W/O)9/J)/J/eraJ

C Hr’fl - ‘y /3Liberal “Mental Health” Reform: A “Fail-Proof” Way to Fail -by Bonnie Burstow

An ever growing number of people are aware that something’s horrendously wrong withpsychiatry—survivors, families, professionals, psychiatrists themselves. Of these asubsection has become actively involved in trying to bring about change. All of which isgood. This notwithstanding, sincere and dedicated though almost everyone is—and it isclear that people are—only a tiny percentage of these are pressing for anything trulytransformative (something beyond the humanistic correctives or additions typically called“reform”). Without question, what people are advocating is of enormous importance. Forexample, for the most part reformers take seriously the deprivation of human liberty andthe reductionism that characterizes psychiatry—and yet somehow they fall short of lettinggo of either the paradigm or the practice. What do people call for? They want lessincarceration, but are not asking it be stopped. By the same token, people call for lessdrugging, while accepting that doctors will continue to prescribe psychiatric drugs. Mostwant to eliminate certain of the diagnoses, while holding tenaciously to others (e.g.,Horwitz, 2002). For obvious reasons—and who could argue with this?—the majoritystipulate that there must be free and informed consent—but not for everyone, and even atthat, there is little evidence that people are giving much thought to how such a thingwould be possible with anything even vaguely resembling the institution as we know it.And the vast majority favour a major expansion of humanistic services such ascounseling and housing as well the introduction of voluntary outreach services whereinhelpers turn up at people’s homes to assist with crises—good in itself, however, onceagain while leaving biological/institutional psychiatry relatively in tact. What goes alongwith this, they want a team approach, with psychiatry only one member of that team.Albeit, of course, there are variations here and there, and some reformers go considerablyfurther than others, here basically is the reformist position. Now I am in no wayquestioning the intentions or the soundness of many aspects of the position. There are anumber of problems with it, however, not the least of which is the fact of leavinginstitutional psychiatry in tact—the elephant, as it were, in the room.

Underpinning the reformist stance, whether it is expressed or not, is the contention thatpsychiatry has something to offer, is worth retaining, moreover, that to do otherwise isreckless. Allen Frances (2014), by way of example, refers to antipsychiatry activists as“blind ideologues” and talks as if it were an indisputable fact that there is “good” and“bad” in psychiatry. His solution, correspondingly, is for the sensible people—the“moderates”—to join together to create the reforms needed (see Frances, 2014).

How is it that the situation gets viewed this way? Obviously there is no simple answer tothis question for reformers differ from one another. Of survivors who are reformers, someare reluctant to phase out psychiatry because they feel that they themselves or people theyknow have benefited from the “services”. Many professionals are likewise so convinced.Professionals, including ones that courageously challenge their own profession,additionally, have vested interests that willy-nilly come into play. Then there is the moregeneral problem: that we all us have difficulty thinking very far beyond what currentlyexists, never mind trusting anything substantially outside the current frame. The pointhere is, changes that are revolutionary inherently strike us as immoderate or to use Allen

Frances’s word “extreme”. All understandable. Nonetheless, let me suggest that thereformist position begs the question.

The purpose of this article is to problematize the reformist stance and the beliefs andtendencies underpinning it. I begin by problematizing the biases surrounding the conceptof moderation. I go on to theorize why something more substantial is called for. Thearticle culminates in an investigation of some uncomfortable truths about the profession,the reality of the various industry interests, and what history has to teach us.

Thinking Beyond “Moderation”

As a species, we have a tendency to think that moderation is always and inevitably best(hence the “middle way” in Buddhism, balance in Aboriginal thought, and the goldenmean in Aristotle). Without question, this bias frequently serves us well. I put it to thereader that there are times, nonetheless, when the concept is inapplicable and/or whereemancipatory principles dictate a pronouncedly different course of action. For example,would we really want to embrace a middle way between murder or rape on one hand, andrespecting the bodily integrity of others on the other? And more pointedly, what wouldhave befallen the major liberatory advances in history had visionaries bowed to theimperative to be moderate? Take the institution of slavery. We would have far morepeople enslaved today if we automatically assumed that the ostensibly “extreme”position—actually abolishing slavery (as opposed to, say, “humanizing” it or resorting toit less often)—was a reckless and otherwise unwise thing to do. And note, abolition didindeed look reckless to the “moderates”. What is clear, in other words, is that what seemslike “sensible moderation” seems that way from a particular vantage point and whatstrikes the average person as moderation, as such, is hardly unassailable. That said, thequestion arises: Under what circumstances is abolition a more sensible course of actionthan reform? While this of course is a complex issue, let me suggest that viable indicatorsare: I) when the practice in question overwhelmingly harms people and 2) when it isinherently oppressive. Auxiliary indicators—and these too can legitimately enter in andin certain cases be pivotal—are when its foundational tenets have repeatedly beendemonstrated to be fallacious, also, when it is backed by a massive industry that by hookor by crook is intent in maintaining the status quo or worse. Lest readers have not as yetnoticed, all of the above pertains to psychiatry.

To begin with the first two, touching quickly on the incarceral and control mission (and itis a historical accident that psychiatry is in charge of this), it is clear that substantiallydepriving people of freedom and control is personally hurtful, however small the numbersand whatever the rationale. Nor is the alleged ‘dangerousness” an acceptable rationale,for there is no evidence that the “mentally ill” are any more dangerous than the averageperson. To be clear, it goes without saying that people should be stopped from harmingothers, whether or not the “transgressors” are deemed “mentally ill”, that actions musthave consequences, that there are moments when figuring out how to enhance anindividual’s safety is far from easy. At the same time, as peacemaking criminologists(e.g., Pepinsky and Quinney, 1991), and critical disability theorists (e.g., Ben Moishe,Chapman, and Carey, 2014) have so cogently argued, a regimen of imprisonment and

control is at once injurious, of dubious value in enhancing the safety of anyone, and ismorally unacceptable. To turn to the “treatments” per se, as documented by critics likeBreggin (1991), the “treatments” overwhelmingly damage people. That is, they give riseto actual brain damage, result in disorders such as tardive dyskinesia, horrific conditionssuch as memory and cognitive impairment. While reformers want to make exceptions forcategories like schizophrenia, suggesting that in such cases “treatment” is necessary, Iwould add, studies clearly establish that mainstream convictions to the contrary,“schizophrenics” never once on the drugs fare better in the long run than any other groupof”schizophrenics” (see Harrow, 2007 and Rappaport, 1978). In other words, even whenit seems as if the opposite were transpiring, everyone is being harmed. The inherentoppressiveness of psychiatry, additionally, is common knowledge among survivors andreformers alike, though one need only look at the classical signs of oppression to realizethat it permeates the industry—the daily coercion, the incarceration, the surveillance andcontrol, the targeting of the “genderized” and the “racialized”, the us-them division, thevery use of concepts like “normal” (for details on how such ruling plays out, see Burstow,2015). Nor would moderating this element eliminate the oppressiveness at the core.

To proceed to this next indicator—and I would suggest this is pivotal—we are blatantlydealing with faulty foundations. The point is that the basic psychiatric concepts and tenetshave no validity either empirically or conceptually. In this regard, as researchers likeBreggin (1991) and Colbert (2001) have repeatedly demonstrated, there is no proofwhatever that any of the so-called “mental illnesses” are bone fide diseases. Nor doconcepts like “mental illness” hold up to scrutiny. As Szasz (1961) so adroitly put it yearsago, irrespective of whether or not people are floundering, it is a category confusion tocall ways of thinking and acting per se a disease. In essence, a medical overlay is butbeing slipped over distressed or distressing ways of thinking and acting. This being thecase, it is no accident that the treatments profoundly harm. Treat people for non-existentdiseases, “correct” imbalances that exist nowhere except in psychiatric credo, and younecessarily create real imbalances and in the process do untold harm. Herein the verynature ofmedicine—what it is and what it does—is all important. Note, in the vastmajority of disciplines and professions, the invalidity of the basic tenets would not in andof itself necessitate abolition or even always make it desirable. It is precisely becauseinvalidity and inevitable harm come together in psychiatry that abolition is critical.

Before I proceed to the other indicators, I would pause to touch on some of the objectionslikely to be posed to my points to date. The first is that there are “extreme cases” wherepsychiatry is needed. Let me suggest, the fact of people being in terrible straits in nomakes something medical when it otherwise is not. If there is no disease, no matter howdire the problem, treating a person as if they had a disease and thereby harming themcannot be acceptable. Equally unacceptable, I would add, is the handling of misery andconflict by resorting to incarceration, surveillance, or control.

A second common place type of objection is predicated on the understandable belief thata plethora of services should be available—and so why not psychiatry?—especiallyseeing as so many people favour the drugs. A quick response is that the state should notbe involved in injuring people, irrespective of whether or not doing so is called

“services”. Moreover, it is blatantly unethical to present and/or promote something as is ifit were a medical treatment in the total absence ofmedical validity. Nor is it the case thatthe elimination of psychiatry would narrow the options available. In point of fact, giventhe amount of money spent on psychiatry and the promotion thereof, eliminate psychiatryfrom the picture, and—presto—there would be ample resources to make a plethora ofoptions available. Additionally, note, abolition does not require that people be deniedaccess to psychopharmaceutical drugs—only that they not be approached as if medical,not promoted, and not prescribed by doctors.

A final objection that I would touch on is predicated precisely on faith of how far areform agenda can transform psychiatry. The contention here would be that in the worldbrought about by a reform agenda, there would be no reason to get rid of psychiatry for itwould just be one ofmany disciplines that converge on the territory. Additionally,psychiatry would itself be reformed, with psychiatrists for the most part providingcounseling or other such supportive services.

Tackling the first part of this objection brings to the fore the whole issue of power and ofdiscourse. Hypothetically, we have a team approach now, but set foot in any hospital andit is clear that one player and one position dominates. Nor do words like “dialogue” alterthe situation. The point is that even with benign intentions, dialogue can only go so farfor the terms of the dialogue are already set/constrained by the psychiatric paradigm. Tovarying degrees, the same may be said of reform within psychiatry. What is equallyfundamental, there are structural realities, vested interests, and contradictions at play thatwe gloss over to our peril.

A crucial factor being ignored here is that medicine is a bad fit, indeed a misfit insofar thedirection sought is non-medical (nor are most medical people likely to excel at it).Correspondingly, there is a palpable danger involved in entrusting this direction, orindeed, any part of it, to psychiatry. Whatever might transpire in the short run—and ofcourse there are individual psychiatrists who are trustworthy —why would we think thatin the long run psychiatry (translation: institutional agents whose very profession isposited on emotional problems being medical) are likely to give up or even substantiallyqualify what, in essence, is the sole basis of their profession? If the point being madeseems confusing, look systemically at what we are dealing with here. Aside from thepower attributed to it, this profession is distinguishable from others such as psychologyby one sizable dimension only—the insistence on the medical. By the same token, look atwhat prepares psychiatrists for the tasks ahead. Psychiatrists in-the-making are peoplewho take extensive training in medicine as if such problems in living were bone fidemedical issues. Indeed, even at the residency stage, they rotate between the variousmedical specialties—biology, anatomy, and so forth—before they even approach“psychiatry” per se. Even were more counseling training added to the mix, the point is itremains part of the faculty of medicine, remains a “medical discipline”, and, indeed, istheorized and taught as such, with all the baggage which that entails.

That said, let us look more closely at this institution. Insupportable though the medicalconceptualization is, psychiatry is “medicalized” through and through. Note, it is presided

over by “doctors”; it is assisted by “nurses”; and its pivotal work happens in places called“hospitals”. Correspondingly, it specializes in the use of substances defined as medical;and its discourse is medically framed (witness, in this regard, the prevalence of terms like“pathology”, “disorder”, “symptom”). Whatever psychosocial factors are added on, being“medical”—as it were—is its defining feature. Which brings us to some key structuralissues: To whit: In the long run, how could be in the interests of a medical institution tosupport any substantial de-medicalization—given medicine is precisely the ground onwhich it stands? By the same token, in the long run how could it be in psychiatry’sinterests to give up what the profession has spent centuries solidifying—their commandover the “madness turf”? Which is not to say that individual psychiatrists are not sincereabout demedicalizing, or the profession as a whole might not be willing to entertain suchdirections at a moment of crisis. What happens in a crisis and what will be supported longterm, however, is a different matter altogether. Bottom line: In the long run, it simply isnot in psychiatry’s interests to demedicalize, decentre itself, or stop expanding. Whatadds to the conundrum, while all institutions to varying degrees pursue their own interest,history teaches us that discourses about care notwithstanding—medicalization,dominance, and expansion has been overwhelmingly what the institution of thepsychiatry is about. This is the profession that historically drove out all competitors—theastrologers, the women healers, for example. This is the profession that sought andgained police powers. And this is the profession/industry that has been intent on declaringever more people “mentally ill” (for details, see Conrad and Schneider, 1984).

What relates to this, from a business point of view (and psychiatry is nothing if not aseries of interrelated businesses), it is obvious that what we are dealing with is a massiveindustry, all parts of which have self interests. Correspondingly—and again, we lose sightof this to our peril—all of these parts are not simply incompatible with but dramaticallypull in the opposite direction than the reform agenda. By way of example, the interest ofthe psychiatric research industry is to continue expanding on one hand and satisfying itsfunders on the other (that is, producing ever more research studies and research resultswhich in some way promote the prevalent treatments and agendas). By the same token,the interest of the shock industry is the continuation and spread of ECT. Of theseindustries, of course, none is more formidable that the pharmaceutical industry.

Profit transparently drives the pharmaceutical industry. And significantly, reform of thetype envisioned will willy-nilly hurt pharmaceutical profits, in other words, transparentlyconflicts with Big Pharma’s interest. (The fact that progressive psychiatrists would like tosee less drugs used, I would add, is beside the point). A demedicalizing of the area doublyconflicts with psychiatry’s interest for, as demonstrated by researchers such as Whitaker(2002 and 2010), psychiatry itself is utterly dependent on pharmaceutical funding fortheir massive research projects, their publications, their educational endeavours. To putthis another way, psychiatry needs the multinational pharmaceutical industry. Ergo,anything that hurts that industry hurts psychiatry. Indeed, at this juncture, the veryexistence of psychiatry is dependent on the pharmaceutical industry; and as such, as theprofessional elite are well aware, breaking with this industry in any substantial waywould be the proverbial kiss of death. The upshot? Despite how individual psychiatrists

may proceed, this is not now, and short of a new somaticizing benefactor materializing,cannot be the ultimate direction of the profession.

In short, besides that psychiatry is foundationless and by its nature harms, we cannotarrive at a better dispensation in the long run if psychiatry is included—not even a newand improved psychiatry. We cannot because it undermines the very raison d’etre of theprofession. We cannot, ultimately, because it is not in psychiatry’s interest, not in theinterests, that is, of the profession, the industry, or the myriad of industries surrounding it.What likewise needs to be factored in, biological psychiatry has a long history ofreasserting dominance, whatever seemingly benign turns are taken in the short run, for itdoes not for long lose sight of where its interests lie. In this respect, we have, as it were,“been there and done that” already—and the outcome was anything but reassuring. Alesson from history:

There was a moment in “modern” psychiatric history where the relentless push tomedicalize and to dominate indeed appeared to be curtailed, and beyond that,substantially reversed. This was with the spread of psychoanalysis and the concomitantrise of the talk therapies. Freudian psychoanalysis was so successful as a movement(however one may judge its tenets and practice) that throughout North America itchanged the face of psychiatry, bringing the psychological as opposed to the medical tothe fore. What is additionally apropos, Freud opened up psychoanalysis to non-medicaltherapists—which itself helped give rise to the spread of a huge variety of talk therapiesand this by “lay” practitioners of various types—psychologists, social workers.Corresponding, increasingly, despite obvious limitations, the agenda was humanist withvarious new and creative way of working with people imagined. The parallels with whatis being sought today are obvious. Then a huge reversal set in. While the full story is toocomplicated to go into here, the salient point is that demedicalization was not in theinterest of psychiatry, and beyond that, what became progressively obvious to thepsychiatric elite is that their interest, on the contrary, lay in medicalizing to a pointbeyond anything heretofore imagined. Hence the unprecedented surge of biologicalpsychiatry and the advent of the highly medicalized DSM-III (transparently “medical”despite the claim to being etiology-free). Hence the declaration that “mental illnesses”were “brain diseases” (e.g., Andreason, 1984). And hence the alliance between psychiatryand the drug companies and the advent of what is euphemistically called “the drugrevolution”. All of which was possible, note, because institutional psychiatry had never inany way been dismantled. Now to be clear, it is not just that the ground gained was lost.The situation which materialized was exponentially worse than what had precededpsychoanalysis, for everything became grist for biologizing agenda—even thepsychoanalytical categories themselves. You can get a quick sense of how this transpiredby looking at what happened with the “neurotic complaints” (originally spearheaded bythe analysts). It is not that these were thrown out by biological psychiatry. Along with thevarious “psychoses” and the various other biological inventions, they were given abiological frame and added to the mix—with the result being an exponential growth inthe number of “mental disorders” in DSM-III, and, in essence, the pathologization ofevery day life (to trace this development, see Kirk and Kutchins, 1997).

Now it might be argued that what happened here arose from a unique concatenation ofcircumstances, and as such, liberal reform is not doomed to fail. While logically that istrue, I would remind readers that a similar dynamic played out centuries earlier, after therise of “moral management”—the one other time in history that a type ofdemedicalization had set in. Note, moral management involved approaching roblems inliving as spiritual issues. This, in essence, was the “reform” agenda of the l8 century. Itbeing nonmedical in nature, not only the mad doctors but also lay people practiced it—the most notable being the Quakers (see Tuke, 1813/1996)—a phenomenon that waswidely accepted. What happened? The direction being pursued was hardly in psychiatry’sinterest, and not coincidentally, the Quakers were considerably better at it. Accordingly,over time moral management gave way to the meteoric rise of biologically orientedpsychiatry, the routing of lay people, and ultimately to the birth of the eugenics era.

In this as in a microscope, we can see the problem with non-foundational reform. It is notthat there are no good tenets or good people involved. Indeed there are. Correspondingly,it is not that progressive psychiatrists have no role to play in the initial stages of atransformational process, for again, they do. However, in refusing to take seriously boththe nature and the seif-interestedness of the profession, reform (as opposed to revolution)leaves in tact an inherently problematic institution, legitimizes rule by “expert”, andpaves the way for a return of biologism and of oppression with a vengeance.

And as such, liberal conceptualizations like “mental health reform” do not and cannotserve us well.

Concluding Remarks

In ending, I would reiterate that we are currently at one of those crossroads in history. Tovarying degrees, people are aware that our “solutions” are backfiring. Survivors are vocalabout wanting something different. The general public minimally suspects that somethingis horrendously wrong. “Helpers” from other disciplines are commonly in dismay. Andprogressively, psychiatrists are sensing that the institution is in a crisis. Indeed, with therampant spread of iatrogenic diseases, society itself is in crisis. A terrible reality on onehand, for it bespeaks the harm being done, but a rare opportunity on the other, for crisesare precisely the time when real change is possible. As a society, this is the time to beabsolutely clear what we are about, for the opportunity for fundamental change does notcome often; and it would be a shame to squander the moment. Do we tinker with the“mental health system”, adding more humane services, while retaining psychiatry? Or dowe adopt an abolitionist agenda—that is, slowly break with psychiatry and co-construct awhole new approach to problems in living and, indeed, how we-are-with-one-another?

As you ponder this, I would invite readers to consider: What kind of world would youlike to bequeath to future generations?—To your great grandchildren? To people sevengenerations hence? Ultimately, who should be in charge of society’s needs—thecommunity as a whole (that is, each of us together) or stated-sanctioned “experts” andmega-industries? Who wins and who loses if psychiatric rule continues? And finally, iftempted to speak of “paradigm shift” and psychiatry in one breath, in the words of Black

feminist Audre Lorde, (1984), when in social change history have we ever known the“master’s tools” to “dismantle the master’s house”?

(For this and other articles on this issue, see: http YwI2i2Pi.cl:nessb cgpct c.... Fordetailed elaboration of dimensions touched on in the article, including a visioning ofservices in a transformed society, see Burstow, 2015).

References

Andreasen, N. (1984). The broken brain. New York: Harper and Row.Breggin, P (1991). Toxic psychiatry. New York: Springer.Ben-Moshe, L., Chapman, D, and Carey, A (Eds.). (2014). Disability Incarcerated:

Imprisonment and Disability in the United States and Canada. New York: PaigraveMacmillan,

Burstow, Bonnie (2015). Psychiatry and the business ofmadness: An ethical andepistemological accounting. New York: Palgrave Macmillan.

Colbert, T. (2001). Rape ofthe soul. Tiscam: Kevco.Conrad, P. & Schneider, J. (1980). Deviance and medicalization: From badness to

sickness. St. Louis: The C.V. Mosby CompanyFrances, A. (2014). Finding a middle ground between psychiatry and anti-psychiatry.

Retrieved from http /ivwv nadinarnerca c. orn/20 14/1 Ui het\ um-psychat ‘ -and-anti

Harrow, M. (2007). Factors in outcome and recovery in schizophrenic patients not onantipsychotic medications. The Journal ofMental and Nervous Disease, 195, 406-414.

Horwitz, A. (2002). Creating mental illness. Chicago: University of Chicago Press.Kirk, S. & Kutchins, H. (1997). Making us crazy: DSM: The psychiatric bible and the

creation ofmental disorders. New York: The Free Press.Lorde, A. (1984). Sister outsider. New York: Crossing Press.Pepinsky, H. & Quinney, R. (1991) (Eds.). Criminology as peacemaking. Bloomington:

Indiana University Press.Rappaport, M. (1978). Are there schizophrenics for whom drugs may be unnecessary or

contradindicated? International Pharmacopsychiatry, 13, 100-111.Szasz, T. (1961). The myth ofmental illness. New York: Paul B. Hoeber.Tuke, 5. (18 13/1996). Description ofthe retreat. New York: Process Press.Whitaker, R. (2002). Mad in America. New York: Perseus Books.Whitaker, R. (2010). Anatomy ofan epidemic. New York: Broadway Paperbacks.