Biology as Ideology (2008)

From the June 2008 issue of the Socialist Standard

For over 40 years there has been an increasing momentum to the wholesale medicalisation of human and social problems

It was in the late 19th/20th centuries that the notion of conceiving of distress/madness as a ‘mental illness’ came to predominate. In particular, the work of Emil Kraepelin, and the notion of trying to classify distress into a number of discrete psychiatric disorders, and that these disorders were diseases of the brain, and that these diseases of the brain were categorically distinct from the normal brain and normal behaviour.

For the last hundred years biological psychiatrists have been looking for pathologies in the brain to explain the different symptoms that ‘patients’ present. What with the 1990s being declared the Decade of the Brain, and with the Human Genome Project, they have had a good twenty years to propagate their view. Indeed, for over 40 years there has been an increasing movement towards the wholesale medicalisation of human and social problems. Virtually every problem is conceived as something that can come under the scrutiny not only of medicine in general but psychiatry in particular. Who are the gurus on TV and the press to whom we turn to for solutions to our personal and societal problems—Dr. Mark or Dr. Joan! The politics is taken out of problems. It is not social conditions that require changing—it is our biology. And for ‘mental illness’, this means the resort to pills—the chemical balance of your brain needs to be adjusted.

Today, the bible of psychiatric approach to human misery is the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV). When it appeared in 1994 (only 7 years after DSM-II), it was some 900 pages long (a revision is due in 2010 and is expected to be 1250 pages). Within DSM are over 300 diagnoses. If you feel in need of a diagnostic label you are sure to find one here.

Over the years of revision from DSM in 1952 the shift has been away from a psycho-analytic perspective to a biological one. Now, the biological perspective is the dominant one, and refusal to toe the line can lead to a psychiatric career coming to an end—not only in terms of posts but also any research grants. No longer is the personal political – the personal has become biological.

The biological approach, however, has come under attack from a number of perspectives. The whole of the conceptual apparatus has been undermined by psychiatric service users, psychologists and sociologists. Yet the edifice still stands and may be gaining in strength. The general public seems to be keen on it, let alone other professional and political interests. It will be a tough nut to crack.

As more mental illness categories are added because more people are showing their misery in different ways, this provides an ideal opportunity for the commodification of happiness—with the solution to unhappiness being offered by the pharmacology industry, often referred to as BigPharma.

No place for culture

The biological approach claims that its diagnostic categories are objective and universal because they are based on the pathologies of the brain. Schizophrenia is schizophrenia in AD 2007 or 2007 BC, in Britain or Borneo. The particularities of culture have no place here.

But this is not the whole story. There are cultural psychiatrists who are opposed to this Western imperialist encroachment. Not only are there differences across contemporary culture but even in the West differences are found across time. To show the difference in how misery shows itself across cultures consider these examples of what are called culture-bound syndromes.

Koko: usually Malaysian males who believe their sexual organs are shrinking, and is accompanied by panic as this is an indication of imminent death.

Latah: experienced by Indonesians who develop an exaggerated startle response, which includes shouting rude words and mimicking the behaviour of those nearby.

Western psychiatry tries to put these cultural forms into its categories.

To show how even in the West psychiatrists have changed their mind, consider what Samuel Cartwright classified as “drapetomania” in 1851. This disease was previously unknown to medical authority, although its diagnostic symptom was well known to “our planters and overseers”. This symptom was found only in black slaves and involved “absconding from service”.

He concluded that what “induces the Negro to run away is as much a disease of the mind as any other species of mental alienation and much more curable”. The cause was not pills but “whipping the devil out of them”. The patient should be treated like a child. But he warned against being too lenient or overly severe whipping—both of which would induce “drapetomania”. The term is derived from the Greek “drapetes”— a runaway slave.

Even schizophrenia has been seen as a disorder that is of recent origin, being rarely noted before the rise of modernity, in traditional or pre-literate societies.

The biological approach is not only wrong, but it is also ideological. This is not to deny that biological factors are not prominent in certain disorders. But whatever role biological factors play, psychological interactions cannot be reduced to the biological. As biological entities, all our activities have a biological component. But psychological activities are constituted in the interaction or transaction of a biological organism and a physical social environment.

Social relationships

A significant difficulty in looking at the literature which makes reference to social conditions is trying to sort out those which are capitalist specific or class specific from those which are a part of social life in general.

Moreover, it is difficult to sort out those sites where capitalist social relationships have direct effect on the conditions occurring there, such as work and unemployment, from where they have a mediated effect. That is, where capital does not directly create that site but works through an already existing institution, such as the family, gender relations, ‘racial’ relations, and personal relations.

In addition to those, there is the problem that capitalism has with the notion of class. Capitalism likes to think that class problems are a thing of the past or is a subjective matter. Therefore, it is reluctant to fund research which looks at this as a variable. It will accept an occupational or educational definition of class but it will not accept a Marxian definition.

Psychiatric research relating to class seems to have gone through three phases:

First, from the Victorian period up to the Second World War. Unlike mainstream medicine which was very much concerned with the environmental and social conditions of the poor—important public health measures, e.g. sewerage and water, were the focus in trying to improve the physical health of the working class—the focus of psychiatric epidemiology was on the identification of types of mental disease and (because of the brain pathology notion) localising the source of these in the constitution of the person and their family inheritance. This was the period of tainted genes and eugenic solutions.

Second, from the Second World war to the 1970s. The period of the long boom and of social reconstruction, of making capitalism modern, saw an interest in the social conditions of the working class. With the rise of the community health movement, the sources of mental health problems were seen to be, at least in part, those of poverty. Eugenics had of course lost all credibility. So, instead of segregating the mentally ill, the issue was to ameliorate social conditions. Studies showed that schizophrenia was more common in the poorer communities, as well as depression and anxiety.

Third, from the 1970s to the present. With the end of the post-war boom and the crises of the 70s and 80s, the social reformism came to an end. Community care was found to be too expensive and so cuts were made. Once again identification of problems, rather than sources of problems, became the main issue. With the introduction of new diagnostic practices and pharmacological treatments there was a return to the biological, and there was a strong bias against showing the effects of social conditions on the origin and development of the disease. There were exceptions, but that is what they remained. If you wanted large research grants from the biologically dominated institutes you put in a biological proposal.

Because of this state of affairs, it is difficult to identify clear-cut research studies which put social class in the forefront. But those few that are available all show that the ‘lower’ the social class and degree of urban poverty the greater the incidence of mental health problems. However, the relationship is not always clear-cut. For example the chronically unemployed are less distressed than those who are poorly employed (i.e. those in stressful, badly paid and insecure jobs).

In dealing with this distribution of mental health problems two, antagonistic, hypotheses have been proposed. The first assumes that social stress causes mental health problems. The second assumes that inherited or acquired causes lead to the patient being socially disadvantaged, and this leads to a downward social drift.

The emphasis on social stresses points toward a change in social conditions, whereas the social drift model with the emphasis on genetic faults or self-induced damage, such as alcohol or drug abuse, points toward blaming the person and the use of individual treatments.

Psychic reformism

Throughout the 20th century there have been movements that have promised happiness to us: Dale Carnegie, Norman Vincent Peale, “Every day in every way I am getting better and better”, Gestalt Therapy, EST, self-actualisation, the human potential movement and so on. They’ve come and they’ve gone. They fail to meet the hype because in part they are confined to merely individual happiness—I’m OK. They argue that if you sort your head out you can be happy. But it ignores the nature of the society in which we live. Unless this necessary condition for being a human being—miserable or flourishing—is taken into account, any hope for change is doomed to failure—yet another form of reformism. But we’ve had enough of reformism dangled in front of us, promising this time that things really will be different.

But is there anything to think that socialism has something to offer as an answer to the problem of human misery? In socialism we will still have some of the problems that make you feel miserable, scared, depressed or demented. Socialism is not a solution to all mental health problems, it is a solution only to those created by capitalist conditions of life, or to class conditions of life. While some of the problems are due to being human beings living within a social setting, others are due to being biological organisms, and as such will break down if we are damaged or just get old (e.g. aphasia, epilepsy, anger management problems, Alzheimer’s, front lobe syndrome, pharmacologically induced psychosis). While there could be a reduced use of medication and an increased use of social therapy, the power to detain people whose condition renders them dangerous to others will still be needed.

Socialism involves the abolition of the wages system. This entails that our ability to use our labour power is no longer subjected to the power of the capital social relationship, to be used only when capital sees a profit. Rather our labour power becomes ours, to be used voluntarily as part of our relationship with others, working in association towards our goals—to production for use to meet our needs.

Socialism also involves:

• The abolition of useless production, freeing up of millions of people from producing products and services necessary only for capitalism.
• Social decision-making on what is useful—no tat, built-in obsolescence or environmental damage.
• Breaking up of the division of labour, having multiple roles in society.
• Voluntary work—from each according to their ability; less emphasis on efficiency so people can work as much as their competence allows
• Co-operation between user and provider: not a commodity relationship; providers doing it because they want to—so less likelihood of abuse; no power differential between providers and users but partners; emphasis on building competencies

The case for socialism as more than an opposition to the economic exploitation of the working class. Throughout their writings, Marx and Engels criticised capitalism because of its effects on the working class as human beings, as more than mere economic agents.

In arguing against capitalism there was a positive model of human being set up in opposition, and as a position from which to evaluate capitalism. This positive possibility of human socialism needs to be put forward. Socialism is about establishing a mode of society which allows individuals to develop their powers to be more than mere producers or consumers. Capitalism has long produced the potential for such individual development, the task now is to realise it, to persuade working people that there is more to living than the shit of capitalism—we are more than pigs, content with mere physical satisfaction.

Ed Blewitt