Overmedicalization and the Crisis of Authority
Proliferating rates of mental health diagnoses reflect a breakdown of traditional forms of authority rather than an excess of medical authority. The self-pathologizing subjects that this breakdown has produced present a barrier to emancipatory politics.
Fifty years ago autism was estimated to affect around 1 in 10,000 people. Today, among eight-year-olds in California, 1 in 22 are diagnosed as having the condition. Rates of diagnosis for Attention Deficit Hyperactivity Disorder (ADHD) have similarly shown marked recent increases. In the UK, adults seeking an ADHD diagnosis increased around 400 percent from 2020 to 2023.
Alongside the steep increase in rates of diagnosis of many long-established conditions such as autism and ADHD, recent decades have also seen new diagnoses proliferate. The first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), published in 1952, listed 106 diagnoses across 132 pages. The latest update, published in 2013, instead contains nearly 300 diagnoses over 947 pages. For the American Psychiatric Association, the second half of the twentieth century and the start of the twenty-first clearly required more categories to classify the damage.
What explains this simultaneous increase in diagnosis and diagnoses? Susan O’Sullivan’s The Age of Diagnosis suggests that there are three possible explanations:
1) We have become better at detecting illness and/or reducing its stigma, such that we are moving closer to an accurate reporting of an underlying rate that may not have changed;
2) We are getting sicker, or have removed enough of the things that used to make us sick such that the ones that are left will be more widespread across the population; or
3) We are coming to understand more of our lives and our struggles in terms of illness.
While the truth likely includes elements of all three, particularly when generalizing across a wide range of mental and physical ailments, it is the third explanation that attracts our attention. This is because, unlike the perhaps more widely-discussed second explanation, it offers the tantalizing prospect that a change in understanding (“we are not as sick as we think”) could lead to an actual, perhaps instantaneous improvement in mental health (“I used to have a mental illness, but I realized it was just capitalism”).
It is certainly the case that our understandings of “illness” and “health” are both socially constructed. As Joseph Dumit argues in Drugs for Life, beginning in the 1960s and 1970s and becoming dominant by the 1990s, the very notion of “illness” became more innate and immutable: instead of seeing health issues as discrete challenges to be solved, we increasingly came to see ourselves as inherently ill, with health never fully achieved, yet always actively pursued. That is, as notions of health moved steadily towards a state of mythic optimality, the threshold for pathological illness became progressively lower.
It's tempting to blame the medical and mental health professions on the one hand and Big Pharma on the other for this slide towards a situation where we are more likely to understand ourselves in ways that need their interventions. But it is clear that a great many patients are not passively submitting to treatment from doctors; rather, they are actively demanding it. Patients (now called clients) are much more likely to come to treatment already convinced of their inherent (and often immutable) illness, insistent on their therapists’ agreement. Therapists are thereby positioned not as the dominant power or authority, but instead as a secondary factor in the drive towards diagnosis. Therapists’ job in this frame is to affirm patients’ subjective experience: authority is ultimately located in individuals’ experience within the therapeutic paradigm, not therapeutic professionals, in a strange amalgam of the subjective and putatively scientific.
Perhaps, then, pressure towards increasing diagnosis paradoxically stems not from an excess of medicalized authority—the “technological sanitationist despotism” that Italian philosopher Giorgio Agamben saw in the management of Covid—but a lack of it, a breakdown of authority. It seems plausible that the negotiated and accelerated process of psychological diagnosis is symptomatic of a broader problem with the very notion of authority, already in an advanced state and much discussed. Devolution and devaluation of various forms of external authority heighten emphasis on subjective experience and identity—including mental health diagnoses. In this reading, greater understanding of distress in personal, psychological terms is a response to diminished understanding of distress in sociopolitical terms.
