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In Nobody’s Normal: How Culture Created the Stigma of Mental Illness, anthropologist Roy Richard Grinker calls on our society to embrace neurodiversity — and makes a convincing argument that capitalism is ultimately responsible for the prejudice long suffered by the mentally ill.

In these challenging times, it is a pleasure to read a book that appeals to our common humanity and urges us to accept people profoundly different from ourselves. That is especially so when this message is delivered with the sensitivity, thoughtfulness and intelligence of Nobody’s Normal: How Culture Created the Stigma of Mental Illness. In this remarkable pastiche of history, cross-cultural analysis, and family memoir, author Roy Richard Grinker explores the development of the construct of mental illness and the prejudice directed against those categorized as mentally ill.

The book tracks the history of these twinned phenomena—mental illness and its associated stigma–from their emergence under the capitalistic pressures of the Industrial Revolution through the rapid rise in the nineteenth century of asylums specifically for the category of people designated “insane.” He documents how the wars of the last century, and their devastating psychological impacts on combatants, helped temporarily reduce the stigma of mental illness—and how societal empathy always waned after the fighting ended. Finally, he explores what he calls the trend toward “medicalization” of mental illness, in which the focus is on “technical or scientific solutions to our problems” rather than the social origins of disease and stigma.

Grinker is a professor of anthropology at George Washington University. His great-grandfather Julius (“by all accounts unlikable”) was a leading neurologist. His grandfather and father were well-known psychiatrists; his grandfather, in fact, underwent analysis with Sigmund Freud in the early 1930s in Vienna. One of his daughters, Isabel, has autism spectrum disorder. Grinker sprinkles stories involving these family members into the account, which provides a personal lens into his passion for the issues—and in particular the need for society to reject the stigma conferred by a diagnosis of mental illness. The book also functions as an illuminating history of the field of psychiatry, which evolved in the nineteenth century as the profession specializing in the study of what were increasingly viewed as illnesses of the mind.

Norton

The book is studded with fascinating historical and anthropological nuggets that keep the narrative humming. I had no idea, for example, that the inventors of corn flakes, the Kellogg brothers, believed this bland concoction of toasted grain chips would help reduce the urge to masturbate. The same was also the case for graham crackers, invented by the nineteenth century Presbyterian minister Sylvester Graham to help prevent what he called “sexual solitaire.” In both cases, sugar was not originally included — blandness was the point.

Grinker opens with vignettes of cultural contexts offering unique perspectives on human differences. While visiting hunter-gatherers in Namibia’s Kalahari Desert in 2017, for example, he encountered a non-verbal nine-year-old who would likely be diagnosed as autistic by Western clinicians. But far from viewing the boy’s condition with despair, his father praised him for having “a great memory” and for being  an excellent shepherd of the tribe’s wandering goats — valuable assets in hunter-gathering communities.

Grinker also recounts how the isolation and inbreeding among early colonists on Martha’s Vineyard led to the spread of a genetic mutation that caused deafness. By the late nineteenth century, a quarter of the residents were partially or fully deaf. All islanders, whether hearing or not, learned to communicate through a unique, home-grown sign language. No one on the island stigmatized “deafness” or considered it strange or disabling—it was just a fact of life.

Grinker also recounts how the isolation and inbreeding among early colonists on Martha’s Vineyard led to the spread of a genetic mutation that caused deafness. By the late nineteenth century, a quarter of the residents were partially or fully deaf. All islanders, whether hearing or not, learned to communicate through a unique, home-grown sign language. No one on the island stigmatized “deafness” or considered it strange or disabling—it was just a fact of life.

“Because people who could not hear were fully integrated into their communities and were able to communicate with everyone, we could even say that no one was really ‘deaf’ on Martha’s Vineyard,” writes Grinker. Both diagnosis and stigma, he reminds us, are contingent on the cultural and social context.

These accounts set the stage for Grinker’s argument that the modern understanding of mental illness emerged out of capitalism—more specifically, out of the economic imperatives that transformed the labor force during the Industrial Revolution. In prior centuries, per this telling, physically and mentally disabled family members were generally cared for at home and were often able to contribute to household production despite their limitations. (Grinker notes that their living conditions were not always good – some were kept in chains – but they were still considered part of the community.)  Those who could not be accommodated were often imprisoned indiscriminately with criminals, beggars and other social undesirables.

“Before the turn of the nineteenth century, there was no distinct category of ‘mental illnesses’ and no distinct disciplines of psychology or psychiatry,” he writes. “Nor were there insane asylums, just general asylums for the lawless and unproductive.”

As production shifted from home to factories, Grinker writes, the expanding need for individual  workers created a growing underclass of people unable to conform to market demands, including many poor families that had formerly eked out a living on the land. As these outcasts were increasingly perceived as belonging to different sub-groups, institutions designated specifically for those deemed “insane” cropped up to separate them from criminals and the bankrupt. With the advent of these insane asylums, the inmates became an object of medical study—and experimentation–and an early taxonomy of mental illness emerged. “In the context of the asylum, ‘insanity’ gradually took shape as a distinct label and a stigma—an actual and deplorable social identity apart from other kinds of difference,” writes Grinker. “The profession of psychiatry also slowly emerged, along with insanity, melancholia, and a small number of other labels.”

In an intriguing analysis, Grinker documents the role of the two world wars in expanding the reach of the psychiatric field, given the enormity of the emotional and psychological toll on soldiers. The Diagnostic and Statistical Manual of Mental Illnesses, the comprehensive compendium of psychiatric diagnosis, grew out of a guide to mental illness developed by the military during World War II. “The military was indirectly teaching civilian society that mental illnesses included a wide range of symptoms that could afflict even the best man when faced with difficult circumstances,” he writes. “Indeed, the stigma of mental illness tends to lessen during wars and return during peacetime.”

Roy Richard Grinker (Credit: Tim Coburn)

Grinker is acutely aware of the medical profession’s historic tradition of using claims of mental illness as a weapon of social control. He cites, for example, the diagnosis of drapetomania, applied in the 1850s to slaves who wanted to run away from their masters. He recounts his own father’s dismissive beliefs about homosexuals, which were typical of that generation of psychiatrists–that most gay men had strong mothers and weak fathers, “would be happier if they were heterosexual,” and were of course unfit to be psychiatrists themselves. In fact, these views disturbed Olivia, another of Grinker’s daughters, who interviewed her grandfather about the subject for a gay history class in college and wrote a paper challenging his views.

Despite this appreciation of some of psychiatry’s questionable claims, Grinker accepts the field’s perspective that bodily complaints resisting easy or standard diagnosis—so-called “medically unexplained symptoms”—should be considered examples of psychogenesis. In other words, emotional or psychological distress is presumed to be causing the physical dysfunctions.

“Who knows how many people who suffer from physical ailments could benefit from mental health care and yet do not seek treatment because they are convinced that bodily symptoms are unrelated to the mind, and also because physical illnesses are more socially acceptable while mental illnesses are stigmatized,” writes Grinker, adding later on the same page, “Uncontrollable movements, nonepileptic seizures, impairments like partial blindness, mutism, and paralysis, skin rashes, diarrhea, and chronic pain can all be psychiatric symptoms.”

Whatever the extent to which skin rashes and paralysis can be psychiatric symptoms, they can also be signs of serious organic disease. Psychiatry has a long, sorry history of gaslighting patients by attributing somatic symptoms and signs to anxiety, depression, or any number of related mental disorders; asthma and peptic ulcers are just two major ailments formerly consigned to the psychosomatic category. When patients resist such explanations, it is not necessarily because they are biased against mental illness, as Grinker suggests. They could be objecting because they believe—reasonably–that doctors are misdiagnosing a medical issue as a psychiatric problem. That reality is the flip side of this issue, but the book does not address it.

To take one example, Grinker describes the emergence of the diagnosis of “shell shock” during World War I as largely a way for soldiers to channel their psychological trauma into physical symptoms that garnered sympathy rather than stigma—a form of what today we would probably call “post-traumatic stress disorder.” But this discounts the possibility or likelihood that many shell-shock victims were suffering from brain injuries sustained under prolonged bombardment during trench warfare but not visible upon physical examination 100 years ago, as a 2015 Johns Hopkins study of veterans’ brains suggested.

Grinker bolsters the argument by noting that men who were not near the fighting also began reporting symptoms characteristic of shell shock. It is not surprising that some people far from the danger zones might have experienced or reported such symptoms for any number of psychological or psychiatric reasons. But that doesn’t justify the broad and indiscriminate attribution of shell shock among actual combatants to emotional rather than to physical trauma, or at least to a combination of the two.

But never mind that. Nobody’s Normal remains an absorbing read. The book’s animating theme–that normality is a social convention used to oppress those who do not conform to community standards and ideals—is an important message for all of us. Grinker finds special hope in the recent successes of the neurodiversity movement, which has helped reframe autism spectrum disorder and related conditions as simply a matter of human difference. That shift has made life more hospitable for people like Grinker’s daughter, Isabel. In a touching and powerful scene near the end the book, Isabel gives a talk at her high school graduation, identifies herself as autistic, and receives a standing ovation.

“It’s about time we recognize that normal is a damaging illusion,” writes Grinker. In Nobody’s Normal, he makes a compelling case.

David Tuller

David Tuller, DrPH, is a senior fellow in public health and journalism at UC Berkeley’s Center for Global Public Health, part of the School of Public Health. He received a masters degree in public health...