A Utopian Vision of Mental Health: Part I
Foundations, historic considerations and the diagnostic paradigm.
In the aftermath of a global pandemic, a prolonged fear-based event that divided, isolated and undermined everyone in its wake, people are mentally sick, indiscriminately falling onto a spectrum of psychic dysfunction. This is not a slight towards anyone in my periphery, near or far—I aim to treat everyone I meet with compassion and refrain from judgement. I have no right to referee the actions of anyone—I myself lived in mental, emotional and physical turmoil for many years, finding my way into countless serious depths of degeneracy, places I would not wish upon another. I am observational, however; I gather data from interactions regularly, either purposefully or subconsciously. Breaking free from the madness, authentically, took a great deal of hard work, devotion, and help from my peers. Liberation did not occur overnight and the journey has been extremely unpredictable—many magnitudes of order beyond linearity. Furthermore, I am far from finished with respect to healing, development and realization; I know my potential yet still I fight daily to sustain propulsion in the right direction.
Unfortunately, the system we reside in does not favor the average person on their path towards genuine betterment—for the most part. I have long felt a twinge of resentment towards the established mental health paradigm, particularly towards diagnoses, psychiatry, and blindly-applied medication. This has stemmed partly from perceived damage at the hands of certain mental health “professionals,” individuals in high places of power who assert dominance and project their own inefficacies onto vulnerable, confused people. Generally, these practitioners operated based on archaic principles, utilizing an approach to wellness that does not factor in real humanity.
The most celebrated therapists are those who have themselves battled in the trenches of crucifying, debilitating anxiety, soul-crushing depression or life-threatening addictions. Many concepts simply cannot be understood based on theoretical methodology alone. Those with the utmost potential to improve the lives of others are those who have fought their own wars internally and survived to tell their tales. For someone with a long and complex history of substance abuse patterns to be instructed on their recovery by some white-coat specialist, who has minimal experience using psychoactive drugs, is deeply unnerving. Well meaning or not, a high-end certification does not suggest an innate understanding of addiction. For this precise reason, 12-step fellowships remain champion in the induction of sobriety—addicts helping addicts, no monetary incentives or conspicuous motives, just a sincere desire to support both the struggling newcomer and themselves through mutually-consented symbiosis.
Well-equipped and capable mental healthcare workers do exist, of course. I have worked with multiple stellar counsellors who assisted in my pursuit of sanity and stability. The commonality amongst these experiences was a fostered sense of equality combined with an unfeigned interest in my evolution as a dynamic, flawed, unique person. In my worst experiences, I had opened myself up and was met with righteous criticality, clearly grounded in judgement, envy or even malice, leaking out from an inflated ego and an insidious complex of superiority. There were also edge-cases; most notably, a complicated relationship with a family physician playing psychiatry, whose negligence or at least inconsistency led me straight into a vicious cycle of benzodiazepine dependency and withdrawal, and a treacherous entanglement with a psychopathic psychiatric-ward doctor hellbent on making me suffer.1
During my trepidations through our society’s offering of psychic healthcare, I began to envision what a healthy framework of mental health would entail. A comprehensive, systemic overhaul is necessary to create an inclusive, effective, rigorous platform from which mental wellness can be instilled, for anyone, regardless of their age, race, status or conditional severity. Here, I attempt to transcribe the beginnings of a utopian perspective on mental health—a preliminary, all-encompassing, ideological architecture which will outline the mechanistic workings of an idealistic system. Such a blueprint could be adapted by future generations in whole or by present-day culture in part; fantastical by design, it is far more of an abstract exploration than a practical guideline. This hypothetical manifesto will also serve as a thorough dissection of modern-day mental health practices and standards, including: stigmatization, monetization, over-complication, discrimination, exclusivity and more.2
What does utopia—the absolute standard of perfection—look like in regards to a collective of mentally healthy people? To unpack such an intricate contemplation, consider first the dominion of diagnoses in our current culture, predominantly led by the DSM—The Diagnostic and Statistical Manual of Mental Disorders—presently available in its 5th iteration. The DSM, published by the American Psychiatric Association (APA), is a vast repertoire of specific, symptomatically-defined conditions that a group of “experts” have deemed to be abnormal, problematic, fitting for treatment and a somewhat lower-tier classification. This model is pervasive and indicative of the state of psychiatry as a field of inquiry. Its history is highly intriguing and was summarized in a 2012 paper by Kawa and Giordano, in which I learned some interesting details:
Although the first official edition of the DSM did not arise until 1952, psychic diagnoses can be traced back to the early 1800s when they were listed on the US Census.3 Essentially, households were polled to determine if residents suffered from obvious mental disturbances. The cited paper states that this was done primarily to improve treatment abilities for those institutionalized; however, I am somewhat unclear on this rationale.
In 1918, the first standardized guidelines of psychopathology were published as the Statistical Manual for the Use of Institutions for the Insane. After undergoing 9 revisions that reflected the then-changing tides of psychiatric ideology, this manual morphed into the first edition of the DSM. That is correct—the historic basis of our present-day diagnostic system was foundationally built for the purpose of categorizing the dysfunction of institutionally-bound men and women.
The DSM-I was largely aligned with psychodynamic theory, which was pioneered in part by historic figures such as Freud and Meyer in early 20th century, replacing the “Kraepelinian” line of reasoning that dominated in the 1918 version of the DSM’s predecessor. Kraepelinian theory views mental disorder as biological disease while psychodynamic theory takes a more holistic approach, considering environmental factors and unresolved trauma as well as neurological malfunction.
The DSM-II, published in 1968, saw a notable return to the “medicalized” view of mental health; namely, that its characterized disorders are inherently pathological, stemming more from genetics and “organic brain dysfunctions” than they are from socio-cultural factors. This supremacy has reigned ever since; however, in the 1980 DSM-III, a multi-axial diagnostic system was introduced, recognizing the relative importance of associated medical conditions and situational/social considerations, yet still adhering to disease-based etiology of mental disorder. Although hailed by many as useful, this axial-system was removed entirely in the DSM-V, despite an internal committee of the APA recommending its continuation.
Homosexuality was considered a mental disorder until the 6th printing of the DSM-II, after which, in 1973, it was finally removed. Labelled as a “sexual deviation,” it was hosted in the same category as necrophilia, pedophilia, sexual sadism and fetishism.
As of the DSM-III, which was purportedly founded on empiricism, the Food and Drug Administration (FDA) in the US required that for any medication to be approved, it must be designed for treatment of a codable, “official” disease, and proven effective in its treatment. This spawned a massive push for incentivized drug studies; in fact, following the inception of DSM-III, “billions of dollars were allocated by the government and pharmaceutical companies for psychopharmacological research.” Also, many insurance providers would necessitate that a diagnosis be attached to their clients should coverage be granted for mental health treatment modalities, continuing to this day.
The number of diagnoses has increased greatly since the days of census-based inquiry. The general trend has been to revise and expand categories to become more precise. Below, I have visualized the increase in diagnoses as a function of time. Strikingly, the data follows an exponential function near-perfectly, at least up until the 4th version. I did not include a value for the latest DSM (5) here as I could not find a reliable number. It seems that this branching phenomena has become so complex that there is debate over the actual number included, a clear argument for simplification. That said, the approximate value can be assumed similar to the last point, creating a statistical plateau.
Obviously, the DSM is sturdily lodged into contemporary culture, influential and tied to major capitalistic endeavors; thus, it should be questioned with rigor. A theme I noticed while reading about the DSM’s history is an underlying desire of psychiatry as a whole to stand as a reputable field of science, one that is fundamentally rooted in medicine. I understand such a longing; for a profession constantly in threat by the whims of ideological trends, the level of insecurity must be crippling. Regardless, if an intrinsic truth were masked due to that fear, it would be highly unethical albeit unsurprising. Clinging onto the disease model of mental health seems desperate, forced even, while ever-important environmental factors have oscillated in clinical importance throughout the maturation of the DSM. The fact that the multi-axial system, which incorporated non-pathological considerations in a substantial format, was removed and replaced with a more subtle assimilation of such factors is telling, as are the links to pharmaceutical and insurance industries, both momentous money-makers.
Whether the DSM as it stands is inherently corrupt or a well-meaning effort to improve people’s lives, I cannot say with certainty—it is far too complex an issue that would be worthy itself of a PhD’s thesis. The truth is likely somewhere between these two extremes—the driving, opposing forces of capitalistic gain and altruistic humanity. If the DSM actually works in helping the general population is an entirely different story. Diagnosis can act as a powerful catalyst, especially to those unaware of the associated implications. These labels hang on the lived experience of those they categorize, leading to perpetuation of symptoms through an active feedback-loop. From a perspective of social integration, the resultant stigmatization of certain diagnoses can follow one around like a shadow.
Some may celebrate newfound diagnoses as a means of explaining their struggle, buying blindly into the disease model of mental health and effectively abdicating themselves from responsibility regarding inappropriate behavior. In reality, personal accountability and ownership of one’s past wrongdoings is paramount in fostering a successful recovery, as demonstrated by 12-step programs that also utilize a disease-based model. This leads to some important distinctions between the methodology of 12-step and the public depiction of myriad unique, pathological mental disorders. Firstly, although communities such as Alcoholics Anonymous and Narcotics Anonymous do make use of such terminology, they do not define addiction as a strictly physiological problem; it is more accurately deemed a spiritual malady that affects all layers of the human experience—physical, emotional, and mental. Secondly, 12-step focuses on a singular affliction, not 200+ as supplied within the overdrawn DSM database. The former is akin to viewing people as either ‘sick’ or ‘healing,’ a binarized differentiation with simplistic underpinnings.
Lastly—the most profound point of comparison—12-step programs offer just that, a program. Disease or not in actuality, the people who are attracted to 12-step and buy into its doctrine are ushered into a reliable framework of healing principles, supported by a compassionate communal vessel and ultimately made safe from their life-threatening ailment, should they choose to engage—the bottom-line of what truly matters. In the case of free-flowing DSM diagnostics, people are handed their burdens and often left to fend for themselves. Judging by how medications are positioned within the psychiatric paradigm, one should wonder if there is a higher-level preference for citizens to become properly labelled so they can be pushed into expensive, efficaciously-questionable, chemical treatment routes that pad the pockets of pharmaceutical executives. The public sphere of mental health treatment, in Canada at least, is a long and winding path, one overladen with hierarchal nonsense and unnecessary complications.4
Picture the following: a person suffering from persistent anxiety, sadness and an inability to focus, all natural responses to an overbearing, hyper-accelerated culture at large, wanders into a psychiatrists office. They endure a 15 minutes symptomatic-assessment wholly focused on present-day manifestation, refraining from any sort of inquiry into their relationships, past trauma, or life stressors. Upon its completion, they hand out a host of clinical diagnoses: generalized anxiety disorder (GAD), major depressive disorder (MDD), and attention-deficit-hyperactive disorder (ADHD). Before showing them the door, the doctor doles out a handful of scripts—prescriptions for benzodiazepines, to treat the anxiety, SSRIs (selective-serotonin-reuptake-inhibitors), to treat the depression, and amphetamines, potent stimulants, to treat their now “unearthed” ADHD. This is a somewhat dramatized example; however, it evolved from personal anecdote—I have been churned through an office of psychiatry in a similar fashion, having only my symptoms elucidated and abandoned with nothing but a recommendation for medication and counselling. All of this was after months of waiting for a somehow renowned professional; frankly, I felt much worse afterwards and was utterly disappointed, jaded and offended by this apparent hallmark of psychiatric theory. Realistically, diagnoses can be downright detrimental to the people they intend to assist; my endeavors through the realm of mental healthcare were immensely frustrating—I wanted real help, not a label.
Does it really matter if mental disorder is definitively disease-based on not? In an idealistic world, the focus would lie in the betterment of people, not in the pathologizing of their pain. With that said, my own experience has led me to hypothesize that the lived-state recognized as mental illness by the DSM is largely an incarnation of unresolved trauma superimposed with the embodied pressures of an entirely sick society, with undertones of predisposition from genetics and biological makeup. A similar view is echoed by the iconic Dr. Gabor Mate, expert in developmental trauma, throughout his recent book The Myth of Normal—extrapolating his postulation that there is no such thing as “normal” in modern-day society, the diagnostic assumption that people who display certain behavioral symptoms are mentally ill is radically flawed. It makes the presumption that there is some baseline standard of normalcy by which the “sick” subset of people can be measured against—a statement that is fallacious and dangerous
What if the trajectory along which our present-day society has evolved is, in fact, unnatural, at least in comparison to our long-ago ancestors? Do we really think it is “normal” for children to grow up with supercomputers as their best friends, just to become hyper-functional adults who compete against factions of others in a divisive, uncertain, and judgmental environment, selling away their precious time just to expand the wallets of some wealthy group of elites? Is it “normal” for children to be medicated with potent stimulant drugs under the guise of a valid “treatment,” just because the DSM says its okay?
Consider this—the National Comorbidity Survey in the US has estimated that roughly half of the American population will, at some point in their lives, exhibit behavior fitting of a DSM diagnosis.5 That is absolutely wild—what started as a means of helping the clinically-insane has contorted itself into a network of classification so vast that it applies to half the persons living in the 3rd largest country in the world. This figure alone casts skepticism onto the credibility of such a system—perhaps useful in origin, the DSM has seemingly become bloated, collapsing under its own weight, rendering its usefulness shrouded in doubt.
To transition into a utopian-esque climate of mental wellness, we must first identify and address fundamental dilemmas that permeate the daily lives of the so-called neuro-divergent populace; then, unassumingly pose solutions using made connections to the faulty components of our current system. To eradicate the rippling effects of something as culturally-extensive as the DSM—or psychiatry in general, even—would be a near-impossible task lest a brand new society were built, a thought I have certainly entertained on occasion. Working within the pre-established infrastructure of the diagnostic-macrocosm may prove itself the only viable option, at least for now. As is poignantly discussed by social-scientist Adam Grant in his book Think Again, human beings, by their very nature, are extremely unwilling to rethink their core beliefs, even if overwhelming evidence is placed bluntly in front of them.
This is definitely a larger-scale problem than that which is apparent on first glance—certain engrained structures in our civilization are so stubbornly cemented into the fabric of existence that nothing short of internal revolt could tear them down. Imagine how many concepts are simply not being investigated, just because we fear the consequences that would arise should they be proven wrong. As argued by Grant, our culture does not incentivize free-thought, unfortunately; to be a straight-thinking, unilaterally-believing individual is the quintessential virtue of modern day socialization. Practically speaking, we ought to be constantly reframing, testing and reworking our hypotheses, not just in science but in everything—the way we live, talk, act, think and believe.
The working model of humanity can be frankly comedic in certain aspects; I would go so far as to describe it as pure comedy, a phrase set forth by the legendary musician and social-commentator Josh Tillman under his clever moniker Father John Misty. Much of what is accepted as status-quo is nonsensical, and the leanings of my opinion towards the DSM and psychiatry, as they presently are, would be to lump such structures into the basket of absurdity, especially if taken dogmatically. I am open to being convinced otherwise; however, to have 200+ separate, clinically-diagnosable conditions defined literally as diseases of biological pathology, the most common solution to which are pharmaceutical drugs which produce billions of dollars in revenue for massive corporations, is unnerving to say the least.
What, then, is a genuinely holistic path forward? Some are opting to go off-grid, creating self-sustaining camps in far-away forests—an undeniably compelling argument that requires one’s prior success in the rat-race and a steady source of unconventional income. Returning to the aforementioned manifesto of psychic wellness, my ultimate hope in studying these matters is to craft a usable blueprint that future generations could discover and implement. I myself do not possess the required manpower to induce a full-scale revolution. What I do have is my voice and my willingness to write, to understand, and to critically examine the architecture of ideology that comprises modern day society. With such a gift I am morally obligated to develop my theories and cast them into the social-matrix, and with divine assistance I will gain traction in my endeavors. Ultimately, awareness is the most powerful tool than any one of us may bear; to effect change on a global scale would take a huge shift in the collective consciousness and a united vision of utopian strivings.
Thank you for reading! Part two of this exploration will look at medications, diagnosing children, spiritual aspects of “disorder,” and the hypothetical blueprint for utopian mental healthcare. If you enjoyed this essay, please consider sharing it with others and if you have not, feel free to subscribe for free weekly essays delivered straight to your inbox.
I later learned that the psychiatry community was aware of this person, who was abusing his power within psychiatric institutions and taking patients off of their medications, such as benzodiazepines, abruptly, which causes sheer agony and potentially death.
If it was not clear, this description is of my end goal—to craft a thorough, novel treatise on mental health in the modern age—and this essay is a mere first dip into such an endeavor, meant to flesh out ideas and garner momentum.
According to a (non-peer-reviewed) historic summary from Cardwell Nuckols, the original diagnosis on the US census was idiocy/insanity, in 1840. He further suggests that the 1880 census included 7 different diagnoses: mania (seemingly, the modern equivalent of bipolar disorder), melancholia (depression), monomania (somewhat similar to obsessive-compulsive or attention-deficit-hyperactive disorders), paresis (paralysis—a physical condition allegedly deemed at the time to be of a psychological nature), dementia (cognitive impairment), dipsomania (alcoholism) and epilepsy. Due to the non-professional structure of this source I cannot authoritatively confirm that this information is accurate; regardless, it is fascinating.
I have, however, noticed improvement in some areas as of late compared to 5 years ago.
This statistic is taken also from the aforementioned 2012 paper by Kawa and Giordano.