What is mental illness? This is a difficult question to answer. Recent debate about this has come to a head with the new Diagnostic and Statistical Manual of Mental Disorders (the DSM-V). Criticisms have been widely expressed ostensibly because of this very question.
The authors of the DSM-V had a nearly impossible task: to reduce the irreducible complexity of psychological suffering into distinct behavioral categories. This is a lofty goal, but a very understandable one. If we, as psychotherapists, could remove complexity, distill mental illness to its fundamental elements, then the daunting task of helping those who are in distress seems more surmountable.
However, I think a more tenable solution is not to reduce complexity, but instead to use it as an essential component to our understanding. Rather than define mental illness as a series of check-boxes, we as clinicians, must acknowledge the intricacy of psychological pain and strive to understand the nature of our patient’s difficulties. I feel that it is only in doing so, that we can truly join our patients and endeavor to help them.
It is with this, and a recent blog post by Dr. Marilyn Wedge about ADHD rates in France, that I am reminded of a former professor’s conceptualization of mental illness.
He defined mental illness as:
- A-cultural (i.e. occurring outside of cultural norms)
- Causing distress and/or suffering to the person
- Causing difficulties in social, academic, vocational, or family situations
- And it cannot be attributed to biological factors/illness
I think this definition allows for the complexity of psychological illness, and feel that it is a clinically useful. It lessens the emphasis on discrete symptoms and instead offers a framework for understanding when a person’s problems rise to the level of needing professional intervention.
Ideas of what constitutes mental illness are, of course, constructed within a context, and a study of any culture will reveal unique symptomology. For instance, in South Africa among the Batu peoples (Zulu, Xhosa, etc.) “Brain Fag” is a common conceptualization of mental illness, in which sufferers experience anxiety, forgetfulness and poor concentration (Yen & Wilbraham, 2003). It is believed to be caused by ‘bewitchment’. Central American people of African descent may similarly blame cognitive, emotional, or psychological difficulties on brujeria, or witchcraft.
This is not unique to non-western cultures, as Dr. Wedge’s post makes clear. She gives data that suggests that attention deficit/hyperactivity disorder (ADHD) is diagnosed in children at a much lower rate in France than compared to the U.S. She speculates that this may be largely a socio-cultural difference. Her argument is that the French see less of a biological basis for ADHD than American psychiatrists and may even feel that medication is prescribed to treat normal behavior which U.S. doctors label as ADHD.
It would be very easy to argue that Dr. Wedge is right or is wrong and give many supporting data to make the case, however I think this misses the point. Claiming one perspective or another would be the same impossible task of making the complex simple. Rather than reducing our understanding to that the American system over-pathologizes ‘normal’ behavior, or to dismissing French or Central American conceptualizations of mental health as ‘primitive’, clinicians (and by turn their patients) may do better to consider my professor’s definition.
Often dogmatic camps arise in which clinicians may espouse the best approach or the most evidence-based treatments for reducing symptoms or lessening suffering. Unfortunately, I think this ultimately decreases one’s ability to be truly helpful and may even be harmful. Melanie Klein, a British psychoanalyst, spoke about a defense called splitting in which humans try to simplify their world by seeing people, actions, etc. as simply as possible: as either all good or all bad. When psychologists and other medical professionals ardently defend one approach, or treatment, I fear they may be doing something similar.
I work with a diverse population of people, and in trying to care for and bring peace of mind to my patients I draw from many sources of clinical wisdom. These include evidence-based treatments, academic and clinical research studies, the clinical experience of both my colleagues and myself, and the definition of mental illness that my professor gave me.
Other clinicians may also pull from diverse bodies of clinical knowledge, but often overlook this last piece: socio-cultural context. I think this is shortcoming in our thinking and fear that patients will suffer as a result. By including an understanding of cultural factors in the definition of what mental illness is, I believe that I, and other therapists are able to offer better care, understanding, and outcomes. Doing so allows us to transcend the dogma and instead focus on the most important thing: our patient.
