Why I am not crazy about the USA

I’m going to the USA in June and it scares me. I feel a bit crazy about the whole thing.

There’s a sense in which I think we all struggle with our sanity. I think it is important to know that.

This week I have been stretched many ways: my children have both reached important life crossroads, two of my friends are struggling with deep personal issues, I’m trying to prepare to go overseas, and my two jobs have both become very busy again... you know the drill. There are days when work/life balance for me is about having bushfires in all categories. And I don’t feel normal while that is happening.

This blog entry is about the prevalence of mental illness and what might help some of us with sub-clinical conditions to live a contented life.

I used to think I was very different to everyone else. I still have that sense of being an outsider in my own life. I don’t want to get too Albert Camus about it, but some days I think everyone is normal but me. Then I look around. There are a lot of people in the world who are only just coping, who are only just ok, who are only just managing their own lives. Or not.

Some people have a personality style, and some people have a disorder. Have you ever wondered about that? How do you know if someone is close to the edge but not over it? What constitutes a disorder?

One of the reasons I applied myself to learn more about these things was my own drive to understand myself and the people I dealt with out there in what, for the want of a better description, we call the everyday world. I wanted, in Mark Twain’s terms, to see the river with the pilot’s eye.

Well, it turns out that the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV TR (which is one of two standard classification manuals) handles this very elegantly. The chief question is one about functioning.

If you gamble a lot, but it doesn’t mean you have lost your job, partner, friends or house, then you can still function and gamble. As soon as the case can be made effectively that your gambling habit is costing you and you’re unable to help that, then your pastime is less of a hobby than it is a compulsion, and bingo! You’re the proud parent of a bouncing baby addiction.

The addiction is called Pathological Gambling, it has its own code (312.31) and it is an Impulse-Control Disorder. Provided the behaviour is not part of a manic episode, a clinician basically works through a checklist and, provided five or more of the ten indicators of persistent and recurrent gambling behaviour are present, then the person is classified as having the disorder. If only four are present they may have a problem, but they aren’t classified as having a disorder.

Here’s where the art of being a therapist emerges. Assessing a real human being is not simply the process of ticking lines on a list. There is a skill to demonstrating the empathy and objectivity required to really decide whether someone is not functioning effectively. One of the items is: ‘has jeopardised or lost a significant relationship, job, educational or career opportunity because of gambling’. Some relationships are easier to lose than others. Some are more significant than others. How do you know when something is really in jeopardy? There’s a sense in which ticking this item can be at the discretion of the therapist.

More importantly, out there in the real world there are many people who are living their lives and not seeing a therapist. We’re all crossing busy roads without enough lollypop people. Over the years I have worked with people who were clearly out of control. Some of them were diagnosed later. Some never were. That was largely irrelevant when dealing with the emergencies of the moment in various workplaces. And yet it was the central emergency.

The DSM is an agreed list, a classification by description. It is one of my favourite books, for sure, but the plot is inconsistent and the characters get up to some very weird stuff. Generally by the time someone is dysfunctional enough for classification, they’re by definition not normal and everyone can see it. The DSM doesn’t really help with why someone is the way they are or what can be done about it. It describes the people who crossed the line, and what they tend to have in common. The S in DSM is for Statistical.

So when I look about the world, really look about the world, there are many things I feel I ought to see. Not everyone who is not coping has a diagnosis of illness. Not everyone who has had a diagnosis is not coping now. I ought to realise this, but we often work with hasty rule-of-thumb judgements and assume the world is divided into those with a mental disorder and those without. And shamefully, we compound the error – I sometimes compound the error – by treating each assumed group differently.

For instance, let’s consider the situation in Australia. According to the Australian Bureau of Statistics’ (ABS’), National Survey of Mental Health and Wellbeing from 2007, the prevalence of mental disorders in Australia for the adult population in the previous 12 months had been 20.0%, or 1 in 5 people. That’s 3,197,800 Australian adults.

One way of representing the categories they considered within those who had a disorder in the 12 months’ previous to the survey could look like this:

This is a very basic depiction of the survey. And this is a blog, after all. I am dealing with the stats summarily to make a point. So please bear the following in mind: the survey is from 2007, so it is a little dated now. The survey had a 60% response rate so it isn’t one of those Australian-election type deals where everyone was forced to answer and you get a tight handle on the whole population. It covered 8,800 Australians aged 16-85 years. The survey covers some specific mental disorders, not all mental disorders – and it is based on the ICD-10 not the DSM-IV-TR. (I use the DSM in preference).

There is also the issue of co-morbidity, where people have more than one condition. See the pack for details.

Here’s an outline which shows the classification categories and prevalence of disorders within the respondents who actually had a disorder within the previous 12 months:

The major point which relates to this blog, though it the point which is made in passing by the survey report:

“Of the 16 million Australians aged 16–85 years, almost half (45% or 7.3 million) had a lifetime mental disorder, ie a mental disorder at some point in their life. One in five (20% or 3.2 million) Australians had a 12-month mental disorder. There were also 4.1 million people who had experienced a lifetime mental disorder but did not have symptoms in the 12 months prior to the survey interview.”

I’ll just take a moment to point out that ‘having a lifetime disorder’ means that at some point in the past they qualified for the diagnosis. Doesn’t mean they ‘have’ the disorder permanently and are diagnosed for life. It’s a survey category people, not a lifetime sentence.

So 45% of Australians, it is estimated, had a mental disorder at some time in their life. Of them, a little under half are diagnosed with having the condition now. To way oversimplify this statistical point (and please understand there are 1,000 flavours of what I am doing with the finer points of the maths, here), if you had one hundred people in a room, you could divide them up into this kind of a table:

The numbers don’t add correctly because of co-morbidity – some people have more than one disorder.

Now the temptation is to assume that 55 people of my imagined 100 have nothing wrong with them, from a mental disorder standpoint. Never mind that this survey leaves out some disorders, WHAT ABOUT THOSE WHO TICK 4, BUT NOT 5, OF THE BOXES? You could argue that they’re the ones in the 45 who have a lifetime disorder but didn’t qualify in the last 12 months. You could. But actually that’s not based in fact. That 25 did at some point previously make the magic 5 cut-off, sure, but I’m betting there are some of the 55 who will have 4 ticks perennially and NEVER meet the criteria for a disorder.

By now your head may well be spinning and you may just wish I’d tell another story about Fairbairn’s housekeeper. Yeah, I know. I love her too. I have the dustiest piano, by the way. But stay with me. I’m nearly done with the maths.

As we wander through the world, trying to live contented lives, almost half the people we meet will have qualified for diagnosis of a mental disorder at some point, and just under half of them qualify for that diagnosis now. 1 in 5. Of the remaining just-over-half, we don’t know how many are pretty close to a diagnosis but don’t quite make the cut. You’d expect there’d be a few.

And what of you, gentle reader? And what of me? Fairbairn tells us we’re the centre of our own universes, and each of us will say ‘I’m perfectly fine’, and yet the statistics are against us en masse. Maybe we are both in the 55 – but do we tick just one, or four boxes? (And Pathological Gambling wasn’t covered by the survey anyway!)

In one of my jobs I am required to ensure I am in a fit state to counsel people. It is a registration, and an ethical, requirement. And a bloody good idea, just quietly – for me and for them. So in the midst of my busy life it is important to enact behaviours which enhance my ability to cope with life.

I mentioned earlier that the DSM doesn’t explain why people have disorders, or what to do about them. The field of evidence-based treatment development lies in other books. How a person gets a disorder is the subject of many debates relating to genetics and environment. Cognitive Behavioural Therapy (CBT), the dominant psychotherapy in Western scientific culture just now, presumes that people get better by adapting their thoughts and thereby changing both their affect (emotions) and behaviour. And if a person is classified under the DSM by their emotional state and the way they are acting, then surely there must be some beneficial way to think which helps us not to have a mental disorder.

So finally we’re back to the point. And Fairbairn. And Bowen. And Frankl, since we’re in the neighbourhood and I like him. And Wolpe, of which more in some other post. And – I hate to say it – Freud.

My life is 10% about what happens to me and 90% about how I respond to it. Ditto for my psychological wellbeing. If I can enact mature ambivalence, and respond with integrity, then I am thinking in the way which (I believe, anyway) will best inform both what I do and how I feel about it.

I began by saying I’ve had a huge week. I’m actually frightened to go to the States. People get shot there. A lot. And some of the people who die are killed by the legally elected and empowered government officers.

And if I am so busy and stretched, maybe it is in my best interests to just forget it and not go.

Maybe sometimes we should just quit.

A friend of mine has a favourite saying that was also her father’s favourite: “Start as you mean to go on”. It means, for me, that what we do now are the basis for our habits later – and running away from stuff can conceivably develop or entrench (currently in 14.4% of Ausralia’s adult population) some kind of anxiety disorder. By contrast, developing a tolerance for enduring scary things is the way to conquer a phobia, and in fact it is a good way to deal with all things that disturb us. Who dares, wins.

So does that mean I have to go, or I’m going to be in the 45%? Of course not. But I have a way of responding to this which stops me disappearing into a logical loop of eternal math and dithering. I need to answer this question: for me and my values, which of the two behaviours will I respect more in myself?

Do I feel I have more integrity if I go, or if I decide not to?

Simple to ask, hard to answer truthfully.

It’s a visceral thing, ultimately. A whole-of-self answer.

I’m going to the United States in June and it scares me.

And that’s a good thing.