Bigotry and extreme prejudice are repugnant to many, including the victims and those engaged in furthering progressive social values. Various attempts have been made to encompass that reaction in social mores and attitudes. A new approach among certain mental health professionals to get extreme prejudice to be declared a diagnosable mental illness included in the official list of diagnoses superficially bears promise in objectivizing that repugnance.
A recent article in the Washington Post, “Psychiatry Ponders Whether Extreme Bias Can Be an Illness,” discusses this attempt to create a new diagnosis for extreme racism and other forms of extreme prejudice. It presents the argument of some that extreme prejudice is so compulsive and damaging to the prejudiced person that it should be viewed as a mental illness deserving its own diagnosis. While radicals and progressives may be tempted to jump on this bandwagon as a weapon in their battle to have racism and prejudice recognized for the personal and social harm they cause, this effort is unjustifiable intellectually and is politically likely to backfire.
Unlike earlier attempts to make racism a diagnosis, the latest attempt justifies itself by the damage that extreme prejudice does to the prejudiced, not to those prejudiced against. This debate reveals the sorry state of thinking in the mental health professions. If conflates two distinct issues: (1) Are there psychological aspects of extreme prejudice that contribute to its tenacity and to its negative effects on the prejudiced (as well as on the victims of prejudice)? And, (2) is it an "illness" with all that that connotes?
The article, and much of the debate, presumes that the question of "illness" is central. If extreme prejudice is an illness (from now on, I will leave off the quote marks, that should always be presumed to be present), then it should be treated, the reasoning goes. If not, then it is either a social issue or an individual proclivity that, no matter how reprehensible, is not the business of those who think in psychological or psychiatric terms.
Mental Illness and Diagnosis
This reasoning reveals the difficulties with the current state of conceptual understanding of the diagnostic process in the mental health professions. Mental illnesses are presumed to be distinct entities that can clearly be distinguished from states of non-illness. I am not one who believes that the concept of mental illness is a logical fallacy.
Like medical doctors, mental health professionals often use diagnosis as a way of categorizing patients and their problems. The use of diagnoses can, at times, help guide treating professionals as to the nature of the problems a patient faces, the origins of those problems, and potential treatment options. Diagnosis can also sometimes be used to straightjacket patients into ill-defined and ill-fitting categories that lend a scientific appearance to socially constructed biases. For example, a diagnosis of major depressive disorder is often used by psychiatrists, and managed care companies as an argument that a person has a "biologically-based mental illness" and thus must receive a biological treatment, such as antidepressant drugs or, more rarely, electroconvulsive ("shock") treatment.
The assignment of the diagnosis mandates a treatment prescription despite considerable controversy among researchers and practitioners as to the relative effectiveness of drug treatment versus psychotherapy. (Of course, the relative costs of prescribing drugs versus talk therapies is an often unacknowledged factor here.)
Some conditions bear enough of the characteristics usually associated with illness to be reasonably referred to as mental illnesses. Among these clearly would be Alzheimer's and other dementias, the general paresis caused by syphilis, and various other conditions known to have clear organic etiologies.
The jury is still out as to the extent organic factors play in schizophrenia. While there is increasing evidence of organic factors -- including genetic factors and illness in the pregnant mother -- playing a role in this condition, no organic factors at this point are known to be either necessary or sufficient. Similarly, there exists evidence suggesting that schizophrenia is a condition qualitatively distinct from other modes of living. For example, epidemiologists find a prevalence of schizophrenia in most societies of about one percent. And anthropologists have found that most, if not all, societies, even those who recognize shamans, also have a category of the crazy whose description resembles that of schizophrenia. On the other hand, there exists evidence questioning this view of schizophrenia as a clearly distinct illness. There is evidence that schizophrenia is the extreme end of a larger spectrum of "conditions." And environmental factors clearly play a role in the prospects for the development of the condition and in its course.
If one concludes that schizophrenia is, indeed, largely a biological condition, then it would be reasonable to describe it as an illness. But what if one decides that environmental factors play a large role?
Once we get beyond the clearly organic conditions, the category of mental illness becomes metaphorical. There is nothing wrong with this. People make sense of the world largely through metaphors. The illness metaphor can be illuminating, but it can also be blinding. The question is whether applying it to the emotional problems and issues people face reveals hidden aspects, or covers over important characteristics. Thus, mental illnesses are like other physical illnesses in that they often appear to be involuntary and they can interfere with normal functioning and/or cause distress. So far the analogy holds, and these are the two conditions at least one of which is considered essential to diagnosable entities included in the American Psychological Association's Diagnostic and Statistical Manual (DSM) in its various editions since 1980.
However, many uses of the mental illness construct ignore its metaphorical quality. Thus, it is sometimes presumed without question that anything diagnosed as a mental illness should be treated, despite the fact that the majority of those identified in epidemiological studies as having such a condition do not seek treatment. Others go so far as to form an equation whereby mental illness equals illness, illness means physical condition, and physical condition requires physical treatment. This logic underlies much of the overuse of medications and the downplaying of psychotherapy for problems in living that characterizes the last few decades.
Each of the three links in this equation is fallacious, of course. As I discussed above, mental illness may resemble other illnesses in certain ways, but in most cases definitely is not the same thing. Certainly, if one extends the concept of illness to include mental conditions with no obvious organic cause then illness does not mean physical condition and there is no necessary reason that it should be treated, much less treated by physical interventions.
Now back to prejudice. Those who argue for extreme prejudice as psychopathology claim that it constitutes obsessive abnormal behavior that, depending on the author, either is claimed to cause subjective distress to the perpetrator or to the victim.
Many of our beliefs have a compulsive quality to them, at least in the short run. Try talking to some war supporters in certain parts of the country, or, for that matter, praising President Bush at many of the meetings I attend. The reaction in each case will not be a careful weighing of evidence or a calm question to elicit further information. Is hatred of Bush to be diagnosed an illness on this basis?
The second argument is that extreme prejudice causes subjective distress and/or restriction of functioning in the prejudiced, at least when they are faced with those they are prejudiced against. I'm sure this sometimes occurs. But I'm also sure that some of my friends would experience severe subjective distress if forced to spend much time with the college Republicans. And many of us cause difficulties for ourselves and others in our extended families when we forcefully express our political and social opinions at family gatherings. If liberal or radical politics is not to be considered a psychopathology on this basis, then neither should prejudice, however repugnant we may find it to be.
The Washington Post article begins with some extreme cases, including delusions and obsessions about the feared or hated group:
The 48-year-old man turned down a job because he feared that a co-worker would be gay. He was upset that gay culture was becoming mainstream and blamed most of his personal, professional and emotional problems on the gay and lesbian movement.
These fixations preoccupied him every day. Articles in magazines about gays made him agitated. He confessed that his fears had left him socially isolated and unemployed for years: A recovering alcoholic, the man even avoided 12-step meetings out of fear he might encounter a gay person.
"He had a fixed delusion about the world," said Sondra E. Solomon, a psychologist at the University of Vermont who treated the man for two years.
"He felt under attack, he felt threatened."
Interestingly, in this case the DSM already contains many diagnoses that one might contemplate applying, including obsessive-compulsive disorder, paranoia, or paranoid personality disorder. I've never known my fellow mental health professionals having too much trouble coming up with a diagnosis when they believe someone has a "fixed delusion." So even if one is playing the diagnostic game, there is no need for new categories or new labels to encompass these extreme cases.
What, then, would be gained by adding extreme prejudice to the list of diagnoses? Presumably, it would be viewed as a political victory by those discriminated against, allowing those doing the discriminating to be labeled as "sick." In the best case, such a label could aid a few victims. It would be a statement by the mental health professions that these behaviors are undesirable and should be changed, perhaps even forcefully if necessary.
Costs of Pathologizing
But, do we want to encourage the expanded use of the diagnostic system to express our moral judgments? This game of labeling political and social attitudes with medical labels is a two-edged sword. Those victimized by prejudice, such as gays or blacks and women who refuse to accept their socially assigned roles, have themselves been labeled with any number of diagnoses. Steps that legitimate assigning medical diagnoses to those with certain social and political attitudes can easily be turned upon other groups when the climate changes. Those who have suffered their share at the hands of mental health professionals covertly pursuing political and social goals had best beware.
Another danger is that creating a diagnosis of extreme prejudice will turn attention to the psychological aspects of bigotry, potentially at the expense of social aspects. This not to deny that understanding the psychological aspects of prejudice isn't helpful. It most definitely is. But bigotry and prejudice entwine the personal and the political, the psychological and the social. Attempts to view these problems through a dualistic either/or lens are not productive. Pathologizing prejudice will obscure these complex relationships, allowing therapy to become another detour from changing the social conditions that utilize the penchant for prejudice in many or all of us in order to protect social inequality. Further, pathologizing prejudice, by distinguishing the sick from the unsick, may allow those of us not so diagnosed to feel comfortable, perhaps even smug, with the biases and bigotries that haunt us all.
Modern medicine and related fields are creating new diagnoses at a rapid rate, thus distinguishing more and more of us and our physical and mental states from those of the "normal." Rather than fostering the view that we humans resemble each other more than we differ, and that a just society will be built on a recognition of our commonalities, on égalité and fraternité combined with liberté, pathologizing prejudice will create a new group of ill from whom we can feel distinct, even superior.
At a more concrete level, the creation of diagnostic categories for prejudice or racism may have perverse and unintended consequences. For example, under the Americans for Disabilities Act, those with mental illnesses are afforded certain protections and accommodations. Will racists and homophobes labeled as ill find themselves a protected group, whose behavior must be tolerated as it isn't their fault, but simply the result of their illness?
Adding this new diagnosis may make antiracists and the victims of racism and bigotry feel vindicated. But the costs in conceptual clarity and in muddying the strategies for change are too great. Progressives should not support this new trend.
Stephen Soldz is a psychoanalyst, psychologist, public health researcher, and faculty member at the Institute for the Study of Violence of the Boston Graduate School of Psychoanalysis. He is a member of Roslindale Neighbors for Peace and Justice and founder of Psychoanalysts for Peace and Justice. He maintains the Iraq Occupation and Resistance Report web page and the Psyche, Science, and Society blog. He can be reached at: firstname.lastname@example.org.
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