Is mental health an issue of subjective identity?

In a reaction to one of my previous posts, I was told I had “no right howsofuckingever” to participate in any discussion of mental health, because, the replying person claimed, I was not suffering from a psychological illness myself. Apart from the fact I believe the person was chasing a strawman in his/her overall criticism, I found this specific argument so inexplicable it kept me thinking, and I’d like to share my thoughts.

The first thing that came to my mind was: How on earth can this person, who I have never met in my life, be so sure I wasn’t in fact mentally ill? I could be the most criminally insane person in the universe as far as anyone on the internet knows (I’m not of course. Really. Maybe. You’ll just have to trust me.). Also, mental health is not a yes/no question, it’s a fluent passage. So when am I mentally ill enough to be allowed to participate in a discussion on mental health? And who determines that? What if I had been suffering from a psychiatric disorder in the past but have overcome it by now? Am I allowed to talk about mental health only when I lack it, and do I forfeit that right the second I recover? Should there be some kind of cut-off value, artificially turning it into a yes/no dichotomy? Or a point system, where people with a higher score get to say more on the topic of mental health that those with only a low one? How the hell is this supposed to work? When you’re going to the doctor because you have a tummy ache, do you say: “What? This doctor never had an ulcer herself? I refuse to listen to what she has to say! I refuse to be treated by her! She has no right to participate in any discussion about all matters digestive!” This is ridiculous.

So I got another idea. What if the person making the argument had a completely different idea of the concept of mental health than I do? What if the person doesn’t see mental health / disorders as something relatively objective, but as a subjective “state”? An “identity”, perhaps similar to, say, gender? I imagine that if this were the case, it becomes plausible that one could “identify” as “mentally ill”, turning the issue of clinical diagnosis into a matter of subjective feeling, something that cannot be objectively measured or validated. Because in the post she/he was referring to I was talking about the need I see for at least trying to find some kind of objective validation of mental health, I could see how that idea would be hugely offensive to someone who maybe believes mental health is a question of a subjectively felt identity.

I’ve encountered a similar argument when dealing with issues of race or gender. However, I believe those are different situations. I would agree that as a member of a certain sociological group you make certain experiences that people who do not belong to that group do not make. Therefore people not belonging to that group should tread carefully when making statements about whether or not members of a certain group have the “right”, for example to feel threatened or disadvantaged. I get mad when a man tells me that feminism is obsolete because “we already have achieved equality”. I would never tell a person of color that any respective movements fighting for their rights were useless. That being said, being a psychologist, I believe everyone has the “right” to feel however they want to feel. Feelings are subjective. Nobody could ever walk up to you and say: “No, it’s not true you’re experiencing this emotion.” when you’re in fact feeling it (They could say they didn’t believe you. But then again, that’s their subjective impression as well, so they have the same right to it.). Feelings are always a subjective reality. Everybody has a right to them. Whether they’re helpful, realistic or appropriate can be a whole different matter when talking about mental health issues.

Take anxiety disorders for instance. It is a reality that people who suffer from (pathological) anxiety experience intense, even mortal fear in some situations (where people who don’t suffer from an anxiety disorder do not experience it). Is that fear real? Definitely. Do they have a right to it? I would say, absolutely. But is it helpful and appropriate to experience mortal fear when you’re, for example, sitting in a cinema and believe with near-absolute certainty that you’re going to suffocate if you stay there? I’d say no, it’s not appropriate, because there is no realistic danger of all the air suddenly disappearing or the person’s lungs to stop functioning (assuming of course, that the person doesn’t have a heart or respiratory condition. And that we have functioning air conditioning. And that the cinema is not built in an airtight fashion because it is located on a spacecraft). And since there is no realistic danger, it is also not appropriate in the sense that it doesn’t fulfill the true purpose of fear, which is to protect us from danger. It has no bearing on, nor does it inform correctly on, objective reality. Which is part of what makes it a disorder. But, a person suffering from an anxiety disorder usually realizes that their fear is exaggerated and irrational when it has subsided.

However, there are psychiatric disorders where the affected people don’t think anything’s wrong. They might not even suffer. This can be the case in psychosis. This is can be the case with delusions. This can be the case with some “personality disorders”. It can also be the case in manic episodes in the context of Bipolar Disorder or also Obsessive Compulsive Disorder (OCD). Some patients who are affected by one of these report feeling absolutely great (i.e. in manic or also psychotic episodes) and hold the firm, sometimes incorrigible belief despite evidence to the contrary that their subjective experiences are correct and true (i.e. delusions, OCD). Should I, as a non-affected person, as a mental health professional, out of respect for their subjectively experienced truth or their subjective identity as the picture of mental health accept their subjective experiences as objectively true and stay out of it, because I get no say in the matter of subjective experience? Should I refrain from diagnosing a person with narcissistic “personality disorder” accordingly, in order to not offend her (This one made me giggle. Good luck with not offending a full-blown narcissist)? That would be naive at best, negligent and even dangerous at worst.

So what am I getting at already? Let’s start with what I’m not saying.

  • What I’m not saying is that any professional knows better than you how you feel.
  • What I’m not saying is that any doctor or psychiatrist or other (mental) health professional has the right to dictate your feelings to you.
  • What I’m not saying that it’s impossible or somehow morally wrong to self-diagnose.
  • What I’m not saying is that you’re not allowed to inform yourself about different psychiatric disorders and try to see if any one of them “fits” the symptoms you’re experiencing. Finally understanding what’s happening to yourself and sometimes, having a “name” for it can be a tremendous relief.
  • What I’m not saying is that I have anything against people suffering from a psychiatric disorder organizing with other affected people to create a sense of community. Realizing one is not alone with one’s experiences and sharing in the unique understanding others affected have for one another can be truly salutary.

Here’s what I am trying to say instead:

  • I believe that we have all experienced some aspects of phenomena or symptoms of psychiatric disorders, which is why most of us can somewhat relate to the experiences of people who suffer from a disorder. Because, again, it’s not a yes/no thing, it’s a spectrum the width of which is accessible to all of us.
  • I believe that psychiatric disorders are characterized by symptoms that can be measured, almost like with the parameters of physical diseases. I’d argue that therefore, one cannot simply “decide” to have a psychiatric disorder based on one’s subjective definition of it. I can have a runny nose and feel generally awful and weak and still not suffer from influenza. Other criteria have to be met for that diagnosis and a doctor is the person most qualified for determining that – irrespective of how often or if at all she has had influenza herself. Congruently, I could feel lethargic and joyless a lot and still not have a clinical depression. Maybe I have a whole different problem. Something could be wrong with my thyroid.
  • I believe that (mental) health professionals, based on their formal education and working experience, do have the right (and, btw the duty, it’s just part of our job) to decide whether the symptoms a patient describes fit one diagnosis or another. We have to do that, because if we didn’t do it, we wouldn’t know what treatment to administer. And it’s difficult, because human nature is not easily put in boxes. Because often, what someone is experiencing doesn’t really fit into any diagnostic category. So I have to use my expertise and take other factors into consideration in order to determine which diagnosis fits best. And I could still be wrong, no doubt about that.
  • I believe that a person has the right to subjectively believe that she has a certain disorder or to subjectively believe she is perfectly healthy and I would always accept the fact she is feeling that way as a reality. But if, based on my professional knowledge, I had sufficient reason to believe she were wrong about either having a disorder or not having it (see examples above) and that person was in my care as a patient I would always and as therapeutically correct and gently as possible, scrutinize her beliefs together with her. Because the guidelines of my craft dictate the therapeutical proceedings in these cases and it would be negligent of me to not follow them.

When a person sits in front of me and tells me about their subjective feelings and experiences, I always take them at face value unless I have reason to suspect the person is being willfully manipulative. I believe that the patient is the only expert on his or her subjective feelings. That’s not me. It’s her/him. I believe, however, that based on my professional education and experience, I am the expert on assessing whether we’re dealing with a clinically relevant disorder and if yes, which one. This does not preclude that a patient who has informed him or herself beforehand could not have come to the same conclusion as I do, before I did. But if a person, to pick up the example from the post mentioned above, tells me she experiences slight discomfort when her DVDs are not aligned straight and reports no other symptoms, neutralizing or compulsive behavior and would insist on suffering from OCD, I would refuse to diagnose her with that. I would then suspect I’m dealing with something else. I would still respect her subjective impressions as true for her and not try to talk her out of what she is feeling. But I would try to scrutinize the conclusions she draws from her feelings, as carefully, transparently and open-mindedly as possible. The subjectiveness of anyone’s feelings I accept unconditionally. But I decide on the diagnosis. Not the patient. Its his or her right to be mad at me for my decisions. Offending people is an occupational hazard to me. If I were afraid of offending my patients, I wouldn’t be able to do my job right.

I realize there are people who claim there is no such thing as psychological illness to begin with. Who claim that all subjective experience, all states of consciousness are their own version of a subjective normality and should therefore never be treated. I disagree with that notion. I do believe that cultural and societal notions of what is considered “normal” behavior and experience are subject to change over time. I definitely believe that having a psychological disorder can (maybe even has to) become engrained, temporarily or even permanently, into one’s identity or self-image in a process of acceptance and personal growth. But I still believe, for the reasons mentioned above, that the act of diagnosis as duty and tool of the practitioner must not be made conditional on the patient’s approval.

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2 thoughts on “Is mental health an issue of subjective identity?

  1. Personally, I think that the more people who haven’t experienced mental illness jump on the support and understanding wagon the better. I’ve suffered off and on for years, I’ve had no end of both support and misunderstanding, from both people who have suffered and who haven’t, but I’ve found that the best way up for me was to be able to discuss my emotions with like minded people who understood, and to be able to lean on people who hadn’t had their own experiences, but just cared about me enough to want to help me get better. It didn’t matter that they didn’t understand what I was going through, some of them didn’t even try, but they didn’t look down on me and that’s what helped.

    1. Thank you for sharing your experience and for commenting. I couldn’t agree more, both on a professional and on a personal level. I wish you only the best! May you be as happy and healthy as a kiwi as often as possible ;)!

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