Discipline as treatment
Sociological research has shown a clear link between the current socio-economic system and severe psychological and social problems. The dominant neo-liberal mindset ignores this fact, and, instead of tackling the causes, focuses entirely on the consequences: namely, the deviant, disturbed, and dangerous others — psychiatric patients, junkies, young people, the unemployed, and ethnic minorities. The supreme irony is that a new market has even sprung up in response, offering advice on upbringing, educational supervision, psychotherapy, parental counselling, and, above all, the medicalisation of psychosocial problems. All these areas have become a lucrative business. They fall under the common heading of discipline.
The words we use often express an underlying ideology, and changes in the way we refer to things are always significant. Not so long ago we talked about psychology and psychiatry; now we speak of behavioural sciences. Formerly, people had psychological problems; now they suffer from behavioural disorders, and psychologists happily refer to desirable and undesirable behaviour. In the old days, we would provide a diagnosis; nowadays we perform an assessment (a term more legal than medical), and we have even got to the stage of early detection among infants. Things have come to a pretty pass.
What we are seeing here is a curious redefinition that goes in two directions. The current tendency to regard people with mental disorders as socially deviant is only a small step away from lumping them in with criminals. On the other hand, just about every criminal is regarded as the product of his or her unhappy youth, and therefore as having a mental-health condition. It won’t take long before we end up in a society as described by Samuel Butler in Erewhon: or, Over the Range (1872), which punishes patients and treats criminals. By way of illustration, in the United States there are now three times as many psychiatric patients in prisons as in psychiatric institutions — a return to the levels of 1840.7
Discipline is inherent to psychiatric practice. This may sound puzzling. After all, isn’t psychiatry a branch of medicine whose goal is to help patients? Absolutely, but that does not rule out a disciplinary element, especially not in an age in which the medical field in general is increasingly telling people what to do. We’re swamped with news items such as ‘Cardiological research shows that you shouldn’t drink more than two cups of coffee a day.’8 The disciplinary aspect of psychiatry can be traced right back to its beginnings, annoying many of its practitioners, who are reluctant to see themselves in this role.9
Indeed, discipline does sound rather suspect. Authority is a dirty word these days, and how do you square this approach with neurotransmitters and genes? Yet it’s not too hard to uncover what’s going on here. All current psychiatric labels have three layers: psychological, social, and medical. The psychological layer is the visible external one; the diagnostic criteria describe mental and behavioural characteristics (‘often appears not to listen’, or ‘shows signs of affective instability’). The social aspect is less easy to spot, being hidden, paradoxically enough, by the most commonly used word in the DSM handbook, ‘too’, and all its synonyms. It crops up ten times in the description of borderline personality disorder, always to the effect that there is too much or too little of a certain characteristic or a certain behaviour. That is to say, too much or too little according to an implicit social norm, according to which the diagnostician must intuitively grasp what is still acceptable and what isn’t.* The third aspect, the medical layer, isn’t much more than a supposition based on the illness model, despite the lack of convincing scientific evidence.
[* My criticism might make the reader think that I deny the existence of these disorders. Nothing could be further from the truth. The group stowed away under the heading ‘borderline’ does indeed have serious problems. But it would be both scientifically and clinically more correct to attribute them to ‘complex post-traumatic stress disorder’. That would also cause an instant change in attitude towards people suffering from this condition.]
In the case of the vast majority of these labels, it is extremely dubious whether psychiatrists and psychologists are occupied with the distinction between sick and healthy in the medical sense of the term. Their main focus is the distinction between what is socially deviant and socially acceptable, a pre-eminently ethical question. In short, the rationale of the diagnostic labelling system boils down to the following: a psychological or behavioural characteristic that comes within its purview is one that is too pronounced or too lacking, giving rise to socially unacceptable behaviour — the silent assumption being that the cause is organic.
A diagnostic system of this type clearly influences the goal of treatment: the ‘too much’ must be surgically removed, or the ‘too little’ fleshed out, so that the patient once again complies with social norms. This built-in link between diagnostics and treatment confirms an intelligent rule devised by the German writer W.G. Sebald: you only know the full extent of a problem when you see the solutions that are proposed. If a child labelled with ADHD is sitting quietly in the classroom attending to the lesson, the problem has been solved. In other words, the disorder doesn’t really bother the child so much as its parents or teachers. But if the child makes a nuisance of himself or herself, he or she is prescribed Ritalin and an obsolete form of behavioural therapy. This explains a very strange medical finding, namely that medication and behavioural therapy aren’t really needed outside school-term times. I would go so far as to say that the aim of most DSM diagnoses is to restore compliance with social norms.
To recap, imposing norms and discipline is inherent to psychiatry — psychiatric diagnoses will always retain this element. The question is whether psychiatry has anything more to offer. When I teach psychodiagnostics, I make a distinction between ‘legal’ and ‘clinical’ psychodiagnostics. The first focuses on protecting the group and society, if needs be at the cost of the individual — take the case of Breivik. The second focuses on protecting the individual, if needs be at the cost of society — take the case of Semmelweis. Both are, of course, necessary, and reconciling these two very different objectives often involves a tricky balancing act.
But a crucial shift is now taking place. The dominant form of psychodiagnostics and associated treatments reveals the psychiatry business to be on a slippery slope. We are fast moving towards a situation in which psychiatric diagnoses will function as screening systems for deviance, social control having taken on a pseudo-medical form. And that is hugely significant, because psychiatry is no longer confined to hospitals and consulting rooms. It has extended its domain to every sphere of life, from education and upbringing to law, insurance, relationships, and the workplace.
Hi, I’m Vanessa, how can I help you?
So what’s behind that shift in psychiatry from treatment to discipline, and why is there so little protest against it, compared to, say 30 years ago? Up to the 1970s, psychiatric practice was all about disciplining patients and preserving the status quo. The then emerging field of psychotherapy took up cudgels against this approach, siding with the individual against the excesses of the patriarchal society as represented by traditional psychiatrists. In those days, patients had a robust, rigid identity and were imprisoned in a straitjacket of norms and values. They were proof of Freud’s claim that people become neurotic because they want to be too principled. Psychotherapy taught them to distance themselves from those overly rigid norms and the guilt and shame they caused.
These days, the situation is quite different. The modern individual has grown up in a highly unstable environment in which almost everything is attainable and just about anything goes — the only rule being that you have to consume. The snag is that you must engineer your own success: if you fail, you must be either lazy or sick. As a result, identity is less stable than before, so more people go off the rails. Just as in the Victorian age, their perceived deviations are merely extreme expressions of the current ideal identity, having to do with a lack of discipline — the opposite, in other words, of the ideals in vogue
30 years ago. And again, therapists are called in, this time not to temper excessive discipline, but to supply a deficiency. So treatment is shifting towards practices like elementary behavioural therapy and psychoeducation, the aim being to keep people on track where possible. Thus psychiatrists and psychotherapists are becoming the new moral authorities who tell us, in the name of science, how to behave. The fact that this meets with little or no protest, by contrast with 30 years ago, shows that many feel it to be necessary.
So the first answer as to why the focus of psychiatric treatment has shifted towards discipline is that society seems to want it. Even if this is true, it is debatable whether this is a task for psychotherapists. And it has far-reaching consequences, especially given the increasing medication involved. Those who can’t sit still are given a pill. What’s more, it’s important to realise that this approach only targets a symptom of neo-liberal policy — the disappearance of a traditional ethics of self-control — without affecting the causes. Psychotherapists, psychiatrists, and remedial educationalists haven taken on the role of Supernanny, battling everything that the flat screens ceaselessly promote: fast food, fast pleasure, the need to be always online.
And yes, it is about Supernannies, not Superdaddies. Responsibility lies with mothers; there are no fathers anymore. They disappeared because their function was undermined. Until recently, the West possessed a tradition of authority symbolically vested in individuals (‘Thou shalt honour thy father and thy mother’). Representatives of authority were themselves subject to the system, and could also be held accountable. These days, we live in a world where power is anonymous and cannot be localised, and therefore no longer exercises any moral authority. Much more importantly, it can also no longer be called to account. It is epitomised by the call centre with its endless menu options (‘Hi, I’m Vanessa, how can I help you?’) that never puts us through to the person who is responsible, for the very good reason that they don’t exist. The seat of power has been abandoned.
There are no fathers anymore because the system has done away with symbolic authority figures. In the best-case scenario, the modern father is a second mother alongside the first. Both yearn for an authority that would also offer them security. The tragedy is that parents are blamed for the consequences of this system, though they themselves are victims of it. Journalist Kaat Schaubroeck sums it up perfectly in the title of her book: Een verpletterend gevoel van verantwoordelijkheid: waarom ouders zich altijd schuldig voelen (A Crushing Sense of Responsibility: why parents always feel guilty). When they seek help for their children, whose disorders are also caused by the system, they find themselves at the mercy of the social-services call centre, which sends them from pillar to post.
And this is the second explanation for the increasing demand for discipline: neo-liberal policies create a need for it by sweeping away symbolic authority and trust in such authority. As a result, everyone mistrusts everyone else, leading to yet more monitoring and measurement, and, despite all the slogans about deregulation and the ‘free’ market, to an endless proliferation of rules, regulations, and contracts. Michel Foucault was perhaps the first to have signalled this process. He speaks of the shift in a clearly identifiable power — the father as symbolic authority figure — towards biopolitics. A shift, in other words, from an authority that can be localised and held to account, to an anonymous and thus generalised disciplinary force.
This means that you can no longer point the finger at power, which makes resistance very difficult. By way of metaphor, Foucault refers to the ideal prison devised by the English philosopher and social theorist Jeremy Bentham. Its unique feature was a single, central watchtower from which all inmates could be watched by an unseen observer. This Panopticon, as he called it, was also extremely efficient and cost-effective, because it only needed a single jailer. According to Foucault, present-day society and the new discipline go much further: the watchperson has left the Panopticon’s tower, and supervision is everywhere. Every time we walk down the street, turn on the television, or open a magazine we are told how to behave and how to attain the perfection expected of us. We all have to jump through evaluation hoops; we are forever being ‘invited’ to participate in health checks, audits, screenings, tests, and so on; and on top of that we are expected to carry out constant self-assessment.
Psychiatry and psychology play a central role in all this, which is why the Belgian historian Jan de Vos speaks of ‘psychopolitics’. The manipulation of our subjectivity by psychiatric science, predicted by MacIntyre in 1981, has become so all-encompassing as to be almost invisible. The best yardstick for the scale of this phenomenon is the rate at which individuals are tossed aside by society. If things go on like this, we will soon live in a cartoon world in which half the population are therapists and the other half are patients.
As a psychoanalyst, I cannot naïvely decide to champion the individual as opposed to society, or society as opposed to the individual. Current mainstream psychology and psychiatry typically opts for society — a backlash against the earlier psychology of liberation, which took the side of the individual. The psychologists who preached liberation forgot that the individual very much needs society, with its norms and values. The therapists of today, who preach discipline, refuse to see that individuals and their disorders are products of society.
In other words, the contrast between a society that makes people ill and a healthy state of nature is misguided. All societies, without exception, induce illness, just as they induce wellbeing. The explanation is simple. Every community defines and shapes its own normality, in the same breath defining and shaping its abnormality. The mindset that dominates this process defines the practices that result. It makes quite a difference whether those practices are shaped by a religious mindset (so that someone who deviates is a sinner to be converted, a heretic, or a witch); a medical one (someone who deviates is a patient needing treatment); or an economic one (someone who deviates is a parasite). The only common element is exclusion. On this side of the line you have us, the normal ones; on the other, them, the abnormal ones. So a single individual can at one and the same time be a martyr (religious mindset), a dangerous lunatic (medical mindset), and a terrorist (economic mindset).
The question, therefore, is not whether a society makes people ill or well. It is rather how a particular society defines deviations, and what consequences this has. When, as is quite conceivable, such definitions are ethically dubious, a society will find itself in conflict with its fundamental principles. In a word, it will destroy the very ties that hold it together.
And this is happening now.
EIGHT
THE GOOD LIFE
Every society defines what is normal, and thus also what is deviant. These definitions are the product of the dominant narrative and the way in which authority is manifested. They follow in the wake of the ideal identity that society holds up to its members. In that sense, every society makes its members both well and ill, and to judge a society we need to look at the balance that is achieved between the two. At present, most psychosocial health parameters point in the same direction: society is more pathogenic than beneficial.
Drawing on our knowledge of identity development, we can sharpen this conclusion yet further. How does our current social organisation relate to the two fundamental processes that shape identity: identification (sameness), and separation (difference), each with their characteristic fears? And, on a broader timescale, how does that social organisation relate to what we know about our behavioural inheritance?
Social organisation: sameness and difference
Our identity is shaped by two basic urges: the desire to merge with the other, and the desire for autonomy. Both need to be kept in balance. The first promotes sameness, and thus group forming and subjugation; the second fosters difference, and thus individualism and autonomy. If social-group formation is too weak, the need for the other is felt much more strongly. People will seek affiliation with others on the basis of common char
acteristics, many of them debatable, from sharing the same illness label to bullying the same victim. If social-group formation is too strong, personal aspirations are stifled. People desperately try to escape the system in a bid to gain some control over their lives. The more totalitarian the state, the greater the urge for autonomy. Pressure to conform breeds defiance: girls forced to wear a school uniform will try to give it a personal touch.
Both urges also create their own brand of fear and aggression. Up to a few generations ago, life was dominated by a fixed, unchanging social order, resulting in a safe lethargy. That social order came to be seen as intrusive and overly controlling, sparking a desire for autonomy. Aggression was directed at central authority and its wish for uniformity. These days, society focuses on the individual. As a result, people feel less secure and more mistrustful of others. They are also much quicker to express aggression, against any ‘other’ they perceive as potentially threatening. Yet at the same time the need for that other is universally felt. The fear of abandonment and, even worse, loneliness, is very great.
The death of public spiritedness and the rise of hyper-individualism can largely be attributed to the current economic model, which systematically pits people against each other, heightening feelings of disparity. If we want to restore the balance between sameness and difference, between public spirit and autonomy, we must transform today’s system of labour organisation, and rethink the economy. And by that I don’t mean adopting a model along the lines of ‘everyone is equal’. Too much parity is as harmful as too much disparity, and both spark their own brand of aggression and fear. The new labour organisation should preferably be based on a meritocratic system where the focus is on quality, and rewards are not just financial. The same should apply on a larger scale to the new economy, which must shed the idea of quantitative growth as fast as possible in favour of qualitative sustainability.* That notion of ‘growth’ is possibly the most pernicious legacy of the Scala Naturae: ever more, ever higher, exalted above the rest.
What About Me?: The Struggle for Identity in a Market-Based Society Page 18
