In Beyond Good and Evil
Nietzsche criticizes Plato and Socrates for holding the belief that their views
are not merely one of a number of ways of seeing the world, but rather a true
account which, for this reason, cannot be resisted. Their assumption of
objectivity obscures not only the genealogy of their ideas, but the need for a
genealogy of ideas. Foucault took up this notion with the idea of discourses,
systems of statements that ‘construct the objects of which they speak’. Ideas
that are free of history, have a unique authority, and in the case of
psychiatry it may be the need for authority that drives the construction of
discourses in the Foucaldian sense. From this perspective it would seem that
philosophical rather than scientific analysis would provide the most likely
critique of psychiatry. In Schizophrenia: A Scientific Delusion? Mary
Boyle is not content to settle for this. She takes on psychiatry on its own
terms: its claim to scientific status, although she has plenty to say about the
epistemological commitments of biological psychiatry. Well aware that there are
powerful historical and philosophical arguments that should be worrying for all
the psychiatric disciplines (not to mention the State, to the extent that it
accepts the legitimacy of psychiatry for the instrumental social control
function it provides) Boyle sets about undermining the authority of psychiatry,
its philosophical assumptions, scientific status and historical origins.

This is the second edition of
Boyle’s book, the first being in 1990. In the past decade the book has gained a
place as one of the standard critiques of psychiatry. As such it is often cited
by authors sketching out a map of opinion in psychiatry, including its defenders.
The book is organized into eight chapters. The first provides an analysis of
the validity of the concept of schizophrenia; the next two an historical
outline of the development of psychiatry in the West, including a critique of
the frameworks provided by Kraeplin, Bleuler and Schneider.  By the end of
chapter three Boyle’s position is clear. Schizophrenia is a concept the
validity of which is doubtful at best. Exploration of its scientific basis,
while it must be undertaken for the sake of completeness, seems superfluous
given that the ‘science’ of psychiatry must proceed from such a dubious
conceptual foundation. The next three chapters explore the development of
diagnostic criteria, the current criteria for inferring schizophrenia, and the
area of genetic research.

Chapter seven asks how such a problematic concept is
maintained, despite what in Boyle’s view is overwhelming evidence against it.
In the final chapter Boyle discusses alternatives to schizophrenia,
particularly cognitive behavioral therapy.

Boyle employs a social
constructionist framework in her critique, and uses this to good effect in
showing the contingent nature of the central concepts and the very enterprise
of psychiatry. She describes the history of the asylum and the claim of the
19th century alienists to an authority to speak on madness. The parallels with
current debates are compelling, especially the promise of a biological
explanation for madness.  A quote from an 1858 edition of the Journal of Mental
Science has a contemporary ring:

Insanity is purely a disease of the brain. The
physician is now the responsible guardian of the lunatic, and must ever remain
so. 

A central function of social constructionist analysis is to
undermine beliefs in ideas we have come to regard as inevitable. Psychiatry is
good target in this regard. Boyle’s analysis of cognitive behavioral therapy
shows that even alternatives to ‘schizophrenia’ are imbued with language that
implicitly accepts fundamental aspects of the dominant model. Terms such as ‘illness’,
symptom’, and ‘treatment’ all suggest that CBT, while proposing a different
conceptual and treatment framework, actually recreates the medicalized view of
schizophrenia.  Boyle draws on comparisons with Tukes ‘moral treatment’ to
provide an historical example of how a dominant group will appropriate its
alternatives, rather than directly contest its territory.

A point that is made more than once
in the book is that psychiatry by itself cannot maintain its authority and
power. It is only by being granted legitimacy by society that psychiatry is
able to command the status needed to speak on madness and its management. Thus
psychiatry does not unilaterally construct the discourses essential to its
power.  However this point is somewhat underdeveloped, as the history of
madness is cast as a struggle between psychiatry and those caught in its web of
vague concepts, dubious diagnostic practices and self-fulfilling research
programs.

If Boyle provides a compelling
critique of psychiatry she is less than fulsome in considering the limits to
social constructionist analysis.  Other critics employing a social
constructionist framework have allowed that there may be, if not an essence, at
least something beyond language and rhetoric, something real that psychiatry is
‘about’. Horowitz, for example in Creating Mental Illness, gives a hierarchy of
concepts of mental disorder, according disease status to disorders like
schizophrenia. Boyle is uncompromising in her application of social
constructionist analysis. Schizophrenia is socially constructed; it therefore
not only has no scientific status, it is just not the sort of thing than can
earn such status. In the last chapter Boyle suggests that what we have come to
know as schizophrenia is a result of power imbalances in society. This argument
is supported by examples of delusional beliefs that on closer examination
reflect prevailing social structures; hallucinations that give voice to
perpetrators of trauma.  The proper way to assist those currently diagnosed is
to help them understand the forces that shape their experience and, presumably
by virtue of this, to overcome them.

There is a polemical tone to this
book. While the critical task of undermining the authority of ideas that
underpin psychiatry is largely successful, there is no convincing account of
what is actually going on in ‘schizophrenia’. Boyle seems reluctant to concede
that there is anything more than language and its employment in enacting power
relationships. Just as ideological biological psychiatrists reduce all
explanations to neurochemistry, Boyle seems unwilling to entertain anything
other than a social explanation for madness. Perhaps Boyle would reject the
idea of looking for anything ‘actually going on’.  Social constructionism,
after all, is anti-essentialist, and Boyle is highly critical of alternatives
that leave the individualism of psychiatry unchallenged. The prospects for a
positive theory of madness appear bleak in the face of such a denial of
essence. But this criticism should not detract from Boyle’s achievement in
showing how ‘schizophrenia’ is a deeply problematic concept. It is
impossible to read this book and not regard schizophrenia, and the psychiatric
enterprise that is wedded to it, as a perspective on a greater something that
is not well understood. But the forces that sustain ‘schizophrenia’ are greater
than psychiatry. They include different sections of society, the media, popular
culture, a wide range of health professionals and caregivers, and people with
the diagnosis ‘schizophrenia’.

As Boyle somewhat ruefully reflects
at, ‘the tendency to remain within traditional systems of thought means that
the cautionary conclusion of the first edition still stands: it is unlikely
that alternatives to ‘schizophrenia’ (as distinct from its replacement with
equally problematic concepts) will develop and persist unless we
face not only the deficiencies of the concept but also the social and
intellectual habits which have allowed it to flourish’ (p. 317, [original
emphasis]). While individual aspects of Boyle’s work have been covered in other
publications (history of psychiatry, alternative theories of schizophrenia,
effects of drugs), Boyle has attempted to draw these diverse strands together.
The book is recommended for those wanting an extended analysis of a single
diagnostic concept, especially one that exerts a powerful hold on the
professional and public imagination.

© 2004 Tony O’Brien

Tony O’Brien, Senior Lecturer, School of Nursing,
University Auckland, New Zealand.

Categories: MentalHealth, Philosophical