"Mental Illness" and Justice as Recognition

Abstract

My friend T was diagnosed with bipolar disorder over a decade ago, just in the midst of his medical residency. Since that time, he hasn't been able to complete his residency, though he's held a variety of different jobs, some of them making use of his medical knowledge (intake physician for insurance companies), others not (golf course attendant). Although T will grant that he needed help at the time of his diagnosis, to this day he doesn't approve of the kind of help he received (relatively coerced but officially "voluntary" commitment, a wide range of ineffective pharmaceutical cocktails, electroshock). Like many people diagnosed as bipolar, he has at various times come off the medications prescribed for him. In part this is due to frustration with their side effects (liver damage, weight gain, hair loss, mental fuzziness, anxiety) and their limited effectiveness. But it's also because he questions whether whatever occurred in his brain and resulted in his difficulty functioning "normally" is chronic, and in any case, he's not convinced that "normal" functioning is always to be preferred. In this judgment, he is echoed by many patients and former patients, both those relatively sanguine about psychiatry (Redfield Jamison) and those who identify with the more radical "psychiatric survivors' network." What he wants is to be respected for his abilities, accommodated for his illness (when it cannot be adequately treated), and treated as capable of making a positive social contribution. When many people hear T's story, they think, "What a sad story; what bad luck!" They understand it through a lens of personal tragedy and misfortune. If they sense unfairness, it is unfairness in an existential or perhaps even divine sense: how could the impersonal world or God treat him so poorly? The idea that some part--perhaps even a large part--of his disadvantage is socially imposed is foreign to them. Most people firmly believe in a medical model of disability, and by extension, a medical model of psychiatric disability. For them, disability is an intrinsic feature of a person, and the best way to help a disabled person is to find a cure. If a cure is not available, the person might be compensated for an inability to work, or pitied and offered charity. But according to my friend and people in the disability rights movement, many of his disadvantages could and indeed should be addressed through social change. If so, then we shouldn't shake our heads in pity over his case; we should wrestle with how to do justice for him. Sociopolitical Conception of Disability Disability scholars often distinguish between an impairment (usually taken to be a non-standard state of the body, such as deafness or paraplegia) and disability (understood to be a lack of fit between the body and the social environment, resulting in disadvantages for the individual who is impaired). With this distinction, the disadvantage of disability is something that calls out for social change. In many cases, people with impairments prefer not to have their bodies altered (as when Deaf individuals do not want cochlear implants), or are simply faced with no known medical treatments for their impairments (e.g., spinal cord injuries result in paralysis that cannot be "fixed"). The disability rights movement has emphasized how such people deserve fair opportunities to work and to engage in a variety of aspects of social life, even if their modes of functioning are non-standard. Indeed, it has celebrated the diversity of ways of living and attempted to help the non-disabled public rethink the concept of disability. One problem with the impairment/disability distinction is that it creates terminological confusion in discussions with people who presume that disability is inherently in the body. One consequence is that the sociopolitical model of disability may appear overstated if it always insists on social change rather than bodily treatments, when many people recognize that some impairments clearly result in bodily disadvantages. …