One of my messages is that parents must inform themselves about the flaws in the current paradigm if they are to have any chance of thinking sensibly about what might be distressing their child — and what might help the most to relieve that distress.
This is a new parental obligation, understanding the grave problems associated with the “mental disorder” or “mental illness” paradigm. Toward that end of providing you with vital information about those flaws, I interviewed Richard Hallam, author of the new book Abolishing the Concept of Mental Illness: Rethinking the Nature of our Woes, which will be published by Routledge in April of this year.
Richard Hallam trained as a clinical psychologist and combined university teaching in London with work in the National Health Service. He now practices independently as a psychological therapist and has published a number of books in the area of self, problem formulation, and the therapy relationship.
Here is the interview.
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Q. The title of your book carries a very direct message. What prompted you to suggest abolishing the concept of mental illness?
A. For a long time I have felt we have been treading too lightly in our criticism of biomedicine as the right approach to take with so-called mental health problems. Our focus has been too narrow — the inadequacy of psychiatric diagnosis, the over-selling of medication, the disregard of psychosocial approaches. These are understandable concerns but they don’t address the irrational core at the center of the mental health industry.
Q. What, for you, constitutes its irrationality?
A. The inappropriate employment of metaphors of health and illness to personal and social situations that are best resolved through dialogue, contextual analysis, and practical action. It is not as if all the various difficulties and problems currently described as mental ill-health or mental disorder have anything to link them together under an umbrella of health. I’m not suggesting we should adopt an equally broad replacement category except perhaps the word ‘woe,’ which could be almost anything that affects our well-being. The concept of mental illness can be quietly forgotten.
Q. If a woe could be caused by almost anything, what about the disorders we are familiar with such as schizophrenia or obsessions?
A. The word ‘disorder’ is a product of the illness myth. I try not to use it because it obliterates the person and the complexities of his or her situation. However, it is not unreasonable to suppose that a dysfunction of brain or body could play a role in causing a woe and it might even be crucially significant. I would not count a biological predisposition to encounter woes as a disorder or illness, especially when the same so-called vulnerability does not necessarily have a woeful effect on others. There is even less reason to use a concept of health and illness when childhood maltreatment predisposes a person to a life full of woes. Using empirical methods, it is not too difficult to unearth somatic and functional differences between so-called ‘clinical’ and ‘normal’ groups, especially when judged against a biological ideal of the way our brains and bodies are supposed to function. However, their contribution to the causes of living in adversity and with distress has been vastly overrated. From the point of view of causality in the opposite direction, we do know that psychosocial adversities and personal characteristics can contribute to causing physical health problems, but in the latter case we are not usually confused by what we mean by illness.
Q. So you are not ruling out a biomedical perspective on woes?
A. There is always the possibility of explaining any aspect of human existence at a biological level. We also respond psychologically to the perceived effects of processes in the body, whether or not we think of these processes as abnormal. However, a person’s primary concern is usually centered on how best to live well despite any deviation from ideal bodily functioning. Anyone of advanced age would probably agree with that. In my view, taking a biomedical perspective is just one line of investigation that might prove useful in some circumstances. But when there is no objective evidence for a somatic dysfunction playing a primary causal role, biomedicine is based on a myth of illness or disorder. The fact that the illness metaphor as an explanation for woes has been around for a couple of thousand years does not make it any more factual or true. I am sure that woes can have multiple causes, but for most of them we can safely assume that a person’s brain and body have the potential to function perfectly normally.
Q. How do your arguments relate to the real problems people bring to their counselor or psychiatrist?
A. Of course, people have problems that demand solutions. What I am focusing on is a mindset that some people adopt when thinking about solutions that derive from the prevailing illness myth. This is to think of themselves as biological machines that have become disordered. The existence of this mindset is explicable if thinking of oneself as ‘ill’ serves a social function in the sense of deflecting attention from disagreeable, challenging, or shameful aspects of a person’s life that a person might not want to think about or bring to the notice of others. I’m not pretending it’s easy to reflect on all of the potential reasons for ending up in a state of woe. It is already too late to change what’s happened in the past, and if adversities of various kinds persist, they may seem impossible to influence. To declare oneself disordered and to take prescribed medication may present itself as an attractive option. The mythology of mental illness is also convenient at the level of public policy. It removes a focus on potentially remediable general causes of woes such as poverty, crime, unemployment, or social inequality.
Q. How do you foresee the concept of mental illness being abolished?
I suppose it will be a gradual change comparable, say, to the loss of the belief in Ancient Greece that the gods could play with your fate, or the idea that a woe has been caused by a spell cast by a witch or sorcerer. Any widespread change in an explanatory fiction is likely to span hundreds of years and so we cannot expect a rapid replacement of one guiding myth by another.
I’m not suggesting that a society can do without myths and that we can just leave it up to science to march on to provide solutions for all the causes of our woes. A subject that I deal with in the book is the myth of free will, which most people share. It is expected that we should be strong-willed enough to solve our own woes, and so to declare the existence of a problem is equivalent to the shameful admission of a weakness. We are often the harshest critics of our own failures.
One of the alleged advantages of the concept of mental illness is that it absolves you (and of course others) of responsibility for having any role in causing a woe. It becomes an unfortunate affliction, rather like a fate decided by one of the Greek gods. However, to be absolved of the consequences of unwise living (or, often enough, of adversities not of one’s own making) is always bought at a cost. In the past, it created commercial opportunities for establishing temples, payment for priestly rites, or the services of someone who could undo a spell. Nowadays, it funds an enormously profitable mental health industry. The myth of mental illness has created so great a fog of mystification for researchers, health officials, and policy makers that we may need to start all over again from first principles.
Q. Don’t your arguments underestimate what the sciences of mental health and a more enlightened outlook have achieved in the past 200 years?
A. Well, it is true that we have made considerable advances in some theoretical areas and in how to go about changing behavior. I hesitate to use the word therapy because it is associated in my mind with a concept of illness. Mental health is not something that really requires its own science but an analysis of the causes of problems, and their solution, is likely to benefit from many sources of knowledge including social science, psychology, neuroscience, and their various technical applications.
However, calling something a woe is an evaluation from a human standpoint. I believe that any analysis should begin by seeing it as a problem of human existence — which usually means that a person has to make decisions and exercise judgment, and this, of course, is an uncertain and fallible process. It is normal to get into a mess at times. In some cases, it is our moral conventions that cause our woes — some so-called mental disorders were simply abolished when we decided to change them.
Q. You described free will as a myth. Doesn’t that undermine your emphasis on choice and morality?
A. I don’t think so. I don’t object to believing in a myth if it has generally beneficial consequences. As I pointed out above, the illness myth confers some effects that are pragmatically useful even if it is not literally true. It covers up human failings, and, without it, some people might receive no help at all or be sent to prison.
Myths have real interpersonal consequences. If we all act on the assumption that we are capable of acting wisely and morally, that may be enough to maintain it as a workable arrangement for a society that functions for the benefit of the majority. A minority will fall by the wayside but the myth of free will (together with a foundation of human rights) is probably preferable to many other political arrangements.
The myth of mental illness, by contrast, leads to the delusion that we could eliminate woes in the same way that we could imagine eliminating malaria. We can at least aim for a humane, tolerant, and helpful attitude toward those who fall into a woeful state. Well-being and woes, success and failure, seem to me to be inevitable consequences of living in a society that maintains certain codes of behavior. We reevaluate these codes from time to time, and policies may be introduced to curb unfair discrimination and moral condemnation. When we become stricter in certain areas, as in the recent example of codes governing gender relationships, woes are created for people who have violated them, while others hopefully benefit from the change.
Q. Do you have any suggestions for future services for people in a woeful state?
A. I think the most important role of government is to develop policies that mitigate the known causes of woes, such as the maltreatment of children. I am not sure it should be a function of the State to provide services for the woeful until other possibilities have been exhausted. In fact, given the expense of residential care and professional salaries, it has become increasingly difficult to persuade the State to spend much more money on services for so-called mental health.
Most people in a state of woe probably rely initially on the support of family and friends or simply wait for their problem to be resolved in one way or another. Informal support could be greatly expanded if it were to receive funding, especially when people who have resolved their own woes are willing to pass on what they have learned to others who face similar difficulties. Resources would be required for opportunities to meet, or communicate in other ways, and sometimes for a refuge or for specialist advice. Although developments of this kind have already taken place, the myth of mental illness still holds sway in the population at large. This has led to an epidemic of legal drug taking, much of which is not beneficial or actually causes harm.
I think that many current mental health professionals have valuable knowledge and expertise to pass on, and of course, they continue to pursue a long-standing tradition of selling their own services. Professionals can work in partnership with the voluntary sector but, as I describe in one chapter of my book, there is a wide range of opinion on how these partnerships should ideally be set up. There remains considerable distrust and skepticism, largely centered on the possibility of being absorbed and sucked into old relationships of power and a medical way of thinking.
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As a parent, you might suppose that these complex issues either don’t concern you or are too abstract and specialized to allow you participate in understanding them. But we all need your attention and involvement if we are to move forward with humane helping and leave behind the inadequate and largely illegitimate mental disorder/mental illness paradigm. How can you involve yourself? Through what we can call alternative education.
A mainstream education will only provide you with the mainstream view: and if the mainstream view is that the earth is flat, that is what you will learn. Where can you get that alternative education? I’ll be recommending many resources, but you can begin with my books The Future of Mental Health and Humane Helping and with Richard’s book Abolishing the Concept of Mental Illness.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.