Normality is not the point—harm is.
—Derek Bolton, What Is Mental Disorder? An Essay in Philosophy, Science, and Values
Some moods or emotional states are so distressing or inhibiting that they call for psychiatric help. Severe depression can be so devastating that medication or therapy can save the person’s life. But is the net drawn too widely? Critics say that feeling depressed over doing badly on an exam, or when left by someone you love, is not illness but normal response. They also say that extreme shyness is wrongly medicalized as “social anxiety disorder.” These expanding boundaries of psychiatry may benefit pharmaceutical companies, but should the range of “normal” emotional life be narrowed in this way? If a line is to be drawn between variations of mood in normal emotional life and those harmful enough to call for psychiatric help, where should it come?
Depression is a disorder of mood, so mysteriously painful and elusive in the way it becomes known to the self—to the mediating intellect—as to verge close to being beyond description. It thus remains nearly incomprehensible to those who have not experienced it in its extreme mode, although the gloom, “the blues” which people go through occasionally and associate with the general hassle of everyday existence are of such prevalence that they do give many individuals a hint of the illness in its catastrophic form. But at the time of which I write I had descended far past those familiar, manageable doldrums.
—William Styron, Darkness Visible
What should be the boundaries of “major depressive disorder”? In DSM-5 this diagnosis is based on having had one or more “major depressive episodes.” An episode is monitored over two weeks. For most of nearly every day the person must show five or more symptoms, in a way that differs from how the person was before. The symptoms must include at least one of two key symptoms: the person must be depressed and/or show loss of interest and pleasure.
The other symptoms are unusual weight change, disordered sleep, agitated or slowed movements, fatigue or loss of energy, feelings of worthlessness, inappropriate guilt, indecisiveness, impaired concentration, and either a planned or attempted suicide or else recurrent thoughts about death or suicide.
The diagnosis is not made where there are likely alternative causes, such as other medical or psychiatric conditions or medical or recreational drugs. The disorder is diagnosed only when the symptoms cause significant distress or impaired functioning.
It is also worth notice that, although mourning involves grave departures from the normal attitude to life, it never occurs to us to regard it as a pathological condition and to refer it to medical treatment. We rely on its being overcome after a certain lapse of time, and we look on any interference with it as useless or even harmful.
—Sigmund Freud, Mourning and Melancholia
Is not grief simply a reaction to a life experience? How can one put it into the same category as the pathological states we call disease? To this we answer that it is “natural” or “normal” in the same sense that [wound or burns are] the natural or normal responses to physical trauma.
—George Engel, “Is Grief a Disease?,” Journal of Psychosomatic Medicine, 1961
In different editions the DSM account of major depressive disorder has varied on whether or not to include grief on being bereaved. In DSM-4 the symptoms did not count if they were part of normal grief when bereaved. (Sometimes bereavement causes mood disorders. To exclude these cases, normal or “uncomplicated” grief was contrasted with grief that lasted more than two months, or that had marked functional impairment, psychotic symptoms, or other symptoms such as preoccupation with worthlessness or suicide.) In DSM-5 this exclusion has been given up. The previous exclusion and the current inclusion of grief have both been controversial.
Should “normal” grief be seen as a disorder, calling for psychiatric help if available? Or is this to wrongly medicalize an experience that is part of normal life?
The exclusion of normal grief has been challenged as arbitrary. Grief, like other sad or low emotional states, involves distress and can impair a person’s functioning. It often involves depression and loss of interest and pleasure. Jerome Wakefield and others found that, for eight out of nine indicators of disorder, the profiles for “uncomplicated” grief are not significantly different from major depressive disorder.1 Where normal grief also causes fatigue, insomnia, and weight change, only its specific exclusion would prevent it from being diagnosed as a major depressive episode.
George W. Brown and Tirril Harris, in their classic Camberwell study of female clinical depression, included bereaved women with major depressive symptoms. They thought that exclusion would let assumptions about causes distort their study.2 They also brought out the role of previous bereavement in causing depression. Unsurprisingly, depression was often triggered by some bad event or major difficulty. Most women in the study had such problems, but of those only a fifth developed clinical depression. A deeper account had to look at the interaction between the triggering problem and other things in their lives. Factors influencing the development and severity of depression included weak or emotionally poor social ties, having more than two children living at home, and having no outside employment. By far the strongest factor affecting the severity of depression was previous bereavement, especially loss of a mother before the age of 11.
The clear parallels between grief and clinical depression, and the link with previous bereavement, make a case against excluding normal grief as a quite separate phenomenon.
But there is a case against including normal grief in “psychiatric” depression. Wakefield and his colleagues observed the similarities but ran the argument the other way. Perhaps “uncomplicated” depression following other losses should also not be seen as disorder. What matters is whether the grief is out of proportion. This is part of a strong case for moving from symptoms abstractly described (“loss of interest and pleasure,” and so on) to states seen in context and evaluated for their appropriateness. This would allow finer discriminations. There is a hint of pathology in grieving for months for a great-uncle you hardly knew. But no pathology is needed to explain why grief for a loved lifetime partner, or for your only child, lasts long and may never quite go away.
George Engel’s analogy with a burn suggests that grief is harmful. But the comparison was too hasty. Yes, a burn still needs treatment despite being a normal response to some physical traumas. But grief is not the same. We do anything to stop the pain and damage of a burn. But for grief, values and interpretation are central: “Before classifying, before thinking, before trying to do anything—we should listen.” Jonathan Shay argued against defining as a breakdown the grief of the Vietnam veterans he worked with. Opposing “crudely medicating soldiers because they weep,” he said the returning soldier needs “not a mental health professional but a living community to whom his experience matters.”3
Is grief harmful? One response is that we would be poorer without it. Perhaps being fully alive means experiencing the deepest things, including painful ones. Intense sadness may be a valued alternative to the disturbing lightness of a person who feels no grief when someone close dies.
What matters is what it means to us. It can be seen as part of the seriousness and depth of the relationship. Julian Barnes, in his Levels of Life, describes his grief at the death of his wife, Pat Kavanagh. He did not want it evaded. He mentioned her name at a dinner with friends. They ignored it. He mentioned her twice more and they still ignored it. “Perhaps the third time I was deliberately trying to provoke, being pissed off at what struck me not as good manners but as cowardice. Afraid to touch her name, they denied her thrice, and I thought the worse of them for it.”4
Another friend of Julian Barnes, who herself had lost her husband, wrote: “The thing is—nature is so exact, it hurts exactly as much as it is worth, so in a way one relishes the pain, I think. If it didn’t matter, it wouldn’t matter.” At first the phrase about relishing the pain struck Barnes as unnecessarily masochistic. But later he realized, “I know that it contains truth. And if the pain is not exactly relished, it no longer seems futile. Pain shows that you have not forgotten; pain enhances the flavour of memory; pain is a proof of love. ‘If it didn’t matter, it wouldn’t matter.’ ”5
To someone who interprets it in this way, grief is emphatically not harmful. Some people do accept medication to ease the pain of bereavement. Others would reject a pill to reduce or eliminate grief. Different people’s grief is linked to the meanings they place on it. The questions of interpretation are of a different order from those raised by a burn.
So what is the proper domain of psychiatry; or rather, of multi-disciplinary mental health services? The starting place is the matter of harm: the patient’s distress and disability. Harm is agreed by (practically) all to be involved in our concept of mental disorder.
—Derek Bolton, What Is Mental Disorder? An Essay in Philosophy, Science and Values
Harm is central. But what is harm? Derek Bolton is right to take distress and disability as the starting place. But their links to harm are not simple. Surgery may be distressing without being harmful. And disability is not always worse than the alternative, as when S.B. was given sight.
Of course some degrees of distress or disability are too acute to be problematic. William Styron’s depression “in its catastrophic form,” or the “eternal hell” of the anonymous person with borderline personality disorder, raise no subtle questions about whether help is needed.
Other cases are more problematic. Gays in the 1950s and later were harmed. They were imprisoned, stigmatized, and endured horrible “cures.” They were assaulted or even murdered. In some places they still are. Of course these indirect harms do not make being gay a disorder. The intrinsic harm of major depression is not the same as the misery caused by prejudices about otherwise harmless conditions.
Even intrinsic harm is a plural and highly contested concept, charged with values. There are two main approaches to the assessment of harm. (Some see them as rivals, others as complementary.)
One view (linked to the idea of respecting autonomy) sees harm as something going against the person’s own values. Following Bennett Foddy and Julian Savulescu, I will call this the “Liberal” approach.6 The main issue raised by that view comes when people make choices that seem strongly against their best interests. Are such choices an authentic reflection of their values? This liberal approach, and its problem of authenticity, will be discussed in the last part of this book, especially in the context of eating disorders.
Here we will start with the main alternative view, to be called here the “Human Flourishing” approach. This takes an Aristotelian view of harm. It sees a condition as harmful when it is an impediment to the person’s being able to live a good human life. This raises obvious questions about what a good human life is. One feature of this approach is that the assessment of harm is to some extent independent of whether or not the person concerned agrees with it. (This is linked to the appeal to a person’s “best interests,” which is generally thought appropriate when people lack the capacity to decide for themselves.)
Psychiatrists aim to help people whose thoughts, moods, emotions, desires, psychological abilities, or personalities are impaired. All this can be understood by contrast with the good life that is limited by the impairment. It is humans, not Martians, who seek psychiatric help. Aristotle rightly treats flourishing, or the good life, as overwhelmingly species-specific. Caging birds is cruel because it is their nature to fly. Solitary confinement of human beings is cruel because we are social animals. As with other species, what is a good life for us is linked to our human nature.
Some ways of mapping the good life, and of mapping the human nature it has to fit, are from outside. One version looks at some social experiments that failed due to unrealistic ideas of what to aim for.
In the early Israeli kibbutzim there were hopes that collective child-rearing would create egalitarians who would cooperate, not compete. The children mostly did not absorb the ideals: “If anything, their experience of group life has turned them away from the group and encouraged them to value individual attainment. They find equality and cooperation boring; they are much more excited by personal achievement.”7
Family homes were replaced by communal children’s dormitories. The hope was to broaden parents’ concern beyond their own children toward impartial concern for all the kibbutz children: “Parental love can be exaggerated … Just as we distanced the children from intimate parental relations, we must lessen and control love from parents to children. We do not approve of uninhibited hugging, kissing and caressing.”8
Children’s dormitories did not last. It was utopian to overlook the depth of parents’ special love for their own children: “I thought our parents were crazy to abolish the communal sleeping for their children. Now that I am a parent myself, I can’t understand how they ever permitted it.”9 The human needs of children were also overlooked: “There was no love … I needed love desperately, but I wasn’t allowed to have it. My feminine side was repressed … I grew up like an orphan. My parents never kissed me until I was thirty!”10
Other, much larger, experiments also tested the boundaries of human nature. Immediately after the Russian revolution, some Russians hoped that an economy driven by people wanting to make money would be replaced by an equal society where people worked for the common good. This would mean a deep transformation of human psychology. Nikolai Bukharin wrote of “the manufacturing of Communist man out of the human material of the capitalist age.”11 This utopian project foundered partly due to human resistance to being reshaped. Efforts to impose the transformation by dictatorship, terror, torture, slave camps, and millions of deaths were a grim tribute to the stubbornness of the “human material,” of people and their nature.
We do not inquire into the human good by standing on the rim of heaven; and if we did, we would not find the right thing. Human ways of life, and the hopes, pleasures, and pains that are a part of these, cannot be left out of the inquiry without making it pointless and incoherent …
It is no simple matter to find out what the deepest parts of ourselves are, or even to draw all the parts to the surface for self-scrutiny. Thus one can reasonably speak of a kind of discovery here: discovery of oneself, and of one’s fellow citizens.
—Martha Nussbaum, The Therapy of Desire
The external exploration of human nature often takes the form of looking across different cultures and historical periods for human universals. Finding them would not settle all questions about the good life. One plausible near-universal feature of human nature is war between different groups.12 But this seems only to show a flaw in human nature, with a deep part of our psychology being a great obstacle to our own flourishing. Values cannot just be read off from behavior. We have to decide what to endorse.
Drawing the contours of a good human life has to go beyond how most human beings have lived, to an inner exploration of human values. “What exactly is it that you endorse or oppose, and why do you do so?” People are often inarticulate about their values. And Martha Nussbaum is right that it is no simple matter to discover the deepest parts of ourselves. Values may be developed, even partly created, by being articulated in the course of the conversation. The thought “I don’t know what I think until we have had the conversation, and sometimes not even then” is not a silly one. In this virtually all of us are like the Broadmoor interviewees. Exploration is likely to be halting and tentative.
Different people and different societies have disagreements about a good life. This platitude is interpreted in two rival ways. Some say that behind surface differences there is deep agreement. Socratic questioning about values can suggest a degree of deep-level consensus about the good life. On the other view, our differences about the good life go all the way down.
How might the Socratic questioning go? A simple utilitarian version of the good life is that it consists of pleasurable experiences and no pain. The first reaction of many is to agree with this. But thought experiments showing the limitations of such a life often make them change their mind. One is Aldous Huxley’s Brave New World. In that world, batches of genetically identical people are conditioned psychologically to want exactly what society provides. So there is no pain or misery. Life is all pleasure.
Teaching philosophy, I often ask people about Brave New World. As Huxley intended, most people are appalled. Reasons tend to be similar. That world is stifling. People care about autonomy and want a richer conception of a good life. It raises the question of whether society should be shaped to fit people, not the other way around. These values and questions complicate the one-dimensional “pleasure and no pain” view of human values.
Another thought experiment with a similar upshot is Robert Nozick’s “experience machine.” This machine gives pleasurable experiences and eliminates bad ones by direct stimulation of the brain. If you want to be an Olympic athlete, the machine can give you the experiences of competing and winning. If you want to be a great scientist, you can be given the “Einstein” cassette. And so on. But the reality behind the experiences is that you are on a table with your head attached to the machine’s electrodes. Nozick asked whether we would choose this for a lifetime.13 As with Huxley’s thought experiment, most people would not.
Some surface objections are practical. Suppose the machine breaks down? Or the operators turn malicious? You may end up in a nightmare. In a thought experiment we can wave practical objections away by stipulating benevolence and infallible technology. This moves discussion to deeper values. Even with permanent pleasure guaranteed, few would go on the machine for life.
People again tend toward the same reasons for refusing. They want to live in the real world, not a simulated one. They want relationships with real people, not fantasy relationships with imagined ones. They want to be active and in charge of their own lives, not passive consumers of the benevolent software program. And they want to make their own real contribution to the world, not to be given the Einstein cassette. This cluster of reasons, roughly Nozick’s, is given by people who have not read his book.
Of course, the people I talk to about Brave New World and the experience machine may not represent the human species. Perhaps very different answers would have come from Chinese villagers or from medieval nuns. The conjecture, to some extent empirically testable, is that some of the reasons reflect near-universal deep-level agreement about the good life.
Looking from the outside at what seems to work or not, or exploring values from the inside, are attempts to get clear about what things really matter to people. They give a rough account of a good human life, contrasting with psychological conditions that subvert it.
But this exploration may not be conclusive. It can give strong evidence, but still it is evidence that can be overridden. Even the discovery of wide and deep agreement about features of a good or a bad life would have its limits. People with body integrity identity disorder feel that some part of their body is not “them.” What they want (often passionately) may be to have a functioning leg amputated. This conflicts with the views of many surgeons and most of society about what is in their interests. Near-universal agreement that amputation of a functioning limb impairs the good life does not show decisively that someone with BIID has “distorted” values. It could just bring the reply “Two legs are fine for them, but this second leg is wrong for me.”