Not long ago, I read a Los Angeles Times article saying 20% of Americans suffered from mental illness in 2010.  The article ended with a warning:  “…we need to continue efforts to monitor levels of mental illness in the United States in order to effectively prevent this important public health problem and its negative impact on total health.”  The story did define what was meant by “mental illness.”  Do I have to keep an eye on every fifth guy in the Post Office line?

Not necessarily.

The Times’ source was a January 19 report by SAMSHA, the Substance Abuse and Mental Services Administration, which said 45.9 million Americans suffered from mental illness in 2010.  Their definition of mental illness is, “a diagnosable mental, behavioral, or emotional disorder (excluding developmental and substance use disorders)” in the DSM-IV, the 4th edition of The Diagnostic and Statistical Manual of Mental Disorders (1994).

Here’s how the DSM works: there are numerous schools of psychotherapy that differ in their approach to treating different disorders, but all have agreed to agree on the definitions of those disorders.  One of my psych professors insisted that the DSM says more about our cultural “norms” than about the health of the population.  For instance, in 1987, homosexuality was dropped from the list of disorders.  Prior to 1987, gays and lesbians were “mentally ill.”  After that, they were not.

Anyone who visits a psychotherapist and wants to submit an insurance claim will receive one of these diagnoses, most commonly, “Anxiety,” or “Adjustment Disorder.”  This fits the vast numbers of clients who are able to cope with life, but seek help with problems at work or problems at home or issues of self-actualization.  The SAMSHA report gave no mention of efforts to factor in the seriousness of the diagnosis.  There is no way to know how many of the 45.9 million Americans who are “mentally ill” suffer from anxiety vs. schizophrenia.

To the best of my knowledge, the rise of “insanity” coincided with the Industrial Revolution.  The US Census first noted the incidence of “idiocy/insanity” in 1840.  By 1880, there were seven types of insanity:  mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy.

According to my psych professor, the DSM grew out of a research collaboration between the American Psychiatric Association (APA) and the US military between the world wars.  Soldiers in WWI suffered high rates of shell shock.  The military sought screening methods for those who would hold up in combat.  Although the screens later proved not to have the predictive power hoped for, the DSM came from this research.  In other words, our current definition of sanity is based the attributes of a good combat soldier.

Voices were raised in protest, almost from the start, notably by Thomas Szasz in The Myth of Mental Illness (1961) and a 1973 article by David Rosenham, “On Being Sane in Insane Places.”

I am not trying to minimize the suffering of those with mental afflictions that cause them to harm themselves or others.  First, I am questioning a report that excludes all forms of substance abuse from its definition of “mental illness.”  I also question defining “anxiety” as “mental illness,” when anyone who was paying attention in 2010 felt anxious.

I have often been struck, since I studied psychology, that our concept of sanity, modeled on the good soldier, also defines the “productive” member of our consumer culture.  It brings to mind a favorite line from a poem by Theodore Roethke:  What’s madness but nobility of soul at odds with circumstance?:

In a Dark Time

In a dark time, the eye begins to see,
I meet my shadow in the deepening shade;
I hear my echo in the echoing wood–
A lord of nature weeping to a tree,
I live between the heron and the wren,
Beasts of the hill and serpents of the den.

What’s madness but nobility of soul
At odds with circumstance? The day’s on fire!
I know the purity of pure despair,
My shadow pinned against a sweating wall,
That place among the rocks–is it a cave,
Or winding path? The edge is what I have.

A steady storm of correspondences!
A night flowing with birds, a ragged moon,
And in broad day the midnight come again!
A man goes far to find out what he is–
Death of the self in a long, tearless night,
All natural shapes blazing unnatural light.

Dark,dark my light, and darker my desire.
My soul, like some heat-maddened summer fly,
Keeps buzzing at the sill. Which I is I?
A fallen man, I climb out of my fear. 
The mind enters itself, and God the mind,
And one is One, free in the tearing wind.
– Theodore Roethke