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Hmmmmmm. Interesting/useful conversation yesterday evening. Lots of thoughts in reaction to various challenges to my "story." To wit ...

Yeah, I really DO think we could do better by finding a framework other than medicine ("illness," focus on "fixing things," "objective expert") to think about "mental health." And that's NOT an attack on medicine per se, but rather an acknowledgment that the issues/problems/challenges of dealing with behavior/human experience are significantly different from those medicine has so far evolved to effectively deal with. Medicine as a profession could certainly move in new directions, and probably will. But I'm not inclined to presume that we have to depend on the medical profession and wait for that. Just as I'm not inclined to presume that biology/neuroscience will in time give us the answers to difficult questions like what "mental health" actually is and when to "cross the border" with treatment, and wait for those. The problems exist now, and have to be dealt with now.

Equally importantly, my guess, as a biologist/neuroscientist, is that such questions have no "objective" answers, and that future research will bear this out. The brain is not designed to achieve "objective" understandings of "reality." It is designed to make the best sense it can of the information it has, to create "stories" that in turn alter what has to be made sense of, and to revise those stories accordingly. Again and again. There is no fixed "standard" to be reached; there is an inherent, and desirable, subjectivity in all understanding. Deciding what "mental health' is, and when to "cross the border" have always been and will always be questions that have no "objective" answer, questions that one has always had to answer and will always have to answer "subjectively," ie in awareness that there is no "god's eye" view, and that one is always acting out of, and testing, one's current understanding.

The argument here is that "relativism," individual and cultural, is actually not something to be avoided but rather something to be embraced. It, and an associated "subjectivity" is part of the very nature of human behavior/experience (see also Fellow Travelling with Richard Rorty). Diversity, among both individuals and cultures, is not a failure to achieve perfection but rather the grist from which new and less wrong things are made. And that movement doesn't depend on any fixed ideal of what is "right" or "good" or "healthy." It depends only on an ability, which all human beings share, to notice things that don't work well NOW by whatever one's standards (individual and cultural) are NOW, to try and fix them, and to learn from those actions, to revise not only our understandings but our standards (individual and cultural). To make effective use of that ability, we need as well a willingness to live with the certainty of the uncertainty, and to allow ourselves to be changed by challenging it.

So, back down to earth. What does this have to do with thinking about "mental health"? First, it suggests that we should avoid identifying some humans as "healthy" and others as "ill." Humans differ from one another along a very large number of dimensions, and those differences have complex causal relationships among them. There is always uncertainty about the value and cost of any particular difference, about which ones need to be "fixed." We all have characteristics that are appreciated by ourselves and others, and other characteristics that either we or others (or both) would at the moment prefer we not have. And we would all be better off thinking of ourselves, and others, as a mix of characteristics, some less appealing and others more so (to ourselves and others). Reducing that richness to a single dimension and identifying people as healthy or ill by some arbitrary cutoff along it seems to me not only impossible but counterproductive. Our goal should be to encourage people to enhance their distinctive and valuable differences, not to try and make them all the same.

Second, this perspective suggests that just as we all are varying mixes of characteristics, we all have varying needs for sympathy and assistance from other people. One doesn't need the concept of illness in order to accept help from other people, nor to offer it to others. Indeed, the concept of illness frequently gets in the way of both accepting help ("I should be able to take care of myself") and offering it ("Are they really sick or are they just malingering, trying to take advantage of me, etc?"). Yes, there are, will always be, uncertainties about when/where/how/who to ask for help and to offer help. But it seems to me that trying to codify this in terms of a healthy/ill dichotomy demonstrably creates more problems than it solves.

Third, this perspective suggests that both research and therapeutic practice should focus less on "fixing problems" in some permanent sense and more on opening new directions, for both individuals and humanity at large. The history of efforts to find a "cure for cancer" are instructive in this regard. Cancer is increasingly understood not to be A symptom with A cause and A therapy but rather an intersecting set of symptoms, causes, and therapies nearly as diverse as the affected individuals. Furthermore, the risk of one or another breakdown of the control of cell growth is almost certainly an inevitable consequence of being a complex multicellular organism. There are a host of therapies for cancer but no "cure." It would be astonishing if human behavior/experience were not still more complex ("Because I relish complexity, I chose psychiatry - its more complicated than neurology" ... Nancy Andreasen, NYTimes, Science Times, 16 September 2000).

This is not at all an argument for not doing more research, but it is an argument for research directed less at what sometimes seems to be the straightforward challenge of finding simple ways to restore the "ideal" or status quo, and more at opening up the range of possible ways to think about what it is to be human, ways that start from a recognition of our complexity (cf A Dissenting Voice as the Genome is Sifted to Fight Disease). And it is not an argument against using particular therapies to try and help particular people in particular cases, but it is an argument that the core of therapeutic practice should not be to "fix" people in the sense of repairing something broken but rather to help people become better able to themselves see and choose from a wider array of possible selves.

Fourth, this perspective encourages us all to see culture not only as something that influences our behavior and standards, but also something that is, and can further be, influenced by our individual behavior and standards. Yes, Culture as Disability diagnoses a problem of cultures without offering a solution. But it would be a mistake to conclude that we therefore have to live with that problem. One could instead read the paper as a challenge: how could we reconceive cultures so they don't have that problem? Yes, doing research on complex entities requires different approaches than that on simpler ones: what kinds of new approaches can we imagine? Yes, "mental health" is at the moment widely thought about in terms of "illness" and its absence. What new, less wrong ways are there to think about it?

Thanks again for everyone's contributions to my thinking more about that question. Looking forward to seeing what new thoughts the conversation yesterday evening triggered in other peoples' minds.