The Definition of Mental Disorder and Discourse Strategies in Psychiatry

Please consider certain elements of my contribution to conference discussion as confidential, since my subject: the “control of public discourse” in the field of psychiatry is sensitive. Yet, my opinions reflect the approach of a philosopher rather than a medical specialist in psychiatry. In effect, the postulated confidentiality can only be considered a rhetorical device at the plan of fiction rather than reality.

My short introduction to the study of this broad and important problem must be preceded by a certain methodological declaration. I venture the ongoing opinions in my capacity of philosopher and rely on the principles of bioethics, which is one of the study fields in philosophy. It is my conviction that the specific mission of bioethics lies in the fact that its objectives are defined in the following way: (1) identification of bridge roads between advanced philosophical concepts and practical issues linked to the human individual’s relation to his/her body and natural environment; (2) the facilitation of mutual contacts between the groups of specialists (e. g. medical doctors) and the broad population deprived of the specialist insights (e. g. the patients). In brief, I consider bioethics a practical philosophical mission contributing to social welfare. Since as philosopher I am involved every day in highly speculative and abstract concepts, it is in this field that I am trying to redeem my utter impracticality, by strong pragmatism in approach to bio-ethical issues which are close to my heart.

Let me offer another methodological reservation. The field of psychiatry-understood broadly as a comprehensive social, legal and institutional entity-is both the border area and model study object of bioethics. It belongs to the border zone, since the psychiatric practice is essentially not involved with physical body, while its moral dimension exceeds the sphere of usual problems arising in biomedical ethics. It is a model object-since the dramatic issue if incompatibility and conflict between the professional expertise of physicians and the expectations of broad public, so frequently encountered in medicine, becomes particularly sensitive in psychiatry: perhaps even more so than it is the case in attitudes to euthanasia or abortion.

Clinical psychiatry-for many historic and methodological reasons needs permanent self-defence and self-legitimisation, even in relation to the medical environment. Politics is the public mode of psychiatry’s existence. In relation to broad public, psychiatry must cope with the burden of historical disrepute castigating it as a field of abominable coercion, while in contacts with other medical scholars, psychiatrists are permanently suspected of deficiencies in “strictly medical” aspect, i. e. the somatic therapeutics. Yet, psychiatry has been most oppressed recently by legislation and leftist politicians. The suspicions and groundless claims for control powers by politicians and officers have been so pervasive that numerous psychiatrists succumbed to indoctrination. These doctors have developed symptoms of self-suspicion and even co-operate with judicial officers pestering psychiatric wards.

In this ideologically oppressive situation, where clinical psychiatry currently stands in the West, the psychiatrists are compelled to undertake defensive measures. They have to pursue active policy aiming at the promotion of their social standing and overall legitimisation. Yet, it must not be understood as opportunism in relation to fears and prejudices surrounding psychiatry. In my discussion over the definition of mental disorder offered next, I systematically relate to this issue-the defence strategy of clinical psychiatry and the possible ways of using the definition topos.

Let me formulate a final methodological remark. Definition cannot be considered the ultimate objective of knowledge, while the construction of definition is no proof of the author’s expertise. The definition is used in motivation and concentration of cognitive activities, the testing of obtained results (applied as a test of conceptual efficiency), but first of all definition has a practical applicability as criterion formulation allowing to classify objects belonging to given categories.

In the case of psychiatry the definition problem is neither essentially cognitive in nature nor indeed intensely desired by psychiatrists themselves. On the other hand, it is a key point in the strategy of those politicians and lawyers who wish to subject psychiatric wards to overwhelming control in the name of the protection of patients’ rights. It follows that clinical psychiatrists do not particularly look forward to the dubious practical benefits resulting of the strict criterion-based definition of mental disorder. Most often, even an utter non-specialist is able to identify a person with mental problems without recourse to any definitions; the mentally troubled person is usually different from all other individuals, being a “queer type” or a “lunatic.” Basically, psychiatrists need the definition of mental disorder as a defensive measure against the unfriendly political trends, while the lawyer looks forward to such definition that would facilitate him the intervention in psychiatric cases. Thus, the issue is more political than cognitive in nature. Alas, the rules of the game require that the psychiatrists don the cap of uninterested scholar and present his motives as purely scientific. At this point, the philosopher comes handy, since he is allowed to proclaim openly what the psychiatrist will never do, i. e. to declare that the issue is essentially political rather than scientific. And this is precisely what I am saying. In further analysis, I shall attempt to identify the difficulties that occur in the formulation of definition strategy that could be of some benefit for psychiatry and provide it with a certain measure of immunity against the incessant political claims.

The general public consists of individuals who are instinctively fearful of mental disorders, fear mentally troubled persons, are afraid of psychiatrists, and-last but not least- are ashamed of their own fears and prejudice. Consequently they are willing to accept all sophisms undermining the real existence of mental disorders in general. Thus, for the sake of this audience it is necessary to adopt the attitude full of understanding and appeasement of possible fears. This is the key to my proposal: mental disorders should be defined in the way that allays fears and reflects the understanding of the social reception of the phenomenon of psychic illness. Yet, it must not mean the embracing of opportunism and joining those who implicitly deny the very existence of mental disorders. Such resignation may be alluring but is obviously destructive for psychiatry.

Michel Foucault’s famous study Madness and Civilisation emphasises the definition problem. In eighteenth century, at the beginning stage of psychiatry, mental troubles were defined as the disorder of moral and intellectual abilities, accompanied by bodily disorders. Thus, the illness was defined through the categories of deficiency: deficiency of reason, deficiency of virtue, or the lack of organic harmony. The illness was considered as illusion, since the nonsense and deprivation of reason apparent in madness, were but deviations from the road of reality towards the wild moors of illusion. In Foucault’s opinion “madness in classicism was not interpreted as a definite change in the mind or body. Rather it was conditioned by nonsense expression accompanied by bodily deficiency or unusual behaviour and mode of speech. Classicist concept of madness is directly and most generally reflected in the word delirium. This word is the derivative of lira, the route. Thus deliro means exactly the deviation from beaten track, from the straight road of reason.” The tendency to repulse the illness as such and to eliminate it from consciousness is clearly visible in these classicist propositions. Of course the patient was expected to adopt the same repulsive attitude towards his illness. The classicist recipe might be formulated along the following lines: if the patient herself were in position to react correctly, she would be the severest judge of her own madness. Indeed it would be in the patient’s interest to support even the cruellest forms of combating the illness. This argument was used to legitimise the coercion and social exclusion which were the hallmarks of pre-modern approach to mental ailments. An essential change in definition strategy occurred in modern times. The moral-intellectual-somatic approaches was succeeded by the emotional-somatic concept. Until very recently the broad categorisation prevailed which differentiated between mental disorders in strict sense, which were treated as forms of “neurosis,” i. e. emotional troubles reflected in the somatic condition, and profound psychoses the origins of which were sought in somatic states, e. g. neurological causes. The fissure between the psychological and somatic approach to psychiatric diagnostics and therapy has remained very evident. In spite of this essential change and the modern predominance of morally neutral categories pertaining to emotions, personality or individual character, i. e. the incursion of emotions psychology in the psychiatry sphere, the old element of repulsion has been subtly preserved: “the possessed” of pre-modern times, the captives of evil powers, subject to moral decay at the moral and intellectual plan, appear now to have been enslaved by another internal power-emotions and imagination. Thus modern concepts have preserved the ambiguous sense of delusion which had always been used in definition of madness. The galley rowers of imagination are the luckless and internally enslaved individuals enslaved by the powers of imagination and irrevocable personality decay, sinking in non-being, which is the very essence of their illness. Antoni Kêpiñski’s psychiatry is wrought with a profound philosophical dilemma: how it is possible to reconcile the concept of illness as essential acute evil and obvious suffering, with the concept of mental disorder as a special condition offering specific high human values. The core of this dilemma can be seen as contradiction between the repulsion of the evil brought by illness, understood classically-as delusion or madness, and, on the other hand, the denial of illness resulting of the identification of some positive values in illness, certain good which cannot be reconciled with illness as absolute evil.

It is my opinion that within the assumed definition strategy we must beware the line of thought which makes the illness unreal (which is a classic approach, though strengthened in modern times by the popularity of so called anti-psychiatry and “reality therapy”), and the repulsion concept. Mental disorder must be understood as real and profound evil, though treatment cannot be reduced to a simple intervention aiming at the elimination of evil from the patient’s soul. Rather, the therapy ought to assist the patient in the internal process, in which he himself struggles with his suffering. It seems that most modern psychiatrists understand their task along very similar lines. Thus, my further strategic remarks may prove realistic. I am going to present them in following numbered paragraphs:

1. The current socially accepted discourse explaining the mental illness relies on positivist motives and leftist political sensitiveness. It is said that “psychoses are health disorders”-implicitly similar to other health problems. Everyone may experience such troubles. It is further implied that they have basically organic causes and can be reduced to the category of ailments with somatic aetiology. Moreover, it is understood that a subtle relation or neighbourhood exists between psychoses and neuroses, i. e. emotional troubles with recurrent fear conditions, which to some extent are experienced by a significant share of population. The pro-social ideology would supplement this line of discourse with the observation about social sources of mental disorders, i. e. implicit social guilt, which a conscious society must assume. In consequence, the mentally deranged should be approached with understanding and assisted if possible. Yet, this strategy may have double effect: it provides psychiatry with a measure of public legitimisation, but, simultaneously, justifies the incursion of state and non-governmental organisations in their efforts to control psychiatric wards.

2. In my opinion, the discourse strategy outlined in section 1 required appropriate modification, which would safeguard the sovereignty of medical authority against the unjustified control incursions. It is recommended to replace the fear-based topos: “everyone may suffer a mental condition” with the dialectic formulation “no one is absolutely mentally sound-but everyone can expect expert psychiatric care when needed.” In order to allay the social fears and repulsion in relation to mental troubles, public discourse ought to link closely psychotic conditions with other-more acceptable mental troubles-such as neuroses, mental retardation or dementia. Thus, a certain moral shield shall be provided to psychotics. It is commendable to promote a broad concept embracing all health disorders having their source or significant component in mental conditions. The re-introduction of the concept of soul would be very helpful. The soul is currently nearly tantamount to psyche but in moral dimension it is much more meaningful. In effect, it would be possible to define a category of ailments corresponding to psychiatric cases as soul conditions.

3. The positivist and naturalist ideological under-structure used to boost the psychiatry’s scientific authority by proposing that the essence of psychiatry lies in medical treatment targeted at the somatic sources of psychiatric cases makes the applied discourse unconvincing. Maybe it would be advantageous for psychiatrists to aim at an independent status-different from medical doctors and psychologists, rather than to cling desperately to the title of medical doctors, first and foremost. Neither the medical area, nor the field of social welfare institutions, is very hospitable to psychiatrists, who experience to some extent the symptom of social exclusion suffered by their patients. I am inclined to recommend the discourse of representative/curator, which has developed in some parts of the world already. The psychiatrist is the patient’s representative and curator, or “ombudsman” helping him/her to survive and representing his/her interests in contacts with hostile social environment. The formal adoption of such role by psychiatrists provides a barrier and de-legitimisation to administrative control incursions and boosts the psychiatrists status as the main principal reference group in the field of legislation concerning mental problems.

4. Considering the fact that majority of politicians voting in parliaments have no knowledge of mental disorders and psychiatry, it is commendable to promote the topos allaying the emotions of fear. According to my fragmentary knowledge, in the first order of importance it is necessary to explain why and when physical coercion is used in psychiatric wards (i. e. more frequently in cases of the patient’s exhaustion caused by mania rather than the cases of violent fury); when the hospitalisation is enforced (the enforcement being relative and gradual); the nature of electroshock therapy. It must be explained that chemical coercion, i. e. the application of strong sedatives, is by far more widespread in psychiatry than physical enforcement of behaviour. In effect, the gravity point of disputes concerning psychiatric practice may migrate from the area of enforced hospitalisation and the patient’s rights towards more professional discussions concerning the application rules and scope of pharmacological therapy. When the discussion in centred on these issues, the psychiatrists may regain the dominant position in public discourse, since few laymen are prepared to question their expertise in the application of drugs and their effects. In consequence of higher public standing, psychiatrists in particular countries will be able to secure more control over legislation process in matters pertaining to psychiatry. They will also have more to say in the solution of key issues such as conditions of enforced hospitalisation, and sensitive problems including the psychiatric aspects of approach to multiple murderers.

The discourse strategy in every intellectual field focuses all its basic issues in definition procedures. Therefore, I shall next attempt to translate the above-proposed directives into definition construction with respect to the phenomenon of mental disorder.

The objective of the definition of mental disorder proposed by psychiatrists ought to be essentially moral and promotional. The definition should aim to boost the low moral standing of the patients, protect them against aggression and-what is equally important-support the political status of psychiatrists. In effect, psychiatrists will have more say in legislative process related to mental care, and will find it easier to find finance sources for research and treatment. Yet, the definition ought to be scientifically sound and introduce structural order at the current level of knowledge.

I suggest the following defining terms. According to the postulate suggested earlier, I rely originally on the concept of spiritual ailments in general, and proceed to specify the mental illness: the spiritual (soul) disorder is a complex of acute or chronic difficulties encountered by individual in independent survival under standard social conditions, including the institutions of general social welfare and in spite of the overall satisfactory physical condition, while:

- the “difficulty” is understood as complete inability or deficiency of will and everyday activities resulting in their ineffectiveness or purposelessness, or accompanied by obvious suffering, and

- “survival” is understood as physical survival not accompanied by permanent hazard of health collapse or legally significant conflict with the environment.

In relation to the general category of spiritual disorders, the psychoses are defined as a subcategory thereof. Mental disorders are seen as such spiritual ailments where, permanently or temporarily, the patient’s consciousness of illness and critical reason is impaired or non-existent, in spite of the overall satisfactory level of intelligence.

The proposed definition terms are purely pragmatic and remain to some degree relative in relation to social and legal conditions. The suggested terms pertain to behavioural aspects, while explicitly avoiding to rely on any existing psychiatric theory. In result, the definition is expected to be stable and effective in building public consensus with respect to contentious social issues related to the psychiatric system. The applied terms emphasise the suffering and the necessity to assist the mentally troubled humans while strengthening and supporting the psychiatrists’ authority. The problem of mental disorder is approached both as inherently medical and social issue, thus fitting very well in the mainstream discourse of socialisation. In effect, psychiatrists are supplied with a good defensive tool in the same area, which has been traditionally the launch pad of threats to their sovereignty and authority. Yet, the law ideology drawing from social-democratic (resp. liberal-in American terminology) policies in relation to psychiatry is but a form of socialisation discourse.

The political quality of proposed definition strategy is advantageous for psychiatry, and, consequently, is beneficial to patients. Similarly to other fields of bioethics, we encounter in the case of psychiatric ethics the problem of disproportion between the knowledge held by a narrow group of experts and relative ignorance of wide publics. Also similarly to other bio-ethical fields, that approach to arising issues is most rational which respects the expertise of the knowledgeable professional group. Such was the intention of suggestions and formulations offered in my paper.