By Sami Tamimi
Editor’s Note: Over the next several months, Mad in America’s Parent Resources section will publish selected chapters of Sami Tamimi’s new book, Insane Medicine. Dr. Timimi is a consultant in child and adolescent psychiatry at the UK’s Lincolnshire Partnership NHS Foundation Trust. His past works include Naughty Boys: Anti-Social Behaviour, ADHD and the Role of Culture and A Straight Talking Introduction to Children’s Mental Health Problems, among others.
Following is Chapter 2, Part 1. All chapters will be archived here.
Hardly a week goes by without another headline about mental health, the epidemic of mental health problems in society, particularly in young people, the importance of talking about mental health, and how our services are stretched and at a breaking point because of lack of resources.
Anybody listening to this would be forgiven for assuming that mental health problems are burying our populations as we buckle under the weight of stress, anxiety, depression, self-harm and worse. Mental illness is to be found in every classroom and around every corner. You’d also be forgiven for thinking that there are real treatments for these real medical conditions and that people get better with treatments delivered by professionals with special expertise.
You’d likely think that our problem with mental health is that we don’t have enough services, that the issue is woeful underfunding and long waiting lists, that the scandal is the lack of quick access and adequate availability of treatment and support for those who have been struck down by a mental disorder.
But here is the uncomfortable conundrum. Wherever you find mental health services to have expanded with more people receiving what is considered to be mental health treatments (whether these are psychological or drugs) you find a parallel increase in the numbers who have been classed as disabled due to a mental health disorder.
Of course, many people do benefit. There remains much that an enlightened mental health service could and should provide that could be helpful to many more than today. However, as things stand, the data that we do have about outcomes from real-life mental health services says this is not currently the case. One of the first problems that confront us is that when people (the media, professionals, and public alike) talk about mental health, they actually don’t know what they’re talking about—literally.
What Is a Mental Disorder?
What do people mean when they talk about mental disorder, mental health, or mental illness? What sort of “thing” is a mental disorder? Where are its boundaries? When does a behaviour become abnormal or disordered or pathological and who decides based on what?
Issues of where to place boundaries between the ordinary and not are something that most of medicine grapples with. When it comes to mental disorders we have a whole new level of potential confusion, uncertainty, and meanings to get through before we can assert something to be out of the ordinary, abnormal, or disordered. In psychiatry, the entire phenomena require interpretation, not just the boundaries.
Take, for example, the fairly straightforward situation where there is minimal confusion about what sort of “thing” we are dealing with. Somebody has an accident and experiences extreme pain and some swelling in their leg and they can’t walk on it. At the hospital an X-ray reveals there is a fracture in the tibia (shin bone). In this scenario the medical model is working at its best.
The fracture of the tibia is what is known as a “natural kind,” so in terms of classification the diagnosis explains an abnormality in the person’s physical body which can be empirically verified and measured. As a natural kind that can be seen, it exists out there in the world beyond our subjective hypothesis. It is a verifiable fact of nature and we can develop knowledge bases that relate to this verifiable reality of a natural phenomenon.
Just as the chair I am sitting on can be weighed, measured, and analysed in all sorts of empirical ways, as it exists out there in external reality, so we can build technical knowledge about fractures of the tibia by comparing many people who have the same condition, trying out different treatment approaches and combinations, grading different types of severity, looking at the various factors (in the fracture, the body of the person, the type of accident, and so on) that might affect responses to different treatments.
Medicine is particularly good at these emergency scenarios where there is an identified abnormality and where the treatment period is relatively short. Here we can gather data on the disease, the treatment, the recovery, complications, and so on, using verifiable empirical evidence. We know what sort of a “thing” a fracture of the tibia is. Once seen on the X-ray, we have an explanation (a diagnosis) for what is causing the patient’s pain, swelling, and inability to walk.
Not all presentations to doctors follow this easy-to-understand idea of what sort of thing we are dealing with. Let’s take diabetes as an example. The connection between symptoms and the underlying cause may not be as immediately apparent. In diabetes a diagnosis refers to an abnormality of sugar metabolism and this can be measured mainly through blood tests but also in other ways, such as through testing your urine for something called “ketones.”
Some abnormality of blood sugar metabolism may exist for a period of time without the patient displaying any obvious symptoms. They may just have some non-specific symptoms such as generalised tiredness or loss of concentration, particularly in type II diabetes, which has an onset later in life when the body becomes resistant to insulin or when the pancreas is unable to produce enough insulin.
Type II diabetes could present just as a susceptibility to infections and so could go unnoticed for months or even years in some. Nonetheless, there is a physical parameter that can be measured, and there is a physiological process present in the physical body and that exists in the world external to the diagnoser and is verifiable with independent data.
So, in this example, whilst the connections between symptoms and disease are not as clear and indeed may involve other factors than just the sugar metabolism and may be missed in the early stages or by a poorly trained doctor, the diagnosis again is explanatory. It is pointing to an abnormality that can cause symptoms in the patient and will cause more if not treated.
But there are many disagreements in diabetes diagnosis and treatments; for example, when to consider the blood sugar has crossed a threshold justifying a diagnosis, whether to just use dietary approaches and for how long, when to use medication, how to deal with complications, the psychological impact of having a chronic disease, the social dimension of long-term care, and so on. But still, we know what sort of “thing” diabetes is.
So far so good. Now we start to get into medical conditions which can have recognisable symptoms and sometimes physical signs and some objective tests, but in which there are mysteries as to the initial cause or explanation. Many types of headaches, such as migraines, are good examples of this category. Diagnoses such as migraine are mainly based on a description of symptoms. We are now moving toward a descriptive rather than explanatory system. However, given that there are characteristic physical symptoms (in migraine, you may get blurring of vision, pain behind the eyes on one side of the face), it is likely that there is physical pathology.
The presentation tends to be characteristic, has physical symptoms, and so it is reasonable to assume that it involves a physiological processes. So we kind of know what sort of a “thing” migraine is, though we are now getting into some more fuzzy territory. With pain and the nervous system so involved, psychological aspects are becoming more prominent. But the idea of diagnosis still stands, even if it’s to conclude that whilst the migraine is a diagnosis (in that it explains the physical symptoms), it can be brought on or sometimes even mimicked by psychological factors.
Once we come to talk about mental disorders we start to get into a whole array of problems in order to support that idea that we have a “thing” that can be considered a diagnosis. The territory for what we have been calling “symptoms” of a mental disorder are now experiences and behaviours that have meanings and that may be interpreted differently by different cultures, different times, and in different settings.
This means we are shifting to an area of practice where there are not only disagreements and debates about where the boundaries are, but we also have to take into account the significance and relevance of the diverse meanings that can be attached to these symptoms, such that they are interpreted as symptoms in one setting, but not in other. We have no signs, no tests, no physical correlates, and so are entirely reliant on observations and reports of the person and/or their significant other(s).
The disputes are no longer about just the boundaries, but also the parameters; indeed, about whether they can even be considered problems in the first place and, if they are, whether they can be thought of as medical in nature. We have now strayed into a different conceptual field.
Is that patient in front of me who reports intense sadness, difficulty getting to sleep, waking up before 5 a.m. every night and not able to get back to sleep, and has a poor appetite, suffering from a “depressive disorder” or experiencing understandable heartbreak and grief after the breakup of a long-term relationship a few months back? If you argue both can be true, then sure, technically speaking, both depression and grief may be said to the patient as what they have.
One, however, cannot be a diagnosis (depression) as it explains nothing, just describes some aspects of the patient’s experiences; the other (grief) could be a diagnosis as it has explanatory pretences. Grief (unlike depression) is, in this scenario, being used as an explanation. But I have no access to the patient’s inner mental workings; none of us do.
With grief, depression, or both, I still do not know what sort of a “thing” I am dealing with. Is it a medical disease in her brain, is it the psychological process of grief, is it the loss of a social network that she had with that partner, is it her concern about how this is impacting her son, is it the fear of returning to work after a long absence, is it all of these things?
In truth, I don’t know anything about what has caused her presentation. I can’t escape my subjectivity, or the patient’s for that matter. I can only guess at the “diagnosis” (proximal explanation), something that attaching the words “Major Depressive Disorder” (MDD) cannot provide.
When it comes to our emotional experiences we just have embodied experience. We then use words connected with cultural meaning-making systems to attach to that experience. The meaning scaffolding we then use can itself transform our experience of the experience. “You are broken-hearted” creates a different scaffold than “you are depressed,” which itself differs from “you are surviving and recovering from a painful experience.”
Mental health, illness, and disorder cannot be thought of as out there in the natural world, existing somewhere within the body of the person, in a way that is identifiable as a concrete “thing.” It is not definable in a causal way in the same way as a broken leg or diabetes or even migraine.
And yet this is the way we talk about mental health and illness, as if we know what sort of “thing” this is and assume that it exists within a person, regardless of their context; that it exists as a known “thing” in objective reality and beyond the subjectivity of the person or the practitioner.
If you hear one in four of the population are possessed by or will be possessed by a mental disorder, be wary. It’s an appalling mistake to make, with appalling consequences for patients and professionals alike. One in four who have what sort of “thing”? Where is this “thing” located and how do I find it? How can I truly develop an accurate way of “measuring” it if I can’t locate it as an empirically knowable “thing”?
There Is No Such Thing as a Psychiatric Diagnosis
In medicine then, diagnosis is the process of determining which disease or condition explains a person’s symptoms and signs. Diagnosis therefore points to causal processes. Making an accurate diagnosis is a technical skill that enables effective matching of treatment to address specific pathological processes.
Pseudo-diagnoses, like for example “bi-polar disorder,” cannot explain behaviours, as there are only symptoms that are descriptions (not explanations) of behaviours or experiences. Even using the word “symptom” is problematic as, in medicine, the word “symptoms” usually refers to patients’ suffering/experience as a result of an underlying disease process and is therefore associated, in our minds, with a medical procedure leading to an explanation for the symptoms.
We are meaning-seeking creatures and so have used classification systems extensively to classify all manner of things. Language is itself a system of categorisations with words that symbolise all sorts of phenomena. But different classifications serve different functions. A diagnostic classification is a classification by explanation—in other words, by cause. That’s why we say “My doctor said that the cause of my chest pain was acid reflux, not a heart attack.” We usually go to the doctor to get the “why” question answered in the hope this will then guide toward the correct treatment.
But psychiatric diagnoses do not explain symptoms. Consider the following example: If I were to ask the question “what is depression?” it’s not possible for me to answer that question by reference to a particular known pathological abnormality. I cannot say that depression is a disease that occurs due to the brain having abnormally low levels of serotonin. I cannot say that because no one has found this (despite extensive research) and so there are no tests done to confirm or refute this.
Instead, to answer the question I will have to provide a description such as “depression is the presence of the low mood and negative thinking” and so on. Contrast this with asking the question “what is diabetes?” If I were to answer this question in the same manner by just describing symptoms, such as needing to urinate excessively, thirst, and fatigue, I could be in deep trouble as a medical practitioner, as there are plenty of other conditions that may initially present with these symptoms and diabetes itself may not present with these symptoms in a recognisable way.
In order to answer the question “what is diabetes?” I have to refer to its pathology involving abnormalities of sugar metabolism, as in, “Diabetes is a disease that occurs when blood glucose, also called blood sugar, is too high.” To move from a hypothesised to a confirmed diagnosis, I would get independent (to my subjective opinion) empirical data to support my hypothesis about what may be causing the patient’s described experiences (such as testing the urine for ketones and/or blood for levels of fasting glucose).
In most of the rest of medicine, therefore, my diagnosis explains and has some causal connection with the patient’s experiences/symptoms. Thus, diagnosis sits in a “technical” explanatory classification framework.
The problem with using a classification like “depression” to explain an experience (i.e., as a diagnosis) can be illustrated by asking another set of questions. If I was asked why someone is feeling low and I answered that this is because they have depression, then a legitimate question to ask is “how do you know that this feeling low is caused by depression?”
The only answer I can give to that question is that I know it is depression because they are feeling low. In other words, if we try to use a classification that can only describe in order to explain, we end up with what philosophically is known as a “tautology.” A tautology is a circular thinking trap. A description cannot explain itself. Low mood and depression are synonymous; you cannot use one to explain the other.
It’s troubling when doctors use a descriptive category like depression to explain and cannot see this problem of tautological circularity. Using depression to explain low mood is like saying the pain in my head is caused by a headache or my cough is caused by coughing disorder. In psychiatry, therefore, what we are calling diagnosis will only describe, but is unable to explain.
If the rest of medicine were practiced like psychiatry, then when you go to your General Practitioner (GP; this is the UK title for a primary care doctor) because you have a recurrent cough, the GP wouldn’t examine you at all; they would just ask you questions about your cough and then some about your relevant history. They would then pronounce that you have a “Recurrent Cough Disorder (RCD)” and give you a steroid inhaler to take once a day.
The inhaler has non-specific effects and will open the airways, so at least in the short term there would be some improvement in symptoms for many with a cough. However, if you had a chest infection, it will likely ultimately get worse, even though initially you might feel better. Furthermore, long-term steroids can have all sorts of unpleasant and dangerous side effects if taken in sufficient quantities.
If RCD was part of what GPs “diagnose,” then there will always be some patients who will have great faith in it (as their cough did improve and so they want to continue taking the steroids long-term), whereas for others the consequences would have been horrible, even potentially fatal.
But you wouldn’t expect your doctor to behave like that. At the very least you would expect them to listen to your chest with a stethoscope, to seek out signs, and perhaps arrange further tests (like a chest X-ray) if they remain uncertain as to the cause of the cough. In the rest of medicine, diagnosis really matters. It will guide the doctor towards a treatment that addresses the initial cause of the cough.
The failure of decades of basic science research to reveal any specific biological or psychological marker that identifies a psychiatric diagnosis is well recognised. Unlike the rest of medicine, which has developed diagnostic systems that build on a causal and physiological framework, psychiatric diagnostic manuals have failed to connect diagnostic categories with any causes or physical markers. Thus, there are no physical tests referred to in any mental health diagnostic manual that can be used to help establish a real diagnosis.
Despite the belief that psychiatric disorders have a significant genetic loading, molecular genetic research is failing to uncover any specific genetic profile for any psychiatric disorder. Possible genetic abnormalities appear to account for an insignificant percentage of possible associated causal factors, and whatever genetic contribution has been found crosses diagnostic categories rather than having a distinct profile for each diagnostic category.
Similarly, brain imaging studies are coming up empty-handed, particularly once you control for possible learning difficulties. I will later look at some examples from my field of child psychiatry to illustrate how the rhetoric that is trumpeted to the media of “scientific breakthroughs” is at odds with what such research is really finding.
The reason why there are no genetic screens, brain scans, or indeed any other physical tests in psychiatry is that no one can find anything that can act as a physical marker. The evidence cupboard, despite the billions in funding allocated to such biological research, is empty. The most likely reason for not finding any evidence is that there are no genetic or other brain abnormalities causing what we call psychiatric diagnoses.
The development of diagnostic manuals in psychiatry has not followed accepted scientific protocol and instead, the diagnoses that have appeared in them have been literally imagined into being by a few influential (largely male and white) individuals.
Not only does the concept of psychiatric diagnosis lack validity, it is also unreliable. Reliability refers to how likely it is that if you went to different psychiatrists and said exactly the same thing about what problem you had, they would agree on what your “diagnosis” is.
Analysis of these reliability studies finds that there is no psychiatric diagnostic category for which reliability is uniformly high. Ranges of reliability have been found to be broad, and in some cases ranged the entire spectrum from chance to perfect agreement, with the case summary studies (in which clinicians are given detailed written case histories and asked to make diagnoses—an approach that most closely approximates what happens in clinical practice) producing the lowest reliability levels.
In 2013, the Diagnostic Statistical Manual fifth edition (DSM-5) was published by the American Psychiatric Association. It is a huge money-spinner for them. In the DSM-5 field trials, measures of reliability were uniformly poor, with some common diagnoses such as Major Depressive Disorder and Generalised Anxiety Disorder having levels of inter-rater agreement so poor that diagnosis was determined more by who was doing the diagnosis than by what the problem was.
In summary, then, psychiatric diagnoses are not valid (cannot explain), have low levels of reliability, and are not even “diagnoses.”
What Is the “Normal” to Which We Are Comparing Our Behaviour and Experiences?
How do we arrive at an understanding of “normal”? This is a crucial question. Our classification of behaviours and experiences considered disordered relies on an idea that the person’s presentation sits outside an imagined normal. How is this defined, by whom, and in what context?
We are not talking here of conditions that can be measured in the same way as the functioning of kidneys. Kidneys don’t have dreams, ambitions, fears, and existential dilemmas. Mental health involves all these subjectivities that relate to our understanding of what it means to be human.
Let’s take the idea of the “self” for example. Where does it reside? Is there such a thing as a “true self”? If so, how do we find it and what does that mean about those experiences and behaviours that we do not consider part of that true self? Do they then not belong to us, have nothing to offer us, and should be something we try to get rid of?
Philosophers, theologians, sociologists, anthropologists, and many others have been grappling with these questions for millennia. These “technologies of self” have emphasised all sorts of phenomena that are thought to shape how we experience and understand our being in the world. From the invisible hands of the supernatural forces of ancestors and gods, to the structures of social power that tell the public what the normal/common sense should be, to the potential for agency and resistance individuals have to dominating beliefs. We cannot escape subjectivity in our attempts to understand subjectivity.
Because of this, the ways we think about the nature of the self are not fixed, but fluid and changeable, with different cultures and different times having different ideals through which to interpret and understand our experiences of self. For example, general tendencies that shape Western compared to more Eastern ideas about the self can be contrasted (Table 1):
Table 1: Contrasting tendencies in technologies of the self
|Control of emotions||Emotions experienced|
|Differentiated (classified) humanity||Common humanity|
These are not absolute positions (as we are at risk of stereotyping when we turn these into totalised realities), just tendencies that are more prevalent and thus likely to influence the ideas that different populations grow up with.
We can also see how cultures approach the self and personal problems by looking at the words they use to describe phenomena. I am half Iraqi (my father is from Iraq) and grew up there until I was 14 years old and so have some familiarity with Arabic—the main language spoken.
There is no direct Arabic word that means “mental,” let alone a concept of mental health. There are several words that could be used for the concept of mental; perhaps the closest is the word “nefseeyah,” which approximately means soul-self (in translation from Arabic back to English it’s also not easy to find an exact word). This word has roots in the word “tenafos,” which means “to breathe.”
Can you already see that concepts of self and mentalising draw on different roots? The common word for “madness” in Arabic is “majnoon” whose roots lie in the word “jinn,” which refers to supernatural spirits and implies a possession state; whereas the English “madness” derives from “mad,” which also means angry.
In the West we tend to think about the self in more logical, rational terms, often using the language of science, and we believe psychology to be a branch of science (because it uses the language of research and numbers) that helps us understand the human condition. Problems of the self (what we in the West call “mental health”) are then dealt with by experts who use this language of science and logic. It would be strange in Western media to turn to a priest or imam to explain a patient’s suffering in religious/spiritual terms.
Western scientific beliefs have shaped our understanding of the self, out of which psychiatry and psychology create definitions of the abnormal. What we see come out of that is a focus on the individual as an entity that is separate from her context, with the idea that what is going wrong can be located as belonging to that individual (whether psychologically or biologically).
This going wrong is thought of in material scientific terms—in other words, as something that can be understood by applying the same principles we use for the natural sciences. This way of thinking assumes we can shed light on experiences/behaviours considered “abnormal” by measurement and experimentation to understand the rules that govern our individualist biology and psychology. Thus we use words such as “psychopathology,” “dysfunctional,” “dysregulated,” “disordered,” and so on to describe and classify mental phenomena considered to be problematic.
Many consequences flow from this way of trying to understand the “normal” and “abnormal.” For example, it results in an obsession with classifying as a starting point for making sense. The process we use starts with analysing the individual for signs of “psychopathology,” “dysregulation,” etc. and then uses these to slot them into a “typology” (which we, as I have discussed, mistakenly call a diagnosis).
The methods we use also valorise logic and thinking and sees emotions as an obstacle to a rational way of living. Thus, much of psychiatric and psychological technology is suspicious of what emotions do to us and uses interventions whose raison d’être is ultimately the control of emotions.
Another consequence of this way of constructing “what it means to be human” is that we have outlined, classified, and advertised all sorts of ways that humans can go wrong mentally. In our psychiatric diagnostic manuals, the number of diagnoses that we can give expands with each new edition, as do the boundaries for diagnosing these disorders. This creates a sense of vulnerability for all of us, as disorder is felt to lurk around every corner.
The extended media coverage of a proposed mental health epidemic, quoting abstract figures like “one in four,” anti-stigma campaigns, and the special pleading Royal Colleges like mine (the Royal College of Psychiatrists) make for parity with physical health and more funding and without pointing out the definitional and outcome issues I am highlighting, all add fuel to the fire of panic and the belief in our individual mental fragility and vulnerability.
How we conceptualise the human condition and its problems cannot be separated from powerful forces that shape our subjectivity. Philosophers and sociologists refer to this as “social construction.” Our understanding of how the world works, and how we work within it, is built up by the stories we are exposed to and how they interact with our real-life experiences.
In that way of understanding, our psychology is the meeting point between our embodied experience (we are after all biological beings with hormones and instincts too) and the experience and messages we receive from our social world. We do not have access to infinite ways of making sense of this experience, but will inevitably draw on the sense-making efforts of those we grow up with and other influences we are exposed to (such as the media).
In any society at any one time, there will be a variety of ways available to make sense of any dilemma, but some will be more dominant than others. Those with more power to sell their version of reality will have more influence on what that dominating story will be.
Just as we socially construct what we consider to be a normal, healthy individual and, by implication, what a disordered one looks like, we also socially construct childhood, growing up, and what we consider to be good parenting. As with how we construct the self, the choice of construct we use has consequences in what we notice, how we notice, and what we then do. In Table 2 you can see some of the differing tendencies in child-rearing approaches contrasting Western and some Eastern philosophies.
Table 2: Contrasting tendencies in child-rearing philosophies
|Control of behaviour||Harmony|
|Material orientation||Spiritual orientation|
|Short infancy||Long infancy|
|Long childhood||Early adulthood|
Broadly speaking, differences between Eastern and Western approaches to children is that in many Eastern cultures, infancy tends to be more prolonged with little expectation that the infant will demonstrate independence and make choices, but with adult-like responsibilities (for example caring for younger siblings and running errands for the family) arriving earlier.
Thus, in Western cultures, the search for evidence of independence, self-reliance, and self-control starts more or less as soon as you are born. In Eastern cultures, you are more likely to encounter more immediate gratification of perceived needs and an encouragement towards emotional dependence with the child. As the child grows older in Western culture, independent thinking, verbal communication, and overt emotional expression are encouraged.
Physical labour and the acceptance of duties and responsibilities do not occur until much later in Western as opposed to many non-Western cultures, to the extent that a new phase in children’s development emerged, a phase between childhood and adulthood, which we call adolescence. In many Eastern cultures, adolescence as a clear life stage with its own culture is not as apparent, with duties and responsibilities, as well as an early introduction to spiritual life, already apparent before the onset of puberty.
Western culture focuses on behavioural control and expectation of demonstrating rational decision making much earlier than in most non-Western cultures. These are just a few of the differences you may encounter and they each have their consequences in how we understand and respond to children’s behaviours.
Psychiatry, Society, and the State
Psychiatric logic has regularly reflected the social dynamics of the society it originates from. As the field of psychiatry developed at the time of colonialism and slavery, it’s not surprising that racist beliefs and practices have been infused into its concepts.
By the end of the 19th century, it was an accepted belief that members of the “African” races had smaller brains, as well as a more natural instinct for physical labour, and were psychologically primitive compared to members of the “European” race. “Drapetomania” was the diagnosis used for the supposed mental disorder that caused Africans to flee from slave captivity. Civil Rights movement leaders and protesters in the 1950s and 1960s were often labelled as mentally disordered due to their supposed “pathological” reaction of emotional disharmony, hostility, and aggression.
The history of psychiatry reveals an appalling role in colluding and popularising prevailing eugenic, racist, and other social trends. German psychiatrist Emil Kraepelin (1858-1926), considered the father of biological psychiatry, whose system for categorising psychiatric presentations is still the basis for diagnostic systems used today, was an ardent eugenicist and racist. Kraepelin complained about a steady increase in psychiatric disorders in civilised people, while arguing that mental disorders remained comparably rare in “primitive” races.
He argued that the effect of large numbers of “idiots, epileptics, psychopaths, criminals, prostitutes, and tramps” who descend from alcoholic and syphilitic parents, and who transfer their inferiority to their offspring, was incalculable. Kraepelin’s pupil and successor Ernst Rüdin (1874-1952), whose influence also continued into the post-war era, also advocated eugenic theories of degeneration, alleging that bad genes entering the gene pool was the main causal factor for the alleged increasing prevalence rates of mental disorders. Kraepelin and Rüdin were both advocates of “racial hygiene,” and came to see people with mental illness primarily as a burden on society.
Rüdin was involved in the introduction of the 1933 Nazi “Law for the Prevention of Offspring with Hereditary Diseases” which allowed for the forceful sterilisation of a range of people, including those with a diagnosis of schizophrenia or manic-depression. This law paved the way for psychiatrists to eventually become involved in the most shameful episode in its history—systematically exterminating their patients.
Nazi-era psychiatrists were instrumental and often enthusiastic advocates for instituting a system of identifying, notifying, transporting, and killing tens, possibly hundreds, of thousands of mentally ill and “racially” or “cognitively” compromised individuals in settings ranging from centralised psychiatric hospitals to prisons and death camps. Their role was critical to the success of Nazi policy, plans, and principles.
Many of those involved were senior professors in academia who sat on the planning committees for developing the euthanasia processes and who provided the theoretical backing for what transpired. They developed the first gas chambers used for mass murder before the plan to annihilate the Jews, Gypsies, homosexuals, and other “undesirables” was put in place. Killing of psychiatric patients was a key mediator in the development of the eugenic logic and technology that facilitated the holocaust.
This legacy of institutionalised and institutional racism still persists today. For example, the higher rates of diagnosis of a psychotic disorder, use of mental health acts, forced treatments, and deprivations of liberty, amongst black patients in countries like the US and UK continues to this day, even though such high rates are not similarly seen in black majority countries in the Caribbean or Africa.
Not only are the concepts used in psychiatry institutionally racist, but in addition, through the process of “psychologisation,” problems that are socio-political become converted into problems that are psychological. The devastating consequences of racism and discrimination, together with the persistent and pervasive inequities in society, are turned into mental disorders needing “mental health care” rather than political action.
Over the past four decades, the mental health industrial complex has continued to oppress disenfranchised populations while benefiting from billions in revenue through individualising and psychologising their mental suffering.
Homosexuality was a disorder right up until 1973, when it was narrowly voted out of the American Diagnostic Statistical Manual (DSM). Out of the 17,910 eligible people to vote in that decision, the vote was 32% in favour of removal from DSM, 21% against, and 47% not voting.
Prevalence of psychiatric disorders also shows an inverse relationship with social class. In addition, the greater the level of inequality in any society, the higher the prevalence of mental disorders. I haven’t even started on gender.
We cannot escape the socially constructed nature of the territory that adult and child mental health ideologies have carved out for themselves. The theories and practices that developed in the dominating professions of psychiatry and psychology have not arisen out of a scientific endeavour that has shed new light on the workings of the brain and/or the mind. They are an encapsulated, jargonish version of the Western folk psychology of the time with immense power, as socially respected professions, to shape the way we understand both the normal and the problematic, with all the consequences that arise from their preferred social constructions.
I no longer use the misleading language of these fake pseudo-sciences. “Normal” and “disordered” are subjective and problematic terms. In practice, we create rather than discover a disorder by the way we choose to talk about and classify what patients bring to us. Instead, I use the two terms, “ordinary” and/or “understandable,” as my preferred constructs. Just about everything I have seen over my thirty-odd years of working as a psychiatrist can easily be captured by those two starting point words.
Next week, we continue this discussion with Part 2 of Chapter 2.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.