Mental Illness: Who Decides?
by Don Benson, Psy.D. ABPP

We live in an age of enlightenment. We’ve all heard this. Yet, since the Freudian revolution and beyond, it also appears to apply to mental illness. We don’t mistreat those with mental illness in the ways that we once did. We understand it better. We aren’t afraid of the demons that we once felt inhabited these poor souls.

Since the advances in therapy and neuroscience, we have expanded the umbrella of mental illness to encompass all sorts of difficulties in daily living. Clinical depression is so prevalent, that it no longer carries a stigma. The successful and affluent are diagnosed with it, not just the marginalized populations. On one hand, this is a good thing. However, there may be more to the story.

How are mental illnesses identified? Obviously, they’re not discovered in a pathology lab under a microscope. Unlike viruses and cancers, they’re not undeniable physical matter. No, mental illness is based on certain interpretations of behavior. They are basically an arbitrary construction of reality.

These interpretations have been constructed and catalogued by the psychiatric establishment since the 20th century and is compiled in The Diagnostic and Statistical Manual of Mental Disorders (DSM). The current edition is DSM IV-TR. All mental health, medical, legal and health insurance professionals subscribe to this text as the definitive understanding of mental illness. It is given the same credibility as documented medical discoveries in the laboratory.

This is at least a little bit strange, given the method used to construct the DSM editions. Essentially, experts in psychiatry create diagnostic categories and list descriptive criteria that must be met for the person to meet the diagnosis. Usually, a person must meet a minimum number of these criteria. If they do, they have the mental disorder. If they don’t, they are free of it. Once again, mental illness is an invention based on a certain social construction of reality.

This is not to say that this is an invalid method. Treating psychotic behavior (hallucinations and delusions) as mental illness is more humane and makes more sense than demonizing or criminalizing it. If certain drugs and therapeutic interventions help the “psychotic” function more effectively in the community, then it’s easy to see the rationale for the psychiatric interpretation. But it isn’t quite that simple. Many “psychotics” do not comply with their medicine. There are serious side effects and they do not like how the drugs make them feel. Some “psychotics” may be reluctant to give up their delusions and hallucinations. They may prefer their reality to the appropriate reality of the establishment.

There are notable reasons to suggest that the psychiatric interpretation of how reality should be defined and even enforced has gone too far. In no small part, economics has driven the widening of the umbrella. Anyone that gets therapy must have a diagnosable disorder if it is to be reimbursable through health insurance. Most insurance companies will not even cover marriage therapy, since this does not signify a mental disorder. In addition, pharmaceutical companies are shameless in their aggressive direct advertising to the consumer. They take liberties with claims of their anti-depressant and anti-anxiety medications, shaky at best, by suggesting the likelihood of a mental disorder as well as its eradication by taking their latest designer drug.

This anti-depressant issue deserves further examination. Research suggests that placebo effects are quite evident with these drugs. Placebos are basically sugar pills, the tendency for people to feel better because they believe they are being helped apart from any actual therapeutic effect. Furthermore, anti-depressants have been found to be more effective with profoundly depressed subjects than with more moderately depressed individuals, euphemistically called the “worried well”. This would certainly be worrisome for the pharmaceutical industry, who would not want to see its population base, and thus its profits, shrink. So, they espouse the benefits of their drugs for a broad range of ailments along a continuum from mild to severe.

Ultimately, it is sometimes difficult to distinguish significant emotional maladjustment from the challenges of the human condition. This line can move in both directions depending on the person or authority in question. While there aren’t simple answers to the issues discussed here, it behooves us all to reflect on the industries that peddle their constructions of reality, and the likelihood of how much of this is driven by personal gain. At the very least, we can stop swallowing their messages in a wholesale manner and develop a more discriminating and critical response to what they want to offer us.