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Reviews Exploring the intersection of autism and the arts.
Brains of many colors with people standing on them, coming out of the shadows
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Book Review: ‘Nobody’s Normal’ chronicles the intertwined history of mental illness and stigma

by  /  26 January 2021

Few scholars are better positioned to tackle the history of mental illness and the stigma we attach to it than Roy Richard Grinker. A cultural anthropologist and autism expert at George Washington University in Washington, D.C., Grinker studies how societies around the world view mental health and illness.

Grinker is also the scion of three generations of eminent psychiatrists and psychoanalysts, giving him a personal vantage point on more than a century of psychiatric thinking. And, as the father of a daughter with autism, he has observed close-up how the modern neurodiversity movement has loosened the grip of stigma.

In the introduction to his vividly told, richly researched new book “Nobody’s Normal: How Culture Created the Stigma of Mental Illness,” released today, Grinker recalls how his grandfather would regale him with stories about his experience as one of Sigmund Freud’s last patients. It was Freud’s wish, the older Grinker told his namesake grandson, that someday psychiatric conditions would be viewed “like the common cold, something everyone gets from time to time,” and that people “might eventually feel no shame in seeking psychological care for their problems.”

That same hope underlies Grinker’s book, which reveals how our very definitions of mental illnesses and our notions of ‘normality’ reek of cultural biases that stop many from seeking help.

Defining ‘normal’:

Grinker traces the ‘invention’ of mental illness and its constant companion, stigma, to economic forces set in motion in late 17th-century Europe by the industrial revolution and capitalism. With industrialization, people with intellectual disabilities, schizophrenia and other serious brain conditions were moved out of their homes and into asylums, along with criminals, debtors and addicts — basically anyone viewed as incapable of being a productive and self-sufficient worker.

Once institutionalized, people were sorted by their caretakers into categories: “idiotic” and “insane,” “probably curable” and “probably incurable,” and eventually more specific, medicalized terms. The words “normal” and “abnormal” were borrowed from mathematics and statistical averages.

As new categories of sickness and perceived deviance were added — mania, melancholia, dementia, masturbation (an actual diagnosis!) — the number of people consigned to asylums exploded in England and the United States. “Experts were at a loss to explain the apparent epidemic created by illnesses they themselves had invented and were now counting,”  Grinker wryly observes.

Among Grinker’s themes is the idea that wars bring greater knowledge of mental illness and sympathy for those affected by it, by showing that even the best and bravest among us can succumb. He notes that psychiatry’s bible, The Diagnostic and Statistical Manual of Mental Disorders (DSM), first published in 1952, was largely adapted from the U.S. Army’s classification of mental disorders.

In peacetime, though, the sympathy and knowledge tend to get lost, and stigma rebounds. Grinker describes how shell shock, defined during World War I, later became associated with cowardice, and how Vietnam War veterans with post-traumatic stress disorder (PTSD) came to be seen as volatile and dangerous.

If there is one silver lining to the never-ending wars in Afghanistan and Iraq, he writes, it is that “these wars have broken the cycle of building capacity for mental health care and then forgetting about all that was achieved.”

The first half of Grinker’s history is studded with odd, captivating facts: The Puritans did not allow their toddlers to crawl because crawling was seen as sub-human; in the late 1600s, nearly 1 percent of the population in Paris, France, was banished to an asylum; cornflakes were originally marketed as a way to deter masturbation; in the U.S., unsightly beggar ordinances, known as “ugly laws,” aimed to keep poor people with visible disabilities and disfigurements off the streets.

The author sometimes gets carried away with his own bold assertions, writing at one point about “the invention of the female, a category of person that didn’t exist before the late 1700s.” He may be referring to the social construct of femininity, but still, this is a little silly.

‘A little OCD’:

Grinker’s book comes alive when it deals with the modern era, where he can tap living memory. He covers big events such as the deinstitutionalization movement of the 1970s, which he details with statistics and a remarkable eye-witness account. Elsewhere he deploys observations from his own cross-cultural field work that illuminate the degree to which stigma and disability are social constructs.

He describes, for example, meeting the family of a nonverbal 9-year-old boy with all the classic traits of autism in a Namibian village of Ju/’hoansi hunter-gatherers. The boy’s father values his son’s talent for herding goats and finding lost items. Asked if he worries about who will care for the boy after he and his wife are gone, the father is genuinely perplexed. He gestures toward his neighbors and says, “We won’t all die at once.”

Stigma is also deeply embedded in language — a point Grinker demonstrates in myriad ways. In 2002, when psychiatrists in Japan decided to change the Japanese word for schizophrenia from a phrase that connoted a permanently ruptured mind to one that implies a treatable “integration disorder,” Grinker notes, it greatly raised public acceptance of the diagnosis. Similarly, PTSD became more acceptable in Nepal when portrayed as a problem of the “heart-mind” rather than the “brain-mind.”

In recent decades, neuroscientists have expressed the hope that uncovering the precise genes and biological mechanisms behind brain conditions such as autism and schizophrenia will make them more equivalent to, say, heart disease or diabetes, and therefore reduce stigma.

Grinker disagrees. He notes that in some parts of the world a genetic basis becomes even more stigmatizing, as it casts doubt on bloodlines. And he believes that mental illness can never be entirely reduced to biology. As with hypertension, osteoporosis, hypercholesterolemia, obesity and many other conditions, the line between healthy and not healthy is constructed, or, as he puts it, “drawn more by culture than by nature.”

Grinker applauds the reconception of neuropsychiatric conditions as continuums or spectrums, as depicted in the current edition of the DSM. To Grinker, it is a sign of progress and shrinking stigma when neatniks refer to themselves as “a little OCD,” in reference to obsessive-compulsive disorder, or nerdy types say that they are “on the spectrum.” Such phrases demonstrate how the stigma attached to these conditions has ebbed, and they bring us closer to Freud’s vision of mental illness as something we are all prone to, one way or another.