In 2004, I was asked to write a short summary of philosohical issues in mental health for the theatre playbill for a production of Joe Penhall's "blue/orange" by The Repertory Theatre of St. Louis, directed by Steven Woolf. The play was later produced by BBC Four in 2005.
The Philosophy of Mental Health
In the tradition of One Flew Over the Cukoo's Nest and Girl, Interrupted, Blue/Orange raises the questions of what counts as normal in our society and who should have the power to decide what is normal. Set in contemporary Britain, Joe Penhall's play refers to some "sections" of the Mental Health Act that give psychiatrists the power to hospitalize mentally ill people against their will for their own good or the protection of society, and some of the details of the law will be unfamiliar to American audiences. But the turning of a noun into a verb will be easy to understand: Bruce wants to section Christopher again, to keep him in hospital care. This language has become part of everyday usage in the UK, not just among mental health professionals, but for ordinary people. "Sectioning" now signifies psychiatric authority as much as "Bedlam," "straightjacket" and "lobotomy."
There has always been controversy and public debate about psychiatric theories and treatments. These days, society mostly agrees that people who are competent to make their own decisions should have the right to control their own lives and bodies, while those who lack mental competence can have guardians appointed to make decisions on their behalf. The central difficulty is in drawing the line between the sane and the insane. In the twentieth century, Sigmund Freud carved the intuitively plausible distinction between the neurotic and the psychotic, and notoriously argued that in modern civilization where we have to repress our animals drives in order to live in relative peace, we are all neurotic to some degree. Neurotics could benefit from psychoanalysis, he thought, but psychotics were so out of touch with reality that mere talk would be of no help to them.
These days, Freud's psychoanalytic theory is largely out of favor with the psychiatric establishment, and psychiatric training includes a mix of neuroscientific facts, psychological theories and sociological perspectives. Most of the research money is in the development of new medications, and public talk about mental health problems is dominated by the language such "chemical imbalances in the brain" and "low serotonin levels," and it is no surprise that some have jokingly referred to depression as a form of "Prozac deficiency." Psychiatry has been largely successful in shaking off its old tarnished image of being "pseudoscientific," and through embracing neuroscience and genetics, it holds its head high with other medical disciplines. Even some talk psychotherapy has been empirically proven to be effective, with health maintenance organizations and medical insurance companies showing more enthusiasm for "brief therapy" and limited sessions rather than the interminable analysis of the Freudian era.
In the 1960s and 1970s, there was great public interest in the "antipsychiatry movement," which was led by the theories of the psychiatrists R.D. Laing and Thomas Szasz and fueled by revelations about the mistreatment and institutionalization of patients in large psychiatric hospitals. With the added incentive of saving money, administrators and policy makers were keen to shut down those large hospitals and provide people with long-term mental health needs with care in the community. Laing suggested that the real problem was not located in the mentally troubled individuals but rather in families and even society at large, and attempted to create radical new approaches to the treatment of mental illness. His experiments did not have much success, and he himself abandoned them for different pursuits. Szasz, now in his eighties, has shown far more consistency in his approach, and is still publishing books on a regular basis denouncing psychiatry as a form of slavery and denying the very existence of mental illness. Szasz continues to believe that each individual must face the problems in living, and should always be morally and legally accountable for his or her actions. His extreme views continue to influence a minority of mental health professionals and are particularly attractive to many former patients who believe that they have been abused by the psychiatric system. On the Internet, one can find many websites created by "survivors" or former patients devoted to revealing the miscarriages of justice and even conspiracies by mental health professionals and multinational corporations.
However, the deinstitutionalization of people with chronic mental illnesses seems to have had little benefit, and it is not clear what practical alternatives the critics of psychiatry have to offer. Community care fails many psychiatric patients. Homeless people are conspicuous in the streets of any major American city are and a large proportion of them have been diagnosed with serious mental illness. Even those in some form of residential care are often neglected or suffer the consequences of minimal funding of essential resources. Groups such as the National Alliance for the Mentally Ill, run by families of people with severe mental disorders, embrace the model of brain diseases and call for more funding for psychiatric research and treatment, and insist on the importance for families to have the power to hospitalize their loved ones when necessary. If one visits the psychiatric wards of major hospitals, one is struck by how little time the patients have to stabilize before they are sent out again to cope on their own. It seems that much of psychiatric care for chronic illnesses focuses on crises, and there are insufficient resources to help people learn to cope with ordinary problems and lead fulfilling lives.
This is some of the background against which Blue/Orange is set. Despite the enhanced scientific status of psychiatry, there are still fierce debates about the objectivity of the classification of mental disorders and the ways that psychiatric authority can be used to oppress disempowered groups. The most developed and articulate criticisms have come from a feminist perspective, with a focus on mental disorders especially associated with women, such as the old category of "hysteria," and the more recent categories of eating disorders, depression, and borderline personality disorders. Equally familiar is the debate over the classification of homosexuality as a mental disorder. These cases have shown very clearly that psychiatric categories often do embody ethical assumptions about normality, and that the psychiatric establishment conceals its values in the guise of "scientific fact." Behind the supposed objectivity of treatment recommendations and research protocols, there are sharp disagreements amongst psychiatrists and other experts, and politics and power struggles can play as much a role in the treatment of patients as "the scientific method." Of course, professional associations have ethical guidelines for the treatment of patients, and most clinicians care deeply about the welfare of their patients. Nevertheless, much of the interaction between clinicians and patients occurs in private with no observation by others and people with severe mental illnesses have little ability to take action against the institutions and professionals who have provided questionable treatment. So it will not be surprising if abuses of power still occur at both the individual and institutional levels.
Compared to the issue of sexuality and gender in psychiatry, there has been less scrutiny of the role of race and ethnicity. In Blue/Orange, there are hints that Christopher is a pawn in a struggle between the psychiatrist-in-training Bruce and his well-established supervisor Robert, and that Christopher's ethnicity is a central factor. In an early scene, Christopher accuses Bruce of seeing him as an "uppity nigga," and of course Bruce denies this. Indeed, Bruce seems young and idealistic, naïve about the limitations of treatment, and Robert's more experienced advice is for him to just let Christopher go back to the community rather than to keep on treating him. But later in the play, Robert becomes keen to use Christopher in a study for his uncompleted Ph.D. He imagines what it would do for his career if he were the man who found the "cure for black psychosis." This immediately raises questions of identity and language, this time about race: who counts as black or African, and indeed whether it is racist to classify someone as black or to consider ethnicity as a factor in mental illness. In the exchanges between Bruce and Robert, these questions are not resolved, but Penhall manages demonstrates how troubling they are. The dialog shows powerfully a way in which minority patients can be reduced to their race in the search for psychiatric knowledge, and their status as a full person can be obliterated. When Robert tells Christopher that he is writing a book about "people like you," Christopher becomes just a label or category, black and crazy. Later, Robert says that Christopher's excitable behavior is normal "where he comes from," and in a moment of dark humor, Bruce points out that the patient is from Shepherd's Bush, a rather boring middle class suburb of London. Robert's categorization misses the simplest of Christopher's individual characteristics.
In a surprising twist, however, Robert is sympathetic to the humanistic existentialism of R.D. Laing, while Bruce, who shows more concern for Christopher's welfare, places his confidence in standard scientific psychiatry. It is Robert who has a more tolerant attitude to Christopher's odd beliefs, ready to interpret them as an expression of surrealism, and defends Christopher's right to live his life as he wants. Both psychiatrists have limited understanding of their patient, and his interests get lost in their battle for power.
Blue/Orange makes a powerful case that at the heart of disputes about how best to treat psychiatric patients are not only disputes about the rights of patients and different value schemes, but also the nature of a person and the concept of mental illness. These are complex philosophical issues, and should provoke audiences into deeper thought. Personally, I also hope that some mental health professionals will see the play, and that it might help those responsible for the training of future psychiatrists and psychologists to see the importance of works of literature and philosophy to understanding mental illness and its treatment.