In an article titled “The Roots of Mental Illness,” the author, Kirsten Weir, tells us about Eric Kandel, MD, who believes that the experiences that doctors refer to as mental illnesses are brain diseases. Dr. Kandel defends his belief with the following statement: “All mental processes are brain processes, and therefore all disorders of mental functioning are biological diseases. The brain is the organ of the mind.”
The article also indicates that Dr. Kandel believes one important value of recognizing that these types of experiences are brain diseases is that it helps minimize the shame often associated with them. For example, Dr. Kandel is quoted as saying, “Schizophrenia is a disease like pneumonia. Seeing it as a brain disorder destigmatizes it immediately.”
Dr. Kandel’s credentials are pretty impressive–he’s a Nobel Prize laureate and professor of brain science at Columbia University. Therefore, if you are among those who believe a person’s credentials should determine who is right and who is wrong, you need not read any further. You must simply conclude that what is referred to as mental illnesses are indeed brain diseases because you would be hard pressed to find someone with better credentials disagreeing with Dr. Kandel.
However, if you are among those of us who believe that regardless of someone’s credentials, the reasonableness of the argument should sway your judgments, then I encourage you to read on. In brief, you will find that the phrase, “disorders of mental functioning” is way too vague for a science of disease, and that Dr. Kandel’s conclusion that seeing these types of experiences as brain diseases immediately destigmatizes it, is at the very least, questionable.
Are Disorders of Mental Functioning Properly Viewed as Brain Diseases?
Colony of pathogen bacterias
Physical pathologists, who are trained in the principles of science, determine if a pathological condition is present by looking for a set of objectively observable body conditions such as tumors, microbe infections, tissue tears, bone fractures, and blocked arteries. None of these have been identified by pathologists as causing the conditions typically labelled by psychiatrists as mental illnesses. If they were to find the physical pathology that causes any of the behavior patterns referred to as mental illnesses, that pattern would no longer be referred to as a mental illness. Instead, the pattern would be viewed as the symptoms of the physical pathology, and the disease would be referred to either as the type of pathology (tumor, microbe infection, etc.) or the name of the person who discovered the relationship between the behavior pattern and the physical pathology.
Dr. Kandel, when trying to make the case that mental illnesses are real brain diseases has, at times, cited articles that show some correlation of a brain difference with some of the concerns that lead to a mental illness label. But these correlations are far too weak to demonstrate they are causing these types of concerns. For example, people labeled as having schizophrenia have, on average, some larger brain ventricles. However, there are many people who have the same size ventricles, or even larger ones, who show no signs of schizophrenia. Moreover, numerous people who have smaller than average size ventricles are regularly classified as having schizophrenia. Thus, quite clearly, it is not the size of the ventricles that are causing the schizophrenic behavior pattern. It is for this reason that the size of one’s brain ventricles is not used to make the so called diagnosis of schizophrenia. Instead, doctors rely on a conversation with the designated patient to make these types of so called diagnoses.
Are such conversations properly viewed as objective criteria for determining a disease state and equivalent to observing the type of pathologies that physical pathologists look for in identifying a disease state? Numerous critics of psychiatry say no. They point to what highly credentialed doctors have, over the course of history, claimed are mental illnesses.
Dr. Samuel Cartwright
For example, in 1851 American physician Samuel A. Cartwright labelled black slaves who tried to flee captivity as having the mental illness of drapetomania. For people who hold the value judgment that the function of healthy blacks is to be slaves, then it certainly makes sense to say that blacks seeking to flee captivity were being dysfunctional.
Freud Practicing the Dysfunctional Habit of Smoking
If you are religious, many highly credentialed medical doctors, including Sigmund Freud, who, like Dr. Kandel, won a Nobel Prize, have claimed this meant you had a mental illness. People who are gay were declared as having a mental disease here in the US. In the former Soviet Union, if you were opposed to communism it warranted a mental illness label by their psychiatrists. In each of these societies, a case was made that the behavior pattern labelled as a mental illness was dysfunctional.
The argument that such labeling practices are not scientific, but, rather, value judgments, was intelligently made by William James when he defended the religious sentiment. He explained that pathologizing these sentiments as mental diseases was superficial medical talk. He called the reasoning doctors used to declare religious beliefs a type of mental illness, “medical materialism.”
Medical materialism seems indeed a good appellation for the too simple-minded system of thought which we are considering. Medical materialism finishes up Saint Paul by calling his vision on the road to Damascus a discharging lesion of the occipital cortex, he being an epileptic.
Woman of Religious Faith
It snuffs out Saint Teresa as an hysteric, Saint Francis of Assisi as an hereditary degenerate. George Fox’s discontent with the shams of his age, and his pining for spiritual veracity, it treats as a symptom of a disordered colon. Carlyle’s organ-tones of misery it accounts for by a gastro-duodenal catarrh. All such mental overtensions, it says, are, when you come to the bottom of the matter, mere affairs of diathesis (auto-intoxications most probably), due to the perverted action of various glands which physiology will yet discover.
James goes on from here to point out that it is true, of course, that psychology has found that there are definite psychophysical connections that “hold good.” Psychology, therefore:
assumes as a convenient hypothesis that the dependence of mental states on bodily conditions must be thoroughgoing and complete. If we adopt the assumption, then of course what medical materialism insists on must be true in a general way, if not every detail…. But now, I ask you, how can such an existential account of facts of mental history decide in one way or another on their spiritual significance? According to the general postulate of psychology just referred to, there is not a single one of our states of mind, high or low, healthy or morbid, that has not some organic process as its condition. Scientific theories are organically conditioned just as much as religious emotions are; and if we only knew the facts intimatelyenough, we should doubtless see “the liver” determining the dicta of the sturdy atheist as decisively as it does those of the Methodist under conviction anxious about his soul. When it alters one way the blood that percolates it, we get the Methodist, when in another way, we get the atheist form of mind. So of all our raptures and our drynesses, our longings and pantings, our questions and beliefs. They are equally organically founded, be they religious or of non-religious content.
James points out that in the natural sciences it never occurs to anyone to refute opinions by putting down their authors’ neurological constitutions. Value is determined by “judgments based on our own immediate feelings primarily; and secondarily on what we can ascertain of their experiential relations to our moral needs and to the rest of what we hold as true.”
All states of mind are related in extremely complex ways to neural functions. There is a crucial distinction to be made between a brain difference and a brain pathology. The significance of each state of mind must be tested, not by some neurological difference, but by the value of its fruits. When the term “pathological” is applied to an experience, rather than an identified physiological pathology, it wrongly implies a neutral science classification.
In my view, what William James says about the religious sentiment and disease states hold just as true for people who are currently declared as having a mental illness by Dr. Kandel and many other doctors. They declare, in a very subjective manner, patterns of behavior are due to a brain disease without objective proof that there is a physical pathological condition causing the pattern. They don’t make a distinction between a brain difference and a brain disease. And they don’t deal effectively with the fact that there are numerous people who display patterns that have been viewed by the psychopathologizing doctors who have brought forth some of the greatest fruits known to the human race.
Calling Mental Illness a Brain Disease: Does It Stop Stigma?
In the above Aldous Huxley quote, apparently it was his opinion that all the normal people in our society are dysfunctional, and thus psychiatry might want to declare all normal people as having a brain disease. I wonder if all normal people might feel less stigmatized upon hearing about this pathologizing of their experiences. Hmmm.
Anyway, if you will, let us turn to Dr. Kandel’s declaration that by getting people to see that mental illnesses are brain diseases it destigmatizes them immediately. He offered no scientific evidence for this. When we actually look at the evidence bearing on his statement, we get a very different impression.
Lincoln, sufferer of depression
Very modest evidence exists indicating people who have become convinced that mental illnesses are brain diseases are somewhat less likely to blame labeled persons for their behavior. However, at the same time, overall stigma actually increases. Biological explanations, for many, imply that people with mental illness are fundamentally different or less human.
Research has also shown, that disease explanations for mental illness provoked harsher behavior toward labeled persons. It is worthwhile keeping in mind that in the not-so-distant past, biological and genetic explanations for stigmatized conditions were linked to a range of harsh policies, including marriage restrictions, sterilization, lobotomies, and even extermination.
Painter who has been said to suffer from mental illness
The biological explanation may also exacerbate yet another key stereotype of mental illness, the belief that people with mental illness are dangerous. Many researchers believe that the stereotype that people with mental illness are violent ranks among the most prejudicial and discriminating of attitudes. Unfortunately, there is evidence that biological arguments may actually strengthen dangerousness stereotypes, suggesting that people with mental illness have no control over their behavior and therefore are unpredictable and violent.
In contrast to biological arguments, psychosocial explanations of mental health concerns have been found to effectively improve images of people who are now being labeled as having a mental illness. It also appears to reduce fear.
Instead of arguing that mental illness is like any other medical illness, psychosocial explanations of mental health concerns focus on environmental stressors and trauma as causal factors. These may include childhood abuse, poverty, and job stress. The idea is to reframe mental health concerns as understandable reactions to life events.
Conclusion
Socrates heard voices in his head that he referred to as guiding demons and was condemned to death by society leaders.
The mental health concerns that most modern day doctors refer to as mental illnesses, have not been shown to be caused by a physiological pathological condition. There are undoubtedly some brain differences that have been correlated with a few types of concerns, but it is way too simplistic to say that such differences are the cause of any of these concerns. It is very possible that environmental and cultural factors may lead to the observed correlations. Despite the fact that a person might be said by some that he or she is functioning below average in some ways under some societal situation, numerous examples can be easily provided that people labeled mentally ill have often produced valued fruits in the fields of science, arts, and philosophy. Finally, labeling someone experiencing a mental health concern as having a brain disease does not automatically decrease stigma, and could actually increase it.
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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.
Today, if your behavior, thoughts, or feelings begin to concern you or a family member, for a fee many doctors will translate your experiences into mental illness terminology. Synonyms for mental illness, are mental disease, mental sickness, mental disorder, and psychopathology. These terms, as metaphors for experiences someone doesn’t like, have been with us for centuries. When used in this way, it can communicate something about an experience that others relate to. However, when we move from using these types of concepts as metaphors to believing wholeheartedly that they are proper scientific terms, we begin to lose the respect of those well grounded in the principles of science.
Illness and its Synonyms as Metaphor
Let’s consider The Tragedy of Hamlet, Prince of Denmark, which William Shakespeare wrote in about 1604. This play offers its audience a magnificent tale of adultery, fratricide, revenge, and feigned madness by a protagonist. When reading Hamlet, we see how Shakespeare uses metaphors to vividly evoke in us the experiences of his characters. Thus, when Hamlet becomes dissatisfied that his mind keeps identifying flaws in his plans for action, he describes these plans as becoming “all sicklied o’er with pale cast of thought.” By extension, the reader senses that when Hamlet’s plans become “all sicklied o’er,” he, too, becomes in a sense, “sicklied o’er” with feelings of frustration, anguish, and helplessness.
Literature regularly uses this type of metaphor. Ralph Waldo Emerson, to take another example, once wrote:
Our young people are diseased with the theological problems of original sin, origin of evil, predestination, and the like. These never presented a practical difficulty to any man–never darkened across any man’s road, who did not go out of his way to seek them. These are the soul’s mumps, and measles, and whooping coughs.
I actually like Emerson’s disease terminology here because the context in which he uses it so obviously reveals that he is using it metaphorically. Notice how he cleverly uses diseases associated with childhood to evoke the feeling that individuals who worry themselves over problems of original sin and so on are acting, in his view, childishly. In this context, disease, to Emerson, was a metaphor for immaturity. If he were a man of science, in contrast to a literary personality, we would expect that he would use terms with clearly defined, objective meaning, that avoid value judgements.
In the science of physiological pathology, a pathologist identifying a tumor is not making a value judgement. The tumor can be seen, measured in size, and its cells observed and described objectively. When pathologists look at a sample of blood to see if a person has a microbe infection, the microbes can be described objectively, and the number present in the blood sample can be counted in a clear, precise manner.
Psychology as a Science
In the late 1800s, William James decided to begin a lengthy project of treating psychology as a science, hoping this would lead to new insights about how the mind works. A few years into this project, he published his Principles of Psychology. There, he laid out his scientific aims, and then he described the sources of error in a scientific psychology, the very first of which “arises from the misleading influence of speech.”
At the time, medical writers were already heavily pathologizing a great number of experiences. Thus, James cited W. Griesinger, the author of The Pathology and Therapy of Psychological Illnesses, and T. S. Clouston, author of Clinical Lectures on Mental Diseases. As James delved further and further into the experiences being pathologized in this way, he came to believe such terminology was “simple minded” and “superficial medical talk.”
The terms pathology, disorder, disease, and illness, when applied to the types of experiences that get classified as mental illnesses by the psychopathologizers of today, often are meant to suggest suffering, dysfunction, and abnormality. Let’s take a look to see why using pathologizing terms in this way is really way too imprecise for scientific purposes.
Suffering
Does it make sense to say that when people are suffering, they have a “mental disorder?” Well, consider the experience of giving birth. It is typically accompanied by suffering, and yet it makes more sense to classify this experience as a natural part of creating new life rather than a pathological condition.
When writers receive rejections from publishers, or a loved one dies, suffering often accompanies these experiences. Yet, we do not typically describe them with pathological terms.
In the Buddhist teachings, the first of the four noble truths is that pretty much all of us will be experiencing suffering as we go through our lives. It has been theorized that in some extremely rare persons a state may be reached at which there is no more suffering, but that is far from the norm.
How much suffering, beyond the “normal” amount that one experiences during life’s parade of disappointments, is required to ascribe a diagnosis of some mental disorder? That is left to the subjective view of the pathologizers, rather than by employing sound principles of science.
There are science minded individuals who have been working on the task of providing objective measures of suffering for decades. Such people have used principles of science to measure short term and long term stress within an individual. For example, cortisol levels in saliva and heart rate variability has some connection with a person’s self-reports of how much stress they have experienced in recent days, while hair cortisol levels have some connection with longer term exposure to stressful experience. Other measures of stress utilize a list of stressors, such as the recent death of a loved one, living in poverty, etc. The person being assessed places a check mark next to each of the stressors on the list that applies to him or her. These check marks are then used to calculate how much stress the person has been experiencing.
Such measures, which are normed on large samples of people that are somewhat representative of the general population, can give us some objective estimate of someone’s level of suffering. But make no mistake, these types of scientific measures of the constructs of suffering are almost never used by the psychopathologizers. In today’s world, if you are a licensed mental health professional, you typically must declare that a person has a mental disorder to permit the person to access mental health services, and this must be done in one visit typically lasting less than an hour using the professional’s subjective judgement.
Dysfunction
Having indicated some of the problems of unambiguously, and non-subjectively applying the descriptors of suffering to the concept of mental disorder, we now turn our attention to the descriptor, “dysfunction.” As with the notion of suffering, the pathologizers almost never use the various scientifically validated measures of functioning to determine if someone has a mental disorder. A pretty good such measure is the Scales of Independent Behavior-Revised. It has norms for functioning in such areas as social interaction (communication skills, language comprehension, language expression), personal living skills (eating and meal preparation, toileting, dressing, personal self-care, domestic skills), community living skills (time and punctuality, money and value, work skills), and gross and fine motor skills. Rather than using measures of this type, pathologizers rely on their professional privilege to make a subjective estimate of dysfunction.
Abnormality
In the most current edition of the DSM, someone who is experiencing abnormal levels of distress might be considered to have a mental disorder. But the issue of the boundary between normal and abnormal experiences lies at the heart of the most contentious disputes in the field of psychopathology today. A major problem with using the term abnormal as one of the defining attributes of mental illness is that it leads us to forget the fact that natural to all organisms is substantial variability across individuals and within individuals. Having above average or below average functioning in various areas of our many areas of functioning is normal. Displaying rare behavior patterns that are highly valued, such as the great altruism of Mother Teresa, are not viewed as mental disorders. Psychopathology is applied when someone does not like a particular experience. Thus, a term that masquerades as a scientific term is really a value judgment masquerading as a scientific term.
Conclusion
Although there are some fairly well developed scientific measures of the three major factors (suffering, functioning, and abnormality) that the psychopatholgizers tend to claim are usually part of the mental illness experience, these measures are almost never used in their “diagnostic” determination. Instead, subjective indicators of these three factors are combined into an even more subjective abstraction called “mental illness.” This process is not scientific despite claims to the contrary.
Rather than a scientific concept, the mental illness concept has been very useful as part of a highly lucrative business plan for the pharmaceutical industry and medical doctors, which includes psychiatrists. This plan has doctors first convincing people that the experiences referred to as mental illnesses are scientifically real illnesses just like physiological pathologies. It then provides license for doctors, in as little as fifteen minutes, to declare that they have provided their patients a diagnosis, and to send them on their way with a prescription for pills. With this plan, billions of dollars flow their way.
It is my sincere hope that this post will lead to more people understanding what is going on here. It is also crucially important that more and more people come to understand that there is an alternative to the mental illness labeling process that would be easy to develop–one based on a “mental health concern” construct (see HERE for a more complete discussion of this alternative). A mental health concern approach would not only be more scientific, but also jargon free and less stigmatizing. Moreover, the research that it would generate would lead to dramatically improved services for people struggling with anguish, sadness, and tears.
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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.
Welcome to “From Insults to Respect.” Regular readers know that I have some serious objections to how mental health service providers treat those seeking their services. As things stand now, unless you can afford to completely pay for such services without any insurance coverage, to access services you are very likely to be required to be labelled as having a mental disorder.
Now, many mental health professionals and service users are fine with this labelling requirement, and for those who are, I’m not seeking to do anything to interfere with them going about this practice to their hearts content. But there are many other mental health professionals who would much prefer to treat each person seeking their services as an individual, and one of the last things they desire is to label people with a “so called” diagnosis well known to be stigmatizing. At the same time, many who seek mental health services, when hearing about the requirement that they be labelled as having a mental illness, object to this, and discover that despite having paid their insurance premiums that cover such services for decades, cannot access these services without accepting this stipulation.
Last year, the American Psychological Association Convention was held in Toronto, and I was invited to present a paper on a proposal that would solve this problem for mental health professionals and those seeking services. I was invited back again this year to speak on this topic for this year’s APA Convention, which was held in Denver last week. A couple of months ago, I provided a summary of what I was planning to say. I now provide to you the full text of my entire speech.
My 2016 APA Speech
As most of you surely know, the DSM and ICD are pretty much the same approach for classifying people who seek mental health services. Mental disorder is the overarching theoretical construct for both, and both share the same coding system used by third party payers. Supporters of the DSM and ICD approach say that it is a classification system that has been helpful because it provides a common language for mental health professionals to communicate about those utilizing their services; its various diagnostic terms, such as Major Depressive Disorder, Anxiety Disorder, etc., are short phrases that are convenient for placing them into search engines to retrieve valued relevant information, and into titles of book and articles; third party payers of mental health services have found that the DSM-ICD coding system works well as part of a practical method for their record keeping; with the aid of these codes, people do manage to access mental health services, mental health service providers do manage to get paid, and for-profit health companies do tend to make a profit.
So, those are the basic reasons supporters of this approach say that it is useful.
Now, it seems to me that if we are to have any hope that an alternative to this approach might be widely adopted, we would have to be able to make an excellent case that the alternative would be at least just as helpful while, at the same time, have significantly less shortcomings.
So, is it really possible to come up with such an alternative? Well, for your consideration, I offer you the Classification and Statistical Manual of Mental Health Concerns, or, for short, the CSM. Not the DSM, but the CSM! Let’s look at what each chapter of the CSM would contain.
Chapter 1: The CSM Basics
This first chapter would begin with the following statement: “The developers of the CSM fully recognize that persons seeking mental health services have far more expertise about what is going on in their lives than any mental health service provider. Moreover, the developers of the CSM fully recognize that individuality outruns any classification system. It is for this reason that the CSM does not seek to classify anyone. Instead, it classifies the expressed concerns of individuals seeking to have their concerns addressed by a mental health service provider.”
This first chapter would go on from here to explain that the CSM begins from the perspective of the person seeking services. Because the expression of a mental health concern is a clearly observable event that occurs at a specific time and place, by making it the event being classified in the CSM it solves the reliability problems that have been plaguing the DSM and ICD approach’s far more abstract theoretical construct of “mental disorders.”
After this statement, the CSM would clearly define its main construct, which is mental health concerns:
A mental health concern occurs when a person seeking mental health services expresses to a mental health service provider a concern about any of these topics: behavior, emotion, mood, addictions, meaning of life, death, dying, managing chronic pain, work, interpersonal relationships, intrapersonal relationships, education, eating, cognition, sleep, and challenging life situation.
So, there’s a summary of the basic ingredients of Chapter 1.
Chapter 2: Classification of Mental Health Concerns and Codes
This chapter would begin by explaining that the CSM has two classes of expressed concerns–Concerns expressed about oneself, and concerns expressed about someone else.
An example of the first class is, Sally is seeking mental health services and expresses a concern to a mental health service provider that she has been experiencing a great deal of anxiety when she enters social situations.
An example of the second class is Bob, a father, upon seeking counseling for his son, expresses a concern about his son’s behavior.
Each of these two classes of concerns would have under each of its headings a list of specific concerns, along with an assigned code to be used for third-party payer record keeping.
So, let’s quickly return to the example of Sally expressing a concern that she has been experiencing a great deal of anxiety in social situations. This would be referred to, for classification purposes, as a “social situation anxiety” concern. Notice that “social situation anxiety” is just three words, thus it is short enough to be used in titles and search engines.
Concerns that would be included in the first edition of the CSM would be selected from survey data. For example, mental health service providers would be asked to list the various concerns that they have been asked to address in their practice in the past year without couching them in psychopathological language and to stick as closely as possible to the language used by those seeking their services.
Chapter 3: The CSM Approach to Psychological Formulation
As noted, the previous chapter would be designed to provide the method for identifying and coding a set of brief mental health concern descriptors suitable for a number of practical purposes. Once this is achieved the CSM then provides a method to develop a two or three paragraph psychological formulation approach that is designed to fill in additional details about the expressed concern.
Thus, Chapter 3 of the CSM would be devoted to describing good practice guidelines for the use of a type of psychological formulation that is consistent with the CSM’s philosophy of not psychopathologizing individuals.
Defending the CSM
Okay, those are the basic chapters of the CSM. I contend that it would achieve all of the benefits that the supporters of the DSM-ICD approach claim for it. It would provide a common language. And, in fact, I actually tested the CSM approach for years. When I worked in a mental health center, although I capitulated to the requirement that I inserted a DSM diagnosis in its proper place on the insurance form, other than that, I had no need to use DSM terms to communicate. When a colleague would ask me to tell him or her about my cases, I would reply with words like, “My 9:00 a.m. case is concerned about feeling depressed, my 10:00 case is concerned about his failing grades, my 11:00 case is concerned about how anxious she is in social situations. If a colleague wanted to know more about a case, we went into the psychological formulation type of information. I found that communication flowed easily and my colleagues readily understood me.
So, I contend that the CSM would provide an easy to learn, non-pretentious, dogma free, common language. Additionally, it would provide a practical approach for third party payers’ record keeping. Let me explain clearly how easy and simple this could work.
Third party payer systems have a form that must be filled out whenever someone seeks mental health services under their plan. This form has a little box that currently typically says, “Diagnosis.” In that box, mental health professionals are required to fill in the DSM or ICD code that corresponds to their so-called diagnosis of the person seeking services.
With the CSM proposal, all that we would be asking third-party payer institutions to do differently in order to add value for their customers, is to slightly change that little box. Instead of just saying “Diagnosis” as it currently says, that box would end up saying, “Diagnosis or Concern.” Then, when mental health professionals fill in the box, they would be given the choice to either write in the letter “D,” thus indicating a diagnosis code will be entered into the box, or they would write the letter “C” thus indicating a concern code will be entered into the box. Once the letter “D” or “C” is written into the box, the appropriate code number would be entered.
With the creation of the CSM, not only will mental health providers have a new option to choose from, but so too will people seeking mental health services. They would be given the choice to go to psychopathologizing mental health service providers or to those using the CSM approach.
So, we would of course have to convince third party payers to make just this small change on their insurance form in order to increase value for a significant number of mental health providers and service users. The rest of their form would remain exactly the same.
In making the case to insurance companies, and others as well, that this choice would be beneficial, we could point to a March, 2008 research article titled, “The Effects of Choice on Intrinsic Motivation and Related Outcomes: A Meta-analysis of Research Findings.” Published in Psychological Bulletin, here we find that 41 studies were examined for the effect of choice on a variety of outcomes in a variety of settings. Results indicate that providing choice enhances intrinsic motivation, effort, task performance, and perceived competence, among other positive outcomes. There are a few studies out there that suggest that if you provide an enormous amount of bewildering options to a targeted population, the typical positive effects begin to diminish, but keep in mind that the CSM proposes just one additional option for mental health professionals and service users.
Here’s another benefit of the CSM approach in contrast to the DSM-ICD approach. The DSM-ICD approach, by using the “mental disorder” construct, simplistically devalues all of the experiences it refers to as mental disorders, providing a cognitive set that they are “bad” experiences. It does so despite the fact that there are a great number of people who have testified that having gone through these very types of experiences it brought forth valued fruits. With the CSM approach, we instead begin by addressing someone’s “concern.” Thus, there is no automatic need to assume that the experience that led to the concern is necessarily bad. Together with the mental health service provider, service users may come to understand that these experiences are part of a useful process; they may be a different than an average process with strengths and weaknesses. Though perhaps not bad, there may be a better approach to be discovered, etc. The DSM-ICD approach that pathologizes these types of experiences tend to close people to such possibilities. The CSM approach opens up these possibilities.
Conclusion
Now my time is almost up, so in closing, I’ll leave you with this; The CSM can do everything that the DSM-ICD approach can do with regards to providing a common language for mental health professionals to communicate about those utilizing their services, providing short phrases convenient for placing into search engines and titles, and providing a practical method for third party payer record keeping. Additionally, when compared to the DSM and ICD approach, the CSM approach would be less stigmatizing, as well as more scientific, person-centered, culturally sensitive and recovery-oriented. Therefore, it is my sincere hope that in the name of justice, we psychologist can fire-up the will to break out of the monopolistic DSM-ICD approach. I’m hoping we can fire up the will to make a real change by having us psychologists roll up our sleeves and then getting down to do the necessary work simply because we believe this is in the best interest of those we seek to help.
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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 and social intelligence. To begin at the very first post you can click HERE.
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.”
The 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:
Here 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.
More specifically, my proposal, which was published in a peer reviewed journal (see HERE) 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.
I 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
William 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.
This 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.
“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. Once 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
Let 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
The 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. The 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
The 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.
Some 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
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.
Similarly, 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.
This 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
Okay, 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.
Some people find that their actions are violating certain societal norms and feel guilty and ashamed about this. When they try to stop doing these actions, they may find they can’t just stop, and thus they end up feeling even more guilty and ashamed.
Some parents, when they see their offspring act in ways that violate certain societal norms, find that they feel guilty and embarrassed. These parents believe that they are to blame for the actions of their children, and they also feel ashamed because they believe others believe they are “bad” parents.
The idea that certain actions that violate societal norms are mental illnesses like any other illnesses is attractive to many people because they believe it helps to reduce this guilt and shame. To understand this a little better, let’s take a look at a quick parable:
The Parable of Rachel
Rachel, the mother of five-year old Jonathan, recently went through a very sad divorce. Now, at Jonathan’s parent-teacher conference, his Kindergarten teacher expresses some serious concerns. “Your son is very hyperactive and he has a great deal of difficulty paying attention. Have you considered taking him to a doctor? He may have ADHD.”
Upon leaving the meeting, Rachel begins to cry. “I feel so ashamed,” she thinks to herself. “It’s all my fault. I shouldn’t have been so critical of Ron (her former husband). That’s why he left me for a younger woman. Jonathan has been so upset since Ron left, and he blames me for the breakup. And it is all my fault! I’m a rotten mother.”
Later, Rachel takes Jonathan to a doctor who, after asking a few questions, states that he has diagnosed Jonathan as having ADHD and prescribes Ritalin.
“I’m so ashamed,” cries Rachel.
“There is no need to blame yourself,” the doctor explains. “ADHD isn’t caused by bad mothering. It is an illness very much like diabetes. Just like insulin is a drug that treats diabetes, the drug I’m prescribing for your son’s ADHD will treat his medical condition.”
As Rachel leaves the doctor’s office she feels a little less to blame. But when she tells her father what the doctor has said, he grumbles and says that the doctor is full of crap. “Jonathan is angry and upset because of the divorce and not having his father with him any more. Anyone can see that!”
“You think you know better than a doctor!” cries Rachel.
Her father waves his hand in disgust, but says nothing more. Rachel interprets his silence as meaning that she won the argument, but her father is not at all convinced.
Later, Rachel discusses what has been happening with her closest friend, Lora. “I felt so ashamed about how Jonathan has been acting at school, but the doctor explained that I’m not to blame, that Jonathan has ADHD, which is an illness.”
“Well, Rachel, I certainly don’t think you are to blame, but I don’t think Jonathan has an illness. I’m sorry to hear you are thinking about putting him on one of those ADHD drugs; they have a whole bunch of side effects.”
“If it’s not an illness, then I am to blame!” Tears start to roll down Rachel’s face. “I shouldn’t have criticized Ron so much. I should have been a better wife!”
“You did your best, Rachel. I think it makes sense that you take some responsibility for what has happened, but blaming yourself isn’t being fair, nor is it helpful. When people blame themselves a lot of the time they think they deserve some type of punishment. In my opinion, a better way to take responsibility for what went wrong is to accept the strong emotional experiences that go along with taking responsibility, accept that you played at least a part in what went wrong, and then set yourself on becoming determined to take steps to improve. The genuine sad, heartfelt feelings that come with taking responsibility leads us to do a search for making improvements.”
Does The “Mental Illness” Construct Help To Reduce Shame and Guilt
In the above parable, a doctor tries to reduce the shame and guilt that a mother is feeling about her son’s behavior by framing the behavior as an illness. Although this initially appears to help, she runs into some people who refuse to go along with this anti-shame/mental illness notion. Let’s explore this notion a little more thoroughly with the help of some of the writings of psychologist and philosopher, William James.
William James’s Letter to his brother, Henry James
In an earlier post, I discussed William James’s bout with a depression that many might refer to as a type of “mental illness.” There, we found that he came to believe he succeeded in overcoming his struggle with the help of his own will and effort, although he also recognized that as he went through the experience he received a great deal of support with the “will and effort” thinking from reading certain poets and philosophers.
Shortly after his recovery, James found that when he met other people who were struggling with their own bouts of depression, if he brought up the topic of will and effort it was not at all well received. James explains this type of reaction to his brother, Henry, in the following 1885 letter:
To suggest personal will and effort to one “all sicklied o’er” with the sense of weakness, of helpless failure, and of fear, is to suggest the most horrible of things to him. What he craves is to be consoled in his very impotence, to feel the Powers of the Universe recognize and secure him, all passive and failing as he is.
Why would one believe that framing one’s difficulties as an illness would lead to the Powers of the Universe providing some type of help? Perhaps it stems from a related experience.
Anyone with even an ounce of maternal feeling is familiar with the altruistic emotions that spring up when a baby is stricken with an illness. Generalizing from such experiences might lead to the belief that an illness is especially worthy of altruism.
Although this may make sense to some, others just don’t buy the illness notion, and feel that it is an excuse to avoid responsibility. Thus, the “mental illness” construct comes with it some pluses and minuses.
From my discussions with people in Alcoholic Anonymous, it seems to me that many of its members found themselves in a state similar to what James describes in his letter. The program seems to provide them a way to stop blaming themselves by using the “I have a real sickness” idea. It also offers a sense that they could put themselves in the hands of a higher power, while, at the same time, they receive a great deal of support from peers who have managed to recover.
I think the real active ingredients in the program are the reduction of blame that is experienced by becoming a member of a group that stops the blaming rhetoric while also providing peer support to its members to work toward their common goal. However, for people who have a religious background, perhaps the additions of the “real illness” and “higher power” ingredients do offer some added benefits, but they come with negative reactions from those who believe in taking responsibility for one’s actions. Some of those who believe in responsibility think mainly that certain actions are “deserving of punishment.” In my view, it is much better if we come to understand responsibility as a strong emotion that spurs us on to actively pursue better ways to deal with the present and the future.
Now, to further our thinking of these issues, let’s turn our attention to something else that James wrote on this topic.
James’s Talk to Teachers
In James’s book titled Talk to Teachers he tells us, “The teacher often is confronted in the school with an abnormal type of will, which we may call the ‘balky will.’ He then explains what he means by this: “Certain children, if they do not succeed in doing a thing immediately, remain completely inhibited in regard to it.”
James then tells us that “Such children are usually treated as sinful, and are punished; or else the teacher pits his or her will against the child’s will, considering that the latter must be ‘broken.’
Clearly, James opposes this approach. “Such will breaking is always a scene with a great deal of nervous wear and tear on both sides, a bad state of feeling left behind it and the victory not always with the would-be will-breaker.”
In his next paragraph, which I quote in its entirety, the theory that pathology as a concept is used by James to protect individuals can be seen rather clearly.
When a situation of the kind is once fairly developed, and the child is all tense and excited inwardly, nineteen times out of twenty it is best for the teacher to apperceive the case as one of neural pathology rather than as one of moral culpability. So long as the inhibiting sense of impossibilityremains in the child’s mind, he will continue unable to get beyond the obstacle. The aim of the teacher should then be to make him simply to forget. Drop the subject for the time, divert the mind to something else: then, leading the pupil back by some circuitous line of association, spring iton him again before he has time to recognize it, and as likely as not he will go over it now without any difficulty. It is in no other way that we overcome balkiness in a horse: we divert his attention, do something to his nose or ear, lead him around in a circle, and thus get him over a place where flogging would only have made him more invincible.
Note that James doesn’t say that the child actually has a neural pathology, only that it would be helpful for the teacher to apperceive the child as having this condition. By apperceiving the case as neural pathology, what does James hope to gain? He does not explicitly say. The technique that he describes of dropping the subject, diverting the mind, then springing it on the pupil later, is stated plainly enough so that many individuals can employ it without first apperceiving the case as neural pathology. I have done so, myself, on numerous occasions.
James appears to feel that some individuals who are prone to apperceive the case as one of moral culpability are likely to use will-breaking and flogging. If, instead, they can apperceive the case as neural pathology, it would be easier to use the technique that leads to a good state of feeling.
Viewing someone as “sick” can elicit altruistic behavior for some people. Feelings of caring, as if for a child with an illness, are conjured up. Such a chain of reactions is more commensurate with James’s circuitous technique than the clashing-wills technique.
Here again, we are faced with the dilemma–whether it is wiser to use the “mental illness” construct to promote caring, which may short circuit the habit of blaming someone in the sense of seeking to punish someone, or is it wiser to promote notions of responsibility that leaves out the desire to punish, while constructively seeking to make personal improvements? Today, I leave this dilemma in the hands of my readers.
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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 and social intelligence. To begin at the very first post you can click HERE.
“Good morning, Barbara,” I say, as my first counseling case walks into my office. I notice she looks a little angry. Upon sitting down, she declares, “I’m terribly frustrated. I’ve been depressed now for over two weeks, and I just can’t shake it!”
It’s easy for me to empathize because I regularly have bouts of what I refer to as melancholy. A deep anguish comes over me, and during this period I often begin to think about how I went through my father’s death when I was twelve, how I’m getting older and can no longer do the many athletic things that thrilled me when I was younger, and on and on. Sometimes these dark melancholy experiences come about because something clearly happened that upset me, and sometimes they seem to come out of the blue.
Beyond Listening in a Caring Manner
After listening in a caring way to Barbara for a few minutes, I ask her if something specifically happened that led her into her current emotional experience. Then I explore with her a question about how often she has these experiences and if she feels she has them more frequently than most people, about as often as most, or less than most. Then, I ask her about how she has been functioning in other areas of her life–sleep, eating, exercise, interpersonal relationships, work/school, household responsibilities.
You see, as people experience depression, or other concerns that often lead to a classification of having a mental disorder, some people go about their lives functioning as they typically were doing before the concern arose, while some find that in some areas they begin to function below the levels that are typical for them, while some find that their functioning increases in one or more areas. For example, some sleep about the same amount, some less, and some more. I have met people who, when they are depressed, start cleaning every inch of their home, while others find it difficult to get out of bed.
Also of interest when exploring a person’s expressed concern is to look at how the person had been functioning before the onset of the presenting concern. If some important relationships had begun to function below average, or if the person had been sleeping less than average to keep up with work demands, these facts can be insightful when seeking ways to address the presenting concern.
Now, once I found out what Barbara was concerned about, what might have precipitated the concern, and how she had been functioning in various areas of her life, I had a pretty good idea as to how to proceed in addressing her concern. I had no need to decide whether or not she had a mental disorder. However, many mental health practitioners are required to declare that the person seeking mental health services has a mental disorder if they want to get paid. Is this mental illness labeling really necessary?
Mental Illness Labeling Versus an Addressing Concern Approach
There are those who embrace this mental illness/disorder labeling. One reason is the pharmaceutical industry’s promotion of this idea to sell people on the idea that they need certain drugs to live a more normal, healthier life.
Beyond that, another major reason for this is that these individuals have a group of people in their lives that blame them for the way that they have been feeling or acting. When a doctor has declared, for example, that John Smith has a mental disorder, he may feel vindicated. “You see, there really is something wrong with me!” he may cry out in his defense.
In actuality, those who are doing the blaming may continue their blaming despite the doctor’s opinion. Moreover, many of us don’t blame people whenever they find some concern has arisen in their lives even if they are going through a non-illness experience. I know I’m not blaming myself when I experience melancholy, and I was not at all blaming Barbara for what she was going through.
Those who are uncomfortable about the use of “mental illness” terminology point out they are stigmatizing because they are used as put downs in our society. Moreover, the media associates the most heinous crimes with those referred to as the mentally ill even though the vast majority of those classified in this manner are not violent.
Among the most articulate individuals to voice objections to the mental disorder labeling was Harvard psychologist and philosopher William James. Over one hundred years ago he wrote a book titled, The Varieties of Religious Experience (1902). At that time many medical doctors argued that people who were religious were all mentally ill. In response, Professor James wrote:
Medical materialism seems indeed a good appellation for the too simple-mindedsystem of thought which we are considering. Medical materialism finishesup Saint Paul by calling his vision on the road to Damascus a discharginglesion of the occipital cortex, he being an epileptic.
Girl (6-8) praying, profile, close-up
It snuffs out Saint Teresa as an hysteric, Saint Francis of Assisi as an hereditary degenerate.George Fox’s discontent with the shams of his age, and his pining for spiritualveracity, it treats as a symptom of a disordered colon. Carlyle’s organ-tonesof misery it accounts for by a gastro-duodenal catarrh. All such mentalovertensions, it says, are, when you come to the bottom of the matter,mere affairs of diathesis (auto-intoxications most probably), due to theperverted action of various glands which physiology will yet discover.(p. 29)
James goes on from here to point out that it is true, of course, that psychology has found that there are definite psycho-physical connections that “hold good” (p. 30). Psychology, therefore:
assumes as a convenient hypothesis that the dependence of mental stateson bodily conditions must be thoroughgoing and complete. If we adopt theassumption, then of course what medical materialism insists on must betrue in a general way, if not every detail…. But now, I ask you, howcan such an existential account of facts of mental history decide in oneway or another on their spiritual significance? According to the generalpostulate of psychology just referred to, there is not a single one ofour states of mind, high or low, healthy or morbid, that has not some organic process as its condition. Scientific theories are organically conditionedjust as much as religious emotions are; and if we only knew the facts intimatelyenough, we should doubtless see “the liver” determining the dicta of thesturdy atheist as decisively as it does those of the Methodist under convictionanxious about his soul. When it alters one way the blood that percolatesit, we get the Methodist, when in another way, we get the atheist formof mind. So of all our raptures and our drynesses, our longings and pantings,our questions and beliefs. They are equally organically founded, be theyreligious or of non-religious content. (p. 30)
James points out that in the natural sciences and the arts it never occurs to anyone to refute opinions, beliefs and experiences by putting down their author’s neurological constitution. Value is determined by “judgments based on our own immediate feelings primarily; and secondarily on what we can ascertain of their experiential relations to our moral needs and to the rest of what we hold as true” (p. 33).
James was additionally concerned that medical materialism greatly overgeneralizes its knowledge of the connections between physiological variables and mind states. In James’s day, the pathology writers would take the few psychophysical correlations that they obtained under highly specialized conditions and then vaguely generalize their findings to discredit, to their satisfaction, all of the states of mind that they disliked.
The Modern Day View
Now, modern day psychiatrists sometimes respond,
“Well, certainly in James’s day we indeed knew almost nothing about such matters, but today our knowledge has vastly increased! Thus, James’s position is no longervalid because we can now make sound statements about the connections betweenphysiological states and mind states.”
To this, I respond that in point of fact there is currently a renewed respect for the extraordinary complexity
that exists during the integration process between mind, physiology, behavior, and environmental variables. Whereas it is true that there have been large gains in our knowledge, these gains are best likened to moving from a few drops of knowledge to a glass almost full; yet, to really understand the integration process, we would need oceans and oceans of knowledge. Trillions and trillions of interactions are involved.
It is for these reasons that the mental illness/disorder terminology is misleading. As Dr. Thomas Insel, the former director of the National Institute of Mental Health, recently said about the psychiatric labeling process known as the DSM.
The weakness [of the DSM] is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half-century as we have understood that symptoms alone rarely indicate the best choice of treatment.
To hear and view other leading scientists further make this point, I highly recommend the following free video:
When individuals express a concern, exploring how they are functioning in the main areas of their life can be enormously helpful. Someone who reports a concern about experiencing depression, whom, by some gentle questioning, we find out has been functioning below average in the areas of sleep, interpersonal relationships, and exercise may benefit enormously if we work together on getting these areas of functioning in a more optimal range. This is true for those who report other types of concerns such as experiencing anxiety, hearing voices, below average range of attention, obsessive thoughts, and on and on. With a model that includes addressing concerns and exploring ways to improve functioning, labeling someone as having a mental disorder becomes unnecessary and may actually interfere with the aims of a counseling/psychotheraputic relationship.
For those who desire, for whatever reason, to be labeled as having a mental disorder, I am not proposing that we interfere with this. But for those who desire to have their concerns addressed by well trained mental health professionals without being referred to as having a mental illness or disorder, I do propose that we do provide a reasonable option for them to access mental health services. In my view, mental health professionals, once we hear our clients’ concerns and how they are functioning in the various areas of their lives, we have the basics to formulate, in full cooperation with our clients, a plan for addressing these concerns. I hope you give this some thought.
For those of you who would like to learn more about how an addressing concern approach would work and be consistent with science if adopted by mental health providers, you can access my peer reviewed article for free by clicking HERE.
Until next week, may you find some kindness out there in this fascinating world of ours.
My Best,
Jeff
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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.
In recent weeks, I have been providing a series of blog posts on psychiatric name calling (see here, here, here, and here). In these posts, I have expressed some negative opinions about the Diagnostic and Statistical Manual of Mental Disorders (DSM).
The DSM provides the names for the various mental health concerns that mental health service providers are often required to use if they want to be paid for their services or if they want to have their research published in professional journals.The language of the DSM places its terminology under the umbrella concepts of “mental illness,” “mental disorder,” and “psychopathology.” In my blog series, I have argued that the pathologizing of human experiences in this way does far more harm than good.
As part of my discussions on this topic, I quoted the opinions of some who agreed, and some who disagreed, with my opinions. The quotes that I used were selected from my own personal readings. Therefore, they may not have been characteristic of how a wider range of different people may think and feel about the DSM approach to labeling the various mental health concerns.
A few years ago, two teams of researchers have sought to obtain a broader range of views on this topic by carrying out surveys. Jonathan D. Raskin and Michael C. Gayle surveyed psychologists who regularly use the DSM, and published their findings in the Journal of Humanistic Psychology (DSM-5: Do Psychologists Really Want an Alternative? 2015, pages 1-18). Lois Holzman and her team surveyed people in some New York City communities, and published her findings on the DxSummit.org website (A Report on Community Outreach: Lay Opinions on Emotional Distress and Diagnosis, http://dxsummit.org/archives/2249). Let’s take a look at their findings.
What the Psychologists Had to Say
Here’s a summary of the survey data by Jonathan D. Raskin and Michael C. Gayle:
Only two published studies, both from the early 1980s, have specifically examined psychologist attitudes toward the Diagnostic and Statistical Manual of Mental Disorders (DSM). The current article rectifies this by presenting the results of a recent survey of attitudes toward the DSM-IV-TR and DSM-5. Though the DSM has changed over the years, psychologist attitudes toward it have remained remarkably consistent. Although more than 90% of psychologists report using the DSM, they are dissatisfied with numerous aspects of it and support developing alternatives to it—something that psychologists over 30 years ago supported, as well. The finding that almost all psychologists use the DSM despite serious concerns about it raises ethical issues because professionals are ethically bound to only use instruments in which they are scientifically confident.
In the above summary, the number 5 after the letters DSM, refers to the fact that the DSM has undergone five major revisions. Since the 1980s, there have been three such revisions. Ideally, users of the DSM would see clear improvement for each revision.
When a survey was done in the early 1980s, psychologists were clearly skeptical of the DSM-2. As described by Raskin and Gayle,
More than 40% felt it (a) distorted clinician perceptions of clients, (b) applied medical labels to psychosocial problems, (c) was not reliable and valid, (d) emphasized diagnosis over treatment, (e) obscured individual differences, and (f) overemphasized pathology. Almost 60% were dissatisfied or somewhat dissatisfied with the DSM-2 with only 17% satisfied or somewhat satisfied.
When the DSM-3 came out in 1983, Smith and Kraft carried out an updated survey on this revision of the DSM-2. The findings indicated that psychologists at that time (a) preferred social–interpersonal diagnosis, nondiagnosis, and behavioral analysis over DSM-3—in that order; (b) felt that most conditions in DSM-3 were best seen as nonmedical problems in living; (c) believed too little had been done to develop scientific alternatives to the DSM; and (d) thought that client welfare and integrity would be better served by abandoning the medical model. Eighty-five percent disagreed that mental disorders are a subset of medical disorders.
In the latest survey that was carried out by Raskin and Gayle, 128 anonymous psychologists participated. Among the questions that were asked was, “How satisfied are you with the changes being proposed for DSM-5?” Their answers indicated that they were significantly more negative about it than neutral. The general attitude about the latest version of the DSM were very similar to what was found three decades ago, namely, that a significant number of psychologists are unhappy with the DSM.
What Community Folks Had to Say
In the community outreach survey of lay opinions on emotional distress and diagnosis carried out by Lois Holzman and her colleagues, people were asked questions at two annual NYC street fairs attended by millions of people. Conversations lasted from five to over ten minutes each. In all, 143 people participated in the survey in the first of these two surveys, which occurred in 2013. The second one had 149 people who participated, which occurred in 2014.
In the 2013 survey, the focus was on how psychiatric diagnosis affected kids. Forty percent felt that psychiatric diagnosis was not valuable. For the 60% that felt that psychiatric diagnoses can be valuable, 90% of them had reservations. That is, they said that it was only sometimes helpful, there was a danger of misdiagnosis, there was racism involved in diagnosis, and it leads to stigma and over-medication.
Ten percent were completely against diagnosis under any circumstance, some sharing their experiences pertaining to children. Examples of comments from this group follow:
“Medication makes you act out. My grandson was hyperactive, not ADHD and they wanted to put him on Ritalin – I told them no. Drugs at an early age can lead to hard core drugs later in life.”
“I worked with kids who had wrong diagnosis, and this is prevalent.”
“Kids get told in 1st grade they’re crazy—then it becomes a self-fulfilling prophecy.”
In the 2014 survey, the researchers:
“tried to go a little deeper and see if we could help people explore the apparent conflict around diagnosis, i.e., its value and its dangers. We also wanted to learn what they thought about the necessity and mandate of diagnosis.
We all know people who have gotten very depressed when they’ve lost a loved one, or children who cannot sit still in school, lots of folks who are angry and demoralized about not finding a job. Do you think any of these people need to get a diagnosis in order to get help with their emotional pain?
(IF THEY SAY YES, ASK THE NEXT 2 QUESTIONS):
Do we need to relate to them as having brain disorders? Or chemical imbalances?
Right now, in most settings, if you want to get help with ANY kind of emotional pain from a mental health professional, they are required to give you a diagnosis. Do you agree with that?
Are there other ways to support people emotionally? What do you think could help them?
Like me, you probably know people in your family, church, or at work who have serious emotional problems, who may have been diagnosed with major depression, bipolar or schizophrenia. Obviously people deserve and need top quality mental health care including access to medication. Do you think that even in these situations a diagnosis can limit the person, label them, and stigmatize them? If so, how?
From our past surveys we have found that people are conflicted about diagnosis and labels. They find it relieving to get a diagnosis and at the same time feel like the diagnosis can stigmatize or label them. Why do you think that so many of us are conflicted about this, feel it can be both helpful and harmful?
Here’s a brief summary of the finding, as described by Dr. Holzman:
Diagnosis Needed: 60% of respondents said no, people did not need a diagnosis to get help with their emotional pain. The majority of the 40% who said diagnosis was needed told us that that was the only way to get to talk to someone.
Only those who said yes, diagnosis was needed (40%), were asked the next two questions.
1a. Biological Basis: 89% of those who said diagnosis was needed said we shouldn’t consider such people as having a brain disorder or chemical imbalance.
1b. Diagnosis Required: 75% of those who said diagnosis was needed did not agree that it should be required.
Other Ways to Support (alternative types of treatment):
Everyone offered an alternative, with most people suggesting more than one. The most frequent responses involved talking to people—therapy, counseling, group therapy being the most common (including, “A center they can go to without getting diagnosed”), followed by family, friends, self-help and support groups.
A wide variety of social activities and life style changes were recommended—volunteering, hobbies, music, dance, writing, meditation, exercise, yoga, diet, prayer and creating community (“Have events that bring people out, like this fair”).
& 4. Concerns about Diagnosis: 90% (including those who thought it was needed) expressed concerns about the stigma of diagnosis, the dangers of misdiagnosis, and/or the over-medication that too often accompanies a diagnosis.
Once you have that label it doesn’t stay at the clinic. You carry it with you for a long time.
People start calling you crazy. It can be a shame for the family.
I had to fight to get counseling for my kid. They just wanted to give him drugs.
Getting a diagnosis limits life experience, you’re treated differently, you feel like an outcast.
It’s helpful to the clinic but not in everyday life.
It’s good to know what’s wrong, but it might make them feel worse about themselves and put them in a box.
It pigeon-holes people and the diagnosis becomes all that I am.
It stagnates them. It keeps them on one path with only one destination.
They think something’s wrong with them.
There is too much use of medication. It is a quick fix to avoid a real understanding.
Against it – children are still growing. Against medication.
So there you have it, some views other than mine about psychiatric name calling. In interpreting these findings, I think it’s important to bear in mind that the views of the people surveyed developed in the context of a multibillion dollar advertisement campaign by the pharmaceutical companies over many years that is designed to convince them that emotional concerns are diagnosable illnesses requiring medication treatment. How might the views of those surveyed been different without this high finance selling of the illness model?
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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.
As some of you may know, Bob Dylan has a show called “Theme Time Radio Hour.” As the title suggests, each episode is centered on a theme. He begins his episode on madness as follows:
“Let me ask you a few questions, friends. Are you disinterested in work or family life? Do you suffer from sleep disruption? Have you had significant changes in appetite? Have you had paranoid thoughts? Thoughts of grandeur or invincibility? Any feelings of persistent anxiety or perhaps panic attacks? Are you hearing voices or seeing people who are not there? Do you have thoughts of dying? Do you exhibit strong or violent anger? Do you have the inability to pursue a normal life, normal activities or normal relationships? Well, I’m no doctor, but perhaps you’re mad as a hatter; crazy as a loon. Have you lost your morals? Are your bats in the belfry? Maybe you’re nutty as a fruitcake? Crazy as a coot? Taxed in the head? Bunkers? Bananas? Deranged? Are you crackers or daffy? Unhinged or loco? Not all there or all around the bend? Maybe you’re cuckoo or buggy or simply non compos mentis? Do you talk to yourself? Do you ever binge out on food? Do you swing suddenly from one mood to another? Do vague acquaintances treat you as though they know you far better than you would expect?
Allan Ginsberg
“Allan Ginsberg once said that he had seen the best minds of his generation destroyed by madness. Now for the next hour we’ll be providing the sound track. We’re going to look at madness, insanity, and craziness.”
Introducing his theme in this way may seem like quite a mouthful for Bob, but he manages to carry it off rather well. There is deep, dungeon-like music in the background, and he varies his voice in a manner that is full of concern and dramatic interest. Besides, if you think Bob’s description of his theme is lengthy, take a gander at the latest American Psychiatric Association’s description of a related topic. In its book titledDiagnostic and Statistical Manual of Mental Disorders, 5th Edition,over 900 pages are consumed describing various “mental disorders.”
The theme of “madness” is relevant to this blog’s theme because when people seek to insult others, we commonly hear words like, “You’re mad,” “You’re crazy,” “You have a mental disorder,” and “You’re mentally ill.” Negative consequences often flow from such name calling. Individuals flinging these efforts to insult often become less respected by those who are their targets. Those who are their targets sometimes end up having less respect for themselves. From here, conflicts can escalate, leading to losing friends, problems at work, and even violence.
Dylan’s First Madness Song
Bob introduces the first song for his show on madness as follows:
“If craziness was a country, this would be the national anthem. Here’s Patsy Cline in a little number written by Willie Nelson–“Crazy.”
Patsy Cline
Patsy’s beautiful voice, accompanied by gentle piano riffs, drifts into its melancholy words–“I’m crazy, I’m crazy, for being so lonely. I’m crazy, I’m crazy for being so blue.”
The song goes on from here to weave the sad story of a woman calling herself crazy for loving a man whom she knows will soon be leaving her. She feels she’s crazy for worrying when he’ll leave, and crazy for trying, and crazy for crying, and crazy for loving this man.
Here we learn of just one type of experience that falls under the enormous umbrella of madness.
Connecting Madness With Genius
As the song phases out, Bob begins to tell us that according to Aristotle, “No excellent mind is without a tincture of madness,” a position with which Bob heartily agrees. He declares that “There is a thin line between genius and madness.” Defending this, he introduces us to several individuals who had been declared mad by some, and yet achieved at impressive levels in many valued fields. Thus, he tells us about the brilliant writer, Ernest Hemingway:
Earnest Hemingway
“Ernest Hemingway, for example, was convinced that people were out to assassinate him. His wife, Mary, tricked him into a mental hospital by telling him it was to treat his high blood pressure. He got shock therapy and maybe a dozen other treatments. It didn’t help. It left him more paranoid, delusional and depressed. He was afraid that his wife would put him away again, which many people believe is what led him to take his own life with a shotgun in July of ’61.”
Bob then tells us about the great jazz musician, Charlie Mingus:
Charlie Mingus
“Charlie Mingus spent some time away, although he later claimed he only had gone in to get papers declaring he was incompetent to get out of a contract with the gangster, Joey Gallo. Whatever the reason, he spent some time in Bellevue and was diagnosed as a paranoid schizophrenic.”
After this, Bob tells us the story of two more jazz greats–Bud Powell and Charlie Parker. Both at times were troubled by demons.
Then there was a comic writer:
One man that was no stranger to madness was Bill Gates. He was the editor of E. C. Comics. He had a series of horror comics in the ’50s, but then he was targeted by the government who said that his comics were ruining the morals of America’s young people. He was supposed to water down all of his books. He had one humor comic he called “Mad.” He changed it to a magazine so it wouldn’t be subjected to the comics’ code of authority. It became a huge hit and generations of kids got their first lessons on comedy from the usual gang of idiots that he assembled. He never sold advertising in the magazine while he was alive and there were no sacred cows. Bill Gates, madman of free speech.”
Bob soon moves on to the story of a hell of a fine baseball player:
“One guy that was accused of cracking up was Jimmy Piersall. He became a professional baseball player at 18, signing with the Boston Red Sox in ’48. On May 24, 1952, just before the game against the New York Yankees, he got into a fist fight with Yankee infielder, Billy Martin. After that, he scuffled with his teammate, Mickey McDermott. The final straw came when Jimmy Piersall spanked the four-year old son of his teammate, Burnt Stevens during a game in the Red Sox clubhouse. The four-year old had tried to tweek his nose and poured lemonade down his shirt. You can see Jimmy’s position–Boy, you need a spanking. There were a number of incidences like this and he was sent down to the minor leagues. He got into a lot of trouble down in the minor leagues, and spent some time in the West Borough State Hospital. He was diagnosed with manic depression, but he still returned to baseball by the opening of the ’53 season. And get this, he finished ninth in the voting for the MVP award, and the next year he was the Sox’s regular center fielder.”
Feeling That We Are Crazy Is A Common Experience
In addition to describing these individuals who were thought to be mad by some and yet achieved greatness in various valued arenas, Bob provides diverse examples of regular Joes and Jills who displayed behaviors that were viewed as crazy by either themselves or others. These examples touch a chord in the listener because they illustrate experiences that are pretty close to what we have all experienced at different points in our lives.
Thus, the show’s take away lesson, as I see it, is that if you catch yourself calling yourself names such as “crazy” note that many of the most talented people have had similar experiences. Note, as well, that such criticism is too vague to be helpful. Learn to become more aware of these thoughts, to stand back and simply observe them passing through your mind–“Oh, there I go again calling myself mad.’ In time, you will come to a point at which you will formulate some more specific approach to make improvements in your life. The practice of meditation can help you to learn this skill.
If you are tempted to call someone else these types of names, remember that such names are way too vague, encompassing thousands of unusual and usual experiences. For criticism to be truly helpful, it is usually best to craft a statement that avoids name calling and statements about what someone did wrong, and instead provides specific suggestions for what the target of the criticism can do to improve. If you can not come up with such a statement right away, perhaps it would be best to delay the criticism until you have some time for your creative impulses to come up with something better than “You’re a crazy, mentally ill fool!”
Although these are my take away lessons for today’s post, let’s end with how the more poetic Bob Dylan ends his madness show:
“Time flies when you’re talking crazy, and we gotta get out of here. But before we do I want to leave you with the words of the man who is the voice of the barroom, poet of the gutter, and Shakespeare of the alleyway. Here’s a poem by Charles Bukowski called “Some People.”
some people never go crazy.
me, sometimes I’ll lie down behind the couch
for 3 or 4 days.
they’ll find me there.
it’s Cherub, they’ll say, and
they pour wine down my throat
rub my chest
sprinkle me with oils.
then, I’ll rise with a roar,
rant, rage –
curse them and the universe
as I send them scattering over the
lawn.
I’ll feel much better,
sit down to toast and eggs,
hum a little tune,
suddenly become as lovable as a
pink
overfed whale.
some people never go crazy.
what truly horrible lives
they must lead.”
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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 clickHERE.
Many mental health service providers well know that there are serious problems with the jargon that is used in their profession. In a recent post titled “Psychiatric Name Calling: Is It Time To Put A Stop To It?” I outline some of the most glaring ones. In a subsequent post titled “Psychiatric Name Calling: Is There An Alternative?” I describe a plan for professionals who have an interest in eliminating the problems inherent in the current psychiatric pathologizing approach. This plan would allow professionals to replace the old model with one that would be practical, more consistent with principles of science, and far less stigmatizing.
As I have been seeking ways to promote these ideas, it has become more and more apparent that the gears of the mental health service provider professional organizations grind slowly. Until the necessary changes occur, what can the average English speaking person do when faced with terms like mental illness, major depressive disorder, psychosis, schizophrenia, etc.?
Three Principles That Can Be Used When Psychiatric Pathology Terms Are Employed by Others So That The Negative Effects Associated With Their Usage Can Be Reduced
Even people who are not mental health service providers will regularly use psychiatric jargon. Thus, a French writer once wrote:
My sadness was without limit, and having got possession of me, it filled my life from the most indifferent external acts to the most secret thoughts, and corrupted at their source my feelings, my judgment, and my happiness. It was then that I saw that to expect to put a stop to this disorder by my reason and by my will, which were themselves diseased, would be to act like a blind man who should pretend to correct one of his eyes by the aid of the other equally blind one.
In this quote, the French writer, to describe some concerns he had about his sad mood and how it was affecting his feelings, judgments, and happiness, uses the words “disorder” and “disease.” This is the type of language most mental health service providers throw around. What is the writer attempting to convey by their use?
Sometimes when these words will be employed, their context will make it clear what meaning the author intends. In this example, the author does provide some context. He clearly indicates he was much sadder than he wished to be, and he believed he was unable to do anything about it. He also expressed a concern about his feelings, judgments, and happiness, but he was less clear about what he meant by this.
When someone begins to use pathologizing language and we simply don’t know what is intended, we might end up with misleading, simplistic associations. And so, here are three principles that can be used when psychiatric pathology terms are employed so that we can avoid unnecessary confusion.
Each Time Someone Uses A Psychopathologizing Term, Ask The User Of The Term For A More Specific Description Of What Is Meant By It
In the example that I provided above, there was some lack of clarity about what the French writer meant about his judgments. We know that he felt that it was disordered and diseased. That really tells us nothing more than he was dissatisfied with his judgments. To clarify, we could ask for some specific examples of when his judgment proved to him unsatisfactory.
As another example, suppose you hear Alice saying that John Doe is “mentally ill.” If you want to use this first principle, you would ask Alice what, specifically, does “mentally ill” mean to her and what has John done specifically that led to her calling John this name. These questions typically lead to further constructive discussions and ends up clarifying the nature of many fascinating experiences.
When Psychopathologizing Terms Are Employed, Express A Concern That This Terminology Simplistically Devalues An Experience
Terms like “mental disorders,” “mental illness” and “psychosis,” even when used by professionals, implies that there is something wrong with the person being described. However, as I described in my post “Are Mental Illnesses Really Potentially Helpful Tools?” there are numerous examples of the types of experiences that tend to be labelled mental disorders that end up being enormously helpful. Moreover, in cultures that recognize this possibility the outcomes for those people undergoing these challenging experiences are distinctly better.
And so, as you begin to use the first principle, asking for the user of pathologizing terminology for more specifics, if he or she seems to be suggesting that the experience is bad, you might wish to point out this well documented observation. At such times, I often say, “Many people with artistic temperaments have these types of experiences. Such people have given the world some of its most valued achievements.”
Instead Of Using The Concept of “Disease” And “Illness” To Encourage Humane Responding Toward Individuals Undergoing Challenging Experiences, Emphasize Rights, Kindness, And Practical Reasons
In seeking to encourage people who are using pathologizing terminology to be more specific, it is not uncommon to find that one reason they use these terms is that they hope it will encourage people to be more humane toward those who have certain challenging experiences. They usually mean well by this, but this approach has been used for centuries and history documents that despite such efforts, people who are being given these labels have often ended up in some of the most horrible, degrading treatment facilities.
Instead of using the concept of “disease” to encourage humane responding toward individuals undergoing the experiences that get labelled with pathological terms, an alternative is to emphasize human rights, kindness, and practical reasons.
Note that when people in a town are hit with a hurricane, we don’t have to resort to calling them ill to encourage some help. Instead, we have set up laws that entitle people to certain rights from the government when emergencies occur. Moreover, as word gets out about what is occurring to those who are suffering, out of kindness, people make donations or join their hands to provide direct assistance in a variety of ways. And lest we forget, there are practical reasons to lend a hand. By doing so, we model for people just what kindness is all about.
Any of us can find ourselves in an emergency situation. The more we promote acts of kindness, the more likely we may find that others will treat us with kindness if we are ever to find ourselves in a very unfortunate set of circumstances.
Using the Three Principles
William James, in his grand book, The Varieties of Religious Experience, tellsus ofsome people who have mystical experiences that tend to be called “mental disorders.” James begins to use the three principles when he seeks out descriptions of the various mystical experiences that go well beyond the simplistic psychopathological descriptions. He then states that these mystical states have the right to be absolutely authoritative over the individuals to whom they come.
It is vain for rationalism to grumble about this. If the mystical truth that comes to a man proves to be a force that he can live by, what mandate have we of the majority to order him to live in another way? We can throw him into a prison or a madhouse, but we cannot change his mind-we commonly attach it only the more stubbornly to its beliefs.
It mocks our utmost efforts, as a matter of fact, and in point of logicit absolutely escapes our jurisdiction. Our own more “rational” beliefs are based on evidence exactly similar in nature to that which mystics quote for theirs. Our senses, namely, have assured us of certain states of fact; but mystical experiences are as direct perceptions of fact for those who have them as any sensations ever were for us…. The mystic is, in short, invulnerable, and must be left, whether we relish it or not, in undisturbed enjoyment of his creed.
In this quote, we find no plea from James that we should treat mystics humanely because they have a mental disease. Instead, James puts forth “rights” and “pragmatic” considerations. He argues that just like we in the majority would not like to be ordered to live in a particular way, these mystics have the right to live their way. And pragmatically, if we do use heavy-handed approaches to try to change them, such as throwing them in a madhouse, they will become more stubborn in their beliefs.
James proceeds from here to state that mystics have no right to claim that “we ought to accept the deliverance of their peculiar experiences, if we are ourselves outsiders, and feel no private call thereto.” His theme is tolerance for both the majority toward the minority and vice versa.
Returning to pragmatic arguments, James tells us in his chapter on mysticism that some have found that their mystical experiences have led to wonderful fruits that they highly valued. Some, for example, suffered for a great period of time and after their mystical experience felt wondrously free from their pain and found in its place increased energy and happiness.
James well realizes that the fruits from mystical experiences are not always positive, but he asks us, at the very least, to realize that they have the potential to “be indispensable stages in our approach to the final fullness of the truth.” Thus, we see that “rights” and “pragmatic arguments” can be used instead of a disease concept to promote humane, kind responses toward those who have the types of experiences that tend to be called mental disorders.
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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.
William James, psychologist and philosopher, passed away over a century ago. Nevertheless, his remarkable body of work remains as fresh as fruit plucked from its tree but moments ago.
His views about his personal bout with a challenging experience developed over many years. Today I think it will be instructive if we spent a little time reviewing what he learned.
A Glimpse at James’s Early Views on Mental Disorders
We begin in April of 1867. James is 25-years old. Suddenly, he interrupts his medical education and flees to Europe.
Later, on describing the feelings that led to his departure, James wrote “it was as if something hitherto solid within my breast gave way entirely, and I became a mass of quivering fear. . . . I awoke morning after morning with a horrible dread in the pit of my stomach.”
William and Henry James’s Father, with Young Henry on the right
Several years went by and then, gradually, James’s spirits lifted. His father, noticing the difference in him, asked about it, and then relayed the news by letter to another son, Henry, in March, 1873:
He came in here the other afternoon when I was sitting alone, and after walking the floor in an animated way for a moment, exclaimed “Dear me! What a difference there is between me now and me last spring this time: then so hypochondriacal” (he used that word, though perhaps in substantive form) “and now feeling my mind so cleared up and restored to sanity. It is the difference between life and death.” He had a great effusion. I was afraid of interfering with it, or possibly checking it, but I ventured to ask what especially in his opinion had promoted the change. He said several things: the reading of Renouvier (specially his vindication of the freedom of the will) and Wordsworth, whom he has been feeding on now for a good while; but especially his having given up the notion that all mental disorder is required to have a physical basis. This had become perfectly untrue to him. He saw that the mind did act irrespectively of material coercion, and could be dealt with therefore at first-hand, and this was health to his bones.
We see in the above that at this time James viewed his experience that led to his departure from medical school as a “mental disorder.” Moreover, his conceptualization of it had begun to develop from a physiological pathology model to one that gives at least some freedom to the will. In time, his views begin to develop even further.
Letter to Henry James, 1885
The two brothers. Henry is on the left and Professor William James is on the right
William James and his younger brother, Henry, shared an especially close fraternal bond. Historians have greatly benefited from this because the letters that the two brilliant men shared reveal insights about their deepest concerns.
In 1885, now a medical school graduate and teacher at Harvard, James writes to Henry:
To suggest personal will and effort to one “all sicklied o’er” with the sense of weakness, of helpless failure, and of fear, is to suggest the most horrible of things to him. What he craves is to be consoled in his very impotence, to feel the Powers of the Universe recognize and secure him, all passive and failing as he is.
In James’s letter to his brother, we see he has discovered that in marked contrast to his own favorable reaction to suggestions about the effectiveness of will and effort, some people react with horror. Such people view themselves as helpless, weak, passive, and failing. Rather than looking to a creative force within themselves, they look for the Powers of the Universe to fix them.
The Mature James
Toward the end of James’s career, he adds a new way of viewing the types of concerns that affected him so profoundly when he was young. We begin to see this new way when James discusses individuals who view themselves as “healthy-minded.” These individuals believe that those who worry are “morbid-minded” and “diseased.”
James responds to this name calling by stating that those referred to as morbid-minded have argued that “the world’s meaning most comes home to us when we lay them most to heart.”
After describing the argument between the so-called “healthy-minded” and the “morbid-minded,” James then states:
In our attitude, not yet abandoned, of impartial onlookers, what are we to say of this quarrel? It seems to me that we are bound to say that morbid-mindedness ranges over the wider scale of experience, and that its survey is the one that overlaps. The method of averting one’s attention from evil, and living in the light of good is splendid as long as it will work. It will work with many persons; it will work far more generally than most of us are ready to suppose; and within the sphere of its successful operation there is nothing to be said against it as a religious solution. But it breaks down importantly as soon as melancholy comes; and even though one be quite free from melancholy one’s self, there is no doubt that healthy-mindedness is inadequate as a philosophical doctrine, because the evil facts which it refuses positively to account for are a genuine portion of reality; and may after all be the best key to life’s significance, and possibly the only openers of our eyes to the deepest levels of truth.
To James, people confront events daily that create feelings of helplessness, pain, sadness, horror, and dread. James argued that the feelings that go along with these kinds of events can lead toward truth. Thus, he counteracts any tendency to assume that those referred to as morbid-minded are automatically inferior to those referred to as “mentally healthy.”
The Development of James’s Views About Mental Health Concerns
And so, starting from James’s own bout with a challenging experience, we see that his views develop over the years. Initially, mental health concerns are “mental disorders” which require a physical basis. He then changes his mind, coming to believe these experiences are not completely controlled by one’s physiology, and therefore they could be dealt with through philosophical and poetic means.
It then occurs to him that in contrast to the benefits that his new perspective had for him, others prefer, even crave, to believe they are helpless in the face of these types of experiences. Finally, James comes to believe that some people can derive benefits from the kinds of challenging experiences that, to many, are properly viewed as symptoms of a diseased mind.
Like James, I have undergone a similar developmental trajectory. As I have dealt with my own challenging experiences, I have, over a good many years, learned to greet them as old friends who have valuable messages to share with me. Sometimes they stay a little longer than I would like, and I may find it frustrating that they don’t always come right out and tell me what these messages are. But my patience, through meditation and the maturity that sometimes comes in the course of passing years, has been steadily improving.
Well, I hope this discussion has deepened the reader’s views of the nature of experiences that lead to people expressing concerns to mental health professionals. Until next time, may all of your concerns be addressed with wisdom, love, and kindness.
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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.
Dr. Kandel’s credentials are pretty impressive–he’s a Nobel Prize laureate and professor of brain science at Columbia University. Therefore, if you are among those who believe a person’s credentials should determine who is right and who is wrong, you need not read any further. You must simply conclude that what is referred to as mental illnesses are indeed brain diseases because you would be hard pressed to find someone with better credentials disagreeing with Dr. Kandel.
The argument that such labeling practices are not scientific, but, rather, value judgments, was intelligently made by William James when he defended the religious sentiment. He explained that pathologizing these sentiments as mental diseases was superficial medical talk. He called the reasoning doctors used to declare religious beliefs a type of mental illness, “medical materialism.”
assumes as a convenient hypothesis that the dependence of mental states on bodily conditions must be thoroughgoing and complete. If we adopt the assumption, then of course what medical materialism insists on must be true in a general way, if not every detail…. But now, I ask you, how can such an existential account of facts of mental history decide in one way or another on their spiritual significance? According to the general postulate of psychology just referred to, there is not a single one of our states of mind, high or low, healthy or morbid, that has not some organic process as its condition. Scientific theories are organically conditioned just as much as religious emotions are; and if we only knew the facts intimately enough, we should doubtless see “the liver” determining the dicta of the sturdy atheist as decisively as it does those of the Methodist under conviction anxious about his soul. When it alters one way the blood that percolates it, we get the Methodist, when in another way, we get the atheist form of mind. So of all our raptures and our drynesses, our longings and pantings, our questions and beliefs. They are equally organically founded, be they religious or of non-religious content.
All states of mind are related in extremely complex ways to neural functions. There is a crucial distinction to be made between a brain difference and a brain pathology. The significance of each state of mind must be tested, not by some neurological difference, but by the value of its fruits. When the term “pathological” is applied to an experience, rather than an identified physiological pathology, it wrongly implies a neutral science classification.
In contrast to biological arguments, psychosocial explanations of mental health concerns have been found to effectively improve images of people who are now being labeled as having a mental illness. It also appears to reduce fear.
Today, if your behavior, thoughts, or feelings begin to concern you or a family member, for a fee many doctors will translate your experiences into mental illness terminology. Synonyms for mental illness, are mental disease, mental sickness, mental disorder, and psychopathology. These terms, as metaphors for experiences someone doesn’t like, have been with us for centuries. When used in this way, it can communicate something about an experience that others relate to. However, when we move from using these types of concepts as metaphors to believing wholeheartedly that they are proper scientific terms, we begin to lose the respect of those well grounded in the principles of science.
Let’s consider The Tragedy of Hamlet, Prince of Denmark, which William Shakespeare wrote in about 1604. This play offers its audience a magnificent tale of adultery, fratricide, revenge, and feigned madness by a protagonist. When reading Hamlet, we see how Shakespeare uses metaphors to vividly evoke in us the experiences of his characters. Thus, when Hamlet becomes dissatisfied that his mind keeps identifying flaws in his plans for action, he describes these plans as becoming “all sicklied o’er with pale cast of thought.” By extension, the reader senses that when Hamlet’s plans become “all sicklied o’er,” he, too, becomes in a sense, “sicklied o’er” with feelings of frustration, anguish, and helplessness.
Literature regularly uses this type of metaphor. Ralph Waldo Emerson, to take another example, once wrote:
I actually like Emerson’s disease terminology here because the context in which he uses it so obviously reveals that he is using it metaphorically. Notice how he cleverly uses diseases associated with childhood to evoke the feeling that individuals who worry themselves over problems of original sin and so on are acting, in his view, childishly. In this context, disease, to Emerson, was a metaphor for immaturity. If he were a man of science, in contrast to a literary personality, we would expect that he would use terms with clearly defined, objective meaning, that avoid value judgements.
At the time, medical writers were already heavily pathologizing a great number of experiences. Thus, James cited W. Griesinger, the author of The Pathology and Therapy of Psychological Illnesses, and T. S. Clouston, author of Clinical Lectures on Mental Diseases. As James delved further and further into the experiences being pathologized in this way, he came to believe such terminology was “simple minded” and “superficial medical talk.”
Does it make sense to say that when people are suffering, they have a “mental disorder?” Well, consider the experience of giving birth. It is typically accompanied by suffering, and yet it makes more sense to classify this experience as a natural part of creating new life rather than a pathological condition.
When writers receive rejections from publishers, or a loved one dies, suffering often accompanies these experiences. Yet, we do not typically describe them with pathological terms.
For example, cortisol levels in saliva and heart rate variability has some connection with a person’s self-reports of how much stress they have experienced in recent days, while hair cortisol levels have some connection with longer term exposure to stressful experience. Other measures of stress utilize a list of stressors, such as the recent death of a loved one, living in poverty, etc. The person being assessed places a check mark next to each of the stressors on the list that applies to him or her. These check marks are then used to calculate how much stress the person has been experiencing.
Having indicated some of the problems of unambiguously, and non-subjectively applying the descriptors of suffering to the concept of mental disorder, we now turn our attention to the descriptor, “dysfunction.” As with the notion of suffering, the pathologizers almost never use the various scientifically validated measures of functioning to determine if someone has a mental disorder. A pretty good such measure is the Scales of Independent Behavior-Revised. It has norms for functioning in such areas as social interaction (communication skills, language comprehension, language expression), personal living skills (eating and meal preparation, toileting, dressing, personal self-care, domestic skills), community living skills (time and punctuality, money and value, work skills), and gross and fine motor skills. Rather than using measures of this type, pathologizers rely on their professional privilege to make a subjective estimate of dysfunction.
In the most current edition of the DSM, someone who is experiencing abnormal levels of distress might be considered to have a mental disorder. But the issue of the boundary between normal and abnormal experiences lies at the heart of the most contentious disputes in the field of psychopathology today. A major problem with using the term abnormal as one of the defining attributes of mental illness is that it leads us to forget the fact that natural to all organisms is substantial variability across individuals and within individuals. Having above average or below average functioning in various areas of our many areas of functioning is normal. Displaying rare behavior patterns that are highly valued, such as the great altruism of Mother Teresa, are not viewed as mental disorders. Psychopathology is applied when someone does not like a particular experience. Thus, a term that masquerades as a scientific term is really a value judgment masquerading as a scientific term.
Although there are some fairly well developed scientific measures of the three major factors (suffering, functioning, and abnormality) that the psychopatholgizers tend to claim are usually part of the mental illness experience, these measures are almost never used in their “diagnostic” determination. Instead, subjective indicators of these three factors are combined into an even more subjective abstraction called “mental illness.” This process is not scientific despite claims to the contrary.
Rather than a scientific concept, the mental illness concept has been very useful as part of a highly lucrative business plan for the pharmaceutical industry and medical doctors, which includes psychiatrists. This plan has doctors first convincing people that the experiences referred to as mental illnesses are scientifically real illnesses just like physiological pathologies. It then provides license for doctors, in as little as fifteen minutes, to declare that they have provided their patients a diagnosis, and to send them on their way with a prescription for pills. With this plan, billions of dollars flow their way.
Welcome to “From Insults to Respect.” Regular readers know that I have some serious objections to how mental health service providers treat those seeking their services. As things stand now, unless you can afford to completely pay for such services without any insurance coverage, to access services you are very likely to be required to be labelled as having a mental disorder.
The 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:
Here 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.
I 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.
William James, in his book, Pragmatism, tells us the following story. 
This 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)
“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 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.
Let 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.
The 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.
The 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 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.
Some 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 
Similarly, 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.
This 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.
Okay, 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.
The idea that certain actions that violate societal norms are mental illnesses like any other illnesses is attractive to many people because they believe it helps to reduce this guilt and shame. To understand this a little better, let’s take a look at a quick parable:
Rachel, the mother of five-year old Jonathan, recently went through a very sad divorce. Now, at Jonathan’s parent-teacher conference, his Kindergarten teacher expresses some serious concerns. “Your son is very hyperactive and he has a great deal of difficulty paying attention. Have you considered taking him to a doctor? He may have ADHD.”
“There is no need to blame yourself,” the doctor explains. “ADHD isn’t caused by bad mothering. It is an illness very much like diabetes. Just like insulin is a drug that treats diabetes, the drug I’m prescribing for your son’s ADHD will treat his medical condition.”
But when she tells her father what the doctor has said, he grumbles and says that the doctor is full of crap. “Jonathan is angry and upset because of the divorce and not having his father with him any more. Anyone can see that!”
“Well, Rachel, I certainly don’t think you are to blame, but I don’t think Jonathan has an illness. I’m sorry to hear you are thinking about putting him on one of those ADHD drugs; they have a whole bunch of side effects.”
“You did your best, Rachel. I think it makes sense that you take some responsibility for what has happened, but blaming yourself isn’t being fair, nor is it helpful. When people blame themselves a lot of the time they think they deserve some type of punishment. In my opinion, a better way to take responsibility for what went wrong is to accept the strong emotional experiences that go along with taking responsibility, accept that you played at least a part in what went wrong, and then set yourself on becoming determined to take steps to improve. The genuine sad, heartfelt feelings that come with taking responsibility leads us to do a search for making improvements.”
In the above parable, a doctor tries to reduce the shame and guilt that a mother is feeling about her son’s behavior by framing the behavior as an illness. Although this initially appears to help, she runs into some people who refuse to go along with this anti-shame/mental illness notion. Let’s explore this notion a little more thoroughly with the help of some of the writings of psychologist and philosopher, William James.
In an 
To suggest personal will and effort to one “all sicklied o’er” with the sense of weakness, of helpless failure, and of fear, is to suggest the most horrible of things to him. What he craves is to be consoled in his very impotence, to feel the Powers of the Universe recognize and secure him, all passive and failing as he is.
From my discussions with people in Alcoholic Anonymous, it seems to me that many of its members found themselves in a state similar to what James describes in his letter. The program seems to provide them a way to stop blaming themselves by using the “I have a real sickness” idea. It also offers a sense that they could put themselves in the hands of a higher power, while, at the same time, they receive a great deal of support from peers who have managed to recover.
It is in no other way that we overcome balkiness in a horse: we divert his attention, do something to his nose or ear, lead him around in a circle, and thus get him over a place where flogging would only have made him more invincible.
By apperceiving the case as neural pathology, what does James hope to gain? He does not explicitly say. The technique that he describes of dropping the subject, diverting the mind, then springing it on the pupil later, is stated plainly enough so that many individuals can employ it without first apperceiving the case as neural pathology. I have done so, myself, on numerous occasions.
