My initial reaction to this article was that it was great, because I was 
focusing on its critique of psychiatry. I particularly like this statement: 
'While the middle classes debate their happiness and psychiatry acquires a 
cultural prestige well beyond its powers, the poor inherit the new 
straitjacket of psychological language'.
Then I noticed some jarring statements about disadvantaged people.
Ahmed wrote [my comments are in square brackets]:
'I become the healer attempting to cure their condition, pretending somehow 
their malaise is one of biology [good point] and not of meaning [semi good 
point, provided meaning is interpreted socially as well as individually]. 
The result is that it can blind them to the possibility their actions may 
have played a role in their problems [victim-blaming].'
I would have much preferred it if he had written:
'I become the healer attempting to cure their condition, pretending somehow 
their malaise is one of biology and not of structural factors, including 
social constructions of what it means to be a person. The result is that it 
can blind them to the possibility their life circumstances may have played a 
role in their problems. It can also blind them to their own agency to change 
some of those circumstances.'
Ahmed also wrote:
'They are hardly poor in a historical sense, for they have enough money to 
eat and are housed, educated and medically treated by the state [This is 
relatively true in Australia (unlike many countries), with the glaring 
exception of remote Aboriginal communities]. In formulating their situation, 
poverty in this sense is more like a psychological condition than one 
determined by socioeconomics [victim-blaming and pathologising; poverty is 
not a psychological condition, although it can be exacerbated and entrenched 
by despair].'
It is a pity that Ahmed's sound criticism of psychiatry is mixed with 
semi-compassionate victim-blaming.
Much of what he says also applies to less disadvantaged people, but they 
have more power to reject psychiatric labelling (and in a few cases they pay 
lawyers to use it to their advantage to escape conviction and punishment for 
bad behaviour).

Terms of unhappiness in a sick world
Tanveer Ahmed
September 15, 2007
As a doctor working in mental health and within the public hospital system, 
I am a regular witness to those living on the bottom rungs of our society. 
They are the homeless, the drug addicts and those suffering from severe 
mental illness. More often than not, they are all three at once.
I am struck by their amazing uptake of mental health language. They 
skilfully weave technical psychiatric language into their reporting of 
symptoms. As a result, comments such as "I'm pretty sure I'm coming down 
with a depressive disorder" or "I think I'm developing a personality defect" 
are not uncommon, even from people with minimal education.
This is in part a reflection of wider society and how the language of human 
distress has been overtaken by psychological terminology. I hear very few 
people tell me they are unhappy. They are almost always depressed, even if 
their life choices or circumstances would be perfectly consistent with them 
being miserable.
Increasingly they no longer suggest they feel depressed, but that they are 
getting depression, in the same way we may catch a cold. The consultation 
then moves to the awkward dance modern therapists play. I become the healer 
attempting to cure their condition, pretending somehow their malaise is one 
of biology and not of meaning. The result is that it can blind them to the 
possibility their actions may have played a role in their problems.
Barely a week goes by when we don't hear of the crisis in mental health. 
Rising depression, worsening drug and alcohol problems and a strained social 
sector make us think that despite our stupendous prosperity, we remain in 
some kind of existential abyss. It is a symptom of the market society and 
individualism that our grievances must be turned on to the self.
This is in spite of psychiatry remaining a hazy field, an arena where 
diagnosis and treatment are poorly correlated and where clinical energies 
focus on symptom relief. It is reflected further in the tremendous amount 
written about happiness studies. If being dissatisfied with life is 
pathological and health is a right, the implication is that happiness is 
also our birthright.
The use of psychiatric terminology is also more and more colloquial. During 
the Andrew Johns saga and his eventual secular confession, bipolar disorder 
was used widely in the press as a synonym for erratic behaviour. The former 
Victorian premier Jeff Kennett, a tireless campaigner in raising awareness 
for depression, openly admits he uses the term not in its medical context, 
but as a synonym for emotional distress.
But just like fashion and baby names, language eventually filters down the 
social ladder. The dominance of mental health language in projecting our 
distress is of dubious value when applied to the most disadvantaged groups. 
Indeed, it may be complicit in helping them to maintain lives of dependence 
and misery, the sick role curing them only of their autonomy and personal 
responsibility.
Bureau of Statistics figures from 2005 show about a third of the 700,000 
people receiving the disability pension have been diagnosed with a mental 
illness. This is a critical group because the vast majority are young and 
otherwise physically able. Many could be in the prime of their lives.
Forty years ago, fewer than in one in 30 working-age adults relied on 
welfare payments as the main source of income. The figure today is one in 
six. In particular, the proportion of the population on the disability 
support pension has doubled since 1981.
An important player in this debate is the doctor, for they determine if 
someone meets the criteria for disability. Patients who are on the margin of 
receiving the pension or Newstart will often ask to receive the pension. The 
disability pension is more generous than the unemployment benefit and there 
is little mutual obligation.
The sick role, however, comes with an obligation to seek and comply with 
treatment. The patient's compliance with treatment is the priority for a 
doctor. There are many times when giving in to a patient's wishes elsewhere 
can ensure their compliance with medication. The pension is often one such 
compromise.
The flipside is that 90 per cent of those receiving disability pensions 
never return to the workforce. This is not a fact well known to 
professionals determining disability. Colleagues working in mental health 
were flabbergasted when they heard the figure.
For many on the margins of eligibility, there is an incentive to remain 
sick. The welfare market operates like any other - a better price will 
increase demand. This lack of incentive to take a more active role in 
society can strip them of meaning in their lives and perpetuate what may 
have started as mild mental illness.
A feedback loop of disability, welfare and worsening mental health is 
created. This is a hidden factor straining both Australia's mental health 
and welfare systems. They are operating in a kind of pathological symbiosis.
This cycle describes many people who are said to be in a state of deep 
poverty. They are hardly poor in a historical sense, for they have enough 
money to eat and are housed, educated and medically treated by the state. In 
formulating their situation, poverty in this sense is more like a 
psychological condition than one determined by socioeconomics.
While the middle classes debate their happiness and psychiatry acquires a 
cultural prestige well beyond its powers, the poor inherit the new 
straitjacket of psychological language. It not only costs the taxpayer 
billions of dollars, but encourages recipients to wallow as victims of 
passive circumstance, stripping their lives of meaning and purpose.
Dr Tanveer Ahmed is a psychiatry registrar and writer.
http://www.smh.com.au/news/opinion/terms-of-unhappiness-in-a-sick-world/2007/09/14/1189276986726.html

Melissa Raven, Adjunct Lecturer
Department of Public Health, Flinders University
GPO Box 2100 ADELAIDE  SA  5001
AUSTRALIA 

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