ABOLISHING THE CONCEPT OF MENTAL ILLNESS In Abolishing the Concept of Mental Illness: Rethinking the Nature of Our Woes, Richard Hallam takes aim at the very concept of mental illness, and explores new ways of thinking about and responding to psychological distress. Though the concept of mental illness has infiltrated everyday language, academic research, and public policy-making, there is very little evidence that woes are caused by somatic dysfunction. This timely book rebuts arguments put forward to defend the illness myth and traces historical sources of the mind/body debate. The author presents a balanced overview of the past utility and current disadvantages of employing a medical illness metaphor against the backdrop of current UK clinical practice. Insightful and easy to read, Abolishing the Concept of Mental Illness will appeal to all professionals and academics working in clinical psychology, as well as psychotherapists and other mental health practitioners. Richard Hallam worked as a clinical psychologist, researcher, and lecturer until 2006, mainly in the National Health Service and at University College London and the University of East London. Since then he has worked independently as a writer, researcher, and therapist. ABOLISHING THE CONCEPT OF MENTAL ILLNESS Rethinking the Nature of Our Woes Richard Hallam First published 2018 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2018 Richard Hallam The right of Richard Hallam to be identified as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book has been requested ISBN: 978-1-138-06764-6 (hbk) ISBN: 978-1-138-06313-6 (pbk) ISBN: 978-1-315-16124-2 (ebk) Typeset in Bembo by Keystroke, Neville Lodge, Tettenhall, Wolverhampton CONTENTS Acknowledgements vii 1 Introducing the issues 1 2 Thomas Szasz and the myth of mental illness 22 3 ‘Mental’ and ‘bodily’ causes of woes: a brief history 43 4 ‘Major depression’: the creation of a mythical disease 57 5 Agency, rationality, and the concept of mental illness 80 6 Medicalisation: resistance or replacement? 103 7 Well-being and mental health 124 8 A future without the concept of mental illness 144 Index 171 ACKNOWLEDGEMENTS I am grateful for the astute comments and editorial suggestions of Glenn Shean, Chris Lee, and Gary Brown on early versions of the manuscript, and for innumerable conversations with other colleagues and friends. 1 INTRODUCING THE ISSUES Absurd! How can you abolish mental illness? I used to have a mental health problem myself. My great-uncle spent years in an asylum and he was definitely insane! The title of this book invites the reader to question the meaning of words in common use and to imagine a future in which we stop referring to mental illness. We have given up thinking about people as being ‘possessed by the devil’. Perhaps it is time to think differently about how to describe and explain the causes of our woes. At present, we seem content to leave it to experts to declare whether or not we are ‘mentally healthy’. The bleak terminology of mental disease or illness is reserved for rather obvious departures from ‘mental health’, but the idea of patho- logy is still present in watered-down terms such as ‘psychological disorder’ or ‘mental health issue’. Mental health professionals may rely on little more than answers to a questionnaire measuring ‘psychological symptoms’ to justify giving out a diagnostic label. If a problem seems to be a ‘serious’ one, a person’s suffering or difficulties will be matched against criteria set out in manuals for diagnosing ‘psychiatric illness’. The idea that the ability to live well has something to do with health and illness has infiltrated our social institutions to a remarkable degree. We have been invited to suppose that ‘mental illness’ is illness, in other words, like a physical illness, some- thing that we either have or don’t have. Mental ill-health encompasses a huge range of undesirable states of being, personal failings, and unacceptable behaviours. I will refer to them using the generic word ‘woes’, without assuming that the latter share anything in common with respect to their causes or how the woeful person experi- ences them. Rather than adopt the phrase ‘a problem in living’, which implies a problem for a particular person, I have chosen the word ‘woe’ to refer to a state of affairs that is social as well as personal. In its archaic use, a woe was a lament about 2 Introducing the issues being afflicted, wretched, or mournful. The thesis of this book is that woes have been medicalised, and recommends that we abandon the concept of mental illness, and imagine a future without it. This thesis is easily stated but immediately stirs up many questions. In this chapter, I set out the principal issues covered in the rest of the book. It needs to be said straight away that, more than fifty years ago, the psychiatrist Thomas Szasz declared that mental illness is a myth (Szasz, 2010 [1961]). I have therefore devoted a chapter to an analysis of his ideas and the arguments that critics have put forward to rebut them. The opposition Szasz encountered did not simply amount to a spat amongst academics and professionals. The debate about mental illness as a myth goes much deeper than this because a connection between health, illness, and woes has existed in ordinary speech for millennia. Although the concept of mental illness is ancient, it competed with beliefs in divine intervention, witchcraft, and sorcery, which have now largely disappeared in Western societies. The phrase ‘mental illness’ is now so commonplace that it is assumed to describe a literal state of affairs rather than constituting an explanation. In brief, it attributes a woe to something amiss in the mind or body of a woeful person. In Chapter 3, I explore the historical origins of this myth. What, then, does it mean to locate the cause of a person’s woe in their dysfunc- tional mind or body? Definitions of disease and illness are controversial, and so this question is not easily answered. However, few people seem to dispute the idea that ‘mental illness’ is a matter of ‘health’. Governments see it as one of their duties to look after the health and welfare of their citizens, and the conceptualisation of woes as illnesses has been accepted across all strands of political opinion. Provisions for ‘mental illness’ form part of services for physical health and social welfare. I will argue that the concept of mental illness is an example of the medicalisation of woes, and that this has led to mystification about causation, misdirection of efforts, and, on occasions, has usurped human rights. The final chapter of the book critically evaluates the role played by a concept of mental illness in policy documents published recently in the UK. Mental illness as myth Thomas Szasz’s belief that mental illness is a myth was vigorously contested. He restated his position shortly before he died (Szasz, 2011) and this invoked a scornful commentary (Shorter, 2011), illustrating how little influence Szasz exerted in some quarters of psychiatry. Shorter dismisses the ‘weasel word’ disorder and places his money on disease. Other experts also express themselves in the uncompromising language of disease. Morgan (2016) states that ‘depression is a common and crippling disease’, even though he accepts that it ‘may be a response to bereavement or other life events’. Szasz’s thesis has been rejected for various reasons. One argument is that mental illness has always been with us, and that we can clearly trace its presence in ancient literature. Another is that no meaningful distinction can be made between diseases of the mind and body, and that the criteria for declaring someone physically ill are Introducing the issues 3 essentially the same as ones that define mental illness. Other critics believe that the causes of problematic behaviour must lie in defective genes or diseases of the brain, even though we have not yet discovered them. It is assumed that once we understand the neural basis of mental functions, we will be in a position to define and explain mental illnesses. None of these objections to Szasz question the concept of mental illness itself. It is as if our woes and suffering must be illnesses because there is nothing else they could be. The idea is so firmly lodged in our way of thinking that to challenge it seems childishly provocative. Belief in the mythical status of mental illness is quite compatible with an assump- tion that there is a biological basis to all behaviour and so, in principle, it is possible to reduce all explanations to bodily processes. However, in order to establish solid grounds for describing woes as illness, it needs to be demonstrated that bodily func- tions deviate (i.e. function differently) when they serve ‘normal’ and ‘distressing or problematic’ behaviour.