Effect Measure

I don’t write about mental health here, but not because I don’t think it is of public health importance. It may be one of the most consequential and expensive maladies we have. It’s not because I don’t know anyone whose life it has touched. I know many. And it isn’t because it is without intellectual interest. It may be one of the most difficult, entangled and ambiguous topics in public health. It is mainly because of lack of expertise on my part coupled with my attention being directed elsewhere. You can’t write about everything and can’t get up to speed on everything. Life is too short. But May is mental health month, something Sharon at Flu Trackers reminded me of. So I sat down to think about it a bit.

We tend to think of health and disease and ability and disability as black and white things. I say “tend to” because most of us, when we really put our minds to it, realize they are not so clear cut. New diseases appear (HIV), new kinds of behaviors are medicalized (think of autism spectrum disorders), others are demedicalized (homosexuality), many who were formerly considered “disabled” now bristle at the label, while what was formerly considered just a behavior variant is a kind of disability (ADHD might be an example, although it is also an example of medicalization). The many variants of behavior encompassed by “mental health” are so multifarious and ambiguous that almost anything general you say about them has exceptions. So I’m not going to wade into such treacherous waters but just confine myself to a few observations.

The first is that despite many shades of gray, there are quite a lot of behaviors — where I mean this in the most general sense, like walking is a behavior, or talking is a behavior, or even breathing is a behavior — that are clearly both pathological and disabling but almost anyone’s standards. Well, maybe not. Hearing voices, seeing things no one else can see and taking instructions from these non intersubjective entities is pathology in my book, but there are people who are considered normal but just deeply religious or observant that could fit that category. But pretty much you know what I mean. Florid schizophrenia. Or deep clinical depression. Or severe bipolar disorder. All of these things exist in a spectrum of severity and there are variant spectra within them, but I’m talking about the extremes of the spectrum. There’s usually not much disagreement that they are truly pathologies of some kind. What is strange about them is that they aren’t considered in the same category as other pathologies. They tend to be hidden, not discussed or denied much more often than other things that are obvious pathologies.

My second observation is that the kind of behaviors we are talking about, unlike walking or breathing, are more often than not behaviors that affect social or interpersonal relationships. So pathology also produces a severe form of disability, the disability to communicate or get along with or have proper relationships with others. That’s a disability that isn’t confined to the person because it is a disability that affects others — often us. We are actually part of that disability and we become disabled in turn. We can’t have a normal relationship with the person. It’s like we can walk fine most places, but when we go in certain areas, the territory of the person with an illness we call a mental illness, we can no longer walk properly. It’s frustrating for us. So we don’t go there. We shun them. And I think it helps explain the first observation, why things that are obvious diseases are still not spoken about in the way we would speak about any other disease.

My third observation is that for the reason that mental illness means we all have a kind of disability, it is even a bigger deal than when considered on its own. Only the hardest of hearts doesn’t understand that it can cause great pain and loneliness, not to mention destructive or self-destructive behavior that can endanger the person or others. But beyond that we usually forget that their disability also is our disability. It is contagious just the way a virus can be contagious. Quarantines restrict people who are exposed but not themselves infected. When we are cut off from people with the kind of behavioral disability we are talking about (whatever you want to call it), i.e., the kind of disability that interferes with relationships with others, we are quarantining ourselves, limiting our own freedom.

This isn’t very sophisticated thinking, I’ll grant you. I have little expertise in public health or clinical aspects of mental health. And I welcome corrections or admonishments for outmoded or sloppy thinking (well, I don’t welcome them, but I am willing to be corrected). In the meantime, hat tip to Sharon for making me think about it. She sent along the link to a website that tries to destigmatize mental illness and encourage people to reach out for help if they need it. My take is that we all need help with this as it affects us all.

Comments

  1. #1 Paula
    May 8, 2010

    Revere, I understand you re the extremes of the spectra, but, having seen both the sort of self-destruction, family destruction, and relationship-destruction caused by “freudian”-cum-Cold-War(etc.)”mental health” theorizing and labeling, especially of woman and gays, followed by the vicious labeling/medicalizing/drugging of children as ADHD and whatever else by school systems needing SED monies to get by, neighbors disturbed by active toddlers–not to mention the everyday misuses of semi-psychiatric labels by nursing staff simply overloaded with patients and work–I’d hesitate to use these terms on anyone. On the other hand, “there was this fellow I had to work with yesterday on a protest project who is clearly a high-functioning autistic or maybe Ansberger (spelling?) case, and wow you should have seen how his e-behavior disabled the communicative functioning of every one of us on the e-list. . .”

  2. #2 Texas Reader
    May 8, 2010

    The difficulties with relationships create a sense of shame for adults like me with ADD who are considered “normal.” We can’t be open about having/being ADD as it would impair our careers. Only a few friends know and I’ve told them the type of difficulty it causes me – like my inability to pick up on social cues. Anytime we have difficult with someone at work or socially we immediately go to the “I’m not capable of normal relationships” meme and feel ashamed.

  3. #3 DRK
    May 8, 2010

    So, this Saturday morning , a relative with schizophrenia called my house at 6:30, 7, and 7:30, then again at about three times in the afternoon, because this person is “getting a message” that a member of our family has been in a bad car accident. “Getting a message” is what she calls the voices in her head. The poor thing. The poor thing. What do you do with a person with schizophrenia? Try to reason with them, play along with them, just don’t take their phone calls at all? If the phone calls are taken, so will your life become this constant drama. If the phone calls are not taken, then you are dooming this poor person to a life of utter loneliness, accompanied only by the hateful nonexistent voices. This person is an adult, thus cannot legally be compelled to take any meds at all, unless a danger to self or others. So what do you do?

    It is true, that this disorder of social connection is one of the cruelest diseases there is. Crueler than Aspergers or ADHD — hell, half my family has those, it just means we’re all kind of self-absorbed short-attentioned span nerds in our case. But the nature of schizophrenia is so isolating (because so unrecognizing of any social boundaries at all) that it constitutes a total hell for the person who has it, and for everyone around them, too.

  4. #4 rijkswaanvijand
    May 9, 2010

    @1
    You’re quite good at the labelling yourself!
    And as long as you’re on the internet, is it so damn hard to look up the correct spelling of Asperger’s??
    Ansberger.. tss that’s not even high-functioning, just plain autism if you ask me.
    Then again, I’m not a skilled psychologist so you shouldn’t ask me; someone who doesn’t even know the name of a certain condition surely knows too little about the same condition to go and make diagnosis on others!

  5. #5 Philip
    May 9, 2010

    Thanks for writing about mental illness. I’m affected, but can’t write about it this well myself, and I had not come across the description of mental illness as a reversed disability, which I like a lot.

    It’s probably impossible to write about mental illness without generating a response criticising your terminology, and I’m afraid this is no exception: I disagree with two of the phrases you used, and I think it would help for you to reconsider why you did, and then decide to reject or accept my criticism.

    The first is the example of “hearing voices” as what feels like the extreme end of the spectrum as far as pathology goes. In fact, many of those who hear voices do so in a way more reminiscent of synaesthesia than schizophrenia: they can classify voices they hear into those induced by their illness and those they can safely act on (maybe they hear just one person’s voice, and that person has died). I understand there is debate about whether a goal of treatment should be to have the patient deny hearing unusual voices, or whether the best course of treatment is one which reduces the impact of hearing voices while accepting the symptom.

    The other phrase is what seems to me to be the idiomatic expression “endanger the [patient] or others”. In a mathematical sense, the phrase is correct: mental illness can result in patients endangering others, sometimes others with no connection to the patient. Those cases are very rare, particularly if the threshold for “danger” isn’t artificially lowered (of course it’s true that driving is slightly more dangerous for the mentally ill, or that mentally ill parents run a slightly higher risk of becoming incapable to respond to their children’s needs. the same is true for heart disease, myopia, or insomnia). Behaviour dangerous to the patient or others just isn’t a good category to think of in the case of mental illness, because it unites two very different forms of behaviour, one of which is vastly overestimated in the public imagination while the other one is still underestimated.

    In particular, it’s very unlikely that any mental illness will take the form of an unremarkable apparently sane person suddenly, without forewarning or an attempt to seek help, killing a random stranger.

    In the case of suicide, that is what happens. In the extraordinarily narrowed perception of a person in a mental health crisis, death might seem preferable to the danger of a dishonourable diagnosis of “endangering to self/others”.

    You’re not responsible, of course, for any person’s misunderstanding, but fighting the distorted perception of mentally ill as tremendously dangerous, and replacing it by a more realistic acknowledgement of the degree of danger, is a good cause, and I think it is worth using a few more words for.

  6. #6 revere
    May 9, 2010

    Philip: Both excellent points which I shall remember. I think I was trying to express the idea that some portion of the reaction to mental illness involves fear, but I said it badly. Thanks for the constructive criticism.

  7. #7 Paula
    May 9, 2010

    rijkswaanvijand: I take it you are unfamiliar with irony, or sarcasm. As for the spelling, do you honestly believe that misspelling a word is the same as not knowing its use?

  8. #8 Renee
    May 9, 2010

    The problem with mental illness is that everyone is mentally ill. That is to say, we all exist on a spectrum of behaviors. Only the people on the tails of the curve for each behavior are “ill” but it’s a slippery slope.

    If you have a hammer, everything looks like a nail, and that’s the problem with psychologists. If you go to one, you need treatment.

    Take this article: http://www.rd.com/living-healthy/are-you-normal-or-nuts-your-questions-answered/article177191-1.html

    In almost all of their answers, psychologists say that the person needs treatment, but more often than not I think the people with questions ARE normal; their behavior doesn’t hurt anyone and it doesn’t really hurt them much either.

  9. #9 Cate
    May 10, 2010

    Not everyone is mentally ill — approximately 1/4 of our U.S. population have serious psychiatric symptoms or frank mental illness. The rest of us are irrational in some of our thinking some of the time — that has nothing to do with mental illness.

    One-quarter of our pop with mental illness is an epidemic proportion. The toll on all of us, as Revere notes, is horrific. Much of the problem is that children are downstream to every adult behavior imaginable — our children are not protected from social ills, in fact they are actively exposed to the worst our society has to offer.

    No one is allowed to drive a car above state decreed BACs, but anyone can parent a child at any BAC or cannibis level they please. Drunks/druggers often think they are good parents, a delusion that is only the beginning of their problems as parents. Our child protection laws do not work, and only target those with low SES.

    When I did my postdoc in child psychiatry, I found that most of the children we saw were exhausted — few had regular bedtime routines, and most were getting much less than the 10 to 12 hours of sleep they needed. Children were privy to their parents sexual, social, and legal misdeeds. Many had no regular meals — dinner was whatever they could forage from cupboards. They were subject to their parents moods, to boarders sexual needs, given drugs or alcohol to entertain adults, or openly despised by their families for no apparent reason. They all craved simple acceptance.

    Many of the psychiatrists saw their role as nothing more than rx provider.

    More simple societies have less mental illness, and those few who are mentally ill — instead of being marginalized — are given shamen roles. Much more humane than our sophisticated shunning.

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