The question that makes up the title of this post is one of the most controversial in the field of mental health. It has been in the air again recently with this post from PsychiatrySHO and this one from Monica Cassini at her Beyond Meds blog.
It’s a clear question, at least syntactically, apparently demanding a simple “yes” or “no” answer. Unfortunately that straightforwardness is entirely deceptive. In order to answer it in an interesting way we need to stay constantly alert to the shifting meaning of the three operative words. What is meant by “mental”? What is meant by “illness”? And what is meant by “exist”? We also need to bring with us a skeptic who will pop up at key moments, refuting controversial points in the argument.
There’s a cheat of an answer readily available. I could say simply “yes”; there are problems which everyone takes to be illnesses and which everyone takes to be mental. Alzheimer’s disease is one that can immediately be reached for. However, this leaves me (and probably you) disappointed. Whoever’s asking this question is probably not asking about problems like Alzheimer’s, a disease whose known physiological underpinnings give it a distinctly “neurological” flavour. It seems to belong to an area separate from psychiatry, a specialism concerned with illnesses which are “mental” but not necessarily “neurological”.
The question-we all surely agree-is about that controversial and fuzzy area of problems that includes (but is not limited to) schizophrenia, bipolar disorder, depression, OCD and so on. These things are “mental” alright, but do they unequivocally “exist”? and are they “illnesses”? (Note the decomposition into at least two extremely difficult questions where originally we only wanted one)
In some rather banal sense these problems do exist. Their names pick out moods and problems which people certainly experience (people get depressed; become manic or disorganised), the problem is whether these words, and the idea of “illnesses”, are the most helpful way of conceiving them. A new question comes up then; are the names linked to things in the sense in which they appear to be? Is there a recognisable thing called depression? Schizophrenia?
There are many ways to answer this. One way is to see if the descriptions fit an actually existing entity in nature. Here’s one way this test might be met: Despite the DSM’s controversial nature, we can probably find people who, if we read them the inclusion criteria for depression or Bipolar disorder, would say “yes, that’s me!”
Has the existence test been passed then? Not yet. Our skeptic is going to say something like “that’s all very well, but I too could draw up a behavioural description which would yield the same response; I wouldn’t have discovered a new thing, I would have created a new boundary”. Now we are in difficult terrain; we are asking what it means for particular classifications to be real. Statisticians approach this by seeing how clusters of symptoms group together and for the DSM, depending on which problem you are addressing, there are some grave doubts. However, we don’t need to answer a question about specific actually-existing categories (are DSM classifications illnesses) to get at the broader query (are any forms of mental health problem potentially illnesses). So for now we are going to leave behind the question of these DSM problems and move on to a modified version of the second question, “are there mental illnesses?”
Let’s agree that the “existence” of the categories picked out by the DSM is questionable, this still gives us the right to ask a further question; “are there illnesses which are mental?” I’ll look at two ways to answer this. The first one mirrors my “ask-the-person” strategy above. If you were to take a group of people who would meet the diagnostic criteria for Bipolar Disorder or Major Depression and ask them “are you ill?” at least some portion of them would answer with an emphatic “yes”. This is no mere hypothetical either, plenty of people speak about their experiences this way. Authors such as William Stryon, Andrew Solomon, Kay Redfield Jamison are only the most high profile examples of people recording that their experience of mental health problems amount to being an illness. For sure these are illustrative rather than definitive cases. Other memoirs (John Modrow’s “How to Become a Schizophrenic” for example) strongly question talk of “illness”, but what we can say is that some people who have mental health problems feel quite strongly that they are “ill”.
At this point our skeptic can say “that’s all very well, but these people could be victims of a sort of false consciousness; they have problems in living, but we don’t know if they are ill by any recognisable standard. They have been led to believe they are ill by society’s treatment of their problems.” What is needed here is an objective way to define mental illness, and of course many of the sophisticated treatments of this topic have started just there. Skeptics about mental illness quite often take this approach to bolster their view (perhaps most famously Thomas Szasz in the Myth of Mental Illness).
This is a sound approach, after all if you start with a definition of mental illness you can build a case by describing the ways DSM diagnoses fail to meet it. However having this in place can give rise to a situation which I find no less uncomfortable; namely that someone with a DSM diagnosis can say “I feel myself to be very ill” and be met with the skeptical answer “I can assure you that you are not.” Is this quite right?
I’m resistant to our skeptic in this instance, though I take her point. My resistance is grounded in my feeling that it is somehow disrespectful to disregard the experience of anyone with a mental health problem who describes themselves as ill. We tend, in other spheres where we are uncertain, to give individuals some benefit of the doubt about the nature of their experience; we admit we don’t yet know. Just think of Chronic Fatigue Syndrome, a poorly understood problem with an uncertain aetiology. Here we seem able to allow ourselves to feel uncertainty and to have far more reticence about claiming strongly that CFS sufferers are not “ill” with something.
The skeptic has a noble goal and may quite correctly bring some proportion of diagnosed people over to the realisation that they don’t need a label, medication and the whole shabang; that they can work and love and live without viewing themselves as stricken or afflicted. We could leave it at that (many critics of mental illness do) but I would find it entirely unsatisfactory. False consciousness about illness seems likely to be a real phenomenon, but the fact that it happens doesn’t provide a negative answer to our question. Sure it means we can say that some portion of people who claim to be “ill” could wrong, but who are they, and do we always feel it’s reasonable to tell them as much?
We are left with the sense that many people with mental health diagnoses feel as though what they have are mental illnesses. Given how little we know about the causes of these experiences, to say unequivocally that they don’t is probably to jump the gun no less than by saying that they always and definitely do.
There are many good reasons for skepticism about mental illness; it doesn’t always accord with what we know about the problems associated DSM categories; it doesn’t for the most part have any widely validated biological substrate; a straightforward belief in it can commit us to treating people in ways that are detrimental to their well being (pharmacological, coercive treatments as a default). What this skepticism should lead us to is an ongoing uncertainty about how far to extend the use of the word “illness”, a respect for how little we still know and a caution about how we treat people. Conversely we should avoid being led into the comforting fallacy that says because we can’t be sure things are of one type, we can be sure that they are of another (the most striking example of this is the statement that all mental health problems are “reactions”). This is logic that simply doesn’t follow, providing more fodder for the entrenchment of ideological positions than for an improved understanding of people’s problems.