Wednesday, December 28, 2005

Mental Health and Social Norms:

The death of Charles Socarides has brought to mind a regrettable tendency (one that often borders on tyranny) of the mental health profession. Socarides, if you don't know, was one of the godfathers of the "homosexuality is a mental illness" school of thought. And (Providentially, in my opinion) one of his sons turned out to be not just gay but one of the leading gay rights activists of the 90s.

The "regrettable tendency" to which I refer is the (mis)use of the concept of "mental illness" to enforce moral or social norms. Back in Socarides's day, it was the 1950s style social conservative morality which was "medicalized." Today it's PC. Previously, homosexuality and other behaviors which violated "traditional morality" were "mental illnesses." Today "racism" and "homophobia" are mental illnesses (or at least, some folks within the profession seriously advance this notion). As Pete Townsend put it: "Meet the new boss, same as the old boss."

This problem within psychiatry doesn't lead me to the extreme position advanced by Thomas Szasz or Michel Foucault that "mental illness" doesn't exist. Psychiatric disorders do exist, some of them rather minor (a moderate anxiety disorder), some of them deadly serious (severe depression, which often results in suicide). But we should realize that underlying mental disorders have (or ought to have) nothing, absolutely nothing to do with social norms. They are "health" problems, not "moral" problems and as such are socially neutral and more analogous to concepts like "race" and "gender." Indeed, mental disorders are protected civil rights categories under the ADA and other related disabilities legislation. To say that someone has a "psychiatric disorder" is to say that their health is impaired in the same way that someone with high cholesterol or hypertension has their health impaired.

[One thinks of the recent hubub on Lincoln and homosexuality. Though historians strive mightily in their battles over whether Lincoln suffered from the "mental disorder" of homosexuality, no one seriously disputes that Lincoln suffered from the true mental disorder of bipolar. Likewise Thomas Jefferson most likely suffered from a physiatric disorder -- depression, as did Madison, who, given that he was convinced he would die an early death (he actually lived into his 80s), most likely had an anxiety neurosis. These conditions don't raise controversy because we properly regard them as socially neutral. Finding out that Madison had an anxiety disorder really ought to be no different than finding out he had male pattern baldness (which I don't think he did; but who knows? they all wore wigs).]

Therefore, properly understood, categorizing something as a "mental disorder" cuts against the moral and social stigma of that condition, and cuts in favor of social neutrality and civil rights protection of the underlying "disorder."

This isn't to say that there is no intersection between behavior that results from "mental disorders" and behavior that is immoral or otherwise socially unacceptable. One thinks of conditions like kleptomania or alcoholism. But still, those who wish to maintain a social stigma on the underlying behavior of for instance, kleptomania (stealing) must do so with no reliance on such behavior resulting from a "psychiatric disorder." Again, to rely on the mental health body of science to enforce your desired social norms is a fundamental misuse of the profession.

Even if tomorrow we discovered that kleptomania doesn't really exist as a "mental disorder" that would not (or at least it shouldn't) do one thing to "normalize" stealing if for no other reason than the vast majority of people who steal aren't kleptomaniacs and had no "mental disorder" prompting them to steal to begin with. They are simply bad people who wanted to get something for nothing. Indeed, take a person with a moral conscience, who truly desires not to steal and does everything he can to pay for his items, but "just can't help himself." And then he feels terrible guilt after the act is done and seeks mental help. Such a person, in my opinion, is more moral than the lazy jerk who wants to get something for nothing. Thus, while the kleptomania doesn't excuse the underlying stealing, it does indeed mitigate the behavior. Therefore, if kleptomania really doesn't exist as a mental disorder, all the worse for thieves.

My personal opinion is that Frank Kameny and Barbara Gittings were on the right side of not just history, but science in helping to get homosexuality removed from the DSM. To hear the social right tell the story, homosexuality was "removed" for "political," not sound medical reasons. But this gets it exactly backwards. Homosexuality was put on the DSM list for "political," not sound medical reasons, and it took some political action to reverse that mistake.

If getting homosexuality removed from the list of "disorders" helped "normalize" it in a "social" or "moral" sense, then that's only because the social right improperly relied on psychiatry for maintaining the social and moral stigma on homosexuality. As with kleptomania, if homosexual behavior were truly "wrong," then removing homosexuality from the list of "disorders" would only make things all the worse for homosexuals.


Anonymous said...

I think you have some fascinating ideas here, but I have to disagree with your final sentence. The central problem with it is that it requires one to believe that a person who engages in homosexual acts does so out of no more than a thrill of acting out depravity. It requires one to believe that such a person could just as easily pursue heterosexual acts, but simply elects not to. Even James Dobson would not accept this proposition--even he acknowledges that a homosexual orientation is not chosen. The analogy to stealing simply doesn't work. There is no such thing as an unchosen stealing orientation.

This is why declassifying homosexuality as a disorder poses such a problem for the religious right--for if a homosexual orientation (or 'preference') is not a disorder, then it is a minority trait--unchangable except in expression, innate, something akin to left-handness. And if it is a trait, then it makes no sense to try to cure it--'ex-gay treatments', to which they point to as the proper course of action for people with homosexual orientations, suddenly becomes a ridiculous course of action.

Of course, there are some groups that accept homosexual orientation as a trait but condemn its expression nevertheless (this is more or less the opinion of the Catholic Church). The duty of homosexuals becomes to live their entire lives in complete celibacy, devoid completely of romance and the possibility thereof. But I think that even if one accepts this, it hardly makes things 'worse' for practising homosexuals from a moral point of view. If homosexuality is indeed a treatable condition (a 'disorder'), then they can be faulted strongly for failing to seek treatment--just as one would condemn alcholics who know that they have a problem but refuse to do anything about it. But if it is a trait, then they become instead a group of people unwilling to bear the undisputably onerous burdens that morality imposes upon them, which I think creates a more sympathetic image, not less.

It is somewhat as if writing with one's left hand were morally wrong, but being left-handed was not classified as a disorder. If it be a disorder, then practicing lefties can be condemned for failing to get help for their left-handed problem. But if it be a trait, then condemning left-handed artists--unable to paint meaningfully with their right hand--for working left-handedly would become (I would think) more difficult, not less.

(In the interest of completeness, the only potential problem that I see with my argument is that it could be argued that I have proffered a false dichotomy, that there is something between disorder and trait. I just don't see how--either something's wrong upstairs and it's a disorder, or nothing's wrong upstairs, which would make it a trait.)

-Dan Larsen

Daniel said...

The primary difference between a disorder and a trait is that a disorder is in some manner dangerous or destructive. A disorder may or may not be treatable.

Most agree that pedophilia is a disorder. Is is usually not susceptible to treatment, but it is certainly not simply a choice that certain people make. In the DSM-IV, most paraphelias are diagnosable only if they cause the person with the paraphelia significant distress. These are political decisions that say that sex with children is harmful, sex using unusual practices is harmful only if it causes significant distress, and homosexuality is not harmful. That they are political decisions does not mean that they are illegitimate. Our decisions about the type of society that we seek will inevitably shape our perceptions of mental illness.

I do agree with you concerning the classificion of homophobia (as commonly defined) or racism as mental disorders. Homophobia may be a real diagnosis, but it is not a disapproval of homosexuals or of certain practices of homosexuals. Racism has some roots in our innate tendency to prefer people like ourselves and some in learned prejudices. Certainly some mental illnesses lead to strong and often bizarre racist ideas, but I can see no benefit in meeting racism with diagnosis and catagorization. Moral condemnation has worked quite well at greatly reducing the level of racism in our society.

Jonathan said...

I don't know Larsen, I think someone could argue that kleptomania itself could be understood as "an unchosen stealing orientation." It's just that the underlying behavior is still wrong nonetheless.

I also disagree with your use of the word "trait." I agree that homosexuality is a "trait" and a neutral one at that, but traits can be good, bad or indifferent.

"The central problem with it is that it requires one to believe that a person who engages in homosexual acts does so out of no more than a thrill of acting out depravity. It requires one to believe that such a person could just as easily pursue heterosexual acts, but simply elects not to."

However, not everyone who engages in homosexual acts is a perfect 6 on the Kinsey scale. A Kinsey "3" can indeed "just as easily pursue heterosexual acts, but simply elects not to." And there are also folks on the "straight" end of the spectrum, those from 0-3, who are MORE attracted to the opposite sex but still, at some point in their lives engage in homosexual sex (and there are alot more of these folks than most people realize. And that's because the overwhelming majority of them identify as "straight" and live their lives as "normal" heterosexuals; hence they are invisible). Like the "straight" guy that has gay sex on a navy boat, in a prison, or at an all boys school, for "release." Such a person doesn't even have a strong desire for the same sex and hence not much of a homosexual "trait," but has homosexual sex anyway.

In my opinion, there is nothing "wrong" with this unless the sex is duplicitous or coercive. It's very much like lefthandedness. Lefthandedness is a neutral trait because there is clearly nothing wrong with the underlying behavior. But people act outside of their "handedness" orientation all the time -- like the "right-handed" batter who "switch-hits."

Jonathan said...

-- That they are political decisions does not mean that they are illegitimate. Our decisions about the type of society that we seek will inevitably shape our perceptions of mental illness. --

I don't agree with this. There is not, nor should there be, a thing "subjective" about what is and what is not a mental disorder. Mental disorders should have nothing to do with "perceptions." What I argue is that mental disorders in and of themselves are "neutral traits" like lefthandedness. If the mental disorder leads one to commit an immoral act, then let's focus on the immoral act.

What is and what is not immoral, however, is where the debate should take place.

Anonymous said...

The points on bisexuality are conceded. I probably should have said so, but when I was referring to 'homosexual orientations' I was referring to Kinsey 5/6s; I was writing that comment and am writing this one in reference to those persons.

I don't know where you think I have misused 'trait.' I thought I had used it in the neutral fashion you describe. I meant for it to be thought of in the way it might be used in a biology classroom.

"I don't know Larsen, I think someone could argue that kleptomania itself could be understood as 'an unchosen stealing orientation.' It's just that the underlying behavior is still wrong nonetheless."

I think you misunderstand me somewhat. Kleptomania is a disorder because it means that the people with it, without treatment, generally can't help themselves. Their psychological need to steal overwhelms their conscience and their will. With homosexuality, however, that's not true. Though the religious right frequently likes to pretend the opposite, homosexuality is not an addiction to gay sex or to gay pornography. (Well, I'm sure that there do exist people addicted to gay sex, just as there are people addicted to straight sex, but that's a whole different issue entirely.) Homosexuals can and have spent entire lifetimes without sexual encounters--and without needing 'treatment' to do so. There is no addiction inherently involved in being homosexual; homosexual acts are entirely chosen.

What I meant to say was that there exists no underlying, unchosen "stealing orientation" distinguished from and independent of the addiction. A person who steals without suffering from a kleptomanic addiction is clearly and easily condemnable for doing so, while a kleptomaniac who knows that they have a problem but refuses to seek treatment is likewise condemnable for failing to seek help.

Homosexuality, on the other hand is a bit more nuanced than that. Let's go back into the world in which left-handed acts are morally wrong (or at least under serious moral disagreement). I guess it's a matter of personal opinion, but morally, which would be worse and by how much: artists who use their left hand because they can't help it but refuse to seek treatment for their problem--and who, if they would just get their treatment could be a right-handed artist no worse than they were before (subject, of course, to the dangers of left-hand relapse)--or artists who use their left hand knowing that it's wrong but are and would be always unable to paint meaningfully with their right hand? In short, if one takes the point of view that homosexuality is morally wrong, the way one should view of someone who does not have a 'homosexual disorder' but engages in homosexual acts should be fundamentally different from (and far more compassionate than) the way one views someone who does not have kleptomania but steals.

This is why I disagree with your assertion that "As with kleptomania, if homosexual behavior were truly 'wrong,' then removing homosexuality from the list of 'disorders' would only make things all the worse for homosexuals." Of course, in some respects it is only a matter of degree and this is quite a bit of ink spilt over what is arguably a minor point, but the analogy just doesn't quite work.

--Dan Larsen

(As an aside: in general, part of the problem in dealing with homosexuality as an issue is that it is so difficult to come up with apt analogies. I think the closest one I have come up with is the world in which we pretend that left-handed acts may or may not be morally wrong, but this one, of course, leaves those who regard homosexual acts as immoral at a fundamental disadvantage, since no one who regards left-handed acts as a moral issue.)

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