One of the sites I’m fond of is Hopeworks Community. A number of things can appeal to me about a site. Some are heartfelt. Some are lyrical. Some provide pragmatic advice. Some take political stances. In fact, most do all these things. Hopeworks provides reasoned analysis of issues relevant to people affected by mental illness (but see Hopeworks and what I write below for some discussion of the ‘illness’ concept). Any time I get engaged in a topic, my fingers go nuts and before long my text has morphed from an intended sentence or two into a mini-essay. That happened yesterday on Hopeworks, when I wrote a comment discussing two posts: ‘What diagnosis depends on‘, and ‘On the words we use‘. The subjects were diagnosis and semantics in mental illness. Important subjects. Since I was happy with my little response, and since I won’t have much time to write today, I am posting my discussion below.
I promised to write about the relationship between ‘who we are’ and ‘what goes on in our brain’. That topic is so vast that covering it in a blog post is presumptuous to the point of grandiosity. But I do have some ideas that can be squeezed into one of my longish essays. The interrelationship between mind and body (especially, of course, brain) fascinates me, as it has philosophers for ages. I want to do it justice. I have touched on it before, and no doubt I will come back to the subject over and over until the day I die (hopefully a long time from now, for those who monitor me for suicide risk). So the much-anticipated essay will be produced soon. But not today.
Instead, here is my 2¢ about diagnostics and the labels that result.
[Comment to Hopeworks with regard to psychiatric diagnosis:] Having had medical training, and even one-time aspirations to become a psychiatrist, I started out with faith in the DSM. The more time I spend as a patient, and reading blogs, and thinking about how I’m going to get to a better place, I see the fallacy in labeling people as mentally ill. My latest thinking is that our brains are as different as our mugs. Maybe I even brought this up on your blog before. You can categorize faces: male, female, European, African, Asian, old, young, attractive, ugly. And you can separate facial expressions: happy, sad, angry, etc. But just saying someone (like me) is a male, of European descent, middle-aged and with a look of concentration at this moment does not mean that is all I am or will ever be. It is not enough information for you to recognize me on the street, or to know what would work to make me more comfortable with being alive.
Psychiatric diagnoses have that level of precision. Some people have fluctuating moods. Some are chronically sad. Some worry all the time about everything. Some hear voices and have ‘odd’ ideas. Each of these persons can be diagnosed with a DSM label, and so by that definition they are mentally ill.
It’s a bit like saying only a particular race or gender is capable of running things. Only a certain emotional make-up is healthy; deviate far from that norm and you have a disease. Maybe you should be locked up and sterilized. You certainly can’t be in a position of leadership or responsibility (is anyone else old enough to remember Thomas Eagleton?).
Like you say, what matters is what works. And what works is what makes life a more satisfying experience. Dulling emotional responses, or squelching internal voices may help accomplish that for some people. But not for all. Some would be happier to be left with their minds in their native condition. Some can get a lot more happiness out of life by accepting their quirky brains than they ever can by acquiescing to long-term psychiatric drugs.
As someone who once bought the mental disease model intellectually and emotionally, I am astounded to find myself about to write that I am not sure that mental illness is a valid construct. I took all my meds diligently for years (I was a very ‘compliant’ patient). But I still felt rotten. Now I feel better even though I am on a milder chemical cocktail (hopefully soon to be none at all). So was I really sick? Or just confused?
I spend time on the local psychiatric unit, counseling patients about their legal rights when they face involuntary confinement. Some of these people are quite out-of-control, and would have trouble being safe on the streets. I can’t say what the answer is in those cases. Maybe when things go that far there really is a sickness going on. But that does not mean that the person has a mind that can never be trusted again. That they now should carry a lifetime diagnosis of, say, bipolar I. That they will require drugs forever, and can never learn to live safely and well without medication. Maybe it is the all-too-frequent permanence of mental illness diagnoses that is their biggest problem.
We are all different. ‘Some of us are more different than others.’ The problem with the ‘illness’ label, is that it automatically means there is something defective. Maybe all that is wrong is that our eyes are open. That we see and feel more pain, or are more in touch with imaginative influences in our minds. Or we are more conscientious and want everything to be just right. Or impulsive. Or scared. These are not illnesses, they are responses to life. Maybe they are exaggerated and do not serve us well. Maybe medications can help us live fuller lives. But I object to being told my brain is abnormal, and that the person who never soars into ecstasy or crashes into sadness is healthier and (by implication) better.
It cannot be overstated: what matters is what works. If having a diagnosis in hand makes one feel vindicated, so now they can show people they aren’t just lazy or selfishly pessimistic, then it is a good thing. If it helps select a medication to get someone balanced enough that they can go home and work on better solutions, then maybe a diagnosis is useful. The same if being given a name of their ‘lllness’ leads a person to the most helpful shelf in the bookstore. But if it means I can never get long-term care insurance (I can’t), or be trusted to practice medicine (a psychiatry program I applied to reported me to the medical board), or that I will always need to take medications that wreck my body and undermine my self-image, then they are most definitely not OK.That kind of thing happens so often, that it is easy to understand why people with mental/ emotional/ behavioral/ brain/ psychiatric – illnesses/ conditions/ disorders/ diseases/ abnormalities/ challenges/ dysfunction/ gifts object to the psychiatric model. When diagnostics work they help a little. But when they are overused, misinterpreted, or otherwise go awry, they do an incredible amount of harm.
(I slightly modified this post on 2009 August 17, c. 08:30 PDT.)
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