TCS Daily


Madness in America

By Max Borders - February 21, 2005 12:00 AM

The passing of Rosemary Kennedy reminds us not only of another stain on the Kennedy legacy, but also of some rather barbaric psychiatric practices that had been acceptable methods of treatment as recently as 1967. That was the year in which Walter Freedman, inventor of the ice-pick method of removing the frontal lobe, executed his last "psychosurgery." Prior to Freedman's last operation, the psychiatric profession had carried out nearly 50,000 lobotomies. Freedman, himself, performed over 3000 lobotomies in his career including that of Rosemary Kennedy in 1941.

It is no wonder that during this period of frontal assaults against the mentally disturbed, psychiatry found a skeptic in Thomas Szasz. Born in communist Hungary, Szasz was all too familiar with stories of political dissidents disappearing into the bowels of state-owned asylums. Like religion, psychiatry could be used as an instrument of control over those whom a majority found disagreeable, or those who simply disagreed. Szasz has thus become a symbol of checks on the authority that psychiatry had claimed for itself -- an authority often shielded by the auspices of government, the ignorance of the layperson, and even the difficulties of unriddling the human mind.

Wikipedia does a good job of summarizing the basic Szaszian position:

        "Illness is defined as an objectively demonstrable biological pathology 
        that affects living creatures. Since mental illness describes undesirable 
        behaviors, thoughts or feelings, there is no objective pathology to observe. 
        The classification of certain behaviors as illnesses is a way of controlling 
        undesirable people in society. By medicalizing their behavior, we give medicine 
        and the state the remit involuntarily to detain and medicate such people 
        to prevent them from behaving in ways society finds intolerable."

In other words, writes Szasz, "mental illness is a myth whose function is to disguise and thus render more palatable the bitter pill of moral conflicts in human relations." Even today, Szasz maintains a view that there is essentially no such thing as mental illness. But what exactly does he mean by this?

In 1984, Orwell's year, Thomas Szasz opened The Therapeutic State with a paragraph that included this sentence:

        "Neurosyphilis...and senile dementia...are conditions in which disorders 
        of behavior, or so-called psychiatric symptoms, are caused by a demonstrable 
        disease, a 'pathology.' However, correctly speaking, these are diseases 
        of the brain, not of the mind.
(My emphasis.)"

Does this mean that illnesses with no observable pathology simply don't exist?

Increasingly -- almost overwhelmingly -- folks in the psychiatric community are coming to acknowledge what philosopher Gilbert Ryle insisted way back in 1948 -- that attempts to find the mind beyond the brain is a kind of error, a search for a "ghost in the machine." In the quotation above, it would appear Szasz is committed to one of two things: a notion of the mind beyond the physical brain; or that manifestations of as yet unobserved brain pathologies are simply "myths" constructed by an authoritarian, psychiatric elite.

Given Szasz's well-known readiness to wield Ockham's Razor against gods, spirits, and neural phlogiston, we might suppose his commitments lie with the latter notion. But while he seems to be dedicated to a materialism of mind, his willingness to call common diagnoses "myths" may reveal Szasz's Cartesian leanings.

Szasz believes the continued use of the term mental disorder is a convenience for psychiatrists to be vague in their diagnoses, and a means for their guild to cling to its power. Jacob Sullum cites Szasz's awareness of the science's materialist turn in the pages of Reason:

        "But as Szasz notes, if 'everything that happens to or is done by human 
        beings is biological, then saying so is a meaningless truism. Attributing 
        mental illnesses, such as addiction and panic disorder, to biological 
        alterations occurring at the 'sub-cellular level' is a parody of the denial of 
        free will, choice, and responsibility.'

Szasz's faith in "free will, choice and responsibility" suggests he may have discarded metaphors of madness only to replace them with chimeras of total human volition a la Rand -- constructs that smack of mind-body dualism. Couple this with Szasz's denial of illnesses not yet fully bridged to the level of neuroscience, and we might be led to ask: will subsequent discoveries of pathological or congenital bases for behavior mean that talk of all mental illnesses will amount to meaningless truisms?

Many would argue that sheering mind from brain creates problems not only for psychiatry, but also for critiques of psychiatry like those found in Szasz's groundbreaking The Myth of Mental Illness (1960). Szasz seems, at times, to echo Descartes who said: "It is only the will or freedom of choice which I experience within me to be so great that the idea of any greater faculty is beyond my grasp."

Even the oft-criticized manual of diagnostic criteria, the DSM, has acknowledged the Rylean turn towards mind-brain unity in its more recent editions -- admitting that the term "mental disorder" is an "anachronism of mind/body dualism." According to the DSM, the term lingers due to its conceptual ease and want of a better replacement. Appreciation for this deep mind-brain connection has begun to challenge our cherished notions of free will -- and such challenges have even leaked into popular culture, as this exchange between Neo and the Oracle in the The Matrix: Reloaded demonstrates:

        Neo: But if you already know, how can I make a choice?

        The Oracle: Because you didn't come here to make a choice, you've already 
        made it. You're here to try to understand why you made it.

But one need not delve into philosophical debates about determinism and freewill to acknowledge that thoughts, moods, hallucinations and behavior are thoroughly dependent upon complex processes in the brain.

And that is why psychiatry, far from eschewing a continued emphasis on biology, seems to be embracing it. In "What is mental illness?" by the American Psychiatric Association, the author writes:

        "The term 'mental illness' is an unfortunate one because it implies a distinction 
        between 'mental' disorders and 'physical' disorders. Research shows 
        that there is much 'physical' in 'mental' disorders and vice-versa. For example, 
        the brain chemistry of a person with major depression is different from that 
        of a non-depressed person, and medication can be used (often in combination 
        with psychotherapy) to bring the brain chemistry back to normal. Similarly, 
        a person who is suffering from hardening of the arteries in the 
        brain -- which reduces the flow of blood and thus oxygen in the brain -- 
        may experience such 'mental' symptoms as confusion and forgetfulness."

The truth is, we understand much more about the complex processes of the brain than we used to. Psychiatry benefits from advances in cognitive- and neuro-science, and vise versa. Indeed, we are no longer able to view all of these as distinct disciplines. As Gazzaniga and Heatherton write in their textbook Psychological Science:

        "Interest in biology permeates all aspects of psychological science, 
        from locating the neural, or brain, correlates of how we identify friends 
        to discovering the neurochemical problems that produced various psychological 
        disorders. Three developments have set the stage for a biological revolution 
        in explaining psychological phenomena: brain chemistry; the human 
        genome; and assessing the brain in action..."

Even therapeutic psychology -- psychiatry's ugly stepsister -- is making the biological turn, and debates over whether psychologists should be allowed to prescribe drugs is heating up.

All this is not to claim that Szasz is mistaken to wonder how a community of practice can be expected to determine a distinct set of criteria for mental illness (even in the absence of direct empirical evidence of an illness's pathology, or given the use of cluster-categories that are often too charitable in their diagnoses). Nor is he wrong to wonder how that self-same community is to establish criteria for what constitutes normal and abnormal behavior while simultaneously respecting people's rights. Even the American Psychiatric Association concedes:

        "Patients sharing the same diagnostic label do not necessarily have 
        disturbances that share the same etiology nor would they necessarily 
        respond to the same treatment. It is therefore critical to understand 
        that the diagnostic terms and categories in the DSM represent only our 
        current knowledge about how symptoms cluster together. We fully expect 
        that, over the coming decades, the DSM system will be radically reorganized 
        as the etiologies of mental disorders become better understood."

But could it not be that vagueness is an inherent aspect of psychiatry, just as the act of judging whether someone is bald is inherently vague? We don't know how many hairs on a head (or lack thereof) mean baldness, but we usually know baldness when we see it. (When we're not sure, we might say someone is "balding").

Language often gives us cognitive placeholders for phenomena that are not readily placed in sets, classes and categories. Mental disorders are among these phenomena. In any case, language -- including scientific language -- is fraught with these sorts of placeholders. Behavior as a symptomatic extension of an underlying pathology is no different. Psychiatry will get better and better at refining this process of inference, and we may become less dependent on metaphor as we narrow the gap between mind and brain.

Recently, I posed the following questions to psychiatric nurse Ann Walker about her experience with the mentally ill:

        "As recently as the sixties, people were lobotomized, etc., because 
        they were simply unusual. What sorts of safeguards are in place to ensure 
        that there are fewer such abuses? What strides (independent standards, 
        criteria) have been set up to ensure that people are not treated or 
        institutionalized against their will -- i.e. that they really are mentally 
        ill and not just difficult or 'immoral'? How much of psychiatric care 
        these days is conducted in tandem with medical treatment?"

Her reply was telling:

        "Whoever is asking these kinds of questions is way out of touch with the 
        current issues in psychiatric treatment. A much greater concern is that of 
        'parity' between physical illness and mental illness in third party reimbursement 
        [Medicare, Medicaid, insurance]. Our society has continued to view mental 
        illness as a character flaw, rather than a biochemical brain disorder 
        (a medical problem). And the mentally ill are far more likely to be inappropriately 
        imprisoned than inappropriately hospitalized."

I am not aware of any brain surgery currently being performed for the treatment of common psychiatric illnesses. The most extreme involuntary treatments that I am aware of would be: hospitalization, medication (I know this requires that at least two physicians sign that there is evidence the individual is a danger to himself or others, and lacking the mental capacity to make an informed decision); ECT (electroconvulsive therapy), far more refined than in its infamous past; tube feedings (done only when an individual's life is in danger). States have different procedures, but all require some judicial approval for involuntary treatment.

If this anecdotal account of the current state of psychiatry is any indication of wider trends, it appears we've come a long way. Szasz is to be commended for a lifetime of work in ensuring that the field has achieved this level of development and good governance -- and continues to improve. His emphasis on individual choice and ethics will be crucial to the future of psychiatric medicine, and his skepticism is a healthy antidote to stagnation within the discipline.

But forty five years after the publication of The Myth of Mental Illness, the long and short of it is: we need psychiatry, warts, metaphors and all. Szaszian psychiatric abolitionism is useful for making sure that psychiatry evolves with a view to an ethic and an emphasis on patient-centered choice in treatment. There are very few indications of a return to the days of psychiatric inquisitions and Nurse Ratcheds. Pure Szaszianism seems to depend on a kind of precautionary principle for psychiatry that would be a hindrance to the field's development -- a field that has already made tremendous strides away from exorcisms and lobotomies.

These days, psychiatrists aren't likely to treat someone simply because they have strange behavior. Consider the story of "Craig" who admits to his doctor that he is a vampire. Craig says he is fond of "drinking chicken blood from the bottom of the package" in order to satisfy his undead urges. Craig would only be required to undergo treatment if such behavior were a clear break from patterns of behavior he had had his whole life, and if the behavior represented a danger to himself or others. So, unless Craig starts talking about his intent to feast on human blood, most psychiatrists would not force treatment -- salmonella risks notwithstanding.

If anything, psychiatric medicine has gone to tremendous lengths -- internally -- to ensure clients choose to be treated. Among these measures is the recent introduction of "advance psychiatric directives," which are sort of like living wills for the mentally ill. You can say "hey doc: I don't want x or y treatment." And you can appoint an "agent" to make decisions on your behalf, in case you are not capable of making them later. Ultimately, however, the standard of evidence of "harm to self or others" -- coupled with rigorously developed diagnostic criteria -- has become the criterion for involuntarily hospitalizing people.

Suppose we didn't know that symptoms of schizophrenia were an outgrowth of some underlying problem associated with neurotransmitter substances in the brain (some think caused by a heritable trait and/or abnormal wiring). Would we then be required to deny that an illness exists, despite the fact that patients have stark breaks with reality, grandiose -- even dangerous -- behavior, and frightening hallucinatory experiences?

To marginalize the inferential and metaphorical handles of contemporary psychiatry by placing them into the category of unicorns misses the way in which so much of science proceeds. As Max Black argued, "metaphorical thought is a distinctive mode of achieving insight, not to be construed as an ornamental substitute for plain thought." Indeed, what if we said something similar about subatomic particles? Try telling an astrophysicist that neutrinos, since we can't observe them, must be myths concocted by his community in order to cling to its NSF budgets.

The psychiatric community is still working steadfastly on the underlying causes of Autism Spectrum Disorder and Asperger's Syndrome, but we cannot simply chalk up the symptoms of these disorders as myths constructed by bad yuppie parents and the doctors they pay. Most people realize that people with autism have a very difficult time communicating and interacting socially. But scientists are beginning to understand through brain-scan technologies, at least, where things are going wrong in the brain.

In any case, these clients aren't merely "difficult" members of society. Their neural development has been severely impaired and this is often revealed in a profound inability to cope with everyday tasks. Again, even though this is akin to knowing baldness when we see it, such diagnostic vagaries are crucial to people who have to live with such illnesses -- including friends, families and those who may have to be lifelong care providers.

One of the most difficult duties of psychiatry is determining whether someone is a rational agent in order to make decisions about treatment: Is he so impaired that he cannot make clear choices for himself? Is he a danger to himself or others? Szasz is correct in saying that this involves interpretation. But difficulties arise not so much in the nature of the psychiatric enterprise, but rather from the nature of mental illness. It's an unpleasant fact that mental illness can be severe enough to rob of us our agency, autonomy and/or normal functioning. But these are precisely what we need to be free citizens, as well as to claim our rights to freedom.

Without going into a lengthy discussion about the current distinction between criminal and clinical behavior, I will mention that the more we come to understand about the pathologies of sex offenders, for example, the more we will continue to blur such distinctions. In any case, our legal system will have to adapt to these kinds of cases, and certain segments of society will have to alter some of its prejudices about these offenders. At the same time, we will have to be sure that any paradigm shift concerning sex offences preserves cherished institutions such as due process and the rule of law.

The co-evolution of psychology, psychiatry, pharmacology, neuroscience, and evolutionary biology will help us realize the Freudian aspirations for a "scientific psychology." Paradoxically, while these disciplines seem, daily, to challenge our favored notions of human choice and free will, they are also helping us to confer more political freedoms. How? Because the more we understand the factors that underlie certain behaviors, the less likely we are to put people in prison when they shouldn't be there. And the more we understand about the mysteries of mind and brain, the greater the range of options we'll have in making our brains (and thus our minds) better.

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