I have been working in an inpatient psychiatric ward in a hospital for almost a year. It has been sad and joyful and sometimes boring or infuriating and full of discovery and very occasionally frightening. Before February, the last time I had been in an inpatient psychiatric facility was twenty years ago when I was a social work student at Columbia and I went on a visit to Ward's Island in New York. In between, I viewed inpatient psychiatry as the place where people who were 'truly mentally ill' were treated. By contrast, the people I worked with, people who were not in hospital beds, didn't seem ill in the same way that someone who is diabetic or has cancer is ill. Of course, I would speak of mental illness when I talked about moderate depression or anxiety or Asperger's syndrome. There are good reasons for this. I have always believed that a person's biology is intertwined with how his or her mind works. The things for which people seek the help of a therapist or a social worker are impacted by their brain chemistry, their genes, in short the organism in which the mind arises. And almost everyone finds having a mental illness -- a biological condition -- less shameful and frightening than being labeled crazy.
But I was never fully convinced that these conditions were illnesses like physical illnesses, either. I am not a doctor and perhaps my layperson's lingering idea of illness -- a microbe from without setting to work to destroy tissues -- is part of the reason I have resisted the description of these conditions as mental illness (most types of cancers and diabetes do not meet this definition of illness). Still, I imagined that behind the doors of a psychiatric ward there were examples of mental illness that clearly demonstrated a causal connection, while yet poorly understood, between disorders of the mind and the physical organism.
I feel like my ideas about mental illness have been made more confused not more clear by working with people whose minds are so disordered they need to be in hospital. I sat in the hospital hallway with a man who positively knew that someone was breaking into his brother's home hundreds of miles away. When I asked him how he knew, he could not give any answer except that he knew. The fact that his idea made no sense to others or to himself did not diminish its intensity. But it saddened him deeply; he understood -- at least in part -- that this thought was nonsensical, yet it was absolutely real for him. It seemed to me, at that moment, that something biological was clearly going on, as if this man had suffered a brain injury and it was only a matter of time before medical science could discover where exactly it was located and how he might be helped. I imagine that almost everyone who has worked with people with schizophrenia must have had this experience and yet the causes of schizophrenia remain unknown after a century of research, and treatment is focused on symptom management. This man has lived much of his adult life absolutely bubbling with paranoid ideas and the accompanying sadness and frustration of not understanding where these ideas come from.
There are people who come into hospital deformed by love. There are the suicide attempts and the severe depressive episodes brought about by failed or elusive love. Occasionally people with no previous history of mental illness come to emergency manic and delusional because love has gone wrong. On the one hand this is the most easy form of disturbance to extrapolate from for most people; everyone has experienced heartbreak or rejection and can imagine him or herself driven to extremes by love. But it is precisely this universality that makes those who end up in psychiatry unusual. After all, what makes one person see his love everywhere, believe she is sending him messages through strangers, chase her barefoot all over the city and fight with police and security guards, when nine hundred and ninety-nine other rejected suitors cry, listen to sad music and then move on? Is that the difference between health and illness? Or is it something else?
In the hospital psychiatry ward you can find people who just about everyone would agree are ill. Even though no one can explain exactly the mechanism, it seems that their biology is making their minds work very differently from the minds of most people and often in ways that feel awful to them and put them in danger. But mental illness of this unmistakable type is a I-know-it-when-I-see-it kind of phenomenon because for every clear-cut case there are people who are odd or sad or exuberant who fall in a grey zone.
None of the disorders treated by psychiatry today have a blood test or pathology lab test for diagnosis. They are all diagnosed by symptoms and reading symptoms remains quite subjective.
How we think about disorders of the mind has a real impact. One of the most powerful impacts is the use of drugs to treat mental disorders to the exclusion of talk therapy. Thankfully we have left behind the era of psychoanalysis to treat schizophrenics (as well as cruel theories about how schizophrenia was caused by bad mothering). But now we have moved to a situation where -- in Quebec, anyway -- talk therapy is almost never viewed as a way to treat mental illness despite its proven effectiveness for many -- though not all -- disorders. People discharged from hospital for surgery can get physio and occupational therapy to help with recovery as part of the services covered under their provincial health insurance. Psychotherapy is almost impossible to get in the public system either in hospital or out. I think that this is partly a function of not viewing talk therapy as a way to address a medical illness. How can an illness be treated by talking? As much as disorders of the mind may not look like illnesses, talk therapy doesn't look like medicine. Not to patients and not to doctors and certainly not to ministers of health.
Here is a story that illustrates the constraints of operating solely with a illness/health model of the mind. A man in his late forties was brought into hospital for running around in traffic. He was a chronic schizophrenic. How did we know? Because that was his diagnosis for many years. It was also possible that he had a mild intellectual handicap. Doctors over the years had examined him and observed symptoms that pointed to these conclusions. The psychiatrist I was working with spent a long time talking to him and his family. What we learned was that the man had experienced a terrible set of traumas when he was young and had used a lot of street drugs. He was very reticent but eventually he talked about the toll that the pain he had experienced had taken and his guilt over what he had done to others. For years he had been a patient of various psychiatrists who saw a painfully inarticulate, inwardly focused man who had gone spectacularly off the rails at eighteen and came to the conclusion that he was schizophrenic. But with time it became clear that he was a confused, deeply hurt person (absolutely no intellectual handicap) with very little if any of the psychotic features that are integral to schizophrenia. The voices that he had reported hearing telling him he was bad were much closer to the 'voice' I hear in my head telling me that I better get my work done than the voice a psychotic person hears which causes him or her to look for someone speaking. He had never, in the course of twenty plus years of psychiatric treatment, been given enough space to talk. When we asked him why he was running around in traffic pulling on car doors, he said "I guess I wanted to get away."
This is not just a story about misdiagnosis, "House goes to the psychiatric floor." It is a story about using the tools of medicine to examine something adjacent to -- but not the same as -- medicine. Not every affliction of the human heart calls for a cardiologist.