Wars Between the Self? The Problems of Trying to Define Mental Illness
First published: 16/08/2020
Author: Alexandria Thurnherr
(Content Warning: This article will contain extensive discussion of mental illness, ableism and state violence, in addition to fleeting references to paraphilias, transphobia, religion, anti-intersex abuse, existential despair, and racism.)
When one tries to pin down the question of what it means to be mentally ill, one inevitably runs into the fact that the concept is a deeply slippery one. What is near-inexorably found is that any attempt to pin the idea down with anything resembling any kind of precision results in the discovery that mental illness is very much an umbrella term covering all kinds of ailments and imperfections be that having what is considered to be the wrong emotional reaction to some event, set of circumstances or stimulus more broadly defined1and/or being so badly out of touch with the objective facts of reality that one believes oneself to be Jesus Christ, and remains totally unswayed by meeting two other people also holding the totally sincere belief that each of them is also Jesus Christ. The result of this is that most definitions of mental illness either exclude conditions that the vast majority of both the profession and the public would agree to be a mental illness, stop having trouble defining the phrase “mental illness” and start having trouble defining any number of new, difficult to gnaw and generally hopelessly vague terms2, or degenerate into little more than a means to control certain ‘undesirable’ sections of the population, which can usually be understood as its most unproductive elements. As it turns out, finding some set of criteria that covers nicely both gender dysphoria and a messiah complex is no mean feat. How, then, do we do it?
Let us be clear that this question is not an idle one. Citizens of the UK can be detained for up to 28 days under Section 2of the Mental Health Act 1983, or up to six months under Section 3of the same, with further renewals. Furthermore, powers of involuntary detention, without conviction nor any criminal charge to speak of, can occur under Section 136. To wit: “If a person appears to a constable to be suffering from mental disorder and to be in immediate need of care or control, the constable may, if he thinks it necessary to do so in the interests of that person or for the protection of other persons — a) remove the person to a place of safety within the meaning of section 135, or b) if the person is already at a place of safety within the meaning of that section, keep the person at that place or remove the person to another place of safety.” Whilst there is much that initially appears frightening within that passage, particularly deserving of your attention is “appears to a constable”. Note especially that appearanceis the factor on which members of the public can be held ‘for their own good’ (or, to use the proper legal phrasing, “in the interests of that person”), despite the fact that constables are not, speaking in the general case, medical professionals, nor are they substantially more adept than an arbitrary citizen at determining who is suffering from a mental disorder. Given the biases that are pervasive within police forcesand the justice system more broadly, one would be quite justified to ask whether individuals whose job it is to enforce the civil and criminal codes of the land can be trusted with the task of choosing which people are to be detained as opposed to trusted to sort out their own burdens.
But since the Mental Health Act has arisen as a point of discussion, we may as well consult thatto see if we can shed, if not a medical or a sociological light on the question before us, at least a legal one. After all, one would expect that a law granting powers of detention on the grounds of mental disorder would have embedded within some workable definition of that term. Here, then, is the definition of mental disorder, as it is given by Her Majesty’s Government: “‘Mental Disorder’ means any disorder or disability of the mind; and ‘mentally disordered’ shall be construed accordingly.”
Well that was bloody useless.
One of the more widely-used approaches for classifying when a person is mentally ill is to try and quantify, if not the question, then at least the answer, and work from a standard of normality – mathematically speaking. To put it less obtusely, to state that a person has a mental disorder if they fall outside of a given proportion of the population in some respect or another. To choose an example from history (this approach having fallen out of favour in many respects), an adult may be classified as a “moron” (scientifically speaking) should their mental age fall between seven and twelve years3– that is, should their cognitive abilities roughly correspond to those of the median child of those ages. Of course, many matters—problematic and otherwise—are strictly qualitative. One plausibly could, should one so desire, define insomniacs as anyone who takes more than 30 minutes to get to sleep once rested, or classify as ‘abnormal’ those with an IQ4above 130, but how does one quantitatively classify a propensity to violence? Or a paraphilia? Or sheer indifference to life?
Even if we are to put aside these purely practical problems with adopting ‘normality’ as our means of determination, other problems remain. For instance, depending on how narrowly the net were to be cast for the setting of standards by which the others in the population were to be judged, one could easily arrive at a situation wherein a person changes their level of mental well-being merely by changing their context. In most instances, to utter unintelligible words and phrases that are without meaning even to the speaker is a mark of madness, but such an act is, though far from expected, hardly a cause for comment, let alone alarm within certain American Evangelical churches.5Furthermore, the ‘cut-off points’ (so to speak) at which a person is deemed abnormal are generally arbitrary at best, and downright harmful at worst—but in all cases they are, by definition, a function of who holds the power to decide where those points exist. Many things which are in a strict mathematical sense abnormalare not undesirable (such as having an I.Q. of 165) and so the question of which abnormalities require treatment and which do not is an inherently moral and political question, and the practical, day-to-day working answer that is offered will necessarily be affected by the prevailing ideologies of psychologists/psychiatrists and those who pay the bills of the former6, a problem further entrenched by the fact that, as a class, the aforementioned tend to be both wealthy and from more privileged backgrounds. If we are to take another example of this, it is estimated that 1-2% of the global population has red hair. Similarly, I.H.R.A. (Intersex Human Rights Australia) suggests that as many as 1.7% of people in the world may be intersex.78Yet it is not redheads that find themselves frequently mutilated at birth. It is not redheads which need human rights organisations set up in their name, nor who find themselves dismissed by the public at large and classified as having ‘disorders of hair development’. And both are substantially rarer than depression, but it is the latter which receives the most attention from the state and public alike, which may or may not be related to the fact that mental health costs the EU28 around €600,000,000,000 each year (by a 2018 estimate by the OECD).9
Further complicating this idea is that normal and abnormal have in our society such strong moral and more broadly judgmental connotations that it is possible for a severe conflict to arise between a patient and the relevant authorities or, alternatively, for the public stigma to be internalised into the patient and for a sense of guilt to arise not even from whatever specific ailment may have come to them, but merely for having strayed from what is the norm at all. Thus, our definition may come to not only be flawed on the most fundamental possible level, but straightforwardly counter-productive.
Having now delved into a few of the flaws in taking a strictly quantitative view of the matter, perhaps we should turn our eyes to a different model, namely that wherein a person is deemed to have mental illness (for the sake of therapies at least, if not in the abstract) if their function (that is, their everyday actions and behaviours) is in some appreciable and serious manner impaired by their mental state, and becomes inadequate. Thus a depressed person would, with their loss of productivity, be classed as mentally ill under this system, as would somebody experiencing hallucinations, assuming that those hallucinations were in some manner an impediment to them. By contrast, our former hypothetical 165-I.Q. person no longer attracts the attention of our psychiatric services, although they will likely draw attention to themselves for other reasons, not that that matters for our purposes. Of course, the major flaw is obvious: that the theoretical and practical definitions of “adequacy” are, as before, a function of power and of its distributions within a given society.10 Taken to its logical conclusion, we would find ourselves classifying as mentally ill anyone who threatened to shake up the status quo to a sufficient level. Doubt not that if the ruling classes of the world had their way, being a union organiser or being sympathetic to the goals or ethos of socialism would be classed as a mental disorder making one unfit to be present in regular society.11 We might even see sluggish schizophrenia make a comeback, although it would take a new form, and most likely under some grotesque new phrase, such as “workplace temperamental disorder” or some similarly verminous concoction. If we suppose, for a moment, that we are to use as the formal medical definition of “adequacy” from this point onwards: “the ability and willingness to fulfil one’s requirements as a member of society”, then opened up before us are all manners of abuses of power on the question of what exactly one’s “requirements” are. The power to define as mentally unfitis an authoritarian’s dream made flesh. Yet even in some hypothetical society wherein the balance of power were not so cruelly skewed as it is within our own, any failure to function adequately would still have its own problems in that no culture has yet arisen without a legion of illogical and arbitrary requirements and standards. It matters not if we withdraw from the bottomless bog of etiquette that makes up so much upper and middle-class interaction, there are ten thousand unreasonable12 rituals and standards to be met within all existing societies, and so a person working along strictly logical grounds will find themselves running perpendicular to society every other day.
Of course, even if we (by means totally alien to all known psychiatric history) were to prevent the litmus tests for adequate function from being corrupted by the ruling classes for the sake of their own interests and profits, we would run into an altogether more fundamental problem, namely that having a mental disorder is not actually incompatible with adequate function within the society in which the mentally ill person lives. It is entirely possible for a person to daily wrestle with cosmic, existential turmoil and nevertheless hold down a job, interact with the community et cetera. Therefore, our proposed means of telling who does and does not have a mental disorder does not fulfil its primary purpose for which it was designed. It is, in a word, inadequate.
Perhaps a slight shift in our terms will be of use to us.13 Instead of setting some vaguely defined ‘adequate function’ which a person does or does not meet, we could instead move to a model wherein a person has a mental illness if they diverge by some great amount from the social norms of their day. Unlike standards of adequate function laid down by some overreaching overseer, we instead compare a person to the functioning of their environment, and determine if they are mentally ill from there, such things being possible to determine empirically, at least to some extent.
Unfortunately, the problems outlined previously have an even more deleterious effect on this latest standard than they did then. Once more, we find ourselves faced with the problem of who decides what is and is not a “social norm” and by what means that is settled. Given that even non-mental medical professionals in the UShave enough bias to killnon-white Americans, there is no reason to believe that the problems of non-white people will be taken seriously, particularly if the social norms are taken within whiter parts of a nation and haphazardly applied to areas with a strong minority ethnic presence. Take, as an example, two individuals with a distinct fear of authority, in particular the police force. One might note that the majority of society has no particular problem with the police and thus declare both to be in need of treatment. But if one’s fear derives from an abusive childhood and the other from being black in a country with systemic police racism, then classifying both as mentally ill would be a disgrace upon the profession and yet another scar of racism upon a profession with no shortage of those.14 15 And of course, there are broader problems with the idea. That a person becomes or ceases to be mentally ill depending solely on the behaviours and attitudes of totally unrelated individuals is not a mark of a sensible system for the determination of mental illness, and the earlier point about the medicalisation and pathologisation of legitimate social criticisms becomes harsher than ever. Consider for a moment the words of radical abolitionist William Lloyd Garrison, speaking on how the United States had turned itself into a lord with the blood of slaves:
“But how long it is to curse the earth, and desecrate his image, He alone foresees. It is frightful to think of the capacity of a nation like this to commit sin, before the measure of its iniquities be filled, and the exterminating judgment of God overtake it. For what is left us but a fearful looking for of judgment and fiery indignation? Or is God but a phantom, and the Eternal Law but a figment of the imagination?...Therefore, thus saith the Lord God, judgment will I lay to the line, and righteousness to the plummet; and the hail shall sweep away the refuge of lies, and the waters shall overflow the hiding-place: And your covenant with death shall be annulled, and your agreement with hell shall not stand; when the overflowing scourge shall pass through it, then ye shall be trodden down by it.”
Even in the present day, when slavery is near universally condemned (even if action is as ever exceeded by rhetoric), this is much harsher language than most have heard used on any topic, and it was only more radical still at the time. Strange indeed will be the day when Mr. Starmer suggests that Mr. Johnson be made the subject of “the exterminating judgment of God”.16Nonetheless, under a system which defines mental illness on the basis of to what extent a person deviates from the norms of a society, clear moral visions such as his would be placed alongside delusion and detachment from reality. Indeed, where society is hypocritical or willing to suppress its most basic moral instincts and standards of decency, to advocate for and to do the right thing consistently would be as the most clear-cut sign of psychopathology.
Now that we have spilt such ink on the problem of paradigms of mental illness being used as a means to stifle social critique, it would be unjust not to account for the fact that the D.S.M.-517does account for this. Quoth its definition of a mental disorder:
“Socially deviant behaviour (e.g. political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”
Of course, that leaves open to the diagnosing psychiatrist the question of what is and is not “dysfunctional” within the individuals which fall under their care, and to pretend that this will not fall prey to systemic racial, cultural and sexist biases in accordance with the prejudices and the social classes of the profession as a whole is most charitably described as bewildering naïveté.
One weakness shared by all lenses discussed prior is their negativity. This is not meant in the manner of emotional negativity, but rather in the sense that it is only possible to lose one’s mind, rather than to actively ascend in one’s health and have something to aim towards. This brings us to the model of mental illness proposed by Marie Jahoda, in which “normality” (as it were) is defined not in terms of some ever-changing, fleeting measurement of broader society, but rather in terms of ideals to meet, those ideals being18:
Autonomy: Having independence and self-reliance. In short, not being excessively dependent upon others.
Resistance to Stress: That a person should be able to handle stressful situations without breaking down (either temporarily or permanently).
Positive Attitude towards the Self: Self explanatory.
Self-Actualisation: Being content and assured that one is as good as one can be.
Accurate Perception of Reality: Largely included for the sake of not inadvertently excluding people with genuinely serious mental disorders (e.g. schizophrenia), this can be understood as correctly understanding the world. It should be noted that this extends beyond perception and into reasoning.
Environmental Mastery: Being able to adapt to new situations.
Putting aside the question of what the precisedistinction is between self-actualisation and having a positive attitude towards the self in this context, it becomes apparent that what lies before us now is nothing more than a paternalistic set of Aristotlean virtue ethics that has skinned a superior mental health model and is now wearing that skin in the manner of Heracles. This is not to say that Madame Jahoda’s ideas are totally without merit—her remark that “...the absence of mental illness is not a sufficient indicator of mental health.” is worthwhile, and there is much to be said for a model of mental health which does more than try to keep the wolves of madness at bay. Nevertheless, nothing will let us escape from the fact that this model is so vague as to be borderline unworkable. Consider criterion II above: it is no shame to be resistant to stress (a person who collapses under the slightest pressure is of no use to anyone), but a person who is totally and utterly dead inside19is “resistant to stress” but that can hardly be seen as something to aspire to. (One could here point out that the other criteria would surely week out such a person, but this does not account for the fact that no help is given as to how muchstress a person should be reasonably expected to handle. No upper ceiling exists for this). Likewise, ‘autonomy’ is a loose concept at the best of times, and – in the words of John Donne – “No man is an island, entire of itself. Each is a piece of the continent, a part of the main. If a clod be washed away by the sea, Europe is the less. As well as if a promontory were. As well as if a manor of thine own or of thine friend's were. Each man's death diminishes me, For I am involved in mankind.” So it is for all of us, such is the nature of solidarity.
Given the length of time and space that has been spent wrangling and wrestling with this matter, perhaps it may be of use to us to ask ourselves why, precisely, we strive for a neat definition or set of criteria at all. Indeed, why not simply take the approach of Potter Stewart and declare “I know it when I see it”. The answer to that question, my dear reader, is that, even if we discard the powers given to police under the Mental Health Act briefly discussed above (to say nothing of other abuses of state power that have occurred to those deemed mentally ill, nor of the conditions those sectioned have to live under), we must nevertheless acknowledge that we cannot ‘solve’ the problem of mental health (if we are to keep such a framework, and the language that necessarily accompanies it) if we do not have at least some kind of idea as to what it is that we are trying to solve. If we are sufficiently foolish as to lay down vague guidelines for qualifying as ‘mentally ill’, then we open the floodgates for all kinds of mischief and abuse by the powers that be, and I will assure any one of you that the beds down which these rivers of evil flow will be to their own ends and interests, and not those of the general public. Moreover, which conditions (for lack of a better word) are considered to be illnesses directly affects which receive treatments – a point of special importance in the UK, where healthcare is paid for by the state and going beyond what healthcare the state will provide is, in a litany of instances, prohibitively expensive to whole swathes of the population. And wealth getting access to better healthcare (both mental and physical) is no unique phenomenon to twenty-first century Britain. In a more just world with better access to treatment, or in one where the state were not so destructive as the presently existing one, or one where psychiatry as a profession did not have quite so much blood on its hands, we might have greater faith in psychologists to take a more blasé approach to the topic of how to tell the sane and insane apart. But we do not.
Doubtlessly some of you have come to question why this essay has been christened Wars between the Self, given that the topic under discussion is which model of mental illness has the greatest value and least potential for abuse by state and other ruling-class actors. Why not entitle the essay Wars of Definition or some such, would that not be more fitting (if a mite hyperbolic)? The response is that too often, people with mental illnesses come to be framed as fighting a war within and against their own brains, engaged in a constant struggle where every combatant is their own self, their own soul. But there is in too many cases to dismiss a more relevant war to be fought. Recall how we earlier discussed the manner in which many of the conversed means of determining to what extent a person is “mentally ill” can give alarmingly divergent results based upon the context in which that person is placed – sometimes the war that needs to be fought is not one fragment of a split mind against the others, but a person against their circumstances. The system and the society in which we live is a cruel, impersonal, and often downright broken in its treatment of its inhabitants. A great many feel that they have been simply abandoned, left to rot in a world in which they are less than obsolete—even an obsolete thing served a purpose, once. Given that, unlike in aeons past, most can no longer take any solitude in the divine as did their predecessors, should we truly be so surprised that many fall into despondence or into despair, particularly when we are staring down the barrel of the apocalypse? What does it mean to call a man sane in a world itself gone mad?
The following are humbly suggested as further reading:
M. Fisher, Capitalist Realism, Zero Books (2001)
1 Whilst depression is the most obvious example of such, paraphilias are also little more than an unorthodox reaction (specifically, sexual arousal) to a specific stimulus.
2 In this respect, it is much like the tactic used by many pseudo-feminist groups of defining the word “woman” as “adult human female”, which exchanges one loosely defined term for three more, one of which is essentially synonymous in this context.
3 It should be noted that this is under the psychological classification system of Edmund Burke Huey in his 1912 work Backward and Feeble-Minded Children, and is not considered to be scientifically valid in the present day; this is only to provide an illustration of how one might go about sorting the ill from the healthy by mathematical and statistical means.
4 Again, this is strictly illustrative and should not be taken as a comment in either direction on the validity of I.Q. tests at this moment in history or any other.
5 Some of you may believe that this is a greater condemnation of the Evangelical churches than of the means of referring to a numerical basis of madness. I could not possibly comment, other than to wish that the other examples prove more convincing.
7 This may not seem like a particularly large number, but consider that this is about 78 million people worldwide, or to bring the scale slightly closer to home, more than the entirety of the United Kingdom plus an additional ten million people.
8 In the interests of intellectual honesty, it should be noted that I.H.R.A. has chosen this figure “despite its flaws”, and acknowledges that the figure may be as low as 0.5% or as high as 4%, although evidence for the latter figure is shaky. It should be further noted that much of the potential disagreement comes from questions of what is required to be considered “intersex”, which is a) beyond the scope of this article and b) essentially a different version of the problem we were already trying to fix in the first place.
9 To be clear, depression is of course more deserving of attention, psychiatrically speaking, than does either red-headedness or any intersex condition. The point is rather that even the most strident defenders of this model must be forced to admit that ‘uncommon’ and ‘undesirable’ are not synonymous – which returns us to the question of who has the power to decide which conditions are undesirable, and on what basis those decisions will be made.
10 Drapetomania rears its ugly head once more.
11 Anyone believing that there is no historical precedent for these words is encouraged to read Chapter 2 of Iain Ferguson’s Politics of the Mind: Marxism and Mental Distress, in particular the three reasons given for the massive expansion in the number of patients in asylums in the UK.
12 In the most literal sense of the word.
13 But then again, probably not.
14 Again, the reader is directed to chapter 2 of Politics of the Mind.
15 Likewise, it would not be of use to the patients either. Trauma from an abusive childhood is a purely personal thing in that it does not derive (except in the abstract, and with arguments to be had about facilitation by economic structures) from the broader shape of society. By contrast, trauma from having to live in a deeply racist society is not something that can be settled on the basis of individuals, particularly when those racist structures and institutions remain intact and unchanged.
16 If he were to do this, I would gain no small measure of respect for him.
17 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition– in short, the American Psychiatric Association’s guide to all mental disorders it recognises.
18 In no particular order.
19 This being the proper medical terminology, you understand.