Who is mentally ill?

Sometimes as the group leader in my psychoeducational groups, I’d start my standard rap on psychopathology by writing two words on the board: sad and depressed. Then I’d ask, “Do these two words mean the same thing?” After listening to responses from group members, I’d proceed in this manner: Yes and no. On the street they’re synonymous, but to a psycho-diagnostician they can be very different things. Sadness is a universal human experience. Sometimes we can identify the reason or reasons for our sadness, other times not. When a person says, “I’m depressed because my friend is moving away,” they’re likely describing “normal” sadness that will probably diminish over time.

Sadness is a mood, and moods come and go. If a sad mood becomes persistent and affects your functioning, depression may be a better description for the experience. This persistent mood may also be due to an identifiable cause, such as a romantic breakup, or it may be unrelated to life circumstances. The former is referred to by some  clinicians as “functional” (caused by some external circumstance), the latter as “endogenous” (caused by internal, biologic factors). This isn’t an absolute distinction in all cases, but it has its utility.

There’s a deeper level of depression that isn’t a universal experience. Even at the lowest points of my life, I’ve never been as sad as the clinically depressed people I’ve known personally and professionally. People living with this kind of depression may experience hopelessness, despair, and suicidal ruminations. I’ve never been there, and I have great compassion for those who have.

One way of classifying psychopathology is assigning people to distinct diagnostic categories. You either do or don’t meet the diagnostic criteria for depression, or schizophrenia, or bipolar disorder, or antisocial personality disorder. If you don’t have the disorder, you may have traits associated with it. Another way of classifying pathological traits is to view them along continuua: straight lines with opposite poles. Everybody can be placed somewhere on a continuum between happy to be alive and suicidal, gentle and violent, honest and dishonest, paranoid and trusting, and other traits and tendencies.

If I’m extremely unconventional but functional, some people may refer to me as “crazy,”  but to others I’m merely eccentric. If I’m unconventional to the point I can’t function in society and may endanger myself or others, I could be mentally ill. In my graduate program in humanistic psychology, we didn’t even have a course titled “Abnormal Psychology”; that was considered too pejorative. Our course was titled “Unconventional Modes of Experience,” lest we apply unnecessary or judgmental labels to people.

Psychopathology is characterized by impairment or disability. I have obsessive-compulsive traits, but I don’t think of them as pathological, because I’ve been able to recognize, control and channel them. I’ve had doctors and lawyers tell me that they never could have made it through medical school or law school if not for obsessive-compulsive traits. You too may have traits of a mental disorder, but not meet the diagnostic criteria, because you’re not impaired by them. For instance, you might have some symptoms of depression, but not be pathologically depressed. Or you might have paranoid traits,  but not be diagnosable as having a paranoid disorder. The hyper- vigilance characteristic of a truly paranoid person might even be desirable, if you’re a spy.

Even if you have a diagnosed mental illness or engage in crazy behavior, you can’t be involuntarily committed to a treatment facility without a Probate Court hearing. (I only refer to behaviors as “crazy,” not people.) In most states you must be interviewed before the hearing by two Designated Examiners (DEs), one of them an MD, and have court-appointed legal counsel to represent you at the hearing. In order for you to be involuntarily committed, both DEs must agree – and convince the court – that you are of danger to yourself or others, due to a diagnosable mental illness. I’ve had the privilege and responsibility of being a DE for most of my career, and in my experience the system works most of the time to prevent people from being “railroaded” onto locked wards against their will.

Mentally ill people are often shunned, and even blamed for their symptoms. With good treatment most mentally ill people can function in society, although some are too disabled to hold a steady job. All people with mental and emotional illnesses deserve good treatment, regardless of income. But unfortunately, state mental health systems all over the country are terribly under-funded, and many folks don’t get the treatment they need to remain functional. A significant portion of homeless people have mental illnesses. Hospital ERs, jails, and prisons have become major mental health service providers. I’ll describe how we got to this sorry state of affairs in a later post.

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