Get off the couch!

The estimate that mental illness afflicts ‘one in four’ people – made by various mental health charities and professionals – reflects a dramatic expansion in 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. 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?

In both the USA and the UK, government agencies and professional authorities have adopted a much higher profile in mental health. Campaigns have sought to raise awareness of depression and other forms of mental illness among the public and among doctors, and have encouraged people to seek professional help. 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.

There has been a remarkable inflation of diagnostic categories in psychiatry. In the 1890s, the influential German psychiatrist Emil Kraepelin 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. By 1994, this had expanded to 384 (plus 28 ‘floating’ diagnoses).

Over the past decade a combination of social, political and economic factors has made many people feel increasingly isolated and vulnerable. Traditional support networks, such as families and communities, have crumbled and collective institutions, such as churches, trade unions and political parties, have disintegrated. 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.

Drug companies have promoted awareness of psychiatric disorders among patients and doctors to encourage demand for medications. In their quest to promote awareness of conditions (such as ADHD, social phobia) linked to particular drugs, pharmaceutical companies have sponsored patient groups and have developed techniques of advertising directly to patients, skillfully negotiating legislative restrictions.

A wide range of therapists has entered the therapeutic marketplace, 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).

A therapeutic culture has become pervasive. It is apparent in the emotionally charged speeches of presidents and prime ministers, 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.

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. 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 is that, instead of conferring strength on the patient, bestowing such labels 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.

If ‘one in four’ of the population accepts the judgment 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.

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.

Dr Michael Fitzpatrick is speaking at the debate Therapeutic Society or Therapeutic State? organised by the NY Salon and taking place in The New School in New York at 7pm this evening. For more information, visit the NY Salon’s website here.