One of the defining features in the socially constructed mental disorders in the DSM is the concept of “impairment.” In order to get a diagnosis for certain mental conditions, significant distress or disturbance in functioning in certain areas of life is required. Functional impairment may seem like a clear criterion on the surface, but in practical application, it is not in the slightest.
Some important questions to consider are: “Who defines the concept of impairment?” and “How is clinically significant distress analyzed as a construct?” Impairment itself is subjective, and the amount of discourse this topic has in the mental health system is sorely lacking considering its importance in clinical settings.
When is someone impaired in functioning? If the client gets to decide when they are impaired, answering the question is entirely in their hands. However, as happens so often in the mental health system, this is defined by other people: parents, clinicians, courts, employers, and so on. Rather than the client seeking therapy, medication, or hospitalization when they feel it is the right for them, others decide that they “need it.” This is where a lot of damage starts.
A parent may see that a formerly high-performing child is experiencing distress from inescapable bullying at school and thus avoiding going on certain days. The parent hires a mental health practitioner, keeper of the social order, to look for signs of distress and impairment in the child. The practitioner determines that the child is experiencing shame, sadness, and a decline in adherence to their scheduled activities. The practitioner then diagnoses them with Major Depression. The diagnostic paradigm encourages people to see the child’s behavior as being caused by illness, rather than understood as an adaptive avoidance of oppression. The child is pathologized, reeducated, and potentially drugged, made to see themselves as ill for not upholding the order that their parents may desire for them.
A clinician may be brought a person who is dressed in a manner society considers bizarre. The person believes grandiose about things themselves which the clinician thinks are untrue and culturally inappropriate. The person being assessed treads off the beaten path, engages in copious intercourse, and upsets some people with their brazen nonadherence to social conditioning. They may feel perfectly comfortable with their personality, but the clinician views them as a manic individual to be reeducated and drugged into normalcy.
A family member may see someone close to them begin to hear voices which are not real and then withdraw from social events. In an environment where society can define impairment, the voice hearer’s withdrawal is viewed from the family member’s point of view as an impairment in social functioning rather than from the voice hearer’s point of view as a step back from society to process their thoughts. The voice hearer is pathologized as a psychotic individual to be locked away and drugged into a being that the family member and clinician perceive as functioning in a more normal way.
Police of an oppressive state may discover an underprivileged individual trapped in exploitative or otherwise abusive circumstances is thinking about suicide. Instead of engaging with the individual and trying to understand the situation, the police force the suicidal individual into a locked ward to be given coercive treatment. Consensual dialogue is not considered viable, as the suicidal individual has been unpersoned. They are overseen and incarcerated by people with biased motives, denied almost all human rights. Their situation is not fixed by their arrest; in fact, it may get even worse, as they can fall behind on obligations foisted upon them by the social order. They are, however, coerced into behaving in a way their keepers find satisfactory for long enough to be released. Suicide, in the eyes of the government, is always irrational and wrong; policies penalizing it must be enacted, regardless of the effectiveness of those policies.
Every person previously listed is a complex being with their own concepts of healthy behavior, correct decisions, and the role of experience in a greater social context. The individuals subjected to coercive treatment may be experiencing very real distress leading up to it, but view the role of their distress differently than those around them do. For a variety of different reasons, individualizing and pathologizing people’s behaviors can bring comfort to mental health practitioners, family members, and society as a whole. Untangling a web of cruelty, oppression, and trauma is more difficult than neatly categorizing and drugging people in an attempt to fix them as individuals while ignoring the problematic structures they are immersed in.
Puritanical, strict norms about what is considered acceptable thought and behavior have been a consistent issue with mental health treatment. When used as a form of social control, toxic countertransference becomes evident: the client is no longer a person with self-determination, but the embodiment of an illness in need of reeducation and drugging. International human rights and treatment guidelines have lacked importance to those in charge of regulating the psychiatric system, as people who think and behave in certain ways must be made “healthy” according to what society defines as normal. Innocent oppressed or eccentric people are “insane,” and thus are subjected to the “sane” man’s burden to correct them.
There have been many criticisms of the mental health system throughout the years, but many of the most striking ones boil down to the concept of impairment, who defines it, and how to address it. The use of psychiatry as social control has been contentious for decades, and the debate becomes ever more relevant as increasing numbers of people are being subjected to coercion. Am I impaired when I say so, or when you say so? And if it’s when I say so, do I get to define the limits and nature of that impairment, or do you?
When faced with criticism about people other than the patient defining impairment, defenders of psychiatric coercion often bring up increasingly “extreme” examples which are not representative of typical victims of coercion. Before addressing these extreme examples, it is important to stop and ask if such extreme examples are simply being used to justify the widespread use of psychiatric oppression in cases that have no resemblance to what is presented. However, even in such “extreme” cases, rarely does the person bringing them up address what steps were taken before resorting to coercion.
For example, they may talk about an individual in an apparently altered state of mind who is yelling about how he is going to kill himself because the government is after him. He believes killing himself is the only way to get the government to stop being after him. This, to the coercive psychiatry defender, is a situation where forcibly locking him up and drugging him would surely be appropriate. However, the critic would stop and say: what else can be done here? A man has a potentially life-threatening misconception; how can it be managed or corrected?
I have talked to such a man in a life-threatening delusional episode myself. I was also the alleged government operative that he believed was out to get him. He was yelling that he would kill me by killing himself. Your standard coercive psychiatrist would call 911 here; I did not. I was patient. I insisted he would be fine. I continued talking to him and distracting him. It took some patience, but he got through the emergency eventually. It took maybe 10-15 minutes of talking, and he calmed down and woke up fine the next day. This worked by treating him as a man with a misconception who could be reasoned with, rather than an embodied illness in need of psychiatric control whether he wanted it or not.
Losing patience with someone who is acutely distressed or disturbed is never the right way to handle a situation. There are always better means, such as starting by simply talking to the person. Plenty of people, all over the world, talk others down from immediate life-threatening situations without arresting those people into wards or drugging them. Having policies authorizing force in place merely terrorizes people or prevents them from opening up. Treating people with extreme distress, or even dangerous misconceptions about reality, as fully human and able to be reasoned with is the most humane way to go about things, even in life-threatening circumstances.
Forced hospitalization and forced drugging are examples of toxic countertransference for this reason: People are disturbed by someone’s thoughts and behaviors, so they lock that person away and drug them into compliance. It has nothing to do with beneficence towards the distressed individual; it is about out-of-sight, out-of-mind social control. They assume that people with extreme emotions and sometimes misconceptions are too ill to be reasoned with; that ableist assumption propels them to justify things they would otherwise consider to be crimes against humanity.
To be truly humane, the distressed person’s experiences, desires, and wishes should always be centered. Treating people, even people with dangerous misconceptions, as fully human and not “too impaired” to be reasoned with is always the best way to go. It would be helpful if, instead of defenders of coercive psychiatry concocting imaginary and increasingly extreme scenarios to defend the status quo, they would address the fundamental problems with their premises. Once you challenge their ideas, they tend to move the goalposts further and further into hypotheticals that never occur in reality or are so rare they have no relevance to standard clinical practice. Their opinions only thrive by completely ignoring the mass-scale violations of bodily autonomy that are occurring.
Regardless of whether one buys into the pathological paradigm regarding distress and delusion, humanizing therapeutic methods should always be used. It’s a framework that has consistently aged well, and one no one would look back at in a few decades just to wonder how humanity went so wrong. People look back and say they cannot believe how lobotomies used to be done, and they are likely to look back not believing the forced hospitalization and drugging of today used to be done. However, no one would ever look back and say, “I can’t believe you treated that suicidal person like a human and reasoned with them to deescalate the situation.” Thinking about everything in healthcare, especially psychiatry, in a broader historical context can help to increase understanding and vision for the future.
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.
Mad in America has made some changes to the commenting process. You no longer need to login or create an account on our site to comment. The only information needed is your name, email and comment text. Comments made with an account prior to this change will remain visible on the site.