The Politics of Psychiatry

Worldwide, annual investments in scientific research to cure devastating mental pathologies such as bipolar disorder, schizophrenia, and clinical depression are huge – comparable to spending on finding a cure for any other disease. But while mental disorders are indeed medical diseases, with their own culprit molecules and aberrant anatomies, they are also different from “physical” diseases in important ways. For no matter how thoroughly “medical” mental illnesses are, they are also thoroughly social. The reasons for this stem from the nature of mental disorders themselves.

There is no question that pathologies like heart disease, pneumonia, or diabetes have a large impact on a sufferer’s sense of self and place in the community. But only in illnesses like schizophrenia, bipolar disorder, obsessive-compulsive disorder, and depression do we find disease processes that directly and profoundly transform a person’s self, identity, and place in the community.

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A person with schizophrenia may experience his self as another, may experience his identity as controlled by others, and may regard the entire community as suspect and threatening. A person in the manic phase of bipolar disorder has, in addition to serious, even life-threatening lapses in judgment, an extraordinary sense of well-being that the mentally well rarely, if ever, experience. The individual with obsessive-compulsive disorder both dreads and is ashamed by irrational obsessions and compulsions, yet finds engaging in these thoughts and actions irresistible. The person with clinical depression finds his or her entire being dark and vapid, devoid of ordinary human feelings like anticipation, pleasure, and meaningfulness.

Patients with mental pathologies commonly ask their doctors, “Is it me or my illness?” The manifestations of illness and the expression of self are not so easily distinguished, and psychiatric treatment often focuses on disentangling the two.

But this intermingling of the self with the manifestations of mental illness often leads patients to have mixed feelings about treatment. For example, treatment for a manic patient jeopardizes that extraordinary feeling of well-being and risks plunging the person into the dreaded depressive phase of the illness. The idiosyncratic beliefs of the schizophrenic are the target of pharmacotherapy, but at the same time they may be a source of personal pride and form a distinct sense of self that the patient wants to preserve.

Because of this “self-illness” ambiguity, mental disorders are linked with personal values, belief systems, and interests in ways that are distinct from physical diseases. Physical symptoms are almost never positively valued, but some symptoms of mental disorders typically are. For example, almost everyone agrees that a broken leg or pneumonia are bad things to have. But many manifestations of mental disorders – such as the increased energy of mania, the euphoria of intoxication for the addict, or the smug satisfaction of the individual with a personality disorder – may not always be viewed that way.

As a result, while many would-be patients might recognize the benefits that psychiatric treatment has to offer, they also may be deterred by the threat to what few sources of self-affirmation they have. When one adds to this the stigma and explicitly discriminatory practices against the mentally ill, it is a wonder that failure to keep appointments and take medications is not more common than it is.

While the “self-illness ambiguity” in mental illness may not be explicitly appreciated, many societies have made accommodations, such as considering a criminal offender’s state of mind in assessing legal culpability. Societies also often provide ways to encourage, even compel, a mentally ill person into treatment, while recognizing that, because psychiatry can potentially invade and overwhelm personal beliefs and values, mental health practices must be regulated in order to preserve civil liberties.

As science unravels many of the puzzles concerning mental disorder, it may become tempting to argue that these problems with politics and diverse values will evaporate. According to this view, broad agreement about the causes of and cures for mental illness will make politics irrelevant, just as a broken leg or a heart attack are not really political in content today.

I am skeptical that this can happen. Consider a bit of science fiction. Let us say that, at some point in the future, neurobiology will explain not only major mental disorders, but also criminality. Indeed, we will have perfected a biology of morality that allows us to explain typical morality as well as deviant morality.

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But even in such a science-fiction scenario, we are left with a serious political problem: on what moral terms can we base desirable and undesirable beliefs and behaviors? Who will define the norms of criminality and mental illness, conditions for which science provides the explanation? Will those norms be based upon my values, your values, prevailing scientific views, or perhaps the values of a political mastermind?

The politics of psychiatry are inescapable, which is why all societies must consider them with the greatest of seriousness.