Illness, Authority, and the Burden of Proof

Psychiatry is beset by a chronic controversy around the world “illness”. Critics and opponents of the specialty have long been engaged in what the philosopher Ian Hacking called an “unveiling” project, questioning the authority of psychiatrists to label people as ill. This has generally worked by highlighting the lack of an unambiguous marker or validator to confirm the presence of illness. Arch critic Thomas Szasz noted the lack of a physical lesion to prove the existence of pathology, and declared mental illness a “myth”. In a famous early 1970s experiment, Rosenhan and colleagues demonstrated that a single malingered psychiatric symptom could, without confirmatory tests, lead to hospitalization.

Herein lay the unveiling Hacking describes; revealing that something supposedly real was in fact constructed. The broad narrative of these critics was that “psychiatric illness” was a term applied to behaviours and experiences that were not pathological. Unlike other medical specialists, who are experts in demonstrably physical disease process, psychiatrists lack an externally validating terrain. They thus lack the authority to say of their patients “this person is ill”.

Notice the form of the argument; without validating evidence that a physically demonstrable disease process is present, we ought not to use the word “illness”. Thus, in psychiatry, we seem to treat illness as being similar to criminal guilt. A person is healthy until proven otherwise; sane until proven insane. Maybe this is the right way for psychiatry to be organized. We all naturally seek to be recognized as autonomous, reasonable individuals, capable of deciding for ourselves. We recoil from the possibility that our vision of reality may be compromised. Putting the burden of proof on the psychiatrist protects us pre-emptively from the possibility our autonomy is compromised and our slant on the world is “off.”

But it is worth contrasting this state of affairs with other forms of medical complaint. In a recent book about psychosomatic illness, neurologist Suzanne O Sullivan reports on a series of patients with serious physical symptoms. In each case, she concludes the most important causal factor lies in emotional conflict or disavowed stress. Although she does not deny these patients are ill, she does deny that the illness is straightforwardly physical in the way they believe. It is interesting to observe that, contrary to the situation faced by many psychiatrists, Sullivan has to work hard to persuade her patients that they don't have a disease.

Here the burden of proof is somehow reversed. The patients approach the doctor claiming to have a physical disease. Only a complex diagnostic process is able to rule out its presence and allow the symptoms to be accounted for as “psychosomatic”. Even then, there is no disease, but the patient is still ill. How can this be? Doesn’t Sullivan lack the same medical authority as psychiatrists in these instances? Isn’t she, like them, forced to conclude that absence of a disease process entails absence of an illness?

Apparently Sullivan cannot observe her patients’ situations and fail to conclude that they are ill. This seems partly to be sympathetic, and partly intuitive. Sympathetic because Sullivan is clearly at pains to communicate to her patients that she takes their experiences seriously. They feel themselves to be ill. Intuitive because and to all intents and purposes, these patients simply seem to be ill. When an individual is unable to walk, or is subject to persistent and debilitating seizures, we readily concur that we are in the terrain of medicine. We havestrong intuitions about where illness is and where it is not present. How otherwise how could the arguments about disorders like ME/CFS could, get so heated and confused?

Somehow our intuitions about physical and psychiatric debilitation are different. We question psychiatrists’ authority to label their patients “ill” in way we don’t bother to with for other specialties. This is not just a question of objective markers, it is written into how we interpret different experiences. This may amount to a systematic bias against seeing illness in the psychiatric realm. Insofar as psychiatry can suffer from “mission creep” (into the medical-labelling of political dissenters for example) this bias may have its uses. However, despite a relatively vocal movement for the demedicalisation of mental health services, there is reason to suppose that a complete movement away from an “illness model” will not serve everyone.

“Illness” is not only a word imposed top down on people’s subjectivity by patrician doctors, it is also a way of giving form to experiences that are painful, disorienting, dangerous or overwhelming. The idea of experience as illness can make sense of it no less than a narrative about its social, traumatic or affective origins, and is in any case not necessarily in conflict with such a narrative.

It is worth wondering then, why we light so easily on the idea of illness in the case of some forms of overwhelm, and so reluctantly in the case of others. In either direction we run the risk of going wrong. We might reasonably ask who has the authority to say that someone else is ill, but we might also wonder who has the authority to decide who is not.