Jun 12

Unmasking the Gods of Psychiatry: A Critical Analysis of Shaffer’s “Equus”

Philosopher Daniel Dennett lamented: “There’s nothing I like less than bad arguments for a view that I hold dear” (cited in Martin, 2004, p. 222). To some, Peter Shaffer’s controversial play Equus (1973) may be guilty of such a crime: disenchanted with Psychiatry’s view of human behavior, Equus adopts an alternate perspective that unfortunately commits the same mistakes as the target of its criticism. At the same time, however, “[a] philosopher who prefers a good argument for a bad cause to a bad argument for a good cause is an immoral or amoral philosopher and a bad person” (Szasz, 2004, p. 114). In this way, Equus should be commended: although it stumbles while making its point, the zeal with which it sets out to slaughter a modern behemoth ripe for criticism elevates it above those endeavors that mindlessly defend Psychiatry.

In Equus, Alan Strang, a 17-year old stable boy, has gouged the eyes of six horses under his care. Thanks to a well-intended, but misguided, court magistrate, Strang is spared from prison and instead committed to a psychiatric hospital, an often worse fate. He is appointed to psychiatrist Martin Dysart, who attempts to deconstruct his patient to remake him into a “proper” member of society. During therapy, Dysart visits Strang’s memories, from childhood to the recent past. We find out that horses have special meaning to Strang: all that is equine is also…erotic. Enamored by Strang’s passion, Dysart comes to doubt not his ability to rid his patient of his deviant sexual interest, but his moral right to do so. Psychiatry, he uneasily realizes, is a cruel and merciless executioner, whose ordained mandate is to sacrifice all those who are different at the altar of its king and sovereign, Normality. Shaffer’s play pointedly asks: as professionals in “Mental Health,” are we willing to commit the sort of moral crimes required to sustain our hungry profession?

My boyfriend and I saw Equus on stage during the Segal Center for the Performing Arts’ past season in Montreal. Impressed with the Center’s previous productions of Arthur Miller’s A View from the Bridge (1955) and Martin McDonagh’s The Lieutenant of Inishmore (2001), we had high hopes for the production that were not disappointed. In fact, my boyfriend claimed it rivaled the recent Broadway revival, featuring Richard Griffiths and Daniel Radcliffe. The set design was a visual treat, mixing sleek, modern curves with organic elements. I was mesmerized by the tall, thin beams sprouting from the floors of the psychiatric hospital: smooth and clinical metal at the base, crude and natural wood at the tip. Background video-projections of Strang’s memories also hovered above the hospital floors, serving as a bridge of sorts between the static space and the animated actors. These visual details served to evoke a sense of infiltration: either Strang’s memories of the earthy horse stables are replenishing the stark psychiatric hospital with life, or alternatively, the hospital walls are slowly closing in on and restricting his roving mind. Despite various levels of stage experience, actors performed their roles with both skill and resonance. Some of their British accents seemed to come and go, but that is a minor quibble since the lines were delivered with intent and honesty.

As suggested by the stage design, there are two disparate worlds at the center of Equus. When the psychiatrist and patient’s worlds converge, however, there is little overt conflict. Rather, something in Strang incapacitates Dysart. He cannot bring himself to impose his medical worldview on Strang, something he has probably done with countless other patients. There is an unmistakable humanity to Strang’s predicament, despite his victims being a different animal. This contradiction provokes a philosophical shift in Dysart: when the cold, clinical touch of Psychiatry can no longer relieve the suffering mind without compromising the mind’s spiritual integrity, what is a psychiatrist to do?

As a clinical psychologist in training, I identified with Dysart’s struggle. Because my educational development has been so influenced by Psychiatry’s view of human (mis)behavior, disposing of psychiatric shorthands when attempting to understand others remains a challenge. In a powerful speech, Dysart eloquently articulates his crushing realization:

“The Normal is the good smile in a child’s eye—all right. It is also the dead stare in a million adults. It both sustains and kills—like a God. It is the Ordinary made beautiful; it is also the Average made lethal. The Normal is the indispensable, murderous God of Health, and I am his Priest. My tools are very difficult. My compassion is honest. I have honestly assisted children in this room. I have talked away terrors and relieved many agonies. But also—beyond question—I have cut from them parts of individuality repugnant to this God, in both his aspects. Parts sacred to rarer and more wonderful Gods. And at what length … Sacrifices to Zeus took at the most, surely, sixty seconds each. Sacrifices to the Normal can take as long as six months.” (Shaffer, 1973, p. 65)

In Aldous Huxley’s Brave New World (1932/1994), The World State has confounded language so that its citizens have come to mistake being controlled for being free (see Bernard Marx and Lenina Crowne’s conversation on freedom; p. 81-82). They have become happy slaves. Psychiatry has achieved a similar feat in our own society: we have come to mistake being abnormal for being sick. Many of us even welcome diagnoses of mental illness! This is regrettable, but not surprising: as existential psychologist Ernest Keen remarks, “[the] possibility that a person might be reassured by medicalizing her distress […] testifies to the extent to which our culture has trained its members that human stresses and distress can be solved by expert scientific attention and that people and their problems need not be taken seriously in their own terms” (2011, p. 67). Since we use language to describe our experience, language matters. It is a testament to Psychiatry’s unique power that by simply labeling a behavior and publishing its definition in a manual, it is able to transform a challenging human experience into a disorder requiring professional attention.

Thus, we voluntarily flock to Mental Health Care facilities, seeking treatment for our so-called “conditions.” But, could it be—at least, in some situations—our “mental health” needs no “care” at all? In a 2010 article, Allen Frances, the psychiatrist who chaired the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) task force, admitted with regret: “Our net was cast too wide and captured many “patients” who might have been far better off never entering the mental health system.” Frances and Dysart are, then, in agreement: when psychiatrists choose to—and are encouraged to—overstep certain boundaries, their actions can be devastating. Still, the net has landed firmly: mental health professionals proudly defend the authenticity of their psychiatric categories, while clients voluntarily submit themselves to these classifications. Happy slaves are very hard to free…

Frances predicts that the upcoming DSM-V will only serve to “extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal.” To satisfy the Normal’s insatiable appetite, we must eventually begin to transform more and more behaviors into deviant behaviors. As mentioned, this is achieved through language. Ironically, though, the more “normal-turned-abnormal” behaviors we sacrifice to the Normal, the less “normal-to-begin-with” behaviors are left. In this way, Normality may consume itself out of existence: I can imagine a future where Normal has become a mere hypothetical, an ideal to strive for that no longer aptly describes any part of reality.

As Frances observes, we are conceptualizing an increasing number of traditionally normal behaviors as abnormal. Of course, there is inherent subjectivity in these terms, normal and abnormal. In fact, there may exist no such things at all. Think, for example, about the exercise that psychologist-philosopher William James (1901-1902/2002) proposes:

“Conceive yourself, if possible, suddenly stripped of all emotion with which your world now inspires you, and try to imagine it as it exists, purely by itself, without your favorable or unfavorable, hopeful or apprehensive comment. It will be almost impossible for you to realize such a condition of negativity and deadness. No one portion of the universe would then have importance beyond another; and the whole collection of things and series of its events would be without significance, character, expression, or perspective. Whatever of value, interest, or meaning our respective worlds may appear endued with are thus pure gifts of the spectator’s mind.” (p. 168; italics in original)

In other words, nature is neutral, uniform. But while we may view everything through our spectator’s mind, that is not to say we are wrong to conclude that some ways of living are more limiting than others or possess features that deserve careful attention. Introducing his now famous study “On being sane in insane places,” psychologist David Rosenhan (1973) assures us: “To raise questions regarding normality and abnormality is in no way to question the fact that some behaviors are deviant or odd. […] Nor does raising such questions deny the existence of the personal anguish that is often associated with “mental illness.” […] But normality and abnormality, sanity and insanity, and the diagnoses that flow from them may be less substantive than many believe them to be” (p. 250-251).

The tension between our desire to describe the world objectively and the inevitable fact that some subjectivity will always leak into any such attempt underlies a pair of comments by philosopher Bertrand Russell. On the one hand, “[what] we think good, what we should like, has no bearing upon what is.” At the same time, however, “we cannot be forbidden to value this or that on the ground that the nonhuman world does not value it” (1957, p. 54).

Thus, while normality and abnormality may not actually exist in nature itself, that does not mean we cannot divide reality into “that which is normal” and “that which is abnormal.” However, it is important to realize that if normality and abnormality indeed do not exist, it follows that how behaviors are divided is determined by systems that are artificial (some of which are, presumably, superior to others). Psychiatry embodies one such system, unique in that any behavior it defines as abnormal is also considered “sick.” Also, because there may not exist a physical boundary between normality and abnormality, it is only sensible that we investigate and acknowledge the value system that leads us to draw a clear-cut line between the two. That is, we must confess our positive and negative attitudes toward various ways of living.

What is Normal?

Dysart worries that ridding his patients of their abnormal behaviors entails stripping from them parts of their individuality, all in the name of Normality. But, there are many ways to be normal. Thus, contrary to what Dysart may believe, humans do not bow to one single God of Normal, but to a host of deities. Taking this into account, a close reading of the play suggests that the tormented psychiatrist is, in reality, only worried about sacrificing a) one particular subgroup of patients to b) one particular God of Normal.

Who are the Gods of Normal? To determine exactly which deities Psychiatry answers to, let us peruse the DSM-IV-Text Revision (TR; American Psychiatric Association [APA], 2000), a previous edition of which likely adorned Dysart’s bookshelf. I would argue that one can distill the behaviors listed in Psychiatry’s nosological compendium into three qualitatively distinct, but sometimes overlapping, categories. Each of these categories includes behaviors that offend (at least) one particular God of Normal.

One of the principle reasons why some are considered mentally ill is that they appear to be exceedingly miserable. Thus, one criterion for what counts as abnormal is the presence of suffering. I here refer mainly to psychic suffering (e.g., anxiety, fear, sadness), which I consider distinct from strictly physical suffering (e.g., a stinging wound). That is not to say, of course, that psychic suffering does not possess physiological qualities, nor that it may not arise in response to predominately physical suffering.

That being said, it is important to keep in mind that there exists no one-to-one connection between mental illness and internal suffering; as we shall see, many mental disorders entail no such thing at all. It is nonetheless true that some disorders refer entirely to behaviors that involve the experience of pain: for example, the depressive and anxiety disorders. But is it truly fair to characterize suffering as pathological? This belief suggests an indiscriminately positive outlook on life. Indeed, excessive sadness and anxiety can only be disordered if we accept that nature does not “mean” for us to ever be so emotionally incapacitated. I wonder, though: is not misery an integral part of life, right alongside pleasure? Arguing against a happy, optimistic outlook on life, which he refers to as healthy-mindedness, James (1901-1902/2002) reminds us:

“[There] is no doubt that healthy-mindedness is inadequate as a philosophical doctrine, because the evil facts which it refuses positively to account for are a genuine portion of reality; and they may after all be the best key to life’s significance, and possibly the only openers of our eyes to the deepest levels of truth. The normal process of life contains moments as bad as any of those which insane melancholy is filled with, moments in which radical evil gets its innings and takes its solid turn. The lunatic’s visions of horror are all drawn from the material of daily fact. Our civilization is founded on the shambles, and every individual existence goes out in a lonely spasm of helpless agony. If you protest, my friend, wait till you arrive there yourself!” (p. 182-183)

Following this passage, James goes on to describe in evocative detail several instances of natural horrors—for example, predators tearing the flesh off of a living victim—as evidence of the “evil facts” we must contend with in our world. To James, the widespread existence of meaningless suffering demonstrates that pain is an intrinsic part of nature, rendering any perspective that does not acknowledge this facet of reality inadequate.

You may be thinking: well, if pain is so integral to life, should then what we call “physical disease” not be referred to as pathological? It is true that many if not most physical disorders involve physical suffering. In the case of physical disorders, however, pain is merely a symptom of disease; it is not the disease itself. Take, for example, sexually transmitted infections, which are often asymptomatic: the infection continues to exist whether the infected person experiences discomfort or not. Thus, when pain occurs, it is a messenger; it signals the presence of a disruption in the regular functioning of the body.

Conversely, in the case of psychological disorders, suffering, when present, is often the disease itself. For example, there is no such thing as asymptomatic generalized anxiety disorder. If there is no anxiety, there is no disorder. Thus, when it comes to mental illness, without symptoms, there is no disease. Psychologist Gary Greenberg (2010b) explains: in medicine, “the symptoms of the disease are only the signs of the disease, not the disease itself. Except in psychiatry, where the symptoms constitute the disease and the disease comprises the symptoms” (p. 63-64). In other words, while in medicine disease and suffering remain separate (albeit related) phenomena, in psychiatry the two are one and the same. It is with this equation of suffering and disease that I object to: suffering can be a sign of disease, but not a disease in its own right, as Psychiatry insists.

But, could it be extreme psychic suffering (e.g., overwhelming anxiety or sadness) is actually a symptom of some as of yet undiscovered physical disease? At present, evidence for underlying pathology is not nearly as conclusive as some would have you believe. The APA itself rather candidly admits that “the field of psychiatry has thus far failed to identify a single neurobiological phenotypic marker or gene that is useful in making a diagnosis of a major psychiatric disorder” (Kupfer, First, & Regier, 2002, p. 33). Even were we to identify such an entity, there would still remain the problem of demonstrating that it is morbid, preferably independently of the negative qualities we assign to its behavioral product. After all, even behaviors not considered psychiatric disorders involve neurobiogenetic processes.

There are, on a fundamental level, many problems in likening psychological pain to physical disease. Should we assume psychic and physical suffering belong to the same category of human experience, that deep sadness about one’s self-worth is no different from an exercise-induced muscle cramp, and that the two are thus subject to similar modes of explanation? Can it be psychic suffering, like its physical variety, is existentially meaningless, that it has nothing whatsoever to do with our experience of a sometimes cruel world, and that it is merely an artificial product of brain chemistry gone awry? Are we to believe we were never meant to suffer that much at all, that humans have evolved in such a way that demands contentment be our status quo? To put it bluntly, to accept the idea that psychic suffering can ever be reduced to aberrant biology is to accept a “felicitous coincidence,” that we are “an organism designed for happiness in a land dedicated to its pursuit” (Greenberg, 2010b, p. 314).

It is true that there are instances of psychic suffering being caused by physical disorders. For example, Kottler (2000) relates the case of a client presenting with panic spells. No improvement came from psychotherapy, though not for lack of effort on either the therapist or the client’s part. It was later revealed that the client did not suffer from an “emotional coping skill-deficiency,” but from gas intoxication due to a furnace leak in his house. Situations such as these, though, only serve to show that behavior is grounded in biology, not that a given behavioral symptom amounts to a psychiatric disorder under ordinary, non-disease-induced circumstances. In essence, upon discovering the true cause of his panic spells, the client ceased to have a psychological disorder and was correctly diagnosed as having a physical disorder. This begs the question: in the case where behavioral patterns are explained entirely by a physiologically pathological cause, what value does Psychiatry provide? In fact, to discover a brain disease underlying all instances of, say, Panic Disorder would serve to discover a medical disorder, not validate a mental one. The disorder would exit the domain of Psychiatry, and enter that of Neurology (Szasz, 2007).

The poet Yevgeny Yevtushenko counseled his readers to reject “the vulgar, insultingly patronizing fairy tale that has been hammered into your heads since childhood that the main meaning of life is to be happy” (cited in Dawes, 1995, p. 277). Using science to make a similar point, psychologist Richard Bentall published in 1992 “A proposal to classify happiness as a psychiatric disorder.” The abstract to his article announces: “[The following review of the literature will show] that happiness is statistically abnormal, consists of a discrete cluster of symptoms, is associated with a range of cognitive abnormalities, and probably reflects the abnormal functioning of the central nervous system” (p. 94). While Bentall’s tongue rests comfortably in cheek, his writing remains straight and scholarly. This is a clever choice, leaving it up to the reader to decide whether happiness should be classified as a psychiatric disorder, or unhappiness declassified.

When we suffer, rarely do we do so for no reason at all. Often, suffering is a normal reaction (e.g., persistent nightmares) to an abnormal situation (e.g., a wartime experience). Simply, life has gotten the better of us. In fact, I would be worried if a client came to me having survived a brutal victimization, yet appeared completely unfazed.

Take, for example, the nameless, almost hidden disorder, numbered 302.9.3, which ends the DSM-IV-TR’s Sexual and Gender Identity Disorders chapter. Should the lure of the subsequent Eating Disorders chapter prove too great, you might just miss it. It is a disorder meant strictly for those upset by their sexual orientation. (In fact, before it became nameless, it was listed in a previous edition as “Ego-Dystonic Homosexuality.”) In this way, the DSM continues to pathologize same-sex sexual interest, despite having removed general Homosexuality from its pages in 1973. After all, it is certainly not heterosexual men and women that psychiatrists had in mind when inventing this modern variant of the retired disease. Let me be clear on this: those who suffer on account of their sexual orientation are not sick; the problem does not reside within them but within the environment continually taking aim at them. Since Psychiatry is so fond of labeling abstract entities, it should instead try its hand at society.

Suffering often arises from lack of skills. For example, depression may stem from rigid negative thinking. In fact, therapy seeks to impart clients with the type of abilities that allow them to overcome life’s challenges and participate in life actively, in the hopes that this will assuage their suffering. Sometimes, however, lack of skills itself is labeled a mental illness: for example, Attention-Deficit/Hyperactivity Disorder, or any learning disability. Thus, another criterion for what counts as abnormal is incompetence.

Is it fair to characterize incompetence as pathological? After all, “[we] do not expect everyone to be a competent swimmer, golfer, chess player, or marksman; nor do we regard those who play games poorly as “sick.” The activities that comprise being a student, parent, worker, etc. are, in many ways similar to the activities that comprise being a golfer or chess player. Yet, we act as if we expected everyone to play his own life games competently; and we regard those who play poorly—at being husband or wife, mother or father—as sick, “mentally ill”” (Szasz, 1973, p. 90). Further, lack of skills (e.g., poor math ability or bad hygiene) is rarely a problem in and of itself, but only becomes one when a person lacking certain skills finds themselves in a situation requiring these skills (e.g., at the bank or on a date). In other words, the problem lies not in the individual, but in the relation between individual and society.

To summarize, the DSM-IV-TR defines suffering and incompetence as abnormal. We have thus successfully discerned the first two Gods of Normal: Happiness and Competency. I have argued that while neither suffering nor incompetence is an ideal behavior, neither deserves to be considered diseased. This does not mean, of course, that we should not attempt to overcome unhappiness (without forgetting there is more to life than pleasure) or master the skills we happen to lack. Because I doubt Dysart is uncomfortable helping clients become more satisfied with and more proficient at life, it is unlikely he wishes to deprive the two aforementioned Gods of nourishment.

Rather, I think Dysart’s problem is exclusively with the third category of abnormality: social deviance. To clarify, the DSM-IV-TR does not officially recognize social deviance as abnormal: “Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual” (2000, p. xxxi). Despite this statement, many of the behaviors included within the manual’s pages are just that: deviant. Besides, as Moser and Kleinplatz (2005) rightfully point out, the “unless” clause—a major clinical cop-out—allows psychiatrists to disregard what came before and interpret “deviance or conflict” as sickness.

Is it fair, however, to characterize social deviance as pathological? After all, many socially deviant behaviors, while offensive to some (including those exhibiting them), are not inherently harmful to the self or others. Some men and women, for example, so identify with the opposite gender that they wish to be the other gender. While same-sex sexual interest is no longer considered disordered, psychiatrists nevertheless continue to stigmatize gender variance (Lev, 2006). Incidentally, the British Broadcasting Corporation (2011) reports that the Australian government has recently added a third gender category on its citizens’ passports: “indeterminate.” Thus, while the DSM-V Sexual and Gender Identity Disorders Work Group is hard at work on the new Gender Dysphoria disorder, the rest of society is busy normalizing it!

Likewise, many of us consider delusions and hallucinations as signs of pathology. In fact, the term “crazy” is often used to refer to those of us who have lost touch with agreed-upon reality. Yet, reviewing the literature on psychosis-like experiences within the general population, Bentall (2003, 2004) found that a considerable number of people not only report experiencing hallucinations and delusions during their lifetimes, but also living fairly happy lives without treatment. Thus, although unshared sensory experiences and unusual beliefs are more rare—but not as rare as we thought—than common, these deviant behaviors results in no harm to the self or others for many of those who exhibit them. Relatedly, social psychiatrist Marius Romme and researcher Sandra Escher (1993; see p. 7-10), who together instigated The Hearing Voices Movement, have suggested that there is nothing inherently problematic in, say, hearing a voice that reminds you of your failings as a person; the difficulty, instead, lies in one’s ability to cope with self-conversation (or what Szasz, 2002, calls minding) that involves not only silent, but also audible thoughts (for differences between copers and non-copers’ strategies, see Romme & Escher, 1989, and Romme, Honig, Noorthoorn, & Escher, 1992).

But, what of socially deviant behaviors that entail purposefully harming the self or others? Should we not consider those pathological? Back when the DSM-IV was being revised, Moser and Kleinplatz (2005) published an article pleading for the removal of the paraphilias (e.g., Exhibitionism, Frotteurism, Pedophilia, Sexual Masochism and Sadism) from the update. In it, the authors argue that while sexual behavior can certainly qualify as antisocial, it can never be sick. In other words, social deviance is never pathological, no matter how much harm it may pose on the self or society.

The Substance-Related Disorders chapter of the DSM-IV-TR represents one of the most glaring examples of the diseasing of antisocial behavior. (It is thus probably not surprising that it also represents the manual’s longest section; Greenberg, 2000b.) Let me state clearly: excessively and narrowly partaking in any single activity is not a sign of a balanced lifestyle. However, neither is this a sign of illness.

There is evidence that addiction, despite everything we know about “addictive substances” and their effects on the brain, may be more of a choice than we think (for a review of research negating the “irresistible impulse” hypothesis, see Fingarette, 1989, and Schaler, 2000). But even that is beside the point. The problem—and a particularly damning one at that—is that what counts as addiction in the first place is not a question of biology, but social values. The APA’s own values become more apparent when we consider that the following disorder is omitted from its manual’s pages: “psychotropic medication-related disorders.” I am not talking here about those of us who illegally consume mind-altering drugs, but those of us who are prescribed them by our family doctors or psychiatrists. After all, psychotropic drugs alter experience in the same way illicit varieties do. Why, then, does abusing the former render one “in treatment,” the latter “sick”? When we strip away the clinicized façade (i.e., state-endorsed, ritualized drug-intake), the prolonged consumption of psychotropic drugs becomes one more form of misuse, right alongside other less recognized, less supervised forms of misuse. It is only social values that make us decide whether one or both categories of excessive drug intake amount to mental disorders. Simply, we prefer the nature and consequences of one drug “addiction,” but not the other.

To reiterate, the DSM-IV-TR defines social deviance as abnormal. We have thus successfully discerned the third God of Normal: Social Convention. In so doing, we have also come across different subgroups of social deviants that offend this deity: those who cause neither harm to themselves nor others (e.g., transgendered individuals), those who voluntarily withstand harm or only cause harm to consenting others (e.g., drug misusers and sexual sadists), and those who cause no harm to themselves and harm to non-consenting others (e.g., child molesters). While I do not believe that any of these suffer from any sort of sickness, the third group strikes me as metaphorically sick: concerned with only their own needs and desires, at the expense of others’ welfare, members of this group are selfish and inconsiderate. However, they are only “sick” the way an economy can be “sick”: they represent the reality that egocentric and careless behavior will, more often than not, lead to harmful consequences.

Because I doubt Dysart is uncomfortable protecting society from harm, this leads me to conclude that he is most worried about a) sacrificing members of the first two groups of social deviants to b) the God of Social Convention. As we shall see next, Dysart’s worries are, in Strang’s case, unwarranted, because he has mistakenly categorized him.

Some of you will argue that I have been unfair in my treatment of the DSM-IV-TR, that many of the disorders I have mentioned cannot be diagnosed without the presence of distress or impairment in interpersonal, social or occupational areas of functioning. In other words, perhaps it is not the behavior itself that is the problem, but the fact that it causes negative consequences.

That is very considerate, but somewhat misguided. A host of behaviors can cause both distress and impairment but have not made it into the manual: engaging in extreme sports, being a social activist, living with parents as an adult, immigrating to a new country, eating fast-food every day, being in a relationship, starting a business, vowing celibacy. The only difference is that these behaviors are generally approved, or at least considered part of the “human experience,” and so the associated distress and impairment are considered acceptable fallout. Thus, it is not distress or impairment that signals psychopathology and warrants a given behavior’s initial inclusion into the DSM, but distress or impairment arising from behaviors we consider undesirable to begin with. Further, some disorders—for example, Delusional or Brief Psychotic Disorder—do not even include distress or impairment in their diagnostic criteria. Even when they do, and a given behavior refers to internal events (e.g., voyeuristic sexual fantasies), sometimes merely acting upon these can take diagnostic precedence (Moser & Kleinplatz, 2006). And so, it is no longer the distressing or impairing consequences that are the problem (since there might not even be any), but the behavior itself.

What of the many behaviors that involve suffering, incompetence or social deviance, yet are not considered disordered? I suspect psychiatrists shy away from applying their very own principles consistently, because carrying their conceptualization of abnormality to its logical conclusion would mean the end of their profession. Psychiatry would become the laughing stock of the Sciences, ultimately loosing its “franchise on our psychic suffering, the naming rights to our pain” (Greenberg, 2010a).

Dysart’s Mistake

Dysart is worried about sacrificing social deviants who cause no harm to others to the God of Social Convention. While his worries are legitimate, they do not apply to Strang. Dysart has committed a category error: he has incorrectly assigned his new patient to the former group, when he truly belongs to the group of social deviants who harm others.

I agree with Dysart: social deviants are not sick. Appropriately, the psychiatrist avoids medicalizing his patient’s behavior. For example, while Strang is tormented by his attraction toward horses, Dysart does not interpret Strang’s distress as a symptom of his “sexual disease.” After all, who among us has never been tormented by love? Whether or not love is directed toward an appropriate subject has absolutely no bearing on the authenticity of our distress when that love disappoints us. Unwilling to rely on psychiatric terminology to conceptualize Strang’s presenting difficulties, Dysart is thus faced with a challenge: how, then, should he describe Strang’s strange sexual obsession?

While searching for an alternate way of conceptualizing Strang’s difficulties, Dysart commits a common mistake: he romanticizes the difficulties instead. He idealizes Strang to the point of jealousy: he confesses he wishes he could know the passion his patient has felt. Strang’s sexual attraction toward animals, however, is not worthy of admiration. It is, after all, comparable to attraction toward children, in that in both cases the object of attraction is incapable of consenting to sexual activity. While most child molesters are probably quite passionate about children, I cannot say I would ever be jealous of such passion, even if I could somehow tease apart the feeling from the source.

In romanticizing Strang’s sexual interest, Dysart inadvertently transforms social deviance into its very own God (of Ab-Normal), describing Him as rare and beautiful. However, neither acceptable nor deplorable behaviors should be revered, for the simple reason that they merely constitute humans’ attempts to master life with the innate and learned tools at their disposal. As such, adding unnecessary levels of meaning to these behaviors, be they psychiatric or romantic, is simply foolish, not to mention un-parsimonious.

When seeking to make sense of his patient, Dysart had at his linguistic disposal a third option, favored by psychiatrist Thomas Szasz (1973): the type of plain language spoken by the educated layman, or secular humanistic language. The behaviors of those who choose to engage in sexual intercourse with children or animals are not sick, but terribly misguided and destructive. Their behaviors are not pathological, but illegal and immoral, since they do not involve relationships between consenting adults (of the same species). Child and animal molesters have no respect for the objects of their attraction, manipulating them to satisfy their own wants. I understand it must be terribly hard to curb one’s sexual interest, especially when there is no socially acceptable outlet for one’s particular brand of impulses. Nonetheless, there is no reason to believe that deviant impulses are, in and of themselves, any harder to regulate than normal ones (Szasz, 2007).

Of course, those entities espoused by speakers of humanistic language (e.g., “good” or “bad”) no more exist in nature than those espoused by speakers of psychiatric or romantic (or religious) language. Humanistic language is arguably superior to these alternatives, however, because it conceptualizes behaviors and relationships in terms of human needs, relying on a framework of secular morals that specifies what hurts us is bad and should thus be spoken of using derogatory terms, and what does not hurt us is good and should thus be spoken of using favorable terms. This approach would flip a medicalized statement such as “Eating disorders are highly comorbid with mood and anxiety disorders, and require intensive treatment” into “Those of us who over- or under-indulge in food are likely struggling with overwhelming emotions at the same time; one should strive to resolve these difficulties, since they distract from participating fully in life.”

Humanistic language is primarily practical: because our core concern as humans is to survive and thrive within reality, it is helpful to define the behaviors we use to orient ourselves within reality according to these needs. Such language is also parsimonious, avoiding any reliance on metaphors, which often taint our observations with superfluous (medical, quixotic or superstitious) content that distracts from what we really mean to say. (Of course, medical and quixotic language is warranted under certain circumstances; namely, when dealing with objects under the jurisdiction of medicine and the arts, like human bodies or bodies of art.) Another benefit of humanistic language is that it acknowledges human subjectivity: as its name implies, humanistic language is based upon our own subjectively human experience of the universe. No less, no more.

Dysart worries he will cause undue harm onto his patient’s individuality if he seeks to “cure” him of his sexual attraction to horses; and this, simply because he is different from the majority. This is honorable. Yet, as we have seen, there are at least three different types of social deviants. Dysart does not realize that his particular patient happens to fall into the group that constitutes a menace to others’ safety. When deviance harms, I believe it is our responsibility to help those acting upon their destructive brand of impulses to fulfill in pro-social ways whichever needs their actions are meant to fulfill (for a model of life change, or “rehabilitation,” based on such a principle, see Ward & Maruna, 2007). If we insist, we could even describe therapy whose aim it is to convince such individuals to adopt this same goal, and to teach them how to do so, as a necessary evil: necessary because it is the least restrictive strategy we have to protect vulnerable others, yet evil because it still restricts the freedom and autonomy of the harmful deviant.

Final Thoughts

At the beginning of Equus’ second act, Dysart asks himself: “[What] am I doing here? I don’t mean clinically doing or socially doing—I mean fundamentally! These questions, these Whys, are fundamental—yet they have no place in a consulting room” (Shaffer, 1973, p. 76; italics in original). It is essential to the integrity of our craft, professional helping, that we think long and hard about a) how we describe our clients’ behaviors, b) whether these behaviors deserve to be considered abnormal in the first place, c) whether, when reasonably deserving of the descriptor, these behaviors should also be considered pathological, and d) which of these “pathological” behaviors should be altered or downright eradicated. Ideally, these issues should be clarified before we even step into the consulting room. Psychiatry has weighed in, but has it painted humanity for what it is? While Equus may add a few unnecessary brush strokes of its own, it answers with a resounding No.


American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.

Bentall, R. P. (1992). A proposal to classify happiness as a psychiatric disorder. Journal of Medical Ethics, 18, 94–98.

Bentall, R. P. (2003). Madness explained: Psychosis and human nature. London, UK: Penguin Books.

Bentall, R. P. (2004). Sideshow? Schizophrenia as construed by Szasz and the Neo-Kraepelinians. In J. A. Schaler (Ed.), Szasz under fire: The psychiatric abolitionist faces his critics (pp. 301–320). Chicago, IL: Open Court.

British Broadcasting Corporation (2011, September 15). New Australian passports allow third gender option. Author. Retrieved April 29, 2012, from here.

Dawes, R. M. (1996). House of cards: Psychology and psychotherapy built on myth. New York, NY: The Free Press.

Fingarette, H. (1989). Heavy drinking: The myth of alcoholism as a disease. Los Angeles, CA: University of California Press.

Frances, A. (2010, March 01). It’s not too late to save ‘normal.’ Los Angeles Times. Retrieved April 29, 2012, from here.

Greenberg, G. (2010a, December 27). Inside the battle to define mental illness. Wired. Retrieved April 29, 2012, from here.

Greenberg, G. (2010b). Manufacturing Depression: The secret history of a modern disease. Toronto, ON: Simon & Schuster.

Huxley, A. (1932/1994). Brave new world. London, UK: Flamingo.

James, W. (1901-1902/2002). The varieties of religious experience: A study in human nature. New York, NY: The Modern Library.

Keen, E. (2011). Emotional narratives: Depression as sadness—Anxiety as fear. The Humanistic Psychologist, 39, 66–70.

Kottler, J. A. (2010). On being a therapist (4rth ed.). San Fransisco, CA: Jossey-Bass.

Kupfer, D. J., First, M. B., & Regier, D. A. (Eds.) (2002). A research agenda for DSM-V. Washington, DC: American Psychiatric Association.

Lev, A. I. (2006). Disordering gender identity: Gender Identity Disorder in the DSM-IV-TR. Journal of Psychology and Human Sexuality, 17, 35–69.

Martin W. (2004). The best liberal quotes ever: Why the Left is right. Naperville, IL: Sourcebooks.

Moser, C., & Kleinplatz, P. J. (2006). DSM-IV-TR and the paraphilias: An argument for removal. Journal of Psychology and Human Sexuality, 17, 99–109.

Romme, M. A. J., and Escher, A. D. M. A. C. (1989). Hearing voices. Schizophrenia Bulletin, 15, 209–216.

Romme, M. A. J., and Escher, A. D. M. A. C. (1993). Accepting voices. London, UK: Mind Publications.

Romme, M. A. J., Honig, A, Noorthoorn, E. O., & Escher, A. D. M. A. C. (1992). Coping with hearing voices: An emancipatory approach. British Journal of Psychiatry, 161, 99–103.

Rosenhan, D. L. (1973). On being sane in insane places. Science, 179, 250–258.

Russell, B. (1957). “Why I am not a Christian” and other essays on religion and related subjects. New York, NY: Touchstone.

Schaler, J. A. (2002). Addiction is a choice. Chicago, IL: Open Court.

Shaffer, P. (1973). Equus. Toronto, ON: Penguin Books.

Szasz, T. (1973). The second sin. Garden City, NY: Anchor Press.

Szasz, T. (2002). The meaning of mind: Language, morality, and neuroscience. Syracuse, NY: Syracuse University Press.

Szasz, T. (2004). Reply to Fulford. In J. A. Schaler (Ed.), Szasz under fire: The psychiatric abolitionist faces his critics (pp. 93–117). Chicago, IL: Open Court.

Szasz, T. (2007). The medicalization of everyday life: Selected essays. Syracuse, NY: Syracuse University Press.

Ward, T., & Maruna, S. (2007). Rehabilitation. New York, NY: Routledge.

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