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.