Do we really “have” mental illnesses?

Should we see our mental illnesses as parts of our genuine selves or as unwelcome, alien entities? I’d be very interested to hear your thoughts on this. Personally I’m open to persuasion.

The current norm is to say “I have depression” or “I have OCD”, as if something foreign has invaded from the outside, like a bacteria.

There are obvious reasons why this is a helpful way of phrasing things. By externalising the problem, stating that the illness is not a part of their real self, the person is absolved from any blame. Their character is instead seen as having been attacked by something they had no control over. This relieves stigma, lessens feeling of self doubt and in so many cases, is a vital part of recovery.

But is it always a good thing?

To be honest, it actually doesn’t make sense to me in the context of some physical health problems. To say you “have” heart failure, for instance, sounds strange. It’s the same heart you’ve always had, except now it isn’t working as well – what exactly have you acquired, except the symptoms of the failing organ?

The same query can be applied to mental illnesses. In some cases, might it make more sense to state the problem in the personal sense, for example, “I am depressed” or “I am someone who becomes psychotic”? After all, it’s the same brain in your head, just working differently. No virus has crept in, no tumour has appeared.

Does externalising the problem prevent some people getting better? Does believing the problem is an outside agent, over which we may have little control, make changing things harder sometimes? Perhaps for some people, recognising that their diagnoses are the result of complex interactions between the outside world and their own personal reactions to it would be more appropriate. Concluding that the illness forms a part of themselves that is as authentic as any other may be a more constructive step.

In the extreme form, if a mental illness is severe and unresponsive to all treatment, could externalising the problem lead to a feeling of being tortured by something foreign that cannot be expelled? Would coming to terms with the cause of suffering as part of oneself bring a relative sense of peace?

This, of course, is a very different stance to arguing that diagnoses themselves should be done away with. As in the heart failure example, the diagnosis can still be solid despite the fact that saying someone “has” it sounds inaccurate. It’s also very different to stating that people with mental illnesses are in some way to blame for them.

So, are mental illnesses things that people partially are, rather than things they get?

About Alex Langford
I am a psychiatrist (now an SpR) based in Oxford after 3 years working in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology. I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights. Don't mention cricket unless you've got the next fortnight free to discuss it.

25 Responses to Do we really “have” mental illnesses?

  1. dramallama85 says:

    Very interesting question.

    I know of some people who seem to find externalising a positive helpful not necessarily to absolve blame but to view it in a more ‘medicalised’ way, like they would a physical issue. I think this often goes along with the rhetoric about ‘beating mental illness’ rather than an idea of resolving issues. This would be positive if it allowed people to feel they were still themselves, but it could be a negative if they found it hard to accept that there might be more complex issues around their illness that needed to be worked through.

    I have Borderline Personality Disorder and I don’t feel I can externalise – I am my illness and it is me. Perhaps some people can find a positive way of approaching that, but I have not been able to. I am glad I received my diagnosis, but it has destroyed the very shaky sense of self I had before. I think there is a risk of over- identifying with the diagnosis, especially for people who have a poor sense of self – BPD is a ready-made identity although perhaps not a very positive one. If you are your illness, how do you go about getting better? It leaves me feeling overwhelmed and as if I cannot be trusted to plan my own ‘recovery’ because I will sabotage myself. I just have a feeling of being trapped in a war of attrition with myself.

    I imagine that different approaches will work for different people and ideally people should be able to explore their feelings around their illness so they can find a narrative that allows them to view themselves as positively as possible.

  2. I find the issue of how language expresses, as well as affects, our own and other people’s experiences of mental health, really fascinating.

    It’s also enormously complicated! For example, In English, we say “I AM hungry” in everyday speech, whereas Italian-speakers say “Ho fame”, or “I HAVE hunger”. Whilst there are alternative ways to express hunger in both languages, these are the typical, every-day ways of doing so. Language isn’t given to us, but adapts and changes depending on how we use it. There is perhaps a sense that users of both languages have ‘chosen’ to express hunger in this way. Does this difference in how we relate the subject to hunger say anything about how Italian-speakers and English-speakers experience the actual feeling of hunger? (That’s a rhetorical question because I don’t know the answer!).

    Because of this complexity of the language issue, it makes it hard to draw conclusions on your initial quesiton: “Should we see our mental illnesses as parts of our genuine selves or as unwelcome, alien entities?”

    You can see the positives and negatives for each. If mental illnesses are seen as “alien entities” that effectively invade us, there is indeed the positive in this that you suggest – the reduction of stigma. Also, the person coming to host this alien is then able to envisage a future in which the alien leaves i.e. there is hope. But the bad side to this way of thinking is that in reality the alien might not ever leave, leading a person to think they are constantly possessed by it, which could surely be damaging. If something is inside your body for long enough, doesn’t it become a part of you? You can tie yourself up in knots about it as, thinking about this further, I now think that if you say “I have depression” it can sound like you are carrying it around like a handbag i.e. it’s something you should just simply get rid off – and thus potentially serve to INCREASE stigma.

    Then if we take the other option you suggested, and see a mental illness as part of our genuine selves, (“I am someone who becomes psychotic”), there is an obvious positive in this on the side of acceptance. It comes to be just an extension or aspect of our personality, and is normalised. It widens our culturally-defined spectrum of what being a ‘normal’ human involves. On the negative side though, such thinking runs a danger of standardising such experiences to the extent that one should just simply get on with it i.e. you are a person who just happens to experience depresison and will do forever – get over it – and again, potentially serving to increase stigma.

    So I’m not sure – I would be interested to hear what others have to say. I am tempted to say the person experieincing the mental illness gets to decide how to refer to whatever it is that they are experiencing. After all, how we choose to express ourselves is an essential part of what we are. Perhaps when individuals experiencing mental health illnesses seek help from professionals, it is up to those professionals to be alert to this ambiguity of language in how the individual is to describe themself, and to possibly use this as a therapeutic tool. There may be individuals who find no such terms useful whatsoever, and may simply want to discuss how they feel. There should be a place for that too.

  3. Withwill says:

    I think it’s very important that we do say ‘I have depression’ rather than ‘I am depressed’ partly because the word depression has association of sadness and exaggerated frustration. No one with cancer would say ‘I am cancerous/cancer.’ We must learn to treat the mind in a similar way to other physical illnesses. I have clinical depression and wish for a phrase similar to ‘I have bipolar’ which has no other associations of emotion and mood. Words are very important, as are labels and diagnoses.

    In relation to your blog my brain feels as if it’s been infected with depression, something is different even though it cant be seen, I was not like this before, I am different.

    We have to normalise, to treat mental illness in a way that removes shame. We need to remember that other illnesses benefit from positive thinking, outlook, attitude, exercise, diet etc as well as medication. To treat ourselves holistically for all illnesses is the only way forward.

  4. Heal the Regulators says:

    Join our health campaign, come with us to 10 Downing Street etc

  5. Hope says:

    Personally, I prefer “I have” anguage for my mental illness. For me, it is something that I got–I have PTSD and a dissociative disorder. If I hadn’t been abused, I wouldn’t have those illnesses. They are not inherently part of me–they are part of the people who hurt me.

    But I really think people should go with whatever terminology works for them. I’m also disabled, and there’s a lot of debate in disabled groups about whether person-first language is helpful or ridiculous. There are cases where each is true. I think the people dealing with mental illnesses should be the ones who decide how they want to be spoken about–not the professionals.

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  8. Ethan says:

    I personally consider better or more helpful to say that you have the mental illness as opposed to it being a part of you, ’cause if it’s a part of you then that could kinda seem like you’re just a depressed person and you will be forever and there’s no way to be anything but that because you *are* it. Whereas if you just have it, like a cold, then there’s hope of it going away and you feeling better.
    I also feel like if you say you are your illness, then it could give the impression that it’s just a personality trait and not causing any harm to you, and/or that you could just choose to act differently and it would not be a problem anymore, whereas if it’s something you have- again, like a cold- then you obviously can’t help having it.
    Though I guess it kinda depends both on the illness itself and the person, and your perspective on it. Like apparently there’s some people who go through depression or anxiety (in the clinical sense) and then they get treated and are better and never have those problems again. But then there’s other people who have something that never goes away, and they can struggle for years and do all kinds of things to try and make it stop but in the end all they can do is minimize it and manage it. So it could maybe be said that the first group “had” depression (etc) whereas the second “are” depressed etc, but it’s probably not that clear-cut anyway.
    (I apologize if I don’t make sense with what I’m saying)

  9. Natalie says:

    I think this is an interesting question and I’m not too sure on the answer. I think it depends on who you are and what the diagnosis is. I also think the use of language is interesting. In spanish there are two verbs for “to be”, estar and ser. Ser is used when saying something permanent like I am British. Estar is used when something is non-permanent like I am happy, I am at home, I am ill. This kind of makes sense if you think about it. You could say to be depressed using estar and it would mean “at this moment I am depressed but it’s not a permanent thing and it doesn’t define who I am.” I think this is quite interesting but in English we don’t have an equivalent way of stating “to be”. The thing with language as well is that different uses go in and out if fashion. In the future it might be normal to use I am rather than I have. A better thing to do is to try to address the stigma as you can change the way you say it as much as you like but the stigma will remain unless we change attitudes towards mental health.

  10. nuwan dissanayaka says:

    Interesting discussion. As a psychiatrist and also a Buddhist I have received conflicting teaching on this subject. I’m afraid I do not think a clear line can be drawn between disease and “dis-ease”. There are the obvious problems with diagnoses which do not carve nature at its joints, but more than that is the difficulty of establishing a clear distinction between me and “not-me”. “Me” implies a stable entity but the more we examine what we consider to be “me” the clearer it becomes that both in body and mind we are in a state if constant flux. Even our most stable attributes and imperfections are subject to change and in both body and mind if we think we own these phenomena and can completely control them we are kidding ourselves. This doesn’t only appear to the emotions and thinking patterns associated with illness but also to our positive mental states and most mundane frames of mind. I have not suffered with ‘mental illness’ but if I did I don’t think an internal/external dichotomy would be helpful to me as I see all of my experiences as just that – experiences, which enter awareness. I personally struggle with our classifications as I find them a bit tautological but if I was finding my experiences a challenge I would seek help as I would for physical problems. Personally I don’t think that diagnosis should define anyone – we are all far more than any word /phrase can capture. However I can see why people find a medical model helpful. I can also see why some people run a mile. Like I said in reply to your tweet. I don’t think there’s a right answer and for me whatever helps the individual is ok.

  11. JJ says:

    It’s a really interesting dilemma but for me to say I have rather than I am implies that there might be a time when I am not suffering with a mental illness. I don’t want to be defined by my problems and feel that they are things that I am prone to developing; I am prone to developing psychotic symptoms but I am not just these things, there is far more that makes up my character.

  12. DJ says:

    I think it depends on how you use the word ‘have’. Is it something transitory – such as having a cold, or chickenpox, or is it something permanent, such as having blue eyes or brown hair? One useage implies something that is ‘caught’ or acquired, while the other is a state of being.
    Using ‘have’ in the transitory sense to describe mental illness externalises it, as you say, but also implies that one can recover from it, in the same way one recovers from a cold or chickenpox. Describing it in the same way as one talks about having blue eyes imples a permanent state – that the person may have it ‘for life’, which can be devastating for some people. I’d say we need to be very careful in how we describe mental illness; especially the professionals talking about people mental illness. How patients and service users describe themselves and their experiences will vary from person to person, and people need to be aware of that. I don’t like the term ‘I have depression’, because I don’t have it all the time. It’s recurrent. So in the same way that I sometimes get a cold, I sometimes get depressed, yet I don’t go around saying ‘I have a cold’ all the time, because that is incorrect. As others have said in the comments here, I am not my depression; I’m far more than that. I’m a person who happens to get depressed from time to time, nothing more.

  13. When discussing adverse effects we use the word “experience” to describe incidences of ill health. Though I experience doesn’t always sound quite right. Not sure where to go with this one.

  14. Patricia Jane Teskey says:

    Alex Langford writes: “To say you “have” heart failure, for instance, sounds strange.” It doesn’t sound as strange to me as saying, “I AM a heart failure.” That would be really strange!! With most conditions, we do not say, “I am…., but I have…. I challenge the statement that saying “I have schizophrenia” rather than “I am a schizophrenic” means the person is externalizing the condition or blaming external sources. It means that schizophrenia is not the person’s self-identity any more than a heart failure is someone’s self-identity.Most important for a physician to note is that research shows that a person is more likely to recover from an illness (mental or physical) if he or she can see themselves as being more than the illness they have.

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  16. alex says:

    I may be off on one, but I’m just going to write it anyway.
    ‘The present king of France is bald.’ Does this make sense? Well France is a republic, the monarchy were removed in the French revolution. So does this sentence actually make sense, because it refers to something (the king of France.)?
    Mental illness refers to something, but the difficulty lies in stating what that is. Unpleasant sensations, pain, unusual phenomena, unusual body movements….The problem is that the language used to describe the phenomena (what you experience) takes the place of the phenomena, as in the king of France example.
    I think when you use the ‘suffering from an illness’ formula then you are creating many senseless arguments. Having said that, I don’t know if this makes any sense!!
    Depression and bi polar disorder are concepts used to describe phenomena, so you can’t have them, but I can give a thought or idea or opinion, I have an opinion, so you can have non physical things, so you can have depression or bipolar disorder. But you can also think things which don’t exist like unicorns, but by thinking them they exist.
    Anyhow, if you think you have depression, the processes in the body might not have any resemblance to the thing you have in the mind.
    So that clears that up.:)

  17. alex says:

    My solution to talking about something which may not exist is to put it in brackets. I have suffered from (clinical depression.) This means that you can talk about it, even though it may be a unicorn.
    There must be a way of dealing with internalize and externalize. I get the feeling that language is being stretched to the limit, and that books on psychology and philosophy are making logical errors.
    A man claimed that the language we have affects the way we see the world. People who live in the snow all year have several names for snow, whereas English has only one.
    I feel uncomfortable saying I have suffered from (clinical depression) because the meanings associated with those sounds limit the relationship and are inflexible. People think about their struggles, and their relationships and their life experiences and they think,not that I can mind read, that those meanings give them some knowledge of my life, which it may do, but that is quite a conclusion to jump to in five seconds.
    I think it is easier to say you suffer from (depression) because you make out it is not a fundamental problem, and so you don’t isolate yourself from others, even though.your struggling to hang in their, lying about how low you feel and your having thoughts about killing yourself. You.struggle with your moods which are ugly, you hate your family, but you fake a sociable personality, dropping in clever normal talk to put people off the scent of your desperate, hopeless inner struggle. You fake it and say ‘how nice to see you’ when you’ve just been planning your suicide. But some part of your appearance betrays you and the coldness creeps into your ‘friends’ body language, and the eyes and the face know that the talking game is a sham.
    That’s hard.

  18. alex says:

    Externalizing means blaming everyone else, when it’s your responsibility. (You feel deep down?).

    Internalizing means blaming yourself, when it you take too much responsibility?

    Both are from psychological terminology based on a supposed lack of self awareness. They are used by people who believe they have insight into the personality of the externalizer/internaliser.

    Can a simpler language be used instead of a difficult one?

  19. alex says:

    I.have a picture of heart failure as a very big heart in which the valves don’t meet up. I have seen it in a specialist book. I find it difficult to picture laplace’s law, and the physics behind that…..the vector component for compression becomes more oblique…..changing the radius of arterioles only slightly has a large effect on resistance so this could create psychiatric illness in the brain if it alters metabolism in a particular place.

    • Patricia Jane Teskey says:

      Alex, heart disease and depression are known to co-occur fairly often and there is a biological basis to both heart disease and depression.As you suggest, the dichotomy between “mental” and “physical” illnesses is quite artificial. The brain is an organ of the body as much as the heart or liver, etc, and the thoughts and feelings created by the brain are affected by a combination of what goes on in the brain itself, what is happening in the rest of the body, and external stimuli.

      • Hope says:

        There are several problems with that thesis. First of all, we can look at a heart and see what the disease or defect is. There are definitive tests. With brains and mental illness, that’s not the case. I say this as someone who’s had brain surgery and more brain scans than she can count. Aside from the defect that required surgery, I’ve been told I have “a perfect brain,” despite the fact that I have severe depression and PTSD. There is a theory that mental illness is caused by an imbalance of neurotransmitters, but there’s still no definitive proof of that. There’s no lab test that can tell if my serotonin or dopamine or norepinephrine levels are off. When psychiatric medications work, we don’t know exactly why, nor do we know why they fail for so many people.

  20. alex says:

    Great debate! I would like to pose the question: how could there not be a biological basis for depression? What other basis are there?
    I mentioned heart.failure because I think you can see it and its more obvious what it wrong when you compare it to a small healthy heart.
    But I can’t picture what is wrong with my brain, when I was severely depressed, or afterwards. Somehow I don’t find the neurotransmitter explanation very convincing because I just can’t picture it and how it works. Something like lights on a Christmas tree?!. And antidepressants make me feel.unemotional too.
    It’s all very frustrating!!

    • Hope says:

      Plenty of people have depression caused by situational factor. Mine, for example, is caused by years of repeated traumas. Other people’s depression is caused by poverty, difficult relationships, or grief.

      There are certainly cases in which there appears to be a biological basis for depression–but we don’t know what that is, so it’s misleading to compare it to heart disease, where doctors can identify what the precise malfunction is. The comment to which I originally replied, Patricia’s comment, states definitively that “there is a biological basis to both heart disease and depression.” And that’s simply not always true with depression and other mental illnesses. My structurally perfect but still very depressed brain is a case in point.

  21. alex says:

    Sorry I wasn’t being unkind, I was just playing devils advocate. What I should have said is that the biology is a set which contains everything from art and music to flesh and blood. In that sense saying depression has a biological basis is meaningless because being alive and reading this has a biological basis. If it didn’t have a biological basis you would be dead.
    I know if you hormonal excesses or lack then you can become depressed, perhaps from a tumour. I’m just trying to make sense of things in purely biological terms. I suppose I’m confusing basis with totality.
    As regards brain scans the uptake of radioactivity labelled glucose can show depression in certain scans, and there may be signs on an EEG for some illnesses. The resolving power of an MRI is not very good.

  22. Scott says:

    I think it is impossible to answer this question outside the framework of diagnosis. Anyone can say that they are depressed but it means something different to have depression. Setting aside infection, I have X is often just a short hand for I have met the diagnostic criteria for X and been diagnosed with X. In turn it is a short hand, in mental illness, for saying that my brain functions in a way that I and medical professions recognise as pathological. That may allow for externalisation.

    As you are no doubt aware there is a lot of literature about sick role adoption, adopting mental illness as an identity, stigma and role engulfment, there is no easy answer to the question particularly given current diagnosing of mental health issues. Lally’s”Does being in here mean there is something wrong with me?” might be of interest to you.

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