We're all crazy now
Blurring the distinction between mental illness and mental health helps nobody, argues Kenneth Mc Laughlin
'One in five children mentally ill' proclaimed the headline in the Daily Telegraph. Alarming stuff - or it would be, if the statistics actually measured the incidence of mental illness.
The one-in-five statistics come from a report by the Mental Health Foundation entitled 'The big picture'. Rather than highlighting mental illness, it focuses on the more elastic term, 'mental health problems'. In this way almost anything can be recast as a psychiatric problem. For example, the Mental Health Foundation has extended what constitutes a childhood mental health problem to include such things as truancy, disruptive behaviour and bedwetting. MIND, another mental health charity, uses similar methods regularly to warn that one in four of us will suffer such a problem at some point in our lives. Just as well, then, that there are over 450 distinct forms of psychotherapy on hand to help us in our hour of need.
But why do mental health charities and professionals now tend to exaggerate the extent of mental illness, and to include in this category types of behaviour once considered unexceptional? It seems to have little to do with the treatment needed by those genuinely suffering from mental illness.
The increasingly loose definitions of mental illness being employed today have come about partly as a reaction to the traditional approach to psychiatry, which set rigid standards of behaviour from which it was considered abnormal to deviate. All too often, these standards reflected political and social prejudices - like the acceptance of women's propensity to hysteria.
Campaigners concerned with challenging oppressive and discriminatory practices have drawn attention to the extent to which mainstream psychiatry has been affected by political, social and cultural factors. For example, 'drapetomania' was said to be a disease that caused black people to run away from slavery. It was only in 1973 that the American Psychiatric Association decided that homosexuality should cease to be classed as an illness. (Today, by contrast, it is more likely that those hostile to lesbians or gay men are seen to have a problem, finding themselves accused of suffering from homophobia.) In the former Soviet Union, disagreeing with the ruling regime was at one time seen as evidence of psychiatric illness.
But in attempting to redress the abuses of the past, mental health campaigners seem to have run too far in the opposite direction. At the extreme end, a conflation of insanity with oppression has caused some campaigners to highlight the 'positive' elements of madness - even trying to organise 'Mad Pride' along similar lines to 'Gay Pride'. Psychotic symptoms, it is said, do not have to be disabling - they can also be a source of enrichment.
A more acceptable argument, and one that has become part of mainstream attitudes towards mental health, is that there is no clear boundary between reason and unreason, health and illness. Abnormal behaviour becomes 'normal variance', an equally valid aspect of life's rich tapestry. So by analysing the speech of academics and politicians (transcripts from the White House, incidentally), the claim is made that normal speech contains the same errors as those found in the speech of patients said to be showing 'thought disorder' (where instead of coherent, structured sentences a jumbled, rambling 'word salad' is expressed).
The danger is that this new 'all unwell together' approach to psychiatry will relativise away those aspects of the traditional approach that were positive and progressive. After all, the Enlightenment theories of reason gave psychiatry its first reference point: by taking a rational view of unreason or madness, a more scientific and objective study could be made than when relying on the divine theories that went before. And unlike a divine theory, a 'rational' theory is open to question: whereas God's will was beyond dispute, psychiatry could be challenged or defended depending on somebody's political viewpoint. So in the nineteenth century even Samuel Tuke, who endorsed many of the racist beliefs of his time, ridiculed the concept of 'drapetomania', claiming that the absence of a propensity to escape slavery would be tantamount to imbecility or incipient dementia.
The value of this rational, scientific approach to psychiatry was that it at least saw insanity as a problem to be cured, rather than as a divine intervention about which nothing could (or should) be done. Although the standards of behaviour it set were rigid and often based on the political prejudices of the time, the existence of these standards meant that some attempt could be made to understand and cure mental illness.
Now, health professionals' sensitivity to some of the problems with the rigid conceptions of 'normal' and 'abnormal' behaviour has led almost to a dissolution of any standard of 'normal' - or mentally 'well' - behaviour. When the waffling of a politician trying to evade an awkward question is likened to the incoherent and disturbed ramblings of somebody who is obviously unwell, the boundary between reason and unreason, health and illness, is no longer clear.
Ironically, the group this is least likely to help is people suffering extreme mental distress. Matt Muijen of the Sainsbury Centre for Mental Health has noted how funds are frequently diverted from the seriously mentally ill to the worried well. Meanwhile, portraying increasing numbers of people as pathologically or psychologically impaired may well mean that fears about increases in mental illness become a self-fulfilling prophecy, as people are told that without professional help they will be unable to cope with the pressures of life.
But then, those who persist in presenting mental illness as just another normal part of life may be on the way to achieving what all previous approaches to psychiatry have failed to do: eradicate madness, not by curing it, but by defining it away until the term becomes meaningless.
Kenneth Mc Laughlin works in a social services mental health team
Reproduced from LM issue 122, July/August 1999