persons killed themselves, but most did not. Now people do not kill themselves, depression kills them, and (virtually) everyone who kills himself is said to have been depressed. And just as people can have cancer and not know it, so they may have depression and not know it, and hence need to be tested for it, lest “it” kill them. On its website, the Depression Is Real Coalition emphasizes: “Indisputable scientific evidence shows depression to be a biologically-based disease that destroys the connections between brain cells.”
Cui bono? The peddlers of psychiatric snake oil who are unfailingly silent about two important risks inherent in every professional contact between an individual and a psychiatrist, namely, stigmatization by psychiatric diagnosis and loss of liberty by psychiatric incarceration. Why do the promoters of psychiatric slavery regularly fail to mention the potential downside of “mental health services”? Because they self-servingly define psychiatric oppression of the patient as beneficial for him, much as the promoters of chattel slavery regarded oppression of the slave as beneficial for him. Lincoln’s answer to this outrage remains relevant: “But, slavery is good for some people! As a good thing, slavery is strikingly peculiar, in this, that it is the only good thing which no man ever seeks the good of, for himself.”
In short, medicalization is neither medicine nor science; it is a semantic-social strategy that benefits some persons and harms others.
“[T]he medical treatment of [mental] patients began with the infringement of their personal freedom,” warned Karl Wernicke (1848–1905), the pioneer German neuropathologist. It still begins with the infringement of their personal freedom.