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3 Feb 08 – Mental Illness: A Social Construction?

3 February 2008

On this day in 1845, Dorothea Dix presented a document to the Pennsylvania state legislature describing her 2-year survey of the state’s treatment of people with mental illness.  She found people with mental illnesses in jails, alms-houses, and cellars of public buildings.  As a result of her presentation, the Pennsylvania State Lunatic Hospital was created.

This story brings up the question of what is mental illness.  How did Dix determine that the mentally ill were to be found in these different locations?  How do we define mental illness? 

We can read a lot about the typical definitions, to be found in our diagnostic manual, The Diagnostic and Statistical Manual of Mental Disorders (DSM) now in its 4th edition (with a text revision).  Essentially, disorders are defined based on expert consensus and research conduct on these professionally accepted constructs. 

An alternative view, however, was presented by Thomas Szasz in his book entitled, Myth of Mental Illness (which was originally published as an article in the American Psychologist).  Szasz traced the history back to the Middle Ages and a pair of monks named Sprenger and Kramer, which always makes me think of a bad daytime talk show.   

[SIDE NOTE: In fact, Sprenger and Kramer did have a bit of a scam going on where they claimed to be clairvoyant.  They would set up a tent.  One of the two would gather information from the people outside the tent.  The people would be ushered in and the one who gathered information would go around the back of the tent and feed information to the one in the tent doing the “clairvoyancy,” thus making the people believe that they knew things they couldn’t know.]

Though the history of people being conceived of as mentally odd probably goes back further than Sprenger and Kramer, these two codified a specific category of mental deviance in a book entitled Malleus Maleficarum (which means “Hammer of Witches”).  In this book, Sprenger and Kramer developed means of determining who witches were.  They defined them based on certain features, which are relatively unimportant to the present discussion.  What is important is that this book was used to determine who were witches.  Then, individuals used it to go out and find witches.  Unfortunately, those finding the witches were paid on a sort of commission, wherein they received the lands of those found guilty of witchery.  So, it is probably not surprising that a number of single women were found to be witches.


At any rate, in the 1960s, Zilboorg discovered the Malleus Maleficarum and made the following statement, “the Malleus Maleficarum might with a little editing serve as an excellent modern textbook of descriptive clinical psychiatry of the fifteenth century, if the word witch were substituted by the word patient, and the devil eliminated.” Essentially, Zilboorg felt that Sprenger and Kramer, who happened to be a couple of con artists, had created a document, which happened to be used selectively to fabricate witchery and claim riches, was an excellent frame of reference for defining mental illness – if only we were to change the word witch to patient and take the devil out of it.

Szasz came along and interpreted both the Malleus Maleficarum and our current diagnostic system as social fabrications.  The point of both were to control people that did not fit neatly into the current social system.  In essence, Szasz said that “mental illness” was a social construction.  Szasz also felt like the “treatment” of this social construction was borderline abusive.  For example, he described the treatment of the “father of modern psychiatry” whose face appears on the DSM, Benjamin Rush.  Benjamin Rush was a signer of the Declaration of Independence, the personal physician of George Washington (and probably bled him – a common treatment at the time – to death), and a psychiatrist.  Rush’s treatments sometimes involved spinning people excessively until they said they no longer were experiencing the aberrant thoughts/behaviors.  He also devised specific treatments for specific individuals.  One person thought he had snakes in his intestines and Rush gathered some snakes from his garden, put them in a bucket, and had the person defacate in the bucket – now the snakes were out!  Another thought he was a plant and Rush urinated on him to kill the plant (or some such).  This, for Szasz, was evidence enough of the origin of poor treatment of those deemed “mentally ill.”

I guess, given this, it is not a far stretch that Dix would find the mentally ill in such destitute locations.  Still, we might benefit from some better understandings of what mental illness truly is.  Instead of accepting particular framings, we might benefit more from understanding the humanity and inhumanity that is involved in such designations and the treatment that stems from it.  What, for example, does it mean for those individuals, without words such as “crazy,” “depressed,” “anxious,” etc., to feel what they feel?  What does it mean for them to be told they are depressed, anxious, crazy, etc.?  What does it mean for them to be treated the way they are?  What are their relationships like?  How do they feel they fit into the world?  How do they conceive of the world?  What do the hallucinations and delusions of schizophrenics mean to them?  If there are some meanings to them, should we dismiss them as the result of a biochemical imbalance and treat them, as a result, with some psychotropic medication and ignore the meaning that these individuals do have?

Fuel for thought, I guess… head to my website for more fuel for thought regarding psychology.


February 3, 2008 Posted by | In Psychology | , , , , , , , , , , , , | 5 Comments

1 Jan 08 – Duty to Protect

1 January 2008

Happy New Year!  This day, in 1986, California enacted the nation’s first “duty to protect” law.  This law was a result of a lawsuit by the parents of a young lady (whose last name was Tarasoff) who was killed by a former client of a therapist in California.  The former client had mentioned in passing a desire to harm the young lady.  Following the young lady’s death, the parents filed suit and won what has come to be known as the Tarasoff verdict.  This verdict mandated that therapists have a duty to protect by contacting either authorities or the individual directly who may be under threat to harm – so they have the ability to be protected. 

Similarly, therapists have a duty to protect their own clients – from themselves, should they indicate that are a threat to themselves (e.g., suicidal).  Interestingly, this is where some controversy lies…though, it originates from more marginalized groups in the therapeutic movement (sometimes referred to as libertarians or consumerists or “the antipsychiatry movement”).  From my perspective, regardless of their marginalized status, if only because they offer a voice of dissension for us to consider, their arguments should be heard, considered, addressed, and assimilated or adequately refuted.  Unfortunately, the tendency is to just ignore the dissenting opinions. 

As one example, Thomas Szasz (who, himself, was trained as a psychiatrist and is also the author of the penetrating and controversial book entitled, The Myth of Mental Illness) argued against the duty protect related to suicidal ideation, intent, and plan.  In his book entitled The Untamed Tongue, Szasz  asserted that suicide is a fundamental human right and that society does not either have the moral right to interfere with a person’s decision to commit suicide.  Szasz’s perspective is that suicide is a personal and moral choice, wherein the individual committing suicide is demonstrating his or her own liberty.  In fact, demonstrating consistency of thought, Szasz maintains this perspective when he argues against physician-assisted suicides (elsewhere), as such is an oxymoron – suicide is a personally intentional act, not one that is supported or assisted by someone else (in this case it is a medical not a personal/moral issue).  

I will not say whether this position is right or wrong.  It is a perspective, however, that requires some considerable debate because it is foundational to the argument regarding responsibility for the act of suicide.  That is, as it is currently conceived, there is little legal repercussion for someone who attempts suicide.  However, the committing of suicide is illegal – but, it appears from rulings such as Tarasoff that the one who commits such acts of violence are not held as the culpable ones (certainly they are not tried following their own deaths for their suicide).  So, if suicide is illegal, who is the victim and who is the perpetrator?  As suggested by the foregoing sentence, therapists are frequently the ones tried – under the auspice of standard of care – for their failure to prevent suicide (and, for such reasons, carry malpractice insurance).  If suicide is a personal choice, and an individual makes that personal choice, then is the therapist really the responsible one for the person carrying out that personal choice? 

I would certainly argue that we do everything that we can, when given indication that the person is contemplating and planning such acts to help them to conceive their life and world in a different frame.  As friends, family, and co-workers, we have a similar social responsibility.  This is, of course, my moral perspective.  My preference would be for those who are considering suicide to seek care (whether outpatient or inpatient) voluntarily (in fact, coercion – in virtually all forms – has been demonstrated to be ineffective and the primary contributing factor to improvement in psychotherapy has been demonstrated to be client motivation). 

Still, lacking an individual who indicates suicidality making such a choice, is it justifiable for a therapist to undertake involuntary commitment of the individual?  It would appear that the legal system not only considers it justifiable but also mandatory.  Does such mandated practice place the responsibility for any subsequent or precedent act on the therapist and not on the client?  Rulings that place culpability on the therapist would certainly indicate such.  Should the therapist be considered responsible for an act of suicide committed by a client, after all the client is considered “mentally ill” and, therefore, handicapped?  If suicide is an act of impulse, coming down to the final moment of the final choice on the part of the individual, is suicide really preventable, in the sense that we can keep someone from making that final decision, even when isolated from all relationships (including the therapist)? 

I do not have ready answers to these questions.  Certainly, as indicated above, those in the libertarian, consumerist, and antipsychiatry movement have their own answers.  I would encourage us all to begin to formulate our own. Fuel for thought, I guess…head to my website for more fuel for thought regarding psychology.

January 1, 2008 Posted by | In Psychology | , , , , | Leave a comment