Naming the devil: The mental health double bind

(Published on The Neuroethics Blog)

The “Bell Let’s Talk” initiative swept through Canada on January 27, hoping to end the stigma associated with mental illness, one text and one share at a time. Michael Landsberg shares his thoughts in a short video on the Facebook page. “The stigma exists because fundamentally there’s a feeling in this country still that depression is more of a weakness than a sickness,” he explains. “People use the word depression all the time to describe a bad time in their life, a down time. But that’s very different than the illness itself.” Perhaps such a bold statement merits closer examination.
Philosophers, psychologists, and neuroscientists find themselves rallying behind two starkly contrasting paradigms of mental health, lobbying for conflicting changes in policy and attitude. On one end of the spectrum lies the medical model of psychiatry – the notion that the classification of mental illness can and ought to be truly objective, scientific, and devoid of value judgements. At the other extreme, a Foucault-esque theory posits that most psychiatric classifications are nothing more than a reflection of the values of those who do the classifying; classification is inherently normative and necessarily serves the interests of those in power.

Most modern paradigms take a more moderate approach, arguing that classification is based on both objective facts about the body and elements of normativity, but that diagnoses are useful nonetheless and do ultimately describe “real” illnesses. Nevertheless, the push and pull of each extreme keeps our current societal approach to mental illness in an uncomfortable double bind. In an over-medicalized paradigm, where we prescribe anti-depressants for those going through financial or relationship crises, we risk prescribing inauthentic neurobiological fixes to the suffering caused by complex social problems. But in an under-medicalized paradigm, we risk inadequately addressing the suffering caused by treatable neurobiological anomalies, under the pretense of total social relativism (more on the issues surrounding naming mental illness here).

For instance, in favour of de-medicalization, the neurodiversity movement (see previous blog posts on the topic herehere, and here)  quite reasonably suggests that conditions like autism ought not to be considered disorders, but rather alternative ways of thinking. Society can holistically benefit from including and adjusting to diverse modes of thought, rather than attempting to change autistic individuals to fit the mold (see also: philosopher Ian Hacking’s “looping effect” which might describe the way in which the very act of being diagnosed with a Diagnostic and Statistical Manual (DSM)-classified mental disorder can alter one’s self- and public perception of the condition, creating an “otherness” where it ought not exist).

 

Interpreting physical illness vs. medical illness, image
courtesy of Buzzfeed
Similarly, the categorization and naming of mental disorders can be damaging to ethnic minorities, women, and the socioeconomically oppressed. Naming compels individuals to misattribute the suffering caused by societal structures to problems intrinsic to their own bodies and brains and prevents marginalized individuals from seeing the reality of their greater social context, which legitimizes and perpetuates harmful social structures. For instance, so-called “Self-Defeating Personality Disorder” (SDPD) was introduced in the DSM III-R in 1987, describing criteria which closely mirrored traditional feminine submissiveness in the context of domestic abuse. An individual with SDPD “Chooses people and situations that lead to disappointment, failure, or mistreatment even when better options are clearly available … Engages in excessive self-sacrifice that is unsolicited by the intended recipients of the sacrifice.” It was subsequently excluded from DSM-IV in recognition that symptoms of abuse are primarily caused by male abusers, and that misguided medical diagnoses can have profoundly damaging effects on the already socially marginalized.

 

The naming of mental disorders is much more socially relative than that of physical disorders. And yet in some cases, the comparison between mental and physical disorders can have incredibly beneficial impacts on mental health discourse. Consider the message of the simple yet effective #BellLetsTalk campaign, or BuzzFeed’s recent pieces on mental illness (exemplified by this video and this listicle). In promoting a liberal stance on mental health in popular discourse, popular media frequently draw on the comparison between mental and physical disorders to reveal contradictory attitudes and social policies. This comparison inherently medicalizes mental health, but to the effect of taking mental illness more seriously, with arguably positive outcomes for de-stigmatization and patient care. In positing that the brain, like the kidney or any other organ, can malfunction and “get sick” for periods during one’s life (as is said to occur during some episodes of depression or mania), we classify mental disorders into discrete categories, in the same, dispassionate way one might be diagnosed with a stomach ulcer.

 

In diminishing the stigma surrounding mental disorders to match that of mundane physical illnesses, the medical classification of mental illness might provide individuals with the emotional detachment needed to seek appropriate help, whether in the form of reaching out to friends and employers, or seeking therapy or medication.

 

Such dispassionate comparison to physical diagnoses may moreover be crucial in legitimizing policy discourse, providing us the linguistic tools to address inadequacies such as sick leave and insurance coverage. As economist Richard Layard and CBT specialist David M. Clark project in “Thrive,” depression, when viewed as an illness like any other, is on average 50% more disabling than physical conditions like angina, asthma, arthritis, and diabetes, yet is much more likely to go untreated in Britain’s healthcare system. There may therefore be a lot of political progress to be made through the injection of objectivity into the public discourse on mental health.

 

Moreover, perhaps we overlook the psychological benefits of medical categorization in the phenomenology of mental illness itself. It may be empowering to be able to conceptualize depression or OCD or addiction as a foreign thing to be beat, rather than festering in the hopeless determinism of one’s (often unalterable) social conditions or previous life decisions. In naming an illness, an individual can recognize her current state as an aberration from her authentic self, positioning herself in opposition to her affliction during the healing process, battling against depression or addiction in much the same way that one might battle against cancer. On a social level, this paradigm might open the door to seeking support, in the knowledge that one’s condition is not one’s “fault,” and no more shameful or unusual than the common cold. Medicalization in social discourse can therefore serve a useful purpose and is not always necessarily a thing to be feared.
The use of biomarkers, including those found through blood tests,
have been found to outperform traditional diagnoses of mental
illness, image courtesy of Wikipedia
Nevertheless, as Sana Sheikh points out in a brilliant piece for Jacobin, we must recognize the disproportionate economic incentives which bias our healthcare system toward over-medicalization. Pharmaceutical innovation in the mental health domain has been stagnant, with very few new psychiatric drugs being developed over the last decade (predominantly because the neural mechanisms underlying most mental illnesses are still largely uncharted).

 

Hoping to bring objective neurological mechanisms to the forefront of mental health research, with possible pharmaceutical applications, the National Institute of Mental Health (NIMH)’s new Research Domain Criteria (RDoC) initiative seeks to redraft our framework for mental health research into its most systematized, objective formulation to date. And as the largest provider of funding for mental health research, the influence of the NIMH in dictating our prevailing views on mental illness must not be underestimated.

 

Rejecting symptom-based DSM groupings as still too subjective, the new system relies nearly exclusively on measurable biomarkers for the categorization of mental illness. Blood tests or genetic screens for depression could soon eclipse subjective accounts. Proponents insist that biotypes (biomarker-based categories) outperform traditional diagnoses of illnesses like schizophrenia or bipolar disorder, in that there is significant biological overlap between traditional DSM groupings.

 

Of course, the system is already under fire for its seeming total lack of consideration for psychosocial or environmental factors in the pathology of mental disease. Moreover, as Sheikh reminds us, there must be an irreducibly subjective element to mental illness – if someone self-reports feeling depressed but the biomarkers in their blood suggest otherwise, it would be bizarre to conclude that they are wrong about their own mental state.

 

The medicalization of mental illness is thus not simplistically good or bad, and the degree to which medicalization is appropriate or beneficial will vary from case to case. Faced with this uncertainty, we must be wary of blanket policies that lean too far in either direction. One-dimensional policies like NIMH’s RDoC may well produce pharmaceutical innovation, but certainly have the potential to lead to harmful, reductionist accounts of mental illness. Conversely, it might be beneficial in policy discourse for conditions like depression to be treated as a veritable mental illness. In light of the rapidly changing policy and funding landscapes of neuroscience and psychology, we must insist on studying the pathology of mental disorders as a constellation of environmental, psychosocial and biological factors, and seek authentic, balanced, and multi-faceted solutions to the unique suffering presented by each.
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