ACADEMIA Letters Medicalization and its clinical discontents Samuel Lézé In this medical anthropology paper, I offer to the discussion a counter-intuitive hypothesis: “medicalization” is a clinical judgment inherited by the functionalist sociology of deviance. In that respect, society is an organism that can be afflicted with pathologies. Does this organicist metaphor affect the sociological concept of medicalization and model its subject matter? To make this clear, I will start from (i.) my fieldwork on French psychoanalysis and its discontents which led me to formulate a paradox: psychiatrists are politically resisting the medicalization of psychiatry. Indeed, (ii.) this instance does not fall within the concept of medicalization studies despite recent attempts to save it from major objections. Since, (iii.) the concept’s filiation shows that it retains the negative values of its origin in theGerman Kulturkritik. This has the methodological consequence (iv) of prompting me to design genealogical analysis on ethnographic materials and study the entire spectrum of values in the judgment formation, their possible transformation from the micro-clinical to the macro-critical scale and vice versa. I. Defending the Clinic as Politics in a Post-Socialist Society During my fieldwork on French psychoanalysis, I have mainly explored the encounter of therapeutic supply and demand as well as the symbolic relationship in the cure. However, I have never isolated this practice from the political situation because French psychoanalysis is a therapeutic system situated between the medical field and the intellectual field. Thus, whatever the site of my field, I have documented the variants of a recurring judgment: “the clinic is political” (Lézé, 2010). Variations of this formula also appear in two other ethnographies in Argentina (Lakoff, 2006) and in Brazil (Béhague, 2009). Between 2000 and 2015 in France, Academia Letters, June 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Samuel Lézé, samuel.leze@ens-lyon.fr Citation: Lézé, S. (2021). Medicalization and its clinical discontents. Academia Letters, Article 992. https://doi.org/10.20935/AL992. 1 this formula became a slogan in psychiatric congresses that increasingly resembled political meetings in reaction to a series of public health policy reforms in the name of modernization. This moto concentrates the clinical components of a repertoire of collective action. First, the clinic refers to a singular relationship that is the primary empirical source of the clinician’s knowledge. Second, the clinical encounter reveals the irreducible singularity of individual suffering. Third, the clinical encounter is the only way to free a subject from alienation in the broadest sense. Psychiatrists are thus indignant about all the political effects that could alter the nature of this clinical encounter. The cause of the evil is clear: the norm and its imposition (normalization). Significantly, the clinical category of “suffering” becomes a critical category for judging civilization and its discontents. This indignation is not only inaudible to public health policy reformers, but also to many psychiatrists around the world. The political defense of the clinic seems to be the protection of an old French “clinical tradition” (belonging at best to the 19th century or to psychoanalysis) resistant to the progress of modern psychiatry. During a major congress of psychiatry in Lyon in 2012 where I was the keynote speaker, I tried in vain to explain why criticism of the medicalization of psychiatry was now inaudible and even worse, counterproductive: medicalizing can politicize as shown by the political benefits for Japanese workers of the medicalization of “depression” (Kitanaka, 2011). So, I caused a great deal of discontent because I was perceived as a medical anthropologist attentive to the central preoccupation of psychiatrists for the clinical encounter and its political defense. I therefore had to justify the clinical resistance to biomedicalization, as I tried to pose and explain the problem (Lézé, 2013). Nevertheless, this discontent seems to me to be very instructive to formulate the following paradox: psychiatrists are politically resisting the medicalization of psychiatry. Is it “the fault” of psychoanalysis? II. Saving Medicalization studies in a Post-Functionalist sociology The first lesson of this discontent lies in the equivocation of “medicalization” which can judge psychoanalysis sometimes as instance of medicalization or demedicalization. More broadly, clinical resistance to medicalization seems not falling within the concept of medicalization studies. Thus, in the 1930s in the United States, it was possible to worry about the “medicalization of psychoanalysis” (Hale, 1995). 30 years later, psychoanalysis was for functionalist sociology the very prototype of the medicalization of deviances (Pitts, 1968). Almost at the same time in France, psychoanalysis and Lacanian criticism of the American medicalization of psychoanalysis was the lever for the demedicalization of psychiatry in its separation from Academia Letters, June 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Samuel Lézé, samuel.leze@ens-lyon.fr Citation: Lézé, S. (2021). Medicalization and its clinical discontents. Academia Letters, Article 992. https://doi.org/10.20935/AL992. 2 neurology (Delille, 2016). It is true that since the 1960s, medicalization studies have been constantly pointing out the weaknesses of the concept of medicalization while still trying to save it by rectifying it. Firstly, the concept focuses only on deviances. Second, the case study looks for redefinitions of deviance in a medical lexicon. Third, pathology can be linked to medical jurisdiction (Conrad, 1992: 211). This definition values the conceptual scale of the definition to categorize a state at the expense of the scale of institutions and doctor-patient interactions. Moreover, it clearly devalues the study of empirical counter-examples: demedicalization. These objections aim to save the concept by showing that it is sufficient to distinguish in a case study (such as the abortion problem in the United States during two periods: 1860-1900 and 1960-1973) the scales of variation of medicalization and demedicalization (macro-meso-micro) from analytical dimensions such as the conceptions, concrete practices and social role of collective actors (Halfmann, 2011). The analytical value of the concept would therefore be proven by focusing on the conditions and social consequences of the undeniable biomedicalization and pharmaceutilization (Clarke, Shim, 2011)as long as specific and new instances are identified (Busfield, 2016). It would thus be enough “to separate the wheat from the chaff” to produce “new wine into old wineskins”.Unfortunately, even with its rectifications, the concept of medicalization remains intrinsically equivocal because it covers at least eight social processes that may appear contradictory even when distinguished: the formation of a new professional jurisdiction, the humanization of social control, the translation of normal life into pathology, the translation of a social problem into a biological problem, the pharmaceutical treatment of a social problem, the political promotion of a way of an healthy life, the vulgarization of medicine, the reduction of clinical medicine through its becoming bioscience or biotechnology. This is why medicalization is indeed a ‘cliché of critical social analysis’ (Rose, 2007: 700). And the critique of this social critique is not a simple “caricature of research on medicalization »(Busfield, 2016), because medicalization is itself a caricature of a very old social critique inherited from sociology and medicine. III. Diagnosing Social Pathologies in a Post-Revolutionary Society The second lesson of this discontent is that the conceptual history of medicalization in Sociology (Lichtblau, 1995) is inseparable from the intellectual history of the concept of Modernization and its discontents in German Kulturkritik (Bollenbeck, 2007). The anatomical metaphor of the social body imports into the sociological concept of society some medical and political values. My ethnographic materials therefore engage me to carry out a genealogical analysis of Academia Letters, June 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Samuel Lézé, samuel.leze@ens-lyon.fr Citation: Lézé, S. (2021). Medicalization and its clinical discontents. Academia Letters, Article 992. https://doi.org/10.20935/AL992. 3 the concept of medicalization as for the cell theory involving the metaphor of the hive and the bees (Canguilhem, 1994). Similarly, the concept’s filiation shows that it retains the negative values and thus this sociological ”macro-tropes” model its subject according to these values (Rumsey, 2004). Modernity is a reversible and reflexive value: sometimes a positive judgment to celebrate progress, sometimes a negative judgment to denounce its misdeeds. The term refers to entangled but distinct processes whose chronology never coincides. Political criticism of medicine can take at least two forms. Critical judgment: Medicine is our new religion and physicians are the new malevolent priests. A clinical judgment: The progress of medicine is, like any claim to modernity, harmful to man: it distorts or transforms him negatively. With symmetrical and inverse premises (religion or modernity), the result is always the same: Health is an ideology to mask the control of this caste over our lives. Criticisms of medicine is therefore to be both modern and anti-modern. Critical theory oscillates between the two poles in the game of demystifying demystifiers, while functionalist sociology problematizes deviance according to the mechanisms of social control restoring order. The concept of medicalization thus has the paradoxical property of designating a deviance (a risk of disorder) and its social control (a restoration of order). It is remarkable that this trope of clinical judgment (diagnosing social pathology) is not specific to sociology but has multiple ramifications that can manifest themselves in medicine. Freudian and Lacanian psychoanalysis base their theory of culture on the work of sociology. But, more broadly, there is an inexhaustible ’psycho-politics’ (Freis, 2019) at the foundation of a specialty such as ’social psychiatry’ (Rosen, 1959). This is why medicalization can also be valued or criticized by psychiatrists. *** The main methodological consequence of this hypothesis is of prompting me to design genealogical analysis for ethnographic materials and study the entire spectrum of values in the judgment formation, their possible transformation from the micro-clinical to the macrocritical scale and vice versa. The value of a concept depends on its ability to solve a problem. Critics of the medicalization concept wanted to strengthen it to make it more analytical. I believe, on the contrary, that it is more fruitful to weaken it because it can respond to at least four distinct problems that do not belong to medical sociology: social transitions, social control of deviances, professional jurisdictions, social movements organizations. My problem was therefore quite different: how are judgments formed and transformed with values? As a result, by making the Medical anthropology and medicine more attentive Academia Letters, June 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Samuel Lézé, samuel.leze@ens-lyon.fr Citation: Lézé, S. (2021). Medicalization and its clinical discontents. Academia Letters, Article 992. https://doi.org/10.20935/AL992. 4 to the borders between the Clinic and Criticism, my fieldwork show “medicalization” as an emic interpretation requiring an explanation and not a useful etic concept. Acknowledgments This study was supported by “The Battle for the Science of Man” Research Program (BATTMAN) funded by the LabEx COMOD, Lyon University (2017-2020). I am very grateful to Elisabeth Hsu and Heidi Rimke for their comments on the manuscript. References Béhague, D. P. 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Academia Letters, June 2021 ©2021 by the author — Open Access — Distributed under CC BY 4.0 Corresponding Author: Samuel Lézé, samuel.leze@ens-lyon.fr Citation: Lézé, S. (2021). Medicalization and its clinical discontents. Academia Letters, Article 992. https://doi.org/10.20935/AL992. 6