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 Moira Hodges

December 2010

Senior Paper

Redefining Mental Health

The term mental illness describes all of the diagnosable mental disorders that are characterized by abnormalities in one’s cognition, emotion, mood, or integrative behavioral abilities. Mood disorders, anxiety disorders, eating disorders, personality disorders, attention deficit hyperactivity disorder, schizophrenia, and autism are the most common types of mental illness (Satcher, 2010). In the United States, clinicians use The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, (DSM-IV), to diagnose mental disorders (Kessler et. al., 2005). Although this is a thorough tool that describes the various mental illnesses, it remains difficult to accurately diagnose a patient because of the wide range of symptom manifestation amongst individuals. Furthermore, because a definitive laboratory test used to diagnose a mental illness does not exist, determining if someone is mentally ill is often a subjective decision, and can be challenging, even for professionals. However, psychiatrists and clinical psychologists are required to label people as either mentally ill, or not mentally ill, everyday (Corrigan, 2005).

This paper will explore some of the benefits and problems that arise from dichotomizing people into the two categories of either mentally ill or not mentally ill. It will argue that this categorization introduces stereotyping and stigmatization. It will also argue that the negative connotation associated with the term mental illness prevents the acknowledgment of possible benefits that may arise from having a mental illness. To avoid these issues, it will be suggested that people might do better recognizing that there are a wide diversity of mental states, with some in need of special assistance.

Diagnosis of Mental Illness

Determining whether or not an individual has a mental illness can be exceedingly difficult for a physician because of the confounding variables that often complicate a diagnosis. Without the proof of a lesion, laboratory test, or visible abnormality in brain tissue that are used to identify the existence of a somatic disorder, diagnosis of mental illness becomes a subjective process (Satcher, 2010). Despite these difficulties, the AMA developed a systematic approach to the classification and diagnosis of mental illness. A doctor uses the patients’ reports of the intensity and duration of the symptoms, signs from their mental health status examination, and clinician observation of their behavior to seek signs of a problem. These clues are grouped together by the physicians into recognizable patterns, or syndromes, according to the DSM-IV. When the syndrome meets all the criteria for a diagnosis, the patient is said to have a mental disorder (Satcher, 2010).

 Unfortunately, patients rarely match the exact criteria for a specific diagnosis. When this happens, the physician must diagnose the patient with the disorder that best describes their symptoms. However, because the characteristics of multiple illnesses overlap, and patients typically describe symptoms of more than one illness, it is often difficult for the physician to determine an accurate diagnosis (Thompson, 2007).

Another factor complicating diagnosis is caused by variation in symptom manifestation. Individuals with the same disorder may experience the same debilitating symptom, they may express the disorder differently. This makes it challenging for the physician to conclude that they have the same illness, and is a primary cause of misdiagnosis (Thompson, 2007).

An additional issue that interferes with diagnosis occurs when a physician is unsure of whether or not an aggravator is a symptom of an illness, or simply a strong character trait. This is not a problem for some diagnoses, such as severe cases of schizophrenia, where it is obvious that the person is seriously ill, however, for other illnesses this can be a difficult distinction. For example, several signs of depression, such as depressed mood or difficulty sleeping, can be viewed as a normal part of the individual’s personality, while someone else may feel these symptoms suggest depression. This raises the question: How pessimistic does one have to be before a psychiatrist says its depression? While the DSM offers a broad set of criteria regarding how to diagnose depression, ultimately, the decision lies with the doctor treating the patient (Prager and Scallet, 2010).

            Cultural differences can also make it difficult for a professional to diagnose someone as mentally ill. The 1960’s psychologist, Eustace Chesser, explores this phenomenon further. He explains that a certain behavior, such as suicide, may be classified in some cultures as a sign of a mental illness, while in other cultures it is seen as a sign of health, in fact, it may even be seen as an act of honor. In Western culture, for example, serious contemplation of suicide and the act itself is considered to be caused primarily by a mental disorder, such as bipolar disorder, schizophrenia, depression, or anxiety. In Japan, however, it is considered honorable to commit suicide after a serious failure. The suicide missions carried out by the Muslim Al-Qaeda operatives in the September 11, 2001 terrorist attacks in the US were committed by individuals who were considered to be martyrs by members of their organization. They showed their dedication to Al-Qaeda by deciding to sacrifice their lives, and this decision made them heroes to those who share their ideology (Thompson, 2007). Various perceptions about behavior, such as what constitutes a problem versus a personal belief, can make it difficult for doctors to determine whether or not someone is mentally ill. Again, it is up to the doctor to subjectively decide if the patient is ill or not (Corrigan, 2005).

The ambiguity surrounding a diagnosis of mental illness supports the argument that there is no definitive way of determining health from illness, or distress from disease. Without solid physical scientific evidence, or obvious symptoms pointing unequivocally to a specific mental disorder, it is impossible to accurately determine if someone is sick, or experiencing symptoms that are in the range of normal behavior. It becomes nearly impossible to decide at what point someone once considered to be normal should now be classified as sick with a mental illness (Satcher, 2010).

Although the confounding variables make diagnosis a subjective decision, people are still categorized as either mentally ill or not mentally ill. There is no recognition of a range of illness with this dichotomy.

The next section of this paper will explore the benefits and problems that arise from categorizing people into two distinct groups, those who are mentally ill and those who are not mentally ill.

The Advantages of Categorization

            Categorization is a fundamental cognitive process that is an important tool in adapting to the very complex stimulus environment in which we live. By grouping people based on similarities, we simplify the world, and in a simpler world, it is easier to understand and relate to one another (Hamilton, 2004).

Although categorizing people as either mentally ill or not mentally ill can cause both individual and societal problems, which will be discussed in the next section of the paper, this dichotomy can also benefit individuals for the reasons presented in the following paragraphs.

Categorization is advantageous because it facilitates diagnosis for those who are experiencing symptoms of mental illness. It is important that the reality of the pain, debilitating effects, and accompanying problems caused by mental illness are addressed and treated (Stangor & Schaller, 1996).

Doctors also acknowledge that having a psychiatric diagnosis can provide important information to the clinician, therapist, patient, and family. It facilitates the prognosis, treatment planning and managing the course of the illness. With more people around the patient aware of the problem, it helps to identify the multiple personnel needed to support the patient (Roberts, 2005). In addition, for someone suffering with an undiagnosed mental illness, receiving a professional diagnosis can alleviate distress and provide the needed medication and treatment (Goffman, 1963).

For some patients diagnosed as mentally ill, it can be comforting to meet other people that have been diagnosed, too. A patient is less likely to feel alone when they recognize that they are one of many with the same condition. Statistics show that patients surrounded by others with relatable problems are more likely to seek treatment, such as group therapy, psychotherapy or medication. This can be a positive step towards recovery (Satcher, 2010).

Finally, the knowledge of a valid diagnosis can prevent friends or family from blaming or rejecting someone because of their atypical behavior. For example, people suffering with a severe psychotic disorder often exhibit symptoms considered to be unusual or even threatening to the general public. These symptoms include hallucinations, inappropriate affect, a lack of personal hygiene, strange speech patterns, talking to self aloud, mood swings, or slow, strange movements. Confused by the person’s erratic or endangering behavior, family members and friends may be inclined to distance themselves from the person, or express frustration in response to their behavior. However, if family and friends are aware of the diagnosis, it is more likely that they will be tolerant and willing to develop an understanding of the person’s behavior. This recognition can provide the patient with the support they need to preserve family dynamics and friendships (Finkel, 1976).

Diagnosis also serves a purpose by assisting the mentally ill if they become involved in the criminal justice system. Mental illness can be a factor that contributes to someone’s decision to engage in behaviors that are against the law. These behaviors can range from misdemeanor offenses to more serious crimes against persons. A diagnosis of mental illness may help the court decide that rehabilitation is a better consequence than incarceration, particularly for less serious crimes where the goal is deterrence rather than protecting the public by separating the perpetrator from the rest of society (Kessler et.al., 2005).

The Disadvantages of Categorization

While the process of categorizing people can benefit society by helping us to understand others, categorizing people can also harm a society by creating divisions within a population. This mere practice of categorization causes people to favor members in their own group over members outside of their group. Outsiders are viewed as being fundamentally different from people within their own group, and are often linked with negative attributes. This facilitates a sense of separation between the groups, causing people to make judgments and draw conclusions about members outside of their category (Hamilton, 2004).                          

One general criticism of categorizing people as mentally ill points to the dangers of labeling. When someone is diagnosed as having a mental illness, they are forever labeled as mentally ill, and this label can have a stigmatizing effect (Finkel, 1976). Stigma is a severe social disapproval of personal characteristics or beliefs that are perceived to be against cultural norms. Stigma comes in three forms: external deformations, physical or social disability, and deviations in personal traits. This final form of stigma includes mental illness (Corrigan, 2005).

This important viewpoint is not given enough consideration by the medical community. Instead, practitioners focus on treatment, and subsequently pay less attention to the stigma of categorizing people into groups of those who are mentally healthy and those who are mentally ill (Stangor & Schaller, 1996).

People who have been labeled mentally ill often face stigmatization because of the public’s misconception that all individuals with a mental illness have a particular look and behave in the similar way (Corrigan, 2005). This misconception arises because of the inaccurate, unfavorable portrayal of mental illness in the media. Movies, television, and newspapers negatively depict mental illness by dramatizing the symptoms of severe mental illnesses. The public then assumes all people labeled as mentally ill fit this exaggerated image, when in most cases this is not true. This is not true because many people with mental illness, especially those suffering with neurotic disorders such as depression or anxiety, receive treatment to mask these symptoms. They behave normally, and the only way one would know that they had an illness would be if the person with the mental illness told the public (Wahl, 1995). 

Stigmatization against those labeled as mentally ill exists in newspapers. It is common practice for newspapers to mention that a rapist or a murderer was once a mental patient. For example, under the headline “Question Girl in Child Slaying,” the story begins, “A 15-year old girl with a history of mental illness is being questioned in connection with a kidnap-slaying of a 3-year-old boy.” A similar story under the headline “Man Killed, Two Policemen Hurt in Hospital Fray” begins, “A former mental patient grabbed a policeman’s revolver and began shooting at 15 persons in the receiving room of City Hospital No. 2 Thursday” (Scheff, 1984, 79). Even though it is unnecessary to include that both perpetrators had been previously labeled as mentally ill, it is still included in the newspaper because of the stigma, or negative reputation, associated with the label of mentally ill. In this instance, the newspaper is associating mental illness with acts of violence, even though there is no need or justification for mentioning mental illness as a way of describing the rapist or murderer (Scheff, 1984).

Although the news media repeatedly portrays people labeled as mentally ill as being more violent than people without the label, there is no evidence for this distinction. For example, under the newspaper headline “Milwaukee Man Goes Berserk, Shoots Officer,” the story describes the events and then quotes a police captain who said, “He may be a mental case” (Scheff, 1984, 79). The association of mental illness and violence evokes fear amongst the general public of people considered to be mentally ill (Sheff, 1984).

Television and movie entertainment continue to distort the image of schizophrenia by creating an association between violence and the disease. Not all people with schizophrenic tendencies are homicidal, for example, as they are often portrayed in entertainment (Wahl, 1995). According to a national clinical survey that collected data on people convicted of homicide in England and Wales between the years of 1996 to 1999, only 5% of the recorded homicide convictions had schizophrenia (Meehan et. al., 2006). 

The media readily exposes an association between mental illness and violent crime, but fails to counter this with positive stories about people with mental illness. The media’s neglect to relate mental illness and success exacerbates the problem of stigmatization. An item like the following is almost inconceivable: “Mrs. Ralph Jones, an ex-mental patient, was elected president of the Fairview Home and Garden Society at their meeting last Thursday.” (Scheff, 1984, 79).

Furthermore, categorization and labeling often lead to discrimination. In addition to being illegal, it is understood and accepted that it is wrong to discriminate against people because of their race, religion, sex or age. Although there is less awareness regarding discrimination against people with a mental illness, it still exists. In fact, a study published in Psychiatric Services showed that it is one of the more frequent sources of discrimination. The study sought to gain further perspective on discrimination experienced by people with mental illness by comparing self-reports of discrimination due to mental illness to self-reports of discrimination due to other group characteristics, such as race, gender and sexual orientation. They found out that more than half of the study participants reported some experience with discrimination, with the most frequent sources of this discrimination being mental disability, followed by race and sexual orientation. Participants with mental illness experienced discrimination regarding their employment, housing and interactions with law enforcement. Discrimination against the mentally ill is not as visible in society as racial, ethnic and religious discrimination, but it exists none-the-less (Corrigan et. al., 2003).

Finally, society views the diagnosis of being either mentally ill, or not mentally ill, as a lifelong way of categorizing someone. That is, once someone is diagnosed as mentally ill, they are permanently described as mentally ill, even if they have received treatment and have recovered. As a result, people are left to face the stigmatization and discrimination that exists against mental illness for the rest of their lives (Brown, 1995).

Farina and Rig (1965) performed an experiment with college subjects that demonstrated this irreversible diagnosis. For one group of subjects, the experimenters introduced fictitious background information about their student partner in the experiment that indicated that a mental illness had occurred in his past. For the control group of subjects, the presenters provided uneventful background information about their partner. The partner was the same student for both groups. His behavior was similar for both groups and did not indicate abnormality. But the subjects perceived the partner with a history of mental illness quite differently. He was seen as helping less and hindering more, and was viewed as a less desirable partner because he was more difficult to get along with and appeared more unpredictable. They attributed negative characteristics to him, although his behavior was deliberately the same in both groups. The experimenters concluded that his label of being mentally ill influenced the group’s perception of him (Finkel, 1976).

Another example showing the permanence of the label mentally ill is reflected by how differently society perceives somatic disorders. If a person recovers from cancer, he or she is not referred to as “being cancer” or “is cancer”. Instead, because we know that cancer is something that we can recover from, therefore he or she is referred to as cancer-free. With mental illness, we say "he is OCD," or "she is bipolar," as if to say that the term OCD or bipolar definitively describes someone. This terminology implies that the person remains mentally ill, regardless of whether or not the person has responded to treatment (Association for Natural Psychology, 2010).

Furthermore, Howard Becker’s Labeling Theory contends that labeling an individual as mentally ill not only stigmatizes that individual, but promotes the very behavior that is defined by the label. His research demonstrates that people diagnosed with a mental illness will choose to behave in ways that exemplify the symptoms of the disorder. It appears to influence their behavior so that they identify with the label and its characteristics (Thompson, 2007).

Categorizing someone as mentally ill results in their being excluded from mainstream society. There is a negative connotation associated with the label, which is unacceptable to society. There is a high rate of unemployment among those labeled with a mental illness. The label makes it difficult for them to gain employment because they are seen as a risk to the employer (Gray, 2002). According to a study in The Psychiatrist published in 2002, the unemployment rate among people with a long-term mental health problem in London was estimated to be around 92%, and the unemployment rate among those with a diagnosis of schizophrenia was estimated to be around 96% (Perkins, 2002).

This phenomenon also explains why so many people labeled with mental illness lose custody of their children in American courts; the label itself defines the person as being an incompetent parent. Few judges want their own competence questioned if they allow a minor to remain with a parent when the public perceives mental illness as compromising the ability to care for a child (Caplan, et. al., 2004).

Another general criticism focuses on the implications of class membership. Once a person is assigned to a class, such as obsessive-compulsive disorder (OCD), other characteristics about the individual are forever lost. This is because society tends to see mental illness as the defining characteristic of a person, rather than recognizing that these people may also have exceptional talents or skills that set them apart from the rest of the general public (Finkel, 1976). For example, frequent references have been made to the similarities between highly creative thinking and psychotic thinking. In an experiment conducted at The Royal College of Psychiatrists, researchers attempted to test the hypothesis that individuals in both of these populations often use common attentional strategies which cause them to take in a wide range of environmental stimuli. They compared a group of highly creative adults and a group of equally intelligent but low creative adults to a group of non-paranoid schizophrenic adults on three tests designed to test attentional and other cognitive styles. They found that both highly creative and schizophrenic individuals habitually sample a wider range of environmental stimuli than less creative individuals do. The results suggest that people with schizophrenia may be more creative than the average person (Dykes &McGhie, 1976).

It takes a lot to overcome being defined by mental illness. Celebrities, however, have been able to accomplish this, Donald Trump and Harrison Ford, for example, are famous public figures known for entertainment, not for suffering from OCD (Lerner, 2006).

As a society, we continue to view mental illness in a negative way. The adverse connotation associated with the term mental illness shapes the way we view and think about people who are labeled mentally ill. They suffer from the social stigma and discrimination generated from the label. For these reasons, in order to alleviate the problems associated with the diagnosis and categorization of mental illness, this paper will suggest an alternative way to thinking about mental health, and it will be explained in the next section of the paper. 

The Mental Health Spectrum 

An alternative way to thinking of people as either mentally ill or not mentally ill, is to think of mental health as a spectrum. Instead of labeling people as either mentally ill or not mentally ill, it would be understood that there are a wide range of mental states, with some in need of special assistance. There is much to be said about adopting an approach to mental health in which everyone’s mental state is viewed as part of a continuum. This new theory would resolve many of the problems that arise from categorization, as well as promote a more accurate description of mental health overall.

It is important to realize that this philosophy is not suggesting that mental illness does not exist, or that it will be eliminated when the label is removed. However, it is suggesting that it would be beneficial to end the practice of viewing mental health as something that can be described dichotomously (Szaz,1974).

            First and foremost, this new understanding of mental health could eradicate the stigma and discrimination that those who are labeled as mentally ill face during their lives. Without a category defining what mental illness looks like, or what behaviors are typically associated with mild cases of mental illness, it would be impossible to label behaviors as being normal or abnormal. Instead, people would understand that variations in behavior exist because people are different from one another, and it is only reasonable to think that behavior will be different from one person to another (Finkl, 1976). With this mindset, it follows then that these behaviors would be perceived as differences, rather than judged to be disorders (Corrigan, 2005).

           Viewing mental health as a spectrum is a more accurate way of defining mental health because it describes mental health as being dynamic, rather than static, or something that cannot be permanently categorized. In reality, a person’s mental state is constantly changing. In one instant it may be described as healthy, while in the next, ill. For example, it is acceptable for a mentally healthy person to experience a range of emotions during the day, in response to what is happening in the environment. Their response is considered situational, without concern that the reaction will be lifelong and irreversible (Szaz, 1974).

Moreover, few people with even the most serious mental disorders are continuously ill. Instead, many long-term conditions are actually episodic. A person with a severe and long-term mental illness may, with appropriate treatment and support, maintain a relative level of well-being most of the time. At other times the person may experience a brief but devastating bout of illness that temporarily pushes him or her to catastrophic dysfunction (Thompson, 2007). This new way of regarding mental health, as a spectrum of conditions, would account for the fluctuation in symptoms over time and acknowledge that there are periods of time when a person is not exhibiting any symptoms.

            The understanding that mental health cannot be permanently defined would remove the problems that come from labeling someone indefinitely as healthy or ill, because people with symptoms of an illness would no longer feel indefinitely outcast from society. The understanding that mental health cannot be permanently defined would remove the problems that come from labeling someone indefinitely as healthy or ill because people with symptoms of an illness would not longer feel indefinitely outcast from society (Brown, 1995). Instead, it would become the norm to perceive the symptoms as being temporary rather than immutable. A change in society's belief system would foster a change in the individual's belief system. An individual with a mild disorder might benefit from viewing the disorder as impermanent, strengthening the individual’s ability to cope. It might also instill hope that there will be times that symptoms of the illness will not be present, furthering their potential to function in society (Scheff, 1984).

            Furthermore, without dichotomous categories defining mental health, we would be less likely to brand symptoms as signs of mental illness. Instead, mild behavioral characteristics would be accepted by society because they would be viewed as part of one’s personality (Finkl, 1976). This would not remove the importance of acknowledging that some do suffer with significant, painful symptoms. Instead, it would eradicate the practice of viewing any eccentricity as a manifestation of a mental health problem. It would normalize how society interprets unconventional behavior. In addition, acceptance of a person’s position on the mental health spectrum, would allow them to give expression to their unique, artistic and creative abilities, which might subsequently benefit society, as well as make the world a more interesting place (Corrigan, 2005).

There is value in changing the language that we use to describe people who are handicapped. In an effort to be less derogatory and more inclusive, American culture has already redefined how we refer to certain physical handicaps. For example, few people today would use the term cripple when talking about a person who is physically handicapped. There is consensus around theses changes; we have come to refer to this as being politically correct. Eliminating the label of mental illness, however, would mean more than just being politically correct. It would enable individuals who have been previously ostracized to gain a positive identity in the culture (Caplan, et. al., 2004).

Although this paper argues that ending the dichotomy of labeling mental health would ultimately benefit the individual and society as a whole, it is also necessary to recognize that potential problems might arise.

 Severe mental illness is a debilitating disorder that causes pain and suffering. A problem could develop if, as the public’s opinion of mental illness changes, services and treatment diminish for those who are sick. It is important for medical professionals to realize that removing the stigma associated with mental illness must not result in reducing society’s investment in medical care for patients with a mental disorder (Hamilton, 2004). A patient’s symptoms should not be minimized or ignored because the label associated with mental illness is gone. Experts must make an effort to acknowledge that some symptoms, even if perceived by the professional to be mild, should receive medical attention if the patient experiences suffering (Prager & Scallet, 2010).

In addition, placing a symptom along a spectrum should not contribute to an individual denying the disorder and neglecting to receive medical attention. A mental health spectrum would normalize certain behaviors that for some individuals should not be ignored (Brown, 1995). For these individuals, a mental health spectrum could exacerbate the misconception that they are healthy, when in reality, they are not. This could cause the person to feel miserable and have a reduced quality of life. If a mental health spectrum were in place, it would be necessary for professionals to stress the importance of receiving medical attention if a person is experiencing discomfort. It would be a problem if removing the dichotomy created the false perception that the disease had been cured.

This paper explains the various benefits and problems that have arisen because of society’s decision to view an individual’s mental state in two ways, as being either mentally healthy or mentally ill. In order to resolve some of the problems that arise from this dichotomy, this paper introduces the idea that viewing mental health as a spectrum may be beneficial to both the individual with the disorder and to society as a whole.

With a spectrum describing all mental states, instead of only those previously labeled as being mentally ill, society would be more inclined to see mental health as dynamic, and understand why there is inaccuracy with categorizing people as mentally ill or not mentally ill. People with unusual behavioral traits would be appreciated and seen as integral members of society who, ultimately, make the world a better place.

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