Our current cultural model for conditions like anxiety and depression uses language like “chemical imbalance”, implying that suffering is related to our brain chemistry. In this post, Dave Keith offers another perspective that looks at our moods as dynamic states related to the context of our living patterns.
- Dave: I’d like to talk to our readers about an idea that appeared in my book, Family Therapy as an Alternative to Medication: An Appraisal of Pharmland. What follows is an excerpt from one of the book’s chapters, Biometaphorical Psychiatry: Family Therapy and the Poetics of Experience.
In our book we dealt with an issue that we address repeatedly in the blog. I made up the term “biometaphorical” psychiatry, to represent the idea that metaphorical language has a physiological effect. “Sticks and stones can break my bones, but words can break my heart (Ogden Nash)”. I am going to begin by developing a distinction between “disease” and “illness”. Turn on the philosophical part of your mind. If you don’t think your mind has a philosophical component, simply gaze at your belly button for 30 to 60 seconds and it will automatically awaken. If at first reading, you feel confused, don’t feel bad. As our president recently asked, “Who knew health care could be so complicated?” Think about it a little, then reread it.
Disease and Illness
In common usage, no difference is acknowledged between “disease” and “illness”. They are synonymous and we go to a medical doctor when we have the disease/illness that produces pain or discomfort. However, in his very readable work, The Illness Narratives, Arthur Kleinman (1987) makes a useful distinction between disease and illness that is relevant as a way to understand the world of human suffering. But, additionally, it helps to understand the pressure to provide pain relief put on practitioners like doctors and therapists in our culture.
What follows is based on Kleiman’s distinction with my elaboration.
Disease. Disease is a disruption of biological structure or function, which the practitioner, with superior specialized knowledge, can diagnose, i.e., measure and name. A disease can be objectively defined in unambiguous, non-metaphorical language. Examples: pneumonia, diabetes, fractured limb, lymphoma. The practitioner institutes treatment that mitigates or eradicates the symptoms and signs. Treatment leads to a reduction of discomfort, especially pain ambiguity. Treatment of disease does not demand attention to the whole person. Bioscientific medicine studies, diagnoses and treats disease.
Illness. Illness refers to a much more ambiguous territory, harder to understand with reason. Illness, in Kleinman’s system refers to the cultural or interpersonal manifestation of a disease. Illness is shared by all involved with the afflicted; patient, family and practitioner. Thus, illness is between persons, it is multipersonal. Illness is a problem of the whole person, not a single organ or organ system. Because I believe an individual is always a fragment of a family, I view illness as a problem of the whole family.
Illness has to do with meaning and therefore is subjectively defined. Illness is not treated; it is contextualized, placed in a context of relationships and events. Illness is not nameable, because it is dynamic and unpredictable. Because illness is not nameable it is easy not to acknowledge or attend to it. Illness represents the totality of a family’s concerns. These concerns are inevitably aroused by a disease or other sources of distress.
By totality of concerns, I refer to the apprehension stimulated by the distress, which awakens all other areas of apprehension in the family’s emotional realm (Have I been gone too much? Should I say something about my spouse’s drinking? I don’t think I love her any longer.). While it is not possible to have a disease without an accompanying illness, it is possible to have an illness without a disease (persistent symptoms with no signs of disease).
Illnesses without disease find their way into the offices of medical practitioners in great numbers. The practitioner finds no disease and may say there is nothing to be done. However, patients are not grateful, they are upset with this response. As a way to interfere with upset, to maintain the relationship, the practitioner provides a name (diagnosis) then does something. The practitioner may give a medication, order an x-ray, get more lab studies, or seek additional consultation from the rheumatologist, endocrinologist, neurologist or allergist.
This behavior matches cultural expectations, but may be unrelated to the reality of the situation, and even be in conflict with the integrity of a practitioner’s beliefs. Illness, that unnamable something, is treated with whatever drugs are currently popular. In the 60’s and 70’s, Librium and Valium, were given freely. We believed they were non-addictive then. These days we use SSRI’s to treat the un-nameable.
Psychiatry is a specialty that deals almost exclusively with illness, that is, with the cultural and interpersonal manifestations of disease or other distress. But, because of our cultural discomfort with the uncertainty that goes with ambiguous symptoms, following the bioscientific paradigm, psychiatric symptoms have been recast as diseases. For example, depression is described as a disease “like diabetes.” It is the result of a “chemical imbalance.”
Now there is no measurable chemical imbalance, as there is in diabetes. But in the logic of modern psychiatry, because some symptoms of depression respond to treatment with chemicals, the illness is thus defined as a “chemical imbalance”. This formulation reduces the ambiguity that goes with feeling depressed. It seals off the totality of a family’s concerns. This pattern of converting an illness into a disease can sometimes appear very useful, e.g. in the treatment of alcoholism. However, with many of the symptoms of illness it produces only a band-aid for the distress when it fails to attend to the contextual components. Then the contextual aspects of the problem are likely to deteriorate.
For example, medications are given to kids who are upset with their families, but have no voice, only their being, actions and emotions with which to protest. The child’s behavior is not viewed as a problem of the family, but as a problem for the family. In our culture there is unlimited freedom to talk about and pathologize children, but there is little language (especially in the clinic) for talking about parents and parenting. In this climate the person who is in pain in, or distressed about, a relationship and who has the least power, is often medicated. The subtle, barely conscious patterns of family living, which are the context for the pain continue.
When I began in psychiatry (1971) we discriminated between reactive and endogenous depression. The term “biological depression” is part of the current cultural semantics. My belief is that these terms, “reactive” and “endogenous,” refer to different styles of history taking. In my style, both reactive and endogenous depression can be found to be responses to the social fabric. Both are therefore illnesses.
The reactive depression is the by-product of an event. The endogenous depression, although it appears to bear no relationship to outside experience, can be seen to arise from the almost unconscious patterns of family living; the non-verbal behavior and subjective experiences of family members (Keith, 2001). Modern psychiatry tends on the other hand to have little interest in history, only target symptoms, assumed to be by-products of molecular events. Therefore, it finds many psychiatric disorders to be endogenous and considers these diseases.
So now you know about a distinction between disease and illness. Keep the distinction in mind as you read the next post where I apply this set of ideas to clinical practice.