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Friday, December 11, 2009

from Lawrence, Pub Philosophy Group, Sunday meeting: Perception of mental diseases in our society.

Dear friends,
This Sunday we are discussing a rather delicate but important topic of
mental disorders, precisely, Perception of mental diseases in our society.
It is delicate because mental health is a sensitive issue and important
because none of us can be guaranteed that we might not pass through
episodes when our brain in not functioning on all pistons. But does all
this sensitivity result in a well structure attitude towards mental
health? Maybe not, let's discuss it on Sunday.
See you Sunday,
Take care,
Lawrence

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Perception of mental diseases in our society.
The brain is a complex system, certainly one of the more complex systems
we find on Earth. It is also a mechanical physical and chemical system
subject to the limits of mechanics, chemistry, and physics.
That the brain sometimes does not operate at an optimal level is a
common phenomenon. We may even expect it not to function optimally
during periods of our lives, memory loss is a common example. Our topic
is therefore about how we react when things go wrong. How we react also
depends on how serious any problems with the brain are?
A question we have to ask ourselves is what can philosophy say about the
topic of mental disorder? A topic that is today the domain of medicine
and psychology. I am using mental disorder here to include terms such as
mental health, mental illness, and mental disease. Moreover, mental
disease is, in retrospect, too limiting for a philosophical discussion
as I hope to show later on. In the meantime a complete discussion on the
philosophical issues of mental disorders is found in the article by
Christian Perring, "Mental Illness", in The Stanford Encyclopedia of
Philosophy (Perring, Christian, "Mental Illness", The Stanford
Encyclopedia of Philosophy (Fall 2008 Edition), Edward N. Zalta (ed.),
URL =
<http://plato.stanford.edu/archives/fall2008/entries/mental-illness/>.)
I will therefore limit myself to a few ideas I think are worth
considering in themselves.
If you enter the web site of the World Health Organisation at
http://www.who.int/topics/mental_disorders/en/ you will see (as at 10
December 2009) a statement part of which includes: Mental disorders
comprise a broad range of problems, with different symptoms. However,
they are generally characterized by some combination of abnormal
thoughts, emotions, behaviour and relationships with others.
This statement practically covers everyone on Earth that has lived or
will ever live. It is therefore not surprising that mental disorders is
a subject that is at best elusive and at worse an unfathomable part of
human nature. So what is a mental disorder is not an easy subject to
establish. Never mind establishing the meaning of "mental disorder" what
about the meaning of abnormal in the WHO introduction? Moreover, there
is also the language gap between the meaning of words such as "mental
disorder" in a professional context and in common day use.
And to compound the situation what we, in the west might call a mental
disorder, in other regions such problems might not even be considered as
mental problems at all. Christian Perring in his article goes even
further, "Indeed, other cultures may not even have a concept of mental
illness that corresponds even approximately to the Western concept."
So the first philosophical issue is precisely what is metal disorder and
what do we mean by it? The de facto references for mental disorders in
medicine, and other professions, are 1) the Diagnostic and Statistical
Manual of Mental Disorders (DSM-V) and published by the American
Psychological Association (a revised version will be published in 2012)
and 2) The International Classification of Diseases is published by the
World Health Organization, and according to the Wikipedia article on
this reference ICD-11 is due in 2015. There is also an European
classification, but we need not go into such finicky detail for our
discussion.
But is philosophy, and for that matter other disciplines, bound to
accept these standard classifications? Even if for the sake of argument
we accept that these classifications are legitimate scientific
classifications, shouldn't a philosophical discussion take a broader
view of the topic? First, philosophy addresses issues that rational
agents usually have to deal with in life. And by rational agent I do not
mean the superhuman being which economists speak of, but rather the
opposite, the down to Earth "normal" or "average" human being who has to
live on this Earth. And that would include you, me and the people we
know. In other words, since the topic of mental disorders is such a
nebulous subject, it is a legitimate topic for philosophical discussion
and analysis.
The second reason why we need to take a broader view of the subject is
that the classifications themselves try to be all things to all people.
Consider this quote from the Wikipedia article (10/11/2009): "Robert
Spitzer, a lead architect of the DSM-III, has opined that adding
cultural formulations was an attempt to placate cultural critics and
that the formulations lack any scientific motivation or support."
However, the reason for a broader term of reference is precisely because
people have different opinions about what is and what might not be
mental disorder.
Take for example one of the current controversy with DSM-V: Gender
identity disorders; 302.85 In adolescents or adults; 302.6 In children;
and 302.6 Gender identity disorder NOS. This classification "describes
the attributes related to trans sexuality, transgender identity, and
transvestism." (Wikipedia, Gender identity disorders). The controversy
relates to the issue of whether transsexuality is a natural phenomenon
some people experience or a mental disorder. Most people in Western
society would regard this as a natural phenomenon and something for the
individual to decide what lifestyle they adopt. In many countries,
including theocratic states, homosexuals are still put to death if they
are caught or discovered. See for example the case of Nemat Safavi, in
Iran, who has been condemned to death for being homosexual.
However, our scope in taking a broader meaning is not to rearrange the
classification references that serves as practical guidelines for the
medical profession. But rather, by taking a broader view we can consider
behaviors that may or may not be part of the concern of other
disciplines. We only want and need to broaden our scope and not
reclassify a scientific document.
For example, by taking a wider view of mental disorder, we can consider
whether discrimination and racism are mental disorders or natural
phenomenon. Indeed, discrimination and racism are very serious issues
not only in our society but throughout humanity especially when bogus
science or bogus ethics are used to declare a mental disorder precisely
to discriminate. The treatment of homosexuality is an obvious case in
point. But it gets worse than that, discrimination against women, short
people, people with mobility problems or obese people are examples of
discrimination were perception plays a important part. Today there are
still countries and societies where discrimination against women is an
institutional and state policy.
Apart from being immoral and probably illegal by international
standards, shouldn't discrimination and racism be classified as a mental
disorder? Something that requires treatment rather than be enshrined in
institutional policies or collective beliefs, that sometimes go under
the guise of culture or religion.
And this is precisely another important issue for philosophy concerning
mental disorders: what kind of methodology is used to establish what is
to be considered a mental disorder? Indeed, the question of
methodologies is identified as an issue in the introduction of the
article on Mental Disorders in Wikipedia: "Mental health professionals
diagnose individuals using different methodologies, often relying on
case history and interview." In the other extreme Spitzer's comments
above suggest that sometimes non scientific criteria are included in a
reference manual that is supposed to be a scientific point of reference.
It is evident that what we perceive as mental disorder depends who we
are and from which point of view do we look at the issue. However, what
seems to be clear is that although establishing the extreme cases of
mental disorders, such as schizophrenia or depression, seems to be an
established science even if it is a difficult one, in many cases the
methodology used to establish a mental disorder is not always based on
the scientific method. What is the science behind homosexuality that
justifies it being a taboo, or worse, a crime? Of course there is not
such science.
One of the complaints against the classification of mental disorders is
that this is a Western classification based on what is taken as science
in the United States, Europe and other Western countries. The charge is
that our science does not take into consideration other cultures and
other beliefs.
Of course, culture can never be the basis or part of the scientific
method, and certainly not religion or collective beliefs. However, from
our point of view as philosophers we have to ask ourselves: is the
scientific method of experimentation, objective reporting of evidence,
statistical analysis and falsifiability of theories being applied
correctly? And once we have establish that the methodology we apply does
conform to the notion of what is science (errors and omissions not
withstanding) we then have to ask ourselves, why would someone want to
include non scientific criteria in the classification of what is or what
is not a mental disorder?
And this is why mental disorders raise important ethical issues that,
maybe, other disorders do not raise. For example, I doubt if a question
such as, what is our perception of cholesterol disorder? makes much
philosophical sense. In my opinion, mental disorders raise ethical
issues, first and foremost, because we all recognize the limitations, if
not imperfections, of the brain.
A number of ethical issues surround mental disorders. I have already
discussed the issue of discrimination and racism in the context of
mental disorder. An other ethical issue is of course treatment for
mental disorders. Never mind the extreme or obvious cases which are the
domain of psychiatrists and neurologists, how should other institutions
such as the law and business deal with mental disorder? And what is
mental disorder for jurisprudence and business? Are bosses or colleagues
at work who are jerks suffering from some form of mental disorder? See
for example a review article by Tom Davenport, Why jerks are bad
decision-makers (BusinessWeek online August 7, 2009)
A practical ethical issues is linked to treatment. If mental disorder is
a health issue, than our perception is that we have to be treated for
it. Indeed, this is the fundamental philosophy of Western medicine. The
anomaly, however, with the WHO and APA documents is that they don't
guarantee treatment. Some countries do not have universal health care at
the point of need and some others do not even have any heath care at
all, at least none to speak of.
The practical ethical issue we have to address ourselves is whether
mental health classifications are elitist charters. These
classifications are alright if we can get treatment for any of these
disorders, but what's the point of a universally valid science if it
does not benefit people universally. Science, after all, can still be
advanced with gentlemen-scientists or lady-scientists financing and
pursuing their hobby. But that is not our perception of science and
technology today. Incidentally, the same argument can used about the UN
Charter of Human Rights.
I introduced the subject of ethics regarding mental disorder by asking
the question, why would someone want to introduce cultural issues in a
scientific methodology? And I have already discussed the scope of
culture in science which is basically nil. But this does not mean that
culture or even collective beliefs do not have a scope in a debate on
mental disorder.
In fact, I would argue that the issues and scope of culture or
collective beliefs in a debate on mental health centres on two basic
questions: 1) is culture introduced in the debate on mental disorders to
protect and safeguard the rights of the person with such disorders? Or
2) is the cultural element introduced to take away the rights of the
individual?
And to answer these questions I will use the same example I used
already: is trans sexuality classified as a mental disorder to protect
the rights of the individual to pursue a life style of their choice or
is it there to institutionalize (or worse) these persons simply because
we don't like their lifestyle? Whether someone's lifestyle should or
ought to be subsidized by the state is a different issue although, maybe
in special circumstances it ought to. But as far as institutionalize
someone because of their lifestyle than most people on this planet
qualify to be institutionalized.
So once we have a genuine scientific classification of mental disorder,
the next obvious concern would be, is someone with mental disorder a
danger to themselves and to others?
Our perceptions of mental disorders also determine the morality we apply
to the debate. And I am not necessarily thinking about stigma,
discrimination and lack of charity towards people with serious and real
problems. These issues have already been discussed elsewhere including
the references I have used so far.
Indeed our perceptions determine directly or indirectly the very
treatment and therapy those who do have real mental disorders receive.
And our perceptions lead us to demand treatment that deals with the
overt and public behavior of people with mental health issues.
Basically, to put it bluntly, we are generally interested in the mental
health problems of others to the point where they stop bothering us.
This may or may not be a natural attitude, what is important, however,
is that this is more or less what happens in society in general. Very
few people take the time and effort, never mind the resources, to
discover and solve the causes of mental disorders. As long as the
behavior os under control, all is well.
Maybe this is unfair, since sometimes the effects (behavior) are
temporally very far removed from the cause. For example, mental health
problems experienced during adulthood as a consequence of child abuse.
Of course, an answer to child abuse is not necessarily to make treatment
available freely when needed in adulthood. But rather to introduce
policies, such as fair housing, income stability, non discriminatory
attitudes that might minimize, even if not eliminate, a hostile
environment in the home. But that's a tall order, certainly more
involved and complex than a forty minute session with a shrink or the
price for a pill.
Our natural distaste of unsocial behavior leads us to demand a short
term solution instead to addressing the causes of mental disorder and
deal with the problem at source. As I have just said, if behavior is
under control, all is well. I started this essay by saying that the
brain is a complex system and every human being on this earth is in
possession of one. However, up till now we have given the impression
that we used our brain precisely to block any perceptions of the causes
that affect many a troubled brain. Maybe the time has come to broaden
our perception enough to consider all aspects of the workings of the
brain and not just the effects.
Take care
Lawrence

from Lawrence, Pub Philosophy Group, Sunday meeting: Perception of
mental diseases in our society.

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