On love... in the time of mental illness

You know how wedding vows often have that clause in them ‘for better or for worse, in sickness and in health...’? Well, then you meet these couples and they’ve been together 20, 30, 40, 50+ years and they are beyond being husband-wife teams; they are friends, lovers, and often also carers to each other. You see them push through illness, which unfortunately becomes more frequent with increasing age. They remain together despite mobility impairments, despite serious acute illnesses, despite chronic degenerative disease, despite even complete machine-dependent living. They remain together because they love each other, because they’ve become interdependent, and because what or who is essentially the person whose life they’ve chosen to share with remains intact despite the machines, the physical illness, and the sensory or expressive deficits. This is true of most illness - expect mental illness.

Centuries ago someone became intent on separating the “mind” construct from that of human anatomical structure. Humans were believed to have this thing associated to them called the spirit which did not occupy a physical place in the human body, but rather was related to it metaphysically. Eventually, through serendipity (or accidents and disease) it was noted that if the brain were to sustain structural damage, often so did the person’s spirit or mind; what we now call ‘personality’ as well as sensory and motor function changes/deficits could occur. So then it was determined that the essence of what we speak of when we use the word “I” inhabits the brain. Soon, others (again, often through accident or disease) became able to map particular human responses, emotions, and sensations to certain areas of the brain. The current understanding is that there is a predilection of certain brain structures to be associated with the central processing of a particular human function, but that this function can be diffusely localized throughout the brain.

Psychiatric illness used to be subdivided into organic brain disease and other mental disorders. Not all problems related to human cognition were thought to be able to be localized to a defect in a particular brain structure or group of structures. For example, a disease like Alzheimer’s dementia was considered an organic brain disease because it causes biological changes in the brain that can be observed macro- and microscopically at autopsy. On the other hand, disorders like depression were by conventional techniques not able to be pinpointed to any particular place or sets of places in the brain; these were the “other”, i.e. non-organic, mental illnesses. With continuously evolving brain imaging techniques, there have been increasingly new biochemical or anatomical related structures or pathways identified that have been found to be associated specifically with the majority of mental disorders. Now the different diseases affecting human cognition are subdivided preferably into classes of acquired or intrinsic aetiology, affecting motor function, affecting sensory function, and related to intellect or cognition, etc. In essence, there is no longer a question of whether any mental illness is related to physical brain substance or not; a physically-related change is implied.

Okay, again back to the “for better or for worse...”. So a person falls in love and he/she makes a commitment to someone else to be a partner to their person. Simple. Right, but what is a person, who is the “person” you marry? If your partner is well and healthy then that person is their physical body and their intellect and everything they express and sense. If that person, say, had a leg amputation, he’s still your partner. If he had a bilateral leg amputation, he’d still be your partner. He could lose gall bladder, arms, a segment of bowel or liver, thyroid, spleen, kidney, bladder, or lung and he’d still be the person you married. You would know this as soon as he communicated with you and you recognised their expressed thoughts as their own.

Now, consider a person who enters a comatose consciousness state suddenly due to either accident or disease. Their partner will have a memory of what this person was like physically, without any medical attachments, and, more importantly, of their “personality”. You can’t suddenly stop loving a person, or even just stop recalling suddenly what they were like. Often the partner will visit the comatose version of their partner for some time until he either succumbs to illness or regains consciousness. Why do they do this? Is it because they love them? Probably to a degree (like I said, you don’t suddenly stop loving a person), but I would argue it has more to do with the fact that you also have a recent memory of their functional personality. You loved the person physically and cognitively, yes, but you still recognise the living body under the hospital clothes, dressings, tubes, wires, etc. as your spouse because you fall in love really with the intellect, the ‘personhood’, the mind of someone. And you are aware, or at least believe, that under all these physically palpable things lies the “person” you knew.

You could call the above scenario an example of an acquired injury affecting brain function. What of “intrinsic” mental illness, then? Let’s consider as an example depression. Okay, so you meet your partner and you fall in love with their personality, what they say and think, and (at least accept) what they look like. Gradually (these things are often gradual) your partner starts to change. Physically he may remain the same or he may change also, but more markedly his mood and thoughts change. The mental illness affects his ability to concentrate, to attend to things, to enjoy things he previously found pleasurable, etc. You notice these things every time you interact with him. He may become irritable or unable to be roused into anything that requires enthusiasm. His expressive behaviour changes as do his cognitions. Maybe you know something about depression, maybe you don’t but you still love him. You recognize this person is going through a low mood stage in their life because everyone has had these at least transiently. You empathize, maybe even sympathize. You notice he’s changed in the way he interacts with you and it is much less desirable or pleasant to what he used to be. You put up with it for a week, two, a month, a year maybe, and then what? Assuming the person makes no dramatic improvement in their mental illness, such as what some medications can bring about, you with time forget that memory you had of the person you fell in love with. Maybe you can remember what they were like a week ago, maybe a few years ago, but with more and more experience with their “depressed self” you start to evaluate the person as they are and have been. Then guess what happens? You just can’t do it anymore. The love, the relationship, and the person has changed so much you can no longer relate to this person and love them like you once did. You fall out of love and either emotionally or physically move on.

What happened to “in sickness and in health...”? Acquired brain injury is a disease but endogenous depression isn’t? It is hard to love in the context of any ailment because it literally changes EVERYTHING! We used to think disease affected one person, but we’ve gradually come to realize that one person bears the sick body, but the disease affects a whole family unit. Having a romantic relationship (and even kinship) in the context of mental illness presents a particularly challenging scenario. No one can tell you who to love and for how long and in what circumstances, but I hoped with this discussion to raise only one point: mental illness is a disease state also. Judge the mentally ill as you would an amputee or a cancer patient.

On guilt and religion

There was something I postulated some years ago now when I noticed the number of people in my Christian congregation who were “depressed”: that there may be a positive correlation between Christian faith and depression. I know, correlation doesn’t imply cause and effect, but let’s explore it.

Mea culpa. It means, literally, “my fault” in Latin. It is one of the commonly recited orations in Catholic worship – but not only that, the concept of “confessing blame” is key to most Christian denominations. Briefly, the concept originates from the belief that Adam and Eve sinned against God and therefore inherited sin to all their progeny. Therefore we are all guilty of sin – and hence the need for a redeemer: the Messiah. Gradually the belief came to be that the greater the guilt expressed by a person, the greater his faith was seen to be. The expression of guilt came to take on the form of martyrising practices like self-flagellation, long pilgrimages, and the walking on bare knees to certain sacred places. In modern times these practices are no longer popular amongst Christians, but their roots may remain in the mental processing modes used by the faithful.

One of the diagnostic criteria in the DSM-IV, a medical text used for the diagnosis of mental illness, for depression includes “feelings of worthlessness or excessive or inappropriate guilt”. Now if you consider what we said previously about how in Christian belief the greater the guilt, the greater the perceived faith, it isn’t hard to see how this characteristic of “faith” can easily become one of a mood disorder. We no longer self-flagellate, but we often torment ourselves with guilt, self-loathing, worthlessness, and eventually hopelessness (which can be thought of as a loss of faith in our own ability for self-efficacy). With the growing guilt and hopelessness, the road can be paved for an external source of hope: God, Jesus, or whatever deity you may choose to worship.

Am I trying to say that religion causes depression? No; in the same way I am not saying that religion can “cure” depression. What I am trying to point out here is the perhaps propensity of certain personality types (e.g. the self-sacrificial, perhaps charitable, nice folk that faithfully report to church regularly) to become both the ideal Christian and, unfortunately, perhaps also the person who struggles with depression in his everyday life. And I think this is how the higher rates of depression in faithful religious-abiding persons comes about. Like I said, maybe not cause and effect, but perhaps correlation by a common personality type.

It is interesting to note, however, that when Christ was asked what was the greatest commandment of God’s law, he mentioned nothing of guilt or sacrifice or of rendering homage. He summarised it all in two simple concepts: “Thou shalt love the Lord thy God with all thy heart, and with all thy soul, and with all thy mind. This is the first and great commandment. And the second is like unto it, Thou shalt love thy neighbour as thyself. On these two commandments hang all the law and the prophets” (Matthew 22:37-40). Really, that was all the masses of laws Moses and others wrote down were about! So what makes a “good” Christian? Certainly not how much mental or physical anguish a person endures by his own means. Isn’t the Christian belief also that God created the heavens and the Earth with all their magnificent glory and beauty? Surely it can’t be a sin to worship God with gratitude and appreciation of all the blessings of creation.

On (some) injustices

Galileo, buried at the Basilica di Santa Croce

There was a time in my life when I used to get really frustrated, really upset, and I felt generally just very bitter at some of the “injustices” I felt were being inflicted upon me. At around that time I had just started reading some of Napoleon Hill’s work and I remember a story he tells about Christopher Columbus. We all know him because he ‘discovered’ the Americas – and yet you could also consider him one of human history’s greatest failures. He set out to find a new shipping route to India via the west – and he failed miserably at his task! But his failure achieved for him the fame and place of pride he holds in human history. Why did this story come to mind to me today? Because lack of “success” (what some may call failure) is such a common finding in people we often call our heroes.

Let’s briefly consider Eva Perón, the argentine political minister who after her death was considered almost a saint for her deeds and passions. In life, though, she had hundreds of enemies in high places. She faced great political opposition and suffered unjust and inflated accusations from her opponents. She was, on the other hand, cherished by the working class - the numerical majority. The harder she fought both for herself and as a representative of the labour and social welfare of her nation, the more she was accused of wrongdoing by those that held the financial majority. Now, what’s my point? OK, I’m not saying that only those with greater social and moral stances face injustice. All I’ve noticed is that the names of those that serve their nations, their societies, that serve with pride in something other than political or financial approval, those who remain true to their humanities, are those who experience true success despite their adversity. What are the names of those that opposed Eva Perón, those that dominated politically and financial while she struggled? Did they succeed? What did they achieve? Where are their admirers and who still recalls them?

Now, a person could feel down because they are accused of wrongdoing, because they are accused of it only to ‘punish’ behaviour that is thought not to be respectful of the authority of those in power. Insolence is often punished by actions aimed to show you who’s boss. It’s not a new concept, that’s the reason Hitler kept ‘yes-men’ around him and those that disagreed with him quickly disappeared. It’s the reason that Jesus humbly declaring his father’s kingdom was punished with death. It’s the reason people who refuse military service – or any other behaviour not condoned by governments – have in the past been incarcerated. I remember a quote by Fyodor Dostoevsky that says that “power is given only to those who dare to lower themselves and pick it up”. Perhaps we should expect no less from our enemies in high places, but that does not mean we should accept their punishment as well-deserved either.

‘If a person slaps you in the face, turn the other cheek’ means to accept that there are people who will act with hurtful intent toward you. It does not mean that you have to believe that you deserved either the first or second slap. In times like these I think it’s better to remember your own name and what you stand for, because no-one will even remember those who wanted to show you who’s boss.

On fate

If you know me, you'll know how I credit Napoleon Hill for the great change in my life that came about in 2006. Napoleon Hill wrote "motivational" material of the kind we commonly associate with self-help books. Throughout the years since, I've read a lot of material from Napoleon Hill and other similar writers, including Tony Robbins.

Back in 2006 I was in a bit of a dark hole, emotionally and spiritually. I took a year off medical school to sort myself out. To re-evaluate not only if I wanted to finish my course, but also if my total existence was worthy of effort. I didn't feel hard-done by the world; I just had allowed myself to exist without a known cause to justify my existence. Now, not many people will go through these "existential crises" because we are either in good environments with supportive people, or we have external passions, or quite simply questioning your reason for existence is just not something that would capture our attention at all given all the other tasks of life. I, however, like to question everything. So I started questioning and I just couldn't identify many reasons why I should continue to be alive. I at that stage wasn't suicidal, no, that's not what I mean. I did however "wish" for an alternative to my current life. I wished for disease, for sudden death, for a road accident, for natural disasters, etc. But it wasn't all negative, I also wished for "love", for money even, for artistic success, for a child, for anything that would take me out of my then empty life to elsewhere. I wanted anything, good or bad - as long as it came to me and I didn't have to do anything to get it. I believed that fate had brought me to this slump, but that it would equally bail me out. It was then I started reading Napoleon Hill's work and realized that all these things, these "good" things that happened to some “lucky” people (unlike myself) didn't just happen due to fate.

Napoleon Hill tells a story at the start of the book 'Success Through a Positive Mental Attitude' about a poor family in which the child asks his mother why his family is poor. The child is pondering his own “fate” to grow up and become a poor man himself like every other member of his family. Now, the obvious response seems at first to be 'we're poor because our parents were poor like their parents before them, etc.' Or ‘we’re poor because we can’t afford the type of education others can’. Or ‘we’re poor because we are of this race, or culture, or religion, etc’. However, is it an unchangeable fate that some families or some people are born either poor or successful? The mother explains "We are poor, not because of God. We are poor because... no-one in our family has ever developed a desire to be anything else”. Now that seems like a simple statement, but if you consider that the family in question was an African-American family, not too many generations removed from slavery and oppression, and that the child that asked the question became a very wealthy businessman, you can begin to understand the paralysing effect our belief in fate can bring.

In relationships many of us believe that fate will bring us the “right” man or woman. And not only that, we also believe that fate will determine the length or strength of that relationship. Fate will decide if we have children or not. Fate will decide if we have a “good” or a “bad” partner and whether we ourselves are good or bad. So no longer are we in control of the relationship, or of our role in it, but this external entity we call fate is. Why try, then, if it is all up to fate? The other comfortable position we can adopt is to say we are simply bad at relationships. And we may well have reasons to be bad at relationships; maybe we didn’t have the best role models, maybe we have low self-esteem due to any number of things, maybe we had a prejudicial childhood or subject to trauma somewhere in our past. All these things shape us, of course, but insight is often the first key to unlock us from this uncontrollable thing called fate. However, you can unlock a person from slavery, from trauma, and then it is up to the person to walk out of his/her cell. As a result of all the abuse and trauma maybe the person is initially too weak to walk through the door alone, but how long should we keep using that excuse? After a week? A month? A year? Ten years? The rest of our lives? It’s really up to the individual person, isn’t it? We may not have been responsible for our pasts but we are in control to shape our futures. Things don’t always just happen to us, some things we can make happen too. Acknowledging that is isn’t accepting blame for our pasts; it is accepting the challenge to steer our own future.

Similarly in our careers or vocational aspirations. Too often I hear people tell me that they wish they could do that job but they’re doing this other one because not many people get to do that job. But somebody will get those jobs, right? Why can’t that somebody be you? People will then proceed to tell you excuses (aka “reasons”) why they believe it can’t be them. They need more education, those jobs are for people who know other people, you need money to get into that field, you would need to relocate elsewhere, etc. So? The great thing about these “reasons” are that perhaps you in fact need to see them as steps rather than excuses. So if you have to know someone, why not get yourself known to someone? If you need more education, why not apply for a further education course? See, yet it is so easy to say that fate would have it that you don’t (yet) know the right people, you don’t (yet) have the money, etc. We become victims of our fate and also of our past – and that is how we remain stagnant. We may in time come to blame fate for the job we don’t have, the money we don’t earn, the associates we can’t exactly call friends. It is easy to blame an external entity – but we don’t have to be victims of any past or future if we take responsibility for our role in our own lives.

The last thing I want to consider is our great fear of control, or what is more commonly called accountability. I know, I know, we think we all want control, right? Everyone wants control, but no-one wants to be held accountable for their actions. So we hesitate to dream, to aspire to anything, to want or demand change. We would rather place our faith in this mystical thing called fate. ‘If fate will have it, I will have a good marriage. If fate will have it, I will enjoy this new job. If fate will have it, I will be financially successful in my career...’ People look to horoscopes to fuel their faith. If a thing I want is suggested by my horoscope, then it is okay to want it. If my horoscope says I am not to have something, then I am bound to have this fate happen to me. Now, you may have heard of this thing called self-fulfilling prophecies. I speak of it in terms of horoscopes because it is the most obvious example. Often a horoscope will tell you a general bit of information that describes you – ok, you agree with it (e.g. “oh yes, I am calm like other virgos). Then it tells you something vague but positive about what will happen to you – and you can always identify at least one instance of this happening. For example, ‘you will meet a handsome stranger’ can mean that guy that looked at you on the bus. You were alert to this and so you see your destiny being fulfilled. Had you not been alerted to the fact you may not even have noticed anyone on the bus even if he was very overtly trying to capture your attention. Similarly, it may be with career success, financial wealth, etc. It is like we are free to allow good things to happen to us – or god forbid and we actually act in order to have good things happen to us – only if we are devoid of the accountability for our futures. Accountability becomes a thing to shun not only in regard to negative consequences, but also in potentially positive ones. No one wants to say they tried and did not succeed at this instance. It is so much easier to say that it was our fate to fail.