Hello, my name is Phil, and I don’t know what mental illness is.
I have an MSc in Counselling Psychology, work full time as a counsellor, and I don’t know what mental illness is. Neither do I know how it differs from mental health. I have a vague, felt sense of what these terms mean, but I don’t know.
Now admittedly, the ‘psychology’ aspect of my MSc wasn’t the kind that has lab rats and Big Brother body-language experts all that, but still, you’d think someone who’s qualified to work with people who are suffering from mental distress (there’s another ambiguous term to throw into the mix) might have a firmer grasp on such basic terms as ‘mental health’ and ‘mental illness’.
But I don’t. Neither do I really understand how ‘mental illness’ differs from ‘madness’ or ‘insanity’, or what place ‘wellbeing’ takes in relation to them.
Sometimes I feel bad about this, and worry that I’m alone in my confusion – that I’ve missed the obvious distinction which everyone else was told about while I was in the toilet. But most of the time I think we’re all just operating in the dark. If you listen to people talk and write about any area of mental health there’s a real muddled mishmash of terms and attitudes which, to me, betrays a fundamental incoherence in the way that mental health/illness is understood both by the professional and the layperson.
Part of the problem is that the world of counselling is a bit scared of ‘proper’ mental illness – the kind we meant when, as politically-incorrect children we talked about people being ‘psychos’ or ‘mental’. We counsellors often shy away from a world we’re taught to see as too serious for our woolly skills (and too physical in cause). Some of us believe that we can help people with ‘proper’ mental illness deal with their problems, but the overriding discourse says that, at a certain point, we have to pass these people on to the big boys: the psychiatrists with the ability to prescribe and to section.
So there’s a whole big chunk of people who deal in mental health but feel they are not permitted to talk about the ‘real’ part, only the minor versions around the edges. And that in itself is symptomatic of the way that mental health and mental illness are (not) spoken about. We’re always banging on about destigmatising mental health issues but there’s a big stigma – a taboo – about deviating from this woolly, all-embracing, muddled approach to mental health [there’s the opposite taboo too, which I’ll deal with below].
There’s a taboo, in other words, about being clear about mental health and illness. A taboo which comes from a good place – not wanting to say something offensive about someone who is vulnerable – but whose effect is emphatically not good. By not speaking clearly we help no-one, in the long run, and we counsellors in particular make reduce our relevance and our stake in the argument to define what counts as mental health. In the interests of clarity, then, here are some of the things I’ve come across recently that have confused me:
Mental Health = Mental Illness?
A little while ago [ed. quite a while now, I’ve redrafted this many many times, and held off on pressing ‘Publish’ because breaking taboos is scary] there was a knife attack in Russell Square. Initially it was thought to be a terrorist attack, but the next day on the radio I heard your man from the police saying that it wasn’t terrorism what done it, it was a mental health problem.
I sat up at that phrase. Mental health?
Without ever explicitly working it out, I think I’d always associated mental health with the softer end of the spectrum – the kind of thing we feel confident to deal with as counsellors: anxiety, distress, questions about purpose and meaning, that kind of thing. I’d linked it subconsciously with things like ‘wellbeing’ – with the everyday kind of things people mean when they say that 1 in 4 of us will experience mental health issues at some point in our lives. Stuff within the normal range of human experience. Not stuff that would lead you to kill a stranger with a knife.
That kind of thing I always, unconsciously, thought of as mental illness. Mental illness which was seen, when I was young (and is still in the tabloid press) a kind of bogey-man; the kind of thing that the headline writers want you to think when they say ‘mental patients’ in front pages like the one on the right.
Mental illness = madness?
When we were children, the people we referred to as ‘mental’ were the same people we’d call ‘mad’. So is mental illness the same as madness? Is one a subset of the other? Clearly in The Sun’s mind ‘mental patients’ = ‘mental illness’ = ‘mental’ = ‘mad’, in the old-fashioned sense of the word. Mental patients are killers – the kind of people whose behaviour or thought is way beyond anything a normal person could understand. Where should we stand in relation to this running-together of madness and mental illness?
On the one hand, it’s pretty reprehensible, I think. It deliberately links all manner of mental illness with threats to your (children’s, granny’s) safety with no factual basis. It plays to an inaccurate picture in order to marginalise vulnerable people in order to sell papers.
But on the other hand, the everyday language notion of ‘mad’ or ‘insane’ is less obviously reprehensible. It is hard not to think of someone who deliberately stabs a stranger as insane, almost by definition. Their actions and thoughts are so far outside the normal range of human experience that they are ‘beyond’. So does ‘mad’ mean the same as ‘mentally ill’?
Clearly they’re not co-extensive – there’s people who we describe as suffering from a mental illness whom we wouldn’t want to say are mad. Those suffering from major depression, for example, I wouldn’t want to describe as mad, but I would want to describe as suffering from a mental illness. But there is a subset of those we define as mentally ill who would also be judge ‘mad’ in normal language: those suffering from paranoid schizophrenia, for example, or experiencing psychotic delusions.
We seem, then, to have a continuum which runs from wellbeing at the softest end (where “we all have mental health” [which, if I’m being really cynical, seems to mean we all have emotions], through mental health, which bleeds messily into mental illness, which at its extreme is madness – the kind you can get sectioned for.
Now it may be that the policeman who set this all off just misspoke: he meant mental illness (the type that is co-extensive with madness), but said mental health. But even if he did, his misspeaking betrays a muddledness which lies just under the surface of the way we talk about everything on the continuum.
This muddle is partly borne of the fact that it’s not at all clear who decides how it works or what standards should be applied along its length – there are no authoritative authorities to defer to. And it’s made worse by the many taboos and fears in this area, which mean that we all discuss the continuum in murky, euphemistic and underhand ways.
I’ve tried to get clearer in my mind by slotting the different parts of the continuum together:
- At the softer end we have a focus on the societal causes, as in the myriad articles and reports focusing on the pressures on Young People from social media and schools and adverts and models and so on. You also see it in the articles which address the way that we organise our working lives, arguing that better mental health (sometimes ‘wellbeing’) could be encouraged through more humane working practices. Individuals are encouraged at this level to take responsibility for their mental wellbeing/health, by seeking out counselling or rearranging the furniture of their lives. Society around them is encouraged to make space for this, as their needs are, in some sense, normal.
- As we move down the continuum we encounter those issues which counsellors typically feel justified in dealing with – relationship crises, mental distress (a very strange term which I see popping up more and more), obsessive behaviour, minor depression, PTS, generalised anxiety, that sort of thing. In all of these the individual is held to be capable of repairing themselves in the right relationship, though the doctor might need to be called to medicate if the intensity gets too high. Notice, though, how already the focus has switched from society to the individual. There’s much less written about how the workplace can change in order to support those dealing with OCD, for example. Instead the rhetoric here is all to do with destigmatising: these people are still normal; they’re just a bit out-of-sorts. They’re still held to be responsible for sorting themselves out, but they’ll need someone to support them through the process.
- Further down the continuum you find mental illnesses of a kind that most counsellors are afraid to work with, and most friends and relatives might consider themselves unable to deal with alone. At this ‘harder’ end you find major depression, psychoses, personality disorders, PTSD – that kind of thing. These people are less ‘normal’, and less responsible for their situation. Neither society nor the individual is held to be in any way responsible for the cause or the solution. Instead the cause is defined as genetic or chemical, their distress is made private, and the treatment imposed.
On this continuum, then, responsibility, agency, and normality are key factors. They are, in the way I’m picturing it, proportional to one another: the more ‘normal’ your experience, the more responsibility you have to sort it out yourself, and the more agency you are taken to have in doing this. The less normal your experience, the less you are seen as able to sort it out, and the less responsibility you are expected to take in doing so. In addition to this, you can add social responsibility, which is also proportional: if the individual’s needs are ‘normal’, we as a society are obliged to help them out in our everyday lives. If their needs are abnormal, we are under no such obligation.
The bleeding continuum
What seems to me to be happening now is that each part of the spectrum is bleeding into the other. The DSM-inspired hard end is encroaching on the softer middle and even the soft end, as the language of mental illness (symptoms, chemical causes, medical treatments, parity of esteem, little individual responsibility or agency) spills into the way we describe less-extreme forms of mental health issues. This comes largely from the ‘experts’ who have a vested interest in turning ever larger numbers of people into patients, and use the DSM to achieve this. But it can also be seen in the way that us woolly liberals advocate for more and more expert mental health provision at all levels. While this is done from noble intentions, the effect is to imply that even lower-level problems need to be sorted out by experts, and that these problems are not the responsibility of the individual or the system they’re a part of. For example, the response to increasing levels of childhood depression has been to bring more mental health services (=, in many cases, more drugs) into schools, instead of encouraging us all to see these problems as ‘normal’ and so seeing society as responsible for changing the system that creates depression in children.
And then there’s the backlash to the hard end’s relentless march, as in this kind of headline, which seeks to reclaim mental illness as softer than the hard-end see it. They seek to limit the extent to which the common-person’s conception of mental health/illness is shaped by those at the extremes. Without wishing to get too deep into the oneupmanship of the ‘they’re not Muslims, they’re insane; they’re not insane, they’re men; they’re not men, they’re evil; they’re not evil, they’re let down by our cultural pessimism‘ Officer-Krupke bullshit, there’s an important re-balancing of the continuum away from the hard end here. Headlines like the one on the right argue that we need to push back at the definition of ‘madness=extreme mental illness’, so that those who are closer to the soft end don’t get infected by the fear created by headlines like the Sun’s.
That is, the soft end (woolly liberals) have argued successfully that lots of people at the soft end should be seen as mentally ill so that they can get treatment, and are now biting back at the hard-end because there’s a risk these people might be re-stigmatised by the focus on ‘mad’ people. This rebalancing is vital (though it could all have been avoided if we’d come up with a different term for low-level mental illness in the first place), but because it’s being done with a sloppy attention to detail, it all ends up feeling confused and unhelpful.
Take, for example, the article on the left. One bit of beef I have with headlines like these is that they focus an awful lot on stigma and an awful little on truth. In the call to stop calling terrorists mentally-ill (which was only done because they wanted to stop calling them religious), there’s very little interest in finding out if they actually are mentally ill. Regardless of stigma, if they are mentally ill, then failing to call them that is a regressive and unhelpful kind of self-censorship. In actual fact, the article concerned is quite well-argued: the author explains that there are many contributing factors to terrorism – that you need to take into account cultural, social, and individual purpose factors to understand how someone becomes a terrorist. In amongst all of this, though, he admits that mental health is a contributing factor, so clearly terrorism is in part a mental health issue, as well as a cultural issue, a social issue, and an individual issue. In his laudable desire to combat the way that mental illness is demonised by the tabloid press, he ends up openly contradicting himself and making an argument that will not change anyone’s mind. This kind of muddle will not help anyone, in the long run, and is intellectually dishonest.
More recently, articles concerning Donald Trump’s mental health have played the same back-and-forth game as ‘experts’ ‘diagnosed’ Trump with various conditions, and then were backlashed by those who argued it was wrong to equate evil/stupidity/meanness with mental illness. Neither side were particularly concerned with the truth of the matter: the experts wanted some official way to mark Trump’s idiocy, while the backlashers were scared that mental illness was getting yet another bogeyman added to their number. Truth, here as elsewhere, mattered little to either side, and so we ended up getting even more muddled.
Another area of much muddle is in the constant call for reducing stigma.
I wrote about stigma a little while ago. I’m not entirely sure stigma is a bad thing. And I think a big part of my problem with the anti-stigmatas is precisely the sliding scale I’ve been banging on about. I think stigma at the softer end is by-and-large a bad thing. The fear or shame which holds someone back from talking to their GP about minor depression or anxiety, for example, is helpful to no-one. In the middle of the scale it’s less clear: stigma here has bad effects but might also provoke action (for example, the person who seeks professional help when they hear voices, in part because they know that if they told their friends they’d probably not understand). And at the furthest reaches, it’s hard to imagine why a society wouldn’t want to say that madness is not a good way to be, and society saying that it’s not a good way to be will, in someone who feels that way, induce a feeling of stigma.
When we talk about reducing stigma we’re almost always aiming our comments at the vast majority of the 1in4 who will experience a mental health issue this year. The vast majority of them are experiencing more-intense forms of the problems that everybody face: stress becomes free-floating anxiety, feeling down becomes depression, comfort eating becomes an eating disorder. These are the things that we don’t want to stigmatise, but the reasoning is wrong: we shouldn’t, as is so often argued, destigmatise them because they’re analogous to physical illness, we should destigmatise them because they’re part of the normal picture of human life – just a more extreme version. They should be destigmatised because that’s a more caring and humane way to approach them, and one which will benefit all of us as we change society to make them less likely to happen.
The other side of mental illness – personality disorders, or ‘madness’ as folk psychology knows it – is a different case. Here, we should aim to destigmatise to the extent that this helps people who are suffering take less personal, moral responsibility for their problems. But we should also make clear that these experiences are outside of the normal expectations of human life. These are like physical illnesses. But with this de-agenting (to reduce stigma) we also strip away humanity. These are high stakes to play with, and the bleeding of the analogy-with-physical-illness argument into the lower levels of mental illness is not helpful: applying the same reasoning to the 1in4 is silly and harmful and confusing.
In fact, this misplaced analogy risks stigmatising normal experience, by putting it within the purview of mental health rather than putting the responsibility on the individual and on society to make conditions more amenable to a good life. For example, one reason that someone with low-level mental health issues may feel more stigma in coming forward to seek support is precisely because higher-level mental health issues have been destigmatised and put in the same category as theirs. The same person may previously have sought changes within their relationships and habits (i.e. taken agency and responsibility for themselves) but will now be encouraged instead to privatise their distress, rendering it the responsibility not of society but of professionals.
I starting writing this six months ago, and have struggled to come up with anything coherent. I apologise for this. If you’ve made it this far, thank you for your patience.
Normally I can’t stand it when people publish things that are unedited or confused or badly-argued, and then apologise for them. It’s better not to put them up at all, until you’ve done a decent job.
But in this instance I’m making an exception, because I’ve spent months sporadically trying to put this into shape and I just can’t: partly this is because I don’t have the intellectual chops I used to, but I think it also reflects the muddledness inherent in the subject matter. It’s so confused there’s nothing to do but be confused. I don’t have a pithy conclusion, but I do feel this is really important. The only way out of the muddle, I think, is to talk openly and honestly about what we all make of mental health / wellbeing / illness / madness and try to come to a better understanding of how we, as a society, want to understand them.