Tuesday, September 26, 2006

Mental Illness, even Hysteria, is Real

So I have been teaching this Philosophy of Psychiatry class this semester. So far, most of the articles students have read are responses to anti-psychiatry, and more precisely, the work of Thomas Szasz, who argued that there was no such thing as a mental illness. Szasz's argument is simple. For him, an illness, or disease, is solely a physical phenomena. Diseases are well understood physical dysfunctions, such as diabetes. Mental illnesses do not look like this, hence, they are not really illnesses. If they did have physical properties, then they would not longer require the qualifier "mental."

Mental illness is a stand in for unacceptable behaviors. Szasz sees psychiatry as largely about forcing people to conform to socially acceptable behaviors, and locking them up or giving the medications--against their will--if they fail to do so. His criticism against psychiatry inspired many, many philosophers of psychiatry and psychiatric nosologists to not only defend psychiatry, but to clarify what sort of things mental illnesses are. In sum, mental illnesses are real, capable of scientific study and treatment, and require us, ethically, to respond to them. Mental illnesses may not resemble some physical diseases, but they are nonetheless rooted in nourishing/biological processes. Certainly there is an evaluative component, which in essence means: suffering is bad and so we should treat that. But, they are not arbitrary inventions, which the state uses (psychiatrists as their proxy) to coerce individuals into behaving like 'normal' people.

The whole time I have been teaching these papers that reconfigure what sort of taxonomic kind mental illnesses are, I took, naively, for granted that most of my students believed in mental illness. I was wrong. Luckily, today I assigned the first chapter from The Noonday Demon, by Andrew Solomon, wherein he describes skillfully what it feels like to be depressed. I also assigned part of William Styron's account. And, to my surprise, this was the first time that many of my students started to "get" what it means to be the kind of depressed that warrants treatment, either medication or institutionalization.

I walk back from my class, to read the Times and lo and behold discover this article on new research on Hysteria. While there is a lot to chew on in this piece, what really draws my attention is the still pervasive belief that folks suffering from conversion disorder are "faking it" or malingering.

“We don’t like them,” Dr. Black said. “Somewhere deep down inside, we really think they’re faking it. When we see a patient with improbable neurological signs, the impulse is to say: ‘Come on, get off it. Sure you can move that leg.’ The other reason we don’t like them is they don’t get better, and when we can’t do well by them we don’t like them.”

The idea that most people, or at least many people, would think that someone in distress is faking it (and I don't mean to suggest that there aren't those who do), is the real enemy here. The real challenge of mental disorders, and luckily neuroscience is helping us out here, is that we must rely on the patient's subjective accounts (if and when they give them). We may not be able to confirm their symptoms with objective signs. However, to make the automatic assumption that they are seeking attention is disturbing. In fact, I find it to be inhumane.

I just keep coming back to this odd fact about interpersonal relationships. We don't seem to believe that which we cannot see with our own eyes.