Thursday, June 27, 2013

Biopsychiatry, neo-eugenics, and prison reform

The biologization/medicalization of psychological distress, as I’ve discussed, serves to depoliticize these experiences. It enhances corporate power and the political authority of drug companies and psychiatrists. It impedes the development of a (post-)humanistic approach to human suffering.

But there are two other complementary aspects of medicalization tying it to conservative politics that don’t receive as much attention. The first is that, in practice, the biologization of psychiatry has tended toward geneticization and then toward eugenics. The second is that it's subverted social justice efforts, turning a genuine wish to help into support for oppression and collusion with authoritarian systems.

A comment in a recent thread alerted me to this 2012 piece by Robert Whitaker, “The Taint of Eugenics in NIMH-funded Research Today.” Whitaker argues that the “Top 10 Research Advances in 2011” celebrated by NIMH head Thomas Insel have, in fact, no real connection to positive therapeutic interventions. He challenges the reader:
See if you can find even one item that tells of research designed to help living, breathing human beings get well and stay well. See if you can find anything that tells of research designed to identify the strengths that can be found in people struggling with their minds, and all the ways that, in fact, such struggles can be an ordinary part of human experience.
He suggests that the original biological-genetic commitment of the NIMH and the organizations involved with psychiatry hasn’t just led to an impoverishment of understanding - of the roots of suffering, of human potential, of possible therapies (of which it’s led to none1). It’s also fostered dangerous assumptions about people labeled “mentally ill” and the social transmission of “mental illness”:
Insel’s list tells of a research enterprise devoted to identifying what is genetically wrong with the “mentally ill.” As the history of eugenics reminds us, that is a pursuit, unless it is handled with great care, that can engender bad social policy and a great deal of harm.
Echoes of the late nineteenth and early twentieth century seem especially clear when it comes to the reception of the Smoller et al. study recently published in the Lancet, which, it’s claimed, finds a genetic link among five different “disorders”: autism, ADHD, bipolar disorder, major depressive disorder, and schizophrenia.2 Used by Insel as part of the rationale for a renewed focus on the genetic roots of “mental illness,” it has the potential to lead to a renewed fear of “neuropathic” individuals and families, which can negatively affect policy. When a web site with the seal of the Department of Health and Human Services declares that “No one is sure what causes schizophrenia, but your genetic makeup and brain chemistry probably play a role,” it’s not a statement that should be passed over lightly.

To be clear, I’m not suggesting that future discoveries are actually going to turn up evidence of the genetic causes of psychological problems and lead to genuinely effective interventions which might have some negative political consequences. It’s a nonzero possibility, of course, but given the extant evidence I’d say it’s pretty damned close to zero. No, the danger lies in the cultural power of the genetic model itself, how it gives a fake scientific sheen to stigmatization and marginalization and how this shapes the treatment of people diagnosed as mentally ill. In other words, the problem isn’t that it’s true; it’s that so many people are convinced that it’s true. (Similarly, as an atheist, I don’t fear a vengeful god. I am, though, concerned about the consequences of millions of people, including those in positions of power, believing one exists.)

It’s easier to see, with the benefit of hindsight, and especially with the knowledge of the extremes to which some of the pseudoscientific notions of a century ago led, a) that they were pseudoscience and b) that they served authoritarian, bigoted ends. But the passage of time has obscured important aspects, like how mainstream and respected many of the people and institutions promoting these ideas were at the time and how many of them regarded the programs based on these notions as politically progressive and helpful.

What makes biopsychiatry palatable and even alluring to many, including many on the left, is precisely that it’s presented not as a means of authoritarian social control but as a therapeutic mission dedicated to combating illness. (This has changed over time: when it was a matter of psychiatrists talking amongst themselves, they could be more open about viewing drugs as tools for better controlling and managing people. As they began to market the drugs to the public, the rhetoric changed to one claiming they’re therapeutic agents, although the language of social control is still very much around in certain contexts, including when speaking of children and adults in various institutional settings and of people deemed criminally violent.)

A huge number of people in mental health professions and government, as well as political activists, believe the model is valid and thus see psychopharmacology in terms of care. It’s presented to the public in humanitarian language. When Thomas Insel writes “Our patients deserve better,” he’s appealing to an ethos of care. He’s also appealing to a paternalistic impulse that is in no way alien to social justice activists.3

Due to the widespread acceptance of the brain-disease-drug model, those who oppose systems which deny people care of any sort and treat them disrespectfully and cruelly tend to join in the chorus calling for better care in the form of improved “accessibility” to psychiatric “services,” including drugs. So entrenched are these beliefs that the unavailability of drugs is seen as a violation of human rights.

I saw this play out recently in an article by Andrew Cohen, “One of the Darkest Periods in the History of American Prisons.” Cohen discusses recent disclosures about the horrendous conditions in US prisons, including a report from the Civil Rights Division of the Justice Department [!] documenting widespread abuses of human rights in violation of the Constitution. All of the reports, as Cohen describes, emphasize the indifferent and brutal treatment of “the mentally ill” – prisoners experiencing extreme psychic distress:
On May 30th, the ACLU filed a long-awaited federal lawsuit against state officials for the atrocious conditions at the East Mississippi Correctional Facility. "The lawsuit filed today," the lawyers wrote, "describes a facility where [mentally ill] prisoners are often locked in filthy cells and ignored even when they are suffering from serious medical issues. Many cells lack light and working toilets, forcing prisoners to use trays or plastic bags that are tossed through slots in their cell doors. Rats often climb over prisoners' beds, and some prisoners capture the rats, put them on makeshift leashes, and sell them as pets to other inmates."
EMCF's solitary confinement zones house dozens of seriously mentally ill prisoners who are locked down in filthy cells for days, weeks, or even years at a time. . . It is commonplace for cells to lack working lights, leaving prisoners with barely enough light to see during the day and in total darkness at night. . . Correctional officers seldom appear on the housing zones and prisoners are left to fend for themselves, sealed behind solid-front doors.
In addition to finding that Cresson routinely resorts to locking prisoners with serious mental illness in their cells for 22 to 23 hours a day, for months or even years at a time, the department also found that Cresson often denies these prisoners basic necessities and subjects them to harsh and punitive conditions, including excessive uses of force. The department concluded that Cresson's misuse of solitary confinement on prisoners with serious mental illness leads to serious harms, including mental decompensation, clinical depression, psychosis, self-mutilation, and suicide.
Examples of mistreatment range from not providing any care at all to punitive responses to distressed behavior. A problem, though, emerges in the descriptions of the problem in the reports themselves and in Cohen’s article:
Prison officials have failed to provide a constitutional level of care in virtually every respect, from providing medication and treatment to protecting the men from committing suicide.
the Jail routinely fails to provide appropriate medications to prisoners with mental illness
missed and inadequate diagnoses
Among the hundreds of mentally ill prisoners at EMCF are many whose untreated illnesses lead to extreme behaviors such as screaming, babbling, throwing excrement and starting fires.
At Cresson, there is not enough staff, not enough medicine, and not enough accountability.
inadequate intake procedures, to negligent supervision of mentally ill prisoners, to inappropriate delivery of medicine and therapy, to the indifference and lack of accountability displayed by prison staff,… [my emphases]
Any decent person will agree that, as we fight the system of mass imprisonment itself, major reforms are urgently needed within that system itself – the conditions described in these reports have to end. But in characterizing denial of “access” to proper psychiatric diagnosis and medication as a major problem, writers like Cohen make themselves complicit with authoritarian and pseudoscientific institutions.

Prisoners are among the most vulnerable people in society, and to assume that “access” to psychiatric diagnosis and drugs is the same as access to medical care is to provide a justification for coercive or forced labeling and drugging. There can be little doubt, given existing laws that allow for forced interventions for people in the general US population, that greater access to “medications” for people in prison would mean in practice the increasing use of drugs to change and control, and even to punish, rebellious or disruptive prisoners. At a time when the US is being challenged on human rights grounds for allowing forced psychiatric interventions, it’s ethically and politically reckless to call for improved “access” to psychiatric “medications” for prisoners.

People on the left readily scoff at attempts to couch imposed austerity programs and the destruction of government protection and support in the language of “access” to markets and freedom, rightly recognizing that this is a cover for exploitation – “access” to the plunder of neoliberal capitalism. But belief in biopsychiatry leads many of the same people to promote similar “access” to coercive biopsychiatry with a clear conscience and the firm belief that they’re helping.

A good part of the problem, in addition of course to inadequate skepticism about the biopsychiatric model, is, I think, a failure to consult people currently or formerly in prison about the reforms they want to see – an inattention to what imprisoned people themselves are demanding. Given the centrality of the problem of forced drugging to the psych rights movement generally, it’s pretty much impossible to believe that people in prisons are clamoring for more access to psychiatric diagnoses and drugs.

To be sure, it’s an enormously complicated and difficult problem. The current regime of violent, punitive responses has to end, of course. The problems transcend the immediate environment, and won’t be resolved through any sort of individual-level or prison-based interventions; at the same time, individual-level and prison-based interventions of some sort are necessary. But these should not be based on a model that further stigmatizes, marginalizes, and disempowers people in prison while empowering those who want to intervene by force to “treat” them.

1 Whitaker’s concern about a lack of any therapeutic value is echoed by Brett Deacon in response to Insel’s 2012 propaganda list. As he suggests:
NIMH director Insel's zeal for the biomedical model is reflected in his list of the “Top Ten Research Advances of 2012” (Insel, 2013). The advances concern topics such as epigenomics, neurodevelopmental genomics, “optogenetics and oscillations in the brain,” “mapping the human brain at the molecular level,” and “mapping the human connectome.” Each of these is regarded by Insel as potentially leading to innovation by suggesting “new vistas for biology that will almost certainly change the way we understand serious mental illness and neurodevelopmental disorders.” None of Insel's “Top Ten Research Advances” concern an actual improvement in the assessment, prevention, or treatment of any mental disorder.
This means that the money thrown into this gargantuan effort is being wasted, diverted from more promising avenues. At the end of his article, Deacon asks: “If decades of biomedical research have not resulted in the development of clinically useful biological tests, innovative psychotropic medications, or improved mental health outcomes, should billions of dollars of taxpayer money continue to be preferentially allocated to biomedical research? Should zealous advocates of the biomedical model continue to head governmental agencies that determine national research and policy agendas?” I agree that these are important questions.

2 Coincidentally, this study is mentioned in a talk I listened to recently by Ian Hacking, “Making Up Autism” (which I didn’t think was very good overall). When he brings up this research, he explicitly suggests that he sees in it “a curious throwback to the 19th century” origins of eugenics. He mentions Jean-Martin Charcot’s arguments about “degeneracy” and how its appearance varied across different individuals and generations of families, taking the form of antisocial deviancy, dipsomania, idiocy. (Whitaker discusses Aaron Rosanoff and his pseudoscientific search for the insanity gene.)

I won’t say much about this – single, unreplicated - study here, but I do find it bizarre. If you’re acknowledging that these aren’t “diseases” or “disorders,” that these diagnoses aren’t valid - as Insel surely is now since he’s citing this study as one factor in the NIMH’s decision to stop using them and explicitly remarked on their invalidity – then you’re admitting that what you’re talking about are shifting constructs and not biomarkers. So you’re looking for a genetic basis for a construct. Grouping these constructs together or dividing them up in new ways doesn’t address the basic problem that they’re constructs.

You might wonder why these five disorders were included. Thinking it wouldn’t make sense for them to include PTSD? Think again.

3 Anarchists have always been relatively more immune to this tendency - if not always to the underlying ideas, at least to the implementation of programs based on them. This has been due to a rejection of coercive authority even in its progressive and therapeutic guise and to a recognition of the political nature of human science.

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