Many years ago, I saw a young boy aged about eight-nine years, waiting in a supermarket queue with his mother, wearing a T-shirt, which had “I am Autistic” boldly printed on it.
I was startled, to put it very mildly. I was working as a trainee in a child psychiatry unit in England then and I asked my trainer about it. I thought it was a very unfair way to label a child and reduce his identity to a disorder.
The ensuing discussion was salutary. I learnt that a number of parents and those who have autism actually do not mind being “labelled”. I subsequently met parents who said that making their children wear such T-shirts makes other people more considerate and tolerant, if they display any disruptive behaviour in public places.
I was reminded of this discussion due to an ongoing debate on social media. Very recently, a well-known person had posted (on social media) something about another person, which was in appallingly bad taste, humiliating another person.
Understandably there was outrage against that particular post. The ensuing discussion about this person’s behaviour was more interesting to me as a psychiatrist. One of the key roles a psychiatrist has is assessment of deviant or unacceptable behaviour. Some posts were requesting that the person’s behaviour to be seen in the light of the person’s psychological frailties due to some neurological/psychiatric illness. An equal number opposed this view. According to them, a large number of people with mental or neurological diseases do not display such crass behaviour. Hence giving the excuse of suffering from a disease was thought to be an inadequate and unjustified excuse.
So, the question is, how much leeway can we give someone because his/ her illness or condition is felt to be a cause or a contributory factor for unacceptable behaviour? There are problems in the question itself — there are no ‘gold standards’ in defining unacceptable or deviant behaviour, but I am not delving into that right now.
Does “labelling” someone with a condition give the person some undue advantage to justify his/her errant behaviour? To illustrate the dilemma, let me give some examples from my own learnings over the years through clinical encounters.
Frontotemporal Dementia
I remember one gentleman in his late 70s brought to me by her extremely distressed daughter and wife. They were concerned about his inappropriate sexual behaviour, which had emerged over eight months. He was a retired teacher who had been impeccable in his behaviour throughout his life. In recent times, he had started using foul language, had seemingly developed an insatiable appetite for sexual activities and was masturbating in public. The carers were angry and horrified. After careful evaluation, it emerged that the person had Frontotemporal Dementia. Dementia is a degenerative disorder of the brain. Memory deficits and inability to carry out tasks necessary for daily living are important manifestations of dementia. Alzheimer’s dementia is the commonest form of the disease, but Frontotemporal Dementia is another important variety. Frontotemporal Dementia is very frequently undiagnosed or misdiagnosed. Impairment in judgment (like this gentleman displayed) and psychiatric problems are prominent features of Frontotemporal Dementia.
After learning about his diagnosis, the family members were comforted to a large extent. The fact that he had a disease was paradoxically comforting for them. The realisation that their father was displaying such behaviour due to a disease and had not suddenly changed into a man of dubious moral values was helpful to reframe their understanding. The disease had actually robbed him of his faculties to exert control over his behaviour. This is an example of “labelling”. In this situation, it helped.
Oppositional Defiant Disorder
Is labelling a child “autistic” bad? It depends on the context. I know of many schools in Calcutta which go to extraordinary lengths to accommodate children with disabilities. Then there are others, who will not touch them with a barge pole. Often taking help of labelling to explain different/difficult behaviour is science. It is not hiding under the covers or trying to offer an apology for difficult behaviour.
However, it is wise to wake up and smell the coffee once in a while. Labelling can be and is grossly misused and the psychiatric fraternity has been co-opted as an agency in validating this misuse. Jailing of dissidents in former USSR after giving them psychiatric labels to very recent ostracisation of LGBTQ community are glaring examples. In these situations, labelling has been grossly misused. Diagnosing Oppositional Defiant Disorder (a valid diagnosis as per psychiatric textbooks) in children and young people gets my goat, as these three-word summary of a person imprints a pejorative image in our brain, ignoring the larger context in which the behaviour has evolved.
Human behaviour is complex
The point I am trying to make is how we “understand” someone’s behaviour is crucial in formulating our response. If we accept alcohol dependence is an illness, then why should we mock and jeer at people who stood in queues to get alcohol during the lockdown? I accept not everyone in the queue had alcohol dependence.
The murky question I am trying to address is how “responsible” we are for our own behaviour? At a much deeper level, it goes down to the debate about free will, a topic which keeps philosophers and scientists awake at night. If we label someone as having a disease, does it condone in some way from his or her actions?
I think trying to see human behaviour through a narrow lens can be simplistic and often erroneous. My point is that sometimes though it can be useful. BUT we need to be cautious trying to explain all errant behaviour through disease models. It is misuse of science.
A child with autism can and does exert enough personal agency to keep behaviour under control until the world around him/her gets overwhelming. A person with alcoholism can and does give up alcohol provided the motivation along with adequate social support is there. In dementia, disruptive and inappropriate behaviour can be reduced and stopped with environmental changes and drug treatment. Providing an explanation of someone’s behaviour arising out of illness is not hiding under the covers. Neither does it insult or disempower other sufferers because hopefully society at large can understand that there are many shades of the same colour.
Human behaviour is exceedingly complex. There are times when all of us are deliberately mean, abusive and exhibit appalling behaviour and judgment. Lack of empathy is one of the key factors, which is responsible for such behaviour. Then there are times when it is purely due to an illness. I remember an acutely psychotic mother trying to kill her baby because the “voices” told her to do so. So, how should we view the behaviour of the person whose actions raised the question in my mind? ‘I do not know,’ is the honest answer. I do not know enough about the person and his/her context, as I guess is true for most of us when we are passing judgments about other people’s behaviour. In therapeutic transactions (patient-doctor transactions), the wisdom is to see the problem (behaviour) as the problem, and move away from seeing the person as the problem. Hand on my heart, despite trying to do so, I do not succeed all the time.
Dr Jai Ranjan Ram is a senior consultant psychiatrist and co-founder of Mental Health Foundation (www.mhfkolkata.com). Find him on Facebook @Jai R Ram