The tyranny of mental health
The concept of mental illness turns problems into conditions.
‘Mental health’ is a phrase everybody uses without thinking. Yet when we subject it to critical analysis, we can see just how slippery a term it really is. It is a term that reduces and reifies human experience to simple categories of good and ill health.
Before criticising the idea of mental health, it’s important to state that to do so is not to diminish or denigrate the mental distress that many people do indeed experience. My aim, rather, is to show how the use of the category of mental health actually detracts from the real suffering of people.
Today, political activists from all political persuasions often campaign for more or better mental-health services, especially the expanded provision of cognitive behavioural therapy (CBT). It is simply seen as a good thing. There is almost no interrogation of the concept of mental health from a critical psychoanalytical or philosophical perspective. The uncritical acceptance of the idea of mental health has damaging consequences.
Chiefly, the mental-health agenda forces people to think of the problems they experience, alienation or estrangement from their work and life for example, as purely psychological problems. This is compounded and perpetuated by the discipline of psychology itself, which purports to be a neutral science. As Svetlana Boym argues in Another Freedom, psychology, rather than contesting the states of alienation and confusion, exacerbates these states, and celebrates them in a positivist ‘carnival of inauthenticity’. Indeed, alienation from ourselves is positively encouraged through psycho-biological frameworks (including genetic theories), which permeate the discipline of psychology and dispute and destabilise ideas of free will and responsibility.
The crucial problem with psychology and its contemporary underpinning, the idea of mental health, is that it views human beings as, essentially, machines. And machines, as everyone knows, become faulty and need fixing. By reducing human beings to machines in this way, so that discontent, estrangement and so on are seen as forms of mental ill-health, the institutions of psychology shore up the status quo. They present the acceptance of the status quo as good mental health.
Allen Francis, who, in 1994, was the lead editor of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the book that gives our present culture the labels we use when it comes to mental health, was himself highly critical of the validity and reliability of these labels when they appeared in the fifth edition of the DSM in 2013. Francis contended that if the method of DSM-V disorder creation was to be used for the categorisation of physical disorders, the medical community would reject it.
The disorders identified in DSM-V are based not just on research, but also on the decisions of assorted committees. That’s because practitioners cannot decide with any consistency who is suffering from a disorder. A good example is schizophrenia. Research shows that barely half of psychiatrists and practitioners schooled in the medicalisation of mental disorders believe that schizophrenia is a categorisable condition. And little wonder: schizophrenia is a hypothetical disorder for which no medical tests or consistent criteria for diagnosis exist. Instead it is a category created by committee. Worse still, the operation of these committees is heavily influenced by the pharmaceutical industry.
It needs to be understood that there is no good evidence to suggest that there are any biological deficits, genetic abnormalities, or chemical imbalances related to mental ill-health or mental disorders. The evidence base for mental illness is very poor by scientific standards. There are no medical tests a physician can give you to test for a mental illness. Like the poor science underpinning the taxonomy of mental disorders (DSM-V), psychometric tests for mental-health problems do not validate the truth of having a so-called mental disorder. Mary Boyle’s research into the idea of schizophrenia, Joanna Moncrieff’s critique of so-called biochemical imbalances, and Herb Kutchins’ and Stuart Kirk’s work on the mythology, nosology and taxonomy of mental disorders, show well enough that the cultural hegemony of mental health from a medico-biological and scientific perspective is on very shaky ground, supported, in the main, by drugs companies (1).
The advent of the UK’s state-sanctioned improved access to psychological therapies programme (IAPT), which makes CBT more widely available, is primarily designed to get people back to work, functioning well enough to fit in with capitalist and neoliberal ideas of normality, positivity and wellbeing; any critical questioning of mental health by patients or workers has no place in such a system.
The Department of Work and Pensions is even now using CBT and other psycho-coercive techniques to get unemployed people back to work. This latest development sanctions the idea that the fault for being unemployed lies with the individual, not with the political and economic conditions that create unemployment. Furthermore, there is more and more evidence accumulating that CBT is nothing more than a quick fix. As outlined by psychologist Jonathan Shedler in 2015, in controlled scientific studies the positive effects of CBT one year after treatment has ended only endures in five per cent of recipients (2). In essence, the hypnotic effects of willing oneself to see the positive wears off.
The problem is that the whole edifice of CBT rests on a mystification. One of the tenets of CBT is to target dichotomous thinking; in other words, to help people out of black-and-white thinking. For example, I am unsuccessful and other people are successful, or I am a failure and other people are not failures. However, theoretically, CBT is itself built on a dichotomy. It is built on the foundation that there is such a thing as mental ill-health and good mental health, or wellbeing, and that there is a ‘good’ way to think and a ‘bad’ way to think. This is a philosophical tautology that infects the very nature of the context in which CBT is delivered and received. Is it not possible that rejecting the theoretical tenets of CBT’s dichotomous thinking, or, better still, the concept of ‘mental health’, could be a positive thought that ameliorates depression?
The happiness demanded by the so-called radicals of mental-health campaigns buys into the capitalist and neoliberal imperative of the well-adjusted, adapted individual, alienated by the modern metaphysics of the self. Our modern state of being, of becoming increasingly unhappy and distressed (not mentally ill), is no doubt created by economic conditions. But it is also a result of the pathological inability to enjoy the myriad satisfactions offered to purchase, or life statuses we are encouraged and tempted to acquire in contemporary society. The psychoanalyst Jacques Lacan was very cognisant of the fact that the modern demand for happiness, and the existence of the happiness/mental-health industry, implies the ultimately unsatisfying nature of customer satisfaction. And he was also aware of the symbolic underpinnings of demand itself, which implies a surplus of excess. That is, happiness is created and articulated through language. As such, it is promised everywhere, but the demand for it overshoots itself, precisely because it is not something that can be obtained under the terms of neoliberal capitalism. But the many marketing and ideological ploys of capitalism would have you think otherwise.
So the next time there is a mental-health campaign we would be prudent to recall and heed these sensible words of Lacan:
‘The aspiration of happiness will always imply a place where miracles happen, a promise, a mirage of original genius or an opening up of freedom, or if we caricature it, the possession of all women for a man, and of an ideal man for a woman. To make oneself the guarantor of the possibility that a subject will in some way be able to find happiness, even in psychoanalysis is a form of fraud.’ (3)
Bruce Scott is a psychoanalyst, based in Jedburgh and Edinburgh. He is a member of the Philadelphia Association and College of Psychoanalysts-UK, and the author of Testimony of Experience: Docta Ignorantia and the Philadelphia Association Communities (PCCS, 2014), and contributing author to RD Laing: 50 Years Since the Divided Self (PCCS, 2012).