The DSM-5 is a misunderstanding of mental health
"Personality disorders" are less like illnesses, and more like poorly designed machines
Depression is more analogous to a badly written codebase than it is to an illness. A bacterial infection is an illness. The treatment is an antibiotic - kill the bacteria, kill the illness. Allow the body to resume functioning in its default state. Simple.
A personality disorder1 is different: it is a fucked up default state. Consider the following:
You start out trying to accomplish something. Maybe you've never had good role models, or a well-functioning example to learn from. But you do you best to set up a system, and it kind of works. Maybe some people even like it, and find it quirky and interesting.2 Then you need to accomplish something else, so you add on top of this without too much thought. Maybe you get away with all of this for a while, and you could even call it a brand, or a personality.
Then problems arise, as they do. Someone asks you to do something. Not only can you not do it; you also spend a great deal of time being frustrated and angry about how difficult the attempt was, and how nobody gives you any credit for trying so hard to do something that ought to come easily. The next time that you look at a problem which might be worth solving, you're tired, and world-weary, and the whole thing feels daunting and unlikely to go well. Before long, even just looking at the damn system itself is painful. The thought of actually trying to change anything within it seems completely out of reach. You just know a bunch of hacks to keep it running. And yes, you could pick one little part of it and make it a little bit better each day. This feels like watering one plant with a teaspoon in the middle of a drought.
This is a description of why depression a shitty codebase makes it hard to get things done. And yes, good habits can prevent things from getting worse. Good habits probably would have avoided this state entirely. And yes, with enough work and faith and tenacity, you probably could refactor things into a better state. But how many people companies actually do, vs just trying to get through one more day?
You can’t “treat” a poorly built system; you can only try to refactor the plane as it’s flying
Our attitude towards “personality disorders” and “mental illness” is largely one of wanting the problem to go away by “diagnosing” and then “treating” it.3 This is an attitude that very quickly stops making sense to anybody who actually struggles with these things. You can largely fix a dry plant by pouring water on it. From reading most discourse around mental health, you’d think that you could “fix” mental health issues by pouring sufficient therapy and medication on them, as if they are unimolecular substances.
The problem is that this makes no sense because there is no functional default state to return to; the dysfunction is built into the system, as a direct result of good intentions and bad execution. “Borderline” is a personalty label that conventional psychology has thrown at me, and is often defined by a list of unhelpful traits. Examples:
Extreme emotional reactions to things that other people would consider “no big deal” (i.e. an innocuous comment or perceived slight, someone being late for plans)
Empty, unstable sense of identity; feeling elated and grandiose or utterly worthless depending on what has happened in the last 15 minutes (which unsurprisingly leads into suicidal ideation)
A black and white view of things: people are either flawless heroes, or the embodiment of evil
But you can also easily see how the above properties could come about as the result of a certain kind of story, as opposed to an illness that “strikes”.4 Being around people who are not upfront and honest about their feelings will precipitate a hyper-sensitivity to non-verbal relationship cues, and the need to guess what is going on because nobody will tell you directly. Being around people whose regard and affection is conditional based on external factors (beauty, achievement, whether or not you fit a specific image) creates the need to constantly monitor and obsess over where your own self-worth stands against the opinions of others. Black and white thinking is an understandable outcome of being around people who are both strongly opinionated about morality (what type of person is “good” vs “bad”), and also massive hypocrites who will not engage honestly with their own capacity for sin.5
Few of us change - but we all want to
Anybody who has ever tried to fundamentally change their approach to writing software daily existence knows that it is simultaneously doable, but also really, really fucking hard. Nobody ever sets out to write crap software, just like nobody ever sets out to be depressed - and yet it is alarmingly common. Certain things - like being surrounded by well-motivated, emotionally intelligent people who understand how incentives interact with personality to shape behaviour - tend to help. Certain things - like poor diet, not getting enough sleep, and feeling disrespected - tend to make even the simplest tasks feel impossible. Functional depression feels a bit similar to working in a tech-debt ridden codebase. You somehow make it through the day, but you’re in no place to imagine some glorious future. There are things you could do to improve matters, but you often just want to close your eyes at the end of the day.
It’s unclear whether things are going to get any better, but the “functional”6 part of functional depression will show up the next day for one more round. At least for the time being.
#152
Depression might not be considered a personality disorder in the DSM sense, but it absolutely is. It is a set of patterns for perceiving and responding to the world which are generally considered undesirable by society. In the vein of TSwift’s “everybody loves pretty, everybody loves cool”, I’ll add that everybody loves productive, optimistic, tenacious, self-respecting, and full of agency.
Depression is a set of tendencies that grind directly against these traits. Outside of therapists whose job it is to tackle them, most people are also limited in their capacity to be around depression; 1) because empathy is curbed by the desire to distance yourself from things that you don’t want to absorb and 2) because it calls for difficult and often thankless emotional labour. A depressed person will be the first person to tell you that depressed people are…honestly pretty awful to be around.
To this day I cannot tell whether this is love, or simply enablement
The rhetoric around mental health issues and “treatment” is surprisingly similar to the language that gets used in 2000s era antivirus software: you “scan” for issues, and you “clean” the problem. What’s happening under the hood is that you’re pattern-matching unwanted code and removing it. This requires a sufficient understanding of what constitutes “unwanted”, and what constitutes “removal”. Anybody who’s ever dealt with, say, an incorrectly symlinked library in Ubuntu knows just how deep this rabbit hole goes, and how much effort it can take to do this correctly.
The vast majority of therapists seem to be doing the equivalent of copy-pasting a StackOverflow answer, and updating their DSM-IV definitions the same way that you download updates for McAfee. Very few seem to understand how to actually refactor. This would be understandable in the general population, but is hard to excuse in an industry whose one job is to help rewrite ineffective personalities.
I once had a therapist ask me if I’d even considered accepting that depression would simply be a part of me forever. Right or wrong, this is the therapeutic equivalent of asking me whether I could simply be ok with writing shit code forever - which is not a helpful premise to start from.
I don’t know if anyone else experiences this, but I often feel less alone after reading literature by authors who are extremely talented at describing inner states (Aldous Huxley, Guy de Maupassant, and most recently Rejection by Tony Tulathimutte) than I have after speaking to 98% of my therapists. I think novelists and short story writers find the story of how a person came to be the way they are both interesting and inherently worthwhile, and the good ones are able to describe the situation with great fidelity and a minimum of judgment. I feel like most therapists (and all of the bad ones) see it as a means to an end: “I am reading this textbook of a person only as much as required to fit them into my exam cheat sheet, so that I can circle the right answer and get on with the task” - of prescribing the right meds, or assigning the right worksheet, or whatever.
With the exception of this notable quote from Solzhenitsyn, secular society is woefully lacking in any powerful rhetoric or mental models for grappling with the idea that we are simultaneously damned and horrifically ugly, but also endlessly deserving of love and capable of goodness:
The line separating good and evil passes not through states, nor between classes, nor between political parties either -- but right through every human heart -- and through all human hearts.
Certain stories from Christianity ring with a similar spirit (i.e. the character of Saul who becomes St. Paul, encapsulating in one person both a persecutor and a saint).
Complex characters are notably lacking in secular media; we like clear heroes and villains. Even anti-heroes tend to redeem themselves as clearly good by the end of the movie. If they ever do lapse into their former capacity for evil and break the faith of those around them, it must happen after the lights go up and the popcorn gets cleaned up, because I’ve never seen it.
When it comes to forgiving our friends or colleagues, the secular advice proffered is usually just a watery “nobody is perfect”. This still implies that “good” people are like shiny objects, perhaps cosmetically scuffed but otherwise fundamentally good - as opposed to the constant oil-and-water swirl of damned-vs-worthy that seems to more accurately describe the vast majority of humans, and that God still miraculously loves anyway.
There is no glory or character or tenacity or strength or redemption in this. It is just a property that is sometimes present.