First, so as to prepare one’s expectations accordingly: People often think, consciously or otherwise, that denying the validity of the theory of mental illness — that is: the dominant paradigm of psychiatry — is tantamount to denying the suffering of people who are called ‘mentally ill.’ Psychiatrists, of course, have both a personal and financial interest in ensuring that people respond to critiques of their discipline with this sort of emotional revulsion. I will attempt here to summarize the core of my problems with psychiatry, much of which is influenced by Thomas Szasz’s excellent critiques. It is crucial to recognize at the beginning of any conversation like this that Szasz never denies that people labeled as mentally ill are suffering (and certainly I don’t). He denies that they are ill. Illness causes suffering (or worse) — but not all suffering is a sign of illness, and if we are to effectively help people, it is imperative to know the difference, and to construct our social systems according to our understanding of those differences.
I would ask anyone reading this to keep an open mind: It is easy to ridicule the dogmas of the past, but all of those past dogmas held themselves up as the pinnacle of human understanding, too — it is the dogmas of the present that deserve the most intense scrutiny. I am convinced that sometime in the not-so-distant future, people will view psychiatry much like they do alchemy: as a precursor; a stepping-stone to real science. Neurology will and should eventually take over all legitimate (but poorly-understood) brain disorders that so happen to have been clustered under the ‘mental illness’ umbrella — just like Parkinson’s Disease and neurosyphilis in the past, real disorders like bipolar and schizophrenia(s) will eventually be treated by brain specialists, not psychiatrists.
What is distinctive about psychiatry, insofar as it claims to be a medical science rather than a humanistic endeavor? It is the only field of ‘medicine’ whose members vote in a central committee on whether or not a condition qualifies as a disorder. It is the only field of ‘medicine’ that purports to be able to ‘cure’ ‘diseases’ through the use of speech — ‘psychotherapy.’ (Can we heal the flu by learning to change our perspective?) It is the only field of ‘medicine’ in which the line between illness and health is a fundamentally political question: consider the status of sexual minorities in the history of psychiatry, including the status of transgendered people today — but, more broadly, consider that the ‘mentally ill’ person is frequently less disturbed by his own thoughts and behavior than by other people’s reactions to his thoughts and behavior — that is: by society’s unwillingness to understand his condition, and its unwillingness to accommodate his problems. We should absolutely help people fit in with society — including, possibly, through the use of humanistic counseling and mind-altering drugs — but that does not necessitate deeming them ‘ill.’ (A TV can be playing an unusual channel without being broken, after all.) Finally, psychiatry is the only field of ‘medicine’ whose professionals are legally permitted to forcibly commit someone who wants to be left alone. The standard here is that one must be ‘harmful to oneself or others’ to justify this kind of action. But a cancer victim who refuses chemotherapy is undoubtedly harming himself. Shall the police forcibly constrain himself and impose treatment on him?
Counseling (‘psychotherapy’) can be very helpful to people, as long as everyone involved respects each other’s boundaries, dignity, and agency. Moreover, free adults ought to be allowed to use any drug they want to relieve their suffering. But the fact that a drug has a positive effect is not evidence that it has ‘treated’ anything. If you buy ketamine from someone on the street to induce euphoria, you are called a ‘drug abuser’ participating in a ‘crime.’ If a Yale professor gives you ketamine to induce euphoria and calls it a ‘research study,’ then ketamine is a ‘medicine’ that ‘treats’ ‘depression.’ This is not ‘semantics’: it is the difference, as Szasz points out, between typhoid fever and ‘spring fever.’ If someone with ‘spring fever’ is given some amphetamine, he will no longer be listless, apathetic, or disconnected from society. Is this proof that ‘spring fever’ is a real illness one can ‘treat’ with ‘medicine’ called ‘Adderall’?
Let us consider ‘depression’ as an example. The arguments I am about to make are mine and not Szasz’s, though he would likely have agreed. Few people doubt that ‘depression’ is an ‘illness.’ Let us first consider, however, that the world is not simply objectively ‘there,’ waiting for us to correctly perceive it. The world, in fact, discloses itself in different ways to different people. (“Our temperament sets a price on every gift bestowed by fortune” says La Rochefoucauld) Some people are actually born with tendencies toward ‘hypomania’ — eager, active, confident, sociable, driven. Others are born with tendencies toward ‘depression’ — reluctant, passive, self-critical, isolated, apathetic. Both tendencies are foreign to most people; their center of gravity is somewhere in between these extremes. Is either class of people described above perceiving the world inaccurately? Is there not injustice as well as opportunity in the world? Is there not cruelty and fear as well as love and hope? Is there not disappointment as well as excitement? Is it a sign of ‘illness’ to fixate on one rather than the other? If someone is melancholic by nature, perhaps it would behoove them to explore perspectives that can mitigate the negative sides of this temperament — and perhaps it would even be to their benefit to take drugs, as those diagnosed as mentally ill are usually advised to do, to help take the edge off of those darker moments. Maybe this is the burden of a melancholic temperament. But where is the tangible evidence of ‘illness’? The empty theory of ‘chemical imbalance’ is finally losing favor among academics, but it is still heavily favored by advertisers (and the people). The notion of a ‘chemical imbalance’ implies that there is a ‘balance’ — which implies, as we have seen, that there is a particular ‘correct’ way of experiencing the world. What does a ‘chemical balance’ look like? How should we properly view the world? Szasz suggests that we will discover the ’cause’ of ‘mental illnesses’ like this at the same time we discover the chemical ’cause’ of being a Democrat, or being a Taoist. Psychiatry, in this sense, is part of a popular political trend toward homogenization and the blotting out of human differences that threaten to undermine the democratic-liberal-capitalist order.
No ‘anti-stigma’ campaign will work; psychiatrists’ insistence that they care about mitigating stigma is either naive or a facade. I am sure most psychiatrists care deeply about making sure most of their ‘patients’ are treated well — but stigma is an unavoidable byproduct of being a patient, an ‘ill’ person. Someone who is sick and in treatment is not ordinarily considered a full and able participant in society. It is impossible to erase the stigma attached to incomplete participation in society — there is a stigma attached to being on welfare, being disabled, being in treatment for a bodily disease, and being very old (or very young) for identical reasons. Why should we anticipate that society would allow for an objection in the case of the ‘mentally ill’? People, fortunately, are actually willing to accept and help others labeled ‘mentally ill’ — but we must state what their problems are in plain English, not in pseudo-medical jargon, in the hopes that the legitimacy usually accorded to real medicine will ‘rub off’ on psychiatry.
Ultimately, there is simply no coherent definition of ‘mental illness.’ There are bodily diseases, including diseases of the brain, and they are the concern of medical science — and there are humanistic concerns, problems in living. Psychiatry approaches problems in living (as well as a handful of real diseases) through the language of medical science. The results are about what we’d expect.
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