By: Dr. Sam Vaknin
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We are all terminally ill. It is a matter of time before we all die. Aging and death remain almost as mysterious as ever. We feel awed and uncomfortable when we contemplate these twin afflictions. Indeed, the very word denoting illness contains its own best definition: dis-ease. A mental component of lack of well being must exist SUBJECTIVELY. The person must FEEL bad, must experience discomfiture for his condition to qualify as a disease. To this extent, we are justified in classifying all diseases as "spiritual" or "mental".
Is there any other way of distinguishing health from sickness - a way that does NOT depend on the report that the patient provides regarding his subjective experience?
Some diseases are manifest and others are latent or immanent. Genetic diseases can exist - unmanifested - for generations. This raises the philosophical problem or whether a potential disease IS a disease? Are AIDS and Haemophilia carriers - sick? Should they be treated, ethically speaking? They experience no dis-ease, they report no symptoms, and no signs are evident. On what moral grounds can we commit them to treatment? On the grounds of the "greater benefit" is the common response. Carriers threaten others and must be isolated or otherwise neutered. The threat inherent in them must be eradicated. This is a dangerous moral precedent. All kinds of people threaten our well-being: unsettling ideologists, the mentally handicapped, and many politicians. Why should we single out our physical well-being as worthy of a privileged moral status? Why is our mental well being, for instance, of less import?
Moreover, the distinction between the psychic and the physical is hotly disputed, philosophically. The psychophysical problem is as intractable today as it ever was (if not more so). It is beyond doubt that the physical affects the mental and the other way around. This is what disciplines like psychiatry are all about. The ability to control "autonomous" bodily functions (such as heartbeat) and mental reactions to pathogens of the brain are proof of the artificialness of this distinction.
It is a result of the reductionist view of nature as divisible and summable. The sum of the parts, alas, is not always the whole and there is no such thing as an infinite set of the rules of nature, only an asymptotic approximation of it. The distinction between the patient and the outside world is superfluous and wrong. The patient AND his environment are ONE and the same. Disease is a perturbation in the operation and management of the complex ecosystem known as patient-world. Humans absorb their environment and feed it in equal measures. This on-going interaction IS the patient. We cannot exist without the intake of water, air, visual stimuli and food. Our environment is defined by our actions and output, physical and mental.
Thus, one must question the classical differentiation between "internal" and "external". Some illnesses are considered "endogenic" (=generated from the inside). Natural, "internal", causes - a heart defect, a biochemical imbalance, a genetic mutation, a metabolic process gone awry - cause disease. Aging and deformities also belong in this category.
In contrast, problems of nurturance and environment - early childhood abuse, for instance, or malnutrition - are "external" and so are the "classical" pathogens (germs and viruses) and accidents.
But this, again, is a counter-productive approach. Exogenic and Endogenic pathogenesis is inseparable. Mental states increase or decrease the susceptibility to externally induced disease. Talk therapy or abuse (external events) alters the biochemical balance of the brain. The inside constantly interacts with the outside and is so intertwined with it that all distinctions between them are artificial and misleading. The best example is, of course, medication: it is an external agent, it influences internal processes and it has a very strong mental correlate (=its efficacy is influenced by mental factors as in the placebo effect).
The very nature of dysfunction and sickness is highly culture-dependent. Societal parameters dictate right and wrong in health (especially mental health). It is all a matter of statistics. Certain diseases are accepted in certain parts of the world as a fact of life or even a sign of distinction (e.g., the paranoid schizophrenic as chosen by the gods). If there is no dis-ease there is no disease. That the physical or mental state of a person CAN be different - does not imply that it MUST be different or even that it is desirable that it should be different. In an over-populated world, sterility might be the desirable thing - or even the occasional epidemic. There is no such thing as ABSOLUTE dysfunction. The body and the mind ALWAYS function. They adapt themselves to their environment and if the latter changes - they change. Personality disorders are the best possible responses to abuse. Cancer may be the best possible response to carcinogens. Aging and death are definitely the best possible response to over-population. Perhaps the point of view of the single patient is incommensurate with the point of view of his species - but this should not serve to obscure the issues and derail rational debate.
As a result, it is logical to introduce the notion of "positive aberration". Certain hyper- or hypo- functioning can yield positive results and prove to be adaptive. The difference between positive and negative aberrations can never be "objective". Nature is morally-neutral and embodies no "values" or "preferences". It simply exists. WE, humans, introduce our value systems, prejudices and priorities into our activities, science included. It is better to be healthy, we say, because we feel better when we are healthy. Circularity aside - this is the only criterion that we can reasonably employ. If the patient feels good - it is not a disease, even if we all think it is. If the patient feels bad, ego-dystonic, unable to function - it is a disease, even when we all think it isn't. Needless to say that I am referring to that mythical creature, the fully informed patient. If someone is sick and knows no better (has never been healthy) - then his decision should be respected only after he is given the chance to experience health.
All the attempts to introduce "objective" yardsticks of health are plagued and philosophically contaminated by the insertion of values, preferences and priorities into the formula - or by subjecting the formula to them altogether. One such attempt is to define health as "an increase in order or efficiency of processes" as contrasted with illness which is "a decrease in order (=increase of entropy) and in the efficiency of processes". While being factually disputable, this dyad also suffers from a series of implicit value-judgements. For instance, why should we prefer life over death? Order to entropy? Efficiency to inefficiency?
Health and sickness are different states of affairs. Whether one is preferable to the other is a matter of the specific culture and society in which the question is posed. Health (and its lack) is determined by employing three "filters" as it were:
In the case of mental health the third question is often formulated as "is it normal" (=is it statistically the norm of this particular society in this particular time)?
We must re-humanize disease. By imposing upon issues of health the pretensions of the accurate sciences, we objectified the patient and the healer alike and utterly neglected that which cannot be quantified or measured - the human mind, the human spirit.
Note: Classification of Social Attitudes to Health
Somatic societies place emphasis on bodily health and performance. They regard mental functions as secondary or derivative (the outcomes of corporeal processes, "healthy mind in a healthy body").
Cerebral societies emphasize mental functions over physiological and biochemical processes. They regard corporeal events as secondary or derivative (the outcome of mental processes, "mind over matter").
Elective societies believe that bodily illnesses are beyond the patient's control. Not so mental health problems: these are actually choices made by the sick. It is up to them to "decide" to "snap out" of their conditions ("heal thyself"). The locus of control is internal.
Providential societies believe that health problems of both kinds - bodily as well as mental - are the outcomes of the intervention or influence of a higher power (God, fate). Thus, diseases carry messages from God and are the expressions of a universal design and a supreme volition. The locus of control is external and healing depends on supplication, ritual, and magic.
Medicalized societies believe that the distinction between physiological disorders and mental ones (dualism) is spurious and is a result of our ignorance. All health-related processes and functions are bodily and are grounded in human biochemistry and genetics. As our knowledge regarding the human body grows, many dysfunctions, hitherto considered "mental", will be reduced to their corporeal components.
Also Read: The Myth of Mental Illness
Note: The Body as a Torture Chamber
There is one place in which one's privacy, intimacy, integrity and inviolability are guaranteed: one's body, a unique temple and a familiar territory of sensa and personal history. The process of chronic disease invades, defiles and desecrates this shrine. It does so publicly, enhancing the sufferer’s sense of helplessness and utter humiliation. Hence the all-pervasive, long-lasting, and, frequently, irreversible effects and outcomes of long-term, intractable illness.
In a way, the torture victim's own body is rendered his worst enemy. It is corporeal agony that compels the patient to mutate, his identity to fragment, his ideals and principles to crumble. The body becomes an accomplice of the affliction, an uninterruptible channel of communication, a treasonous, poisoned territory.
It fosters a humiliating dependency of the abused on medicines, doctors, and bureaucracies. The impersonal character of modern healthcare objectifies the patient, further adding to his or her alienation. Bodily needs denied in the course of the ailment – sleep, toilet, food, water – are wrongly perceived by the victim as the direct causes of his degradation and dehumanization. As he sees it, he is rendered bestial not by the inadequacies of society and medicine but by his own flesh.
The concept of "body" can easily be extended to "family", or "home". One’s sickness often affects kin and kith, compatriots, or colleagues. The inexorable processes of degeneration and decrepitude disrupt the continuity of "surroundings, habits, appearance, relations with others", as the CIA put it in one of its torture manuals. A sense of cohesive self-identity depends crucially on the familiar and the continuous. By attacking both one's biological body and one's "social body", the patient's psyche is strained to the point of dissociation.
Beatrice Patsalides describes this transmogrification thus in "Ethics of the Unspeakable: Torture Survivors in Psychoanalytic Treatment" (it applies equally well to hospital settings, for instance, or to the patient’s death-bed):
"As the gap between the 'I' and the 'me' deepens, dissociation and alienation increase. The subject that, under torture (read: disease – SV), was forced into the position of pure object has lost his or her sense of interiority, intimacy, and privacy. Time is experienced now, in the present only, and perspective – that which allows for a sense of relativity – is foreclosed. Thoughts and dreams attack the mind and invade the body as if the protective skin that normally contains our thoughts, gives us space to breathe in between the thought and the thing being thought about, and separates between inside and outside, past and present, me and you, was lost."
Illness robs the patient of the most basic modes of relating to reality and, thus, is the equivalent of cognitive death. Space and time are warped by sleep deprivation. The self ("I") is shattered. The chronically sick have nothing familiar to hold on to: family, home, personal belongings, loved ones, language, name. Gradually, they lose their mental resilience and sense of freedom. They feel alien: unable to communicate, relate, attach, or empathize with others.
Terminal or debilitating illness splinters early childhood grandiose narcissistic fantasies of uniqueness, omnipotence, invulnerability, and impenetrability. But it enhances the fantasy of merger with an idealized and omnipotent (though not benign) other: the medical doctor, often the inflictor of agony. The twin processes of individuation and separation are reversed.
Being treated for an illness is the ultimate act of perverted intimacy. The medical professional invades the victim's body, or probes his psyche (if he is a psychiatrist). Bed-ridden, deprived of contact with others and starved for human interactions, the patient bonds with his caregiver (hence pathological phenomena such as the Munchhausen Syndrome). "Traumatic bonding", akin to the Stockholm Syndrome, is about hope and the search for meaning in the brutal and indifferent and nightmarish universe of the hospital or the outpatient clinic.
The medical doctor becomes the black hole at the centre of the victim's surrealistic galaxy, sucking in the sufferer's universal need for solace. The victim tries to "control" his caregiver by becoming one with him (introjecting him) and by appealing to the practitioner's presumably merely desensitized humanity and empathy.
This bonding is especially strong when the doctor and the patient form a dyad and "collaborate" in the rituals and acts of treatment (for instance, when the victim is asked to select the implements and the types of surgery to be inflicted or to choose between two equally vile and agonizing “cures”).
The psychologist Shirley Spitz offers this powerful overview of the contradictory nature of torture in a seminar titled "The Psychology of Torture" (1989). Substitute the words “chronic and terminal illness” for “torture” in the following text:
"Torture is an obscenity in that it joins what is most private with what is most public. Torture entails all the isolation and extreme solitude of privacy with none of the usual security embodied therein... Torture entails at the same time all the self-exposure of the utterly public with none of its possibilities for camaraderie or shared experience. (The presence of an all powerful other with whom to merge, without the security of the other's benign intentions.)
A further obscenity of torture is the inversion it makes of intimate human relationships. The interrogation is a form of social encounter in which the normal rules of communicating, of relating, of intimacy are manipulated. Dependency needs are elicited by the interrogator, but not so they may be met as in close relationships, but to weaken and confuse. Independence that is offered in return for 'betrayal' is a lie. Silence is intentionally misinterpreted either as confirmation of information or as guilt for 'complicity'.
Torture combines complete humiliating exposure with utter devastating isolation. The final products and outcome of torture are a scarred and often shattered victim and an empty display of the fiction of power."
Obsessed by endless ruminations, demented by pain and a continuum of sleeplessness, the patient regresses, shedding all but the most primitive defence mechanisms: splitting, narcissism, dissociation, Projective Identification, introjection, and cognitive dissonance. The sick person constructs an alternative world, suffering in extremis from depersonalization and derealisation, hallucinations, ideas of reference, delusions, and psychotic episodes.
Some patients come to crave pain – very much as self-mutilators do – because it is a proof and a reminder of their individuated existence otherwise blurred by the incessant process of disease. Pain shields the sufferer from disintegration and capitulation. It preserves the veracity of his unthinkable and unspeakable experiences. Pain is like a decoration for valour and courage under fire: something to be proud of and flaunt.
These dual processes of the patient's alienation, on the one hand and his addiction to anguish on the other hand complement his view of himself as increasingly "inhuman", or "subhuman". The medical doctor assumes the position of the sole authority, the exclusive fount of meaning and interpretation, the source of both evil and good. The patient is self-vitiated.
Illness can be perceived as a reprogramming the patient to succumb to an alternative exegesis of the world, proffered by the medical profession. It is an act of deep, indelible, traumatic indoctrination. The sick typically swallow whole and assimilate the doctors' point of view and their opinions (regarding the patients as objects, statistics, or corpses-in-the-making) and at times, as a result, are rendered suicidal, self-destructive, or self-defeating.
Chronic disease has no cut-off date. The sounds, the voices, the smells, the sensations reverberate long after each episode has ended: both in nightmares and in waking moments. The patient's ability to trust the rationality and benevolence of the world has been irrevocably undermined. Social institutions are perceived as precariously poised on the verge of an ominous, Kafkaesque mutation. Nothing is either safe or credible anymore.
Long-term patients typically react by undulating between emotional numbing and increased arousal: insomnia, irritability, restlessness, and attention deficits. Recollections of the traumatic events intrude in the form of dreams, night terrors, flashbacks, and distressing associations.
The sick develop compulsive rituals to fend off obsessive thoughts. Other psychological sequelae reported include cognitive impairment, reduced capacity to learn, memory disorders, sexual dysfunction, social withdrawal, inability to maintain long-term relationships, or even mere intimacy, phobias, ideas of reference and superstitions, delusions, hallucinations, psychotic microepisodes, and emotional flatness.
Depression and anxiety are very common. These are forms and manifestations of self-directed aggression. The sufferer rages at his own victimhood and resultant multiple dysfunctions. He feels shamed by his new disabilities and responsible, or even guilty, somehow, for his predicament and the dire consequences borne by his nearest and dearest. His sense of self-worth and self-esteem are crippled.
In a nutshell, the terminally and chronically ill suffer from Complex Post-Traumatic Stress Disorder (PTSD). Their strong feelings of anxiety, guilt, and shame are also typical of victims of childhood abuse, torture, domestic violence, and rape. They feel anxious because the disease's “behaviour”, progression, and trajectory are seemingly arbitrary and unpredictable – or mechanically and inhumanly regular.
They feel guilty and disgraced because, to restore a semblance of order to their shattered world and a modicum of dominion over their chaotic life, they need to transform themselves into the cause of their own degradation and the accomplices of their torment.
Inevitably, in the aftermath of bodily trauma and protracted illness, the victims feel helpless and powerless. This loss of control over one's life and body is manifested physically in impotence, attention deficits, and insomnia. This is often exacerbated by the disbelief many patients encounter when they try to share their experiences, especially if they are unable to produce scars, or other "objective" proof of their ordeal. Language cannot communicate such an intensely private experience as pain.
Spitz makes the following observation:
"Pain is also unsharable in that it is resistant to language... All our interior states of consciousness: emotional, perceptual, cognitive and somatic can be described as having an object in the external world... This affirms our capacity to move beyond the boundaries of our body into the external, sharable world. This is the space in which we interact and communicate with our environment. But when we explore the interior state of physical pain we find that there is no object 'out there' – no external, referential content. Pain is not of, or for, anything. Pain is. And it draws us away from the space of interaction, the sharable world, inwards. It draws us into the boundaries of our body."
Bystanders resent and shun the sick because they make them feel anxious. The ill threaten the healthy person’s sense of security and her much-needed belief in predictability, justice, and rule of natural law. The patients, on their part, do not believe that it is possible to effectively communicate to "outsiders" what they have been through. The torture chambers known as hospital wards are "another galaxy". This is how Auschwitz was described by the author K. Zetnik in his testimony in the Eichmann trial in Jerusalem in 1961.
But, more often, continued attempts to repress fearful memories result in psychosomatic illnesses (conversion). The patient wishes to forget the pain, to avoid re-experiencing the often life threatening episodes and eruptions and to shield his human environment from the horrors. In conjunction with the patient’s pervasive distrust, this is frequently interpreted as recalcitrance or hostility.
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