Mental-health continuum: the unhelpful myth that we’re all a bit mad

Speaking at a recent Manchester Salon event on the subject of Talking Therapies, I was impressed by the level of public discussion that ensued, with a variety of interesting and opposing perspectives expressed.

One argument put forward by several participants was that to understand mental health/distress it was necessary to view it as a continuum, with mental health at one end of the continuum and mental distress at the other. We are all placed somewhere on the continuum and we will all, at some point, move along it, for better or worse, in one direction or another. In other words, there is no rigid divide between mental health and mental illness; therefore, to classify some people as mentally ill sets up an ‘us and them’ situation, with ‘them’ being stigmatised and oppressed. The continuum model is one that is advocated by many in the mental-health field today, and one which seems to make sense. Yet in truth, it is a flawed and unhelpful model which does little to help those in need but much to categorise us all as mentally vulnerable.

It is easy to understand where those who promote the continuum thesis are coming from. The classification and diagnosis of aspects of human experience as mental disorders is far from an exact science, and the medicalisation of distress is a relatively recent historical phenomenon. For radical critics such as Thomas Szasz, a psychiatrist himself, the very concept of mental illness is a myth, one that is used to control people who exhibit behaviours that we as a society cannot understand or tolerate. The mind, like the economy, can only be sick in a metaphorical, not literal, sense. Mental illnesses, from this perspective, do not exist as discrete entities but are created by the psychiatric profession. Whereas you have a disease such as cancer irrespective of whether or not a doctor has diagnosed it, you do not have schizophrenia unless the psychiatrist says so. In effect, the psychiatrist creates illness by naming it.

It is also the case that, once labelled as mentally ill, a person’s status can change in ways that can undermine his humanity. Others may cease to see him as a person, with a history, desires and aspirations, but as ‘the schizophrenic’, the mad, as object rather than subject. The person becomes the patient and liable to lose many of the rights of citizenship that most people take for granted, such as the right to liberty unless convicted of a crime, and the right to refuse medical treatment from doctors. Once given a psychiatric diagnosis, the now patient, subject to certain conditions being met, can be detained indefinitely under mental health legislation and given medical treatment against his or her will.

Proponents of the continuum model also point out the influence of wider political, economic and cultural factors on psychiatric theory and practice, classificatory systems and ‘medical’ interventions, many of which were influenced by the prejudices of the time and which also individualised and pathologised social and economic problems.

The above insights are extremely useful and serve to make us aware of the dangers of medicalising human experience; nevertheless there are many problems with the notion of mental health and illness as operating on a continuum.

First, the continuum argument may be valid in the sense that all mental experiences involve the emotions and also that there is no rigid, ahistorical or apolitical dividing line between what gets classed as normal or abnormal; yesterday’s naughty child is today’s ADHD sufferer, the shy adult now has ‘avoidant personality disorder’. However, to conflate all emotional states as belonging on the same continuum, for example severe depression with life’s ups and downs, is as absurd as conflating my child’s sand pit with the Sahara desert; both may contain sand, but that is where the similarity ends.

Another weakness in the continuum proponents’ case is that, in reality, they themselves do not believe it. Many of them frequently make decisions as to who is ‘different’ to the vast majority of the population. For example, even the most radical and progressive mental-health resource programmes, such as therapeutic communities and user/survivor asylum and support interventions, make assessments as to who should and who should not access their services. In other words, they operate eligibility criteria, making a distinction between people on the basis of their mental state. They may reject the medical model of classification and treatment, but they themselves classify and differentiate. Whatever model of mind is used to make the distinction, the end result is the same: the continuum is broken.

The continuum advocates’ main strength is the way in which they highlight the historical construction of contemporary psychiatric theory, diagnosis and practice, including the role of politics and social change in our understanding of the causes of, and attempts to alleviate, mental distress. However, their main weakness is a failure fully to appreciate the impact of such factors on the current mental-health debate. If the traditional concept of mental illness arose due to the interplay of wider social phenomena, so too did the current trend to view us all as on a continuum and in need of therapeutic help to maintain our equilibrium. Today, the tendency is to view us all, to a greater or lesser degree, as mentally ill, as weak and irrational subjects in need of control and guidance by government and an assorted array of therapeutic professionals. Even organisations that would in the past have emphasised the collective strength of their members, such as trade unions, are now more likely to make demands on the basis of the individual vulnerability of workers.

The influences on such developments are numerous – and the continuum argument is a contributory factor. In another time, the idea that we are all weak and in need of professional therapeutic advice would be viewed as insulting to the many and unhelpful to the few. The lack of historical analysis, or to be more precise the use of a historical analysis that stops short of adequately analysing the present situation, is itself reflective of a situation in which the self can become the sole reference point. This is one reason why many people who have experienced mental distress and/or psychological intervention get upset when today’s therapeutic culture is criticised. Rather than seeing the widespread embracing of the sick role as a historically specific phenomenon, such critiques are experienced as an attack on the integrity of the self.

In an attempt to avoid such reactions to this piece I shall misquote the singer Carly Simon: ‘You’re so vain, you probably think this article’s about you.’ It’s not – but there is a pressing need to stop blurring the lines between everyday troubles and genuine mental distress.

Ken McLaughlin is a senior lecturer in social work at Manchester Metropolitan University, England. His latest book, Surviving Identity: Vulnerability and the psychology of recognition, will be published in November. (Order this book from Amazon(UK)).