A Diagnosis and Its Damages: Orna Ophir’s “Schizophrenia: An Unfinished History”

I got an advanced reviewer copy of Schizophrenia: An Unfinished History by Orna Ophir (Polity, 2022) because I wanted to see if the conversation around “mental illness,” especially such a stigmatizing diagnosis like schizophrenia, had changed among the professionals of the mental health industry. Ophir is a New York State-licensed psychoanalyst in private practice and also a historian, which proved to be a fascinating combination as far as her latest book was concerned. The first four chapters are full of a historical overview of how priests, philosophers, politicians, “patients” and people in general have wrestled with the set of experiences the DSM has labeled “schizophrenia.”

Such overviews, especially if you’re starting as far back as the Bible, are notoriously difficult to pull off as each topic—from psychoanalysis to religion to each historical figure that plays a key role in the evolution of this diagnosis—could be a book on its own. Ophir covers this ground skillfully, piquing the interests of readers coming from many different backgrounds and disciplines. As a Christian, I would have loved a deeper exploration of “mental illness” and spirituality, particularly because the mainstream seems to think “exorcism” when they hear religion and “mental illness” in the same sentence. Ophir emphasizes that many people who today’s culture would slap a diagnosis on and get into “treatment” were actually considered wiser and/or closer to God than those who did not experience what we today call “symptoms.” She does not go into depth about why such conclusions were drawn then or explicitly explore why our current culture has nearly eliminated such beliefs from its repertoire of explanations for “mental illness,” which is understandable since tomes could be written on this subject alone.

It is worth noting, however, that, while it might be expected for an ever-more secular society would sluff off “overly” spiritual concepts, even modern-day Christianity has largely abandoned the idea that someone who would be diagnosed with a DSM label today might be seen as special or chosen by God in biblical times. The church eventually did start to use “mental illness” as a way to demonize and silence people—mostly women—that threatened their power, like Joan of Arc and Julian of Norwich, but our culture lacks the knowledge that what we call “mental illness” in modern times was at any point associated with wisdom or closeness to God at all. So that was a gem to find in Ophir’s work. And perhaps it’s my job as someone who earned a degree in Christian theology to take that up as a consideration; I’d be really interested in a historian’s perspective as well since the Church does not exist in a vacuum. But I credit Ophir for my realization that the Church, when it comes to “mental illness,” is almost indistinguishable from the culture in terms of wholesale acceptance of the secular mental health “treatment” model, and, as a theologian, I do not see that as self-evident.

Ophir provides a history of schizophrenia as it appears in another “bible,” the diagnostics bible also known as the DSM. She includes the philosophies that shaped each of the five editions of the “diagnostics bible,” which make evident why each edition included and excluded the various diagnoses that it did, but her seeming neutrality toward the DSM and its pathologizing more and more of the human experience comes off as advocacy. It’s also quite a notable omission to not mention anything about the various DSM committee members’ increasing ties to the pharmaceutical industry. It left me curious as to why she wouldn’t mention that at all: did she have to stay silent on the question of Big Pharma in order to get her book published? Did she really not know about these conflicts of interest?

There was very little about medication in this book in general, which is, among other things, revealing of just how taut and fraught the conversation around medication is. Psych meds have known iatrogenic risks, yet it seems that anytime the subject of medication comes up in relation to mental health, disclaimers about not giving medical advice and people need to keep taking their meds as prescribed, etc. are quick to follow. It’s highly unlikely that Big Pharma hasn’t made bank on the diagnosis of schizophrenia in particular since it’s marketed in the United States as well as many other Western countries as lifelong, incurable and thus in need of “management” with medication for decades. Yet there are few peeps from Ophir about the drug industry’s deep influence on the DSM, clinicians’ training and treatment skills, and the broader culture’s understanding of “mental illness.”

Ophir does acknowledge culture differences in how people who hear voices understand and experience those voices. She quotes a “radical” interpretation of the claims of the Hearing Voices Movement (HVM): “if we listen, voices may be heard to tell us more about broken societies than broken brains.” Ophir does not explore “broken societies” further: why do voice hearers in developing countries have less adversarial, even friendly, relationships with their voices while the voices of people who grew up in the American West are more likely to be violent, command violence and berate the voice hearer? Why do voice hearers from developing countries report their voices keeping them safe while voice hearers from Western countries experience their voices telling them to hurt or kill themselves? Similarly, though Ophir states that voice hearing used to be socially valued throughout much of history and the West made it a first-order symptom of disease, she does not delve into why that might be. Of course these are generalizations, but the fact that we can make them, and the reasons why, are arguably more important than what mental health industry experts vote on to include in the DSM, whatever their philosophy or training is.

In fact, if the mental health industrial complex or the clinicians it employs were truly interested in “treating” and “helping” people, wouldn’t they want to know why Americans and those in Western societies have violent voices while the dispossessed world has friendlier, more supportive, even life-saving relationships with theirs, so they could develop more effective treatments? While Ophir’s history of the schizophrenia diagnosis and the DSM’s role in that is interesting, cultural criticism is essential when discussing “mental illness,” especially with such glaring differences in the experiences of voice hearers. Ophir’s book is stronger and richer in terms of the history, which is odd since Ophir is also a clinician, but culture is inextricably tied with history.

But that brings up an even bigger problem: the divide between clinicians and “patients” continues to persist and even deepen, even as the conversation about “mental illness” has started to shift culturally to be more acceptable, even trendy—only for certain diagnoses, of course. Anxiety and depression are trendy to identify as having, people are parading their ADHD on TikTok by the hundreds, and we think we’re “talking about mental health” as a culture. Who’s not in the room? People with stigmatized labels: borderline personality disorder, Autism still to a degree, and schizophrenia. Even in Ophir’s book, people with the label schizophrenia are marginalized just as they are in the culture: their voices show up mostly only in the epigraphs that start each of the seven chapters. And even then, it seems like their voices and experiences are being used as examples of clinical symptoms rather than stand-alone experiences for what they are.

Ophir does acknowledge the importance of shifting from “expertise” to voice hearers themselves, which is already underway and which she attributes largely to the Hearing Voices Movement. She includes a quote from the founder of the movement that provides as accurate a summary of the history she covers in her book as one quote can: “Those of us who hear voices are probably living in the wrong century.” Of course the mainstream medical/psychiatry establishment discredits HVM by claiming it needs more “empirical research.” Why?

She credits HVM with “Caution[ing] against the tendency to systematically medicalize individuals with unique experiences to directly or indirectly force them to change into what they are not (i.e. non-voice-hearers), often with the full weight of the psychiatric, medical and even political institutions backing these questionable efforts.” In its typical pattern of discrediting anything that threatens its business model, the mental health industry unsurprisingly has yet to fully recognize HVM’s claims that voice-hearer is a fully valid identity totally apart from any diagnosis, including schizophrenia.

Ophir acknowledges that HVM has not been “fully validated” but doesn’t sufficiently challenge the system doing the validating, or the cultural influences of this system and the feedback loops that are keeping it in place: the mental health field signals authority by telling us it’s “dangerous” to rely on anyone but an “expert,” making people “earn” official-sounding titles like psychologist/clinician/therapist, requiring higher education and degrees to perform certain tasks they call “treating” “patients” with “mental illness.” Then the mainstream culture, in turn, questions anything outside this realm of what we are taught is “expertise” (which, notably, still involves very little #ownvoices of the people whose experiences are being debated, labeled and, most importantly for the people in charge, medicated and monetized). I again have the question about why there wasn’t much time spent on these dynamics pinning the stigmatization, marginalization, and silencing of people with the label of schizophrenia firmly in place even in a book that does call out stigma and considers ways to reduce it.

Ophir emphasizes the ways race compounds and deepens the stigma of diagnosis in general, and in particular ones that are still seen as “dangerous,” like schizophrenia. She also calls out the weaponization of diagnosis to silence political dissenters, similar to how the church framed those that challenged its power as “mentally ill.” What she doesn’t state is how the DSM has increasingly been creating “spectrums” of diagnosis, which serves to pathologize more and more of the human experience and capture more and more people who may be threats to existing power structures, funneling them into “treatment” and dismissing their legitimate complaints against these very structures. She simply states “spectrumizing” disorders as a fact, missing another opportunity to challenge the structures that use “mental illness” to enforce division and suffering while keeping current power structures firmly in place. She goes into great depth about how various countries have changed the name of schizophrenia; while acknowledging that language is important, changing the conversation is not sufficient and can actually backfire. And she’s right when she says that we can change the name all we want, but what matters is changing how people are treated—if “treated” is not limited to what the mental health industrial complex does but what society as a whole does.

A few final issues with Schizophrenia: 1) no mention of the insane toxicity of psych meds and the harm they cause and how the people experiencing brain-chip “delusions” might not, in fact, be experiencing “delusions.” Elon Musk’s Neuralink literally wants to implant chips into people’s brains in order to merge humans and machines and further the transhumanist agenda. Just saying. 2) Ophir advocates for “better treatment” instead of challenging the idea of treatment itself. This is unsurprising since she’s a clinician and treatment is part of the business model.

Overall, Schizophrenia is a worthwhile read, especially for those that are really interested in history and philosophy as it relates to mental health, if you take it as a pulse on the professional conversation around highly stigmatized labels. Every book has gaps, so, while reading, keep in mind questions like: Who are the people creating these labels that they would have the measuring stick for “normal?” Who benefits from labeling human beings the way the DSM-5 guides us to (or at all)? Why is “normal” a desirable quality even if it could somehow be measured or attained?