As England cricketer Jonathan Trott takes another break from the sport because of anxiety, a leading philosopher asks whether the time has come to reconsider our labelling of mental distress
We are often told that there is still a stigma surrounding mental illness. It is therefore strange that the England cricketer Jonathan Trott was stigmatized for allegedly not having one. Trott left the England tour of Australia in November citing a “long-standing, stress-related condition”. But when he gave an interview last month explaining that he was burnt out rather than depressed, the former England captain Michael Vaughan said that he felt “a little bit conned”, saying, “When I hear players talking about burnout, I suspect it is an excuse.”
Now Trott has taken another break from county cricket as his anxiety issues have recurred. Even Vaughan has tweeted his sympathy (“Very sad and I wish him a full recovery”), though others may be muttering about whether Trott is simply not made of tough enough stuff for top-level sport.
But why do people believe it matters whether the psychological distress that Trott is suffering is an illness or not? We have increasingly come to describe mental difficulties in medical terms, using the language of illness and disease. But is that becoming more of a hindrance than a help to true compassion and understanding? It is important to start by recognizing the upside of the medicalization of psychological problems. Most importantly, to talk of them as health issues normalizes both the problems and those who suffer with them.
The depressed, the anxious and the phobic are not “mad” or “crazy” but ordinary people who happen to have developed debilitating problems. This also encourages people to seek help, without feeling that they have failed or will be judged in some way.
These are real gains, but they come at a price. Although the health paradigm in one sense normalizes psychological distress, in others it sets it apart from ordinary experience, creating an artificial distinction between problems of living and bona fide “conditions”. If depression, for example, is an illness, then it follows that there must be a clear difference between people who have it and those who don’t. But although the difference between severe depression and ordinary unhappiness is as clear as that between night and day, there is much twilight between the two.
Once this is accepted, it becomes clear that there is no neat distinction between mental illness and problems of living. Whether someone has a “condition” depends on where the lines are drawn, and different people draw them differently at different times. Whether that person has a diagnosable condition depends a lot on whether they choose to see someone prepared to offer a diagnosis, and there is almost always a doctor who will happily oblige. Indeed, Trott could even have been given one. In Brisbane, England’s team doctor told him, “If I was a GP I’d sign you off for three weeks from work.” Trott declined because he thought that such an act was not the done thing on an Ashes tour.
Furthermore, what diagnosis is offered would also depend partly on when Trott sought it. The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association remains the international reference point for this and its different editions and revisions have changed the definitions of various conditions at the stroke of a few keys.
It is possible to accept that mental distress is on a continuum and retain the language of illness and disease. In psychiatry, several conditions are classified as “spectrum disorders”, with no sharp separation point between those that are suitable for professional interventions and those that are not. The highest profile example of this to date was when the fifth edition of the DSM replaced the separate diagnostic labels of Autistic Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) with the single term “Autism Spectrum Disorder”. But we might question why we need quasi-medical diagnostic criteria in the first place. One reason is that people seem to believe that if something is a condition, with a proper name, then it is somehow more real. That is perhaps one reason why people often report relief when they are given a label for their problems. Someone whose self-esteem has been battered by crippling shyness, for example, can feel much better knowing that it is a social-anxiety disorder. Awkwardness ceases to be a personal failing and becomes an impersonal affliction, relieving the sufferer of the burden of guilt and responsibility. Instead of “I’ve failed” or “I’m inadequate”, the thought can be “I have a condition”.
I wouldn’t want to dismiss the real benefits that this kind of shift can have. But I do think that a similar positive effect is possible without resorting to medical models, and that to do so would avoid many problems that come with them.
First and foremost among these is the thorny issue of responsibility. One obstacle people often face when thinking about psychological problems is that it seems hard to imagine anything in between the individual being seen as a helpless victim of an illness or as someone who just needs to “pull themselves together”. So, as it sounds as though Trott is discovering, those who are not deemed ill are not seen as deserving of sympathy. Michael Vaughan said of him: “We were allowed to believe he was struggling with a serious mental-health issue and treated him with sensitivity and sympathy.
He was obviously not in a great place but he was struggling for cricketing reasons and not mental [reasons], and there is a massive difference.” Vaughan’s comments reflect the widespread assumption that a person’s problems are either non-medical and so entirely their responsibility, or the result of an illness which is entirely out of their control.
Once spelt out, it is obvious how absurdly simplistic this is. And it really matters from a practical point of view. Blaming people for their problems is pointless and unfair, but that should not stop us from encouraging them to take responsibility for getting out of their plights, while fully recognizing that they can’t do so by themselves. People often need to be helped to see how they have more power over their situation than it seems, and that they can take more responsibility.
This is perhaps clearest in addiction. People talk about alcoholism as a “disease” but if so, it is a very strange one. Talk of illness invites thoughts of cures and treatments. Psychotherapy and psychiatry have long embraced this lexicon and society has implored the professions to deliver on its promise. People concerned about alcoholism or depression, for example, are always calling for the government to make “treatment” more widely available. But no treatment can cure anyone of alcoholism who does not first decide they want to be better. Alcoholics are neither powerless victims of a disease nor the willing authors of their own self-destruction: the reality is much more complicated than either option suggests.
Psychiatric drugs might well be a solution for some problems, for some people. I’m agnostic about this. It is a fiercely contested issue, with some favoring pharmaceutical treatments for a wide range of problems and others claiming that even bipolar disorder is best dealt with without the use of drugs.
Whoever is right on this issue, it seems very clear that most psychological problems do not fit the model of illnesses requiring treatment. Therapists can help someone to get over their problems or at least cope with them better, but they cannot simply prescribe cures or apply treatments. Someone who goes to a therapist expecting to be “treated” as a “patient” will soon learn that therapy is a much more collaborative enterprise with uncertain outcomes.
Many people get very upset when the appropriateness of medical terms for psychological problems is questioned, wrongly believing that this belittles their suffering. But people do not need a diagnostic label to accept that a problem is a real one. Nor are they being blamed for being in the hole they are in if they are encouraged to think about how they themselves can take charge of the way out of it.
On the other hand, it doesn’t seem at all clear that medicalizing mental problems really has removed the stigma of psychological distress. In some ways, it might add to it, as people are set apart as the sick “others”, rather than the well “us”. Trott’s experience suggests that there may be something in this. “It was difficult when I got home,” he said. “I was a little bit worried about going out in public because people look at you, and I’d been all over the press and you don’t know what people are thinking. They think ‘there goes that nutcase’ or whatever.” People would come up to him and say “it’s good to see you’re out and about” as though having a genuine psychological problem means you can’t participate in society.
Thinking in terms of illness and disease perpetuates unhelpful myths. There is no neat distinction between people who are mentally ill and those who are not. The seriousness of a problem does not depend on it being clearly defined in DSM. And there are no treatments or cures that can simply be dispensed by “mental-health professionals”.
The case of Jonathan Trott should stand as a clear example of how a truly compassionate attitude towards psychological distress neither needs nor is helped by the desire to apply medical categories. Trott had ceased to be able to deal with the world he found himself in. “Just coming down to breakfast, I’d sit on my own away from the guys with my cap over my head because I didn’t know how I was going to react to having to go to the cricket ground again,” he said. “I was waking up looking at the clock hoping the clock had stopped, or that a pylon had fallen on the field and the game had been cancelled, or the stadium had collapsed – as long as there was no one in it, of course. You end up thinking of all sorts of ways you wouldn’t have to go to the ground.”
Whatever label we apply, this kind of suffering is very real. It may seem enlightened to think of Trott and others like him as ill, but if that leads us to make invidious distinctions between the genuinely sick and the merely unhappy, and to dispense support and help accordingly, then that is not enlightened at all.
For more mental health news, Click Here to access the Serious Mental Illness Blog