We Shouldn’t Treat Mental Illness Like Physical Illness

Mental illness is stigmatized because psychopathology is annoying.

Posted Nov 25, 2014

The latest confusion about mental illness is this meme that demonstrates the absurdity that would ensue if we reacted to physical illness the way we do to mental illness—telling someone with a gunshot wound that they’re just not trying hard enough, for example. The implication is that we should treat, say, depression the way we do a gunshot wound, something like, “Of course you didn’t do the dishes, you poor dear; you have depression.”

The first confusion is the way we lump primarily biological illnesses in with primarily behavioral problems. Almost all schizophrenias, an unknown but probably high percentage of bipolar disorders, and about 10% of depressions and maybe a similar percentage of anxiety disorders are biologically based to the point where they might be called illnesses. Schizophrenia used to be different, closer to 90-10, but new definitions of the term have all but eliminated the behavioral ones. Of course, all psychopathology or disadvantageous behavior has a biological base, since it is all expressed by a body, but there is a difference between a behavioral response to a peculiar learning history and a behavioral response to a broken biological system.

These biological disorders often resemble in public the condition of being partially deaf. A woman who is deaf in one ear is repeatedly treated as if she is rude, because she doesn’t respond to what people say to her. It’s fine to ask the public to treat every non-responsive person as if they are deaf, but you might as well ask the public to become Buddha or Jesus. Instead, the person with an invisible disability is likely to find more peace by making her disability visible. It’s simple to say, I can’t hear out of that ear; it’s more complicated to know what to say about schizophrenia or autism. Maybe, “My brain is wired so that I don’t always react emotionally.” And that would be fine for under-reacting, but nothing is going to make people welcome histrionics, prolixity, or violence. Even a gunshot victim can be annoying if he screams long enough.

But most so-called mental illnesses are not of this type. Personality disorders and most depressions and anxieties are learned. The normally operative reinforcers are ineffective, and the person behaves accordingly, seeking (instead of affection, approval, intimacy, and achievement) admiration, chaos, clarity, destruction, or sexual validation (among others) at other people’s expense. Or the person has given up on reinforcement after a history of failure. Or the person doesn’t know what to do and over-reacts to mistakes. Calling these behavioral repertoires “mental illness” allows for payment by insurers, which would be a good thing except that it also allows for them to be treated chemically, and insurers prefer the cheaper chemicals (even though psychotherapy may be cheaper in the long run).

These varieties of psychopathology are best described as disadvantageous behavior, and since our social world is so important, that means that the kinds of things commonly called mental illness are actually behavioral repertoires that other people find annoying. With personality disorders, the fundamental annoyance is the recognition that you are just not that important to the person, that you are a stage prop or a minor character in the other person’s drama. Virtually the only hope of motivating the person to change is for the person to get a dose of your annoyance. If we treated such people the way we treat people with the flu, we’d spend all our efforts hiding from them, because we avoid annoyances we cannot express annoyance about. Are we really supposed to say, “She takes up all the space in every room she’s in, but that’s because she has a personality disorder, so let’s let her keep doing it”? The term, “mental illness,” when used with such people, is nothing other than an effort to insulate them from the natural social consequences of their behavior. If you don’t like the way the world reacts to your behavior, behave differently (again, thinking for the moment of those who can).

I think it was Talcott Parsons who re-interpreted Freud’s ideas about toilet training and control. The idea was that there is a natural interaction between the child and the social environment in which the child’s soiling is treated as excusable and normal until the parents get sick of it. This leads to the questions of control and autonomy, not anything about anal needs. Similarly, someone said that people grieve until their community gets tired of their grieving, at which point they get messages that it’s time to start behaving differently. Most people won’t sacrifice their normal reinforcers for grief, and then we say that they are making peace with their loss (for extreme losses) or getting over it (for minor losses), but what we really mean is that the affection and approval that was unbroken during their grief is starting to depend on a little more effort.

Similarly, other people are sympathetic to anxiety and depression up to a point. You don’t insist on going to a party when your spouse is feeling blue, and you learn to shrug about your spouse’s excessive worrying when you drive in the snow. But when your spouse demands that you call her when you get there or spends weeks sulking in a darkened room, you put your foot down in a way you never would if your spouse were gravely ill. Otherwise, you’d be enabling, not empathic.

Besides discouraging those who can change from doing so, the analogy to physical illness misses the point that for many serious mental illnesses and personality disorders, the issue is that they don’t “get” other people. Making allowances for that is asking us to treat ourselves as much like objects as the person in question does. Such allowances also defeat recovery, since they treat the illness as causing the annoying behavior rather than treating the behavior as something that the person is doing to themselves and others.