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Articles    H2'ed 9/4/10

Ethics for Mental Health

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Ethics arise from stories that strike us as right or wrong. Brian Boyd (On the Origin of Fiction, p. 288) writes that "stories regularly engage the moral emotions, because these emotions matter so much to social life." Indeed, stories arose as part of the developing prominence of social life for humans so much more important than it was for other primates. "Before a year and a half, infants look longer at visual displays depicting violations of arbitrary social rules than at similar displays that do not."

"Children from the age of three, like adults, search for any detectable violations of social rules, especially for "permissions, obligations, prohibitions, promises, and warnings', but they do not notice and detect violations in other types of reasoning."

We attend to social violations, and they stir our emotions. Across cultures, whether Apache, Dogon, or Sami, stories and storytellers are valued for their ability to inculcate the values of the community by depicting social violations and their consequences. Coyote stories are the classic North American version of these teachings, in which coyote does everything wrong and shows us what can happen to people who break the rules. Through the humor of these tales, the moral teaching becomes fun and easy.

The social emotions are present in rudimentary form even in creatures like the worm, C. elegans, with a brain containing only 302 neurons compared with billions in the human brain. Complex social emotions, like empathy and a sense of fairness, or behavior like punishment and reconciliation, have been observed and tested in many species, especially in social primites.

So, stories form our ethics and help us detect deviations from the ethical principle that is the conclusion to be taken from the story. When we make statements of ethical principles we are creating abstract summaries of the conclusions we have drawn from the collection of stories that inform us about what is right and wrong.

What concerns me is how we invent stories about people who are different from us, especially people who may be irritating and annoying. In Michel Foucault's archaeology of the mental health industry, these professionals begin with the birth of the European middle class who want the annoying and the irritating removed from the streets around their shops hence, the rise of the asylum. We have moved through a variety of stories about people we don't like. Once upon a time, they were possessed by spirits, then they came to have inferior morals, and now they have defective brains. I suspect they fared best when they were possessed, for this elicited our compassion; or when they were having visions and other worldly experiences, for these aroused our interest and fascination. Defective brains are of less general social interest.

Behavior lies on a continuum. I expect that some individuals will lie at the edges of these continua at any time in history. Culture and the stories that form it tell us what to call these people. Today, people at the extremes of joy and/or elation are called bipolar manic, while people at the extremes of sadness that knows no bounds are called bipolar depressive. People who make no sense whatsoever are called schizophrenic, unless they're very emotional about it, and then they are called schizoaffective. People who make sense but are annoying and demanding are called borderline, unless they commit crimes, in which case they are called antisocial. If they're too flamboyant and provocative, they are called histrionic; if too eccentric, schizoidal; if too withdrawn, schizotypal. We manufacture labels to define those whose traits are sufficiently extreme as to violate our social norms.

We invent stories about these people. In an article, The Americanization of Mental Illness, Ethan Watters writes about the dangers of the global spread of our American story that people with suffering and pain that cannot be explained by pointing to an ailing area of their physical body, have defective brains, and that's why they violate our social norms or sit at the extremes of social acceptability. Professor Mehta of Auburn University in Alabama did studies which showed that people whose suffering was explained by biochemical brain difficulties inspired less compassion than people whose suffering was related to childhood trauma. Apparently ordinary people were more forgiving of trauma during childhood as an explanation for suffering than they were of biochemical abnormalities.

Thus, the stories we generate to explain social violations matter greatly to how we treat the violators. Watters makes the observation that sufferers in the Third World fared much better when their afflictions were due to spirit possession or vision than when their suffering came to be due to having a bad brain.

If we think people have been damaged during childhood or possessed by spirits or cursed, we're more likely to have compassion for them and expect them to recover than if we think the biochemistry of their brains are defective. Then we do what has happened in North America we separate these people from the rest of us in hospitals, jails, or group homes in bad neighborhoods. When I worked in the locked psychiatric hospital in Tucson, we located all the group homes to which we sent patients on the map of the city, finding that all were in the worst possible neighborhoods. Our patients were surrounded by crack houses, criminals, and drugs. An invisible intent can be seen here in relegating the unusual to the same status as drug abusers and criminals. As happened in Foucault's description of Renaissance France, the bizarre appearing and unusual people are kept away from our middle class neighborhoods. Because they are seen as having defective brains, they are medicated until their symptoms go away, usually well beyond the threshold for unacceptable side effects.

The World Health Organization found in a study of about 20,000 people that Third World countries had better outcomes for schizophrenia, because they didn't isolate paper and remove them from their homes and communities, but kept them integrated into the family and community. Families found ways for their afflicted relatives to have meaning and purpose even if they had to give money to neighbors to here the person to do work. More people recover in these situations than in the expert-driven hospitals and mental health centers of the United States and the U.K.

I'm saddened by how we isolate the strange, the annoying, the irritating, and the different people in hospitals, ghettoes, and jails. How can we create communities for them, even if their families don't want to include them anymore? How can we help them help each other and help and even heal each other? How can we transform our views from defective brains to defective social networks with defective stories that weren't possible to live by? How can we create compassion and tolerance for people who are different or even bizarre?

I suspect we in mental health must find ways for ordinary people to interact with our patients. My favorite idea is the healing circle in which patients and ordinary people can mingle and be healing for each other. I have seen people who have been labeled chronic paranoid schizophrenic provide exquisitely sensitive energy healing to others who have the "normal" label in the contexts of a healing circle.

Thus, we need a new ethics for the treatment of those who are annoying and irritating, bizarre or unusual, and otherwise different. To find this new ethics we need more stories about their value as messengers from the spirit world, as explorers of the extraordinary realms, and as people with gifts of vision and prophecy who have been excessively traumatized by difficult childhoods and lives. We need stories to allow us to see people as having been shaped by defective stories rather than having defective brains.

Neuroscience is coming to support these ideas. We are learning that the brain is created from the outside in more than arising de novo as the result of genetic interactions. Our neural circuits are formed through social interaction. They are socially generated. Learning to read is an excellent example of this. No circuits exist for reading. Through social interaction with a person who has learned to read, we hook up brain areas that were never before linked in those ways. We do this in each generation. We start from scratch with each learner. Eventually these circuits are well-formed and strong. Initially, the whole brain is involved in reading, but, slowly the left hemisphere specializes in understanding the words to free our right hemisphere to daydream and to visualize the images inherent in the words, to associate the text with past experiences, and to have the experiences that make reading so richly pleasurable and exciting. Learning to read permanently changes our brains.

This developing story of neuroplasticity can give us better stories for people who suffer unacceptably. As a community, we can come together to give them experiences to change their brains from the outside inward. We can do this socially more effectively than through medications, though drugs may have their place to make unbearable emotions more bearable so that social reconstruction can occur. Nevertheless, we eventually do best to shape our brains to function well without medications; though some never arrive at that goal.

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Lewis Mehl-Madrona graduated from Stanford University School of Medicine and completed residencies in family medicine and in psychiatry at the University of Vermont. He is the author of Coyote Medicine, Coyote Healing, Coyote Wisdom, and (more...)
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