An ever-present question for therapists, patients, and anyone else who so much as wonders about mental illness is: What’s the distinction between mental illness and life?
A colleague discharged a patient shortly after assessing her, saying: ‘She has a difficult life, but she’s not mentally ill — I can’t do anything for her.’
See? The implication is that there’s a clear-cut distinction between mental illness and life, and that my colleague could sense it. In fact, based on his description of the patient, I agreed wholeheartedly — we each could sense the distinction.
At the other end of the scale, GPs prescribe psychoactive drugs for stress, sadness, lack of energy. Where’s the distinction gone?
Strange and exciting
One factor in all this is that mental illness is strange and exciting. It involves such great words: psychotic, borderline, anorexic, depressive... It’s great to use these words about people we know.
Alf’s team loses on Saturday. Alf gets angry. Everyone knows why, so they goad him. Alf gets angrier, and they goad him more until he hurts someone or smashes something, finally able to make his point. ‘You’re a nutter, Alf! You’re psychotic!’
Beth is difficult to get through to. She seems unhappy and distant. Everyone thinks she’s a bit spooky. ‘Beth? She’s borderline,’ they say.
Claire is always on some kind of diet. In fact, she’s on every diet she can lay her hands on. A new diet comes out…she’s on it. Everyone who sees what she has for lunch shakes their head: ‘Claire’s anorexic, poor girl.’
Dave never joins in, always has his head stuck in some book. Everyone’s going to the pub except Dave. ‘Dave’s a depressive.’
The effect of this is to rob these words of their meaning, to drain the colour out of them, making them just catchphrases for day-to-day social comment. When someone really is psychotic, borderline, anorexic or depressive, there are no words left in ordinary language to describe the intensity, the severity, the terror, the nearness to death. All the words have been used up for everyday things.
Scary and weird
Another factor is that mental illness is scary and weird. That very intensity, severity, terror and nearness to death are not what we want to know about. It’s too scary.
And even if we do want to know, it’s too difficult to imagine. We would have to think right back to our own early childhoods to remember what it is like to be really immersed in such intense feelings that blot out reality. And even if we can remember what that was like as a little child, it’s hard to imagine what that must be like for someone who is not a child. It’s too weird.
Ed really is psychotic. Frank really is borderline. Gwen really is anorexic. Helen really is depressive. All of them might die in the next few weeks, months or years as a direct result of their illnesses. Too scary. Too weird.
It’s nicer to pretend that Ed is just like Alf, that Frank is just like Beth, Gwen is just like Claire, and Helen is just like Dave — that they don’t really have weird, scary illnesses.
Other examples
There are some other examples around, apart from those made-up ones. (You worked out they were made up — something about those names seemed suspicious — right?)
Photographer Lauren Greenfield, interviewed about the documentary film Thin she directed, says:
I feel like one of the things about an eating disorder that makes it hard to understand by family members and friends and by the culture is that it looks so similar to what we see every day, which is this kind of obsessive dieting that many, many people participate in. And I think sometimes it gets trivialized as an illness. And that’s what I hope people really get out of the film and the book is how serious it is. And the reason I say it’s “unfathomable” is because it makes no sense.
Lauren understands that an eating disorder (mental illness) is serious (scary) and unfathomable (weird), not just the same as obsessive dieting.
Blogger Melissa in her review, Thin: The HBO Documentary, (thanks, Melissa!) agrees:
I do want to put it out on the table that, for all my disordered eating behaviors, I just can’t imagine getting to that point where death would be welcome. Psychologically, it just doesn’t compute.
Melissa understands that she just can’t imagine (weird) the point where death would be (scarily) welcome.
Sociologists Allan V. Horwitz and Jerome C. Wakefield, in their 2007 book The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder tell how two psychiatrists diagnosed a character in Arthur Miller’s play Death of a Salesman as having a depressive disorder, but the playwright responded:
Willy Loman is not a depressive… He is weighed down by life. There are social reasons for why he is where he is.
The two psychiatrists were confused. Willy is only suffering from life, but they thought he had a illness.
And blogger DeeDee Ramona commented elsewhere regarding borderline personality disorder, making it sound like it has nothing whatever to do with personality:
The diagnostic criteria for BPD says…it’s all about depressive-type symptoms and feeling disconnected…it appears the medical definition is “lost in a sea of pain” and doesn’t involve illtreating others at all.
DeeDee is confused (though she explains some more in a later comment). She thinks borderline personality disorder (BPD) is only like being depressed and disconnected, and doesn’t affect other people, but all personality disorders are severe illnesses with severe effects on other people, and BPD frequently ends in the death of the sufferer.
Time and again, we want to apply the words to people who do not suffer from mental illness, just from life, so that there are no words left for people who are mentally ill, and whose illness we cannot and do not want to imagine.
Blurriness and clarity
So when a psychiatric term is used to describe somebody’s actual mental illness, there are two factors making us hear the meaning wrongly: 1) Those words are often overused in everyday life to mean everyday things that have little to do with mental illness, and 2) the real meaning is scary and weird, not something we really want to know. This is how the blurriness of words causes blurriness of ideas.
Die Philosophie ist ein Kampf gegen die Verhexung unseres Verstandes durch die Mittel unserer Sprache.
Philosophy is a battle against the bewitchment of our intelligence by means of our language.
Ludwig Wittgenstein: Philosophische Untersuchungen §109
Words are only descriptions, though. If the meanings of words are blurred, it doesn’t follow that the things the words refer to are in fact blurred. There still should be a real distinction between mental illness and life, even if problems with language make that distinction difficult to describe.
CBT theory characterizes the real distinction. In CBT, mental illnesses that are disorders of thinking, feeling and personality are caused by faulty processes in the mind, and it is possible to become consciously aware of those processes and evaluate them. If the underlying processes make sense and work, then the patient is just suffering from life, (and life does not require psychotherapy). If the underlying processes make no sense or don’t work, then the patient is suffering from a mental illness, and replacing the irrational processes with rational ones will lead to recovery.
Take Alf, above. Does Alf get angry and violent for a reason? Does it work? If he does it for a reason and it works, then Alf is not ill.
Take Beth. Is there something in her life that makes her unhappy and distant? Does seeming unhappy and distant work to protect her in some way? If so, then Beth is not ill.
Claire’s life revolves around the latest diet. Is she simply choosing a lifestyle and an identity that makes her life less boring? If so, then Claire is not ill.
And Dave with those books. Is he studying for an Open University degree? Does he dream of being a writer? If so, then Dave is not ill.
So that’s the distinction between mental illness and life. Mental illness is when the cause of a person’s problems is a faulty process in their mind. Life is when a person just has problems.
To tell the difference in practice, you have to get to understand the underlying mental processes. If there’s a mental process that makes no sense or doesn’t work, then that’s an illness (and while you’re about it, you might as well fix the process). If the mental processes all make sense and work, then the person’s problems are just life.
Do people ever not have any problems? No. Problems and life are the same thing, but the reason for that is a story for another time.
