The relevance of the social dystony of psychotic people to their public and psychiatric treatment

Introduction

The notion of psychiatrists as agents of social control has been both dismissed (Roth, 1973) and acknowledged (Szasz, 2003). The goal of this article is, first, to show that because people with psychosis challenge sociality, the symptoms of psychotic disorders cannot help but have a socially disturbing effect, and, second, to denote that society has to protect itself against people suffering from psychosis. To achieve this goal, I will explain the ways in which psychotic people are socially dystonic, how they challenge sociality which is the basis of social life and how society protects itself. Also, I will explore the specificity of mentally disturbed people as deviants by comparing them with other deviants, and by situating them in the context of the need for mental health.

Psychotic people are socially dystonic

People with psychosis are socially disruptive insofar as they do not generally use the same symbols that non- disordered people use and, if they do, they give them an idiosyncratic meaning. There is a rupture between a mentally disordered individual and the sociolinguistic community in which they are nested (Rodrigues and Banzato, 2010).

‘“Normal” mental functioning signifies belonging to a community of shared practices, emotions and beliefs, in which one person makes sense to another and is included in “we”’ (Bolton, 2008: xiv). In contrast, this scholar argues, disordered mental functioning ‘signifies a break in perceived sense’ (2008: xiv); hence, it does not make sense to mentally healthy people. Responses of psychotic people to social stimuli are quite often at odds with the kind of responses of the majority of people. As the latter cannot comprehend the verbal and non-verbal behaviour of the former, they cannot empathize with them and therefore feel confused (Kendell, 2004). Moreover, psychiatric illnesses, primarily psychotic ones, include changes in approach and behaviour that can, in most cases, violate social conventions and challenge, if not undermine, basic assumptions about personhood and social reality (Fabrega, 1991).

Given these attributes of psychotic people, it is small wonder that those who are mentally healthy perceive the former as unreasonable, unintelligible, outlandish and, therefore, unpredictable (Angermeyer and Dietrich, 2006; Arboleda-Flórez, 2003; Serino, 1987). As a great deal of the sense of social safety of mentally healthy people rests on the reasonableness, intelligibility and predictability of those people with whom they, directly or indirectly, communicate, people with psychosis endanger their sense of social appropriateness and consequently their social safety. People with psychosis challenge not only their status as social beings, but also the key framework of the community to which they and mentally healthy people belong. Therefore, ‘it is normative behaviour to perceive people with mental illness as dangerous and violent’ (Overton and Medina, 2008, p. 145).

Indeed, today’s societies are not homogenous; they are pluralistic in nearly every regard. The norms that are cherished by some people are not the norms preferred by others. However, there is a core culture that is common to all members of a community. It is hard to determine how people could live in a group and how they could coexist and even cooperate with other group members without all of them respecting the same core culture that constitutes the common denominator of mutual communication and understanding. And when mentally disordered manifestations put that core culture into question – when psychosis, as Devereux (1970) put it, deculturalizes the culture – individuals and the community as a whole cannot help but feel threatened and endangered.

Thus, socially dystonic is everything that ignores or distorts the socially acknowledged code of verbal and non-verbal behaviour in the given community.

How society protects itself from psychotic people

The two main ways in which mentally healthy people protect themselves against the perceived threat from psychotic people are through stigma and psychiatric care.

Stigma is ‘a characteristic of persons that is contrary to the norm of a social unit’ where ‘the norm’ is defined as a ‘shared belief that a person ought to behave in a certain way at a certain time’ (Stafford and Scott, 1986, p. 81). Stigmatized persons are excluded: they are kept at a distance. Their socially disquieting effect is under check so long as they are not allowed to participate in the sociocultural and economic life of the community (Thornicroft, 2006).

Psychiatric treatment, for its part, is intended to smooth over or efface the symptoms of a mental illness. By doing so, it mitigates or lifts the socially unsettling effects of the symptoms. ‘Therapy is a distinctive style of social control … When some sort of damage is perceived to result from disordered personalities rather than from deliberate rule breaking, accident, or negligence, therapy is a likely response’ (Horwitz, 1990: 80). Furthermore, mental suffering is one of the nearly mandatory symptoms of those who seek psychiatric assistance or are forced to receive it. Thus, apart from addressing social dystony of people with psychosis, psychiatrists are expected to releave their suffering as well (Casey, 1993).

Even though stigma and psychiatric treatment serve the same purpose – the protection of the mentally healthy population from those who are mentally deranged – the effects of stigma counteract the goals of psychiatric care. Stigma not only increases the suffering of people with mental illness but also thwarts psychiatrists’ efforts aimed at helping patients to take on as many social roles as they used to have before they fell ill. In reality, stigma cannot render the symptoms of mental illness more socially disruptive; however, in people’s representations about mental illness, it does just this. On the one hand, social dystonia is the reason for someone’s stigmatization; on the other hand, those who are stigmatized are perceived as more socially disruptive than they actually are.

The fact that stigma counteracts the effects of psychiatric treatment does not question its protective role. It only indicates that protection against people with mental illness cannot fully rely on psychiatric treatment. Sometimes, psychiatric treatment is efficacious; at other times, it proves partly successful or unsuccessful. However, stigma cannot fail to marginalize people with mental illness, especially those who are psychotic.

Why mental illness stigma is universal and global

The public’s apprehension of psychosis is compounded by observing how people suffering from psychotic disorder behave, what they say and how they relate to themselves and other people, and by the social representations of psychosis. These two components of the notion of psychosis are so closely intermingled that they cannot be clearly distinguished.

Sontag (1991) wrote that three diseases have been encumbered by the trappings of metaphor. The phantasies inspired by tuberculosis in the 19th century, and by cancer and acquired immune deficiency syndrome (AIDS) in the 20th century, ‘are responses to a disease thought to be intractable and capricious – that is, a disease not understood – in an era in which medicine’s central premise is that all diseases can be cured’ (1991: 5). Sontag failed to identify psychotic disorders as an all-time plague whose metaphor is as intimidating as the perception of those suffering from psychosis. She also maintained that a disease can be a metaphor for an epoch’s evil until its aetiology becomes clear and its treatment effective. Yet this does not hold for psychotic disorders. What makes psychotic disorders a metaphor for what is feared and deplored is the way in which they present themselves as well as the specific imagery that surrounds psychotic manifestations (e.g. personal weakness, indulgence, ancestors’ sins, loss of control, impaired test of reality, delinquency) rather than unclear aetiology and ineffective treatment.

In this context, it is worth noting that endeavours to decrease mental illness stigma by promoting the biological model of mental illness have had no effect on social distance from mentally ill people (Jorm and Oh, 2009) or have even increased it (Pescosolido et al., 2010).

Indeed, it is not only social deviance that triggers stigma. The stigma of mental illness might also be accounted for by other factors such as deeply entrenched attitudes towards madness (‘deep currents’) (Department of Health, 1999; Hinshaw, 2007; Kendell, 2004); evolutionary and biocultural underpinnings of stigma (Kurzban and Leary, 2001; Neuberg et al., 2003); and the fight against chaos and death (Hinshaw, 2007).

Discussing the roots of mental illness stigma, Radden and Sadler wrote:

What we can be sure of is that although the religious and moralistic prejudices that used to attach to madness may be for the most part forgotten in today’s Westernized cultures, such cultures still cleave – for better or worse – to the traditional Western ideals … They value the capabilities on which agency, personhood and self-identity depend; they also prefer independence over dependence, rationality over illogic, communicative transparency over unintelligibility, self-control over impulsiveness, agency over passivity, and unity of the psyche over its fracture and disintegration. Only if we acknowledge this can we recognize how deep and intransigent are the roots of stigma over mental disorder. (2010: 44)

It is doubtful whether cultures – if there are any such cultures – in which impulsiveness, the disintegration of the psyche and communicative unintelligibility are more valued than self-control, the unity of the psyche and communicative transparency could survive. Hence, what Radden and Sadler (2010) described as traditional Western ideals could easily – mutatis mutandis – be extended to any culture. If we do so, it becomes clear why mental illness stigma is universal and global (Hinshaw, 2007; Thornicroft, 2006).

Could personal contact with a particular person suffering from psychosis diminish the social distance from them? It depends on a host of factors and circumstances: is the patient in an acute phase or in remission; are they in the hospital or in the open community; how much has the psychotic disorder damaged the façade of their personality and impaired their social functioning, to name just a few. Thus, it is hard to say what a truly psychotic person is like: is it the one in a stable remission with a comparatively well-preserved façade of the personality, or the one in an acute psychosis whose perception of reality is severely distorted (Penn and Couture, 2003)? Given the imagery associated with the notion of a psychotic person – for example, of someone suffering from schizophrenia – it seems that the image of a person who is delusional, unintelligible and unpredictable is prevalent in the public representation of psychotic individuals.

It should be pointed out that the dichotomy between people enjoying mental health and those experiencing mental illness underpins the stigma of mental illness. The stigmatizer is supposed to be a mentally healthy person and the stigmatized a mentally disturbed one. Could the blurring of the distinction between normality and pathology be instrumental in alleviating and even eradicating the stigma of mental illness? Could psychiatry dispense with diagnoses so as to make the formation of mental illness stigma less likely or even unlikely? First, psychiatric diagnosis is not the only prerequisite for the creation of the stigma of mental illness. Behaving unreasonably, unintelligibly and unpredictably is sometime sufficient to be stigmatized as mentally ill. Second, psychiatrists cannot work without diagnoses and without differentiating the normal from the pathological (Kecmanovic, 2011a). Furthermore, it soon becomes evident ‘after only a cursory perusal of the literature that workers motivated by the idea of a continuum find it impossible to resist setting a threshold above which a hallucination or delusion may be defined’ (David, 2010, p. 1936).

As this article deals with the social dystonia of people with psychosis, it appears appropriate to ask whether there is a continuum of social dystonia of psychotic disorders. In other words, are there different degrees of social dystonia, and if yes, what determines the degree of social deviancy? The public’s perception of the social dystonia of psychotic disorders is mostly determined by two factors: (1) how much a particular behaviour deviates from a socially acknowledged code of verbal and non-verbal behaviour; and (2) how much people assess that particular behaviour as reactive and expected. The more it is deviant and regarded as non-reactive and unexpected, and unintelligible and unpredictable for that matter, the more it is regarded as socially dystonic.

Social deviancy and its control

Mentally ill people are not the only social deviants. However, they constitute a distinct kind of social deviants. Unlike other forms of social deviancy, mental disorders are not predominantly caused by social circumstances; they nearly always entail mental pain; they are beyond one’s will and control; and they mostly positively respond to psychiatric assistance. In the context of this article, it is worth paying attention to the distinction between the social control of psychiatric patients as deviants and the social control that is carried out by labelling deviant people as mentally deranged.

The first type of control relates to the use of psychiatric means to minimize, eliminate or normalize a mentally disordered qua deviant behaviour. The second type of control is instantiated in the kind of social control that involves ‘defining a behaviour or condition as an illness primarily because of the social and ideological benefits accrued by conceptualizing it in medical terms’ (Conrad, 1979). Sometimes, society, through medicine and psychiatry respectively, labels as medical (psychiatric) a particular behaviour or condition that seems primarily, if not exclusively, associated with particular social circumstances. Society medicalizes this behaviour or condition so as to disguise its putative social origin. The point is that when manifestations considered to be mental illness-related are read in biological terms, the inconveniences of the existing social situation cannot be pointed out as their (most likely) place of birth. If psychiatry’s explanatory schema ‘locates the source of pathology it identifies in intra-individual forces’ – and biological forces are one of them – ‘it is of great potential value in legitimizing and depoliticizing efforts to regulate social life and keep the socially disruptive in line’ (Scull, 1991, p. 168).

These two types of social control are substantially different. In the first case, society, by means of stigma and psychiatric treatment, protects itself, i.e. protects mentally non-disordered people from the socially disquieting effects of mentally disturbed people. In the second case, those in power, through psychiatrist-mediated psychiatrization, strive to prevent blaming society for a state of affairs that gives rise to social deviancy and thus tarnishes society’s image. The protective potential of psychiatrization is found in the biomedical psychiatric concept dominant in today’s psychiatry. According to this concept, mental pathology reflects a brain rather than society’s dysfunction.

The above two cases of social control instantiate the difference between the psychiatric and labelling perspectives. ‘When observers’ labelling practices are reflective of actors’ behaviour, the psychiatric perspective is supposed. When, on the other hand, social contingencies best predict the labelling of mental illness, the labelling view is upheld’ (Horwitz, 1982: 7).

The psychiatric perspective that is the focus of this article is explored further in the next section.

Surveillance and control are instrumental to sustaining mental normality

The common denominator of every form of medical practice is found in the goal of medicine. The medical approach serves the purpose of sustaining human life and the survival of the human species. Even when medical treatment does not result in curing disease and postponing death, by its basic intention and determination, it is in the service of sustaining the life of individuals and of groups.

Since life that is not impaired by disease is one of the preconditions for the development of an individual’s and the collective potential, and thereby for the survival of the community, medical care to preserve life constitutes a basic human need that could be put on the same footing as self-defence and the drive for procreation (Malinowski, 1948). Thus, the need for health is one of the fundamental human needs. Medicine is a cultural response to the need for health.

Just as there is no need to teach people to defend themselves or to procreate, it is superfluous to instruct them that health is an asset and that they should be afraid of disease. Biological forces more powerful than knowledge urge people to care about their biological existence and the existence of their kith and kin. It is purposeful to inform people about how they could better prevent disease and how they should deal with disease; however, it is unnecessary to teach them the need to care about their own biological existence, their survival and the survival of their progeny.

Indeed, there is a touch of obligatoriness as far as the need to look after one’s own health goes. When people fall ill, they are expected to take on the sick role which comprises rights and obligations. There are two rights: the sick person is exempted from ‘normal’ social roles, and they are not considered responsible for their condition. Also, there are two obligations: the sick person should try to get well, and they should seek competent help and cooperate with the physician (Parsons, 1958).

The need for mental health is not of the same order as the need for somatic health. It is more social than biological. Even though the mortality rate of mentally ill patients is higher than that of the general population (National Mental Health Commission, 2012), mental disorders are not a biological menace but rather a social one. They challenge human sociality and consequently the respective community. By sociality, I mean the acknowledgment of both a common social code that enables interpersonal communication, and an individual’s compliance with the socially defined meanings of things, events and symbols. The unimpaired sociality of the individual members of a community is one of the key requirements for participating in the social life of a given community; at the same time, the unimpaired sociality of the majority of the members of a community makes and keeps community life functional.

In contrast to the need for health that is one of the basic (primary) needs, the need for sociality and participating in social life is a derivative (secondary) need (Kecmanovic, 2011b). It is through socialization that people incorporate the dominant behaviour and the belief standard of the social milieu. Apart from modelling, the process of social learning comprises rewarding those who learn well and quickly, and surveying and controlling those who, for whatever reason, do not accept and/or do not respect the dominant code (e.g. those with developmental difficulties and/or mental illness, or those who are reluctant to accept or respect the code).

Talking about the syncretic nature of psychiatry, Pilgrim and Rogers (2005) asserted that ‘although psychiatry is a medical specialty, its activities are not purely scientific. They are clearly syncretic … because there is a strong normative aspect to the profession’s role’. They then added: ‘this normative role is one major reason why it has been so controversial especially as it has been regularly characterized by coercion’ (p. 2552).

With few exceptions, surveillance and control are rarely required when fulfilling vital, primary, biological needs; exceptions include: quarantine in the case of a specific infectious disease, or mandatory vaccination of children or when visiting some regions. On the other hand, as they are not biologically driven, learning, acknowledgment and the respect of the common social code, of the dominant behaviour and belief standard, demand ongoing social surveillance, control and/or even coercion. In the case of people with mental illness, psychiatry is ‘an agency of social control that helps stabilize and maintain the integrity of society’ (Armstrong, 1988, p. 162). The specificity of psychiatric surveillance and control is evidenced in the specificity of psychiatric diagnostic and therapeutic methods. By using these methods, psychiatrists minimize or eliminate mental illness symptoms and relieve mental suffering; by the same token, they smooth and/or efface the socially dystonic aspects of the symptoms of mental illness. That is how they, among other things, secure or restore as much of the mentally ill person’s sociality as possible. And that is why ‘unlike other doctors, psychiatrists have the role of warder as well as therapist’ (Lader, 1977: 193). Contrary to Lader’s claim, this does not imply that psychiatrists have dual professional responsibilities – to their patients and to society – as I discuss in the next section.

The double agent problem: who controls whom?

It is said that psychiatrists cannot help but be divided between loyalty to the patient and loyalty to society. Thus, psychiatrists’ allegiance is split (Chadoff, 1999): they suffer from identity confusion (Leifer, 1982).

Moreover, multiple agentry reportedly creates serious ethical dilemmas. ‘The ethical dilemmas of psychiatry cannot be resolved as long as the contradictory functions of healing persons and protecting societies are united in a single discipline’ (Szasz, 2003, p. 227).

My contention is that these ethical dilemmas do not exist if psychiatrists work in the best interests of patients. Whenever psychiatrists do so, they act in the best possible way to protect society from the socially dystonic manifestations of mental illness. Healing a person means alleviating their socially disturbing symptoms, and thereby protecting the given society and its mentally healthy members. Healing and protecting are not contradictory: they go hand in hand in psychiatry.

The double agent problems arise when the primary interest of society is not to protect itself by psychiatric treatment against the disociality of mentally ill people and to relieve patients’ mental suffering, but rather to use psychiatry for purposes that have nothing to do with efforts to improve patients’ mental condition.

Conflicts of obligations towards the patient and third parties ‘have occasioned myriad legal and ethical disputes’(Bloche, 1999, p. 269) – over duties to patients versus the military, the justice system, insurers, employers, the family and other social institutions. It is likely that the potential for conflicting obligations towards an individual patient and another party or group is secondary to the fact that society endows the profession of psychiatry with powers beyond most other professional groups (Robertson and Walter, 2008). Wherever psychiatrists take on the role of evaluators or assessors for the ones who, openly or covertly, care more about the interests of third parties than about bettering the patients’ mental state, they, to a great degree, betray their original duty to the patient. By contrast, when they are primarily committed to improving the patient’s mental condition, they provide the greatest help to society, to both its mentally healthy and mentally ill members. The particular interests of individual sections of society with regard to psychiatric patients somewhat derail psychiatry from its original mission and create the double agent problem. It is not society that via psychiatry controls the socially disturbing aspects of mental illness; rather, it is the individual sections of society that use psychiatry for their own purposes. They, one might say, largely impose control on psychiatrists’ activities.

Conclusion

Psychotic persons are socially dystonic because psychosis impairs their sociality. Also, it challenges the sociality of mentally healthy people and thereby threatens the life of the community. That is why society, through stigma and psychiatric treatment, has to be protected against the threat and danger to which psychotic people give rise.

The social dystonia of people suffering from psychosis shapes the public’s response to them. It also plays a prominent role in how psychiatrists treat their patients. That is why, in deliberations about the specificity of mental illness and about the relationship between society and people with mental illness, due attention should be paid to the fact that these people are socially dystonic.

Psychiatrists are agents of social control. The key contribution of this article is that it has shown that control of the socially unsettling aspects of psychotic people and psychiatric treatment of these kinds of patient are not at odds. The latter serves the former. Healing and protection are united in the discipline of psychiatry.

In that sense, psychiatrists’ allegiance is not divided between loyalty to the patient and loyalty to society. Whenever psychiatrists provide appropriate assistance to people with mental illness, they, in the best way, serve the interests of both patients and society.