The following is a rather long essay I wrote a while back. Although edited since then, it is imperfect. Nevertheless, upon reading it over more than six months after the fact, the vast majority struck me as substantially true. And my qualms with the rest were small enough as to warrant no immediate remedy. All in all, I think its length makes up for at least 2 months’ worth of missing posts…
The Definition of Disease
Psychiatry resides within the realm of medicine. Medical professionals try to make people healthy, which means the treatment of disease. Psychiatrists, by extension, treat the mental version of that, namely mental illness. How do we define disease; and how mental illness? I define disease as a biological entity foreign (in some sense) to the human body or to its homeostasis, which has these two common characteristics:
- A loss of functionality in the region affected, ie it is harmful
- A predictable course of events leading up to and including the loss of said functionality.
Thus, something like Ebola is a disease, as it causes loss of functionality (read: death) in something like 90 percent of those afflicted, and does so in a manner predictable by doctors who observe its consistent course through the human body.
As it is commonly used, mental illness encompasses a host of entities seen as various diseases, disorders, syndromes, all of which afflict the mental life of an individual in some detrimental way. It is inexact, indeed utterly incorrect, to lump such things together under the medical umbrella. Their only common characteristic is a similar pattern of behavior of varying severity. This is why schizophrenia, major depression, dementia, and bipolar disorder are lumped together with Asperger’s, attention-deficit hyperactivity disorder, habitual addiction, and bulimia. The former group are diseases of the brain, as they seem to affect the physical workings of the brain (its chemicals and so forth) and in so doing tyrannize human behavior. They are, more or less, diseases in the medical sense because they fit the criteria mentioned above: they impair biological functionality and do so in a predictable manner.
The latter are not diseases at all. It is clear that they impair functionality in varying degrees, but their diagnosis is subjective, their course variable, their outcome, should treatment be forsaken, is not known with any kind of certainty.
Medically, biologically the afflictions lumped together under the metaphorical term “mental illness” share nothing in common: some are diseases, some are not. What they have in common is social in nature and has been mentioned already, namely similar patterns of behavior. The one thing that the mentally ill have in common with each other is that their behavior is considered by Society to be, in one way or another, unacceptable. So we have declared the paranoia of the schizophrenic, the psychosis of the cocaine addict, the inactivity and suicidality of the majorly depressed, the manic energy of the bipolar, the eating habits of the bulimic, the defiance of the ODD, the dominating proclivities of the habitual addict to be against the accepted norms of our culture. Psychiatry, indeed, does not subscribe to cultural relativism. No, these patterns of behavior, many having nothing to do with medical disease in the least, are thought to be objectively bad, unhealthy, and by implication evil. The majority has deemed such deviant behavior to be in need of rectification. And the current trend is for the course of correction to fall under the direction of medicine. Unpopular behavior is therefore a sickness that must be cured.
That many of these activities are harmful to the doer is obvious. Endorsing suicidal thoughts might presage an end to the endorser’s life. We cannot predict the outcome. Nor do suicidal thoughts necessarily inhibit functionality. I myself “endorse passive suicidal ideations” from time to time. Huh, I wonder what it would be like to just veer into oncoming traffic… Yet somehow I manage to go to work, love my wife, and read voraciously. Such thoughts, in and of themselves, mean little, except that the mind is constantly bubbling with weird, sometimes uncomfortable, always unconscious activities that now and again rise to the surface of consciousness. That is part of being human, and not in and of itself indicative of anything harmful, unhealthy, or demonic.
That many of these activities are harmful to others, which is to say metaphorically contagious, is another matter all together. It will be dealt with elsewhere, but suffice it to say, most “deviants,” most mentally ill pose little actual threat to those around them. Their behavior makes others uncomfortable; that discomfort leads to fear; and that fear produces in the imagination of the many the impression of imminent danger. Forceful, even violent intervention is then seen as necessary.
Psychiatrists have, therefore, accepted for themselves a two-pronged role in society. On the one hand, they purport to treat illness, accepting, diagnosing, and attempting to treat things like schizophrenia or bipolar. On the other, they police social mores, deeming certain sets of social behaviors as deviant from an established, accepted, and sought after Norm, and thus in need of corrective action. Because they confuse their dual role, and indeed are oft ignorant of it, the very notion of what makes an acceptable psychiatric patient, let alone what constitutes effective treatment, has fallen under a cloak of mystery, mysticism even. Psychiatrists have taken on the role of priests–for better or worse.
The first thing we must establish, then, is what the psychiatrist ought to be doing with himself. It is my contention that he does little in the way of medical healing, but in fact spends most of his time policing deviant social behaviors that are not linked to biological disease. This is because brain disease, when rigorously diagnosed, is uncommon; whereas deviant social behavior can be found wherever the subjective eye decides to look.
Let us flesh out the biological, diagnostic difference between these two classes of ailments, one actual the other metaphoric. First let us examine the mental illnesses that are actual, biological diseases. For the sake of accuracy, I will refer to these as diseases of the brain, as in some fashion (often a mystery to us) the brain is afflicted in such a way as to produce extreme and antisocial behavior on the part of the patient. To my mind, these include the following (subject to amendment):
- Major Depression
All five of these diseases, once diagnosed, meet our two criteria for disease. They are states that are foreign to the body that:
- impair functionality and;
- do so in a way that is predictable on the part of the clinician.
Thus major depression saps the patient of all drive and energy, leaving them a motionless lump often afflicted with symptomatic thoughts of hopelessness, purposelessness, and suicide. Major depression is the result of some abnormality in the brain, and has nothing to do with the outside social or relational world of the patient. Hence, “bouts of depression” brought about by the death of a loved one, or some other trauma, have no place here. They come and go with or without medical intervention. Major depression, conversely, responds consistently to medical treatment, ie medication or ECT. It has a consistent course and thus responds predictably to intervention on the part of the practitioner.
Dementia is the most tragic of this list. Psychiatrists seem able to diagnose with relative consistency the onset of dementia, especially in the elderly. This is because the criteria for it are stringent and less susceptible to interpretation. This consistency is rendered moot, however, by the complete lack of effective medical interventions. Thus, while doctors can identify dementia, they can but watch its progress in passive silence.
Schizophrenia manifests itself, at the latest, in the early 20s of the patient, and produces within his mind a web of delusion, paranoia, and fantasy from which some recover, in which some remain, and into which some plummet further. It is too little understood to respond vigorously or consistently to treatment, but it is probably a brain disease, as evidenced by its seemingly consistent and accurate diagnosis. Such accuracy has fallen by the wayside of late, as parameters have gotten looser and looser. This is why when Thorazine was introduced fifty years ago, many schizophrenics who were treated with it were almost miraculously healed by it. Whereas now, far fewer people diagnosed “schizophrenic” respond strongly to treatment. The problem is, at least in part, one of mislabeling, miscategorizing, misdiagnosing.
Bipolar, what was once more accurately referred to as manic-depression, consists of alternating states of complete lethargy and dangerously high levels of energy. The pendulum of the mind swings with reckless abandon, impairing functionality and doing so in a predictable manner. It responds consistently to treatment when it is correctly diagnosed. Here again we run into serious diagnostic issues. Unobservant psychiatrists often see a similar pattern of behavior in someone who is simply energetic, sad, hopeless, angry, or temperamental; and in their haste to diagnose, overreach themselves, labeling someone bipolar when they are nothing of the sort. Here we have an instance of the danger of associating similar patterns of behavior with each other under the general term “mental illness,” as the diagnostic criteria become so vague as to fit almost any situation, should the prejudices of the psychiatrist deem it so.
Psychosis is thought to be the result of a chemical imbalance within the brain. We think this because psychotic symptoms consistently accompany heavy cocaine usage, and cocaine affects certain chemical balances in the brain. However that may be, psychosis sometimes has a predictable pathology and can respond to treatment. But here again, the problem of diagnosis rears its ugly head. And what one psychiatrist might term psychosis, another might diagnose as schizo-affective disorder. It seems clear that cocaine affects the chemical balance of the brain in some way, producing unreasonable and sometimes violent behavior. This pattern of behavior, however, is too easily confused with others to be consistently diagnosed. There is enough of a physical cause, however, for us to put psychosis on the list while at the same time reminding ourselves that it is an imperfect label. Indeed, the word psychotic is used to describe a great deal of behaviors, including paranoia, delusions, hallucinations, and violent, to us unreasonable aggression. This constellation is loose enough as to invite misnaming; so that what one astronomer might name Orion another might call Taurus. The illness is increasingly in the eye of the beholder–each starry grouping tied together by a different mythology.
As the list goes on, we can clearly see a decreasing level of diagnostic certainty. This is because psychiatrists diagnose based on behavioral patterns that share too much in common to be useful in many cases. The extreme ones, however, like the long term and seemingly random lethargy of major depression, are rare enough as to be consistently identified. That is something worth reiterating: brain disease is rare, and so are the extreme behaviors that accompany it.
We would do well to note that the issue of misdiagnosis is not a problem in psychiatry alone. Medical doctors fall prey to it not infrequently, as many diseases share common symptoms. One symptom check on WebMD makes that abundantly clear. We cannot, all of us, be afflicted with cancers alone! The difference is that while medical doctors can often verify the veracity of a given diagnosis, whether through means of tests like an MRI or via the success or failure of a given treatment, often times psychiatric patients are assigned a diagnosis without the possibility of change. Objective tests like those that are used to identify cancer hardly exist in the realm of psychiatry; at the same time, the failure of a given line of treatment rarely results in a different diagnosis. The only time that consistently happens is when a patient is seen by a different psychiatrist. Then the pattern of behavior is evaluated by a different set of subjective eyes, and a new (often arbitrary) label is assigned. Neither medicine proper nor psychiatry is perfectly consistent, but the latter’s consistency is so lacking as to call into question the whole diagnostic enterprise.
Psychiatrists and Psychologists
But let us leave these more or less medical diseases for the moment and focus upon psychiatry’s primary role, that of social police. This has been medicalized more and more over the past two centuries, resulting in a pitiful ignorance on the part of psychiatrists. They talk of medicine and disease, but they deal chiefly with problems of social organization. Most of what psychiatrists “treat” is not the extreme anti-social behavior of the brain diseased; no, it is the social misbehavior of the personality disordered.
What is personality disorder? Here, I define it exactly as its constituent parts dictate. Personality is that web of interests, skills, proclivities, temperaments, emotions, experiences, phobias, hopes, and beliefs that constitute the mental life of a person. If they dictate a person’s behavior in such a way that society sees them as consistently troublesome, then they can be said to have a disordered personality. In psychiatry as it is currently practiced, all kinds of ailments fall under personality disorder so defined; ADD, ODD, ADHD, habitual addiction, eating disorders, ASDs, the DSM 5 is dominated by such things, all of which share common patterns of behavior, habits of action, that are seen by those observing them to be a problem requiring a solution. In psychiatry, these are social problems addressed by medical solutions.
Personality disorder is an inability to function in society, not owing to biological factors alone (God only knows how biological mechanisms and the resultant pattern-maker/breaker we call the mind interact). This is generally manifested in an unreasonable obstinacy or inflexibility when confronted with something a person does not like. Alas, society is a continuing convergence of conflicting ideals and desires; men must be able to compromise if they are to live peaceably with their neighbors. What is needed, therefore, is something of a school of diplomacy. Compromise, after all, is the essence of effective diplomacy, as it is the essence of effective social involvement. Psychiatry does not provide this. Instead, it seeks to medicate the problem. It works under the false assumption that such medical, chemical, biological means are suitable answers to questions of a predominantly social, habitual nature.
The long misstep American psychiatry has taken over the last 60 years and five incarnations of the DSM is, more than anything else, a medicalization of these misbehaviors. Now, a difficulty emerges here wherein it can be justifiably argued that legitimate cases of ASD (Autism Spectrum Disorder), to name but one example, are legitimate ailments (read: diseases of the brain) requiring some sort of medical intervention. This I do not dispute. What I question is the diagnostic criteria used to label someone as afflicted by such a disorder. Remember, using patterns of behavior as your sole means of diagnosis is very problematic. Saying that a child has ASD simply because he has six (or is it seven, five, three?) of a list of behaviors is dangerously arbitrary and subjective, to the point where it loses all utility–the defining characteristic of any scientific endeavor. Notice that ASD contains within it so many behaviors, so many facets, and such loose boundaries as to void most of its practical value as a set of diagnostic criteria. And that is the solution we are after here, practicality. The problem is one of functionality.
It is likely, to my mind, that legitimate ASD is the manifestation of a disease we know nothing about, some ailment of the brain itself, that we are miscategorizing as something which it is not because of our ignorance. Please keep in mind, our knowledge of the human body is haphazard, incomplete, and grossly inadequate compared to our perception of that knowledge. Indeed, most of the great medical breakthroughs of the 20th century were happened upon by pure accident or coincidence. Need we rehash the miraculous discovery of penicillin? The hand of God, we might say, has had far more to do with our medical advances than the billions pumped into systematic research each year.
So, psychiatry has medicalized personality disorder, and in so doing inherited the optimism and then the arrogance of modern medicine. It has lumped together the sick-nonfunctioning with the unsick-nonfunctioning and so mangled the meaning of the word treatment as to fail to heal the sick or police the miscreant.
Let us resurrect and clarify a distinction, that of the psychiatrist and the psychologist. The psychiatrist’s domain is that of the brain and the diseases thereof. His therapy, his treatment is that of medicine, for he is trying to fix biological problems with biological solutions, realigning unbalanced chemicals with more chemicals, faulty electric signals with jolts of his own design, etc. Psychologists, on the other hand, would be those professionals who specialize in persons who, while not medically ill, have abnormal difficulty functioning within society. They help disordered personalities, those who are so inflexible that they fail to mix with the great globs of people around them.
So, let us leave the medical diseases of the brain with the psychiatrists, or whatever set of professionals best have the biological knowledge and expertise to identify, diagnose, and treat things like major depression; and cast our eyes upon those who we would have deal with personality disorders. There is, in fact, an imperfect precedent for the profession of psychology as I envision it, one that dates back to the early twentieth century.
Freud and Psychoanalysis
Freud founded the modern movement of psychoanalysis, its basic goal being the unearthing of the unconscious workings, motivations, desires of people such that they might better be able to live in society. He referred to personality disorder as neurosis; whilst brain disease he called psychosis. He never used his methods on the sick as I have defined them, and indeed pleaded with his disciples that psychoanalysis not become the handmaiden of psychiatry. Laymen, he said, could be psychoanalysts, if only they had the proper training. A medical degree was not necessary. He did make the mistake (in my hindsight) of describing neuroses as pathologies. We may smile at the metaphor and more accurately describe them as disorders, but he, as a neurologist, clung to the pseudo-medical nature of the anti-social behavior which he attempted to treat (read: correct).
At any rate, Freud saw before him behavioral patterns that cried out for correction. Their defect was their anti-sociality. The neurotic was narcissistic, selfish, destructive, childish, mean, vindictive, paranoid, incestuous, violent–in a word, they were nonfunctional with regards to society. He thought he discovered the source of their behaviors within their childhood development. The chief structure of Freudian childhood was the Oedipus Complex, whereby the child sees the mother as its source of protection and as the object of its affection; simultaneously, it sees the father as a source of love in his own right. The ensuing struggle within the infant has him first desirous of supplanting the father as the cohort of the mother, then of pleasing the father so as to gain his patriarchal love and ward off castration (the baby’s autoerotic tendencies being met with such parental reactions as “do that again and I’ll cut it off!”).
This abozzo is highly condensed and doubtless inaccurate, but the point is that Freud saw within a child a relatively regular series of developments viz-a-viz its relationship with its parents and the world at large. The infant’s sexual experiences and complexes subside with time, only to reappear later in life at the onset of puberty. This has to do with the advent of neuroses because of what Freud called repression, wherein a person’s regular journey through the vicissitudes of its Oedipus Complex is somehow abnormal, thus causing it psychological trauma which it then seeks to forget in the oblivion of time. In order to do so, it represses such memories away from the conscious gaze of its Ego (the self, consciousness). They are not removed, however, but continue to reside, albeit in an often mutilated form, within the child’s Id (the unconscious swirling of instincts and drives with which the Super-Ego (conscience) is in constant antagonism). Repression, therefore, is incomplete, and its imperfection manifests itself after puberty via the behavioral patterns Freud referred to as neuroses–the ineffective balancing of the overzealous desires of the Id with the unreasonable expectations of the Super-Ego. We here refer to this unbalanced inward battle as personality disorder.
Freud built an entire scheme upon the foundations of Oedipus and the importance of childhood development, and in so doing devised a method of treatment that he thought would be able to unearth the repressed trauma, throw the light of day upon it, and allow the neurotic to carry himself once more into the current of society. This he called the psychoanalytic method. The basic idea was to talk with the patient, get an intimate history of their lives, collect their most bizarre and nonsensical dreams; then, interpret that information using knowledge of the unconscious drives of human behavior. After that, the source of a given neurosis could be unearthed, like a slow archeological dig, then brought into the light of the present–where we are to hope the patient learns to cope with his new-found self-knowledge.
Above all else, I must commend Freud’s attempt to enter into a dialogue with his patients. Despite his mislabeling them as sick, he very much wanted to get to the bottom of their lives, as his theory of neurosis depended upon an in depth knowledge of his patient’s personal history. Hitherto, psychiatrists sought only to observe the “mentally ill” within the confines of an asylum or hospital. For perhaps the first time in modern history, someone actually sat down and systematically talked with people society had deemed insane. He seems to have quickly realized that his methods would not work on what I have referred to as the brain diseased. Conversations with a schizophrenic patient are not conducive to introspection, nor of slow and patient analysis. They are too explosive, too paranoid, too sick to dialogue with, at least on the Freudian model. Keep in mind, he sat with his patients for hours a week. These were long, drawn out, very thorough sessions. Keep in mind also that for a person to have a legitimate brain disease, the capacity for such long and engrossing conversations would surely be lacking. Here again, Freud did not treat sick people. He treated those with disordered personalities.
So, Freud is to be commended for his attempt at dialogue. We must also praise him for his understanding that what he was doing was helping civilization against the extreme narcissism of the individual. He recognized in his psychological theories a series of implications for the formation and maintenance of society and civilization which he elaborated upon late in his career. Of paramount importance here is the idea that:
- Civilization developed as a way for humans to combat nature.
- Individuals, when they are not united in this fight, strife against each other, as they both loath the work necessary to maintain society and cannot argue past one another’s passions.
- Civilization is thus in a constant battle against its own constituents, who are led more by their instincts than their reason. Hence the necessity of laws and governments.
The objective of psychoanalysis is therefore the defense of civilization against those especially asocial, selfish, and narcissistic minds by way of dialogue, self-discovery, and cathartic return to more social behavior. Anti-social behavior is thus policed into acceptable modes; and human community is in some small measure maintained.
This is important for our purposes because it is so unmedical in its objectives. Or rather, the two fields of medicine and psychoanalysis are as cousins. Both seek to maintain human civilization. Whereas medicine seeks to perpetuate and extend the trenches of humanity against nature, psychoanalysis seeks to correct the soldiers who go AWOL.
Psychoanalysis and American Psychiatry
Psychoanalysis, despite its nonmedical objective, was presented by its founder as a science, specifically a medical one. It is excusable, therefore, that American psychiatry latched onto it in the first half of the twentieth century. It is even excusable that in the latter half of that same century, with the advent of psychiatric drugs and different kinds of therapeutic techniques, medicine discarded any conscious adoption of psychoanalytic method but opted to continue the treatment of the neurotic under the umbrella term of “mental illness.”
American doctors did this because it was their belief that people with disordered personalities were sick in the same way as those with diseased brains. Their treatments, then, reflected this idea of behavioral pattern as sickness, and so entailed nursing measures, medications, hospitalizations, outpatient therapies, and insurance companies. It has been my experience, however, that such methods work so inconsistently as to call into question their efficacy.
Psychiatrists persist in their belief, despite the evidence all around them, that their methods work–if only the patient would listen to them, take their meds, live by the psychiatrist’s creed! No doubt there are occasions where the psychiatrist’s plea is justified, as when the schizophrenic patient does not take their medication for six months, becomes unhinged enough to maybe be a danger to himself or others, and ends up in the hospital once more. Most of the time, however, we are dealing with personality patients. Since they are not medically ill, medical intervention such as the psychiatrist wishes to impose upon them are ill suited to the problem at hand. And yet the psychiatrist persists…and meddles…and pleads…
What problems are we talking about when we talk about personality disorders? Look through the DSM 5 and take your pick. Kids who are obstinate in the face of authority, women who eat too little or too much, children who are anti-social in the extreme, men who rise to anger at seemingly little provocation, the lack of any reasonable attention span…all of these behaviors, and the patterns that surround them, fall under the purview of personality disorder. It is these things the psychoanalyst tried to treat; that the medical psychiatrist fails to treat; and that the psychologist must needs find a way to deal with.
An Historical Analogue to the Methods of American Psychiatry
Before we even try to grapple with an answer to the question “how do we deal with personality disorder?” I must stop and comment upon the certainty with which psychiatrists approach their patients. The faith they possess regarding the accuracy of their diagnoses–and the efficacy of their treatments–is simply astounding; indeed, it is inexplicable except when we compare it to the behavior of the religious. Faith, after all, is in part a persistence in a belief despite physical evidence to the contrary.
This smacks, in my mind, of the practices of the Catholic Inquisition. I do not wish to demonize the priests in charge of that endeavor, any more than I wish to do so with psychiatrists. We are, all of us, only human. I would like to point out, however, a few similarities between the inquisitors and American psychiatrists, between those who honestly defended a religious creed and those who claim scientific skepticism.
Both proceed from a position of certainty. The inquisitors approached their subjects with the notion that they had in their possession the Truth, divinely revealed and elaborated upon by a church, the organization of which was divinely ordained and sustained. It made sense, then, for them to take issue with those who by word or by deed went against established doctrine. To do so struck them as lunacy. If God knows all, and has bequeathed that knowledge to man in the form of the Bible, and established the Church as the human interpreter of that Truth, then how could a man go against their dogmas and still be considered in his right mind? Given a certain set of beliefs, the position of the inquisitor makes perfect sense.
In order to combat this tendency towards error, the Church established the Inquisition in various countries, the object of which was to collect testimony regarding potential heretics, assess the validity of such accusations, test them in court if they found the evidence substantial enough, and issue judgments and sentences to convicted heretics. In the English speaking world, the Inquisition in Spain is the most infamous; and apparently it was the most active and vigorous incarnation of that institution. In actuality, it was far less bloody than popular imagination has hitherto supposed. Nevertheless, as an institution it shares with American psychiatry the utter certainty that what is being done is infallibly correct.
For psychiatrists, too, approach their field from a position of certainty. This was excusable for the inquisitors of the middle ages, since they were acting within the confines of a religion. To do so under the auspices of modern science is grotesque in its dishonesty. Scientific inquiry is based on the presumption that we don’t know everything. Indeed, a hypothesis ought to be proffered only after observations have been made, not the other way around. Psychiatrists do not do this. When a patient enters the ward, they are assumed insane until proven otherwise. The hypothesis is asserted before observation is made. By the same token, psychiatrists show a remarkable inability to adjust their diagnoses in the face of new, often contradictory evidence. Related to this, they often cherry pick what the patient does or says to substantiate claims of mental illness. Examples in the notorious study entitled “Being Sane in Insane Places” abound. Several people with no psychiatric history got themselves admitted to seven different hospitals by lying about hearing “voices,” acted as normal and polite as they were able upon admission, and were, to a man, labeled as sick (most as schizophrenic). The seven were left to their own devices as to getting discharged. They had to convince the staff that they were stable enough to leave. The shortest stay was nine days, the longest fifty-five.
A good scientist seeks to disprove his hypothesis. A good theologian seeks to prove an axiom he already holds to be true. The one approaches his task with skepticism, the other with faith. They both use human reason, but from different starting points.
This certainty in psychiatric diagnosis bespeaks a faith that is not justified. This faith is most spectacularly apparent in the universal and unquestioning adoption, in the clinical setting at least, of the DSM and its various installments. Yes, it is prefaced by a brief caution to the user. It mumbles something about the vague idea of normalcy, the subjective nature of many of their diagnoses, etc. But these are as the whisper of the careful scholastic theologian against the roar of the lay preacher. Indeed, the DSM is treated as something of a Bible amongst many in the psychiatric field. Its verdicts are final. Certain. Divinely inspired. And billable to your insurance.
Around this faith has been erected, over the course of the last few decades, a system that is certain of its pronouncements, confident in its treatments, and eager to reap the financial rewards for another soul saved. Time after time I have seen patients beset with disordered personalities float in and out of the psych hospital at which I was employed. Again and again they came, heard the gospel, partook of the Eucharist (are not medications miraculous things?), and went on their way in a week or so, their stays covered by insurance that, often enough, was applied for at our hospital! Does that strike no one else as a conflict of interest?
This reeks of the ignorant simony that ran rampant (although not to the extent that later Protestants would like us to believe) among the clergy of the Catholic Church of the Renaissance. There were well meaning priests then, and there are well meaning psychiatrists now; but then as now an uncomfortable emphasis on money reigns. Hence the giving of money for the reduction of the sentence of purgation, and hence the readjustment of a patient’s medication so that their insurance company will continue to fund their stay.
There was a tendency within the Inquisition to think itself infallible. Hence the Inquisitors would never accuse themselves of error or heresy. In exactly the same way, modern American psychiatrists possess the same self-imposed infallibility. This is why the psychiatrist sees the behavior of the Other as sick, while his own problems are “understandable given the circumstances”; the patient is depressed and in need of medication; the doctor is sad and just needs some cheering up; the patient has an unfounded fear of the government; the doctor is rightly concerned about the overreach of the NSA.
Once he has made a decision, the psychiatrist rarely recants, especially if it goes against established psychiatric dogma. This is why a patient can be documented as not suicidal and then discharged; only to be readmitted twenty-four hours later for suicidality–and no one admits that they either made a mistake in discharging too early; or admitted a person who was not even “sick” in the first place. The possibility that the person’s suicidal thoughts (if actual) were the result not of illness but of social situation, that no medical intervention would change that situation, that she would be returned to that selfsame situation upon discharge never occurs to the psychiatrist. Why would it? Social components have little to do with medicine. And medicine is all the psychiatrist wants to talk about. He is a technician, and has little time for the subtleties other lives are possessed of.
Psychiatry pays lip service to such things via the labors of the social worker, but she works under the same medicinal chains as that of the therapist. Her advice, her aide, her often miraculous ability to find housing or what have you for the patients under her care are rendered moot by the simple fact that their social problems are buried under medical jargon, only to be unearthed once hospitalization has ended. Thus does the patient leave, look at the same shattered life she left, and return to the hospital once more. It is a vicious cycle that leads only to dependence on the part of the patient, dominance and contempt on the part of the medical staff.
This infallibility is especially dangerous with regards to psychiatry because it has the unintended consequence of dehumanizing the patients psychiatrists say they are trying to help. Everything they say is twisted, everything they do is documented, to provide evidence of their insanity. If a patient asserts he is not sick, it is a symptom of his illness and his “lack of insight.” If he refuses medication, he is “non-compliant with meds.” If he paces the halls, he is considered “anxious” or “paranoid.” Conversely, if he agrees that he is sick, then he gets to stay for treatment. If he comes back again and again, the staff suspect he is milking the system or a drug addict–and admit/treat him with an air of condescension. If he is too eager for his medicine, he is thought to be “med-seeking.” If he stays in his room, he is “isolative to self.” Literally everything he says or does is refracted through the psychiatrist’s infallible prejudice towards illness to be proof of some kind of disorder or sickness. Never does the legitimate possibility of health ever come up. What other kind of doctor brooks so vigorously towards nay saying?
The inquisitor found heresy practically wherever he looked. The Spanish found every recently converted Jew suspect; other inquisitions found multitudes of heretics, witches, and the simply misguided. It should be noted that few were killed, more imprisoned, some made to endure years of monastic life, and some freed entirely. Many inquisitors were judicious, careful, pious. Many were corrupt or careless. None doubted that heretics were a very real threat. Outside of the Spanish Inquisition, few doubted that witches were numerous (and even the Inquisition in Spain did not doubt the existence of witches). Looking back, it seems clear that many supposed heretics were the victims of observation bias, extortion, or betrayal at the hands of a neighbor. In the same way, psychiatrists, in their infallibility, find sickness wherever they look. Everyone is compulsive, addicted, bipolar, possessed of a deficient attention span, suffering from the stress of trauma after the fact…And men, then as now, are understandably susceptible to the allure of money, to the temptation to lock an enemy up where they will not soon be let out.
How We Might Proceed
Let us tie together some of these divergent strings and then proceed on to what might be done by way of remedy or alternative. I have tried to show that:
Disease, in its medical context, is an ailment foreign to the natural state of the human body, either in the form of an alien organism or in that of an alien configuration of the human body itself; and that it must meet the following two criteria:
it must disrupt the functionality of the human body in some way;
it must possess a predictable pathology or course of events.
Mental illness is a metaphor turned illusion. It seeks to couple together medical diseases that affect the brain with disorders in a person’s personality–the web of beliefs, proclivities, passions, and the like that make up one’s mental life.
The former are the result of a biological system thrown into turmoil by other biological forces; and, with varying degrees of success and consistency, are treatable by medical means, usually, but not always, in the form of psychiatric drugs. They are properly called brain diseases and are the purview of the doctor or psychiatrist.
Diagnosis is not perfect. Medical diseases, however, have these two defenses against misdiagnosis:
Objective tests to determine the biological dysfunction (which with regards to brain diseases is still in its infancy);
Submission to the outcome of a given treatment as the final arbiter of the accuracy of a diagnosis.
The latter are the result of a bio-social organism’s inability to interact functionally with the society in which it resides. Such disordered personalities are so inflexible in their desires as to be unable to get along with those around them. They cannot compromise. They are as the obstinent Hitler compared to the diplomatic Metternich. Such disorders, whatever their nomenclature, are the domain of the psychologist.
Freud referred to personality disorder as neurosis. He looked to childhood development for its cause, and thought he found it within the interruption of its normal course of sexual growth.
He made the mistake of calling neurotics ill, but tried to treat them through dialogue, such that he might help them to uncover their repressed traumas and correct their deviated course of development; the end result hopefully being a degree of reintegration into a society threatened by the dysfunctional selfishness of the neurotic’s pattern of behavior.
Despite Freud’s arguments to the contrary, psychoanalysis became the handmaiden of psychiatry in America.
With the advent of antipsychotic drugs, psychoanalysis fell into disuse; but American psychiatry continued to treat the neurotic (personality disordered) as well as the psychotic (brain diseased). It kept the medical outlook that was Freud’s chief error, whilst discarding the dialogue he used as his means of treatment in favor of more medical avenues of treatment.
American psychiatry has persisted in this medical treatment of personality disorder in spite of the inconsistent results of their treatment methods, meaning medication does not treat personality disorder. It is not a chemical problem. It is a social one.
This lack of efficacy bespeaks a level of certainty unbecoming of a scientific effort but uncomfortably like that of religious faith.
Indeed, there are disturbing similarities between American psychiatry and the Inquisition of the Catholic Church. They are:
Axiomatic certainty, the idea that an assertion is made and then proof found. This is the opposite of the scientific method.
Faith in the unassailable assertions of the psychiatrist and his staff, evinced chiefly by the use of the DSM as the Bible of psychiatry–as an unquestioned and seemingly divinely inspired document of Truth.
The uncomfortable emphasis on money found both in the Catholic Church of the Renaissance and in the American psychiatry of today.
The infallibility of both the inquisitors on the one hand, and the psychiatrist and his staff on the other. The accusation of the heretic and the diagnosis of the mentally ill both evince a domination of an Other and a complete lack of introspection, restraint, or humility on the part of the Institution.
Having reiterated all that, what is psychiatry left to do? Let me preface these remarks with an admonition for skepticism and debate. I do not pretend to divine revelation, either explicitly in thought or implicitly in action. My reflections are only those of someone who has experienced American psychiatry within the confines of a single hospital over but two years and five months, and who has read perhaps ten books directly concerning the topics currently under discussion. Let this not be the final word on the matter; let thought be stimulated and discussion provoked.
First, psychiatry must discard the medical pretense. Let physicians treat the diseases of the brain, major depression, dementia, bipolar, and the like. Too often patients are admitted to the ward with physical ailments that affect their behavior: urinary tract infections, unbalanced electrolytes, brain tumors, syphilis, etc. These are or by right ought to be the realm of the physician.
Second, the psychiatrist must embrace his role as a social policeman, of psychologist. He must admit that the personality disorders he is desirous of treating are not diseases as such, but only by way of metaphor, that they are patterns of behavior society has deemed unacceptable and in need of correction.
Note: I am suspicious that psychiatrists would necessarily make good psychologists. Freud’s admonition that medical licenses are not necessary for psychotherapy rings true in my ear. Doctors are technicians. Everything is or ought to be cut and dry with them (sometimes literally). Psychologists, however, are dealing with human personality, which is irritatingly and beautifully subject to individual differences and contextual variation; it seems to defy the natural laws of development we seek to impose upon it.. Even Freud had to entertain the notion, as his career twilighted, that the Oedipus Complex was not the only mode of development for a child’s sexuality. Let us make use of scientific skepticism and methodology whilst at the same time forgoing the construction of objective laws of behavior. Society is too flowing to be confined within the iron grids of Science. Let it run its course within the arbors of Art. Let the psychologist be more artist than scientist, being flexible, personable, and empathetic. He is the subjective studying subjectivity itself. He must never forget that.
Third, he must follow the spirit of Freud, if not the letter. His single greatest contribution to the normal’s interaction with the abnormal was the initiation of consensual dialogue. We might disagree with the theory of mind underpinning psychoanalysis, but surely there is something to be said for talking with those we seek to help! (In the study “Being Sane in Insane Places” the average length of time a psychiatrist spent talking with his patients was recorded as mere minutes per day. That was in the 1970s. The hospital wherein I worked was no improvement.)
Fourth, having established the object of our endeavor, and something of a rough means, it remains for us to determine the desired end goal of our New Psychology. In simple terms, we desire to turn disorder into order, dysfunction into function. Personality disorder is an inability to function in society, not owing to biological factors alone. This is generally manifested in an unreasonable obstinacy or inflexibility when confronted with something a person does not like. Alas, society is a continued convergence of conflicting ideals and desires; men must be able to compromise if they are to live peaceably with their neighbors. Psychology, therefore, is something of a school of diplomacy. Compromise, after all, is the essence of effective diplomacy, as it is the essence of effective social involvement.
Fifth, we must do away with the current criteria for involuntary commitment. Currently, at least in Pennsylvania, a person can be incarcerated in a mental hospital if:
- They have recently tried to commit suicide.
- They are a credible danger to themselves or others.
- They are unable to care for themselves such that death might ensue within the next 30 days if commitment is not carried out.
These criteria are too broad, and lead to the destruction of individual liberty. Yes, we are trying to serve the public good; but the spiritedness, skepticism, and self-criticism that comes from individualism seems worth the effort to balance against the needs of the collective. Sometimes private vices does equal public virtue.
Again, Freud provides an alternative. A paramount law of psychoanalysis, at least as Freud practiced it, was the voluntary nature of the therapy. A serious problem with incarcerating neurotic people is that, really for no justifiable reason, they are having their rights trampled. To my mind, the only justifiable cause for involuntary commitment is the clear and present danger one man posses to his fellows, not some nebulous notion of the imagination where no hard proof is forthcoming.
A Criminal Digression
This brings us to a subject that has been simmering under the surface of our discussion of personality disorder: criminality. Recall that Freud understood the laws of society to be one part of its protection against the extreme narcissism of the individual. This makes a great deal of sense to me. I, however, have perhaps something of a different political outlook than did Freud, being an American (he loathed America). To my mind, one is breaking the spirit of American law when he tramples upon the rights of others. What are our rights? In the broadest of terms, life, liberty, and the pursuit of happiness. Let the lawyers determine the specifics. Should an individual strip you of one of them, intervention on the part of the majority (read: the government, the majority in action) becomes necessary.
What does this have to do with psychology as we have so defined it? Such behavior, like murder, rape, censorship, things of that nature, I define as criminal, as they break the spirit of the law. This kind of criminality requires the action of the policing arm of the legal system. I said earlier that psychologists are something of a social police force. They deal with neurotic behavior, disordered personalities, inflexibly dysfunctional members of the community. One has a right to ask if that includes criminals. After all, such unlawful behavior fits the bill of asociality. Things like murder are so zealously selfish, narcissistic, and anti-social as to warrant psychological intervention, no?
This, however, brings up another issue (will this never end?), namely the objective of the prison system. Take a look even at the names we use in the prison system: departments of correction, correctional officers, penitentiaries, detention centers, penal system–notice anything strange about them? Their meanings are all different, even contradictory. Are our prisons meant to be places of correction, whatever that might mean? Are they places where offenders do penance, to whomever we might say penance is owed? Are they places where the criminal are separated from society, confined for the protection of the majority? Or are they merely places of punishment, to where the crime is justly fitted? We must needs ask ourselves what we are trying to accomplish with our philosophically justified and practically necessary incarcerations before we can find a fitting place for the psychologist. Perhaps he might aid in correction. Perhaps he might guide penance. Perhaps he might make the punishment meaningful for the punished. We cannot know, because we do not know what prisons are really for, beyond separating a deviant minority from an offended majority.
Still, if behavior is anti-social to the point of infringing upon another’s rights, separation from the community would seem to be necessary. If such behavior is the result of a chemical imbalance, then the individual would need to be locked in a psychiatric ward for treatment. If it be the result of a narcissistic, what we might call sociopathic personality type, then the individual would belong in jail. For the most part, it has been my observation that those with disordered personalities do not behave criminally. They may break the letter of the law and incur the wrath of the injustice system, but they hardly infringe on the rights of others, thus leaving the spirit of the law intact. There are those who do break the spirit of the law, and perhaps they are more numerous than I imagine them to be. That would make some sense, as inflexibility often has violence as its only recourse.
The objective of the psychologist might, then, be two-fold. Outside prison, he would voluntarily dialogue with those people who seek out his help, who want to get along better in society. Within prisons, he might serve a similar, albeit state-mandated function. This latter scenario strikes me as difficult, however, since the criminal is hardly likely to trust someone assigned to “coach” him into a lifestyle he has little willingness to adopt. Again, though, until we as a society decide what, exactly, our prison systems are for, until we repeal those laws which serve only the moralizing, meddling impulses of the few rather than protecting the rights of the many, the psychologist might better spend his time outside the gridiron.
A Return to Reformation
Back to involuntary commitment: the criteria is only that of harm, not harm to the self (which falls under a man’s right to do what he pleases with himself without infringing upon others), but only the harm of others. Does this include the potential for harm, or actual violence alone? Is actual violence on the part of the majority ever necessary in the face of potential violence on the part of the individual? Remember, incarceration is a violation by the majority of the individual’s rights. To do such a thing requires stringent trammels, lest abuse run rampant. Let us, then, remain cautious, even to the point of allowing harm to come to some.
We can only justify action if an individual has committed a crime. Potentiality is not enough, as all of us have that potential within us. Thus, even those with diseased brains ought not to be forcibly hospitalized–imprisoned, if we are being honest–unless they have done violence to others. Without actual violence, the only way a schizophrenic or majorly depressed individual would be able to receive treatment is as the vast majority of diseased persons: voluntarily. The actual violence of the schizophrenic is like a car accident where both parties are injured. In the former case, one individual does violence, is incarcerated, identified as sick, and treated against his will but to the best of our abilities. In the latter, two parties come together violently, are rushed to the hospital (if they are in critical condition they are unable to give consent for treatment), where they are healed as best as can be. The point is that under extreme conditions, like when a person is not physically able to give their consent, even medicine treats involuntarily. Here again, the emphasis is on extremes. Medicine only treats involuntarily those in a condition too critical to say otherwise. By the same token, the branch of medicine we call psychiatry (that treats diseased brains) can only treat involuntarily those who are at the extremity of illness, meaning their diseased brains have caused them to act in such a way as to infringe upon the basic rights of a fellow citizen.
Sixth, let us curtail the meddling impulse. The goal of psychology is to defend society against the asocial, specifically by helping such people as have disordered personalities to live independently but in an integrated manner within our civilization. To that end, we must be willing to talk and listen and on occasion advise those who seek our council; but at the same time, we must caution ourselves against living vicariously through others. Psychologists are human too, and like all men are better at giving advice than taking it. We would do well to remember our fallibility in the face of neurotics who so obviously would live better lives if only they would take our advice. In the long run, it does the client better if we dialogue with them and allow them to take an active part in the discovery of solutions, rather than simply play the part of the passive listener. Let them enrage us with a dissenting opinion, force us to bolster or reconsider our point, and we will find that both parties come out stronger for the effort.
A Final, Personal Digression
I have said that personality disorder is characterized as inflexibility, by an inability to live effectively within the confines of society. Besides criminality, which is perhaps the extreme end of that concept, is there not another difficulty that I have yet to address? Namely, how useful is this label, this category? It certainly should not be used as a diagnosis. People are not neurotic or psychotic merely, with perhaps those on the fence referred to as “borderlines” thrown in for good measure. Behavior is not split nicely between abnormal unreasonableness due to biological illness or abnormal inflexibility due to mental illness. As I have tried to show, such inflexibility that has a social origin merely is not a sickness, does not brook diagnosis, and requires the mending of dysfunctional interpersonal relationships, not medical intervention. Such problems in living, such dysfunctional relationships, are not abnormal. People spend their whole lives grappling with relationships that are far from ideal. We get the impression that the majority have adapted in such a way as to make do with these imperfect relationships. Some, however, seem unable to get along with others in a functional way. They are constantly involved with the police, the lawyer, the judge, or (God help them) the psychiatrist. These are the people whose personalities might be accurately described as disordered, who would benefit from voluntarily walking into the office of the psychologist, learning habits with which they might make their relations to the rest of the world more sociable, and in so doing lead, at the very least, more tranquil lives.
I have tried to use the term to differentiate that great mass of people that are unsick from those few that are, but who are one and all treated or mistreated within the confines of medical psychiatry. It has been my experience that a large portion of these myriad unsick have the same problems that many of us have–problems in living, meaning poor interpersonal relationships. Others wrestle with issues resulting from their perceived or actual minority status within society, things like addiction, sexual queerness, or poverty. Society puts them down for their troubles and they happen upon psychiatry as a means of help or escape (it’s hard for problems to bother you when you’re high on Seraquil). Many of them deal with trauma, but that is nothing special. Humans all must cope, must grapple with traumatic events, starting with being born. It is my earnest hope that the patient, detached (not objective) dialogue had between psychologist and client, when done in an atmosphere of consent and mutual respect, might yield for these normally (not abnormally) troubled souls a bit of perspective, advice, maybe even the possibility of self-improvement.
Seventh, we would do well to keep, if not an open mind, then at least one with a reasonable immigration policy. Having dragged psychiatry from its scholastic undeath, and having separated it into medical psychiatry and personal psychology, let it not fall back into the cobwebs of complacency and dogma.