Ill or Injured? Looking beyond the symptoms of mental illness

“During my thirteen years in the mental health system, I believed that I was broken and incapable of being fixed. That I needed psychiatry to create a life that came anywhere close to being considered normal. That my emotional suffering was due to something wrong with my brain, and not to the fact that I was a young girl trying to make sense of herself in a culture based so much on performance, achievement and perfection.”

Laura Delano, 2014¹.

I have a question about mental illness. It’s about the way we see both the causes of it and the way we define it. But more than that, it’s about what we fail to see. Or, more importantly, who we fail to see.

I’ll come to the question a bit further down, but first, we need a little background.

‘Not Like Us’ – The Mental Illness model

People love a label. Whether it’s your politics, the music you like, your fashion taste, or your social status, there are all sorts of ways we like to identify someone as different: ‘not like me’ or ‘not like us’. But there are some cases where this does more harm than good, and mental health diagnoses can be one of them. Why? Because when a label of mental disorder is applied to someone, it can carry an underlying message that someone is:

Not normal. Certainly, not how a normal human should be.

For the last fifty years or so, we have been living in an age obsessed with diagnostic labels. We stick labels on children such as ADHD, Oppositional Defiance Disorder, Autism, and so on. As adults we throw diagnoses around like Depression, Anxiety Disorder, Bipolar Disorder, OCD and so on. From a clinical point of view, these labels are very useful as a shorthand for medical and healthcare professionals. They offer a common vocabulary, which saves a lot of time in communicating a patient’s condition to those responsible for their care, and helps in sharing the necessary understanding needed to help them.

Often, though, these diagnoses become a definition of the person they are applied to. For many people, being given a diagnosis of ‘mental illness’ can come with a lot of baggage. As well as having to cope with the symptoms which led them to seek help, they are often left believing that having those symptoms means there is something wrong with them. That they are somehow ‘not like normal people’. The explanation they will most probably have been given is that they have a chemical imbalance in the brain, which may, or may not, have been caused by a genetic defect handed down to them at birth. In short, it’s just bad luck they have a defect which causes depression or schizophrenia or a myriad of other possible mental disorders.

The solution to this, according to the doctor, will be medication. Reset the chemical imbalance and things will be better. And why not? After all, it’s an illness, a disorder. It is biochemical, and medications can be prescribed to correct it. Chemicals alter the serotonin or dopamine in our brains with the promise that our symptoms will soon be greatly reduced, and you will soon feel well again. Nice and simple, at least in principle.

But it’s not, though, is it? Because we’re not talking about a faulty toaster. We’re talking about a person with a history and a story to tell. Somebody with life experiences, situations and relationships. Someone who may also have emotional wounds from traumatic experiences, and a need for those wounds to heal. The illness/disorder model ignores pretty much all of this. Medications are prescribed and the patient is left to cope with their situation with hardly a single question being asked as to how they got there.

The truth is that the ‘Mental Illness’ model is flawed. Did you know there is no biomedical test for a single mental illness?² What do I mean by that? Okay, if you have a physical illness, there will be a test for it so that doctors can verify that you have it. People with cancer have markers in their blood. Same with inflammation or infection. Blood tests do a lot to prove a condition is real and can be properly treated. Broken vertebrae? X-ray or MRI scan. Bladder pain or burning? “Just have a widdle into this cup and we can have a look at what’s going on down there”. Talk to any pathologist and they will give you chapter and verse on what you can be tested for so that you can be treated ethically and appropriately. Medical doctors are hot on this because they don’t like to kill or damage their patients through incompetence or negligence.

Not so for mental illness. There is no MRI scan for anxiety or depression, no standard blood test for schizophrenia, or bipolar disorder, or borderline personality disorder. Just approximate groups of diagnostic criteria (usually symptoms and timescales) decided on every few years by committees of psychiatrists, who vote on which symptoms define each disorder.^3,4 Yet people are told with absolute certainty that they have these conditions and that they are illnesses or disorders. Diagnoses are made with the same medical certainty as a broken leg. Powerful medications are prescribed and labels pinned on to patients like namebadges. And this is what I want to question.

When we blame these conditions on brain disorders and chemical imbalances, we dismiss the person and their experiences. A common complaint from people in the mental health system is that, beyond enquiring about symptoms and their consequences, doctors and psychiatrists rarely ask patients about what happened to them⁵. All of a sudden, the sexual violence, the emotional and the physical abuse, have no validity because it’s depression, and depression, according to the theory, is a chemical imbalance.

But what happens when we choose not to consider somebody’s story? If the chemical imbalance theory fails to consider the abuse inflicted on the patient then it completely refuses to acknowledge that somebody else abused them. Abusers are implicitly off the hook. This is an appalling dismissal of the patient’s experiences. A devaluing which can only add to the grief and shame they are already struggling with.

All this, I feel, lays the blame at the door of the person suffering with their symptoms. That, if you have a mental disorder, as a result of a brain imbalance, then you have no-one to blame but your own genes and physiology. For a moment, let’s consider what happens when this is applied to children. In the last twenty years, diagnoses like ADHD, ODD (Oppositional Defiance Disorder), depression and anxiety have been given to children in the west in numbers unimaginable fifty years ago⁶. They fit the criteria (as mentioned above) and the diagnosis is made. As a result, parents are being told that their children have a mental disorder.

But is it fair to say a child is mentally disordered if all they are doing is reacting to intolerable situations in their own lives? If their anger, misbehaviour or inability to concentrate is down to abuse at home or bullying at school, then putting this down as a mental disorder completely ignores the cause of their suffering. In fact, it may add to it because the child is now left believing that there is something ‘wrong’ with them, and they have to take tablets to make them ‘normal’.

If the illness/disorder model isn’t appropriate, then what is? The symptoms of depression, bipolar disorder, addiction and schizophrenia are real enough. So are many other mental conditions with which people struggle everyday. Is there a different way to look at this? Well, yes. I think there is.

Ill, or injured?

Why is it that somebody who has been traumatically abused, at any age, is seen as having injuries in their body, but illnesses in their mind?

What if we take a look from the other end of the street and see these conditions, not as illnesses, but as injuries. Injuries resulting from extreme or chronic life trauma. To try to see that the people experiencing symptoms of PTSD, anxiety or depression are not ill, but wounded emotionally by what has been done to them. Would this help?

Well, I can think of three reasons why it might:

Firstly, it means the person is not deficient, nor a failure, nor faulty. It acknowledges that, for many people, life has been hard, unkind, cruel, and that these experiences have left a wound which is as valid as any physical injury.

Secondly, whereas a brain deficiency or chemical imbalance seems fixed and absolute, understanding this person from a perspective of injury allows hope for change. Injuries and wounds can begin to heal with care, understanding and, above all, compassion. Medications and psychotherapy might well be needed on this journey, and it may be a long one. But it is a journey of self-recovery, not being ‘stabilized’ or ‘maintained’.

Thirdly, and most importantly for me, seeing the injuries means seeing the whole person in the context of their life experiences. It invites us to respectfully ask the question: “What has happened to bring you to this place?”. And it obliges us to listen.

More than this, it obliges us to look at the emotional context of the person dealing with these issues. The things which are going on in their lives right now. These injuries are real and, even though they may have been inflicted a long time ago, everyday life can contain plenty of reminders to bring them into the present moment. For example, what if your depression was not some unfathomable emotion, but profound grief you still feel for the loss of your safety or innocence long ago⁷. Or the feelings you have of being ‘bad’ or ‘worthless’ come from a deeply instilled shame over something done to you⁸. Both grief and shame are often treated as ‘depression’ and medicated, completely missing the human story behind them.

All of this matters because we are all entitled to post-traumatic growth. We are allowed to have a journey of recovery from the mental injuries which have left us grappling with internal terror, grief, anxiety, visual or auditory hallucinations, internal voices, flashbacks, chronic shame and many other emotional manifestations. We are allowed to heal.

If somebody’s symptoms are not caused by some biological or genetic defect then why should they be made to feel ‘disordered’ or ‘deficient’ because they have them. Particularly if past emotional injuries are the cause of their present emotional distress. Which brings us to the question I talked about at the start of this piece:

If somebody’s symptoms are the result of emotional injuries, is there actually anything ‘wrong’ with them?

Before we go any further, I would like you to imagine this scenario:

Every day, around lunchtime, somebody comes up to you and slaps you very hard in the face. No reason. They just do it. Then they walk away and you’re left there with the side of your face sore and starting to swell up.

Then the next day, they do it again. And the day after that. The same slap in the same place. Day after day.

After a week you might find that your face is continually swollen. After a month, the redness has become a bruise which just keeps getting darker. After several years of this treatment, the damage to your face is becoming permanent, with changes to tissue structure and blood vessels unable to heal to their former state.

You might be thinking by now ‘Well, that wouldn’t happen because I’d slap them right back. That would put an end to it”. Except you can’t. Because, in this scenario, you’re not an adult.

You’re an eight-year-old child.

In this story, it’s clear that this child is being injured, and that the effects of this repeated physical trauma are likely to stay with them long into adulthood. I don’t think many people would be surprised at this outcome, or indeed, fail to be outraged at the idea of a child being treated this way.

So, let’s change the story to something more hidden, but far more prevalent. Something which, everyday, is affecting tens of thousands of children in the UK alone. Instead of a physical assault, this child is being subjected to repeated emotional assaults. Humiliated, bullied, treated as worthless, living in terror of when the next screaming barrage of hatred is coming their way.

Slowly, bit by bit, just as the physical attacks leaves their cuts and bruises, these constant attacks of fear, shame and uncertainty begins to do the same emotionally. The constant expectation of emotional violence starts to have permanent effects on how this young person develops.

There are so many ways children are abused. But I think it is worth recognising that it isn’t only physical attacks that do the damage. The only weapon an adult actually needs to destroy a child is a voice. Plenty more get used, without question, but whether it is the screaming threats or the quietly whispered humiliations, the violence that words can do to a child is devastating. Particularly when they come from the adults whom they have no choice but to believe and trust. To paraphrase the old rhyme, sticks and stones may well break bones, but the words can break your soul.

The damage is invisible to the naked eye. But it’s there, and it may not re-surface for years until, one day, the grown-up adult discovers they cannot deal with their feelings. Emotions which they have desperately tried to supress or ignore begin to overwhelm them. Perhaps they are drinking or taking drugs, crippled by addiction. Perhaps they cannot handle relationships, or are violent with those close to them. Perhaps they live in a constant state of terror and struggle to get through every day. Because, on the inside, the wounds are still open.

Having to cope with what someone did to you is not a mental disorder

If someone had experienced a devastating physical injury in an accident or battle, nobody would think twice about how normal it would be to have scars, a limp, missing parts or false limbs. So why don’t we see mental injuries in the same way, and show the same level of understanding and compassion. To try to understand that the person who can’t leave the house, or has no house, who gets hooked on drugs or alcohol, hallucinates or takes a razor blade to themselves, is like this because of their, sometimes catastrophic, emotional injuries⁹.

There is nothing ‘wrong’ with them. They are not weak or cowards. They are not stupid or ignorant. They are not bad or evil. They are profoundly hurt and desperately trying to cope with a level of emotional suffering which is almost impossible to communicate, and even harder to live with. This is why I ask: Is there actually anything wrong with you? Not to deny your symptoms or your experiences, but to give them validity, and to stop them being dismissed as disorder and abnormality. To see how they shape your world, right here, right now, and see you as more than a few aspects of your behaviour. Your story has a right to be told and you have a right to be heard.

Let me be clear: this isn’t about trivialising serious mental illnesses, or denying the value of medications. For conditions like psychosis or Bipolar Disorder, medications can be a vital part of helping people find a better way to live in the world. Nor would I want to suggest that anyone stop taking their medications without carefully discussing it with their doctor. What I’m standing up against here is the stigma and the blame which are implicit in every diagnosis of a mental disorder. The next time you hear of someone described as having a ‘mental disorder’, try replacing those two words with ‘emotional injury’ and notice how it changes your view of them. You might be surprised.

I should point out, before I finish, that I’m far from being the only one who thinks like this. Debates about how mental distress should be viewed have been going on for decades and will continue, I hope, until change comes. One video which touched me deeply was by a lady called Khaliya, which you can find in the references below¹⁰. It is a heartfelt presentation and I especially recommend it.

Far too many people are struggling alone when they shouldn’t. Many are harming themselves and some are taking their own lives. If we want to stop the stigma and shame of so-called ‘mental disorders’, if we want to stop blaming the silent victims of abuse, rape and sexual violence, and especially if we want our children to feel safe enough to ask for help, we need to recognise the overwhelming emotional burden life inflicts on them and see the person struggling underneath.

References:

1: This statement was made by Laura Delano, a participant in the following video. Her contribution appears at 34:50 and it echoes the feelings of so many struggling with mental distress, whatever the causes.
Kotzia, McKenzie et al. 2014. “Bipolarized – Rethinking Mental Illness”. You Tube. https://www.youtube.com/watch?v=qPzIsou-r8g. Shaw Media.

2,3,6: Davies, J, 2013, ‘Cracked: Why psychiatry is doing more harm than good’, Icon Books, London. Anybody who has sought help for mental health issues should read this book. So should everybody else.

4: American Psychiatric Association, 2013, ‘Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision’ APA, Washington DC.

5: McCarthy-Jones, S, 2017, ‘Can’t you hear them? (the science and significance of hearing voices), Jessica Kingsley, London.

7: Worden, William J., 1983 ‘Grief Counselling and Grief Therapy (2nd Ed)’, Routledge, London.

8: Nathanson, D.L, ‘Shame and Pride, (Affect, sex, and the birth of the self), Norton, New York.

9: Mate, G, 2018, ‘In the realm of hungry ghosts (close encounters with addiction)’. Vermillion, London.

10: Khaliya, 2017, “What if most of what we knew about mental health was wrong?’, TED talk (TEDx Beacon Street), https://www.youtube.com/watch?v=EgxO1uu_9Rc

Chris Pilling M.Sc. is a psychotherapist based on the Isle of Wight.