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110 Responses

  1. boredclerk
    boredclerk February 22, 2012 at 1:17 pm |

    I don’t think it’s possible to have a personal definition of health – at least, not one that is useful for anything. I think that the word “health” itself implies a kind of conformity to social norms and standards about the body and about behavior. The most you can have is a personal understanding of what those norms and standards are. A wholly personalized and independent sense of what it means to be healthy, though, seems like a contradiction in terms.

  2. Dominique
    Dominique February 22, 2012 at 1:25 pm |

    As someone who is a survivor of many things, I take íssue with the cavalier way in which so many commenters – and the occasional blogger – so liberally throw around contempt-filled words like “nutjob”, “headcase” and “psycho” in the name of snark against anyone whose opinion they don’t like. I’d like these people to grow up, already. I’ve been ridiculed more than once for calling people out. This is pure hypocrisy. If you think the words “pussy” and “sissy” are offensive, you should think twice about terms used to deride the mentally ill.

  3. Nahida
    Nahida February 22, 2012 at 1:30 pm |

    YUSSS! I’ve been hoping William would get a guest post!

  4. Jadey
    Jadey February 22, 2012 at 1:41 pm |

    I am excited beyond belief about the prospect of this series. As a ‘research’ psychologist* who nonetheless works alongside clinical psychologists in a field where clinical interests predominate (forensics), this is one of those subject areas which is quite relevant to me, but which I only gather information on in passing from my more plugged-in peers. Who have been, as far as I can tell, mostly brought up in one particular approach which also dominates this field – CBT (with a smattering of psychoanalysis from the older guys who are still willing to admit it). From our many comment conversations, William, I know that you have much to say on this score which challenges the assumptions I am surrounded by and tend to default to for want of a more informed perspective.

    As for how I define health and illness… Disability activists have given me much to think about over the last few years. I think of both as relative concepts operating on a lot of different intersecting axes (physical health, mental health, emotional health, etc.) in relation to a lot of different standards (e.g., normative health defined by social expectations around accepted levels of functionality, conventional behaviours and appearance, etc.; personal well-being and one’s own sense of “wellness” at a given time; and ‘optimal’ vs. ‘sufficient’ standards), which may not always be in congruence with each other (and for some of us, often aren’t).

    Basically, whenever I’m in a seminar or symposium now and someone utters the phrase “healthy behaviours” without qualifying it, I can derail that conversation for *hours*. :D

    *I freely admit that distinguishing between “research” psychologists (or “experimental” psychologist, as some say, though many of us do not always do truly experimental work) and clinical or counselling psychologists has all the makings of a false dichotomy, or at least another one of those gross oversimplifications! For the uninitiated though, it’s worth noting that there are many streams of psychology, only some of which are specifically focused on the identification and treatment of psychological disorders or madness or however one wants to refer to that. Which is why someone referring to themselves a “psychologist” does not make them the expert on all things possibly psychology-related, unless they’ve really, really diversified over a very long career!

  5. wriggles
    wriggles February 22, 2012 at 1:49 pm |

    how do you, personally, define health and illness?

    Are you referring to mental or physical health (or both)?

  6. Cécile
    Cécile February 22, 2012 at 1:52 pm |

    William, thank you so much for this post! Given that you are a trauma survivor and a practicing psychologist, and I anticipate that you probably are familiar with what I am about to post and look forward to what you might have to say about any of it. Please don’t take this as being directed “at” you, it’s more of an aimless rant on my part than anything, but I hope it sparks some interesting exchange:

    I’ve been really struggling lately with a sense of futility against the towering giant of the DSM, which I presently view with spite and resentment. The DSM, essentially, shapes the public’s conception of mental illness as starting with an “observation of symptoms” and then deducing some type of disorder within the individual.

    I’ll jump to the point: I think trauma is grossly underrepresented in diagnostics. I despair that so many “symptoms” in the DSM are also totally capable of representing the vast network of characteristics of person who has been traumatized—which, of course, left untreated, ‘permanently’ alters the functioning of the brain. The lack of emphasis on trauma in the DSM therefore creates the high risk of “deducing” that the patient has a “mental illness,” which might actually be a “psychic wound” or “psychological injury.”

    While I am not asserting that all mental illness is actually unrecognized trauma, I think MUCH of it is. And the problem is that the interpretation of symptoms often is bent to answer the question, “What’s wrong with you?” rather than the more psychoanalytic** inquiry of “What happened to you?” (I know the latter being highly subject to public outcry… but that only emphasizes the politics of the ‘source’ of ‘mental illness,’ as far as I’m concerned.)

    Consider, for example, how the symptoms of bipolar disorder or schizophrenia are strikingly parallel to the triage of hyperarousal-intrusive-dissociative symptomology of traumatic disorders, such as PTSD or C-PTSD. (C-PTSD is not officially recognized in the DSM, but there exists such a vast amount of research and documentation surrounding it that I think it deserves to be spoken about with utmost legitimacy.)

    Judith Herman, who coined the term and proposed the framework for C-PTSD in Trauma and Recovery: The Aftermath of Violence—from Domestic Abuse to Political Terror, succinctly implies the delicacy and fallibility of symptom interpretation in the following quote:

    The beauty of the complex posttraumatic stress disorder concept is in its integrative nature. Rather than a simple list of symptoms, it is a coherent formula of the consequences of prolonged and repeated trauma. When I first proposed the concept, it was an attempt to bring some kind of order to the bewildering array of clinical presentations [....] my co-investigators and I found that somatization, dissociation, and affect dysregulation—three cardinal symptoms of complex PTSD—were found particularly in survivors of childhood abuse [...] Moreover, these three groups of symptoms were very highly intercorrelated.

    I’ve been becoming more in-tune to the politics of the DSM. C-PTSD and Developmental Trauma continue to be rejected by the DSM—from what I remember off the top of my head, some of the reasoning from the APA is that neither concepts “fit neatly” into their current methods of categorization. And consider this jaw-dropping statement:

    As van der Kolk pointed out, if developmental trauma were to make it into the DSM, it would be… the first admission by the DSM that what we do to children matters.

    (link: http://www.goodworksintrauma.org/blog1/2009/07/14/bruce-perry-weighs-in-on-dsm-dust-up/ — van der Kolk and Perry are two of the clinicians I admire most)

    In other words, aside from perhaps Attachment disorders (not sure offhand if those are in the DSM as diagnoses?), there is no formal recognition that childhood abuse creates lasting “psychological afflictions” throughout life! Months of ruminating upon this notion keep pointing me back to the politics of ‘why the bloody hell this would be denied’—how dangerous it is for parents, and for the cherished conservative notions of the unquestionable wholesomeness of private, nuclear family life, n’est pas? As Herman outlines in her book, domestic abuse often parallels the tyrannical patterns and methods of, say, totalitarian governments. And yet there is no “diagnostic” way to recognize the lasting impacts of this within people, aside from co-morbid arrays of DSM diagnoses.

    Below is the rejected proposal for Developmental Trauma Disorder. As it is arranged and presented “in terms” of the DSM here, I would also recommend van der Kolk’s independent research, such as Traumatic Stress, and Bruce Perry’s video series Neurosequential Model of Therapeutics.

    http://www.goodworksintrauma.org/blog1/suggested-reading/dsm-submission/

  7. Donna L
    Donna L February 22, 2012 at 1:54 pm |

    Would it be correct for me to interpret your question as specifically directed and limited to mental health and illness? I understand that the paradigm of a mind-body dichotomy can be of very limited utility and doesn’t necessarily reflect reality, but I’m still not sure how anyone’s personal definition of strictly physical health and illness would be relevant to your post, except insofar as physical health and illness affect one’s mental state. So I won’t try to answer the question until that’s clarified.

    But thanks for this, William, and I’m very happy to see a guest post from you. Definitely a better choice than the last one, unless you too have a train wreck of a blog out there waiting to be discovered! I kind of doubt that.

  8. William
    William February 22, 2012 at 1:55 pm |

    Are you referring to mental or physical health (or both)?

    Go with whatever works for you. I was more thinking mental health, but once we start talking about definitions of health and illness we’ll start talking about disability and I suspect that the division between mind and body will begin to break down a bit.

  9. EmmaSofia
    EmmaSofia February 22, 2012 at 2:09 pm |

    musings:

    as human animals, we recognize healthy, non-human, non-domesticated animals. as enculturated humans, we recognize what falls outside of social norms as healthy. these two recognitions exist in some kind of dissonant relationship.

    we swim in the waters of the cartesian split between mind/body and often partition ourselves further into emotion/spirit as well. there are attempts to allow for reintegration of these partitions into an embodied, interwoven, shifting ‘self’ — we have no name for this entity yet.

    wholeness suggests an internal monoculture that reflects a constructed external monoculture — neither exist. we are mosaics, collages, 3-d mobiles in constantly shifting relationships w/self and not-self.

    Is there a norm of health for our beautiful human-animal bodies? I think there may be — and I know that I fall well outside of that norm, not by choice but through environmental/genetic dis-order. I know that I/we also have the choice (rational? a-rational? irrational?) to deliberately step outside that norm and create body as creative/political expression.

    Madness? Why that value-laden sign over others? Consider how non-normative behaviors/symptoms/experiences/relationships are labeled by cultures/languages other than white european — by other times and places. create that collage and let it lead toward individual/personal responses rather than blanket terms that cover up too much.

    allow for not/never knowing — for taking the burden of responsibility of creating meaning and expressioning personal values.

  10. Cécile
    Cécile February 22, 2012 at 2:11 pm |

    My own view of symptoms is that they are a complicated interaction between the things someone had to do to survive trauma, the ways they have found to communicate these experiences which are not readily spoken, and the taboos which rob patients of their voice. Because of this, I don’t really treat symptoms.

    Also, I really appreciate this. I had been through multiple therapists over the course of about a decade, and numerous diagnoses and prescriptions, before last spring, when I made the profound discovery that I was actually operating under a traumatized most of my life (which of course compounded exponentially as time went on). I’ll never forget the moment I recognized this—there was a moment of stricken, shocked clarity, and then I instantaneously broke out into the most intense, violent fit of sobbing for about 20 minutes straight. Suddenly, all my “weird” and seemingly meaningless, capricious “mental problems” all made sense; the pieces, at that moment, fell into place—the ‘comprehensive formula,’ as Herman said. (And this was before I even knew about Judith Herman.)

    I fell into several months of mourning and depression after that. I thought, if only someone had recognized this, if only I could have known long ago.

    If I had only known, there are so many devastating things in my life that never would have happened. For real.

  11. Jadey
    Jadey February 22, 2012 at 2:12 pm |

    Someone want to dig me out of moderation, please? I got stuck already…

  12. wriggles
    wriggles February 22, 2012 at 2:19 pm |

    Physical health I’d have to stick with the absence of disease as I’ve yet to hear a better one. Illness would be a breakdown or crisis in that state, either under pressure of pathological conditions such as stress, infection or degeneration.

    Mental health or sanity is harder. I suppose it comes down to having enough self awareness to able to function well enough to keep body and soul together at least.

    Thing is, I’m not sure you need to meet definitions of sanity to do that and some who “pass” as can’t manage it.

    So many people who are sane seem to exhibit more objective or pronounced symptoms of madness-such as a peculiar take on reality-than those who have a diagnosis, but then many of the latter do seem to have some underlying fundamental schism that can be hard to properly define.

  13. Cécile
    Cécile February 22, 2012 at 2:38 pm |

    Me too, Jadey :-(

    I’ll make sure to keep an eye out for your comment—the problem with the selective moderation is that a lot of comments that are longer or contain links have a way of getting buried without being noticed if people aren’t vigilantly looking back for the “delayed releases.”

  14. IrishUp
    IrishUp February 22, 2012 at 2:46 pm |

    Well, I’ve come to abhor the construct of a division between mental health and physical health for one thing :)

    I have a very functional definition of health, which centers on the question “can I get by my day-to-day life, getting my gottadoos done?”

    Meaning: Am I groomed to some minimal standard, have I eaten and slept adequate amounts, am I able to maintain my important relationships, hold a job and housing, and be decent towards other people to the extent that these things are possible given my environment? And is this true if not every day, then most days of a given week or month?

    Insofar as I can answer “yes” to these, I’m healthy. A “no” would indicate a problem that needs attention.

  15. CBrachyrhynchos
    CBrachyrhynchos February 22, 2012 at 2:52 pm |

    I don’t see the paradigms you describe as mutually exclusive. I see few conflicts between between:

    1) this is a problem that has origins in my history (psychoanalysis)
    2) this is a problem that doesn’t necessarily apply to my current situation (CBT and meditation)
    3) this is a problem which can benefit from medical treatment (psychiatry.)

    History describes how I got got here, CBT and mindfulness helps me be aware of exactly where I am, and medication helps to turn down the thermostat so that I can be mindful of what’s really happening.

    I identify them as problems/symptoms because they’re terrifying (nearly to the point of suicide), painful, and involve deeply weird states of cognitive dissonance. For example, I can both know there’s not ants under my skin AND have completely authentic sensations of ants under the skin.

  16. Cécile
    Cécile February 22, 2012 at 2:53 pm |

    As a ‘research’ psychologist* who nonetheless works alongside clinical psychologists in a field where clinical interests predominate (forensics), this is one of those subject areas which is quite relevant to me

    Jadey—

    As this conversation is taking off, I’m wondering if you could frame out some details about the type of work you do, your areas of expertise/allegiance, and/or the “stream(s)” of psychology you are most involved with. Thanks!! :-)

  17. Mo
    Mo February 22, 2012 at 3:00 pm |

    Being that I have Fibromyalgia and am home from work with the flu as I type this, (and having Clinical depression on occasion), I can only define health for myself. Healthy, for me, would be operating at the most optimal condition that is right for me. Illness, at least physical, is a deviation from that optimum range. Most days, I’m mostly healthy within my limits. Today, I just want to take a scrub brush to my sinuses and scream. :)

    Mentally, that’s hard to say. I think there’s a basic way people can optimally function in their society that could be defined as health. But there are some societal influences on what is healthy and what isn’t. I’m put in mind of two books I’ve read that make me think that: Orson Scott Card’s “Xenocide”, in which the people on the world named Path have varying degrees of OCD, and the more you have, the more blessed you are; and “The Spirit Catches You and You Fall Down” by Anne Fadiman, where an American doctor learned how to interact with Hmong immigrants and their beliefs about their child’s epilepsy.

    I am also fascinated by forensic psychology. I personally believe that there has to be something that is intrinsically wrong, or maybe missing, with serial killers that allows them to do what they do and still function in society. But that’s an extreme. Milder things? It’s really hard to say. I think I have to go with whatever keeps you from optimally functioning, whether that’s depression to the point it interferes with your life, or the guy who has to check his door locks 20 times before bed, or the woman who can’t watch “Family Guy” because of all the disgusting rape jokes on the show that make her cry. In any case, they’re not functioning as best they could, so something isn’t in a state of health.

  18. Foglet
    Foglet February 22, 2012 at 3:06 pm |

    I personally take a stand that the dividing line, if there is one, between mental illness and health, as you put it, is a matter of degrees of coping. I’m also generally on the side of analysis as well, so I’m not going to expand on that. I as well take it that symptoms are things that are meant to be understood and used to attain some sort of insight onto one’s life.

    The reason I take this outlook is to take the focus away from society as much as possible and instead how the individual. It’s not that one can completely remove society from the picture, as much of the reasons symptoms are seen as problematic is because they disrupt society and often in return the quality of life and safely of the individual (potentially others, but often that is used as a fear tactic to criminalize and incarcerate). I’m suspect of strict definitions of mental illness that do not take into account how the individual is coping, without regard for the social.

    I’ll give an example from my own life and why I find this useful: Before I came out as a trans* woman I had a lot of internalized fear and discomfort that was unable to be named. Often this would result in self-destructive behavior and thoughts. Though a lot of this went un-noticed by others and mostly played out in my head and caused shame. There was a lot of avoidance and over compensating on my part. But hey! I fit in… sort of? So in society’s view I was healthy but to me I was ill. After coming out the reverse could be said, I’m in the process of transitioning (does anyone really stop?) and feel much better about myself. I’m coping with my own truth, but this is not always supported my society. People (even “experts”) call me ill and would much rather shut me away.

    Of course this is less of an issue today and there has been much progress made. There are people in the psychological community who support me and don’t pathologize me. I’m grateful and better off thanks to those people. However, this is a result of mainly time, location, and many privileges. This state of being for me has only be the result of a lot of work by those who have critiqued the psychological system. I’m in a big city with sympathetic doctors and a support network.

    I have the privilege of being healthy because of these figures. And make no mistake it is a privilege not many have access to.

    Thus society as a whole and those with a vested interest in keeping me ill such as Dr. Kenneth Zucker and Dr. J. Michael Bailey (the Dr. part gives them the social power to do so) would much rather me be miserable, but silent. I’d be a picture of health on the outside. This is why I put more weight on the individuals own view of themselves and their coping with life in general.

  19. boredclerk
    boredclerk February 22, 2012 at 3:16 pm |

    @ wriggles (#12):

    I feel like there might be a potential problems with the “absence of disease” definition for “health.”

    The reason I think your definition might not work very well is that any definition of “disease” (and therefore by implication “health,” which you defined as the absence of disease) necessarily invokes a sense of what a physical body should be like. Think of how most people intuitively call an obese person unhealthy. By saying that a given body weighs too much, they are implicitly saying that a body is supposed to be under a certain weight. That’s an easy example, but it works the same way with all kinds of other conditions that most of us would call unhealthy. The cataplexic is unhealthy or diseased because a body is not supposed to go limp in response to strong emotion; those with mitral valve stenosis are unhealthy because a body is not supposed to have such tight valves in its heart; and tuberculosis is unhealthy because that’s not one of the countless types of bacteria that a body is supposed to house. In most (but certainly not all) cases, we’re all in agreement about what a body is supposed to be like, so this is uncontroversial.

    So sure, you can define health by reference to “disease,” but if both “health” and “disease” are just ways to talk about how a physical body does or doesn’t deviate from some community standard of what a body is supposed to be like, then your definition isn’t really useful. The informative question is how we arrived at the standard we have for what a body should be like, not whether or not the body has a “disease.” When and how did we decide that weight is a component of what a body should be? Why does a body’s strength or agility have to be part of our conception of what a good body should be like (and, therefore, our conception of health)? Those are the definitional questions I’m more interested in, and defining health as the absence of disease doesn’t address them.

  20. Cécile
    Cécile February 22, 2012 at 3:20 pm |

    Hi wriggles—

    So many people who are sane seem to exhibit more objective or pronounced symptoms of madness-such as a peculiar take on reality-than those who have a diagnosis but then many of the latter do seem to have some underlying fundamental schism that can be hard to properly define.

    Wondering if you’d mind elaborating on this point a bit?

    Also, the way you worded this hits on an interesting dynamic: “those who have a diagnosis” communicates (to me) your recognition that diagnoses themselves are subjective and that there is a lot of room for questioning and further examination of said diagnosis and/or a person’s psychological state(s).

    The word “sane” is a word that takes itself for granted—but it groups people who a) don’t appear, or experience themselves, to have any type of psychological dysfunction, b) people who simply may not have had a diagnosis “bestowed” upon them or “detected” by others, or c) people who, as you described, exhibit “symptoms” while still being perceived or described by others as being “more sane than not”—all could be described as “sane.”

  21. Carol
    Carol February 22, 2012 at 3:46 pm |

    Mo,
    I think the inability to watch a show like Family Guy that has multiple rape jokes is an indication of health/wisdom/compassion/self-preservation, not dysfunctionality! If avoidance of things that promote rape culture is interfering with my life, bring on the interference, I say!

    Anyhoo, as the original question how do I define health, it’s very interesting. If I try to define “good health” as “Having the physical or mental/emotional capacity to accomplish all the things I want to” then I’d have to take a look at my severe procrastination which often keeps me from accomplishing things as…an illness or disorder? That seems a bit severe. I also have no conditions except basic lack the coordination that keep me from fulfilling dreams such as to be an awesome dancer, sew my own clothes, and play a great game of Ultimate Frisbee. So is lacking certain physical skills a problem of health? Is my shyness “unhealthy”? Opening up the notion of “health” in terms of what may or not be a barrier to goals of productivity/happiness/love/art/friendship, etc. can go all over the place.

    boredclerk’s point about health needing to be defined as more than just absense of disease is a good one.

  22. Emolee
    Emolee February 22, 2012 at 3:50 pm |

    the woman who can’t watch “Family Guy” because of all the disgusting rape jokes on the show that make her cry.

    Some would argue that it is mentally healthier to not be able to watch/cry at rape jokes than to be able to tolerate them.

    This makes me think- is being able to function in society a marker of health? Any society?

  23. matlun
    matlun February 22, 2012 at 4:01 pm |

    how do you, personally, define health and illness?

    Personally, I generally don’t.

    As someone who is not really neurotypical, I have thought a bit about this. In the end what is really needed is trying to get an understanding of yourself and trying to find the best way to get on with life. Whether you should be classified as sane, insane, or by some other term is just semantics.

    Medical science needs structure, theories, and study of symptoms as a way to try to find this best way – be it medication or psychoanalysis. Only by classifications and empirically testing different theories are we doing medical science. So from this viewpoint the DSM may be the best we can come up with.

    But in the end these classification systems and theories are just tools and real people are more complicated than a specific diagnosis.

  24. Cécile
    Cécile February 22, 2012 at 4:03 pm |

    My conception of “psychological dysfunction” has also been heavily influenced lately by trauma research investigating bottom-up interactions throughout the brain. Here is a very simplified conceptualization by Bruce Perry:

    Trauma-related symptoms originate low in the brain, in the brainstem and the midbrain. So when you have a child come into your office for one hour and you talk with them, and you are forming a relational interaction with them—you are providing patterned, repetitive activity for the cortex and for the limbic system. You are trying to connect with them relationally, which is very appropriate, and you’re trying to teach them some new ideas, which again is very appropriate, to try and help them with issues like self esteem, and ‘try this next time,’ and all these strategies—but the fact is: the origin of their problems is not in the cortex. It’s in the brainstem.

    —from Neurosequential Model of Therapeutics (video)

  25. Hannah
    Hannah February 22, 2012 at 4:06 pm |

    As someone who survived very little trauma as a child my connection with my own diagnosis feels almost like I’m faking or exaggerting. So my definition of health is one where you’re comfortable with where your head space is as well as your physical health and that you’re good and functional.

  26. Cécile
    Cécile February 22, 2012 at 4:15 pm |

    I think the inability to watch a show like Family Guy that has multiple rape jokes is an indication of health/wisdom/compassion/self-preservation, not dysfunctionality!

    Carol, I think there are two different things at play here. “Morally,” or “cognitively,” I agree that the intolerance for rape jokes is healthy rather than dysfunctional, as it indicates a capacity for empathy. (Or absence of sociopathy!)

    Where intolerance for rape jokes could be regarded as “dysfunctional” (though totally comprehensible) is when someone has been traumatized by experiencing rape, and so reminders/associations on a show like Family Guy then “trigger” dysfunction in the brain, in the form of “intrusions” or “physiologically reliving” the experience. It is dysfunctional in that sense that the way the brain operates/responds has been assaulted by past experience with rape.

  27. Jadey
    Jadey February 22, 2012 at 4:21 pm |

    Jadey—

    As this conversation is taking off, I’m wondering if you could frame out some details about the type of work you do, your areas of expertise/allegiance, and/or the “stream(s)” of psychology you are most involved with. Thanks!! :-)

    Hi, Cécile. I won’t actually go into it that much because I think it’s a bit off topic for what this thread is about. Really, what I was trying to get at is that even as a “psychologist”, there’s much about psychology I don’t know when it’s not within my specialization. In terms of my role within the forensic field, my work is less focused on understanding why people commit criminal offenses, how to identify them, and how to get them to stop (which is what many of my colleagues, clinical and otherwise, are working on, and what most people think about when it comes to forensic and correctional psychology) and more on understanding what (and why) “non-offenders” think about offenders and the criminal justice system and how to apply this knowledge to improve our approach to justice and offending as a societies/communities. So the actual relationships between mental disorder/illness and offending behaviour are less relevant to my specific work than what people *think* those relationships are, although insights into the former do provide important context and are important questions regardless of what I’m working on.

    I am also fascinated by forensic psychology. I personally believe that there has to be something that is intrinsically wrong, or maybe missing, with serial killers that allows them to do what they do and still function in society.

    It’s an interesting area! It gets quite murky. To be honest, there are very few serial killers out there, compared to all the people prosecuted for even serious violent criminal offenses, so most forensic psychology is focused on less extreme, but nonetheless quite complex cases. There’s a lot to wrestle with in between these two massive (and largely socially constructed) concepts of criminal offending behaviour and mental illness/disorder. Whether criminality can or should be treated like psychopathology; the extent to which incarceration exacerbates and even iatrogenically produces mental illness and whether this is or is not the point of incarceration (if you think it absolutely, definitely isn’t, think again); and the possible causal or incidental relationships between the two. It also tends to dredge up issues around “criminal personalities”, like some of the DSM-recognized personality disorders, and how (or if) these can be equated with more conventional mental illnesses such as depression or anxiety. Addictions alone are a minefield – an illness? A mental illness? A symptom? A coping mechanism? Criminal itself, a precursor to criminality, or selectively criminalized?

    The pathologization of criminality and the criminalization of pathology go a long way toward demonstrating just how much “mental health” is about social conformity, and not personal well-being. (Though some would argue that one can only be truly well when one sufficiently conforms to one’s social norms, but that’s a debate in and of itself.)

  28. Mandolin
    Mandolin February 22, 2012 at 4:22 pm |

    I really love your posts about madness, William, and have very much appreciated your commentary in the past.

    I guess I feel like there’s something in your view of symptoms… well, I do think a chunk of madness is biologically based and I’m not sure how much room there is for that in the psychoanalysis you describe. I don’t think I can discard or grow out of or voluntarily choose to keep my symptoms any more than I could discard or grow out of or voluntarily choose to keep organic pain. Maybe I’m not reading very well and that’s not what you mean.

  29. EG
    EG February 22, 2012 at 4:38 pm |

    William, I respect both your conclusions and your expertise, but my experience with my own conditions has led me to find different models applicable for myself.

    Being diagnosed as dysthymic with periods of severe depression was one of the most freeing things that ever happened to me, which is why I embrace the terminology of illness (as an aside, I’m not claiming that anybody who is not me or, even more importantly to my mind, has a different kind of what I would call mental illness, has to agree; I think there are significantly different conditions within the umbrella of “mental illness,” and I’m not convinced that my experiences with depression make it possible for me to have any insight into, oh, narcissistic personality disorder or something).

    Realizing that the feelings of worthlessness and loneliness that I had lived with years and years were not, as I had thought, inherent parts of my character that I just had to do battle with every day, but were symptoms indicating malfunctions in my nervous system (I know this is something we disagree about, William, and I’m not meaning to attack, just to answer your question about health and illness and we define/experience them) that ran very strongly in my family was intensely liberating and made me feel hopeful about my life and my self in a way I’d never felt before–liberating in that after a decade of talk therapy, medication allowed me to shuck the ongoing misery that lay over me like a gray fog, obscuring everything else.

    I had so much more energy–all the energy that I had previously been forced to use to hold back my depression long enough in order for me to get through the day was suddenly freed up. I started writing creatively again, something I had not done since puberty, and also getting my stuff published. All kind of little experiences and unhappinesses that I had assumed were just normal and caused everybody to suffer just…vanished. Were not there. And I could do so much more!

    I had experienced something like this once before. When I was in my early twenties, I came home one day and started crying because I could not find any position, not standing, not sitting, not lying down, in which my back did not hurt. A lot. I’d had this kind of back pain since I was five years old, and it had done nothing over the years but increase. Regular meditation practice helped somewhat…but only somewhat. My boyfriend asked me what was wrong and when I told him, he looked aghast and asked me if I’d ever been to a doctor.

    “No,” I said. “I mean, everyone has days like this, right? Like when people say they have a crick in their neck?”

    Apparently, not everybody has days like that, and that kind of pain is not what people mean when they say that. I went to a doctor, who sent me to a physical therapist who notes that I had a significant amount of damage in my back, caused partly undiagnosed minor scoliosis, and partly by a physical trauma when I was a small kid. And that was the same kind of liberation–I didn’t have to be miserable and suffer! I wasn’t crazy (well, in the case of the depression, I had to amend that to “I am crazy, but not the kind of crazy I meant)! I wasn’t just a big baby making things up! Something was actually wrong! And it could be, if not fixed, treated very aggressively.

    So, those experiences and a couple others have led me to a working definition of health that is something like “a state of being in which you are able to take pleasure in the things that traditionally and usually have made you happy, and not be prevented from taking part in them due to pain or internal incapacity, and not have difficulty with essential life functions (eating, sleeping, breathing, in my case, being upright).”

    I’m not sure it’s a definition that will work for everyone, but it does work for me.

    One philosophical difference that I have with you, William, has to do with the treatment of symptoms. It’s one that for myself I feel very strongly about, and in fact, I’m in the process of changing psychiatrists because my previous one fell far to one extreme, of treating root causes rather than symptoms. In one of our discussions about this, I brought up my most recent episode of major depression, which, as usual, had exacerbated every other problem I have as well, including the aforementioned neck, back, and shoulder problems to the point that holding a pen and trying to write sent hot stabbing pain shooting up my arm and through my shoulder and neck.

    “So you treat the root case, the depression,” she said.

    I looked at her. “Sure,” I said. “But I also took two aleve, four advil, and made an appointment with a massage therapist for the following day.”

    Because that pain was not helping me in any way. It was not giving me any new information. It wasn’t reminding me of anything that was not constantly on my mind. All it was doing was hurting me and preventing me from doing what I needed and wanted to do. So fuck that symptom, pass the drugs, and here’s a check for a massage.

    My two cents, anyway.

  30. Donna L
    Donna L February 22, 2012 at 4:47 pm |

    Thus society as a whole and those with a vested interest in keeping me ill such as Dr. Kenneth Zucker and Dr. J. Michael Bailey (the Dr. part gives them the social power to do so) would much rather me be miserable, but silent. I’d be a picture of health on the outside. This is why I put more weight on the individuals own view of themselves and their coping with life in general.

    Thank you.

  31. CBrachyrhynchos
    CBrachyrhynchos February 22, 2012 at 4:54 pm |

    Where intolerance for rape jokes could be regarded as “dysfunctional” (though totally comprehensible) is when someone has been traumatized by experiencing rape, and so reminders/associations on a show like Family Guy then “trigger” dysfunction in the brain, in the form of “intrusions” or “physiologically reliving” the experience. It is dysfunctional in that sense that the way the brain operates/responds has been assaulted by past experience with rape.

    I have this problem with television news. It’s not that I want to stop having a negative reaction when I see/hear TV news pieces on rape or childhood sexual abuse, I’d like for it to not be so overwhelming that I’m avoiding places that show the news.

  32. Carol
    Carol February 22, 2012 at 5:07 pm |

    Agreed Cecile, being triggered and re-traumatized can be very dysfunctional, and is an entirely different matter than being bothered or disgusted by a show.
    I would think “health” could mean something like getting to the point where you can say, “I choose not to watch shows with rape jokes, but if I run across one on the internet or wherever, I can react in a way that isn’t going to completely destroy my plans for the day or my sleep.” My wish for today is healing for everyone on that journey.

  33. Shoshie
    Shoshie February 22, 2012 at 5:10 pm |

    Yay! I find your comments generally very thoughtful, even when we disagree, so I’m really looking forward to this series.

    As far as my definition of health, I think that, for me, there’s the cultural construction of health…I guess, society’s definition of what a healthy body looks and acts like and encountering troubles when bodies deviate from that definition of health. But, personally, I really like Mo’s definition.

    Healthy, for me, would be operating at the most optimal condition that is right for me. Illness, at least physical, is a deviation from that optimum range.

    And that “healthy” status must take into account all aspects of mental and physical health. I’ve thought about the convergence of mental and physical health most from a disordered eating perspective. My relationship with food and eating was screwed up royally from years of dieting and seeing my fat body as the very definition of unhealthy. I wrestle with eating food that makes my body feel good and engaging in joyful activity (things that allow me to operate at its optimal condition), while not falling back into disordered eating patterns and not rebelling wholesale and going on a binge. And, of course, also dealing with the repercussions of society describing my body as “unhealthy.”

  34. Foglet
    Foglet February 22, 2012 at 5:36 pm |

    This makes me think- is being able to function in society a marker of health? Any society?

    That’s exactly what disturbs me about defining health in terms of social norms. As a descriptive qualifier it makes sense. “Abnormal” behavior is marked as the symptom of illness. There is implied a standard that the individual is deviating from.

    But this merely descriptive forms of defining illness removes any ethical considerations or judgments. These ethical considerations need to be applied and evaluated because perhaps it is society that needs to change, not the individual.

  35. Maria
    Maria February 22, 2012 at 5:53 pm |

    how do you, personally, define health and illness?

    Health is the state of self you want more of and illness the state you want less of.

  36. William
    William February 22, 2012 at 5:53 pm |

    So many great responses! Also, for whoever is doing the mod, Foglet and I aren’t sock puppeting, she’s just on my couch (not in the clinical sense, but in the watching-project-runway-with-my-wife sense).

    Cécile:
    I’m with you on the frustration with the DSM. It is, primarily, a medical document written by psychiatrists. I’m of the opinion that its a pretty dangerous document which does a lot of damage but, for what its worth, most of the clinicians I know don’t treat it as much more than an insurance billing tool. Thats problematic in it’s own right, but it can mean that patients are treated with more nuance.

    I get your comments on trauma, too. Telling the difference between bipolar, any of the cluster B personality disorders (like Borderline or Antisocial), major depression w/ psychotic features, and PTSD or C-PTSD is a clinical nightmare. Its also a diagnostic question that often doesn’t get answered until treatment (which is often the same either way) is over. Personally, I’m not always certain its worth it.

    EmmaSofia:
    Theres a lot of reasons I choose to use madness. Aside from the reasoning mentioned in my post, I like madness because it leaves a lot of room and it recognizes the incredible stigma that comes with non-privileged experiential forms. In the western society in which I live and work being mad isn’t ok. People suffer for it, they lose jobs and loved ones for it, they are hounded and oppressed for it. I’d be hesitant to use a word or phrase that erased that incredible discrimination. Also, and this is a personal thing, I want to reclaim madness. My experiences have been used to hurt me, I’ve felt wrong, like a monster or a freak, and that comes down to not being able to own who and what I am. Fuck that, this is my hill. Part of why I use madness, and why I describe myself as mad, is to dare someone to use it against me. Madness is part of how I take control of my own identity, and by using a word which has been used against experiences like mine I not only wrest the privilege of defining my experience from those with more power but I do so in a manner that reduces the tools at their disposal.

    Wriggles:

    So many people who are sane seem to exhibit more objective or pronounced symptoms of madness-such as a peculiar take on reality-than those who have a diagnosis, 

    An excellent catch. Part of this is that madness is a matter of privilege. People with more relative power can get away with presentations which others cannot. I’ve had more than one patient “joke” that they’re wealthy enough to be eccentric instead of crazy…

    Cbrachyrhynchos

    I don’t see the paradigms you describe as mutually exclusive.

    They might not be on a personal level or from the perspective of a patient, and I certainly agree that they can be interrelated. This might be a moment of me being stuck in the industry. Unfortunately, on the industry level,the CBT folks and the analysts don’t get along well and tend to actively try to marginalize and destroy one another. There is also a problem, because of some complicated clinical practice and therapeutic technique issues I don’t have the space to get into here, with trying to do therapy from two different perspectives with basic assumptions and understandings that are mutually exclusive.

    BoredClerk

    So sure, you can define health by reference to “disease,” but if both “health” and “disease” are just ways to talk about how a physical body does or doesn’t deviate from some community standard of what a body is supposed to be like, then your definition isn’t really useful.

    And what, then, happens when we’re no longer talking about bodies and instead in the messy world of deviation from subjective norms, ideals, communications, and thoughts?

    Matlun:
    I’m pretty sure that what I do isn’t medical science. To use a trauma example: say I have a patient who has never lived in a stable home, who has come to see themselves as an imposter, who is prone to melancholia and seeking oblivion through drug use, and who is a victim of chronic abuse at the hands of romantic partners. Is it useful to call them a substance abuser? Does the label of “Major Depressive Disorder” do anything for them? I’d argue no. I’d want to look at the anger that tends to lurk beneath depression, I would want to examine life experiences that lead to poor self esteem, I would challenge the avoidance that drug use represents. Thats what leads to improvement, to a happier patient, to someone more able to live a life they want to lead. Empiricism and taxonomy? Not so much…

    Everyone:
    I’m loving hearing how you grapple with the question of health and illness. Theres really no right answer, but I’ve found that the more subjective responses I hear the better I’m able to understand how my patients see themselves. Also, I don’t have anything to add, but I’m loving the discussion about whether reactions to social phenomena like rape jokes are healthy or not.

  37. CBrachyrhynchos
    CBrachyrhynchos February 22, 2012 at 5:54 pm |

    These ethical considerations need to be applied and evaluated because perhaps it is society that needs to change, not the individual.

    Yeah, I’m cautious about that as well. First because I’d love to be in a world and workplace that can accommodate the fact that some days I get up in the morning and the world tastes like Lovecraft and Poe.

    On the other hand, since I’m a high-functioning madman, my mental illness is largely invisible, and is most likely to manifest when I’m in the privacy of my own home. I want to change, not because I distress others, but because I distress myself.

  38. Emolee
    Emolee February 22, 2012 at 6:32 pm |

    I’ve thought about the convergence of mental and physical health most from a disordered eating perspective.

    Shoshie- Me, too. When I started working with my current therapist several years ago, one of my concerns was that I was unable to diet (i.e. stay on a literal starvation level eating plan to induce weight loss) anymore. She looked at me and said, “Maybe you are too healthy to do that to yourself anymore.” Whoa. That was a wake-up call for me. I had never, ever had any professional or person in a position of authority (perhaps anyone at all) suggest that NOT starving myself was a sign of mental health. As a person with a fat body, I always assumed- and was repeatedly told- the opposite.

  39. Carol
    Carol February 22, 2012 at 6:52 pm |

    A couple of comments on william’s post.
    First, the phrase “I perform the shit out of some masculinity” made me laugh out loud. Love it. I would start adopting the phrase “I perform the shit out of some femininity” but it doesn’t have the same ring.

    I appreciate william’s trying to find some new vocabulary by using “madness” instead of a term saying what someone lacks or does wrong. Maybe also he is attempting to destigmatize a label by deliberately applying it, a la queer or slut.

    But seriously is using “madness” going to give people “ownership over their experiences”? Is the core problem truly that other people don’t believe that madness is “real” and “an experience of something”?

    Why would it help to be a “mad person” other than adding a tinge that might be appealing to an American fan of Downton Abbey? The issues he discusses later regarding whether to treat the symptoms or not, or the difference between treating it with CBT, medication or psychoanalysis are still there.

    Also, what does this mean: madness is “an experience of personal history”? It’s maddeningly vague.

  40. Tony_
    Tony_ February 22, 2012 at 7:10 pm |

    To me, mental health is simply the absence of any identifiable dissatisfaction with one’s mental behavior. According to Medline Plus, it is “how we think, act, and cope with life.”

    These ethical considerations need to be applied and evaluated because perhaps it is society that needs to change, not the individual.

    True, assuming that something needs to change. That is where it all starts. I think you could have identical behaviors in two different people, and if one is dissatisfied or dissatisfied those around them and the other is not, then the former is ‘unhealthy’ and vice versa.

    Even if you just focus on the individual, sometimes they are confused as to whether they really want to change a lot. I’ve sometimes felt that I wanted to change something, only to realize later than I don’t want to change. Overall I feel that “health” is too amorphous to be truly defined, it only acts as a symbol to measure one’s satisfaction (and the satisfaction of society, which is institutionalized by lists of diseases and symptoms).

  41. Cécile
    Cécile February 22, 2012 at 8:10 pm |

    Hi all,

    Just wanted to say that I agree with a lot of the comments on here that emphasize individual perspective and evaluation of one’s state of mental health, and the many ways it is connected with society.

    One wrench to throw in, as Mo mentioned in #17, is society’s “predators,” who often don’t perceive or regret their “harmful” behavior, and even justify it or take pride in it.

    There are many types of predators, such as serial killers, but the following quote emphasizes abusers: child, domestic, political, workplace, etc. (Or Chris Brown) One thing that this quote doesn’t convey, out of context, is the recognition of a given: that to commit abuse without remorse is obviously “not normal.”

    Little is known about the mind of the perpetrator. Since he is contemptuous of those who seek to understand him, he does not volunteer to be studied. Since he does not perceive that anything is wrong with him, he does not seek help—unless he is in trouble with the law [accused of domestic violence or child sex abuse, for example]. His most consistent feature, in both the testimony of victims and the observations of psychologists, is his apparent normality. Ordinary concepts of psychopathology fail to define or comprehend him.

    This idea is deeply disturbing to most people. How much more comforting it would be if the perpetrator were easily recognizable, obviously deviant or disturbed. But he is not. The legal scholar Hannah Arendt created a scandal when she reported that Adolf Eichmann, a [Nazi] who committed unfathomable crimes against humanity, had been certified by half a dozen psychiatrists as normal: “The trouble with Eichmann was precisely that so many were like him, and that the many were neither perverted nor sadistic, that they were, and still are, terribly and terrifyingly normal. From the viewpoint of our legal institutions and of our moral standards of judgment, this normality was much more terrifying than all the atrocities put together.”

    Authoritarian, secretive, sometimes grandiose, and even paranoid, the perpetrator is nevertheless exquisitely sensitive to the realities of power and to social norms. Only rarely does he get into difficulties with the law; rather, he seeks out situations where his tyrannical behavior will be tolerated, condoned, or admired. His demeanor provides an excellent camouflage, for few people believe that extraordinary crimes can be committed by men of such conventional appearance.

    —Judith Herman, from Trauma and Recovery (of course—I hope not to annoy anyone too greatly with my fixation on this book)

  42. Vee
    Vee February 22, 2012 at 8:30 pm |

    This subject has been on my mind a lot lately, especially since I work with people with mental disorders.

    I’m excited to hear what you have to say, about oppression especially, because goodness knows, I’ve seen it.

  43. Emolee
    Emolee February 22, 2012 at 9:00 pm |

    To me, mental health is simply the absence of any identifiable dissatisfaction with one’s mental behavior.

    Do you mean that as long as a person is ok with hir mental behavior that ze is mentally healthy? Because what if the person has no problem with a mental process, or is unaware of a mental process, which causes others distress? I’m thinking of everything from a person who is emotionally abusive to a serial killer. Obviously, not all (or even most) abuse or killing is due to mental illness, but some is. Does objectivity play a part at all, or is health *only* a personal assessment?

  44. Jadey
    Jadey February 22, 2012 at 9:21 pm |

    Hmm, just a reminder to people following this thread – it looks like there are a lot of longer comments that are only just now getting out of moderation (including one of William’s!), so it’s worth it to go back through and re-read. So much interesting stuff being talked about!

  45. Cécile
    Cécile February 22, 2012 at 9:26 pm |

    Even if you just focus on the individual, sometimes they are confused as to whether they really want to change a lot.

    I’ve felt that way, too, Tony_. I was seeing a therapist for awhile that was going to use EMDR with me, which is a therapy that can reverse or alleviate the “mechanized”/biological symptoms of trauma. (That’s my description, anyway.) However, I ended up not going through with it (for the time being)—I realized I was way too uncomfortable with our therapeutic relationship, and how she seemed to regard EMDR as a way to indirectly “fix” my brain rather than engage me cognitively, and respect my need to emote and understand, throughout the EMDR process. (Just a note: EMDR seems to have quickly fallen to reductivist consumption, both among some clinicians and certainly on the internet. Reading Francine Shapiro’s—who ‘discovered’ the process—publications on EMDR reflect a totally different, and deeper and more dynamic, conception of what it is and what it seeks to achieve.)

    Anyway, there were some insinuations my therapist made about how therapy could “help” me—that really enlightened me to some things about myself and society (I bet most people who have sought mental health services have stories like this). I was eventually able to see that while I did have certain “symptoms,” or “difficulties” that I identified in myself, they were identified by me in ways that differed from conventional society or mental health evaluations.

    For example: Yes, therapist, I have intimacy issues. I say so because, yes, I often feel threatened, suspicious, worried, insecure, cagey, shut down, etc. when people, especially people I don’t know well but don’t cognitively regard as threatening, display interest or affection toward me. However, I would not deduce that my inability lack of desire to establish long-term monogamous relationships is a symptom/extension of that (**though it could be for some people, who might have such a desire). Therefore, making me “capable” and “desirous” of joining into a heteronormative relationship is not a goal, or a sign of recovery.

    This goes without saying on Feministe, but I am routinely reminded of how removed mainstream society can be from this rationale.

    I spent a long time feeling terrified and resistant during therapy, at the prospect that EMDR (as practiced by my former therapist) would turn me into some kind of “Clockwork Orange”-type “normal, healthy” female in society. I kept catching myself wondering if my contempt at the thought was a sign of how truly “sick” I was. But as Foglet and Donna L have been discussing, this resistance helped me separate the “internal trials and afflictions” I experience as I pursue my particular notions of fulfillment in life, from the “non-normative” behaviors and desires that society arbitrarily designates as abnormal and illegitimate. And thus, it also helped me recognize which of my symptoms directly resulted from the ways that society ostracizes, condemns, and abuses people who are outside the status quo.

    Again, I realize all this is unnecessary to spell out on Feministe. But here it is anyway.

  46. karak
    karak February 22, 2012 at 9:41 pm |

    I was a case manager of mentally ill adults, and I found that I like the term “mental illness”, and I take it to mean:

    1. someone who is distressed by thoughts or behaviors they cannot control –and is unable to function properly in society
    2. someone who distresses others with their thoughts and behaviors–and is unable to understand why others are distressed, or stop engaging in those behaviors–and is unable to function properly in society.

    I’ve found the idea of “healing” or “recovery” from mental illness to be incredibly cruel to some people, who cannot ever achieve what we think of as “normal” thought. This person is not broken, they are simply different. And they need help.

    Some people can, with therapy, with medication, with time, manage their symptoms and live the life they want to live–and it’s often a neurotypical life. Sometimes they will never, ever do these things, and it doesn’t make them less of a person.

    Some people reluctantly or even joyfully accept the “symptoms” of their illness, and it would be cruel to take it away from them.

    Some people are not helped by their meds. Yes, they’ve stopped cycling or hallucinating, but they are fucking dead inside now. If someone is suicidal off meds, then you need to find them some kind of help, if they’re merely “weird” or “annoying” don’t chemically fucking lobotomize them.

    1. Vee
      Vee February 22, 2012 at 9:51 pm |

      You’re not a case manager for them anymore? Care to share why?

  47. William
    William February 22, 2012 at 9:49 pm |

    EG:

    William, I respect both your conclusions and your expertise, but my experience with my own conditions has led me to find different models applicable for myself.

    I’m really glad to hear that. The world would be a boring place if there was nothing left to learn.

    Honestly, your comments are a big part of why I think a discussion about health and illness is so important, especially in the context of a broader discussion about madness. We need to have room for different experiences because, really, thats what we’re talking about here. Some people will want to rid themselves of symptoms, some will want to use them as barometers, some will want to just be given the space to live their madness in peace without being tossed into an institution or forced into treatment. Aside from my philosophical axes to grind, the most important thing I want to get people thinking about is the ethics that need to surround madness. We need to be able to have room for everyone and we need to respect autonomy. We need to be able to have as many voices in the discussion not to find out who is right but to allow for different people to find the things they need to live the lives they want to live.

    So I’m not thinking about your great comments as divisive or disagreeable. They’re what I want to be seeing here, because nobody should be the last word regardless of their training or perceived authority. How on Earth can we expect patients to be able to give informed consent and seek the treatments they need if we cannot have an open and honest discussion about the different kinds of experiences we have?

    Carol:
    Using the term “madness” has certainly given me some ownership over my experiences because it helps me to remind myself that what I feel isn’t necessarily the province of the medical world but rather something else. Madness, for me, has tinges of the religious, it suggests an experience of the world different from the mundane, it gives me the power (in my own head) to approach my madness on my own terms. I know that many of my patients have had the same experience. You’d be amazed what a sense of control can do if it comes at the right time in the right context.

    As for “an experience of personal history,” well…I think of madness as a kind of communication. Psychoanalysis is rooted in the idea that what has happened to us shapes who we become, and that symptoms are a means of expressing something that we can’t otherwise express. Its amazing what you can tell about someone once you get an understanding of their symptoms.

    Emolee

    Because what if the person has no problem with a mental process, or is unaware of a mental process, which causes others distress? I’m thinking of everything from a person who is emotionally abusive to a serial killer. Obviously, not all (or even most) abuse or killing is due to mental illness, but some is. Does objectivity play a part at all, or is health *only* a personal assessment?

    43 posts before the myth of the dangerous madman is invoked.

    Mad persons are far more likely to be oppressed than to oppress, more likely to be abused than to abuse. By invoking the idea of mad persons who are dangerous I think we’re in extreme danger of turning this from a discussion about the nearly universal majority of mad people who don’t hurt others into an erasing focus on the aberrant minority (probably less than the general population) of mad persons whose symptoms end up hurting someone else.

    So, no, I don’t think the outliers call for derailing the discussion and I think that personal assessment ought to dominate considerations of madness in all save the most extreme of cases.

  48. Cécile
    Cécile February 22, 2012 at 9:53 pm |

    Jadey,

    I won’t actually go into it that much because I think it’s a bit off topic for what this thread is about.

    Gotcha—I had initially assumed that this sort of info would add clarity to your comments, but now I see the distinction!

    There’s a lot to wrestle with in between these two massive (and largely socially constructed) concepts of criminal offending behaviour and mental illness/disorder.

    Agreed. This has been on my mind a lot with the recent news surrounding Alyssa Bustamante.

  49. Tony_
    Tony_ February 22, 2012 at 10:07 pm |

    @Emolee,

    It could be the person’s own dissatisfaction, or someone else’s dissatisfaction (that they are hurting them, for example). And I should have added “actionable” dissatisfaction. We’re dissatisfied with our or others’ mental responses to little things on a daily basis, but unless it’s considered something that action needs to be taken on (by someone), then it’s not an indicator of unhealthiness. Obviously, my definition is totally subjective and leaves up the possibility of differing opinions on what is healthy. For example, smoking is an addiction and a mental health problem if the smoker wants to quit and can’t, but if they don’t want to quit, then it’s not a mental health problem, even if the chemical nicotine effects in them are identical as the other person.

    At the same time, I’m reluctant to completely subsume the idea of health within ethics or morality, for there can be mentally healthy people who just do evil things which we either cannot or should not attempt to ‘cure’. I realize it’s a bit of a cop-out answer, but I can’t think of anything more objective.

  50. karak
    karak February 22, 2012 at 10:10 pm |

    @Vee–

    A few reasons:

    1. I was laid off due to cutbacks.

    2. My caseload was 35 clients. I was working at least forty and often sixty or more hours a week. I distinctly remember my boss giving me a huge “you’re so great!” speech because I logged a day with 12 hours of face-time. That meant my real day was closer to 18 hours, and I didn’t eat that entire time. I was a broken, fried, sick mess and I believe he chose me for the layoff because he knew I was eating a container of tums every 3-4 days.

    3. I felt helpless to help my clients. Some didn’t have medicaid, or weren’t covered, desperate for help but I couldn’t do it or help them access it. Some were slowly killing themselves by addiction (incredibly common) or were horrifyingly ill, but just sane enough to keep from pinging on the system. One of my clients got cancer and it was undiagnosed for agonizing months. I’m took him the to hospital for his biopsy and had to deliver the news of his incredibly bad prognosis. I felt like I was watching people drown v-e-e-e-r-y s-l-o-w-l-y.

    4. I’ve found my real passion is people with development disabilities, especially those with profound mental and physical impairments. I feel like I can actually improve their lives and empower them, not just…watch them.

    5. This is terrible–but some people with mental illness become incredibly emotionally dependent, manipulative, and life-sucking, often as a symptom or a reaction to their illness. I’m the kind of person who gives till it hurts, and I got hurt. I can’t maintain healthy boundaries and my feelings of resentment and anger were becoming worrisome and unhealthy, for myself and my clients.

    1. Vee
      Vee February 22, 2012 at 10:24 pm |

      @Karak

      So, you didn’t have much control over what happened to your clients? Were you able to advocate for them at all? Also, what area did you work in, and when?

      I’m considering becoming a case manager, that’s why I’m asking.

  51. EG
    EG February 22, 2012 at 10:44 pm |

    there can be mentally healthy people who just do evil things which we either cannot or should not attempt to ‘cure’.

    As a note: there can also be mentally ill people out there who do mean or bad things that have nothing to do with their mental illnesses, because not all mental illnesses, or madnesses, are all-encompassing conditions all of the time. There is a certain set of selfish behaviors I’m more likely to engage in when and because I’m depressed, but depression is not at the root of every single thing I do–not even close–and sometimes I do mean or bad things thoughtlessly that are no more related to mental illness than they would be a person who did not have depression.

    To say nothing of what I think is the pretty obvious fact that this is kind of a derail: there are just not enough mentally ill people in the world to account for all the acts of cruelty and evil out there. Is there any evidence out there that the incidence of evil and cruel behavior among the mentally ill is significantly higher than that among the non-mad? Before we start talking about how to separate madness from evil, it would be good to know if there’s any significant link in the first place.

    I can see how certain conditions can predispose one to evil, cruel, or selfish acts, because that’s how it’s played out in my family. But honestly, a whole lot of those acts have come out of selfish asshole-ness as well.

  52. EG
    EG February 22, 2012 at 10:46 pm |

    And thanks for your supportive reply, William. I very much appreciate it.

    (the “and” references a post currently in mod)

  53. Alexandra
    Alexandra February 22, 2012 at 11:20 pm |

    As I’ve blogged periodically about the intersection between philosophy and the treatment of mental illness – on a blog named “A Philosophic Madness” – I can’t say how nice it is to see another person who also likes the sound, the shape, the content of the word “madness” as a description of the way in which minds can deviate from the norm.

    I’ve been diagnosed as bipolar I (for whatever that’s worth) and while overwhelmingly my experiences since I first went crazy have been of depression, often suicidal and sometimes violently self-destructive, there have also been aspects of incredible energy and creativity: of a few beautiful months in the summer when it felt like everything was suffused with light; being able to write twenty pages in an hour, the thoughts tumbling out of my head like water rolling down a mountain; and dreams – such dreams! Every night, strange unearthly visions, entire worlds with such beauty and terror that if I had a thousand years I couldn’t tell all the stories my mind creates for me in the average week. Inevitably I try to write them down, but I do not have the gift to capture these images which linger in my mind, ghostly images recalled with great strength by something seen out of the corner of my eye.

    Medication occasionally dulls my depression, makes me a little less suicidal. But lithium makes me ill – gives me terrible migraine headaches that last for days, and makes me vomit or have constant heartburn. Most of the atypical antipsychotics are incredibly sedating for me. Lamictal is just about the only drug that doesn’t have unpleasant side-effects (except for the risk of horrible life-long debilitating rashes if your dosage varies – better not miss a pill!).

    Therapy? Hah.

    Here’s something that might make you laugh: because of my school schedule, I cram all of my psych stuff into Wednesdays. Today I saw my psychologist at 9am, my psychiatrist at 11:30, I went to my mental illness support group on the inpatient floor at 3:30 and I went to an al-anon meeting at 7. By the end of the day my head is spinning from the dissonance of all these different people and systems that are sure – just sure! – they can fix me. My psychologist wants me to practice calming techniques, set positive goals and try to internalize them instead of relying on external motivations. My psychiatrist wants to up the dose of my anti-depressant. My support group leader thinks I need to be more assertive at home and that my parents are abusive bullies (but she says that about literally everyone’s parents, which makes me wonder whether mad folk are gifted with an unusually high amount of abuse in their lives, or whether she’s just projecting). And at al-anon, I learn that I should detach, let go and let god, and try to find strength in powerlessness.

    Phew! And then add in the fact I’ve seen more than ten different psychiatrists, more than ten different psychologists, therapists, and LCSWs, and more social workers and general support staff than you can shake a stick at. I’ve been given a lot of conflicting advice over the years, much of it well meaning, some of it inept, and a lot of it deeply confusing.

    So: should I try to solve my problems with self-discipline and self-awareness? Are my problems primarily organic in nature, and should I keep looking for the right chemical combination to restore my brain to “normality”? Would I be happy if I just cut myself off from all the “dysfunctional” people in my lives and drew stronger boundaries? Or do I need to trust that a higher power, a power higher than myself (and by implication, higher than other humans) is required to “restore me to sanity” (if I’ve ever known such a thing)?

    I’ve done CBT, I’ve done DBT, I’ve met with psychodynamic guys (one of whom, no joke, was named Sigmund), my psychiatrist grandfather has sent me to see his psychiatrist friends up at Stanford. I’ve been told I should do EMDR to get over sexual trauma, I’ve been told that I should keep a dream journal, or else sketch my feelings every day in pastels.

    Hell, back when I was self-medicating with philosophy (I know, I know – at least it wasn’t alcohol) I believed that if I followed the teachings of Epictetus, and truly devoted my life to virtue, I would become strong, self-sufficient, upright and emotionless, able to conquer all problems in my life with dispassionate reason leavened with wry humor.

    Now, somebody more eclectic and holistic than me would say, try to take the truth from all of these approaches. But it isn’t easy! After all, without a sound framework, without sound first principles, how are you to know what’s truth and what’s garbage? How am I supposed to decide whether my psychologist is right – I should defuse the violence in my home by being less deliberately provocative – or the support group leader, who says I should buy a ticket for Providence and go live with my Aunt and Uncle and never speak to my parents ever again? One is focusing on what I can do to affect myself, the other is focusing on how externals affect me. Who’s got the right of it?

    Damned if I know.

  54. Cécile
    Cécile February 22, 2012 at 11:30 pm |

    @CBrachyrhynchos:

    I’d love to be in a world and workplace that can accommodate the fact that some days I get up in the morning and the world tastes like Lovecraft and Poe.

    lol! I love that, and totally relate.

    William,

    I’m with you on the frustration with the DSM. It is, primarily, a medical document written by psychiatrists. I’m of the opinion that its a pretty dangerous document which does a lot of damage but, for what its worth, most of the clinicians I know don’t treat it as much more than an insurance billing tool.

    I hope that this is the case in general. However, I’m in an intense place right now, just with the fairly recent recognition of how my past misdiagnoses have profoundly shaped my life, particularly in the past 8 or 9 years.

    In some document that isn’t turning up for me via a quick Google search at the moment (I’ve done a lot of my reading at the library too, so it’s hard to remember where I get certain things), van der Kolk used some phrasing that absolutely struck me: he described how [biological] dissociative triggered responses can actually debilitate (gahh, that’s not the word he used, but I can’t remember the right one) people from “preventing their own rapes.” (**I know this is controversial—even offensive—wording, but please allow me to explain.**) In my experience, I’ve found this to be true. I’ve had many unwanted sexual experiences in the past decade that I’ve never felt comfortable describing as rape, simply because I was unable to articulate “no.” In each of these instances, I was extremely compliant and probably appeared willing (or “eventually won over”), though rather emotionally cold. “I followed him into his room and I removed my own clothes.” <–There are a few instances I remember thinking this, as I tried afterwards to make sense of what happened and how I felt. I wouldn’t utter a word of resistance. But inside, I would feel confused, conflicted, resistant, distraught. Inside, I felt, NO! This dissonance made me feel guilty and panicked, but, paradoxically, in the disorienting and “dumbed” fog of dissociation, I would feel compelled to hide my internal feelings that I didn’t understand, or feel capable of expressing, and out of a sense of intimidation and anxiety, I would make an effort to smile, as if to reassure the person I simultaneously felt was coercing/raping me.
    (Just to clarify: I think any of my partners, if they had been committed to consensual sex, would have been able to identify these as non-consensual situations through my body language and changed, reluctant demeanor—however, on the surface, the argument could definitely be made that I was either acting consensually, or that they didn’t explicitly violate my consent.)

    If I only could have learned years ago that I have a traumatized mind, and that undesired sexual advances could intimidate/trigger me to the extent that I’d promptly dissociate (because of my particular past experiences), thereby depriving me of my full capacity for self-efficacy, communication, and even internal evaluation of my desires. I WISH, for my own sake, that I could have been aware of this in myself, understood how it worked, and anticipated it.

    I imagine this happens to any number of people without their being aware or understanding of the possibility that they, too, are suffering an undetected traumatic disorder, and possibly dissociating when they truly want to be saying no. (Again, this is NOT to excuse or divert blame from the people who would continue making sexual advances in spite of non-verbalized reluctance/confliction from their partners. I just mean that dissociation, as an altered state of consciousness, is a state of functional impairment that could help people to recognize in themselves, if it exists, because having the foresight that your psychological functioning could change when your sexual boundaries are being crossed is something a lot of people could find as helpful to simply know about themselves.) <—sorry this is SO inarticulate, I'm not quite sure how to convey what I'm trying to say without sounding like a rape-apologist, which I certainly am not :-/

    That's one of the reasons I feel such an urgency about trauma-awareness. I feel like it also has a big role to play in discussions about consent. There are murky areas with consent, that I've seen discussed on this blog a lot, and I think traumatic/dissociative responses, such as this, as well as 'dominant energies' have a big place to play in these discussions. However, I question whether many people have knowledge about the former. (or if other people have other perspectives/information/experiences than I)

    I get your comments on trauma, too. Telling the difference between bipolar, any of the cluster B personality disorders (like Borderline or Antisocial), major depression w/ psychotic features, and PTSD or C-PTSD is a clinical nightmare.

    Unfortunately in greater society, many people don’t even exhaust themselves in ethical grapples with these overlaps—another resentment I have with the DSM is how its structure (in my opinion) enables ‘larger society’ to ignorantly and shallowly label others, perpetuating misinformation, stereotypes, and devaluation.

  55. Alexandra
    Alexandra February 23, 2012 at 12:10 am |

    [Trigger warning for rape. - C]

    In my experience, I’ve found this to be true. I’ve had many unwanted sexual experiences in the past decade that I’ve never felt comfortable describing as rape, simply because I was unable to articulate “no.” In each of these instances, I was extremely compliant and probably appeared willing (or “eventually won over”), though rather emotionally cold. “I followed him into his room and I removed my own clothes.” <–There are a few instances I remember thinking this, as I tried afterwards to make sense of what happened and how I felt. I wouldn’t utter a word of resistance. But inside, I would feel confused, conflicted, resistant, distraught. Inside, I felt, NO! This dissonance made me feel guilty and panicked, but, paradoxically, in the disorienting and “dumbed” fog of dissociation, I would feel compelled to hide my internal feelings that I didn’t understand, or feel capable of expressing, and out of a sense of intimidation and anxiety, I would make an effort to smile, as if to reassure the person I simultaneously felt was coercing/raping me.

    I have experienced this in many, many sexual encounters and with almost all of the sexual partners I have ever had. My first sexual experience of any kind – I had never even been kissed before – was a rape at the age of sixteen. I was in complete denial about the nature of that experience, and continued to date my rapist for two years. I remember at one point during our relationship having sex with him, and it was incredibly painful for me because of some medical problems I was having at the time. I remember lying there thinking, “This is what it must feel like to be raped,” not making a sound, just lying there waiting for it to be over.

    It progressed much further in other relationships I have had: at one point I was deliberately seeking out men who would hurt me before and during sex because I couldn’t imagine any other way to have sex. It’s been a nightmare untangling what aspects of my genuine sexual nature are compatible with some version of BDSM and in what ways I’ve been using BDSM as a means of self-harm and reliving trauma; I was lucky enough to have an incredibly positive BDSM experience with my female best friend recently that was deeply healing. I sometimes wonder whether I will ever be able to have sex with a man without falling into a state that’s worse than passivity, though – a state where I’m actively helping someone hurt me, while pretending everything is fine.

  56. CBrachyrhynchos
    CBrachyrhynchos February 23, 2012 at 12:10 am |

    There’s a whopper of a family history involved, and I strongly suspect that there’s a few bad genes in the mix along with my grandmother’s crazymaking.

    So my biggest fear is that I’ll turn into her. My second greatest fear is that I’ll eat a bullet during one of my private freak-outs. And after that, I fear an afterlife because the only kind that makes sense to me would involve carrying that crazy as karma. I can’t imagine a state of peace for either of us.

    But mostly it’s just a lot of low-grade self-sabotage, that’s mostly invisible to everyone but my partner.

  57. Kristen J.
    Kristen J. February 23, 2012 at 12:24 am |

    how do you, personally, define health and illness?

    Emotionally, I define it for myself as difference from how I remember being. Panic attacks are healthy. Depression is an illness. Asthma is healthy. Sciatica is an illness. Makes no sense. But there it is.

  58. Cécile
    Cécile February 23, 2012 at 1:11 am |

    William and Alexandra, thanks both for your responses. I just want to make a quick distinction that what I was trying to convey in my post is different in that I don’t regard the rapes as subconscious replications/seeking out on my part: I experienced it as a “psychological shutting-down” in response to unanticipated, unwanted sexual advances. I would go completely “dumb” and not feel certain how to respond, and so I would comply and try to hide this from my… “partner.”

    A non-sexual example of this happening was one time when I was walking in city with a friend at night when I was 16. A man on the street, who appeared to be homeless, reached out and gently, but firmly, grabbed my arm. (I’m not sure why exactly, but I didn’t detect any violence or threat in the action.) I stopped in my tracks and felt myself “softly” hunch slightly, turn to face him with wide, unblinking eyes. My body was totally arrested (in its own immobility), I couldn’t move, couldn’t think, couldn’t speak. All I felt was an overwhelming desire to get away, but a fear of letting him be aware of this desire, so I just had this weak, vacant little smile plastered to my face, and I was dumbly trying to stammer something polite. My friend was calling me to go with her, but I couldn’t move, I was afraid to move “because I was afraid to offend him” (yeah…?…) and I stood there, frozen like that, staring in his face with my sad little smile until my fearless friend marched back, grabbed my other arm, and physically pulled me away.

    So, for me, learning the concepts of “dissociation” and “trauma” have been invaluable for me in identifying an “illness” or “injury” or “dysfunction,” which I would otherwise probably have endlessly blamed as being my own inexplicable, inherent weakness.

    I remember lying there thinking, “This is what it must feel like to be raped,” not making a sound, just lying there waiting for it to be over.

    Alexandra—It’s amazing how fluid consciousness is. I know exactly what you’re describing—it’s amazing how you can be aware of something but it doesn’t “hit you” right away. This, indeed, is also dissociation, which I understand to be a term that describes an number of things (from a defense mechanism, to a triggered response, to a biological phenomenon that can be observed by MRI, and to a structural separation of the personality or affective states.)

  59. Cécile
    Cécile February 23, 2012 at 1:22 am |

    They care that I hear them, that I show my comprehension, that I draw lines between experiences and help make meaning from things that they cannot easily discuss.

    Bingo! Your patients sound lucky to be working with you!

  60. Annaleigh
    Annaleigh February 23, 2012 at 1:28 am |

    I’ve found the idea of “healing” or “recovery” from mental illness to be incredibly cruel to some people, who cannot ever achieve what we think of as “normal” thought. This person is not broken, they are simply different. And they need help.

    Yep. For some people, that very concept is out of the question, and it can indeed be cruel to even impose it on some people. As far as I’m concerned, I have my own ideas of what healing or recovery means, and it generally does not line up with what others may think. For me “healing” or “recovery” means reaching a state where I am happy, fulfilled, and living a balanced life while living with mental illness. To me it does not mean living up to everyone else’s expectations of what kind of “progress” I should make, or how other people think I should function, think, feel, or act. I tease my mom sometimes and tell her that she will never have a normal child, but I’m only half-joking when I say it. I know that the experience of mental illness, and my introverted, somewhat eccentric personality put me in a category of nowhere near “normal.” I think she is finally beginning to accept this, to stand up to bigoted comments by the able-minded, and to stick up for me among our extended family…for the aforementioned reasons I have been a black sheep of the family and she is finally no longer trying to pressure me to fit in.

  61. f.
    f. February 23, 2012 at 5:32 am |

    I wish I had a comprehensive way to discuss health and illness right now. I have just been diagnosed with a severe depressive episode.

    Yesterday I had a pretty scary panic attack and went to my GP to ask if I should be doing anything differently, be on panic meds of some kind, etc. To my amazement, she proceeded to write down phone numbers for crisis hotlines and tell me I could always go to the emergency room, and that if things got bad enough, there was inpatient care for my condition. I must’ve had a horrible, shocked look on my face because she also said, “This should be comforting to you, that you have these options. They’re good options”.

    I guess that hearing the words “emergency room” jolted me out of my complacent feeling that my depression is just me being lazy or indolent or something, or just having the blues, or something that I should really be able to just shake off. “Emergency room”? Oh my goodness, I must really be ill.

    It’s so strange because I’ve always been basically healthy. I don’t get bad colds, I’ve only ever been hospitalized once, for a broken bone. Now, my body is OK, but this is the sickest I’ve ever been in my life. It’s so weird to actually be ill and actually have to take action. I thought I had a good understanding of mental health being equal in importance to physical health, but now that this is happening, I have to remind myself multiple times a day that I am actually very sick and I need too take this seriously.

  62. Pam
    Pam February 23, 2012 at 7:10 am |

    I like that you’ve spun some personal responsibility into the patients work towards positive mental health. I’m looking forward to reading and engaging in this conversation.

  63. Angie unduplicated
    Angie unduplicated February 23, 2012 at 9:17 am |

    I am concerned about blurring the boundaries between the definitions of madness and anger. A sick society’s demands on us will generate anger and the perpetuaters of institutional abuse will stereotype change agents as mad or mentally ill, to impugn credibility of social movements.
    So will abusive individuals-the cops who arrested me for disorderly conduct after I called out someone who insulted me for my deformity but who did not arrest the insulter. My family of origin fights with each other as their preferred recreation, and my high school dropout sis diagnosed me as passive-aggressive for nonparticipation, scant months before that diagnosis was dropped from the DSM. As a child abuse survivor, I was accused of somaticized asthma and allergies until a new allergist asked “Do you have the condition when upset? (no). Do you have attacks during pollen season? While cleaning closets?(yes)”.
    So I see health and illness, mental, physical, and social, as continuous and participatory. Knowing that dissociation can be brain-wave based is a huge help, since I do it when anyone starts screaming, and I might be able to utilize meditative techniques to forestall it. Balancing weak areas with strengths, working for social change, and finding new ways to opt out of personal and social scapegoating are crucial, because behaviors which might appear “mad” or unbalanced to outsiders often are simple indicators of internal anger, and the issues causing the anger can be addressed.

  64. EG
    EG February 23, 2012 at 10:52 am |

    Symptoms tend to be expressions, and most depression (with, sometimes, dysthymia being excepted) has rage at it’s roots.

    That’s interesting, William, and it certainly speaks to how my father feels about his depression–that it stems from the anger that he has, uh, always had severe problems managing in an appropriate manner (I don’t mean socially acceptable; I mean not being an asshole). My experience of the relationship between depression and rage, though, is the opposite: I walked around full to the brim with anger that had no specific source that I could find, but would be set off at the slightest provocation until I went on anti-depressants. For me, the rage was a result of the depression–or at least, it felt that way. Perhaps that’s because I’m dysthymic?

    I had always wondered, when it came to my father’s and my experiences, which are similar in many, though I’m pleased to say not all, ways, if the difference was a matter of gendered conditioning, that as a man, my father had been socialized to understand anger as an acceptable expression of self, but not self-loathing, but for women, it’s reversed. But I don’t have enough breadth of experience or knowledge to really know.

  65. EG
    EG February 23, 2012 at 10:53 am |

    That said, I don’t mean to say it’s not important to validate anger. It’s hugely important.

  66. Codi
    Codi February 23, 2012 at 11:06 am |

    Gross oversimplification ahead: Blogs about psychology and comments pertaining thereto, are, to me, about as scintillating as watching paint dry. Psychology is right there close to philosophy in its actual usefulness. It can be, to certain people, an interesting exercise in discussion, but that’s about it. Perhaps the good doctor can fess up to the law of thirds and then give his explanation as to how it’s not relevant or has been discounted in the field or whatever. I’m very close to agreeing with scientologists about psychology. Not as (excuse the term) nutty as they are, but hey, they do make some good points about it.

  67. Li
    Li February 23, 2012 at 11:23 am |

    Psychology is right there close to philosophy in its actual usefulness.

    Given how useful I find things philosophy and sociology in understanding my experiences of trauma and madness, I’m not sure I took the meaning you intended from that statement.

  68. boredclerk
    boredclerk February 23, 2012 at 11:32 am |

    @ William, #36:

    And what, then, happens when we’re no longer talking about bodies and instead in the messy world of deviation from subjective norms, ideals, communications, and thoughts?

    Well, I think if you approach it from the standpoint that what we mean by “health” – whether physical or mental – is really conformity to a community norm about what a body or personality is supposed to be like, then it leads you to interrogate where those community norms came from in the first place. It’s messier, but I think more productive. I mean, if you’re talking about “health” with someone and both of you think that “health” is something that can be defined purely by reference to empirical science or medicine, you may end up just talking past each other even if you both agree on the empirical data, just because you may find that you have different understandings of what a person is supposed to be like. I’m pretty sure that this is what is happening in the debates about the Georgia obesity ad campaign, actually. Both sides are talking about “health,” and both have access to the same data. It’s just that they are operating with different understandings of what a person is supposed to be like.

    I also think there’s a kind of illustration of this in the definition several other commenters have used. A bunch of people have said that “health” should be defined as an individual having the capability to live the life they want to live and to accomplish their goals. However, if you really take that definition, then it seems to me that you’ve got to call a whole bunch of behaviors “healthy” that pretty much all of us would call downright unhealthy. For example, illicit steroid abuse in professional sports is absolutely a way to get the capability to accomplish your goal of athletic superiority. So is anorexia, in a sense – it helps you to accomplish your goal of being thin.

    We don’t call these behaviors healthy, however, because they violate our community sense of what a person is supposed to be like. A person isn’t supposed to chemically ruin their bodies in the long term in order to excel at athletics in the short term (although, interestingly, ruining your body for the long term with overexercise is often lauded). A person isn’t supposed to totally sacrifice the functioning of their organs and muscles in order to be thin. Because those behaviors don’t fit our norms of what a person is supposed to value, they are, in and of themselves, unhealthy goals to have. Thus, the idea that health is a measure of a person’s ability to accomplish their goals implicitly assumes a norm that some goals just aren’t supposed to be pursued.

    Again, I think this approach is a way to start a discussion about what we as a society really think people should be like, and why. Any time we’re talking about health, we’re at least implicitly talking about it already; I just think it’d be a more productive conversation if it were explicit.

  69. Psychoanalysis « Clarissa's Blog
    Psychoanalysis « Clarissa's Blog February 23, 2012 at 11:37 am |

    [...] for example, has just started a series of guest posts by a psychoanalist who has the following to say: We can, like the psychoanalysts, understand madness as an experience of personal history, with [...]

  70. Cécile
    Cécile February 23, 2012 at 11:44 am |

    Angie:

    As a child abuse survivor, I was accused of somaticized asthma and allergies until a new allergist asked “Do you have the condition when upset? (no). Do you have attacks during pollen season? While cleaning closets?(yes)”.

    Thanks for mentioning how it can go both ways.

    Has anyone heard about Watson being groomed as a potential medical diagnostic tool?

    Watson will be able to analyze 1 million books, or roughly 200 million pages of information, and provide responses in less than three seconds, according to leaders of the project.

    That’s important, they say, given the challenge faced by doctors to keep up with an explosion of medical information.

    One of my first thoughts was how this could really help to bridge the gap between “mental health” and “physical health.” Most practitioners on “either side” presumably haven’t had enough time to garner significant knowledge about their “counterpart” on the side.

  71. Cécile
    Cécile February 23, 2012 at 11:46 am |

    Gross oversimplification ahead: Blogs about psychology and comments pertaining thereto, are, to me, about as scintillating as watching paint dry.

    Okay…? Great!

  72. SnowdropExplodes
    SnowdropExplodes February 23, 2012 at 11:58 am |

    I started thinking of how to comment, but ended up writing an entire blog post of my own with the amount of thoughts I had.

    There’s bits that touch on several of the topics raised in comments so far:

    * Recovery/healing and what that means or doesn’t mean (I actually like to self-identify as “broken”, because I think in terms of having a jury-rigged mind to regain functionality/stability, and for me, saying “broken” acknowledges that things can’t be put back together perfectly).

    * The discussion of the different theories about symptoms (I relate them to my own experience of depression).

    * How definitions relate to social justice matters and marginalisation.

    One thing I didn’t really mention is the discussion of “Symptoms tend to be expressions, and most depression (with, sometimes, dysthymia being excepted) has rage at its roots.” In some ways, that relates to stuff that I promise myself for my own health not to go into in public spaces, but there’s sort of two strands for me: there’s a rage thing and a self-loathing thing from different sources, and it’s kind of hard to identify which came first – the whole “chicken-and-egg” type of deal. But the point about gendered expression is curious because I do know that in my worst depressive periods my destructive thoughts have tended more often to be directed outwards, while still having an element of self-loathing/suicidal inclination in them (that is, thoughts of destruction taking forms that often had some implication or conception of it rebounding back on myself). On the other hand, the very first warning signs I get of depression coming back are the signs associated more with women: crying, worry, sadness. (Although worry alone doesn’t count for much: it’s an ever-present thing so I would be more worried if I stopped worrying!)

  73. boredclerk
    boredclerk February 23, 2012 at 12:57 pm |

    @ William, #78

    Well, yes. The downside of allowing individuals to define their own health is that some people will choose definitions that you do not like. I’m comfortable with that moral trade. I don’t think we ought to be medicalizing drug addiction, I don’t have much of a problem with an adult consenting to steroid use, and I’ll even fess up to supporting the idea of a person’s right to choose the time and manner of their death. The problem with calling other people unhealthy is that that power almost always ends up becoming oppressive. Hell, I’d argue that eating disorders are a distortion of the ability of one person to judge another’s body.

    I’m definitely sympathetic to that argument. As a legal matter, I’m in absolute agreement that a person should have the right to total sovereignty over their own body, even including killing it. In terms of social norms, though, I’m not willing to make the trade-off. I really do think we should have social norms that tell us how a person is supposed to live and what a person is supposed to be like. I think those social norms should include things like “a focus on thinness at the expense of organ function is bad,” and “huffing paint in reckless disregard of your future brain function is stupid.” Insofar as a discourse of “health” is one of the ways that those social norms are promulgated, I’d like to keep the concept of “health” as we have it now. I just want the norms that underlie the concept to become not sexist, not homophobic, etc.

    Out of curiosity, if you don’t think a person should call another unhealthy, what do you think the word “healthy” means? Does it have any meaning? Do we even need to keep the word?

    PS: Thanks for starting this great discussion!

  74. karak
    karak February 23, 2012 at 1:13 pm |

    *not to mods: my first comment posted before I was done, can you delete it and post this one instead?

    @Vee:

    So, you didn’t have much control over what happened to your clients? Were you able to advocate for them at all? Also, what area did you work in, and when?

    I’m considering becoming a case manager, that’s why I’m asking.

    My clients often needed a level of support society would not give them. They mostly lived on their own, on disability, no friends, no real family, extremely poor, very mentally ill, with whatever lesser health issues they had getting worse. Some of my clients wouldn’t leave their house/apartment for a week at a time–what for? They had nothing out there. Cable TV was the one highlight in their life. And there is no way to grab the world by the shoulders and scream, “HELP THEM. They live like fucking zoo animals! They need friends! They need better meds! More support! More money!” And that’s never going to change.

    I did a few good things. I got one woman disability, I helped at least two clients stay out of jail (crime: being mentally ill in public). I raged for one client until I pushed through his doctor’s appointment, he’s the one with cancer (six fucking months of an obvious growth, jesus fucking christ). Right before I was laid off, I got one woman on the reserve list for an excellent supportive facility, we’d been trying to convince her to do it for years and I finally wore her down. And I often brightened my client’s day by simply being there to talk, to visit, to listen to them without telling them they were crazy or laughing at them, for respecting them as people.

    I was able to advocate–my job was mainly to make sure they got the proper social programs (disability, food stamps, public housing) got to doctor appointments, monitor them and report to their psychiatrist if they needed to be committed, and work with landlords, neighbors, parole officers, banks, whoever else was giving them a hard time because they were sick. But, again, all I was really doing was making sure their lonely life was maintained–they weren’t getting better.

    I worked in a rural area in central Illinois, at a job that only required a Bachelor’s Degree.

    The worst part about the job was the payment system. I was graded on how much money I made for the company (which was sinking due to mismanagement, my boss was a saint but our CEO was a fucking…just… bad).

    SO. I get a client who’s pinged on the state radar as needing monitoring (involuntary institutionalization, usually). She doesn’t have medicare. I’m legally obligated to see her as much as she needs….but I only get paid for 10 hours of face-time a year. Every other time I spend with her is money my company is pissing away. But I can’t refuse to take her. These people were hated and often dumped to the bottom of the pile for ruining numbers.

    I get a lucky client who IS Medicaid/Medicare. Yay! It take me 30 minutes to drive to his house, we meet for an hour, and 30 minutes back to the office to file 15 minutes of paperwork. I am now into my day for 2 hours 15 minutes, but I can only bill for 1 hour of face-time. I was required to bill for a minimum of four and a half hours a day. Transportation and paperwork did not count. I was actually expected to do closer to 5-6 hours a day. My furthest client lived over an hour away. Two hours of the day gone just to see him, fifteen minutes of paperwork, plus driving to all of my other clients… lots and lots of 12 hour days.

    That, of course, was one place, it might not be the same at all case manager jobs. But if you’re not a strong person, well-organized, and able to leave your work at work, you won’t make it.

    There was a saying in my office: When you start having nightmares about your clients, quit. You’re too stressed and too involved. It’s good advice.

    1. Vee
      Vee February 23, 2012 at 1:52 pm |

      @Karak

      That’s really depressing. I live in Michigan, near Detroit. I’m going to try to intern with an agency that does casework for the mentally ill this summer. I hope it’s different over here! Guess I’ll find out.

  75. EG
    EG February 23, 2012 at 1:33 pm |

    There certainly do seem to be some real differences between the ways in which men tend to experience depression (irritability, aggression) and the ways in which women tend to experience it (sadness, crying spells, worry).

    There’s also the content of the expression as well as the form. My father’s depressive ruminations tend to take the form of how worthless his professional achievements are and how he never lived up to what was expected of him vis-a-vis his career. Mine tend to be all about how there’s something essentially wrong with me and so I will never be able to be with somebody romantically blah blah blah. You can’t tell me that’s not the result of gendered socialization, that men are taught to value themselves by their professional achievements and women by romance.

  76. Sock Monkey
    Sock Monkey February 23, 2012 at 1:53 pm |

    @Cecile at #6:

    I just wanted to stop reading for a moment and thank you for posing such excellent questions. I look forward to scrolling back up and reading the responses. I was diagnosed with C-PTSD a few years ago, and I have had many similar thoughts and questions run through my mind since then.

    I am lucky enough to be in treatment with a group that claims Judith Herman as one of its directors. Her book, “Trauma and Recovery,” has changed my life dramatically for the better. Before I read about C-PTSD in this book, I knew that my anxiety and depression were a result of the child abuse I had suffered, but I had no idea there was a body of knowledge that offered help for someone like me. I look forward to C-PTSD being formally recognized, and seeing more research into effective treatments.

  77. Donna L
    Donna L February 23, 2012 at 1:59 pm |

    My father’s depressive ruminations tend to take the form of how worthless his professional achievements are and how he never lived up to what was expected of him vis-a-vis his career. Mine tend to be all about how there’s something essentially wrong with me and so I will never be able to be with somebody romantically blah blah blah.

    And I have frequently ruminated about both, in exactly the way you mention. One of the many wonderful advantages, I guess, of living as both a man and a woman during one’s lifetime!

  78. Emolee
    Emolee February 23, 2012 at 2:23 pm |
    Because what if the person has no problem with a mental process, or is unaware of a mental process, which causes others distress? I’m thinking of everything from a person who is emotionally abusive to a serial killer. Obviously, not all (or even most) abuse or killing is due to mental illness, but some is. Does objectivity play a part at all, or is health *only* a personal assessment?

    43 posts before the myth of the dangerous madman is invoked.

    Mad persons are far more likely to be oppressed than to oppress, more likely to be abused than to abuse. By invoking the idea of mad persons who are dangerous I think we’re in extreme danger of turning this from a discussion about the nearly universal majority of mad people who don’t hurt others into an erasing focus on the aberrant minority (probably less than the general population) of mad persons whose symptoms end up hurting someone else.

    So, no, I don’t think the outliers call for derailing the discussion and I think that personal assessment ought to dominate considerations of madness in all save the most extreme of cases.

    William, I respectfully disagree that I was derailing the discussion. A commenter had proposed a definition of health, which I found very interesting, but wanted to question hir a little bit on so that I could understand more fully. I thought that how we define health was indeed the topic here, as you asked,

    how do you, personally, define health and illness?

    I really like the idea of defining health for ourselves. I would like to get to this place, but I had a few concerns about it that I was trying to work out. If you think my concerns are groundless, I am actually very interested in hearing that and learning from you and others here. We may agree or disagree, but my comments were on topic.

    I do understand what you are saying about common tropes being centered, even though they are the fringe of cases. I did not mean to imply that mad people as a group are dangerous or abusive and should have clarified that. I probably should have left serial killers out of it. I apologize to those for whom my comment was hurtful.

    What I am about to say may also offend some people, but I really am trying to understand, and while I know it is not anyone’s job here to educate me, I am hopeful that I will gain insight from you or one of the other commenters who are knowlegable on this subject. I am coming at this from my personal experience which includes being non-neurotypical myself, having a partner with severe PTSD and another close family member who has been diagnosed bipolar.

    When I made my previous comment, I was thinking of this last family member. She thinks she is healthy (or at least says so) and will not seek treatment. But some of her behaviors hurt both herself and others, including me. Badly. The way it has been explained to me is that her condition itself prevents her from understanding her condition. My heart really breaks for her, because from my viewpoint, it looks like her life, and certainly our relationship is being stolen by an illness for which one of the symptoms is not wanting to treat the illness. So this is where I start to question health being defined only by the perspective of the person hirself: what if the illness or madness alters perception?

  79. EG
    EG February 23, 2012 at 2:24 pm |

    Oh dear! I should have phrased that better–I didn’t mean to imply that it was as simple and neat a division as that, with no blurring or crossover or anything, more broad outlines that seemed to map quite well onto my and my father’s experiences. I find the differences in our depressions very interesting, largely because they are so very similar otherwise.

  80. Donna L
    Donna L February 23, 2012 at 2:46 pm |

    ^
    No criticism intended; I didn’t think you were implying that. I was just amused, given my history, at the thought that both kind of ruminations you mentioned mapped my own experiences so closely.

  81. Rob in CT
    Rob in CT February 23, 2012 at 4:41 pm |

    The worst part about the job was the payment system. I was graded on how much money I made for the company (which was sinking due to mismanagement, my boss was a saint but our CEO was a fucking…just… bad).

    SO. I get a client who’s pinged on the state radar as needing monitoring (involuntary institutionalization, usually). She doesn’t have medicare. I’m legally obligated to see her as much as she needs….but I only get paid for 10 hours of face-time a year. Every other time I spend with her is money my company is pissing away. But I can’t refuse to take her. These people were hated and often dumped to the bottom of the pile for ruining numbers.

    Holy hell, that’s messed up. Graded on how much money you made in a job that was obstensibly about helping people. That’s just… nauseating.

  82. number9
    number9 February 23, 2012 at 6:44 pm |

    Wow, karak, that’s a nightmare of a job! I worked as a case manager for homeless youth, until I burned out (the nightmare part – so true) and it was a totally different set up. The pay was shit, of course, and the agency wasn’t supportive, and the hours were intense to say the least, but nowhere near as bad. The fact that I was on-site (well, two sites) really helped.

    This does actually sort-of tie in to mental/emotional health, for me. For some reason, I was always able to handle my own trauma, but the secondary trauma from working with youth and hearing their stories of abuse? That was really hard to process. One could argue that I compartmentalised, or processed my own experience theoretically rather than emotionally, but it was a healthy way of processing for me (as in, I was – am – functional). But I couldn’t do the same with secondary trauma. I was a wreck, by the end. William, any thoughts about processing own trauma vs. how your patients’ trauma affects you?

  83. Emolee
    Emolee February 23, 2012 at 9:41 pm |

    You know what, I’m just going to go ahead and issue a mea culpa here. The dangerous madman meme is a really sore subject for me and I got to ranting. I didn’t feel like you were derailing, but I definitely didn’t do a good job relating that. I’m sorry for that, I was an asshole.

    William, I appreciate your apology. I don’t think you were an asshole; I just think we misunderstood each other. I felt bad that I had inadvertently implied hurtful things about mad people, things that I don’t even believe. I tend to do this: generalize/use vague abstractions (like mentioning abusers or serial killers) instead of talking about what I am actually thinking about- my own, real, emotional experience (such as my specific struggles with my mad family member) and this never comes across well. It is a protection mechanism of mine, I think, to try to avoid being too vulnerable. Anyway, I appeciate your answer as well.

  84. LotusBen
    LotusBen February 24, 2012 at 2:12 am |

    This is an especially timely and interesting post for me William. I’m planning to start seeing a counselor in March for the first time in two and a half years, as I believe my finances finally allow it. I’ve also been doing a lot of thinking about my career future over the past few months as I’ve become waaaay too sick of being stuck in deadend jobs with no autonomy and no intellectual stimulation. And I’ve decided I want to go to grad school for psychology. I’m debating whether I’ll go for a Master’s of Counseling or a PhD in clinical psychology. My dream is to have my own private practice.

    I think I might identify as mad, too. Deep down, I’ve always felt like I was significantly different than other people. But I haven’t really claimed the mantle because I’ve been able to cope, at least from the perspective of outside observers, and I don’t have a stereotypical “major” condition like schizophrenia or whatever. But the older I’ve gotten and the more I’ve talked to other people, the more different I’ve realized I am. For example, as stupid as it sounds, I’ve always been the guy in the room with the loudest laugh. Me depressed? It was actually just last fall that I finally realized I’ve been a chronic depressive my entire life, with a few brief sunny periods. I mean–I’d thought that everyone experienced life as one neverending wall of pain, absurdity, and shittiness. Turned out it was just me!!

    Anyway, in no particular order, I also suffer from: social anxiety, chronic insomnia (which is why I’m always posting on here at 4 am), self-injurious behavior (scratching my skin until it bleeds. And bleeds), and what I used to call “sexual addiction,” although I’ve since rejected that label as shaming (maybe better as–a kink I haven’t integrated into my normal sense of self yet?)

    To me the biggest component of health is self-acceptance. I really do need to be my own best friend–to use a cliche–and work with what I got–to use another. I don’t believe in the legitimacy of our society’s standards on anything, really, and certainly not “health” or “illness.” So I try to center my worldview on myself: knowing myself, trusting myself, loving myself, and experiencing as much happiness and pleasure as I possibly can. I like to stick to a few other rules of thumb. Exercising regularly and eating a balanced, nutritious diet. Being honest with other people. Developing close relationships with others based off mutual respect and love. I definitely lean toward the humanistic Maslowian/Rogerian school of psychology.

    Oh, BTW, great to read so many wonderful comments from all the posters on here. I appreciate the courage and honesty y’all show in opening up about your lives.

  85. konkonsn
    konkonsn February 24, 2012 at 3:19 am |

    @karak

    I’m from rural, central Illinois, though I don’t currently live there. Nothing else to add, it just brightened my day (though I guess concerning your post, it really shouldn’t).

    Personally, I stand with psychoanalysis. My own view of symptoms is that they are a complicated interaction between the things someone had to do to survive trauma, the ways they have found to communicate these experiences which are not readily spoken, and the taboos which rob patients of their voice.

    I tried to read through most of the thread, but I did skim a few posts, so sorry if this has been addressed.

    I feel like this isn’t always the case, though? I mean, my OCD and GAD weren’t bad enough that I couldn’t slip by everyone for 21 years, but all the same, they did cause me a lot of pain. Yet I would be hard pressed to think of a trauma I experienced to cause them. It’s either my very first or second memory (not sure if my diaper box race car is a real memory or one cobbled from photos) is of intense fear of a shadow on the wall that seemed, to me, a skeleton. And then, after that, years of needing a light on in the room, hiding under covers until I was soaked with sweat so the monsters wouldn’t get me, unable to watch frickin’ Lassie because one episode had this guy getting sucked into a tar pit and that terrified me…

    I mean, I grew up in pretty ideal conditions. In a family full of proud Catholic, racist, sexist, and homophobic Republicans, I got the only liberal, agnostic as my father (he can be racist sometimes, but that’s a different story…). I was told I could be whatever I wanted when I grew up, always praised for my good grades, never told I had to act or dress a certain way because I was a girl. My parents and babysitter didn’t use corporal punishment, and there weren’t any traumatic deaths or accidents among my close family. So if trauma was part of it, then it happened very early in my life, before I was forming discernible memories, and I’m not even sure how a psychotherapist would treat something like that.

  86. Lucas
    Lucas February 24, 2012 at 3:44 am |

    I agree with others that mental health has personal and social dimensions, which interrelate.

    For the personal dimension, I think it only makes sense to talk about sufficient health and not good/optimal health. Sufficient health I would define as not being overwhelmed by one’s inner workings. You may have daemons, but you feel on an even footing with them, able to grapple and work with them, alone or with help. The outside circumstances of the individual influence their personal health. The same person as a soldier in battle may find hallucinations overwhelming while working on a farm they may not.

    I don’t think you can talk about health beyond this level because you cannot call someone who’s inner world is uncomplicated and harmonious ‘healthier’ than someone with persistent inner tensions and concerns.

  87. Emolee
    Emolee February 24, 2012 at 11:19 am |

    I don’t think we give enough credit to the kinds of constant low-grade trauma … Its subtle, so subtle you don’t notice it, but eventually you begin to believe that this is just how the world works.

    I think this is an excellent point, and I relate to this a great deal. So many people around me have experienced acute trauma- like combat or rape, and I have always been looking for that “piece of my puzzle,” to explain my own madness. However, my therapist pointed out that a lot of the stuff that I describe about my childhood and adolescence was very traumatic, especially in a cumulative sense. I never really realized that; I just thought it was normal becuase I was so enmeshed in it. I now see that the few times I experienced violence don’t affect me nearly as deeply as the years of constant, low-grade emotional exploitation.

  88. Cécile
    Cécile February 24, 2012 at 12:48 pm |

    I now see that the few times I experienced violence don’t affect me nearly as deeply as the years of constant, low-grade emotional exploitation.

    Very good point, Emolee. And something I didn’t emphasize well in my post about Developmental Trauma (#6) was that childhood ‘maltreatment and neglect’ (so, “emotional” could certainly qualify either of those) can absolutely create developmental trauma. There are too many reasons for it for me to get in at the moment, but the most concise way I can think to explain it is that many things that traumatize children are disproportionately traumatic—that is, things that adults might wave off as “not being a big deal, not enough to scar you for life,” when actually, that’s not the case for the child.

    If anyone is interested, I’ll copy and paste something I wrote recently, where I attempted to outline how one little incident that didn’t involve physical or sexual abuse, or even words, really, was an extremely intense experience for me at the time. It’s one of the many things that has stuck with me and contributed to some of my maladaptive-ness—subsequent experiences have made certain types of perceived ‘abandonment’ or ‘rejection’ unbearable to me—my CNS completely loses itself, and my body is accosted by the strangest feelings of physical pain and physical illness, and I become an emotional wreck. It was so helpful to me to write out this very vivid memory and just revisit the moment that some of these things were “fusing” together internally:

    I was always the “outcast” of the family, even when I was very young. There are a hundred things I could say about what I mean, but that’s for another day. Anyway, there was a bad day. I guesstimate I must have been about 7 at the time. It was summer. My mom was driving us home–my brother, sister, and I. We all sat in the back seat, because we were young. I don’t remember what happened, or where we were coming from, but I had been throwing a fit about something. (My frequent tantrums seem to have sad implications to me now.) My mom, I imagine overwhelmed and furied, slammed on the breaks and commanded me to get out of the car. Because this was certainly a singular incident, I was stunned, and scared at her anger. I froze in the back seat and started stammering, protesting. But she insisted. Get out.

    At that moment: Shock. Shame. Vulnerability, denial, smothered desperation and clinginess. Humiliation, as my “good” siblings stared at me, silent and wide-eyed. Voyeurs! ! I had a stuffed animal, Robert Bear, with me. I clasped him and bewilderedly slunk out of the car, my mom glaring me down. I stepped out into the street and shut the door, with a painful, submissive complicity as though I were being told to dig my own grave, and then the car took off, cruising block after block until it disappeared. And I stood still. I was siezed by uncertainty if she was going to come back. She meant to make me feel abandondoned, and she did. Those terrible minutes, I was overcome with a handful of intense, rigidly identifiable emotions: I was terrified and confused… I didn’t know what to do. She had kicked me out on the side of the road near a park. Parents were everywhere with their kids, and my defensive response at the time was not to attract attention. I didn’t want anyone to see me and come over to me and ask me questions—I wouldn’t know what to say and the shame would be unbearable. So this defensiveness translated into aggression: I hated all those parents and kids at the moment—my potential enemies, because a question from any one of them would confront me with the ‘horrible reality’ that I was such a terrible child that my mom didn’t want me in the family anymore. I would be confronted with my own ‘hatefulness,’ and I would be exposed and recognized by those other parents as a “bad” kid. So I tightly pinned Robert Bear to my chest with both arms and began walking stiffly down the sidewalk, trying to be inconspicuous, trying not to attract attention. My eyes stared trance-like and fixedly ahead as I tried to remain collected; my mind stunned and blank with fear, and my body churning with all those spiking, terrible emotions. Involuntary tears started streaming out of my otherwise rigid face—they devastated me—No, no one can see me! No one can find out! They humiliated me—onlookers would know. They’d see me and figure out what happened, and would know I was a bad, banished child. They would gather their “good” happy children close to them and tell them not to look at me or go by me. I tried to stop the tears but I couldn’t. I felt ugly with my leaking tears and nose and my red contorted frozen face, and I felt a vicious conviction that I didn’t want anyone to look at me.

    In reality, my mom probably left me for about 5 minutes. But I had so quickly wheeled out of control that I hadn’t been able to tell if she was going to come back. When I heard car tires slowing down behind me, and saw the family car stopping out of the corner of my eye, intense, contradicted feelings suddenly morphed into new intense, contradicted feelings. This time, there was a distinct sense of simulteneously feeling two opposing emotions very intensely: rescued/resentful, humbled/angry, refuge/hatred, safety/hurt. I couldn’t help relievedly bolting to the car, but when I opened the door, I tried to kill that feeling of relief. I didn’t want my mom to have the “satisfaction” of “providing” me with relief after what she had done. I got into the car, alienated to a new, humiliating degree. These vulnerable emotions—alienation and hurt—I immediately began oppressing with a militant intensity. My eyes flicked at my mom for a moment, accidentally, but I couldn’t hold eye contact for longer than a second or I’d reliquish my “pride” and “composure.” She looked back at me with a somber expression that I loathed: she looked sorry, sad, concerned, ashamed, and yet a bit indignant. I didn’t want to look at her… I didn’t want to acknowledge her pain—it enraged me that she seemed to want me to feel sorry for her. I hated her, at that moment. I hated my siblings, who, to me, seemed self-righteously silent and superior; them in all their “stately goodness.” I glared out the window as the car started home, feeling like I was betraying myself for being increasingly overcome with security and relief. The more relieved I felt inside, the more determined I was that I wasn’t going to “play along” and let everything be all better. I was sealing myself away from them, securing the locks, and making myself cold, bristly, and sharp on the outside. I hated, hated, hated them, but where else could I go…

  89. Cécile
    Cécile February 24, 2012 at 1:02 pm |

    (And I should add that, compared to many maltreated children, I come from a mostly happy, caring home, with only infrequent bouts of physical abuse. I interpret many of my issues with my mom, who was abused as a child, to be a result of “failure to bond” (which also easily passes throughout generations) during the first weeks of my infancy—a surprisingly common, and secret, affliction that devastates many biological mothers, and often sets the stage for emotional neglect/abuse, if not worse.)

  90. Emolee
    Emolee February 24, 2012 at 1:17 pm |

    Cecile,
    I think what happended to you sounds very traumatic. It doesn’t sound like a little thing to me. Reading it made me angry at your mother, but then I realize also that she probably meant it as a little thing, or didn’t mean it at all because she was acting out of anger herself. But even the things that parents do unintentionally (meaning without intent to harm) can end up being very traumatic.

    Your story also reminds me of how as children, we often feel that the injustices/abuse that happens to us is normal or even somehow deserved, and then looking back on it as adults, we realize that, no, in fact it was wildly inappropriate and harmful. I am thinking, for example, your fear as a child that the other parents at the park would see you as a bad kid, when in fact, many of them would probably have condemned your mother instead. I experienced instances like this, too, where as a child I was so ashamed of mistreatment because I thought it reflected badly on me, instead of understanding that it was the adult in the wrong- and in the wrong in such a way that most other adults would have recognized so.

    I also would like to second your comment upthread:

    The lack of emphasis on trauma in the DSM therefore creates the high risk of “deducing” that the patient has a “mental illness,” which might actually be a “psychic wound” or “psychological injury.”

  91. chava
    chava February 24, 2012 at 1:20 pm |

    Rambling ahead:

    “Mental” health, for me, tends to be “not like I was when I was a child/THEN.” I’m fairly sure I was diagnosable with depression up until my late teens (worst between around 7-12ish) but between the Scientologist thing and the mad parent thing, it was something less than a critical issue.

    That said, I’m not crazy about the term mental health, either. Personally, I feel “healthy” with the “love and work” Freud bit; however, I don’t like equating health with happiness or the inverse. It plays into our national health=morality/morale obsession, among other issues.

    I’ve recently slowly starting admitting that some of the things that happened, even if other people had it worse, do, yes “count” as abusive. Both of my biological parents and my stepparent had “real” abuse done to them, and so I always wrote off what happened to me as “not the real thing.” And it wasn’t the same kind of horrifying shit, this is true. But it was pretty damn traumatic, all the same.

  92. chava
    chava February 24, 2012 at 1:36 pm |

    OK, that was far too many air quotes. I apologize on behalf of rhetoric everywhere.

  93. EG
    EG February 24, 2012 at 9:54 pm |

    And I’ve decided I want to go to grad school for psychology. I’m debating whether I’ll go for a Master’s of Counseling or a PhD in clinical psychology. My dream is to have my own private practice.

    A little OT, but have you considered an MSW? It’s a shorter program than a PhD, and I’ve known some really good therapists who began their professional training with an MSW, and then carried on educating themselves at family therapy institutes, etc., according to their main area of interest. Obviously, it may not be the right route for you, but if you hadn’t considered it, I thought I’d throw it out there.

  94. LotusBen
    LotusBen February 25, 2012 at 4:37 am |

    A little OT, but have you considered an MSW? It’s a shorter program than a PhD, and I’ve known some really good therapists who began their professional training with an MSW, and then carried on educating themselves at family therapy institutes, etc., according to their main area of interest. Obviously, it may not be the right route for you, but if you hadn’t considered it, I thought I’d throw it out there.

    Thanks EG, that actually really good to know! I have considered an MSW, but only in a pretty cursory way. I’m just inherently fascinated by psychology, so part of me wants to study it for that reason. I feel like I need to pursue what I’m passionate about, not merely what’s pragmatic. But I probably shouldn’t rule out MSW programs. I mean I have a lot of considerations to balance. For example, a lot of psychology programs I don’t think I’d like if they’re at a big research university and overly conventional. Whatever program I start I want it to be somewhat alternative, whether it’s psych or social work. I’m looking at Antioch University, for example, which has a campus in Seattle that might be cool for me. That’d mean living closer to my parents and old friends who still live back in Oregon. And escaping Texas before global warming turns it into a desert.

  95. EG
    EG February 26, 2012 at 9:51 pm |

    So, I’m hoping to reawaken this thread. I’m beginning treatment for a condition that, unlike my depression, I believe is socially constructed, which is why I’m not quite comfortable calling it a mental illness. I’m not conflicted about the treatment–indeed, I’m quite hopeful that it will help me a lot–but it is interesting to think about how the condition is different from my depression.

    I’m beginning treatment for “high achieving inattentive-type ADD,” and I do think that it’s socially constructed. I have absolutely always been absent-minded and forgetful and lost track of things and procrastinated and been incredibly disorganized (except in my thinking about my work), and I have absolutely always hyperfocused on things that capture me (I think all academics, do, to a degree). But it hasn’t been until the last three years that these things have interfered with my life in a significant way, and that’s because I have been fortunate enough to have attended good schools that I found fascinating and because I have gone out of my way to play to my strengths in life, and have had the option to do so. But in the past few years, I have had increasing amounts of administrative and clerical work, work that I have too often come close to forgetting to do, getting in late, doing wrong–and in significant cases, actually doing those things. My ability to return my friends’ emails and phone calls has degenerated.

    In a society that was not so bureaucratic, my inability to handle administrative paperwork easily would not be a problem. In a society that funded public higher ed. well enough that our offices were even halfway adequately staffed with administrative assistants and managers, my weakness in that area would not be a problem–I would just be a classic absent-minded professor. In a society where we weren’t all expected to be in touch 24/7, my difficulties keeping track of the huge number of messages that come in every day wouldn’t be a problem. So I do think of this condition of mine as a socially constructed problem rather than an endemic one, like my depression.

    That said, I’m still happy to medicate and CBT it. Because this is the society I live in, and I don’t want to lose all the things that make me happy, like my career and my friends/family, and I am kind of excited about the possibility of leaving the house without having to go back twice for something I forgot and then realizing once I’m halfway where I’m going that I forgot something else anyway. It would be nice to actually remember to do something ahead of time instead of scrambling at the list minute. But what this indicates to me is that not all mental/emotional conditions are alike, and that may be part of why one paradigm regarding them will always fail some group of people.

  96. DonnaL
    DonnaL February 26, 2012 at 10:31 pm |

    Everything you just said sounds very familiar to me, unfortunately. I’m glad to hear that treatment for it exists, and hope it helps you. It’s very hard for me to imagine myself ever getting to the point of overcoming my similar issues, or even of trying to get help for them. Of course, I’ve had a lot more years to let them become entrenched than you have.

  97. Artur Cortez
    Artur Cortez February 26, 2012 at 11:51 pm |

    William, that was an awesome post. I was having a hard time trying to find people to talk about MADNESS!

    I’ll try to be short in answering your question.

    In 1927, Freud wrote a paper called Fetishism. In his own words:
    “There’s for though no doubt a fetish is recognized by its adherents as an abnormality, it is seldom felt by them as the symptom of an ailment accompanied by suffering.” (http://www.scribd.com/frcw/d/31127300-Freud-Fetishism-1927e)

    I’m using this to point out the importance of suffering here. Psychoanalysts will never see illness where there is no suffering. We don’t get to decide what’s wrong with someone.

    But, in Freud’s case, Health is described as absence of illness. He surely got a point, but to me, it’s a lazy way to describe health.

    On the other hand, Winnicott makes an effort to conceptualize health.
    He describes health as capacity to feel real; be creative; to make use of ilusion; to experience non-integrated states (of mind); to develop independence; to be concerned (about others).

    Winnicott defines health positively, not by absence. And that’s what I like about this.

    I was deluded when I said I could be short about this…

  98. Andrew Pari
    Andrew Pari February 27, 2012 at 9:45 pm |

    I’ll start out stating that I’m a clinical therapist from an MSW background. (*Separate note to LotusBen backing up what EG said: if you’re not planning to go the full doctorate route, the MSW will likely serve you better professionally. This is true in most states, but CA in particular. Most of the MFTs I know tell me they wish they had gone the other route.)

    So, given my background (and if someone else already wrote this, I apologize, I read through about 70 of the comments), I offer that discussions of health and illness MUST happen in the context of culture and societal viewpoints. There are a wealth of “conditions” that are viewed completely differently depending on the country/area they are diagnosed in.
    Especially from a feminist or any social justice viewpoint, this has to be recognized.
    To use an obvious and simple example, the symptomology and reactions that typically accompany sexual assault and rape can be seen as survival reactions versus “symptoms” of a condition. Those survival reactions can protect someone from further assault or, in some cases, lead them INTO greater abuse.
    The idea that was raised earlier about health emerging when someone is ready to let go of the symptoms that get in their way is a good framework.
    Just today I was discussing a case about an abused child who is behaving in an angry, assaultive way towards others. Someone recommended referral to a psychiatrist. I reframed the behavior as the normal outcome of someone who had been abused and who experienced little positive relation to a parent.
    Context has meaning and is extremely important. Personal context, family context, cultural context, etc.
    My simple definition for health: being able to function at a level that brings you a sense of accomplishment and pleasure.

  99. Does social stigma against extreme emotions provide cover for domestic abusers? « Pissed Off Woman

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