LAST week, I had a conversation with an acquaintance who raised an interesting debate on whether mental disorders are valid illnesses.

I mentioned that I was researching on access to mental health services in Malaysia, a revelation that surprised him.

My friend was curious to know why my research was necessary and whether there was any real proof that mental illness is actually a significant problem in our society.

“Su Lin, don’t you think that everyone goes through some kind of struggle in their lives and that it is up to them to decide how they want to deal with it?

“It’s not that I am trying to dismiss your work,” he continued.

“But sometimes I don’t get why people say they have a mental illness when they are actually just facing the same problems as others.

“Everyone has the same freedom to choose how they want to respond to challenges, so what is the basis for some be labelled as ‘mentally ill’ and others not?”

The myth of mental illness

Though my friend meant no offence, his remarks did leave a slight sting.

More than anything, I was left haunted by the question which he had indirectly posed: does mental illness truly exist or is it just a label that society has conjured up to describe what might otherwise be considered ‘normal’ human distress?

In 2015, the famed (now deceased) psychiatrist Thomas Szasz wrote a treatise called ‘Psychiatry: The Science of Lies”, a searing critique of mental illness and the associated field of mental health care.

In that book, Szasz argued that mental illnesses are not real, in the sense that cancers and other medical illnesses are real, because the criteria used to detect and diagnose these illnesses lack objectivity.

Following Szasz’s logic, psychiatrists and other mental health professionals tend to rely heavily on reports of a patient’s behavioural symptoms to make their diagnosis.

However, certain symptoms, like delusions or feelings of worthlessness, are not ‘objective’ in a scientific sense, because each patient will interpret their experience uniquely, depending on the context of their culture, region, class and gender.

According to Szasz, except for a scant few identifiable brain diseases, there are no objective methods for detecting the presence or absence of mental illness. Therefore, from a scientific point of view, mental illness is a flawed concept.

If this were not enough, Szasz hammers the nail to the coffin with an even more scathing verdict:

‘Attributing a medical diagnosis to a healthy person does not transform him into a bodily-medically ill person, whereas attributing a psychiatric diagnosis to him does indeed transform him into a mentally-psychiatrically ill person’.

This is what he meant: if a doctor were to wrongly diagnose a patient as suffering from cancer, the inaccurate diagnosis would not make the patient sick. However, if a patient were told that he was suffering from clinical depression, that label would affect the patient’s internal beliefs, whether or not the diagnosis was true.

 An invented concept?

Szasz’s radical arguments have damning implications for the validity of mental research on mental sickness and health care.

If his views are to be accepted, then the entire philosophy of mental health and disease must be discarded as null and void. Psychiatry as a medical discipline would be totally invalidated, along with its associated theories and treatment measures for mental disease, and mental health diagnoses would be little more than fanciful ‘self-fulfilling prophecies’.

How does one begin to mount a defence against such strong criticisms?

At the outset, we must consider two rather abstract, but deeply practical, questions: what exactly is a ‘mental disorder’, and how can we know if someone has one?

Though I am not a qualified mental health professional, I have read enough to know that thinking about and conceptualising mental disorders is a complex issue that cannot be reduced to black and white terms.

In general, any effort to understand a concept must be shaped by one’s underlying beliefs. These internal beliefs might be called our ‘explanatory principles’ or ‘worldview’; in short, the way in which we seek to make rational sense of a particular notion, in this case, mental disease.

Szasz argues that mental diseases do not exist because they have no underlying physiological basis. However, science has proven that this is not entirely true. Neurochemistry, the study of brain’s organic structures, has shown how certain structural and chemical defects in the brain can lead to dysfunctional behaviors that have been classified as mental diseases (examples include Alzheimer’s’ disease).  

That might be very well, but what about those mental illnesses that lie on the rest of the spectrum? Behavioural conditions such as depression and anxiety tend to be diagnosed based on ‘non-visible’, psychological causes, which is the very premise of Szasz’s critique.

We must first understand what is meant by the word ‘disease’. The term comes from the Old French language desaise, a combination of two root words des, or “without” and aise, or “ease”. In English, the closest equivalent would be discomfort or distress.

Anyone who has experienced distress will surely agree that the sensation involves more than just physical aches and pains. There are a swirl of emotions, thoughts, feelings, responses to social and environmental pressures involved- all of which will cumulatively add up to a ‘sense’ of distress.

In the same way, non-organic mental diseases might be thought of as a state of prolonged distress, in which an individual’s emotional and psychological state is negatively affected.  

Szasz’s worldview, which sees organic symptoms as the sole proof of whether or not a person is unwell, is not just a narrow interpretation of health and disease but is, to some extent, also inaccurate because it ignores the important role that emotions play in our overall state of wellbeing.

Psychological symptoms are valid markers of health

It may be true that there is a very fine line between mental illness and the human condition, but it is no less true that emotions are important and valid indicators of health and wellbeing.

Our state of health, or the lack of it, cannot be determined simply by measuring physical conditions, as one might do with a robot. It must also encompass our emotions, for these also shape and affect the way we experience and participate in life. 

In closing, it is worth recalling the details of a tragic suicide case that happened not too long ago in Penang.

On May 3, Teh Wen Chun, a 20-year-old engineering college student, jumped to his death from the upper floors of a flat at Tanjung Bungah at 5.41 am. Interviews with friends revealed that he had been experiencing stress in his studies, as he was having trouble keeping up with the course taken.

Prior to the incident, Teh had posted an apparent intention to commit suicide on his Facebook page. Two weeks beforehand, he also left a telling post on his Twitter account – an image of a young man, staring into the screen with the caption: “I come from a world you don’t understand.”

Was Teh’s experience just a weak response to the normal rigours of university life, a regrettable but ‘normal’ succumbing to the pressure of studying hard for a degree?

Or, if the pain and distress he experienced was real to him, would that truth be enough to legitimise his suicide as the outcome of a neglected mental health concern?

It bears thinking about. – June 18, 2017.

* Lim Su Lin is a Policy Analyst with Penang Institute in Kuala Lumpur. She graduated in 2013 with a degree in History from Cambridge University. Her research interests lie primarily in psychosocial health and wellbeing. She explores these in the context of making recommendations to improve social and development policies. The long-term goals of her work are to advocate for more equitable outcomes and reduced inequalities in society.

* This is the opinion of the writer or publication and does not necessarily represent the views of The Malaysian Insight. Article may be edited for brevity and clarity.