I read recently that in the USA, 40,000,000 people from the current population of almost 320,000,000 are diagnosed as mentally ill. What’s more 30% of the population have seen or are currently seeing, mental health professionals or psychological therapists of one form or another. While Australians don’t seem to have the same appetites for therapists as Americans, I suspect our statistics would be less but still disturbingly high.
It is natural that we might wonder how this came to be.
It might be argued that it all started with Freud and his emphasis on the impact on our behaviour of the subconscious mind. But this was not strictly correct. As one of the founding fathers of psychology, William James, pointed out, Schopenhauer, Von Hartman, Binet and others had before Freud developed concepts of mind which included the “subconscious” and/or the “unconscious” which Freud was later to popularise. But it was Freud and then of course Jung, who argued that much of our behaviour is driven out of these elements of mind of which we, at best, have only vague awareness. They postulated that we were at the mercy of drives we didn’t even know we had! As Daniel Akst writes, “….. to the extent we came to believe our subconscious was in the driver’s seat, we lost faith in our own agency.”
Following Freud the role of the psychoanalyst came to be one of bringing to consciousness these forces of which we were previously unaware in order to bolster our “self-control”. The corollary of course is that the unanalysed masses will remain at the mercy of dreams, childhood traumas and potent drives that arise unbidden from the depths of our unconscious minds. To the extent that the behaviours of such people are fashioned in this way, then we of course can’t hold them responsible for such behaviour. And certainly, at least from a psychological viewpoint, victimhood which seems to permeate our modern society was born. Unacceptable behaviour could be explained away by the fact that the individual had an alcoholic father, was molested as a child, was deprived of mother’s love or whatever. I am not suggesting that these are trivial things – because they obviously are not. But for many, instead as Freud intended, the bringing into consciousness of this trauma is not seen as a step towards greater psychological competence but as an excuse for continued inappropriate behaviour.
Hence we seem to have got from Freud a much more nuanced view of transgression – one that takes account of various personal and social forces and is more likely to see “wrongdoing” as a manifestation of an illness.
As the American psychiatrist and bioethicist, Willard Gaylin has observed, “The extension of sociological and psychological exculpation will essentially prove self-defeating if it becomes all-inclusive. The law demands some acknowledgement of self-control.”
For Freud these were obviously unintentional outcomes. He believed in, and (apart from his addiction to cigars which apparently eventually led to his death by cancer) practised unusual self-discipline.
The goal for Freud in psychoanalysis was autonomy. In his words, “..to uncover repressions and replace them by acts of judgment.”
From the concept that aberrant behaviour is caused by a dysfunctional mind, the medical model of mental health developed. If a doctor prescribes a course of antibiotics to ward off an infection it seems only natural that a psychiatrist would prescribe selective serotonin uptake inhibitors (SSRI) or other such antidepressant to ward off depression.
One who has fought strenuously against the disease model of mental health is Thomas Szasz. He wrote, “While people behave in ways that are very disturbing, and that may resemble a disease process (pain, deterioration, response to various interventions) this does not mean they actually have disease.”
There is of course a natural variation in normal human behaviour. There is always an arbitrary line drawn between what is “normal” and “abnormal” behaviour. Some of those around us whose behaviours deviate somewhat from our own we are happy to label as quaint, individualistic or even eccentric. However once these behaviours become a little more extreme we tend to label them as mental illnesses.
A problem then that results from the disease model is defining the symptoms that would indicate the presence of such a “disease”.
As I have written previously, one of the more graphic illustrations of this phenomenon is Attention Deficit Disorder (ADD) in adults or Attention Deficit Hyperactive Disorder (ADHD) in children. So let’s look briefly at ADHD, according to the Australian Psychological Society if a child demonstrates the following symptoms for six months, then they should be diagnosed with ADHD:
- fidgeting with hands or feet, squirming in seat
- leaving seat when remaining sitting is expected
- running about or climbing excessively
- difficulty playing or engaging in leisure activities and often ‘on the go’
- talking excessively and blurting out answers before a question is completed
- interrupting others
At this stage, via this rather arbitrary classification process, the child passes from someone who has a behavioural problem that they should be encouraged to correct to a helpless victim of a disease which must under the medical paradigm of mental illness be treated by drugs. They and their parents are now relieved of any responsibility to “own” the problem and are encouraged to believe that the condition is a medical one and they can rely on their doctor to prescribe the right drugs which through addressing some supposed chemical imbalance will then lead them to adopt more acceptable behaviours! So now disorganised, compulsive people are caught up in the medical model and relieved of any personal responsibility for their behaviour.
Psychologist Rogers H Wright when writing about ADHD rightly points out:
“Certainly there are deficiencies of attention and hyperactivity, but such behavioural aberrancies are most often indicative of a transitory state or condition within the organism. They are not in and of themselves indicative of a ‘disorder’. Every parent has noticed, particularly younger children, that toward the end of a particularly exciting and fatiguing day children are literally ‘ricocheting off the walls’. Although this behaviour may in the broadest sense be classified as hyperactivity, it is generally pathognomic of nothing more than excessive fatigue for which the treatment of choice is a good night’s sleep. Distractibility (attention deficit) is a frequent concomitant of excessive fatigue, particularly with children under five years of age, and can even be seen in adults if fatigue levels are extreme or if stress is prolonged. However such ‘symptoms in these contexts do not rise to the level of treatable disorder.”
The point I am trying to make is that in an effort to destigmatise mental illness, we have created a plethora of diagnoses that are really just a description of aberrant behavioural patterns. The problem is exacerbated when some of these behaviours are somewhat ameliorated by psychotropic drugs.
To infantilise such people and deprive them of their need (and the right) to have a sense of responsibility for overcoming one’s problems, damages the self-respect that comes from self-responsibility and the importance of being confirmed as an autonomous entity.
Whilst those so anointed might get a sense of temporary relief, there is no enduring joy from victimhood. The role of the victim is generally accompanied by a sense of shame and powerlessness. That is why we must be careful in expressing our sympathy for those so afflicted to ensure we do not create a passive dependency.
In an essay titled “The Psychology of Victimhood”, the psychologist Ofer Zur concluded:
“Understanding types, origins and mode of operations of victims will allow therapists and non-therapists alike to recognise, prevent, and intervene in violent systems, enabling all participants to live better lives. For this to occur, victims must be helped to overcome their feelings of helplessness and low self-esteem. They must not focus on blame, and they must avoid moral self-righteousness. Victims have to believe that they have a say in what happens to them and learn to overcome their victim patterns. The healing process should empower them to become conscious contributors to the unfolding of their lives which can become dignified and meaningful.”
The famous American Psychiatrist Dr William Glasser, the founder of Reality Therapy, referring to the many patients he has dealt with that have no indication of brain pathology writes, “The most accurate way to describe these unhappy people is that, although they are not mentally ill, they are not nearly as mentally healthy as they would like to be.”. Whilst conceding that they may be benefited by counselling he continues, “I believe unhappy people can be taught to improve their own mental health…..”
Glasser believes that we fall into a trap when we try to draw parallels with physical and mental health. The problem is that we have been led to believe that only two states of health exist. We have come to believe we are either healthy or unhealthy. But this is demonstrably not true. The best way to describe physical health of the whole population, he suggests, he suggests is along a continuum:
Physically Ill——————-Out of Shape———————-Physically Healthy
Similarly, he suggests there is a mental health continuum:
Mentally Ill——————–Unhappy—————————Mentally Healthy
He asserts that, “The ‘mental illnesses’ that establishment psychiatrists diagnose, treat and list in DSM-IV (the then Diagnostic and Statistical Manual of the American Psychiatric Association) should not be labeled illnesses because none of them is associated with any brain pathology.” He maintains that these “illnesses” are the many ways in which unhappy people express their unhappiness. Comparing the two continuums above, the mental equivalent of being “out of shape” physically, is being “unhappy”. Most times when we become aware of being out of shape physically, we know what to do – most likely to pay attention to our diet and to exercise. When we become aware we are out of shape mentally we present to a doctor steeped in the medical model who will take over responsibility for our unhappiness and probably prescribe drugs.
Of course there are real and devastating mental illnesses, some of which are best treated by drugs. In this essay I am merely suggesting that we should think twice before we treat those with somewhat aberrant behaviour as mentally ill which often automatically confers victim status and pushes the sufferer into the medical model where they are more than likely to be prescribed drugs of dubious value. This concern is heightened by the fact that (as we saw above) diagnosing mental illness is a problematic and seemingly often almost an arbitrary process. [Many reputable psychologists and psychiatrists are chary of relying unduly for example on the current Diagnostic and Statistical Manual (DSM – 5) published by the American Psychiatric Association to aid diagnosis. I notice in the Weekend Australian of 18 May the Royal Australian and New Zealand College of Psychiatrists has also expressed its reservations about this diagnostic tool.]