Disclaimer: This is an article about the definition of mental health. It is not meant and should not be used as advice on how to treat mental health problems. If you feel that you have mental health problems, please consult a specialist.
Can we draw a line between people with psychiatric disorders and those without? If we zoom in on a single individual, can we draw a line between that which is them or their self, and that which is the psychiatric condition? Well, in a sense it’s always possible to draw a line; all you need is pen and paper. But does the line track a real distinction, a truth which is out there for us to find? Or is it a construct? In short, is the line between people with psychiatric disorders and those without, and the line between a single person’s self and their condition, more like a shoreline or like a country border? I argue for the latter.
Can we draw a line between people with psychiatric disorders and those without?
Some people have a psychiatric diagnosis, whereas others don’t. This is an either-or-thing – either you have gotten diagnosed, or you haven’t. But what about the underlying reality that diagnoses are meant to track? Research indicates that things are less black and white if we look at people’s psychology. Most, or even all, psychiatric conditions exist on a spectrum.
This is, of course, not unique for psychiatry – we often find the same phenomenon if we look at the physical side of medicine. We might confidently say that Billy’s blood pressure of 105/70 is perfectly fine and normal, whereas Abby’s blood pressure of 170/95 is dangerously high. It would clearly be wrong to say that blood pressure is too high as soon as it exceeds 100/65, and also wrong to say that it only becomes too high if it exceeds Abby’s numbers. Still, the cutoff point of 120/80 is somewhat arbitrary. The difference between having 119 or 121 in systolic pressure is no more dramatic than the difference between having 117 or 119.
Psychiatric diagnoses are made by talking to people rather than measuring anything in their bodies, and the diagnostic criteria typically contain lots of vague words. However, there is no reason to assume that we would find sharp cut-off points even if we found reliable “bio-markers” for various conditions. Suppose that scientists were to prove that people with ADHD have less dopamine in their brains than others, and we subsequently began diagnosing ADHD through some kind of dopamine-measuring brain scan. We would likely find a continuous spectrum of dopamine levels, and would have to draw a somewhat arbitrary line to distinguish those qualifying for a diagnosis from those who don’t, much like with blood pressure.
It might seem obvious that a condition like ADHD, with symptoms such as forgetfulness, restlessness, impatience and so on exists on a spectrum – all people can struggle with these issues, and we diagnose someone with ADHD if their problems become severe enough. It might seem less plausible that psychosis disorders could exist on a spectrum – isn’t there a clear difference between on the one hand people who hallucinate and experience themselves as drifting into other realities and other worlds, and normal ones? However, it is common to occasionally “disassociate” to some extent, and feel the world around oneself grow dreamlike and unreal – unless it happens too often or is too distressing, this isn’t considered a disorder. Modern research even shows that a substantial minority of people who are not psychiatric patients regularly have little hallucinations, like hearing voices that no one else can hear – they’re just not distressed or impaired by it.
Thus, there is no neat divide, out there, in nature, independently of our diagnostic systems, between on the one hand those with a psychiatric disorder or condition and on the other the rest, the “normal” people. Likewise, there is no neat divide inside a diagnosed individual, between on the one hand those parts that belong to them, to their selves or their personalities, and on the other those parts that belong to the disorder or condition.
Thus, there is no neat divide out there between on the one hand those with a psychiatric disorder or condition and on the other the rest, the “normal” people.
This might seem surprising to some. People who have a psychiatric diagnosis are often told that it’s important not to identify with it. In the psychiatric literature, we find discussions of the self-illness ambiguity – the problem of not being able to distinguish between oneself and one’s mental illness – and how crucial it is to resolve it. So let’s unpack these ideas.
To identify with one’s diagnosis might lead to problems, depending on the details. First, your diagnosis might change over time, even if you, as far as you can tell, have stayed the same. It might change because you switched psychiatrist, since different psychiatrists often interpret the same patient’s story and symptoms differently, or because the DSM (the Diagnostic and Statistics Manual, which American psychiatrists use to diagnose their patients, and which has a large influence across the globe) was changed and your old diagnosis got replaced with a new, somewhat different one. For instance, the DSM used to contain the diagnosis “multiple personality disorder”, but it was replaced with “dissociative identity disorder” in 1994. Psychiatry professor David Spiegel, a driving force behind the change, argued that people don’t actually have several personalities; rather, DID patients have less than one full personality. (But who knows? Perhaps the diagnostic pendulum swings back again in the future.) Now, if you identified very strongly with your previous diagnosis – for instance, you thought of yourself as a system of several distinct personalities, and felt validated by your MPD diagnosis – you might feel upset or even have an identity crisis when the diagnosis suddenly changes.
Even if you don’t tie your identity to a particular diagnosis, you might strongly identify as mentally ill and feel attached to your “sick role”, for whatever reason. This can be problematic too if it leads you to fear the prospect of recovery. Finally, it’s usually a bad idea to hang your entire identity on one single peg regardless of what that identity is. Imagine, for instance, a football player who lives for the sport, has no friends outside of the sport, and no life plans except becoming a successful football pro, and then must give up their career due to a persistent knee injury. This might lead to a real crisis.
To draw a line between a person’s “self” and their mental illness or condition, we need some idea of what the self is.
However, you might identify with your diagnosis in some other way, not subject to the problems described above. Is it still bad to do so? Is it, perhaps, just false that I am an autistic, an ADHD’er, a bipolar, a schizophrenic, or whichever psychiatric diagnosis I have? Is it true that I am rather a person with autism, a person with ADHD, a person with bipolar disorder, or a person with schizophrenia? Is it a matter of fact that my condition is something other than me?
No. But neither is it a fact that my condition is a part of who I am – there is no fact of the matter here at all.
To draw a line between a person’s “self” and their mental illness or condition, we need some idea of what the self is. When we know what the self is and what it contains, we can also note what falls outside of its borders. And the more narrowly you conceive of “the self”, the more mental phenomena will count as external to it.
Some philosophers discuss what they call the deep self. My deep self is identified only with those traits, habits, desires and so on that I endorse or value. Bad habits, embarrassing personality traits, and inconvenient desires that I would rather do without, do not count as parts of my self on this narrow view. It would thus seem a promising candidate for a self-conception that can exclude the psychiatric condition from whom I really am. Nevertheless, not even a self-conception this narrow is guaranteed to keep everything that psychiatry counts as pathological out. If I endorse and value some symptoms, they might belong to my deep self!
My deep self is identified only with those traits, habits, desires and so on that I endorse or value.
Suppose, for instance, that I suffer from schizophrenia. I have some cognitive difficulties, as well as frightening and uncanny experiences of sliding into a different world where everything is distorted and nightmarish, and I experience threatening hallucinations of hostile voices and presences creeping around in the periphery of my vision. Despite all this, I think that my schizophrenia has certain positive sides as well: I write and paint, inspired by my schizophrenic experiences, and think to myself that I wouldn’t be the artist I am without it. Alternatively, I might value and embrace some vaguer experiences of shifting realities, even though I whole-heartedly detest the hostile voices. In any case, insofar as I come to embrace at least some aspects of my schizophrenia and see them as part of me, they might belong inside my deep self.
Notice, too, that the deep self view does not only allow for the possibility that one person’s cherished personality trait is another person’s ego-alien mental illness symptom – the same mental phenomenon in the very same individual can go from personality trait to symptom or the other way around over time. There are limits to how shifty and changing someone’s deep self can be, because it’s defined in terms of what we value, embrace, and identify with, not in terms of what we feel like or want in the moment. Nevertheless, given time, our values and identities can change and evolve.
In present-day philosophy and other fields, narrative self theories are popular. If I think of “my self” as the main character in the story of my life, there are clearly different options for how much goes inside the self and how much is left outside – there are different ways to describe the same chain of events, and different stories to tell. Psychiatrists Patrick Bracken and Philip Thomas have illustrated this fact with a case study, presented in two different ways. A woman diagnosed with an affective disorder was hospitalized for the third time in her life. She kept talking very fast to the point that it was difficult for others to keep up, she had mood swings, was easily irritated, spent way too much money on shopping, and was simultaneously obsessed with religion and the past. We can tell a story where she is the victim of a disorder which causes all these symptoms; a story in which talking all the time, spending lots of money and so on are events that happen to her. It’s like catching a cold, we might think; the common cold causes many symptoms, and sneezes, snot and fever can happen to the sufferer. According to an alternative picture, which the woman herself eventually came to embrace, she reacted to a tense and conflicted family situation at home; given this background, her behaviour and all her actions had explanations and made some kind of sense. In this second story, she did things for reasons rather than having various behavioural symptoms.
If I think of “my self” as the main character in the story of my life, there are clearly different options for how much goes inside the self and how much is left outside.
There doesn’t seem to be a one-size-fits-all-solution when it comes to which stories we should tell ourselves, and whether our behaviour should be understood as symptoms or purposeful actions. In Bracken and Thomas’ case study, the woman became much better when she came to think of what she had done as purposeful, comprehensible actions taken to solve a complicated family situation; doing so allowed her to talk things out with other family members, reach acceptable compromises, and even quit her mood-regulating medication. However, Mark Rego, another psychiatrist, has written about people with addictions and phobias who feel helpless to control themselves until they begin to see their condition as something external to them, which they therefore must learn to handle through more indirect means. Very likely, people with the same diagnosis can also differ in what’s the best approach for them – after all, the same psychiatric diagnosis usually covers a pretty heterogenous bunch of people.
There is no objectively existing border inside my mind between that which is “me” or “my self” and that which is “my condition”. Not only are there conflicting philosophical views on how to understand “the self” (and this is a philosophical question – we can’t move over to empirical science to settle the matter), not even a narrow self-conception like that invoked in deep self theory can support the idea that psychiatric conditions and all their symptoms are external to the self as a rule.
All we have are different narratives and different interpretations. This doesn’t mean that all narratives and all interpretations are equally good. Some may help with recovery or just make me feel better about myself, whereas others might be self-destructive. Still, it’s important to realize that we only have pragmatic and ethical metrics to use here – there is no independent fact of the matter, which my personal narrative might acknowledge or not.
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Sofia Jeppsson is an associate professor of philosophy at Umeå University, Sweden. She has published articles about free will and moral responsibility as well as more applied ethics papers on topics such as criminal justice and animal ethics. She currently focuses her research efforts on the philosophy of psychiatry and madness.
Cover image from Canva.