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Are Mental Illnesses Really Illnesses?

And Why Do People Care?

In 1961 psychiatrist Thomas Szasz published an article in the American Psychologist titled, “The Myth of Mental Illness.” There he proposed that the set of experiences, behaviors, and thoughts viewed as “mental illness” are more aptly construed as “problems in living.” Columbia University has made the entire article available for free and it can be accessed HERE.

SzaszThe following year, Dr Szasz published a best selling book by the same name. Some loved it while others writhed in anger. One reviewer, for example, gave it five stars out of five, and wrote:

Incredibly eye opening book. Shows how “mental illnesses” are not illnesses at all. Mental illness is best viewed as a metaphor. This isn’t to say that what we normally refer to as “mental illness” doesn’t exist, clearly these many psychological experiences do exist…but they are not genuine illnesses and when they are assumed to be this can lead to profound misunderstanding.

In contrast, another reviewer wrote:

bed-of-nails-sharp.jpg.653x0_q80_crop-smartHere is my curse on you, Thomas: May you suffer ten minutes of acute clinical depression. Ten minutes in that “over-heated room”, that “bell-jar”, that “bed of nails” which we sufferers know oh too well.

Why were there such strong reactions to a proposal for describing something in a new way? I began to get some understanding of this when I recently began to advocate that the phrase “mental health concerns” is a more apt alternative for referring to the patterns now referred to as either mental illnesses or mental disorders.

Relationship issues - middle aged couple with hand on chin

More specifically, my proposal calls for the development of a scientifically defensible classification system that would be called, “The Classification and Statistical Manual of Mental Health Concerns,” or, for short, the CSM. With this alternative, people who have mental health service insurance coverage would be given a choice–they could access this service either by going to a mental health service provider who requires that they be labeled as having a mental disorder (which is currently their only option), or they could choose to go to one that would only label their expressed mental health concerns. Like Dr. Szasz’s proposal, mine, too, has been met with enthusiastic support from some, while others have angrily called me a mental illness denier and dangerous.

angerI was initially puzzled about the anger that appears to come from many who genuinely believe, and demand others believe as well, that without any doubt mental illness is an illness like any other illness. My puzzlement stemmed from my experience that oftentimes when someone proposes a different way to describe something, it doesn’t create great uproars. The proposal is either met with feelings that the new way to describe something is either helpful, or not.

After much thought and discussions with others, I now see that this mental illness conflict is not purely about how to describe what is now typically called mental illness. Rather, it is about the feared consequences that may flow from any new way to describe this set of phenomenon.

To help others to see this clearly, today I’ll present a William James anecdote illustrating why definitional issues often don’t lead to conflict, but rather clearer understandings. Then I’ll seek to explain the unique resistance to questioning whether or not the patterns now called mental illnesses are best construed as illnesses.

A Definitional Issue Anecdote

PragmatismWilliam James, in his book, Pragmatism, tells us the following story

One day the good professor, being with a camping party in the mountains, returned from a solitary ramble, and found everyone engaged in a dispute about a squirrel. The squirrel is clinging to a tree trunk trying to hide from a person by moving to the opposite side of the tree where the man is looking.

Squirrel_on_tree_trunkThis human witness tries to get sight of the squirrel by moving rapidly round the tree, but no matter how fast he goes, the squirrel moves as fast in the opposite direction, and always keeps the tree between himself and the man, so that never a glimpse of him is caught. (p. 43)

So, given this set of agreed upon facts, the dispute was about this: Does the man go round the squirrel or not? Apparently everyone agreed that the man does go around the tree, and the squirrel is on the tree; but does he go round the squirrel?

Half the participants involved in the dispute felt the man did go round the squirrel, and half disagreed. Upon returning to the campsite, each side appealed to William James to help explain who was right.

going-around-in-circles“Which party is right,” I said, “depends on what you practically mean by ‘going round’ the squirrel. If you mean passing from north of him to the east, then to the south, then to the west, and then to the north again, obviously the man does go round him, for he occupies these successive positions. But if on the contrary you mean being first in front of him, then on the right of him, then behind him, then on his left, and finally in front again, it is quite obvious that the man fails to go round him, for by the compensating movement the squirrel makes, he keeps his belly turned towards the man all the time, and his back turned away. (p. 44)

Once James simply explained to those involved in the dispute that there are these two different ways to define the verb “to go round” the majority appeared to think that the distinction settled the dispute. One or two who had strongly taken a different position before James showed up, mumbled an objection to his argument, stating the decision really should be made based just on plain honest English, but this soon passed.

I tell this anecdote because it clearly illustrates that when someone describes a new way to look at a phenomenon, it has the potential to clarify the nature of the phenomenon. Disagreements that had sprung up because of vague descriptions may have gone on and on with no progress in sight. disagreementOnce the process of comparing and contrasting two or more descriptive approaches gets underway, it can lead to an understanding of just how vague some of the descriptions were, and they can be abandoned for more precise descriptions. Of course, the new description may also be so terribly vague as well, and nothing positive occurs. In such cases, a little time was wasted, and people get on with their lives without furious reactions.

So, with this in mind, why do people so angrily resist even considering an alternative to describing the set of phenomenon now referred to as mental illness? In the next section, I’ll try to provide some answers.

The Three Major Consequences that People Fear Might Flow from a Change in Descriptive Terms

moneyLet me begin here by asking you to note that in the squirrel anecdote, those who discussed whether or not the squirrel went around the tree were not going to lose their job, money, freedom, or any other highly significant valued thing depending on who ended up being proved correct. Once everyone declared their positions, each might have had a little sense of prestige that might be derived if they could convince others that they came up with the most respected answer. But for people who like to discuss issues, learning from the discussion is typically the most important reward for them, and they can well handle their emotions that come from having taken a position that ends up being faulty.

How about the issue of whether or not mental illness is, or is not, really an illness? From my discussions with supporters of the mental illness descriptor, I theorize that they fear three major consequences of any change.

Diminished Profits of the Pharmaceutical Industry and Prescribing Physicians

pillsThe pharmaceutical companies make billions of dollars convincing people that their experiences are illnesses like any other illnesses. Thus, they claim that taking a pill to manage their illness is not any different than taking insulin for diabetes. Psychiatrists and other doctors who prescribe these drugs have an enormous financial interest in keeping this position unchallenged.

For me, I find this sales pitch unconvincing. BuddhismThe facts are that there are numerous examples of people who could have easily been classified as having a mental illness who come to a state of enormous improvement either through a religious experience, a philosophy such as Buddhism, a delightful romantic love, an exciting new job, a support group such as AA, counseling, etc., You don’t see diabetes being “cured” by changes in relationships, work settings, religious beliefs, and thinking patterns. The fear of those invested in pharmaceutical company profits and the prescribing of their pills leads to great resistance to any descriptive changes that are not in line with the illness approach.

The Risk of Losing Access to Services

mentalhealth servicesThe second consequence that I think people fear is that people who now have access to mental health services might lose them if people stop thinking that the patterns now viewed as real illnesses are really not illnesses. Dr. Szasz’s “problems in living” alternative and my “mental health concerns” approach, they fear, will trivialize these experiences.

mental-health-servicesSome argue that if everyone could go to a mental health professional merely to have their concerns addressed, then the system would soon be overloaded with clients, and insurance policy costs would soar. Because insurance companies only cover people with more serious conditions known as mental disorders, so the argument goes, this limits the number of people who can get to see a mental health professional. However, I believe that third-party-payer executives would readily come to understand, with a little explaining, that mental health service providers now using the current mental illness approach do not turn anyone away who has mental health insurance coverage and comes to their office expressing what my approach refers to as a mental health concern. Professionals are in the business of increasing their clients. The current relevant definitions are so vague that with little imagination, anyone can be “diagnosed” as having a mental illness.

Fears About Blame

one couple man and woman Criticism concept

Finally, many people believe that the mental illness conceptualization absolves them of any blame for certain actions. For example, many parents believe they were unfairly blamed for the serious actions that their children began to display. They think that by saying that their children have an illness they are no longer blamed, or at least shouldn’t be blamed.

blame 3Similarly, people who seriously hurt others while drinking alcohol or in some furious fit might be blamed for their actions. Thinking that they have an illness, somehow makes them blameless.

In my view, not everyone who hears that their conduct is due to an illness suddenly feels relief from any guilt that they may be feeling. There is a process that one must undergo to learn how to effectively handle guilt feelings and this can occur at least as well with a mental health concern approach as with an illness approach.

william-james-philosopher-why-should-we-think-upon-things-that-areThis process involves learning that there is a dramatic difference between taking some responsibility for what has occurred and blaming oneself for what has occurred. Blame suggest that you should be punished for your actions. Taking some responsibility for your actions allows one to realize that there may indeed be some very strong conditions that are out of your control regardless of whether or not you have an illness. Blaming yourself for these is not helpful, but allowing yourself to experience deeply the dissatisfied feelings about whatever control you do have can spur you to make valued changes.

Giving people the opportunity to choose a mental health concern approach rather than an illness approach does not necessarily mean that people will be blamed any more or less for certain actions. The competition between these two models can improve outcomes for both approaches.

Conclusion

Illness 2Okay, so those are the three feared consequences that I have come to believe ignite anger whenever there is a discussion about conceptualizing the set of concerns now called mental illnesses. In my view, “mental health concerns” are a more apt way to conceptualize these concerns than “illnesses.” However, I fully support that for those who prefer the illness approach, that they be free to access services using that model. At the same time, I believe that ending the monopoly of the illness approach could very well stir up some valuable competition that will improve services for all.

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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional intelligence. To begin at the very first post you can click HERE.

 

The Mental Illness Construct: Does it Reduce Shame and Guilt?
My Upcoming APA Speech on Psychiatric Diagnosis

About the Author

Jeffrey Rubin grew up in Brooklyn, received his PhD from the University of Minnesota and has taught conflict resolution there as well as at a psychiatric clinic, a correctional facility and a number of public schools. He has published articles on anger and conflict resolution and has authored three novels.

8 Comments

  1. Fear, as you are likely aware, drives most of the resistance to change, especially when dealing with such a nebulous construct as mental illness or pharmaceutical treatment of mental illness, both of which have very little to no science supporting the claims.

    • Thanks for your comment, Dr. Zaejian. I think there is much truth to your views on this topic.

  2. Another very illuminating post, Dr. Rubin. I very much appreciate your thoughts on this matter and thank you for taking the time to voice them. I strongly feel that alternatives to the diagnostic model currently dominating the mental health world are essential for progress toward superior mental health services being available.

    Another reason that I feel people get angry toward an alternative like this, is that a disorder diagnosis gives many people a sense of explanation for why they feel sad, anxious, etc. and many people really desire to easily understand why they are feeling the way they do. It seems that an alternative to the diagnostic model is making some people feel that their “explanation” is being invalidated. I also feel that many people develop a sense of belonging with a community also labeled as the same diagnosis they have been given. Again someone coming along and giving an alternative to this model may cause some individuals to feel that the reason for their sense of belonging is being thrown into question.

    • Hi Jack Star,
      Very insightful comment. This is one of the main reasons why I enjoy writing these posts, to learn from my readers. I appreciate the subtlety of your thinking on this.

    • I’m afraid changes in the diagnostic model will accomplish little. Changes in training models, letting go of rigid thought not based on science or research (unversity curriculums consistently avoid naming what is not research based and fill students with theory, most of which is unproven.) And courage of university departments to confront old, unsubstantiated beliefs, and open receptivity to novel therapeutic approaches may have a chance of altering current rigidity

      • You may be right about this, Jasenn. Nevertheless I’m going to continue to do at least something to try to make some changes. My Best, Jeff

  3. I think the impulse to modify the labeling system is a positive and thoughtful one. One of the recurring issues with DSM labels is that the label so rarely opens the door to a resolution of the condition. This in turn implies that the model generating the labels is flawed. If the pragmatic approach is not included in modeling and labeling mental conditions, the door is left open for superstition of the rankest sort.

    • Hi A, H. Jessup, good to hear from you. Yes, many of the conditions labeled mental disorders are declared lifelong conditions that can only be managed. The approach I support is aimed at being more scientific, person-centered, culturally sensitive and recovery-oriented.

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