Has madness become normal? (Part 2)
In the first two lectures of the Studium Generale series on “Everyday Madness” (Dutch: Alledaagse Gekte), we learned that mental disorders are currently receiving much attention in academic and public debates. After that, there were still three lectures to come.
Who is afraid of fear?
The third speaker was Damiaan Denys, Professor of Psychiatry at the Academic Medical Center (AMC) in Amsterdam. He was also introduced as a graduate of Philosophy and a theater actor. This introduction foreshadowed his talk, as he was speaking freely without PowerPoint slides and touched the edge of Existential Philosophy in his lecture: Why be afraid of fear? (Dutch: Waarom angst vrezen?)
Denys started out by gathering support for the hypothesis that we are living in a fear society. Although society is much safer than ever, he argued, fear seems to be everywhere: fear of climate change, technology, or terrorism, to name just a few examples. He called this the “fear paradox”. Most of the ingredients of our food have been associated with cancer, Denys claimed, and the media would contribute to this perception. Because we had hardly any contact with things that we really must be afraid of, like wild animals that could kill us, our thinking about and feeling of fear would easily lead us astray.
According to Denys, psychologists do not have one consistent view on what fear is. He made this point by summarizing different theories emphasizing different biological or psychological aspects. He also stated that neuroscience does not provide a clear answer either. The very long list of brain structures such as the amygdala, thalamus, and hypothalamus, to name just a few, that have so far been related to fear processing, undergirded his statement. Neither did he have the final answer. Instead, he quoted Neil deGrasse Tyson who said that
The universe is under no obligation to make sense to you.
While Denys emphasized the social costs of fear, such as erroneous beliefs or the loss of trust, he also presented a personal example for how it could set someone free: During a balloon ride he suddenly became afraid that he might fall down. To him, this thought was not only uncomfortable, but also made him realize that he has the existential freedom to end his life at any moment. The lecture certainly provoked people’s thoughts, although – or perhaps even because – it left more questions unanswered than some people might have liked.
Beware of reification!
The Professor for Philosophy of Science Trudy Dehue from the University of Groningen focused on several historical and theoretical aspects pertaining to mental disorders, particularly those related to the process of reification (from Latin res, thing). Using the examples of ADHD and depression, Dehue explained how mental disorder classifications are misunderstood as things with causal powers and a biological essence, while they are human-made definitions that are also changing in the course of time.
Reification not only leads to confused statements, for example, when people may say they are sad because of their depression, when in fact being sad is just one symptom of the classification (or definition) of depression. This was also reflected in the lecture’s title “Disorders are ‘hitting hard’” (Dutch: Stoornissen die ‘toeslaan’). Beyond causing confusion, Dehue pointed out, the reification of mental disorders has wide social ramifications, such as the legitimation of disorders in mild or hidden form or the decontextualization and depolitization of people’s problems.
For the former point she showed examples of researchers now looking for “hidden” autism, that is people not exhibiting the classical symptoms of the disorder, although it is originally defined by difficulties in social interaction, among other aspects. It is a challenging question whether people showing some brain abnormality but no behavioral problem can be said to be autists, whether hidden or not. The latter point, decontextualization and depolitization, refers to the risk that when people’s problems are located in their own bodies, particularly their own brains, social causes and interventions might be neglected.
Towards the end of her lecture Dehue pointed out several political and financial conflicts of interest in mental health care and research. For example, current health policy fits the neoliberal meritocratic idea that success is a choice and failure as well, and thus individuals are stimulated to feel responsible for their mental health. Moreover, lobby groups like the European Brain Council present a reified account of mental disorders and suggest that society could save billions of euros once clinical neuroscientists discover the biomarkers underlying people’s psychological problems.
Empowering patients: Let them become their own doctor
The speaker of the last lecture was Jim van Os, Professor for Psychiatry at the Maastricht University Medical Center (MUMC). He started with talking about current organization of the Dutch health care system, but quickly switched to his specialization: schizophrenia (Dutch title: Deconstructie van de waanzin).
Van Os presented figures suggesting that the increasing diagnosis of mental disorders is, at least partially, the result of how the mental health care system is organized, namely as a market: Multiple mental health care institutions compete for their ‘clients’ and have financial interests in expanding diagnosis and treatment. From 2004 to 2010, the percentage of people in the Dutch mental health care system doubled from 3,5% to 7%.
Van Os pointed out that environmental factors play a large role in schizophrenia, while the genes that so far have been associated with it – more than 100! – contribute only little. Almost anyone has such schizophrenia risk genes, but few who do actually develop clinically significant symptoms. Van Os also stated that the term ‘schizophrenia’ itself is mystifying and makes it difficult for people to explain their experiences to others. Instead of accepting that forms of psychosis such as attributing meaning to random events, seeing a world full of threats, or seeing things that do not exist can be quite common, people are told that such experiences must be eliminated instead of being taught how to live with them.
Van Os not only presented quite a revolutionary view on schizophrenia, but also on how to organize psychiatry as a whole. His critique of the classifications currently influencing the clinical work of mental health professionals can be explained best using the four questions he proposed as a guideline: What happened to the person? How is this person vulnerable and resilient? What does the person need to function? And what are her or his aims? Where possible, people should be empowered to become their own doctors, rather than become dependent on mental health care institutions operating in a competitive market.
To the podium!
The Studium Generale series was successful in many ways: Renowned speakers presented a variety of novel views on mental disorders and attracted a broad and very diverse public of all ages. The five lectures spanning more than six full hours of presentation and discussion raised many challenging questions not only for a lay audience but also for clinicians.
How could realizing that mental disorders as we know them are based on definitions that should not be reified affect the lives and work of patients and experts? And how can patients express their problems in such a way that others understand their experience? How can they learn to become their own doctors to function in the way they want to? Unfortunately, not all of these questions can be solved in a lecture series. Organizing a panel discussion with the speakers and the informed public may provide a chance to go a step further.
Disclaimer: Trudy Dehue is the author’s superior at the University of Groningen. Thanks to my colleague Marije aan het Rot for helpful comments on the posts about the lecture series.
Image source: günther gumhold / pixelio.de