Feb 11

Rhetoric in Psychiatry: Reality Misrepresented

Most are familiar with the story of the original sin. According to psychiatrist Thomas Szasz’s interpretation, Adam and Eve, in their infinite innocence, sampled critical thinking from the Tree of Knowledge. Preferring His creatures to be foolish and subservient, God promptly evicted them from His heavenly Garden. Szasz, however, identifies a second sin committed by humanity later in its history: having become critical thinkers, humans began to accumulate more and more knowledge, elevating themselves, along with their Tower of Babel, to godly altitudes. Jealous of this, God sabotaged humans’ intellectual ascent by confounding the one language they spoke at the time: the language of critical thinking. As a result of God’s interference, language was muddied and humans forgot how to speak clearly.

In The Second Sin (1973), Szasz reclaims the type of plain language that God and other authority figures—religious leaders, psychiatrists, politicians—so despise, by dedicating an entire book to the clear and simple discussion of a wide variety of human-related topics. Divided into thirty-four sections, The Second Sin features a collection of razor-sharp and often humorous aphorisms regarding subjects such as marriage, ethics, emotions, law, psychiatry and mental illness. Its sequel, Heresies, was released in 1976. Defining “heresy” as “being right when the right thing to do is to be wrong” (p. 1), Szasz continues to expose the truth behind topics historically distorted by so-called authorities.

In a way, The Second Sin is less about what is said, and more about the way it is conveyed. Indeed, the book is an experiment, an exercise in plain writing. To be sure, its goal is not to simplify, but to not complicate.

There are many advantages to speaking clearly. Szasz quotes 1984 author George Orwell, who explained: “If you simplify your English, you are freed from the worst follies of orthodoxy. You cannot speak any of the necessary dialects, and when you make a stupid remark its stupidity will be obvious, even to yourself” (1973, p.  xxi). However, Szasz adds, “[when] a person speaks or writes in political, psychiatric, or sociological jargon, he expresses himself with a certain indirectness and ambiguity; and like the hysteric, he dramatizes what he says as something profound, although it may be trivial” (p. 24).

This inappropriate use of language is dangerous, as the more language is used improperly, the more confusion ensues. And therein lies its power, for as confusion arises, so does the opportunity to dominate, since confusion incapacitates defenses. Indeed, “[in] the animal kingdom, the rule is, eat or be eaten; in the human kingdom, define or be defined” (Szasz, 1973, p. 20). In life, the opportunity to define embodies a rare commodity. Unfortunately, the most powerful among us have the ability to force the rest of us to adopt their definitions (even if these are one of many possible working definitions). In fact, “[those] whose social defenses are weak […] are most likely to contract invidious definitions of themselves” (p. 23).

This is not to say that there cannot be advantages to choosing to not speak clearly. The misuse of language can appease uncomfortable states, such as the angst inherent within the difficult questions of existence. For example, the concept of mental illness is often used to explain troublesome and seemingly incomprehensible breakdowns in individual and social human behavior. Indeed, “[mental] illness is a myth whose function is to disguise and thus render more palatable the bitter pill of moral conflicts in human relations” (Szasz, 1973, p. 98). Since mental illness is simply a metaphor meant to help us make sense of behavior, it is crucial that we do not confuse the metaphor with reality. However, the metaphor does confuse and distract: “[It] is precisely the technical idiom of medicine and psychiatry that stands in the way of recognizing and remedying these moral problems” (p. 30-31). (For more details on Szasz’ views regarding mental illness, see The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, 1961).

If the rhetoric of medicine and psychiatry is not appropriately suited for the task of describing humans and their experiences in accurate and constructive ways, which type of language should we favor? It is interesting to note that Szasz uses religious terminology to title both books: The Second Sin and Heresies. This begs the question: could we use the language of religion? On the contrary, psychiatry merely perpetuates the mistakes of religion: the former medicalizes (unacceptable behavior becomes mental illness) whereas the latter mystifies (unacceptable behavior becomes sin).

Indeed, in many of his books (e.g., The Myth of Psychotherapy: Mental Healing as Religion, Rhetoric, and Repression, 1978), Szasz observes that psychiatry appears to have replaced religion in modern society: we no longer kneel at the altar of God, but at the altar of Mental Health. (Some of us, of course, hedge our bets on both sides of the God/Mental Health spectrum.) Both concepts, incidentally, are symbolic representations of the same thing: the ideal human situation. In other words, religion presents a picture of ideal moral behavior, whereas the mental health system presents a picture of ideal healthy behavior. Yet, for some reason, we prefer to avoid labeling these behaviors simply as “ideals,” preferring instead to couch them beneath extraneous layers of meaning.

If not the language of religion, should psychiatrists simply adopt the language of their clients? Szasz counsels against this, arguing that either party’s attempts to impose his image of the world on the other is ultimately fraudulent because of their underlying motivations. In fact, a client’s claim that he will not venture outside his house because the world is a cruel place is no more accurate a description of his predicament than his psychiatrist’s contention that he suffers from something called agoraphobia.

Alternately, we could use anti-psychiatric language. Ironically, language that romanticizes mental illness (e.g., viewing “schizophrenia” as a transformative journey leading to untold insights) is as equally misleading as its psychiatric counterpart. Still, the romanticization of deviant experiences dates back centuries. In The 120 Days of Sodom (1785), for example, the Marquis de Sade details the sexual adventures of four libertine men, explicitly describing a wide variety of sexual crimes committed on a quest for hedonistic bliss. The resulting text is a narrative survey of different types and varieties of sexual behaviors, normal and deviant, in which people engage. By glorifying all that is sex, and doing so indiscriminately, De Sade infused sexual activity with meaning it does not inherently own.

Unfortunately, De Sade’s romantic take on sexual deviance was replaced 100 years later with psychiatrist Richard von Krafft-Ebing’s medicalized approach. In Psychopathia Sexualis (1886), Krafft-Ebing approached sexually deviant behaviors from a scientific point-of-view, attempting to survey, categorize, and explain them. By sanitizing and clinicizing all that is sex, Krafft-Ebing committed the same kind of crime against meaning that De Sade did. Approximately 80 years later, the anti-psychiatry movement, with psychiatrist R. D. Laing as its poster-child, attempted to reverse the tables on psychiatry by elevating the mentally ill to idealistic heights, much in the same way De Sade did with the sexually deviant. Resenting the suggestion that he is associated with this movement, Szasz rather affectionately titled his book on the subject: Antipsychiatry: Quackery Squared (2009).

In sum, the languages of religion, psychiatry and anti-psychiatry are equally unsuited for the task of describing humans and their experiences, adding extra layers of meaning that are not warranted and are potentially misleading. In regards to anti-psychiatric romanticization, however, I am inclined to think that its impact is less damaging than religious mystification and psychiatric medicalization: romanticization strips power away from the oppressor (i.e., the righteous, mentally healthy) and confers power upon the oppressed (i.e., the sinful, mentally ill), however misguided the exchange might be. While not perfect, at least this system of thought flips everything on its head.

Sadly, helping professions are wrought with misusers of language. This is not surprising, as modern psychotherapy is, to put it bluntly, the bastard offspring of the religious and medical schools of thought; as such, it is inevitable that its linguistic development suffered. Psychoanalysis is, in my experience, perhaps the biggest culprit, with its inscrutable layers of symbols upon symbols. Psychoanalytic language is also terribly conceited: when a client does not cooperate, we call it “resistance,” and when the client responds to the therapist the way he would to someone else, we call it “transference.” While not exempt from blame (think of the laughable term “cognitive restructuring”), cognitive-behavioral therapy fares somewhat better, limiting its range of terms to basic and more salient facets of human experience: cognitions, emotions, physiological reactions, and behaviors.

In his diminutive On Bullshit (2005), philosopher Harry G. Frankfurt explores the philosophy of bullshit in a suitably tongue-in-cheek fashion. According to Frankfurt, bullshitting is marked by an absence of concern for truth. The bullshitter, he explains, uses words to describe concepts without bothering to submit to rules of enquiry that may increase the accuracy of his descriptions. “[His] fault is not that [he] fails to get things right, but that [he] is not even trying. [The bullshitter]’s statement is unconnected to a concern with the truth” (p. 32-33). In this sense, the bullshitter stands apart from the liar because the latter is (at least) familiar with the truth; he merely chooses to misrepresent it. Indeed, bullshit may be objectively truthful; its supplier simply does not care.

Here’s a personal example: during a conversation with a colleague, she stated an argument as agreed-upon fact. When I asked if any research supported this perspective, she replied: “There must be.” That, readers, is bullshit epitomized. This is not to say that my colleague was wrong. In fact, she could very well have been right. Her argument was bullshit, however, because she did not care if her statements represented reality. What was more important to her in that particular moment was making her point.

Frankfurt identifies advertisers and politicians as bullshitters. But how about psychiatrists? If they have looked into the veracity of their truths (especially the extent to which they stem from and involve the proper use of language) and are convinced of them, they are neither liars nor bullshitters. I submit, however, that those who have never bothered to investigate and instead mindlessly adopted their so-called truths during their training qualify as bullshitters. Indeed, such psychiatrists are probably not concerned with truth to begin with, for “[the] bullshitter does not care whether the things that he says describe reality correctly. He just picks them out, or makes them up, to suit his purpose” (Frankfurt, 2005, p. 56). In the case of bullshitting psychiatrists, I suspect that purpose to be existential: they are unable to accept the drama of life, and wish to thwart its finality by elevating their life work (i.e., helping others overcome the drama of life) to the level of medicine, perhaps society’s most respected profession.

Following is an example of psychiatric nonsense: a psychiatrist teaching a course on psychopharmacology I completed during my own training once warned the class that psychotherapy, like medication, has its own side-effects. While this is metaphorically true, he said this without an ounce of lightness. He was, in fact, dead serious. That, to me, is bullshit. If that man had taken the time to think twice about what he was trying to say, he would have probably realized that beneath his metaphor laid a basic truth about relationships, such as the one between a therapist and his client: while some may prove helpful in overcoming difficulties, complexities inherent to relationship development may still obstruct the helping process.

If psychiatrists are full of (bull)shit, and clients’ own accounts of their experiences are potentially unreliable, how are we to describe clients and their experiences? Szasz (1973) proposes that “[a] dignified and humane understanding of man—his experiences and conflicts, his strengths and weaknesses, his saintliness and his bestiality—all this requires a rejection of the languages of both madness and mad-doctoring, and a fresh commitment to the conventional, disciplined, and artistic use of the language of the educated layman” (p. xx).

Thus, if I may be so bold to present my helping philosophy: when attempting to understand my clients and represent their experiences in my mind, I try to resort to the simplest terms possible. In addition to helping me better appreciate all that my clients are and want to be, refusing to add unnecessary levels of meaning helps me avoid confusing both myself and my clients. If my clients are not assaulted and incapacitated with deceitful language, they can correct me should my understanding be mistaken, affording them power and ownership in the process of reaching their personal goals. In the end, I believe my clients and I are better able to work together toward overcoming whichever difficulties trouble them. Of course, I am not immune to misuses of language, but I find it helpful to at least consciously strive to avoid committing semantic crimes. When one treads a thin line between sense and nonsense, he is often told: “choose your words carefully.” In an age when medicalized jargon has become the default, this maxim could not come more recommended.

One Comment

  1. Jerusha says:

    I loved this. I can relate in a sense to my own work in graphic design. Words in and of themselves have a message and what words or jargon we choose say just as much as what we are saying with them. So with design, what typeface and color we use has just as much a message to it as the words it is set in.

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