The DSM-IV, in its introduction identified as one of the components of the definition of mental disorder the fact that ‘the syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one.’ Now bereavement is a no brainer to me. I don’t think it was too big of them to say it is ok to be sad after a loved one dies. It’s the reasoning that gets me though. The bereavement sadness is not a mental disorder because it is (a) ‘expectable’ and a ‘culturally sanctioned response to a particular event’. This seems to capture the essence of the DSM and of the approach to madness more generally.Madness is an arbitrary, politically constructed entity, designed to suit the prevailing culture.
Richard Bentall also notes that there were a series of landmark studies carried out in the 1970’s demonstrated that psychiatrists in the United States and Russia were almost twice as likely to diagnose their patients with schizophrenia than their counterparts in Britain or elsewhere in Europe. In China there is no depression just lots of people with somatic disorders featuring lethargy and other physical complaints. The diagnoses are made to suit the culture. It suits the the United States and Russia to have more schizophrenia. It suits the Chinese to place no focus on the subjective mental state of depressed people and create a physical condition in its place. The culture is characterized by a marked focus on the group to the exclusion of the individual. The Japanese seem to do away with the idea of mental illness altogether.
There is an interesting blog post entitled - ‘Can Culture create Mental Disease? The Rise of ‘Hikikomoris’ in the wake of the Economic downturn in Japan.’ It deals with the social withdrawal of young adults in the wake of waning job security and the linkage of self-esteem. This to my mind is very much a problem that has been manufactured by the culture. Further equating having a job to self-worth another cultural invention has resulted in a special location, the sea of trees, for committing suicide. Rather than dealing with the problems created by a cultural insanity it is ignored and people Aokigahara to kill themselves.
Culture then can not only distort the mental life of the individual but it can also create problems where otherwise there would be none. The illusion of rigid separation between the different categories of diagnoses is reinforced by the arbitrary exclusion rules inserted in the DSM. Taking DSM-IV as the example it states that patients may not be diagnosed as suffering from schizophrenia if they also meet the criteria for schizoaffective disorder, major depression or mania. The DSM’s makers have not adequately addressed the issue of false positives that arise under their system. They ignore the issue of diagnoses being comorbid by arbitrary exclusion.
The DSM provides the following gem of a disorder to illustrate the cultural point- Oppositional defiant disorder. I would like to thank Gareth Stack for discussing this in his Open Learning talk. This disorder is characterized defiant behaviour towards authority figures and refusals to comply with the requests of the majority. So madness could theoretically just be the result of thinking for yourself and trying to be an individual. Conduct disorder similarly manufactures an illness out of not following the rules. Culture then not only creates real problems where would otherwise be none but if creates fake problems where there are none. Perhaps being 'mad' is the sanest response. Breaking the rules in societies where politicians are corrupt and venal, groups regressive in the pressures they exert on the individual and rules patently absurd, counterproductive and odds with one another seems understandable. Also at least when we are feeling our feelings our experience is our own. This seems superior to the position in the modern capitalist society - a fragmented life lived for the approval of others. This clip below from network captures some of the feelings that we might experience in today's fragmented society. In that film Howard talks about the feeling of just wanting to be left alone in our living rooms or being told of horrible events that occur on the news as though that is the way things are supposed to be.
Sanity in this society is supposed to be represented by what Richard Sennett described as the new ‘flexible character’ in an ever accelerating, globalized capitalistic society by using terms that very much resemble the features of the narcissism or borderline pathology. There is an acceleration of momentary events, mobility of work life, futility of communication, fragility of relationships, receding loyalty and commitment. The symptoms of a growing fragmentation of society as a whole. This trend is only mirrored by the individuals who more and more tend to ‘compartmentalize’ their lives, their relationships and their attitudes, without striving for coherence. People today live in worlds, simultaneously or successively, that are not related to one another. Society then is stark raving mad even on the terms of the DSM.
The colonization of normal life experience by madness
The problem with this taxonomical approach to mental health is that everyone is different. It is all about individual context. Mental health is a lot more than just psychomotor retardation and disturbed sleep. Our experience is our own. Our feelings and our reactions to things are our own personal things. In fact if we were to take a book like Irvin Yalom’s Existential psychotherapy to heart we may be accused of imbibing depression. Yalom suggests, here and in his other writings, that we should take heed of Thomas Hardy’s proposition that ‘If a way to the better there be, it exacts a full look at the worst.’ He discusses the fundamental isolation which each person is forced to bear. He also deals with the idea of the meaninglessness of life and the ever present spectre of death. Were he not a world famous Stanford psychotherapist he might be accused of having a morbid preoccupation with death. We might suggest that he feels worthless or that because his life has no inherent meaning he must have a disorder of some sort.
R D Laing, in The Divided Self, says that he ‘is quite sure that a good number of ‘cures’ of psychotics consist on the fact that the patient has decided, for one reason or another, to play at being sane. At another point in that book talking about the onset of psychosis that in many cases there is no such qualitative change, but a transition extending over years, at no single point in which it may be clear whether any critical point has been passed. What this tells us is that the outward signs and behaviours may bear no relationship between the underlying ‘sanity’ or insanity. Additionally there seems to be a closer relationship between the so called signs of mental ill health and positive mental health than might be expected. But then society may actually have no interested in improving the internal world of individuals but merely in manufacturing passive consumers, who work and don't disrupt things.
In a society where market research and media elements are trying to find out and sell our patterns of behaviour. Maybe I am a woman falling into such and such a socio-economic category and am on my way home from work. There are a half-dozen companies that 'know' what I think and will that information or exploit it to sell me something I don't know. The division of labour is such that, as discussed in Alain de Botton's book, the Pleasures and Sorrows of Work, there are people whose only job it is is to write the copy for the 'moment' chocolate biscuit angled at women from a lower socio-economic background. Their break from the pressures of life is the angled exploitation of a biscuit company's cynical marketing department. When confronted this sort of world it is hard not to sympathize with characters like that played by Michael Douglas in falling down. One feels that my life experience is my own and perhaps I need to do something destructive or out of the ordinary so that my experience cannot be packaged and sold back to me. The two clips should capture some of my feeling here.
The first clip captures the idea of our experience being fabricated just to sell things to us in Mad Men. The second clip captures a bit of insanity from michael Douglas that seems on one level to be a thouroughly sane reaction to an insane society. Symptoms then can come from a rational place. This argument is twofold. First of all ‘symptoms’ can come from a rational place. Richard Bentall in his book Doctoring the mind offers the following link between victimization and paranoia. He points to a population survey conducted by sociologists in El Paso in the United States, and Juarez in Mexico, that found that ordinary people who are highly paranoid tend to live in socially marginalized circumstances that left them powerless and prone to victimization. This reminds one of the joke that just because you are paranoid doesn’t mean they aren’t after you.
So a ‘symptom’ could be an understandable response to life experiences. More than that the ‘symptom’ might possess a greater inherent rationality. R D Laing talks about psychotics delusions capturing an existential truth.He mentions Julie, the Schizophrenic, and says that we can see existential truth in her statements that she is not a person, that she is unreal, and we can understand what she was getting at when she said that she was trying to become a person, and how it may have come about that she felt at once so empty and so powerfully destructive. Laing suggests that even when what the patient is striving to tell us is told in as clear and straightforward a way as he knows how, the nature of his anxieties and his experiences, structured as they are in a radically different way from ours make the speech content necessarily difficult to follow.
So what we have said first of all is that sanity is a political and cultural construction. We have said that the human condition presents us with a number of human givens that it is perfectly reasonable to think about. We have then argued that symptoms can come from a rational place or have a rational purpose as their driving force. Advancing this what we are now going on to say is that the good and the bad reside closely together.
In Carl Rogers’ book Client Centred Therapy he talks about change occurring when people are feeling at their bleakest. This he suggests is because the process of therapy involves a painful process of letting our guard down and reorganizing our personality. The self, as Hegel suggested, depends on an internal dialectic for its intrapsychic structures and operations. Any meaningful interaction with a person involves an engagement with the way they choose to represent and symbolize their experience. Two examples can be furnished from Yalom’s writings. The first of Carlos, a man who suggested that he would enjoy rape if it were legal. It was not from first principles that these abhorrent views were changed but from following the dialectical logic of his own representations and logic to their conclusions. The second is a woman who viewed her anger as a black ooze which caused all those who touched her either to abandon her or to die. Again it was only by engaging this patently irrational symbolization of experience that Yalom was able to communicate in a meaningful way with this patient. He was able to show her that he was able to come into contact with this ‘black ooze’ without becoming ‘tarred’ by it. Taking the argument one step further we could view one’s ‘madness’ and unique symbolizations as representative of our unique specialness.
The symptom of mental ill health is also the creative impulse that spurs someone to paint a picture or create a beautiful piece of music. It is the vulnerabilities and the flaws that to a large extent make the person special. Yalom talks about the myth of specialness which is shattered by an awareness of mortality in his terminal patients.Our lives will be forgotten by all but a few who are close to us and our life purposes are our own artificial constructions. If we accept this and that we will never be the strongest or the most special we have to look somewhere else we have to look somewhere else for our individual specialness. We have to find our specialness in the unique and even skewed way in which we perceive the world. If we take Alfred Hitchcock we can make this point. Alfred Hitchcock is described as a brilliant director and as a great ‘auteur director’.
The reason he is seen as this great auteur director is because there is no question of his authorship. With other directors they can produce perfectly good films but they are not bringing anything of themselves to the films. The auteur on the other hand has a creative vision. His creative voice is distinctive enough to shine through the collective process. Hitchcock’s voyeurism, his paranoia, his preoccupation with guilt and his chauvinism towards women are unmistakably imprinted on each of his films. Here they are not evidence of a mental disorder but evidence of high art. One does not have to be a famous director to be special or to see the world uniquely. Your experience is your own and you life is your own.Any sort of thoughtful interaction with life’s existential questions or preoccupation with the fact of death does not have to be symptomatic of depression.
These elements should be treated as highly individual natural ways of responding to human experience. However, even if we were to treat these as symptoms of a disorder we would still need a highly individualized inquiry. Markova and Berrios suggest that the structures underlying mental symptoms and subjective complaints should be primarily seen as unstable, and as dissimilar to structures underlying tables and trees. In their view, the structure of a mental state such as ‘depressed mood’ is fuzzy because it depends on the individual judgment of the person experiencing the state. In their view mental symptoms are above all personal constructs: ‘They are constructs in the sense that subjects create sense or construct a meaning out of an inchoate preconceptual and preverbal experience. They are personal in that although social and cultural influences will aid in their articulation,the experiences themselves are unique to the individual and inaccessible to anyone else’.
So a preoccupation with death, being an outward manifestation, does not necessarily relate to the inchoate preconceptual and preverbal experience upon which things like depression are based. Arnold H Modell talks about metaphor as being a link with this internal preconceptual and preverbal experience. In his book metaphor and the meaningful brain he points to Giambattista Vico, his Descartes, in support of the idea that 'metaphor is not simply a figure of speech but primarily a mode of thought. Trying to get in touch with the psychic turbulence of the unconscious may the root of masses of art. Modell suggests that it clear that metaphor exists apart from language because we have gestures, visual images, feelings and bodily sensations which can all function as metaphors. Art and creativity often comes from this metaphoric process. We take something base and we convert it into something and higher with aesthetic quality. We are able to transfer meaning from one area to another, make comparisons and elevate ordinary painful experience to art like in the Greek tragedy and all of its variants. Striving after the painful raw fucking experience of sensations gives us the material to produce.
Giambattista Vico says that it is noteworthy that in all languages the greater part of the expressions relating to inanimate things are formed by metaphor from the human body and its parts and from the senses and the passions'. Could it be that a large chunk of our art is as a result of trying to get in touch with the very experience that the establishment would label as a symptom of mental disorder. In Yalom's books he refers to himself and his feelings as his instrument of therapy. His Stradivarius of therapy. He included a lengthy and toxic rant about fat people and his countertransference towards fat controlling women like his mother for a reason. That reason is the same reason Maroda pays such attention to her initial feelings with a patient. Their feelings are a useful source of information and a part of their experience that is not be denied. Some people call it madness I call it being a human being. I will leave you with this clip to enjoy.