According to the 'Mind out for mental health' campaign launched by the UK Department of Health, one in four people suffer from some form of mental illness every year. The campaign aims to promote greater awareness of issues of mental health and to encourage more professional intervention to deal with these problems.
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'One in four' is the pi of the therapeutic society. With a remarkable consistency, surveys of the prevalence of different forms of illness or victimhood yield the same 'one in four' result. Thus 'one in four' women have experienced domestic violence, 'one in four' children are victims of abuse, 'one in four' children live in poverty, 'one in four' adults abuse alcohol or drugs.
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Such surveys confirm that whatever social or psychological problem is being investigated is much more common than was previously believed, and that it demands intervention on a population-wide level. Therapeutic pi confirms human degradation on an unsuspected scale and reveals a scale of 'unmet need' that requires a further expansion of the therapeutic state.
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Though 'one in four' has the character of a mathematical constant, it cannot be calculated to an infinite number of decimal places. In fact, it may vary, though only between the strict limits of 'one in five' and 'one in three'. The former indicates a serious lack of awareness of the problem in question (and that more intensive promotion is necessary); the latter that it has become even more serious than previously thought (and that active intervention is urgently required).
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The tendency of surveys commissioned by agencies of the therapeutic state to produce 'one in four' results suggests that this ratio has a particular appeal. It is easily grasped, even by the innumerate, and is readily interpreted as 'could affect pretty well anybody'. Any problem that occurs with this sort of frequency must affect every family and every household. The promotion of 'one in four' statistics both normalises the problem and legitimises the intervention offered in response to it.
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The estimation that mental illness afflicts 'one in four' people reflects a dramatic expansion of the range of psychiatric diagnosis. Familiar conditions, such as anxiety and depression, are now discovered in a much higher proportion of the population. Disorders that were only identified 20 years ago - attention deficit hyperactivity disorder, post-traumatic stress disorder, social phobia - and were considered rare only 10 years ago, are now found to be common. It is clear that psychiatry has expanded its boundaries to take in a wider range of human experiences and behaviours and has redefined them in terms of its diagnostic categories. How has this come about? Why should we be concerned about it?
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Considering the inflation of psychiatric diagnosis, it is possible to identify a number of forces that have contributed to this process. The major factors are government promotion of mental health initiatives, psychiatric imperialism and the individual frailty of members of an increasingly atomised population. The minor factors are pharmaceutical 'disease-mongering', the activities of therapeutic entrepreneurs and the growth of a therapeutic culture.
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Starting at the top, the 'Mind out for mental health' campaign is sponsored by the Department of Health. As part of its wider involvement in the sphere of health, the government has adopted a much higher profile in mental health. In the early 1990s, the then Tory government backed the Defeat Depression initiative organised by the Royal College of Psychiatrists and the Royal College of General Practitioners. This aimed to raise awareness of depression among the public and among doctors, and tried to encourage people to seek professional help with this problem.
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More recently, the New Labour government has also promoted greater recognition of work-related stress among employers. Challenging discrimination against people with mental illness in the workplace is a key theme of the 'Mind out for mental health' campaign. The modernisation of mental health services is identified as one of the priorities in the July 2000 NHS Plan. In the era of globalisation, when governments' capacity to influence economic affairs seems limited and politicians have lost authority, interventions in matters of health (including mental health) offer a means of restoring contacts with the public and regaining popular approval.
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Developments in psychiatry have contributed to its own expansion. The emergence of psychoanalysis in the early years of the twentieth century allowed psychiatrists to move away from an exclusive focus on psychosis to extend their influence over the much wider field of neurosis.
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As Allan Horwitz puts it, Freud 'made the neurotic normal and pathologised everyday life': as psychoanalysis reached its apogee in postwar America, psychiatrists claimed authority over diverse manifestations of human unhappiness as well as much deviant and delinquent behaviour. When Freud rapidly fell from favour in the 1970s, a novel form of biological psychiatry took over the full range of conditions that psychoanalysis had brought under the psychiatric umbrella, and redefined them as biomedical disorders.
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The inflation of diagnostic categories over the past century has been remarkable. In the 1890s Kraeplin distinguished two forms of psychosis (schizophrenia and manic depression). In 1918 the first US classification included 22 categories (21 forms of psychosis and one category for all other disorders). In 1952 the first edition of the Diagnostic and Statistical Manual of US psychiatry recognised 60 diagnoses.
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The landmark 1980 third edition of DSM that signalled the hegemony of biological psychiatry included 265 disease categories; by 1994, DSM-IV had expanded to include 384 psychiatric disorders (and 28 'floating' diagnoses). Psychiatry has extended its empire from dealing with madness to take in an ever-increasing range of sadness (and some of what used to be regarded as badness).
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The third major factor driving the expansion of psychiatric diagnosis is the scale of individual insecurity in contemporary society. Over the past decade a combination of social, political and economic factors has made many people feel increasingly isolated and vulnerable. At the same time, traditional support networks, such as families and communities, have crumbled and collective institutions, such as churches, trade unions and political parties, have disintegrated.
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An increasingly atomised and disengaged population has responded positively to initiatives from the government and the psychiatric establishment to interpret personal distress through the framework offered by the therapeutic state. As David Wainwright puts it in his book Work Stress: the making of a modern epidemic: 'In a society with a heightened sense of physical and mental vulnerability coupled with the diminished subjectivity characterised by the agency-robbing culture of victimhood, therapeutic "diagnosis" and "treatment" can provide an important sense of existential security.' (1)
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The role of the drug companies in promoting awareness of a particular condition among patients and doctors because it provides a market for a particular medication has been exposed by a number of critics - such as David Healy and Ray Moynihan. It appears that such promotions had a significant influence on the decline in the diagnosis of anxiety and the parallel increase in depression after the development of Prozac and other drugs marketed specifically as 'anti-depressants'.
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'Social phobia' and 'ADHD' are diagnostic labels which have been promoted by drug companies seeking to boost the demand for products marketed specifically for these conditions. In their quest to promote awareness of conditions linked to particular drugs, pharmaceutical companies have sponsored patient groups and have developed techniques of advertising directly to patients, skilfully negotiating legislative restrictions.
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In addition to psychiatrists, a wide range of therapists have entered the therapeutic market place, both fostering and responding to the demand for supportive services. These include followers of different schools of psychotherapy, from Freudian to New Age, clinical psychologists (offering increasingly popular courses in cognitive and behavioural therapies), and counsellors (whose services are now available in doctors' surgeries, workplaces, schools, prisons, hospitals).
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A therapeutic culture has become pervasive. It is apparent in the emotionally charged speeches of the prime minister, in the conduct of royal funerals, in the numerous confessional TV shows, in the shelves full of self-help manuals in every bookshop. It seems that everybody now speaks the language of 'self-esteem' and 'support'; displays of emotional incontinence and claims of victimhood are guaranteed social approval.
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The therapeutic society represents its own advance as the result of scientific progress in psychiatry (notably in neuroscience and genetics) and of the growth of humanitarian awareness of hitherto unrecognised distress. Yet the inflation of psychiatric diagnosis has resulted in its devaluation. Whereas diagnoses previously suggested the limited character of the condition, modern disease labels imply disorders that are unrestricted in the scope of the symptoms to which they give rise and in the duration of their effects.
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Post-traumatic stress disorder or recovered memory syndrome, for example, can be expressed in the widest variety of symptoms, which may arise long after the traumatic events believed to have triggered them. There is also a widespread conviction that these may continue indefinitely as people are 'scarred for life' by past traumas. Today's sufferers from addictions or compulsions can never claim to have been cured; they live their lives 'one day at a time' in an ongoing process of 'recovery'.
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The depersonalised character of traditional diagnoses allowed the sufferer to objectify the condition as something 'out there', perhaps a somewhat forced abstraction, but one with some pragmatic value. By contrast, a diagnosis like 'chronic fatigue syndrome', or 'ME', is inescapably personal and subjective in character. Every sufferer exhibits a different range of symptoms, and there is no way of objectively confirming or monitoring the course of the illness. The net effect of the dramatic expansion in the range of psychiatric diagnosis is that, instead of conferring strength on the patient, bestowing any such label is more likely to intensify and prolong incapacity. The proliferation of diagnoses and the tendency to apply them to ever-wider sections of the population reflects a profound demoralisation of society and a deep crisis of subjectivity.
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If 'one in four' of the population accepts the judgement that they are mentally ill and surrenders themselves to the authority of the therapeutic state, the conception that we live in a democratic society based on autonomous citizens is gravely undermined. Any notion of agency assumes that individuals are mentally competent. The acceptance of the status of being mentally ill implies acceptance of a passive and diminished subjectivity. The act of subordination to a therapist or counsellor means symbolically relinquishing sovereignty over the self to agents of the therapeutic state.
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The medicalisation of personal problems may relieve the individual of moral responsibility, but at the cost of allowing the therapeutic state to control personal behaviour and psychic life.
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Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).
(1) Work Stress: the making of a modern epidemic, David Wainwright and Michael Calnan, Open University Press, 2002, p159
Also see:
Ray Moynihan et al, 'Selling sickness: the pharmaceutical industry and disease-mongering', British Medical Journal, 2002; 324: 886-891.
David Healy, The Antidepressant Era, Harvard, 1999
David Healy, The Creation of Psychopharmacology, Harvard, 2002.
Allan V Horowitz, Creating Mental Illness, University of Chicago, 2002
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