Mental health and illness in traumatic times
More and more, the popular media are often transforming societal issues and wounds into individual problems. Every time someone shoots up a school, threatens or attacks a public figure, the public voices shout, “mental illness” and initiate a search for early individual problems that should have been a sign to others of events to come. Yet, over and over, we are also told that “He seemed normal to me. Maybe just a little quiet and withdrawn.” More recently, we are told of radicalization by some sort of cult or terrorist group. Are these individuals mentally ill and, are their acts a consequence of this illness?
The insistent and life-changing presence of Covid in the last two years, perhaps more than any other event in recent memory, is also being implicated as a cause rather than an effect of individual mental illness. So many are suffering not just from physical illness, but from anxiety, depression and other psychological effects of isolation, and fear of contamination. Psychologists and psychiatrists, along with other mental health professionals, may hold the key to alleviating such suffering, but do we? Can we provide understanding and relief?
Yes, Covid has had more psychological fallout than any of us knows yet, much of it is delayed. We call it anxiety, depression, or trauma. But what do these words really mean? We must pause and ask a few important questions such as, “What is mental illness?” and “What sort of relief can mental health practitioners offer?”
It is time then to examine the foundation of this idea and to ask directly, “What is mental illness?”
This question is alive and well among psychologists, researchers, and practitioners alike. Criticism has come from feminists, philosophers, and practitioners of non-medical approaches. Yet the mainstream idea of mental illness persists among the public and within the popular media and does not easily yield its prominent position. In fact, the current diagnostic manual for mental health practitioners (DSM-5R) has been a New York Times best-seller in recent years.
In this way, complex societal problems are reduced to individual ones; morality is replaced with medicine, appropriate fear with anxiety and depression and little or nothing changes in the larger world.
Each of us turns to our own private practitioner or therapist, isolating us even more from each other and from more appropriate solutions to societal problems.
That is, societal problems demand societal solutions. Diagnosing and even medicating individual reactions not only doesn’t address the issue at hand but actually perpetuates the problem.
Of course, it is the case that each of us reacts to stress and wounding in our own personal way and through the lens of our own personal experience. But is this reaction, metabolizing social context into personal experience, deserving of the name mental illness? Yes, we distract from social problems with personal explanations, but what else do we implicitly accept when we turn to mental health as a goal, mental illness as the problem? We are invoking what is known as the medical model. Let’s see just what that model entails. And so, I ask the first question:
What is a psychological diagnosis?
The official diagnostic system presented in the Diagnostic and Statistical Model (DSM-5R), the book known as “the bible” of psychiatry and clinical psychology, draws historically and currently from the medical model. That is, the principles known to define physical medicine are applied metaphorically to psychological conditions. By use of this sleight of mind, suffering becomes an illness to be cured by treatment of an expert practitioner.
The use of metaphor makes this approach more literary than scientific, but this point is often lost in translation. There is much less empirical scientific support for the concept of mental illness than the public realizes. What is known is a result of contemporary neuroscience and is a result of technological advances that permit observation of some of the functions of the brain itself. This information was not available when the medical model was first proposed and imposed, but is coming from current neuroscience and its limited ability to spy technologically on the brain in action. These data may eventually provide a new approach to psychological diagnosis and treatment, but so far are not the basis for medical treatment and certainly not for the therapy or use of medication involved.
Even within the confines of the medical model, there is an important distinction to be made between illness and injury that is generally overlooked. I and other critics of this approach have been calling for this important distinction for decades now (Kaschak, Engendered Lives, 1992). One response to this critique has been the development of the field of Trauma and the acknowledgment that extraordinary injury has its effects and differs from illness. The field of trauma and recovery (Herman, Trauma and Recovery, 1992) was first introduced in the 1970s as a response to the severe and seemingly intractable psychological problems of returning veterans of the Vietnam War (known as the American War in Vietnam). Feminist psychologists and psychiatrists were able to lobby and pressure the American Psychiatric Association into including female traumas, such as rape and other violence against women, to be included in this emerging diagnostic category.
It is important to note that the success of this feminist political endeavor was made possible by the fact that diagnoses are not developed empirically but are added to the DSM by a majority vote of the members of the American Psychiatric Association. That’s right. Not by scientific discovery, but by popular vote. To return to the model and the metaphor, imagine for a moment that medical diagnoses were also made this way. Could we then simply vote out cancer or diabetes instead of curing them? Of course, this idea is absurd, so then why is it still being used by psychiatry?
Yet, I don’t want to oversimplify. Of course, psychiatry has been trying mightily to add empiricism to its approach, but so far with limited success and without questioning the basic model thoroughly. In service of that goal, the newer edition of the DSM proposes a statistical analysis to strengthen the medical, introducing the term “disorder” to replace “disease.” Still, these are not individual disorders at all, but flow in a direct and orderly way from certain wounds. They are injuries, not illnesses. If you came upon someone lying in the street bleeding, wouldn’t it make a difference if he had hemophilia or had just been stabbed? This is the difference between mental illness and injury.
Diagnosis also ignores or, at best, freezes and eliminates time. In other words, you are looking at a snapshot rather than a video. It also eliminates the complexity of the individual and social contexts. Every experience occurs in the full context of who the individual is, what her prior experiences have been, and within the fullness of her social context, including but not limited to gender, race, ethnicity, religion, social class, financial situation, etc. Also, the times in which one lives matter. For example, being a lesbian or gay person is a very different experience in 2022 than it was in 1952. Being Catholic in Costa Rica is quite different from being a practicing Catholic in San Francisco. Medical diagnosis is viewed out of time, generation and other aspects of the individual or the social experience.
The same trauma is metabolized differently by different individuals. Another way of saying this is that individual experience cannot be collectivized, and any attempt must inevitably destroy the texture of that experience and so its resolution. Making the subjective objective, by reducing it to categories, ultimately fails because categories necessarily eradicate differences.
What is the role of medication?
I ask this question to expose the fact that it is, by custom and thought, fully implicated in the first. If problems are medical, then, of course, solutions can and should be medical. What happens when we separate these two questions and expose them to some light?
Let’s consider then the second question. Physical medicine relies on just that, medication as a primary solution. Early on, penicillin cured bacterial diseases. Other medications cured other diseases. Does any medication cure any mental illness? No. Perhaps there are analgesics, temporarily permitting suffering to subside. Is this because big pharma has not yet discovered/invented them or because brain disorder is only one kind of psychological issue? Or are there no cures because suffering is not a disease?
It is often said and taken as fact that medication treats an imbalance in brain chemistry. This is not a fact and not a result of contemporary neuroscience. It is instead an idea, a proposal, a metaphorical guess as to why psychotropic medications create the changes that they do when they do.
The actual use of these medications involves a great deal of guesswork and trial and error in each individual case. Medication to “treat” anxiety, depression or even psychosis is not penicillin. They cure nothing. Sometimes they ameliorate some of the pain and suffering, usually temporarily, and with a great cost paid in the currency of side effects. In essence, we are medicating human suffering as if it were a mere infection.
It is time to look beyond the medical model for solutions to human problems and suffering. It is time to replace metaphor and medication. It is time to stop seeking “mental health” and misnaming wounds as illnesses. Some of these very orderly “disorders” are, in fact, inevitable as we are exquisitely sensitive creatures thrust into an often brutal world, an inevitable mismatch of self and context. Societal problems cannot be solved by individual solutions and especially not by medicalization. It is overdue to replace the idea of mental illness with a fuller and deeper understanding of human suffering, its real sources and its potential amelioration.