Pharmacracy, Medicine and Politics in America

I only gave this book 3 cups because I found it a little hard to read. However, it has some great information in it, some of which I will quote. I can't say that I totally agree with everything the author says in the book, but I think he has many things right.

The author shows that 'mental illness' is a misnomer. He also shows how we have started attributing bad behavior to disease, making the person who committed the wrong blameless. We no longer require people to do right, if they can claim they have a disease. He shows in the book how America is doing what the Soviet Union did and what Nazi Germany did, yet we are embracing it and calling it good.

The truth is that no psychiatric diagnosis - not merely this or that one - names a condition that meets the classic pathological criterion of disease. (page 31)

Troy Duster, professor of sociology at the University of California, in Berkeley, phrases it more professionally: "Once the third party steps in to pay the physician for delivering health-care to the patient, the interests of the third party will typically supersede those of the patient." Economists recognize that once people  cease having to pay for the medical services they want, the demand for services skyrockets. It is odd, then, that economists and health-care policy experts refuse to recognize that once the physician ceases to be paid directly by his patient for the services he wants, and is instead paid by others to deliver services the patient ostensibly needs, the physician's propensity to make certain diagnoses or discover new diseases by creating disease names skyrockets. It is even odder that the experts stubbornly deny that, in the West, the first physicians paid for their services by the state rather than their patients were the mad-doctors, now called "psychiatrists": that psychiatrists were the first manufactures of diagnoses masquerading as diseases; and that, ever since, psychiatrists have been leading producers of the conceptually and economically important commodity we call "mental illnesses." (page 39)

Once governments decide that it is their duty to provide health care services for people, recourse to some mechanism to determine "medical need" and "effective treatment" becomes a practical necessity: Health-care bureaucrats, economists, and statisticians promptly rise to the occasion and develop "fair" and "equitable" schedules of reimbursement. (Private health insurance companies follow their lead.) Thus begins the game in which hospitals and physicians are the principal players: Winning means maximizing reimbursement by placing every patient into the most financially favorable diagnostic category. (page 43)

In the short, the term "psychiatric disorder" is useful because it enables psychiatrists to waffle: "It" may be a disease, or may not be; may render the patient incompetent, or may not; may annul intentionality, but not necessarily; may cause dangerousness to self and others, but not always; and be an excuse for crime, and may not be. It all depends on the psychiatrists' interpretation of their so-called clinical observations. This discretion enables them - aided and abetted by other physicians, lawyers, politicians, journalists, and the general public - to transform personal, marital, moral, political, social, and spiritual problems into mental diseases. (page 79)

Similarly, psychiatrists base their clinical diagnosis on the patient's appearance and behavior. For example, a patient may appear to be sad and his wife may report that he has threatened to kill himself, and the psychiatrist may attribute the problem to depression. Here the similarity ends. There are no objective diagnostic test to confirm or disconfirm the diagnosis of depression; the diagnosis can and must be made solely on the basis of the patient's appearance and behavior and the reports of others about his behavior. (page 81)

The person who views brain disease as a material entity or process and mental disease as a nonmaterial construct, and who nevertheless wants to defend the disease status of mental illness, faces a dilemma. Either he must conclude that the term "mental illness" is a metaphor or he must recast the definition of illness from biological terms to socioethical terms. Many psychiatrists recognize that they do just that, but they do not acknowledge that by so doing they redefine the concept of disease. (page 91)

Today, psychiatrists are divided between those who endorse the scientific definition of disease and claim that mental illnesses are brain diseases, and those who reject or ignore that definition and instead boldly embrace criteria for what counts as illness completely unrelated to it. The views of Lawrie Reznek, author of A Philosophical Defense of Psychiatry, exemplify the latter approach. He writes: "Whether we ought to punish serial killers or treat them is not something that depends on the facts… If we feel we ought to treat psychopaths, then they are ill. If we feel they should be punished, they are not… It is our intuition that we ought to be treating depressive and schizophrenic murderers that leads us to classify them as ill and therefore not responsible. On the other hand, it is because of our intuition that we ought to be punishing Nazis that we do not classify them as ill." In other words, Reznek proposes to replace the descriptive-biological concept of disease with a tactical-political concept of it, seemingly unaware that this method was popular in both Nazi Germany and the Soviet Union. (page 92)

Let us keep in mind that physicians cannot treat competent adults without their consent; cannot treat (incompetent) minors without the consent of their guardians (typically, the parents); and cannot treat incompetent adults (disabled by medical illness) without the consent of their guardians (chosen by the patients in advance directives or appointed by courts). The guardians of medical patients are never the physicians who treat them. In medical practice, treatment decisions for incompetent patients are made by their guardians, not their physicians. By contrast, in psychiatric practice, competent patients are routinely treated against their will and treatment decisions are routinely made for them by their treating psychiatrists (whose decisions are, if necessary, routinely rubber-stamped by judges). (page 96)

As long as we regard mental illness as a cause of crime, much as we regard the AIDS virus as a cause of HIV infection, established psychiatric practices will endure. Whenever a person factually guilty of a serious crime pleads insanity, the jury is asked to answer a stupid question, namely, what "caused" the defendant to commit his wrongful act: his self or his illness? If the former, then he is a guilty victimizer. If the latter, then he is an innocent victim. The question is badly framed. Regardless of whether a person is deemed sane or insane, a person has reasons, not causes, for his actions. If we reject the actor's reasons as absurd, crazy, or meaningless, then we consider and call him mentally ill. That, however, hardly constitutes proof that his alleged condition caused him to commit the forbidden act. In short, the insanity defense combines and conflates two problematic aspects of mental illness: 1) What is it as a phenomenon? (2) Does it cause and excuse bad behavior?

For the sake of clarifying the issue before us, let us admit as true the erroneous claim that insanity is a brain disease. In that case it is similar, say, to parkinsonism or a stroke, brain diseases diagnosed and treated by neurologist. A brain disease may, indeed, be a cause. But a cause of what? Typically, of a functional deficit, such as weakness, blindness, paralysis. No brain disease causes complex, coordinated behaviors, such as the crimes committed by John W. Hinckley, Jr.

The insane person, is, after all, a person, a  human being. "The madman," as Gilbert K. Chesterton put it so memorably, "is not the man who has lost his reason. The madman is a man who has lost everything except his reason." Only legal tradition and psychiatric-professional self-interest, not facts or logic, compel the law to frame the jury's task as a choice between deciding whether an insane defendant is bad or mad - guilty (by reason of free will) or not guilty (by reason of insanity). If a person guilty of assault or murder is deemed to be mentally ill, he should be sentenced for his crime, imprisoned, and offered treatment for his "illness"; that is, he should be dealt with just as we deal with the criminal who has diabetes or tuberculosis. Millions of people are said to be mentally ill, but most of them do not commit crimes. (page 96-97)

The assertion that "all mental processes are ultimately biological" sounds better than it is. It is the principle that leads us to attribute suicide to depression, and depression to neurotransmitters - which is like attributing marriage to lust, and lust to hormones. If, as I noted, everything that happens to or is done by human beings is biological, then saying so is a meaningless truism. Attributing mental illness, such as addiction and panic disorder, to biological alterations occurring at a "subcellular level" is a parody of the denial of free will, choice, and responsibility. Scientists require strict proof before they accept an etiological explanation for an infectious or neoplastic illness. Psychiatrist and the public uncritically accept unproven claims as an etiological explanation for mental illness. (page 104)

When I say that mental illness in not an illness I do not deny the reality of the behaviors to which this term points, or the existence of the people who exhibit them, the suffering the denominated patients may experience, or the problems they create for their families. I merely classify the phenomena people call "mental illnesses" differently than do those who think they are diseases. When a lesion can be demonstrated, physicians speak of bodily illnesses. When none can be demonstrated, perhaps because one exists, but when physicians and others nevertheless want to treat the problem as a disease, they speak of mental illnesses. The term "mental illness" is a semantic strategy for medicalizing economic, moral, personal, political, and social problems. (page 115)

To future students of American history, 1999 by well seem like a peaceful year. This is not the way the medicalizers of life see it. "The world as we approach the millennium," intones a physician in JAMA, "is full of horrific events, in addition to warfare, that can lead to posttraumatic stress disorder (PTSD). Survivors of natural disasters and life-threatening violence, including recent attacks at schools, religious centers, and other venues not normally associated with bloodshed in the United States, may develop PTSD, particularly if they do not receive mental health care."

Since the diagnosis of PTSD rests on the concept of trauma, we must be clear about what we mean when we use the term. Webster's primary definition of trauma is "an injury or wound to a living body caused by the application of eternal force or violence".  The diagnosis of PTSD, like that of mental illness itself, thus rests on metaphorizing the word "trauma," changing its meaning from physical injury to the body to psychological injury to the mind. Making the diagnosis does not require that the subject suffer an actual injury. Having witnessed a "traumatic situation" is enough. Every such witness is presumed to suffer from or is a candidate for PTSD, unless he receives prompt mental health care to prevent it.

PTSD is now routinely imputed to people, especially to children helpless to reject the label. A child is murdered or kills himself. Instantly, his classmates - perhaps all children in the school - become patient fodder for "grief counselors," forcibly imposed on them by heal care commissars of the therapeutic state. Adults, too, are treated as if they could not manage their own grief unassisted by helpers they do not seek. A plane crashes. Relatives and friends of the victims are met by "grief counselors." What in the past Americans would have considered ugly meddling, they now accept as medically sound mental health care. (page 150-151)

In the United States today, the indoctrination to help - actually, to judge, condemn, report, and stigmatize - other people's behavior, from relatives to schoolmates, begins in early childhood and never ceases. The view that certain disapproved or disliked behaviors are not necessarily "problems" and might not be the business of others is considered heresy. The individual as informant -"helping" others with their "health problems" - has become our ideal of the "responsible" person and model citizen. The fact that many such persons are unwilling or unable to assume responsibility for their own behavior only enhances their image.

It takes a lot of helpless people to keep all the helpers happy, and the helpers, thanks to their diligence and army of informants, are never at a loss to find people who are in dire need of their help. This is where medicalizing everyday life becomes useful. Most people have come to accept - apparently without anyone in a position to object - that bad deeds are due to diseases and hence the doer is blameless, while good deeds are due to free will and hence the doer deserves credit for them. (page 151)

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