Revisiting Medical Nemesis: Sociological Studies of Psychiatrization

Troubled Persons Industry: The Expansion of Psychiatric Categories beyond Psychiatry. Edited by Martin Harbusch (Palgrave Macmillan, 2022) One cannot avoid observing that, while Goffman opened his primary investigation of mental health by featuring its form as an institution (Goffman 1961:1–125), Martin Harbusch opens his book by featuring its current form as an industry: a troubled persons industry (TPI). For Harbusch, that was a good decision, in that an industry, as a social apparatus, is a complex of such things as products, services, transportation, supervision, and so on—possibilities integrated by regulations and capital, all of which is part of the revolution in the sociology of mental health since Goffman's time. Indeed, the TPI should be studied as an organized and organizing macrostructure along with other interdependent macrostructures that frame the micro-dwelling of social actors, even and especially those whose interaction forms the living, social experience of them—what is in one sense the political economy and in another the context and experience of the lifeworld. Being a part of all this, the TPI is impelled to undergo transformations, including expansion, as do other industries; and Harbusch's book treats the TPI as an expanding conglomerate of mental health services characteristic of global, Western medicine. Of course, we have been recently reminded of medicalization in general within the political economy, consequent to the degree that medicine's economic and social activities have been radically altered, first by fate, but also in recent practices associated with scientific assessment, political decision, media reporting, manufacturing (e.g., masks, test kits, vaccines), and even censorship. Who at this point, for example, could argue that science has a dispassionate character! To be sure, mental health concerns also fall under medicine and health more broadly, which is why the term psychiatrization is used repeatedly in this volume, effectively to identify it as a satellite to the ideas of medicalization, although the two can work in tandem, treating health as a whole. In any case, each term is structurally resonant with its quite familiar cousin or maybe uncle: nationalization, a term also associated with the establishment of regulated, territorial dominance. In the case of psychiatrization, the TPI provides the organization, foot-soldiers, and cavalry, making it a focal-point for sociologists studying mental health resources-and-practices, as well as outcomes. The book is composed of articles written by more than a dozen authors with distinct approaches to the TPI, varying in topic, from case to case. Despite the variety, however, there are a number of recurrent themes, and it is possible to get a good sense of the whole by looking at some of those themes as well as brief reviews of the several articles. Whereas the TPI has evolved as an integrated resource of the political economy writ large, it has done so within relevant pre-existing settings that could put the ambitions of TPI into effect (e.g., hospitals, schools, prisons, rehabilitation centers). So it is no surprise that the TPI is composed of broadly-distributed agent-roles, even those with no apparent, practical interconnection (e.g., school teachers, prison officials, pharmaceutical salespersons, social workers, journalists) as well as diverse practices (teaching, supervising, researching, guiding, facilitating, enforcing, documenting). Indeed, the identity-states of TPI clients can also be hybridized by such a context. A social worker who visits them at their place of employment, for example, may press such clients into a hybrid role that combines being a troubled person with being an employee, along with all the nuances of interaction-routines that hybrid position might require. Thus, not only in the case of workers, but even in the case of serviced clients, the TPI takes form through regulated assignments of roles for social actors with varying talents, competencies, and inadequacies, as such roles emerge in what would be characterized as the authoritative caretaking and management of mental health, and constituted by role emergence in a form that is both mutable and malleable. It is no surprise that Muzzatti and Rothe (Ch. 5) find themselves turning to Zygmunt Bauman's discussion of “liquid modernity” as well as a sense of contextual vertigo when describing it (p. 114). Boundaries and limits are thus multivalent in the social spaces constituted by the TPI, and one must be alert for changes when accommodating them. Harbusch, for example, floats the idea that the industry could be bracketed narrowly as a means to reference service-providers for psychiatry, though not psychiatrists themselves. The distinction could be used, from time to time at least, as a boundary-variant that would position psychiatrists as “outside” or “above” the TPI; and, if that were so, those not trained in psychiatry would operate in a hybrid collective space that was neither client nor clinician—a space of its own. At 16, for example, I was hired to water-rescue distressed patients on the lakefront property of a residential mental-health facility, which likened my experience to those workers “whose mode of production and background lie outside of their expertise,” (p. 13) particularly in that I spent more time preventing these emergencies by calming and befriending the patients. Now, in the same way, schoolteachers, prison authorities, parole officers (some trained professionals, in their own right) also must practice their routines under an umbrella of psychiatry, an umbrella that supersedes or constrains their involvement, even though it also demands their involvement. Clearly, they enter as workers in mental health, but the manner of their participation carves for them a “liminal role-space,” which obliges them to “maintain their appearance as laypeople,” (Harbusch, p. 13) an obvious performance dilemma for study by symbolic interactionists. Indeed, the effects of TPI hybridity upon symbolic interaction can even occur when a taxi or Uber driver is advised that, “the passenger is going through some difficult things,” initiating a conveyance-performance that is also intended to manage an interaction with a “troubled person” by suggesting that label, though not making it explicit. Thus, although the various authors have not come to accord on the margins of membership in the TPI, it appears that, even with respect to work in general, social agents commonly carry a general alertness to the idea or possibility of troubled-persons; duties with respect to particular behavioral routines of their own associated with the event and the interaction, or even a refusal to engage in them (e.g., “I drive a car—if you need more than that, call an ambulance.”) Apparently, under one circumstance or another, we are all interactants, if not members, of the TPI, with our interaction-processes guided by explicit labels or subtle indications that this is taking place, another general principle informing the contributions to the book. Not much is said about the identity-ambiguity of psychiatrists, themselves in the middle of such dynamics, but even for them, certain contexts can lead to alterations in role and practices with respect to what is permissible and what is not. The context of TPI can thus lead to liminality and hybridity, even for specialists such as “clinical or academic actors within psychiatry” (p. 13). Certainly they can be set apart from other industry-actors in terms of their superordinate field-training, licensing, and insight, nevertheless their routines are by times adjusted under cohort pressure within a TPI context. Thus, in McBride's contribution, “Carceral Psychiatry” (Ch. 10), that contributor points out the effect of co-workers with TPI status pressuring psychiatrists to “‘do something’ about prisoners behavioral problems” (p. 230) or “to participate in disciplinary proceedings and ‘work with administrators in determining sanctions;’” (p. 230) and he demonstrates the effect of a narrowly conceived TPI composed exclusively of those without roots in psychiatric training by suggesting that, under their influence, a general process of mental-health servicing for people understood as “prisoners-and-clients” erodes and demoralizes carceral, psychiatric practice, “to the point whereby mental health services and supports are often rudimentary” (p. 229). Thus, studies of TPI appear to be growing in their sociological understanding, much as the TPI, itself, is expanding, by virtue of the services, products, and regulation it provides, whether acting through educators, social counselors, cafeteria staff, or janitorial workers. And just as persons included under its umbrella are in the process of discovering and adapting to the norms that constitute their situation, study-and-reporting on the area can also inspire reflexivity with respect to its emergence, formalizing an area that quite naturally gives rise to the ambiguities of uncertainty, making research critical. Indeed, the four essays that immediately follow Harbusch's introduction are curious about the manner that a TPI interacts with education as an industry in itself. Timimi and Timimi (Ch. 2) note, for example, that educators report a new burden of accountability in their primary profession as teachers, one that emerges in association with TPI's transformation of what is for them the definition of the situation, from classroom-situation to classroom-plus-psychiatric-situation, wherein, for example, the longstanding idea of the problematic student is re-characterized through psychiatric labeling, creating anxiety among interviewed teachers with respect to their professional responsibilities and leading to requests for more formal training associated with the new dimensions of their role. And it should also be mentioned that these same interviewed teachers observe that students, either as troubled persons or as persons-at-risk, are developing new psychiatric understandings of what was till recently regarded as “the emotional turmoil of growing up” (p. 40)—a social construction of the troubled student's emergence with the quality of a looping effect described elsewhere, as a consequence of interaction routines fostered by times in the TPI. McLeary and Powell (Ch. 3) remind us that this re-labeling of what were till recently the “problems of childhood” may foster a tendency to convert a student who is sad into a candidate for depression within such a mental health context, facilitating or rendering facile any “suspicion of ‘illness/unhealthiness’ that requires ‘curing,’ ‘fixing,’ or ‘helping’” (p. 54), driven by various needs for its services and the various ways that they are entwined with its viability as part of the lifeworld of all those employed in it, forces that facilitate the “expansion of troubled persons professions in the society” (p. 59). And it is by virtue of this that Marley and Fryer (Ch. 4) regard TPI activities as “tactical, strategic and political processes” (p. 78), in their case with respect to the efforts “to provide ADHD with a ‘realness’ with which it was difficult to argue.” (p. 81) The authors note, for example, that evaluators and counselors largely disregard broad social factors that could explain a child's reduced, attention-capacity—possibly financial or social instability at home, for example. Instead, the TPI's judgment-tendency strongly inclines toward the “continued use of medication.” (p. 100). Muzzatti and Rothe (Ch. 5) identify problems related to this psychiatrization ideology, focusing upon its role within the symbiotic cultural form of neoliberal capitalism, always ready to make a business out of a crisis—in other words the search for a product or a productive act that promotes capitalism to an ethical form with avenues of penetration and growth into political and social institutions as well as public consciousness. (pp. 107–108) The industry issue would be more evident if it were plastic surgery, of course, as few will deny that plastic surgery is driven by ambitions of capitalism. By contrast, TPI is able to adorn itself in a myth of care that may be more self-congratulatory than it merits. Yet, while Muzzatti and Rothe do acknowledge that the part of the TPI they examine offers a helping and caring hand, they do not let the caring myth draw a curtain over their ability to read the full range of TPI effects: the neoliberal “student-customer-cum-victim,” (p. 121) and its tendency to degenerate the moral rigor of college life. They thus observe that higher education, which is “not immune from neoliberalism's totalising affect,” (p. 108) has “pathologising effects on students,” (p. 108) what they regard as (based on their reading of Christopher Lasch) “pathologies of hyper-individuation” (p. 114). In the end, they predict the advance of “a broader trend of infantilisation … (that will grow them into) … adult troubled subjects” (p. 124). These early chapters related to education would provide a superior source for graduate-seminar classes in education departments. However, having only reached page 130, we are effectively 1/3 of the way through the volume, the forthcoming essays as compelling and controversial as the ones I have already glossed. There is one by Cohen (Ch. 6), a pivotal figure with substantial contributions to both medicalization studies and, thanks to his recent publication of Psychiatric Hegemony (Cohen 2016), psychiatrization as well. Fixsen and Cheshire (Ch. 7) offer an essay on the current investigation into how care-of-the-self as a diet-form can give rise to “new opportunities to problematize fundamentals of human life” (p. 165), when that practice falls into the clutches of diagnosis through the ongoing expansion of labeling. For this case, the authors examine a condition called, “orthorexia” a name that suggests the paradox of excessively “proper eating,” what some might call “excessive” concern with organic vegetables, grass fed meat, nutrition supplements, and so on. Like the Timimi and Timimi (Ch. 2) chapter, these authors also provide a sense of what Kenneth Burke referred to as a “trained incapacity” (Burke 1965, p. 3) regarding the TPI's ability to shape a balanced perspective in its agents, now skewed because of the tendency to repeatedly see exclusively through a TPI lens, and therefore offering a mental health interpretation for all problems and solutions. And, in keeping with this idea that Burke also called an “occupational psychoses,” (ibid.) In like form, Tseris (Ch. 8) rightly insists that the appearance of stress behavior around the challenges of pregnancy and the earlier stages of infant management and care is “over-psychiatrized” among mental-health agents when they read these normal reactions to excessive burdens, as “signs of mental illness.” Again TPI practices are said to give scant regard to the practical issues associated with “late-pregnancy and post-pregnancy parents,” once they fall under the sense-making of a TPI that tends to give little respect or attention to social solutions to the problems of living (p. 172). Larocque, Brossard, and Namian focus explicitly on a theme that appears or is implied in many of the other troubled persons essays here: the tendency to create or recycle labels that accelerate the encroachment of the mental-health model (p. 193). Already developed in Scheff (2010), to be sure, these authors make their contribution through a detailed examination of a substantive issue: the sex addiction label. McBride (Ch. 10), as already mentioned, examines how TPI agents working in prisons (e.g., warden, guard, orderly, psychiatrist, nurse, prisoner) may act in manners that constrain the freedom and dignity of their prisoner-patients, thereby ironically creating counter-therapeutic outcomes, what was in essence the theme of Kesey's Cuckoo's Nest so many years ago. Dolphin and Newhart (Ch. 11) address the problems associated with cannabis-use as a treatment for troubled persons, with particular attention to its contested status as a mental health resource, another expression of liminality. The authors note the various reservations against cannabis by medical professionals possibly persisting in the drug's earlier symbolic associations, which appear to have created a persistent prohibition, at least for medical professionals (p. 272). Nuckolis (Ch. 12) argues that psychiatric categories evolve out of more broadly anchored cultural types. Starting with America's independence/interdependence dialectic the author asks how such “dynamics work themselves out in mental health classification in the United States?” (p. 293). He explains that each quality of the aforementioned dialectic has its “corrupted” variant: independent-male-gone-bad who tends to be ascribed to a mental health classification of “paranoid,” and interdependent-female-under mental-health care who ends up situated in a “histrionic” classification (p. 300). He briefly follows with another cultural form from New Zealand as well. The essay performs a series of fascinating acrobatics over an expansive terrain of formidable thinkers and thinking. Dellwing and Harbusch (Ch. 13) offer a useful and interesting conclusion. The book brings notice to unexamined sociological terrain, and the authors deserve credit for their efforts to map it. It is a true learning experience to give it study, study rather than simply reading because its central value should be the ways that it or the of any student to it. It is an with do however, and they upon each role and the of labeling, the political economy of medicalization and psychiatrization, and tendency to social problems as psychiatric with all this, there is an that symbolic interaction will and have within the TPI, suggesting a for symbolic to attention as it done psychiatry and mental health patients in the it should be said that the book provides by on forms of as well (e.g., medical as a condition for Indeed, it was the ability to give it such a reading that the effect on this and the Thus, though I it to in psychiatric and the TPI I also it to who takes notice of current social in medicine and I its and its well beyond the of psychiatrization and into the of medicalization in is a at studied and at of He in such as and and of

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