Newsletter‎ > ‎

Interview Part Three: The Dangers of "Pathology Risk Syndrome" and Conflicts in the Profession Psychology

posted Oct 17, 2018, 3:59 PM by Rahni Jere Sumler   [ updated Oct 24, 2018, 11:03 AM by Rahni Sumler ]
Originally published on Psychology Today from Christopher Lane, Ph.D. 

In the late-1960s, schizophrenia's profile as a disease changed dramatically. This is part 1 of an interview series where Dr. Chritopher Lane interviews Dr. Jonathan M. Metzl, MD, PhD, author of The Protest Psychosis: How Schizophrenia Became a Black Disease. He is dedicated to illuminating issues of mental illness and gun violence, with a particular focus on gender and race.
Dr. Metzl is also Director of the Center for Medicine, Health, and Society at Vanderbilt University, a Psychiatrist, and the Research Director of the Safe Tennessee Project, a non-partisan, volunteer-based organization that is concerned with gun-related injuries and fatalities in America and in Tennessee. 

I don't know if you're following DSM-5 developments closely, but there's been an enormous amount of controversy over "psychosis risk syndrome," which is being proposed for inclusion in 2013 as a way of improving the "early detection" of psychosis, especially in teens and children. Given the history you've unearthed about schizophrenia, are you confident that "psychosis risk" will function largely as the APA intends or are there likely to be unintended consequences if it's included in DSM-5?

Louis Wain's Cats

Louis wain cats

6 paintings of cats by Louis Wain between 1886 and 1939 with an increasing degree of abstractedness. This might have been attributed by some to his suffering from schizophrenia. 
By Louis Wain paintings [Public domain in the United States], from Wikimedia Commons
Yes, I'm following this very closely. On one hand, I have to say that there is something very admirable about a profession that is willing to throw its entire diagnostic system up for grabs every fifteen years or so, and to seriously consider each and every word of its diagnostic bible. I also think that psychiatry has made great strides toward understanding the causes of mental disease, so in this sense the revision of the DSM represents progress on many fronts.

Yet, history teaches us to be wary of language that might broaden Diagnostic Categories -- or, in this case, might pathologize risk in addition to Illness

Especially when that broadening is not supported by clear-cut scientific facts. Also, it goes without saying that the language that appears in the DSM has tremendous implications for the lives of a great many people, patients and doctors both. Even in an era dominated by neuroscience, diagnosis remains a projective act—one that combines scientific understanding with a complex set of ideological assumptions.

You're a psychiatrist, and one who's critical of your profession's history as is clear from both this book and your earlier one, Prozac on the Couch (Duke, 2003). How do you personally negotiate such professional tensions? Also what, in your opinion, would help to narrow and alleviate them for other psychiatrists concerned about the state of their discipline?

Let me say, first, that in no way is my work meant to suggest that mental illness is socially fabricated, or, worse, that people's suffering is somehow inauthentic. As a psychiatrist, I have seen the tragic ways in which hallucinations, delusions, social withdrawal, cognitive decline, and profound isolation rupture lives, careers, families, and dreams in profoundly material ways. I know that such symptoms afflict persons of many different social, economic, and racial backgrounds, most all of whom are deeply aware of the sense of loss that their disease represents, even if society is less attuned. I also strongly believe that persons diagnosed with schizophrenia and other mental illnesses benefit from various forms of treatment or social support, and that our society should invest more in the care and well-being of the severely mentally ill.

I also believe that vigorous debate is good for psychiatry—both from outside the profession, and from within it. In previous eras, critics adopted a so-called antipsychiatric stance that advocated the near-overthrow of the profession. And to be sure, important critics still advocate for massive change. We know all too well from plagues past that the rhetoric of mental health and mental illness can become effective ways of policing the boundaries of civil society, and of keeping undesirable persons always outside.

Today you also see increasing numbers of scholars like myself who believe in the therapeutic and even potentially liberatory promise of the profession.  All while remaining deeply concerned about such issues as the impact of the pharmaceutical industry, the stigma surrounding diagnosis, and the expanded use of psychotropic medications, to name but a few.

I would like to think that books like mine help us understand how tensions that seem timeless or eternal—whether related to mental illness stigma, the overuse of psychotropic drugs, racial stereotypes surrounding psychiatric diagnosis, or even mistrust of psychiatry by members of minority communities—in fact result from particular decisions made at specific moments in time. 
I write in the book, "only during the civil-rights era did emerging scientific understandings of schizophrenia become enmeshed in a set of historical currents that marked particular bodies, and particular psyches, as crazy in particular ways. 
"The tensions of that era then changed the associations that many Americans made about persons with schizophrenia. Ultimately, recent American racial history altered more than the meaning of mental illness: it changed the meaning of mental health as well."