The Illusion of Inclusion – Roadblock #4

The problem with Labels,
Inconsistent Definitions,
Generalization of Symptoms,
& Identity

Depending on one’s personal experience and field of expertise, the terms mental illness, mental disorder, mental impairment, and mental disability can have quite different implications.  While definitions appear vague, and seem to fluctuate; the fact is, each of the DSM’s labels represents a group of “symptoms,” which emanate from the brain.

What does “crazy” really mean?

While there are certainly eccentric individuals, who do NOT have mental disorders; the word “crazy,” is typically used in jest, and should undoubtedly NOT be directed toward someone, who is NOT a close friend or relative, or could possibly be struggling with an authentic mental disorder.  Calling someone with a mental illness “crazy” is far from funny, and is likely to exacerbate that individual’s pain.  Within the workplace such dialogue can alter the perceptions of colleagues; and subsequently interfere with the respect and support they share with the employee, who is already having difficulty coping.

In the majority of cases, a mental disorder is NOT observable.  It is an internal subjective experience within which most people suffer in silence.  While an employee may seem “different” from his/her own “typical” self, the individual’s conduct is unlikely to appear substantially different from the behavior of his/her peers.

For insight into what mental illness “might” look like, see “How can I tell if someone is mentally ill?”  And, discover why Depression is humiliating in an archived post on Reddit; followed by the the reactions of colleagues (once they are aware of the “illness.”)

Why do we use the term “mental” illness at all?

Juliette Jowit, a political correspondent for The Guardian wrote,

A century ago, even the greatest mind doctor of them all, Sigmund Freud, predicted that one day mental illnesses would be explained physically once scientific techniques for the study of the brain became possible.  In a typically prescient but off-the-mark way, he even experimented with treating patients with a chemical remedy – cocaine.

According to Jowitt, psychiatrist Tim Cantopher claimed that drawing fluid from a depressed patient’s spinal cord would reveal a deficiency of serotonin and noradrenaline; essential neurotransmitters responsible for regulating a number of functions within the body and brain.  According to Cantopher, “Depressive illness is not a psychological or an emotional state and is not a mental illness.  It IS a physical illness.  This is not a metaphor; it is a fact.” Jowit writes, “If such a categorical statement can be made about depression – and it may be even more applicable to other psychological problems – it raises the question of why the term “mental” illness is used at all.”

While Jowit’s article was written to address the need for health service parity; it illustrates the issue that discrimination and bias toward “mental” illness is hypocritical, given scientific proof “physical,” chemical, electrical, and/or structural differences exist.  While the word “mental” is of greatest concern, it would be wise to also address the term “illness,” in our attempt to eliminate the stigma of “mental illness.”  Would the word “disorder” be more accurate…or is there an even better term?

Facts…

• Mental “disorders” can be managed; but rarely “cured.”
• Mental disorders are not contagious.
• Mental disorders are not caused by a lack of morality, evil, or a “bad” attitude.

Society has come to use the terms disease, illness, syndrome, disorder, and condition interchangeably; however, it is not only inaccurate, but harmful.

Why Words Matter

Communication is complicated.  Most words have multiple meanings.

The expressiveness of language comes from the implied meaning of a word, or its connotation (the association or set of associations that a word usually brings to mind).  A word’s connotation determines when it is used.  By definition, synonyms have the same denotation or literal meaning, but almost always have different connotations, or shades of meaning.  For example, the word “boat” has many synonyms, including: ship, yacht, dinghy, and ferry.  All these words refer to the same thing, but each elicits a different association in the reader’s mind.

To avoid misinterpretation, it is necessary to consider a word’s denotation AND connotation.  In recent years, “political correctness” has swept through the English language, due to our increased sensitivity to negative connotations.  While some ridicule expressions considered “PC,” such as “differently-abled” (instead of “crippled”) or “with autism,” rather than being “autistic;” these adjustments have had some positive influence within society.

In addition, the meaning each one of us assigns to a word is based on our subjective experience and understanding. When a speaker uses a word to represent an idea, it may connote an entirely different meaning to the listener.  While we may attribute the same denotation to a word, the meaning a word suggests or implies is based on emotion and personal associations, which vary from one person to the next.

Medical Anthropology

The field of Medical Anthropology is dedicated to studying how health and illness are shaped, experienced, and understood.  It addresses the complexity of disease, diagnostic labels, and how we define health.  Cultural, social, and biological factors influence the human experiences of pain, illness, suffering, medical care, attitudes, beliefs, and healing in different settings.  Medical anthropology investigates the social, political, and economic contexts in which health behavior and health systems are shaped.

In Health, Illness, and Healing , Barbara D. Miller notes the differences across cultures, suggesting…

Euro-American popular and scientific thinking emphasizes a separation of the mind from the body.  Thus, Western medicine has a special category called “mental illness,” which treats certain health problems as though they were located only in the mind.  In contrast, in the many cultures in which a mind–body distinction does not exist, there is no category of “mental illness” and treatment is more holistic.

Health systems everywhere are facing accelerated change in the face of globalization.  Thus, our awareness and sensitivity to the connotations of labels is more crucial now than ever.

The labels used by doctors and the general public can also have a huge impact on the way individuals see themselves, the supports available to them, and our success in creating an authentically inclusive society.  Numerous research studies have demonstrated that labels influence the way teachers perceive and treat students with disabilities; as well as the students’ self-perception, self-esteem, and academic success (independent of, and in response to the way they are perceived by others).  See also Labels: Catch 22.

Disease versus Disorder

Definitions tend to vary depending on who your ask, which resources you access, and when the information was obtained.

The Journal of the American Medical Association suggests the difference between the concept of disease and that of disorder implied in these definitions lies in the fact that

A disease is a malfunctioning of the organism initiated and maintained by an infectious process.

whereas,

A disorder is a disturbance of structure or function, or both, due to a genetic or embryological failure in development or as the result of exogenous factors, such as a chemical substance, injury, or disease. It may be inborn or acquired.

A disorder may or may not be initiated by an infectious process, but, however initiated, the malfunctioning is NOT maintained by an infectious process.  A disorder may be the result of an infectious process, remaining long after the infection has ceased.  A disorder may also be the result of a noninfectious process, such as an inborn error of metabolism due to an enzymatic deficiency, or chromosomal abnormality.  In this class of conditions the disorder IS maintained by a noninfectious derangement of chemical conditions.  All malfunctioning and mal-development due to genetic factors and chromosomal abnormalities are disorders or syndromes, NOT diseases.

Whether or not one considers mental illness a disease, is likely to depend on whether they deem it necessary to have specific proof of the cause of the malfunction.  If the diagnosis is based solely on subjective symptoms, the experience would be termed an “illness.”

Impairment

An impairment (denotation) is the state of being diminished, weakened, or damaged, especially mentally or physically.  When (and IF) a mental disorder causes difficulty, it is said to cause impairment.  The question still remains as to where one draws the line between being “below average,” and being “impaired,” “disordered,” or “disabled.”

Disease versus Illness

The word “disease” describes a malfunction; whereas an “illness” represents the subjective experience of the patient, and the meaning of that experience.  It is the patient’s perspective on his/her ill-health.  Most cases of disease are accompanied by illness; which include the psychological, social, and cultural reaction to the disease process.  There can be a circular relationship between the disease and the illness; whereby the individual’s perception of the problem exacerbates the disease, and in turn the disease intensifies the illness.  Disease may not lead to the experience of illness in cases where physical trauma or serious infection causes shock.

When patients are asymptomatic, and do not perceive “illness,” they are not likely to receive treatment for the disease…until it is too late.  In the case of a mental disorder, challenges might be considered “normal.”  And, while coping mechanisms can serve as a crutch in the short term; they may, or may not, be sufficient over time or in alternate environments.

Illness can also occur in the absence of disease, when an individual is not feeling well, but there is no indication of a physical cause.  While the symptoms may be psychological in origin, they should not be dismissed.  Tests can produce a false negative, or a medical professional may fail to perform the appropriate tests, thereby missing the cause.  Left untreated a patient may self-medicate or get progressively more ill.  While many contend that mental impairments are illnesses, because there is no clear evidence of disease, more and more practitioners are in fact discovering evidence of chemical, neurologic, structural, and genetic differences in individuals with brain disorders.

The difference between disease and illness also comes into question, when psychiatric disorders are based on society’s definition of deviance and “abnormal” behavior, despite the fact that individuals do not “suffer” as a result of an “illness.”  Such as when a “quirky,” yet “happy” individual, receives an autism diagnosis.

And…if impairment, such as anxiety is diminished with proper treatment, the question arises as to whether the individual has “recovered.”  And, if so…Should they still be said to have a “disorder?”

Implications of Recent Developments

In Mental illness vs brain disorders: from Szasz to DSM-5, Awais Aftab says,

The notion of mental illness began to change with the emergence of biological psychiatry. Most psychiatrists today do not believe in the mutual exclusivity of mental illness and brain disorders. Most mental disorders are presumed to have a neurobiological basis even in cases in which this basis is poorly understood. Although the terms “mental illness” and “mental disorder” are still used, the manner in which they are understood is very different from the old psychoanalytic view (and for that reason many psychiatrists argue that the terms should be abandoned). The notion of mental illness as distinct and divorced from the notion of a biological disorder reflects a dualistic understanding of the mind-body relationship, a dualism that has become increasingly untenable given the advances of neuroscience.

This brings us to the question of the division of psychiatry from the rest of medicine – and neurology in particular. If at least some mental disorders also have underlying neurobiological dysfunction, then why should psychiatry exist as a separate specialty from neurology? This argument assumes that the division between medical specialties, in particular the division between psychiatry and neurology, exists on the basis of the ontological natures of the disorders they treat. This is an erroneous assumption. There need not be any ontological difference between neurological diseases and psychiatric diseases, in the sense that both depend on the brain as a necessary and sufficient condition for their existence.

In At Issue: Stop the Stigma: Call Mental Illness a Brain Disease, Patrick W. Corrigan and Amy C. Watson explain,

The social, political and economic resources dedicated to illness do not always take mental illness by itself or as a consequence of physical illness into account. This is the challenge that psychiatrists need to address as a matter of urgency especially when attempting to manage individuals with chronic severe mental illness. A clearer understanding of the definitions and characteristics of disease and its conversion to illness and resulting impact on the individual must form the starting point when setting up services and delivering what is needed.

The controversies regarding the definitions, and the interactions between mind and body, make it difficult to reach a consensus as to the most appropriate labels to embrace…even within a single culture.  It is unlikely that we will come to an agreement in the near future.  Although eliminating labels altogether may be appear to be advantageous in reducing stigma; those same labels are provide information, which is necessary in the effort to discover the causes, treat, and provide accommodations to those experiencing mental illness.

In order to BRING DIVERSITY TO MIND, and to attain an AUTHENTICALLY INCLUSIVE WORKPLACE, we must (at least) be mindful of the words and labels used both within the medical profession, and throughout society.

⇒ Roadblock #5 – Conflicting Campaigns Reinforce Stigma