In his new book, No More Normal , psychiatrist Alastair Santhouse recalls an experience from the 1980s when he was a university student in the UK helping deliver supplies to "refuseniks" - Soviet citizens who were denied permission to leave the USSR. These people often faced harsh treatment, losing their jobs and becoming targets of harassment. Some were even diagnosed with a psychiatric condition called "sluggish schizophrenia".
Author
- Caitjan Gainty
Senior Lecturer in the History of Science, Technology and Medicine, King's College London
By the time Santhouse encountered this diagnostic category, sluggish schizophrenia had been kicking around psychiatry in the Soviet Union for some time. It first entered the diagnostic lexicon in the 1930s, coined to describe cases in which adults diagnosed with schizophrenia had displayed no symptoms of the disorder in childhood.
This notion of a symptomless disorder gave it tremendous value to Soviet officials in the 1970s and 80s, who wielded it ruthlessly against those who suddenly suffered from delusions of wanting a better society or hallucinatory desires to emigrate.
But they weren't the only ones to wield psychiatry to repress and control. "Punitive" or "political" psychiatry has proven to be quite a useful tool in many parts of the world. One well-known case is that of Chinese political activist Wang Wanxing , who marked the third anniversary of the 1989 pro-democracy student protests in Tiananmen Square by unfurling his own pro-democracy banner on that same spot.
He was immediately arrested, jailed, and then diagnosed with "political monomania": a "condition" characterised by the irrational failure to agree with the state. For treatment, he was confined for 13 years in a psychiatric hospital, part of the Ankang ("peace and health") network of psychiatric institutions where dissidents like him were forcefully medicated and subjected to "treatments" such as electrified acupuncture.
More recent applications of punitive psychiatry pop up periodically in our news feeds and disappear just as quickly. Some women who removed their headscarves or cut their hair as part of anti-government protests in Iran in 2022 were diagnosed with antisocial behaviour, forcefully institutionalised and subjected to "re-education".
In 2024, in Russia, an activist's choice of T-shirt , bearing the slogan "I am against Putin", was considered so problematic that it required the summoning of a "psychiatric emergency team".
As in the Soviet Union, the advantages of punitive psychiatry were not a little Orwellian: diagnosing a citizen with a mental illness made it easier to isolate their ideas, cut them off physically and discourage similar behaviour.
Not just authoritarian regimes
While authoritarian regimes certainly seem to wield it with the most abandon, punitive psychiatry has not been absent in the west. Indeed, at the height of the civil rights movement in the US, black activists protesting generations of racial prejudice and injustice were subjected to much the same diagnostic regime.
One example was the pastor and activist Clennon W. King, Jr. who was arrested and confined to a mental institution in 1958 after he attempted to enrol at the all-white University of Mississippi for a summer course. It was an act so inconceivable that the state of Mississippi thought he must be insane.
And, according to his FBI record , the militant civil rights leader Malcolm X was a "pre-psychotic paranoid schizophrenic": a diagnosis made based on his activism and protest speech. As Jonathan Metzl has shown , the descriptors used to "diagnose" Malcolm X were later enshrined in the American Psychiatric Association's 1968 updated definition of schizophrenia. Dissent in the US was as potentially pathological as dissent anywhere else.
Though each of these cases undoubtedly constitutes a gross misuse of psychiatry, the practice of making distinctions between what constitutes normal and abnormal behaviour is fundamental to the discipline. And, as Metzl's account of the shifting definition of schizophrenia implies, psychiatric disorders are especially sensitive to social change.
Unlike most physical illnesses, psychiatric illnesses often have few physiological signs. Whereas a broken bone on an X-ray can be declared unambiguously broken, psychiatric problems are diagnosed in terms of constellations of symptoms, written on but not in the body, and recounted by patients in conversation with their therapist, or via a listing of these symptoms on one of the many diagnostic questionnaires that make up the psychiatric diagnostic arsenal.
Psychiatry's bible
These are then matched to symptom clusters listed in psychiatry's bible, the Diagnostic and Statistical Manual (DSM). Though in the everyday practice of mental health, there is much more to this process, in theory, the closeness of this match designates the absence or presence of disease.
That psychiatric diagnoses are unusually socially responsive is by and large unavoidable. Our mental health is itself socially specific, so much so that some have argued that something as apparently universal as depression , for example, is actually an illness specific to western or even just anglophone cultures.
Whether that hypothesis is true or not has no bearing on whether depression is in fact real. It only suggests what psychiatry intrinsically acknowledges already: that mental health has a critically significant social component.
As the use of psychiatry for these punitive purposes makes clear, this necessary malleability lends itself to abuse. The radical psychiatrists of the 1970s certainly believed so when they re-examined the very notion of normal, exposing its role in policing society and enforcing categories of exclusion. It's how homosexuality ended up as a diagnosable psychiatric illness in the 1952 edition of the DSM - a pathology built by and for the norms of the American mainstream.
But it's a malleability that can also lead to change in the opposite direction, where society - we, you and I - revisit and change these boundaries. Homosexuality was removed from the DSM in 1973, not because of any new scientific information, but because of a targeted gay rights activist campaign and, more indirectly, the slow shift over the intervening decades toward greater social inclusion.
In his book, Santhouse reflects on where we are now in psychiatry, at a time when there is, to quote his clever title, "no more normal". Though the definition of normal is always in a state of flux, ours is a moment of diagnostic surfeit, in which mental health clinicians have had to cede space to a superabundance of resources that allow us - even encourage us - to diagnose ourselves.
And that makes this an interesting moment: one in which we explicitly see our vision of mental health being remapped onto the shifting politics of identity and inclusion that permeate now. Insofar as this forces us to reckon with the social aspects of our mental health in a more explicit way than we are used to, perhaps this is no bad thing.
Caitjan Gainty has received funding from the Wellcome Trust.
