Category: Mental Disorders

The Man Who Was Afraid of the Weasel – A Rant About Mental Disorders

“But the man who was afraid of the weasel had a disease”.

Who? What? Where did this come from? Aristotle doesn’t tell us. As usual, he’s not talking to us – presumably he’s lecturing to some free citizens of his city state, of which there are – what, 35,000?  – who presumably all know the same gossip. With these people he can refer to “the man who was afraid of the weasel” just like you could refer, talking to people at your academic institution, to “the student who published that article in defense of sweat shops a few years back”.

I admit it: I have always been oddly curious about this example. Who was that man who was afraid of the weasel? What was the incident like? Why did Aristotle think it was a disease? For a while, whenever I met an Aristotle expert, I asked them if anything further was known about this story. They always told me that no, it is lost to posterity, and so I am left with my fantasy version of the event, no doubt influenced by my childhood in Israel: a very dark night, an Athenian military encampment, some soldiers sneaking a weasel into a sleeping man’s tent, or whatever they had back then instead of a tent, the man shrieking with terror and looking silly as he jumps to his feet and runs away. Later, the embarrassment, the humiliations reserved for a man who failed a harsh ideal of masculinity (either you are the type who is willing to die in battle, or you’re a coward!) in a tightly knit society. He wonders if he’ll ever live it down, and would not be totally dismissive of the thought that people might still read about him 2,500 years later.

Mustela nivalis -British Wildlife Centre-4.jpg
By Keven Law – originally posted to Flickr as On the lookout…, CC BY-SA 2.0, Link

Sadly, we will never know what happened, but the question of what makes a fear – or some other mental state or behavior – a disease or a symptom of disease is still with us. Suppose we try to settle the question of whether someone should count as having a mental illness or not. Is this child what some anti-intellectual cultures call “a nerd”, or does she have a mild version of “autism spectrum disorder”? Is this man grieving for his late wife, or does he suffer from a “major depressive episode” triggered by her death? I wrote in my post before last that very often, we still go about answering this question in a way that has nothing to do with science or with what metaphysicians call “carving the universe at the joints”. Those who are in favor of taking the nerdy child or the grieving man to have a mental disorder argue for it on the basis of the premise that the girl or the man could receive some help if so categorized. The girl could use some breaks at school, the man could use some therapy and some compassion from his employer, say. They often cannot, in this society, receive these things if we don’t call them mentally ill, so it’s practically a moral imperative to call them mentally ill. Therefore, they are mentally ill. If the concept of mental illness or mental disorder is to be anywhere near scientific, this is a pretty bad argument. True, wanting to help is a good motive. We are not talking some evil pharma companies plotting to include the grieving man in DSM so that they can sell him pills. But it’s a bad argument, all the same.

Those who hold that the girl or the man does not have a mental disorder also use arguments that have nothing to do with science or whatever joints the universe might have, though they, too, have good intentions. “I don’t want this child to be stigmatized as having a mental disorder just because she is nerdy, it will make her feel bad, therefore she does not have a mental disorder” is one. “It is insulting to me and to the memory of my wife to call my grief a mental disorder, so I don’t have one” is another. Full disclosure: I am often intuitively sympathetic to the conclusions of these bad arguments. Calling fairly ordinary aspects of grief an illness sounds problematic to me. I have a few doubts (I do mean doubts, not certainties) about the idea of “autism spectrum”, as it seems questionable to me that a child who is so terrified of human closeness that she refuses, from infancy, to be hugged or touched by mom or dad and a child who craves affection as much as anyone but fails to make friendships with peers because he can’t figure out how one starts a conversation suffer from two varieties and/or degrees of the same problem or trait. Still, that does not allow me, or anyone else, to argue that a diagnosis is dubious simply because it’s insulting. Some people who are so depressed that they spend most of their time crying on their apartment floors are firmly convinced that their depression is due to their superior insight into the nature of the world, or the fact that they have figured out that happiness is not valuable and only shallow people think it is. Such people often take offense if you suggest that the problem is their neurotransmitters, which made them gloomy long before they could spell “nihilism”. Still, it might very well be true – spoken as a person who had pretty bad depressive episodes herself – that the insulting diagnosis is, for some of them, correct.

So what? So “mental disorder” is not a scientific concept as long as we decide who “gets” to have a disorder or not to have it on the basis of practical rather than theoretical considerations. This is a problem, because ultimately, seriously scientific research into mental disorders is the best way to help those who have them, and for that we need “mental disorder”, as well as “autism”, “depression” etc. to be theoretically respectable concepts. What has to go, I think – not that I know how to make it go! – is the medicalization of suffering. By that I mean not merely the fact that more problems are considered diseases than before – that’s a mixed bag, as it is plenty good that epileptics are viewed as sick rather than possessed by the devil. Nor do I merely mean that some problems are considered diseases which are probably not diseases. When I say that suffering has been medicalized, I mean that a person who is suffering can increasingly receive neither help nor sympathy unless her suffering is regarded as a medical problem, and “medical” suffering is somehow perceived as more “real” and more deserving of remedy than ordinary suffering. In a morally ideal world, a person whose life is a mess because she’s in the middle of a divorce could come to her employer, explain her situation, and get a bit of slack from her. In this world she needs to go to a doctor, tell the doctor exactly what she would have told her employer, and, on the basis of that, get a note that says she has clinical depression – a disorder – and needs, well, exactly the type of consideration she would have asked for. There is something ridiculous about this.

The predicament of a kid who is bullied by everyone in class or who is simply friendless through k-12 is a bad one, both in terms of experience and of impact, and should be treated seriously. If I had to reincarnate as a child and had the choice, I would take a mild bona fide medical condition over this predicament. If the nerdy girl from my example is facing it, and if there is anything we adults can do without making things worse in another way (there often isn’t), we should do it. It shouldn’t matter one iota if the problem is literally a matter of health. Health is not the only good! illness is not the only bad! If we remember that, perhaps we can approach the question of whether she is best described as having a mental disorder, or autism spectrum disorder in particular, in the spirit of inquiry unfettered by the sense that if we say no, we thereby deprive her of help or sympathy, and so yes is the only decent thing to say. Such inquiry can bring with it better help for both those with autism and those without it. But the blogger who was obsessed with the man who was afraid of the weasel finished her rant.

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.