How Do We Define Mental Health and Illness?

What Exactly is “Mental Illness?”

  • Think about someone who says they talk to God

    • They could be diagnosed with a psychotic disorder

    • Or, they would be considered holy

  • The concept of “mental illness” is plastic (changeable), elastic (flexible), and heavily debated

  • Two people show the same symptoms. One person is diagnosed, while the other isn’t. It all depends on context, and the circumstances.

  • Scholars and clinicians don’t always agree on key issues: the nature of mental illness, who “has” it, what we ought to do about it, whether it exists, is all debated

Contentious Topics

  • Some see mental disorders as essentially diseases of the brain, best treated by somatic interventions like medications

  • Others believe that medications change how you feel

    • Minimalist perspective: not having a diagnosable mental disorder means that a person is mentally healthy

    • Maximalist perspective: being mentally healthy involves a host of qualities: empathy, self-confidence, independence, happiness, etc.

  • In short, both “mental illness” and “mental health” are moving and evolving targets, constantly shifting in terms of what these phrases describe.

Defining Mental Health (Problems)

  • “Mental Health” relates to our thoughts, moods, and behaviour

  • ”Mental Illness” is a general term that describes a situation in which there is a disruption related to these phenomena

  • The term “Mental Disorder” refers to specific subtypes of mental illness

  • But why is it called “Mental”?

    • Many symptoms are physical in nature (i.e. fatigue, mania)

    • Some believe cause is ultimately biological

  • Yet some things differentiate mental and physical health:

    • Not isolated to an organ, but the whole of the person

    • Stigma

    • Not always seen as entirely negative

      • Ex. some people like the feeling of mania (feeling energised, creative)

    • Power of psychiatry (ex. forming or sectioning)

      • They can order for someone to be treated without consent, against their will

    • There is a non-absolute, value judgement involved in diagnosis of mental disorder

A History (and Present) of Uncertainty

  • Some of the same central questions and perspectives on mental illness have existed for hundred of years, with only the details (like vocabulary) changing

  • People have historically thought about mental health issues as:

    • A somatic problem

    • A spiritual problem

    • A problem of awareness

    • A result of social pressures

    • A “problem in living”

What Are We Describing?

  • Are we talking about abnormality? Deviations from the norm in terms of moods, thoughts, and behaviours?

    • Is “abnormality” still the right descriptor?

    • What do we do with the fact that norms are culturally mediated?

  • Are we talking about personal suffering? Is a person “mentally ill” because they’re experiencing psychological pain?

    • Should anguish and pan be simply reducible to a diagnosable disorder? What does that imply about being human?

  • Are we actually just talking about poor functioning?

    • Maybe, yet how should we determine good functioning? Is functioning not equally about a person’s environment?

Key Questions and Arguments

  • A major question occupying scholars: are mental disorders best understood as intrinsic diseases (having a specific, organic brain-based pathology), or are they better understood as metaphors that describe a series of experiences and behaviours?

  • Key argument: how we think about and define mental health and illness says a lot about society, its principles, goals and concerns.

Who is Involved in Mental Healthcare?

  • Psychiatrists

  • Psychologists

  • Psychotherapists

  • Social Workers

  • Psych nurses

  • These professions are all regulated. If they do not meet the standards of their profession, they could lose their licence

Models of Mental Illness

  • Three broad models dominate how most scholars and clinicians understand what mental illness is, what causes it, and what we should do about it

    • (Bio)medical model

    • Psychological/behavioural model (although once distinct, lots of conceptual overlap)

    • Social model (actually two models rolled into one)

  • These models are conceptual ideals: most people’s beliefs - including professionals - involve some combination of all three, albeit to differing degrees.

The Medical Model

  • Mental disorders are biological diseases. They involve specific sets of causes, symptoms, and treatment

  • With problems rooted in biology, biological interventions thus needed to treat these dysfunctions

  • Further notes:

    • Still lots of debates among adherents of this model

    • Some see this model as an attempt to elevate some professions and to cut out others

Psychological / Behavioral Model

  • Mental disorders essentially reflect internal psychological phenomena. Located in the abstract mind

  • mental disorders reflect unhelpful patterns of thought and/or unresolved feelings

  • People “learn” or “develop” their mental disorders through previous experiences

  • Because mental disorders are not physical diseases, they believe it’s treatable via psychotherapy

Social Model

  • Emphasises society as the genesis of mental disorder, specifically the way in which a society is organised. Two variants:

    • The first accepts the existence of mental disorders. Assumes that social structures act as determinants that cause mental illness

    • The second is skeptical about the existence of many mental disorders. It sees mental disorders as labels used to discipline people who behave in ways that contravene society’s dominant values

Why So Many Models?

  • Some explanations work better with different types of disorders

  • Some people find particular models offensive / gratifying

  • Groups may benefit from one model more than another

  • Many advocate biopsychosocial model

    • Some argue that we only pay lip service to this idea; in reality, the medical model dominates mental healthcare

  • Remember, these models are merely ideals

Classification of Mental Disorders

  • The DSM and ICD act as official lists of mental disorders and their symptoms

  • DSM:

    • First published by APA in 1952, now on DSM-5

    • Consistent growth in disorders since 1st edition: from roughly 100 to nearly 400

    • official, accepted account of disorders - used by clinicians, governments, researchers, insurers, etc.

    • Symptomatic focus: diagnosis made on basis on symptoms rather than cause

    • What gets included / excluded (both disorders and symptoms) decided by committees

Defining Mental Disorder

  • DSM: “a mental disorder is a syndrome characterised by clinically significant disturbance in an individual’s cognition, emotion regulation, or behaviour that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.”

  • Key Questions:

    • How do we determine clinical significance? What about “significant distress?” Who gets to decide?

    • Is this excessively broad? Seems to take an agnostic approach on what causes mental illness.

    • Is this too vague? What might count as “other important activities?”

Criticisms of the DSM

  • Despite central place in mental healthcare, MDs, patients, many critiques of DSM

    • Issues with validity. How can we know it actually exists? How do we know its pathological? Can we validate its existence?

      • Heuristic: concept you hold onto temporarily until a better concept comes along

    • Ignores context

    • Doesn’t convey actual experience of mental illness

    • Doesn’t address treatment

    • Shouldn’t pressure alone change what counts as disease?

  • This, some have said that the DSM serves to essentially reinforce particular ideas about “good” behaviour and to discourage / punish “bad” behaviour

The Difficulty With Diagnosis

  • Diagnosis, formed after an interview. Some challenges:

    • Subjectivity: where is the line drawn between normal distress, and something clinically significant?

      • Gary Greenberg: “There’s a conflict of interest - if I don’t determine clinical significance, I don’t get paid.”

    • Comorbidity: describes when a person meets the criteria for more than one mental illness.

      • Are these illnesses separate diseases?

      • Two sides of the same coin?

    • Heterogeneity: what to do with “a person must meet 5 of 10 symptoms.”

      • Are people with distinct symptoms experiencing the same thing?

    • Culture (of both patient and practitioner) may shape whether something is judged or reported as a symptom

How Common Are Mental Disorders?

  • Roughly 24 - 50% of people report symptoms of mental disorder at some point in life

  • Are we in an epidemic of psychopathology?

    • Recent increases in social anxiety disorder, panic disorder, PTSD, OCD, generalised anxiety disorder, anorexia nervosa, bulimia, depression, ADHD, dissociative identity disorder, and apotemnophilia, among others.

  • How can we understand this?

    • Less stigma, more awareness and willingness to come forward?

    • Is this a consequence of a real rise in mental illness?

    • Medicalization?

Debates

  • As we move through, here are some of the key debates we’re going to consider:

    • Are mental disorders value-free scientific concepts or are they better understood as a reflection of the socio-political climate?

    • What is the relationship between mental illness, mental healthcare, and social norms?

    • What functions are served by a diagnosis?

    • With mental healthcare, are we talking about a science or an art?