An excellent explanation of why mental health in society is rapidly
deteriorating, and why the medical-psychiatric establishment has no
solution for the crisis.    Tony Abdo

World Socialist Web Site www.wsws.org
A comment by Frank Brenner
24 March 2000
This is the first of a two-part series. The concluding part will appear
tomorrow.

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.[1] 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.[2] 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.)[3]
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."[4] 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.[5]

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 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.[6] 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 for 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.