What do We Mean When We Talk of Mental Illness?

Stand outside a psychiatric ward and you’ll find the markers of madness. They lie in no particular order, and convey no message, except a kind of covering up. Fag ends for forgetting. Maybe the drugs dispensed inside spur nicotine craving or maybe cigarettes are the only solace when society turns away. Whatever, butts are the carpet the mentally ill stand on. They build up in unlovely piles with a smell that suggests despair. It is not the same with physical illness. Pleurisy and kidney infections can be confronting, but they usually pass. And even when you are bed-ridden, life is more than a disassociated smokescreen. Cancer can kill you, but it does not impel you to kill yourself, as happens with severe mental illness. Rating these things is problematic but according to those who sift through suffering, schizophrenia is twice as bad as being blind: Which is saying something. My greatest fear as a child was going blind, not because of the usual warning parents issue to young boys, but because I had to wear an eye-patch, and worried that the darkness on one side on my face would not go. It did, but that does not happen with a lot of mental illness. It can hang on, even when your eyes are open. “Darkness visible” the writer William Styron called it, and it can draw a curtain over the most serene day and sanguine prospects. This much is clear, if not conceded by Governments who under-fund and over simplify mental health.

What is less clear is what we mean when we talk about mental illness, and how it is that the one in five Australians said to suffer from it remain opaque. If it is just a question of under-funding – as the Australian of the Year, professor Pat McGorry, and recently resigned chair of the National Advisory Council on Mental Health, John Mendoza, suggest – then we must already have an answer and not be spending the money. (If money could buy mental health, would not the rich be symptom-free?) McGorry and Mendoza favour community based services, notably for psychosis and early intervention but, while helpful, these do not address the needs of the vast majority of those said to be suffering who are neither young nor psychotic. There is something wrong with the way the debate is being framed, and it is this: Firstly, by leaning to a medical model, McGorry and Mendoza run the risk of underplaying the therapeutic alliance, that is, the relationship with the therapist which an overwhelming amount of research shows to be the most helpful factor. Secondly, this alliance is fostered in private treatment settings, often by allied or non medical, practitioners.

In other words, what we call mental illness – mostly mood states such as depression, but also including the less extreme, violent forms of psychosis – respond best to a relationship with a skilled therapist, not a quick turn around by an over-worked case manager in a community health centre. But with mental illness said to be a brain break down, rather than a crisis in human subjectivity, no one is interested in spending the time to find out what’s behind the distress. This has arisen because governments and insurance companies think (wrongly) it is cheaper to treat by drugs, or a set number of sessions of feel-good advice, and because the medical lobby (mistakenly) sees the biological explanation for mental illness as scientific. Being abandoned, poor, or, as fourth century poet, Menander, realised, gutted just because life, necessarily means loss, is sidelined, which is a curious state of affairs. As Douglas Coupland, the author of Generation X, notes, the spin on Prozac is not that it faces your frailties; rather it “creates a parallel brain.” The lack of interest in aetiology is, however, recent, arising only since psychiatry – which has so clearly failed to locate the cerebral substratum of human discontent – ditched psychoanalysis and a model of the mind linked to the emotions.

The problem then is one of framing the discussion in terms that address the reality of suffering. But this is complicated by psychiatry’s categories –schizophrenia, bi-polar and paranoia – which are supposed to be discreet disorders but are so blurred that what one psychiatrist calls schizophrenia another calls bi-polar. “We have,” as Manchester University’s professor Richard Bentall, notes in Madness Explained, “been laboring under serious misunderstanding about the nature of madness for more than a century.”

And it is not just the categories of psychosis, which after all, despite being the most serious and troubling, afflict by far the smallest number. It is the assumption that the biggest category of mental illness – depression – is a discrete disorder when it is in fact a range of conditions, none of which match up to the medication prescribed for it. The reason for this is that psychiatry baulks at the idea that the symptoms we suffer have anything to do with the people we are. This is a madness of its own. In its attempt to become scientific, psychiatry has decreed that we no longer have to search our mind, motivation or memory: it is all down to nerve endings.

So, now when we are mentally distressed, we either get a prescription or, if we are a threat to ourselves or others, get patched up and pushed out of an over-crowded mental ward. It is an appalling result that has arisen, I think, because the organic explanation for mental illness is claimed to be scientifically rigorous, when it is, in fact, a sleight of hand. As University of NSW psychiatry professor Gordon Parker, points out, “the barons of the new order of psychiatry” have joined drug firms to “promote depression as a medical disorder”. We have broken the historic link between cause and effect in mood states, leaving its sufferers little else to do but create a carpet of fag ends. This was not the case in the days before psychiatry saw mental illness as a heart attack in the brain. Then, human beings had reasons other than their neurotransmitters to be distressed. “Man”, as the playwright Eugene O’Neill told us, “is born broken. He lives by mending”.