Abstract
As anyone familiar with the history of twentieth-century psychiatry knows, the field has been wracked on and off since World War II by often bitter disagreements over the fundamental cause and most effective treatments of mental disorders. On the one side are those researchers, educators and clinicians who argue that psychiatric diseases are caused by biochemical factors and are therefore as natural as cancer, heart disease or diabetes. Such a viewpoint is usually called ‘the biomedical model’. On the other side of the debate are those who contend that psychiatric diseases are due to emotional disturbances largely caused by a patient’s environment, notably human relations with family members or authority figures in society. To the chagrin of many in the latter camp, the biomedical model swept to ascendancy in the 1970s and continues to dominate the field in the early twenty-first century, thanks largely to the enormous consumption, marketing, and manufacturing of psychiatric drugs around the world.
In this debate Michael Staub in Madness Is Civilization tries to take a middle position, but his sympathies clearly lie with the ‘environmentalist’ camp. As he writes: ‘biological data alone cannot fully explicate the complex contributory sources’ of mental illnesses (p. 193). Staub is heartened by the signs that psychiatry is ‘in the process of (again) changing its mind’ (p. 190), and fondly looks back to an era in the history of psychiatry when the ‘psychosocial risk factors’ for mental disease were taken more seriously than in 2010. Indeed, his book’s main strength is that he revisits the period spanning the early 1950s to the 1970s, a time when ‘social diagnoses of madness’ were in vogue and (not coincidentally) anti-psychiatric ideas flourished as never before. Critics of psychiatry had been around for over a century but nothing compared with the torrent of attacks on the field launched by individuals such as Michel Foucault, Erving Goffman, RD Laing, Ken Kesey and Thomas Szasz. Staub is to be commended for reconstructing this volatile, influential and largely neglected era in the history of psychiatry, as well as his coverage of research into the family origins of severe mental diseases during the 1950s. Anti-psychiatry and such family studies, argues Staub, left researchers unable to answer the question: what were the differences between healthy and sick families. Without clear-cut distinctions between mental health and mental illness, it was easy to conclude (as many did in the 1960s) that there was no such thing as a mental disease, strictly speaking, and that only ‘good fortune and chance’ – not biology – saved someone from madness (p. 50).
As Staub notes, it was the very success of Szasz and company in changing minds about psychiatry which sparked a backlash that paved the way for the rise to power of the biomedical model, spearheaded by the 1980 publication of the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Diseases (DSM). Staub’s thesis is that the time has come for a recovery of the many insights into psychosocial development which flared brightly in the 1960s.
Yet in making the argument for ‘reintroduc[ing] highly sophisticated and deeply thoughtful attention to environmental risk factors’ (p. 194), Staub never quite shows how such a return will solve the biggest problems facing the mental health care field in the early twenty-first century. He does an admirable job of documenting how the anti-psychiatry movement warned about the onset of a ‘therapeutic state’, in which experts reduced all conflict and struggle in life to psychological categories and people sought emotional fulfilment from their therapists rather than engage in the world around them. The therapeutic state, based on the notion that the boundaries between mental normality and abnormality are blurred, justifies the relentless expansion of diagnoses over the last half century just as surely as does the biomedical model. The number of diagnoses in the DSM has more than tripled since the first edition in 1952. There is worrisome over-diagnosis of emotional and cognitive problems in children in the name of prevention and treatment. Similarly, experts predict that the upcoming DSM-V will broaden the criteria for social anxiety disorder, a diagnosis already reaching epidemic proportions. Ethan Watters and others have warned about the globalization of the American psyche currently underway, involving the exporting of western diagnoses such as depression, post-traumatic stress disorder and anorexia nervosa to Third World cultures where these symptom clusters were unknown until very recently. The cost alone to third-party insurers of these developments threatens to bankrupt mental health care services. At the very least, such trends divert valuable resources from the severely ill, such as schizophrenics, to the so-called ‘worried well’. Madness Is Civilization has very little to say about all this.
Ultimately, Staub’s call for a return to a time when psychiatric diagnoses were social fails to answer the biggest question looming over twenty-first century mental health: how do all the stake-holders in the mental health care system unite, stand athwart history and yell ‘stop’ to the widening boundaries of mental illness?