Chapter 3 of SICK and SICKER: Essays on Class, Health and Health Care

In the normal course of its functioning, capitalism deprives, injures, sickens and kills millions of people. What prevents the dispossessed from rising up to end this oppressive social arrangement?

To sustain itself, the ruling class erects institutions of social control backed by ideas that justify the way things are. One of these institutions is modern medicine, which developed as a system of diagnosing and treating individuals, not their social conditions.(1)

Medical ideology assumes that individuals malfunction for reasons that have nothing to do with the social world. The physician treats the injured worker, not the unsafe workplace that injured her.

Mental illness presents special problems for capitalism. The fact that social conditions generate mental distress is so obvious that a psychiatric industry is required to convince us otherwise.

Psychiatry presents itself as a branch of medicine that diagnoses and treats mental illness in the same way that other branches of medicine diagnose and treat physical illness. This claim does not hold up under scrutiny.

The science of diagnosing physical illness developed from an understanding of human physiology and diseases that cause the body to malfunction. A correct diagnosis identifies the problem, guides treatment and suggests an outcome. For example, a diagnosis of bacterial pneumonia identifies a type of lung infection that can usually be cured with antibiotics.

Diagnosis is a science because physical diseases show characteristic biological changes or “markers.” Almost everyone with a particular disease will show similar biological markers, while those without the disease seldom show these changes. The biological basis of disease makes it possible to diagnose physical illnesses scientifically and reliably. Mental illness is very different.

The Mind is not the Brain

Parkinson’s Disease, Alzheimer Disease, Huntington’s Disease, Multiple Sclerosis, Neurosyphilis, etc. are all diseases of the brain. These diseases display characteristic biological markers that make it possible to diagnose them.

However, the mind is not the same as the brain. The mind is not a physical organ but develops out of a complex inter-relationship between the brain, the body and the social environment.(2) Mental distress can result when any of these components or their relationship is negatively affected.

Because the mind is more than the brain – studying the brain tells us nothing about the physical and social environment that shaped the mind.

Mental distress takes many forms, all of which create misery and none of which is a disease. Science has yet to detect biological markers in the brains of people with different forms of mental distress that are not present in people without those forms of mental distress. This is true even for schizophrenia, a disabling form of mental distress that is widely assumed to be genetically-based. The evidence says otherwise.

Studies from different countries show that living in a city gives a person a higher probability of developing schizophrenia than having a family member with schizophrenia. Moving from rural to urban centers increases the risk of developing schizophrenia, while moving in the other direction reduces the risk.(3) City living is associated with increased exposure to lead,(4) infection,(5) malnutrition,(6) and racial discrimination(7) – all of which have been linked with higher rates of schizophrenia.

These studies suggest that, while schizophrenia is not a genetic disease, it might still be a physical disease. However, schizophrenia has no biological markers. Schizophrenia is identified by evaluating behaviour.

Evaluating behavior is highly subjective, and the process for identifying schizophrenia is complex and confusing. As a result, mis-identification is common and leads to faulty research findings. For example, studies that report a higher incidence of schizophrenia in twins cannot confirm if these individuals actually have schizophrenia, because there is no objective way to confirm this diagnosis. If we don’t know what we are measuring, then we can’t measure it accurately.

Psychiatry is not a medical science; it is pseudoscience – ideology disguised as science.(8) Psychiatry developed to meet capitalism’s need for social control and psychiatrists’ need for paying customers.

Sigmund Freud

Before the 20th century, life stresses were viewed as spiritual problems or physical illnesses, and sufferers sought the help of religious advisers or physicians. Medical doctors treated “hysteria” and “nerves” as physical problems. Psychiatry was restricted to the treatment of severely disturbed people in asylums.(9)

The first classification of psychiatric disorders in the United States appeared in 1918 and contained 22 categories. All but one referred to various forms of insanity.

In 1901, Sigmund Freud revolutionized psychiatry by breaking down the barrier between mental distress and normal behavior.

In The Psychopathology of Everyday Life,(10) Freud suggested that commonplace behaviors – slips of the tongue, what people find humorous, what they forget and the mistakes they make – indicate repressed sexual feelings that lurk beneath the surface of normal behavior. Freud believed that repressed feelings should be treated to prevent them from generating anti-social behaviors.

By linking everyday behavior with mental illness, Freud and his followers released psychiatry from the asylum. Between 1917 and 1970, psychiatrists cultivated clients with a broad range of problems, and the number of psychiatrists practising outside institutions swelled from 8 percent to 66 percent.(11)

What were these psychiatrists treating? Because mental distress has no biological markers and is not a disease, psychiatry adopted the term, “mental disorder.”

Dictionary definitions of “disorder” refer to: a lack of order or regular arrangement (confusion); a disruption in mental or physical functioning; a breach of civic order or public disturbance (disorderly conduct); or any condition in which things are not in their expected places (deviation).

Who decides what is “order” and what is “disorder,” what is “normal” and what is “deviant”? These are not scientific or medical questions, but social and political ones.

Those who rule society make the rules. The ruling class defines orderly behavior as that which serves its interests and disorderly behavior as that which threatens its interests.

Because the needs of ruling classes change through history, what is considered normal and deviant has also changed. In contrast, real diseases do not change over time. Pneumonia in prehistoric times looked exactly the same as it does today.

Psychiatry doesn’t question the class system that generates mental distress; it targets the victims of the system and those who protest against it. Mental distress becomes the problem to be treated, not the social conditions that create distress.

Growing the Industry

Psychiatrists do not “diagnose” in the scientific sense of the word; they categorize and label. In North America, these categories and labels are determined by matching the patient’s complaints with groups of symptoms and behaviors listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is often called “the bible of psychiatry.” This is a fitting label because the DSM is based on dogma, not science.

The first edition of the DSM was published in 1952 and provided statistical information on 106 mental disorders. In 1980, the American Psychiatric Association (APA) expanded the DSM to include whatever psychiatrists think might be a disorder.

If there is general agreement among clinicians, who would be expected to encounter the condition, that there are significant number of patients who have it and that its identification is important in the clinical work, it is included in the classification.(12)

Since then, the DSM has grown on the same basis – the desire to maintain existing patients and include new ones who might seek help for any number of problems. The more people seek treatment, the more conditions can be entered into the DSM, and the more people can be encouraged to seek treatment for these new conditions. A profitable and self-perpetuating industry was born. According to one critic,

the DSM-IV is a catalogue. The merchandise consists of the psychiatric disorders described therein, the customers are the therapists, and this may be the only catalogue in the world that actually makes its customers money: each disorder, no matter how trivial, is accompanied by a billing code, enabling the therapist to fill out the relevant insurance form and receive an agreed upon reward.(13)

The DSM-IV, published in 1994, contained hundreds of disorders – everything from social phobia (shyness) to frotteurism (an irresistible urge to sexually touch fellow passengers on public transit).

The DSM-V, expected to appear in 2013, will offer “dimensional assessments” or degrees of severity (mildly neurotic?). This change will make it easier to label even more adults with mental disorders. And a new category – Temper Dysregulation Disorder with Dysphoria – could be applied to any angry, unhappy child. (14)

In 2005, a major study announced that “About half of Americans will meet the criteria for a DSM-IV disorder sometime in their life…”(15) How is this possible? Has it become normal to be mentally ill, or has the definition of mental illness expanded beyond reason? Both are true.

Capitalism is a sick social arrangement that damages physical and mental health. And by expanding the definition of mental illness, more people can be labelled as sick and more profits can be made from selling them treatments. In Creating Mental Illness, Alan Horowitz observes,

…a large proportion of behaviors that are currently regarded as mental illnesses are normal consequences of stressful social arrangements or forms of social deviance. Contrary to its general definition of mental disorder, the DSM and much research that follows from it considers all symptoms, whether internal or not, expected or not, deviant or not, as signs of disorder.(16)

Most people know the difference between normal behavior (such as grief over the death of a loved one) and abnormal behavior (hallucinations) that might need treatment. However, with one exception, Post-Traumatic Stress Disorder, the DSM lists and categorizes symptoms outside of any cause or social context. This artificially inflates the number of people who are considered mentally ill and expands the potential market for drug treatment.

DSM population surveys include the grieving widow as well as the woman who is depressed for no apparent reason. These surveys also include people who are physically ill.

There are at least 60 physical diseases that can generate psychological symptoms.(17) Researchers estimate that from 41 to 83 percent of people being treated for psychiatric disorders are actually suffering from misdiagnosed physical diseases like hypo- or hyper-thyroidism, heart disease, kidney failure, liver failure, immune-system diseases, malnutrition, nervous-system diseases and cancer.(18) These diseases cripple or kill when not properly treated. And many psychiatric drugs worsen physical diseases, sometimes fatally.

DSM-inflated rates of mental illness are typically accompanied by the warning that not enough people are getting treatment.(19) Whether all these people need or want psychological treatment is never questioned.

What is Being Treated?

The first edition of the DSM described mental distress as a reaction to some event, situation or biological condition. But when the second edition was published in 1968, the word “reaction” had disappeared.

By severing cause from effect, psychiatry removed mental distress from the realm of science. From then on, a mental illness would be anything the psychiatric profession chose to identify as a mental illness.

Most of the symptoms listed in the current DSM describe normal human responses to deprivation and oppression (anxiety, anger, depression) and ways that people try to manage unbearable feelings (obsessions, compulsions, addictions). However, psychiatry treats mental distress as a sign of inner malfunction instead of a reasonable response to unreasonable social conditions.

During the 1960s, psychiatrists medicated distressed women so they would accept their oppression. The Rolling Stones mocked this practice in their song, Mother’s Little Helper (1966):

Mother needs something today to calm her down

And though she's not really ill, there's a little yellow pill

She goes running for the shelter of a mother's little helper

And it helps her on her way, gets her through her busy day

Social activists attacked psychiatry’s role in maintaining oppression. Dr. Alvin Poussaint recalls the 1969 convention of the APA,

After multiple racist killings during the civil rights movement, a group of black psychiatrists sought to have murderous bigotry based on race classified as a mental disorder. The APA’s officials rejected that recommendation, arguing that since so many Americans are racist, racism in this country is normative.(20)

The DSM lists hundreds of mental disorders covering a wide variety of behaviors in adults and children. Yet, sexism, racism, bigotry, homophobia (fear of homosexuality) and misogyny (contempt for women) have never been listed as mental disorders. In 1999, the chairperson of the APA’s Council on Psychiatry and the Law confirmed that racism “is not something that is designated as an illness that can be treated by mental health professionals.”(21)

Homosexuality was listed as a mental disorder until activists pushed for its removal in the 1974 revision of the DSM-II. However, the 1980 DSM-III listed feeling bad about being homosexual as a mental disorder.(22) In They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal, Paula Caplan explains,

In a culture that scorns and demeans lesbians and gay men, it is hard to be completely comfortable with one’s homosexuality, and so the DSM-III authors were treating as a mental disorder what was often simply a perfectly comprehensible reaction to being mocked and oppressed.(23)

Caplan describes the campaign to prevent “Masochistic Personality Disorder” from being included in the DSM. Women who refused to leave abusive spouses were being labeled with this disorder on the assumption that they enjoyed suffering. In fact, many abused women lack the resources to leave and risk being murdered if they try. Despite much protest, “Masochistic Personality Disorder” was added to the 1987 edition of the DSM, although it was later dropped.

Activists also rejected the inclusion of “Pre-Menstrual Dysphoric Disorder” (PMDD) in the DSM. According to Caplan,

The problem with PMDD is not the women who report premenstrual mood problems but the diagnosis of PMDD itself. Excellent research shows that these women are significantly more likely than other women to be in upsetting life situations, such as being battered or being mistreated at work. To label them mentally disordered – to send the message that their problems are individual, psychological ones – hides the real, external sources of their trouble.(24)

Human beings protest their oppression with open rebellion and through symptoms of sickness and distress. The prison system crushes the rebels, medicine treats the sick, and psychiatry subordinates the distressed. The goal of psychiatric “treatment” is to resign the discontented to their lot and drug the resisters into submission.

A Marketing Gold Mine

The psychiatric industry has provided a gold mine for the drug industry.

The Food and Drug Administration (FDA) will approve a drug to treat a mental disorder only if that disorder is listed in the DSM. Therefore, each new listing is worth millions in potential drug sales. Because most of the experts who construct the DSM are financially linked to the pharmaceutical industry, it’s not surprising that each new edition of the DSM lists more disorders than the previous one.

For DSM-IV, all of the experts working on the mood disorders (anxiety, depression, etc.) and “schizophrenia and other psychotic disorders” had ties to drug companies. The pharmaceutical industry also funds conventions and research related to disorders proposed for entry in the DSM because “what is considered diagnosable directly impacts the sale of their drugs.”(25)

Once the DSM lists a new mental disorder, drugs for that disorder are promoted for anyone who might fit the symptom checklist.

As soon as the DSM listed Pre-Menstrual Dysphoric Disorder (PMDD), pharmaceutical giant Eli Lilly repackaged its best-selling drug Prozac in a pink-pill format, renamed it Serafem, and pushed it as a treatment for PMDD. By creating Serafem, Lilly was able to extend its patent on the Prozac formula for seven more years.

The numbers of people diagnosed with any particular mental disorder rise rapidly after a drug is approved to treat that disorder.

Until the 1990s, Bipolar Disorder was thought to be uncommon in adults and non-existent in children. The recent explosion of Bipolar diagnoses followed approval of anti-psychotic drugs to treat it.

Beginning in the 1990s experts connected with the pharmaceutical industry began to argue that Bipolar Disorder was under-diagnosed in adults. Shortly after that, child psychiatrists began to argue that Bipolar Disorder was more common in children than previously thought.

Between 1995 and 2000, the rate of boys aged 7 to 12 labelled with Bipolar Disorder more than doubled. Today, Bipolar Disorder is the fastest growing psychiatric label applied to children.(26)

The New York Times reported that,

Some diagnoses of bipolar disorder have been in children as young as 2, and there have been widespread reports that doctors promoting the diagnosis received consulting and speaking fees from the makers of the drugs.(27)

By 2005, US drug companies were spending $4 billion a year on television and print ads to give their products the same level of brand recognition enjoyed by soft drinks and breakfast cereals.

Some drug companies offer coupons, free samples, free trials, and money-back guarantees for prescription drugs.

In 2002, hundreds of Florida residents were mailed a one-month starter supply of Prozac Weekly, a long-acting anti-depressant. The recipients were not taking this drug, had not requested it and had no idea why they received it. Investigators later discovered that doctors’ and pharmacists’ records had been mined to identify people who might try this anti-depressant.(28)

Drug companies bombard physicians with full-page ads promoting the broadest possible use of mood-altering drugs. Drug maker, GlaxoSmithKline, urged doctors to “Look for the Paxil spectrum in every patient,” adding, “The Paxil Spectrum. Treat One. Treat them all.”

Since Paxil was introduced as an anti-depressant in 1993, GlaxoSmithKline has paid almost $1 billion to resolve lawsuits over the drug, including $390 million for suicides or attempted suicides and $200 million to settle addiction and birth-defect cases. Compare these sums with the $11.7 billion that the company made from US Paxil sales between 1997 and 2006 alone.(29)

The more drugs are advertised, the more patients request them and the more doctors prescribe them.

In 2008, sales of prescription drugs in the US reached $291 billion, equivalent to $950 for every man woman and child in America. Sales of anti-psychotic drugs topped all other types of prescription drugs.(30)

To serve a sick system, psychiatry extracts the individual from society, splits the brain from the body, severs the mind from the brain and drugs the brain.(31)

The Assault on Children

Children are especially vulnerable to deprivation and have a limited capacity to articulate what’s wrong. So they protest in the only ways they can – with symptoms and behaviors that alert us that something is wrong in their world. And so very much is wrong!

In most schools, youngsters are forced to sit still in closed rooms for long periods of time and memorize information that has no connection to their lives. The ones who fall behind can be labelled with Reading Disorder, Mathematics Disorder and Expressive Language Disorder. The restless, defiant ones can be labelled with Attention-Deficit/Hyperactivity Disorder, Conduct Disorder, Oppositional Defiant Disorder, and Disruptive Behavior Disorder Not Otherwise Specified. Once labelled, these children can be forced to take toxic, mind-altering drugs.

Even in families that can provide the material necessities of life, overstressed adults have insufficient time to meet their children’s emotional needs. When children protest by acting out, parents are encouraged (more often pressured) to consult doctors and other experts who “diagnose” these children, not the situation to which they are reacting.

Anxious youngsters who are not getting enough attention, or the right kind of attention, can be labelled with Separation Anxiety Disorder. Children who have suffered severe abandonment, abuse, trauma or neglect can be labelled Reactive Attachment Disorder. Although these children are reacting predictably to their plight, the DSM-IV declares them mentally ill. Such labels do nothing to change children’s situations so they can get what they need.

Using DSM criteria, millions of American children have been diagnosed with serious mental disorders. And drug companies are actively seeking more.

A 2007 DSM survey of 8- to 15-year-olds found that 9 percent met the criteria for Attention Deficit/Hyperactivity Disorder (ADHD). The study’s authors complained that fewer than half of these children had been diagnosed or treated. Noting that poor children were less likely to be on medication, the authors recommended “further investigation and possible intervention.”(32)

The new DSM V proposes to identify “risk syndromes” or the risk of developing a disorder like schizophrenia. Yet, studies of teenagers who were identified as having a high risk of developing psychosis found that 70 percent or more never develop the disorder. Defending this addition to the DSM, one prominent psychiatrist stated, “Concerns about stigma and excessive treatment must be there. But keep in mind that these are individuals seeking help, who have distress, and the question is, What’s wrong with them?”(33) (My italics)

No one is asking, “What do these children need, and how can we provide it?” To preserve a crazy-making system, the healthy, protesting child is labelled “crazy” and medicated into a subordinate, defeated child.(34)

Raising Living Standards

Depression is strongly linked with poverty, and alleviating poverty can lift depression.(35) This was demonstrated when a gambling casino opened midway through an 8-year study of child psychiatric problems.

This casino was owned by the First Nations and paid each aboriginal family a financial bonus that rose every year. These payments elevated 14 percent of the families out of poverty, while 53 percent remained poor. Thirty-two percent of the families were not poor to begin with.

Before the casino opened, the poor children were diagnosed with more than four times as many psychiatric symptoms as the children who had never been poor. After the casino opened, psychiatric symptoms among children who were no longer poor fell to the same level as children who had never been poor. In contrast, psychiatric symptoms remained high among the children who remained poor. Similar results were found in non-aboriginal children whose families had also moved out of poverty during the same period.(36)

Why would rising income improve child behavior?

At times, all children are impulsive, hyper-active, aggressive, and defiant. Children need supportive adults to help them manage strong emotions. When overstressed parents can’t meet their needs, children protest by acting out.

Rising incomes can meet enough of the parents’ needs that they, in turn, are more able to meet their children’s needs. Social support has the same beneficial impact.(37)

Since the 1980s, cuts in funding for education, family support and child services have led to an escalation in the number of children being diagnosed with psychiatric disorders and prescribed psychiatric drugs. Prescriptions for school-aged children commonly peak in September and drop in June – the duration of the school year.

One program offered an alternative to drug treatment. A trained social worker met weekly at home and at school with children diagnosed with ADD and their parents. While they were participating in this program, none of the children needed medication. When funding for the program ended, all the children became distressed and were put back on medications.

Child misbehavior always signals a crisis in their world. In a sane society, distressed children and their caregivers would get the support they need.

The psychiatric assault on children is fuelled by drug company propaganda that child behaviour problems are the result of “chemical imbalance,” not social injustice. Instead of challenging the deprivation that agitates children, psychiatry imposes conformity through medication. To force compliance, access to insurance benefits, medical care and social services depends on “having a diagnosis.”

Blaming the Victim

Capitalism not only denies the majority any real control over their lives, it also insists that this unfair arrangement be accepted as normal. To contain rebellion, all who are impoverished and oppressed are treated as personally inadequate, biologically defective, mentally ill – anything other than the victims of a heartless and exploitive system.

During slavery days, experts argued that Black people were psychologically suited for a life of slavery, so there must be something wrong with those who rebelled.(38) In 1851, the diagnosis of Drapetomania (runaway fever) was applied to slaves who showed a seemingly inexplicable longing to escape.(39)

During the Great Depression of the 1930s, American supporters of “racial purity” argued that social problems were best solved by preventing the “unfit” from propagating.

The Third International Congress of Eugenics, that convened in New York City, called for mass sterilization of unemployed workers and their children to eliminate “the existence among us of a definite race of chronic paupers, a race parasitic upon the community, breeding in and through successive generations.” One speaker declared that,

a major portion of this vast army of unemployed are social inadequates, and in many cases mental defectives, who might have been spared the misery they are now facing if they had never been born.(40)

In 1934, the editor of the New England Journal of Medicine proclaimed, “Germany is perhaps the most progressive nation in restricting fecundity among the unfit.”(41) Psychiatrists were especially enthusiastic. In 1931, the president of the American Psychiatric Association advised,

I believe the time has arrived when we should, as an Association, again most strongly express our approval of the procedure of sterilization as an effective effort to reduce the number of the defective population.(42)

Between the 1930's and the 1950's, the American Journal of Psychiatry published numerous articles in support of eugenic sterilization and euthanasia. One article recommended euthanasia for mentally disabled children, who “should never have been born — nature’s mistakes.” An editorial in the same issue advised psychiatrists to convince parents of such children “that euthanasia is the most humane solution.”(43)

While the Nazi genocide discredited talk of racial purity and euthanasia, psychiatry continues to champion the interests of the capitalist class by portraying its victims and opponents as sick or deviant and in need of “treatment” or punishment.

How should we diagnose this sick system?

We know what is wrong. A few people accumulate wealth and power at the expense of everyone else.

What is the treatment? Capitalism must be replaced with a socialist society that puts human needs first.

Who can deliver the medicine? The global working-class majority.

What’s holding us back? Lack of clarity and organization.

I don’t expect this diagnosis will ever appear in the DSM.

References

1. The only branches of medicine that examine social conditions – public and occupational health – are poorly funded and politically restricted.

2. Siegel, D.J. (2001). The developing mind: How relationships and the brain interact to shape who we are. The Guilford Press.

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