Browsing the blog archivesfor the day Thursday, November 22nd, 2007.

Head Boxes

big picture stuff

I want to address a post by Grim, at Blackfive. To be clear, this is a Right Blogosphere blog, but I don’t intend to snark or disagree with the post as much as look at the same issue from another angle.

The issue is post-traumatic stress (PTS) or post-traumatic stress disorder (PTSD), of which Grim writes from the perspective of a combat veteran,

What you need to know, first and last, is that so-called PTSD is not an illness. It is a normal condition for people who have been through what you have been through. The instinct to kill and war is native to humanity. It is very deeply rooted in me, as it is in you. We have rules and customs to restrain it, so that sometimes we may have peace. What you are experiencing is not an illness, but the awareness of what human nature is like deep down. It is the awareness of what life is like without the walls that protect civilization.

Those who have never been outside those walls don’t know: they can’t see. The walls form their horizon. You know what lays beyond them, and can’t forget it. What we’re going to talk about today is how to come home, back inside those walls: how to learn to trust them again.

There is a sense that combat changes people, but it really doesn’t. It brings out parts of yourself that were always there, but that you hadn’t encountered directly. Those parts are in everyone else as well. No one has clean hands. No one is different from you. That is important, so let me repeat it. Everyone around you is just like you. They don’t know it, but they are. You are not sick; you are not broken. Everyone else is just the same.

One’s opinion of whether PTSD is or is not an illness probably has less to do with PTSD than with how one understands “illness.” There are a range of conditions — physical, mental, emotional, behavioral — that are or have been labeled “illnesses,” “disorders” or “diseases,” and the labels in turn tend to color how we understand these conditions. When the condition impacts one’s thought processes, emotions, or behaviors, people can disagree sharply over the labels. The very fact that we make a distinction between “physical” and “mental” disease is a problem, says the Mayo Clinic.

Why does stigma of mental illnesses continue? For one thing, the term “mental illness” suggests that it’s not the same as a medical or physical illness. To some, the word “mental” suggests that the illness is not a legitimate medical condition but rather a problem caused by your own choices and actions. People may blame you and think your condition is “all in your head.” They may think that a mental health disorder means that you’re weak or lazy. They may think that you should just “get over it.” And you may begin to think these things about yourself, too.

In reality, mental illnesses have very complex causes, often a mix of your genetics, your biology and your life experiences — most of which are beyond your control. Neuroimaging studies, for instance, show physical changes in the brain associated with mental disorders. And studies show that some mental illnesses run in families, suggesting that they may be due in part to your genes.

Grim says that PTSD is a normal condition for people who have experienced war, and I respect that. But most illnesses are, in a sense, normal reactions to something — germs, toxins, injury, aging. I believe what he’s saying here is that the soldier experiencing PTS or PTSD is not unnatural or flawed of character. I’d like to think we can all agree on that, even if we disagree on how we label it.

We tend to treat language as if if were something solid and precise that cleanly transmits bits of reality from transmitter to receiver. But in fact language is liquid and messy. Words themselves are weighted down with centuries of connotation that color understanding. And language does not convey reality, just concepts and ideas about reality. People very often get hung up on words and miss the reality, and I think that’s what is happening here.

The better course is not to run away from the word “illness,” but to get over our medieval attitudes about illness. In medieval times to be ill was to be morally evil or malevolent. Sick still carries that meaning sometimes, as in “That pedophile is one sick puppy.”

The word disease originally meant, simply, “without ease,” and came to be a synonym for illness or sickness over time. The words disorder or disturbed suggest chaos, something out of control or out of place. And I would argue that while PTSD may not be a sickness, it is a disorder, in that it’s something out of place. Behaviors and habits of mind essential to surviving on a battlefield are out of place in peacetime, and vice versa.

Another word for out of place is deviant. To be deviant is to be abnormal and possibly dangerous. Although the word disorder is relatively clean and clinical by comparison, the connotations of deviant cling to it stubbornly for some people. My calling PTSD a “disorder” is an attempt to be helpful, but someone else might perceive it as threatening or stigmatizing.

In social animals such as we there is a deeply hardwired urge to eliminate deviant individuals from the pack. I suspect that from the point of view of evolutionary biology, this urge is useful. It isolates those animals carrying infectious diseases and prevents an animal with unfortunate characteristics from reproducing. This trait lingers in humans and, unfortunately, accounts for some of the worst of our behaviors. We have all manner of ways, some subtle and some not, to isolate and expel people whom we judge to be “weird” or “different from us” from our society. Only those who can rise above their programming see how unjust and how stupid this is.

There is no logical reason why a mood, emotional, or cognitive disorder should be any more stigmatizing than a broken bone or a bullet wound. A lot of people have crusaded to get PTSD recognized as an illness so that people with PTSD will get the treatment, compassion, and respect they require and deserve. I can commiserate, because I’m on a similar crusade regarding clinical depression. It’s still common for people, including doctors, to dismiss the depressed as whiners. In this case the point of the label “illness” is not to stigmatize people, but just the opposite.

What’s “normal”? What’s “abnormal”? Grim speaks of “what human nature is like deep down,” as if there is a fixed baseline “normal” and all other aspects of human nature can be judged by degrees away from the baseline. Over the ages countless philosophers have tackled this question, and they’ve come up with countless answers. I suggest it’s more pragmatic to judge what’s “normal” entirely in context of circumstances. “Normal” is responding appropriately to what’s going on around you. If something is getting in the way of appropriate responses, then it’s a problem no matter what label you slap on it.

Intense experiences, good and bad, can leave considerable residue. After an intense experience, good or bad, often someone will say, “Wow, that was real.” Whenever you bring whole body-and-mind focus to anything, the experience takes on a bright clarity that makes “ordinary” experience seem dull and muddled. People who have shared that intense experience know what’s “real,” and everyone else seems to be sleepwalking. After this intense experience it can be terribly disorienting to leave the company of those who shared it with you and move among those who have not. The ones who weren’t there may care about you, but they don’t “get it.” They don’t “know.” You can tell by their questions and comments that what they imagine you experienced is light years away from the reality. You find that trying to explain it to them is futile.

What’s worse, you may not yet be ready to leave that experience; you may want to linger in that clarity awhile longer. But the ones who weren’t there seem to want to drag you out of the clarity and bring you back to their fuzzy, mundane world, and this makes you angry. You have acquired several new layers of behavioral conditioning, and you no longer conform to the expectations they have of you, and that makes them angry.

This phenomenon is well documented as common (but not limited to) soldiers returning from war, going back at least to the Civil War and probably earlier. Yet it still catches us by surprise. It shouldn’t. It’s normal.

Further, I argue that war is no more or less “real” than cooking soup or sorting socks. It’s what you bring to the experience that makes the difference, not the experience itself.

I’ve never tried to wade through Immanuel Kant’s Critique of Pure Reason, and there seem to be hundreds of diverse and conflicting interpretations of what Kant was getting at. However, I was struck by something Mark Lilla wrote:

According to Kant, thinkers like Hobbes, Locke, and Hume had a crude notion of how the human mind works. While they were right to think that the “faculty of understanding” (Verstand) can deal only with objects of possible experience in space and time, they failed to see that the “faculty of reason” (Vernunft) has a very different function. It not only draws inferences from evidence, it also places a kind of “architectonic” order on them by means of ideas, making sure they cohere. These ideas are not themselves drawn from experience; they are useful notions that the mind employs to organize what it does experience in space and time. … One of reason’s functions is to develop fictions like this and employ them to regulate the employment of our understanding, which is limited to what can be experienced in space and time. [Mark Lilla, The Stillborn God: Religion, Politics, and the Modern West (Alfred A. Knopf, 2007), pp. 135-136]

The way I understand this — borrowed heavily from talks by my first Zen teacher — is that we all have mental filing cabinets in which we sort everything we learn and experience. These filing cabinets may or may not be organized in any logically defensible way, but logical or not they are artificial. Construction of the filing cabinets begins as soon as we are born as our parents imprint upon us the norms and common assumptions of our culture. We are so accustomed to using our heads this way we don’t see the artificiality of it, but generally when somebody says something is self-evident or common sense, he’s saying “this nicely conforms to my mental filing system.”

So when we sort PTSD or anything else into “normal” or “abnormal,” “illness” or “not illness” files, we’re using an artificial construct. Ultimately, arguing about whether PTSD is an illness or not isn’t arguing about PTSD, but about an artificial classification system. Advocates for home birthing will tell you that pregnancy and childbirth are not illnesses. Deaf people often are militant about not being called “sick” or “diseased.” Again, these arguments are not about the realities of childbirth or deafness; they’re about the artificial classification system.

What things are is one thing, and how we understand them is something else entirely. Don’t get hung up on the labels.

Sorta kinda related: In a different context, Ian Welsh considers “how do we know what we know?”

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