Several decades ago the philosopher Ludwig Wittgenstein said it was time to start comparing mental “illnesses” to something different. That is, to move away from the “illness” metaphor. I could not agree more. Insisting on thinking of people with mental problems as “diseased” has been and still is a strategic and practical failure.
It was at the start of the 20th century that medicine managed to wrest control of the treatment of the insane away from non-medical moral treaters, many of whom were Quakers. There then commenced what my friend the sociological historian Andy Scull has called an “orgy of experimentation” on the mad (see Scull’s wonderful book, Social Order/Mental Disorder, UC Press). Medicine had no clue what to do. The mad were injected with horse’s blood and malarial fever, placed in refrigerated “mummy bags,” given camphor derived seizures, subjected to various “heating” therapies--the list goes on. One theory, proposed by Henry Andrews Cotton, held that all forms of insanity, from juvenile delinquency to schizophrenia, were caused by infected third molars or “wisdom” teeth. His treatment? Tooth extraction. All such approaches were steeped in biological reductionism, and they all boasted astronomically high cure rates of 70, 80, even 100 percent. It was during this time that the “illness” model took firm hold. Soon there would be additional types of seizure models, coma models, and eventually lobotomy. At last antipsychotics arrived, and when they did they were referred to as “chemical lobotomies” because their chief effect was to produce disinterest and apathy (just like today, in my opinion).
The sad fact is that in over 100 years of research into mental “illness” driven by a defect-based disease model, the yield in terms of true understanding has been negligible. That may sound unrealistically unkind, but here is what I mean. Still today, we have no idea what schizophrenia even is, let alone what causes it or how to effectively treat it (to take just one example). As a disorder it is extremely heterogeneous; it looks different in everyone who “has” it. This heterogeneity bedevils research into causality since to find what causes something we have to first know what that “something” is. And speaking of causality: no causal model of schizophrenia has ever panned out. No specific site of brain pathology has been reliably identified. And the biochemical models focusing on dopamine (or D2 receptors) are deeply flawed, as most will readily admit. Lastly, as to treatment, antipsychotics are simply terrible drugs. A recent study (in the New England Journal of Medicine) of the newer agents found a 72% discontinuation rate. Why so high? Because the side-effects are debilitating.
Although it may seem different, the case is much the same for depression. We do not know what causes it—though there are lots of theories—and the antidepressant medicines on average only slightly outperform placebo in clinical trials (one study, for instance, found a 89% placebo duplication rate for Prozac in particular).
I’m no simple-minded Szaszian, but let’s be honest: mental problems do not resemble most illnesses in the least. My daughter had a compound fracture of her wrist. The MD took an X-Ray, and lo and behold, there was the break, for all to see. There was no mystery as to what caused the break, and also no mystery as to how to treat it. With mental problems, diagnosis is sketchy and almost never definitive (no UA or blood draw or brain scan tells me what you “have”), causality is a mystery, and treatment is trial and error (for instance, no one knows with any degree of certainty which antidepressant will work for which individual).
Prima facie, the disease model makes very little sense. And, even more importantly, it hasn’t gotten us anywhere. Psychiatry is in the stone ages.
A new metaphor, one to replace “illness” and “disease,” is called for. The question is: What form should it take?
I'm going to have to
I'm going to have to disagree with you on this one.
I agree that psychiatry as a discipline has not made nearly as much progress as would be desirable, and that many of the drug treatments we currently have frankly suck.
However, claiming that because we haven't found consistent physical signs of mental illness makes them not diseases is ridiculous. To steal a point someone else made today (http://blogs.psychologytoday.com/blog/in-practice/200807/debunking-a-neu...), the exact physical cause of Parkinson's disease is still rather fuzzy, but no one is claiming that it's time to pitch the "disease model" for that disorder. There are many other diseases that we still don't understand the basis for, but that no one doubts are medical problems.
Secondly, it doesn't make sense to say that a problem with the mind is not a disease, disorder, syndrome, illness... pick your medical term. We know SOMETHING is wrong with how "mentally ill" people experience the world, we understand that our experience of reality arises from the mind... therefore there is something wrong with the mind, which means there is something wrong with the brain. When there is something wrong with a part of one's body, we call that an illness. I don't understand how that's debatable.
Third, I don't understand why you think calling mental illness is something else is going help anything. There will still a problem that people are having that we don't understand, and that problem will still need to be investigated in a systematic scientific way, considering all aspects of the problem, and as I've already stated, this problem occurs in the brain. And on a more practical note... I assume you still think people with mental illness should get some kind of help/treatment.. if this isn't disease, then where will that treatment come from. I assume, for instance, that health insurance doesn't cover non-disease related problems. Insurance already does a shitty enough job paying for therapy.
I also know that the failures of medical treatment for mental illness are frustrating, I entirely agree that treatment for most mental illnesses should involve a more comprehensive solution than drugs alone, and I agree that the reductionist simplistic models of mental illness that we have (chemical imbalance!) are crap. But the brain is a very complex thing that medicine as a whole is still working to understand, which is why many other brain disorders not traditionally called "mental illness" still stubbornly resist attempts at treatment/cures. And maybe it's too complicated for us to ever understand enough to make the tweaks we'd like to make with drugs. But that doesn't mean we should stop trying to understand the biological basis for these disorders... which means calling them what they are, disease.
I understand that the idea of calling something that we consider to be really the essence of who we are... our personalities, our experience of the world, our thoughts... diseased or disordered is difficult and unpleasant. Believe me, this is something I've struggled with personally, as I have spent about a third of the time since I started high school falling into, drowning in, or struggling out of a severe episode of depression. Even when out of it, the fear of it, the distrust of my own mind, became a big part of who I was. Figuring out how to deal with the fact that much of the experiences I've had in my "adult" life have been distorted by a disease isn't pleasant. And I do work hard to avoid a mindset of deterministic victimhood... but this is what it is to be human. We are physical beings. No part of us is exempt from the possibility of breaking, or at least getting a little screwed up, disregulated. Even our minds.
Honestly, I hear the "it's not an illness" thing a lot, and I think it is always either a 1) purely academic argument that is very disconnected from how changing what we call things like depression will change our rate of success with fixing it or 2) anti-psychiatry babbling. I'm all for change, open-minded-ness, new ideas, etc. in treating mental illness... no one has got me deluded into thinking we have all the answers. And there are some aspects of treating mental illness as a disease that are rather... dehumanizing and distressing for the person being treated. But whether or not you can put a brain scan up on the wall like an x-ray and say look, the problem is here, it's still an illness.
In fact, demanding that kind of visible proof in a brain illness completely disregards the complexity of the brain. Brains are a hell of a lot more complicated than broken bones.