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The Neopositivistic Turn in Medicine and Psychiatry

Parallel to the DSM system’s great interest in empirical research, a development emerged in medicine as a whole in the eighties and nineties of the twentieth century. It is the movement initiated by Sackett and others called Evidence Based Medicine (EBM). This movement, which in a short time is strongly gaining influence, presumes that nowadays it is possible to determine links between medical interventions and their effects on the basis of research. Research methodology is so advanced nowadays, that results provide reasonable certainty. This makes it possible to decide which intervention for a certain illness is most effective, and at the same time the least expensive. Later, consideration of the motivation and goals of the patient is added as an objective. In EBM different methods of research are compared, and a hierarchy is established. At the top are the methods rendering the “hardest” evidence, below them the less certain methods. At the bottom is clinical experience.

In medicine this research is of a pronounced biomedical neopositivistic character. After all, the effect of all sorts of treatments on bodily deviations can be determined with quantitative methods borrowed from the physical sciences. Psychiatry appears to be following the same path and is also taking a neopositivistic turn. Using questionnaires and structured interviews, qualitative criteria are “translated” into quantitative data. This is how empirical research into the effects of all kinds of pharmaceutical and other interventions can be done in psychiatry just as it is done in somatic medicine. One of the developments stimulating this course in a neopositivistic direction is the spectacular progress in the field of genetics. Research into disorders that occur in certain families and research into identical and non-identical twins has been able to demonstrate the great significance of hereditary factors in many disorders. The Human Genome Project has further inspired and added to this research. In this light vast optimism is growing about future research and therapeutic possibilities.

In addition, these years saw spectacular developments in neurobiology. Increasingly, elements of the function of the Central Nervous System (CNS) are mapped. Gradually we are beginning to understand the nature of interneuronal connections, the synapses. More and more pieces of the puzzle are falling into place. This fascinating development, too, evokes enthusiasm. Imaging techniques, such as PET and MRI scans, provide us with a stream of information about the function of the CNS.

Spectacular discoveries in these areas of research are regularly reported in professional publications and the general media, receiving widespread attention. However, the great expectations, perhaps more than the actual achievements, have a darker side. They tend to narrow the ideological horizon, because attention is focused on the body and the CNS. Some neuroscientists express the expectation that some day neuroscience will explain all psychiatric disorders. This can go so far as to cause all of humanity to be considered materialistically and monistically. That way the concept of “mind” is regarded superfluous. To determine who a person is, we need only examine his CNS. In The Meaning of Mind (1996) Szasz keenly criticizes this reductionistic attitude, as it makes man as social, political, and above all, moral, responsible being, extraneous. Szasz attacks these neuroscientists with mordant irony in this laudable book.

By the way, Szasz notes that these developments are leading to increasingly more coercion in psychiatry. In the past the realms of voluntary and involuntary treatment were plainly demarcated. This demarcation has been erased now that biological psychiatry presents itself as a new, value-free science. He states, “Coercive psychiatric practices are now more common, affect more persons, and are believed to be better justified than they have ever been.” (Liberation by Oppression, 2002, p.8).

The view that scientific proof for the existence of underlying neurological mechanisms of psychiatric disorders would justify coercion is based on a complicated misunderstanding. Somatic medicine deals with objective, demonstrable bodily deviations. Coercion, in somatic medicine, is a rare exception. From a medical point of view, finding objective, demonstrable deviations in connection with psychiatric disorders does not justify coercion. Yet the argument is used. The motto “Those people really have something wrong with them” conflates facts with ethics.

Nonetheless, these developments could have another perspective. For instance, nowadays, the treatment of schizophrenia is possible, but still only in a very limited way. Treatment cannot turn the tide of the schizophrenic process. At most it can slow it down somewhat. Ongoing intervention by mental health workers remains required. Only the symptoms are treated. This treatment has serious side effects, and may, in the long run, be more harmful than refraining from treatment. Suppose, hypothetically speaking, that an effective medical treatment for schizophrenia were found. I doubt it will ever happen considering the extremely complicated problems involved, but it is tempting to fantasize about it. Such a therapy could put coercion for schizophrenia out of business. In this way, neuroscience would contribute to the reduction of coercion. Unfortunately, this time has not arrived yet. But there is a historical parallel, the history of the treatment of epilepsy, as recounted by Szasz in Cruel Compassion (1994): “When the treatment of epilepsy was nonexistent or rudimentary, psychiatrists used the epileptic’s alleged need for treatment as a pretext for confining him. Subsequently, as the physician’s pharmacological power to treat epilepsy increased, his political power to deprive him of liberty, in the name of therapy, diminished and quickly disappeared.” (p.62)

So, in summary, there are reasons for vesting high hopes in the neopositivistic direction of psychiatry: the development of new research methods and the development of genetics, neuroscience, and imaging techniques. This direction largely dominates modern scientific discourse. This has two important implications. One affects views on the nature of psychiatric disorders. The other affects psychiatry as a medical specialty.
Regarding the former, the view that psychiatric disorders are basically defined by physical deviation is held much more strongly today than two decades ago. The expectation that the physical or biological determinants for all kinds of psychiatric disorders will someday be discovered, as discussed in Chapter V, 3.2, is greater than ever. Ideologically speaking, the old hypothesis that psychiatric disorders exist only in connection with biological abnormality is again gaining terrain.

The other implication is that we can observe psychiatry moving toward medicine on the whole. The theme of the 2004 annual convention of Dutch Psychiatrists was: “The psychiatrist as a medical specialist under the sign of Asclepius.” This slogan implies two positions, as the chairperson of the Association for Psychiatry declared at this convention. One is that psychiatrists are medical specialists, the other that psychiatric disorders are “real” (i.e. biomedical) disorders. The first is indisputable. The second is open to debate, as Szasz’s work and also this book testifies. In itself, the fact that this slogan nonetheless can be launched like this in 2004 illustrates how far the ideological pendulum has swung in the direction of biological abnormality. Aside from the significance for understanding disorders, this move of psychiatry towards medicine also has strategic significance. Szasz has frequently observed (as early as in The Myth of Mental Illness in 1961) that psychiatry has always endeavored to be recognized as a medical specialty in order to share in medicine’s prestige. In a moral sense, psychiatrists often were and are considered substandard specialists by their somatic colleagues. They are tolerated, but not as equals. Indeed, the point of this strategic approach is mainly gaining recognition for psychiatry in the eyes of somatic colleagues, the state, and medical insurance companies. In the seventies and eighties of the twentieth century this recognition was considered less important than psychiatry’s independent status, but nowadays psychiatry clamors for status inside medicine.

On the one hand, the DSM’s classification system has conquered the “market.” With this the fundament of categorizing and treating psychiatric disorders is explicitly the biopsychosocial concept of illness. On the other hand, the biomedical view has gained the upper hand, in particular in scientific discourse. This ambiguous attitude can be characterized as “biomedical in principle but biopsychosocial in practice.” The dilemma sketched in Chapters V and VI looms greater today than ever.
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