Defintions

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I’ve been thinking a lot about the language we use around mental health, and whether the way we describe mental health is reflective of people’s experience, or if instead it tells us more about the way society defines people. The way we think of mental health and specific ‘disorders’ have changed quite significantly over time, with explanations involving evil spirits to the biomedical model. One view is that these changes in definition arise because we are constantly improving and refining our definitions to fit with reality, and although there may be blips along the way, the trend is thought of as a positive one towards truth and understanding. An alternative view is that mental health diagnoses are social labels reflecting existing power structures and societal biases, rather than our best scientific understanding. There is so much to write on this topic, and much more to say about language and mental health, but for the moment I’ll use examples of sexuality and depression to show that the definition of mental health may tell us just as much about the society which defines as it does the subjects of definition.

In the US and Europe the most widely used tools for diagnosing mental health are the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Statistical Classification of Diseases (ICD). It is often cited that homosexuality was only removed from the DSM in 1987 and the ICD in 1992 (although the concept of ‘ego-dystonic sexual orientation’ is still included today). What is less commonly mentioned is that in 1901 Dorland’s Medical Dictionary defined heterosexuality as an “abnormal or perverted appetite toward the opposite sex”. The concept of homosexuality only exists because of the invention of heterosexuality – prior to 1868 there were no ‘heterosexuals’ or ‘homosexuals’, which does not mean that people didn’t have differing sexual desires, but that people had not been classified by them. Sexual behaviour was classified, and some acts forbidden, but the emphasis was on the act not the person. This highlights that while sex is a naturally occurring phenomenon, sexuality is the meaning that we humans have attached to it. And meanings change over time, defined by the societies in which they are constructed. Differing sexual behaviours and identities have been defined as ‘abnormal’ either through treating them as mental illnesses, or as criminal behaviour. In India and across their Empire, the British sought to control their subjects through redefining behaviour including sex. The brilliant recent news that India has decriminalised homosexuality is not a story of the country becoming ‘Westernised’, but of India re-embracing it’s past by removing one of the shackles of colonisation.

Even depression, which has had one of the most consistent definitions throughout history for a ‘psychological disorder’, has often been difficult to understand and identify. Psychiatrist Kurt Schneider identified two types of depression in the 1920’s – “endogenous depression” resulting from changes in mood, and “reactive depression” resulting from reactions to external events. In the 1980’s the emphasis moved away from external events onto individuals – a very convenient (at least) move for Western neoliberal societies wanting to disregard the impact of their policies on mental health. More recent research results from 2000 and 2010 seem to challenge the idea that major depression is a homogeneous category. But in 2018 comes the news that technology can predict depression by analysing text and audio conversations. How you react to that news may depend upon whether you believe that we have a solid definition for depression, or whether defining depression as a homogeneous category is helpful or even possible. It reminds me that technology is analogous to a hammer – a force which can be used for good or ill. From my limited counselling practise, individual experience of depression varies greatly. It has seemed more helpful to focus on that individual experience, and what it means to someone, over an official diagnosis. The example of homosexuality being so recently defined as a mental illness in the UK shows how cautiously we should treat labels and try to avoid the trap of thinking that we are as knowledgeable and as understanding as ever. There is a lot about the human mind that we don’t understand, and those with the power to define are usually those trying to maintain the status quo.

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