Wednesday, January 24, 2018

The Rest of the Reflections for my Independent Study Course Last Fall

Well, seeing as the Fall 2017 is, and has been, over, I guess I can and should post/share the remaining reflections I wrote for that course. This is a 'dump' of sorts, so please do not in any way feel obligated to read all of it. Thank you all for your support with this course/journey:

Week 9 Reflection:

The Noonday Demon, Chapter X, “Politics”
            This chapter begins with “Politics plays as big a role as science in current descriptions of depression” (Solomon 361). If politics affects the descriptions of depression, I would think it would affect the DSM and the changes in each of its new editions. Politics is a fundamental part of the treatment and ‘medicalization’ of mental illness as that APA votes to decide what should and should not be included in each edition of the DSM, and although the APA probably does not seem intrinsically political, I am sure that each member of the APA is affected both directly and indirectly by more evident government and politics when making decisions and interpretations regarding mental illness.
Solomon continues: “The vocabulary of depression, which can be enormously empowering to marginal people who have no way to describe or understand their experiences, is endlessly manipulable” (Solomon 361). This vocabulary seems to be a double-edged sword – depending who is doing the manipulating of the vocabulary, and by manipulating vocabulary, you also (are at least able to) manipulate the entire situation/process (of depression, how it is viewed/classified/categorized, and, thus, treated).
“Definitions of depression strongly influence the policy decisions that in turn affect the sufferers. If depression is a ‘simple organic disease,’ then it must be treated as we treat other simple organic diseases – insurance companies must provide coverage for severe depression as they provide coverage for cancer treatment. If depression is rooted in character, then it is the fault of those who suffer from it and receives no more protection tan does stupidity. If it can afflict anyone at any time, then prevention needs to be taken into consideration; if it is something that will hit only poor, uneducated, or politically underrepresented people, the emphasis on prevention is in our inequable society much lower. If depressed people injure others, their condition must be controlled for the good of society; if they simply stay home or disappear, their invisibility makes them easy to ignore” [emphasis added] (Solomon 361). It is understandable that people want and need to understand depression in terms of other illnesses (i.e. depression being cause by a biological chemical imbalance), but based on my previous readings, it is clear that there is a lot more to the cause(s) of depression than chemical imbalance. By only looking at a chemical imbalance as the cause of depression, it may be easier to think that “lower” people, people who are less educated and/or live in poverty, are more prone to depression. Also, although the chemical imbalance explanation is relatively simple and easy to understand, it deemphasizes the complexity of depression and the many other ways depression can be treated besides, or in addition to, antidepressants. If the government that is making laws regarding insurance companies policies regarding depression does not have a full or complete understanding of depression, how will their laws ever be truly beneficial to those suffering from depression? Solomon later explains: “Like all political movements, this one [fight for insurance coverage for mental illness, more specifically, equal coverage as compared to other diseases] depends on oversimplification [chemical imbalance as the explanation for depression]” (Solomon 370). If those who research and treat depression admit (at least sometimes and on some occasions) that they do not have a full or complete understanding of depression, how can we expect lawmakers to have a true understanding of depression?

Finally, there is the issue of mental illness and violence. It comes up nearly every time there is a mass shooting in the United States, and politicians and lawmakers discuss gun control, once again, but little change is ever put into effect. The fact that at least for some period of time after open carry laws were enacted in Texas mental health patients were allowed to bring a gun into a state/county mental health hospital is absolutely absurd. If I remember correctly, the law was relatively quickly changed so that patients were not allowed to have a gun but those working in the hospitals could still carry a gun on them in their workplace. If someone is desperate enough to end their life, and being committed to a mental hospital against their will could easily be the final straw to make them end their life, they should not have any kind of access to a firearm. Mental health hospitals have rules against allowing things like clothing with zippers or shoes with shoestrings in their facility; why on earth would a firearm be allowed? Solomon states: “The focus on mentally ill people who are dangerous increases stigma and reinforces negative public perception of people suffering from mental illness. It is, however, extremely effective for fund-raising; many people who will not pay to help strangers will gladly pay to protect themselves, and using the ‘people like that kill people like us’ argument enables political action. A recent British study showed that though only 3 percent of the mentally ill are considered dangerous to others, nearly 50 percent of all press coverage of the mentally ill is focused on their dangerousness” (Solomon 373). It is sad that it takes an act of violence and fear for one’s own life to cause others to supply help to those who are mentally ill, and desperately need, and often, want that help. I wonder if depression generally results in a greater number of homicides or suicides. Neither is good. They are both terrible, but should we really characterize the mentally ill as a threat to others or more as a threat to themselves, and, ultimately, maybe that initial view that they are a threat to others is fundamentally a threat to themselves as a hidden desire for someone else to end their life for them by doing something drastic and terrible that would warrant their own death by the hands of a law enforcement official.

Week 10 Reflection:

Darkness Visible by William Styron
            This has been, by far, the easiest and most enjoyable reading I have encountered so far for this course because it is a personal account of an individual’s experiences with depression. I also truly appreciated this reading because Styron as a talented author, very eloquently, and with great description, depicted depression. This can be so difficult to accomplish as it is a rather abstract disease/experience. I also appreciated the fact that Styron had done fairly extensive research on his own into depression, reading up on the DSM and the Physician’s Desk Reference.
            Towards the beginning of Styron’s description, he states “Depression is a disorder of mood, so mysteriously painful and elusive in the way it becomes known to the self – to the mediating intellect – as to verge close to being beyond description. It thus remains nearly incomprehensible to those who have not experienced it in its extreme mode, although the gloom, ‘the blues’ which people go through occasionally and associate with the general hassle of everyday existence are of such prevalence that they do give many individuals a hint of the illness in its catastrophic form” (Styron 7). The idea that depression can be both “painful” and “elusive” is not only extremely relatable but also feels incredibly insightful. Yet, I feel that those who have not personally experienced depression would not really be able to make sense of this combination, which seems at odds with one another. How can pain be elusive? Don’t you just feel pain in the body and can point to a doctor where it hurts? This is one of the many reasons why depression is so incredibly difficult to describe to others. As Styron says, “Depression is…so mysteriously painful and elusive in the way it becomes known to the self…” (Styron 7). If it is difficult for even the individual to become aware of what is happening to him/herself, how can that individual possibly describe what is happening to them to another? I think what Styron is describing can also relate to how depression has a tendency to seemingly ‘sneak up’ on individuals. Only once someone is in the throes of depression can an individual say, “Wow there were so many signs and triggering events that led to this downward spiral.” Looking back, everything is apparent in 20/20 vision, right?
This is why it is so necessary for all medical professionals to have knowledge of mental illness so that they can detect any early signs of it in order to prevent a major break down in an individual. Of course, the stigma associated with mental illness does not help either. If an individual is beginning to feel “off,” they certainly will not seek out immediate help from a mental health professional. So often, help is only sought out, or provided, when an individual is experiencing extreme symptoms. By that point, it may be too late. So many diseases, like cancer, have protocols for early detection and treatment. Conversely, with many mental health disorders, detection of any kind can be nearly impossible. Treatment only occurs when the patient is at a point similar to stage 4 of cancer. It is known that the earlier cancer is treated, the more likely the patient will have a full recovery and not encounter a relapse. Why, then, do we wait so long to intervene when it comes to mental illness?
The following is perhaps my favorite descriptor Styron provides of depression: “…the gray drizzle of horror induced by depression takes on the quality of physical pain. But it is not an immediately identifiable pain, like that of a broken limb. It may be more accurate to say that despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely over-heated room. And because no breeze stirs this cauldron, because there is no escape from this smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion” (Styron 50). As soon as I read this description comparing depression to being stuck in a sort of furnace it struck me as being so accurate. Yet nothing that I would ever have been able to put together on my own. Accordingly, I sent the description to a friend who also suffers from mental illness. He immediately responded that he, too, wholeheartedly agreed with this description. It comforted me to know that someone who also experienced depression had the ability to articulate this so well. In addition to me and the writer, another peer who also suffers from this horrible disease also agreed with the description. This ability to articulate such a specific description comforted me. What I experience and have experienced is not simply something that “is all in my head” – though to an extent it is. If someone else can put words to this abstract experience and multiple people agree that it is accurate, then there is more realness/validity to the experience. It’s as empirical as we can get to describing the feelings we experience with this incredibly abstract and often nuanced disease.

Week 11 Reflection:

Endogenous versus Nonendogenous Depression
            Endogenous Depression is generally defined/categorized as depression that is rooted in biological causes, such as a chemical imbalance in the brain. Nonendogenous depression is defined as depression that is caused by some external event/conflict. If nonendogenous depression does not have a biological component is it really a “disease”?
            In the first article by Feinberg, he argues that depression is not a “homogenous illness” and that it is necessary to recognize the different types of depression (which cause it to be a nonhomogeneous illness) and separate the subtypes when researching treatment as the different types respond differently to various treatments (Feinberg 670). Feinberg’s article begins with sharing the “history” of naming endogenous depression and shares that this type of depression has been referred to as “endogenous, endogenomorphic, psychotic, or melancholic” (Feinberg 670). The presence of multiple names for one recognized type of depression only contributes to the confusion and misunderstandings related to mental illness, and, specifically, depression. Has a consensus been reached on which name should be used to refer to this type of depression? Feinberg also states that this type of depression (endogenous depression), “[is] likely to respond to somatic treatments for depression (antidepressant drugs and electroconvulsive therapy)” (Feinberg 670). If patients respond to somatic treatments, it makes sense that these patients would also experience somatic symptoms such as physical pain. Because this type of depression has a biological cause and responds to treatments that can be explained biologically, it is easier to understand in terms of a disease.
            Feinberg goes on to discuss other studies that researched endogenous and nonendogenous depression to further identify the differences between these two types of depression. One study Feinberg cites tested endocrine function. This study, conducted by Carroll and colleagues (1981) “found that one half to two thirds of endogenous depressed patients had abnormal DSTs [dexamethasone suppression tests – a standard test of endocrine function], whereas less than 10% of nonendogenous depressed patients had abnormal tests” (Feinberg 672). This is another indicator of biological ‘malfunction’ in the body for patients with endogenous depression. If a patient’s endocrine function is abnormal, could their metabolism also be negatively affected – explaining the appetite and weight changes many depressed patients experience?
            Feinberg concludes his article by citing another example of research that highlights the differences in response to various treatments between patients with endogenous and nonendogenous depression. Patients with endogenous depression can be found to have normal DSTs and are referred to as “escapers or nonsuppressors” because people with endogenous depression generally have abnormal DSTs. This abnormal result can be overcome if a patient is able to “resume corticosteroid synthesis in less than 24 hr” (Feinberg 672). Essentially, these patients have the ability to ‘outsmart’ the DST, and, although their DSTs are normal, this does not mean they do not have endogenous depression (Feinberg 672). Feinberg also discussed a study of REM latency as well as other indicators of sleep disturbance, such as REM density. It found that patients with endogenous depression have abnormal results from these types of tests, which are an indicator for endogenous depression (Feinberg 671-672). In a study conducted by Rush and colleagues (1982), patients with both endogenous and nonendogenous depression were studied using DST and EEG tests. It led to the conclusion that “of five patients with endogenous major depressive disorder…, about normal (nonsupressor) DSTs, and shortened REM latencies, not one responded to cognitive therapy. In contrast, eight of nine patients with nonendogenous depression, normal DSTs, and normal REM latencies responded well” (Feinberg 672).  Those with endogenous depression did not respond to cognitive therapy, indicating something on the biological level needed to be altered. How long were these patients in cognitive therapy? Maybe these patients would have responded if they participated in therapy longer, allowing for a biological restructuring/reorganization of the brain via neuroplasticity.
            The second article I read this week on endogenous and nonendogenous depression by Harkness and Monroe led to the conclusion “…severe levels of childhood adversity were significantly associated with severe endogenous depression. These results may enlarge thinking about the traditional etiological distinction between endogenous and nonendogenous depression and are consistent with emerging research outlining the neuropathological consequences of childhood adversity” (Harkness and Monroe 392). This conclusion is very interesting because it shows that a traumatic event can lead to endogenous depression. Although in most cases the event occurred years before this research was conducted and a diagnosis of depression was made, it challenges the view that endogenous depression is a solely biological event and nonendogenous depression relies only on external events.
            This article begins by stating: “The last decade has seen a surge of interest in the role of childhood adversity in the onset of major depression” (Harkness and Monroe 387). The types of childhood adversity researched in this article included “…parental neglect, antipathy, and physical and sexual abuse…” (Harkness and Monroe 387). I found it very interesting that this research also highlights the significance of childhood adversity as a factor in the onset of depression in comparison to Styron’s statement in Visible Darkness that the death of a close loved one in childhood is generally a precursor for depression later in life. Although both argue and show evidence that difficult events in childhood can lead to depression, Harkness and Monroe’s article and research does not include a major loss of a loved one early in life as one of their factors/definitions of childhood adversity.
            Monroe and Harkness follow this discussion of childhood adversity with a helpful definition/distinction between endogenous and nonendogenous depression: “Kraepelin originally characterized endogenous depression by 1) a distinct pattern of symptoms (e.g., anhedonia, morning worsening, psychomotor disturbance), 2) a presumed biogenetic etiology, and 3) an absence of precipitating stressors (4, 5). By contrast, the more loosely defined nonendogenous subtype was traditionally conceptualized as a reaction to environmental adversity” (Harkness and Monroe 387). Two things from this distinction/definition caught my attention: 1. That the second characterization of endogenous depression includes the word “presumed” in context with endogenous depression having a biological origin. 2. That nonendogenous depression is so “loosely defined” that even its name indicates that there is no distinct indicators other than it being ‘nonendogenous.’ It seems that there is less knowledge about nonendogenous depression than endogenous depression as any type of depression that does not fit the qualifiers for endogenous depression falls into the nonendogenous category.
            The results of this study of childhood adversity and depression “….examined more fine-grained distinctions in the severity of childhood adversity…while nonsevere levels of childhood adversity were indeed associated with a higher risk of nonendogenous depression, severe childhood adversity was consistently associated with at least double the risk of endogenous depression” [emphasis added] (Harkness and Monroe 391). I found this result very interesting because it seems to indicate that severe childhood adversity led to some kind of biological change in individuals, leading to endogenous depression. Childhood adversity that is considered ‘nonsevere’ would most likely not lead to a biological change in the child/victim, or, at least not as significant of a biological change as compared to the biological change that can/could result from severe childhood adversity.
            Harkness and Monroe discuss a possible explanation for their results: “Endogenous depression has traditionally been associated with a neurobiological etiology, and it is compelling to find it here preceded by severe environmental adversity. However, a large body of research suggests that severe, prolonged, and uncontrollable stress, such as that inherent in severe sexual abuse and poor parental care, has enduring effects on developing brain networks…prolonged and uncontrollable stress has been proposed as an animal model of anhedonia, provoking behavioral signs analogous to the symptoms of endogenous depression” (Harkness and Monroe 391). These arguments make sense in that a traumatic event in childhood could easily have a long term psychological effect on the individual as well as a biological effect as the brain is in various critical stages of development throughout childhood. It would be interesting to see if individuals who sustained similar types and levels of adversity at later ages would also experience endogenous depression or if age was the main factor in the diagnosis/cause of endogenous depression. I would also be interested to see whether these individuals with endogenous depression also experience abnormal/heightened levels of anxiety in their day to day lives; I’m very interested in links between anxiety and depression because they are so often polarized. There are the popular explanations that ‘depression is a result of looking at the past, and anxiety is the result of looking too closely at the future.’ In my opinion, the two conditions are not that simple, and, often, are linked to one another and can feed off of one another.

Week 12 Reflection:

Touched with Fire
            Dr. Kay Redfield Jamison, a professor of psychiatry at the Johns Hopkins University School of Medicine, examines the seemingly inescapable relationship between manic-depressive illness (aka bipolar disorder – I have no idea why there are multiple names for one illness) and creativity. Jamison emphasizes the significance of manic-depressive illness and its characteristics versus ‘simply’ depression; the symptoms that distinguish manic-depressive illness from ‘just’ depression are the ‘highs’ or ‘manias’ an individual experiences in addition to the melancholic lows of depression. These manias may be qualified as ‘hypo-‘ or ‘hyper-‘ depending on their severity. In Jamison’s introduction, entitled “That Fine Madness,” Lord Byron – one of the most notable creatives diagnosed with manic-depressive illness (Jamison later devotes an entire chapter to Byron) – is quoted “Some [creatives/artists] are affected by gaiety, others by melancholy, but all are more or less touched” (Jamison 2). Jamison goes on to explain “This book is about being “more or less touched”; specifically, it is about manic-depressive illness…” (Jamison 2).
            Jamison examines the argument that “all poets are mad” as Robert Burton asserted in the seventeenth century (Jamison 4). Jamison states “A common assumption, for example, is that within artistic circles madness is somehow normal” (Jamison 4). Jamison then uses an excerpt from the biography of the poet Robert Lowell: “…they could see no reason to think of Lowell as ‘ill,’ indeed, he was behaving just as some of them hoped a famous poet would behave” (Jamison 4). If an ‘ordinary’ person were to behave in a similar, outrageous manner, this person would most likely have been sent to an asylum. Artists, however, are praised for their outlandish behavior as it is thought/believed that this exact behavior will lead to some kind of great, creative work, and the more extreme the behavior, the greater the work/creation.
            In Jamison’s third chapter, entitled “Could it be Madness – This?” the evidence and controversy surrounding the notion of madness in artists is examined. The title of this chapter is a quote from Emily Dickinson. The entire excerpt presented at the beginning of the chapter follows as: “And Something’s odd – within - / That person that I was - / And this One – do not feel the same - / Could it be Madness – this?” (Jamison 49). Directly above this quotation is an excerpt from Joyce Carol Oates presenting an argument that Dickinson was not afflicted with any kind of mental disease (Jamison 49). It is almost disorienting to see these two antagonistic views on the same page, directly following one another. Dickinson’s testimony to her personal experience seems painstakingly obvious that she, herself, felt ‘mad,’ and was seeking some form of help, or, at the very least, some perspective, and, yet, Oates vehemently argues that nothing was ‘wrong’ with Dickinson.
            Jamison opens this chapter with the sort of ‘history’ of this concept of madness and artistic genius and follows its sort of ‘rise and fall’ throughout history. For example, “…the Renaissance [accompanied] a renewed interest in the relationship between genius, melancholia, and madness” (Jamison 51). In contrast to this time period and its interest, and maybe even support of this concept, “The eighteenth century witnessed a sharp change in attitude; balance and rational thought, rather than ‘inspiration’ and emotional extremes, were seen as the primary components of genius” (Jamison 52). This ebb and flow of different time periods either supporting or fighting this concept is followed through until current times (this book was published in 1993). A particularly interesting notion is presented by Charles Lamb in the nineteenth-century (Jamison 53). Lamb’s argument “for a balance of faculties” went against others, who, at the time, “emphasiz[ed] the mysterious, irrational, and overwhelming forces that gave rise to genius…” (Jamison 53). Jamison utilizes an excerpt from Lamb’s The Sanity of True Genius; in this excerpt, Lamb states “Madness is the disproportionate straining or excess of any one [faculty]…The ground of the mistake is, that men, finding in the raptures of the higher poetry a condition of exaltation, to which they have no parallel in their own experience, besides the spurious resemblance of it in dreams and fevers, impute a state of dreaminess and fever to the poet. But the true poet dreams being awake. He is not possessed by his subject, but has dominion over it” (Jamison 53). This quote/excerpt made me think of Mark Twain’s assertion that “truth is stranger than fiction.” If an individual experiences something during a period of madness that he “[has] no parallel in their own experience” (except for when in an abnormal/not fully conscious state), why is it wrong or bad or unrealistic? Just because this experience may not be possible or replicated in “real life” does not mean there is some level of ‘truth’ or even ‘nobility’ to it.
            Jamison goes on to compile the arguments of past views that it is important to distinguish the extremes of madness and that, essentially, only a ‘mild madness’ can lead to great productions of art and creativity, and, also, true creative/artistic genius is achieved when madness is accompanied by “…discipline, rationality, and sustained effort in the execution of lasting works of art and literature” (Jamison 54-56). Jamison also compiles arguments that madness can only lead to creative genius in an individual with a high intellect; people with relatively low intellects will not experience an ability to create masterful works if they experience madness of any kind (Jamison 54-56).

Week 13 Reflection:

Mad Travelers by Ian Hacking
            One of the concepts I found most interesting in this reading was Hacking’s discussion of a “transient mental illness.” The discussion of Albert’s fugues, which led to him traveling in an obsessive and not entirely conscious manner. Hacking defines a “…’transient mental illness’…[as] an illness that appears at a time, in a place, and later fades away” (Hacking 1). He further explains “I do not mean that it comes and goes in this or that patient, but that this type of madness exists only at certain times and places” (Hacking 1). These illnesses are “…transient, not in the sense that they come and go in the life of a single person, but that they exist only at a time and a place” (Hacking 13). I cannot help but think there is some kind of unintentional connection. There is something also more than mere coincidence, between the term ‘transient mental illness’ and the illness Albert experiences which involves physical movement and travel. Hacking uses the words “come and go,” and, although he uses these words in context of defining what a transient illness is NOT, I think these words can be connected to the rest of his explanation in which he defines what a transient illness truly IS. Hacking very clearly explains that a ‘transient mental illness’ is not some kind of contagious epidemic and only comes and goes in the sense that it only presents itself under certain conditions. Hacking uses a fantastic metaphor of a required “ecological niche” that allows the ‘transient mental illness to occur and thrive – it seems necessary to me to make the connection between the traveling Albert accomplishes and this idea of a non-permanent illness that appears in various parts of the world based on the current conditions found in any certain specific area.
            I also found the use of the term “fugue” very interesting in describing Albert’s illness. Hacking defines fugues as “…strange and unexpected trips, often in states of obscured consciousness…” (Hacking 8). When I first encountered this term in this text, my first thought was of its use in the realm of music – the only time I had seen this word prior to this reading. When I looked up the word “fugue” in Merriam-Webster’s online dictionary, the first definition is: “a musical composition in which one or two themes are repeated or imitated by successively entering voices and contrapuntally developed in a continuous interweaving of the voice parts” (Merriam-Webster). The second subset of this first entry for the definition of “fugue” emphasizes “interweaving repetitive elements” (Merriam-Webster). The second definition for the term “fugue” describes Hacking’s use of the word. The music definition of fugue made me think of the concept of two themes in Hacking’s first chapter. One, the relationship between Albert and his doctor, Philippe Tissié, and secondly, Tissié’s supervisor, also a man named Albert (but distinguished from the patient Albert by the use of his last name in conjunction with his first – Albert Pitres). Hacking states “ Tissié did not choose Albert by chance. The man and his doctor were made for each other, opposite but parallel” (Hacking 14). The doctor and his patient were similar in the sense that Tissié  “…was always close to movement,, keeping books at night in the train station, that center of all movement, or delivering, or on the good ship Niger whose very name is redolent of colonial travel and adventure in darkest Africa” (Hacking 14). There is an element of destiny for this doctor and patient to come together. Perhaps the doctor would not have been able to understand his patient or treat him as successively had he not had his own characteristics that led him to travel and understand the need and/or compulsion to travel.
The second instance of a sort of ‘repetitive’ theme in Hacking’s first chapter is presented with the idea of “double consciousness” (Hacking 26). Albert was thought to have almost two separate identities. It did not quite qualify him for the diagnosis of multiple personality or dissociative identity disorder, yet, unquestionably contributed to the characterization of Albert’s illness. One of Tissié’s colleagues, Azam, argued “…that Albert was more intelligent in his second state of ‘total somnambulism’ than his ordinary waking state” (Hacking 26). My understanding from this reading is that Albert essentially had one state where he was ‘normal.’ He then entered a second state when he was travelling once he completed his ‘mission,’ Albert often was not able to recall details from his travels. I think Azam’s argument for Albert’s two states could be connected to the two states previously described. These depend on whether or not Albert is in a state of mind that leads to compulsive traveling. Consider Azam’s argument and Albert’s traveling states. Does this mean Albert was more intelligent or maybe even more connected to a greater state, above reality, while traveling in a not entirely conscious state? Is it necessary to free ourselves from the constraints of what is widely known and agreed upon as reality in order to obtain access to higher states of thinking?

Week 14 Reflection:

Mad Travelers, Chapter 2 “Hysteria or Epilepsy?” and “Making up people” by Ian Hacking
            Hacking’s “Making up people” discusses the effect classifications and diagnoses have on people and the effects people have on those classifications and diagnoses – a phenomenon Hacking terms “the ‘looping effect’” (Hacking 1). Hacking states “We think of many kinds of people as objects of scientific inquiry. ….Sometimes to change them for their own good and the good of the public.” (Hacking 1). But which comes first? The individual person’s good or the good of the public? What if the sum of individuals in a certain category/with a particular diagnosis makes up a significant portion of the population? And, who gets to determine what “their own good” is? Hacking goes on to say “We think of these kinds of people as definite classes defined by definite properties. As we get to know more about these properties, we will be able to control, help, change, or emulate them better. But it’s not quite like that. They are moving targets because our investigations interact with them, and change them” (Hacking 1). This process is also not so simple because it involves humans and humans are constantly changing and evolving. There are many variables involved with humans, making it difficult to categorize/group them because they may ‘belong’ in a certain category on a given day but not a subsequent day, or, at least, not without a caveat or two. Is the process of classifying people also a process of de-humanization? 
            Hacking describes the ‘beginning’ of the diagnosis of multiple personality in 1970 (Hacking 2). He states “A few psychiatrists began to diagnose multiple personality. It was rather sensational. More and more unhappy people started manifesting these symptoms. At first they had the symptoms they were expected to have, but then they became more and more bizarre….” (Hacking 2). Maybe people who feel a lack of self-identity unintentionally/unconsciously ‘create’ multiple identities in order to fit into a man-made classification, allowing for a specific identity (an individual with multiple personality). I think this could easily happen with other diseases/disorders/classifications.
            Hacking goes on to discuss the difficulty in classifying or in his words “making up people,” as “there are different schools of thought” (Hacking 2). In terms of multiple personality, Hacking argues “…there are rival frameworks, and reactions and counter-actions between them further contribute to the working out of this kind of person, the multiple personality. If my skeptical colleague convinces his potential patient, she will very probably become a very different kind of person from the one she would have been had she been treated for multiple personality by a believer” (Hacking 2). Hacking’s use of the term ‘believer’ makes this whole way of thinking seem akin to religious doctrine in terms of believers and non-believers and that there is often little or limited evidence for certain beliefs or schools of thought.
            Hacking then relates the formation of the multiple personality diagnosis to his concept of ‘transient mental illnesses’ discussed in Mad Travelers (Hacking 3). He then moves from multiple personality (which was renamed Dissociative Identity Disorder) to autism and obesity; Hacking describes all three of these diseases/disorders as “epidemics” (Hacking 3). Autism can easily be seen as one of Hacking’s transient mental illnesses, particularly in his description of a need for an “ecological niche” in order for the illness to essentially take hold. As soon as the argument that immunizations caused autism came out, a significant drop in childhood immunization was found in Marin County in California. Marin County was a ‘suitable’ ecological niche because of its renowned wealth. If the children of Marin County became ill from a disease that could have been prevented via immunization, their parents would most likely be able to afford treatment. Other, less wealthy, areas of the United States did not necessarily have this option/freedom as healthcare can quickly become extremely expensive. Even if parents in a less wealthy area feared immunizations would cause their child to become autistic, it was likely they would not actually avoid commonly recommended immunizations because they would not easily be able to afford medical treatment should their child become gravely ill as a result of lack of immunization.
            Throughout this article, Hacking looks at two different ways to look at an illness ‘suddenly appearing’ in a population and the idea that it did not previously exist in that population (Hacking 2-3, 4). Hacking begins with an extremely simplified version (A) and then follows it with a much more developed version (B). For example, with high-functioning autism: “A. There were no high-functioning autists in 1950; there were many in 2000. B. In 1950 this was not a way to be a person, people did not experience themselves in this way, they did not interact with their friends, their families, their employers, their counsellors, in this way; but in 2000 this was a way to be a person, to experience oneself, to live in society” (Hacking 4). Hacking goes on to explain: “Before 1950, maybe even before 1975, high-functioning autism was not a way to be a person. There probably were a few individuals who were regarded as retarded and worse, who recovered, retaining the kinds of foible that high-functioning autistic people have today. But people didn’t experience themselves in this way, they didn’t interact with their friends, their families, their employers, their counsellors, in the way we do now” (Hacking 4). This led me to a sort of ‘chicken or the egg’ question: Does the way one acts with others determine how one experiences himself or vice versa? A similar parallel can be drawn to Hacking’s second chapter in Mad Travelers when he discusses how treatments were/are used as a means for diagnosis: “Is a person depressed or manic-depressive (bipolar disorder)? If the condition responds well to a substance such as Prozac, she is probably depressed while if she gets better when taking lithium, it is more likely to be bipolar disorder. In those days there was at most one specific drug in psychiatry, potassium bromide for epilepsy (chloral was also used widely but less specifically)” (Hacking 36). Contrarily, Hacking shares another patient case: “…she was cured by hypnotism. This was critical. Epileptics did not respond to hypnotism” (Hacking 39). Currently, there is another, newer drug specifically for bipolar depression – Latuda. I do not know much about it, but I assume it is a more complex drug, chemically, than ‘just’ lithium. If this is the case, can Latuda also be used to diagnose depression versus manic depression? Is it responsible to diagnose via medication that could result in sometimes serious side effects?
            Next, Hacking examines and analyzes ten different engines “…for making up people” (Hacking 4). The ninth engine, Bureaucracy, is accompanies with the following explanation/example: “Most prosperous nations have quite complex bureaucracies that pick out children with developmental problems in the early years of schooling, and assign them to special services” (Hacking 6). Hacking uses this example to describe the process of identifying autistic children (Hacking 6). Personally, I remember going through scoliosis screenings in public school in fifth and eighth grades. Since receiving my depression diagnosis and realizing that I have had some degree of depression for the majority of my life, I have often wondered why school children do not periodically undergo ‘mental health checkups.’ It has led me to wonder how my life may have been different had my depression/dysthymia been detected prior to going off to college.
            Hacking’s tenth engine, Resistance, gives power back to the diagnosed/categorized individuals. Hacking states “Kinds of people who are medicalized, normalized, administered, increasingly try to take back control from the experts and institutions, sometimes by creating new experts, new institutions. The famous case is homosexuality, so highly medicalized from the time of Krafft-Ebing late in the 19th century. That was the very period in which legal institutions became active in punishing it. Gay pride and its predecessors restored to homosexuals a control of the classifications into which they fall” (Hacking 6). The idea that a certain subset of humans should be able to classify themselves makes profound sense to me – after all, who understands them and their ‘issues/disabilities’ better than them?
            Hacking goes on to further describe various processes of categorizing and naming humans: “Often when we try to generalize we go into the species mode. Indeed, there are books called The Autistic Child and The Obese Child. But some autism advocates strongly object to speaking of ‘the autistic child’ and prefer ‘children with autism.’ One can sense what they are opposing. To speak in the species mode about people is to depersonalize them, to turn them into objects for scientific inquiry. Other thoughtful people feel that ‘autistic child’ is just right. A parent who founded the Autism Society of America, and wrote one of the first books about the topic, did so because ‘autism is who my son is, not just a characteristic.’ It is part of the boy’s nature to be autistic. Except in very rare cases, I am disinclined to say the same thing of an obese person. Being overweight is always just a characteristic: disinclined to say the same thing of an obese person. Being overweight is always just a characteristic: it is never who the stout man is, just one of his enduring, and maybe endearing, properties” (Hacking 7). The first part of this passage emphasizes the importance of semantics; for example, I have been taught to try to not think “I am depressed,” but, rather, “I have depression.” This is a way to allow myself to keep some distance from depression and to remember that it is not really who I am, though it may affect my personality and/or thought processes, which are generally thought of key properties that make up a human. The second part of this passage leads me to an important distinction: if a disability is in anyway neurological/a mental disability, the it is “part of the person.” But if the disability is solely physical, then it is simply a characteristic of that person. Here, autism is embraced as a key part of an individual’s identity, whereas obesity is seen as one of many individual’s characteristics? What about depression? Since there is such a stigma associated with depression (a diagnosis of depression is far from desirable), it may be another reason why there is such an emphasis on biological causes. It is a means to distance the individual from the diagnosis and make it more of a physical entity. It is clear that there are many components and facets of depression and it could never truly be reduced to the physical/chemical. Similarly, Hacking analyzes the attempt to distinguish two types of fugue: those caused by hysteria and those caused by epilepsy. Hacking states “…hysterics were basically attractive people with a problem. But epileptics given to sudden impulses were described in a somber, indeed sordid, light. Latent epileptics who experience sudden attacks ‘are filthy and lewd, they exhibit their genitals, urinate in a salon, at the theater or in a church, make shocking gestures, or at least are found naked in the staircase, in the courtyard of their home, or in the street’” (Hacking 41). I find it very interesting that epileptics faced a much more significant stigma than hysterics. It seems hysterics were almost romanticized, similar to the ‘mad genius’ concept. I think part of the stigma unbalance was also due to a belief that hysteria was understood better than epilepsy. (At least at the time) it was an attempt to cover up for their lack of knowledge about the disease/condition. Doctors help create this idea that epileptics are crazy, uncontrollable people, simply because the doctors/experts did not themselves understand how to control them. They were able to control hysterics, at least to a degree, via hypnotism, strengthening a doctor/expert’s self-esteem as hypnotism is a ‘treatment’ solely accredited to the hypnotist.

A Sort of Post-Semester Follow Up:

Thomas Szasz: Primary Values and Major Contentions
            I found it very interesting that a lot of Szasz’s work/arguments focus on the rhetoric of mental illness. I definitely agree that it is extremely important to use the ‘right’ words when diagnosing (essentially telling an individual what is wrong with them) someone. It is imperative that a doctor, of any specialty, has the ability to be empathetic with his or her patients. This is especially important in the field of mental illness because, as I have shared before, it often seems that a mental diagnosis has some implication that there is something wrong with you, as a person/being, as the illness is in your mind/brain. I also see Szasz’s emphasis on rhetoric similar to Hacking’s argument against categories. In order to have categories, each of these categories must have names. Most likely some, if not a majority, of the categories are not truly necessary, and if each of the categories does not have the ‘right’/’best’ name, it could be damaging to an individual’s psyche once put into a category with a ‘wrong’ name or a name that could easily be stigmatized.
            Szasz writes in the foreword of this book: “The first fact is that there is no mental illness: The term is simply a socially validated verbal construct. The second one is that psychiatric inquiry and practice are not empirical, rational, or scientific: Indeed, how could they be if their aim is to empirically investigate and treat an alleged disease, mental illness, that cannot be empirically identified?” (Szasz 10). Is Szasz saying mental illness is in no way a ‘condition’? That it should in no way be treated and/or researched? This book was published in 1983. I’m assuming at that time MRIs of brains of ‘normal’ and ‘depressed’ patients were not available at this point. Today, you can easily find images of these scans and see that the depressed patient’s brain looks very different from the ‘normal’ patient’s. Generally, the depressed patient’s brain has a smaller portion than the normal patient’s that is able to, essentially, activate, or in the case of the image ‘light up’ under certain stimuli.
            Szasz goes on to say: “Although psychiatrists perform many other acts as well, these two sets of psychiatric performances [“inculpate and imprison the innocent” and “exculpate and imprison the guilty”] stand as important reminders of what I regard as the central moral-philosophical act of psychiatry: transforming individuals from responsible moral agents into non-responsible, insane patients” (Szasz 10). From this, I took that Szasz is arguing that psychiatrists cause mental illness patients to act insane. I could see this being true if one were to receive a certain psychiatric diagnosis and then after either being informed of the symptoms of this diagnosis or of finding out on one’s own – most likely from the news, which highlights extreme cases of mental illness, one could easily get certain ideas of him or herself planted in one’s mind of how they are supposed to act, given their diagnosis. 

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