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.
By George Hoare and Amber Trotter
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.
Importantly, any account of medical authority that does not link back to wider questions of political authority risks missing the context most important to understanding how diagnosis and our fundamental idea of mental health might be changing. After all, both mental health and politics are social processes based on making and coming to understand what subjects are. In its most directly political sense, authority is a material relation between national populations and their states, which has been weakened by the hollowing out of the representative mechanisms (centrally, political parties) that once secured that relation. For Antonio Gramsci, a crisis of authority emerges when a crisis of representation precipitates the detachment of the masses from the ideologies that have traditionally structured and secured mass consent. In his view, this crisis of authority results in a direct and visible crisis of ruling-class hegemony.
Today we are in a situation of a crisis of authority without an alternative to a crumbling hegemony. This hegemony is brittle, appearing robust not because of its internal coherence or deep reach into the hearts and minds of the populace but because of the absence of an alternative political vision to a discredited and visibly collapsing liberalism. Consequently, today it is the dynamics of decay rather than renewal that characterize our politics. It is not surprising that subjects turn away from this situation towards their inner damage, looking for answers in an increasingly therapeutic mode of self-understanding and action. Diagnosis provides an explanation for suffering; it makes meaning of the very real subjective damage individuals experience. Social decay can be internalized through the prism of psychopathology because a zombified liberalism is unable to explain its own exhaustion. More widely, we lack the political resources to grasp decay: ideologies that were once live options no longer command mass support, and so it is hardly surprising that as life is increasingly understood as a private affair, we internalize the dialectic of decay to an ever greater extent.
Paradigms over Practitioners
The breakdown of traditional institutions and the attendant breakdown in the subjective experience of authority has been much discussed, perhaps most famously and trenchantly by Christopher Lasch. Drawing on psychoanalysis, Lasch explains that healthy individuals develop in the tension between their own particularity and the collective society of which they are a part. Individuals need a robust authority to internalize, rebel against, and so on, to progress from the narcissistic world of childhood to the adult world of collectivity and responsibility. Moral thinking and behavior (the superego in psychoanalytic terms) in childhood involves a relationship between the child’s instinctual needs and desires and the social repression thereof. At first, morality is fairly harsh and rigid, counterpoised by the primary narcissism (feelings of essential goodness, specialness, importance) that buoys the young child against overwhelming vulnerability. In the context of rational, compassionate, legitimate authority, ethical thinking and conduct develops into an adult superego that is firm but flexible, rooted in a non-compulsive or fear-based internalization of social mores. Absent adequate authority, however, pathological superego formations develop.
Lasch, writing in the aftermath of the sixties, and the widespread parental and cultural permissiveness generated then, theorized that the ostensible removal of external prohibitions against instinctual urges and the devolution of social institutions and their perceived authority, led to a perpetuation of infantile morality—at once readily absolving of blame and guilt, and moralizing and punitive. Without firm adult authority to develop in dialogue with, the ego or self remains weak and narcissistic, driven in its moral thinking by early childhood repression of libidinal drives. Lasch was preoccupied with the question of what it means for the subject when these structures of authority fundamentally change. Although traditional sources of authority still held some sway, they were already starting to be partially replaced by the authority vested in science and expertise, and in various forms of self-help, including psychotherapy, which contained an important injunction: to be yourself, to follow your bliss, compounding the narcissistic tendencies of arrested development.
Today, by contrast, the authority vested in science has significantly eroded, proving insufficient even within educated liberal spheres, and roundly rejected elsewhere. Therapeutic authority in the person of the therapist has also weakened, as expertise of all forms is under broad attack, dissolved into something that is accessible not through therapeutic skill or training but by each of us in our own lived experience of psychological damage. Just as students, not teachers, are now seen as the authorities on education, so too are patients seen as the ultimate authority on their own mental health. Thus the therapeutic paradigm still wields considerable power, but mental health practitioners less so. If in Lasch’s era the injunction to achieve personal happiness came with some sort of guidance from authority outside themselves, individuals today are thrown back on themselves as the source of their own authority in a more radical way. Amidst broad mistrust and even anger towards social institutions of all kinds, the self is the only place left to turn. Individuals today thus feel acutely responsible for their own happiness (or unhappiness); they have no authority to develop through, to rebel against, or blame.
Diagnosing the Failed Self
Myriad forces have contributed to the all-pervasive “therapy culture” we find ourselves in today. In addition to the historical ascendance of cultural narcissism and self-help described by Lasch, emphasis on mental health dovetails with the neoliberal narrative of unlimited potential personal gain through adequate effort. It is a form of the valorization of individual control and responsibility that runs deep in the American psyche, and carries strategic advantages. Pledges to take charge of one’s mental health, take responsibility for oneself, to “do the work,” and so on, are often rewarded. Even for the working class, fluency in mental health speak is pragmatic. Moreover, the near impossibility of traditional material gains (a college degree, a home) for broad swaths of the population turns young people inwards as an alternative source of meaning and accomplishment.
As Jennifer Silva details in Coming Up Short, growing up today in America is to be confronted with an elaborate system of risk that working-class young people manage by increasingly resorting to therapeutic language and self-conceptions. This pivot to mental health and self-development can indeed bring both relief and fulfilment. However, being fully responsible for your own happiness, with no one to turn to besides yourself, is a highly pressurized and ultimately impossible position. If the self is seen as the final source of happiness and success, then the self is also the greatest obstacle. Managing one’s mood becomes a personal and often an economic imperative. Mental illness or medicalization actually softens this position. Medical diagnosis responds to a pervasive absence of legitimate authority with an assumption of personal responsibility at precisely the same time that it responds to the colossal socioeconomic damage wrought by pervasive abdication of legitimate authority with an insistence on personal weakness. In a world where “making it” in traditional material terms is far too difficult for far too many people, without anyone external to blame, the self becomes the source of failure, paradoxically both blamed and absolved of blame through the language of illness.
Ultimately, any focus on self-development without the material conditions for its realization will produce self-lacerating subjects ready to demand diagnostic relief from the reality of “coming up short.” Accordingly, the explanation of—and only possible solution to—our age of diagnosis is not to be found in the individual. The suffering that contemporary subjects experience is very real, but explained through the language of psychopathology because the external authority needed to constructively externalize it is absent. It is a serious pre-political challenge to any sort of emancipatory politics if we increasingly find subjects who are ill and self-pathologizing, buttressed by a culture insistent that people pull themselves by their own bootstraps. To a Left still marked by a deep streak of sixty-eighter scepticism of authority, defending the notion of authority might seem like a conservative, even reactionary position. But recognition of the need for authority in a society that cannot create anything authoritative is instead a step towards a mature acceptance of both our limits and our agency. The task of any political project that wants to arrest the implosion of our current political system—let alone replace it with something more human—is to constitute a collective authority that allows people to develop their agency while coming to an awareness of their limitations.
George Hoare is a writer and co-host of Bungacast living in London. His most recent book is An Introduction to Antonio Gramsci: His Life, Thought and Legacy (with Nathan Sperber).
Amber Trotter is a clinical psychologist in San Francisco.