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Every postie worth his or her or its weight in Foucault volumes will tell you that mental illness did not always exist: it’s just a convenient label that our rational and modern age, accustomed to scientists measuring and classifying things, employs to describe deviant behaviors. Every psychiatrist will likewise tell you that mental illness has always existed, and it’s only in the modern era that we’ve developed the means to identify and treat it as something other than a malevolent spirit or divine curse. It’s difficult to deny that a lot of people who would otherwise put themselves in harm’s way, directly or indirectly, have been helped by modern psychiatry. It’s also hard to deny that the body of knowledge that mental health experts use to describe and treat mental illness often seems flawed, sometimes disastrously so. One has a normal state, they reason, and perhaps it grows and is transformed by experiences, but it’s that fixed state that psychiatry seeks to preserve, to restore, and to guard. This notion of personal identity is one of society’s few remaining unassailable citadels, standing squat and sturdy while religion, faith in institutions, and good storytelling are eroded by the churning forces of progress and market capitalism. It’s at the core of the way both psychiatrists and many of their critics view the world. It may also be very wrong.

Jon Ronson’s book The Psychopath Test, and the TED Talk that it inspired, crystallize a lot of the classic concerns about psychiatry. The central anecdote of the TED Talk concerns a man in an institution for the criminally insane who claims he only faked his illness in order to avoid prison. A dozen years later, and seven years after his sentence in a normal prison would have ended, the man is vainly trying to get out of the institution, but every attempt he makes only convinces the doctors in charge that he is a manipulative psychopath devoid of empathy. Regular behavior, like not wanting to talk to the serial killers that are his neighbors on the hospital wing, gets transmogrified into paranoia, standoffishness, and other tidbits of evidence of his supposed mental illness.

This anecdote recalls an experiment by the psychologist David Rosenhan which sought to test the ability of mental health professionals to accurately diagnose mental illness. The experiment, profiled in part in Adam Curtis’s wonderful documentary The Trap, produced spectacular controversy. Rosenhan and his compatriots arrived at mental hospitals around the United States complaining of hearing the word “thud” one time, and reporting no other symptoms. All of them were committed, and despite the fact that they showed no further signs of mental illness, were diagnosed with various disorders. Their attempts to leave the hospitals and assert their own sanity were met with skepticism and, one imagines, renewed belief by the doctors in the paranoia of their new patients. Eventually, Rosenhan’s compatriots managed to leave the institutions they had been committed to, though it took some several months. Rosenhan published his sensational results and was immediately challenged by one hospital to try again. The hospital soon after claimed to have found numerous fakes; Rosenhan stunned the psychiatry world again when he revealed he had sent no fakes.

It’s easy to grow suspicious of the practice of psychiatry when one hears about incidents like these, to say nothing of the thousands of nameless homosexuals that psychiatrists doubtless caused undue trauma to until 1973, when the American Psychiatric Association finally declassified it as a mental illness. It’s unfortunate that such criticism puts Ronson and other critics in bed with a lot of New Age rifraff and the totalitarian corporation that is the Church of Scientology, but bad company does not and should not keep one from remaining skeptical about the practice. What Ronson’s, and indeed Rosenhan’s criticism turn on is the notion that mental illnesses are in no way like other physical illnesses. Expertise or not, mental health care professionals are not dealing with something as easily spottable as an ingrown toenail, whose causes and symptoms are both apparent and exhibit few variations.

Joshua Buckholtz, a psychologist at Harvard University, provides a probable way out of this problem, at least in part. Buckholtz wants to reconceptualize mental illness. For too long, mental health professionals have regarded the labels we use to talk about disorders and mental phenomena that deviates from normal as categories that have an objective existence outside of our language. They’re not, Buckholtz argues. Rather, they’re a shorthand we use to describe different sets of symptoms that we’ve observed together but which also have brain chemistry or a biological fact of the matter that can overlap with other, supposedly different illnesses. We’re trapped in a nomenclature that scientists created in an earlier era when mental illness was not as well understood. Breaking down that creaking and sclerotic body of classifications and replacing them with categories more firmly rooted in biology would go a long way toward preventing misdiagnosis and more accurately identifying true, chronic deviations from normal.

Still, the question remains whether that even should be treated. The danger of the baby being thrown out with the bathwater balefully lurks behind every corner of this issue. A lot of people, including people personally known to the author, have benefitted from modern psychiatry. Not minor quality of life issues, but a restoration of the ability to function normally in society: this is the gift they’ve been given. And it’s a gift that should not be taken away. At the same time, many of today’s medications so profoundly alter a person’s outlook that they’re tantamount to destroying one person and creating another in their same body.

Crystals, herbs, incantations and Dianetics aside, there are not many strategies for dealing with mental illness that fall outside the realm of modern psychiatry. There is, however, a rival tradition of treatment that existed (and perhaps still exists) within psychiatry itself which viewed mental illness as just another form of consciousness. While the French philosopher and historian Michel Foucault gets a lot of attention for his works analyzing the tendency of medicine to pathologize different forms of behavior, Dr. R. D. Laing, a Scottish psychiatrist, put the same ideas into concrete practice. Laing ran a clinic in which schizophrenics were allowed a space to pursue their goals, however demented. One could visit Laing’s clinic and find people smearing themselves with shit and scribbling furiously on the walls without interference from the staff. This was because Laing believed that the lived experience of the mentally ill was worthwhile. The varieties of their experience should be accepted at face value, and though problems would arise that might require some form of treatment, but not necessarily one that altered the character of their lived experience in a fundamental way. This being the 60s, and Laing being a man fighting against some kind of establishment, his caused was embraced by New Leftists of various stripes. The Socialist Patients’ Collective, a radical group that that identified the mentally ill as the core of a new revolutionary movement that would overthrow the capitalist class that had alienated them, represents a sort of comic epilogue to Laing and his work. A small Belgian town called Geel, which lets its mentally ill roam around freely and stay with host families, represents an interesting and likely completely-unscalable prologue.

This tradition’s probable heir today is Temple Grandin and other proponents of “neural diversity.” Grandin, a high-functioning autistic woman, works as a professor of animal science at Colorado State University and moonlights as an author and activist on behalf of autistic people, as well as animal-rights related causes. Her arguments are similar to what Laing and others argued decades earlier: autism is a different form of consciousness, rather than a pathology. It should not be “treated” in the sense that autistic people should be taught to approximate non-autistic people in behavior and psychology, but parents and friends of autistic people should collaborate with them in order to make their existence in society easier and more rewarding. Coming from Laing, a medical doctor, this type of thinking could easily be dismissed as a crackpot theory; coming from Grandin, a person who actually experiences the different form of consciousness that Laing would have talked about, it is more difficult to shunt aside.

Since Descartes, we’ve all been living with the notion that personal identity is a fixed and static thing. The implications for Western religion are obvious and critical: if personal identity was not fixed, then we’d run the risk of meeting an infant or a senile version of our beloved spouse when we get to heaven, rather than them at their most lucid and handsome. But fixed personal identity is a more powerful and hegemonic notion than that. Things as disparate as our legal system, many of our books and movies, and the newspaper horoscope rely on it as much as the great monotheistic religions. Rather than manufacturing scores of new, law-abiding citizens, prisons are supposed to teach existing people the error of their ways. Rather than transform the main character in our favorite movie into a totally different person, we watch that character grow, their identity subtly evolve. And we, ourselves: we are Aquariuses and Libras and Cancers and other animals, and we are them for our entire lives.

Maybe, like many present-day psychiatrists who lean too heavily on ontological categories that don’t always exist, we too lean too heavily on a bogus concept of personal identity. A century or so ago, pragmatist philosophers like William James and John Dewey tried to reconceptualize the self as a thing constantly in flux, changing from moment to moment, that thing that mediated experience and the experiencer. This radical notion did not really take. People like to believe that their identity is fixed and stable, even when the hard knocks of biology demonstrate that it’s not. The truth may not be so extreme as the Pragmatists believed, but it’s certainly not as concrete as the Pope or the psychologist down the street believe it is. Maybe there’s a party of selves, who all have similar identities that overlap in certain ways. Maybe the self dies every time we go to sleep and spawns a new self when we wake up. Maybe the self should not be thought of as something distinct from the body. I don’t really know.