A recent article in the Washington Post [Psychiatry Ponders Whether Extreme Bias Can Be an Illness] discusses this attempt to create a new diagnosis for extreme racism and other forms of extreme prejudice. It presents the argument of some that extreme prejudice is so compulsive and damaging to the prejudiced person that it should be viewed as a mental illness deserving its own diagnosis. While radicals and progressives may be tempted to jump on this bandwagon as a weapon in their battle to have racism and prejudice recognized for the personal and social harm they cause, this effort is unjustifiable intellectually and is politically likely to backfire.
Unlike earlier attempts to make racism a diagnosis, the latest attempt justifies itself by the damage that extreme prejudice does to the prejudiced, not to those prejudiced against. This debate reveals the sorry state of thinking in the mental health professions. If conflates two distinct issues: (1) Are there psychological aspects of extreme prejudice that contribute to its tenacity and to its negative effects on the prejudiced [as well as on the victims of prejudice]? And, (2) is it an "illness" with all that that connotes?
The article, and much of the debate, presumes that the question of "illness" is central. If extreme prejudice is an illness [from now on, I will leave off the quote marks, that should always be presumed to be present], then it should be treated, the reasoning goes. If not, then it is either a social issue or an individual proclivity that, no matter how reprehensible, is not the business of those who think in psychological or psychiatric terms.
This reasoning reveals the difficulties with the current state of conceptual understanding of the diagnostic process in the mental health professions. Mental illnesses are presumed to be distinct entities that can clearly be distinguished from states of non-illness. I am not one who believes that the concept of mental illness is a logical fallacy.
Like medical doctors, mental health professionals often use diagnosis as a way of categorizing patients and their problems. The use of diagnoses can, at times, help guide treating professionals as to the nature of the problems a patient faces, the origins of those problems, and potential treatment options. Diagnosis can also sometimes be used to straightjacket patients into ill-defined and ill-fitting categories that lend a scientific appearance to socially constructed biases. For example, a diagnosis of major depressive disorder is often used by psychiatrists, and managed care companies as an argument that a person has a "biologically-based mental illness" and thus must receive a biological treatment, such as antidepressant drugs or, more rarely, electroconvulsive ["shock"] treatment. The assignment of the diagnosis mandates a treatment prescription despite considerable controversy among researchers and practitioners as to the relative effectiveness of drug treatment versus psychotherapy. [Of course, the relative costs of prescribing drugs versus talk therapies is an often unacknowledged factor here.]
Some conditions bear enough of the characteristics usually associated with illness to be reasonably referred to as mental illnesses. Among these clearly would be Alzheimer's and other dementias, the general paresis caused by syphilis, and various other conditions known to have clear organic etiologies.
The jury is still out as to the extent organic factors play in schizophrenia. While there is increasing evidence of organic factors -- including genetic factors and illness in the pregnant mother -- playing a role in this condition, no organic factors at this point are known to be either necessary or sufficient. Similarly, there exists evidence suggesting that schizophrenia is a condition qualitatively distinct from other modes of living. For example, epidemiologists find a prevalence of schizophrenia in most societies of about one percent. And anthropologists have found that most, if not all, societies, even those who recognize shamans, also have a category of the crazy whose description resembles that of schizophrenia. On the other hand, there exists evidence questioning this view of schizophrenia as a clearly distinct illness. There is evidence that schizophrenia is the extreme end of a larger spectrum of "conditions." And environmental factors clearly play a role in the prospects for the development of the condition and in its course.
If one concludes that schizophrenia is, indeed, largely a biological condition, then it would be reasonable to describe it as an illness. But what if one decides that environmental factors play a large role?
Once we get beyond the clearly organic conditions, the category of mental illness becomes metaphorical. There is nothing wrong with this. People make sense of the world largely through metaphors. The illness metaphor can be illuminating, but it can also be blinding. The question is whether applying it to the emotional problems and issues people face reveals hidden aspects, or covers over important characteristics. Thus, mental illnesses are like other physical illnesses in that they often appear to be involuntary and they can interfere with normal functioning and/or cause distress. So far the analogy holds, and these are the two conditions at least one of which is considered essential to diagnosable entities included in the American Psychological Association's Diagnostic and Statistical Manual (DSM) in its various editions since 1980.
However, many uses of the mental illness construct ignore its metaphorical quality. Thus, it is sometimes presumed without question that anything diagnosed as a mental illness should be treated, despite the fact that the majority of those identified in epidemiological studies as having such a condition do not seek treatment. Others go so far as to form an equation whereby mental illness equals illness, illness means physical condition, and physical condition requires physical treatment. This logic underlies much of the overuse of medications and the downplaying of psychotherapy for problems in living that characterizes the last few decades.
Each of the three links in this equation is fallacious, of course. As I discussed above, mental illness may resemble other illnesses in certain ways, but in most cases definitely is not the same thing. Certainly, if one extends the concept of illness to include mental conditions with no obvious organic cause then illness does not mean physical condition and there is no necessary reason that it should be treated, much less treated by physical interventions.
Now back to prejudice. Those who argue for extreme prejudice as psychopathology claim that it constitutes obsessive abnormal behavior that, depending on the author, either is claimed to cause subjective distress to the perpetrator or to the victim.
Many of our beliefs have a compulsive quality to them, at least in the short run. Try talking to some war supporters in certain parts of the country, or, for that matter, praising President Bush at many of the meetings I attend. The reaction in each case will not be a careful weighing of evidence or a calm question to elicit further information. Is hatred of Bush to be diagnosed an illness on this basis?
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