Defining Mental Illness

One of the biggest challenges in working with the term ‘mental illness’ is how imprecise it is. Finding other terms and frames of reference is often important to me, because mental illness has so many problems. I’ve written before about my frustration with the way mental illnesses are conceptualised in a couple of posts:

  • I don’t believe in Mental Illness (or, rewriting the DSM) – a critique of the way the DSM groups symptom clusters using a medical paradigm. “Psychological illness, injury, and normal functioning become tangled. Defining abnormal becomes nearly impossible”
  • Mental Health needs better PR – exploring the ‘upsides’ of ‘mental illness’ and the way mental health can be presented as merely the absence of symptoms. “No more soaring mania, no more anguish, no more blood, no more voices. Mental health is silence, clipped wings, drugged stupor, numb blankness.”

Mental illness as an idea is rather like a huge drag net pulled by a fishing boat. It captures a lot more than it should, and it also misses some really important things that fall outside of the net. We use mental illness as a shorthand term for experiences and problems that are actually outside of the scope of the idea. One of these is suffering.

When we talk about preventing mental illness or reducing the incidence of it we are often talking about suffering. We want to reduce the horrific pain people are in, the suffering experienced by their friends and families who are struggling to understand and support them and find them help. The losses of relationships, careers, self esteem. But a great deal of the suffering that happens and needs addressing simply is not captured by the term ‘mental illness’ unless we stretch it so broadly that almost everyone qualifies as mentally ill. Grief is one example of this. The suffering caused by poverty and inequality which can present in ways that fit our categories of mental illnesses but also may not. Racism and discrimination which lock people out of opportunities, resources, connection, and self respect. Addictions. Abuse, bullying, domestic violence, rape culture. Loneliness, that subtle, pervasive, deadly experience buried beneath so many clinical terms for pain. Alienation, where those who are not invited to be part of the good life start setting fires to the lives of the fortunate. Destructive cultural ideas about happiness, optimism, the value of people, what it is to be ‘normal’, what success means, who the ‘nobodies’ are, what it means when bad things happen to us, and how we heal from pain and live meaningful lives. So much of this is critically important to discuss when we are talking about health of people and health of communities. There are threats, risks, and losses that go far outside the net of ‘mental illness’.

Mental illness also captures too much. Like a drag net that brings in fish as well as turtles, octopuses, and dolphins, there are valuable experiences and important aspects of what it is to be human that are currently tangled into the idea of mental illness. One of these is psychological injury where the mind is behaving exactly as it should under the circumstances. Nothing at all is wrong with the person, but they are distressed and need support. Needing support does not mean there is something wrong with you, this is how humans navigate loss, pain, and challenge. When you start to look at the symptoms of mental illnesses a question arises about whether we are describing the problem or instead capturing and focusing upon a healthy response to the problem. To put it another way, if a wound on my arm has clotted into a scab, my blood is doing its job. My blood is not the problem, the car crash I was just in is the problem. If I am suffering severe emotional pain in an abusive relationship, my mind is working the way it is supposed to and telling me that there is danger I should avoid, just the way it would if I put my hand on a hot stove. Feelings, even painful ones, serve important psychological purposes. The pain is meaningful and purposeful and represents a healthy mechanism, not a sick one. If we ‘cure’ people of emotional pain we make them psychological lepers. Leprosy does no harm  to the general body by itself, but those who cannot feel pain struggle to protect themselves from the risks of life and without extra care small injuries cause severe harm. Many of us have seen psychological lepers – people who are not in pain exactly but who seem stripped of some vitality and oddly incapable of caring for themselves. Psychological leprosy is also called institutionalisation.

Mental illness often also captures diversity and eccentricity. There is a natural diversity to the human experience that includes a variety of thresholds for experiences such as psychosis. Under some conditions such as sensory deprivation, everyone will hallucinate. As a community we have a variety of thresholds for these conditions, meaning some people will hallucinate more readily than others. Often this experience causes no harm and in our culture people who experience hallucinations that do not distress or impair them usually keep them secret. There is a massive gap in all our knowledge bases about normal diversity because most of what we know about experiences like this come from people who are too overwhelmed to hide them. Everyone else stays underground.

Idiosyncrasy, that is, the absolutely unique aspect of each of us is a deeply important aspect of living a meaningful life. However it is also in tension with being part of a community in which shared language, beliefs, and ways of doing things are important. We are highly social, as a species, and also highly individual. Creativity and idiosyncrasy have a relationship we are still exploring in research. ‘Normal’ and ‘healthy’ are often defined in such narrow community focused ways that individuality and uniqueness wind up conceptualised as mental illness. The example of a psychologist in a grey pant suit diagnosing a flamboyant black queer man with Histrionic Personality Disorder is a classic example of this. One of my psychology textbooks had a photo of beautiful black man in makeup and fishnets as the illustration of this mental illness. People who fit the conventional culture better often see authentic but less conventional people through the lens of mental illness.

Not only does this lens distort what is normal and healthy about us, it often reframes our greatest strength as a weakness to be overcome. For many of us, the pathway out of the anguish of mental illness is not about becoming more normal (fitting the social norms better) but about becoming more idiosyncratic and then more wisely fitting the social norms we need to. It’s about tuning in to ourselves and learning how strange we really are. What we really need. It’s the reason I don’t tell other people that they should heal their mental illness through art, even though that has been essential for me. One size does not fit all. Only individual approaches genuinely connect with people’s needs. But approaches cannot be individual and people cannot even tune in to what their real needs are when the focus is about restoring ‘abnormal’ thoughts, feelings, and behaviours to ‘normal’. It is a skill, or at least a capacity, to not fit in. To retain individuality in the presence of a strong collective. We are socialised to navigate our community and there is a tension between the I and the We. When things go wrong in any number of ways, that tension can eat us alive. The push to navigate the We aspect better, to fit in and be less strange, can destroy the process actually needed to ‘recover’, in which being different and connecting to how we actually work is skipped for platitudes about reducing stress and the bland roll out of top ten ways to be less crazy and in less pain (have you tried a cup of tea or snapping a rubber band against your wrist?).

All of these ideas also shape our sense of what mental health means. When we think mental health means ‘not suffering’ we limit it to a badge worn by the privileged who have experienced few of the challenges of life and are now satisfied to take credit for their ‘good mental health’ as if it was a personal attribute rather than good fortune. When we think it means being happy we pathologise the suffering and obliterate the dignity of enduring challenge and loss. Pain is part of a healthy, rich, deeply lived life. Lives with tragedy and less privilege are bound up in navigating pain in ways that are difficult for those who have not shared these experiences to comprehend. Trying to eradicate all pain or teach people to be pain averse can destroy rather than develop mental health. Conceptualising pain as unhealthy sets people at war with their hearts and minds. And yet there is also needless suffering, and pain that absolutely demands a response from a compassionate society. Shame, fear, loneliness, self hate, and self destruction are all real. Some suffering must be navigated and for that we need support and self compassion and an appreciation that mental health can actually look like sobbing face down on the bathroom floor because that is a healthy response to circumstances. Some suffering demands alleviation. No child should be raped. Nobody should be treated as scum by services designed to filter out only the ‘deserving poor’ for resources. Some of us are going to hallucinate sometimes. Maybe we play music on our guitar on those days, or maybe we wind up chasing the idea that making the things that make us different go away will make our lives better. A lot of that is down to how we label it.

One thought on “Defining Mental Illness

  1. This is brilliant, in every way. It’s so important to look at who conceptions of “mental Illness” come from, that is, not from the oppressed and the abused, but from psychologists and other professionals who came from a protected and privileged backgrounds. Some come to it later in life, after surviving oppression but the vast magority do not. Geraldine Moane on the psychology of the oppressor:

    “Like the oppressed, the oppressors have difficulty developing an accurate self-concept, in this case because of myths of superiority, and because they lack direct feedback about themselves. Their position of power and control leads to feelings of aggrandizement and even delusions of grandeur, as well as high levels of self confidence.

    At the emotional level, oppressors have difficulty admitting emotional needs and vulnerabilities and tend to suppress feelings of sensitivity and love. The capacity to foster growth and development is underdeveloped in favour of an emphasis on taking action. Repressed guilt and the need to justify the oppressive situation can lead to dehumanization or lack of compassion, which may be fueled by hostility and challenges to the status quo by the oppressed. Fear of loss of status and the need to defend the status quo can lead to rigidity and an inability to admit mistakes.

    Oppressors experience tension between colluding with the status quo or aligning themselves against it. Relationships with subordinates lack authenticity, while those with oppressors are marked by competition. Overall, oppressors may also experience a sense of alienation from themselves and from each other, and from the status quo, especially if they doubt the legitimacy of the oppressive situation.”

    This accurately describes most people working in “mental health” who I have met, and that is a tragedy.

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