The Social and Political Contexts of Psychiatry

American Journal of Psychiatry, January 2002

By Elliot Roy Singer, M.D.

As one of the bastions of the American establishment, medicine has long been an inviting target of the countercultural forces first spawned by the New Left of the 1960s. Seen as insular, arrogant, elitist, and a guardian of the patriarchal social order, medicine was one of many obstructions to the implementation of an emerging socially activist philosophy in which the failure to thrive of disaffected elements was to be solely attributed to oppressive forces in society as a whole.

In recent years, following their failure to radically restructure American institutions in the Vietnam War and post-Vietnam War years, many left-wing 1960s extremist activists have pulled back to redoubts in the universities. There, as tenured faculty, they have promoted their liberationist ideologies recast as a new victimology facilitated by multiculturalism, rejection of competitive meritocracy, and repudiation of fixed truths and individual autonomy. In such a determinist scenario, victim populations have little or no individual responsibility for their life situations; nor do they have the means to elevate themselves, outside of a wholesale restructuring of society that emphasizes redistribution of wealth and power.

According to Dr. Satel, it has now fallen to the public health schools of the universities to apply the New Age truths to the redress of the physical and mental illnesses of those identified groups whom medicine has allegedly improperly diagnosed or is itself oppressing through its continued failure to embrace a treatment philosophy employing radical social change.

Dr. Satel is a lecturer at Yale University School of Medicine, staff psychiatrist at a Washington drug treatment program, and scholar at the American Enterprise Institute. Her extensive contributions to academic journals and the lay press alike on a wide spectrum of medical and psychiatric issues have opposed the increasing tendency to assign victim status to an ever broader range of identified afflicted subgroups. She understands that in so labeling people we may be relegating them to chronic debilitating dependency, waiting for external change that may never come. Even worse, in blaming society alone for their ills, we may be withholding individualized treatment better able to minimize disability and suffering than politically inspired measures in pursuit of larger societal goals.

Among the more shocking but representative examples cited in PC, M.D. of how illness in one victim group is being cynically subordinated to the larger purpose of “redesigning society” is the statement attributed to Sally Zierler of Brown University’s Department of Community Health that AIDS is a “biological expression of social inequality.” Speaking at the 1998 annual meeting of the American Public Health Association, Zierler’s recommendations for curbing the AIDS epidemic were reportedly all in the area of promoting social and economic justice rather than in the area of care of the self.

It is indeed fitting that in this book a practicing psychiatrist should be sounding the clarion call of alarm signaling the dangers to health care and patients of implicitly allowing the counterculture to negate the scientific basis of medicine and the role of individual accountability in the promotion of diseases in which choice plays a part. At the heart of psychiatry’s optimistic ethos is the near universally held belief that self-exploration in psychotherapy facilitates growth in autonomous functioning and enhancement of both motivation and capacity for healthful choices in living.

In first writing “Opiates for the Masses” (1), Dr. Satel took issue with those who support heroin maintenance and then-U.S. Health and Human Services Secretary Shalala’s endorsement of needle exchange programs for addicts. She objected to a philosophy of “harm reduction,” which contends that drug abuse cannot be avoided and “consigns [addicts] to their addiction, aiming only to allow them to destroy themselves in relative ‘safety’ and at taxpayer expense.”

In PC, M.D., Dr. Satel expands on her earlier article to caution that acceptance of drug addiction in the United States may soon reach the “zenith” it has attained in the Netherlands, where addict activists believe that “drug abuse is a human right and the government has a responsibility to make it safer to be an addict.” In such a scenario, “addicts represent a class of oppressed citizens,” notwithstanding that it is their own behavior that leads to their oppression. Dr. Satel also expresses a similar concern over the destigmatization of pregnant mothers who take crack cocaine, another group of substance abusers who are ambivalently being pressed for change. She introduced this theme in “The Fallacies of No-Fault Addiction” (2). Although the well-meaning might find favor in arguments supporting the avoidance of coercive measures in both of these groups, in reality they are much in accord with victim politics, which detracts from the need to change of those who are dysfunctional and sapping their will to do so.

The seriously mentally ill are not exempt from accountability for socially unacceptable or threatening behavior. Recounting in her current book the tragic circumstances prompting the passage in New York of “Kendra’s Law” in late 1999, which mandates involuntary outpatient commitment of the potentially dangerous mentally ill, Dr. Satel fails to take credit for her editorial promotion of such a measure earlier in the year, which may well have influenced the outcome. Braving the expected opposition of civil libertarians, in “Real Help for the Mentally Ill” (3) she found herself on the right side of emerging public opinion. In this instance, as in the case of recalcitrant drug addicts, Dr. Satel allied herself with the position that even those who are dismissed as intractable can both respond to and benefit from the concern implied in society’s efforts to treat them, even if coercively, while safeguarding public safety.

In a commentary titled “Are Women’s Health Needs Really ‘Special,’? ” (4), Dr. Satel proved herself unafraid to take on her psychiatric peers when they appeared to support the emerging popular myth that women have been systematically excluded as subjects of research. In PC, M.D. she meticulously cites study after study in debunking this politically correct canard still firmly ensconced in university, government, and some medical circles. Further, she continues to decry the marginalization that “special” issue designation creates for women as well as “increasingly popular ‘feminist therapy,’ a victim-oriented form of psychotherapy that interprets women’s distress as a product of patriarchy”—the latter by implication consigning the ills of individual women, as with other victim groups, to externally mediated societal causation not amenable to individual growth or change.

Although “indoctrinologists,” Satel’s term for those who are driven by ideology and not by science, have yet to exercise control over mainstream medicine, she admits they are making steady progress in that regard. However, her description of the burgeoning successes of oppression-based feminist therapy and multicultural counseling, in which “psychological distress is a product of conflict between the individual and the sexist and racist society in which the patient lives,” should give us cause for even greater concern. Increasingly, our institutions are being battered and we are being encouraged to think of ourselves as members of one or another oppressed minority group, be it of gender, sexual orientation, race, ethnicity, illness, or disability.

PC, M.D. ends on the author’s encouraging note that “fortunately, there are built-in limits to the corrupting influence of PC medicine,” in that the American people continue to expect and receive the best in medical care. This assurance, however, may not long continue to hold sway. Those who labor in senior leadership positions in medicine are aware of an almost palpable malaise in both private and institutional medical practice that has somewhat to do with the current fiscal straits of both physicians and hospitals. It is more a result of the daily grinding away of moral authority by regulators, accrediting bodies, government agencies, and payers, all reflecting to an unknown degree a slow but steady suffusing of society by at least some of the increasingly prevalent negative forces of which Dr. Satel writes. Eventually, if not now, the average American will feel the result, and some may suffer. If the doctors are not allowed to provide the right care, who will?

In closing, Dr. Satel deserves praise for the good works she continues to pursue in this and other efforts to remind all of us that in keeping with the age-old precepts of the Hippocratic oath and of all like-minded physicians, the patient comes first, before all else.