Terms of unhappiness in a sick world

As a doctor working in mental health and within the public hospital system, I am a regular witness to those living on the bottom rungs of our society. They are the homeless, the drug addicts and those suffering from severe mental illness. More often than not, they are all three at once.

I am struck by their amazing uptake of mental health language. They skilfully weave technical psychiatric language into their reporting of symptoms. As a result, comments such as "I'm pretty sure I'm coming down with a depressive disorder" or "I think I'm developing a personality defect" are not uncommon, even from people with minimal education.

This is in part a reflection of wider society and how the language of human distress has been overtaken by psychological terminology. I hear very few people tell me they are unhappy. They are almost always depressed, even if their life choices or circumstances would be perfectly consistent with them being miserable.

Increasingly they no longer suggest they feel depressed, but that they are getting depression, in the same way we may catch a cold. The consultation then moves to the awkward dance modern therapists play. I become the healer attempting to cure their condition, pretending somehow their malaise is one of biology and not of meaning. The result is that it can blind them to the possibility their actions may have played a role in their problems.

Barely a week goes by when we don't hear of the crisis in mental health. Rising depression, worsening drug and alcohol problems and a strained social sector make us think that despite our stupendous prosperity, we remain in some kind of existential abyss. It is a symptom of the market society and individualism that our grievances must be turned on to the self.

This is in spite of psychiatry remaining a hazy field, an arena where diagnosis and treatment are poorly correlated and where clinical energies focus on symptom relief. It is reflected further in the tremendous amount written about happiness studies. If being dissatisfied with life is pathological and health is a right, the implication is that happiness is also our birthright.

The use of psychiatric terminology is also more and more colloquial. During the Andrew Johns saga and his eventual secular confession, bipolar disorder was used widely in the press as a synonym for erratic behaviour. The former Victorian premier Jeff Kennett, a tireless campaigner in raising awareness for depression, openly admits he uses the term not in its medical context, but as a synonym for emotional distress.

But just like fashion and baby names, language eventually filters down the social ladder. The dominance of mental health language in projecting our distress is of dubious value when applied to the most disadvantaged groups. Indeed, it may be complicit in helping them to maintain lives of dependence and misery, the sick role curing them only of their autonomy and personal responsibility.

Bureau of Statistics figures from 2005 show about a third of the 700,000 people receiving the disability pension have been diagnosed with a mental illness. This is a critical group because the vast majority are young and otherwise physically able. Many could be in the prime of their lives.

Forty years ago, fewer than in one in 30 working-age adults relied on welfare payments as the main source of income. The figure today is one in six. In particular, the proportion of the population on the disability support pension has doubled since 1981.

An important player in this debate is the doctor, for they determine if someone meets the criteria for disability. Patients who are on the margin of receiving the pension or Newstart will often ask to receive the pension. The disability pension is more generous than the unemployment benefit and there is little mutual obligation.

The sick role, however, comes with an obligation to seek and comply with treatment. The patient's compliance with treatment is the priority for a doctor. There are many times when giving in to a patient's wishes elsewhere can ensure their compliance with medication. The pension is often one such compromise.

The flipside is that 90 per cent of those receiving disability pensions never return to the workforce. This is not a fact well known to professionals determining disability. Colleagues working in mental health were flabbergasted when they heard the figure.

For many on the margins of eligibility, there is an incentive to remain sick. The welfare market operates like any other - a better price will increase demand. This lack of incentive to take a more active role in society can strip them of meaning in their lives and perpetuate what may have started as mild mental illness.

A feedback loop of disability, welfare and worsening mental health is created. This is a hidden factor straining both Australia's mental health and welfare systems. They are operating in a kind of pathological symbiosis.

This cycle describes many people who are said to be in a state of deep poverty. They are hardly poor in a historical sense, for they have enough money to eat and are housed, educated and medically treated by the state. In formulating their situation, poverty in this sense is more like a psychological condition than one determined by socioeconomics.

While the middle classes debate their happiness and psychiatry acquires a cultural prestige well beyond its powers, the poor inherit the new straitjacket of psychological language. It not only costs the taxpayer billions of dollars, but encourages recipients to wallow as victims of passive circumstance, stripping their lives of meaning and purpose.