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"Some voices- who claim to dominate, who top the hierarchy, who claim the centre, who possess resources-are not only heard much more readily than other, but also are capable of framing the questions, setting the agendas, establishing the rhetoric's much more readily than the others" (Plummer, 1995:30).
Critically evaluate this statement in relation to the argument that psychiatry is an instrument of power.
Psychiatry can be defined as "the branch of medicine devoted to the diagnosis, classification, treatment and prevention of mental disorders" (Coleman, 2009). In history the Greeks were the first to make sense of the concept of madness (Porter, 1987). Greek philosophers recognised that by using the art of 'reason' and 'rationality' order within society could be maintained, leading to the idea that the irrational in society were a problem. The medieval period added an element of religion to the explanation, seeing it as a war between Satan and God for the soul, madness being a punishment from God. The 'Enlightenment' during the seventeenth century, saw those who appeared to lack reason and rationality punished for 'foolish' or 'childlike' behaviours. These irrational beings were seen as a threat to the development of a fully functioning society, as only the perceived reasonable and rational members of society had the power to succeed. The period of the 'Great Confinement' saw an increase in institutions and prisons to house the irrational (Foucault, 1995). Those with reason had the power to imprison the mad along with the poor and the bad members of society. One percent of the population in Paris during this period were confined in such institutions, for this reason Foucault sees the Great Confinement as a "deliberate policy" (Porter, 1987, p.16). The following century saw the 'Rise of the Asylum', where the "insane were clearly distinguished from other 'problem populations...'" (Scull, 1993, p.1). Asylums were established by the government, allowing the mad to be completely separated from society due to their newly recognised medical problems. Foucault (2006) refers to the asylum as a "specialized world" defined by the knowledge of "medical power" (Foucault, 2006, p. 166). The recognition of madness as a medical condition saw the introduction of the psychiatry we are most familiar with today. The medical association of madness allowed psychiatry to become increasingly "extensive, pervasive and influential..." in the 20th century (Bracken & Thomas, 2005, p. 93). Anyone who associated themselves with the mental health field, were ultimately surrendering themselves to the developing discourse of psychiatry. Today, in the twenty-first century, psychiatry still has an influence on government policy (Scull, 1993). The scientific basis of psychiatry encourages the public to believe all they say is true. The psychiatrist's perceived expertise of deviance (illness), gives them the authority to eradicate such members of society. The psychiatrist in turn influences government policy, and plays a part in social order or control. It is this high social status that gives the profession of psychiatry power-which is not a good thing to those underneath it.
Power and Knowledge
Before understanding why psychiatry is an instrument of power, it is important to firstly understand what is meant by the term power. Power has been defined as "the exercise of control or force over an individual or social group, by other individuals or social groups..." (Edgar & Sedgwick, 1999, p. 304). Foucault (1976, p. 11-23, as cited in Spierenburg, 2004) stated that "power is something which certain people possess, while others are excluded from doing so". This relates to the way in which a psychiatrist has power over his patient, the psychiatrist being at the top of the hierarchy. He believes that power allows people to be excluded and repressed through legalities (Foucault, 1980). This process begins when the "function of power in society is defined..." (Foucault, 1980, p.90), as this power is then most likely to be politicised, then ingrained into society through institutions such as psychiatric ones. Foucault highlights that in order for a power to be established within society it requires the "circulation and accumulation of a discourse" (Foucault, 1980, p.93). This presumably is the circulation of scientific knowledge, which is seen as the truth behind the power. Roberts (2005), discussing a comment made by Foucault, suggests that scientific knowledge allows the 'exercise of power' to be "intensified". The knowledge that a profession obtains is important for the justification and 'legitimisation' of the power it exerts (Scull, 1993). Knowledge allows the profession to 'dominate and control' a certain entity, without question or the need for approval. In history the first public exercise of power was the panoptican. The prisoner is seen by the guards, but cannot see them so never knows when he is being watched. Foucault refers to the prisoner as an "object of information, never a subject in communication" (Foucault, 1991, p.200), implying that the prisoners role is to be observed, not to interact. The fact that the prisoner does not know when he is being watched ensures that order is maintained, and power remains within the central tower. The observation in the panoptican enables the staff to learn how to control the behaviour of man, thus an increase in knowledge to further enhance power. As a legacy, panopticiscm has enabled its principles of power to be applied to disciplines such as psychiatry (Roberts, 2005).
The Power of Psychiatry
Porter (1987) refers to the history of madness as the history of power, in the sense that madness can only be controlled by the means of power. Hence, the starting point in the power of psychiatry is its association with the law. In society the power of the law is seen to be imposed for a good reason (Edgar, & Sedgwick, 1999, p. 305). The medical profession is based on a valued area of knowledge (science), so is able to have high social power (Allsop, 2006). A lack of the ideal knowledge does not allow for one to "determine the policies" or dictate the practices within mental health (Stickley, 2006). Being based on this knowledge, thus gaining credibility, the original 1983 Mental Health Act (Department of Health, 2009) could be developed and implemented with a just reason. This policy allows the compulsory admission and treatment of people if it is felt to be necessary (Bracken & Thomas, 2001; Roberts, 2005), allowing initial psychiatric power. Bracken and Thomas (2005) state that the mental health policy has the power to 'control and exclude', with the discourse provided by "medical psychiatry" (Bracken & Thomas, 2005, p. 94). Laugharne and Priebe (2006) discuss how this policy discriminates against the mentally ill, removing their power to decide when they are treated. Psychiatric power has the aim of "imposing" a medical intervention on a patient "against his will", which is allowed through this legislation (Barker & Stevenson, 2000, p.45). The government encourage its acceptance by the public, through claiming the Mental Health Act sets out to protect society from 'madness', something which has gone on for over 300 years. With the government's authority to politicize mental illness, it seems as though they are the true holders of power (Calinas-Correia, 2001), acting out their wishes through the valid science of psychiatry. Kogan (2005) highlights the appeal psychiatry has, through its ability to "tackle visible and practical problems" in society. Psychiatry appears to be able to deal with issues beyond its field, through its contribution to public policies, which gains it power. A recent example of this is the development of the DSPD act (Cordess, 2002; Corbett & Westwood, 2005). In reality psychiatric power can be seen as a form of social control, as there is no medical basis for psychiatry (Foucault, 2006, p. 11-12). To enable the act of social control within society, it is important to diagnose mental illness. The knowledge obtained from power allows humans to be 'classified' thus controlled (Roberts, 2005). Brown (1990) sees the psychiatrist's power and ability to label an individual, as central to this. Strauss (1958) recognises that the psychiatrist's status allows them to "yield more power than anyone else". Through diagnosis the psychiatrist has the power to define what is normal and abnormal in society, therefore is socially constructing the knowledge of mental health. The DSM is the necessary tool for the basis of diagnosis, as it "authorizes" the removal of an individual from society (Kovel, 1988, p.131), hence highlighting its power. Within the text is the definition of the known mental disorders, therefore in a sense it is this discourse (DSM) that is responsible for this construction of the knowledge on mental illness in society (Bracken & Thomas, 2001; Phillips, Lawrence & Hardy, 2004). Every improvement to the text increases the power and control to the user, further defining society (Kovel, 1988). The DSM, therefore, is the basis for the application of psychiatric power which in turn results in control. The power between a doctor and patient is established at diagnosis and maintained through knowledge. From the onset the direction of power needs to be defined to create imbalance between the doctor and patient (Foucault, 2006, p.146). Without an in depth knowledge of their condition, the patient is unable to question or challenge the psychiatrist (Barker & Stevenson, 2000). It is assumed that the mentally disordered patient has a "naive knowledge" that does not compare to the 'scientific' knowledge of the psychiatrist (Foucault, 1980, p. 82). Psychiatry deals with a sort of knowledge the 'layperson' would find difficult to understand, which gains it power (Kogan, 2005). The DSM is an example of the difficult knowledge of psychiatry. Through its medical professionalism the DSM cannot be questioned (despite the evidence that it is unreliable) due to its perceived credibility (Baker and Stevenson, 2000). The power relationship between the psychiatrist and patient, allows the maintenance of the powerful "dominant discourse" within psychiatry (Stickley, 2006). Foucault (1995) talks of how the patient sees the psychiatrist as a 'thaumaturge', someone with a miraculous power to cure. This impression is gained through his seemingly unlimited knowledge of psychiatry, resulting in the patient's acceptance of all the doctor says and thus reinforcing his status of power. Through this trust of the psychiatrists abilities the patient has been said to "abdicate his own reasoning capacity" (Freidson, 1970, as cited in Scull, 1993, p.382), due to the inferiority of the patients knowledge. If the patient attempts to challenge the doctor, this is where institutional powers are used (Scull, 1993). Institutional powers are a form of disciplinary action, forcing patients to co-operate- in other words panopticiscm. Within a psychiatric hospital the psychiatrist is the main keeper of power, at the top of the organisations hierarchy (Strauss, 1958; Rushing, 1964; Lunbeck, 1994; Spierenburg, 2004; Stickley, 2006). This implies that the patient is at the bottom, receiving instruction and power from all higher levels. Power being exercised from the top down makes sure that resistance is avoided. Rushing (1964) states that nurses lack the power to disagree with a psychiatrist, being his subordinate they must obey his orders. The psychiatrist answers all questions at all levels (Scull, 1993). Lunbeck (1994) highlights that once a patient is admitted to a psychiatric ward, they belong to the professionals. All personal thoughts and writings are to be taken, and used for assessment of the patient's condition. This would appear to be part of the psychiatrist's job, but Lunbeck points out that it is only an exercise of power. It almost seems that on admission, the patient forfeits all of his or her rights (or power), as a result of their condition.
The Power of the Patient
Through admission of being ill, the patient effectively gives up his own power. However, psychiatry gives the patient the power of illness (Barker and Stevenson, 2000). Psychiatry has the power to reinforce the 'sick role', in society (Haug & Lavin, 1981). The label given to the patient defines who they are socially, and is a subtle form of oppression (Kovel, 1988). The patient is seen as being their illness (e.g. being a Schizophrenic), not as person with an illness, therefore it seems to describe them as a whole and stigmatizes them (Nelson, Lord & Ochocka, 2001). Bracken and Thomas (2001) recognise how damaging a diagnosis of a mental illness can be compared to a diagnosis of a physical illness, i.e.: being diagnosed with diabetes will not result in the powerful detainment of being diagnosed with schizophrenia. Someone with diabetes will feel as if they can independently control their illness, opposed to a schizophrenic who is being treated like a minor under constant watch. In order for a patient to gain power back from the psychiatrist, empowerment is needed (Barker & Stevenson, 2000). This empowerment helps to re-establish the equality of the patient and doctor/nurse power relationship (Price & Mullarkey, 1996, as cited in Barker & Stevenson, p. 27). While the patient's knowledge lacks medical status, they will never be perceived as equal to the psychiatrist (McQueen, 2002). The scientific knowledge of psychiatry has the power to exclude other valid forms of knowledge e.g. life experience (Robertson, 2006). In the past what the patient had to say was deemed irrelevant, due to their lack of reason as a result of being mentally ill. Porter (1987) refers to the way in which it was believed that the "words and movements of the mad were just automatic spasms of the vocal chords..." (Porter, 1987, p. 33). This is still true today as Haug and Lavin (1981) found that few medics are willing to listen to the demands of a patient. Support for this comes from Rose (2008) who, in her time spent in a psychiatric hospital, found that in airing her views resulted in degrading comments. She interprets this as the voice of unreason still being inferior to the voice of reason, as the users' comments (knowledge) seemingly lacked scientific basis. Not listening to patients can be potentially damaging as certain cases what the patient has to say (narrative), may be the key to recovery. White (2002) suggests that that if the psychiatrist and the patient share their knowledge, it will result in a better system of treatment. With equal knowledge the patient has the ability to gain some power back, to tackle their illness with the doctor. There is evidence to suggest that the internet is reducing the knowledge gap between the psychiatrist and patient (Dooley & Malone, 2004). Tann, Platt, Welch and Allen (2003) found that patients that used the internet to self diagnose, and then discussed their findings with their doctor had a better relationship during treatment. The internet enabled the power to be equally distributed, something which some psychiatrists object to. Tann et al. (2003) found that some psychiatrists felt that patients using the internet doubted their expertise, which perhaps is a way of saying they felt their power was being taken away from them. There is a need for a change in the type of language used between the patient and doctor. Goffman (1963, as cited in Vante & Holmes, 2006) suggests that the language used in psychiatric institutions is of a 'diagnostic' nature, which 'stigmatizes' against the patients. The medical and scientific language used by the psychiatrist highlights his power over the patient (Barker & Stevenson, 2000; Stickley, 2006), as the patient lacks understanding of what is being explained to them. In some cases the language (therefore knowledge) barrier between the patient and psychiatrist is so great that inaccurate conclusions can be drawn from what is being explained by both parties (Brown, 1990). It has been suggested, to eradicate the language barrier, that psychiatrists should "move from monologue to dialogue" in consultations (Seikkula, Aaltonen, Alakare, Haarakangas, Keranen & Sutela, 1995, as cited in Barker and Stevenson, 2000, p. 28). This removal of monologue refers to the way in which the psychiatrist often dictates to or lectures his patient, rarely offering the patient a chance to participate in conversation. Dominating the conversation, allows the psychiatrist to maintain his power throughout the consultation. Most importantly the patient wants the psychiatrist to work with them (Barker & Stevenson, 2000), despite the psychiatrist being seen as "superior" to them (Foucault, 2006, p147). The patient does not want to be a 'subordinate' to the psychiatrist (Nelson et al. 2001), as the psychiatrists controlling power can limit the healing process. The patient wants the power to be in control of their treatment, understanding their illness and being able to choose what medication and therapies they have. However this goes against the usual power of the psychiatrist to prescribe an appropriate treatment, which the patient must 'accept'. Through allowing the patient to make their own decisions, will allow the transfer of some power back to the patient (Hamann, Leucht & Kissling, 2003; Masterson & Owen, 2006).
The recognition of madness in history has allowed the development of the 'necessary' powers to control it. The growing scientific understanding and knowledge of mental health, has resulted in the power of psychiatry to be intensified, as the "psychiatric power and medical metaphors associated with it have manufactured madness" within society (Roberts & Hitten, 2006, p. 786). The power of psychiatry is engrained in society through the development of institutions and government backed policies, as it is responsible for the "corruption" of not only the psychiatrist, but the "patient and community" (Barker & Stevenson, 2000, p. 53). The patient needs empowerment, but it has been suggested that the concept of 'service user involvement' has been reinforced by the "dominant discourse" (Stickley, 2006) suggesting this will never happen. However, while mental illness is prevalent in society psychiatric power will always be accepted, as the psychiatrists vast knowledge and powers are ultimately 'relevant to his job' (Barker & Stevenson, 2000, p. 52).