The disorder of mental disorder

Writers on mental health and illness sometimes complain that the psychiatric use of the term ‘disorder’ is a conceptual embarrassment. “I am wary of the word ‘disorder’,” writes Ian Hacking (Hacking 1995: 17). Wary or not, however, the term serves as a potentially useful alternative to a number of other terms. It is common to speak now not just of a mental illness, for example, but of a mental disorder. This is not because the expression ‘mental illness’ is no longer used. It widely is used. I use it in the subtitle of this book. I use it interchangeably with talk of disorder. The general intention behind the concept of a disorder when applied to a mental disturbance

or distress is to try to capture at least three facts central to a disturbance. These three facts help to explain why a mental disorder is undesirable and something bad or disorderly as such. A condition that people ought not to be in. (I say ‘help’ because other features are also proper to disorders as such, as we will learn in later chapters.) It is important to recognize, in preparation for describing the three facts, that the classification

of a mental condition or state as undesirable or bad for a person is different from saying that it is undesired or believed to be bad by the person themselves. A disorder may be undesired, depending upon the condition, but it may not be. An addictive behavior pattern may be undesired, for instance, but perhaps not when its subject is high on a drug or winning wagers at a casino or horse track. Such a pattern, however, still is undesirable, whether or not the person appreciates this fact. So, what are the three facts that help to explain why disturbances or distressing conditions

which are classified as mental disorders are undesirable and ‘disorders’? The first fact is that a disorder is harmful or dangerous. A person is much worse off or markedly more poorly off when

the subject of a disorder than if mentally well-ordered, sound and healthy. So, for example, a person in the midst of, say, a major depressive episode, or someone in the grips of an obsessive compulsive disorder, is poorly off. Not only may these particular conditions feel bad (again, not all disorders or episodes of a disorder feel bad), but they are associated with harmful or deleterious behavior. The harm of a disorder may take the form of pain and suffering. It may take the form of death or a significant risk of death or of a severe decrement in personal freedom and mobility. Or it may take the form of being unintelligible or incomprehensible to oneself. To speak briefly of one of these: Being incomprehensible to self is no mere insignificant

occurrence, like the transient ignorance associated with occasional absentmindedness or garden varieties of forgetfulness or muddled thinking. Self incomprehensibility is a severe burden, a selfstultifying impairment. Victims of certain disorders just do not understand why they think, feel or act as they do. They vigorously distrust their own husband, although he has done no harm to them. They are deeply despondent, although they have just won a Pulitzer Prize. They are in the dark about themselves. Being in the dark about one’s own person means that an individual is incapable of rational

self-scrutiny or taking proper responsibility for self. Consider the disorder of clinical depression. One of the most intriguing hypotheses in Freud’s psychopathology is his notion that in a case of depression a person may develop free-floating or content-diffuse anxieties or concerns as well as loosened affective or emotional connections with previous sources of pleasure and satisfaction. Some depressed people care indifferently or are emotionally equally concerned, to employ Jennifer Church’s apt terminology, “for everything and nothing” (Church 2003: 181). Which is to say: Everything matters just as much to them, but also alas, just as little, as everything else. So, in effect, nothing matters or stands-out, neither the activities of daily living nor normal bonds of home or heart. A person loses resonant emotional connectivity with previously cherished goods. Engagement with the world may go flat or become sullen. Yet such an individual has perhaps just won, say, a Pulitzer Prize or married a much desired soul mate. So, why can’t the person in such a situation get their world to be emotionally resonant again – to be affectively and perhaps passionately cared for again, and with a set of emotional priorities which reflects that some things or persons matter much more to them then others? A depressed person just may not know why. They may be in the dark about themselves. “How could this happen to me?” “Why aren’t I happy?” “I should be happy.” “Shouldn’t I?” “I used to care for my spouse and children or my physical health much more than I do.” Depression is commonly classified as a mood disorder. But, of course, depression is much

more than that. A remark made by Annette Karmiloff-Smith about neurodevelopmental disorders applies to depression as well as to other sorts of mental disorder. This is that “a totally specific disorder [is] … extremely unlikely,” (Karmiloff-Smith 1998: 390). Depression, for instance, is not just a mood disorder or specific to a person’s feeling or affect. It also is a disorder of care and commitment as well as, oftentimes, of self-comprehension and self-understanding. The second fact about disorder that helps to make a disorder undesirable concerns its

non-voluntary and personally uncontrollable nature. Experiencing a mental disorder is not something a person willfully does. The onset of a disorder is not deliberate. It is not a self “disordering” – not a self-authored or deliberate effort to become disordered. One becomes disordered without intending and despite wanting not to be disordered. So, too, getting oneself

out of a disorder is not under direct or voluntary control. A disorder “gums up the works” and upsets the “proper working order” of mind and behavior (Feinberg 1970: 287-88). It psychologically impairs or incapacitates. So, a person can no more ‘snap out of it’, say, out of an obsessive compulsive or paranoid delusional disorder, than a person can snap out of scurvy or malaria. I do not mean by this that a mental disorder is all-over involuntary or that each and every

one of its parts, elements or phases is involuntary. Disorders are temporally persisting conditions. They stretch out over time. They are patterns of mind and behavior that recur, with different variations, in the texture and trajectory of certain pronounced phases of a person’s life. Take addiction. An addict may find it just too hard to free themselves of a self-destructive

behavior pattern. But the ambivalence about such patterns that characterizes many addicts, and the complex series of choices in which they engage while in pursuit of a drug or opportunity to make wagers, means that some aspects of the condition are under voluntary control (see Chapter 7 for detailed discussion). Or take the example of clinical depression. Depressive conditions include characteristic

thoughts, feelings, judgments, and dispositions to behave in different ways in interaction with other people and the environment. Some of these elements may, on occasion, be under voluntary control. For example, in thinking about whether to tell a clinician or family member that one is contemplating suicide, a depressed person may deliberately pick one or more circumstances or forms of expression in or through which to reveal their state of mind. My point about being involuntary is this: A person does not choose to be addicted. Or choose

to be depressed. Also: a clinically depressed person cannot be persuaded to cease having the disorder just by being told of the costs, risks or liabilities associated with being depressed. Being depressed is not a choice to be frowned upon and rejected after a concerted risk assessment or analysis of its costs and benefits. A person can’t help it. Often depressed people are acutely aware of its costs, but they cannot do anything about them. The same is true with addiction. Many addicts eventually do stop, apparently of their own accord (just as a depression remit or fade away seemingly of its own accord). But, in the meantime, addicts pass through numerously repeated cycles in which the ability to refrain becomes a depleted resource and ‘snapping out of it’ cannot be expected of a person. All of which may mean that an individual in the grips of a disorder, like depression or addiction, may require help or assistance from others or mental health professionals to be free of its incapacitation or to reduce its range or prominence. A person with a disorder may be unable to live decently, if live at all, without the aid or assistance of others, especially during crises or periods of reason-unresponsive and imprudent risk. We are used to people needing aid and assistance with somatic disease or injury. A victim of

breast cancer may be unable to survive without assistance (drugs, surgery, and so on) and the generosity and competence of others. So, too, a person who suffers, say, from a mental disorder like agoraphobia or delusional disorder (or depression or addiction) may be unable to function well or appropriately without the aid of others. The third fact presupposed by the concept of disorder is that a disorder is not excised or

extirpated from a person’s psychological makeup or economy just by the mere addition of other

psychological resources. The mind of a mental disorder is not made orderly or healthy merely by endowing it with other psychological assets. So, someone who suffers from, say, paranoid delusional disorder and is incorrigibly and imprudently distrustful of others, is not released from the grip of paranoia just by being fed with added doses of creative imagination. Added imagination may make their paranoia worse. A vivid imagination may more deeply entrench unwarranted convictions about why other people should be distrusted. A depressed patient who suffers from low self-esteem is not automatically cleansed, psychologically, of their excessively self-critical habits merely by being given special opportunities for social affiliation (a larger family, extra friends, and so on). Social contact may worsen a depressive condition when, in a darkly mood-ridden contrast and comparison with others, a person feels less successful, lovable, or worthy of the betterments of social life than other people. Compare the situation of a mental disorder with a somatic injury in this respect of not

being excised merely by compensatory additions. A person with a broken leg is not freed of this misfortune, the misfortune of the break does not disappear, just if they are endowed with more muscular arms or enhanced ocular acuity. As long as the leg remains broken, they are injured or in ill-bodily health. Likewise, as long as a depressed patient remains pessimistically self-critical, or a paranoid person persists in unwarranted social distrust, they are worse off. They are in mental ill-health. Such is the undesirability of a mental disorder. It gums up, impairs or partially incapacitates not just the mind’s works but the ready or simplistic repair of those works. So, a mental disorder is no mere “alien condition involuntarily suffered” (like a transient

headache, for example), to use an apt expression of the philosopher Joel Feinberg (1926-2004), quoted also just above, but it is something for which the simple grafting on of other psychological capacities, so to speak, neither heals nor covers up its wound (Feinberg 1970: 287-88). Unless the disorder itself is addressed, and its ‘gum’ removed by means that are proper and specific to a condition’s content and character, a disorder gets in the way of a person with the condition. It makes life worse. Just how much worse depends on circumstances, cases and contexts. Being worse off does

not mean that disorders are always and utterly devoid of some measure of compensation or secondary gain. It has been claimed, for example, that susceptibility to paranoia may encourage a healthy distrust of others in aberrant and truly threatening social environments or sub-cultures (Jarvik and Chadwick 1972). It also has been said that several prominent scientists and creative artists have flourished in certain particulars of their craft, if not whole person, despite (because of?) the travails of a bipolar disorder or other mental disorders (Simonton 1994). Different contexts or cases may offer different forms of compensation. But who would voluntarily and knowingly pay such steep prices for those ‘professional gains’? The alleged gains, no matter how arresting, do not eliminate the disorder. A disorder leaves an individual in harm’s way and typically in need of reconstitution or address. So: It’s no wonder that conditions classified as disorders are undesirable or thought of as

‘disorders’. They are harmful, non-voluntary impairments and not directly addressed or treated with mere added ingredients, no matter how worthwhile such ingredients may otherwise be or for other purposes. Added doses of imagination, for example, may be wonderful for a writer, but not if he or she suffers from delusions of persecution or paranoia.