Nobody’s Normal: A Book Review

Source: Roy Richard Grinker/Norton Books, 2021

“I am disgustingly sane,” Gerald R. Ford declared in his 1973 Senate confirmation hearing when asked if he’d ever seen a psychiatrist. “Under no circumstances have I ever been treated by any person in the medical profession for psychiatry.”

It was a time when mental illness and suffering were cloaked in shame. An appointment at a prominent New York psychiatrist’s office was merely a “social visit,” Ford protested. That he was even asked about it tells us volumes.

As Roy Richard Grinker notes in his insightful new book, Nobody’s Normal: How Culture Created the Stigma of Mental Illness (Norton), 1973 was an especially turbulent year for American psychiatry. While veterans were pressing for recognition of “post-Vietnam syndrome,” psychiatrists were reviewing their criteria for “protest psychosis,” supposedly a “paranoia and delusion caused by civil disobedience.” After raucous conference panels that in some cases turned into shouting matches between psychiatrists and protesters, the American Psychiatric Association voted later that year to remove homosexuality from its official Diagnostic and Statistical Manual of Mental Disorders.

“The APA had to figure out a way to protect a post-Vietnam syndrome from the antiwar bias of its membership,” writes Grinker, a medical anthropologist at George Washington University, as military psychiatrists were accused of a greater commitment to the war than their patients. Meanwhile, conservative psychiatrists such as Charles Socarides defended career-long associations of homosexuality with “abnormality” on the grounds that psychiatry itself had upheld the same characterization for most of its history.

Firmly in the liberal-reformist camp on these issues, Grinker is adept at explaining why the move pitched conservatives into crisis:

In fact, homosexuality was one of the key psychological conditions that helped psychiatry remain a method to regulate behavior. By turning homosexuality into a mental illness in the first half of the twentieth century, psychologists and psychiatrists would highlight the dangers of sex and sexuality, as a watch tower in the center of a prison yard illuminates everything around it.

“A method to regulate behavior”: In Grinker’s telling, psychopathology has for decades served as an “alibi for surveillance and discipline,” its models and ideals framed as neutral, universal, harmless, and inevitable when they are in fact culturally inflected and acutely normalizing, often at great personal and social cost. As American anthropologist Ruth Benedict warned in 1934, in words that orient Grinker’s book, “The concept of the normal is properly a variant of the concept of the good. It is that which society has approved.” And that process of approval and disapproval, we learn, was often tied to moral judgments and other 19th-century ways of thinking about illness and disease, suffering and cure.

Across 17 chapters that span the rise of the asylum and the recent return to biological psychiatry, Grinker shows that American norms are buttressed by complex, long-standing stigmas, particularly around sex and race, which crucially aren’t “in our biology, [but] in our culture.” That “idioms of distress vary widely according to culture and history.” And that “normality and abnormality are fictional lands no one actually inhabits.”

This does not mean norms are empty illusions and ideals, devoid of power. Quite the contrary, in their poor definition, they mostly escape scrutiny but wield large amounts of power, Grinker shows, including from the kinds of difference and “deviance” they organize and, in psychiatry’s case, diagnose and attempt to treat.

Since for Grinker “perception [is] a cultural process, and [can] therefore be changed,” it follows, logically and most optimistically, that “stigma decreases when a society accepts some of the blame.” Caveats aside, on that success rate, the stigma we internalize may be tough to identify and harder still to discard: “Because people internalize the values of their time, they no longer need society to shame them; they can do it on their own. Guilt needs no audience—only the reflex to stigmatize oneself.”

Source: Roy Richard Grinker/Tim Coburn

Weaving autobiography into an already rich cultural history, Grinker traces several generations of psychiatric thought within his own family, from his great-grandfather Julius Grinker, an influential late-19th-century neurologist and psychoanalyst who “believed people with mental disorders were biologically inferior,” to his grandfather (also called Roy Grinker), who strove to eradicate stigma and was one of Freud’s last patients. Grinker describes an elderly Freud as “liberating” his grandfather by freeing him from judgments his own father had helped to popularize through psychiatry a generation earlier.

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Alert to the subtleties of language in psychiatric classification and diagnosis, including for determining how suffering and distress are culturally interpreted, Grinker uses his grandfather’s and his own expertise in military psychiatry to document the implications of renaming “insanity” as “mental alienation.” We learn why “shell shock” later superseded “male hysteria” as preferred terminology after World War I, and why subsequent generations and wars adopted, then discarded, “combat fatigue,” “battle exhaustion,” “war neurosis,” “post-Vietnam syndrome,” and “Gulf War Syndrome.”

One reason “post-traumatic stress disorder” (PTSD) outlasted these alternatives, Grinker notes, becoming “to a large extent an all-purpose diagnosis,” is because it “offers a relatively nonstigmatized diagnosis by blaming an environmental stressor rather than an individual’s distinctive personality and history.” We also see American psychiatry as closely aligned with the nation’s military conflicts, as each 20th-century conflict resulted in significant diagnostic changes.

Nobody’s Normal charts the complex tradeoffs involved in the framing and criteria of each psychiatric condition. The book describes their sweeping implications—for instance, after numerous reactions became full-blown disorders when the DSM-III superseded the DSM-II in 1980. But Grinker also downplays the role of error, misattribution, and diagnosis creep in the process, broadly accepting the complete redrawing of key psychiatric terms as part of a concerted push for uniformity, a notion earlier chapters characterized as coercive and normalizing:

“Without standardization, there was little hope for a scientific psychiatry; patients with the same symptoms easily received different diagnoses depending on the whims of a doctor; epidemiological rates varied widely depending on what criteria the researchers used to decide what constituted a ‘case’ or not.”

The statement tells us much about the needs of scientific psychiatry, not least as sizable differences remain over divergent diagnoses and first principles. “Psychiatry’s impact on public health will require that mental disorders be understood and treated as brain disorders,” Thomas Insel is quoted as insisting as director of the National Institute of Mental Health in 2005. “Not only do scientists know very little about what causes most mental illnesses,” Grinker counters, “mental illnesses are, almost by definition, illnesses without a known cause.”

Perhaps surprisingly, that difficulty hasn’t hindered American psychiatry, whose domains of interest in the 19th century expanded, in Grinker’s telling, “to include anything that was not in order—from divorce to delusions, mania to masturbation.” A similar impetus gave rise to still more radical expansion, as “the 1968 DSM-II had 193 diagnostic categories; in 1980, the DSM-III had 292; in 1994, the DSM-IV had 383; and since 2013, the DSM-5 has 541.”

Given the arguments against normalcy driving the first half of the book, some readers may be surprised that Grinker accepts the sweeping changes, agreeing that there was “an actual increase in the incidence of mental illnesses and that the United States was becoming a sick society.” As he also uses DSM criteria to argue that “in any given [recent] year, nearly 20 percent of American adults—more than 60 million people meet the criteria for a mental illness,” it’s worth remembering that the DSM-III task force issued guidelines stating of the criteria they were meeting to approve, “A diagnosis should be made if the criteria for that diagnosis are met” (APA, 1974).

“Given all the variability across cultures and in the past,” Grinker concludes, “it would be foolish to assume that any current method of approaching mental illnesses is the best or only way.” Yet as diagnostic accuracy and effective treatment clearly matter, and how psychiatrists conceive of “mental illness” determines how they will try to treat it, it’s important to note that “there’s little evidence that ‘illness like any other’ models have ever succeeded in reducing stigma.” As a result, “we should resist the broken-brain model,” for it “remains wedded to the feckless, centuries-old struggle to disentangle disease and culture… It’s as simplistic, and dehumanizing, to reduce a person to his or her brain as it would be to reduce someone to their genes, ethnicity, religious, sex, or sexual orientation.”

In its rich cultural history of psychiatric practice and associated stigmas, Nobody’s Normal recovers the context and cultural values informing a sizable number of diagnosable conditions. None of the 541 disorders listed in DSM-5 arose in a vacuum. Each of them, Ruth Benedict warned in 1934, and Nobody's Normal reaffirms in 2021, began as “a variant of the concept of the good,” bound by untold layers of stigma and judgment.