This is the first of a two-part series.
The Surgeon-General's report
The numbers tell a nightmare. According to a major report on mental health recently issued by Surgeon-General David Satcher, the top public health official in the US, one in five Americans suffers from a diagnosable mental disorder each year and half the entire population have such disorders at some time in their lives. Half the population! A staggering figure, hard to get one's head around: is a term like epidemic even adequate to characterize a situation of this magnitude? And yet, horrifying as these numbers are, they aren't that surprising, certainly not to anyone professionally involved in the field nor, I suspect, to a large section of the general public. If the discussions I've had or heard on this issue are anything to go by, a not uncommon reaction to this information is: "Only half?" It isn't just that everyone seems to know someone who's had "mental problems" or that, with the wholesale shutdown of mental hospitals, the mentally ill (and the wretchedness of their lives) have become a much more visible presence on city streets; it is also the widespread feeling these days that people no longer have much (or any) control over their lives and hence that there is something "crazy" about what is happening to them.
There are a lot more numbers in the report, most of them tokens of suffering:
* mental illness, including suicide, is the Number 2 cause of disability (defined as “years of life lost to premature death and years lived with a disability of specified severity and duration”), less than heart disease but worse than cancer and AIDS combined;
* a fifth of all children show signs and symptoms of a diagnosable mental disorder in any given year, though only 5 percent suffer “extreme functional impairment”;
* among adults, ages 18 to 54, 15 percent suffer anxiety disorders, 7 percent have mood disorders and a little over 1 percent have schizophrenia;
* depression is common among people 65 and older—this is the age group with the highest suicide rates, though the report offers the dubious consolation that “suicidal thoughts are sometimes considered a normal facet of old age.”
Five hundred pages long, the report ( Mental Health: A Report of the Surgeon General) brings together a huge amount of data from the findings of hundreds of recent studies. It would be hard to imagine a more comprehensive document: this is the state of the art, as far as mental health is concerned, at the end of the twentieth century. And, as The New York Times points out, it carries added significance because it “puts the imprimatur of the government on the findings”; the hope of those involved is that, like the 1964 Surgeon-General's report on smoking, this new report will become a catalyst for a major shift in public attitudes to mental illness. Accordingly, the basic tone of the report (to use current bureaucratic jargon) is "pro-active": though the suffering due to mental illness is widespread, the expert opinion of the report is that most of that suffering is avoidable. One of the document's key findings is that nearly two-thirds of people who have mental disorders don't seek treatment, even though effective treatments already exist. The report highlights a number of reasons for this: simple ignorance that one has a disorder or that it can be treated; a fear of being stigmatized as mentally ill by family and friends; and—what is no doubt the decisive factor for a great many people—the fact that they can't afford treatment since they have no medical insurance or else the insurance they do have doesn't cover mental illness.
Changing attitudes to mental illness and improving access to treatment are, of course, laudable aims. Not so laudable is what the report says (or doesn't say) about how to achieve them. It insists that its proposals won't cost a lot of money; similarly, it assures HMOs and medical insurers that cost increases from covering mental illness would be minimal. This is nonsense: if the great bulk of people who need help and aren't now getting it start showing up for treatment, it's obvious that they could only be accommodated by a major expansion of mental health services, and that means a major increase in funding. Why this denying of the obvious? Because to admit it would clash directly with the economic agenda of the Clinton administration (which, in case anyone missed the point, let it be known when the report came out that it “was not seeking a big budget increase” to fund any new initiative on mental health). And, as to the insurance industry, the Surgeon-General has no power to compel it to change its coverage while Congress, which does have the power, is hardly likely to do much about a "frill" like mental health when it won't even act to provide rudimentary medical insurance to more than 40 million of its citizens. You can't help feeling, with reports like this, a sense of déjà vu all over again—well-meaning rhetoric, a few more stock speeches from the Clinton crowd about "feeling your pain" and, at the end of the day, nothing changes, the misery goes on.
But sadly predictable as that is, it isn't the most troubling thing about the report. At least if we knew why so many people are afflicted by mental illness, that would make a big difference in understanding not only what the illness is but also what needs to be done to overcome it. And you would expect in a comprehensive document like this, where the primary objective is to educate public opinion and heighten awareness of this problem, that the causes of mental illness would be a major focus of discussion. But this isn't the case at all; instead we are told: “The precise causes of most mental disorders are not known.” In some ways, this statement is more frightening than the statistics on mental illness. How can you effectively treat these disorders, to say nothing of preventing them, if you don't know what gives rise to them in the first place? And what accounts for this ignorance at the end of a century that has seen remarkable progress in medicine on virtually every other front and when the illness we are dealing with is not some mysterious new outbreak but an affliction that has been around for a very long time?
A picture from hell
What the report has to say in addressing these issues doesn't provide much comfort. First, it contends that while precise causes may be unknown, “the broad forces that shape [mental disorders] are known: these are biological, psychological, and social/cultural factors.” But this is so broad that it really tells us very little. What aspect of an individual's life isn't covered by “biological, psychological, and social/cultural factors”? One might as well say that, "broadly speaking", you have to be alive in order to be mentally ill. What we need to know is which factor is the decisive one; otherwise, we're still wandering in the dark. And that's just where we seem to be when it comes to the crucial question of prevention: the Surgeon-General admits that “progress in developing preventive interventions has been slow” because, of course, how can you be effective in preventing a disease if you don't know why it's happening?
And you have to wonder about treatment as well, even though the report keeps insisting that most disorders can be treated successfully. Given that the causes are unknown, mental disorders are defined “by signs, symptoms, and functional impairments,” and it is these that get treated. In medicine, if all you can do is treat the symptom rather than the disease, this is an admission of failure, not a sign of success. What is more, if you are treating only symptoms, how can you be sure that the treatment isn't actually making the patient worse? In this regard, the pervasive use of extremely powerful drugs within psychiatric treatment is deeply troubling: the concern seems far less with curing patients than with tranquilizing them to the point that they stop being a "problem." The report admits that financial considerations play a role here, and it isn't hard to see that drugs are much more "cost-effective" than psychotherapy, which takes a long time and therefore costs a lot of money. A cheap way to police an unruly population—to an appalling extent, that is what this kind of "treatment" seems to be about. (Which isn't to say that all drugs are always bad: as a last resort, they clearly have a legitimate role, but what is appalling is the extent to which they have become a first resort.)
As if that weren't disturbing enough, it seems that electroconvulsive therapy (ECT)—better known as shock treatment—is making a comeback. Though the horror stories from the past associated with this kind of treatment are widely known, the report assures us that things have changed and that now ECT is safe and effective. But this isn't how patients who have been subjected to this treatment see it. A group called the Committee for Truth in Psychiatry, made up of ex-ECT patients, expressed its outrage over the Surgeon-General's recommendation, saying that the report largely ignored evidence of the treatment's harmful effects, including permanent memory loss and brain damage. (The group also pointed out that 15 of the citations used by the report on ECT were from “men with known financial ties to ECT machine companies” and that the Surgeon-General's claim that modern ECT uses one-third less electricity than earlier versions is actually not true.)
The deeper you dig, the darker the story gets. Just how dark is evident in the response of one advocacy group (the National Mental Health Consumers' Self-Help Clearinghouse) to the Surgeon-General's report: Noting that about a third of all homeless people have a mental illness, the group goes on to say: “Meanwhile, there are still far too many people warehoused in state mental institutions; there is an ever-increasing utilization of a barbaric procedure called electroconvulsive therapy; there are too many patients misdiagnosed and drugged beyond sensibility; there are huge numbers of people with mental illness dumped into the community with little in the way of follow-up care.” To complete this picture from hell, it should be added that many of those“ dumped” in the community end up in jail—about 200,000 inmates, 10 percent of the national prison population, have mental illnesses.
The mind and the brain
Amid these horrors, the report's attempt to explain why we are still so ignorant about the causes of mental illness provides an amusing interlude. It seems that René Descartes is to blame. The crime of the seventeenth century French philosopher was his conceptualizing of the mind as completely separable from the body. This “partitioning” of mind and body “ushered in a separation between so-called ‘mental' and ‘physical' health” which has bedeviled the mental health field throughout most of this century. Even the stigma attached to mental illness stems in part “from the misguided split between mind and body first proposed by Descartes.” But not to worry: in the last few decades, this split has finally begun to be overcome due to the “breathtaking progress” made by “modern integrative neuroscience.”
It's odd to run into a reference to philosophy in a scientific paper, especially in America, where there is a deeply ingrained prejudice against theoretical thought. Still, in this case, the result isn't very enlightening. If philosophical speculations four centuries ago (albeit of a great and influential thinker) are responsible for the current impasse of an entire branch of science, then this itself calls for some explanation. Every science has had to contend with unscientific thinking of one kind or another: Newton, for instance, spent more time on alchemy than gravity and even Einstein left the door open for a divine maker of the universe (as does Stephen Hawking), yet none of this has brought physics to its knees. Ideas don't exist in a vacuum, and if an entire discipline persists in holding on to misguided ideas for so long, it can only be because those ideas serve some other, nonscientific, purpose. Besides, blaming Descartes is a dodge: the real problem that has plagued the mental health field isn't the partitioning of mind and body but rather a crudely mechanical outlook which "reduces" the mind to biology. Far from addressing the misguided nature of that outlook, the report enthusiastically endorses what amounts to a refurbished version of it.
This is the “modern integrative neuroscience” touted by the report as a great leap forward.
Its basic outlook is evident in its name: the focus is on the brain and consequently mental illness is to be understood essentially in biological terms, as diseases of the brain. According to the report, “Mental functions, which are disturbed in mental disorders, are mediated by the brain. In the process of transforming human experience into physical events, the brain undergoes changes in cellular structure and function.” Get at those changes and you have the key to understanding and treating mental illness. As a general approach, there isn't anything new about this: "insanity is brain disease" was already a basic tenet of psychology in the nineteenth century and, more broadly, the treatment of mental disorders as physiological illnesses has been the traditional standpoint of the psychiatric profession since its origins; indeed the belief in this position is so fundamental that it has been enshrined in the requirement (at least in North America) that psychiatrists have medical degrees.
But there is a big problem with this approach: for most mental illnesses, it's impossible to find a physiological cause. As the report admits, “there is no definitive lesion, laboratory test, or abnormality in brain tissue that can identify [mental] illness.” So, it would appear that most people with mental illnesses have normal brains. And, it needs to be added, people whose brains aren't normal are suffering from neurological disorders, not mental illnesses. Again, this isn't news: the problems with treating mental illness as brain disease were already evident at the beginning of the twentieth century, and gave rise to radically different approaches to psychology, notably Freudian psychoanalysis. A century has gone by, one in which all sorts of technological marvels have been developed which allow us to probe the brain as never before and understand its workings right down to the cellular level (though obviously our knowledge of the brain is still far from exhaustive). And yet, as important as these discoveries have been for neurology, they have made virtually no difference to the treatment of mental illness.
Why? Because mind and brain aren't the same thing. Of course you can't have a mind without a brain, but that doesn't mean that the one is reducible to the other: it's just as misguided to ignore their differences as to contend that they have no relationship at all. Though the brain provides the physiological potential for the mind, the realization of that potential can only take place through the individual's interaction with other human beings, i.e., through society. (This is why children who are locked away for long periods and denied such interactions inevitably suffer serious mental impairments.) To reduce the mind to the brain is to blot out the fundamental role of society in mental development. And if the mental health field keeps sticking to this misguided reductionism, despite its long-standing failure to produce results, this must mean that there is a powerful resistance to examining this social factor.
An ideological blind spot
The report claims that the new neuroscience isn't really reductionist. There are repeated references to “sociocultural,” “experiential” or “environmental” factors, and the report emphasizes the "integrative" nature of the new science. But what is telling about these references is their vagueness—a term like "environmental" factors can mean virtually anything—whereas, when it comes to the neuroscience side of things, the language is much more concrete. Addressing the issue directly, the report states: “The study of the brain requires reducing problems initially to bite-sized bits that will allow investigators to learn something, but ultimately, the agenda of neuroscience is not reductionist; the goal is to understand behavior, not to put blinders on and try to explain it away.” This is at best a tenuous acknowledgment of the problem (since the crux of the matter is how one gets from “bite-sized bits” of brain science to a meaningful understanding of human behavior), but even this is largely undercut in the next paragraph: “Ultimately, however, the goal is not only human self-understanding. In knowing eventually precisely what goes wrong in what circuits and what synapses and with what chemical signals, the hope is to develop treatments with greater effectiveness and with fewer side effects.” So, human self-understanding is all well and good (take that, Socrates and Aristotle!), but what we really need to get down to are those circuits, synapses and chemical signals.
(In practice, the reductionism is much more flagrant. Recently, a Canadian research team made headlines by claiming to have found a genetic link to suicide. The claim was hailed by the press as “confirming a 2,000-year-old belief that self-destructiveness runs in families” and it immediately gave rise to speculation about a “suicide test” which could screen people for the particular genetic marker. It turns out that the study, involving only 120 patients, had actually come up with a “bite-sized bit” of information apparently linking a genetic mutation to lower impulse control in the brain; add to this the fact that suicides are often impulsive and presto—you have a gene for suicide! The whole question as to why people should have suicidal impulses in the first place gets completely overshadowed, and the most advanced medical techniques are enlisted to confirm age-old prejudices about suicide and mental illness generally.)
As the old saying goes, there are none so blind as those who will not see. If the brain isn't responsible for mental illness, then society must be. Mental illnesses are social diseases. And this is confirmed by a number of their features, which are inexplicable from a reductionist perspective:
* There is “no bright line separating [mental] health from illness;” rather the two are part of a “continuum.” Just the opposite would be true if mental illness were really brain disease. The social character of these terms is evident in their definitions: “mental health is a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity.” Mental illness, on the other hand, is “characterized by alterations in thinking, mood or behavior associated with distress and/or impaired functioning.” It is "functioning" that is the key term here, and this is a social criterion: you are well if you can function within this society and you are ill if you cannot.
* The report admits that “what it means to be mentally healthy is subject to many different interpretations that are rooted in value judgments that may vary across cultures.” A virus knows no borders. If mental health and illness are rooted in cultural values, this only confirms their social character. The same goes for the impact that socioeconomic status, gender and race have on mental disorders.
* The report notes that “relatively few mental illnesses have an unremitting character ... rather, for reasons that are not yet understood, the symptoms associated with mental illness tend to wax and wane.” Once these are seen as social diseases, this waxing and waning isn't such an enigma: it clearly bears some correlation (though a highly complicated one) to the waxing and waning of the social pressures which caused the initial breakdown in the individual's ability to function.
Something else that now becomes apparent is why there is such resistance in the mental health field to understanding mental illness this way. Can anyone imagine the Surgeon-General of the United States issuing a major report declaring that the epidemic of mental illness in America is due to ... American society? This is inconceivable because the social and political implications of such a report would be explosive. It is ideology which is the determining factor here, not science. This isn't to impugn the motives of the professionals who contributed to the report or even, probably, of Surgeon-General Satcher himself. What we are dealing with here isn't cynicism but an ideological blind spot: how could it be that the best, the wealthiest, the most advanced society in the world, the apex of human civilization, is responsible for the terrible ravages of mental illness? This is the ideological blind spot that cripples the mental health field (as it does other social sciences in capitalist society). If an individual can't function in this society, then surely the problem is within the individual, in his brain or his genes, etc. But what happens when the number of such individuals keeps growing and growing, when we finally reach a point where half the population can't, at one time or another, function? Who, then, is really sick—the individual or society?
The recognition that mental illnesses are social diseases doesn't make the problems of the mental health field any easier, but it does make them clearer. One can understand now why prevention has been a failure because the only way to achieve effective results is through fundamental social change; in other words, this isn't a public health issue in any conventional sense but a social and political struggle. Even if we consider practical measures that can be taken now (i.e., within a sick society), the issue of prevention inevitably brings us back to politics because the focus of such measures should clearly be on childhood and this would entail a major expansion of daycare and preschool programs as well as measures to improve home life, including financial assistance for impoverished parents and decent, affordable housing. The only thing one can expect from the Democrats and Republicans on these issues is that they will make matters worse, much worse: the Clinton administration, by its destruction of welfare alone, has probably guaranteed that millions more children will grow up to be afflicted by mental disorders.
Treatment raises similar political issues: as the epidemic grows, the money vanishes for therapy, counseling and community support. But in a deeper sense, a recognition of mental illness as a social disease defines the limitations of treatment: so long as we live in a sick society, all that treatment can amount to is "first aid", bandaging up the psychic wounds so that patients can go on functioning in the very world that made them sick in the first place. This isn't to downplay the value of treatment (or at least of those treatments where the patient's needs—as opposed to cost or "keeping him quiet"—are the primary concern): mental illness is a painful and often devastating affliction and anything that can alleviate it is worthwhile. But alleviating suffering isn't the same thing as a cure, and to lose sight of that is to obscure the underlying social conditions responsible for that suffering. The basic truth is that there are no individual cures for a social disease.
Continued in Part Two
1. Mental Health: A Report of the Surgeon General, Dec. 16, 1999. The report is available on line at www.surgeongeneral.com
2. The New York Times, Dec. 13, 1999
3. Committee for Truth in Psychiatry, press release, Dec. 14, 1999
4. The statement is available on line at www.mhselfhelp.org/politact.html
5. The New York Times, Mar. 5, 1998
6. Toronto National Post, Jan. 28, 2000