What is mental illness?
The term "mental illness" refers to a way of conceptualizing particular types of mental or psychological experiences and related behaviours that are considered problematic for the individual who is experiencing them or potentially problematic for other people. Problematic psychological experiences are generally considered mental illness when:
1) The experiences meet the diagnostic criteria for specific "mental disorders" as defined by psychiatric and psychological researchers and clinicians as laid out in the Diagnostic and Statistical Manual (DSM) or another categorization system.
AND
2) There is evidence, a belief, or a philosophical assumption that these problematic mental experiences or "disorders" are best understood as medical problems in the same way as organic biological illnesses (e.g. cancer, diabetes).
How do I know if have a mental illness?
You may be able to find online assessment materials that can help you determine if you meet the diagnostic criteria for a particular mental disorder or buy a copy of the DSM, but the most common way is to arrange for an assessment with a psychologist or a psychiatrist to inquire whether or not you meet the criteria for a specific mental disorder. There are no medical tests that can be done to determine if you have a "mental illness". You would need to meet with someone and talk about the challenges you are facing and they would use their professional judgment to determine if you meet the criteria for a mental disorder.
Is it really an illness?
It is important to note that there is a great deal of debate within the psychological and therapeutic community about the helpfulness and legitimacy of defining problematic mental experiences as "illnesses" or even disorders for that matter. There is very little in the way of definitive evidence that suggests that psychological and emotional problems are "illnesses" in the way that we generally understand illnesses – as biological diseases. The label illness or disorder, and the specific name of the disorder, is used as a short hand to refer to sets of experiences and behaviours that tend to cluster together and that often painfully affect peoples lives. However, these clusters of symptoms also tend to overlap with both what is considered to be "normal" human experience and behaviour and also with other "mental illnesses" and "disorders". These categories have changed over time and are very much influenced by politics and contemporary attitudes and understandings of what is acceptable and normal. For example, homosexuality was considered a mental disorder in the DSM until 1974.
The debate is not just about the use of specific language to define experience, but also the assumptions that come with this language and consequences in terms of expectations regarding the need for and type of treatment. These assumptions, which come out of the Western medical tradition, are that mental processes and problems are best understood and treated in the way that physical/biological processes and problems are. This includes using the same medical language/terminology (e.g. illness, symptoms, treatment, diagnosis, chemical imbalance, brain circuitry), the same assumption that there is a root or proximal cause of the "mental illness" that can be found biologically (i.e. the problem is in the brain - chemical imbalances, problematic neural pathways), and the assumption that the ideal solution is to treat "mental illness" biologically (e.g. pharmaceutical medications, electroconvulsive "shock" therapy, transcranial magnetic stimulation). Since there is widespread debate about the causes of mental disorders and the very existence of these mental disorders as "illnesses", referring to them as illnesses is somewhat dubious and certainly reflects a bias toward a bio-medical rather than social or humanistic understanding of causation. Social or humanistic understandings might suggest that mental disorders arise from complex social contexts, relationship issues, discrimination, poverty, trauma, societal messages and attitudes about what is acceptable and normal.
Implications for treatment
What makes this debate particularly contentious is the preferred method of treatment that arises from adherence to the bio-medical model: pharmaceuticals. Despite the reality that millions of people around the world take these medications, they are often less effective than psychotherapy and may come with serious and sometimes permanent side effects. There are, therefore, substantial risks in claiming that these are indeed "illnesses" if the assumption is then that illnesses must be treated with drugs.
Certain mental health issues undoubtedly have biological causes, such as when depression or psychosis results from traumatic brain damage or brain deterioration with old age. The existence of a biological basis in these circumstances is undeniable, however, the best method of treatment is not always biological. Despite the prevalence of prescription drugs for mental health concerns, there are many medical professionals who fully recognize the limitations of the bio-medical understanding and treatments for mental illness and who see psychotherapy as the preferred method of treatment. As a psychotherapist, I have witnessed and heard from clients who have had remarkably good experiences with drugs intended to treat their mental health concerns as well as from those who have had remarkably bad experiences. There are some conditions, and some moments of crises, that I personally believe are best treated by a combination of medications, psychotherapy, and increased social support. Too often medications become necessary because clients do not have access to psychotherapy or the level of social support that they need to get through difficult times. The ideal circumstance is to have an open-minded collaborative team helping clients rule out biological causes that could result from disease, while working to improve the psychological and social context of clients lives.
Why is it called an "illness" then?
Despite the lack of definitive evidence to suggest that most psychological problems are illnesses, the medical model is both pervasive and appealing for a number of reasons, including:
1) We would all like clear answers and treatments for problems that feel mysterious and frightening.
2) We have put a lot of money, resources, and faith into the medical community with tremendous results for illnesses that are clearly physical and biological (this does not include "mental illness" - the results have not been very impressive in this domain).
3) There is a tremendous amount of money being made through medicalizing mental health issues. Pharmaceutical companies are some of the most lucrative and powerful corporations on the planet and they use this money to fund a lot of research on biological treatments for mental health concerns as well as lobby policy makers to create more markets for their products. This process is no different than the economic and political influence that other large corporate lobby groups possess when it comes to public policy and perception.
4) Using medical language and terminology sounds impressive and provides an air of expertise. This can be reassuring for some mental health practitioners and for some clients/patients who would like to believe that their mental health provider is competent and has the capacity to cure them.
5) Medicalized understandings and diagnoses mean that health insurance companies are more likely to cover treatment programs (including psychotherapy) and researchers are more likely to be able secure funding than if these problems were considered "life problems" or stress resulting from painful life circumstances (e.g. discrimination, trauma, poverty, violence).
6) Conceptualizing psychological challenges as "illnesses" can serve to destigmatize problems that many people face. Stigma refers to negative associations or judgments that people may carry, in this case, with regard to people experiencing challenges with mental health. These beliefs may include thinking that people with mental health issues are crazy, weird, incapable of contributing to society in meaningful ways, or that they brought it on themselves. These tragic misconceptions can lead to discrimination and make life harder for those with mental health challenges.
Alternatives to "illness"
Of all the above compelling reasons to want to understand psychological issues as illnesses or medical problems, none is as compelling to me as the potential to challenge the stigma associated with mental health concerns. Too many people feel that they have failed in some way because of the problems that they face, fear that they are simply "crazy", or struggle to get the same opportunities afforded to others because of discrimination. Seeing these challenges as illnesses can free people from self-blame and open up opportunities for support. There are, however, other ways of challenging stigma and self-blame without needing to hold assumptions about the nature of these challenges that evidence may not support or prescribing treatments that may have serious negative side effects. Psychotherapy can serve as an alternative way of challenging stigma and self-blame while also gaining support and practical tools for managing or healing from these mental health challenges. It can provide an opportunity to develop insight into painful experiences and life challenges, release shame and self-judgment, learn how to alter problematic behaviours and attitudes, and develop a more gentle compassionate approach toward the painful experiences that we encounter in our lives - regardless of causation. Therapy may also afford the opportunity to create your own meaning and understanding, as well as your own labels for the challenges that you are facing that reflect your personal values and worldview.
The medical model and psychotherapy are in no way mutually exclusive. They become exclusive when the assumptions and beliefs go unchallenged or are taken as facts. Many medical practitioners recognize the value of psychotherapy, regardless of their understanding of the cause of the problems, and it is important when facing serious, especially sudden mental health challenges to make sure that there aren't underlying medical issues giving rise to them (brain tumours, strokes, hypo/hyperthyroidism, anemia etc.)
For those of you who are interested in reading more about both the pitfalls of applying the medical model to psychological experiences as well as alternative ways of understanding these same experiences, you may be interested in the following articles by psychiatrist and family therapist Karl Tomm, MD.
http://www.familytherapy.org/documents/CritiqueDSM.PDF
http://www.familytherapy.org/documents/HIPsPIPs.PDF
Nat Roman is a Registered Psychotherapist with a Master of Science in Couple and Family Therapy and a BA in Psychology and additional specialized training in Nonviolent Communication (NVC) processes, community based restorative conflict circles, and fifteen plus years studying, practicing and teaching mindfulness meditation practices and Buddhist psychology. In an earlier stage of life Nat worked as a professional musician and strongly believes that creativity is an essential part of life, whether one is engaged in a formal creative discipline, problem solving, or attempting to get kids off to school in the morning.