Two interesting articles in the 6 February 2013 of the New York Times raise the question of how we categorize people according to their position on the spectrum of human variation.
First, in The Stone series, philosopher Gary Gutting talks about Michel Foucault’s critique of modern psychiatric practice, A History of Madness. I haven’t read Foucault, but I find a lot to agree with in the claim, attributed to him by Gutting, that categories of mental illness defined by psychiatrists are based not only on empirical observations about people’s behavior, but also on moral judgements about how people compare to socially accepted norms. Homosexuality was at one time defined, presumably with great certitude, as a mental illness. So was the refusal of some women to accept traditional feminine roles in society.
Gutting uses Foucault as a point of departure to criticize the modification of how depression is defined in the next edition of the DSM. The new definition eliminates the so called “bereavement exception,” which excluded states of grief triggered by, for example, the loss of a loved one. This distinction is captured pithily by Andrew Solomon in his book, The Noonday Demon: “Grief is depression in proportion to circumstance; depression is grief out of proportion to circumstance.” Gutting says:
“People grieving after the deaths of loved ones may exhibit the same sorts of symptoms (sadness, sleeplessness and loss of interest in daily activities among them) that characterize major depression. For many years, the DSM specified that, since grieving is a normal response to bereavement, such symptoms are not an adequate basis for diagnosing major depression. The new edition removes this exemption.”
An important issue at stake, according to Gutting, is how “normal” is defined. Retaining the bereavement exception assumes that there are normal and abnormal kinds of sadness–ways of defining when a person “ought” and “ought not” to feel sad. Eliminating the exception implies that the only thing that matters is the symptoms, which are very similar for grief and depression. Gutting argues that this may miss essential information about how people experience sadness, and even about how to treat it. He still sides with Foucault, however, in arguing that such normative judgements are potentially dangerous because they grant psychiatrists (and drug-pushing Pharma companies) a privileged role in deciding what are appropriate and inappropriate paths to happiness.
I would take Gutting’s critique one giant step further. It is not enough to question the division of human behavioral variation into categories that are then labeled normal or abnormal using whatever moral judgements. We also must question how that behavioral variation comes about, and in particular whether it is sculpted by societal pressures larger than anything the psychiatric profession can exert. Much has been written, for example, about the increasing rate of diagnosis (and pharmaceutical treatment) of ADHD over time. It is entirely unclear whether this increase reflects a rise in the proportion of children with some objectively defined condition, a broadening of the definition, or a broadening awareness of the condition (driven, for example, by the marketing of new ADHD drugs).
In addition to these possibilities, we must not ignore the additional possibility that what has changed is the environment into which children have to try to fit themselves–in particular the shift in schools and in society away from opportunities to be outdoors and engage in physical activity, and toward contexts where people must sit quietly and work for long periods of time. Rather than asking how we should treat the children in this environment, which little resembles the context in which humans evolved, should we not consider how we might align the environment with our nature?
The same question can be raised about depression. People who struggle with the pressures and expectations of modern life, and succumb to deep depression in the face of this struggle, are treated as if they are abnormal; few of us ask whether it is the environment that is abnormal–a misalignment of society’s structures with our needs as human beings.
In this way I might question Andrew Solomon’s tidy distinction between grief and depression. We can say that “depression is grief out of proportion to circumstance,” but this implies that the abnormality is in the depressive rather than in the environment that overwhelms him.
To Gutting, psychiatrists are like Procrustes, stretching or sawing at the legs of travelers to make them fit his iron bed. What’s missing is an explanation of who built the bed. (Actually, there were two beds, making the problem all the more devilish.)
The second story in the New York Times was about the prevalence of smoking among the mentally ill, and the changing attitudes of mental hospitals toward smoking by inmates. What struck me was the following paragraph.
“New data from the Centers for Disease Control and Prevention shows that the nearly 46 million adults with mental illness have a smoking rate 70 percent higher than those without mental illness, and consume about a third of the cigarettes in the country, though they make up one-fifth of the adult population.”
…especially the last sentence. Are you kidding me? One fifth of the adult population is mentally ill? Can this statistic possibly be real? Is it possible that it is society that is sick?