Abolishing the Concept of Mental Illness

Rethinking the Nature of Our Woes

Richard Hallam

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9781351664769
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

In Abolishing the Concept of Mental Illness: Rethinking the Nature of Our Woes, Richard Hallam takes aim at the very concept of mental illness, and explores new ways of thinking about and responding to psychological distress.

Though the concept of mental illness has infiltrated everyday language, academic research, and public policy-making, there is very little evidence that woes are caused by somatic dysfunction. This timely book rebuts arguments put forward to defend the illness myth and traces historical sources of the mind/body debate. The author presents a balanced overview of the past utility and current disadvantages of employing a medical illness metaphor against the backdrop of current UK clinical practice.

Insightful and easy to read, Abolishing the Concept of Mental Illness will appeal to all professionals and academics working in clinical psychology, as well as psychotherapists and other mental health practitioners.

1
INTRODUCING THE ISSUES

Absurd! How can you abolish mental illness? I used to have a mental health problem myself. My great-uncle spent years in an asylum and he was definitely insane!

The title of this book invites the reader to question the meaning of words in common use and to imagine a future in which we stop referring to mental illness. We have given up thinking about people as being ‘possessed by the devil’. Perhaps it is time to think differently about how to describe and explain the causes of our woes. At present, we seem content to leave it to experts to declare whether or not we are ‘mentally healthy’. The bleak terminology of mental disease or illness is reserved for rather obvious departures from ‘mental health’, but the idea of pathology is still present in watered-down terms such as ‘psychological disorder’ or ‘mental health issue’. Mental health professionals may rely on little more than answers to a questionnaire measuring ‘psychological symptoms’ to justify giving out a diagnostic label. If a problem seems to be a ‘serious’ one, a person’s suffering or difficulties will be matched against criteria set out in manuals for diagnosing ‘psychiatric illness’.

The idea that the ability to live well has something to do with health and illness has infiltrated our social institutions to a remarkable degree. We have been invited to suppose that ‘mental illness’ is illness, in other words, like a physical illness, something that we either have or don’t have. Mental ill-health encompasses a huge range of undesirable states of being, personal failings, and unacceptable behaviours. I will refer to them using the generic word ‘woes’, without assuming that the latter share anything in common with respect to their causes or how the woeful person experiences them. Rather than adopt the phrase ‘a problem in living’, which implies a problem for a particular person, I have chosen the word ‘woe’ to refer to a state of affairs that is social as well as personal. In its archaic use, a woe was a lament about being afflicted, wretched, or mournful. The thesis of this book is that woes have been medicalised, and recommends that we abandon the concept of mental illness, and imagine a future without it.

This thesis is easily stated but immediately stirs up many questions. In this chapter, I set out the principal issues covered in the rest of the book. It needs to be said straight away that, more than fifty years ago, the psychiatrist Thomas Szasz declared that mental illness is a myth (Szasz, 2010 [1961]). I have therefore devoted a chapter to an analysis of his ideas and the arguments that critics have put forward to rebut them. The opposition Szasz encountered did not simply amount to a spat amongst academics and professionals. The debate about mental illness as a myth goes much deeper than this because a connection between health, illness, and woes has existed in ordinary speech for millennia. Although the concept of mental illness is ancient, it competed with beliefs in divine intervention, witchcraft, and sorcery, which have now largely disappeared in Western societies. The phrase ‘mental illness’ is now so commonplace that it is assumed to describe a literal state of affairs rather than constituting an explanation. In brief, it attributes a woe to something amiss in the mind or body of a woeful person. In Chapter 3, I explore the historical origins of this myth.

What, then, does it mean to locate the cause of a person’s woe in their dysfunctional mind or body? Definitions of disease and illness are controversial, and so this question is not easily answered. However, few people seem to dispute the idea that ‘mental illness’ is a matter of ‘health’. Governments see it as one of their duties to look after the health and welfare of their citizens, and the conceptualisation of woes as illnesses has been accepted across all strands of political opinion. Provisions for ‘mental illness’ form part of services for physical health and social welfare. I will argue that the concept of mental illness is an example of the medicalisation of woes, and that this has led to mystification about causation, misdirection of efforts, and, on occasions, has usurped human rights. The final chapter of the book critically evaluates the role played by a concept of mental illness in policy documents published recently in the UK.

Mental illness as myth

Thomas Szasz’s belief that mental illness is a myth was vigorously contested. He restated his position shortly before he died (Szasz, 2011) and this invoked a scornful commentary (Shorter, 2011), illustrating how little influence Szasz exerted in some quarters of psychiatry. Shorter dismisses the ‘weasel word’ disorder and places his money on disease. Other experts also express themselves in the uncompromising language of disease. Morgan (2016) states that ‘depression is a common and crippling disease’, even though he accepts that it ‘may be a response to bereavement or other life events’.

Szasz’s thesis has been rejected for various reasons. One argument is that mental illness has always been with us, and that we can clearly trace its presence in ancient literature. Another is that no meaningful distinction can be made between diseases of the mind and body, and that the criteria for declaring someone physically ill are essentially the same as ones that define mental illness. Other critics believe that the causes of problematic behaviour must lie in defective genes or diseases of the brain, even though we have not yet discovered them. It is assumed that once we understand the neural basis of mental functions, we will be in a position to define and explain mental illnesses.

None of these objections to Szasz question the concept of mental illness itself. It is as if our woes and suffering must be illnesses because there is nothing else they could be. The idea is so firmly lodged in our way of thinking that to challenge it seems childishly provocative.

Belief in the mythical status of mental illness is quite compatible with an assumption that there is a biological basis to all behaviour and so, in principle, it is possible to reduce all explanations to bodily processes. However, in order to establish solid grounds for describing woes as illness, it needs to be demonstrated that bodily functions deviate (i.e. function differently) when they serve ‘normal’ and ‘distressing or problematic’ behaviour. In medical practice, various biomarkers, such as high blood pressure, are used to indicate a state of ill-health of the body. By contrast, there are almost no biomarkers for ‘mental illness’. Behaviour that deviates from the norm in a problematic way may be just that – behaviour that is distressing to self or offends others.

It is possible to maintain that mental illness is a myth without denying the existence of a very complex relationship between a person’s biological characteristics and their problematic behaviour. In certain cases, it is incontrovertible that problematic behaviour can be attributed to demonstrable bodily dysfunction. Szasz accepted this but drew too sharp a distinction between what he called neurological illness and problems in living. The main reason for arguing that mental illness is a myth is that in the vast majority of these so-called illnesses, the hypothesis of a dysfunction of body or mind lacks supporting evidence. Without this support, there are few grounds for suggesting that the best way to deal with a woe is an intervention directed towards altering the state of the body through medication or other physical interventions. Similarly, when therapy addresses the mind, there is no reason to suppose that this is treatment for an illness or disease of the brain.

There are, of course, differences in bodily functioning between woeful and non-woeful persons, but this is not sufficient to validate a concept of mental illness. Any difference could be an effect of environment or behaviour – that is, what people do, have done, or what they have been, or are, exposed to. They might also indicate a biological predisposition to behave in a certain way. This type of biological diversity is not necessarily a sign of illness or disease. Although a person might be biologically predisposed to exhibit problematic behaviour, a predisposition is not a bodily dysfunction. It is quite likely that the same predisposition could be found in persons who are not in a woeful state. With respect to the category of woes called ‘common mental disorders’, the evidence that these are expressions of any kind of dysfunction or distinctive biological characteristic is slight or non-existent.

The concept of ‘psychopathology’ is another expression of the illness myth. It leads us to believe that we should search in the brain or mind for the causes of our woes. It stems from an assumption that ‘the mind’ is simply a way of describing what the brain does (Hallam, 2012). In fact, there is no widespread agreement on what a ‘normal brain’ looks like, nor, conversely, a pathological one. It is much easier to describe a pathological liver. So-called neural dysfunctions are often inferred from the social and behavioural effects of an alleged pathology, whatever the brain happens to reveal under empirical examination. It seems that all too often the brain is viewed as a stand-alone organ of the body without regard to its plasticity in changed conditions or its relationship to higher-order processes relating to concepts of person, self, and society. In Chapter 4, I review some biomedical hypotheses used to explain severely depressed mood and consider alternative interpretations of the evidence.

The myth in action

Let us imagine an example of so-called mental illness. A man has made a series of poor career choices, is currently being subjected to bullying by his employer, and all of this has led to a period of low mood, lethargy, spells of crying, and a sense that life no longer has any meaning. Nothing seems to be achieved by calling this episode in his life an illness. The events I have described are not uncommon and the reader might counter with the argument that what I am describing is not an example of a ‘real’ or ‘serious’ mental illness. However, whether mild or serious, circumstances like these are often said to result in illness. Everyday conversation abounds with references to ‘mental health problems’ and ‘disorders’ (e.g. ‘depressive illness’, ‘eating disorder’, ‘obsessive-compulsive disorder’). But what has any of this to do with ‘health’, which we normally understand to be a medical matter? We may suffer ‘bouts’ of physical illness, but to refer to bouts of depressed mood suggests that something has overwhelmed us for no apparent reason. We ‘suffer’ from a physical illness because there is often little to be done except retire to bed. A feeling of depression may descend suddenly but it is not imposed like influenza, as a sequence of events that can be given a medical explanation. If our fictional person overcame his depressed mood, would we want to say that he had recovered from an illness? Perhaps he was successful at an employment tribunal, changed his job, moved to a new area, or made new friends. His circumstances changed and he felt optimistic again.

In recommending abolition of the concept of mental illness, I am arguing for a change in the way we describe and explain woes. There are, of course, a multitude of ways in which a person’s life can be sent off course and disturb self or others. The reference point for a woe should be well-being rather than health; in other words, a woe hinders the possibility of pursuing a worthwhile life. Woes can, of course, take on a highly idiosyncratic nature, and also reflect unusual beliefs or the influence of destructive relationships. Woes can have complex causes that are not easily put into words. It is not surprising that over the course of human history people have turned to metaphor. Metaphor allows us to express complex intuitions by drawing on common experiences that we understand through direct involvement with the world. Few of us are now farmers but most of our ancestors worked in agriculture. That world has furnished us with a wealth of words and phrases that are still in common use. A person may ‘plough their own furrow’ in life. Projects ‘bear fruit’. Investments are ‘harvested’. Illness, in the form that debilitates the body, is something that everyone encounters directly, and when used metaphorically it captures some of the essential features of a woe. If a woe feels like an illness, it is not a bad metaphor. It might convey the sense that the woe is imposed, that it is unfair, and that there is very little one can do about it.

Metaphors should not be taken literally. Financiers do not harvest their investments with a sickle. However, if a woe feels like an illness, it is not surprising that people might look for a credible bodily explanation. When in doubt about the cause of feeling ill, we seek out an expert with relevant training who can identify a cause and offer a remedy. Many woes have effects on the functioning of the body but we do not have to assume an underlying pathological cause. The lethargy of depressed mood need not be attributed to a bodily illness even though it is a bodily experience. The remedies we seek for our woes normally match our suspicion about likely causes. Anyone with a chest pain might wonder whether to consult a cardiologist or an expert in psychological stress.

To assert that mental illness is a myth is to say that illness is a mistaken way of explaining woes. It is as spurious as supposing that a woe has been caused by giving offence to a god or being under the influence of a spell cast by a sorcerer. In practice, in face-to-face dealings between service-users and professionals in the mental health system, the question of diagnosing an illness rarely comes up unless this is required for bureaucratic purposes or it seems necessary to disabuse a person of false information. People usually relate to their woe with the aim of finding a solution to a problem, not to discover their diagnosis. After decades of research into pathological causes of so-called mental illnesses, it must be concluded that this line of investigation has come up with very little. It is time to accept that woes presently called illnesses can have a multitude of causes that lie outside the body. It may not require anyone who is trained in medicine, psychology, or neuroscience to resolve them. In future, we may be able to dispense with the services of a large number of mental health professionals, just as we no longer need experts in casting out spells.

This apparently radical position concurs with the views of people who have been diagnosed as mentally ill. In a recent survey of the attitudes of users or ex-users of the UK mental health service, there was general agreement that a medical model based on deficits and pathology was damaging and unhelpful (Beresford et al., 2016). As the authors state: ‘It was clear that language and meaning were very important to people, highly contentious, and that there was no consensus’ (ibid.: 24). Participants were not sure that they wanted to be seen as impaired, disabled, or mad. Rather than tackle stigma, users were more inclined to advocate the removal of unhelpful diagnoses. A lack of consensus amongst service-users is entirely unsurprising if mental illness is a myth.

Abolition of the concept of mental illness has to be seen in the context of how society conceives of ‘health’ and what this means in political terms. Definitions of woes as illness also implicate the medical profession and the legitimate scope of its expertise.

Health as a political concept

There are two distinct everyday meanings given to health in most dictionaries, namely ‘freedom from illness or injury’ and ‘soundness and vigour’. Freedom from illness can be interpreted in two ways. In one sense of illness, a person’s health is degraded in a rather obvious way. One feels unwell. In another sense of illness, a medical diagnostic test proves that one is ‘ill’ or ‘not ill’ regardless of how one feels. A suspected disorder of bodily dysfunction has been assessed and a verdict given. The second common meaning of health, ‘soundness and vigour’, is a different sense of feeling well or unwell, and it is compatible with either the presence or absence of a diagnosed dysfunction. A person can feel ‘sound and vigorous’ without giving any thought to an empirical assessment of their bodily functions. It is simply a state of well-being. Given these nuances of meaning, health, as a political concept, can signify in a variety of ways. For this reason, it seems inadvisable to propose a definition of health that manages to encompass all of these meanings within one concept.

Nevertheless, since 1948, the World Health Organization (WHO) has adopted an all-encompassing definition. It defines health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (WHO, 2017). The clear implication is that disease can degrade health but its absence does not define it. However, by equating health with well-being, the WHO definition opens up the possibility of describing a lack of well-being as a state of ill-health (i.e. illness or disease). In order to be true to distinctions made colloquially, and to clarify what mental illness might mean, it is desirable to put some kind of boundary around a concept of illness/disease.

The WHO definition of mental health does not mention either illness or disease:

Mental health is defined as a state of well-being in which every i...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• 1 Introducing the issues
• 2 Thomas Szasz and the myth of mental illness
• 3 ‘Mental’ and ‘bodily’ causes of woes: a brief history
• 4 ‘Major depression’: the creation of a mythical disease
• 5 Agency, rationality, and the concept of mental illness
• 6 Medicalisation: resistance or replacement?
• 7 Well-being and mental health
• 8 A future without the concept of mental illness
• Index