Are mental health issues the same as mental disorders? And how can better understanding mental disorders help us treat people with them?
Every second article on my newsfeed at the moment seems to be about the mental health crisis and how the New Zealand health system is struggling to manage it (see articles X, Y, Z). This includes the recent mental health review.
It is easy to understand why this is the case. Even if not affected ourselves, the vast majority of us will know someone who carries the weight of a mental disorder with them. The World Health Organization recognises that mental disorders represent a huge (and growing) chunk of the international burden of disease.
But what is mental disorder?
For my PhD in psychology, I am trying to answer to answer this question and to develop a new way of thinking about mental disorder.
Are mental disorders something you get or something you do?
Are mental disorders more like a disease you 'get' or is the disorder more a part of the affected person? Does somebody 'have' depression or are they themselves depressed?
This question is very important because it has direct implications for how we, as a society and as individuals, respond to someone having a mental disorder.
If a mental disorder is a disease or a difference in someone's brain, the afflicted person is seen to have little control over it. It also then seems like the sort of thing we might treat with medication.
If mental disorder is something people do, the afflicted person is seen to have more control over their actions. It then seems like they may be able to learn to do things differently, i.e. it seems the sort of thing we might treat with therapy.
Many people have the intuition that seeing mental disorders as diseases or brain-differences will encourage compassion because the person is no longer seen as responsible for their actions.
However, a researcher from Australia, Professor Nick Haslam, has previously shown this does not seem to be the case. If people see mental disorders as diseases, they tend to see people with disorders as dangerous. They also have less hope regarding our ability to treat them. The disease model therefore seems to actually increase stigma.
Does a mental disorder exist inside someone’s brain or is it dispersed across their brain, body and environment?
Mental disorders don't happen randomly, nor are they determined purely by your genes. Certain factors in the environment increase the frequency with which people experience them.
For example, things like stress or trauma, eating badly, lack of exposure to emotional language at a young age, or lack of exercise, can all play a role either facilitating or maintaining mental illness.
With this in mind, is a mental disorder a dysfunction in someone's brain and behaviour or can it be a dysfunction in their environment?
For example, imagine someone is working in really stressful conditions. This stress is maintaining their depression and anxiety. If you take them out of this workplace, you may find they are no longer depressed and anxious. This raises the question: were they disordered or was their environment dysfunctional?
While there are many people who would choose either of these options, perhaps the question itself is at fault. In reality, both person and environment are always going to play a role.
There is also the question here of what role the body plays in mental disorder.
Leaving aside more obvious examples such as the gut-biome and hormonal systems, take a minute to think about your experience of emotions.
What do you feel when you feel happy, sad, angry, nervous, stressed? Where do you feel these things? For most people, these feelings are associated with sensations, actions and postures across different areas of their body.
Emotions are 'embodied' in this way. Emotions, meanwhile, play obvious roles in many mental disorders – yet when we think about mental disorder we often ignore the body.
(If you are interested in this embodiment of emotions, I can recommend this book.)
Are mental disorders defined by facts or by social norms and values?
In the 1960s and 70s, psychiatrist and philosopher Thomas Szasz famously made the claim that mental disorder was a myth. He believed mental disorders were labels for people that didn’t follow the unspoken rules of society. He saw psychiatry as society’s tool for dismissing those that refused to conform.
At the other end of the continuum, we find the disease model again. If mental disorders are simply diseases or brain abnormalities, they seem to be facts about the world and not defined by social norms at all.
So which is it? Norms or facts? If I take someone who is socially anxious in a New Zealand context, and put them in a cultural context where there is much less pressure to talk in front of groups of people, does this mean they are no longer disordered?
Alternatively, if I take someone who can communicate with spirits from a culture where this is accepted and put them into another where this is not accepted, do they suddenly manifest schizophrenia?
This question is not just related to hypothetical situations either.
In the US at least, diagnosis of attention deficit hyper-activity disorder has been found to negatively correlate with the age of children compared with others in their classrooms.
In other words, younger and less mature children are more likely to be diagnosed, seemingly not because of any underlying neurological difference, but because they stick out from the classroom norm.
A related question can be asked here. When a psychiatrist or clinical psychologist diagnoses someone, are they evaluating the person in front of them or simply describing them?
Ultimately, it seems naïve to think the act of psychiatric diagnosis is merely a description. But if values are at play in the act of diagnosis, whose values are we talking about? The client, the therapist and the wider society in which they are embedded all bring a different set of values to the table.
Are mental disorders discovered or constructed?
Finally, are mental disorders discovered by science (like a new atomic element or a new animal species) or are they at least in part invented by society (like money or gendered behaviour)?
It is important to remember here that the answer to this question does not change the validity of someone’s distress – socially constructed things can still be real.
For example, take what is commonly called multiple personality disorder, or more currently 'dissociative identity disorder'.
The rate of occurrence and the symptoms of this diagnosis tend to shift dramatically with cultural expectations across time and cultures.
It therefore seems to be a behaviour shaped or even elicited by the expectations of therapists and society (themselves informed by TV and provocative early case studies). But this doesn't mean the behaviour is any less of a problem for the afflicted person.
This question, of whether disorders are constructed or discovered, has implications for classification, treatment and policy.
For example, currently rates of anxiety are sky rocketing. It may turn out something we are doing, either culturally or by policy, is actually facilitating anxiety disorders. Our failure to respond consistently due to a strained health system and myriad other factors is surely playing a role, but it may also be that some of the ways we are responding are actually discouraging people from finding their own ways to cope.
(Another possibility is our threshold for labelling anxiety as disordered is getting lower – anxiety is, after all, a very normal thing to experience, yet we often talk about it like it is synonymous with disorder. See the phenomenon of concept creep regarding this.)
As a final example, something like depression has been referred to since the time of Hippocrates (400BC). Back then it was referred to as 'melancholia' and was seen as reasonably rare.
However, melancholia referred to a more specific set of symptoms than the current concept of depression. This means the modern diagnosis captures a much larger set of people.
This expansion of the depression label occurred in 1980 with the publication of the DSM-III (the DSM being the Diagnostic and Statistical Manual of Mental Disorders). Since this time, the number of people diagnosed with depression has climbed and climbed.
Was this change one for the better, where we are capturing previously unrecognised mental disorder? Or is it perhaps in error, where we are now capturing people experiencing normal sadness? The fact we have to ask this question suggests that at least some degree of social construction is at play.
(If you are interested in this history of depression, there is a chapter by Dr Allan Horwitz in this bookthat covers it well.)
Enough questions, what about the answers?
My PhD project is built upon recognising that our answers to these questions, and others like them, tend to align with our different understandings of how the mind works.
If you think we are like computers, you might think mental disorder is like a virus in our 'software'.
If you think we are richly social creatures, you might be more inclined to think disorders are socially constructed in some way. If you think we are brains driving our skeletons around like cars, you are probably going to think mental disorder is in the brain.
Over the past 20 years or so, a new position on 'how the mind works' called embodied enactivism has been developing. Embodied enactivism draws on psychology, biology and philosophy, and tries to carve out a scientifically valid understanding of what the mind is. I won't break it all down here – but if you are interested, my favourite book on the topic is probably this one.
I have been arguing that embodied enactivism is a useful position to take when studying mental disorder. I have been trying to develop an understanding of what mental disorder is when viewed through this lens.
So far, my research has suggested that, at its simplest, mental disorder is when someone’s behaviours and ways of thinking aren’t working for them.
This sounds simple, but immediately opens up complex questions. Embodied enactivism can provide answers to some of these questions. It does so largely by providing a way to think about the complex interactions between biology, behaviour, environment and culture, all of which underlie human functionality.
But what are the answers? Well, I don't have them for certain. Answers will vary for different disorders.
Also, the embodied enactive perspective I am developing is only one among many understandings of the nature of mental disorder (although obviously I think it is a good one).
For each question asked above, an embodied enactivist view of mental disorder would:
1. Encourage us to view mental disorder as something people do rather than get.
This will vary somewhat with different disorders. For example, what is currently called schizophrenia seems to be primarily caused by brain-differences.
By this I mean that compared with other disorders it seems reasonably 'organic'. However, even in schizophrenia there are still things people do that maintain distress and dysfunction.
Recognising this puts more power in the hands of the person diagnosed because it affords more options for treatment. From this view, therapy, management strategies and self-learning make more sense (alongside prescribed medication), compared with if their condition is simply a fact about their brains.
Such a view highlights the person rather than the disorder. The research by Professor Haslam mentioned earlier suggests such a view may reduce the stigmatisation and fear of people with mental disorders. Remember, people with severe mental disorders are much more likely to be the victims of violence than the perpetrators of it.
2. Highlight the relationship between the person and their environment (both physical and socio-cultural), and that you can't really consider one without the other. It would also highlight the role of the body and lived personal experience.
People learn how to live their lives within the cultures and environments they are raised in. There are therefore many ways to live life, across both individuals and cultures.
3. Suggest that a diagnosis should be given based on the functionality of the person's behaviour, rather than because it is statistically 'abnormal'. Diagnosis should be given in the interest of the person diagnosed.
If we are going to diagnose someone with a mental disorder, we need to be certain we are not just doing so because their way of living is different. It needs to not be working for them.
4. Hold that mental disorders are real things independent of our naming them. It would also highlight that that mental disorders are likely very complex things.
Because of this, our current diagnostic labels are probably not perfect. Instead of taking apart the jigsaw puzzle of mental illness piece by piece, they are probably cutting it into large artificial chunks.
Embodied enactivism also understands people as richly ‘embedded’ in their socio-cultural environments.
The labels we give to people experiencing mental disorder therefore probably 'loop back' and affect how people experience them (much like the earlier example of dissociative identity disorder). There is therefore probably both discovery and construction going on when new diagnoses are labelled. We need to be careful that our ways of labelling people don't actually encourage or create more distress and disorder.
I'm afraid that probably asks more questions than it answers. But I hope I have at least managed to communicate why this area is important.
What we understand mental disorders to be has direct implications for how we explain them.
And how we explain mental disorders then directly informs how we go about treating them, and ultimately how people with mental disorders are treated by society.