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The Quest for Mental HealthReview - The Quest for Mental Health
A Tale of Science, Medicine, Scandal, Sorrow, and Mass Society
by Ian Dowbiggin
Cambridge University Press, 2011
Review by Tony O’Brien, RN, MPhil
Feb 7th 2012 (Volume 16, Issue 6)

The subtitle of Ian Dowbiggin's review of mental health in the modern era suggests something of the wide scope of this book. It is an historical study of what we now call mental health, and of the various pathways taken in its pursuit since the eighteenth century. Dowbiggin does not confine himself to the activities of mental health experts and professionals; he employs a much wider lens to examine all aspects of the past 200 years in terms of what he regards as a relentless quest for mental health. In consequence, readers will find that a vast range of social developments have implications for mental health, beginning with Rousseau's humanistic vision and including everything that can be said to have relevance for mental health. Underlying this history Dowbiggin finds the idea of "democratization": that consistent with Rousseau's universalism, mental health should be equally available to all. The Quest for Mental Health is therefore an ambitious undertaking, the more so for being restricted to just 200 pages. If Dowbiggin is not wholly successful in integrating the diverse strands of the book he at least achieves a notable synthesis in showing how "mental health", whatever it is called at different times and places, it is embedded in a wider social and political context.

The book is presented in five chapters, arranged chronologically, each dealing with a specific historical period, from the Enlightenment to the twentyfirst century. The different chapters cover the Enlightenment legacy, asylum building, the mental hygiene movement, postwar psychiatric expansionism, and the recent professionalization / medicalization of everyday life. Most attention is paid to mental illness, to its emergence as a medical construct through to its commodification at the hands of pharmaceutical companies in current times. Not that commodification is new. As Dowbiggin shows, markets (in lunacy, professional services, drugs etc) have played a prominent part in concerns about mental health. But the current concern with "emotional welfare" as a public health issue represents the mass bureaucratization of what is at heart an understandable need to feel better.

The Quest for Mental Health is a clearly written and accessible presentation of Dowbiggin's thesis that what may have been, in earlier times, regarded as the pursuit of happiness, has in the twentyfirst century become the pervasive, insidious, and unhelpful practise of "therapism": the engagement of experts in every aspect of life that people find even vaguely problematic. Worse, widespread therapism has become government policy in many countries and shows no sign of letting up. As Dowbiggin notes in his introduction, governments and the World Health Organization (WHO) are showing increasing enthusiasm for advancing mental health as a crucial issue of our time. This is, of course, somewhat ironic, given the continuing stigma about mental illness. It has even been argued by some that the medical model of mental health followed by governments and organizations such as WHO contribute to stigma.

Readers familiar with the history of psychiatry will recognize the arguments about provision of asylums, phrenology, psychoanalysis and the burgeoning categories of the DSM. They will also be aware of the huge range of "therapies" spawned by psychoanalysis, and the "discovery" of previously unrecognised mental illnesses by pharmaceutical companies who have already found (and trademarked) their pharmacological treatment. However readers may not have seen these episodes treated as part of a history of pursuit of mental health. Rather, they have been studied so far as histories of institutions, professsions, treatments, families and patients et cetera. Dowbiggin's integration of these sometimes disparate histories within a single narrative of "mental health" is bold and original, although I thought it only partially successful. It is obvious to state (and Dowbiggin makes this clear) that the notion of "mental health" is a very recent one, and so there is great risk in framing two hundred years of history within such a modern concept. No doubt the creation of modern nation states is relevant to an understanding of mental health in current times, but only by providing the social structure within which new concerns could be experienced and addressed. Seeking a better, more fulfilling life, seems an inherent part of Western history, and more than a drive towards mental health. It is also hard to see madhouse confinement in the same light as the construction of shyness as a mental illness. Indeed, it is hard to see some contemporaneous developments as closely related, such as the drive towards biological models of mental illness and the psychologization of everything from dating to homicide. However I may be overstating Dowbiggin's argument here, and readers may well feel that eighteenth century attempts at personal improvement have reached their apotheosis in twentyfirst century therapism.

Dowbiggin makes some interesting points. For example the organization of psychiatry as the first medical specialism is not well recognized, and is usually lost in critique of the asylum and its apparently primitive methods. It is also no mean feat to have identified and described the cause of general paralysis of the insane. The role of phrenology in invigorating interest in a physical basis for mental illness, even although phrenology itself was soon discarded, is also not well understood, although Andrew Scull makes a similar observation in The Most Solitary of Afflictions. Dowbiggin's is not a singularly critical view of psychiatry, and in most cases, from asylums to electroconvulsive therapy, he is able to identify benefits from frequently derided psychiatric interventions.

There is no question that "mental health" is a concept with great social and political purchase these days. Epidemiological studies report enormously high prevalence of mental disorder, so much so that one would have to question their validity. Can in really be that 30% of the population will experience mental illness in their lifetime? If it is true, is it meaningful? Dowbiggin's historian colleague Edward Shorter (A History of Psychiatry) clearly thinks not. And should all those people be offered treatment? There is plenty of room for scepticism about such claims, and Dowbiggin's book encourages a healthy attitude of doubt, especially as professionals and government bureaucracies are not about to abandon psychiatric authority as a dominant influence on policy any time soon. If past experience in official, even judicial, support for dubious psychiatric categories is not enough to commend a cautionary response to medicalization, it may, ironically, be left to the market (or at least government treasuries) to limit the spread of therapism. With the American Psychiatric Association seemingly about to define hoarding as a mental disorder the end is not yet in sight for the dream of a professional solution for every problem, at least within the affluent West.

The Quest for Mental Health is a welcome contribution to the literature on the history of mental health and psychiatry. In addition to historians, it has particular relevance for those concerned with mental health and social policy. Clinicians will also benefit from Dowbiggin's wide ranging analysis, and perhaps feel more inclined to normalize rather than medicalize the increasing number of problems for which people seek professional intervention. Dowbiggin clearly sees a place for psychiatry and mental health care; he is not an iconoclast who sees a single cause for a complex modern issue. He therefore does not advocate a single solution, either philosophically or politically. But he does ask us to respond with caution to the relentless pursuit of happiness in the form of mental health.

 

© 2012 Tony O'Brien

 

Tony O'Brien is a lecturer in mental health nursing at the University of Auckland, New Zealand


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