The field of mental health is often presented as dichotomous in its thinking. There is a common presumptions that we focus on symptoms and declare you ‘ill’ if you meet a certain (usually arbitrary) number of criteria. Like many presumptions, it’s not strictly true.
I came across this recently, in which an America soldier declares that PTSD is ‘not a disorder’. For the uninitiated, PTSD is post-traumatic stress disorder, characterised by exposure to some kind of significant trauma during which the person was (perceived risk of death, injury or sexual violence. It needs to cause some kind of uncontrollable response – nightmares, perhaps, or flashbacks. It must manifest itself in heightened awareness to perceived threat and there must be a marked effect on mood or thinking style, such as blaming yourself for the event. It is, unsurprisingly, common in those who engage in military combat and there is much research into the (often profoundly negative) effect of combat on veterans’ mental health and their level of substance misuse. So for a soldier to say that PTSD is not a disorder is unusual, but his reasoning is perfectly sensible: if you have seen active combat and witnessed death and destruction, if you have been involved in scenarios in which you thought you might die, why wouldn’t you expect to experience some adverse consequences?
It doesn’t just apply to PTSD. If you’ve lost your job, you’re about to evicted from your home and your relationship is breaking down from the stress of it all, why wouldn’t you experience a dip in mood? If you were mugged and seriously assaulted to the extent that you avoided going out I wouldn’t think it bizarre if you developed agoraphobia. If you’ve had a bout of terrible physical health and the doctors couldn’t work out what was wrong it might be entirely expected that you would become anxious about your health. For most people, psychological difficulties arise in a context which means that the person is finding it difficult to cope, in some way. It doesn’t make them weak, it makes the human. If you push your body too much it will start to break down and the mind is not so different. But there is real debate about the language of disorder.
It’s a difficult one. It is generally accepted that well-being and distress exist on a continuum and to some extent, our diagnoses are arbitrary. We might have six criteria and say to have to meet three. We might say you have to experiences the symptoms for at least three months or two weeks. Why do we say this? Because we feel the symptoms need to be problematic for a certain length of time and that we should be past the point at which they resolve themselves. So there is a logic to it all, but it is fundamentally arbitrary. And because of the history of psychology, the language is one of ‘disorder’, of ‘illness’, of ‘deficit’. That’s really difficult to reconcile with a belief that sometimes we all find life tough and that that is human. Physical health is not usually defined as ‘disorder’ or ‘deficit’, and if it is it is generally localised (‘your pancreas is not producing insulin and this means that you are diabetic and we need to give you injections’). We can;t say for sure that psychological problems ‘exist’ in any particular part of the brain – we know that the frontal lobe is responsible for empathy, but we don’t know that ‘depression’ lives in any part of the brain. And when we suggest that poor emotional well-being is ‘mental illness’ we are pathologising you and your sense of self and that means a lot more than pathologising your thyroid.
Personally, I don’t find diagnostic labels all that useful because they’re no more than a label. What matters to the person is not what a group of psychiatrists think they have, what matters to them is why they are feeling the way they are feeling and how to stop feeling that way. We refer to it as ‘formulation’, which is simply a personalised explanation, put together with the person who is accessing mental health services and built up over time, of what is causing the problem, what keeps it going and how we might be able to do something about it. But we exist in a system which does apply diagnostic labels and which does treat you as ‘ill’ if you meet our criteria (and they are ‘our’ criteria; they’re not fail-safe, like the criteria for coronary heart disease, for example). It’s a real struggle – how do we make people feel that they are not the only ones who feel the way they fail whilst also helping them understand that the fact they are seeing mental health professionals does not make them deficient? There are strong voices on both sides of the debate (strong enough to warrant a blog post of their own), but for most us , who spend our time trying to reduce people’s distress, it’s less about the ethics of diagnosis and labelling and more about the meaning these concepts have to the people we see. I don’t talk to the people who are referred to me about diagnostic criteria. I talk to them about what isn’t going as well as they would like to and how I might be able to help. I worry about the language we use and I try to adapt mine accordingly. I wonder, though, if I worry about it more than the person I see, who often, simply wants life to be good again.