The ‘myth’ of mental illness?

The assumption that mental disorders are medical conditions is challenged by Thomas Szasz's famous assertion that ‘mental illness is a myth’ (Szasz Reference Szasz1960). Szasz insisted that ‘disease’ and illness are the consequence of a bodily biological dysfunction: ‘pathology’. From this position it is misleading to extend the use of ‘illness’ to situations that are characterised by patterns of personal conduct rather than by evidence of physical pathology. He argued that ‘mental illnesses’ are properties of human beings, not of biological systems. It is whole human beings who think, speak and act, and as humans are social creatures, behavioural abnormalities considered evidence of mental illness are identified by reference to social norms. Furthermore, defining unwelcome behaviour as a ‘mental illness’ amounts to a social interaction, not something wholly explained by reference to a single individual.

Much has been invested in a search for biological evidence that would allow mental disorders to be considered ‘true’ diseases by this logic. Szasz's response was always that, were this to be successful, the result would be a category shift whereby the condition would cease to be considered a ‘mental illness’ and become a ‘neurological’ one instead. Despite decades of intensive research, there is still no conclusive evidence that enables any of the major categories of mental disorder, including schizophrenia, depression, anxiety and attention-deficit hyperactivity disorder (ADHD), to be considered a neurological condition in this way (Joseph Reference Joseph2003; Sullivan Reference Sullivan, Kendler and Neale2003; Moncrieff Reference Moncrieff2008; Leo Reference Leo, Cohen, Timimi and Leo2009; Moncrieff Reference Moncrieff2013; Ripke Reference Ripke, Neale and Corvin2014). The fact that there are some subtle group differences between people with some diagnoses and ‘normal controls’ in aspects of brain structure or function does not demonstrate the presence of a neurological disease. None of the findings are sufficiently specific or capable of differentiating between a person who is thought to have a particular mental disorder and one who is not. Diagnosis is still made on the basis of behaviour, thoughts and feelings that are reported by the individual or those around them and that depend, of course, on judgements about what is ‘normal’ and what is not. Moreover, the variations in brain structure or function that are detected, are most likely attributable to other differences between people who are labelled with psychiatric disorders and those who are identified as ‘controls’: differences in life experiences, social class, IQ and the use of psychiatric medication (Ho Reference Ho, Andreasen and Ziebell2011; Kendler Reference Kendler, Ohlsson and Sundquist2015).

Szasz lived long enough to defend his thesis in person for more than half a century. Criticisms of it include the view that, although mental illness is not adequately understood in biological terms, a distinction between mental and physical illness is too categorical. Some critical psychiatrists have expressed this view: that the assignation of all illness and disease reflects a negative evaluation, and mental and physical suffering cannot be wholly disentangled (Bracken Reference Bracken and Thomas2007). Others suggest that Szasz was right to highlight how concepts of disease and illness are fundamentally biological and are different from the situations we regard as constituting mental disorder (Moncrieff Reference Moncrieff and Schaler2017). Yet others argue that use of terms such as ‘pathology’, ‘disease’ and ‘illness’ is at root a semantic choice reflecting common usage. Their use by psychiatrists is determined by wider social forces which favour the identification of mental disorders with medical problems in order to facilitate a number of otherwise difficult social or political problems (Scheff Reference Scheff1999; Middleton Reference Middleton2015).

Although Szasz's ideas have not been widely embraced by psychiatry and are variously interpreted, they do open debate about the consequences of viewing mental health difficulties through the same conceptual and institutional lens as physical illness. Viewing conditions as illnesses or diseases sets them in a particular social context, where certain professions have jurisdiction and certain arrangements (in this case the sick role and its entitlements) automatically apply. It also facilitates mental health legislation, though not necessarily in the most fair or transparent manner (see below).

Psychiatry's knowledge base

The link between psychiatry and medicine confers legitimacy on psychiatry as a professional enterprise because its practitioners are seen to hold and exploit expert medical knowledge. Medical knowledge is identified with the scientific approach that was developed to study the natural world; systematically investigating assumed-to-be immutable truths by measurement and manipulation of particular elements in a controlled environment. The application of this form of knowledge-seeking to the world of human affairs is referred to as ‘positivism’, an approach that has been criticised for oversimplifying human affairs. Earlier scholars distinguished between Geisteswissenschaften, human or moral sciences, and Naturwissenschaften, natural sciences. The distinction remains a core feature of social science, where it is argued that the study of human beings is irreducibly different from the study of the natural world. Human behaviour is intentional, interactive and inextricable from its social setting. It has meaning, rather than causes, that can only be discerned by reference to its context.

Therefore, if mental disorders are to be understood as human reactions rather than as physical diseases, a positivist perspective cannot provide adequate or comprehensive knowledge. Different approaches are needed that can study social phenomena appropriately.

Hermeneutics is one such alternative. A hermeneutic approach emphasises how mental disorder should be regarded not as intrinsically meaningless phenomena that arise as a result of an underlying morbid process but as meaningful responses to individuals' life histories and particular social, cultural and familial contexts (Bracken Reference Bracken and Thomas2007). In this way mental disorder is not fundamentally different from all human thought and behaviour. This view was embraced by the leading mid-20th-century American psychiatrist Adolf Meyer, who argued that mental disorders can be seen as meaningful, if misguided, reactions to real-life challenges. His thought prefigured later thinkers such as R. D. Laing, and similar ideas inspired clinical innovations, including therapeutic communities. Recent therapeutic movements such as open dialogue also embrace hermeneutic principles.

Social constructivism presents another challenge to positivism by emphasising the social nature of cognition and knowledge. Knowledge is the product of interactions among members of groups or societies and expressed in ways that are particular to that group or culture. Social construction also emphasises the role of language in expressing locally accepted ideas and values. Examples from psychiatry include cross-cultural research exploring variations between cultures in the way that mental distress is expressed, and analyses of how diagnoses evolve over time. Two examples are outlined in Box 2.

From this perspective people come to define their own or others' behaviours and experiences through the discourse that is prevalent within a particular culture. Feelings of distress can be perceived as depression, anxiety, bipolar disorder or neurasthenia, depending on the cultural availability and promotion of different concepts. These concepts are, in turn, shaped by social and cultural developments, including the expansion of Western medicine and pharmaceutical marketing.

In other work, philosopher Jeff Coulter describes the social construction of concepts relating to more severe mental disorder. According to Coulter, communities designate certain patterns of behaviour that infringe rules of conduct and social expectations as ‘mental illness’. He argues that it is this social process that defines situations as requiring official, psychiatric attention, rather than professionally constructed categorisations or ‘diagnoses’, and he highlights how this process contrasts with the process of diagnosis in physical medicine (Coulter Reference Coulter1979).

Psychiatry as a social institution

Historical analyses also reveal how psychiatry has evolved out of institutions developed to manage troubling behaviour or ‘deviance’. Productive interactions between people depend on the maintenance of social order. Confusion, despair, misunderstanding and dependency are all disruptive, though not necessarily unlawful. How they are understood and responded to is determined by prevailing social and political structures. Critical psychiatrists have highlighted how contemporary psychiatry is a current embodiment of the need to contain disruptions of social order, a perspective articulated by French philosopher Michel Foucault (Reference Foucault1965) and historian Andrew Scull (Reference Scull2015), as well as by Szasz.

Foucault traced how attitudes to madness were transformed over the 17th and 18th centuries. As industrial society started to emerge, conformity and discipline became important. In France, the economically unproductive were brought together in the hôpitaux généreaux; Foucault identified this as the ‘Great Confinement’. In England, those without means were provided with minimal subsistence in the community under the Tudor Poor Laws, and then increasingly in the workhouse. Asylums reflected the segregation of ‘paupers’ into the ‘able-bodied’, who were kept in the workhouse and who could be obliged to work, and the incapacitated, who were moved to the workhouse hospital or the local asylum. Thus, the birthplace of institutional psychiatry can be considered arrangements for managing unproductive behaviour in a system of wage labour and industrial production. The growth of psychiatry in the 19th century legitimated this system by presenting it as a medical and therapeutic endeavour. From Foucault's perspective, ‘psychiatry is a moral practice, overlaid by the myths of positivism’ (Foucault Reference Foucault1965: p. 276). In the 20th century the medical framework became more strongly cemented, so that the social functions of mental institutions and services were further obscured.

The sick role

Psychiatry's institutional functions are legitimated by the designation of its clients or patients as ill or ‘sick’. This inevitably enters them into a ‘sick role’. The ‘sick role’ (Parsons Reference Parsons1951) is a contract between the sick person and society, whereby the sick are provided for and the social costs of sickness are minimised. The ‘ill’ person enjoys relief from responsibilities and access to care in exchange for submission to expertly defined treatment. Through its association with medicine, psychiatry has extended the sick role to a wider range of situations. Most would concur with a need for care and support of the mentally disturbed, but using the sick role to achieve this has limitations. Power relations enshrined in it encourage long-term passivity, impair investment in change and can contribute to dissatisfaction as the promised cure (the physician's part of the contract) may fail to materialise.

Psychiatry and social control

Anti-psychiatrists highlighted that when behaviour is designated as disease, individuals' rights and liberties can be overridden in the name of acting in their own interests. The fact that this can be presented as an objective, scientific endeavour means it is easily open to abuse, and powerful groups can define any socially repudiated behaviour as ‘mental illness’ in order to eradicate or control it. Generally agreed examples of this include the designation of male homosexuality as a mental disorder up until the 1970s, and the application of a ‘diagnosis’ of drapetomania to African American slaves intent on escaping.

Unlike anti-psychiatrists, most critical psychiatrists accept the need for recourse to coercion in circumstances where individuals are so overwhelmed, confused or desperate that they fail to cope with everyday demands or place others in intolerable or dangerous situations, and that under such circumstances lawful restraint and other related measures are justified. However, veiling these situations as ‘medical disorder’ disguises the real reasons for taking coercive action, which are usually to maintain social order and to support the dependent. A more transparent approach would acknowledge these pressures and scrutinise authorised interventions more rigorously. Legislation based on the concept of ‘capacity’ rather than the presence of ‘illness’ (or its legalistic pseudonym, ‘disorder’) is one such possibility (Szmukler Reference Szmukler and Applebaum2008). This would avoid the medicalising assumptions woven into current legislation and would require explicit justification for coercive and paternalistic actions. It would also challenge the extension of coercion into the community, as occurred with the introduction of ‘community treatment orders’. Most patients able to live in the community would be considered to have capacity to decide whether or not to take psychiatric medication. However, capacity-based legislation, such as the Mental Capacity Act 2005, requires contentious and subjective judgements about the best interests of individuals and the safety of society. Replacing a medically justified system of control is not easy, but balancing the interests and freedoms of different groups and individuals is inherently fraught and deserves greater attention and transparency.

There is a substantial body of work addressing the political implications of the ‘medicalisation’ of human experience, which dates back at least to the writings of Ivan Illich in the 1960s and 1970s (e.g. Medical Nemesis, Illich Reference Illich1974). The widespread, pharma-funded promotion of the idea that unwanted emotions or behaviour can be understood as ‘abnormal brain chemistry’ has taken this process to a new level, encouraging large swathes of the population of Western countries to view life difficulties as brain events that need chemical correction. Several commentators, many in the Marxist tradition, have highlighted how this helps to support a pliable society in which imperfections are attributed to individuals rather than social injustice, obscuring the systemic difficulties that cause widespread misery and distress (e.g. Cohen Reference Cohen2016). American sociologists Conrad & Potter (Reference Conrad and Potter2000) discuss how the availability of the diagnosis ‘adult ADHD’ can be seen as a form of ‘medicalisation of underperformance’, which diverts attention from the increasing competitiveness and performance-driven culture of modern society. Gary Greenberg (Reference Greenberg2011) highlights how the concept of depression as an illness obscures social and economic hardships and discourages opposition to the structures that maintain these.

Drug treatment

There is considerable criticism of the dominant role drug treatment plays in contemporary psychiatry. Critics point to the enormous influence of the pharmaceutical industry, accusing it of overselling its products, inflating their benefits and understating adverse effects (Whitaker Reference Whitaker2010). Prescriptions for most drugs are rising steadily, with little evidence that this is producing better outcomes (Ilyas Reference Ilyas and Moncrieff2012).

Critical psychiatrists do not eschew drug treatment. Instead, they offer an alternative framework for understanding and using it that is more transparent and involves patients more centrally in determining how it happens.

Models of drug action

Conventional psychopharmacology assumes that psychiatric drugs work by modifying an underlying physiological abnormality responsible for the disorder. This might be referred to as a ‘disease-centred’ model of drug action. Drug treatment is presented as restoring a normal or healthy state. Psychiatric drugs ‘counter or compensate for the abnormal pathophysiology’ (Hyman Reference Hyman and Nestler1997). However, critical psychiatrists have argued that there is little evidence to support the disease-centred model and they propose an alternative, ‘drug-centred’ model. This suggests that, as psychiatric drugs are psychoactive substances, they modify symptoms through the alterations they produce in normal mental processes, emotion and behaviour (Moncrieff Reference Moncrieff2008; Breggin Reference Breggin2008) (Table 1).

TABLE 1 Psychoactive effects of psychiatric drugs

a. The effects of different drugs within each class vary, particularly drugs classified as antipsychotics. The information provided is necessarily a summary which glosses over distinctions between individual agents. For more detail and references see Yeomans et al (Reference Yeomans, Moncrieff and Huws2015).

Antipsychotics, antidepressants, anxiolytics and ‘mood stabilisers’ all induce significant cognitive, emotional and behavioural alterations in animals and in normal volunteers. The drug-centred approach focuses on making judgements about when these alterations might be useful. Intrusive psychotic symptoms may be muted and rendered less distressing by the cognitive slowing and emotion-blunting effects of antipsychotics, for example. Intense anxiety may be relieved by the state of mental and physical relaxation induced by benzodiazepines. However, although drugs may reduce unwanted feelings and behaviours, this approach also highlights their adverse effects on other aspects of mental and physical functioning. A more detailed discussion of disease- and drug-centred approaches to the use of psychiatric medication was published in Advances in 2015 (Yeomans Reference Yeomans, Moncrieff and Huws2015).

Psychological therapies

Differing psychotherapeutic models have reputations for greater efficacy in certain situations, are claimed by some to be effective in all conditions, and all are sometimes ineffective. This questions distinctions between them and whether ‘psychotherapy’ really differs from other forms of therapeutic encounter; questions which are taken up by critical psychiatry.