THE FUNCTION OF THE THERAPEUTIC STATE
"Just as oncologists often become numb to death, so do psychiatrists tend to grow insensitive to the everyday exercise of what is, after all, an incredible degree of social power." - Dr. Neil Scheurich, Psychiatric Times, January 1997.
"It is not by confining one's neighbor that one is convinced of one's own sanity." - Fyodor Dostoevsky, Diary of a Writer, quoted in the Preface to Michel Foucault's Madness and Civilization
I am convinced that the current Therapeutic State serves a function that complements, and in many cases perpetuates or enforces, cultural norms, acceptable social behavior, and, most importantly, economically expedient values such as efficiency, productivity, profitability, and consumerism. Dr. Albert K. Cohen of the University of Connecticut commented that "so much behavior that was once regarded as vicious, depraved, or criminal is now widely regarded as a manifestation or symptom of an illness. Indeed, this trend is one of the major cultural movements of the past 50 years or so, but it has been only meagerly documented and its determinants scarcely investigated." The assertion made herein is one that is met with skepticism (as should be expected of any theory that challenges the interests of power) and is usually abandoned since the few who have claimed it as truth have not been able to provide viable solutions to the problems illuminated. Even more than this, however, the history of the changing nature of what constitutes "mental disorder" reveals that mental illness, like gender identity or economic situation, is a social construct - it is a product of socioeconomic forces that are circumstantial, that are rooted in the politico-economic system that society adopts or has inflicted upon it, and are the result, however far down the line, of a minority of powerful individuals exercising decision-making power in a manner that benefits their own class.
Modern psychiatric practice has its roots in the Enlightenment, in the works of people such as French health reformer Philippe Pinel. Pinel is famous for his insistence in treating the mentally ill according to what were, for his time, much-improved humanitarian standards. (He did, however, employ the dubious technique of the "surprise ice bath" to teach patients how to act the "right" way.) Upon reviewing a ward of confined mental "patients" and observing their eccentric behavior, a colleague was reputed to have asked him, "Now, citizen, are you mad yourself to seek to unchain such beasts?" To this Pinel gave his succinct reply: "Citizen, I am convinced that these madmen are so intractable only because they have been deprived of air and liberty." Beyond merely questioning the effectiveness of treatment, therefore, Pinel did something greater: he called into examination the entire dynamics of power that enable and allow one segment of the population to effectively label another segment as being "mad" and thus deserving of an existence usually reserved for violent criminals. But it was also more than this: Why, of all particular available solutions, was a dimension of confinement, enclosure, entrapment, and surveillance chosen as a fitting consequence for those whose behavior qualified them as "madmen"?
Too many questions appear that cannot easily be answered, even today. The contemporary practice of mental hospitals establishing hierarchies, daytime routines, and otherwise enacting strict bodies of rules that must be obeyed if one is to be considered "getting better" calls into question whether or not psychiatrists believe themselves when they increasingly say that mental disorders are products of chemical imbalances in the brain (or of other neurophysiological factors). If an illness of the mind should be regarded as being no different than an illness of any other bodily organ, then why does the "care" of the mind necessitate a sort of well-meaning fascism as a means of curing it, as in the case of institutionalization? If someone undergoes a failure of the liver, for example, and is hospitalized, are they expected to comply to the same sorts of routines and behaviorally-minded authority structures that mental patients are? In recent times more and more physicians have placed emphasis on the biological and genetic roots of mental disease. Placing emphasis on this aspect of mental affliction could very well serve to de-stigmatize the patients that these same physicians diagnose. But if it is truly believed that the causes of these patients' maladies are inherent in biological make-up and are not of the patients' choosing, then treating the patient as if s/he were a child who must learn to overcome, through systems of reward and punishment, their "sick" mental processes, makes no sense. It makes no sense in the same way that it would make no sense for a doctor to take away hospital cafeteria privileges to a cardiac patient who had recurring heart attacks. It seems to be the case that mental institutions increasingly profess outwardly that the source of mental disease is biological, yet inwardly, behind the closed doors of the hospital, patients are still treated as if this were not true. And because patients are treated this way, the stigma of the mentally ill never disappears entirely - they are continually associated with the criminal, whose behavior also lends him to confinement, enclosure, and entrapment. Indeed, the fact that there exist separate hospitals for the treatment of mental disorders seems to reinforce the fact that, despite the rhetoric, mental illness is really not the same as medical illness. If the spokesmen and experts in the field of mental illness say one thing but act in another fashion, then people will learn to mimic what they are told while still intuiting - from the structure of the Therapeutic State - that the mentally ill really are in need of being confined and regimented.
The Futile Science
The science of psychiatry, as it exists now, is futile. Its form is altogether dependent upon the stability of the social and economic norms within which psychiatric diagnosticians operate. Because social norms, morals, and folkways are never stable, however, there can never be any consistent diagnosis or criteria for mental illness. Psychological "diseases" vanish and re-appear on the horizon of science as social standards of acceptable behavior fluctuate. This was essentially admitted when, in 1950, a psychiatric organization issued a report to the government stating that in legal "statutes the use of technical psychiatric terms should be avoided whenever possible. Psychiatric knowledge and terminology are in a state of flux. Once having become a part of public law such a term attains a fixity unresponsive to newer scientific knowledge and application." Thus, someone is either a genius or is delusional, is either a quaint hermit or has avoidant personality disorder, is schizophrenic or is a mystic shaman, is quirky or is insane, depending upon the time, place, and economic class within which the subject happens to find himself.
Much of the public is given the impression that psychiatry progresses in linear fashion - that the science was discovered in the nineteenth century and has since held within its ranks practitioners hard at work finding cures for age-old mental afflictions. We are given the impression that cures for things like depression or anxiety are just around the corner; we think of psychiatrists closing in on mental disorders with each successive experiment, the way police officers narrow the distance between themselves and a car full of criminals in a chase. But this perspective on mental disorders is incorrect. Instead, mental afflictions are never really cured once and for all the way some diseases, such as smallpox, are. Rather, they pop in and out of psychiatric manuals as the cultural climate allows for certain behaviors or places taboos on others. In fact, it is because of this that the Therapeutic State remains a fairly lucrative place within which to pursue a career. Unlike conventional medicine, which can point to concrete causes of illness in petri dishes or in microscopic slides of virii, mental health professionals can only point to much more nebulous things such as social behavior or modes of thinking. And because of this, virtually anything is available for some entrepreneur to invent a cure for, as long as the public will buy it. What the public will buy and accept, however, are things that do not cure what is supposed to be "normal" or "reasonable" behavior - things that are, again, defined in large part by the Therapeutic State. While conventional medicine can recognize a disease, find the source of it, neutralize it, and move on, psychiatry is not so simple: what constitutes a "mental illness" is malleable and can be influenced by economic or authoritarian factors. Disorders can be manufactured if there may be a lucrative market for a cure, and other behaviors can be labeled as being abnormal if they conflict with these goals.
The Therapeutic State is not, however, the sole judge of what constitutes normalcy or abnormality. Rather, the composition and purpose of the Therapeutic State reflects the interests of those who have power over a nation's economy and polity; it serves to medicalize or psychologize those elements in the greater society that conflict with the agenda of the powerful. By rehabilitating behaviors that do not lend themselves to the use of the wealthier class, it is hoped that mental patients will become productive members of society. By eliminating behaviors that are not conducive to the production of profit - by labeling these behaviors as disorders or diseases - it is hoped that such behaviors can be rid of and that conformist workers can be made of as many as is possible. For example, addictions to drugs that adversely affect one's workplace or occupational performance are rehabilitated and "cured"; however, the usage of drugs - such as caffeine - that help one adapt to workplace demands is taken as normal behavior. In the economic system in which the Therapeutic State exists, it will label as deviant those behaviors that are not congruent with the values the economic system reflects. So, for example, in a State-subsidized capitalist economy such as our own, behaviors such as the stealing of property, unwillingness to work at a wage-paying job, and an aversion to respecting others' authority can be diagnosed as "sociopathy." In another form of economy, however, these same behaviors may not be signs of a mental disorder. In fact, in a purely Socialist economy in which there is no private property, the desire to hoard or fence off resources might be considered sociopathic, whereas in modern day America such behavior is considered to be the key to financial success. In either instance, the Therapeutic State helps the powerful categorize and rehabilitate those behaviors that do not mesh with the attitudes of people who help maintain the system that the elite have done well by. The latter group of people - those who do not exhibit behaviors that cannot be integrated profitably into the economy - are more often than not the "sane" ones, while those who behave in ways that are not profitable for the ruling class are the ones with the disorders.
Cases in Point
In 1959, Louisiana governor Earl Long was confined to a mental institution after he was found to be suffering from a mental disorder that rendered him in need of supervised rehabilitation. Under the auspices of "political imprisonment" (the governor did indeed feel himself to be a prisoner of conscience), he was able to exercise his gubernatorial powers to cause the hospital superintendent to be fired. The superintendent was replaced with one that was appointed by Governor Long himself. Under the new superintendent's authority, the governor was immediately discharged and his diagnosis was stricken. After leaving the hospital, the governor returned to the capitol where he resumed his duties as the state's leading politician. Governor Long claimed to be the victim of a political conspiracy - a claim that in itself could be taken as further evidence of a delusional mind. Afterwards, The Washington Post commented on this dramatic affair: "It may, of course, be true that Earl Long has been the real victim of an almost macabre plot and, to use his own words, that he has 'never been insane a second of my life.' If so, there should be some ... better law to protect sane governors. And if not, there must be some better way ... to protect the public welfare in a state of three million people."
The case brings up a few interesting questions, most notably ones that relate to how authority interrelates with mental diagnosis and subsequent confinement. Could it be that, in this case, the Therapeutic State was really the pawn in a political war, used by the enemies of Governor Long to do away with him? Or could it be that the governor really was in need of treatment of some form, but that Governor Long's exercise of power - in the form of effectively firing an insubordinate doctor - served to remind the Therapeutic State that figures of authority such as himself are not the ones that mental health specialists have a duty to "rehabilitate"? Indeed, the very fact that someone holds a position of power such as that of statesman often exonerates them from the danger of being diagnosed as having a disorder serious enough to merit institutionalization. Facts of unemployment, poverty, tendency to illegal activities, and a failure to honor "financial obligations" are often seen as indicative of severe mental illness, the diagnosis of which increasingly places importance on "impairment in occupational activities." Someone who is apparently successful (in the material sense) will often, by virtue of his worldly status, escape the scrutinizing eye of the mental health field.
In the 1980s, Robert Freedman was apprehended by police for begging for dimes in front of a Chicago bus stop. Freedman urged the police not to arrest him, claiming that he did not realize that street begging was illegal. Police were baffled when they found $24, 098 in small bills on him. The judge who saw the case suspected him of having a mental disorder: "From the evidence, I decided that the man lacked good judgment. If he didn't have the $24,000 my interpretation of his judgment would have been different." Freedman was therefore committed, involuntarily, to a mental institution. Although he did, in fact, legally own the large amount of money he had, his illogical behavior (begging) was taken as a symptom of madness. While institutionalized, hospital fees and other medical expenses quickly ate away at the $24, 098 he possessed; although he had been forcibly hospitalized, he was also liable for paying for his own "care." "The courts even ordered him to pay the fees for the lawyer who argued for his commitment," a paper stated. Freedman was locked up in the mental institution for three months, drained daily by costs he was legally responsible for, when suddenly he died. Responding to public outrage over the events that had transpired, the judge who had ordered his confinement said that part of his motivation for confining Freedman was a concern for his safety: he was "protecting Freedman from possible bodily harm by thugs who might be after the cash he carried." For someone to be accosted and mugged by street thugs is one thing; for a man to be committed for improperly acting poor and then be mugged by the daily fees of the Therapeutic State is quite another.
Thomas S. Szasz, a dissident psychologist who became well known for critiquing what he saw to be the illegitimate power that psychiatry has assumed over society, stated bluntly that "there are two basic ways in which a person can be deprived of liberty in the United States. One is by breaking the criminal law; if someone does that, he may get locked up in prison. The other is by breaking the mental hygiene law; if someone does that, he may get locked up in a mental hospital." Szasz's works are mostly concerned with unjust confinement of individuals that have broken no criminal laws. Even today, it is improper to commit someone against their will unless they not only are suspected of having a mental illness, but also are assumed to be "a danger to themselves or to others." However, by "danger" it is not necessarily meant "life-threatening danger"; it could be interpreted arbitrarily so that what ends up happening is that those who are "unpleasant to others" or "annoying" or "inconvenient to others" also get put away. "[W]ords like depression and schizophrenia are ... important; they give unsuspecting people the impression, which is totally false, that certain persons exhibiting certain unpleasant behaviors are sick," Szasz says. "The belief that such persons are crazy and do not know what is in their own best interests makes it seem legitimate to incarcerate them. This is a socially useful arrangement: it allows some people to dispose of some other people who annoy or upset them." I would disagree slightly with Szasz here when he says that the arrangement is "socially useful," which, no doubt, he meant in irony. It is not useful for all of society to live under a shadow system of jurisprudence that bases itself on how peoples' minds operate. It is functional, however, if such a system of diagnosis, confinement, and rehabilitation can be crafted for the benefit of that segment of society that holds the largest stakes in preserving existing social order (viz. the wealthiest). If we ask, as Szasz does, who the people most affected by the unwritten laws of mental hygiene are, it would be hard to disagree with his answer: "The powerless. That is why poor people, uneducated people, people who do not speak the language well, children, and the very old are the people most likely to be committed.... The poor, the old, and the young are committed to mental hospitals - not because they have more schizophrenia and depression than others, nor because they are more dangerous than others, but because they have less power than others. How often are psychiatrists and lawyers committed? I suppose it happens, but I have never heard of such a case." Modern social order, in an effort to preserve itself - no matter how just or unjust it may be - has invented psychologically unacceptable behavior that can be catalogued, cured, and locked away.
Oppositional Defiant Disorder, Conduct Disorder, and Antisocial Personality Disorder
Szasz, Foucault, and others have largely been concerned with the confinement aspects of mental illness: they note the very arbitrary and self-serving rationale that can be employed to lock people away. This has generated such debate as "Do the mentally ill deserve due process?" or "How do we protect patients' rights?" It is my intention, however, not to focus so much on the imprisonment of the mentally ill as it is to elucidate the standards of what makes one "mentally ill" to begin with. Imprisonment is the extreme; incarceration is the grotesque deprivation of liberty that is the ultimate result of one's being dubbed insane. But the supposed afflictions that can lead to such incarceration merit their own examination. If imprisonment is the result of diagnosis, then what is diagnosis the result of?
The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, defines the current state of mental illness for the United States. The United Nations World Health Organization likewise publishes an International Classification of Diseases (ICD) that serves as the backbone for diagnosis in other parts of the world, especially Europe. It is a well-known fact that "Homosexuality" was technically considered a mental disorder in the United States until the second edition of the DSM (the DSM-II), which came out in 1973. The World Health Organization, however, did not remove homosexuality from its list of disorders until 1992. What remain in the DSM-IV (1994) and in the ICD-10 (1992), however, are many other disorders that comprise a body of questionable mental "illnesses." These reflect the utilitarian benefits of being able to label and enact liberty-depriving procedures on certain people.
"Oppositional Defiant Disorder," "Conduct Disorder," and "Antisocial Personality Disorder" are three such "diseases" (I will speak of others later). The former of these two diseases are primarily (although not exclusively) applicable to minors, while the latter, "Antisocial Personality Disorder," is to be found only in adults. Adults who have "Antisocial Personality Disorder" are checked against histories of the other two disorders whereas minors who have either "Oppositional Defiant" or "Conduct" disorders are thought to be more likely to later develop antisocial personalities. The three disorders are thus inextricably linked in the minds of psychiatrists and other therapists.
The diagnostic criteria for "Oppositional Defiant Disorder" includes :
A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:
1. often loses temper
2. often argues with adults
3. often actively defies or refuses to comply with adults' requests or rules
4. often deliberately annoys people
5. often blames others for his or her mistakes or misbehavior
6. is often touchy or easily annoyed by others
7. is often angry and resentful
8. is often spiteful or vindictive
B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
Many of us who have had either bad experiences with our parents, with our school systems, or with other systems of authority while growing up might wonder if we could have ever had this "illness." For example, let's posit that a physically abused child often argues with his parents, is angry or resentful, defies or refuses to comply with his abusive parents' requests - is that a mentally ill child? And what if the political system that one happened to be living in at the time was the equivalent of that sort of situation: What if one lived under a truly fascist regime (such as that of Nazi-era Germany) that one could find all manner of problems with? Would one's dissidence and failure to comply therein also be symptomatic of a mental illness? If not, then we must admit that what here passes for "mental illness" is a social construct, and thus is not a real "illness" at all, which would exist regardless of what the cultural or familial milieu was, like the flu. This "mental illness," however, merely translates to a manner of behaving that is inconvenient for established order. Now, though I am no doctor, I would think that if an otherwise normal child displayed chronic destructive or "angry" behavior that seemed to be devoid of reason, one would want to find out why he displayed this behavior and see what circumstances led to it. If it were because he felt depressed and hopeless, I would think he had some form of depression; if it were because he was hearing voices that told him to commit certain acts, I would think he suffered from some form of psychosis, etc. "Oppositional defiance" seems, to me, to be an attitude that might result from one trying to resist what was perceived to be wrong in one's life, society, etc. Yet the very name of this "illness" implies that having an attitude of "oppositional defiance" is the sickness. We have to wonder how King George and the English might have put such diagnoses to use when confronted with an increasingly rebellious population in their colonies.
I should note here that the authors of the DSM-IV, in their Introduction, state that "neither deviant behavior ... nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of dysfunction...." This doesn't help clarify the issue very much, however, for if the dysfunction is to be determined through its symptoms - symptoms that may include deviance and conflict - then the "mental illness" amounts to a social control any way.
"Conduct Disorder," like its brother "Oppositional Defiant Disorder," is a disorder that involves violating social norms as represented in laws, rights, standards of humane treatment, and the like. "Conduct Disorder," however, seems to describe much more severe behavior that not many of us could find to be favorable under any circumstances: physical cruelty to people and animals, rape, setting fire to others' property, and other behaviors are included in the diagnostic criteria. However, whereas one had to meet at least four of the criteria listed under "Oppositional Defiant Disorder" (Section A) to warrant its diagnosis, one only has to meet three of the criteria (Section A) listed for this one. These criteria could include bullying or intimidating others often, lying to obtain goods or favors, and stealing items from people without directly confronting them (as in the case of computer fraud). Many would say that this accurately portrays the personalities of corporate executives or bosses. But there is a further criterion that must be met: the individual must, due to these actions, be "significant[ly] impair[ed] in social, academic, or occupational functioning." So, for those executives or politicians for whom the above behaviors aid in their occupation - and do not impair it - they can not be said to suffer from this illness. In any event, the overview that the DSM-IV gives to "Conduct Disorder" admits its social relativity; the disease, it says, is a "repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated...." No matter what the societal norms or rules are that are violated, their violation merits consideration of this diagnosis, we are led to infer. It does not take into account the fact that sometimes it is ultimately best if societal norms and rules are violated if that is the only way that more just and humane societal norms can be achieved.
If there is evidence of an onset of "Conduct Disorder" before age 15, and this persists into adulthood, then the DSM-IV claims the subject could very well suffer from "Antisocial Personality Disorder." The diagnostic criteria for this disorder includes :
A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:
1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
2. deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
3. impulsivity or failure to plan ahead
4. irritability and aggressiveness, as indicated by repeated physical fights or assaults
5. reckless disregard for safety of self or others
6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
Again, a mental disorder, such as this one, that takes "repeatedly performing acts that are grounds for arrest" as a symptom or criterion is a control mechanism. It seems to assume that the laws that happen to be on the books at the time are valid laws, and that if anyone repeatedly breaks them, it is symptomatic of mental disturbance. Civil disobedience and other forms of arrest-provoking behavior have been engaged in for ultimately noble purposes by people such as Martin Luther King, Jr. and Mohandas Gandhi. The ability to maintain a consistent work history or meet one's financial obligations are also subject to socioeconomic forces that are not entirely within one's control (as anyone living in the Great Depression could have attested to). So, again, we are left with a disorder that is largely relative to whatever one wants to define as a "social norm" - something that is consistent neither through time nor in place. Such an illness as this is not really an "illness" but is a catchall excuse for putting unacceptable people away. In the application of "disorders" such as these we are reliant upon the open-mindedness, benevolent intent, and sociopolitical worldview of the diagnosing physician - and having their freedom, livelihoods, and lives rely on these sorts of factors is a position not many people are comfortable with.
"Antisocial Personality Disorder" is the root classification of those who are usually more leisurely referred to as "sociopaths" or "psychopaths." People who are diagnosed with this disorder include serial killers, rapists, and others that have committed extreme acts of violence. But the criteria are so vague as to make it a "wastebasket diagnosis" that can be slapped on anyone whose reputation and actions have found ill favor in society. Dr. Seymour Halleck, author of Psychiatry and the Dilemmas of Crime, stated that "there is widespread disagreement as to whether psychopathy is a form of mental illness, a form of evil or a form of fiction." The diagnosis is most often associated with career criminals or with those who perform extremely brutal acts and who seem to have no guilt about doing such (or at least, no guilt that is believed to be true). Dr. Robert D. Hare, in a 1995 issue of The Harvard Mental Health Letter, gave an example of the type of person for whom the designation of "psychopath" might be warranted: "Psychopaths use charm, manipulation, intimidation, and violence to control others and satisfy their own selfish needs. Lacking in conscience and in feelings for others, they cold-bloodedly take what they want and do as they please, violating social norms and expectations without the slightest guilt or regret. Although their numbers are small - perhaps 1% of the population - psychopaths account for a large proportion of the serious crime, violence, and social distress in every society." The picture herein created - that of a devilish, cunning libertine devoted to his own gratification at whatever cost - seems like that of a caricaturesque villain from an old comic book. Psychopaths are also adept at "working the system," Hare says. While confined, "[t]hey had learned enough psychiatric and psychological jargon to convince therapists, counselors, and parole boards that they were making remarkable progress, but they used that knowledge only to develop new rationalizations for their behavior and better ways to manipulate and deceive." Here it is that following doctors' orders and obeying the controls of the Therapeutic State are seen as yet more evidence of how the subject must be disordered. Psychologists at the University of British Columbia, finding the criteria from the DSM to be inadequate, outlined prominent psychopathic characteristics as "glibness and superficial charm, arrogance, lack of realistic long-term goals, inflated self-esteem, manipulativeness, lack of remorse, callousness, impulsiveness, irresponsibility, and shallowness of feelings." In short, the category of "psychopath" or "sociopath" seems to be a repository for those character traits that most of us would find to be disagreeable in anyone. As such, the label covers all people who are basically "bad." Because it is so nebulous, Dr. P. Roche commented, in his seminal work on criminology, the "term 'psychopathic personality' is no longer regarded by psychiatry as meaningful: yet it will probably remain embalmed for some time to come in the statutes of several states where the pursuit of demons disguised as sexual psychopaths affords a glimpse of a 16th Century approach to mental illness."
Homosexuality, Transvestic Fetishism, and Gender Identity Disorder
Writing in the late 1960s, when homosexuality had not yet been removed from either legal or psychiatric lists of "unacceptable" things, Dr. Albert K. Cohen stated:
Homosexuality in certain of its forms - e.g. between an older man and a youth - has been positively valued in some cultures, as in ancient Greece. In Christian countries it has generally been regarded as a vice. In many quarters today, however, the homosexual is regarded as a sick person, although homosexuality is conceded to be an obscure sickness and peculiarly difficult to treat, possibly "incurable."
Although as a sufferer of an illness a homosexual was accorded a degree of mercy, his or her homosexuality was still symptomatic of a state of unhealthiness, and therefore warranted preventive or rehabilitative action. This allowed what was basically a social control to commence under more humanitarian auspices than might be allowed for in the legal/penal system. Although the "illness" categorization of homosexuality has officially disappeared, many still consider it to be deviant, "socially inappropriate," or otherwise "unnatural" behavior. If, as some researchers say, there is a gene that causes homosexuality (a theory that I believe to be patent absurdity), then its presence in one's genetic makeup should be regarded as a "birth defect," these same people say. In any event, its classification and subsequent declassification as a mental disorder illustrates to what extent psychiatry, presumably an objective science, fluctuates with the tide of social acceptability.
In the 19th century, mental disorder was more commonly associated with women than with men; women were often portrayed in the literature of the day complaining of their "nerves" and as being easily prone to fits of swooning or fainting. The psychological phenomenon of "hysteria" was thought to be a mainly female affliction caused by a loosening of the uterus (compare the root hyster in "hysteria" to words like "hysterectomy"). Similarly, African slaves who exhibited a tendency to try and flee from their masters were thought to suffer from a singular mental disease known as "drapedomania." Although we can laugh (perhaps bitterly) at these diagnoses now, there exist on the books mental disorders that, in decades to come, may seem just as silly as these do. "Prehomosexuality," under the diagnosis of "Gender Identity Disorder of Children," and "Transvestic Fetishism," are two such "illnesses."
Katherine K. Wilson's "Gender As Illness: Issues of Psychiatric Classification" is one of the most incisive modern articles to be written on these diagnostic categories. "Gender Identity Disorder of Children," (DSM-IV) she states, has the following diagnostic criteria :
A. In children, the disturbance is manifested by four (or more) of the following:
1. repeatedly stated desire to be, or insistence that he or she is, the other sex
2. in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing
3. strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex
4. intense desire to participate in the stereotypical games and pastimes of the other sex
5. strong preferences for playmates of the other sex
B. In children, the disturbance is manifested by any of the following:
in boys, assertion that his penis or testes are disgusting or will disappear
or assertion that it would be better not to have a penis,
or aversion toward rough-and-tumble play
and rejection of male stereotypical toys, games and activities;
in girls, rejection of urinating in a sitting position,
assertion that she has or will grow a penis,
or assertion that she does not want to grow breasts or menstruate,
or marked aversion toward normative feminine clothing.
As in other diagnoses, a criterion for this disturbance is that it must cause "significant distress or impairment in social, occupational, or other important areas of functioning." If a boy has an "aversion toward rough-and-tumble play," demonstrates a "rejection of male stereotypical toys, games, and activities" (whatever "male stereotypical" is perceived to be), and if he is made fun of at school thereby causing "significant impairment in occupational functioning," it may be the boy who is mentally disturbed and not the intolerant society around him, according to the DSM-IV. Likewise, a girl who does not want to menstruate, who has a "marked aversion toward normative feminine clothing," and who has an "intense desire" to participate in "stereotypical pastimes" of the other sex (police officer? lawyer? football player?) may be mentally ill. Would her cure be evidenced in a reformed attitude wherein she enjoyed having her period, wanted to wear frilly skirts, and had decided to pursue a career as a receptionist?
Many psychiatrists claim that the presence of "Gender Identity Disorder" in psychiatric nosology protects those diagnosed from societal intolerance because, since the disorder is shown to be a quantifiable illness, intolerant people have no grounds upon which to fault patients' behavior. Nevertheless, tolerant psychologists are often dismayed to find that worried parents will impress upon them the need to diagnose their children with this disorder "because they don't want their kid to be gay." The fact that "Gender Identity Disorder" exists as a "disorder" reassures the intolerant that it is, after all, wrong and that if one were mentally healthy one would not have it. Thus, irrational hatred of certain behaviors and attitudes can be exacted under maternalistic measures of understanding, concern, and ultimate "rehabilitation." "Gender Identity Disorder of Adults," once known as "Transsexualism" (DSM-III), is much the same; the irony, however, is that this diagnosis is needed if a transgendered person wants to have sexual reassignment surgery (a "sex change operation").
"Transvestic Fetishism," known in the DSM-III simply as "Transvestism," has the following in its diagnostic criteria (DSM-IV) :
A. Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. Specify if: With Gender Dysphoria: if the person has persistent discomfort with gender role or identity.
Criterion A asserts that this illness is only to be found in heterosexual men. Thus it is implicit that, for heterosexual men, there is a psychologically acceptable wardrobe or taste in clothing. Criterion C asks the diagnosing doctor to consider whether or not the patient is comfortable with his "gender role" - if not, that could be a further sign that he is suffering from this disorder. What constitutes one's "gender role" is something that many feel should be left up to the individual, but the DSM-IV seems to think that there is an absolutely-defined "gender role" that exists for men and that non-compliance to it could indicate mental illness.
Major Depression and My Own Experiences
It is one of the most common of human errors to take one's own capabilities and skills as the standard against which others' are to be measured. It is just as wrong to use nothing more than one's own personal experience when drawing conclusions on subjects other than one's own memories. So, for example, someone that says, "Because I can run a mile in five minutes, everyone should be able to" is no more right than someone who says, "Because I have had bad personal experiences with dogs, all dogs must be bad." In both instances, broad conclusions are drawn from a purely first-person, egocentric standpoint. A more objective conclusion would be one that was informed from a variety of sources and not limited to one's own history. And while I recognize this, and believe that it would be poor logic to base my conclusions only on my own recollections, I feel my own experience with mental illness and the Therapeutic State merits mentioning. For while my own experiences have not been as harsh and authoritarian as one might think (based on this article's content), they do fit into my overall theory that the mental health field is largely subservient to the interests of capital and "economic prudence."
The diagnosis that I have that comes closest to pegging down the essence of my "illness" would have to be "Major Depression." Indeed, it is because of this that, as I mentioned at the beginning of this article, I am considered by the state to have a mental disability. Mental disabilities do not necessarily have a correlation with low IQ, inadequate verbal skills, inability to reason abstractly, or poor mathematical abilities. (Low IQ or inability to reason, on the other hand, could be symptoms of the mind's malfunctioning, and thus of a mental disability.) The causes and nature of the disorders of the brain are nebulous; the reason they are so elusive, so troubling, and so frustrating is because they are indeed irrational. Autistic people may seem oblivious to much of the world yet display otherworldly mathematical skills; chronically depressed people (like Edgar Allan Poe) may exhibit literary genius yet find it hard to function in other areas of life. I believe that, ultimately, there are such things as mental afflictions because I feel certain that, at some level, I suffer from at least one of them. I do not feel, however, that medical science has progressed to the point where what others and I suffer from can be effectively treated.
At the age of 11 or so, I began to miss school and become increasingly reclusive. At that time I had not the verbal capacity to articulate myself well or the ability to adequately elucidate, much less totally understand, how I felt. Because of this, my truancy was treated as every schoolboy's truancy is: the hard hand of discipline, threats of failure and of low grades, the specter of the police - all of these were invoked. Though I took these threats as very real, it seemed to many that by my behavior I did not: I continued to miss and to refuse to cooperate. I hated school and was obstinate in staying away from it. Because of my "deviant" behavior, I was shuffled off into the world of therapy, where my associations with the Therapeutic State began. Some therapists tried a congenial and permissive approach, saying that if I did not want to attend school I should not feel compelled to go, but should explain why to those who felt I should be in a classroom. Others were more paternalistic and insisted that no one wanted to go to school, but that I was no better or worse than anyone else and so would be dragged into class through whatever authoritarian means were available. It became obvious, after several years of worsening isolation and truancy, that it was no simple matter of adolescent rebellion. Still, some therapists came at me from the standpoint that I needed to be taught a lesson, had to be shown that I was not in charge of my education (since I was still a minor), and that I had to respect the law. The possibility of my mother being cited by the police for my refusal to comply was continually held over my head as a kind of threat - or, as many of my therapists liked to say, a "consequence" - of my actions. The stress and guilt that such warnings caused only worsened the situation for me. To be sure, I was not skipping school to go fishing, to use drugs, or to loiter at the mall with my friends. Sustaining friendships was difficult for me, and the days I spent away from school were usually spent at home, either in bed or in the darkness of my room. I was not having a fun time. The pressure that was put on me, though ostensibly well intended, did not make it any more fun. Three months after my 15th birthday I tried to kill myself.
I've heard it described as a boiling black cloud that smothers all one's thoughts and emotions, as a dark beast that follows its victims around and keeps them steadfast in its yoke, or as a deathly pale dungeon into which its sufferers are condemned to live a Purgatory-like existence. But, for those who have never had to deal with the crippling effects of severe depression, there really are no words, analogies, or images that will convey the immediacy and brutality with which it smites one's entire being. Dr. O. Carl Simonton has stated, "When you're depressed, the whole body is depressed, and it translates to the cellular level." Its effects extend beyond the mind and afflict the body. Depression is, at its worst, disabling in that somehow it can sap the very will to wake up, to get out of bed, to talk or interact with others, to keep one's appearance up, to eat, and to care about anything. When I read the writings of those who take an embittered and cynical stance towards depressive illness, dismissing it as "feeling sorry for oneself," as being indicative of a lack of self-discipline or responsibility, or as an attempt to manipulate others by gaining their sympathy, I know I am hearing the words of someone that has never grappled with its effects personally. And when I hear the well meaning counsel of others that "depression is just a part of life" and that I should work on "snapping out of it," again I know I am not hearing the words of someone that has truly felt its effects. Although the summer of 1999 saw Al and Tipper Gore announce a renewed government campaign to de-stigmatize those diagnosed with mental illness, I think it will always be misperceived until some doctor, somewhere, can point to a black blob on an MRI scan and say "That is depression; we will now commence surgery to remove it from the brain."
This will never happen, of course, because "Major Depression" and its predecessors are conceived of in the wrong fashion. "Major Depression," as a mental disorder, is relatively new; it came onto the horizon of science after "Depression," "Melancholia," "Spleen," "Saturnalia," and "Black Bile" had all left. Each of these is not the same disease - each is a wholly separate disease, each defined by the Therapeutic State of the society in which it existed. Hippocrates felt that four "humors" were to be found in the body (blood, phlegm, yellow bile, and black bile) and that equilibrium of them all was necessary for one's good health. A superfluous amount of black bile would cause one to experience symptoms much like those that we associate with depression today. In the Middle Ages, herbalist-physician Nicholas Culpeper, in his The Herbal, recommended the roots and leaves of the tamarisk tree as treatment "for melancholy, and the black jaundice that arise thereof." (Interestingly, St. John's Wort, now en vogue as a treatment for depression, was dismissed by Culpeper as being beneficial mainly for the treatment of nausea). Since the roots and herbs most commonly prescribed for treatment of this "black jaundice" were related astrologically to Saturn, so did extreme depression also become known as "Saturnalia." We still refer to a black mood as a "saturnine" mood. It was later thought that feelings of melancholy and bitterness originated in the spleen, which seemed to serve no apparent physiological purpose unlike other organs such as the stomach. Hence, someone who was continually morose or suffering from feelings of despair was said to have a "splenetic" disposition. In fact, Charles Baudelaire, in his 19th Century "Spleen" cycle of poems, wrote what is probably one of the most accurate portrayals of depressive illness to be found in literature: "And giant hearses, without dirge or drums,/ parade at half-step in my soul, where Hope,/ defeated, weeps, and the oppressor Dread/ plants his black flag on my assenting skull." ("Spleen (IV)") Today, "Major Depression" is thought to be caused by an imbalance of neurotransmitters in the brain. But decades from now this may seem as dated and ridiculous an idea as that of the spleen or of the planet Saturn affecting our moods.
I think the source of much of what constitutes "Major Depression" and other types of mental illness is to be found as much in the chemical composition of the mind as it is in the structure of the economy surrounding the depressed person. The ways that the surrounding structure of society can eventually wear down the resolve of the human mind is little studied, but I think it is reasonable to expect that a people, trained though they may be to outwardly believe that they are living in a social order that is the embodiment of all sorts of wonderful values, will eventually intuit or subconsciously sense that they are being taken for a ride. The continual stress of pursuing a career and living up to others' expectations while internally suspecting that, in the end, it will only amount to so many wasted hours of one's life, can create a form of stress or anxiety by itself. People will indeed become depressed if they begin to suspect that a life of continually renting themselves out to whoever will have them for the most money is all that they will ever have. For our current economy is indeed composed of a very particular melange of laws, codes, and values; it is not a state of anomie in which all options are fluid and available to be pursued. People are limited to a certain set of options in our economy, options that are restricted ever more so the poorer someone is, just as someone in a feudalistic or Socialistic economy will have a certain set of realistic life expectations or options available to them. As long as a person feels that he or she has no voice in their own economic being, or in that of the economic structure of society (through a lack of economic democracy or other kind of meaningful participation), the more sensible it is to expect that dejection, alienation, and a gloomy outlook on life will predominate.
Rarely, however, does one find psychiatric research that focuses on socioeconomic alienation as a possible source of depression (or other mental illness). This is either regarded as something to be focused on by "Conflict Theory" Sociologists or as "radical theory" to be discussed only in underground, revolutionary zines alongside neo-Marxist diatribes. A climate of conformity and the desire to keep up an appearance of professional respectability, is, I suspect, the reason that so few psychiatrists have ventured into this territory. Instead, the search for a "cure" for depression becomes ever more insular, ever more focused on the patient and either his outlook on life, or in his mind's chemical make-up. Psychiatrists are slow to criticize any social institutions or power structures that may have adverse psychological effects on people. Rather, those who feel bad can be medicated and thus more easily made to adapt to whatever social structures are at hand. In fact, in the past decades, psychologists have insisted ever more frequently to their clients that "you can't change how other people are, but you can change yourself." This places the burden and responsibility squarely on the shoulders of the person who is ill - and responsibility is deserved, but not the responsibility of pursuing phantom causes of their illness. Rather, people are, to a degree, responsible for the quality of life they have in that if they feel they are oppressed, they have a responsibility to fight against that oppression and try and free themselves. But if taking responsibility is equivalent to adapting to, or better coping with, conditions that make one feel depressed to begin with, then all that is created by a therapy that encourages such a singular form of "responsibility" is a passive-adaptive pawn who will do whatever he must to make himself happy in whatever manner of oppression is inflicted upon him. Such a means of correcting people so that they fall back into order is especially valuable to existing systems of economic coercion and domination.
To illustrate this point, we need only imagine the United States as it was in the 19th Century, when a primitive industrialist economy in the north sat alongside an agrarian slave economy in the south. For the purposes of this analogy, let us imagine a slave that has been allowed by an exceptionally kind master to see a psycho-therapist for problems of depression or stress that the slave has recently complained of. From our standpoint nowadays, we can imagine very easily that a life of slavery would make one feel depressed or stressed out. In fact, this may be the obvious cause of the slave's maladies to those of us who know how miserable it can be to be forced, by other people, to do things we don't want to do. Nevertheless, as the slave sits before his therapist, exploring his feelings, discussing how his mood darkens and how he begins to feel overwhelming pressure at meeting deadlines and living up to his responsibilities as a servant, it is not hard to imagine the psycho-therapist suggesting the same possible "cures" that are suggested to patients today. First of all, the slave could see if his master would allow him to see a psychiatrist to get medication that might relieve him of his troubled moods and allow him to return to his normal life. Secondly, the slave and the psycho-therapist could work out a plan of things that the slave might change in his own life that would make him happier. If the slave felt too stressed out on certain days, perhaps he could politely ask his master to ease his workload or, if that didn't pan out, perhaps he could request that he be put back up on the auction block and sold to a different master who needed slaves for lighter, or more agreeable, duties. The psycho-therapist could always write a note if it might help get such a thing approved. If the slave felt put down or demeaned by his master's behavior, then the slave should be reminded that he can't change others' behaviors, but that he can change himself - and so strategies of coping with his master's harsh attitude could be developed. If we were present at such a therapy session, we would probably find it hard to restrain ourselves from suggesting to the therapist that the problem could lie in the fact that the slave was, well, a slave. Because his socioeconomic condition presented him with a relatively bleak forecast for his life, he became depressed. He does not have a "disorder" because he finds it hard to happily be a slave; rather, his "disorder" is a healthy neurological response to conditions that are spiritually and emotionally demeaning to him. That depression might be a healthy neurological reaction to a damaging environment might be seen by this therapist as a cop-out, though: the slave should accept responsibility for his feelings and not expect to blame society or other people for making him feel bad. After all, nobody likes a victim. But, we might counter, recognizing this is not a cop-out or a denial of responsibility: to make himself better, the slave would need to overcome and destroy the institution (slavery) that caused his depression. This would be acting responsibly, as it would put the responsibility of freeing himself on the slave, and place the blame of enslavement on those who had, indeed, enslaved him. Would the psycho-therapist himself be responsible and advocate such a revolutionary course of action, or would he continue to suggest that "blaming others" and the like was irresponsible, and that the answer lay in more medication, more session work, and more trivial changes in his slave lifestyle?
We would like to imagine that, had contemporary psychiatry existed in the antebellum south, the entire Therapeutic State would have rallied to the cause of freeing the slaves and helped to accord them equal political and social rights. We would like to imagine that if such a thing were needed now, they would do the same. But, either purposefully or not, it seems that most of the doctors of the Therapeutic State see their patients' problems with a sort of tunnel vision that limits all solutions for recovery within the parameters of existing economic order. This is for reasons as practical as they are doctrinaire. A psychiatrist, who must make his living by seeing clients and thus by having a continuing supply of mental disorders to diagnose, would be hard-pressed to put his career on the line by advocating any truly revolutionary reform. To be marginalized off into the corner of "experimental psychiatry" or "radical social psychological theory" is not appealing to most mainstream therapists. Such a reputation could lead to a drop in income or could make one attractive only to a more disenfranchised clientele that had not the same means to pay as would, say, a wealthy Beverly Hills clientele. This alone can be incentive enough for doctors to play the game as it is. Psychiatrists, like those whom they diagnose, must find some way to eke out a living and pay their bills; anything that might threaten their ability to do this, even if it was the right thing, could dissuade even the most irascible of them from such a course of action. Although a spirit of humanitarianism motivates many doctors, the fact remains that many choose a career path in the health field for more temporal reasons. Such doctors will act the part of caring about others' health only inasmuch as it means they will be able to honor their own financial obligations. (When it comes to your choosing a doctor, however, would you rather go to one that had pursued a career in health because he thought it meant big bucks, or to one who had an altruistic desire to relieve the suffering of others?)
Mental illness is not a myth. People that suffer great mental or emotional pain, people that have auditory or visual hallucinations, and people that otherwise find great difficulty in meeting the requirements for a dignified standard of living, do deserve help. But only if they want it. If such people do seek out psychologists, social workers, or doctors, then these mental health experts have a responsibility to use their power in the best of interests of their patients. If this means challenging slavery because that is the source of the person's distress, so be it. If it means prescribing a drug that will get rid of the voices that tell someone to hurt himself, so be it. If it means campaigning for a non-authoritarian economy that is not ruled by a maxim of profit-at-all-cost, then that should be considered as well. If a doctor wants to really act as one of mankind's benefactors, and not as some lackey who will define inconvenient or challenging behavior as a "disorder," he should let himself be open to the very real - and perhaps very uncomfortable - truths that may exist. If the mental health field in general notices a growing number of people seeking treatment for depression, stress, and anxiety - as it has claimed to over the past decades - then how long will doctors let themselves be convinced that it is simply because of a new "culture of victimization," a "culture of complaint," or because of some other pop culture theory that attempts to place the blame back on those seeking help?
Carl Gustav Jung, one of Sigmund Freud's closest and best-known colleagues, extolled the rise of fascism in Germany since it, he implied, complemented the psychological needs of the Teutonic man. I am sure that there have been doctors in every age of man, in every sort of socioeconomic system and culture, that have performed a similar conformist function, whether they were conscious of it or not. While Jung's students helped "rehabilitate" patients so that they might function better in a fascist society, and while social maladjustment in the USSR was "rehabilitated" so that patients could better function in that world, so in our own culture do doctors mostly "cure" others so that they might become successful citizens here. It is hard to look outside the walls of one's own social conditioning; cynical and tiresome tracts that claim resistors (be they mentally ill or not) are pity-mongering whiners - tracts and "theories" that thereby discredit non-conformity - have existed in our world, in the USSR, and in the Third Reich, too. The duty, however, is to truth, regardless of how fashionable or inconvenient it may be. It is possible that some day we could live in a world where those who found nothing wrong with ordering others about, those who sought power through politics or finance, or those who rationalized the laying off of thousands of workers as "good business sense" would be diagnosed with an "authoritarian personality disorder" and appropriately medicated. But it is also possible that we could live in a world where those who do not internalize the values that benefit their rulers will be drugged or locked up - not as criminals, but as "mentally incompetent." It is the responsibility of mental health practitioners to recognize truth and to not be co-opted by government agencies or insurance companies so that all the practice of health care amounts to is "curing" people to better function in whatever social system best benefits governments or corporations.
The recent trend in the unionization of doctors is one that, if extended into the mental health care industry, could have beneficial effects for both patients and their therapists. The increased meddling of insurance and pharmaceutical corporations into health care is something that should be combated. (At age 15, when institutionalized, I remember speaking on the phone to an insurance company representative who was, supposedly, trying to ascertain whether or not I needed less intensive care; after speaking on the phone with me, he spoke with my psychiatrist to convince him that less costly forms of treatment should be given to me.) In either instance, mental health clinicians need to be vigilant in separating ideological fluff from scientific fact when diagnosing patients. If Anglo-American jurisprudence prides itself on the concept that it would rather have one hundred guilty men go free than one innocent man imprisoned, so must we also insist that one hundred "madmen" be free rather than one healthy man institutionalized. In any event, mental "hospitals" should be restructured so as to make their form consistent with the claims of mental health professionals that true mental illness is neurophysiological; if it is a matter of brain chemistry that the mental health patient can't help, the patient should not be incarcerated and treated like a child who must be taught by sane people how to function properly. Structuring mental hospitals like regular medical hospitals would thus be advisable. Public interest groups that support the rights of the mentally ill, groups that act as advocates for those incarcerated for being mentally ill, and groups that otherwise perform charitable functions for the mentally ill should be supported, as always. These measures, and the insistence that doctors perform socially useful (as opposed to ideologically functional) services, will serve to ensure that somewhere down the road the Therapeutic State does not act merely as a servile organ dedicated to the unquestioning preservation of social order. Rather, therapists and other mental health workers will have the opportunity to at last serve no interest save that of promoting their patients' good health.
Brian Oliver Sheppard