Metaphors for mental illness

Last summer, my son began having severe, unexplained panic attacks several times a day. At the time, my only framework for understanding his symptoms was the medical model of mental illness. I was introduced to this model in Peter Kramer’s Listening to Prozac, which I read after my sister’s first suicide attempt in the early 1990s. Since then, I have had several mental health crises of my own and received two DSM diagnoses. My sister has six or seven. My four-year-old son has five and counting. So 3/5 of my household is “mentally ill.”

The medical model felt counterintuitive at first; I had always thought of mental illness as a reaction to life experience. When I was depressed, I believed it was because I was poor, because I didn’t have a boyfriend, because something bad was happening in my life. I had to consciously train myself to remember that really, I was depressed and anxious because my brain was wired wrong.

Years of cognitive behavioral therapy drilled the medical model into me. A string of therapists criticized “I’m depressed because of x event in my life” as a cognitive distortion. The “right” way to think about it was in terms of neurotransmitter levels—depression was a disease of the brain. My sister and I share many symptoms, which helped me accept that our mental health issues were the result of genetic brain wiring.

But the reductive medical model—the idea that neurological differences are exactly like physical illnesses and should be treated as “brain diseases”—is really a little bit of science and a whole lot of metaphor. Nobody understands brain chemistry well enough to completely explain human emotions and behavior. Theories about the causes of mental illness are products of culture, and they shift over time even within the same culture.

Today, mental health practitioners generally agree that biology plays some role, but so do life circumstances such as trauma, abuse, poverty, and physical illness. Yet our primary metaphor for describing, understanding, and treating psychological distress is the medical model. Our vocabulary (pain, suffering, symptoms, pathology, illness, diagnosis, treatment, recovery) is drawn directly from our understanding of physical illness.

NAMI touts the medical model as a way to destigmatize mental illness. NAMI’s mission statement reads, in part, “mental illnesses are no-fault, biologically based, treatable, and may eventually be curable.” They got the “no-fault” part right, but arguing that mental illness is no-fault because it is biologically based is an unnecessary leap. Wouldn’t mental illness still be “no-fault” if it were entirely the result of trauma? Wouldn’t psychological distress and neurological difference be “no-fault” even if we didn’t frame them as illness?

In America we stigmatize all illness: Diabetes? Your fault for eating so much junk food. Cancer? Quit smoking, already! The word disease connotes contagion, rot, uncleanliness, and moral inferiority. The stigma associated with mental illness is even more insidious, because it’s bound up with personality and identity. People with mental illness are “just not trying hard enough;” they’re “overreacting;” they need to “buck up.” This stigma discourages sufferers from seeking support, informs public debate about funding services, and marginalizes and dehumanizes people with neurological differences.

So decreasing stigma is a noble goal. But this fascinating New York Times article (The Americanization of Mental Illness, via Amanda Baggs) presents evidence that the medical model actually increases stigma. The author cites a study in which subjects were more willing to administer electrical shocks to people said to be suffering from “brain diseases” than to people who suffered from a mental illness because of “things that happened in [their] childhood.” This is a very powerful argument against referring to neurological differences as “diseases.” When metaphors have a measurable effect on the way people are perceived and treated, we ought to choose them carefully.

The medical metaphor often fails on a practical level. Observation of psychological distress in another person is not like a bacterial culture or an X-ray. Diagnosis is highly subjective, is affected by the practitioner’s cultural background and biases, and depends on the patient’s ability to communicate verbally. Much of psychiatric diagnosis is a description of observed behavior, which begs questions about who does the observation, how the norm is defined, and who decides which behavior is non-normative.

In America, mental health treatment usually involves medication. But the metaphor breaks down here too. Antidepressants and anti-psychotics are not like antibiotics. Psychiatric medications work differently on different people in different circumstances, and culture determines their use and perceived effectiveness. Choosing the correct drug and dosage usually requires trial and error for each individual. When medication relieves suffering, it is useful and welcome treatment. But psychiatric medication is also used to suppress non-normative behavior. In this case it is not medical treatment; it’s a tool of social control.

I don’t believe in spirit possession. But the New York Times article argues that in cultures in which this belief is widespread, people who experience mental illness are treated with more dignity and humanity, are more likely to stay with their family and community, and have better long-term outcomes than people whose treatment follows Western medical protocol. The relative stigma attached to the two metaphors is part of the explanation: spirit possession is temporary, and “brain diseases” are perceived as permanent.

When my son’s panic attacks began, my first instinct was to look for an environmental cause. I spent several days convinced he was afraid of the beach, because the first attack happened while we were on vacation. When we returned home and the panic continued, I remembered — oh yeah, I’m doing it wrong again. I should be thinking about brain wiring. Thus began an exhausting trek through our HMO’s mental health service delivery system. At the end of it were several psychiatrists offering anti-anxiety pills.

After some consideration (I’m not opposed to medication on principle, and have seen it work effectively for anxiety in other family members), I decided against it. My son, at the time, was three years old and weighed less than 35 pounds. I couldn’t find any long-term studies on safety or effectiveness of anti-anxiety drugs in kids his age, much less any thoughtful dosage recommendations. By the time we clawed our way far enough into the bureaucracy to see an actual doctor, the attacks were less frequent and more manageable, so it didn’t seem worth the risk.

Each doctor we saw offered a different diagnosis. The most ridiculous was “disruptive behavior disorder,” proposed because my son’s response to his anxiety often involves verbal and physical aggression. The doctor who suggested it seemed shockingly uncurious about the underlying psychological distress that drives the behavior. Defining suffering strictly in terms of the way it inconveniences other people is callous, unimaginative, and not very useful. “Disruptive behavior” implies a willfulness, an agency, that I just didn’t see in the involuntary thrashing of a frightened three-year-old.

The panic attacks recurred daily for a month, then tapered to a few a week, and then disappeared. Neurological difference may be hard-wired, but symptoms are transient. In the same person, over time, they can range from completely disabling to nonexistent. Partly because of their transience, the panic attacks remind me of a weather system; a storm that came through and then moved on. We have some understanding about what causes extreme weather — but we can’t prevent it, or even predict it with much accuracy. And like most psychological suffering, our ability to predict and control it is less important than how we cope with it.

Ultimately, I realized that understanding the cause and finding the right name for the “illness” didn’t matter. What’s most important is how we respond in the moment of distress. What worked in my son’s situation was not a pill or magic “cure,” but helping him find ways to soothe himself — to acknowledge and accommodate the anxiety rather than try to suppress it. The next time a storm comes through, we will both be better prepared.

Sarah Schneider blogs at Kitaiska Sandwich.

Metaphors for mental illness appears here by permission.

[image from Henri Rousseau via Michael Franks' Tiger in the Rain; performance here]

He’s a tiger in the rain. It’s the thunder and lightning he can’t explain.
Just a tiger in the rain, who’s frightened.

on 12/6/11 in Art/Play/Myth, featured | No Comments | Read More

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