Social dystonia and psychosis: An alternative perspective

Introduction

This is an alternative perspective on social dystonia and psychosis to that provided by Kecmanovic (2013), who draws highly limited and conservative conclusions about both the role of psychiatry as a medical specialty and the warranted inevitability of stigmatisation. He uses the term dystonia metaphorically to indicate that the conduct of psychotic patients has a painfully distorting impact on personal relationships and societal functioning.

In essence, he presents three core arguments. The first is that psychotic patients are inherently socially dystonic. The second is that, as a consequence of this inherent impairment, society must inevitably protect itself from its practical consequences. The third is that psychiatry fulfils a legitimate and ethical role in society, by combining care for psychotic patients and protection for society. I will deal with these issues briefly one by one.

Social dystonia

The author is correct to highlight this aspect of psychotic functioning. Indeed, it is not the presence of idiosyncratic experiences (hallucinations and delusions in medical terms) that is the challenge for others of those acquiring a diagnosis of psychosis, but the conduct flowing from them. Having idiosyncratic experiences is not the issue here, but acting on them can mean that some forms of social crises become psychiatric crises. Psychiatry does not create these problems; they are transmitted from the lay arena of society (Coulter, 1973).

Auditory hallucinations can prompt some of us to speak out loud unintelligibly about sensory experiences outside of the apprehension and thus comprehension of those nearby. We may even act on the commands of those voices. Delusions can trigger perplexing, frightening or comical conversations, when one person talks to another with a set of assumptions about reality, which make no shared sense. We may even act on those idiosyncratic beliefs, given that thoughts guide our conduct.

Kecmanovic (2013) discusses such social phenomena as psychiatric impairments warranting corrective action within the remit of medicine. However, he also alludes to the interpretations offered by the symbolic interactionist wing of the Chicago School of Sociology in the past 50 years (labelling theory). Within that tradition, variable biological, psychological and social causal mechanisms for psychological oddity (which it calls residual deviance) are conceded, with a research focus thereafter on the reaction of others in society. It is the reaction of others then that makes a mental disorder into an important investigation for social science. By contrast, a medical approach dwells narrowly on characteristics of the identified patient in isolation.

Notwithstanding the potentially offensive phrasing of some his arguments, Kecmanovic (2013) is pursuing an important line of reasoning, but he does not dwell sufficiently on two tautologies. The first is that psychotic phenomena and the social rejection they can elicit are deemed to be global and universal. These two words can mean the same thing in English and it may have been that global and transhistorical is what was more precisely intended (deduced from the text more widely). The implications of this global and transhistorical assumption are picked up in my next section.

Second, if it is the actions, not the experiences, associated with psychotic phenomena that are of practical concern to society, then why should medicine (or any other single community of interest) have any immediate and self-evident authoritative claim to either describe and explain that social process or proffer ameliorative interventions? Surely, the rationale and authority of medical descriptions about insanity in the past 200 years have been derived from their socially administrative, not scientific advantages, with the latter only being defended by very weak circular arguments of this sort:

• Q. How do you know that this patient is suffering from schizophrenia?

• A. Because they report hearing voices others do not in their presence and they have strange ways of speaking and acting.

• Q. Why do they present in such an odd way?

• A. Because they are suffering from schizophrenia.

Functional disorders in psychiatry are functional for the very reason that their aetiology is either unknown or contested. Indeed all forms of functional diagnosis are caught in this tautology, not just those alluding to the presentation of psychotic symptoms (Pilgrim, 2007). Despite these inherent logical and empirical problems with psychiatric diagnoses, Kecmanovic’s central point about social dystonia is fair and reasonable. The problem is that he limits it too readily to psychosis, which is a cue for the next section.

Warranted social rejection?

Social dystonia is a very wide notion and refers to the offence and disruption created by some forms of conduct within a normative context. It is so broad that while it would subsume psychotic conduct, it would not be limited to it. Any socially disruptive conduct warrants lay recognition and labelling of deviance, even before professionals become involved. For example, antisocial and criminal acts, which neither lay people nor psychiatric professionals would necessarily, or even ever, consider to be mentally disordered, are experienced as being socially dystonic.

One reason, then, that, taken in its totality, the Kecmanovic article may come across to some readers as offensive is that it limits its consideration about social dystonia to psychotic conduct. This silence about the wider normative context means that psychotic patients appear to be singled out. However, the author is not alone in this regard. He is merely mirroring a norm himself with that silence: what Aristotle described as doxa (common belief) or a taken-for-granted assumption in a culture.

In this case about social threat, take the example of young people binge drinking at the weekends. If we were to construct a form of legislation to ensure a curfew from Friday dusk to Monday dawn of all under-30-year-olds, then much harm would be prevented. Accident and emergency admissions would drop dramatically as would the incidence of sexual assaults, domestic violence and road traffic accidents. The suggestion of such as curfew may seem bizarre because it is at odds with our current doxa. However, the presence of mental health law that removes liberty is considered to be self-evidently worthy and even socially progressive.

Thus, it is not dangerousness that is at issue in relation to psychosis but the manner in which one is dangerous (Szasz, 1963). Many people smoke, eat fatty foods and have unprotected sex. This has dystonic consequences but we have no socially legitimised legal arrangement, as we do with mental health law, to coercively control these actions. Likewise, as part of our doxa, we venerate mountaineers, racing car drivers and bellicose political leaders, who take us into wars that kill thousands of people. They are not locked up without trial and treatments imposed on them against their wishes. Mental health law is thus inherently discriminatory because it singles out one form of social threat for peculiar legislative scrutiny. Our current doxa entails a collective silence about the different ways that risky conduct is dealt with, depending on whether its perpetrators are deemed to be sane or insane (Pilgrim and Tomasini, 2012).

Thus, mentally disordered conduct is indeed socially dystonic but it is by no means the only way in which adults in society act in a dysfunctional manner. Moreover, psychiatric patients are not even unequivocally more dangerous than other social groups. For example, several analyses of the link between psychotic conduct and violence have revealed only ambiguous results (Appelbaum et al., 2000). Some have suggested an elevated risk for some specific groups (e.g. those who experience command hallucinations with violent content), some a slight general elevation of risk and some no elevated risk (Steadman et al., 1998). Substance misuse certainly substantially raises the risk of violence in psychotic patients, but it also raises that risk in non-psychotic citizens (Regier et al., 1990). For example, in a variety of ways, alcohol use and its behavioural consequences are harmful for all of us in society.

These ambiguous findings and a wider consideration of the ecology of non-psychotic risk should have been rehearsed by Kecmanovic (2013). By not rehearsing the wider context of the ecology of risk in society, his article appears to reinforce popular prejudices about the disproportionate objective threat of psychosis (given that its inherent lack of intelligibility invokes a recurrent subjective fear in others). However, it is the job of academic researchers in the field of mental health to challenge the fairness or validity of that fear, rather than take it for granted as a legitimate response in the public imagination.

Kecmanovic (2013) is correct to point out that attempts at mental health literacy have so far failed in this regard (Pescosolido et al., 2010). However, the obdurate character of stigma, prejudice and discrimination about people with mental health problems and the adverse impact on them will never be challenged, in principle, if we simply accept that stigma is actually a legitimate position for ‘society to defend itself’ (see Link et al., 2001). This is what at times is being argued by Kecmanovic and it reveals a lack of socio-historical sensibility on his part.

Madness in antiquity had certain themes about lay stereotyping; then and now there were assumptions of aimless wandering and violence (Rosen, 1968). However, other assumptions were at large about madness in the past. In Ancient Greece, madness was assumed to be (like everything else) given by the gods. Accordingly, it was afforded an ambiguous, unclear pathological status, when considering the madness of poets, the madness of lovers and the madness of prophecy (Screech, 1986). It is only in our current Western, medically framed set of assumptions about madness that we habitually understand it as a self-evident impairment and worthless form of pathology that creates a threat or burden for society.

The legitimate role of psychiatry?

Having introduced doxa in the previous section as a way into thinking about taken-for-granted cultural assumptions in Kecmanovic’s (2013) article, this theme continues in his uncritical assertion that a win-win situation exists when psychiatry cares for psychotic patients and protects society. If patients at all times indeed felt that they benefitted, then this assertion would be warranted, but clearly they do not. For example, psychiatry has tolerated wide-ranging clinical iatrogenesis, with professionals pressing on with treatments with adverse impacts on patients because they are considered to have wider social benefits (Finn et al., 1990; Keogh and Doyle, 2008).

And while mega-dosing and polypharmacy are poor practice across medicine, it is only in psychiatry that this occurs in a context of coercion, where the patient may have few or no rights of protest (Moncrieff, 2007). This constitutes a serious human rights matter and so it is not surprising that a whole new social movement has arisen to protest about the personal damage and social disability it creates (Crossley, 2006). It is possible to read the whole of Kecmanovic’s (2013) article and be unaware of this human rights crisis for psychiatry, which in the past has been limited within its own discourse to the abuse of psychiatry by the state (Reddaway and Bloch, 1978), whereas now that crisis extends to its use not abuse (Johnstone, 2000).

For example, at the General Assembly of the European Network of (Ex)-Users and Survivors of Psychiatry, held in Thessaloniki, Greece, on 30 September 2010, delegates voted to agree a campaign for Truth and Reconciliation in Psychiatry. This demanded a formal apology from psychiatry for the iatrogenic damage it has done over the past century to its victims. This extraordinary but understandable campaign highlights why the use, not just the abuse, of psychiatry has become a social policy question. Kecmanovic (2013) depends largely on sociological reasoning but he is then silent about these critical wider discussions about the role of psychiatry in society. This might reinforce the fears of his critical readers that he is simply restating, unreflectively, common prejudices about psychosis.

Psychiatry can only be depicted as caring for psychotic patients in an unambiguous sense, if we only listen to the voices of conservative clinicians and concerned relatives. But if service user (or consumer) voices are represented in a sociological account, instead of being ignored in silence, then it is not at all clear that psychiatry is a caring sub-specialty of medicine. Its coercive powers in society do point unambiguously to its social control role; a point Kecmanovic (2013) does concede in parts of his argument. Coercive psychiatry by definition is there to warrant loss of liberty and intrusions onto resistant bodies, without legal charges of assault being brought against professionals (Szmukler and Appelbaum, 2001).

That picture is hardly a comforting encouragement for those thinking about accessing psychiatric care. And since the 19th century, those sane by common consent have expressed strong fears of unfair detention, when mental health legislation is debated (Bean, 1986). For this reason, Kecmanovic (2013) does seem to be unquestioningly legitimising, rather than sceptically querying, coercion as a form of care. Many parties in society simply cannot accept this taken-for-granted Orwellian logic, and as a social scientist he has a responsibility to represent those dissenting voices.

Conclusion

This has been a brief response to a complex topic. It has focused on weaknesses in Kecmanovic’s (2013) article in relation to his three key points about social dystonia, warranted social rejection and the legitimate role of psychiatry in society. While he has provided a useful stimulus to debate these important matters, his article is expressed at times in a language that many might find offensive and which takes for granted, in an unwarranted way, the legitimacy of both daily stigmatisation and the non-problematic and benign role of medical paternalism, underpinned by mental health law. A fuller account from social science reveals that stigmatisation still constitutes its own form of collective irrational stance and that, as a medical specialty, psychiatry is frequently not benign in its routine practices.