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by Mary Boyle
Routledge, 2002
Review by Tony O'Brien on Aug 19th 2004

Schizophrenia: A Scientific Delusion?

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.