What is a Mental Illness?
I’d like to briefly, though also hopefully clearly and thoroughly, address a specific but significant issue that has been on my mind since Ben Shapiro’s speech at YU a few weeks ago. This matter, which was tangentially referenced in Doron Levine’s recent editorial, struck me as obvious at first, but it became clear to me after several conversations that it is far from clear.
Before I lay out my claim, I ask the reader to please consider my arguments carefully. Unfortunately, I anticipate several ways of misreading my article; the best antidote to such miscommunications is, I think, to hear me out fully.
When I heard Ben Shapiro claim that “transgender people are unfortunately suffering from a significant mental illness,” it was not immediately obvious to me whether or not he was correct. I say this with full knowledge that Shapiro’s position conflicts with popular scientific opinion; debating popular scientific opinion, I think, may sometimes be justifiable. As for this specific case, though, I have no set opinion on whether or not gender dysphoria is a mental illness. I’m not sure whether or not Shapiro was correct, but I wouldn’t rule out the possibility.
Levine, in his piece, suggested that the post-speech debate about whether or not Shapiro was mean is a façade for a more substantive ideological disagreement. Unfortunately, my sense from my modest exposure to various conversation forums is that even at the core of the argument (whether or not Shapiro was correct that gender dysphoria is a mental illness), there are two very vocal, diametrically opposed voices talking loudly at each other, and both of these sides are missing the point.
I will try explain how I (and several others I have spoken to and read in print) understand the notion of defining mental illnesses. Let me note at the onset that my thoughts here have nothing to do with issues such as gender reassignment, preferred pronouns for transgender people, etc. I am addressing a very specific term (“mental illness”) and the question of what it means. I hope to contribute to thoughtful, respectful dialogue about this idea, and perhaps a change in perspective.
I suppose the obvious place to start is with the modern meaning of “mental illness.” The American Psychiatric Association, the largest and one of the most reputable psychiatric organizations in the world, classifies and diagnoses mental illnesses in its Diagnostic and Statistical Manual of Mental Disorders, a dense manual now in its fifth edition (DSM-V). In “What is a Mental/Psychiatric Disorder? From DSM-IV to DSM-V,” published in a journal called Psychological Medicine (volume 40 issue 11, November, 2010), several certified psychologists describe the nuances behind defining mental illnesses. After suggesting no fewer than ten criteria, they conclude that “the explicit DSM-IV position that mental/psychiatric disorders cannot easily be precisely operationally defined seems basically correct… The situation in psychiatry is reminiscent of some other areas of medicine, where there are also shifting boundaries between normality and abnormality, with evidence-based changes made over time… Disorders cannot be perfectly defined in necessary and sufficient terms, and there are likely to be particularly robust disagreements about more atypical categories.”
This position is similar to those of the National Institute of Mental Health, the American Medical Association, and other preeminent doctoral associations. In other words, a mental illness is not as easily identified as a standard physical illness. Mental illnesses do exist, and the term “mental illness” is something meaningful inasmuch as most people agree about most of its applications. But the psychiatric organizations themselves concede (some more clearly than others, although the truth stands regardless of their admission) that defining mental illnesses is difficult. It is not at all clear-cut.
To get to the point, what is the difference between a mental illness and a physical illness? Only regarding the latter does humankind en masse agree about the axiomatic necessities. Defining features of physical illness include classic symptoms such as: bringing about pain, shortening lifespan, or harming the body. In short, it is the common consent of mankind that these things are bad. Given these a priori established requirements, it makes sense that, for definitional purposes, doctors and scientists with relevant knowledge are the people we should look to. A physical illness is something bad (by the common definitions) to the body, and doctors know best whether or not something is bad to the body, so it follows that doctors are who we should trust in the matter of what is a physical illness.
Such is not the case for mental illnesses. While a person’s mind may be related to the body (philosophers for centuries have discussed what exactly the mind is, how physical or metaphysical it is), mental reality is not just a matter of neurons and brain states. Consider schizophrenia, depression, autism, and insomnia, all of which are commonly considered mental illnesses. While there are biological phenomena associated with these states of being (I address some specific examples later on), they are fundamentally separate from the physical. These mental conditions cause certain thoughts and feelings, on the same plane as any other mental state such as introversion or extroversion, friendliness or detachedness, insecurity or confidence. The difference between these mental states and other mental states like schizophrenia, depression, autism, insomnia, and other conditions is that only the latter are determined to be bad (to the individual, to society, etc.).
This is where many fall prey to an unwarranted association. Are both physical illnesses and mental illnesses states of being that people think are bad? Yes. Therefore, should they both be defined by the same people? No. Given that mental states are about how people perceive the world, how they act, how they think, and are not primarily about the physical body (although they may have associated physical symptoms), why should professionals such as doctors (even those who are experts in the biological causes of these mental states) have a monopoly on evaluating which mental states are good or bad?
Let’s consider some examples to demonstrate this point. Take left-handedness for starters. Different societies have historically viewed this mental inclination for a dominant left hand as something bad. Today, we don’t view it as bad. Here’s a more complicated state: being suicidal. To many it may be obvious that suicide is bad, but this matter does not have widespread consent. Euthanasia in the Netherlands is not punishable in certain cases, and the moral sentiment is shifting elsewhere as well (consider Brittany Maynard, a young brain cancer victim who garnered much sympathy in 2014 for her efforts to attain legal assisted suicide, resulting in the End of Life Option Act that took effect a few months ago in California). Given the shift in attitude, I would not be surprised if psychiatric organizations will soon update their positions on people who desire to take their own lives, reevaluating when they are and when they are not mentally ill. Causing a certain amount of badness is a necessary requirement of illness, so as the attitude toward suicide becomes less and less negative (i.e., coming to see suicide as less and less “bad”), the instance of mental illnesses classifications related to suicide intentions will decline accordingly.
One doctor in Israel described to me how he was part of a board of ethicists who had to evaluate a patient’s request to surgically remove his arm, simply because the patient had the desire to do so. This board of doctors was split on the issue. Is it bad for a person to remove his arm for no reason, or not? Is he mentally ill? It was not so clear to these doctors, and is not so clear to me. (It is worth nothing that my previous two examples – suicide and pointless limb-removal – have the apparent features of causing harm to the body and shortening lifespan. One might argue that, for these reasons, doctors are in fact the ones who ought to determine if these states of being are illnesses. I think, though, that enough people deny the harmfulness in these cases, so suicide and pointless limb-removal are not axiomatically bad. Given this, my examples should stand.)
To invoke a controversial, but relevant, logical extension, it is imaginable that a future society will consider clinical lycanthropy (the delusion of being an animal) to not be a mental illness. Or some other society might consider shyness (an arguably negative character trait) to be a mental illness. While perhaps unlikely and certainly weird, these situations are imaginable. Ethical sentiments change, and definitions of mental illness can change accordingly.
As it happens, the recent DSM-V, released in 2013, determined that gender dysphoria is not a mental illness. But the APA position since its founding in 1952 was otherwise. The ICD (International Classification of Diseases), a major classifier of health disorders, published by the World Health Organization, still uses the term “gender identity disorder,” implying something bad about this mental state. Again, though, the positions of psychiatric organizations are not the be-all, nor the end-all, of defining mental illnesses. At the end of the day, it probably makes sense to trust organizations such as the APA for most definitions, especially for conditions that have near-widespread consent as to their badness. This is especially clear regarding mental conditions that are associated with many physical ailments (Generalized Anxiety Disorder, a friend pointed out to me, has been known to bring about physical symptoms), even if they are primarily mental phenomena. But we should realize that these organizations are not the objective arbiters on the matter, and that some of their classifications might be debatable.
By this point I may be guilty of flogging a dead horse, so I’ll conclude with the following. I wrote this piece for the main purpose of adding to the discussion space, hopefully in a positive way. I unfortunately expect some acerbic reactions, some gross simplifications, and perhaps even some unwanted applaud, that will result from a misreading. To offer some remedy before the blow, let me address some potential misinterpretations that I anticipate:
- “He called gender dysphoria a mental illness.” This is not so. I claimed that defining mental illnesses is complicated. Doctors and scientists are not necessarily the ones who should determine the matter. As for my personal belief, I am undecided on the specific issue of how to classify gender dysphoria, and am unsure who specifically (if anyone) should have the main word on the matter (I happen to be inclined to draw from Jewish sources, such as the Torah and the Rabbis, for support on unclear ethical dilemmas).
- “He didn’t quote enough sources.” I drew from a few scientific journals only to highlight my arguments, which stand just as well without any academic backing. Any sourcing I did was only for clarification or support. They were by no means the main stuff of my argument.
- “He associated gender dysphoria with other bad illnesses.” This statement is not telling the whole story. My comparisons were only for the purpose of the important ethical question, and don’t carry over to any other aspects of illnesses, physical or otherwise.
- “He said that Ben Shapiro was right.” As it happens, my own view is that Ben Shapiro is probably less trustworthy on these matters because of his flawed arguing and discourse styles. So I would not, and did not, say that he was right. But, insofar as he is intelligent and worldly, he is as justified as anyone else in evaluating whether or not a certain mental state is a mental illness.
- “He said that doctors are wrong about classifying mental illnesses.” I am not saying that doctors are wrong. People with undesirable mental states (depression, for example) should certainly seek out relevant professionals for treatment. Doctors are in the best position to determine how to change the body to treat a condition. As for the ethical question, though, doctors (and psychiatric associations) are not inherently, by virtue of their positions, the highest authorities on determining what is and what isn’t a mental illness.
This piece is in no way meant to delegitimize very serious and very real mental illnesses. In fact, I hope it has the opposite effect of igniting the incredibly important conversation about the seriousness of mental illnesses and the need for minimizing any stigmatization of the topic. Whether or not some state is technically a mental illness, a person suffering from any condition deserves respect and support. Those exhibiting mental illnesses must not be unjustly looked down upon.
Again, please read my words slowly and prudently. If you, dear reader, find yourself reacting viscerally, you probably missed my point. Take another look, and you just might find my claims more interesting and reasonable than you thought. Of course, after a careful reading, I welcome leveled debate on the matter. As I implied at the onset, I remain open to new ideas on this issue. I would very much enjoy to learn from interesting perspectives that you might add.
