Disorder or Dependency: How Labels Reinforce State Control

Mental health-related labels, similarly to drug use-related labels, can act as an extension of the state's instruments of control. Source: Null xtract

To get a handle on someone’s drug consumption or on the state of their mental health, we - society - often apply a label. It can seem to be a useful shorthand in conversation or provide a platform from which to prescribe treatment.

But the label in question will be loaded and likely to cause damage.

Using labels like ‘heroin addict’ or ‘manic depressive’ allows someone be physically restrained within a controlled zone like a prison or hospital; it allows them to be categorised and contained; and it prevents us from seeing them in a kaleidoscopic, nuanced light. 

Labelling in relation to drug use and mental health has an intricate, insidious history. The terminology in both areas has evolved alongside a particular understanding of the relationship between the individual and society. 

In his brilliant and illuminating paper Inventing Drugs: A Genealogy of a Regulatory Concept, Toby Seddon shows how the concept of illicit drugs emerged in tandem with the idea of the individual’s role in society. Societies by the second half of the 19th century had undergone massive transformation: industrialisation had made cities richer, denser in population, and more productive - a productivity that depended on reliable resources, not least reliable workers. The person whose use of drugs affected their reliability and capability to work presented a threat to society’s productivity, and in turn, to the laissez-faire ideal of the individual. They were an unwieldy, ungovernable and unpredictable part of the population; an internal threat that needed to be monitored and managed.

The way in which societies have regarded those with mental health issues has gone hand in hand with attempts to control them. Philosopher Michel Foucault argues that mental illness cannot be understood in isolation from institutions of coercion and discipline. The spread of disciplinary institutions throughout Europe in the 17th and 18th centuries were created to ‘neutralise dangers, to fix useless or disturbed populations … and to increase the possible utility of individuals.’ This mission was facilitated by the asylum, an institution created to induce conformity.

In both the areas of drug use and mental health, the need to control ‘deviant’ or socially unproductive groups has inflected the way we think and talk about them.

And the way we think and talk about them continues to be very arbitrary. In the 18th century, it was argued that ‘prisoners deserved a better fate than one that lumped them with the insane’. Prisoners should be granted mercy, it was said, not punished by being confined with ‘the mad’ who continually tormented them. In the early 19th century, it was emphasised that ‘madmen’ deserved better treatment than common criminals since, unlike criminals, they were innocent. Today, the International Network of People who use Drugs (INPUD) issued a statement suggesting that it prefers the term ‘drug dependency’ rather than ‘substance use disorder’, and that those who use drugs ought not to be grouped with those with mental disorders since it pathologises the former.

Labelling - and the way in which it confers social value - shifts between one epoch and another, which shows just how much of an artifice any given label is, and just how much any given grouping is based on the social mores of the day.

It’s worth saying at this point that a label can, sometimes, be a useful starting point for further exploration so long as its origins are kept in mind: where has it come from, in what context was it first used, why was it created, who or what does it benefit? But using labels as endpoints, as a basis for government policymaking or as a way of characterising individuals and providing corresponding - often single - solutions, can be very damaging.

Splitting drugs into the category of ‘legal' or ‘illegal’, for instance, has had severely harming effects in the US. Public health law experts Leo Beletsky and Corey Davis found that crackdowns on the supply of opioids and harsh criminal penalties for people who use heroin fuelled mass incarceration and drove the adulteration of opioid drugs with stronger synthetic opioids like fentanyl. This in turn led to opioid poisonings and a nation-wide health crisis of synthetic opioid-related deaths.

Using the label ‘mental health disorder’ and subsidiary labels - such as bipolar and cyclothymia, schizophrenia and clinical depression - all too easily become the lens through which society views an individual, and the lens through which they see themselves. The same label can too unquestioningly determine models of treatment and underpin government action.

For instance, the UK government recently commissioned a review on modernising The Mental Health Act (MHA) of 1983. This act gives the state the ability to take away someone’s liberty and to treat that person even in the face of their refusal. This is done through the provision of sectioning by which someone with a mental health disorder can be detained in hospital if their safety or the safety of others is seen to be at risk.

But sectioning is fundamentally at odds with the review’s recommendation to ‘respect the autonomy’ of patients; ‘increase choice’ so that patients have a greater say in decisions, and ‘reduce compulsion’. The MHA and the review itself rely too readily on the label ‘mental health disorder’ and the tool of sectioning as solutions to managing someone in jeopardy. This is a problem: first, because - as we’ve seen - how we understand mental ill health changes over time and according to dominant social mores and political agendas. Second, by depriving someone of the right to decide courses of action over their own bodies, their dignity is immediately and irrevocably taken away, as is the means of building their capacity for self-trust.

Labels are slippery; you may try to rectify one judgement by finding yourself making another. Let’s use a label only if to tear it apart at the same time.