Definitions of madness

Famously, madness is sometimes described as "doing the same thing repeatedly and expecting a different result" (in other words, a rejection of inductive reasoning).

William, a psychodynamic psychotherapist guest-posting @ Feministe, asks more searchingly how we define madness, and what words we use to describe it.

Terms we have like “mental illness,” “insanity,” “pathology” and the like all come with pair of problems: they define mad persons by what they lack or their perceived deviation from the mean and they come with a built in negative value judgement of the experiential reality of mad persons. “Madness,” at the very least, observes that what it describes is something in itself rather than a lack of some privileged value. It gives a nod to madness as real, as an experience of something.

I've always preferred to talk about my depression and related symptoms (more on which later) as an illness, because it's something that I deeply experience as a deviation from my usual disposition and functionality. I have a norm defined in terms of my own natural balance (rather like, in physical health, my GP thinks that my resting blood pressure is "normally" towards the high end of the normal range of a human at rest - my natural balance isn't slap bang in the middle of the average). When I have depressive episodes, I deviate strongly from that norm. This has definitely negative effects in various ways.

But at the same time, it is an experience in and of itself. Not every depressive attack is disastrously bad or dangerous or horrible, and sometimes I can ride it out quite comfortably (although I would not call the experience particularly comfortable at the time). On this blog I have happily identified as "crazy" or "mad" as well as "mentally ill" or "having a mental health problem" with respect to depression.

William's discussion of symptoms (see, I told you it would be back!) strikes me as being very potent, at least in terms of getting me to think deeply about what my experience means (which, at nearly 5 in the morning, is not necessarily helpful, but hey - I'm here now!)

Take symptoms, for instance. Everyone knows what a symptom is, right? A symptom is how we know a patient is mad, its the mark of weirdness, something that disturbs the patient or those around them enough to make them seek (or be forced into) treatment. That answer, while sufficient for saying “hey. I’ve got this symptom,” is only the very beginning of our understanding of what a symptom means and that meaning is deeply informed by how we understand madness. -warning, gross oversimplifications ahead- If we understand madness as a mistake of reasoning or perception, then a symptom is something to be disproved. If we understand madness as pathological conditioning, then a symptom is something to be trained away. These two understandings underly the thinking of Cognitive Behavioral Therapy (CBT). If we understand madness as a chemical, medical, neurological disease then symptoms become the subject of medical interventions. We could understand madness as a state of incongruence, of being out of step with one’s self as the Rogerian/Person-Centered movement does. We can, like the psychoanalysts, understand madness as an experience of personal history, with symptoms being the expressions of things otherwise incommunicable. Each of these understandings come with values and dictate very different forms of treatment.

Now, in a very real way I have experienced depression as presenting symptoms that were examples of false perception or reasoning. The trouble is, because they function on an emotive and not factual level, treating them as "things to be disproved" is boxing shadows. The approach that I have found helpful has not been disproving the mistaken thoughts and feelings, but finding different ways of reasoning about them. I don't know a huge amount about CBT (except that the initials make me snigger, because there's a BDSM practice with the same abbreviation) but from what I've gathered, it's closer to the way that I deal with stuff when I'm not depressed, which is also a system of emotional reasoning - for instance, when I decided I wanted to start exercising, I set limited targets that I knew I could manage and as I got better at it, gradually extended my programme, producing a string of "success" mental rewards (a similar approach reflects my attitude towards to-do lists vs schedules). In that sense, I suppose, it does work to "disprove" the notion that I cannot do exercise.

But the main functional cause of symptoms seems to be a neurological chemical imbalance of some kind - such that when I had a really bad episode in 2007, being prescribed an SSRI really did help to steady the ship and bring the perceived symptoms within the scope of other types of therapy.

When I wrote above about having a personal norm, from which my depressive episodes are a distinct and clear deviation, I was talking more in terms of the Rogerian/Person-Centred counselling approach. But wrapped up in that is that my "normal" sense of how things are is often really skewed and broken when I'm suffering from depression, which also affects how I see myself leading to the "incongruence" mentioned by William.

Finally, I can pretty much trace back to issues I don't talk about in any public space, and to the difficulties of growing up kinky in a world that defined that as a mental illness/perversion in itself. That has been its own long journey of healing in other ways, that has not been smooth or comfortable. It also hasn't stopped depression attacking every so often, and the healing isn't fully over, as my breakdown last year pretty much proves.

Crucially, I haven't found that knowing or understanding how these troubled childhood experiences (I'm assuming you guessed that the reason I don't talk about it here is because it's troubling, right?) affected me, has helped a huge amount in overcoming the issues that I have encountered since, so for me, the psychotherapeutic approach hasn't been very valuable in terms of helping me. I like to understand stuff, and I think there is certainly a lot of weight to be given to the ways in which our experiences shape us. But it is not always useful knowing where the troubles come from originally, to say what should be done about them now.

As CBrachyrhynchos says in comments @ the Feministe thread:

I don’t see the paradigms you describe as mutually exclusive. I see few conflicts between between:

1) this is a problem that has origins in my history (psychoanalysis)
2) this is a problem that doesn’t necessarily apply to my current situation (CBT and meditation)
3) this is a problem which can benefit from medical treatment (psychiatry.)

History describes how I got got here, CBT and mindfulness helps me be aware of exactly where I am, and medication helps to turn down the thermostat so that I can be mindful of what’s really happening.

I've tended to find looking at the present and what needs to be fixed to keep things working, to be more helpful than looking at the past. It helps to know where things came from (A personal mantra is, "know your past, understand your present, choose your future" - the slogan from the Timerope novels), but that in itself doesn't fix things, for that I need to know not only how it came to be broken but what the nature of the break is and what I need it to do (this is how I also deal with household repairs that I attempt myself). To figure that out, we look to the present and the future.

That "household repairs" paradigm is what works for me in terms of describing my own ongoing mental state. At home, I cobble things together, jury-rig, figure out a way to get the functionality I need from a thing. Similarly, I recognise that some of the breaks and troubles in my mind are permanent, so instead of "repairing" them, I find a way to fit the bits together so that they work day-to-day.

William asks at the end of his post:

how do you, personally, define health and illness?

I struggled with this one, because initially I wanted to talk about congruence: being comfortable with one's own mental state. But I realised that that wouldn't really work on its own, because in the past I have had mental states that didn't distress me at the time but perhaps should have done (and that lack of distress in itself counted as a symptom). Those mental states were directed towards others.

Commenter karak gave the following:

1. someone who is distressed by thoughts or behaviors they cannot control –and is unable to function properly in society
2. someone who distresses others with their thoughts and behaviors–and is unable to understand why others are distressed, or stop engaging in those behaviors–and is unable to function properly in society.

[NB: now finishing writing the post at a more sensible hour of the day, after some sleep!]

I feel that this is still incomplete, because not all thoughts that would be distressing to others lead in the end to distressing behaviours and, if at the time of those thoughts they go unexpressed as either word or deed, then the people who would be distressed if they knew about them are not going to be distressed after all. But the thoughts are the mental events that serve as symptoms; people reacting to them doesn't seem necessary in order to say that there is a mental illness present.

There's also a problem in that the wording of point 2. could conceivably be understood as referring to homosexual behaviour: it seems rather obscene and oppressive to say that LGB** folks should "understand why their behaviour causes distress" to those people who are distressed by the fact that homosexual thoughts and behaviours happen, or that when society is still built around an ideal of hetero-monogamy, that gay folks who struggle to function in society should be considered "mad". Sometimes, being unable to function in society is a sign that society needs to change.

[**The rest of QUILTBAG identities could obviously be presented as a similar argument]

Alternatively, you could flip it around: homophobes, racist people (i.e. nigh-on everyone in a society where racist messages infiltrate so many of our sensory/media experiences), sexist gits etc, all act in ways that cause distress to others. They often seem unable to grasp why their behaviours cause distress and often use the excuse that it's "just the way I am", either unwilling or unable to change their behaviour. The only thing that makes these people not "mentally ill" according to karak's definition, is that far from being "unable to function in society", society is built around the ways that they function, thus making the people who experience distress because of them seem like the ones who are "mad" when they respond to the distressing behaviours. Heck, that's pretty much the essence of the "Tone Argument" fallacy.

While I like the idea of saying that racism, sexism, homophobia etc are types of mental illness, the fact that it can be used either way around seems to indicate that karak's definition, while the closest one I've read yet in the comments there to how I feel, still is in some ways too narrow, and in some ways too broad, to be useful.

I think "distress" is a key factor. I think the subjective experience of loss of voluntary will (that is, whether or not a person can actually stop it or not is not so important, as long as they feel like they are powerless to do so) is another key factor. But some things that are healthy thoughts get caught up in that: for instance, I experienced a lot of distress over my BDSM sexuality as I was growing up, and I certainly don't seem to be able to turn off those thoughts. But it turns out that those thoughts are a healthy part of who I am: they form the basis of my sexual orientation (which in my experience is much less to do with a partner's gender or primary sex characteristics). How do I tell the difference between the healthy thoughts that cause distress (e.g. BDSM in my case), and thoughts/behaviours that are decidedly unhealthy?

One possibility is to look at the nature of the distress involved: is it caused purely by a clash with societal norms (for example, being gay or, in my case, being kinky) or is it caused by a personal relationship to the distressing thoughts or behaviours (that is, they affect/relate to another person, personally and directly, or else they cause a dissonance with the sufferer's own value system and sense of self)? It certainly seems to cover the distinctions between the healthy and unhealthy thoughts that I have experienced, although there are some that are kind of blurry under both (I believe that my depression is caused in part by the distress that I felt growing up kinky, so there's some overlap between the healthy and unhealthy processes).

As I have become more able to handle things, and have built better jury rigs for the parts of my mind that need them, the line of what is "unhealthy" and what is "healthy" seems to be shifting, so that more things are healthy now than used to be. More things are under my control, or I can handle the things that aren't so easy to control so that they don't cause as much distress. I am "normal for me", which sometimes means protecting those jury-rigged bits (i.e. avoiding triggers or distressing environments) and sometimes means experiencing lows and difficulties from depression, but mostly my mind seems to be in good order as long as I keep a half-competent engineer (moi!) looking after it (my brain: the mental equivalent of the TARDIS or a Firefly! Possibly more like the TARDIS, because it often doesn't take me where I want to go, but where I need to?)

On the other hand, with this idea of personal vs social pressures, it seems important to recognise that I don't mean pressures such as overwork leading to stress-related illness. While it is hard to articulate why there is a distinction, I am sure that there is one and that stress does count as a mental illness.

So something closer to my internal definition of mental illness would be:

1. Experiences thoughts and/or behaviours that cause distress to self or others, or could reasonably be expected to cause distress to others if they know of them
2. Is unable to control these thoughts or behaviours, or feels as though they are uncontrollable
3. The distress is caused by a conflict on a personal level rather than caused by a conflict with purely social pressures

It is interesting to note that my "jury-rigged mind" still feels "mad" to me, even when I am functioning well and not in any particular distress over anything (that is, not "mentally ill"). Those things I mentioned of manoeuvring to protect the damaged areas, of experiencing some dark periods, even though I control their impact well, and so on, these things still feel like elements of being non-neurotypical. So there's a definite distinction in my thinking between madness and being mentally ill. Mad means to me simply that there's some condition or experience to deal with; illness is when the dealing isn't going so well.