Monday, August 10, 2009

On Blame and Psychiatry

We’re still three years from the release of the DSM-V, the updated version of the Bible of psychiatry, but the controversy has already begun. Debate has swirled around this book from the very beginning—this is, after all, the reference work that until 1974 classified homosexuality as a mental illness. But the American Psychiatric Association seems determined to outdo themselves this time around, as this article from Slate demonstrates:
The APA isn’t just deciding the fate of shopaholics; it’s also debating whether overuse of the Internet, “excessive” sexual activity, and even prolonged bitterness should be viewed, quite seriously, as “brain disorders.” If you spend hours online, have sex more frequently than aging psychiatrists, and moan incessantly that the federal government can’t account for all its TARP funds, take heed: You may soon be classed among the 48 million Americans the APA already considers mentally ill.
I am by no means hostile to psychiatry, not in a knee-jerk manner, anyway; but I’m disturbed by this relatively recent pathologization of day-to-day life. The problem is not so much that psychiatrists are now free to see “normal” things as harmful—excessive sexual activity can certainly be a problem, if it results in the breakdown of relationships—but that it turns them into behaviors outside of our control.

I’m torn even on that phenomenon, however; I believe that alcoholism and drug addiction exist, and I believe to some extent that addiction is beyond the individual’s power to correct. (I’ve not read the “Big Book” of Alcoholics Anonymous, but I suspect I could get behind most of it.) But once we start to see all harmful behaviors as symptoms of mental illness, we step into a world where individual actions don’t count for much. Addiction medicine—especially once it gets applied to the world outside of drug abuse—can result in an odd destruction of the human being. We become machines, completely controlled by the data that gets put into our systems.

An example: I’ve listened to the radio program Loveline for several years now, and I enjoy it and respect Dr. Drew Pinsky for what he does for his callers. (If Pinsky annoys you on the radio or on the television, I highly recommend his memoir, Cracked, in which you’ll see an entirely new side of him—you’ll see exactly how much he bleeds for those under his care.) My wife and I both read his latest book, The Mirror Effect, this summer, and while I was intrigued by his examination of celebrity narcissism and could get behind some of his assertions about how it destroys our society—I’ve seen what he calls the Don’t you know who I am? phenomenon in my students—I was disturbed by his steadfast refusal to label narcissism as anything other than a mental illness.

His concern for his patients, then—including many of the celebrities he interviewed for this book—cuts both ways. It allows him to treat alcoholics without their feeling that he thinks they’re terrible people, but he, and those of us who would like to listen to him, is left without the capacity to make moral judgments. (Because of this, Loveline was much better when Adam Carolla co-hosted the program—Carolla was always perfectly willing to judge. His harshness and Pinsky’s gentleness balanced each other out in helpful ways.)

So I’m left with a bad taste in my mouth after reading Pinsky’s book, to the extent where he’s starting to irk me even on the radio; there’s no doubt in my mind addiction hardwires the brain to harmful behavior, and there’s no doubt that narcissism in some cases springs from childhood abuse or tragedy. But for us to be human beings in what that has always been understood to mean we must be able to be jerks and to be held accountable for it.

The same goes for the DSM-V: If my (hypothetical) debt is the product of a mental illness, should the credit card company let me off the hook? If my (very real) bitterness is turning people off, should they assume I’m a good person who’s suffering from a “brain disorder”? As usual for critiques of psychiatry, I turn to Walker Percy to make my point for me:
suppose you could show me one “sin,” one pure act of malevolence. A different cup of tea! That would bring matters to a screeching halt. But we have plenty of evil around you say. What about Hitler, the gas ovens and so forth? What about them? As everyone knows and says, Hitler was a madman. And it seems nobody else was responsible. Everyone was following orders. It is even possible that there was no such order, that it was all a bureaucratic mistake.
Percy is right; for us to be human beings—for us to be capable of doing good—we must be capable of doing wrong, and we must be held responsible for it when we do so. I’m afraid that the APA is moving further and further away from this, into a world where human beings are mere medical cases, lab rats waiting for the doctor’s cure for issues of the soul.

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