Social Control in Mental Health

This post is by Jason Moehringer, a doctoral student in clinical psychology at George Washington University

As part of my duties in a part-time job, I recently spent three days in a conference listening to experts and industry leaders discuss the intersection of technology and neuroscience. Specifically, so-called “brain training” as a primary or secondary treatment for chronic psychiatric disorders is being explored. The idea is that cognitive deficits (for the uninitiated: difficulties with concentration, organization, memory, attention, or emotional recognition and/or regulation) are frequently, if not always, an underlying component of psychopathology. These deficits derive from subtle brain dysfunction: their brains “misfire” or don’t have the proper “wiring.” So, treating these deficits (in this case, through remediation or skill-building provided by video games, ranging from Medal of Honor to Lumosity) will improve individual functioning and treatment outcome. Additionally, these improvements will be visible in changes in brain functioning or structure that can be seen in MRIs.

Alongside this, a growing trend in mental health treatment is to measure outcome based on how a patient’s functioning “improves.” In this context, “functioning” represents the idea that the individual or group in question can perform the activities necessary for living. So, a low-functioning individual may have trouble with personal hygiene, holding down a job, forming or maintaining relationships, or controlling their impulses (anything from inappropriate angry outbursts, to excessive shopping, to wearing tin-foil hats in public). As you might have guessed, a high-functioning individual will have little difficulty completing these activities.

As a clinician in training who works intensively with individuals who have moderate-to-severe personality and psychotic disorders – a population that was of particular interest to a subset of the attendees of this conference – I was hard-pressed to set aside my attention to the undercurrents of social control implicit in this approach to mental health treatment. Central to this unwitting adherence to conformity is the unquestioned fallacy of the emerging mainstream clinical phenomenon of “functioning.”

Without intending to (I hope), this metric involves all sorts of elements of social control. Deviance from accepted norms of behavior is a sign of sickness that must be addressed through increasingly intensive and onerous treatments. As my colleague frequently critiques on this blog, health is understood as having a job, a nice haircut, a spouse, and a capacity to sit quietly on the subway. To a distressing degree, illness is essentially understood as anything non-normative. Screaming at pigeons in the park? I can construct a rationale to understand that as a symptom of illness. But an eight-year-old boy staring out a window in school has a disease? Surely there have been people whose lives have been destroyed by ADHD. However, slowly but surely, idiosyncratic elements of the individual are re-labeled as beyond the pale and thus necessitating treatment and psychological intervention.

While this is a trend that inevitably runs through all forms of mental health training (we are asking people to change, after all, and “for the better” is hopelessly relative), I had the time to reflect on this unfortunate and destructive tendency while watching endless PowerPoint presentations. The compulsory aspects of these treatments are incredibly clear. Symptoms – i.e. divergence – are observed, catalogued, and quantified. I thought it was indicative of the spirit of the conference when one expert framed his talk about the wonders of computerized brain training for ADHD by reminding the audience of how sufferers can play video games for hours: if we can just disguise our treatments as video games, we can finally get through to them! His response to this fact was not to wonder why, not to question the paradigm that there is something wrong with the individual’s brain that interferes with attention – given that there is something that he can attend to quite well – and never to ask anybody with the disorder about the nature of their experiences. Modern mental health research periodically throws up its hands at the fact that individual sufferers don’t report the same symptoms or similar histories. Remarkably, this is seen as a failure of the individual as an accurate source of information. This is a true shame, for ignorance of the individual’s experience separates any other knowledge about the disease from its crucial foundation in the viscera of life – and thereby renders it meaningless.

As we have seen over and over (I think), this kind of knowledge without meaning invites a particularly insidious kind of domination. Researchers and therapists, armed to the teeth with quantified correlations and brilliant statistical models, are free to impose their personal projections onto the life of their clients, of whom they have little, if any, real understanding. This has been the consequence (or possibly purpose, depending on your opinion of “industry-sponsored” research) of most of the psychological and psychiatric research in the United States in the last 50 years: to construct “knowledge” about individual lives without needing to become involved in the dirty, difficult work of being interested. How much easier to already know it all!

Of course, deriving such specific information from an aggregated average limits the scope of what can be tolerated in thoughts, feelings, and behaviors of individual patients. “Functioning,” in the sense that I discussed earlier, comes to represent this aggregate, and this in turn informs the expectations of modern mental health. As a mental health provider, I strenuously resist this implied position of equating norms with health. I think it is imperative that we collectively maintain the position that we do not, in fact, know what is best for other people in most situations, and that we do violence to their freedom and integrity as individuals, and therefore ourselves, by imposing the will of the third/big other. Towards this end, I am frequently reminded of something once said by the prominent psychoanalyst Otto Will: “As I see it, my task is to help this person look at, and evaluate, his life and his prospects. I don’t know how he should live, but I may be able to help in discovering this for himself. I am not an expert at living.”

10 thoughts on “Social Control in Mental Health

  1. I am part of L’Arche, community for people with intellectual disabilities (group home sort of thing, but some differences), and we regularly encounter similar issues with normalcy and functioning.

    I feel the “cult of normalcy” during every outing basically. I want to let those I’m assisting be who they are in their particularity, but feel the social pressure at the same time of “this is how one (if normal) ought to act in public”.

    With a medical model of disability, disability is a problem to overcome. With a social model, disability is only a problem because society is set up in such a way that it forces people to adhere to the structures. Structures should be changed then.

    Mental illness is different than disability (though when mass shootings occur all sorts of important distinctions begin disappearing), but I wonder if its something like this you are advocating?

  2. Jordan, don’t get me started on the mass shooting thing. Every time I hear Wayne LaPierre talk about “our broken mental health system,” I have to go to my happy place.

    I do think I’m advocating for the same thing. I also feel a great deal of pressure to subtly act as if I approve of the social order, especially as most of my clientele demands to be helped to integrate into it.

  3. Jason, what do you make of the class biases of the delivery of these clinical interventions? Aren’t middle-class interests driving these treatment programs which are primarily provided to lower-income folks?

  4. I should’ve replaced with traditional or conservative. In other words a belief in the goodness and sustainability of the social order and hence the value of integrating into the social order.

  5. I think the answer has to be yes. I was reading a critique of the mechanism by which social expectations are established (I can’t remember where), and the author pointed out how the search for wealth organizes how different strata of society organize their conceptions of value. So, the wealthy tell a lie about the necessity of “hard work” and “family values” in order to create a workforce dedicated to toil and exploitation, while the lower classes seek to emulate these stories in order to move on up the ladder that they erroneously believe will make them rich.

    I think this plays out in the whole social compulsion/control arena when anyone with a mental illness engages in some non-normative behavior. In so far as this violates the psychological framework that the middle-class has erected to excuse their misery and relative poverty (when compared to the wealthy class), the “ill” person is perceived as threatening the social order. With the label of “mentally ill,” it then becomes morally justifiable to remove them from their communities through hospitalization and jail, and to ply them with treatments that aim to reintegrate them into the social order.

    So I couldn’t agree more. Psychological and psychiatric treatments frequently serve to support the conservative middle-class value system so that the larger class structures can remain in place.

  6. Two ideas come to mind:

    1) Marx said, “The ideas of the ruling class are in every epoch the ruling ideas.”

    2) One wonders about how the idea of the biologization of mental illness has been a way for society to turn a blind eye to the psychological & social mechanisms of severe mental illness. Read has critiqued how the bio-psycho-social model of mental illness is really just the bio-bio-bio model. Social and psychological factors are relegated to secondary realities because the real problem lies in the faulty biology (genetics or neurology) of the person. There has been a strong desire to remove sociocutural discussions regarding schizophrenia. The grounding idea seems to be that everyone can impacted by severe mental illness (which is true) and thus we have no reason to consider social realities such as poverty, racism, homophobia and patriarchy are impacting the individual with psychological disturbances. Second, the desire to avoid discussions about how psychological trauma (particular childhood abuse) might be contributing to psychosis has been a way to exonerate anyone of responsibility for the mentally ill person’s lot in life. In Agnes’s Jacket by Gail Hornstein she quotes Jacqui Dillon who says that psychiatrists should “stop asking what’s wrong with you and start asking what happened to you?” Apparently Dillon was chronically sexually abused as a child and began having psychotic experiences such as hearing voices. She makes the provocative claim that psychiatry in its desire to mute the voices are colluding with the abuser who also demands that the abused remain silent about the trauma. Third, NAMI is also a powerful voice that has attempted to exonerate parents’ of responsibility for their children’s mental illness. While we should avoid unnecessary blaming and guilt, it is the case that many people’s psychological problems were caused by abusive and neglectful parents. It’s amazing that American mental health refuses to accept that reality in the rush to biologize all psychological problems. Fourth, I think society should have some collective guilt about the awful and dehumanizing treatment many of these individuals experience, especially in the way that jails are the new asylums and the mentally ill (much like the homeless) have been criminalized. Notice how quickly the mentally ill are the scapegoat for depressing social realities such as gun violence.

  7. In an effort not to respond to everything you said, Jeremy, I want to point out how interesting it is that the guilt that should be experienced throughout society for the creation, maintenance, and disavowal of mental illness has now managed to be turned back entirely onto mental health providers. We have gained for ourselves a reputation for “blaming your parents.” I love it. A couple of days ago, person I work with said, “My brother finally got a therapist. I told him that, even though he would never really get better, at least he was doing a good thing trying to manage his illness.” I laughed and cried at the same time.

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