Prior to attending medical school, I briefly entertained the desire to become a psychiatrist. I was privileged to co-teach two honors psychology courses as an undergraduate, and my master’s thesis in graduate school briefly looked at empathy from a psychological perspective. Nevertheless, I have always been a bit skeptical of psychiatry, perhaps due to the fact that Americans are constantly inundated by TV shows, such as “Scrubs” and “House, M.D.,” movies, cartoons and books, which usually paint the portrait of a psychiatrist as a quack who does not practice “real” medicine.
Yet when nine black individuals were horrifically slaughtered in an historic black church in South Carolina by a white male (Dylann Storm Roof) who said, “You rape our women and you’re taking over our country — and you have to go,” all of a sudden psychiatry and mental illness become the legitimate explanation. Of course, Roof later confessed that he hoped his actions would start a “race war” and he was seen in pictures wearing a jacket with flags of apartheid South Africa, as well has sporting a license plate with the Confederate flag.
But a friend of his, John Mullins, reports that Roof used drugs heavily. Roof was also arrested for drug possession in February. So the line of thinking goes: it must be some kind of mental illness. The term “mental illness” is thrown around too frequently without any serious consideration about what is meant by the term.
In 2013 the American Psychiatric Association published the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5). Serving as the Bible for psychiatric diagnosis in the United States, the DMS-5 defines a mental disorder as:
… a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above. (DSM–5, 2013, p. 20)
From this definition, willy-nilly stating that Roof has a mental illness is a meaningless statement. As of right now, we know nothing about the states of Roof’s cognition, emotion regulation or behavior, specifically in the context of some underlying dysfunction. What we do know, however, given remarks he made while slaughtering blacks in an historical Church, and by comments made to his friends, is that Roof exhibited socially deviant behavior and had a conflict with society, which is not a priori a mental disorder.
But let’s look a little bit closer at the somewhat arbitrariness of the use of “mental disorder” from a psychiatric perspective. In the DSM-IV, the progenitor to the DSM-5, a mental disorder was defined as:
… a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. (DSM-IV-TR, 2000, p. xxxi)
The definition here is a bit shorter and a bit less comprehensive than its descendant, the DSM-5. Although there’s not enough room to explain the rationale behind expanding the definition from one edition to the next, I want to emphasize here that a mental disorder is a variable social construct and not a historical scientific axiom. But what do I mean by this?
In his book “Madness and Civilization, the famed-French philosopher Michel Foucault observed a “major paradox” in the conceptualization of madness during the Classical Age (later 17th and 18th centuries). Foucault notes that mental illness was both a “disorder of the will” and, at the same time, a kind of “innocent animality.” He considered this a major paradox because this perspective of mental illness postulates that the mentally ill are both accountable and unaccountable for their madness (often societal-defined deviant behavior), and he traces this line of thinking to our current understanding of the conception of mental illness.
The DSM is frequently changing how it defines various categories of mental illness. Often, these changes are brought about by changes in cultural norms and orientations to previously defined deviant behavior, or behavior that violates social norms. A great example of this historical trend is the classification of homosexuality as a mental disorder in the DSM. In DSM-I, homosexuality was classified as a mental illness. As social pressure mounted from gay activists and dissents within the discipline, however, the 1973 DSM-II no longer classified homosexuality as mental disorder, though it was still in this Bible of psychiatry under a new diagnosis of sexual orientation disturbance. In 1987, homosexuality was removed from the DSM.
In a brilliant analysis of theses historical iterations of the DSM, Case Western Reserve University medical anthropologist Atwood Gaines suggests that psychiatry, a type of “ethnomedicine,” is an “unfinished product of culture history.” Form this perspective, the DSM is an historical document that gives the reader insight into how the ethnic Western self organizes and classifies the Other, or those who do not look, think, and act the way “we” do. In academia it is difficult enough to sort out these historical trends, and it makes me pause for a moment when I see in the news the use of ‘mental illness’ thrown about to explain deviant behavior.
There is an eerie link between how the media, and often medicine, approach mental illness and deviant behavior. Delving deeper into this topic, medical sociologist Peter Conrad, in a riveting chapter within the anthology “Critical Psychiatry: the Politics of Mental Health,” observes that when deviant behavior is medicalized, medicine (or the media appealing to medical jargon) thereby extends its jurisdiction by rearticulating moral categories in scientific-technological language. In a profound sense, the medicalization of deviant behaviors, such as racism, shifts our focus away from structural violence and pathologies of power and, rather, has us focus our attention on a seemingly isolated event.
Speaking of structural violence, according to the Federal Bureau of Investigation (FBI) breakdown of 5,922 single-bias hate crime incident reports in 2013, biases based on race accounted for 48.5 percent of these incidents: “Of the reported 3,407 single-bias hate crime offenses that were racially motivated, 66.4 were motivated by anti-black or African-American bias, and 21.4 percent stemmed from anti-white bias.” But surely mass murder must be due to mental illness and not solely due to racism?
According to the Institute of Medicine’s review on violence and mental illness, “although studies suggest a link between mental illnesses and violence, the contribution of people with mental illnesses to overall rates of violence is small … the magnitude of the relationship is greatly exaggerated in the minds of the general population.” Stated another way, individuals who are mentally ill usually are not violent in the kind of way Roof demonstrated violence. Although more epidemiological data is needed in order to ascertain trends of mass murders with mental illness, meta-analyses from other countries suggests that it is extremely rare for individuals with psychosis to murder strangers.
Given these observations and what we currently know about Dylann Storm Roof, the leading assumption based on data should lead us to assume that his actions that lead to the death of nine innocent black individuals within an historic black church in South Carolina was due to racism as an act of terrorism and not mental illness. Moreover, mental illness does not explain why family and friends did not find it alarming that Roof was espousing racist ideations. Where was their moral outrage? Why didn’t they report this alarming behavior?
The only potential psychiatric symptom here is the illusion that we live in a post-racial society where a white male who has racist ideations kills nine black individuals and somehow it is not due to racism. An illusion is “a misperception or misinterpretation of a real external stimulus, such as hearing the rustling of leaves as the sound of voices” (DSM-5, 2013). White America sees the massacring of blacks and, despite the lack of evidence, uncritically and automatically categorizes (or sees) this race-based homicide as mental illness. If this perspective is not at its core due to illusion, then it is an insidious léger de main that shifts our attention away from the pervasiveness of racism that continues to lynch black people throughout the United States.
Contributing Writer
Cleveland Clinic Lerner College of Medicine
Joshua Niforatos is a medical student at Cleveland Clinic Lerner College of Medicine. Born and raised in the suburbs of Chicago, he eventually made his way to University of New Mexico (UNM) where he earned bachelor degrees in both cultural anthropology and biology. He then went on to earn a Master of Theological Studies at Boston University School of Theology where he studied theology, anthropology, and ritual.