Mental health labels move with the times
Is the world becoming more mentally ill, or are we just becoming more effective at labelling conditions? The University of Auckland's Dr Bruce Cohen considers the state of mental health
As shocking as it is fascinating, few would disagree we are facing a global epidemic of mental disease. That’s what the statistics tell us: 450 million people currently affected globally with such a condition - that's one in four the UK and the US. This situation is increasing year on year. In the US, the number of adults with a debilitating mental illness has risen six-fold in the past 50 years. In that time, the number of identified psychiatric disorders has more than tripled, from 106 to 374.
Closer to home, and according to the Ministry of Health’s Mental Health Survey, it is predicted that 47 percent of New Zealanders will suffer from a mental illness at some point in their life and that 40 percent have already been affected. It is estimated that 21 percent have experienced a mental illness in the last 12 months, with 12 percent affected in the past month.
So is the world becoming madder? Many of the current explanations offered by mental health professionals, social epidemiologists, health scientists, neurobiologists and anthropologists claim it is. Yet my research suggests we may be looking for the answer in the wrong place. No one wants to talk about the elephant in the room which is the on-going problem in identifying what mental illness actually is. Even the latest edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders reflects this issue.
This book is the most important medical manual on mental disease produced today. It is meant to tell us what mental illness is, what causes it, what forms it can take, and how it can be treated. However, the committee responsible for producing this latest edition came to the disturbing conclusion that, firstly, the cause of mental disorder remains unknown (for example, there is no useful biological marker or genetic test that has yet been identified) and, secondly, that psychiatrists cannot distinguish between mentally healthy and mentally sick people, meaning that mental health professionals have so far failed to define their own area of expertise in any scientifically rigorous manner. And of course, without an accurate identification of disease, a medical discipline cannot claim proof of causation or evidence of successful treatment, and they certainly cannot predict future cases of that disease.
Psychiatry reflects dominant norms and values of our society, and this is reflected in mental illness classifications.
My recent book, Psychiatric Hegemony: A Marxist Theory of Mental Illness, outlines this evidence in detail. It is part of my ongoing research into the historical and contemporary production and proliferation of mental illness diagnoses, treatment options, and professional practices. The logic for my research focus is pretty obvious – we have witnessed an incredible increase in the classification of people with a disease that has not yet been adequately defined. This leads us to question which political, social, economic, and cultural forces have made this so, and who benefits from the medicalisation of human behaviour. Frankly, it should be the duty of all scientists within mental health that, in good conscience and putting the needs of the public first, they ask themselves these crucial questions.
The first stage of my research has been to survey the history of categories used for diagnosis by the psychiatric profession and identify any patterns which brought them into being, or accounted for their disappearance from mental health work. My results illustrate how mental illness diagnoses changed over the 19th and 20th centuries to meet the norms and values of society at those times.
For example, the diagnosis of ‘masturbatory insanity’ was a popular classification among the psychiatrists of Victorian Britain, a society in which masturbation was associated with idleness, particularly among working class men.
Castration was one suggested ‘cure’ for such an affliction.
In contrast, the diagnosis of ‘hysteria’ was most commonly applied to women, particularly those considered to have sympathies with the suffrage movement at the end of 19th century. Psychiatrists considered women to be prisoners of their biology; if they ventured beyond the domestic sphere and followed ‘unfeminine pursuits’ such as education or employment, they were considered as vulnerable to hysteria. You may be surprised to know, the diagnosis has not disappeared from psychiatric work and actually remains in the DSM as ‘histrionic personality disorder’.
Contrary to appearances, there is no evidence of a world getting madder. Instead, there is a more effective system of mental illness labelling which has aided expansion beyond the asylum and been a great success for those associated with the ‘business of mental health’, including pharmaceutical companies, psychiatric professionals, insurance companies and therapeutic enterprises.
It’s clear to me that psychiatric classifications reflect conservative morality and serve political purpose by providing a way to manage deviant populations in society. This is most obviously illustrated by the fact that the DSM classified homosexuality as a mental illness until 1973.
The fact is, psychiatry reflects dominant norms and values of our society, and this is reflected in mental illness classifications. What we are seeing over time in the DSM is a growing use of terms associated with work, school and the home, and phrasings that emphasise productivity (in this case the problems associated with being unproductive). These diagnoses speak more specifically to our problems of living in neoliberal society – for example, the symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) – such as forgetting or losing homework, failing to complete assigned tasks in the workplace, poor time-management, and so on – clearly denote the requirements for more productive and efficient students and workers.
So contrary to appearances, there is no evidence of a world getting madder. Instead, there is a more effective system of mental illness labelling which has aided expansion beyond the asylum and been a great success for those associated with the ‘business of mental health’, including pharmaceutical companies, psychiatric professionals, insurance companies and therapeutic enterprises.
I now plan to work with mental health professionals to understand how they justify their practices and rationalise their work. This is crucial to make sense of how the credibility of this phantom global epidemic is maintained on a day-to-day level.
* Dr Cohen’s books include Mental Health User Narratives: New Perspectives on Illness and Recovery, Being Cultural and the Routledge International Handbook of Critical Mental Health.