Psychotic patients and other social deviants

Pilgrim, in his comment (2013) on my paper ‘The relevance of the social dystony of psychotic people to their public and psychiatric treatment’ (Kecmanovic, 2013), argues that I drew limited and conservative conclusions about both the role of psychiatry as a medical specialty and the warranted inevitability of stigmatization. He promises instead to provide an alternative perspective on social dystony and psychosis to mine.

What are Pilgrim’s critical comments on my three key assertions and what alternative perspective does he propose? To jog our memory, my three points were: people with psychosis challenge sociality; society has to protect itself against people suffering from psychosis; and psychiatry fulfils a legitimate role in society by combining care for psychotic patients and protection for society.

Social dystony

Pilgrim concedes that I am correct to highlight social dystony as an aspect of psychotic functioning. As if to correct my description of psychotic manifestations as dystonic, and thereby triggering a social reaction, he argues that it is the acting on psychotic experience that stirs up social reaction. I would say that verbal behaviour of people with psychosis has the same effect. When someone produces delusions without acting on them, they prompt other people’s reaction because delusions have no shared sense: they are expressions of sensus privatus rather than of sensus communis to use Radden’s terminology (2011) in identifying the specificity of delusions.

Pilgrim furthermore asserts that, while talking about society’s reaction to psychotic verbal and non-verbal behaviour, I allude to the interpretations offered by symbolic interactionists. This claim is not appropriate because as far as mental disorders are concerned, symbolic interactionism primarily deals with the social genesis of mental disorder. Yet I do not thematize the causation of these disorders. It is beyond the scope of my paper. As for labelling theory, I explain at length, in the third section of the paper, the distinction between social control of psychiatric patients as deviants and the control that is carried out by labelling deviants as mentally deranged.

Further, in the text, Pilgrim asks: ‘if it is the actions, not the experiences, associated with psychotic phenomena that are of practical concern to society, then why should medicine (or 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’. There is a difference between the social deviancy of people with psychosis and other social deviants. I highlighted it in the above-mentioned section of the text. To reiterate, unlike other forms of social deviancy, mental disorders, psychotic ones in the first place, are not predominantly caused by social circumstances; they nearly always entail the impairment of one or more mental functions and mental pain; they are beyond one’s will and control, and they mostly positively respond to psychiatric assistance. Psychiatrists are professionally qualified and socially empowered to deal with such kinds of problems.

Warranted social rejection

As there are many sorts of social deviants, Pilgrim wonders why I have singled out psychotic patients. The category of deviant forms of behaviour is very large. It is legitimate to deal with one sort of social deviancy without analysing in the same paper all the other sorts of this kind of behaviour.

There is another issue Pilgrim raises that seems better placed. He asks why I am silent about the normative context within which a deviant behaviour appears, and argues that, in my key assertions, I merely mirror the given normative context, or what Aristotle described as doxa (common belief). Whether he likes it or not, in psychiatrists’ considerations, the normative context has always been the given normative context, that is the normative context of the respective society. A universal normative context, or something like a trans-mundane and/or trans-historical normative context, is not the context within which psychiatrists operate. Besides, a supposed universal normative context is also value-laden. The only question is which values or norms one reads into the context that is presented as universal.

Pilgrim is also not happy with the way in which I talk about the fear of mentally ill people and their stigmatization. Not going into a discussion about the objective threat of people with psychosis, those people, my argument goes, represent a symbolic threat because they are perceived as unreasonable, unintelligible, unpredictable, and thereby dangerous. This is the finding of the greatest majority of studies on how people with psychosis are viewed. They endanger the exiting social order that mostly rests on reasonable, intelligible, and predictable people’s behaviours.

Pilgrim furthermore claims that the job of academic researchers in the field of mental health is to challenge the fairness and validity of the fear of mentally ill people. My position in regard to this extremely important issue is as follows. It would appear that the fear of people with psychosis is one of the anthropological-psychological inherencies of the same order as is, for example, the fear of Other, of Unknown, of Darkness. It is not by accident that to date the greatest number of actions aimed at preventing stigmatizing people with psychosis proved only partially successful or unsuccessful. I do understand the fear of people with psychosis. Yet I think it is worth fighting it. It is superfluous, however, to challenge this kind of fear whenever its existence has been highlighted, and its role described.

The legitimate role of psychiatry

I indicated in my text that psychiatrists serve two basic functions. They care for psychotic patients, attempt to minimize or remove their symptoms, and release their mental suffering. By easing patients’ symptoms, by making them less manifest, they render patients’ behaviour less socially dystonic. By the same token, psychiatrists protect society, meaning the non-clinical population from socially disruptive psychotic manifestations. The more psychiatrists are efficacious, the more society is guarded. These two functions of psychiatry are mutually dependent.

Pilgrim on his part argues that there is no win-win situation as far as the double function of psychiatry is concerned (it cares for psychotic patients and protects society). Why? Because today’s psychiatry, in his view, does more harm than good. To substantiate his claim he cites iatrogenesis, mega dosing, polypharmacy, coercive forms of treatment, loss of liberty. On the whole, his argument goes, there is a human rights crisis in psychiatry. And then the most poignant allegiance comes. This crisis now extends to the use, not abuse of psychiatry. Thus, how could patients possibly benefit from a psychiatry that is more than anything else harmful? To put it another way, since psychiatrists do not ameliorate the condition of psychotic patients they cannot protect society.

Unlike Pilgrim, I do not think that today’s psychiatrists do more harm than good. Psychiatry is meant to provide assistance to those in need of psychiatric help, and it mostly does so. At the same time, I am aware of the imperfections of today’s psychiatry (Kecmanovic, 2011). However, psychiatry’s weaknesses and countless forms of its abuse should not incite us to throw out the baby with the bathwater (Kecmanovic, 2009).

Pilgrim’s position in regard to today’s psychiatry is the expression of a wider approach called postpsychiatry, which is, in fact, a recent version of antipsychiatry. When compared to antipsychiatric and postpsychiatric claims and conclusions, and especially their alleged revolutionarity, my approach is ‘conservative’ indeed. Pilgrim is right on that point.

Conclusion

Pilgrim has overlooked my clarification of what is common and what is different in psychotic manifestations and other forms of deviancy. As a result of this disregard, he imputes misinterpretations and asks questions he would not have done had he paid due attention to my above-mentioned distinction.

He has paid much attention to the themes that are beyond the topic of my text. His deliberations did not target my assertions, and thus did not provide meaningful counter arguments.

Pilgrim insists on the need to question the wider social context in discussion about psychiatry (in society). However plausible is the demand, it is debatable whether psychiatrists could or should respond to it. It is worth remembering how the movements within psychiatry that claimed that psychiatrists’ duty is to fight against society ‘without human face’ have finished.

Finally, what is Pilgrim’s alternative perspective to mine that he promised to provide? Apart from his drawing on anti- and post-psychiatric postulates, I could not discern, in his text, the contours of any new perspective.