Reflections on the Concept of Mental Disorder

“Nomy, our purpose here is to help you become just like everyone else”.

That’s what the school counselor told me when I was a kid. And then another school counselor. And then another. I am not paraphrasing, or dramatizing, or anything. Translating from Hebrew to English is all. They all referred my parents to psychologists and psychiatrists, who would help me even better toward this goal, being like everyone else, which they firmly assumed I shared, no matter what I said. Little wonder, then, that by the time I became a teenager, I was certain that the concept of a mental disorder was nothing but a tool of oppression used against unusual people by those who want everyone to become just like everyone else.

(PSA: if you have a child who is beaten up by the other kids because she’s reading Great Expectations at 11, like I did, or because she looks unusual, or because of some incidental vagary of child social dynamics, or even because she has bad social skills, do think carefully before sending her to some kind of shrink. You need to make sure your child does not get the message “the other kids beat me up because there is something wrong with me, and my parents agree, so they are sending me to be fixed”.)

Years later I had to give up my Szasz-ian extremism, because depression, along with hypomania and anxiety, threatened to kill me. Slowly it dawned on me that while the professionals of my childhood were wrong to try to cure me of reading Great Expectations, there was a case for calling some things mental disorders. Seeing my roommate react with fear and trembling to a small spider provided one datum: there was no way that her suffering was “socially constructed” in the English department sense of the term. It was real, and the term “disorder” seemed to fit it. It also seemed to fit my depression, hypomania and anxiety.

So what is a mental disorder, then? I knew what I wanted cured: my suffering. So, was I going to call any extended mental state or brain state constituting or leading to significant distress a mental disorder? That used to be pretty close to the DSM definition, and many shrinks will still tell you that if it causes either distress or disruption in functioning, it is a mental disorder. But this plausible-sounding theory is pretty terrible upon reflection. My love of Spinoza as a teenager caused me significant distress, because it caused kids to beat me up. It also interrupted my functioning, because it’s hard to function when you are beaten up. Still, loving Spinoza is not a mental disorder. Being gay in the 1970s caused one enormous suffering – everything from self-hatred to trouble with the law – and that helped keep homosexuality in the DSM till 1973 and “ego-dystonic homosexuality” (homosexuality, provided that one wants it “cured” in oneself) till much later. The distress-bad functioning based definition of mental disorder, in other words, does not block the term from being used, in the oppressive manner typical of the school-counselors of my childhood, by those who want to tell gay people to be just like everyone else.

Some later DSM writers tried to solve the problem associated with defining a mental disorder as a state of mind/brain/behavior/whatever that causes distress or trouble functioning by simply adding to it a disclaimer along the lines of “the problem has to be with the individual, not with a conflict between the individual and society”. That didn’t work, because it is the job of a definition of a mental disorder to tell us when there is a problem “with the individual” and when there isn’t. Presently, we don’t have a definition that can do this job. The reason we no longer think that a woman who refuses to be a homemaker is showing a problem with functioning is not that our definition of mental disorder improved. It’s that our moral outlook did.

Part of the trouble with defining mental disorder the way philosophers try to define things is that this would be at cross purpose with what the writers of DSM are trying to do. Philosophers look for the true, or at least the coherent. Shrinks look for the useful. Let me explain. The Diagnostic and Statistical Manual of Mental Disorders is becoming a thicker and thicker book. More and more things are called mental disorders. There is a cynical hypothesis about the cause: shrinks want people to go to them and give them money. However, there is also a charitable hypothesis: shrinks want to help people, and nowadays, however obvious a person’s suffering, she can’t get the insurance company to fund psychiatric help if the suffering isn’t defined as a disorder. If a person who suffers from grief wants to take some pills to help with insomnia or make it easier to go back to work, her grief needs to be redefined as a major depressive episode, and therefore a disorder. You have to call something a mental disorder if people are to receive help for it.  Thus, however they define “mental disorder” in the introductions to their books, when you look at the long list of things that are classified as mental disorders you see that the one thing they have in common is popular demand for insurance coverage. The trouble is, of course, that “something is a mental disorder iff people want psychiatrists to help them with it” does not sound like a definition that captures a natural kind. It is basically another incarnation of the distress/bad functioning thing.

What about natural language? “Mentally ill” replaced terms like “insane”, “crazy” and “nuts”, which are, in many ways, colloquial ways to say “patently irrational”. The things that were considered forms of insanity or forms of “neurosis” when Freud was alive and are still considered paradigmatic mental illness today basically are forms of gross irrationality, or cause gross irrationality. These would be: psychosis that leads a person to think, irrationally, that he is Napoleon; depression that becomes so bad that the person thinks that the fact that she forgot to buy milk makes her as despicable as a Nazi, or, against all evidence, that her family will be delighted to see her dead: mania that leads a person to spend all his money and run off with his secretary to pursue a business deal that he is normally plenty smart enough to see is nonsense: terrible fear of tiny, harmless spiders: etc. To this day, being told that one’s thoughts or feelings or actions are symptoms of a mental disorder can be insulting or reassuring in a way that only being told one is being grossly irrational can be. Let me explain.

Maybe I’ll start with the reassuring. Suppose you are really afraid that there is a monster under your bed – literally or figuratively – and someone convinces you that your fear is a symptom of a mental disorder. That can be wonderful news. When I express fearful or self-hating thoughts, being told “Nomy, that sounds crazy” can be music to my ears.  I am irrational! The fact that I forgot to answer an email from the secretary does not mean I am worthless! My fear or sadness is unwarranted!  Now for the insulting: if you are very sad purely because your attempts to make your country a democracy have failed, and someone refers to your sadness as a clinical problem, it can be infuriating. No, you think, I am not irrational. I am responding appropriately to reasons. Calling it a disorder is refusing to see that. This is one reason people have been angry when the last DSM amended the definition of depression in such a way that it now includes many grieving people. People who don’t want their grief in the DSM do not deny that they are suffering and do not always deny that they could use some professional help. What they want to deny is that there’s anything grossly irrational about their grief. Of course, rationality and irrationality can be woven fine. A person can start being depressed because he lost his job – presumably a reason to be sad – but then, despite the fact that he was fired due to a recession, start feeling worthless or bad because he’s unemployed, and that’s where irrationality can creep in – even gross enough irrationality for the person to count as having a disorder.

So paradigmatic mental disorders involve serious irrationality. To that you can add conditions often thought of as disabilities rather than disorders, in which the problem is not irrationality but cognitive impairment of some sort (e.g low intelligence, lack of some kind of know-how). Perhaps they too belong in some divine version of DSM.  But what about conditions that do not grossly affect one’s rationality and involve no cognitive impairment? My hunch is that there is something very problematic in calling them mental disorders, as opposed to problems, troubles, eccentricities, ways of being neuro-atypical, or sometimes even vices. If you think the DSM, considered from the aspect of truth and not insurability, is getting too thick, this just might be what’s bothering you.  But to be continued.