Every few months the news remembers that mental health is a thing. The news remembers that some percent (high!) of people will experience something in their lives (sad!), and that it costs the economy some amount of money (high!) and that it doesn’t get the funding it deserves despite this (boo!). Then the news forgets.
Along the way a familiar argument is trotted out about parity of esteem – an argument which the news and everyone on it accepts wholesale. It runs thus:
we will only have a decent mental health service if the NHS and society at large view mental and physical health services as equally important and equally things.
I’m fine with this bit; they are both things, and mental health is underfunded and looked down on. The problem is the argument that lurks often unspoken behind this one. On the radio last week it came from a psychiatrist who pointed out:
you wouldn’t feel any shame or stigma about going to your doctor with a bad liver, so neither should you feel shame about going with depression, generalised anxiety, or a phobia. The stigma / shame / underfunding will persist unless and until we treat mental illness as a disease of the mind just like a disease of any other body part.
Let me be clear: there’s a compelling argument for more investment into mental health, and I think the stigma that many people experience around their own mental health issues is horrible. However, I think the argument which holds that mind diseases should be treated like physical diseases is flawed, and also masks a deeper, more important point. Before we get to that point, though, what’s the problem with the argument as it stands?
Is the Mind a Part of the Body?
Ugh. Really? And next you’re going to ask if the chair I’m sitting on really exists, right?
I’m sorry; I’ll be quick. It’s a typical move of the medical model and of scientistic thinking (as best exemplified by the angry athiests like Dawkins and Ince) to blandly presume that mind/emotion/fear/brain/habit/person are all basically the same thing. It’s assumed that all things are fundamentally physical and so are best explained in causal chains involving physical things like brain chemicals. Regardless of whether or not physical reductionism is true (it’s not), it is certainly not the case that the best explanation for mental illness is to find a precursor gene or chemical imbalance. The best explanation for a mental illness (as well as for mental wellness) varies according to the illness and the person that has it. I’m told by people who appear to know that there are a small number of mental illnesses for which good causal physical explanations, but for a lot more the brain chemistry and biology are ambivalent. Physicalising a mental illness does not give us the best explanations in every case, or even in most, and so does not help us to understand, diagnose or treat.
But it’s useful for destigmatising, right?
This is the point that your man will argue, and that everyone seems happy to accept:
we’re best off regarding mental health issues as at root physical because this has positive social impacts on the sufferers. Regardless of truth or explanatory power, if you consider your compulsive habits as being caused by a mind which is basically a brain which is just a bodily organ, you take less personal responsibility for the symptoms and this allows you to strip out a whole level of anxiety and shame.
So, is physicalising useful for destigmatising? My answer to this question is maybe. Sometimes it will be helpful, sometimes not. Self-involved show-off Stephen Fry talked about something similar in his bipolar documentaries, discussing how some people are incredibly grateful for a diagnosis which locates the problem outside of their person – their self, their choices, their personality – and merely in an ‘imbalanced’ body part. Some time ago I remember being given a tentative diagnosis of mild acute depression and finding it incredibly useful because it tied together a range of physical and emotional symptoms under one label which I could then take on in practical ways. In fact it was precisely by de-physicalising my physical symptoms (chronic tiredness, non-specific aches) that the diagnosis helped me.
But your man Fry also spoke with people who found such a physicalising/externalising diagnosis incredibly alienating. One person who had received a diagnosis which came pre-loaded with medication felt disempowered because the illness was something they had lived with and come to integrate into their sense of self, and this was suddenly being taken away from them. They were told that the understanding they had developed was wrong and silly and beside the point. Charles Watkins, the hero of Doris Lessing’s excellent Briefing for a Descent into Hell experiences a more extreme case of this, as his wonderfully rich and enriching experience is diagnosed as a psychotic episode which needs to be treated.
My point is this: any two people experiencing the exact same experiences would make sense of these in a different way; it is the individual’s own telling of their story that determines the extent to which physicalising is useful or not.
But people do not exist in vacuums, and neither do they tell purely personal stories. They exist in societies which constrain and enrich the stories they can tell. So we can only address the question of whether phsyicalising mental illness helps us if we look at the broader social context. South Park makes this argument very well in an episode called Bloody Mary [you can watch it in french here]. Randy is caught drunk driving and told to attend AA. Despite his claims that he just drinks a bit too much, he is told at the meeting that he is not responsible for the disease of alcoholism – a disease of the brain just like any other body part – and that he can only get better if he accepts that responsibility for his disease lies outside of himself. Given this permission to externalise moral responsibility for his behaviour, he gets steadily worse and becomes properly alcoholic.
The individual’s understanding of their mental state – their story – needs to gain some purchase within society if it is to stick. It is no good me regarding my depression as an important part of my personality if my social context demands that I cheer up and get back to work. Similarly, Randy’s own understanding (that he was not alcoholic but just drank a bit too much) was silenced by his social context and he fell into a narrative which was much more harmful both to himself and to society at large.
And there’s another side to the social dimension: personal stories of mental health can challenge society and make it better. For example, given the fact that increasing numbers of primary school children are experiencing serious depression, we can ask whether this is a problem with their brain chemistry or a problem with our increasingly industrialised school system? By listening to the voices of the children who are making sense of their depression we can learn important lessons about our society. Conversely, by treating the children we can hush their voices and avoid their disruptive influence.
I’m not being facetious here: it’s not obvious whether the problem in this instance is brains or society. Almost certainly it’s both. Children do, sometimes, need to be treated with drugs to improve their lives. My point is that there is no definitive answer to be found at the end of a microscope or RCT: this is not a question of fact. It is a fundamentally moral question.Which brings me to the third and most important aspect of mental health which the physical=mental equation obscures:
The decisions we make about mental health are at root moral decisions.
Because we are so unused to talking about moral issues, we often flee from these into the security of RCTs and evidence-based-practice. The comfort provided is twofold: not only have we worked out the best way to treat you, we have also denied you the ability to tell us anything about ourselves. We’re safe from contagion. In the case above, I would argue strongly that the rise in childhood depression is a moral indicator of one of our society’s most egregious faults. But increasingly this kind of argument is not available to me, because we’re all (in the name of good mental health and more funding for the NHS) buying into the parity of mental and physical. We just don’t have the discussion. The parity argument obscures our opportunity to really engage, on a moral and social level, with mental illness and wellness.
Is physical health best addressed by the medical model?
But I want to take this argument one final step further: not only should the treatment of mental illness be open to moral aspects, so, I think, should the treatment of physical illness. For the past three years I have been suffering with a chronic pain condition which has recently been diagnosed as “some kind of arthritis”. Along the way I’ve struggled immensely with pain – both in terms of its reduction and its meaning. While the medical system is great at prescribing drugs for pain (well, actually no it’s not – pain is an anomaly within the medical model: too variable, too subjective, too personal), it’s not very good at dealing with meanings. Because I played along obediently with the diagnosis-treatment approach to pain which I was offered, it took me about a year and half’s treatment before I realised that the meaning of the pain was much more important than the pain itself, and that my focus on pain reduction was stopping me from engaging positively with the meaning component. It is only by moving to the moral sphere, where I have considered my pain in terms of the impact it has on my emotional and practical life, and on the life of others, that I have been able to live a better life.
Similarly, by treating diseases of affluence such as my own arthritis and other peoples’ diabetes and heart disease, we silence any chance these diseases might have had to talk back to us: to tell us something about how badly (morally badly) we’re living as a society.
I think a better argument for parity should aim not to reduce the mental to the physical, but to open both mental and physical health up to a broader kind of engagement. I think it would be better if both could come together to a middle ground where the whole person-in-society – including the moral and social components essential to living a good life – can be engaged in medical treatment. This idea is a struggle because in our increasingly technicalised professions, we have lost faith in our ability to engage with moral or cultural wholes, and prefer to focus increasingly on isolated elements.
The journey to recover or improve or integrate or ignore or live with or whatever verb you choose with mental or physical illness is not a simple one, and it is one which must be meaningful to the person who is suffering, and to the society of which they are a part. Externalising mental illness is one particular story. It is a powerful one, but it is not the only one.