Entry 4:

Dear Walter,

Perhaps you are right that it is best not to stray too far from the John Rocker case. Surely you are right that we mostly agree--that our difference is one of focus. I would like for the moment to try to bring that difference to the fore. This morning I flipped through the online responses to our correspondence--"The Fray." Only a few of the comments addressed the points on which we differ, but those few all agreed with you. They said, in effect, that the moment we allow speech (racist remarks) to be a trigger for psychological inquiry, we give the state a weapon it will use indiscriminately. This is the danger you refer to when you write that "psychiatry, one of the healing arts, could be transformed into an agent of social control and punishment."

I share this worry. Were this case to have occurred in the public sector--based on a government requirement for psychiatric evaluation--this worry might push aside all others. My question is whether, in the case at hand, the use of psychiatry for social control ought to be our sole worry. Let us imagine, even if this assumption is counter to the publicly known facts, that Rocker is seriously mentally ill and that his intemperate behavior is in part attributable to that illness. Let us further imagine that awareness of the illness would contractually entitle him to a different sentence--treatment and a minor sanction rather than a major sanction. Then the question becomes, given our shared fear of the misuse of psychiatry, would we still prefer (before the facts are known) that Rocker not be evaluated? Ought Rocker be made to sacrifice his rights in order that psychiatry and all of us be protected from state tyranny?

That question strikes me as a serious one--of serious moral consequence, however trivial the question of punishment for Rocker. The answer depends on our assessment of the current and likely future governments. I would say that the liberal position, which is what I am calling my position, is that we can afford to be nuanced in our judgments, that we do not need to dumb down our system of justice now in anticipation of future governmental misuse of precedent. But I respect the opposing point of view, which embodies a different sort of liberalism or is simply conservative--the view that the state is so untrustworthy that we must forgo certain liberties in order to maintain a clear set of boundaries, in this case in order to bound the use of mental health evaluation.

I am likewise of two minds as regards your claim that as a culture, we too often turn to psychiatric explanations for moral transgressions. If that were so, wouldn't the insanity defense be wildly successful? In practice, it almost never succeeds. Yes, lawyers use the insanity defense, or diminished capacity, when there is no where else to turn--when a defendant has been caught "dead to rights," as we say; what else should they do? But the judge and jury never buy it. How many financial transactions are reversed because in retrospect one of the principals was manic? Virtually none. A few notorious cases notwithstanding, there is no important area of the law where psychiatric excuses are decisive.

Psychiatric excuses are prevalent primarily in social (and I would include political) intercourse. A man strays sexually and attributes his behavior to alcoholism or a "midlife crisis." Here the explanation is generally pro forma, and as psychiatrists we may have a range of responses. We may be pleased that some sorts of mental illness have been destigmatized. We may regret that our profession's diagnostic system has been misused. My own inclination is to wish that the excuse were more fully psychological. What do you mean by midlife crisis? If this is your fourth episode of major depression and your mother and father were both hospitalized for depression, those facts place the "midlife crisis" in a more complex light. What was the texture of the depression? In the midst of crisis, do you tend to have contempt for wife, children, voters? Tell us more. Of course, I ask these questions in jest. The clear purpose of this sort of explanation is not to reveal but to hide. The "explanations" have little to do with psychiatry as it is practiced. The tendency (to use psychological excuses) does some social harm, and doubtless some good as well. To my mind, it beats political puritanism or McCarthyism.

As to the other questions: You make a good point in terms of the overlap of racism and mental illness--it depends very much on the ambient culture. I would put it this way: In a country where racism is the norm, few racists will be mentally ill. Certainly in Nazi Germany, we would not want to say that most of citizens were mentally ill; as full moral agents, they participated in evil. Normal people are capable of great evil. By contrast, though, in a country, or even a subculture, where racism is rare, racism--and especially violent racism--may well be an indicator of mental illness. This is not because racism is a mental illness, nor even a medical sign of mental illness, but because low-frequency anti-social views or behaviors tend to correlate with mental illness. I certainly agree that violent, extremist subcultures may attract the mentally ill.

I agree also that responses to psychotherapy are various, but I think that on the whole people feel less virulent hatred once their depression or anxiety (or psychosis) is diminished. It may be that I see a stronger connection between affect and cognition than you do. I find that when they are less depressed or anxious, people tend also to be more flexible in the range of explanations they will entertain. That said, psychotherapy is hardly a cure for racism. On the whole, people believe what they were raised to believe, or what it is convenient for them to believe, or (as you say) what they have believed in the past. Certainly psychotherapy would have no power against state-sponsored racism.

As for the present moment, my judgment is that we should have the freedom to apply psychiatric judgments in critical situations. To do so requires that we enter the evaluation with clean hands--as you did when you evaluated Russian dissidents. For the profession, that means striving for greater clarity in our diagnostic system and greater openness about its limitations. Is it really true that 20 percent of Americans suffer mental illness, or might there be differences recognizable to psychiatrists, even on a biological basis, that do not rise to the level of illness? My fear is not so much that psychiatry will be politicized from the outside as that it will be politicized from the inside, in the service of more research grants or more extensive reimbursement. If we can struggle with ourselves for an honest assessment of what we know, we will not need to be so worried about our role when another profession--sports, entertainment--asks us whether in a given case mental illness is at issue.

Regards,

Peter