Psychiatry employs a biomedical model of disease to define madness. It does so because it reflects a scientific and philosophical tradition of ideas about human nature which are deeply rooted, and focus on the assumed mechanistic characteristics of the material body. This has meant that, in western cultures and societies, madness has been seen as a functional disorder of the brain. The brain, therefore, is the presumed site of an organic failure, which needs to be rectified through organic means. In light of this, the use of physical treatments, such as medication and ECT, seem perfectly appropriate methods to apply to a person whose brain has failed to function as it should do.
There is no scientific or medical evidence to support this assumption about the nature of the brain, or that its malfunctioning causes madness. It seems a perfectly logical conclusion to make when the body is seen as a collection of major and minor organs which do malfunction. There is a fundamental difference, however, between the evidence for heart disease, lung disease, or brain tumours, and the lack of evidence of brain malfunctioning when madness is diagnosed as a psychiatric disease. The evidence of organic failings in the major organs of the body, and the application of the model of disease, has led to spectacular medical advances in both the theory and practice of western medicine. However, this is not, and cannot be, the case in relation to understanding madness, and mental health in general, because madness is not an organic disease.
The notion of disease is critical in defining health and illness, and separating them into opposite conditions of human nature. The evidence for the existence of disease has to be deterioration in the functioning of the affected organ, which can be detected and seen. The observation of the disease is a crucial component of the diagnosis, and the development of sophisticated technology in western medicine has enhanced this capacity to both diagnose and treat physical illnesses. Mental illness, however, cannot be observed through a physical examination of the body, and no sophisticated technology can be designed to discover physical symptoms of madness in the brain.
The brain and mind are not synonymous. Whilst one brain looks very much like another, each person develops a mind of their own. The brain can be seen, physically examined, and operated on, whereas a mind is not visible. In fact one of the major stumbling blocks in the observation of madness is that there can be no physical evidence to prove the state of mind. The absence of observable organic symptoms requires the person experiencing their emotional or psychological distress to explain what is wrong with them.
A state of mind is difficult to explain. But it becomes a lot more straightforward when the idea that the mind is a physical object to be examined is no longer assumed. The brain can then be set aside as a malfunctioning cause of madness, and the examination and analysis can proceed, with an attempt to understand the complex content of the mind. The focus would then shift to understanding the reasons for a person’s feelings, thoughts, and actions, and why they are deemed to be mad.
The western scientific and philosophical tradition has emphasised the critical importance of reason as a conscious human characteristic, which distinguishes a human being from an animal. The application of reason is proclaimed in western cultural traditions to represent the apogee of civilised society, facilitating the most effective and efficient organisation of a society, its knowledge, its institutions and its governments.
This application of objective, scientific reason to the organisation of society and its institutions during the nineteenth century is exemplified in the emergence of psychiatry as a specialised branch of the medical profession. The largescale industrialisation of society resulted in the creation of factories, prisons, workhouses, and asylums. The asylums and workhouses accommodated the designated mad or poor people respectively, because they were deemed unemployable. Medical doctors were employed in the asylums as the physical needs of the inmates were recognised. The separation of people diagnosed as mad from society gradually reified a difference between the sane and the insane, based on their confinement rather than their state of mind, and the asylum doctors assumed the mantle of specialised experts, giving birth to psychiatry as a branch of medicine.
The elevation of reason as the key component in the conscious creation of social, economic, and political institutions, such as psychiatry as a branch of medicine, seems somewhat misplaced, however, because different and often opposite ideas are seen to be reasonable. The aspiration to create a capitalist, socialist, or a communist society, for example, highlights the impossibility of a collective agreement on what is more or less reasonable. Reason, therefore, is defined and agreed upon in any given society, determined by the dominant attitudes, values, and beliefs of those with the political, social, and economic power to do so in each culture and era.
As medical science developed in the nineteenth century, so doctors became the profession with the power to distinguish health from sickness. The concept of disease was an essential component of this process, and it became a foundational building block for the profession, and the discovery of more diseases followed inevitably as a consequence. This process of continual medical discoveries, once ideas take hold, is evident both in general medicine, and in the creation of the Diagnostic and Statistical Manual (DSM), which reflects the ever-expanding number of psychiatric diagnoses and psychological disorders. The creation of this Manual has firmly embedded psychiatry as an integral branch of medicine in the powerful western tree of scientific knowledge.
The choice of the term “Manual” for this body of knowledge seems apt, because it confirms the assumption that it incorporates diagnoses as descriptions of “disorders” in a biological machine. Its claim to identify specific diseases and disorders according to objective criteria, based on reason and scientific fact, can only be speculative at best. This is because there is general acknowledgement, even amongst psychiatrists, that there is no definitive explanation for any diagnosed mental illness. Even the proponents of the Manual accept that it is created by consensus of opinion, and that there are no objective tests for the “illnesses” described in it. It is not logical or reasonable, therefore, to claim it is based on scientific fact.
In the nineteenth century reason became the hallmark of science and philosophy, which harnessed logic, objectivity, and truth to create a way of thinking which has come to be seen as normal. The opposite of thinking rationally is to think irrationally, and so it is no surprise that madness became defined as being irrational, not only in thinking, but also in feeling and behaving. To be rational, therefore, was incorporated into medical terminology as the gauge for the right way of thinking, and a benchmark for the psychiatric diagnostic separation of normal from abnormal people, and the sane from the insane. Whilst the medical profession adopted reason as its indicator of sanity so the legal profession adopted it as a means of separating criminals from non-criminals. However, whilst this attempt to distinguish between the medically mad, and the legally bad, person seems useful as a means of trying to create distinct rational medical and legal “systems”, a definitive dividing line is impossible to draw.
Just as the diagnostic criteria for the various categories of madness are culturally determined rather than scientifically based, so laws are similarly determined by those with the power and authority in society to do so. The criminal justice system defines “acting rationally” as “following the agreed-upon laws of society”. Criminals are, therefore, acting “irrationally” by definition, and consequently ought to be punished. Yet the inequalities that plague the implementation of laws, such as the racial bias in sentencing and enforcement, demonstrate that what society considers “irrational” enough to punish is dependent on subjective, cultural factors.
Psychiatric diagnoses are based more on agreed opinion than objective reason, and laws similarly are not really based on “reason”, but on agreement among the powerful. A rational argument, for example, could just as easily support breaking the law, especially if the law is seen by many to be unjust or harmful. There are many historical and contemporary struggles for changing the laws on human rights, which illustrate how laws supported by those in power do change, as a result of active protest and defiance. Active protests against the apartheid regime in South Africa, against laws prohibiting abortion, against racial injustice, in favour of a woman’s right to vote, and against the criminalisation of homosexuality, exemplify some of these challenges to discriminatory and unjust laws.
Reason depends on logic to justify an argument, and so discriminatory laws and psychiatric diagnosis and treatments are justified by those who create and dispense them. It is logical, for instance, to administer drugs to “cure” a person’s madness, if it is deemed to be a result of a chemical imbalance in their brain. Other physical treatments of madness, such as ECT, follow the same logic. But these logical propositions only work if we grant the assumptions of the premise. If we do not agree with the premise that the brain is chemically imbalanced (and there is no evidence that it is), then it is only logical to argue that medication cannot target the causes of madness.
Reason and objectivity are critical components of scientific thinking, and these provide the “truth” of the psychiatric theory and practice, and the rationale for its diagnostic criteria. They also cement the “truth” that is the foundation stone of criminal justice systems around the world. However, “truth” also depends on who is telling it, in whose interests, and for what purpose. Objective truth might be an aspiration, but impossible to achieve, when trying to create objects from people’s subjective experience. Science, however, depends on creating objects in order to achieve its aim of objectivity.
A human being is, therefore, assumed to be like a machine, comprising mechanisms in the brain, including one designed for reasoning. This reasoning mechanism is assumed to enable us to argue, evaluate arguments, and create objective truth. The mechanism is credited with human evolution and intelligence, which are manifested in advances in western civilisation, including technological inventions and innovations, space exploration, moon landings, transplant surgery, and so much more.
But the body and brain are not machines with mechanistic characteristics and attributes. The application of reason as a human attribute is meaningless without the many other characteristic attributes required to have and develop ideas. Without imagination, for example, the ideas would not exist and without intellectual ambition, emotional desire, and dedicated physical and mental effort no material advances or achievements can be effected. Similarly, the great works of art, music, and literature depend on the application of learning and high levels of technique and creativity, including inspiration and imagination. Reason alone, therefore, cannot furnish a comprehensive understanding of the mind, because its content cannot be dissected into meaningful and separate components of a person’s brain.
The notion of madness has never fitted comfortably with medical science, because there is a fundamental difference between the physical nature of an observable disease and a person’s state of mind. The idea of disease is consistent with the notion that the body is mechanistic. When a diagnosed condition occurs, the ostensible machine has malfunctioned, and requires some physical treatment. However, reducing the body to the sum of its parts is not always helpful, even when trying to understand the causes of a physical illness, because the body works as a whole. The state of a person’s mind can be both a factor in the causes of physical illnesses, in relation to stress for example, and in the outcome of the medical treatment. Whilst the application of reason is largely useful, therefore, in diagnosing and treating physical illness, because of its focus on the material body, there are no organs at fault when madness occurs.
The role of psychiatry in western societies has come to shape and define madness as the object and subject of its expertise. The creation and continual updating of its DSM is a testament to the consolidation of its power as a profession, and its importance in defining what constitutes a normal and an abnormal state of mind. The irony of the attempt to reduce the complexity of the human mind to the DSM compendium of madness is that its size, and the number of diagnoses and conditions it tries to define, reveal the impossible nature of its objective. Whilst the definitions are supposed to provide some certainty and reasoned argument to the existence of the diagnoses and conditions, it cannot achieve its ambition, because it has no definitive explanation for the madness it claims to define.
The historical path to power which psychiatry has taken is exemplified by the expanding nature of the DSM. It signifies the profession’s increasing hold on the western consciousness, and the textbook has enshrined and institutionalised psychiatry’s knowledge to such an extent that it seems essential for the whole world to absorb the “truth” of its theory and practice. Like the bible of the Christian missionaries, who “persuasively” operated as the religious justification for the European colonising powers in the nineteenth and twentieth centuries, so the DSM can colonise for western psychiatry the mental health of the world’s population.
The powerful role of psychiatry cannot be underestimated. As the arbiter of normality and sanity it can be used as a means of trying to make people comply with a set of attitudes, values, and beliefs, which comprise what it is to be normal. It can be used politically, religiously, or socially as a tool of persuasion, dissuasion, or oppression, on a collective or individual scale. It has huge advantages, therefore, in all societies, but particularly those that feature repressive political or religious regimes, as a means of enforcing compliance, and eliminating any opposition and independence of mind.
Whilst psychiatry can be used as a tool by those in power, it also reflects the dominant attitudes, values, and beliefs of a society. The madness psychiatry has defined in western cultures, therefore, has reflected the dominance of white, male Europeans and North Americans. Hysteria, for example, had been typically applied to women by men in ancient Egyptian and Greek cultures, before it was incorporated into the western lexicon of psychiatric diseases in the nineteenth century. This long western tradition of female susceptibility to madness was extended and reinforced, as their madness was diagnosed as a consequence of their lack of control over their feelings, thoughts, and actions. The dominant patriarchal belief was that this absence of self-control required men to exercise control over women, through their natural superior intellect and capacity to reason. Although the notion of being hysterical remains in use today as a description of someone, usually a woman, losing self-control, the diagnosis of borderline personality disorder is the modern equivalent. This diagnosis is defined as being “emotionally unstable” and “acting without thinking”, and is typically ascribed to women more than men.
The enslavement of Black people by the European colonisers required political, social, and economic justification, as the product of unreasonable and immoral notions of white male superiority. Psychiatry also reflected these unreasonable and immoral premises in its creation of a diagnosis of drapetomania, which it ascribed to “enslaved Africans fleeing captivity”. This idea reinforced the scientific racism, which was encapsulated in theories of evolution and eugenics, as well as psychiatric diagnostic ascriptions, throughout the nineteenth and twentieth centuries.
The ascription of schizophrenia to Black men and women from the 1960s, particularly in Europe and North America, is also testament to the inherent bias and diagnostic disparities in psychiatry, as in society generally. The first antipsychotic drugs were marketed using racist imagery as tools to tranquilize “aggressive” Black men. Even today, Black people are three times more likely to be involuntarily hospitalized than White people, and more likely to be subjected to a higher dosage of antipsychotic medication.
The lack of any clear definition of biological symptoms of psychiatric disease has been replaced with the DSM’s extensive categorisation of mental illnesses and psychological conditions, which suggests there has been scientific refinement and confirmed exactitude. But it is the lack of precise definition which facilitates the infinite number of conditions and disorders which multiply with each edition, thereby extending its reach into the minds of more people. This extension of psychiatry’s reach is evident in the research into, and diagnosis of, mental health in both adults and children.
The diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) in children in the USA and the UK is proving to be an important extension of psychiatry’s reach into the minds of children. It has resulted in a redefinition of childhood behaviour previously accepted as normal, and represents psychiatry’s attempt to apply a notional scientific standard of reason and normality to a child’s behaviour. But it presumes there are criteria for social compliance, which the child diagnosed with ADHD is disobeying. It also fits in with the belief that, if adults develop mental illnesses, then so must children who will have early symptoms of illnesses, yet to be discovered, such as bipolar disorder and schizophrenia.
The discovery of psychiatric symptoms in children mirrors that in adults. The social and medical consensus of what characterises normal feelings, thoughts, and actions provides the yardstick for diagnosing what is abnormal. The description of symptoms for ADHD in children, therefore, includes, “inattention in a classroom”, “trouble organising tasks and activities”, “avoiding or disliking schoolwork or homework”, “losing things necessary for tasks and activities”, and being “easily distracted”, or “forgetful in daily activities”. These are clearly subjective observations and judgements, rather than objective descriptions of a child’s behaviour, and it is difficult to believe they can be taken seriously, as reasonable and scientific facts
The treatment for ADHD is primarily medication, which is prescribed “to help children manage their ADHD symptoms in their everyday life”, and to “help them control the behaviors that cause difficulties with family, friends, and at school”. Stimulants are the most widely prescribed medication, and it is claimed “between 70 to 80% of children with ADHD have fewer symptoms when taking these fast-acting medications”. It is hardly surprising that this early diagnosis of madness in children has opened up a whole Pandora’s box of diagnosed psychological conditions in children, such as paediatric bipolar disorder. The impact on children of the consequent mass prescription of powerful stimulants, antidepressants, and antipsychotic medication is a terrifying prospect.
Diagnosing one child with ADHD implies their mental health can be compared with other children in the same school. But there is no objective standard of normality which can be applied to a child’s feelings, thoughts, and behaviour, and comparing one with another typically leads to stereotypical and subjective bias, especially in relation to gender, race, and sexual orientation.
The racial bias in relation to Black men as “aggressive” exists also for children, and so there is a much higher rate of Black than White boys being excluded from classrooms and schools, because they are seen as, and are often expected to be, more disruptive, defiant, and disobedient. The assumption that psychiatry does have objective, rational criteria for the assessment of children consolidates its institutionalised power and authority further.
The assessment of a child’s mental health in school must inevitably extend psychiatry’s influence into the home, because the parents of each child diagnosed with ADHD, or other psychological condition, will be involved in any treatment plan. Their skills and knowledge as parents will be evaluated as a consequence.
The institutionalisation of psychiatry in society as the arbiter of normality in the education and home-life of children is also increasingly reified in the criminal justice systems. Its role as the arbiter of good and bad in relation to a child’s behaviour is mirrored in its responsibility for diagnosing criminal insanity in children and adults. This is a critical role as it reifies its responsibility for drawing the distinction between mad and bad in society. This entails distinguishing between whether a person is conscious of their actions, for instance, in murdering their victim, or whether they were “insane” at the time. The psychiatrist is entrusted with determining whether a person’s actions are rational or irrational, and whether or not they were in conscious control of their feelings, thoughts, and actions at the time they perpetrated their crime. The ultimate arbiter of this is the judge, but the psychiatrist’s opinion carries the most weight as to the person’s sanity and rationality.
The judgement of whether a child or adult is medically or legally sane or insane is subjective rather than objective, because neither psychiatry nor the law can define either definitively. Only generalised psychiatric and legal opinions can, therefore, be applied, based on diagnostic and legal criteria, and so consistency is impossible to achieve. The subjective nature of the decisions means that bias in individual professional judgements is inevitable, in addition to the bias reflected in the dominant values and beliefs in society. Each judgement of a person’s madness or criminality depends on an interpretation of their state of mind from an evaluation of their expressed feelings, thoughts, and actions, and of the attitudes, values, and beliefs which fuel them.
The complexity of the person’s state of mind, which is judged as mad or bad, ought to take into account the contribution of their unconscious content, and its meaning in relation to their conscious mind. But feelings and thoughts consigned to the person’s unconscious content are not, by definition, easily accessed, or indeed recognised, by the professionals making their judgments of madness and criminality. This is a crucial omission when a judgement is made, and distinctions drawn, as to the person’s state of mind, because the strength of unconscious feelings and thoughts are typically manifested in their behaviour.
The dominant biomedical perspective in practice means that the diagnosed patient has great difficulty in challenging the legitimacy and accuracy of the psychiatrist’s expert opinion. Similarly, the patient’s family, friends, and colleagues have no alternative theory which has any chance of challenging that of the psychiatrist. In effect this means that the dominant medical perspective must prevail, because otherwise the person who is experiencing the madness will receive no “treatment”, and the family will receive no support. Only an acceptance of the diagnosis and “treatment” guarantees any available assistance within the mental health system. The patient and their family and friends are, therefore, equally helpless and powerless, when confronted with the institutionalised weight and power of the psychiatric diagnosis and prescribed “treatment”.
This sense of being powerless and helpless, as a family member, friend, or colleague, compounds their own distress at trying to help a person who is in a distressed state of mind. If there was a greater understanding of the reasons for the madness, then these reasons might be more beneficially acknowledged, addressed, and potentially resolved. The reasons, of course, will only ever be exposed through an empathic response to the person from professionals, family, and friends alike. Everyone will have their own ideas on what has gone “wrong”, and so there will be inevitable differences of perspectives and opinions between, and among, professionals and family and friends.
Madness is not an easy state of mind to understand from inside or outside the experience. But if the biomedical model was put aside rather than clung onto as a ready-made explanation, and everyone focused on trying to understand the person’s feelings, thoughts, and actions, which express the conscious and unconscious content of their mind, then there would be a greater chance of generating an agreed-upon, consistent, and helpful response to their distress. This method of response would emphasise the role professionals and family and friends can have in restoring the person’s sanity. It might not be possible to resolve what has driven the person crazy, but at least they would be given an opportunity to express their thoughts and feelings openly, with dignity and respect, compassion and care, and not be dismissed, rejected, and ignored, or stereotyped as foolish, dangerous, and mad.
A positive way forward, however, would require everyone, including the professionals, family, and friends, to put aside their different and conflicting opinions and interpretations, and try to grasp and accept the meaning of their madness from the mad person’s point of view. This would include an empathic response to their feelings, thoughts, and explanations for their actions, rather than imposing opinions on them.
This can often seem an insurmountable challenge because of the complex meaning of the conscious and unconscious content of their mind. However, different opinions and interpretations might be far fewer, and the mental health system potentially more helpful and healing, as a consequence of a collective realization that madness is not an organic disease, that the diagnostic criteria are misconstrued, and the body is not a machine that needs to be repaired or rewired. These assumptions ought to produce a far more positive starting point.
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.