Ontology? of mental illness

Chris Burford cburford at gn.apc.org
Wed Jun 28 18:28:06 MDT 1995

On Sat 24th Hans D expanded on the concept of ontology and gave
an example from the debate about mental illness which I said I would
come back on separately as it is of specialised interest.

O.K. let me give my last example something
that Chris B. will (hopefully) appreciate.  The relation between
psychologists and patient, there is a debate whether the relationship
itself specifically "creates" the ill, or whether mental illness
truly exists.  I would suspect that Chris B. will argue
ontologically that mental illness does exist.  Those who oppose this
however, suggest that somehow this "illness" is imposed on the patient
by way of the specific relationship of patient/doctor.  Those who
reject the ontological (quasi-)existence of mental illness suggest
that psychology not only fails to help the patient but worsen the
the hypo-condition.  Personally I think arguing over the ontological
existence of mental illness is quite limited, but certainly the
specific relationship between the psychologist and patient will
determine the success of the treatment.

I have to deal with this issue as part of my daily work. It is a hot one
because the young black afro-caribbean males have about six times the
expected incidence of schizophrenia. As a community psychiatrist
committed to trying to keep people out of hospital, I work with staff
from a non-medical background who at times are passionately opposed to
the "medical model". Hans D has chosen a hot illustration: is it all
empirical data or is there something there?

My own view is that there is illness behaviour which may occur in many
contexts with or without the presence of a doctor. In illness behaviour
the individual presents themselves to those around as unwell, whether from
physical or mental causes, and seeks understanding and release from
the previously accepted network of obligations and rights. In return there
is an implication that the individual will act appropriately as a sick
person, usually to do things to get better. Eg. to take medicine, rest in
bed, go to a witch doctor, have an exorcism, have electro-convulsive
therapy, go into hospital.

As Shakespeare's plays show, the concept of mental illness was a vivid one
before anyone knew how to spell the word psychiatrist. So I believe there
is a dynamic going on, which has its own momentum and this I think
corresponds to Hans D's concept of ontology: it is not just scattered
random empirical data. It may involve a sense of individual disability or
discomfort but above all for mental illness it is a psycho-social event,
between the individual and those around them.

Once in this role it can be very difficult for the mentally ill person
to get out of it. They many be infantilised or institutionalised.
Doctors, but also many other people may do this. Doctors may get blamed for
it sometimes justly, but behind the doctor there may be family or
friends totally convinced that the individual is ill and putting pressure
on the doctor to do something. I have had a relative threaten to kill me
if his brother came to any harm as a result of my reluctance to admit him
to hospital.

Anyway that is how I see it and try to tread through the minefields of
mental illness. I do think there is a powerful dynamic, if you like
an ontological reality to mental illness, and it is a psychosocial
phenomenon in which the doctor may be caught up. But not necessarily.

Chris Burford, London.

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