Medicine is where hope is alive and well in America. During the past fifty years, due to rapid advances in microbiology, many persons who once might have died prematurely, or suffered debilitating diseases or disorders, instead enjoy productive lives, albeit often with chronic illnesses to manage. Through its near-miracle successes, the field has engendered the belief that if we delve deeply enough into the secrets of the human genome (and other microscopic aspects of our bodies) we will eventually escape many afflictions and much suffering — an attitude that seems similar to what the first America settlers believed about heading West to make a fortune. But now the human body is the place to find a better life than the one initially inherited.
In medicine many find a remedy as well as a philosophy for what it means to be human, and as a society, we have increasingly become fixated on the body as the source of suffering and the place where healing occurs. Many of us are also increasingly uncomfortable with distinctions between what is right or wrong in our multicultural society, preferring instead to discriminate between what is normal or abnormal, identifying what is ‘healthy’ in ourselves and others — in effect treating life as the pursuit of chronic health as much as an avoidance of death and chronic disease.
But could America’s reliance on medicine as both cure and guiding philosophy inhibit us from making changes that would actually end the damaging situations and conditions that lead to disease and disorder? Because of our preference for the cure, if not expectation of it, have we become overly reliant on fixing problems rather than avoiding them? And as a result, have we come to expect suffering more than we have to?
My fear is that when medicine becomes the final arbiter of the so-called “Truth” about the human condition, it may inadvertently silence sources of suffering that cannot be reduced to pathology in the human body. This is most evident in the lives of people who have suffered trauma, especially trauma that results from being harmed by another.
Some argue medicine, and psychiatry in particular, should have no role in treating trauma. By locating trauma in the body, medicine implicitly severs connections between human suffering and inhumane conditions such as racism, oppression, violence, childhood abuse, and neglect that cause traumatic reactions (Burstow, 2003; Wilkerson, 1998). Nevertheless, biological changes do occur when a person is a victim of interpersonal trauma, as human cruelty is most often called. Furthermore, successful treatment of trauma’s effects have involved medications, psychotherapy, or both (Davidson, 2003).
For me, the greatest concern has been that the awareness of the impact of trauma has not impeded its occurrence like a vaccination halts the spread of polio. Rather, while our awareness of the properties and treatment of interpersonal trauma increased over the past century, savagery against women and children, wars, genocide, and other manners of violence continued, and there seems no limit to the human imagination for ways to inflict cruelty. With medicine — and in particular biomedical psychiatry — as a primary method for treating psychological trauma, opportunities to find ways to stop violence and cruelty in the first place may not have been as forthcoming if we weren’t so fixated on the “cure.”
The reason for medicine’s continued role in treating trauma, despite that it has failed to halt the conditions that lead to trauma, may be found in how medicine enforces a particular sense of responsibility, and hence a particular form of society. As several leading trauma psychiatrists have observed, “The issue of responsibility, both individual and shared, is at the very core of how a society defines itself” (van der Kolk, McFarlane, & Weisaeth, 1996, p. xi).
Thomas Szasz went so far as to argue that the prominence of medicine is a major reason for the decline of democracy in American society (2001). Szasz claimed we have become a pharmacracy, a society governed by medicine’s understanding of humanity in which “people perceive all manner of human problems as medical in nature, susceptible to medical remedies” (p. xvi). As medicine became a dominant arbiter of truths about, and solutions for, the human condition, values were also transformed. Szasz proposed that an ethic has emerged that supports accountability for our good deeds while excusing our bad deeds (and less than desirable traits), depicting the latter as the result of diseases and disorders. The outcome, Szasz contended, is a nation of people who evade responsibility for their actions, blaming diseases and genetic inheritance for behaviors that at one time would have reflected poor character or irresponsibility. In effect, Szasz argued, medicine undermines personal responsibility, and consequently, the very fabric of society.
Medicine’s influence on how we perceive ourselves, and the solutions we create to address our problems, is hard to ignore. Many behaviors once deemed sinful — such as drug abuse, mental disorders, suicide, and even violence — are often related to defenses against trauma unhealed or denied, and through the medical model they are recast as influenced by the body and genetics, and thus they are conceived as at least partially outside individual responsibility. This has its advantages. The dominant genetic-based understanding of mental disorders validates the belief that compassion and assistance are needed for overcoming our limitations, and thus it often opposes the judgment and alienation that sometimes meets the most troubled members of society. As the philosopher and historian of science Georges Canguilhem put it:
Through genetics the sick person is no longer a “bad boy,” but instead is like a “poor land” that is bad due not to moral fault but to physical constitution: “disease is no longer related to individual responsibility; no more imprudence, no more excess to incriminate….as sick men we are the effect of universal mixing, love, and chance (1966/1991, p. 278).
A cursory glance at the events that led to the creation of the United States of America also reveals an underlying reason genetic-based understanding of human nature and the medical model are so appealing in this country today. From its inception, American democracy was designed to balance the rights of citizens with their responsibilities to society, and through this balance a commonwealth would be created that benefited all members of society. The attention to personal rights reflected the conditions of the people whose exodus from their home countries led to the creation of the United States. Many had escaped religious persecution and other forms of oppression in their homelands. Though they came from many different societies and held many different beliefs, they shared the traumatizing effects common to all people with histories of oppression and persecution.
The formation of American democracy and law may be inseparable from the trauma many experienced. Avoiding the repetition of past traumas led to a new understanding of what it meant to be human that not only protected against threats to religious freedom, but also elevated individual rights above social responsibilities. As Martha Nussbaum (2006) observed, in America human consciousness became depicted as a self-directed, albeit fragile space that must be protected from the impingement of social forces. This understanding of what it meant to be human was based on Enlightenment ideals that upheld human qualities such as rational choice, free will, intentionality, and agency. This emerging sense of humanity was also a subtle and convenient defense against the deep emotional wounding that drove many people to America in the first place. Anthony Giddens remarked, “The emotional life of modern civilization was essentially written out of Enlightenment philosophy,” which was done to escape societies perceived as tightly bound by tradition (1994, p. 68).
Through democracy and the image of humankind as rational beings, the yolks of orthodoxy and aristocracy were thrown off, and the belief began to hold sway that all humans were created equal through the faculty of human reason. Granted, in the beginning only men of European descent profited from full recognition of this quality, but a blueprint for equality was set for future efforts to recognize the free will of all citizens, irrespective of gender, race, disability, or any other difference.
Today genes challenge human reason for the role of the great equalizer. Rather than the principle of universal, inalienable rights uniting us, many are increasingly bound to the belief that deep down all are made of the same stuff — genes — and it is our common biology that makes us equal. Genes also have the potential to be much more equitable than the notion of human reason ever was. Unlike the faculty of reason, genes have always been identified as belonging to everyone — not just men of European descent as reason once was conceived. And while genetics has been used to oppress — eugenics is a cautionary reminder of how easily science can be exploited to nefarious ends — it has also undermined notions about superior races and inferior bodies by revealing our shared traits along with our shared vulnerabilities. In this gene-based form of democracy, Szasz (2001) seems at least partially correct; medicine has become a common hope for salvation from disorders and diseases that might otherwise limit social standing and opportunities for equal access to achievement.
Szasz (2001) is also correct that responsibility is a problem in our emerging pharmacracy, but rather than our sense of personal responsibility undermined by a proliferation of diseases for every human condition, it is the absence of shared responsibility that I believe is most threatening for democratic ideals. Rights without responsibility may not have been intended by the American notion of democracy, but it has become an undeniable outcome. It is in this social context that the term trauma and genetics (as our collective origin story) have taken root, rapidly growing in our common vernacular, becoming socially acceptable, no-fault ways of talking about the scars left by emotionally damaging human encounters without requiring changes in the conditions that perpetuate the need for such discourse.
Despite the appeal of the genetic story of human origins, evidence reveals the social environment plays as much, if not more, an influence on the kinds of people we become (Jablonka & Lamb, 2005). Especially in psychiatry, the genetic explanation for what it means to be human appears more myth than science when it is used to identify the origin of mental disorders. For example, studies that claimed a serotonin transporter gene (5-HTTLPR) is responsible for the development of depression were shown through a meta-analysis to be patently false (Risch et al., 2009). Furthermore, despite claims that schizophrenia is likely a genetic disorder, seven out of 10 instances of schizophrenia arise without any evidence of family history of the disorder (Maxmen, Ward, & Kilgus, 2009, p. 305). In fact, after decades of analyses, no correlations have been found between specific genes and specific mental disorders as the Mendelian model of genetics demands. According to one researcher, psychiatrist Kenneth Kendler:
For psychiatric disorders, individual genes appear to have a quite modest association with psychiatric illness. While they may have an impact on risk, individual genes hardly predetermine illness, as would be expected if we had discovered “genes for” mental disorders (2005, p. 1247).
The practice of treating mental disorders with medications is theoretically supported by the belief that genetic inheritance is the fundamental mechanism for their transmission. Certainly a biologically-based approach to treatment would make sense if the origins of mental disorders are genes, the fundamental building blocks of the human body. However, not only is there insufficient evidence to support this conclusion, the medications themselves have failed to lead to health as once believed. For example, in 2008 a review article revealed the duplicity surrounding published accounts of the efficacy of selective serotonin reuptake inhibitors, or SSRI antidepressants (Turner, Matthews, Linardatos, Tell, & Rosenthal, 2008). The article concluded pharmaceutical companies and psychiatric researchers mainly published studies that confirmed the effectiveness of the SSRI antidepressants, generally excluding studies that had negative or questionable results. The review showed there has been an overstatement of the efficacy of these antidepressants by as much as 30 percent.
Some of the most damning evidence against the medial model of mental disorders comes from investigative reporter Robert Whitaker. Combing through decades of psychiatric research, Whitaker reached the conclusion that the current practice of treating mental illness as chronic disorders requiring continual treatment with medications is a “failed paradigm of care” (Hall, 2009). According to Whitaker, psychopharmacology is actually creating chronic illness. He observed that since the arrival of Thorazine and Haloperidol, which marked the beginning of the widespread treatment of mental illness with medications over 50 years ago, patient outcomes are getting worse; more people have become disabled by mental illness; patients are suffering from more physical ailments and are more chronically ill; they are straddled with higher unemployment; and they are dying as much as 25 years earlier on average. Furthermore, there is evidence to suggest that the medications perturb otherwise normal functioning — including normal mental functioning.
Genes certainly play a role in the development of mental disorders (and humankind), but presently how they do, and to what extent, remain unknown. However, ample evidence supports the conclusion that stressful and traumatic life events are highly correlated with the later development of mental disorders (Whitfield, 2004). Indeed, Risch and colleagues reached a similar conclusion about depression, stating, “Stressful life events have a potent relationship with the risk of depression” (2009, p. 2468).
While theory failure is a natural event in the progression of any science, the probable demise of the genetic theory of mental disorders does not follow the course of normal scientific enquiry. Despite lacking substantiated evidence, it has been treated as an already proven fact. As the researchers of the meta-analysis of serotonin gene studies concluded, the biggest problem may not be the failure to provide genetic evidence, but rather “the findings of…nonreplicated genetic associations are now being translated to a range of clinical, legal, research, and social settings such as forensics, diagnostic testing, study participants, and the general public” (Risch et al., 2009, p. 2469).
That so many have become attached to the genetic story of mental disorders stirs my suspicions that there is much that cannot be said about why we suffer. As Michel Foucault observed, “Silence itself…is less the absolute limit of discourse…than an element that functions alongside the things said” (1984/1990, p. 27). I believe what has been silenced is our collective need for a deeper, more meaningful sense of community, which has become anemic in current American society as a result of the cavernous division between the public and private spheres of life and America’s emphasis on protecting individual rights at the expense of communal needs. I am not arguing there is anything wrong with protecting individual rights. Rather, I am challenging the idea that human nature is determined more by nature (genes) than nurture (social environment), which is proposed by the medical model of mental disorders.
For me, looking for the contours of the silences that support the emerging pharmacracy involves asking why so much money, time, and energy is spent on developing the genetic theory of mental disorders — and devoting copious funding for developing psychotropic medications — when environmental stressors and human cruelty are rigorously associated with mental disorders and emotional suffering already.
And I believe I have found one of the answers: we fail to sufficiently mobilize against human cruelty because we have come to rely on medicine to silence trauma. Through psychotropic medications, feelings are numbed. Through the genetic model of human nature, our collective responsibility to relieve human suffering is ignored. In the end, the situations that led to suffering in the first place fail to change — although the elevation of individual rights over collective emotional needs remains in place.
In many regards, interpreting the aftereffects of human cruelty through the medical model is similar to traumatic responses witnessed in the survivor of chronic abuse who avoids reminders of the traumatic event and the intense emotions stirred when unconscious memories are triggered. Those who treat trauma’s effects describe this fragile forgetting as dissociation: the human capacity to wall off the emotions and memories connected to traumatic events, splitting them off from conscious awareness (Steinberg & Schnall, 2000). But dissociation is not limited to individual minds. As trauma specialist Judith Herman pointed out, “Repression, dissociation and denial are phenomena of social as well as individual consciousness” (1997, p. 9).
Today both individuals and the collective American society show signs of dissociative defenses signaling traumatic pasts. With regards to individuals, dissociative defenses are understood to become pathological when they are no longer needed to ward off the threats of a traumatizing environment or event (Herman, 1997). Similarly, the conditions of late modern society reveal a pathological continuation of an early defense system that emerged with the split of the modern world from traditional forms of social organization, elevating rational thought while debasing emotional needs. Furthermore, not only does our peculiar form of democracy no longer serve us, it may eventually lead to our demise. If the current form of American democracy continues to be exported across the world, with its particular association of individual rights with economic freedoms and commodity-driven individualism, the result may not only be the end of civilization, but also the destruction of the planet.
Granted, we have medicine to thank for bringing attention to the long-term impact of human cruelty on our psyches. The psychiatrist Charles Samuel Myers coined the term shell-shock, which recognized that the very nature of war was psychologically damaging for men exposed to its brutal conditions (van der Kolk, Weisaeth, & van der Hart, 1996, p. 48). Furthermore, in America it took medicine defining child abuse as a medical category in 1965 for a nationwide movement to take hold devoted to protecting children (Hacking, 1991). To be sure, without medicine, we would not only have failed to identify how cruelty harms psyches, we would also lack methods for healing the wounds left in its wake. Yet with each discovery of the impact of trauma, there has been a counterforce guaranteeing its erasure. Trauma theorist Bessel A. van der Kolk and colleagues saw how this erasure mimics the forgetting of trauma that occurs in people: “Mirroring the intrusions, confusion, and disbelief of victims whose lives are suddenly shattered by traumatic experiences, the psychiatric profession has gone through periods of fascination with trauma, followed by periods of stubborn disbelief about the relevance of patients’ stories” (van der Kolk, Weisaeth, & van der Hart, 1996, p. 47).
Living in a world steeped in cruelty and disregard for the suffering of others impacts us intuitively and emotionally, although these aspects of human experience are not always amenable to scientific investigation. Yet stopping cruelty will likely require resuscitating and valuing the intuitive and emotional parts of ourselves, for they also hold our sense of responsibility to the suffering of others. But perhaps the first step towards ending violence is the commitment to being aware that violence is always going on, and that this ongoing violence is hurting us — both collectively and as individuals — even if we cannot ‘test’ for, or find ‘evidence’ of, its effects.
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© 2013 Laura K Kerr, PhD. All rights reserved (applies to writing and photography).