Limits to Medicine: Medical Nemesis: the Expropriation of Health by Ivan Illich

Limits to Medicine is one of those books that dare to question modern society's deepest-held beliefs, and to imagine a radically different way of living. ^{Reference Illich1} Illich was a remarkable man, an academic and a one-time priest, who lived according to his principles. He developed a searing critique of industrialised society and its institutions, medicine among them, the thesis being that technological hubris has led us to forget the limits of the human condition. We have come to believe that technology can eradicate all human suffering and provide unblemished and everlasting happiness. We have paid for this irrational expectation with our autonomy, our dignity and our ability to endure.

I re-read this book in order to write this piece, and although dated in parts, it remains as inspiring as I remember. Illich described disease-mongering and the ‘pharmaceutical invasion’, and pointed to the importance of evidence-based medicine and patient and public involvement long before they started to be accepted by mainstream medicine. His criticism of diagnosis for denying the autonomy of ‘self-definition’ is more profound than any of the current debates about the DSM-5. Limits to Medicine is also an incredibly scholarly book, drawing on literature from anthropology, the epistemology of sickness and the linguistics of suffering among other areas.

Illich's utopia is a community that fosters the autonomy of individuals, but recognises the necessity of interdependence and mutual support. It would integrate the most useful aspects of modern technology, including medicine, but submit these to greater democratic scrutiny.

Limits to Medicine has much to say about psychiatry, and the Pharma-driven mental health industry epitomises Illich's ever-expanding, technocratic monster. His suggestion that medical intervention, with its promise of a quick fix, may inadvertently diminish the capacity of individuals and communities to deal with suffering and difference is, I believe, a message we need to take seriously.

Das Kapital by Karl Marx

Marx's view of human nature and society is highly relevant to psychiatry. ^{Reference Marx2} For Marx, human beings are social producers. We express our essential nature through our ability to transform the world around us, and this activity is always conducted in conjunction with other people. Human production is a collaboration. Our thoughts and ideas too are profoundly moulded by the history and organisation of the society we inhabit.

Das Kapital is the most powerful book I have ever read. It lays bare the inner workings of the capitalist system of production in a way that traditional economists have tried to sweep under the carpet ever since. It describes the ‘juggernaut’ of capital in its various forms, and how it harnesses the creative human impulse in the interests of profit. In capitalist industries, most workers are estranged or alienated from their productive nature.

Marx's analysis helps us to appreciate the marginalisation that accompanies unemployment. It also shows how modern work, with its focus on productivity and uniformity, may not offer many the sort of opportunities to engage in the meaningful social activity that people need for a sense of fulfilment and belonging. Providing secure, rewarding employment opportunities for everyone in society would increase human flourishing and reduce the vast pool of misery and distress that fills our waiting rooms.

Philosophical Investigations by Ludwig Wittgenstein

Wittgenstein resolved the problem of dualism, but not through eliding mind and body as many psychiatrists seem to want to do. ^{Reference Wittgenstein3} For Wittgenstein, knowledge is a product of the interaction of a subject with her surrounding world. Subject and object occupy different perspectives. Sceptical worries about the certainty of knowledge are misplaced. Knowledge is inherently uncertain, because it is knowledge of something else. The certainty we have about our own thoughts and feelings is not knowledge. It is simply the experience of being an individual organism.

Wittgenstein's work suggests that understanding human activity is a different sort of endeavour from understanding the material world. His view that the methods of natural science are not transferable to the study of human behaviour is shared by many other philosophers and social scientists. For Wittgenstein, mental states and actions are properties of people, not of brains or an abstract mind. Through his theory of language, Wittgenstein, like Marx, stresses the social nature of human thought. Our language derives its sense from the way it is used within a particular social milieu.

In order to understand human thoughts and feelings we must look outwards, not inwards. The meaning of madness and distress is not waiting within neural processes for us to decode, and nor is it to be found in abstract psychological theories. Mental disorders are social events. This perspective has been fleshed out by sociologist Jeff Coulter, who contrasts the processes of medical and psychiatric diagnosis. ^{Reference Coulter4} He shows how the concept of ‘mental illness’ is a designation, conferred by social groups when behaviour infringes unwritten rules of conduct.

Ideology and Insanity by Thomas Szasz

Consistent with Wittgenstein, Szasz argues that mental illness is not like physical or bodily illness. ^{Reference Szasz5} It is not a material thing residing in an individual's brain or mind. It is a pattern of behaviour that is socially disapproved of or unwanted. Szasz is often accused of disregarding or minimising the suffering that people deemed to be mentally ill experience. However, he does not deny that the behaviours associated with mental disorders can cause suffering to the individual, or to people around them. He just maintains that the problem is not an illness, in the sense that the term ‘illness’ is properly used.

Szasz emphasised the ‘strategic’ nature of the concept of mental illness. Defining a situation as an illness has social consequences. It authorises the right to care, but also the right of others to enforce ‘treatment’ and control. Moreover, it disguises the moral and political judgements that infuse social responses to people who are labelled as ‘mentally ill’.

Szasz can be criticised for underestimating the difficulties of defining physical illness and over-simplifying the relation between brain, agency and behaviour. ^{Reference Fulford6} Nevertheless, in my view he pinpoints the central contradiction of psychiatry – that it is a medical speciality that deals with a predominantly social rather than a biological phenomenon. Szasz wrote dozens of books, and it is difficult to pick a single one. He gave me a copy of Ideology and Insanity when I invited him to speak at the Maudsley Hospital 20 years ago. It is a collection of essays that clearly convey his core ideas, and it is what I most frequently turn to when I want a quotation.

Madness and Civilisation: A History of Insanity in the Age of Reason by Michel Foucault

Although French philosopher Michel Foucault distanced himself from French Marxism, like Marx his work highlights the links between modes of thought and social and economic conditions. In Madness and Civilisation, the abridged English translation of his first book, Foucault traces how attitudes to madness were transformed over the 17th and 18th centuries in response to the emergence of Protestantism and the beginnings of capitalism. ^{Reference Foucault7} As industrial production starts to emerge, hard work and discipline become important virtues. Any condition that threatens the social order and the injunction not to be idle must be corrected. Anyone who will not or cannot work, must be removed from society, and taught the error of their ways. Like Szasz, Foucault suggests that medical explanations for madness and the medical approach to treatment are imposed later onto what is essentially a moral and political enterprise.

The ‘Great Confinement’ that removed the mentally disturbed from society along with other undesirables occurred at different times in England and France, but in both countries psychiatry emerged from the institutions created to manage the problem of the poor and the destitute. As the historian Andrew Scull explains, in England, the asylum was an integral part of the workhouse system, designed for those inmates who were disruptive to workhouse discipline and could not be forced into work. ^{Reference Scull8}

Understanding that the origins of psychiatry lie within the welfare system helps to illuminate the social functions that mental healthcare still performs. In England, asylums replaced pre-existing arrangements, whereby care and financial assistance were provided on an individual basis through local parishes. ^{Reference Rushton9} Today, we are in some ways returning to this older system of care, albeit now refracted through an established medical lens.

Brain Disabling Treatments in Psychiatry by Peter Breggin

American psychiatrist Peter Breggin's much neglected work has had an important influence on my thinking about the nature of drug treatment. ^{Reference Breggin10} This is the book where he sets out his theory that psychiatric drugs, along with other brain-based treatments like electroconvulsive therapy (ECT), work by disabling normal brain functions. The beneficial effects we observe with drug treatment or ECT, when they occur, are the result of this reduced level of functioning seeming preferable to the pre-existing mental distress and disturbance.

Although Breggin concludes that it is almost never right to use drugs that have these sort of effects, I believe there are some situations in which it is the lesser of two evils. The emotional restriction and mental slowing produced by antipsychotics may help reduce acute psychotic preoccupations, for example. The relaxation produced by benzodiazepines may provide welcome and useful relief from intense anxiety. However, Breggin is right to make us feel uncomfortable about the treatments we use. Psychiatrists should be more aware of the potential for drugs to hinder normal mental functioning and emotional expression, and more hesitant about prescribing them.

Ward No. 6 by Anton Chekhov

Maurice O'Connor Drury, a pupil of Wittgenstein's who became a psychiatrist, suggested that it is through art and literature, not scientific experiment, that we come to comprehend the human ‘mind,’ including its distortions and torments. ^{Reference Drury11} Ward No. 6, a long short story by Chekhov written in 1892, demonstrates his point beautifully. ^{Reference Chekhov12} It is the story of a world-weary doctor, Ragin, running the hospital in a provincial town in 19th-century Russia. When he first took up his post, we are told, Ragin worked hard, but he became demoralised by the difficulties of improving the hospital, and by his lack of ability to genuinely help people. He is oppressed by his impotence, but consoles himself with the stoical outlook that suffering is part of life, and that nothing ultimately changes. The story also recounts the paranoid breakdown of a local clerk, who becomes an inmate of the locked and forbidding ‘Ward No. 6’, the ward reserved for ‘mental patients’. Dr Ragin befriends the young man, and they have long intellectual conversations, which provide a respite for the philosophically inclined doctor from the tedium of local life. When a modernising regime is instituted at the hospital, and a new, younger doctor arrives, Ragin no longer fits the bill, and is ousted by the hospital authorities, precipitating him into his own personal decline.

I sense there is an ambivalence towards change and modernity in the story. On the one hand, Chekhov condemns Ragin's passivity and indolence. Ragin is aware of medical advances, like antiseptic treatment, but fails to institute them. Overall, however, he is a sympathetic character who is interested in people's lives. Chekhov is also far from flattering about the new doctor, who is painted as jealous and self-serving. He liberally dishes out bromide, but has no time for understanding or empathy. The story is, of course, a fable about the corruption and inertia of pre-revolutionary Russian society, but it also encapsulates an age-old dilemma for psychiatry. Therapeutic enthusiasm may improve the social status of mental healthcare, but, quite apart from the harm it may inflict on patients' bodies, it comes at the cost of a deeper understanding of the nature of madness and the individuals it affects.

Mary Barton by Elizabeth Gaskell

This 19th-century novel was originally going to be named ‘John Barton’, after the father of Mary, but the publishers made Gaskell change it. ^{Reference Gaskell13} It is the character of John Barton that makes the novel interesting and that embodies its tragedy, but the publishers no doubt felt that naming a novel after a morose, working-class opium addict might affect sales!

John Barton is a factory hand in 19th-century Manchester, who is bringing up his daughter, Mary, after the death of his beloved wife. When he loses his job, he descends into a state of dejection and despair, and he turns to opium for comfort. Gaskell describes his state of morbid preoccupation as if she were writing a psychopathology text, and she even notes that had he come before a physician, he would have been diagnosed with ‘monomania’. For Gaskell though, Barton's feelings are an understandable reaction to the terrible conditions in which he lives, and the suffering and privation all around him. She understands the immediate attractions of opium-induced oblivion, as well as being aware of its addictive properties.

I am struck by the contrast with how we would characterise this situation today. Barton would be diagnosed as having a moderate or severe ‘depressive episode’ and offered an antidepressant, which would be presented not as a salve for his despair, but as a physiological corrective. Individual therapy might be offered, but with much the same aim as drug treatment – to re-orient his negative thinking.

Gaskell's approach is so much richer. In her hands Barton's circumstances are not just ‘social factors’, and his emotional state is not some disorder or entity that is independent of himself and his history. Gaskell, who was a strong dissenting Christian, naively believed the solution to John's problems was a brotherly reconciliation with his class enemies, but she nevertheless sympathised with the human desire for an immediate balm for physical and emotional pain. In Barton's position, ‘Would you not be glad to forget life and its burdens?’ she asks.

Manufacturing Depression: The Secret History of a Modern Disease by Gary Greenberg

This book is one of the most entertaining critiques of modern psychiatry I have read. ^{Reference Greenberg14} Greenberg has a knack for expressing profound philosophical arguments engagingly, and combines these insights with a sweeping history of modern notions of depression, interspersed with his own experiences.

Greenberg follows Wittgenstein and Szasz in arguing that depression is not something that emanates from (and will eventually be identified in) the brain. It is a property of human conduct and relations. Moreover, designating something as an illness is to make a moral judgement that it is unwanted and needs eradicating. Instead, Greenberg makes a plea for depression to be understood as a legitimate response to an increasingly demanding and destructive society.

One of the most valuable parts of the book for me was Greenberg's account of participating in a randomised controlled trial. Greenberg is surprised when his tendency to pessimism, despondency and indecisiveness is diagnosed as ‘major depressive disorder’, rather than a more minor condition, but he takes the tablets on offer and goes along with trial procedures. His description of trying to make his feelings fit into rating scale responses is hilarious in places. Even the trial doctor admits that: ‘You know, this question condenses a lot of areas of life into just a number. It doesn't work well.’ In this sentence the edifice of ‘scientific’ evidence on depression collapses. We cannot capture the enormous complexity and variety of problems people endure in a label or a symptom score. Yes, we need to evaluate our interventions in a systematic manner, but we should not delude ourselves that quantifying human experience helps us to know it better.

I Had Trouble in Getting to Solla Sollew by Dr Seuss

Dr Seuss' books are illustrated poems about strange, furry creatures who have crazy adventures. They are great fun to read with children, and many of them have a moral or message. The Lorax describes environmental degredation. The Grinch is a critique of the commercialism of Christmas.

In Solla Solew, a small furry creature is having ‘troubles’ with nasty looking birds and insects that leap out of nowhere to peck and bite him. ^{Reference Seuss15} A larger, older animal comes along and persuades him to leave his troubles behind and go in search of the wonderful ‘City of Sola Sollew, On the banks of the beautiful river Wah-Hoo, Where they never have troubles! At least very few!’ After an arduous journey in which the hero of the story is abandoned by his companion, swept away in a mid-winter storm, and has to do battle against the Poozers of Pompelmoose Pass, he finally arrives at Solla Solew. There he finds that the one problem in this dreamlike city is that you can't open the gate to get in. At this point he decides not to go on to the ‘City of Boola Boo Ball, On the banks of the beautiful river Woo-Wall, Where they never have troubles! No troubles at all!’ but to go home and face down his troubles instead.

The parallel is obvious. Searching for the schizophrenia gene, so we can switch it off or breed it out, or the magic pharmaceutical bullet that will abolish depression or anxiety is doomed to failure, just like the quest for Solla Sollew. ‘Troubles’ are part of the human condition, and always will be. The art of living is to learn to manage them ourselves. The art of being a psychiatrist is to help others to.