Healing, brokenness, and the mental health industrial complex

It’s interesting to watch — from the safe vantage point of vast ignorance — cracks in the gleaming exterior of Western mental health care. To say the least, it’s not like flying a plane, where highly trained people, following international standards of safety and expertise, successfully take people to places they want to go. Psychiatry and psychology are not like that. They may want to look like that, but they are not like that. ¹ Here are some of the cracks:

1. The standards aren’t, well, standard. The American Psychiatric Association publishes a thing called the DSM (the diagnostic and statistical manual of mental disorders), currently on its fifth edition, DSM-5. It’s widely referred and accepted and is the product of much scholarly endeavour. But it changes, and practice changes with it. After DSM-4 was published, ADHD diagnoses tripled, autism diagnoses increased 20-fold and bipolar diagnoses 40-fold. ² This was not a sudden epidemic of mental illness, it was a consequence of widening the categories. So, beware, with the next edition of the book, your illness could become a variant of normalcy, or your normalcy be re-categorized as illness.
2. It’s subjective, not objective. Physical medicine is at least a mixture of both, blood tests and MRI scans complementing the doctor’s own judgement. Mental illness appears not to be independently testable. This subjectivity on the part of mental health professionals has consequences: I have seen people bounced between diagnoses of Borderline Personality Disorder, PTSD, Bipolar, and schizophrenia in a process that seems a bit like different practitioners sticking random Post-It stickers on people’s heads. (Though it’s worth remembering that people who practice mental health care all are there to do something good for the broken and damaged people whom they meet every day and they want to help them thrive. They are not dabbling with words; getting it right matters. The bitterness of the debate is because everyone cares, not because no-one does.)
3. Commercial interests are involved. As one kept alive by various drugs, I am very fond of big pharma, but I do acknowledge that they have a commercial interest in selling drugs for mental health, and that must influence their own influence in this subjective area. Certainly different groups of all stripes campaign to change the DSM in their favour, which must mean each DSM is a product of power struggles as well as pure evidence.
4. It victimizes people. Telling my liver that it is abnormally swollen does not upset my liver too much; telling my head I have a personality disorder, and that, no, they haven’t really found a cure, affects my whole sense of who I am and what I am to do about it.
5. It oversimplifies, or at least wrongly frames, the problem. Have mental health problems rocketed, powered by social media, relationship breakdown, unwise romantic choices, and covid-19 exclusions? Or have otherwise normal people across our communities been battered by exceptional stresses? Are they, at root, diseased or injured? That matters a great deal for how, and if, you can get well again.
6. It’s not been great for children. Apparently (according to my source article again) as late as the 1990s it was ‘unusual to prescribe medication or give diagnostic labels to under-18s.’ That is no longer the case. It would be good to know what the evidence is for this change. I hope it’s solid. I can’t help thinking that diagnosing children -a subjective process and one that is inconsistent across practitioners- on the basis of the child’s own grasp of the problem, is a shaky place from which to start chemical intervention or medical labelling.
7. Can it mean that problems are treated here in the West as primarily medical, rather than, say, primarily to do with relationships, poverty, trauma, abuse, poor choices, or just the kind of ennui that doesn’t know what to aim for or what to aspire to be, or what the point of living is; that we are attempting to treat medically a kind of lostness?
8. Can it be that we are underplaying the social, the relational, the physical, and the spiritual and overemphasising the medical? This I find really intriguing because I think I have learnt that healing in any sphere is basically about shalom, peace and contentment; that’s the mark of the healed, even if those same healed ones limp around in broken bodies and perhaps with damaged minds. To thrive before God and people, in all circumstances, that’s healing.

So much to learn!

1. I found the website of the Critical Psychiatry Network interesting, and I was heartened that the UK’s NHS was somewhat interested in research prompted by their questions.
2. I’m grateful for the New Statesman article by Sophie McBain, ‘Are you mentally ill, or very unhappy? Psychiatrists can’t agree’ (Feb 2022) for this reference and much else in this post.