Mental illness: the last taboo?

September 13, 2011 by
Filed under: Social Brain 

People with mental health problems are the last minority group against whom it’s socially acceptable to discriminate. Sometimes this discrimination comes about accidentally or covertly, Lisa Appignanesi’s recent piece in the Guardian being a case in point. Appignanesi writes that the mental illness ‘industry’ is medicalising normality to a greater extent than ever before. She raises the question of whether the apparent increased prevalence of mental illness is genuinely down to a rising toll of suffering, or whether we have collectively learned to complain more. Appignanesi suggests that the more evidence there is about the increase in mental disorder in the public domain, the more likely we are to label our own problems of living as requiring the attention of a doctor. She goes on to suggest that attending reading groups or going running might do more for sufferers of depression than taking medication and questions the usefulness of psychiatric classification in helping people deal with the problems of their lives.

While I’m sure Appignanesi does not intend to cause offense to people with serious mental health problems, there is a dangerously stigmatising undercurrent to her argument. A distillation of the points she makes might roughly translate as “There’s nothing much wrong with you, you don’t need any pills, pull yourself together.” This might be a useful message for someone who’s struggling slightly with a mild case of the blues, and has the wherewithal and capacity to make a few positive changes in their life. But, for someone with a seriously debilitating mental illness, it is a potentially very damaging message.

‘Mental illness’ is no more a discrete entity than is ‘physical illness’, and no physician would deign to lump diabetes in with cancer when trying to understand patients’ ways of dealing with their illness.

A serious problem which Appignanesi does not attend to, is that the category of ‘mental illness’ is extremely dense. ‘Mental illness’ is no more a discrete entity than is ‘physical illness’, and no physician would deign to lump diabetes in with cancer when trying to understand patients’ ways of dealing with their illness. So, when we talk about mental illness, we might be referring to depression, anorexia, schizophrenia, or any of the other 300 or so disorders in the DSM. Within any one of those diagnostic categories lies a huge variation of patient experience and no two cases of any one of these conditions is ever the same. Just as we all have different pain thresholds, we all have differing levels of resilience to mental distress. But, whatever your threshold, there is a level of serious mental suffering which is as intolerable as the most excruciating physical pain.  Within the classification of depression, there exists a whole spectrum of experience ranging from unpleasant but bearable gloom which allows one to continue functioning, right down to crippling despair which makes it impossible to get dressed in the morning or go to sleep at night. For those at the dark end of the spectrum, attending a reading group or going for a run are utterly inconceivable activities, and no substitute for proper medical intervention.

Appignanesi is caustic about the use of antidepressants, and it seems to me that this might be because she has in her mind people who are just a bit down in the dumps rather than those who have a serious mental health difficulty. The ‘definite lift’ Appignanesi tells us participating a reading group provides would certainly not have helped Sandra, a woman I met some years ago, who at that moment was desperately waiting for her annual ECT treatment. She told me that ECT was her lifeline, the only thing that lifted her depression sufficiently to make her life liveable, and that without it she would have killed herself ‘several times over’.

I think the point Appignanesi is really trying to make is that it has become very easy for pretty much anyone to walk into the doctors, have a bit of a moan, and leave with a diagnosis of depression and prescription for Prozac.

I think the point Appignanesi is really trying to make is that it has become very easy for pretty much anyone to walk into the doctors, have a bit of a moan, and leave with a diagnosis of depression and prescription for Prozac. Cultural factors have made it possible for mental illness to be a lifestyle choice. If you can’t be bothered to exercise, eat well, engage in wholesome activities like reading groups, you don’t have to take responsibility anymore because you can just opt for the convenient excuse that you’re ill. Once your GP has agreed that you’re ill, you can slip into the role of patient, and passively wait for treatments to work and experts to make you better. The overlapping agendas of pharmaceutical companies, the health service, and government have come together to feed this situation.

normalising mental illness is a far more urgent priority for social progress than is preventing the medicalisation of normality

Although Appignanesi’s attack of the usefulness of psychiatric classification is understandable, what we need to understand is that there is a difference between everyday, normal suffering and serious mental illness which requires specialist intervention. It is true that deciding on the cut-off point at which normal suffering becomes mental illness can only be determined using subjective means, and that the boundary is inevitably arbitrary. I agree with Appignanesi that there is something crazy about a world in which literally any kind of idiosyncrasy can be identified as a symptom of mental illness, and that there is a complex range of reasons which explain the apparent increase in prevalence of mental disorder. But, we need to exercise caution when drawing attention to these problems because there are real dangers associated with arguing against the medicalization of ‘normality.’ Firstly, that people who are really suffering and genuinely need help are not taken seriously, and secondly that the advantages that come with understanding that mental health is on a spectrum which we all occupy, are lost. Or in other words, that the stigma of mental illness is encouraged. People with mental health problems are routinely discriminated against at all levels, and normalising mental illness is a far more urgent priority for social progress than is preventing the medicalisation of normality.

 

 

 

 

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Comments

  • Sam Mclean

    Good blog. I really enjoyed it! I strongly agree with
    your main argument – society needs to better understand the complexities of
    mental illness and be more compassionate towards those who suffer with a mental
    illness and require medication to help them. As you say, some people depend on
    it.

    But I disagree with your final
    conclusion: “…normalising mental illness is a far more urgent priority
    for social progress than is preventing the medicalization of normality.” 

    What you’re arguing has wider more profound unintended
    implications.

     

    Have you read Foucault’s first book, Madness and
    History (earlier versions like mine are Madness and Civilisation)? You might
    not agree with him, but Foucault makes a very powerful argument against ‘normalising
    mental illness’. He shows and argues in great detail and brilliance how psychiatry
    and mental institutions were originally created (and continue to often function)
    as a ‘system of domination’ (he would later describe it as a ‘power-knowledge’
    complex) designed not to liberate human beings from their madness (or mental
    illness) but to normalise and control those who are different. On this basis, is it really more socially progressive to normalise mental illness or medicalise difference?

    • Emma Lindley

      Yes, I’ve read Foucault, and I am quite convinced of what he has to say about psychiatry as a means of social control. Perhaps I’ve gone for the wrong language in talking about ‘normalising’ – what I’m really trying to get at is acceptance and solidarity. So, I don’t mean we should hastily get rid of symptoms of mental illness in order to eradicate difference, but rather that a broader understanding and acceptance of that difference should be a priority. 

  • Sam Mclean

    Good blog. I really enjoyed it! I strongly agree with
    your main argument – society needs to better understand the complexities of
    mental illness and be more compassionate towards those who suffer with a mental
    illness and require medication to help them. As you say, some people depend on
    it.

    But I disagree with your final
    conclusion: “…normalising mental illness is a far more urgent priority
    for social progress than is preventing the medicalization of normality.” 

    What you’re arguing has wider more profound unintended
    implications.

     

    Have you read Foucault’s first book, Madness and
    History (earlier versions like mine are Madness and Civilisation)? You might
    not agree with him, but Foucault makes a very powerful argument against ‘normalising
    mental illness’. He shows and argues in great detail and brilliance how psychiatry
    and mental institutions were originally created (and continue to often function)
    as a ‘system of domination’ (he would later describe it as a ‘power-knowledge’
    complex) designed not to liberate human beings from their madness (or mental
    illness) but to normalise and control those who are different. On this basis, is it really more socially progressive to normalise mental illness or medicalise difference?

  • Sam Mclean

    Good blog. I really enjoyed it! I strongly agree with
    your main argument – society needs to better understand the complexities of
    mental illness and be more compassionate towards those who suffer with a mental
    illness and require medication to help them. As you say, some people depend on
    it.

    But I disagree with your final
    conclusion: “…normalising mental illness is a far more urgent priority
    for social progress than is preventing the medicalization of normality.” 

    What you’re arguing has wider more profound unintended
    implications.

     

    Have you read Foucault’s first book, Madness and
    History (earlier versions like mine are Madness and Civilisation)? You might
    not agree with him, but Foucault makes a very powerful argument against ‘normalising
    mental illness’. He shows and argues in great detail and brilliance how psychiatry
    and mental institutions were originally created (and continue to often function)
    as a ‘system of domination’ (he would later describe it as a ‘power-knowledge’
    complex) designed not to liberate human beings from their madness (or mental
    illness) but to normalise and control those who are different. On this basis, is it really more socially progressive to normalise mental illness or medicalise difference?

    • Emma Lindley

      Yes, I’ve read Foucault, and I am quite convinced of what he has to say about psychiatry as a means of social control. Perhaps I’ve gone for the wrong language in talking about ‘normalising’ – what I’m really trying to get at is acceptance and solidarity. So, I don’t mean we should hastily get rid of symptoms of mental illness in order to eradicate difference, but rather that a broader understanding and acceptance of that difference should be a priority. 

  • Rachel Fenwick

    Excellent article. As a psychotherapist, I agree with both authors. A lot of low-level mental ill health is written of with a perscription and time from work/stresses. I believe meaningful activity can help with these people and should be actively encouraged by all who support them. Those are at the other end of the spectrum do and should have access to the necessary drugs and therapy to help them with symptom management – because that’s what it is – symptom management. As someone who works in the NHS, I have found too much emphasis on medication and not enough on therapy and recovery. Recovery can and does happen and we should work towards that.

  • Rachel Fenwick

    Excellent article. As a psychotherapist, I agree with both authors. A lot of low-level mental ill health is written of with a perscription and time from work/stresses. I believe meaningful activity can help with these people and should be actively encouraged by all who support them. Those are at the other end of the spectrum do and should have access to the necessary drugs and therapy to help them with symptom management – because that’s what it is – symptom management. As someone who works in the NHS, I have found too much emphasis on medication and not enough on therapy and recovery. Recovery can and does happen and we should work towards that.

    • Emma Lindley

      I absolutely agree that getting involved in meaningful activity is a very important part of recovery from mental illness, as well as maintaining wellbeing. There is definitely a problem with regarding depression as being purely biochemically based and therefore principally treatable with medication, not least because it can make people feel like it’s beyond their control to do anything about it. 

  • Jeremy Holmes

    Well blogged Emma  – Apaginesi  of course has a point but she and others (I would put Darian Leader in a similar boat) are hitting easy targets — the right-on cheers are almost audible.   I have a friend — a very distinguished doctor – who once told me that he had suffered a severe heart attack and major depression, and that the pain and incapacitating effects of depression far exceeded that of cardiac pain.  I don’t think any one would suggest joining a reading group as an immediate treatment for heart attack — although it might well form part of a rehabilitation programme, as indeed it might for someone recovering from depression with the help of psychotherapy and antidepressants.  Also,  reading groups are so Guardian – what about cinematherapy (for those who don’t like reading — yes they exist Lisa), jogging, bingo, pilates, favourite TV show with friends — anything active and communal.

    jeremy holmes

  • Jeremy Holmes

    Well blogged Emma  – Apaginesi  of course has a point but she and others (I would put Darian Leader in a similar boat) are hitting easy targets — the right-on cheers are almost audible.   I have a friend — a very distinguished doctor – who once told me that he had suffered a severe heart attack and major depression, and that the pain and incapacitating effects of depression far exceeded that of cardiac pain.  I don’t think any one would suggest joining a reading group as an immediate treatment for heart attack — although it might well form part of a rehabilitation programme, as indeed it might for someone recovering from depression with the help of psychotherapy and antidepressants.  Also,  reading groups are so Guardian – what about cinematherapy (for those who don’t like reading — yes they exist Lisa), jogging, bingo, pilates, favourite TV show with friends — anything active and communal.

    jeremy holmes

    • Emma Lindley

      Thanks for this. Yes, I have to admit the reading group suggestion made me cringe, although to be fair to Appignanesi, I suspect she was intending it to be interpreted as a signifier for communal activity generally. You also helpfully draw attention to the fact that there are no quick fixes for mental illness, and rehabilitation usually requires a combination of approaches, requiring input from a physician, a psychotherapist, the patient themselves as well as their friends and family.

  • B Meyers

    Go to any prison, in any country, you will find that most of the inmates will be suffering from several of however many hundred of whichever version of DSM is current ( I love/hate the fact that they are going to “remove” some personality disorder diagnoses from the next version.) Many of these people can’t read or write and can’t access any beneficial exercise, food or medical care. The death rate for these people after getting out of prison approaches that of some malignancies.
    Well, they deserve it you say? What about the (conservative) 10% that have been wrongly convicted? What about political prisoners? What about, in my country, the “boat people”, even children, detained because they got out of a war zone and tried to get into a (relatively) peaceful country illegally? One of our politicians summed it all up with the quote “Life wasn’t meant to be easy.”
    Let’s get back to the basics.
    Get rid of Danger first (read Taliban, Al-Qaeda, Somalian famine,Libyan dictators etc etc), see if there is a Response from the patient/population, and if there isn’t, summon expert help (MSF, other aid organisations), make sure there is a clear Airway (Stop burning fossil fuels and remove pollution), and that they are able to Breathe (Replant the Amazon, the Earth’s lungs), if there is no Circulation (eg Sovereign debt) one must attempt CPR (IMF,UN interventions), if you don’t, there is a 100% chance that they will die, and if you do attempt CPR about a 4% to 15% chance of success.
    Do unto others as you would wish done to yourselves.

  • B Meyers

    Go to any prison, in any country, you will find that most of the inmates will be suffering from several of however many hundred of whichever version of DSM is current ( I love/hate the fact that they are going to “remove” some personality disorder diagnoses from the next version.) Many of these people can’t read or write and can’t access any beneficial exercise, food or medical care. The death rate for these people after getting out of prison approaches that of some malignancies.
    Well, they deserve it you say? What about the (conservative) 10% that have been wrongly convicted? What about political prisoners? What about, in my country, the “boat people”, even children, detained because they got out of a war zone and tried to get into a (relatively) peaceful country illegally? One of our politicians summed it all up with the quote “Life wasn’t meant to be easy.”
    Let’s get back to the basics.
    Get rid of Danger first (read Taliban, Al-Qaeda, Somalian famine,Libyan dictators etc etc), see if there is a Response from the patient/population, and if there isn’t, summon expert help (MSF, other aid organisations), make sure there is a clear Airway (Stop burning fossil fuels and remove pollution), and that they are able to Breathe (Replant the Amazon, the Earth’s lungs), if there is no Circulation (eg Sovereign debt) one must attempt CPR (IMF,UN interventions), if you don’t, there is a 100% chance that they will die, and if you do attempt CPR about a 4% to 15% chance of success.
    Do unto others as you would wish done to yourselves.

  • Abi Stephenson

    Absolutely brilliant piece, Emma, and more than due.  Ironically, the rise of CBT and similar therapies (although hugely effective in certain cases) has tended to over-emphasise the exact amount of control an individual has over their mental health or illness, and sadly, seems to fuel the ‘you can simply pull yourself together if you only tried hard enough’ brigade.

    It does seem agonisingly archaic that to say ‘I suffer from depression’ or ‘I have OCD’ still prompts awkward looks, nervous shufflings and embarrassed coughs, and most people would rather throw themselves off the nearest building than ‘confess’. The Time to Change campaign http://www.time-to-change.org.uk/ aims to change all that – check it out.

  • Abi Stephenson

    Absolutely brilliant piece, Emma, and more than due.  Ironically, the rise of CBT and similar therapies (although hugely effective in certain cases) has tended to over-emphasise the exact amount of control an individual has over their mental health or illness, and sadly, seems to fuel the ‘you can simply pull yourself together if you only tried hard enough’ brigade.

    It does seem agonisingly archaic that to say ‘I suffer from depression’ or ‘I have OCD’ still prompts awkward looks, nervous shufflings and embarrassed coughs, and most people would rather throw themselves off the nearest building than ‘confess’. The Time to Change campaign http://www.time-to-change.org.uk/ aims to change all that – check it out.

    • Emma Lindley

      Thank you very much. I’ve had some involvement with Time to Change, and it’s great that this work is happening. What you say about CBT made me think about the fact that with all this evidence that it ‘works’, there’s considerable potential for people who receive it and don’t recover to be blamed. 

  • Frances

    Yes to normalising mental illness.
    There is something crazy in the world if every non acceptable (to whom?) emotion has to be medicalized or diagnosed. In my experience clients can vary between wanting to be diagnosed or wary. Wanting because it then relinquishes them of any responsibility, “this has happened to me”. However this can also lead to depression and isolation as they feel they can do nothing.
    Others being wary because it could take away their autonomy, the “illness” ceasing to be theirs alone and having to report to someone else.
    Other therapist are scared of working with clients who have been diagnosed  – why?
    or think that they need only the specialist help of a  Psychiatrist and/ or psychologist this may be true to be kept safe.
    Some counselling courses seem to teach fear.
    People who have influenced my practice  are Richard Bentall,  the Soteria network the  magazine “Asylum”  and Rufus May.
    Sorry just a rant really.
    Frances  

  • Frances

    Yes to normalising mental illness.
    There is something crazy in the world if every non acceptable (to whom?) emotion has to be medicalized or diagnosed. In my experience clients can vary between wanting to be diagnosed or wary. Wanting because it then relinquishes them of any responsibility, “this has happened to me”. However this can also lead to depression and isolation as they feel they can do nothing.
    Others being wary because it could take away their autonomy, the “illness” ceasing to be theirs alone and having to report to someone else.
    Other therapist are scared of working with clients who have been diagnosed  – why?
    or think that they need only the specialist help of a  Psychiatrist and/ or psychologist this may be true to be kept safe.
    Some counselling courses seem to teach fear.
    People who have influenced my practice  are Richard Bentall,  the Soteria network the  magazine “Asylum”  and Rufus May.
    Sorry just a rant really.
    Frances  

    • Emma Lindley

      Thank you. I think you’re right to highlight the tension between the relief a diagnosis can bring and the potential for the diagnosis make people feel defined by it, with no control to change. It’s interesting you say that some therapists are afraid of working with clients with a diagnosis – itself a kind of stigma.

  • http://www.starwards.org.uk Marion Janner

    Thanks for excellent blog, elegantly disentangling a mess of issues. I have a severe mental illness (borderline pesonality disorder, with the classic self-harming, suicidal package) and my support dog comes everywhere with me. I struggle with whether I’m ‘advertising’ my mental illness (her yellow support dog jacket constantly results in strangers asking me ”What is a support dog?”) It’s complicated with an ‘invisible’ disability. Is it almost ostentatious to be communicating the fact that I’m mentally ill, or is that just internalised stigma?

    • Emma Lindley

      Thanks very much for this Marion. It’s a really interesting point – the invisibility of mental illness means that people have a choice about whether or not to disclose it, which might be one of the reasons why it’s stigmatised. I think it’s fantastic that you have a support dog and are able to use her as a talking point. Far from being ostentatious, it seems to me that you have found a great strategy for communicating something which is extremely difficult to express. How did you get the idea for a support dog?

  • http://twitter.com/BeatriceJBray Beatrice Bray

    It is not just a question of recognising our needs. We people with mental health problems have many facets to our characters. We have many talents and accomplishments but we often do not win the recognition that we so richly deserve.

    We should not have to try twice as hard to win the acknowledgment that comes freely to people without illness.

  • John

    Great article Emma. Another perspective could come frome Erich Fromm’s ‘Sane Society’. To very roughly summarise, the point is that people are people, and the fact that greater numbers of them are unable to cope says more about the inhuman character of modern society than it does about any defect in the individuals themselves. Worthy a cause as it is to reduce the unfair stigma attached to mental illness, more important may be identifying and criticising the environmental causes, and seeking to address them. Prevention better than cure and so on

  • Anonymous

    Fantastic blog. You have very greatly describe the useful information about the symptoms of mental illness. I would like to appreciate your post. Great job

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