Mental Health and Social Norms

[This was from 2005.]

The death of Charles Socarides has brought to mind a regrettable tendency (one that often borders on tyranny) of the mental health profession. Socarides, if you don’t know, was one of the godfathers of the “homosexuality is a mental illness” school of thought. And (Providentially, in my opinion) one of his sons turned out to be not just gay but one of the leading gay rights activists of the 90s.

The “regrettable tendency” to which I refer is the (mis)use of the concept of “mental illness” to enforce moral or social norms. Back in Socarides’s day, it was the 1950s style social conservative morality which was “medicalized.” Today it’s PC. Previously, homosexuality and other behaviors which violated “traditional morality” were “mental illnesses.” Today “racism” and “homophobia” are mental illnesses (or at least, some folks within the profession seriously advance this notion). As Pete Townsend put it: “Meet the new boss, same as the old boss.”

This problem within psychiatry doesn’t lead me to the extreme position advanced by Thomas Szasz or Michel Foucault that “mental illness” doesn’t exist. Psychiatric disorders do exist, some of them rather minor (a moderate anxiety disorder), some of them deadly serious (severe depression, which often results in suicide). But we should realize that underlying mental disorders have (or ought to have) nothing, absolutely nothing to do with social norms. They are “health” problems, not “moral” problems and as such are socially neutral and more analogous to concepts like “race” and “gender.” Indeed, mental disorders are protected civil rights categories under the ADA and other related disabilities legislation. To say that someone has a “psychiatric disorder” is to say that their health is impaired in the same way that someone with high cholesterol or hypertension has their health impaired.

[One thinks of the recent hubub on Lincoln and homosexuality. Though historians strive mightily in their battles over whether Lincoln suffered from the “mental disorder” of homosexuality, no one seriously disputes that Lincoln suffered from the true mental disorder of bipolar. Likewise Thomas Jefferson most likely suffered from a physiatric disorder — depression, as did Madison, who, given that he was convinced he would die an early death (he actually lived into his 80s), most likely had an anxiety neurosis. These conditions don’t raise controversy because we properly regard them as socially neutral. Finding out that Madison had an anxiety disorder really ought to be no different than finding out he had male pattern baldness (which I don’t think he did; but who knows? they all wore wigs).]

Therefore, properly understood, categorizing something as a “mental disorder” cuts against the moral and social stigma of that condition, and cuts in favor of social neutrality and civil rights protection of the underlying “disorder.”

This isn’t to say that there is no intersection between behavior that results from “mental disorders” and behavior that is immoral or otherwise socially unacceptable. One thinks of conditions like kleptomania or alcoholism. But still, those who wish to maintain a social stigma on the underlying behavior of for instance, kleptomania (stealing) must do so with no reliance on such behavior resulting from a “psychiatric disorder.” Again, to rely on the mental health body of science to enforce your desired social norms is a fundamental misuse of the profession.

Even if tomorrow we discovered that kleptomania doesn’t really exist as a “mental disorder” that would not (or at least it shouldn’t) do one thing to “normalize” stealing if for no other reason than the vast majority of people who steal aren’t kleptomaniacs and had no “mental disorder” prompting them to steal to begin with. They are simply bad people who wanted to get something for nothing. Indeed, take a person with a moral conscience, who truly desires not to steal and does everything he can to pay for his items, but “just can’t help himself.” And then he feels terrible guilt after the act is done and seeks mental help. Such a person, in my opinion, is more moral than the lazy jerk who wants to get something for nothing. Thus, while the kleptomania doesn’t excuse the underlying stealing, it does indeed mitigate the behavior. Therefore, if kleptomania really doesn’t exist as a mental disorder, all the worse for thieves.

My personal opinion is that Frank Kameny and Barbara Gittings were on the right side of not just history, but science in helping to get homosexuality removed from the DSM. To hear the social right tell the story, homosexuality was “removed” for “political,” not sound medical reasons. But this gets it exactly backwards. Homosexuality was put on the DSM list for “political,” not sound medical reasons, and it took some political action to reverse that mistake.

If getting homosexuality removed from the list of “disorders” helped “normalize” it in a “social” or “moral” sense, then that’s only because the social right improperly relied on psychiatry for maintaining the social and moral stigma on homosexuality. As with kleptomania, if homosexual behavior were truly “wrong,” then removing homosexuality from the list of “disorders” would only make things all the worse for homosexuals.

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3 Responses to Mental Health and Social Norms

  1. The situation isn’t quite as simple as this, I don’t think. Szasz’ point of view can certainly be criticised for missing the obvious: that people in acute crisis or prolonged and severe distress simply cannot function as properly independent social, emotional, intellectual and financial agents. His work in Ideology and Insanity and so forth appears to elide this dimension of severe mental distress of all kinds.

    However, one way of supporting dimensions of his work whilst bringing to bear the difficulties that his work avoids is to introduce a distinction between brain-injuries, degenerative brain diseases and ‘functional’ distress/’illness’. Clearly many areas of brain injury and disease are already distinguished from ‘mental illness’ and usher forth brain specialists, which psychiatrists are not.

    They are not brain specialists since functional ‘mental illnesses’ are in effect highly complex and individualised adaptation obstacles, problems and/or avoidances. The larger majority of identified mental illnesses in 21st Century are better described using metaphors of bruising, cutting and strangling, of crashing, drowning and breaking than metaphors of ‘disease’ and ‘cure’.

    Most of us suffer from falling before a hurdle, and the fear of getting up; falling from a pedestal and fearing to show our face; running round in circles til we’re dizzy and exhausted and can’t remember why we began….. Not from catching a germ and running mad, or some spontaneous genetic bomb going off and triggering a lunacy, or leaving us sluggish and lifeless..

    Were the metaphors to catch up with experience and stay linked with experience then I think the ‘disease’ model of functional mental ‘illness’ would fall. In its place metaphors of breakage, splintering, bruising, collisions or ‘repetitive strain injury’ might usefully enter the picture – presumably physicians and OT’s might begin to elaborate a helpful set of metaphors that could indicate a possibly helpful treatment programme. To some, limited degree, tranquilisors, used in short to medium term in the overwhelming number of cases would continue to play a role for those who wish for or need them, just as pain killers are used for more the pain of more visceral injuries. Just as pain assists us to recognise we have a wound, however, pain also helps us to recognise an injury in our mind/heart that impacts on our social/personal mobility. Pain killers are for a space to think straight again, or to enable/optimise functioning not to replace healing.

    This is a simple suggestion, the change of a set of metaphors. I think that we can see that ‘functioning’ will remain to some extent a political football. There will always be those who make judgements upon others’ inclinations or habits or lifestyle and who will choose to regard these as ‘abnormal’, who could build a case for pathologising decisions that do not fit with their own values. How any of us can legislate against this happening I don’t know. It is still the case that if some people ‘hear voices’ others will have them labelled ‘mentally ill’ regardless of how ‘ill’ this experience does or does not otherwise make them. Undoubtedly we have ‘illnesses’ registered in the DSM etc that are quite as bizarre as the so recently removed ‘illness’ of homosexuality. We just happen to be so blind within our prejudices to date that we can’t identify them.

    Most importantly we cannot remove one item from DSM and assume that the framework is sound, just an error got in somehow. The entire framework is as unsound as the unsound error. Until we begin to recognise this we’re polishing up the sewer and calling it a palace.

  2. Pingback: Blast From the Past…(Psychiatry) « MissMiracle's space

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