Mental Health and the Brain: Starting Context

This is something I always think about ... After the advent of Thorazine in the '50s, when hundreds of thousands of beds in state run institutions were closed, the number of homeless people in the US rose dramatically (and currently, the percentage of homeless people with severe mental illness is very high compared to the general population). There is something that seems great about the idea of medication allowing severely "mentally ill" populations to assimilate into society ... But these medication only work if administered regularly, and sometimes they work in limited ways. The idea of an institution, particularly a permanent or semi-permanent period on institutionalization, has become an anathema to us. But is that segregation necessarily the worst possibility? Or, from another standpoint, if we agree as a society that institutionalization (quite possibly unwilling) is *not* an appropriate choice, have we created any real, sustainable, preferable alternatives yet?

Last weekend my family went up to Boston to visit my younger sister who is currently a sophmore at BU. One of the cities many transportation systems is called the T (train/metro) and when riding the T I have determined that anything can happen. During this last visit a woman came on to the train that was clearly having some type of a mental issue. The minute she got on she threw her bag across the floor and it happened to land at my father's feet. She proceeded to cuss, rant and rave about absolutely nothing at all. She the began to harass a young Indian couple whose baby was fussing. She went as far as to say something along the lines of "shut that thing up before I cut its head off". When the train jolted the woman lost her balance grabbing onto the child's stroller for support. What amazed me during this whole thing is that everyone on the train was ignoring her. It was as though we were back in the Middle Ages and the best way to deal with people who were not mentally sound was to ignore them! I kept thinking that the government needs to be able to provide these people with the help they need because not only can they be a danger to themselves but also to others. This particular woman was in my opinion without shelter, food or medical care. If she were offered help though would she take it? Should she be forced to take it?

Another instance that comes to mind was a program on Oprah, actually this program was what totally turned me off Oraph. On this particular show Oprah focuses on homeless people and decides to leave 100,000 dollars for a homeless person to find. The money is found as planned and the young man who finds it begins to give it away and some of it he loses. Six months later the young many has absolutely nothing, the issues turns into one of mental health. The young man is invited on to Opraph's show where he begins to be interogated about his spending and he breaks down mid-episode and begins to cry, he clearly has no idea what is going on. This inability to recognize mental illness astonished me. Has our society reached such a point as we are no loger capable of not only helping but recognizing those that need it the most? 

I think in part the stigma and misconceptions surrounding mental illness originate from the idea that we want to believe we control our own behavior.  It is scary to admit that our genetics and environment can affect us in ways that we are not aware of.  If this is true, how much of our behavior should we be held accountable for?  An example that stuck with me in class was one of the axe murderer.  Should this person be punished for his or her behavior or should they be given help to try and understand and overcome their deviant desires?  

In a less extreme example, I think the idea of mental illness is so scary to some people because they fear their own vulnerability.  Who hasn’t been depressed at some point?  Maybe people who perpetuate these stigmas want to distance themselves from what they perceive as weakness.  

I think it's really hard to listen to and believe all of this talk about treatment for mental illnesses when we don't even really know what a mental illness is. We talked about the borders between someone's personality quirks versus mental illness, and how the line is often blurred. Who are we to say, unless there is a serious threat of harm to the public, that someone else needs help? While we're finding different types of treatments that can reduce "symptoms" of mental illnesses, it seems almost artificial in a way. I'm inclined to think that when we refer to someone as mentally ill, that there's something beyond the surface, beyond the symptoms, that can never really be cured- that it's a large part of the person affected, that we can maybe numb what we see and make ourselves feel better and feel safer, but not the deepest part of what the person feels.  A professor once asked me why anyone had to be defined as "crazy", or mentally ill. She was suggesting that it was a label we gave to people that we didn't understand. I think that concept is interesting- we find ways to label people in different ways- fat or thin, poor or rich, smart or dumb, crazy and sane, etc. Is mental illness nothing more than a label? However, this is easy for me to say, and I recognize that- when schizophrenics say they "hear voices", and that's why they commit crimes and hurt people, of course, then, who can say that those people don't need some kind of help or need to be kept away from society. It's a hard line to talk about. I want to believe that there are no real "crazy" people in this world- that the people who hurt other people are people who were treated badly or hurt themselves, or had others hurt, and that's why they ended up the way they are- vengeful, but not essentially born "crazy". As for other, perhaps less severe symptoms we call "mental illness", maybe these "symptoms" are our reactions, just the result of living through difficult things, in different combinations, that ultimately we have to find ways to make peace with and get through on our own. Maybe the ultimate treatment is realizing that we're what we have, and that we have to find ways to be okay ourselves. 

It seems that people are making a distinction between nature versus nurture. One of my psychology classes spent a lot of time trying to break this dichotomy down because it seems to be quite unhelpful. What I took home from the class was that behavior (normal or otherwise) isn't broken down between nature (you have no choice, it is something that happens to you) and nuture (all mental illnesses are character flaws and the people who have them are to blame) but rather nature via nurture.

For example: there are certain alleles (for those of us who aren't biologically inclined: each gene can come in several "flavors" each flavor is a different allele: they do the same thing, but in a slightly different way) anyway, some alleles of certain genes lead to a predisposition to depression. But, you could find 10 people with all the predispositions we've found to depression, and maybe only 7 of them will ever become depressed. The flip side is also true: 10 people could, genetically, have no predispositions toward depression, but life circumstances could cause 2 or 3 to eventually become depressed. (Certain, big, life changing experiences have been found to help precipitate depression and they aren't even all sad: getting married, going to college and having a baby can all "cause" depression).

Outlook, experience and genes all play an interconnected role and influence each other. Experience can cause a change in how/when genes are expressed (anyone who's gotten a tan proves this!). And outlook/personality can change both how someone experiences something and how their bodies respond to the environment (they say that optimists recover after surgery significantly faster than their pessimistic counterparts). And a person's genetics at least partially influences their experiences/outlook (at 5' 2" tall, I'm never going to be an NBA superstar...)

Sorry for joining the fray so late ... I was confused about where this discussion was located/what the parameters were, etc. (But I'm here, so ...)

I like what Sophie is saying a lot, and Ryan -- and to some extent Martin, too, even if there is disagreement between the three. I think it does get complicated when we begin to talk about a truly biological perspective, though, because what does that mean? In a way, what Martin is describing can be both biological and also purposeful ... A person might be born with less of a predisposition to enjoy social behaviors,  and might end up choosing to live alone -- and therefore this (and other factors) could trigger depression ... But this depression could have not only some more of biological basis, but also a biological manifestation (complete with chemical changes in the brain). So has this person made a choice? I know that, at least in terms of personality disorders, at least under today's dianosis rubric, many practitioners factor in whether or not the person's behavior is disturbing to the "afflicted." Lots of people who could be diagnosed with schizoid personality disorder will never find themselves in therapy, because they are perfectly happy (or not imperfectly unhappy). So are they making a choice to be less social? Maybe not. And yet is it depressing them? Or is it even necessary to diagnose them? Perhaps not, as well.

I think the stigma discussion is interesting as well ... Certainly, as theories of biology have changed, the stigma towards families with "mentally ill" progeny have changed. (Up until relatively recently Theodore Lidz' theory of the "schizophrenogenic parents" directly causing schizophrenia held widespread acceptance.) Still, it is true that destigmatization can neither "cure" a perceived illness, or is it really possible. Certain behaviors are deemed socially unacceptable -- in my mind, some for better reason than others. Still, as my writing mentor has reminded me while I try and market a novel about, of course, a depressed person, "People don't like to hang out with depressives," and this is generally true. Anxiety, depression -- the manifestations of other "mental abnormalities" -- are generally unpleasant, not just for the afflicted, but also for those around them.

I found this paper on Serendip that I think is very relevant to our conversations about the the medical scientific model of health and mental health.  Hope you all enjoy. 

"She Blinded Me With Science"

A Critical Analysis of the Scientific Model of Health

 

A senior thesis by Georgia Griffin submitted to the Bryn Mawr Philosophy Department

in partial fulfillment of the Bachelor of Arts Degree.

Thesis advisor Christine Koggel

 

April 18, 2005

 

 

Abstract

In this thesis I examine the predominant western theory of health, known as the scientific model, using the accounts of Christopher Boorse and Leon Kass. Together these two accounts provide a thorough representation of the salient points of the scientific model, which are in short: that health is a natural entity and is therefore objective, that it is opposed to disease, that health is not relative, that health is accordance with species design and that physical health is distinct from mental health. I argue contrary to Boorse and Kass that health is necessarily normative (value-laden), that it cannot be abstracted from the human experience of it, that perspective and power play an important role in the delineation of health standards, and that the scientific model of health leads to the discrimination of a large number of individuals. To support my arguments I examine the accounts of a number of theorists who take issue with the scientific model of health, including Martha Nussbaum, Amartya Sen, Michel Foucault, Ian Hacking and Shelley Tremain. I also use these accounts to outline what I believe to be a more appropriate theory of health. Such a theory begins from within human experience and therefore takes into consideration people's individual conceptions of the "good" in relation to health. This new theory of health also restores agency and "personhood" to the patient, thus circumventing many of the difficulties that arise within the scientific model regarding disability and mental health considerations.

 

The danger, in my mind, in reducing the etiology of “mental illness” simply to biological causes, as Paul suggested, is that it depersonalizes the illness experience and may lead to an increased sense of alienation from one’s own mind (body), while also, potentially, overlooking elements that may contribute to perceptions, attitudes and behaviors of individuals. A systemic shortcoming of western biomedicine, in general, is a tendency to champion the organic genesis of disease as being the only valid measure of one’s health/wellness; the logical outgrowth of this tendency is to embrace diagnostic criteria that require increasingly technological interventions that do not take into account differences in individual experiences, ethnicity, education, etc. While imaging techniques, such as fMRI (http://www.fmri.org/fmri.htm ), have enabled incredible insights into the relationship between brain structure and function, does this information lead to a useful/constructive amelioration of mental distress for the patient or, once again, imply the need for a psychopharmacological agent to correct the brain “abnormalities”? While, certainly, psychopharmacological interventions have altered the delivery of care for people with mental illnesses, this seems to have been in some cases, a leap forward, and in other a disastrous step back. Perhaps it is more useful to treat every individual, in the context of mental health evaluations, as just that, individual. And while medications for some may well be the difference between slipping into a paralyzing depression and being able to lead a rich life, for others, medications may ignore the underlying source of distress and may mask, at best, and ignore, at worst, the real source of the problem. And what of illnesses that defy categorization and can be identified as a cluster of symptoms of unknown origin with diffuse clinical manifestations and great individual variation, such as fibromyalgia (http://www.fibromyalgia.com/) ? If we cannot determine an organic or biological root of mental “illness” does this make the experience of the individual less “real”?

I think I disagree with Martin, if I understand his point correctly. I think the stigma associated with mental illness seems to arise, in part, from a fear of that which we do not understand. As a society, if a certain finite range of behaviors is normative, that which strays from the prescribed norm is a source of fear, confusion and disbelief, amongst other things, leading to a view of those with somehow aberrant behavior as being pariahs, who should be imprisoned, medicated, or otherwise relegated to the margins of society. It is difficult to deduce which behaviors constitute “choice,” which can be attributed to biology and which are “illness” manifestations and I think it somewhat perilous to impose a culturally determined set of values on an individual as a means of evaluating whether their behaviors are the result of “choice” or impaired brain function. “Doing something you know you shouldn’t do” doesn’t imply weakness, moral inferiority or even choice; sometimes people either cannot or believe they cannot control their behavior and their thoughts. Either possibility may lead to the same result, and neither is necessarily indicative of “choice.” Ryan’s point about mental illness being seen as a “character flaw” is a salient one. And, I think, has some historical basis, in terms of attempts in recent history to correct the behaviors of those deemed to be social misfits or those who were mentally ill either through behavioral modifications or other means of molding behavior to conform to norms. I agree, too, that identifying causes of mental illnesses as being biological will not remove the stigma associated with mental illness. People with mental illnesses or limitations are seen to be less fit, therefore less able to participate in society. As a result, those people are marginalized because they are perceived as “weaker” and unfit for modern life. This is not to suggest that society, as a whole, lacks a collective unconscious, or that individual members do not care for the well-being of others; however, our culture is one that relishes the triumphs of the individual success story as much as we judge those whose “choices” we deem less worthy, thereby vilifying certain ranges of behavior.

Involving people who have dealt with mental illnesses, their families and friends in the call for dialogue that many of the above organizations have suggested, seems a potentially important component to a conversation that often involves various mental health professionals and politicians to the exclusion of those actually affected. One of the goals of the National Institute of Mental Health is to work towards “prevention, recovery and cure…” of mental illnesses. It seems more than anything, the voices left unheard are those of the patients themselves, to whom “cure” may be foreign and mitigation of suffering might be a more appropriate goal, or the ability to participate more fully in daily life. Regardless, the stated goal seems somewhat removed from the realities of mental illness for many, and more aligned with a biomedical paradigm that seeks to identify a problem and blot it out, where behavior is so often murky territory without finite bounds or convenient explanations/resolutions.

I completely agree with the idea that mental illnesses are medical diseases and affect individuals by chronic conditions. Even though a genetic predisposition could play a determinant role in the evolution of a particular mental illness,I believe that, in some cases, also the style of life, intrafamilial relationships and culture give a significant contribution to the process of developing that particular mental illness. Some mental disorders, such as paresis, can be recognized as a specific biomedical problem, while other disorders, such as hysteria, need a different explanation. For example, I find very interesting the psychodynamic models, offered by Freud’s followers. In these models, mental disorders are considered manifestations of unconscious psychological conflicts, originating in one’s childhood. Other theorists came up with  the learning models, in which mental disorders result from maladaptive learning and can be corrected with remedial learning. Each of these approaches are constructed on the idea that biomedical factors play an important role in producing some forms of psychopatology; childhood experiences or maladaptive learning contribute as well, but it would probably be a mistake to point to any of these factors by itself as the cause of any mental illness. I believe that mental disorders have biopsychosocial roots; many individuals have a predisposition toward them, but it also exists a trigger that “turns” the predisposition into an actual disorder.

I have been thinking about the idea of the 'mind' being a part of the brain. In reality, the brain is the final frontier in terms of medicine and biology. We know so little about it and it is a very complex and subtle machine. The problem, I think, comes from searching for the 'ghost' in the machine. For that reason, I believe that dealing with mental illness is very difficult. For many, there is some kind of disconnect between the brain and the 'soul'. In fact, the idea of the brain having any CONTROL over the 'soul' makes the whole study of mental health very political indeed. Some believe that scientists reduce the human experience to a set of electronic currents and chemicals. All this disagreement about the idea of soul,self,mind and body as being seperate entities makes the study of mental health a fractured and incongruous practice. To which part do we owe the most loyalty and which part needs to be cured? 

Coming from a background in biology, I would be more comfortable saying all mental states, whether or not dubbed "disorderd" by a culture or who/whatever else, are biologically describable, rather than necessarily based (not to deny the idea that some cases may be more influenced by biology than other/outside factors). And on that note, I like at least part of the quotation from the NIMH "...to further discovery in the evolving science of brain, behavior, and experience", which would seem to promote a more open-ended definition of mental illness/health/phenomena/whatever.