Welcome to From Insults to Respect. On this blog, from time to time, we have been discussing depression. To help us better understand this deeply troubling experience, we have looked at the biographies of several individuals who, despite their mighty struggles with depression, still managed to earn the respect of millions. Today, we quickly review three of these biographies, that of the brilliant psychologist and philosopher William James, the remarkable musical performer Joni Mitchell, and the great Russian writer Leo Tolstoy.
After this quick review, we’ll move on and take a close look at several instances of General U. S. Grant’s experience with depression. The useful understandings that come from considering these challenging experiences will be addressed in my conclusion section.
A Brief Look at William James’s Experience
William James
As we discussed in an earlier post (see here), William James, for several years, had an experience that he described as follows:
“…it was as if something hitherto solid within my breast gave way entirely, and I became a mass of quivering fear.”
James initially believed that there was some physical basis that led to his becoming “morbid-minded” and “diseased.” And then, in some of the books he was reading, he was introduced to the idea that there was no need to accept that he had a physical disease causing his depression. Instead, he began to learn about the attitude that many viewed as “healthy minded,” which involves averting one’s attention from evil, and living in the light of good–a kind of “look for the silver lining whenever skies are blue” perspective. He came to believe that this approach,
“…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.”
However, for him, and for many others as well,
“…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.”
Noting that many of the most creative people of his day experienced depression, Professor James finally fully gave up the belief that he had a pathological condition. Instead, he adopted the view that his deep melancholy experiences were a natural part of a positive creative process, and this not only lifted his spirits, it also was “health to his bones.”
A Brief Look At Joni Mitchell’s Experience
In addition to William James’s experiences with depression, in an earlier post (see here) we also looked at musical artist Joni Mitchell’s similar experiences. To deal with it, Joni tells us that, she bought every psychology book she could lay her hands on. She ended up throwing them all against the wall. And then she was introduced to Nietzsche, and learned from him that to live is to suffer, to survive is to find meaning in the suffering.
As she poetically expressed it in her song, “Hejira,”
There’s comfort in melancholy When there’s no need to explain It’s just as natural as the weather In the moody sky today
With this realization, she decided to spend some extensive alone time in nature along the beautiful coast of British Columbia. It was there that she discovered that,
“Depression can be the sand that makes the pearl…. Most of my best work came out of it. If you get rid of the demons and the disturbing things, then the angels fly off, too. There is the possibility, in the mire, of an epiphany.”
A Brief Look At Leo Tolstoy’s Experience
Finally, in an earlier post (see here) we looked at the great writer, Leo Tolstoy. In his painfully personal book, My Confession, Leo Tolstoy tells us about his two-year period of despair. At about the age of 50, his life had become “flat, more than flat: dead.” Suicidal thoughts were all too frequent.
Tolstoy went on to explain how his melancholy stimulated a gnawing questioning that eventually led to one insight after another.
In reviewing the experiences of William James, Joni Mitchell, and Leo Tolstoy, we discovered that each came to conceptualize their experiences, not as a pathological state needing some type of psychiatric drug, but, instead, as something of value, as painful as it was to go through. Once they came to this realization, they found that their lives dramatically took a turn for the better.
Interestingly, William, Joni, and Leo’s experiences with depression seem to them, at least at first, to come out of the blue. To them, there was no obvious reason why they were feeling so down and out. In contrast, U. S. Grant’s depressions came out of distinct deeply disturbing events.
Grant’s Experiences With Depression
In some ways, General Grant was less inclined to become depressed than many of us. For example, one of the most common way that we begin to hurtfully treat ourselves is when we perceive someone is treating us disrespectfully. Well, according to Ron Chernow’s best selling biography of Grant, the great general was relatively immune to this. There we learn about John Rawlins, who acted as General Grant’s Chief of Staff during the Civil War:
Rawlins “was always getting excited about something that had been done to Grant,” recalled Lieutenant Frank Parker. When someone showed disrespect for Grant, “he would prance around and say, General, I would not stand such things’ to which Grant would say, ‘Oh, Rawlins! what’s the use in getting excited over little things like that; it doesn’t hurt me and it may make the other fellow feel a little good.’”
Although he could withstand criticism of his actions better than many of us, nevertheless, Chernow’s biography of Grant reveals a man who was prone to depression. Those who are interested in a description of many of the bouts that the general experienced can go to the book’s index, and under the heading “Grant, Ulysses S.” they will find a section titled “depression.” Chernow identifies ten incidences. Here, I will confine myself to describe just three of these, the first of which occurred shortly after he turned forty-two.
While Grant was gunning for Richmond, at one point, General Robert E. Lee mounted a furious attack. As Chernow described the event,
Robert. E. Lee
Exploding shells ignited dry brush and pine needles, heating the forest into a raging inferno…. Wounded men were roasted alive in the forest floor, their agonized cries audible everywhere…. Characteristically the tightly buttoned Grant allowed himself release only once the crisis passed. He carried the full weight of the Union cause on his shoulders, an impossible burden for any man. So, perhaps not surprisingly, he submitted to an overflow of feeling. “When all proper measures had been taken,” Rawlins related, “Grant went into his tent, threw himself face down on his cot, and gave way to the greatest emotion.” The man of extreme self-control surrendered to his feelings. Rawlins asserted he “had never before seen him so deeply moved” and that “nothing can be more certain than he was stirred to the depths of his soul.” Charles F. Adams Jr. confirmed that he “never saw a man so agitated in my life.”
A month later, the northern public was demanding ever more bold action. Grant, at Cold Harbor, responded with a risky attack against Lee’s army that inhabited swampy terrain that played to Lee’s strong suit. A labyrinth of trenches defied any forward movement by Grant’s forces. By the day’s end it became apparent that the Union had lost four or five men to every Confederate. Grant, in his Memoirs, expressed special remorse for what had happened: “I have always regretted that the last assault at Cold Harbor was ever made.”
Those who saw Grant immediately after the Cold Harbor battle sensed a deep sadness. As Chernow tells it,
Wrenshall Smith encountered him returning from the battle and depicted him as “much depressed. He dismounted and took a seat on the stone. What is the situation, I asked? Bad–very bad, he replied.” Samuel Beckwith noticed that after Cold Harbor Grant’s face developed “a careworn expression that indicated sleepless nights and fearsome days.” When he delivered a message to the general’s tent, he found him sunk in thought. After absorbing the telegram, Grant sighed, “Beckwith,” he said, “the hardest part of this General business is the responsibility for the loss of one’s men. I can see no other way out of it, however; we’ve got to keep at them. But it is hard, very hard, to see all these brave fellows killed and wounded. It means aching hearts back home.”
A couple of weeks later, the death of thirty-five-year-old General James B. McPherson was a terrible shock. McPherson was felled by a bullet while surveying Confederate defenses. He and Grant were particularly close. Chernow describes how Grant took the news:
It fell to Captain Samuel Beckwith, the chief cipher operator, to deliver the heartbreaking news to Grant in his tent. He handed the dispatch to Grant, who “read it silently. He was hard hit, I could readily see that. His mouth twitched and his eyes closed as if he was shutting out the baleful words. Then tears came and one followed the other down his bronze cheeks as he sat there without a word of comment.”
Throughout this period, Grant continued to run the Union Army with the enthusiastic support of his boss, President Abraham Lincoln. That support, along with the support of General Grant’s Chief of Staff John Rawlins, who, among his other duties, acted as a personal counselor, providing the general with unconditional positive regard when he needed it most. The importance of such support to get one through the hardest of times, will be discussed shortly in the next section.
My Conclusions
Dr. Jeffrey Rubin
The above three examples of Grant’s heart wrenching reactions to some traumatic experiences belies his image as stolid and unemotional. Importantly, in each case, he recovered without the need to pathologize his experience or to be saddled with antidepressants, with all of the side effects that go along with such a tangled path.
If Grant did go to a modern day psychiatrist’s office, what would be the likely outcome? Most likely he would meet up with a sales pitch that argues that his depression is a real disease and the risk of untreated depression is greater than the risk of any adverse effect of antidepressants. As someone who has participated in a number of debates on the use of psychiatric drugs, I have heard physician after physician make this claim about the risk of untreated depression. Whenever I asked these doctors what risks they were referring to, the answer most often has been an increased risk of suicide.
The doctors’ statements about this imply that if treated with “antidepressants” this can decrease the risk of suicide enough so that the depressed patient, by taking the drug, is better off than facing the risk of any adverse effects of the drug. But the doctors don’t know what the long term effects of taking the drugs are. What’s more, the scientific evidence currently available indicates that these drugs do not reduce the risk of suicide, and may actually increase it by as much as 8 percent (see HERE for the most recent review of the research).
In today’s post, we have looked at an alternative to the pathologizing medical model of depression. This alternative is uplifting, less stigmatizing, and conducive to a recovery point of view. It is a view that posits that depression has the potential to open our eyes to the fullness of truth. The suffering that goes along with the experience is a natural part of life, a view held by Nietzsche, as well as Buddhists and many other wisdom traditions. Additionally, it is an enormous source for creativity, and as we go through it, it can lead to one insight after another.
The experience of General Grant teaches us something that adds to the William James, Joni Mitchell, and Leo Tolstoy point of view; that is, even a person viewed as one of our most successful generals can experience anguish, sadness, and tears. This is an important lesson for so many of us who were brought up being taught to feel embarrassed and guilty when experiencing deeply sad emotions. In fact, for those who were brought up this way, they often believe that it is proper to lose respect for people who experience such emotions. They often end up having, each time they, personally, experience depression, a double depression. That is, not only do they at times begin to become depressed because of the reasons that would normally lead to feelings of melancholy, but they are additionally depressed about feeling that there is something terribly wrong with them, that they have bad genes and a stigmatizing illness requiring medication with all kinds of negative side-effects.
Giving up this tendency to feel a double depression for those who learned it throughout their childhood and well into their adult life often requires a relationship with someone providing quality social ties and social support. Substantial evidence (see here for a research literature review) has accumulated over the past few decades showing that social ties and social support are positively and causally related to mental health, physical health, and longevity. Evidence also documents that social support buffers the harmful physical and mental health impacts of stress exposure.
Although it is least expensive to receive this kind of support from warm, close friends and family members, sometimes those whom we are most close to hold the very same pathologizing beliefs that is holding one back from real recovery. At such times, finding a professional personal counselor who does not hold to the pathologizing point of view can be enormously helpful if the financial situation can be reasonably worked out. Discussions with the professional who typically responds in a very supportive manner, models for the person receiving counseling the type of skills that is helpful when we look within as we experience melancholy. Instead of berating ourselves for acting pathological, we come to learn to be kind to ourselves and to nurse hope that something positive will come from what we are going through.
Some non-pathologizing counselors will also encourage you to learn to meditate and utilize other mindfulness techniques. Here you practice observing your physical sensations when you are dealing with the disrespectful perceptions. In time, the disrespectful words that you tend to direct at yourself come to lose their disturbing nature. For a period of time these words still come, but you end up smiling at them as you realize they are not matching reality. In time, they may completely fade away as you embrace the physical sensations that come with melancholy.
This has been described as decentering. In essence, to decenter is to take a figurative step back from our beliefs and thoughts. That is, when we find ourselves believing, “I can’t do anything right,” we learn that we had a thought, “I can’t do anything right.” We come to learn, moreover, that we do not need to believe all our thoughts that were learned over many years from people who treated you in less than respectful ways.
An important component of mindfulness practice is to not resist our thoughts. Otherwise, marked frustration may ensue. We notice them, accept that they have come, observe them, and peacefully observe the physical sensations that come with them. Throughout, we embraced the whole experience.
Now, I understand that many people will find it hard to find in their community the type of counseling services I am describing. This may be because many professional counselors have adopted the same pathologizing approaches as psychiatrists, although they do believe counseling services, when combined with drug treatment, can be beneficial. For those who would like to work with a non-pathologizing personal counselor but find it difficult to find one within a convenient distance from home, I highly recommend two who can work with you individually via Skype–my son, Jack Star Rubin, and his lovely wife, Emily Whyte Rubin (see here to learn more about the counseling approach of these two personal counselors and their contact information).
For many struggling with depression, personal counseling can be too expensive. It is for this reason that I have been writing this blog. It provides a free, accessible way to learn helpful skills to deal with distressing experiences at your own pace. By going to the first post of this blog and then systematically going through each of the other posts over an extended period of time, a more supportive style of dealing with these types of problems are described, along with simple exercises that are required to really learn the skills well enough so you can actually carry them out in real life situations.
Well, those are some thoughts for this week. Until next time, may you be kind to yourself even when dealing with your most troubling experiences.
Welcome to From Insults to Respect. I hope the beauty of spring is helping to make your daily challenges more pleasant.
Regular readers know that from time to time I write a post advocating that mental health service providers change the way people access their services so that it becomes more respectful and more consistent with the principles of science. What I mean by this, is that currently those who have a health insurance policy that includes mental health services discover that when they seek to access those services they have to first be declared as a person with a mental disorder. Not everyone is happy about this, as the following parable suggests.
The Parable of Julianne and Dr. Robles
“Hi Julianne,” says Dr. Robles, as he greets his new counselee. “What can I help you with?”
“Well, Dr. Robles, I…I….” Tears begin to form in Julianne’s lovely hazel eyes. She takes out a tissue, blows her nose, wipes her eyes, and continues. “You see, I have two young children, age 3 and 5, and my husband left us a couple of months ago. I’ve been trying to keep it together, especially for the children, you know, and, well, it’s been so hard.”
“I can imagine it would be,” Dr. Robles replies gently. “Raising two kids even under the best of circumstances is quite a challenge.”
“Yes. And now I’m trying to do it all bymyself, and I’ve been feeling so depressed, and if I get any worse…. I mean I thought I better come in to prevent myself from crawling into bed and not getting out. I have to think of the children. I checked and I have mental health coverage on my insurance policy.”
“Yes, my secretary looked into that, and you do have mental health service coverage. Your insurance company requires that I must place a diagnosis on your health insurance form for you to access that service. I hear, so far, that you are concerned about….”
“Wait! What do you mean you have to place a diagnosis on my health form? You aren’t going to write in there that I have some sort of mental disorder, are you?”
“Well, I wish we didn’t have to get into this labelling issue. Personally, I think it’s best to treat each person that I provide counseling to as an individual. It is understandable that many people don’t want to be placed in a diagnosis box, especially one known to be stigmatizing. But the insurance companies do require a diagnosis.”
“That’s not fair! I’ve been paying insurance premiums for years and I never signed any agreement that to access this service I had to be labeled like this?”
“Well, I can easily see why you feel that it is unfair. I actually agree with you. Perhaps it would help if I let you know that in the vast number of cases the information in your medical records remains confidential?”
“No, it doesn’t help! Even the most confidential government records have been hacked, and my husband and I are in a legal fight over custody of the children. If he petitions the court to see my medical records, what guarantee do I have that the court won’t end up seeing them?”
“Computer hacks do occur, and I have heard about very rare instances when courts did manage to view a person’s medical records over the patient’s objections, so your concerns are reasonable. I wish I knew of some way around this labelling requirement, but for now we are stuck with this system.”
The Purpose of the Above Scenario
In today’s scenario, we see an example of both the person seeking counseling and the mental health service provider desiring that a certain requirement of accessing mental health services be eliminated.
Unlike them, some people actually find it reassuring when a doctor declares that they have a diagnosable condition, and they experience no objection when they learn that this condition is to be placed in their medical records.
For those who believe the current mental disorder classification system is helpful, I seek not to interfere with their ability to access services in the manner that they prefer. What I do seek is that for the significant number of people who do object to the current psychiatric labelling system, they nevertheless have equal access to mental health services without the mental disorder labelling requirement.
The above scenario provides readers an example of why some object to this type of labelling, but recent surveys indicate there are many others as well. In an article published in the Journal of Humanistic Psychology (Click HERE to access the article), I discuss these surveys.
Jonathan D. Raskin, PhD
For example, here’s what Jonathan D. Raskin and Michael C. Gayle wrote when they summarized their survey data of psychologists who regularly use the standard mental disorder classification system known as the DSM(DSM-5: Do Psychologists Really Want an Alternative?2015, pages 1-18).
“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 my journal article, I go on to propose a practical, more scientific alternative to the DSM. I call this alternative, the Classification and Statistical Manual of Mental Health Concerns (CSM). The first words in the CSM would be: “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.”
After publishing my journal article, I discovered at a number of forums that many people after hearing me out, expressed that the CSM approach makes a great deal of common sense. Some also readily saw that its scientific merits are enormous because the expression of a mental health concern is a clearly observable event that occurs at a specific time and place, and therefore its use would beautifully solve the reliability problems that have been plaguing the DSM’s far more abstract, vague, theoretical construct of “mental disorder.”
On the other hand, some resisted the CSM approach. As I began to question them, seeking to figure out where exactly the disconnect was, I discovered that for some, it had to do with their belief that the DSM is a classification system based on solid principles of science and nothing could possibly be better. As I questioned them further, I discovered that their understanding of what a scientific classification system is designed to do was a bit incomplete. So, in today’s post, I explain in an easy to understand manner the nature of scientific classification systems, beginning with a description of a classification system with which we are all so very familiar–birds. This will enable us to see clearly why the bird classification system is useful as a scientific instrument. We will then look at the DSM classification system in light of what we learned about the bird system, and this will reveal the DSM‘s serious scientific shortcomings. Finally, we will compare and contrast the DSM system with the proposed CSM system in a manner that can make the superior scientific merits of the latter crystal clear.
The Bird Classification System
A branch of science begins with something some people are so interested in that they want to study it carefully and share what they find with others, while at the same time learn from others what they find out. As it turns out, there are some people very interested in birds.
The next thing that happens in a branch of science is careful observation of the topic of interest. After some early observations, the scientists begin to put together a classification system, which is also known as developing a taxonomy. This begins with explicitly defining what that something is that they are interested in. Said in another way, they describe that something of interest in a clear and detailed manner, leaving no room for confusion or doubt. So, in our example of “birds,” scientists have decided that they are a group of endothermic vertebrates, characterized by feathers, toothless beaked jaws, the laying of hard-shelled eggs, a high metabolic rate, a four-chambered heart, and a strong yet lightweight skeleton.
Once scientists carefully define their general topic of interest, they describe different types of what they are interested in. So in our bird example, the scientist interested in them came up with a taxonomy that lists bluejays, pigeon, sparrow, and so forth as subtypes of the general category of birds, describing each subtype in a precise manner that can reliably distinguish each from the others on their list. Why bother to do this?
The main reason is that when they discuss their findings with others, they want to make sure they are using words that mean the same thing, and it is a great time saver. For example, let’s say John is a bird scientist and he says to Judy, another scientist, “I saw a bird the other day and I didn’t know what type it was; can you help me figure out what it is?” Notice that since both of these scientists know the meaning of a bird, it saves John quite a few words. Just imagine if instead every time John uses the word bird he had to say, “I saw something that had an endothermic vertebrae, characterized by feathers, toothless beaked jaws, the laying of hard-shelled eggs, a high metabolic rate, a four-chambered heart, and a strong yet lightweight skeleton.” That’s quite a mouthful to have to say each and every time you refer to a bird. In this example, just saying bird saves a scientist about 30 words each time the word bird is used.
The word bird, once explicitly defined also saves time in other ways. For example, let’s say there was no agreed upon definition of what a bird is and no classification systems at all. And let’s say John, the scientist, wants to find in a library some information about a particular type of bird. He would have to waste time looking at every single book in his library until he found one that seemed to be talking about what he was interested in.
As another example of the time saving value of classification systems, let’s say “bird” was vaguely defined as a flying creature. This would result in John having to unnecessarily wade through numerous books on flying insects, of which there are hundreds of thousands of types, bats, and some fish that sort of can fly. With the current bird classification system, anyone can go to a library and quickly find the specific section that houses information on just birds. Similarly, placing the word “bird” in a search engine enables John to more quickly retrieve relevant information than would a less explicit definition.
The DSM Classification System
Dr Ralph Slovenko
The DSM‘s overarching topic of interest is something it calls “mental disorders.” Dr Ralph Slovenko was a renowned psychiatrist. Prior to his death in 2013, he authored hundreds of articles and more than 10 books, including Psychiatry in Law/Law in Psychiatry, which went into a second edition in 2009. Let’s take a look at how he described the definition of mental disorder:
“Although this manual [the DSM] provides a classification of mental disorders, it must be admitted that no definition adequately specifies precise boundaries for the concept of “mental disorder.” The concept of mental disorder…lacks a consistent operational definition that covers all situations. All medical conditions are defined on various levels of abstraction–for example, structural pathology (e.g., ulcerated colitis), symptom presentation (e.g., migraine), deviance from a physiological norm (e.g., hypertension), and etiology (e.g., pneumonoccal pneumonia). Mental disorders have also been defined as variety of concepts (e.g., distress, discontrol, disadvantage, disability, inflexibility, irrationality, syndrome pattern, etiology, and statistical deviation). Each is a useful indicator for a mental disorder, but none is equivalent to the concept, and different situations call for different definitions.”
Dr. Slovenko goes on from here to tell us what the definition was used in the edition of the DSM back in 1994.
“In the DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significant increase risk of suffering death, pain, disability, or an important loss of freedom.”
Now I ask you, does this definition meet your standard for being explicit? To me, it is like saying that the definition of a bird is, something that has feathers, or scales, or teeth, or is beaked, or is warm blooded. It is actually worse than that, because the difference between such descriptors as teeth and a beak can be determined with excellent reliability. Can we determine the difference between “clinically significant” and “not clinically significant” with the same degree of precision? Clinically significant is subjective, in contrast to being objective, and science requires objective definitions.
The latest edition of the DSM (DSM-5) is just as vague. It begins, “Although no definition can capture all aspects of all disorders in the range contained in the DSM-5, the following elements are required.” Although it says the following elements are required, it then makes it clear that the elements that it lists are not required. As I provide the rest of the definition, notice the use of the word “or” and “usually.”
“A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognitive, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”
Again, the descriptor “clinically significant” is used, as it was in the previous edition of the DSM. This is about as vague a descriptor as one can possibly conjure up. How about the descriptor “dysfunction?” This, too, is left to the subjective opinion of mental health providers who often have financial interests in declaring that someone has a mental disorder.
My above critique of the mental disorder definition begs the question, Can scientists reliably distinguish those with a mental disorder from those who do not?
There is a simple scientific way to determine this. It involves randomly selecting a few hundred people from the population. Then, perhaps 20 scientists familiar with the definition would interview each in the time period usually devoted to making a so-called diagnosis in clinical practice. After each interview, each scientist would separately indicate on a piece of paper his or her decision about whether or not the person has, or does not have, a mental disorder. Each decision would be made independently from the other scientists, that is, without knowledge of the other scientists’ decisions. After this data were collected, statisticians would look to see how well the different scientists agreed with each other.
Recently, I tried to retrieve this type of study using Google Scholar by putting in the search window, “Reliability of determining who has a mental disorder and who does not.” Nothing of value came up. I tried other search terms to retrieve this basic scientific information. Again, nothing.
Eventually I found some relevant information. The vast majority of mental disorders listed in the DSM were never assessed for reliability, and the few that were indicate that this is a major area of weakness for this classification system.
Barbara S. Held, PhD
Relevant to this issue is a recent peer reviewed article by Barbara S. Held in the Review of General Psychology (2017) that discusses the various mental disorder categories (p. 82-94). She states that these heterogeneous categories have produced a lack of scientific progress because of their “internal incoherence, such that any given instance (diagnosed person) may share few and, in some cases, none of the category-defining features of other persons given that same categorical label.” (p. 83)
Dr. Held goes on to say:
“This is called the problem of “polytheticity” in the theoretical/philosophical clinical literature, and is seen as a primary source of obstacles to building a progressive science of mental disorder; it is also seen as related to the daunting problem of comorbidity, which calls into question the presumably discrete nature of disorder categories.”
So, boiling down the above critique of the mental disorder construct to its basics, the construct violates principles of science because its definition is neither explicit nor objective.
The CSM Versus the DSM
I, for one, am interested in a phenomenon that I, and others, call mental health concerns. Obviously there is wide interest in this. After all, there are numerous educational institutions that provide training to people so they can become credentialed to address mental health concerns. Numerous people actually voluntarily go to these educational institutions, devoting considerable time and expense. Once completing the credentialing requirements, they apply to their state credentialing board, pay a fee, and then after the board checks to see if all of its requirements have been fulfilled, it grants a license permitting the person to legally provide mental health services. That person then sets up a practice that offers mental health services. People wishing to access these services first devote some time to decide where to go. They then make an appointment, show up for the appointment, and then express their mental health concern to the mental health service provider. Aspects of all of this occur each and everyday and involves tens of thousands of people working in a coordinated fashion to have mental health concerns addressed in a professional manner.
Now, as someone interested in this mental health concern phenomenon, I have spent some time observing the phenomenon by matriculating into undergraduate and graduate programs, and then meeting all of the requirements to provide some mental health services in my state. I’m not permitted to prescribe psychiatric drugs, and if you think electroconvulsive shock treatment is a mental health service, I can’t provide that service either.
But other then those two services, people have made appointments with me for over thirty years and expressed various mental health concerns, and I did my best to work with them to address these concerns.
So, now that I carefully observed this something that I am keenly interested in, I’m ready to put together a classification system with others interested in scientifically studying the same something. To begin the process, I first proposed in a peer-reviewed format a tentative proposal which was accepted for publication (see HERE). It defines my something of interest as follows:
A mental health concern occurs when a person seeking mental health services expresses to a mental health service provider a concern that he or she wants to have addressed.
This definition of a mental health concern requires all of the following items for a mental health concern to exist:
A person seeking mental health services
A mental health service provider offering his or her services
The mental health service provider had to fulfill undergraduate and graduate training that meets the standard of his or her state licensing department.
The person seeking services expresses a concern to a mental health service provider with the desire that he or she will work to address the expressed concern
Notice that the phenomenon that I am talking about requires that all of the various items listed exist in order for a mental health concern to be present. It is therefore far more explicit about what constitutes a mental health concern than the DSM‘s set of criteria for a mental disorder which uses language indicating that a disorder can’t really be defined clearly, but sometimes this is present, or maybe this, or maybe this, unless it is this other thing….
Also notice that no one doubts that each of the 4 listed items that, taken together, make up the mental health concern concept exists. Everyone agrees that there are people who seek mental health services in our society. Everyone agrees there are people licensed to provide mental health services. If you go further down the list, there is no question whatsoever, that these other conditions also exist. So the definition, I contend, meets the scientific standard that it describes the something of interest (mental health concern) in a clear and detailed manner, leaving no room for confusion or doubt. Once the CSM classification system comes to be fully developed, people would be able to use the term “mental health concern” as a short way to indicate a phenomenon that contains all four of its defining characteristics.
With regards to the various types of concerns that mental health service providers are asked to address by those seeking their services, two major types would be, 1. concerns expressed about oneself, and 2. concerns expressed about someone else. Under the headings of each of these two major types would be concerns regarding behavior, emotion, mood, meaning of life, death, dying, managing chronic pain, addiction, work, relationships, education, eating, cognition, sleep, hearing voices others don’t hear, and challenging life situations. This, of course, is just a preliminary list of types, and through survey data that ask psychologists and mental health advocacy groups about the various mental health concerns that they are asked to address, the list would become more fully developed.
Conclusion
The above explanation was designed to clarify just one of the reasons why the proposed CSM’s mental health concern concept provides a far more solid scientific foundation on which to build a classification system than the DSM‘s mental disorder concept. Despite the fact that many people have become convinced that the DSM‘s classification system is a sound scientific instrument, its definition is far more vague than how I propose defining a mental health concern.
Many people, including professionally trained psychiatrists and psychologists, have long argued that the mental disorder concept fails to meet the very basic principles of a valid scientific concept. We can do better by using the basic scientific standard of explicitly defining core concepts in our mental health classification system, and giving people seeking mental health services a choice about whether or not their expressed mental health concerns are to be converted into pathologizing language.
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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.
Regularreaders know that I have, from time to time, been dealing with a conflict regarding psychiatric diagnosis. Said briefly, there are many people who immediately lose respect for anyone who questions the validity of the mental illness/mental disorder theoretical construct. On the other hand, many people have lost respect for the psychiatric profession because of its pathologizing approach of addressing concerns related to thinking, mood, behavior, or challenging life situations. Amidst this conflict, I have been trying to put forth on this blog, and in a number of other publishing outlets, an alternative approach with which the disputing parties can live in relative peace.
Last year, I presented a paper on this topic at the American Psychological Association convention in Denver (see HERE). That paper defended my alternative approach by focusing on the reasons it would, when compared to the current psychiatric approach, be more respectful, beneficial, and fairer to those seeking mental health services while being just as practical for mental health service providers. This year, I will soon (8/5/17) be presenting a paper at the American Psychological Association Convention in Washington D.C. on this topic, but this time I plan to focus on the scientific merits of my alternative. I am hoping to get some feedback about my preliminary draft. So, if you will, please take a look at it. All are encouraged to provide suggestions for improvement or to raise any questions.
My Speech
Albert Einstein created a revolution in the branch of science known as physics. Prior to the 20th century, physicists explained the propagation of light with the use of a theoretical construct known as the ether. There were experts in the ether who described ways to define it, along with its various characteristics. It was thought, for example, that the ether didn’t move in any direction, but it could vibrate. There was much discussion about an ether wind. And then Einstein came along and described the nature of light without resorting at all to the ether.
There was a great deal of resistance to Einstein’s theory at first, but in time his theory came to be accepted as a distinct improvement. Today I want to make the case that the theoretical construct known as mental disorder is the ether of psychology. Here’s a little of what I mean by that.
For a long time now, when people seek to access mental health services, they find that in most settings the concern they want addressed must be converted into mental disorder terminology. In the United States, the text used for this purpose is typically the DSM.
Criticism of the mental disorder construct began at the very beginning of American psychology when William James declared that it was nothing more than superficial medical talk. Criticism continued throughout the 20th century, and when the latest version of the DSM came out, there was a ton of media and professional articles that once again pointed out its numerous scientific shortcomings. Many throughout general psychology expressed deep concerns that psychologists utilizing the DSM approach had sold out to psychiatry and the pharmaceutical industry. Moreover, they bitterly complained that a paradigm that utilizes the mental disorder construct brings down respect for psychology as a legitimate branch of science. What can be done about this?
Well, in thinking about this I hasten to mention that Thomas Kuhn’s (1972) classic book, The Structure of Scientific Revolutions, rightly points out, for real change to occur in a branch of science, it is not enough to point out the weaknesses of a paradigm, there needs, as well, a new approach that is a distinct improvement over the old paradigm. So, is it possible to really come up with a distinct improvement over the current DSM approach? I think our APA can do this easily if it set its mind to it, and it can do so within a year.
What would this new approach look like? Well, for your consideration, I offer you the Classification and Statistical Manual of Mental Health Concerns, or, for short, the CSM. Let’s look at a summary of what it would contain.
It would begin with the following statement:
“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.”
Now think about this for a moment. The expression of a mental health concern is a clearly observable event that occurs at a specific time and place. Thus, by making it the event being classified, it beautifully solves the reliability problems that have been plaguing the DSM’s far more abstract theoretical construct of “mental disorder.”
Here’s the CSM’s definition of its main construct:
A mental health concern occurs when a person seeking mental health services expresses to a mental health service provider a concern about thinking, mood, behavior or challenging life situation.
That’s it—that’s its definition. If a service provider is not certain if a mental health concern has been expressed, he or she could easily verify that it has indeed occurred. Here’s a simple example of what that would look like.
Let’s say Mary Doe comes to a licensed practicing psychologist and says she has been feeling a great deal of sadness much of her days. The psychologist, for verification purposes can say, “I hear you saying that you are concerned about how sad you have been feeling much of your days, and you would like us to work together to address this concern, is that correct?” If the service seeker says yes, this would verify that a mental health concern has been expressed, and what the concern is.
In the CSM, the various concerns would be provided, along with a code for insurance company record keeping. Concerns that would be included in the first edition of the CSM would be selected empirically from survey data that asks practicing psychologists to identify the types of concerns they were asked to address in their practice over the past year, but to avoid utilizing pathologizing words.
The creation of the CSM would provide a common, jargon-free language for mental health service providers that utilizes a distinctly more scientific alternative than the DSM approach. It would stimulate research programs that compare outcomes for services that utilized the DSM approach with that of the CSM approach. Moreover, it would provide a new choice to mental health service consumers, challenge old ideas, and stimulate fresh perspectives.
The scientific merits of the CSM approach, when compared to the DSM approach are numerous. Unfortunately, there is not enough time here to go into them in any detail. For those of you who are interested in the details, you can readily find an article that I recently wrote that is now published in The Journal of Humanistic Psychology. Up on the screen is the reference. [Click HERE to access the journal article]
Call for Feedback
Well, there you have it. I only have seven minutes to present the paper, so many of the essential points that I would love to make have to be left out. There will be some time for questions and discussion, so some additional information could be shared then. And, for those who are interested, as I point out in my paper, they can now readily retrieve a far more complete presentation of my proposal by assessing the journal article I wrote that was just published last month.
Chiefly, my objective in presenting my paper at this year’s APA convention is to stir up the interest of as many psychologists as I can in the hope that a coalition will begin to form that can lead us toward making a significant improvement in the state of the current conflict. Again, I urge readers to let me know their thoughts on this topic, and to make any suggestions they would like aimed at improving my presentation.
With some regularity, former President Trump has been accused of being mentally ill. Here at From Insults to Respect, we’re going today to takea discerning look at this. We’ll begin with some pieces that appeared in the media when he was president, and then see if we can move ahead to make our own informed personal decision.
The Washington Post Article
Bernie Sanders
In a Washington Post article titled, “Bernie Sanders Calls Trump a ‘Pathological Liar’” Ed O’Keefe wrote, “Al Franken says ‘a few’ Republicans think Trump is mentally ill.”
What are the specifics that led to this determination? According to Senator Sanders,
“When somebody goes before you and says that 3 to 5 million people voted illegally …. there is not a scintilla of evidence to believe that, what would you call that remark? It’s a lie. It’s a delusion.”
In the same article, Franken, who was a senator at the time the article was written explains his statement about what he heard from Republicans:
Al Franken
“In the way that we all have this suspicion that — you know, that he’s not — he lies a lot, he says things that aren’t true, that’s the same thing as lying, I guess.”
Having read this article, I came away thinking that there are people who are very sympathetic with what the two senators were trying to say. At the same time, it is also conceivable that the former president knows full well when he is lying but he is using it as a strategy.
Perhaps he has come to believe that many of his most ardent supporters actually believe him when he lies, and it is the media who are telling the lies. Trump may also believe that others of his supporters don’t care that he lies because they believe business folks always exaggerate as they promote their goals, and that Trump is just promoting causes that match their values. Many Americans may therefore see his behavior not as a sign of mental illness, but simply that he is a shrewd businessman.
Finally, Trump may believe that there are other supporters who don’t like it that he lies, but believe that his opponents lie as well. They therefore cancel out this negative, and rely instead on one or more hot button issues such as abortion, immigration, burdensome regulations, health care, etc., for throwing their support behind him. Trump may believe that this group, when combined with those who believe his lies, and those who accept lying as part of doing business, provides him a worthwhile calculated risk that he will have enough support to achieve his personal goals. After all, it worked well enough to get him elected.
Now, to me, some of the solutions Trump was proposing to deal with these issues seemed completely irrational. For example, when he emphatically claimed that if elected he would send back to Mexico the millions of dreamers who had come to the U.S. illegally when they were children, and he was going to get Mexico to pay for building a “beautiful” wall the entire length of our southern border, I could hardly believe my ears. And yet, I soon met quite a few Americans who said that these ideas made perfectly good sense. Does it make sense, therefore that I consider all of these people who disagree with me as having some type of mental illness? What good would that do?
Let’s move on now to take a look at three psychiatrists that object to calling Trump mentally ill.
A Fox News Article
Dr. Keith Ablow
Recently, Fox News published an article by Dr. Keith Ablow titled, “Relax, Trump is Stone Cold Sane.” This doctor is a psychiatrist and a paid member of the Fox News Medical A-Team.
According to Dr. Ablow, the fact that Trump did become elected president is one indication of his soundness of mind. But that, in itself, is not sufficient to give him a clean bill of health. As the doctor explains,
“I should note that nothing I am saying should besmirch the reputations of men like President Abraham Lincoln or Sir Winston Churchill, both of whom are said to have fought the ravages of major depression or bipolar disorder. One was instrumental in ridding America of slavery. The other was instrumental in saving the world from tyranny. Mahatma Gandhi, by the way, also reportedly suffered from depression. Psychiatric illness does not, a priori, disqualify a person from rendering extraordinary service to mankind.”
So, according to Dr. Ablow, if you can become a country’s leader you can still be mentally ill. If that is the case, why then does Dr. Ablow claim that Trump is not mentally ill? It is because, “neither Lincoln nor Churchill nor Gandhi led a nation after becoming a business sensation and television star.”
Hmmm. Well, let’s keep this thought in mind as we move on to hear what another psychiatrist has to say.
Dr. Allen Frances’s Opinion
In the February 14, 2017 edition of the New York Times, there appears a letter to the editor titled, “An Eminent Psychiatrist Demurs on Trump’s Mental State.” The author of the letter is Dr. Allen Frances. In his opinion, “It is a stigmatizing insult to the mentally ill (who are mostly well behaved and well meaning) to be lumped with Mr. Trump (who is neither).”
Dr. Frances goes on to say in part:
“Bad behavior is rarely a sign of mental illness, and the mentally ill behave badly only rarely. Psychiatric name-calling is a misguided way of countering Mr. Trump’s attack on democracy. He can, and should, be appropriately denounced for his ignorance, incompetence, impulsivity and pursuit of dictatorial powers.”
Wow, pretty strong words. As we reflect on this for a few minutes, let’s move on to take a look at one more psychiatric opinion on this subject before we seek to draw our own conclusions.
Dr. Richard A. Friedman’s Opinion
Dr. Richard Friedman
Dr. Friedman’s opinion piece appears in the February 17, 2017 issue of the New York Times. There he tells us that it is unethical for psychiatrists to diagnose mental illnesses in people they have not examined and whose consent they have not received. However, psychiatrists can pretty much get around this principle by describing the common characteristics of a particular mental illness and then say how they might explain Mr. Trump’s behavior. According to a Huffington Post article, several mental health professionals have used this very approach to strongly suggest Trump is mentally ill.
Dr. Friedman then tells us, that even if a doctor did diagnose Trump as mentally ill after a thorough exam, it doesn’t mean he couldn’t be fit to be president. He then concludes:
“So the nation doesn’t need a shrink to help it to decide whether President Trump is fit to serve, mentally or otherwise. Presidents should be judged on the merits of their actions, statements and, I suppose, their tweets. No experts are needed for that — just common sense.”
I fully agree with Dr. Friedman’s conclusion. But it leaves us still up in the air with regards to whether or not it makes sense to view Trump as mentally ill. Let’s see if it makes sense for us to make this judgment for ourselves.
So, Is He, Or Isn’t He?
Since those articles that I discussed above were published, Trump has now been charged with a series of serious crimes regarding taking top secret documents that he was told did not belong to him. Do such actions legitimize viewing him as having a mental illness?
Most doctors would object to untrained individuals making this type of determination, arguing that this should be left to mental health professionals and only by a thorough examination of a patient, a detailed history and all relevant clinical data. This sounds like a pretty thorough way to make a decision as important as this, but from speaking to patients over the years, I’m under the impression that they have been given a so called diagnosis simply by having a discussion with a mental health professional for less than an hour, and often in less than twenty minutes.
The latest version of the DSM, which is used by mental health professions to make this type of determination, states:
“Although no definition can capture all aspects of all disorders in the range contained in the DSM-5, the following elements are required:
“A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognitive, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”
Notice how broad this definition is. It makes mention of a “disturbance” that reflects a “mental dysfunction in the individual.” The DSM definition doesn’t direct us to any reliable or valid way too assess functioning. The process described in the DSM for assessing the subjective notions of “disturbance” and “dysfunction in the individual” is left to the clinician who decides if these are “clinically significant.” Thus, it provides clinicians an opportunity to include anything that benefits their set of values.
Most clinicians have a financial interest in deciding whether or not their clients have a clinically significant condition. When they judge that their patients’ conditions are significant, they indicate this on the third party intake forms and this allows them to continue to see these clients and to get paid for additional visits. On the other hand, clinicians who work in an underfunded community government clinic that is being swamped by those seeking to access mental health services might apply a more stringent standard for what constitutes a mental disorder. Thus, we can hypothesize that this type of clinical judgment may often be based on financial self-interest or clinic treatment capacity than one based on principles of science.
Let us look a little more at the DSM’s attempt to draw distinctions between what is a mental disorder and what is not. According to the DSM, certain socially deviant behavior and conflicts are not mental disorders, although they may be. If the deviance or conflict results from a “dysfunction in the individual,” then a mental disorder exists in the individual. How does one make this type of distinction? Can it be done in some recognized precise manner? In practice, this too is left to the subjective judgment of the clinician that can be biased by financial interests and the capacity of his or her clinic. Might it also be influenced by political points of view as well?
Upon reading the DSM, we find that there is no documentation that people, whether they are clinicians or not, can reliably and objectively distinguish between those who have mental disorders from those who do not. The whole concept of mentally illness is really used to serve the business interests of the pharmaceutical industry and psychiatrists.
Yes, there are people who act in ways that make no sense to the average Joe or Jill. There are indeed people suffering and concerned about their emotions and behaviors. Labeling someone as mentally ill really fails to clarify what is going on, though it creates the illusion to many that it does.
In my view, we become much wiser when we drop the mental illness descriptors and stick to more specific descriptors of behaviors, attitudes, levels of functioning, and our personal values.
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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.
At 39-years of age, Ron had been a respected employee in a department store for nearly ten years. If he had made it to ten full years, he would have qualified for some extra benefits. Upper management chose to replace him with someone new a week before the ten years were up. Discovering that landing a new job was leading to one rejection after another, Ron fell into an anguishing depression.
Observing him having sleepless nights and losing weight, Ron’s wife urged him to see a mental health professional. “You’ve been paying for mental health coverage on your health policy for over fifteen years. You might as well take advantage of it and see if a professional can help you through this.”
Ron resisted, but when he received yet another terribly anxiety producing employment rejection, tears streamed down like two little waterfalls.
At his first appointment with Dr. Sigmund, a cigar smoking psychologist, Ron discovered that to access mental health services with his health policy, he would have to be labeled as a person with a mental disorder. “I don’t want that kind of nonsense in my medical record,” he told Dr. Sigmund. “I’m not mentally ill! I’m just going through some tough times right now and I can use some professional help getting through this.”
“After a long drag on his cigar, Dr. Sigmund sadly explained, “I have to place on the insurance form a mental disorder diagnosis or I can’t see you.”
Thoughts began to race through Ron’s head. Sometimes, on a job application form it asks if I had ever been treated for a mental disorder. If I answer truthfully, that could end up costing me the job. If I lie and someone broke into the insurance records system and released them to the public, I could be convicted of fraud. I was thinking of some day going into politics. If anyone ever got wind of the fact that I was given a so called mental disorder diagnosis, that could be the end of that.
“Listen, Doctor, I’ve been paying for this mental health coverage for years and no one ever told me I had to be given a stigmatizing label to access services. That’s not fair.”
“You feel it’s unfair,” said Dr. Freud. He then paused, frowned, and said, “I’m sorry, but that’s how the system works. And, after all, these are real disorders, based on sound science. In fact we have recently learned that these disorders are properly viewed as genetic diseases. The evidence is pretty plain. We have learned that these types of conditions run in families, and genetic research has even identified the actual genes that are involved.”
Upon hearing this, Ron chose to walk out of the doctor’s office feeling more miserable than when he arrived.
In the above parable, Dr. Sigmund makes three statements.
“I have to place on the insurance form a mental disorder diagnosis or I can’t see you.”
“these [mental disorders] are real disorders, based on sound science.”
“these disorders are properly viewed as genetic diseases.”
I have discussed extensively in earlier posts the issues surrounding the first two statements, so I’ll just briefly address them in the next section while providing the links to those earlier posts. Then we’ll go into a more in-depth discussion about the third statement which declares that mental disorders are properly viewed as genetic diseases.
Dr. Sigmund’s First Two Statements
First, Dr. Sigmund declares that “Without a mental disorder diagnosis, which I must place on the insurance form, I can’t see you.” This is pretty often true. In the United States, if you want to take advantage of your mental health insurance coverage, insurers require a mental disorder diagnosis [see HERE]. Some mental health service providers will see paying customers without the necessity of labeling if the customer pays the entire cost for the services. Paying for services that are not at least partly covered by insurance typically are too costly for the average Joe or Jill.
The second statement made by Dr. Sigmund is, “these are real disorders, based on sound science.” In my opinion, it is not sound science that came up with these types of labels, but rather, a business model that serves the pharmaceutical industry and psychiatry. Psychologists have gone along with the plan for practical reasons. Additionally, some actually are convinced that the labeling system is indeed based on principles of science. For a full critique of their position, see HERE.
In my view, the various conditions that get classified as mental disorders are more aptly construed as concerns about the following group of 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. This group of concerns, for the purpose of accessing mental health services would, under my proposal, be called “mental health concerns.” The concerns, rather than a person, would be classified for insurance purposes. Emphasis would be made on the fact that individuality outruns any classification system.
The Third Statement by Dr. Sigmund
In the parable, Dr. Sigmund declares that “these disorders are properly viewed as genetic diseases.” Is this a fair statement? The simple answer is no. To reasonably arrive at this answer, we’ll have to spend some time going step by step through some basic ideas.
Dr. Sigmund provides two general statements as a defense for his declaration–“We have learned that these types of conditions run in families, and genetic research has even identified the actual genes that are involved.”
When psychologists say that a certain set of characteristics that is classifiable as a mental disorder runs in the family, it doesn’t mean that if someone in the family has that set of characteristics, everyone in the family will have the same set of characteristics. Even identical twins won’t always have the same set of these types of characteristics despite the fact that a pair of identical twins have the same set of genes.
What psychologists typically mean by saying a set of characteristics run in the family, is that there is evidence that there is an increased probability that if one member of the family has the set, other family members are more likely to also have that set. Should this type of evidence lead us to conclude that such a set indicates the presence of a genetic disease?
To understand why the answer is no, we have to first understand that all species have a great number of characteristics, and each of their characteristics vary to some extent between different members of their species. For example, human beings have a typical height, they can run at a typical speed, etc. The average height of male humans is about 5 feet, 9 inches. Some, men are, however, somewhat taller, others are somewhat shorter, and some are quite a bit taller or quite a bit shorter. Similarly, some men can run at the average speed for men, while others can run at various rates that are different from average.
If someone is above average in height, this does not mean he or she will be above average in running speed. Each of our numerous characteristics can be either within the average range, above average, or below, and because someone is below average in some set of characteristics does not mean that he or she will not have some characteristics that are average or even above average. And these differences are a great boom to the human race. If everyone was brilliant in academics and also had a strong genetic desire to be a professor at Ivy League universities, who would build the roads, drive our trucks, grow our crops, serve in law enforcement, cut our hair, tend to the sick, serve as fire fighters, staff stores, serve us in restaurants, etc.? People with different interests and talents enhance our own lives.
Now, clearly some human characteristics do run in the family. How tall you become is one such characteristic. Nevertheless, even if both of your parents are taller than average, you may still end up shorter than average.
If you do end up shorter than average this does not mean you have a genetic disease, even if we can demonstrate that taller people tend to have some advantages over people who are shorter. Saying that people who are shorter than average have a dysfunction would be stigmatizing while clouding the fact that we cannot determine a person’s overall functioning based on just one set of characteristics. Being shorter, when combined with the rest of a person’s characteristics, can lead to him or her being more useful in a variety of ways.
Let’s move on now from discussing a person’s height to a more complex set of characteristics–athletic performance. There is some evidence that athletic performance might be a set of characteristics that, to some degree, runs in the family. Deliberate practice seems to be a much greater predictor of skill in a particular sport, but let’s say for argument sake that at least to some extent there is indeed some inheritability to this set of characteristics. If a physical education teacher sees a child performing below average in athletic achievement, even if we are completely confident that this characteristic runs in the family, does this mean that this child has a genetic disease?
We could, if we wanted, label the child as having a “Muscle Deficit Disorder,” and claim that he or she rightfully has a genetic disease which is treatable with steroids. That would not, in my opinion, be in the child’s best interest. Admittedly that is just my value judgment. But I also contend that if we wanted to label the child as having a “Muscle Deficit Disorder,” that too would be a decision based on a value judgment, rather than one based on being consistent with principles of science.
Rather than pathologizing below average athletic skills, I’ve seen physical education teachers who encourage such children to participate in some after school programs that develop skills in sports that can be practiced non-competitively, such as running, bicycling, and golf. Some of these children take to such programs willingly and end up staying in fine physical shape the rest of their lives. If they don’t, they suffer the consequences and all of us end up paying higher health premiums because they are at an increased risk of getting sick. At the same time, their other sets of characteristics, when combined with their couch potato ways, may offer them and the rest of us some valued fruits.
Just because some people have a different group of genes that might increase the likelihood that a certain set of characteristics will be expressed does not mean these people have a disease. I know that some psychologists say, it is only the sets of characteristics that can be linked in some way to a “dysfunction” that are properly labeled as a disease. But the dysfunctional descriptor is so vague that it can be applied to the vast majority of people, and, perhaps, everyone.
Let’s say we can identify a set of genes that increase the chances that someone will enlist in the military. Now, let’s say we find that joining the military places these people at greater risk of harm, and even death. Would the finding of this type of connection require us to say that this means all who join the military have a dysfunction and therefore they also have a genetic disease? How about people who have become addicted to smoking, like old Dr. Sigmund? At one point, most Americans were smoking. Smoking can be labeled a dysfunctional characteristic. If it tends to run in the family, would that justify our declaring that all of this majority had a genetic disease?
How about becoming a psychiatrist? This may run in the family. If we find that becoming a psychiatrist increases the likelihood of committing suicide, which some data suggests, are all of them to be viewed as having a genetic disease, or would it be clearer, and more scientific, to say their set of characteristics is a “risk factor” for some negative outcome? I believe the latter is more scientific.
How about just being a male? Being a male increases the risk of violence. Or how about being a woman? Being a woman increases a person’s risk of becoming depressed, which psychopathologists are eager to tell us is a dysfunction. Don’t these facts pretty much indict us all with regards to having a genetic disease?
Now let’s turn to the statement that genetic research has identified the actual genes that are involved in mental disorders. I have read this research carefully and came away convinced that we are not even close to making this claim. Evaluating the research is complicated, but I’ll just make two simple points about this that can help readers to better understand this issue.
First of all, if Dr. Sigmund’s statement was true, mental disorders would be diagnosed by doing a test of one’s genes. This is not how mental disorder diagnoses are made. Instead, psychologists have a conversation with the person seeking mental health services.
Second, if genes determined whether or not someone had a particular set of characteristics that gets labeled a mental disorder, what happens to those genes when someone who was labeled as having a mental disorder recovers, which often occurs? Do the genes somehow float out of the person’s body, and rise up to heaven? Actually the genes in the body remain right where they were when the person was said to have a mental disorder.
As I read the research on this issue, it became plain to see that genes can be likened to the buds of a beautiful flower. If they meet up with the right soil, sunlight, water, and care, they typically blossom into something beautiful. But even with a great deal of wonderful nourishment, sometimes they get tangled up with some surrounding weeds. Stigmatizing labels don’t help in such situations. Instead, some wise gardening can make a beautiful difference.
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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 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.
Welcome to From Insults to Respect. On this blog, from time to time, we have been discussing depression. To help us better understand this deeply troubling experience, we have looked at the biographies of several individuals who, despite their mighty struggles with depression, still managed to earn the respect of millions. Today, we quickly review three of these biographies, that of the brilliant psychologist and philosopher William James, the remarkable musical performer Joni Mitchell, and the great Russian writer Leo Tolstoy.
Finally, in an earlier post (see here) we looked at the great writer, Leo Tolstoy. In his painfully personal book, My Confession, Leo Tolstoy tells us about his two-year period of despair. At about the age of 50, his life had become “flat, more than flat: dead.” Suicidal thoughts were all too frequent.
Wrenshall Smith encountered him returning from the battle and depicted him as “much depressed. He dismounted and took a seat on the stone. What is the situation, I asked? Bad–very bad, he replied.” Samuel Beckwith noticed that after Cold Harbor Grant’s face developed “a careworn expression that indicated sleepless nights and fearsome days.” When he delivered a message to the general’s tent, he found him sunk in thought. After absorbing the telegram, Grant sighed, “Beckwith,” he said, “the hardest part of this General business is the responsibility for the loss of one’s men. I can see no other way out of it, however; we’ve got to keep at them. But it is hard, very hard, to see all these brave fellows killed and wounded. It means aching hearts back home.”
The doctors’ statements about this imply that if treated with “antidepressants” this can decrease the risk of suicide enough so that the depressed patient, by taking the drug, is better off than facing the risk of any adverse effects of the drug. But the doctors don’t know what the long term effects of taking the drugs are. What’s more, the scientific evidence currently available indicates that these drugs do not reduce the risk of suicide, and may actually increase it by as much as 8 percent (see HERE for the most recent review of the research).
This alternative is uplifting, less stigmatizing, and conducive to a recovery point of view. It is a view that posits that depression has the potential to open our eyes to the fullness of truth. The suffering that goes along with the experience is a natural part of life, a view held by Nietzsche, as well as Buddhists and many other wisdom traditions. Additionally, it is an enormous source for creativity, and as we go through it, it can lead to one insight after another.
This is an important lesson for so many of us who were brought up being taught to feel embarrassed and guilty when experiencing deeply sad emotions. In fact, for those who were brought up this way, they often believe that it is proper to lose respect for people who experience such emotions. They often end up having, each time they, personally, experience depression, a double depression. That is, not only do they at times begin to become depressed because of the reasons that would normally lead to feelings of melancholy, but they are additionally depressed about feeling that there is something terribly wrong with them, that they have bad genes and a stigmatizing illness requiring medication with all kinds of negative side-effects.
Giving up this tendency to feel a double depression for those who learned it throughout their childhood and well into their adult life often requires a relationship with someone providing quality social ties and social support. Substantial evidence (see here for a research literature review) has accumulated over the past few decades showing that social ties and social support are positively and causally related to mental health, physical health, and longevity. Evidence also documents that social support buffers the harmful physical and mental health impacts of stress exposure.
Although it is least expensive to receive this kind of support from warm, close friends and family members, sometimes those whom we are most close to hold the very same pathologizing beliefs that is holding one back from real recovery. At such times, finding a professional personal counselor who does not hold to the pathologizing point of view can be enormously helpful if the financial situation can be reasonably worked out. Discussions with the professional who typically responds in a very supportive manner, models for the person receiving counseling the type of skills that is helpful when we look within as we experience melancholy. Instead of berating ourselves for acting pathological, we come to learn to be kind to ourselves and to nurse hope that something positive will come from what we are going through.
Some non-pathologizing counselors will also encourage you to learn to meditate and utilize other mindfulness techniques. Here you practice observing your physical sensations when you are dealing with the disrespectful perceptions. In time, the disrespectful words that you tend to direct at yourself come to lose their disturbing nature. For a period of time these words still come, but you end up smiling at them as you realize they are not matching reality. In time, they may completely fade away as you embrace the physical sensations that come with melancholy.
Now, I understand that many people will find it hard to find in their community the type of counseling services I am describing. This may be because many professional counselors have adopted the same pathologizing approaches as psychiatrists, although they do believe counseling services, when combined with drug treatment, can be beneficial. For those who would like to work with a non-pathologizing personal counselor but find it difficult to find one within a convenient distance from home, I highly recommend two who can work with you individually via Skype–my son, Jack Star Rubin, and his lovely wife, Emily Whyte Rubin (see here to learn more about the counseling approach of these two personal counselors and their contact information).
Your insurance company requires that I must place a diagnosis on your health insurance form for you to access that service. I hear, so far, that you are concerned about….”
“Well, I wish we didn’t have to get into this labelling issue. Personally, I think it’s best to treat each person that I provide counseling to as an individual. It is understandable that many people don’t want to be placed in a diagnosis box, especially one known to be stigmatizing. But the insurance companies do require a diagnosis.”
In my journal article, I go on to propose a practical, more scientific alternative to the DSM. I call this alternative, the Classification and Statistical Manual of Mental Health Concerns (CSM). The first words in the CSM would be: “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.”
On the other hand, some resisted the CSM approach. As I began to question them, seeking to figure out where exactly the disconnect was, I discovered that for some, it had to do with their belief that the DSM is a classification system based on solid principles of science and nothing could possibly be better. As I questioned them further, I discovered that their understanding of what a scientific classification system is designed to do was a bit incomplete. So, in today’s post, I explain in an easy to understand manner the nature of scientific classification systems, beginning with a description of a classification system with which we are all so very familiar–birds. This will enable us to see clearly why the bird classification system is useful as a scientific instrument. We will then look at the DSM classification system in light of what we learned about the bird system, and this will reveal the DSM‘s serious scientific shortcomings. Finally, we will compare and contrast the DSM system with the proposed CSM system in a manner that can make the superior scientific merits of the latter crystal clear.
As it turns out, there are some people very interested in birds.
Once scientists carefully define their general topic of interest, they describe different types of what they are interested in. So in our bird example, the scientist interested in them came up with a taxonomy that lists bluejays, pigeon, sparrow, and so forth as subtypes of the general category of birds, describing each subtype in a precise manner that can reliably distinguish each from the others on their list. Why bother to do this?
The main reason is that when they discuss their findings with others, they want to make sure they are using words that mean the same thing, and it is a great time saver. For example, let’s say John is a bird scientist and he says to Judy, another scientist, “I saw a bird the other day and I didn’t know what type it was; can you help me figure out what it is?” Notice that since both of these scientists know the meaning of a bird, it saves John quite a few words. Just imagine if instead every time John uses the word bird he had to say, “I saw something that had an endothermic vertebrae, characterized by feathers, toothless beaked jaws, the laying of hard-shelled eggs, a high metabolic rate, a four-chambered heart, and a strong yet lightweight skeleton.” That’s quite a mouthful to have to say each and every time you refer to a bird. In this example, just saying bird saves a scientist about 30 words each time the word bird is used.
And let’s say John, the scientist, wants to find in a library some information about a particular type of bird. He would have to waste time looking at every single book in his library until he found one that seemed to be talking about what he was interested in.
This would result in John having to unnecessarily wade through numerous books on flying insects, of which there are hundreds of thousands of types, bats, and some fish that sort of can fly. With the current bird classification system, anyone can go to a library and quickly find the specific section that houses information on just birds. Similarly, placing the word “bird” in a search engine enables John to more quickly retrieve relevant information than would a less explicit definition.
“In the DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significant increase risk of suffering death, pain, disability, or an important loss of freedom.”
The latest edition of the DSM (DSM-5) is just as vague. It begins, “Although no definition can capture all aspects of all disorders in the range contained in the DSM-5, the following elements are required.” Although it says the following elements are required, it then makes it clear that the elements that it lists are not required. As I provide the rest of the definition, notice the use of the word “or” and “usually.”
“A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognitive, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.” 
This is about as vague a descriptor as one can possibly conjure up. How about the descriptor “dysfunction?” This, too, is left to the subjective opinion of mental health providers who often have financial interests in declaring that someone has a mental disorder.
I, for one, am interested in a phenomenon that I, and others, call mental health concerns. Obviously there is wide interest in this. After all, there are numerous educational institutions that provide training to people so they can become credentialed to address mental health concerns. Numerous people actually voluntarily go to these educational institutions, devoting considerable time and expense. Once completing the credentialing requirements, they apply to their state credentialing board, pay a fee, and then after the board checks to see if all of its requirements have been fulfilled, it grants a license permitting the person to legally provide mental health services. That person then sets up a practice that offers mental health services. People wishing to access these services first devote some time to decide where to go. They then make an appointment, show up for the appointment, and then express their mental health concern to the mental health service provider. Aspects of all of this occur each and everyday and involves tens of thousands of people working in a coordinated fashion to have mental health concerns addressed in a professional manner.
This definition of a mental health concern requires all of the following items for a mental health concern to exist:
Also notice that no one doubts that each of the 4 listed items that, taken together, make up the mental health concern concept exists. Everyone agrees that there are people who seek mental health services in our society. Everyone agrees there are people licensed to provide mental health services. If you go further down the list, there is no question whatsoever, that these other conditions also exist. So the definition, I contend, meets the scientific standard that it describes the something of interest (mental health concern) in a clear and detailed manner, leaving no room for confusion or doubt. Once the CSM classification system comes to be fully developed, people would be able to use the term “mental health concern” as a short way to indicate a phenomenon that contains all four of its defining characteristics.
With regards to the various types of concerns that mental health service providers are asked to address by those seeking their services, two major types would be, 1. concerns expressed about oneself, and 2. concerns expressed about someone else. Under the headings of each of these two major types would be concerns regarding behavior, emotion, mood, meaning of life, death, dying, managing chronic pain, addiction, work, relationships, education, eating, cognition, sleep, hearing voices others don’t hear, and challenging life situations. This, of course, is just a preliminary list of types, and through survey data that ask psychologists and mental health advocacy groups about the various mental health concerns that they are asked to address, the list would become more fully developed.
The above explanation was designed to clarify just one of the reasons why the proposed CSM’s mental health concern concept provides a far more solid scientific foundation on which to build a classification system than the DSM‘s mental disorder concept. Despite the fact that many people have become convinced that the DSM‘s classification system is a sound scientific instrument, its definition is far more vague than how I propose defining a mental health concern.
Regular readers know that I have, from time to time, been dealing with a conflict regarding psychiatric diagnosis. Said briefly, there are many people who immediately lose respect for anyone who questions the validity of the mental illness/mental disorder theoretical construct. On the other hand, many people have lost respect for the psychiatric profession because of its pathologizing approach of addressing concerns related to thinking, mood, behavior, or challenging life situations. Amidst this conflict, I have been trying to put forth on this blog, and in a number of other publishing outlets, an alternative approach with which the disputing parties can live in relative peace. 
Last year, I presented a paper on this topic at the American Psychological Association convention in Denver (see 
Albert Einstein created a revolution in the branch of science known as physics. Prior to the 20th century, physicists explained the propagation of light with the use of a theoretical construct known as the ether. There were experts in the ether who described ways to define it, along with its various characteristics. It was thought, for example, that the ether didn’t move in any direction, but it could vibrate. There was much discussion about an ether wind. And then Einstein came along and described the nature of light without resorting at all to the ether.
Criticism of the mental disorder construct began at the very beginning of American psychology when William James declared that it was nothing more than superficial medical talk. Criticism continued throughout the 20th century, and when the latest version of the DSM came out, there was a ton of media and professional articles that once again pointed out its numerous scientific shortcomings. Many throughout general psychology expressed deep concerns that psychologists utilizing the DSM approach had sold out to psychiatry and the pharmaceutical industry. Moreover, they bitterly complained that a paradigm that utilizes the mental disorder construct brings down respect for psychology as a legitimate branch of science. What can be done about this?
Well, in thinking about this I hasten to mention that Thomas Kuhn’s (1972) classic book, The Structure of Scientific Revolutions, rightly points out, for real change to occur in a branch of science, it is not enough to point out the weaknesses of a paradigm, there needs, as well, a new approach that is a distinct improvement over the old paradigm. So, is it possible to really come up with a distinct improvement over the current DSM approach? I think our APA can do this easily if it set its mind to it, and it can do so within a year.
Let’s say Mary Doe comes to a licensed practicing psychologist and says she has been feeling a great deal of sadness much of her days. The psychologist, for verification purposes can say, “I hear you saying that you are concerned about how sad you have been feeling much of your days, and you would like us to work together to address this concern, is that correct?” If the service seeker says yes, this would verify that a mental health concern has been expressed, and what the concern is.
Well, there you have it. I only have seven minutes to present the paper, so many of the essential points that I would love to make have to be left out. There will be some time for questions and discussion, so some additional information could be shared then. And, for those who are interested, as I point out in my paper, they can now readily retrieve a far more complete presentation of my proposal by assessing the journal article I wrote that was just published last month.
Perhaps he has come to believe that many of his most ardent supporters actually believe him when he lies, and it is the media who are telling the lies. Trump may also believe that others of his supporters don’t care that he lies because they believe business folks always exaggerate as they promote their goals, and that Trump is just promoting causes that match their values. Many Americans may therefore see his behavior not as a sign of mental illness, but simply that he is a shrewd businessman.
“I should note that nothing I am saying should besmirch the reputations of men like President Abraham Lincoln or Sir Winston Churchill, both of whom are said to have fought the ravages of major depression or bipolar disorder. One was instrumental in ridding America of slavery. The other was instrumental in saving the world from tyranny. Mahatma Gandhi, by the way, also reportedly suffered from depression. Psychiatric illness does not, a priori, disqualify a person from rendering extraordinary service to mankind.”
In the February 14, 2017 edition of the New York Times, there appears a 
At 39-years of age, Ron had been a respected employee in a department store for nearly ten years. If he had made it to ten full years, he would have qualified for some extra benefits. Upper management chose to replace him with someone new a week before the ten years were up. Discovering that landing a new job was leading to one rejection after another, Ron fell into an anguishing depression.
“You’ve been paying for mental health coverage on your health policy for over fifteen years. You might as well take advantage of it and see if a professional can help you through this.”
At his first appointment with Dr. Sigmund, a cigar smoking psychologist, Ron discovered that to access mental health services with his health policy, he would have to be labeled as a person with a mental disorder. “I don’t want that kind of nonsense in my medical record,” he told Dr. Sigmund. “I’m not mentally ill! I’m just going through some tough times right now and I can use some professional help getting through this.”
“Listen, Doctor, I’ve been paying for this mental health coverage for years and no one ever told me I had to be given a stigmatizing label to access services. That’s not fair.”
In fact we have recently learned that these disorders are properly viewed as genetic diseases. The evidence is pretty plain. We have learned that these types of conditions run in families, and genetic research has even identified the actual genes that are involved.”
First, Dr. Sigmund declares that “Without a mental disorder diagnosis, which I must place on the insurance form, I can’t see you.” This is pretty often true. In the United States, if you want to take advantage of your mental health insurance coverage, insurers require a mental disorder diagnosis [see 
In my opinion, it is not sound science that came up with these types of labels, but rather, a business model that serves the pharmaceutical industry and psychiatry. Psychologists have gone along with the plan for practical reasons. Additionally, some actually are convinced that the labeling system is indeed based on principles of science. For a full critique of their position, see 
In the parable, Dr. Sigmund declares that “these disorders are properly viewed as genetic diseases.” Is this a fair statement? The simple answer is no. To reasonably arrive at this answer, we’ll have to spend some time going step by step through some basic ideas.
Even identical twins won’t always have the same set of these types of characteristics despite the fact that a pair of identical twins have the same set of genes.
To understand why the answer is no, we have to first understand that all species have a great number of characteristics, and each of their characteristics vary to some extent between different members of their species. For example, human beings have a typical height, they can run at a typical speed, etc. The average height of male humans is about 5 feet, 9 inches. Some, men are, however, somewhat taller, others are somewhat shorter, and some are quite a bit taller or quite a bit shorter. Similarly, some men can run at the average speed for men, while others can run at various rates that are different from average.
If someone is above average in height, this does not mean he or she will be above average in running speed. Each of our numerous characteristics can be either within the average range, above average, or below, and because someone is below average in some set of characteristics does not mean that he or she will not have some characteristics that are average or even above average. And these differences are a great boom to the human race. If everyone was brilliant in academics and also had a strong genetic desire to be a professor at Ivy League universities, who would build the roads, drive our trucks, grow our crops, serve in law enforcement, cut our hair, tend to the sick, serve as fire fighters, staff stores, serve us in restaurants, etc.? People with different interests and talents enhance our own lives.
If you do end up shorter than average this does not mean you have a genetic disease, even if we can demonstrate that taller people tend to have some advantages over people who are shorter. Saying that people who are shorter than average have a dysfunction would be stigmatizing while clouding the fact that we cannot determine a person’s overall functioning based on just one set of characteristics. Being shorter, when combined with the rest of a person’s characteristics, can lead to him or her being more useful in a variety of ways.
Let’s move on now from discussing a person’s height to a more complex set of characteristics–athletic performance. There is some evidence that athletic performance might be a set of characteristics that, to some degree, 
Rather than pathologizing below average athletic skills, I’ve seen physical education teachers who encourage such children to participate in some after school programs that develop skills in sports that can be practiced non-competitively, such as running, bicycling, and golf. Some of these children take to such programs willingly and end up staying in fine physical shape the rest of their lives. If they don’t, they suffer the consequences and all of us end up paying higher health premiums because they are at an increased risk of getting sick. At the same time, their other sets of characteristics, when combined with their couch potato ways, may offer them and the rest of us some valued fruits.
I know that some psychologists say, it is only the sets of characteristics that can be linked in some way to a “dysfunction” that are properly labeled as a disease. But the dysfunctional descriptor is so vague that it can be applied to the vast majority of people, and, perhaps, everyone.
How about becoming a psychiatrist? This may run in the family. If we find that becoming a psychiatrist increases the likelihood of committing suicide, which some data suggests, are all of them to be viewed as having a genetic disease, or would it be clearer, and more scientific, to say their set of characteristics is a “risk factor” for some negative outcome? I believe the latter is more scientific.
Instead, psychologists have a conversation with the person seeking mental health services.
As I read the research on this issue, it became plain to see that genes can be likened to the buds of a beautiful flower. If they meet up with the right soil, sunlight, water, and care, they typically blossom into something beautiful. But even with a great deal of wonderful nourishment, sometimes they get tangled up with some surrounding weeds. Stigmatizing labels don’t help in such situations. Instead, some wise gardening can make a beautiful difference.
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, 
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.