June 3, 2024

Content warning: This article analyzes ableist language and mentions suicide.

An article by Clare Wilson in New Scientist reports the results of a study published recently in the academic journal, JAMA Psychiatry, which suggests that mental health disorders can be “transmitted” across peers. It helps to read both the New Scientist article and the JAMA Psychiatry article (“Transmission of Mental Disorders in Adolescent Peer Networks”) together, as Wilson does some additional reporting which contextualizes Alho et al.’s findings. However, I also felt that the New Scientist article fell short in its reporting, particularly in its unquestioning replication of pathologizing language from the original article.

The idea that mental health issues can occur in clusters within social networks is not new, though there is no evidence to support the idea (or the use of attendant language to imply) that mental health conditions can be literally “transmitted.” Despite its sophisticated methodology, the rates of “transmission” reported in the study were small, but what I found most problematic was the authors’ unfounded use of medicalizing language to imply the presence of pathogenic vectors despite that, as Wilson notes, “the transmission idea doesn’t imply that mental health conditions are literally contagious, caused by bacteria or viruses.” Yet the deliberate use of words like “transmission” and “harmful contagion” (from the JAMA article) do indeed have connotations of infection and it’s not a logical leap to realize how this framing shapes our approaches to mental health intervention. So, I think it’s important to understand why we conceptualize mental health in this way, and to determine whether it’s actually helpful. (It’s not.)

Because language constructs and reflects our belief systems, changing the ways that we talk about disability and mental health are important — just as important as the other fronts on which we combat ableism. If we’re not cognizant of the ways that words shape our ideas and have the power to constrain or liberate our thinking, then it becomes almost impossible to imagine better systems. These are Audre Lorde’s ideas, of course, expressed in her essay, “The Master’s Tools Will Never Dismantle the Master’s House.” Nick Walker, Lydia X. Z. Brown, and others have translated these ideas to neurodiversity and disability advocacy. Nick Walker, for example, recommends ditching the word “disorder” to help us reconceptualize neurotypes such as ADHD (Attention-Deficit / Hyperactivity Disorder) away from a pathologizing paradigm. Lydia X. Z. Brown notes that “linguistic ableism is part of the total system of ableism, and it is critical to understand how it works, how it is deployed, and how we can unlearn our social conditioning that linguistic ableism is normal and just how things are or should be.” This is why I disagree with apologists who claim that correcting language is not as important as other forms of disability activism.

Fortunately, people are increasingly conscientious around some of the problematic and harmful language we use when discussing mental health, particularly in the use of the word “committed” when talking about people who have died by suicide, which invites judgment and shame. I’m glad to see people making these corrections, but I’m less convinced that people understand how ableist phrases like “committed suicide” and how ableism generally helped to manufacture and normalize our criminalizing approaches to suicide prevention by, for example, motivating and legitimizing the use of law enforcement as the default response to mental health crises as a matter of public safety. Similarly, using medical concepts like “transmission” and “contagion” to describe the occurrence of mental health conditions in communities, even if used figuratively, is not a neutral act, and helped to set the stage for our heavy-handed approaches to mental health in which the focus has been on protecting the community rather than the individual who is experiencing distress.

The use of medicalizing and pathologizing language has important consequences, as it reflects a belief system that individuals with mental health conditions are a threat to the community and need to be contained. This is why I find it troubling that Wilson suggests that the study’s findings “mean our approaches to helping troubled teens with conditions such as depression need re-examining,” i.e. that we need to approach mental health from a more medicalizing lens, when in fact, our approach to mental health intervention, especially in educational settings, has been dominated for over a decade by the ideology of containment. I still remember my heart sinking in 2018 as I read an op-ed in the Columbia Daily Spectator by the Mental Health Action Committee, in which they wrote, “Right now our campus’s response to mental health is reactionary, targeting individual students after they have hit rock bottom and already sent a ripple of negativity across their peer groups.” [emphasis added] Earlier in that same essay, the authors mention the contagious effect of negative emotion, illustrating the disease model’s important role in motivating carceral approaches to mental health. It’s also curious to me how we use medicalizing language to frame mental health, but still manage somehow to come across as judgmental and intolerant.

There is also no evidence that our heavy-handed approaches to mental health have actually been helping the people who need support, though they do conveniently serve administrators, managers, and others who are eager to get rid of people who are perceived as difficult or troublemakers. In our approach to mental health, I’m reminded of the “happiness clause” at the once exalted, now ignoble corporation, WeWork, that created a cultish environment where any sort of dissent or grievance was treated as an immediately dismissible offense, as happened to Justin Zhen, a WeWork tenant who dared to raise questions about the health of WeWork’s customer base. As documented in the film, WeWork: Or the Making and Breaking of a $47 Billion Unicorn, and recounted in Vox:

Zhen’s company posted something about it on their blog, and within hours a WeWork community manager appeared. According to Zhen, they told him he’d “violated our membership happiness clause” and had 30 minutes to pack up his company and leave the premises.

It’s striking, the parallels between the corporate response to whistleblowers, as described above, and the university’s response to students in distress, as in this account from The Chronicle of Higher Education:

In the hospital, “a residence dean visited [Jacob],” the court document says, “and told him that he had caused his dormmates psychological harm,” and that “it was unfair for him to impose a burden on other students and staff.” The dean “threatened Jacob with legal action and a ban from his dormitory.” Jacob’s friends later assured him that the “statements about the impact he had had on them were not true.”

Pathologizing and medicalizing language that falsely constructs mental health issues as transmissible diseases are part of the “Master’s Tools” that encourage us to think of mental health issues as a problem to be eradicated and silenced rather than a type of communication signaling that individuals’ needs aren’t being met. People need safe spaces to discuss their problems without fear of retaliation or coercive intervention, but the medicalization and criminalization of distress often makes spaces less safe to do so.

Despite using medicalizing and pathologizing language to frame their results, Alho et al. inadvertently elevate the role of social and other contextual factors in the occurrence of mental health conditions since there are no known biological vectors to account for transmission. It’s also important to point out that the process of diagnosis is inherently an interpersonal one. Because of its subjectivity, diagnosis can be prone to error or abuse, and because of the lack of biomarkers, a diagnosis is not verifiable by testing. Although discrepancies in diagnostic rates and morbidity among localities were accounted for in the model by using a random intercept, the social component of the diagnostic process indicates that we would also expect to find some effect based on locality and recent diagnostic histories independent of the actual occurrence of mental health issues by locality. These effects can’t be untangled in Alho et al.’s current model. As the authors note, “One plausible mechanism is the normalization of mental disorders through increased awareness and receptivity to diagnosis and treatment when having individuals with diagnosis in the same peer network.”

In this context, the use of the word “transmission” in mental health epidemiology is therefore loaded, full of conjecture, and hence inappropriate as it could imply the effects among diagnosed peers, but it could also mask the process of transfer of diagnosis outside of peer networks (e.g. between clinician and patient) as well as the process of social construction of disorder within communities (e.g. among families, school counselors, administrators, and non-diagnosed students).

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