Keywords

In this chapter, we discuss concepts and theories that allow us to better understand and explain the prominent role of medicine and psychology in the German welfare state. Although most medical doctors and psychologists are paid by public health insurance and some also work as employees in public organizations, welfare state research has considered both professions—if at all—only in terms of their relevance to healthcare. However, over the last 10–15 years, several scholars have proposed that processes of medicalization and psychologization are linked in a more fundamental way to the welfare state and its institutions (Buffel et al., 2017; Holmqvist, 2012; Olafsdottir, 2011; Pulkingham & Fuller, 2012; Sage & Laurin, 2018; Schram, 2000; Wastell & White, 2012; Wong, 2016).

In fact, medicine and psychology have been relevant to the welfare state since its beginnings in the nineteenth century. Nikolas Rose (1996), for instance, claims that psychology and the welfare state developed not only around the same time (at the end of the nineteenth century), but also as part of an interdependent relationship: “As the human soul became the object of a positive science, human subjectivity and intersubjectivity became possible targets of government intervention” (Rose, 1996, p. 68). Nevertheless, recent contributions suggest that medicalization and psychologization in the welfare state have taken on new significance in parallel to changes to Western welfare states over the last three decades. “Concern with the psychological dimension has always been present in welfare practices but has typically played a subordinate role in political constructions of policy. We raise the idea that we have entered an epoch in which the ‘psycho’ resonates as surely as the ‘social’ alongside ‘welfare’” (Stenner & Taylor, 2008, p. 415).

Our conceptual framework is based on the concepts of medicalization and psychologization. This framework contrasts with many recent contributions in the field, which are based on the notions of therapeutization, therapy culture, and/or biopolitics (e.g., Ecclestone & Hayes, 2009; Illouz, 2008; Lupton, 1995; Nolan, 1998; Rose, 2006). While these concepts were developed in order to better grasp a broader phenomenon independent of disciplinary and professional boundaries (Anhorn & Balzereit, 2016), we are explicitly interested in these boundaries as well as in relationships between these disciplines and professions. The processes of medicalization and psychologization certainly share many commonalities, and the boundaries between the two fields can quite often seem blurred, as, for example, with psychiatry. However, important differences also exist between medicalization and psychologization. These differences are evident not only in the professions themselves and in their roles and foundations in the (welfare) state, but also in terms of their consequences for individual subjects and for the welfare state.

In both this and the following chapter, we outline how we can identify, understand, and explain processes of medicalization and psychologization in the welfare state. To that end, in Chap 3, we first discuss medicalization theory, followed by accounts of psychologization, and we conclude with a systematic comparison of both processes. In Chap. 4, we integrate these theoretical approaches to welfare state theory in an analytical framework that specifies how we can (a) understand the role of medicine/psychology on different dimensions (actors, institutions, ideas) and levels (micro, meso, macro) of the welfare state and (b) explain cross-national differences and (c) changes over time.

2.1 Making Things Medical…

is how Peter Conrad (2007)—one of the most prominent American scholars in this field—synthesizes the concept of medicalization. At its core, the concept centers around understanding how and why social problems or conditions move into (and out of) the medical realm.

The significance of medicalization stems from its potential to describe and explain why the number of life problems and social conditions that have become medical has grown substantially in recent past decades. What used to be considered madness is now understood to be mental illness. Drunkenness is now acknowledged as alcohol dependence, chronic stress at work has been re-defined as burnout syndrome, and maladjusted child behavior has been classified as various forms of childhood and adolescent behavioral and emotional disorders, including ADHD. Most notably, this medicalization of society is visible in the rising number of medical diagnoses, for instance, in the International Standard Classification of Disease (ICD), which grew from 14,000 codes in Version 9 (1978) to 375,000 codes in Version 10 (1990) (Winters-Miner et al., 2014).

“Deviant behaviors” were among the first problems to become medicalized. With their seminal contribution, “From Badness to Sickness,” Conrad and Schneider (1992) revealed that many phenomena that were once treated by religion or the justice system are now understood to be medical problems. This transfer of the social control of deviance to the field of medicine has accompanied the modernization of societies. While deviant behavior was among the first examples that sparked interest in processes of medicalization, later research has shown that the reach of medicalization goes much further. Two other frequently medicalized phenomena are “natural life processes,” such as childbirth, involuntary childlessness, menopause, and impotence, and “everyday problems of living,” such as sadness, loneliness, shyness, and fear (Davis, 2016, p. 221).

It was this empirical observation—namely, that more and more things were becoming medically defined and controlled by the medical profession—that sparked the development of medicalization theory from the 1950s to the 1970s. Early work took a predominantly critical perspective on the rising medicalization of society (Freidson, 1995; Illich, 1974; Szasz, 1960). On the one hand, researchers highlighted the risks and problems associated with labeling individuals as ill. Ironically, these risks and problems included both the concern that individuals would no longer take responsibility for their own problems (i.e., what individuals themselves can do) (Szasz, 1960) and the fear that responsibility would become individualized and that social causes would be ignored (i.e., what society can do for individuals) (Zola, 1972). On the other hand, concern was voiced over the fact that social control for many social problems was being transferred to the medical profession. This transfer was considered problematic because medical doctors’ actions are generally perceived by the public as objective and scientific despite the fact that medical doctors are also guided by their own values and political objectives (Zola, 1975). As Robert Nye (2003, p. 116) put it, the “medical discourse reinforced a conception of reason as the enlightened self-interest of the rich and powerful and located the domain of unreason among women, the mad, the poor, and the criminal classes.”

This early critical perspective of medicalization was attenuated in the further course of medicalization research. Peter Conrad, in particular, maintained that medicalization should first be seen as a descriptive and analytical concept that allows us to measure how the role of medicine has changed both for specific empirical phenomena and for society at large, independent of the consequences of this development. A vibrant body of research by Conrad and many others called a number of the early assumptions of medicalization theory into question.

First, medicalization is not a binary category (i.e., problems are not simply medicalized or not medicalized); instead, medicalization can be assessed “on at least three distinct levels: the conceptual, the institutional, and the interactional levels” (Conrad, 1992, p. 211). Thus, medicalization can mean that a problem is described in medical terms on the conceptual level, that it is treated with a medical approach on the institutional level, or that it involves the medical profession directly on the interactional level. Problems can be medicalized on these levels to varying degrees, such as minimally, partially, or fully.

Using such a differentiated perspective reveals that the hypothesis that medicalization has been continuously expanding—that is, that all aspects of society are becoming more and more medicalized—does not hold. Instead, the definition and treatment of problems is much more dynamic and regularly involves both medicalization and de-medicalization, sometimes simultaneously (Halfmann, 2012).

2.1.1 The “Medical” in “Medicalization”

While this differentiated perspective on medicalization is generally agreed upon, controversy exists around the core of the concept: In other words, what exactly should count as medical? How can we distinguish medical from non-medical? What are the necessary conditions for medicalization? Three positions are outlined here:

  1. (1)

    Narrow the concept 1: No medicalization without the medical profession: At one end of the spectrum, Davis (2006) argues that the definition of medicalization has become blurred because the social control of the medical profession is no longer a necessary part of (conceptual) medicalization. Instead, the “medical” framing of a problem suffices in order to consider the problem medicalized. Davis warns against relying solely on language when diagnosing processes of medicalization since there is no clear guideline as to what constitutes a medical word, and indeed, many words (e.g., “symptom,” “diagnosis”) have both a medical and a non-medical meaning: How can a problem be fully medicalized, Davis asks, if no responsibility is transferred to the medical profession? Based on this analysis, Davis suggests that the concept of medicalization be sharpened and refocused on medicine as an institution.

  2. (2)

    Narrow the concept 2: No medicalization without a medical label: Similar to Davis, Williams et al. (2017) argue for a narrower or stricter application of the concept of medicalization, but from a different angle. The authors claim that if medical treatments and technologies are used without defining the underlying problem as a medical problem (i.e., pathology), these medical treatments and technologies should not be considered a form of medicalization. The example the authors provide that they do not consider medicalization is the use of pharmaceuticals for purposes of enhancement (e.g., to sleep or concentrate better, even if no diagnosis has been made that indicates a problem). Thus, from their perspective, conceptual medicalization is the essential component of the concept.

  3. (3)

    Extend the concept: Medicalization outside of Western biomedicine: At the other end of the spectrum, Correia (2017) asserts that the concept of medicalization remains overly narrow and overly conflated with both the biomedical model and the Western medical profession. Correia therefore suggests that anything that has the ontological features of medicine from a philosophical perspective—regardless as to whether it is currently accepted in a medical context—should be included in the concept. According to Correia, “medicine can be defined as the use of discretionary-based skills that are taught to turn abstract principles into concrete situations according to specific truths aimed at health recovery” (Correia, 2017, p. 6). Correia thereby takes the opposite position from Davis and aims to undo the coupling of medicalization with the (Western) medical profession.Footnote 1

This discussion is important because it illustrates how challenging it is to pinpoint the definition of medicalization. It is therefore critical to be clear with what we mean with our use of the term and how we aim to measure it empirically. In this book, we follow Halfmann (2012) in considering three dimensions of medicalization: For our purposes, medicalization includes (1) a rising use of medical ideas and concepts, (2) a stronger involvement of medical doctors as actors, and (3) an increasing institutionalization of medicine, for example, through the requirement that a medical opinion be given. All three dimensions capture one aspect of medicalization and highlight the different mechanisms through which medicalization happens in discourses, in practices, and in institutions (see Chap. 3).

2.1.2 What Causes Medicalization?

An obvious first attempt at explaining medicalization involves investigating who benefits from the process. Thus, the power and activities of the medical profession are considered a source of medicalization. This notion has led many to believe that the concept of medicalization implies that it is driven by medical doctors who actively extend their jurisdiction and thereby increase their power. Pawluch (2017), for instance, argues that with the improved health of children after World War II and the declining number of children during the 1970s, “the specialty began to suggest that primary care pediatrics could be revitalized if pediatricians addressed themselves to children’s unmet needs, particularly those that were not strictly medical” (Pawluch, 2017, p. 222). Thus, strategic actions by the medical profession are considered in this case to be a cause of medicalization. While these actions have certainly played a role in some cases, extreme versions of this argument that consider medicalization to be a form of “medical colonization” or “medical imperialism” are now rejected by most scholars in the field as they are not in line with empirical data (Busfield, 2017). Medical doctors are surely the central gatekeepers of the healthcare system and are therefore generally involved in processes of medicalization (Conrad, 2005), but they are quite often not the initiators. In fact, comparative-historical analyses indicate that whether, how, and when medical doctors engage in medicalization varies substantially across time and contexts, which suggests that the reasons for medicalization are more complex (Halfmann, 2019; Nye, 2003).

A second, important driver of medicalization includes activities by individuals and social movements that fight for the recognition of their problems as medical conditions. One example is alcoholism, which was advocated for by a social movement (Alcoholics Anonymous) and was only later accepted by the medical profession (Conrad & Schneider, 1992).

While medical doctors and social movements were seen as the primary drivers of medicalization in the twentieth century, Conrad (2005, p. 10, emphasis added) argues that “the engines of medicalization have proliferated and are now driven more by commercial and market interests than by professional claims-makers.” This increasing importance of pharmaceutical, biomedical, and biotech companies in expanding the definitions of diseases has been a prominent feature of medicalization researchFootnote 2 in US sociology due to the system’s market orientation. This idea has also been taken up by Adele Clarke et al. (2003) in their concept of biomedicalization, in which they highlight “technoscientific innovations” and the “commodification of health” as fundamental aspects of biomedicalization.

However, not only the market but also the state is another important force behind medicalization. Early medicalization theorists highlighted this aspect and warned about the growing link between state power and medical power (Zola, 1972). This early perspective of the state’s strategic use of medicalization to oppress groups has lost influence. To some extent, this is the result of the fact that much of the research on medicalization is based in the US, where market forces are comparatively strong and the welfare state’s influence is considered to be modest. More importantly, the understanding of the role that the state plays in processes of medicalization was transformed by the work of Michel Foucault (1991, 1976 [1973]). Both his late work and the research it has inspired consider medicalization to be a form of governance in modern liberal states. These governmentality studies have “abandoned the notion of an essentialized and willful state” (Nye, 2003, p. 118). In other words, medicalization is still linked to processes of knowledge, power, and governance within states. However, the state as an actor in its own right—as well as its specific institutions and their direct legal, material, and coercive power—has received little emphasis in this line of research.

Newer medicalization research, however, has posited that the state in general and the institutions of the welfare state in particular need to be reconsidered and seen as having a powerful influence on processes of medicalization (Buffel et al., 2017; Halfmann, 2019; Holmqvist, 2012; Olafsdottir, 2007). This claim is often the result of a comparative perspective that has shown that medicalization works quite differently across nations due to the way the welfare state is organized. The role of the state (i.e., its institutions and bureaucracies) can vary from that of an engine that powers processes of medicalization to that of a break that halts these processes (Reibling, 2019). More importantly, the existing institutions of the welfare state provide the context that shapes how medicine and psychology are included in both the discourse and practices around social problems. These institutions can be political and deal with topics ranging from constitutionalism (Halfmann, 2019) to the general welfare state regime (Olafsdottir, 2007), or they can belong to specific fields of government activity, such as unemployment insurance (Buffel et al., 2017).

2.2 Making Things Psychological?

The growing importance of psychology in modern societies has paralleled trends of growing medicalization (Castel, 1979; Gross, 1978; Havemann, 1957; Lasch, 1979; Rieff, 1987). However, while medicalization research has been strongly centered in medical sociology, the debate on psychologization is centered in other (sub-)disciplines, especially cultural sociology (Furedi, 2013; Illouz, 2008; Rieff, 1987), philosophy (Rose, 1996; de Vos, 2013), and critical psychology (Madsen, 2018; Madsen & Brinkmann, 2016). Even though medicine and psychology are used to address similar social problems, have similar consequences, and interact as professions in many social systems, debates on medicalization and psychologization have evolved separately and are only rarely compared or discussed (to some extent; see Madsen & Brinkmann, 2016). One reason for this is that the concept of psychologization has gained less ground than that of medicalization since psychologization has often been theoretically absorbed by the concepts of therapeutization or therapy culture. In these concepts, the focus has traditionally been on the therapeutic approach rather than on the psychological profession or on psychology as a discipline.

Nevertheless, existing definitions of psychologization generally center around the concept of a process that is similar to that of medicalization. For instance, Madsen (2014, p. 171) suggests that psychologization denotes a process in which “increasingly more non-psychological phenomena are understood as something that arises from and thereby has its natural solution in the psyche of the individual, or, even better, in the brain.” This definition highlights the conceptual dimension of psychologization. This dimension—which describes the idea that psychologization works by forming knowledge and shaping discourses on social phenomena—has had a very strong focus in the literature. Rose (1985, 1996), however, advocates for another orientation and argues that we should also examine the technologies of psychology, such as diagnostic manuals, assessment tests, and therapeutic techniques. Rose argues that psychology has developed historically not through the scientific growth of psychological knowledge—as is commonly argued in histories of psychology—but rather as due to psychologists’ work on solving practical problems in various organizations, such as “the school, the reformatory, the court, the army and the factory” (Rose, 1985, p. 5). Finally, some work has also examined the growing influence of the academic discipline and practical profession of psychology as an indication of psychologization. However, since the visibility and power of the profession is considered comparable to that of other academic professions (and lower than that of older professions, such as medicine), it is unclear whether the growing number of psychologists and psychotherapists represents psychologization or whether it is merely an expression of a general professionalization trend in modern democratic societies.

Numerous social issues reveal trends in psychologization. Such issues include romantic relationships (Illouz, 2008), education (Ecclestone & Hayes, 2009), social work, childhood development, religion, sports (Madsen, 2014), work, poverty (Thomas et al., 2018), and various deviant behaviors. Psychologization has also been studied in terms of the importance of specific psychological concepts and discourses, such as the idea of mental hygiene in the 1920s and 1930s (Rose, 1996), the self-esteem movement in the 1980s and 1990s (Cruikshank, 1993), the stress discourse (Becker, 2013), and the currently popular concept of resilience (Gill & Orgad, 2018). Psychologization has also been attributed to the rising popularity of psychological techniques, such as intelligence tests, assessments of personality traits, psychological experiments, and various therapeutic techniques (e.g., cognitive behavior therapy, transactional analysis). However, psychologization is usually conceived as more than the process of growing popularity of certain psychological concepts or techniques. Indeed, psychologization is considered a fundamental element of modern societies that undergirds the notion of (a good) life: “Psychology not only provides us with a conception of what we are but also offers us an image of what we could be and a toolbox for achieving this image” (Neill, 2013, p. vii). It is this vastness of psychologization that scholars have criticized because it has evolved into a system of meaning without alternatives (Madsen & Brinkmann, 2016). It is therefore no longer possible for modern societies to think outside of the box created by psychological categories and meanings.

Various critical perspectives on the psychologization of modern societies exist. For instance, early “communitarian critique” (Illouz, 2008, p. 2) posited that psychology encourages self-involvement and narcissism, thereby undermining social relations and culture. Social problems become depoliticized, and social solutions based on values such as solidarity are rendered difficult—if not impossible—to achieve (Lasch, 1979; Rieff, 1987). A second line of critique has highlighted the social control aspects of the process of psychologization and argued that people become overly dependent on experts for dealing with their own lives instead of taking responsibility and action themselves (Furedi, 2013). The involvement of therapeutic professions can go hand in hand with paternalistic monitoring and control and the devaluation of individuals’ personal values, particularly for marginalized groups of society (Polsky, 2008). More recent work has stepped back from the influence of professions and the notion of social control. Inspired by Foucault’s (1991) ideas of systems of knowledge and governmentality, psychology has also been considered a paradigmatic discipline that provides “technologies of the self”—that is, techniques through which individuals govern themselves and transform their subjectivity (Rose, 1996). Psychology provides both the knowledge and the ethical resources for government through self-governance in which societal needs and personal objectives become aligned. For instance, individuals take responsibility for their own health or parenting, but the internalization of these goals and the used techniques are based on the psychological knowledge and psychologized discourses in our society.

The wide concern about the negative consequences of psychologization, however, has itself been reflected upon by various authors. For instance, von Kardorff (1984) argued that to deem psychology to have complete social control would be to overvalue the discipline and to undervalue individuals’ critical resources. In a similar vein, Illouz (2008) suggests that we should ask why citizens so happily endorse psychological concepts and techniques and posits that they do so because these concepts and techniques provide meaning and resources for individuals’ lives that enable them to understand and lead their lives in our current society. Finally, as Madsen and Brinkmann (2016, p. 197) state, “[c]ertainly, there should be a space for critique and utopian thinking; but rather than being safe from psychologization, shouldn’t we be worrying about being saved from global warming, flooding, and hunger?” Thus, psychologization is generally viewed from a critical perspective, but concern exists around the notion that in certain respects, its negative consequences might be exaggerated.

2.2.1 What Is Psychology, Anyway?

In order to assess how extensive the phenomenon of psychologization is, it is also necessary to understand its core: In other words, what is psychology, anyway? This question is even more difficult to answer for psychology than for medicine. The simple notion that psychology is what psychologists do has been rejected by most of the literature. Indeed, the discipline has gained professional prestige, rights, and resources over the course of the twentieth century, and the number of psychologists has increased tremendously. Nevertheless, the prestige of psychologists is lower than that of the medical profession (Ebner & Rohrbach-Schmidt, 2019), and the political power that psychologists wield is weaker. This power difference is particularly evident in corporatist healthcare systems such as Germany, where medical associations have an institutionalized role and are highly visible in public debates (Klenk, 2018). But why has psychology come to have such a dominant role in modern societies? The argument put forth in the literature is that it is precisely the fact that psychological knowledge and techniques have been shared with other professions as well as with patients and clients (Madsen, 2014; Rose, 1996) that has made psychology so powerful. Thus, unlike medicine, which strongly protects its knowledge and rights, psychology has been rather open with its ideas and inventions. This diffusion of psychology should not be seen as an intentional strategy of the psychological profession, although the profession has clearly advocated for and actively extended its jurisdiction. Instead, this transparency is the result of the history of psychology, which has developed by solving practical problems in various inter-professional organizations (Rose, 1996). Moreover, therapeutic techniques require therapy patients to understand and apply the methods themselves. As a result, psychological concepts have not only been adopted by many other professions, but they have also gained a strong foothold in everyday life and popular culture (e.g., in self-help books) (Illouz, 2008).

Psychology contains a wide variety of subfields, research areas, theories, and methods. Nevertheless, certain aspects are generally put forth as the core of what psychology does: Psychology develops an objective, scientific understanding of what it means to be a person (de Vos, 2013). The psychological concept of a person includes many elements (e.g., perceptions, cognitions, behavior); however, emotions have been highlighted as a specifically important contribution of psychology because they have historically received little attention in society (Furedi, 2013; Nolan, 1998). Finally, psychology provides techniques for differentiating between individuals (e.g., their intelligence, personality, motivation, and capabilities) (Rose, 1996). While psychology does engage with individuals and sets norms and thresholds for when they and their behavior are considered pathological or non-normal, the discipline’s focus is broader and includes not only mentally ill individuals. Especially, The turn toward positive psychology in the late 1990s has meant that psychological insights are relevant for everyone because these insights provide knowledge and techniques that can be used to lead a productive, happy, and healthy life.

2.2.2 What Causes Psychologization?

The literature on psychologization has put less emphasis on explaining why psychologization has evolved in comparison with describing it and evaluating its consequences. However, various ideas have been posited as to why psychology has become so important in modern societies. Actors have mostly been considered less relevant to psychologization, at least in the sense of strategic actions made by social movements, psychological professions, and so on. Nevertheless, actors are indeed mentioned in works on psychologization. For instance, Rose (1996) argues that psychologists who work in social organizations (e.g., factories, the army) and who aim to solve the practical problems that these organizations face were critical in leading to the development of psychology as a profession. Illouz (2008, p. 20) points to individuals as agents in the process of psychologization and argues that psychology provides “a cultural resource” for individuals and that its techniques would not be adopted if these techniques did not accomplish something for the individuals. Thus, by adopting psychological techniques and embracing their ideas, individuals contribute to psychologization. Finally, Polsky (2008) argues that philanthropists and personnel in welfare services and agencies have been influential to psychologization because they have continuously advocated for a therapeutic approach to dealing with marginal groups. As public employees, social personnel have a vested interest in demonstrating that the continued need for their techniques and services is present. In addition, their jobs allow them to use bureaucratic and street-level strategies to maintain this approach, even if their social organization and political power as a group is limited (Polsky, 2008).

A second, more influential hypothesis for the rising influence of psychology involves the role of ideas. Many scholars depict psychologization as a functional solution to the problems and needs of modern societies. Indeed, as Nolan states in The Therapeutic State, “[t]he therapeutic ethos is a system of meaning that is right for the time” (1998, p. 18). Bureaucratized modern institutions, flexible and individualized work and private life, and the lack of other forms of authority and legitimization—such as tradition and religion—create a need that is filled by what psychology has to offer. Thus, psychological ideas resonate with the conditions and requirements of modern life. As a transcendent orientation to life is no longer pursued by most citizens, health, happiness, and self-realization have evolved to become life’s ultimate goals, and it is psychology that provides the scientific knowledge, techniques, and professional services that can help individuals to reach these goals. The underlying cultural narrative of psychologization depicts the process as a form of liberation—that is, a beneficial force that is good. In other words, the more psychology, the better (Madsen, 2014)—a view not only endorsed by most psychologists, but also held in public. However, critical psychologists such as Madsen have argued that psychologization can no longer be conceived as an alternative to social norms and traditions. Because psychology has become so popular, psychological interpretations of our world have become the norm, and the techniques used in psychology have become the standard for dealing with life’s problems.

Finally, institutions are also considered a relevant force behind psychologization. Psychology and the welfare state developed around the same time, and there seems to be an interdependency between the two. According to Rose (1996, p. 68), “[a]s the human soul became the object of a positive science, human subjectivity and intersubjectivity became possible targets of government intervention.” Psychological knowledge has allowed for a new form of governance that provides a natural fit with the idea of liberal democracies and their citizens as responsible and rational individuals (Madsen, 2014). Individual behavior is aligned with governmental goals through experts and technologies of the self, which have become institutionalized in the welfare state. Thus, throughout the expansion of the welfare state, psychology and its practices have become institutionalized in schools, clinics, companies, and so on (Furedi, 2013). In return, the “therapeutic ethos” has legitimized the broad activities of the state, as shown in Nolan’s (1998) historic analyses of fields of state activities in the US. This symbiosis between the welfare state and psychologization should not be interpreted as an intentionally built system of power relations. Indeed, “‘[t]he state’ is neither the origin nor puppet master of all these programs of government. Innovations in government have usually been made, not in response to grand threats to the state, but in the attempt to manage local, petty, and even marginal problems” (Rose, 1996, p. 76). However, the result is nevertheless that psychology has become an important part of the way that social control is organized in advanced, industrialized democracies. This form of guided self-management is generally less coercive and repressive than other forms of control, but it still represents a form of governance. However, the state has not given up coercive measures altogether. This notion is important in the therapeutic approach to marginal groups, where psychological solutions are often coupled with (the threat of) coercive measures (Polsky, 2008). For instance, in the welfare state, a lack of cooperation or conformity (e.g., school absence) has been tied with a reduction in or cancelation of welfare benefits (e.g., Cantillon & van Lancker, 2012; Friedli, 2016).

2.3 Similarities, Differences, and Suggestions for an Integrated Analysis

Psychology may be defined as the study of experience and behaviour. Medicine concerns itself with those areas of experience and behavior known as sickness and health (however one wishes to define these words). It might be expected that the two subjects would be inextricably linked through their common interest in human functioning. History has, however, erected barriers between them, leading to a lack of understanding on both sides. (Hunt, 1974, p. 105)

Thus far, we have discussed the fact that one interdisciplinary body of literature has studied how medicine has become more important in societies while another interdisciplinary body of literature has conducted similar research for psychology. As both disciplines share many interests, subject areas, and scientific methods and also often work together professionally, the general lack of debate on how medicalization and psychologization are interlinked is quite striking. We therefore next aim to compare and integrate these two processes. In so doing, we do not mean to suggest that medicalization and psychologization generally co-occur or are interdependent, nor do we view the two processes as mere dimensions of a more abstract societal process, such as scientization (Ziemann et al., 2012) or modernization.

Instead, we argue that analytically combining the two processes allows us to sharpen and reflect on existing concepts and categories in both research areas, including what is considered to be (or ignored as) as their driving forces. This analytical combination also draws attention to the boundaries of the disciplinary and professional ideas, practices, and identities and thereby creates new puzzles and theoretically engaging research questions. Finally, a combined framework wields new analytical leverage in the empirical analysis of issues in which both disciplines are involved. The welfare state is the subject on which we focus in this book because it is in the welfare state that much of the activity around psychology and medicine occurs.

Table 2.1 compares medicalization and psychologization and displays their commonalities and differences. The descriptions of medicalization and psychologization may appear oversimplified, but the idea is to accentuate the differences concisely and illustratively. We thereby highlight the ideal-typical differences between both processes, but the empirical reality is more complex than the model suggests.

Table 2.1 Comparison of medicalization and psychologization (attribution of responsibility based on Brickman et al. (1982))
Full size table

2.3.1 Differences Between the Disciplines and Their Institutional Anchoring

Medicine is a large academic discipline that has a long history as a field of study since the foundation of the first medieval universities. Moreover, the medical profession continues to be among the most prestigious and politically influential professions and occupations in advanced, industrialized countries (Ebner & Rohrbach-Schmidt, 2019; Klenk, 2018). However, with the development of psychology in the middle of the nineteenth century, “the boundaries among medicine, psychiatry, and psychology had to be negotiated” (Pickren & Rutherford, 2010, p. 109). Since then, psychology has grown substantially and has become a well-established discipline and profession in its own right. Nevertheless, medicine has remained the more powerful discipline in academia, with entire schools and faculties dedicated to the field, whereas psychology is usually subsumed into the humanities, the social sciences, or the life sciences. In the healthcare system in general and in hospitals in particular, psychologists usually work under the formal supervision of medical doctors, but not vice versa. While both disciplines have become more diverse and interdisciplinary, it is critical to consider their different histories when aiming to understand their different disciplinary and professional identities.

Medicine remains oriented toward the physical, the material, and the objective, whereas psychology—with its focus on cognition, emotion, and motivation–is centered around the mind and the subjective (Hunt, 1974). Although most topics in medicine are difficult for laypeople to grasp (due in large part to medical jargon), concepts and evidence from psychology are “by and large still at the stage where [they are] comprehensible to most people” (Hunt, 1974, p. 106). Medical knowledge is therefore strongly monopolized by the medical profession, which means that medical doctors have special and exclusive rights over many processes. For instance, only medical doctors (can) practice medicine. In contrast, psychological knowledge is widely diffused in other fields (including social work, pedagogy, educational science, and economics) (Rose, 1996) and is also deeply ingrained in everyday life. For example, many psychological concepts (e.g., self-esteem) have become widespread in everyday language. Eva Illouz therefore talks about the “dual status of psychology” as both a profession and an aspect of popular culture (2008, p. 7). While general knowledge about psychology may be very influential in society at large, it weakens the professional power that psychology wields.

Another significant difference between medicine and psychology is that medicine remains much more strongly oriented toward the pathological. Indeed, “[t]he business of medicine is the diagnosis and treatment of illness” (Zola, 1975, p. 83). Therefore, medicine has a clear purpose to its research—namely to identify pathologies and to find solutions to them. While the prevention of illness and the improvement of public health have certainly been strengthened throughout the history of medicine, pathology has remained the major focus of the curriculum and of the process of the professionalization of medicine.

Moreover, research and practice are strongly coupled. Medical doctors are professionalized to be able to make life-and-death decisions when facing uncertainty. Their professional training and motivation are therefore strongly practical and are less concerned with expressing uncertainty or with the scientific process per se (Hunt, 1974). Even though many psychologists later also work with patients, their academic discipline is focused on understanding human behavior, cognitions, and emotions more broadly: Like most natural and social sciences, psychology is oriented at the development of general scientific laws (basic science), while medical research has a strong applied focus and aims to develop evidence and techniques that can be used in medical practice (Hunt, 1974). Thus, psychological research contributes at least as much to what makes people smart, productive, happy, and healthy as it does to understanding and helping people with (mental) illness. Psychology has become important in gaining newer understandings of health, which is now no longer defined as the absence of disease, but as the ability to assume social roles (Anhorn & Balzereit, 2016). This concept of health—famously introduced by the World Health Organization’s Ottawa Charter—sets the course for nearly infinite possibilities for individuals to work on themselves. As a result, self-optimization via psychological methods and self-enhancement via pharmaceuticals are considered important aspects of psychologization and medicalization, respectively. Moreover, both disciplines also engage in the general discourse on public health and health promotion, which focuses on health rather than on illness (Lupton, 1995). While this example reveals that the two disciplines have been coalescing over the past decades in many ways, it is important to bear in mind that the historic differences between them remain potent in terms of the disciplines’ identities, practices, and interactions with each other.

2.3.2 Driving Forces Behind Medicalization and Psychologization

Despite the notable differences between medicine and psychology, the influence of both disciplines on society has expanded substantially since the nineteenth century (Nye, 2003; Rose, 1985). Thus, one of the most important questions involves finding an explanation for the rising role of medicine and psychology in modern societies.

Medicalization theory is rooted in a social constructionist perspective and is strongly interested in the role of actors as driving forces behind medicalization. The notion that “some active agents are necessary for most problems to become medicalized” (Conrad, 2007, p. 6) has been a primary assumption in the literature. The explicit aim is to identify the causal factors and processes that underlie medicalization (Brown, 1995) using a perspective of social causation that assumes that social action is the basis of change. Thus, it is actors who discover, diagnose, claim, fight, and decide what is considered a disease and what is dealt with by medicine. In its initial work, the medical profession was considered the primary agent. In the 1980s and 1990s, however, social movements were acknowledged as important actors in campaigning for the medicalization of social problems (Ballard & Elston, 2005; Davis, 2016). More recently, Peter Conrad outlined the myriad “engines of medicalization” (Conrad, 2005, p. 5) and argued that their relative importance has changed over time. While actors have been considered the major driving force behind medicalization, cultural context—such as the role of rationality and modernity—has also been suggested to have played a role in shaping medicalization (Ballard & Elston, 2005):

It is likely that the very idea of a consciously driven process needs to be rethought. Institutions like the medical profession in the past or the pharmaceutical industry in the present may reap some of the benefits of medicalisation but the process itself is an outcome of a cultural dynamic rather than the intentional behaviour of individuals. (Furedi, 2008, p. 101)

More recent accounts have pointed toward the role that institutions play in shaping processes of medicalization (Halfmann, 2019; Olafsdottir, 2011), such as characteristics of the political system or of welfare state institutions. These accounts have thereby broadened the scope of the driving forces that are considered in current research.

In contrast to the social constructionist medicalization research, research on psychologization has a different theoretical and epistemological stance. For many scholars, Foucault’s work serves as a central reference point and with this a methodology that aims to deconstruct discourses and practices rejecting the concept of social causation (e.g., Rose, 1996).

Psychologization either is presented as the result of cultural transformations (e.g., modernization) or points to the role of psychological knowledge and practice in the current political-historic regime of (neo-)liberalism. Actors are less prominent, though they are also important in the literature. However, rather than collective actors, it is individuals who are discussed as being able to create their own subjectivity through technologies of the self that are based on psychological knowledge and practices. In this sense, psychologization—much more than medicalization—could be argued to be the result of individuals’ search (even in the absence of manifest problems) for health, happiness, and self-realization, for which modern psychology provides concrete techniques and strategies (Illouz, 2008).

2.3.3 Concept of the Individual

While both disciplines can be distinguished by many elements, they also share the key feature of placing focus on the individual (Bunge, 1990). Whether through dealing with genes, biology, behavior, emotions, or cognitions, both psychological and medical theories and practices work with the individual. While the two disciplines are well aware of the influence of the social context, this influence is allocated to specific subfields (e.g., social psychology or social medicine) and does not constitute the core of medicine or psychology.

However, the concept of the individual differs between medicine and psychology, and the processes of medicalization and psychologization therefore have different implications both for individuals and for society at large. The typical difference can be illustrated using Brickman et al.’s (1982) four models of helping and coping (i.e., a moral model, a enlightenment model, a compensatory model, and a medical model), which are based on two dimensions: (1) attributing responsibility for problems to the self and (2) attributing responsibility for solutions to the self. In the medical model, the individual bears responsibility neither for the problem nor for the solution. For the individual, the model has the benefit of relieving them from blame and justifying their acceptance of help, their state of being weak, and their decision to not participate in social obligations. The downside is the dependency associated with the medical model, which can make the individual passive and transfers power and social control to medical doctors. Psychology, on the other hand, builds on the compensatory model, in which the individual is also not considered responsible for the problem, but for its solution. The compensatory model is considered empowering since it considers the individual to be both good and competent. However, the compensatory model also has downsides. As Brinkmann and colleagues put it, “[t]he potential deficiency of the compensatory model lies in the fact that those who see themselves as continually having to solve problems that they did not create are likely to feel a great deal of pressure in their lives and to wind up with a rather negative or even paranoid view of the world” (Brickman et al., 1982, p. 372).

These different attributions of responsibility are relevant for the welfare state, in which the perceived legitimacy of benefits and services is crucial and continuously debated (van Oorschot et al., 2017). Medicalization and psychologization are therefore intertwined with changing welfare policies that also adjust their institutions based on cultural concepts of responsibility that are based inter alia on ideas and expertise from medicine and psychology.

While even today, medicine is more strongly associated with the medical model and psychology with the compensatory model, compensatory logic has gained importance in medicine over the last decades (Furedi, 2008). Indeed, with increasing knowledge about lifestyle risks as causes of diseases, the (perceived) responsibility that individuals have for becoming ill has grown. At the same time, patients have additionally become more responsible for dealing with their illnesses, for example, through chronic-disease-management programs.

2.3.4 The Consequences of Medicalization and Psychologization

What are the consequences of medicalization and psychologization? While many authors warn against viewing the contribution of these processes as representative of a case for or against medicine/psychology, the implications of the processes nevertheless motivate a significant proportion of the research. The consequences that we can theoretically consider are numerous: What are the implications for how individuals view themselves and conduct their lives? How do medicalization and psychologization affect social relationships? What are the consequences of medicalization and psychologization for social problems? How do medicalization and psychologization relate to the development of society more broadly and to the state more specifically?

A first approach to these questions stems from the observation that medicalization and psychologization would not be successful if they did not “work” in some way. For individuals, medicine and psychology offer concepts that provide meaning to their experiences as well as guidelines for their actions (Illouz, 2008). Thus, medical and psychological professions can be approached with problems of daily life (Conrad, 2007). The same is true for organizations and for the state. Medicine and psychology offer strategies and tools that help individuals in governing their behavior and in aligning it with their own goals (Rose, 1996). Due to their objective-scientific grounding and to the professional ethics of working in the interest of their clients, medical and psychological professionals legitimize the actions of organizations and of the state (Rose, 1985). This “positive” perspective on the consequences of medicalization and psychologization becomes particularly clear when considering the historical alternatives to these fields, such as the religious moral judgment of deviant behavior or legal punitive measures. In comparison, medical and psychological approaches are generally considered more humane (Conrad & Schneider, 1992). The medical model provides benefits for individuals with diagnosed diseases by offering accepted explanations that de-stigmatize personal problems and enable access to treatment (Broom & Woodward, 1996). As Parsons suggests, medical doctors continue to maintain an important role in assigning individuals to the sick role, thereby relieving these individuals of their social obligations—particularly the obligation to work. Psychology’s influence is simultaneously more subtle and more extensive. As it provides explanations as to how an individual is, thinks, feels, and acts, the effects of psychology are visible in everyday life. Statements such as “that was a traumatic experience” and “I am so stressed right now” represent interpretations of everyday experiences. While medical expertise guides political decisions on health and illness (as has been borne out during the COVID-19 pandemic), the influence of psychology is nevertheless more encompassing because psychology provides expertise on so many issues, including child development, relationships, and work and productivity. The influence of psychology in these various social problems has many benefits for the affected groups (e.g., children, families, employees) because members of these groups receive access to benefits and services. Moreover, psychology and other social professions often advocate for these groups, thereby bringing the groups’ needs both public and political attention. For instance, using the example of inquiries into institutional child abuse, Wright (2018, p. 189) revealed that a therapeutic framing can promote “processes of democratization in which people who have traditionally not had a public voice now have new avenues to assert claims for justice.”

Despite the myriad positive consequences of the increasing influence of medicine and psychology in modern societies, the early literature on medicalization and psychologization between the 1950s and 1970s began from a critical perspective. Since then, much of what has been written on medicalization and psychologization has been a critique of the idealistic view of medicine and psychology in society and of the low level self-reflection in both disciplines (e.g., Madsen, 2018; Szasz, 1960; Zola, 1975). Similar critiques have been levied against medicalization and psychologization. First, even if medicine and psychology can be considered to provide more “humane” ways of dealing with social problems, the processes still constitute forms of social control. For medicalization, in particular, the major concern has been the power that is given to the medical profession when diagnosing and making decisions about the pathological nature of human life. Processes of de-medicalization—as has been the case for homosexuality—have revealed that such diagnoses are strongly interwoven with social and ethical ideas. Even evidence-based medicine must be perceived as being socially constructed when the selection of research questions and research designs is guided by ideas such as specific concepts of gender. Moreover, because the role of medical doctors remains institutionally strongly tied to sickness (or to the lack thereof), medicalization is often associated with the pathologization of social phenomena. Thus, medicine usually includes a diagnosis and thus gives individuals the message that they are sick, which commonly results in the development of a (chronic) illness identity (Schneider, 2013). This implication of medicalization is related to the institutional configuration of the medical practice: Physicians in hospitals and private practices have a limited set of medical practices, which include diagnosing, deciding on a medical treatment, referring to a healthcare professional, and granting an individual sick leave. Thus, even if the source of a problem originates in a social context (e.g., work, an abusive relationship), medical doctors may use options such as pharmaceuticals or sick-leave certificates because they have no jurisdiction to intervene further.

The concept of social control is also important in relation to the rising influence of psychology. Psychologists are considered to represent a “new elite” who have a wide-ranging influence in society (Madsen, 2018). Their social control mechanism is based on technologies that rely on self-governance; thus, individuals control themselves through certain forms of thinking, techniques of emotional control, and so on. These technologies of the self—which are part of why psychology is perceived as helpful—can also have oppressive implications. While both medicine and psychology have been criticized for their tendency to individualize social problems, the assumption of psychology—namely, that individuals are responsible for finding solutions to their own problems by changing their own cognitions, emotions, and behavior—means that not only is the problem associated with the individual, but the responsibility for the problem is also attributed to them. Since the focus of psychology lies in competences, resources, and capabilities, such as resilience and self-efficacy, the field of psychology suggests that strengthening individuals’ resources and developing adequate coping mechanisms are key to solving problems. The concept of taking charge of one’s own problems, however, is more than a mere suggestion by psychologists. Instead, the concept has evolved into a moral imperative that is reproduced in popular culture and that has become institutionalized in organizations. For example, educational institutions are considered a suitable setting for psychological interventions, regardless as to whether a problem has already occurred (Ecclestone & Brunila, 2015; Ecclestone & Hayes, 2009). For instance, while children were expected to be God-fearing and well-behaved in nineteenth and early twentieth centuries (Nolan, 1998), they are now evaluated in terms of their emotional intelligence and character skills (Heckman & Kautz, 2013). Thus, not only is psychological therapy a targeted strategy for dealing with children who are considered to fall outside of the norm, but psychological assessments and techniques have also become part of the general curriculum. While these techniques are frequently considered meaningful or helpful, problems occur when they do not do the trick and particularly when individuals are unwilling or incapable of engaging with this way of thinking. Not living up to the expectation of taking charge of one’s own life or to the imperative of self-optimization leads to new problems for the self, such as feelings of guilt and social stigma. Moreover, in the context of social institutions and welfare programs, not accepting or complying with psychological strategies is often coupled with material consequences or coercive measures (Polsky, 2008). Since socially disadvantaged groups often find it more difficult to adopt this psychologized way of life, psychologization often reproduces existing inequalities (Friedli, 2016).

What unites both processes is that their general approach is focused on the individual, be it on the individual’s body, psyche, or both. The growing role played by medicine and psychology over time is therefore associated with attributing more and more problems and solutions to the individual. Thus, medicalization and psychologization have also been criticized for undermining the impetus for finding social and political solutions to problems (e.g., Zola, 1972; Conrad, 1975; Conrad & Schneider, 1992, for medicalization; Madsen & Brinkmann, 2016; de Vos, 2012, for psychologization).

[D]efining a condition as an illness and adopting a medical approach can have major social consequences and close off alternatives. While it is clear that in some instances medicalisation can lead to important gains for individuals, in others the issue becomes one of the individual and the task to treat what is judged as their pathology, depoliticising the problem and largely ignoring the wider social and institutional context of individuals’ physical and mental states and behaviour and the deficiencies of the society in which we live. (Busfield, 2017, p. 771)

As medicine and psychology become increasingly institutionalized, their practice contributes to a consolidation of existing power structures and social systems. The classical medical model remains primarily oriented around the old idea of the welfare state and acts as a gatekeeper to the benefits and services that are solitarily financed. However, reformed medical practice and psychologization align strongly with neoliberalism and with the social investment paradigm, both of which advocate for equality of opportunity and individual accountability. In the long run, this narrative can undermine support for both the political system and the welfare state. Indeed, according to Foster, “[t]he new form of managed freedom poses a threat to democratic self-organization through its evisceration of the notions of public welfare, collective responsibility and social solidarity” (Foster, 2016, p. 109).

In this chapter, we described medicalization and psychologization as two processes that have exerted growing influence in modern societies. These processes share many features, but they are also distinct and sometimes have subtle yet important differences. Their concepts, techniques, and expertise have been readily adopted and integrated by the welfare state in advanced, industrialized countries. In the following chapter, we describe in greater detail the important connection between the two processes and explain how they can be linked to theoretical ideas on the welfare state from the social policy literature.