Creating Mental Illness

by Allan V. Horwitz

In this surprising book, Allan V. Horwitz argues that our current conceptions of mental illness as a disease fit only a small number of serious psychological conditions and that most conditions currently regarded as mental illness are cultural constructions, normal reactions to stressful social circumstances, or simply forms of deviant behavior.

"Thought-provoking and important. . .Drawing on and consolidating the ideas of a range of authors, Horwitz challenges the existing use of the term mental illness and the psychiatric ideas and practices on which this usage is based. . . . Horwitz enters this controversial territory with confidence, conviction, and clarity."—Joan Busfield, American Journal of Sociology

"Horwitz properly identifies the financial incentives that urge therapists and drug companies to proliferate psychiatric diagnostic categories. He correctly identifies the stranglehold that psychiatric diagnosis has on research funding in mental health. Above all, he provides a sorely needed counterpoint to the most strident advocates of disease-model psychiatry."—Mark Sullivan, Journal of the American Medical Association

"Horwitz makes at least two major contributions to our understanding of mental disorders. First, he eloquently draws on evidence from the biological and social sciences to create a balanced, integrative approach to the study of mental disorders. Second, in accomplishing the first contribution, he provides a fascinating history of the study and treatment of mental disorders. . . from early asylum work to the rise of modern biological psychiatry."—Debra Umberson, Quarterly Review of Biology

Genres: Psychology, Mental Health, Psychiatry, Sociology, Nonfiction, Medicine, Academic

315 pages, Hardcover

First published January 15, 2002

Reviews

[Christina · Rating 2 out of 5]

This book is well-organized and its points are well-argued, and as a geneaology of mental health practices, it is useful. However, its ideological angle is still evident, despite what seems to be an attempt at neutral language in many instances. While the utility of discrete disease entities in editions of the DSM for financial and political purposes is clearly demonstrated in Horwitz's arguments, the other side of the argument is missing. Horwitz argues, for example, that reimbursement for psychiatric services and medications by insurance companies was an important factor in the delineation of a panoply of mental disturbances as distinct disease entities. I have no quarrel with this assertion. However, the need of patients to use insurance to cover treatment they wouldn't otherwise be able to afford for problems that have simply not reached a particular research threshold to qualify as biological diseases with proven biological causes, but which cause the patients themselves considerable suffering, isn't discussed.

Similarly, the formulation of the DSMs to encompass any mental disturbances already being treated in the field, allowing their use by various potentially competing schools of psychiatric theory and practice, is presented primarily as an unscientific unwillingness to cause mental health professionals to lose clients. Again, the argument misses a different perspective. WOULD these mental health professionals lose clients as a result of a DSM becoming more exclusive? Or would their practice simply become less standardized? In other words, if ADHD, for example, were removed from the DSM, some practitioners would continue to treat it; others would diagnose the symptoms as something else; and still others would be freed to stop treating sufferers of ADHD, validated in their disbelief that ADHD is "real," and ADHD symptoms, lacking a medical definition, would fall back into the quasi-religious realm of moral failings, or lack of self-discipline. The standardization of the broad array of conditions helps to protect patients, as well as practitioners, which Horwitz fails to account for. I'm happy to accept that the more cynical angle is the primary driver; but I think it's important to discuss the other aspects as well.

Finally, Horwitz argues that "mental disorders arise when psychological systems of motivation, memory, cognition, arousal, attachment, and the like are not able adequately to carry out the functions they are designed to perform. These functions are not social constructions but properties of the human species that have arisen through natural selection" (12), but fails to recognize that even conceptions of how human bodies are designed to perform is culturally designated. By this criterion, homosexuality, along with asexuality, pansexuality, bisexuality, and all other non-strictly-heterosexual desires, could legitimately be considered mental disorders, since sexual arousal is still considered in most cultures to primarily facilitate reproduction. Arousal in a situation that could not result in reproduction, or lack of arousal in a situation that otherwise could, would be classified as mental un-health in a social context (most of them) in which reproduction is considered to be the primary, if not sole, purpose of sexual desire and arousal. Conversely, acute stress disorder might NOT be considered a mental disorder in people in active conflict zones or abusive domestic situations, despite its adverse and deleterious physiological effect, because it is not caused by psychological malfunctions, but is actually the brain responding appropriately to extreme stimuli.

Many of these discrepancies arise from the fact that there is still comparatively so much to be learned about human brains. What is the distinction between "biological" causes of a disorder and "life events" as a cause? The distinction, in my view, arises from a belief in "rationality" that is independent of actual neurological processes. If genes and life experiences both physically impact a human brain, then what is the distinction between a "biological" disorder and one that results from life events? The distinction seems to be a moral one, which attempts to distinguish between a "legitimate" disorder and....whininess? Overall, the book seems to be overly focused on the perspective of professionals, while ignoring the needs of sufferers themselves. (I know that's not the best way to refer to people, I just don't have an easier term, I'm sorry.) If depression is causing significant disturbance in a person's life, for example, does it matter if they inherited it at birth, or if it's because of a breakup? While exploitation by mental health practitioners of their suffering patients is certainly something to be vigilant about, sufferers have a right to try to feel better. Why is it the right of someone else to say, "Sorry, lots of people feel upset when they get divorced, this isn't the kind of thing you need professional help with"? An overhaul of our understanding of mental health/unhealth, I think, is crucial, moving our society toward a more holistic approach to treatment (therapy, diet, life coaching, and, yes, pharmaceuticals, all as components that may or may not be useful in a given situation), as well as an understanding that individuals should be the authority on what they themselves are feeling and what is causing them problems in their own lives.

[Faaiz · Rating 3 out of 5]

Written nearly 20 years ago, this book although useful from a historical perspective is bit outdated as it came out at the time of the DSM-IV R and therefore misses the developments that came as a result of the DSM-V not to mention the fact we are now expecting the release of the DSM-V-TR in 2022. However, the broader point about psychiatry that the book makes in the shift from dynamic to a diagnostic model of psychiatry will in all likelihood hold, maybe even be more poignant than ever.

My overall impression of the field of psychiatry can be characterized as dissatisfaction, both from the academic/scientific/intellectual perspective as well as a user of these services. The whole thing is rife with problems from head to toe. Before the current model of discrete symptom-based diagnostic categories of mental illnesses, there was the dynamic model which built off of the work of Freud and his followers with the emphasis on unconsciousness, repression, projection, and so on. That model was rife with problems of reliability and validity, but its replacement with the diagnostic model did not eliminate those problems. Instead, more clusters of symptoms have been constructed into disorders without the identification of a clear (or as clear as it can be) etymology, prognosis, and in some cases even specific treatments. The argument posited in this book is that the fundamental weakness of the diagnostic model for psychiatry is in its insistence on discrete categories (which the existence of comorbidities defeat the purpose of anyways) made up of symptoms (which may also be in other disorders anyways) that have to be shown to be "real" illnesses. The confluence of socioeconomic factors such as the rise of third-party insurance, the interests of pharmaceutical industry, and the crisis of respectability within the psychiatric field played a crucial role in how we got here. Pharmaceutical companies can only advertise drug treatments for real/specific illnesses; the insurance industry will only pay for treatment of specific illnesses with prognoses and effectiveness of treatments, and so on.

The problems range from conception of mental illnesses, the construction of specific mental illnesses based on clustering of symptoms, the measurement of illnesses, the societal norms and cultural worldviews surrounding not just the conception of mental illnesses but their manifestation too, and treatment of mental illnesses. Even when critiquing the contemporary issues with mental illnesses one runs into problems. Consider this example by the author:

George Vaillant observes that borderline and narcissistic personality disorders are usually found only in American cities that have opera houses and psychoanalytic institutes. They are rarely seen in Iowa City or in Mobile and are never present in Tangiers or Bucharest.

Where does one begin with this? Is it the case that American cities with opera houses, indicating that they are larger and wealthier than Iowa city and Mobile, would attract not just more psychiatrists which would enable the diagnosis of more people with BPD/NPD, but also contain people with the right sort of outlook and openness towards modern psychiatry to enable themselves to be diagnosed? Is it also the case that American cities with opera houses would contain psychiatrists schooled in the APA's DSMs compared to psychiatrists in Bucharest and Tangiers; and would have people with different methods and cultural outlooks towards not just psychiatry in general but also the specific symptoms of BPD/NPD which affects their help-seeking behavior and approach towards psychiatry in the first place? So, what does NYC/Boston having more BPD/NPD diagnoses than Tangiers/Bucharest even mean or prove the point of? There is a lot of that going on in this book, where even the critique of the current psychiatric paradigm isn't well argued and doesn't address the myriad of confounding variables that impact a clear-cut interpretation.

[Kristín Hulda]

Rakst á tilvísun í þessa þegar ég var að skrifa mastersritgerðina mína, googlaði bókina lauslega og fannst hún virka mjög spennandi þannig ég keypti hana dýrum dómum. Það runnu hratt á mig tvær grímur þegar ég var búin að lesa svona 30 blaðsíður og höfundur minnist á DSM-3 geðgreiningarkerfið, enda er í dag notast við fimmtu útgáfu þess umdeilanlega kerfis. Kemur í ljós að í öllum spenningnum hafði mér láðst að fletta upp útgáfuárinu en bókin kom út árið 2002 og það varð alveg ljóst eftir aðeins meiri lestur að það er of mikið af úreltu efni í þessari bók til að ég nenni að lesa hana, mikið af hugmyndum sem voru kannski framúrstefnulegar árið 2002 en eru old news í dag.

[P. Es · Rating 5 out of 5]

great book, lays out the pathologizing paradigm.

[Bob · Rating 3 out of 5]

The author says that if his arguments are correct than many of the 50 million Americans who meet the criteria for a mental disorder in community studies do not have valid disorders but suffer from distress that is rooted in stressful social arrangements and that will disappear when these situations improve. I believe the author does indeed prove his point.

I think the author does not come out strong enough with his conclusions, but this could be because the book was written in 2002. Many studies done since then strengthen his arguments and show that our society’s understanding of mental illness only fits a small number of people.

Basically psychological well-being & distress commonly originate from social factors. Happiness, sadness and the like arise from acute life events, chronic lifer circumstances, social roles and collective systems of meaning, all of which the author explains very well throughout the book. Most people who have been labeled mentally ill are not they are actually responding appropriately. In other words they should be sad, experiencing grief, and anxiousness, etc.

Psychological conditions that fluctuate with social situations indicate normality, not mental illness.

It is an important book but ones published since 2010 do a better job and offer better, clearer and stronger conclusions.

[culley · Rating 4 out of 5]

The sociology of psychiatry— important historical information if you or anyone you know have received a diagnosis, complete with compassion for the current paradigm. The writing is moderately academic, but intelligent and readable. Good science!

The biological foundations of mental illness (not including psychotic disorders like schizophrenia and bipolar) is debunked, psychotherapy is reframed as “social support” no better than other forms of social support, and the vast majority of mental disturbances are seen as resulting from stressful social situations. Psychiatry’s switch from an inquiry into unconscious motivations in the days of Freud to drug treatments for discreet mental conditions is described as a response to clinical psychologists and social workers infringing on psychiatry’s hegemony in providing social support. Medical training is what distinguished psychiatry from other forms of therapy, so they increased their ties to the medical establishments and the medical model in general as a means of securing professional legitimacy.

[Ashley · Rating 4 out of 5]

All in all he makes some very interesting points about the conceptualization surrounding what we consider mentally ill and the current categorical based system now used for diagnosis (DSM). He covers a lot of the basics (Kraepelin, Eyseneck) and his notes section can lead you to a lot of other current thought (Wakefield, Szaz, ect. ) I’d definitely recommend it if your considering working diagnosing mental illness.

[Caitlin · Rating 5 out of 5]

This book is great! Many people don't like it because it causes them to have to rethink how mental illness is defined but I highly recommend it... Like really, really recommend it.

[Henrik · Rating 4 out of 5]

3.5 *
Boken er bra, men det begynner å merkes at den er 20 år gammel på forskningen som nevnes, samt at DSM 5 ikke hadde kommet ut ved utgivelse. Argumentasjonen står imidlertid fremdeles godt ettersom DSM 5 på ingen måte har løst problemene presentert i Creating Mental Illness. Den har heller presentert et helt sett nye problemer som må drøftes... Det historieske og sosiologiske perspektivet står fremdeles godt, men dette kan også plukkes opp i Horowits andre bøker - sammen med DSM 5 kritikken. Sluttsitatet er boken oppsummert og noe jeg definitivt tar med meg videre:

Those who are concerned with mental health and illness should not assume either that mental illness labels are appropriate whenever they are applied or that they are never appropriate. Instead, they should strive to specify when people have internal dysfunctions or, alternatively, when they are making normal responses to the social situations in which they find themselves. Ultimately, they need to consider when restoring normality is best accomplished by changing individuals and when it is best done by transforming social conditions. - s.229

[Luke · Rating 5 out of 5]

Great book that challenges the hegemony of disease-model of mental health. Horwitz' chapters on the history of psychiatry should be required reading for all people working in the mental health field. The only issue I take with the book is Horwitz' constant reference to schizophrenia, bipolar, and depression as actual latent-disease entities. We still have not proven this and likely never will, and for this reason he never provides a real defense for this suggestion except for the fact that their numbers (at least for schizophrenia) are uniform across cultures around the world. But this alone is not adequate evidence of a latent disease model. Nevertheless, it's a fantastic and invigorating read!

[Amanda Hewitt · Rating 4 out of 5]

gives a good multidimensional and historical view of mental illness as well as mental health. would have appreciated better concepts and history applied about the humanistic perspective, but does give a lot of enriching information about issues in psychodynamic vs. empirical practice. It also would have been helpful to include in the book about the histories of practices more and the evolvements of them. some important factors including why psychiatrists don't counsel in their training anymore, and what exactly a future holds for LMHC's and LCSW/LICSW.

[Gary Johnson · Rating 5 out of 5]

Superb

Read lots of books on the reality of mental illness. This is by far the best. Scholarly, readable, and Incredibly insightful.

[Emily · Rating 4 out of 5]

A thorough account on how and why our understanding of madness has been homogenized, and what implications this has for the individual and society at large. A compelling and provocative book that challenges current conceptions of mental illness as a disease.

For people interested in this topic, I highly recommend the following authors:
- Thomas Szasz
- Robert Whitaker
- Ethan Watters