Cricket and mental illness

There is a lively debate in the philosophy of psychiatry over what makes a condition a disease. The debate is particularly heated with regard to addiction: it is a moral failing, a brain disease or something else altogether? People who hold that addiction is a brain disease often claim that their view is more humane, because it removes the stigma from a condition that is not the sufferer’s fault. Unfortunately matters are not so clear cut: there is some evidence that the disease model actually increases stigma, or at least makes mental illness seem more a fixed part of the person’s identity.

Some of the complexities surrounding this debate, and the way in which it relates to public understanding of mental illness, are well-illustrated by the recent ill-tempered dispute about Jonathan Trott’s withdrawal from the English cricket team’s tour of Australia. Trott withdrew from the tour, citing a “stress-related illness”, after failing in the first test. “Stress-related illness” was widely understood to be code for depression, and Trott was responded to sympathetically. Recently, however, Trott has said that he was suffering from “burnout”, not depression. Trott’s reasons for the claim, and the response to it, have been fascinating.

Led by former England captain Michael Vaughan, several people have been quick to condemn Trott. Vaughan says he feels “conned” by Trott. It turns out, he says, that Trott was suffering “for cricketing reasons and not mental”. Burnout, Vaughan suggests, is “an excuse” (presumably it is unlike depression in this regard).

One of the interesting aspects of this response is the way in which it echoes distinctions made within debates in psychiatry. The distinction between “cricketing related” and “mental” reasons echoes a common distinction between exogenous and endogenous depression; the former, because it is caused by life events (say, the death of a loved one) is not an illness whereas the latter is. But the fact – if it is a fact – that exogenous depression is not an illness does not make it less disabling, or more a person’s fault, so even if Vaughan is right in thinking that depression is a disease and “burnout” is not, it hardly seems to follow that the latter is simply an excuse. If anything, Vaughan’s reasoning seems to show the limits of asking a disease model to do normative work. Whether it is a disease is one thing; whether it excuses is quite another.

Even more interesting is Trott’s reasons for emphasizing that he thinks was suffering from “burnout”, not depression. “I’m not crazy I was just burn’t out”, he was quoted as saying, and repeatedly mentioned his worry that he would be seen as a “nutcase”. Even if the label “depression” removes some kinds of stigma – the kind that would lead Michael Vaughan to think someone is looking for an excuse – it threatens another: then kind that has one labeled as a “nutcase”. Trott’s worry seems well-founded. Believing that depression is a disease does not make one less rejecting of the sufferer. Again, these facts suggest that normative considerations should play less of a role in deliberations about disease than they currently do. If reducing stigma is our aim, we should look for other ways to do it.

If nothing else, the responses illustrate a catch-22 with regard to mental illness, given how it is understood by most people today. Having a mental illness is grounds for sympathy; if you are ill, you can’t help the way you respond. Or so most people seem to think (whether rightly or wrongly: it is not obvious that people always have more capacity to “help” how they act when they are not suffering from a disease). But having an excuse for how one acts is not an unalloyed good: it comes at the cost of being identified with the mental illness. There are no good options, for those who might be labelled mentally ill, only choices between bad options. Given that whether or not they have a disease they are certainly suffering, we should look for ways to make things less bad for them; our current responses seem to fail that basic test.