By Lilith C.J. Roberts
Content Warning: Mental health, stigmatisation, pathologisation.
Mental illnesses are fuzzy things. This is not to say they aren’t real – they very much are – but they are difficult to define and delineate, in a way that is starkly different to physical health.
If someone says they’ve hurt their ankle, for example, we can run tests to figure out exactly what is wrong with it. We can see whether it’s broken, or sprained, or twisted, or whether there’s nothing wrong with it at all, and we can run those tests with sophisticated equipment or simply by using our own senses. We can see if the ankle is at an odd angle, or if the bone is sticking out, or if there’s a major wound. If we need to, we can crack open an x-ray machine or something similar and take a closer look. There are some exceptions, as there always is, but for vast swathes of physical health matters diagnosis is easy, or at the very least straightforward.
It is different for mental illnesses. An illness which by definition exists within someone’s mind can’t be easily poked, prodded and probed. It can’t be easily tested. There is no easy, sure-fire way to check if someone has depression or anxiety. There is no x-ray machine for mental health.
Instead, mental health practitioners – therapists, clinical psychologists, psychiatrists, etc. – have to find other ways of figuring out whether someone has a mental illness, and if so, what that mental illness might be best described as. This is why we have books like the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD) to aid in diagnosis.
It is from these books (generally in Anglophone countries the DSM is used, while the ICD is particularly prominent in developing countries where it is sometimes distributed for free) that we get the list of mental illnesses that we are familiar with. We’ve had a litany of names for the mental illness where one struggles with past trauma, arguably starting with shell shock coined in 1915, but it is post-traumatic stress disorder (PTSD), immortalised in the 1980 edition of the DSM, that has become the go-to name. It is the same with the various forms of depression, anxiety, and schizophrenia, and with autism spectrum disorder (ASD), a broad category of neurodiversity created for DSM-5 in 2013 which groups together autism with Asperger’s syndrome and other social communication disabilities into a single set.
Every mental illness listed in the DSM or the ICD has a criteria for diagnosis, and this is where things get complicated. Generally, there are more total symptoms for a disorder listed than however many a patient needs to display in order to be diagnosed; for example, the DSM diagnosis for major depressive disorder outlines a total of eight symptoms, but only five or more of those (including depressed mood or loss of interest or pleasure) need to be met by a patient for a diagnosis to be issued.
This isn’t too dissimilar to how diagnosis might take place for physical health, but again the issue comes from how the symptom can be proved to exist. It means that in order to be diagnosed with a mental illness or some form of neurodiversity, you need to convince someone else that you tick enough of their boxes. This is harder said than done. If we go back to the example of a broken ankle, you can quite easily prove to a doctor or nurse if the bone is sticking out; they can see it. It’s difficult to ‘prove’ anything the same way when it comes to mental health, and the onus is therefore on the mental health practitioner.
It is safe to say that this is not a system without flaws. There are major areas for abuse or neglect, and there are a number of examples of how this has led to misdiagnosis, in many cases on the basis of bias.
An ongoing example is the continued under-diagnosis of girls with ASD. There is debate on this, but one of the most broadly accepted theories is due to the fact that several of the diagnostic criteria for ASD are linked to stereotypically “boyish” childhood behaviour and interests. While a girl might clearly fit the diagnosis for ASD in a number of very clear ways, they might not be diagnosed because they don’t fit the perceived notion of what an autistic person might look like in the eyes of a mental health practitioner. There are a number of anecdotal stories of girls who otherwise fit the diagnosis going un-diagnosed because they don’t have a special interest in something stereotypical, like trains or numbers.
Another example is that of the over-diagnosis of Afro-Caribbean people living in the UK with schizophrenia. This has been an ongoing trend, but was most prominent historically, though there are still high rates of schizophrenia diagnosed in British Afro-Caribbean people. Essentially, in the past a good chunk of these diagnosis were due to a fraught relationship between these people and the psychiatric establishment in Britain. The cultural ignorance of White British mental health professionals led them to view cultural differences in first generation Afro-Caribbean immigrants as part of the diagnostic criteria for schizophrenia; for example, Afro-Caribbean speech patterns were viewed to fill the diagnostic criteria of disorganised speech, while the negative stereotype of Black immigrants as lazy made practitioners more likely to say that Afro-Caribbean patients met the criteria of avolition and occupational dysfunction. This also links to a trend in American hospitals to diagnose African Americans with schizophrenia in the 1960s and 80s, due to the perceived “hostility” of African Americans who were passionate about civil rights being pathologised as a symptom of schizophrenia.
I think it’s clear in these examples how the misdiagnoses are intimately tied to culture; women with autism are under-diagnosed because our Western conception of autism is tied up with male cultural mores, and the White British understanding of Afro-Caribbean culture can be easily stigmatised and pathologised to meet the criteria of schizophrenia. Diagnosis is not free from bias; indeed, sometimes it can be led by it. Mental health practitioners are only human.
So if there is bias in diagnosis, is there bias in what we list as a mental illness and what we don’t? Is there bias in what we list as a symptom and what we don’t? Well, yes. There is a reason there are five editions of the DSM; past versions were seen as biased and outdated, either culturally or scientifically, and so improvements were made.
Psychiatrists and their creations are not infallible. Now, this does not mean we should chuck all copies of the DSM out the window, it is a useful tool for helping people, but it does mean we should be vigilant of the impact that culture can have on our perception of mental illnesses. There are many examples of disorders – some published in reputable journals, or as part of the DSM and other diagnostic manuals – which showcase the impact that culture and cultural bias can have on our perception of mental illnesses.
The most infamous of these are intimately tied up with oppression and the pathologisation of marginalised groups, and that is not a coincidence.
In the antebellum Deep South, scientific racism extended to mental health. Samuel Cartwright was a physician emblematic of this, and in 1851 he invented the term drapetomania, in reference the supposed mental illness which afflicted African slaves who had the gall to try and escape slavery. There was little evidence for this mental illness outside of Cartwright’s interpretation of scripture and the bias of the times, but it was nevertheless another plank used in the systematic repression of Black people in the Deep South, and arguably contributed to later attempts to pathologise African American culture.
A better known and longer-lasting example is that of hysteria. Hysteria as a concept has a long history in the West, but it wasn’t until the 19th century that it was pathologised into a mental condition. Hysteria was considered to be a condition where the patient – almost always a woman – was considered emotional and “irrationally” upset. In essence, it was the pathologisation of having feelings and of female sexuality, and it was used largely by male mental health professionals to pathologise women. If it wasn’t clear enough that this is the case, I should point out that the name is quite explicit in this, being derived from the Greek word for uterus. Hysteria was used as a catch-all mental illness for women who strayed from societal norms or were considered troublesome; after all, the Suffragettes were Christened Hysterical women. Hysteria faded in more recent years, in part thanks to the efforts of third-wave feminism, but similarly to drapetomania, the legacy of Hysteria is long and deep.
There are even other, more recent examples, listed in the DSM. In the first DSM, published 1952, one of the disorders listed was homosexuality, and it wasn’t removed until 1973 in spite of fairly overwhelming evidence even at the time that categorisation as a disorder was unfounded. Similarly gender dysphoria (or in the ICD, gender incongruence) has been listed on the DSM under various names such as gender identity disorder since the third edition of DSM, published 1980. Unlike homosexuality, gender dysphoria is still listed on the DSM as a disorder, in spite of evidence that such pathologisation is unhelpful and inaccurate. The reason for this is another influence on diagnosis; the outside world. If one wants to receive gender-affirming care in the United States, you need to provide a diagnosis of gender dysphoria to your health insurance provider, and in the United Kingdom if you want a Gender Recognition Certificate, it is a requirement to have had a diagnosis in gender dysphoria. So, despite evidence pointing against continuing diagnosis in gender dysphoria, it has yet to be removed from the DSM or ICD.
So; how does all this relate to alternate history? Well, in alternate history you tend to find alternate cultures. These are sometimes wildly alien, sometimes similar to what we know, and sometimes an admixture of these. If we now know that culture can impact perceptions of mental illnesses, and can inform the course of diagnosis, then it stands to reason that different cultures would produce different perceptions and have difference impacts on their society’s understanding of mental health compared to our own.
Case in point, gender dysphoria. The evolution of gender dysphoria as a condition that can be diagnosed is linked heavily to the culture and history of our timeline, and the work of largely American and British psychologists and physicians. In a world where the Institut für Sexualwissenschaft was not burned down by the Nazis, things might have been different. We might have seen a development in the understanding of gender identity which focused more on the individual’s experience, and was guided more by sexology. More broadly speaking, of course, if the prevailing culture in your timeline is not Western at all you might find that gender dysphoria is never really pathologised at all, as many cultures have long traditions of less binary gender norms, such as the Samoan third gender fa'afafine, the hijra in South Asia, the kathoey in Thailand, and various gender expressions that contributed to the term two spirit among Indigenous North American peoples. If these cultures were dominant in your timeline – or even if they were merely the focus – then instead one might find no pathologisation of gender dysphoria, or more likely a kind of pathologisation less like our own.
This does not stop at gender or its pathologisation, either. As we’ve discussed, culture can impact the perception and diagnosis of a whole host of disorders. The symptoms of schizophrenia – such as auditory and visual hallucinations and delusions – are considered highly abnormal in western society, and therefore in our timeline it has become something of a hallmark among mental illnesses. In other cultures and other timelines, however, this might not be the case. I’ve already mentioned how cultural ignorance among White British mental health professionals led to the pathologisation of Afro-Caribbean speech. In a world where Afro-Caribbean culture is more prominent, or a setting where it’s more accepted, this might not be the case. Similarly, many cultures do not share the western perception that hallucinations and delusions are abnormal or undesirable. In a number of Papuan New Guinean cultures, for example, auditory hallucinations are seen positively, as an example of a spiritual blessing or possession by a beneficial spirit. This is in contrast to even other Papuan New Guinean cultures, which view such hallucinations as an example of possession by harmful spirits. Furthermore, belief in the reasoning for the hallucinations or delusions can differ by culture. In Buddhist Vietnamese families, haunting by spirits – sometimes ancestor spirits – is a common explanation for the auditory hallucinations common in schizophrenia. Suffice it to say, in an alternate timeline, schizophrenia may not be considered the typical example of a mental illness as it is in our timeline. Instead, we might find that the symptoms we associate with schizophrenia are instead associated with heightened spirituality.
We can go even further, and speculate that in alternate timelines, there might be certain behaviours which we consider to be perfectly normal and healthy which are instead pathologised and considered symptoms of a mental illness. In the western world, we have the diagnosis for sociopathy. The diagnosis uses a list of symptoms such as a lack of empathy, impulsive behaviour, using intelligence and charm to manipulate others, lying for personal gain, among others. It has been noted among some that many of these symptoms are exhibited by highly successful businesspeople, but those symptoms are advantageous and even considered normal in a cutthroat business environment, and there is little pathologisation of those behaviours, particularly historically in the west. In a timeline where culture is more collectivist (such as in a number of eastern cultures) or where success in business is seen less favourably (the easy example is some kind of socialist or communist culture, but I think you can even play this in a more traditional monarchy where the bourgeois are seen as nouveau riche upstarts), we might see this be different. We might instead see those kinds of businesspeople highly pathologised, and considered very much in need of help from mental health professionals. It might even get a separate disorder to sociopathy, highly specific to the business environment.
In conclusion, it is important to remember that culture and mental health do not exist separately from one another. Just as much as a world without the Scientific Revolution might have a completely different understanding of the scientific method to us, so too might a world without Freud or with the Institut have a different understanding of mental health. That understanding might be better, or it might be worse, but it’s important to remember that it will face the same pressures as our understanding did; the bias and beliefs of those developing it will have an impact, as it continues to in our world.
Lilith C.J. Roberts has a story in the anthology Emerald Isles.