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Mental Disorders

by Denise Russell
Blackwell Publishers, 1995
Review by Christian Perring, Ph.D. on Dec 31st 1997

Women, Madness and Medicine

A Full Feminist Assault on Biological Psychiatry

Denise Russell shows no reluctance to come to strong conclusions in her book Woman, Madness & Medicine. In the introduction she writes that "biological psychiatry has, on balance, produced more harm than good," (p. 1) and it is "a degenerating research programme and that it is time to look in completely new directions if we want to understand mental distress" (p. 2). Later, she says "there are no solid findings from genetics, neurophysiology, or computer studies which show that biological psychiatry is on the right track" (p. 95). So this Russell's work is firmly in the tradition of antipsychiatry. It is also strongly feminist. She argues that as far as psychiatry is concerned, the normal human being is male, so women are by nature abnormal. Of course, that's what she thinks is wrong with psychiatry.

Russell's arguments are basically simple and easy to understand. Subtlety and sophistication are not in the foreground here, and the book is more of a summary of an argument rather than the argument itself. Most of the major psychiatric disorders are discussed in the space of 70 pages, with 5 for personality disorders, 10 for depression, 10 for PMS, 10 for schizophrenia and 10 for eating disorders. In each case, Russell mentions studies which fail to show any clear brain or genetic disorder responsible for the psychiatric disorder. Of course, she prefers sociological or psychodynamic explanations of people's problems, and more fundamentally, she is reluctant to categorize a condition as that person's problem or enforce any category system whatever. As models for alternatives to the psychiatric approach, she looks to the ideas of Phyllis Chesler, Luce Irigaray, Virginia Woolf, and Janet Frame.

I don't agree with her conclusions, and I think her arguments for them are not well-founded. They couldn't be convincing, given how quickly she sets out the argument. Such a view would take much longer to argue for. My general disagreement with Russell does not mean that I am unsympathetic to some of her claims. At points, her arguments are detailed and convincing. For example, she is surely right that debates about some proposed diagnostic categories are politically charged; premenstrual syndrome is a good example, and borderline personality disorder would have been another good one. Russell also builds on the work of others, such as Susan Bordo, in her argument that eating disorders reflect the role of women in western culture, the identification of women with nature and men with intellect, the importance of controlling the body, and the ideal of slenderness as a symbol of beauty.

It's her big picture that I have trouble accepting. I could try to set out what I see as the mistakes in her discussion of depression and schizophrenia, and explain why it is reasonable to suppose that these have a biological component. But I don't want to get into a discussion of the interpretation of the scientific evidence here. I think it is more profitable to take a step backwards, and ask whether her portrait of current psychiatry as biological is indeed accurate.

There are of course some psychiatrists who believe in a purely biological approach with an almost zealous faith. There is also variation from country to country, even hospital to hospital. For instance, psychiatry in Britain has a reputation for being very biologically oriented. In most western countries today, and especially in the US, there are financial pressures towards using biological psychiatric treatments, since it helps large corporations to make a profit from selling drugs, and often those drugs cost less than psychotherapy, which makes them more attractive to people with mental disorders who are looking for a quick cheap fix. Psychotherapy can also be emotionally painful, forcing a person to face difficult issues, while the main problems caused by drugs are their adverse side-effects. Some think that psychotherapy will provide a real solution in the long run, while drugs can only relieve symptoms, but this is hard to prove. But, before I digress any further, let me make my main point, which is that at least in the US, mainstream psychiatry does not rely exclusively on a biological viewpoint.

The diagnostic system that we use, now embodied in DSM-IV, is not tied to a biological point of view. It is expressly designed to be atheoretical, although many have said that it is not possible to avoid all theory, and that implicit theoretical assumptions will inevitably be smuggled into definitions of disorders. The system of implicit theoretical assumptions that end up in one set of criteria assembled by a committee may well be incoherent or at least disunified. There may well be political or moral considerations involved in the creation of some diagnostic categories. But none of this shows that mainstream psychiatry is at root biological.

The phrase 'biological psychiatry' does not refer only to theories of the etiology of mental disorders and their classification. In fact, its most important referent is not the causes of problems, but their solutions. Biological solutions come in the form of pills, electroshock treatment and psychosurgery. These are all ways to change what happens in the brain. It is often supposed that biological problems should be treated by biological solutions, and psychological or social problems should be treated by psychological or social solutions. I don't know why anyone supposes this, because there is interaction between all three levels. We know that psychotherapy can affect the chemistry of the brain, and that drugs can affect our psychology. Social changes can make people happier, and this in turn changes brain chemistry. The availability of drugs, pharmaceutical or recreational, can contribute to changes in social structure. So even if Russell is right that women's suffering or self-destructive behavior are caused by social problems, it does not follow that the only or best solution is social change.

In her last chapter "Beyond Psychiatry," Russell's ideas suggest how she would respond to these criticisms and shows her full hand. She wants to abandon completely the distinction between sane and mad. We should see all behavior and experience as human. We should do away with constraints on human freedom as much as possible. All abuse should be stopped, by giving the abused ways to escape their situation, and children should be taught how to handle abuse. These are the seeds of the research program that Russell is proposing should grow to compete with psychiatry. It would grow into a theory of the interrelation of individuals, families, and society, to help us achieve a world free from oppression and repression.

It's unusual to read such a utopian project these days. Completely programmatic, and having far less empirical backing than even the supposedly shaky foundations of biological psychiatry, Russell's vision does not carry conviction. We can all have our dreams, of course, but Russell doesn't give us any strong reason to share hers. Her book is a mixture of interesting suggestions and implausible generalizations.

For the full review of Denise Russell's Women, Madness & Medicine, click here.