A Cycle of Progressive Infirmity
As I see it, there is a cyclical process at work in society that functions to expand the population of the “mentally ill”, along with the costs of treatment, in an ever increasing degree. In effect, without major changes in conceptions, practices, and policies, we confront a process of exponentially increasing infirmity, with an ever-increasing proportion of the population requiring treatment and pharmaceutical support. To explore this cycle, for analytic purposes we can distinguish among four separate phases.
Phase l: Deficit Translation
We may begin historically during a period in which people begin to accept the reality of “mental illness” and can identify a profession responsible for its diagnosis and cure. Roughly speaking, this historical shift occurred largely toward the end of the nineteenth and the beginning of the twentieth century. During this period standardized diagnostic categories began to emerge, and psychiatry became a recognized profession. Under such conditions, persons who are otherwise anguished or distressed find themselves with potentially valuable resources: experts who can identify (“understand”) their problems and have the means of alleviating them.
Required, however, is a public that is willing to abandon the ordinary language for describing and explaining their problems, and to accept what they believe to be more “advanced,” “objective,” or “discerning” accounts of their lives. One sacrifices such common characterizations as “feeling blue,” “bummed out,” “deeply sad,” “feeling lost,” or “finding life hopeless.” This “profane” or marketplace language of the culture becomes translated into the “sacred” or professional language of mental illness. Sacrificed as well are the associated cultural practices for commonly dealing with personal problems (e.g. personal resolve, conversation with close friends, inspirational reading). It is also clear that there are no principled limits over the potentials for such translation. All problematic behavior becomes a candidate for reconstruction as a mental illness.
Phase 2: Cultural Dissemination
With mental illness now an accepted reality, recognized by both professionals and those under treatment, it becomes a professional responsibility to alert the public to the dangers. The public must learn to recognize the signals of mental disease, not only for possible prevention, but also to learn of available treatment. Such attempts to inform the public range from the mental hygiene movement of the early 20th century, through the recent dedication of $140 million by the Obama administration to identify people with mental illness.
Instructive is the public outreach of the National Institute of Mental Health. The organization provides pamphlets and offers a public website that informs the public that all the following, for example, are indicators of the illness of depression:
A sad or anxious mood
Feelings of hopelessness, pessimism
Feelings of guilt
Loss of interest or pleasure in activities
Difficulty in concentrating or remembering
Inability to sleep
Stomach ache, indigestion, headache
This presentation is instructive inasmuch as it demonstrates the means by which the profane language of the public is re-constructed as mental illness. Everyone can identify weight loss or gain in common terms, for example, but now they are informed that this is only a symptom. What is really wrong is taking place off stage, inside the mind, a domain for which they are not the experts. Why these are symptoms of depression is never made clear. Indeed, why they are defined as “symptoms” at all is an open question. Is weight loss a symptom of something that is not weight loss, or irritability a symptom of yet something that is not irritability? Is it possible, for example, that one could simply become worried over gaining weight, try desperately to lose it, and become restless and irritable at the inability to maintain control. And, after continued lack of success could he or she not develop a sense of guilt and hopelessness? The term “depression” is a questionable accessory, serving to remove the problem from the common sphere and to place it into professional hands.
Phase 3: The Cultural Construction of Illness
As vocabularies of deficit are disseminated to the culture, they slowly become absorbed into the common language. They become part of “what everybody knows” about human behavior. In this sense, terms such as neurosis, trauma, addiction, obsession, attention deficit, autism, and depression are no longer “professional property.” They have been “given away” by the profession to the public. Terms such as split personality, identity crisis, PMS, Aspergers, and mid-life crisis are subjects of daily conversation. And, as such terms make their way into the cultural vernacular, they become available for the construction of everyday reality. Young Peter is not simply “very lively,” but afflicted with “attention deficit disorder; Robert doesn’t simply “hate gays,” but is “homophobic;” and so on. As deficit terms become increasingly available for making the social world intelligible, that world becomes increasingly populated by deficit. Once terms such as “stress” and “addiction” enter the commonsense vernacular of the working person, for example, they become lenses through which he or she can reexamine life and find it wanting. What was valued as “active ambition” can be reconstructed as “workaholic,” the “smart dresser” can becomes “narcissistic,” and the “autonomous and self-directed man” becomes “defended against his emotions.” As we furnish the population with hammers of mental deficit, everyone can be pounded – even oneself.
Nor is it simply deficit labeling that is at stake here. For as forms of “illness” are described in the media, educational programs, public talks, and the like, the symptoms come to serve as cultural models. In effect, the culture learns how to be mentally ill. Consider the spread of “anorexia” and “bulimia,” once the concept of “eating disorders” became publicly recognized. So fully depicted were these “illnesses” by the media that any discontented adolescent is furnished with a mode of expression. Similarly, depression has become such a cultural commonplace that it is virtually an invited reaction to failure, frustration or disappointment. Indeed, if one were to respond to such situations with equanimity or joy – they might be viewed with suspicion.
Phase 4: Demands for Mental Health Services
As people’s actions are increasingly defined and shaped in terms of mental illness language, there is also an increasing demand for mental health services. Counseling, weekend self-enrichment programs, and regimens of personality development represent a first line of dependence; all allow people to escape the uneasy sense that they are “not all they should be.” Others may seek organized support groups for their “incest victimization,” “co-dependency” or “addiction to gambling.” And, of course, thousands enter organized programs of therapy, or become institutionalized. The result has been a steadily expanding demand for mental health practitioners, and a radically expanding supply. Thus, for example, the American Psychiatric Association was founded in 1844 by 13 physicians and hospital administrators. By the end of the century the organization had grown to 377 members. At present there are over 33,000 members of the association almost 90 times the number existing at the beginning of the 20th century. And, of course, the capacity to prescribe drugs for mental anguish now extends to all general practitioners. Further, the number of psychologists providing mental healthcare services has also expanded. Between 1960-1983, the number of psychological health providers per 1000,000 citizens doubled within the first decade; between 1972-1983 it again trebled.
Phase 5: Vocabulary Expansion
The stage is now set for the final revolution in the cycle of progressive infirmity: Further expansion in the vocabulary of deficit. As people increasingly construct their problems in the professional language, as they seek increasing help, and as the professional ranks expand in response to public demands, there are more professionals available to convert the common language into a language of deficit. There are also subtle pressures on the professional for vocabulary expansion. In part, these pressures are generated from within the profession. To explore a new disorder within the mental health sciences is not unlike discovering a new star in astronomy: considerable honor may be granted to those who discover or can provide guidance or cures for “post-traumatic stress disorder,” “identity crises,” and “mid-life crisis.” At the same time, new forms of disorder can be highly profitable for the practitioner, often garnering book royalties, workshop fees, corporate contracts, and/or a wealthier set of clients. In this respect such terms as “co-dependency,” “stress,” and “occupational burnout” have become able economic engines. Nor can one over-estimate the impact of the entry of the pharmaceutical industry into the economic mix. The construction of ADHD, and its application to populations of both children and adults, has unleashed a virtual epidemic of deficit.
Illustrative of the expansion in deficit vocabulary is the expansion of diagnostic categories in the DSM. Prior to the publication of the DSM, there were fewer than 50 common diagnostic terms. As evidenced in the following,
Expansion in DSM Diagnostic Categories*
DSM-I DSM-II DSM-III DSM-IV DSM-5
1952 1968 1980 1994 2013
130 pages 134 pp. 494 pp. 886 pp. ca, 1000 pp.
100 Categories 150 Categories 250 Categories 297 Categories 300+ Categories
*Source: Blech, J. (2013) Wahnsinn wird Normal, Der Spiegel, 4/2013, pp. 111-119.
in the 61 years since its initial publication, the number of ways in which people can be declared ill has increased by 300%.
Toward Infinite Infirming
As I am proposing, when the culture is furnished a professionally rationalized language of mental deficit, and persons are increasingly understood in these ways, an expanded population of “patients” is created. This population, in turn, expands the ranks of the professions, and with this expansion, there is an increase in the number of mental illness terms available for cultural use. More problems are thus constructed within the culture, more help sought, and the deficit discourse again inflates. One can scarcely view this cycle as smooth and undisrupted. Some schools of therapy remain committed to a single vocabulary; others have little interest in disseminating their language; some professionals attempt to speak with clients only in the common language of the culture, and many popular concepts within both the culture and the profession lose currency over time. Rather, we are speaking here of a general historical drift, but one without an obvious terminus.
The results in terms of cultural costs are staggering. There is first the dramatic increment in economic expenditures for mental health. Although mental health expenditures were minuscule during the first quarter of the 20th century, by 1980 mental illness was the third most expensive category of health disorder in the U.S., accounting for more than $20 billion annually (Mechanic, 1987). By 1983, the costs for mental illness, exclusive of alcoholism and drug abuse, were estimated to be almost $73 billion (Harwood, Napolitano, and Kristiansen, 1983). By 1981, 23% of all hospital days in the U.S. were accounted for by mental disorders (Kiesler and Sibulkin, 1987).
Such increases occurred largely before the entry of pharmaceutical companies into the treatment regimens. Here it is noteworthy that the number of disabled mentally ill has increased dramatically since 1987, the year Prozac was introduced . Prozac was touted as the first of a second generation of psychiatric medications said to be so much better than the preceding. Prozac and the other SSRIs replaced the tricyclics, while the atypical antipsychotics (Risperidone, Zyprexa, etc.) replaced Thorazine and the other standard neuroleptics . The combined sales of antidepressants and anti-psychotics jumped from approximately $500 million in 1986 to nearly $20 billion in 2004 (from September 2003 to August 2004), essentially a 40-fold increase. According to the Department of Health and Human Services, between 1997 and 2001 pharmaceutical expenditures grew by an average of 24 percent a year.
Implications for Action
While these may seem to be arguments for abandoning diagnostic categories and abolishing drug treatments, they are neither. It is not their existence that is at the heart of the problem, so much as their increasingly monopoly in defining and treating the population. Indeed, many anguished people are nourished by the knowledge that they are suffering from a recognized ‘illness”, and that there are available pharmaceuticals. And, while we are witnessing a massive increase in the infirming and drugging of the “worried well,” there remains a small percentage of the population for whom pharmaceuticals may be the best option. However, the preceding discussion does put into historical perspective a range of recent critiques of what may be viewed as an irresponsible expansion in both diagnosis and pharmacological treatments (e.g. Carlat, 2011; Horwitz, 2003; Waters, 2011; Whitaker, 2011). In my view, several significant lines of action are invited:
– Inclusive Dialogue. There is an extensive array of stake-holders in issues of human suffering – from those who suffer and treat, to families, communities, religious institutions, activists, insurance providers, and governments. Until now, the dialogues and decisions on such matters have been limited to small and sometimes insular enclaves. Even within the field of therapy, there are many schools and points of view that have been effectively dismissed. Comparatively speaking, there are also nations of the world in which promising alternatives are in motion. The need, then, is for far more extended and inclusive dialogue on creating a more viable and inclusive future. Of specific concern, attention should be directed to:
– enriching the range of perspectives from which to understand human suffering
– unlinking diagnostic categories from third party billing
– restricting pharmaceutical prescriptions
– developing programs to terminate pharmaceutical dependency
– Public Awareness. Thus far the general public has primarily received information that converts the common understandings into mental illness categories, along with promises of pharmaceutical cure. Far more needs to be done to alert the public to the many available alternatives, as well as the limitations and side-effects of common treatment practices.
– Enriching the opportunities. Dialogue should be mounted within therapeutic circles, and the health-care community more broadly, to determine the range of practices that may carry therapeutic value. Such dialogue should also be directed to enriching the range of perspectives from which to evaluate efficacy. Existing competition among schools of therapy not only reduces confidence in the therapeutic mission more generally, but is ultimately detrimental to those who suffer.
Carlat, D. (2011) Unhinged: The trouble with psychiatry – a doctor’s revelations about a profession crisis. New York: Free Press.
Harwood, H.J., Napolitano, D.M. and Kristiansen, P.L. (l983) Economic costs to society of alcohol and drug abuse and mental illness. Research Triangle, NC: Research Triangle Institute.
Horwitz, A. (2003) Creating mental illness. Chicago: University of Chicago Press.
Kiesler, C.A., and Sibulkin, A.E. (1987) Mental Hospitalization: Myths and Facts about a National Crisis. Newbury Park, CA: Sage.
Mechanic, D. (1987) Mental health and social policy. Englewood Cliffs, NJ: Prentice-Hall.
Waters, E. (2011) Crazy like us: The globalization of the American psyche. New York: Free Press.
Whitaker, R. (2011) Anatomy of an Epidemic: Magic bullets, psychiatric Drugs and the astonishing rise of mental illness in America. New York: Broadway Books.