“Good morning, Barbara,” I say, as my first counseling case walks into my office. I notice she looks a little angry. Upon sitting down, she declares, “I’m terribly frustrated. I’ve been depressed now for over two weeks, and I just can’t shake it!”
It’s easy for me to empathize because I regularly have bouts of what I refer to as melancholy. A deep anguish comes over me, and during this period I often begin to think about how I went through my father’s death when I was twelve, how I’m getting older and can no longer do the many athletic things that thrilled me when I was younger, and on and on. Sometimes these dark melancholy experiences come about because something clearly happened that upset me, and sometimes they seem to come out of the blue.
Beyond Listening in a Caring Manner
After listening in a caring way to Barbara for a few minutes, I ask her if something specifically happened that led her into her current emotional experience. Then I explore with her a question about how often she has these experiences and if she feels she has them more frequently than most people, about as often as most, or less than most. Then, I ask her about how she has been functioning in other areas of her life–sleep, eating, exercise, interpersonal relationships, work/school, household responsibilities.
You see, as people experience depression, or other concerns that often lead to a classification of having a mental disorder, some people go about their lives functioning as they typically were doing before the concern arose, while some find that in some areas they begin to function below the levels that are typical for them, while some find that their functioning increases in one or more areas. For example, some sleep about the same amount, some less, and some more. I have met people who, when they are depressed, start cleaning every inch of their home, while others find it difficult to get out of bed.
Also of interest when exploring a person’s expressed concern is to look at how the person had been functioning before the onset of the presenting concern. If some important relationships had begun to function below average, or if the person had been sleeping less than average to keep up with work demands, these facts can be insightful when seeking ways to address the presenting concern.
Now, once I found out what Barbara was concerned about, what might have precipitated the concern, and how she had been functioning in various areas of her life, I had a pretty good idea as to how to proceed in addressing her concern. I had no need to decide whether or not she had a mental disorder. However, many mental health practitioners are required to declare that the person seeking mental health services has a mental disorder if they want to get paid. Is this mental illness labeling really necessary?
Mental Illness Labeling Versus an Addressing Concern Approach
There are those who embrace this mental illness/disorder labeling. One reason is the pharmaceutical industry’s promotion of this idea to sell people on the idea that they need certain drugs to live a more normal, healthier life.
Beyond that, another major reason for this is that these individuals have a group of people in their lives that blame them for the way that they have been feeling or acting. When a doctor has declared, for example, that John Smith has a mental disorder, he may feel vindicated. “You see, there really is something wrong with me!” he may cry out in his defense.
In actuality, those who are doing the blaming may continue their blaming despite the doctor’s opinion. Moreover, many of us don’t blame people whenever they find some concern has arisen in their lives even if they are going through a non-illness experience. I know I’m not blaming myself when I experience melancholy, and I was not at all blaming Barbara for what she was going through.
Those who are uncomfortable about the use of “mental illness” terminology point out they are stigmatizing because they are used as put downs in our society. Moreover, the media associates the most heinous crimes with those referred to as the mentally ill even though the vast majority of those classified in this manner are not violent.
Among the most articulate individuals to voice objections to the mental disorder labeling was Harvard psychologist and philosopher William James. Over one hundred years ago he wrote a book titled, The Varieties of Religious Experience (1902). At that time many medical doctors argued that people who were religious were all mentally ill. In response, Professor James wrote:
Medical materialism seems indeed a good appellation for the too simple-mindedsystem of thought which we are considering. Medical materialism finishesup Saint Paul by calling his vision on the road to Damascus a discharginglesion of the occipital cortex, he being an epileptic.
Girl (6-8) praying, profile, close-up
It snuffs out Saint Teresa as an hysteric, Saint Francis of Assisi as an hereditary degenerate.George Fox’s discontent with the shams of his age, and his pining for spiritualveracity, it treats as a symptom of a disordered colon. Carlyle’s organ-tonesof misery it accounts for by a gastro-duodenal catarrh. All such mentalovertensions, it says, are, when you come to the bottom of the matter,mere affairs of diathesis (auto-intoxications most probably), due to theperverted action of various glands which physiology will yet discover.(p. 29)
James goes on from here to point out that it is true, of course, that psychology has found that there are definite psycho-physical connections that “hold good” (p. 30). Psychology, therefore:
assumes as a convenient hypothesis that the dependence of mental stateson bodily conditions must be thoroughgoing and complete. If we adopt theassumption, then of course what medical materialism insists on must betrue in a general way, if not every detail…. But now, I ask you, howcan such an existential account of facts of mental history decide in oneway or another on their spiritual significance? According to the generalpostulate of psychology just referred to, there is not a single one ofour states of mind, high or low, healthy or morbid, that has not some organic process as its condition. Scientific theories are organically conditionedjust as much as religious emotions are; and if we only knew the facts intimatelyenough, we should doubtless see “the liver” determining the dicta of thesturdy atheist as decisively as it does those of the Methodist under convictionanxious about his soul. When it alters one way the blood that percolatesit, we get the Methodist, when in another way, we get the atheist formof mind. So of all our raptures and our drynesses, our longings and pantings,our questions and beliefs. They are equally organically founded, be theyreligious or of non-religious content. (p. 30)
James points out that in the natural sciences and the arts it never occurs to anyone to refute opinions, beliefs and experiences by putting down their author’s neurological constitution. Value is determined by “judgments based on our own immediate feelings primarily; and secondarily on what we can ascertain of their experiential relations to our moral needs and to the rest of what we hold as true” (p. 33).
James was additionally concerned that medical materialism greatly overgeneralizes its knowledge of the connections between physiological variables and mind states. In James’s day, the pathology writers would take the few psychophysical correlations that they obtained under highly specialized conditions and then vaguely generalize their findings to discredit, to their satisfaction, all of the states of mind that they disliked.
The Modern Day View
Now, modern day psychiatrists sometimes respond,
“Well, certainly in James’s day we indeed knew almost nothing about such matters, but today our knowledge has vastly increased! Thus, James’s position is no longervalid because we can now make sound statements about the connections betweenphysiological states and mind states.”
To this, I respond that in point of fact there is currently a renewed respect for the extraordinary complexity
that exists during the integration process between mind, physiology, behavior, and environmental variables. Whereas it is true that there have been large gains in our knowledge, these gains are best likened to moving from a few drops of knowledge to a glass almost full; yet, to really understand the integration process, we would need oceans and oceans of knowledge. Trillions and trillions of interactions are involved.
It is for these reasons that the mental illness/disorder terminology is misleading. As Dr. Thomas Insel, the former director of the National Institute of Mental Health, recently said about the psychiatric labeling process known as the DSM.
The weakness [of the DSM] is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half-century as we have understood that symptoms alone rarely indicate the best choice of treatment.
To hear and view other leading scientists further make this point, I highly recommend the following free video:
When individuals express a concern, exploring how they are functioning in the main areas of their life can be enormously helpful. Someone who reports a concern about experiencing depression, whom, by some gentle questioning, we find out has been functioning below average in the areas of sleep, interpersonal relationships, and exercise may benefit enormously if we work together on getting these areas of functioning in a more optimal range. This is true for those who report other types of concerns such as experiencing anxiety, hearing voices, below average range of attention, obsessive thoughts, and on and on. With a model that includes addressing concerns and exploring ways to improve functioning, labeling someone as having a mental disorder becomes unnecessary and may actually interfere with the aims of a counseling/psychotheraputic relationship.
For those who desire, for whatever reason, to be labeled as having a mental disorder, I am not proposing that we interfere with this. But for those who desire to have their concerns addressed by well trained mental health professionals without being referred to as having a mental illness or disorder, I do propose that we do provide a reasonable option for them to access mental health services. In my view, mental health professionals, once we hear our clients’ concerns and how they are functioning in the various areas of their lives, we have the basics to formulate, in full cooperation with our clients, a plan for addressing these concerns. I hope you give this some thought.
For those of you who would like to learn more about how an addressing concern approach would work and be consistent with science if adopted by mental health providers, you can access my peer reviewed article for free by clicking HERE.
Until next week, may you find some kindness out there in this fascinating world of ours.
My Best,
Jeff
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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional intelligence. To begin at the very first post you can click HERE.
On August 8, 2015, I spoke at the American Psychological Association’s annual convention that was held in Toronto, Canada. My speech was part of a two hour symposium titled: “Beyond the DSM–Current Trends in Devising New Diagnostic Alternatives.” The DSM’s letters stand for the Diagnostic and Statistical Manual of Mental Disorders. It is currently used by most mental health professionals to classify people seeking mental health services.
When the latest version of this manual came out, it was widely criticized. Consequently, a group of psychologists began to work together to think about possible alternatives. Several members of that group spoke at this symposium.
My Speech
Of late, I have been discussing today’s symposium theme with quite a few people. I have found that supporters of the DSM 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 article titles, book titles, and search engines to retrieve valued relevant information; third party payers of mental health services have found that the DSM 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, from my discussions, those are the basic reasons supporters of the DSM say that it is useful. Actually, there is another usefulness of the DSM that, interestingly, I never hear supporters of the DSM mention, and yet critics of the DSM often mention. That usefulness is this: by using medical sounding terms to refer to all of the experiences that the DSM classifies as “mental disorders” it legitimizes in the minds of many the prescribing of drugs for these experiences.
There is an enormous amount of money being made from this approach because it takes less than a penny to manufacture each pill, and it can be sold for more than one thousand times that amount. With so much money being generated from this enterprise, the drug companies have managed to make it clear to powerful groups that what benefits the drug companies also benefits them. Examples are, major media outlets gain enormous revenues from drug company advertisements, and political campaigns get substantial support from the industry.
So this benefit is in a sense the elephant in the room. I fully see it, but nevertheless, I want to move it off to the side of the room for now, and ask you all to briefly ignore it. After I complete my main ideas, I’ll return to the elephant in my concluding remarks.
Keeping in mind just the usefulness of the DSM that its supporters tend to mention, it seems to me that if we are to have any hope that an alternative to the DSM might be widely adopted, we would have to be able to make an excellent case that the alternative would be just as helpful while, at the same time, have significantly less shortcomings.
What are these shortcomings? Well, in brief, critics of the DSM have expressed concerns that it tends to be stigmatizing to mental health service users; the DSM also simplistically devalues all of the experiences that it classifies as mental disorders 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.
Leo Tolstoy
For example, Leo Tolstoy reported in his biography, My Confession, that by going through a period of suicidal depression, it led to one valued insight after another.
Joni Mitchell
As another example, the fine song writer, Joni Mitchell apparently went through, during her life, a number of very challenging emotional experiences that first received the full DSM psychopathologizing treatment. In time, her perspective changed, and at one point she expressed her new perspective in a song titled, “Hejira.” She wrote, “There’s comfort in melancholy where there is no need to explain, it’s just as natural as the weather in this moody sky today.” Thus, for many, the framing of their experiences as mental disorders dramatically misses the mark; critics of the DSM also point out that it violates basic principles of science because of its vaguely defined constructs and thus low inter-rater reliability; the DSM also violates basic principles of humanistic psychology; and within the mental health field the DSM is a monopoly, with all of the drawbacks associated with such an organizational situation.
So, those are, in brief, the DSM shortcomings. Keeping them in mind along with its perceived benefits, is it possible to come up with an alternative that indeed does achieve all of the benefits that the DSM supporters claim for it, while, at the same time, has far fewer shortcomings? 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 would contain.
Chapter 1
The first chapter would begin by stating that 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’s far more abstract concept of “mental disorders.”
After this statement, the CSM would clearly define 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 any of these topics: behavior, emotion, mood, addictions, meaning of life, death, dying, managing chronic pain, work, relationships, education, eating, cognition, sleep, and challenging life situation.
So, those are the basic ingredients of Chapter 1.
Chapter 2
Chapter 2 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 child’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 article titles, book titles and search engines.
Each of the actual expressed concerns would be just as useful as the DSM terms for providing those in the mental health profession a common language for communication about those utilizing their services.
In this chapter 2, it would be explained how the creators of the CSM identified the list of concerns included in the CSM. These concerns would be identified by a survey of a sample of mental health service providers. Those filling out the survey would first read the definition of a mental health concern. Then they would list, in order of frequency, the various concerns that they had been asked to address in their practice over the course of the previous year. At the back of the CSM would be a summary of the findings of this survey and its related statistics.
Moving on to Chapter 3
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 lengthier 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. This type of psychological formulation provides an approach that expands on the brief expressed concerns of individuals by developing a narrative of several paragraphs. It can be defined as the process involving a mental health service user and a mental health service provider co-constructing a hypothesis or ‘best guess’ about the origins of the mental health service user’s concerns in the context of his or her strengths, relationships, social circumstances, cultural heritage, life events, and the sense that he or she has made of them.
Defending the CSM
Okay, these are the basic chapters of the CSM. Now let’s quickly recall that supporters of the DSM believe that it is a classification system that is useful because it provides a common language for mental health professionals to communicate with one another. I hope from what I have already said, that you can plainly see that the CSM would provide an alternative plain, humane language that would be just as practical as the DSM. But let’s look a little more closely at this via an example.
When I was doing my practicum at the University of Minnesota’s Counseling Center, I worked there for a whole year and we had no need to use the “mental disorder” jargon of the DSM to communicate. When my advisor asked me to quickly tell him about my morning 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 my advisor wanted to know more about a case, we went into the psychological formulation type of information. Communication flowed easily. This is how the CSM would work in practice.
The idea that the DSM’s coding system is a practical approach for third party payers’ record keeping is an essential point made by DSM supporters. With the following description, I think you will readily see that the CSM approach is just as practical.
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 says, “Diagnosis.” In that box, mental health professionals are required to fill in the DSM 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 add two simple words, so it 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 letters “DSM-5” and its code number that corresponds to its so-called diagnosis, or they would write the letters CSM and its code number that corresponds to the expressed concern.
With the creation of the CSM, not only will mental health providers have a new option to choose from, but so too will mental health consumers. They would be given the choice to go to psychopathologizing mental health service providers or those using the CSM approach.
So, for third party payers, that’s all the change that would be required in order to increase value for a significant number of mental health providers and service users. And a major goal that all third-party payers have is to increase value for their customers. The cost and effort for adding this new option for these payers would be minimum.
Conclusion
In conclusion, the creation of the CSM would improve value for consumers of mental health services. It would provide a practical approach that offers a new choice for those mental health service users and providers who are dissatisfied with the DSM. It does so in a manner that is more scientific and humanistic. Moreover, the creation of the CSM would break up the DSM monopoly.
Now, let’s return to the elephant in the room. Let’s bring it forth, front and center.
Yes, the DSM’s medical jargon has an enormous benefit to the pharmaceutical industry. However, with the creation of the CSM, the elephant would still get fed. Those who prefer the DSM to the CSM would be able to continue to use it. The pharmaceutical industry will still be able to promote the drugs with images of a patient looking miserable and family members distraught, all in grey, black and white, followed by images of the same patient taking a pill, now smiling in vibrant living color, with the sun shining, and family members gathered around, and bouquets of flowers brightening the whole world. There will be plenty of people who will still seek to have their concerns washed away with the ease of swallowing a pill.
Despite drug companies being able to still make a great deal of money even if the CSM was to become widely adopted, no doubt the industry as a whole would still seek to try with all its might to maintain the monopoly it currently enjoys. No doubt, big money can be very influential in putting a stop to competition. I get that. But to help us to think a little more clearly about this, let’s use a metaphor fitting to our country’s current enormous interest in the presidential primary campaigns.
You all know about the discussions going on about how a few billionaires has so much influence on who will get to win. There is much truth to this concern, but I ask you to keep in mind that every now and then, a dark horse comes along that does manage to win despite all of the big money that went to supporting the favorite of the super-rich.
In my view, the CSM has the potential to be that type of dark horse. I’m hoping that this is so because there exists enough psychologists out there who are willing to roll up their sleeves and get down to do the necessary work of joining their efforts with those of other allied professionals and mental health consumer advocacy groups because they believe this is in the best interest of those they seek to serve.
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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional intelligence. To begin at the very first post you can click HERE.
In recent weeks, I have been providing a series of blog posts on psychiatric name calling (see here, here, here, and here). In these posts, I have expressed some negative opinions about the Diagnostic and Statistical Manual of Mental Disorders (DSM).
The DSM provides the names for the various mental health concerns that mental health service providers are often required to use if they want to be paid for their services or if they want to have their research published in professional journals.The language of the DSM places its terminology under the umbrella concepts of “mental illness,” “mental disorder,” and “psychopathology.” In my blog series, I have argued that the pathologizing of human experiences in this way does far more harm than good.
As part of my discussions on this topic, I quoted the opinions of some who agreed, and some who disagreed, with my opinions. The quotes that I used were selected from my own personal readings. Therefore, they may not have been characteristic of how a wider range of different people may think and feel about the DSM approach to labeling the various mental health concerns.
A few years ago, two teams of researchers have sought to obtain a broader range of views on this topic by carrying out surveys. Jonathan D. Raskin and Michael C. Gayle surveyed psychologists who regularly use the DSM, and published their findings in the Journal of Humanistic Psychology (DSM-5: Do Psychologists Really Want an Alternative? 2015, pages 1-18). Lois Holzman and her team surveyed people in some New York City communities, and published her findings on the DxSummit.org website (A Report on Community Outreach: Lay Opinions on Emotional Distress and Diagnosis, http://dxsummit.org/archives/2249). Let’s take a look at their findings.
What the Psychologists Had to Say
Here’s a summary of the survey data by Jonathan D. Raskin and Michael C. Gayle:
Only two published studies, both from the early 1980s, have specifically examined psychologist attitudes toward the Diagnostic and Statistical Manual of Mental Disorders (DSM). The current article rectifies this by presenting the results of a recent survey of attitudes toward the DSM-IV-TR and DSM-5. Though the DSM has changed over the years, psychologist attitudes toward it have remained remarkably consistent. Although more than 90% of psychologists report using the DSM, they are dissatisfied with numerous aspects of it and support developing alternatives to it—something that psychologists over 30 years ago supported, as well. The finding that almost all psychologists use the DSM despite serious concerns about it raises ethical issues because professionals are ethically bound to only use instruments in which they are scientifically confident.
In the above summary, the number 5 after the letters DSM, refers to the fact that the DSM has undergone five major revisions. Since the 1980s, there have been three such revisions. Ideally, users of the DSM would see clear improvement for each revision.
When a survey was done in the early 1980s, psychologists were clearly skeptical of the DSM-2. As described by Raskin and Gayle,
More than 40% felt it (a) distorted clinician perceptions of clients, (b) applied medical labels to psychosocial problems, (c) was not reliable and valid, (d) emphasized diagnosis over treatment, (e) obscured individual differences, and (f) overemphasized pathology. Almost 60% were dissatisfied or somewhat dissatisfied with the DSM-2 with only 17% satisfied or somewhat satisfied.
When the DSM-3 came out in 1983, Smith and Kraft carried out an updated survey on this revision of the DSM-2. The findings indicated that psychologists at that time (a) preferred social–interpersonal diagnosis, nondiagnosis, and behavioral analysis over DSM-3—in that order; (b) felt that most conditions in DSM-3 were best seen as nonmedical problems in living; (c) believed too little had been done to develop scientific alternatives to the DSM; and (d) thought that client welfare and integrity would be better served by abandoning the medical model. Eighty-five percent disagreed that mental disorders are a subset of medical disorders.
In the latest survey that was carried out by Raskin and Gayle, 128 anonymous psychologists participated. Among the questions that were asked was, “How satisfied are you with the changes being proposed for DSM-5?” Their answers indicated that they were significantly more negative about it than neutral. The general attitude about the latest version of the DSM were very similar to what was found three decades ago, namely, that a significant number of psychologists are unhappy with the DSM.
What Community Folks Had to Say
In the community outreach survey of lay opinions on emotional distress and diagnosis carried out by Lois Holzman and her colleagues, people were asked questions at two annual NYC street fairs attended by millions of people. Conversations lasted from five to over ten minutes each. In all, 143 people participated in the survey in the first of these two surveys, which occurred in 2013. The second one had 149 people who participated, which occurred in 2014.
In the 2013 survey, the focus was on how psychiatric diagnosis affected kids. Forty percent felt that psychiatric diagnosis was not valuable. For the 60% that felt that psychiatric diagnoses can be valuable, 90% of them had reservations. That is, they said that it was only sometimes helpful, there was a danger of misdiagnosis, there was racism involved in diagnosis, and it leads to stigma and over-medication.
Ten percent were completely against diagnosis under any circumstance, some sharing their experiences pertaining to children. Examples of comments from this group follow:
“Medication makes you act out. My grandson was hyperactive, not ADHD and they wanted to put him on Ritalin – I told them no. Drugs at an early age can lead to hard core drugs later in life.”
“I worked with kids who had wrong diagnosis, and this is prevalent.”
“Kids get told in 1st grade they’re crazy—then it becomes a self-fulfilling prophecy.”
In the 2014 survey, the researchers:
“tried to go a little deeper and see if we could help people explore the apparent conflict around diagnosis, i.e., its value and its dangers. We also wanted to learn what they thought about the necessity and mandate of diagnosis.
We all know people who have gotten very depressed when they’ve lost a loved one, or children who cannot sit still in school, lots of folks who are angry and demoralized about not finding a job. Do you think any of these people need to get a diagnosis in order to get help with their emotional pain?
(IF THEY SAY YES, ASK THE NEXT 2 QUESTIONS):
Do we need to relate to them as having brain disorders? Or chemical imbalances?
Right now, in most settings, if you want to get help with ANY kind of emotional pain from a mental health professional, they are required to give you a diagnosis. Do you agree with that?
Are there other ways to support people emotionally? What do you think could help them?
Like me, you probably know people in your family, church, or at work who have serious emotional problems, who may have been diagnosed with major depression, bipolar or schizophrenia. Obviously people deserve and need top quality mental health care including access to medication. Do you think that even in these situations a diagnosis can limit the person, label them, and stigmatize them? If so, how?
From our past surveys we have found that people are conflicted about diagnosis and labels. They find it relieving to get a diagnosis and at the same time feel like the diagnosis can stigmatize or label them. Why do you think that so many of us are conflicted about this, feel it can be both helpful and harmful?
Here’s a brief summary of the finding, as described by Dr. Holzman:
Diagnosis Needed: 60% of respondents said no, people did not need a diagnosis to get help with their emotional pain. The majority of the 40% who said diagnosis was needed told us that that was the only way to get to talk to someone.
Only those who said yes, diagnosis was needed (40%), were asked the next two questions.
1a. Biological Basis: 89% of those who said diagnosis was needed said we shouldn’t consider such people as having a brain disorder or chemical imbalance.
1b. Diagnosis Required: 75% of those who said diagnosis was needed did not agree that it should be required.
Other Ways to Support (alternative types of treatment):
Everyone offered an alternative, with most people suggesting more than one. The most frequent responses involved talking to people—therapy, counseling, group therapy being the most common (including, “A center they can go to without getting diagnosed”), followed by family, friends, self-help and support groups.
A wide variety of social activities and life style changes were recommended—volunteering, hobbies, music, dance, writing, meditation, exercise, yoga, diet, prayer and creating community (“Have events that bring people out, like this fair”).
& 4. Concerns about Diagnosis: 90% (including those who thought it was needed) expressed concerns about the stigma of diagnosis, the dangers of misdiagnosis, and/or the over-medication that too often accompanies a diagnosis.
Once you have that label it doesn’t stay at the clinic. You carry it with you for a long time.
People start calling you crazy. It can be a shame for the family.
I had to fight to get counseling for my kid. They just wanted to give him drugs.
Getting a diagnosis limits life experience, you’re treated differently, you feel like an outcast.
It’s helpful to the clinic but not in everyday life.
It’s good to know what’s wrong, but it might make them feel worse about themselves and put them in a box.
It pigeon-holes people and the diagnosis becomes all that I am.
It stagnates them. It keeps them on one path with only one destination.
They think something’s wrong with them.
There is too much use of medication. It is a quick fix to avoid a real understanding.
Against it – children are still growing. Against medication.
So there you have it, some views other than mine about psychiatric name calling. In interpreting these findings, I think it’s important to bear in mind that the views of the people surveyed developed in the context of a multibillion dollar advertisement campaign by the pharmaceutical companies over many years that is designed to convince them that emotional concerns are diagnosable illnesses requiring medication treatment. How might the views of those surveyed been different without this high finance selling of the illness model?
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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional intelligence. To begin at the very first post you can click HERE.
As some of you may know, Bob Dylan has a show called “Theme Time Radio Hour.” As the title suggests, each episode is centered on a theme. He begins his episode on madness as follows:
“Let me ask you a few questions, friends. Are you disinterested in work or family life? Do you suffer from sleep disruption? Have you had significant changes in appetite? Have you had paranoid thoughts? Thoughts of grandeur or invincibility? Any feelings of persistent anxiety or perhaps panic attacks? Are you hearing voices or seeing people who are not there? Do you have thoughts of dying? Do you exhibit strong or violent anger? Do you have the inability to pursue a normal life, normal activities or normal relationships? Well, I’m no doctor, but perhaps you’re mad as a hatter; crazy as a loon. Have you lost your morals? Are your bats in the belfry? Maybe you’re nutty as a fruitcake? Crazy as a coot? Taxed in the head? Bunkers? Bananas? Deranged? Are you crackers or daffy? Unhinged or loco? Not all there or all around the bend? Maybe you’re cuckoo or buggy or simply non compos mentis? Do you talk to yourself? Do you ever binge out on food? Do you swing suddenly from one mood to another? Do vague acquaintances treat you as though they know you far better than you would expect?
Allan Ginsberg
“Allan Ginsberg once said that he had seen the best minds of his generation destroyed by madness. Now for the next hour we’ll be providing the sound track. We’re going to look at madness, insanity, and craziness.”
Introducing his theme in this way may seem like quite a mouthful for Bob, but he manages to carry it off rather well. There is deep, dungeon-like music in the background, and he varies his voice in a manner that is full of concern and dramatic interest. Besides, if you think Bob’s description of his theme is lengthy, take a gander at the latest American Psychiatric Association’s description of a related topic. In its book titledDiagnostic and Statistical Manual of Mental Disorders, 5th Edition,over 900 pages are consumed describing various “mental disorders.”
The theme of “madness” is relevant to this blog’s theme because when people seek to insult others, we commonly hear words like, “You’re mad,” “You’re crazy,” “You have a mental disorder,” and “You’re mentally ill.” Negative consequences often flow from such name calling. Individuals flinging these efforts to insult often become less respected by those who are their targets. Those who are their targets sometimes end up having less respect for themselves. From here, conflicts can escalate, leading to losing friends, problems at work, and even violence.
Dylan’s First Madness Song
Bob introduces the first song for his show on madness as follows:
“If craziness was a country, this would be the national anthem. Here’s Patsy Cline in a little number written by Willie Nelson–“Crazy.”
Patsy Cline
Patsy’s beautiful voice, accompanied by gentle piano riffs, drifts into its melancholy words–“I’m crazy, I’m crazy, for being so lonely. I’m crazy, I’m crazy for being so blue.”
The song goes on from here to weave the sad story of a woman calling herself crazy for loving a man whom she knows will soon be leaving her. She feels she’s crazy for worrying when he’ll leave, and crazy for trying, and crazy for crying, and crazy for loving this man.
Here we learn of just one type of experience that falls under the enormous umbrella of madness.
Connecting Madness With Genius
As the song phases out, Bob begins to tell us that according to Aristotle, “No excellent mind is without a tincture of madness,” a position with which Bob heartily agrees. He declares that “There is a thin line between genius and madness.” Defending this, he introduces us to several individuals who had been declared mad by some, and yet achieved at impressive levels in many valued fields. Thus, he tells us about the brilliant writer, Ernest Hemingway:
Earnest Hemingway
“Ernest Hemingway, for example, was convinced that people were out to assassinate him. His wife, Mary, tricked him into a mental hospital by telling him it was to treat his high blood pressure. He got shock therapy and maybe a dozen other treatments. It didn’t help. It left him more paranoid, delusional and depressed. He was afraid that his wife would put him away again, which many people believe is what led him to take his own life with a shotgun in July of ’61.”
Bob then tells us about the great jazz musician, Charlie Mingus:
Charlie Mingus
“Charlie Mingus spent some time away, although he later claimed he only had gone in to get papers declaring he was incompetent to get out of a contract with the gangster, Joey Gallo. Whatever the reason, he spent some time in Bellevue and was diagnosed as a paranoid schizophrenic.”
After this, Bob tells us the story of two more jazz greats–Bud Powell and Charlie Parker. Both at times were troubled by demons.
Then there was a comic writer:
One man that was no stranger to madness was Bill Gates. He was the editor of E. C. Comics. He had a series of horror comics in the ’50s, but then he was targeted by the government who said that his comics were ruining the morals of America’s young people. He was supposed to water down all of his books. He had one humor comic he called “Mad.” He changed it to a magazine so it wouldn’t be subjected to the comics’ code of authority. It became a huge hit and generations of kids got their first lessons on comedy from the usual gang of idiots that he assembled. He never sold advertising in the magazine while he was alive and there were no sacred cows. Bill Gates, madman of free speech.”
Bob soon moves on to the story of a hell of a fine baseball player:
“One guy that was accused of cracking up was Jimmy Piersall. He became a professional baseball player at 18, signing with the Boston Red Sox in ’48. On May 24, 1952, just before the game against the New York Yankees, he got into a fist fight with Yankee infielder, Billy Martin. After that, he scuffled with his teammate, Mickey McDermott. The final straw came when Jimmy Piersall spanked the four-year old son of his teammate, Burnt Stevens during a game in the Red Sox clubhouse. The four-year old had tried to tweek his nose and poured lemonade down his shirt. You can see Jimmy’s position–Boy, you need a spanking. There were a number of incidences like this and he was sent down to the minor leagues. He got into a lot of trouble down in the minor leagues, and spent some time in the West Borough State Hospital. He was diagnosed with manic depression, but he still returned to baseball by the opening of the ’53 season. And get this, he finished ninth in the voting for the MVP award, and the next year he was the Sox’s regular center fielder.”
Feeling That We Are Crazy Is A Common Experience
In addition to describing these individuals who were thought to be mad by some and yet achieved greatness in various valued arenas, Bob provides diverse examples of regular Joes and Jills who displayed behaviors that were viewed as crazy by either themselves or others. These examples touch a chord in the listener because they illustrate experiences that are pretty close to what we have all experienced at different points in our lives.
Thus, the show’s take away lesson, as I see it, is that if you catch yourself calling yourself names such as “crazy” note that many of the most talented people have had similar experiences. Note, as well, that such criticism is too vague to be helpful. Learn to become more aware of these thoughts, to stand back and simply observe them passing through your mind–“Oh, there I go again calling myself mad.’ In time, you will come to a point at which you will formulate some more specific approach to make improvements in your life. The practice of meditation can help you to learn this skill.
If you are tempted to call someone else these types of names, remember that such names are way too vague, encompassing thousands of unusual and usual experiences. For criticism to be truly helpful, it is usually best to craft a statement that avoids name calling and statements about what someone did wrong, and instead provides specific suggestions for what the target of the criticism can do to improve. If you can not come up with such a statement right away, perhaps it would be best to delay the criticism until you have some time for your creative impulses to come up with something better than “You’re a crazy, mentally ill fool!”
Although these are my take away lessons for today’s post, let’s end with how the more poetic Bob Dylan ends his madness show:
“Time flies when you’re talking crazy, and we gotta get out of here. But before we do I want to leave you with the words of the man who is the voice of the barroom, poet of the gutter, and Shakespeare of the alleyway. Here’s a poem by Charles Bukowski called “Some People.”
some people never go crazy.
me, sometimes I’ll lie down behind the couch
for 3 or 4 days.
they’ll find me there.
it’s Cherub, they’ll say, and
they pour wine down my throat
rub my chest
sprinkle me with oils.
then, I’ll rise with a roar,
rant, rage –
curse them and the universe
as I send them scattering over the
lawn.
I’ll feel much better,
sit down to toast and eggs,
hum a little tune,
suddenly become as lovable as a
pink
overfed whale.
some people never go crazy.
what truly horrible lives
they must lead.”
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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional intelligence. To begin at the very first post you can clickHERE.
Many mental health service providers well know that there are serious problems with the jargon that is used in their profession. In a recent post titled “Psychiatric Name Calling: Is It Time To Put A Stop To It?” I outline some of the most glaring ones. In a subsequent post titled “Psychiatric Name Calling: Is There An Alternative?” I describe a plan for professionals who have an interest in eliminating the problems inherent in the current psychiatric pathologizing approach. This plan would allow professionals to replace the old model with one that would be practical, more consistent with principles of science, and far less stigmatizing.
As I have been seeking ways to promote these ideas, it has become more and more apparent that the gears of the mental health service provider professional organizations grind slowly. Until the necessary changes occur, what can the average English speaking person do when faced with terms like mental illness, major depressive disorder, psychosis, schizophrenia, etc.?
Three Principles That Can Be Used When Psychiatric Pathology Terms Are Employed by Others So That The Negative Effects Associated With Their Usage Can Be Reduced
Even people who are not mental health service providers will regularly use psychiatric jargon. Thus, a French writer once wrote:
My sadness was without limit, and having got possession of me, it filled my life from the most indifferent external acts to the most secret thoughts, and corrupted at their source my feelings, my judgment, and my happiness. It was then that I saw that to expect to put a stop to this disorder by my reason and by my will, which were themselves diseased, would be to act like a blind man who should pretend to correct one of his eyes by the aid of the other equally blind one.
In this quote, the French writer, to describe some concerns he had about his sad mood and how it was affecting his feelings, judgments, and happiness, uses the words “disorder” and “disease.” This is the type of language most mental health service providers throw around. What is the writer attempting to convey by their use?
Sometimes when these words will be employed, their context will make it clear what meaning the author intends. In this example, the author does provide some context. He clearly indicates he was much sadder than he wished to be, and he believed he was unable to do anything about it. He also expressed a concern about his feelings, judgments, and happiness, but he was less clear about what he meant by this.
When someone begins to use pathologizing language and we simply don’t know what is intended, we might end up with misleading, simplistic associations. And so, here are three principles that can be used when psychiatric pathology terms are employed so that we can avoid unnecessary confusion.
Each Time Someone Uses A Psychopathologizing Term, Ask The User Of The Term For A More Specific Description Of What Is Meant By It
In the example that I provided above, there was some lack of clarity about what the French writer meant about his judgments. We know that he felt that it was disordered and diseased. That really tells us nothing more than he was dissatisfied with his judgments. To clarify, we could ask for some specific examples of when his judgment proved to him unsatisfactory.
As another example, suppose you hear Alice saying that John Doe is “mentally ill.” If you want to use this first principle, you would ask Alice what, specifically, does “mentally ill” mean to her and what has John done specifically that led to her calling John this name. These questions typically lead to further constructive discussions and ends up clarifying the nature of many fascinating experiences.
When Psychopathologizing Terms Are Employed, Express A Concern That This Terminology Simplistically Devalues An Experience
Terms like “mental disorders,” “mental illness” and “psychosis,” even when used by professionals, implies that there is something wrong with the person being described. However, as I described in my post “Are Mental Illnesses Really Potentially Helpful Tools?” there are numerous examples of the types of experiences that tend to be labelled mental disorders that end up being enormously helpful. Moreover, in cultures that recognize this possibility the outcomes for those people undergoing these challenging experiences are distinctly better.
And so, as you begin to use the first principle, asking for the user of pathologizing terminology for more specifics, if he or she seems to be suggesting that the experience is bad, you might wish to point out this well documented observation. At such times, I often say, “Many people with artistic temperaments have these types of experiences. Such people have given the world some of its most valued achievements.”
Instead Of Using The Concept of “Disease” And “Illness” To Encourage Humane Responding Toward Individuals Undergoing Challenging Experiences, Emphasize Rights, Kindness, And Practical Reasons
In seeking to encourage people who are using pathologizing terminology to be more specific, it is not uncommon to find that one reason they use these terms is that they hope it will encourage people to be more humane toward those who have certain challenging experiences. They usually mean well by this, but this approach has been used for centuries and history documents that despite such efforts, people who are being given these labels have often ended up in some of the most horrible, degrading treatment facilities.
Instead of using the concept of “disease” to encourage humane responding toward individuals undergoing the experiences that get labelled with pathological terms, an alternative is to emphasize human rights, kindness, and practical reasons.
Note that when people in a town are hit with a hurricane, we don’t have to resort to calling them ill to encourage some help. Instead, we have set up laws that entitle people to certain rights from the government when emergencies occur. Moreover, as word gets out about what is occurring to those who are suffering, out of kindness, people make donations or join their hands to provide direct assistance in a variety of ways. And lest we forget, there are practical reasons to lend a hand. By doing so, we model for people just what kindness is all about.
Any of us can find ourselves in an emergency situation. The more we promote acts of kindness, the more likely we may find that others will treat us with kindness if we are ever to find ourselves in a very unfortunate set of circumstances.
Using the Three Principles
William James, in his grand book, The Varieties of Religious Experience, tellsus ofsome people who have mystical experiences that tend to be called “mental disorders.” James begins to use the three principles when he seeks out descriptions of the various mystical experiences that go well beyond the simplistic psychopathological descriptions. He then states that these mystical states have the right to be absolutely authoritative over the individuals to whom they come.
It is vain for rationalism to grumble about this. If the mystical truth that comes to a man proves to be a force that he can live by, what mandate have we of the majority to order him to live in another way? We can throw him into a prison or a madhouse, but we cannot change his mind-we commonly attach it only the more stubbornly to its beliefs.
It mocks our utmost efforts, as a matter of fact, and in point of logicit absolutely escapes our jurisdiction. Our own more “rational” beliefs are based on evidence exactly similar in nature to that which mystics quote for theirs. Our senses, namely, have assured us of certain states of fact; but mystical experiences are as direct perceptions of fact for those who have them as any sensations ever were for us…. The mystic is, in short, invulnerable, and must be left, whether we relish it or not, in undisturbed enjoyment of his creed.
In this quote, we find no plea from James that we should treat mystics humanely because they have a mental disease. Instead, James puts forth “rights” and “pragmatic” considerations. He argues that just like we in the majority would not like to be ordered to live in a particular way, these mystics have the right to live their way. And pragmatically, if we do use heavy-handed approaches to try to change them, such as throwing them in a madhouse, they will become more stubborn in their beliefs.
James proceeds from here to state that mystics have no right to claim that “we ought to accept the deliverance of their peculiar experiences, if we are ourselves outsiders, and feel no private call thereto.” His theme is tolerance for both the majority toward the minority and vice versa.
Returning to pragmatic arguments, James tells us in his chapter on mysticism that some have found that their mystical experiences have led to wonderful fruits that they highly valued. Some, for example, suffered for a great period of time and after their mystical experience felt wondrously free from their pain and found in its place increased energy and happiness.
James well realizes that the fruits from mystical experiences are not always positive, but he asks us, at the very least, to realize that they have the potential to “be indispensable stages in our approach to the final fullness of the truth.” Thus, we see that “rights” and “pragmatic arguments” can be used instead of a disease concept to promote humane, kind responses toward those who have the types of experiences that tend to be called mental disorders.
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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional intelligence. To begin at the very first post you can click HERE.
William James, psychologist and philosopher, passed away over a century ago. Nevertheless, his remarkable body of work remains as fresh as fruit plucked from its tree but moments ago.
His views about his personal bout with a challenging experience developed over many years. Today I think it will be instructive if we spent a little time reviewing what he learned.
A Glimpse at James’s Early Views on Mental Disorders
We begin in April of 1867. James is 25-years old. Suddenly, he interrupts his medical education and flees to Europe.
Later, on describing the feelings that led to his departure, James wrote “it was as if something hitherto solid within my breast gave way entirely, and I became a mass of quivering fear. . . . I awoke morning after morning with a horrible dread in the pit of my stomach.”
William and Henry James’s Father, with Young Henry on the right
Several years went by and then, gradually, James’s spirits lifted. His father, noticing the difference in him, asked about it, and then relayed the news by letter to another son, Henry, in March, 1873:
He came in here the other afternoon when I was sitting alone, and after walking the floor in an animated way for a moment, exclaimed “Dear me! What a difference there is between me now and me last spring this time: then so hypochondriacal” (he used that word, though perhaps in substantive form) “and now feeling my mind so cleared up and restored to sanity. It is the difference between life and death.” He had a great effusion. I was afraid of interfering with it, or possibly checking it, but I ventured to ask what especially in his opinion had promoted the change. He said several things: the reading of Renouvier (specially his vindication of the freedom of the will) and Wordsworth, whom he has been feeding on now for a good while; but especially his having given up the notion that all mental disorder is required to have a physical basis. This had become perfectly untrue to him. He saw that the mind did act irrespectively of material coercion, and could be dealt with therefore at first-hand, and this was health to his bones.
We see in the above that at this time James viewed his experience that led to his departure from medical school as a “mental disorder.” Moreover, his conceptualization of it had begun to develop from a physiological pathology model to one that gives at least some freedom to the will. In time, his views begin to develop even further.
Letter to Henry James, 1885
The two brothers. Henry is on the left and Professor William James is on the right
William James and his younger brother, Henry, shared an especially close fraternal bond. Historians have greatly benefited from this because the letters that the two brilliant men shared reveal insights about their deepest concerns.
In 1885, now a medical school graduate and teacher at Harvard, James writes to Henry:
To suggest personal will and effort to one “all sicklied o’er” with the sense of weakness, of helpless failure, and of fear, is to suggest the most horrible of things to him. What he craves is to be consoled in his very impotence, to feel the Powers of the Universe recognize and secure him, all passive and failing as he is.
In James’s letter to his brother, we see he has discovered that in marked contrast to his own favorable reaction to suggestions about the effectiveness of will and effort, some people react with horror. Such people view themselves as helpless, weak, passive, and failing. Rather than looking to a creative force within themselves, they look for the Powers of the Universe to fix them.
The Mature James
Toward the end of James’s career, he adds a new way of viewing the types of concerns that affected him so profoundly when he was young. We begin to see this new way when James discusses individuals who view themselves as “healthy-minded.” These individuals believe that those who worry are “morbid-minded” and “diseased.”
James responds to this name calling by stating that those referred to as morbid-minded have argued that “the world’s meaning most comes home to us when we lay them most to heart.”
After describing the argument between the so-called “healthy-minded” and the “morbid-minded,” James then states:
In our attitude, not yet abandoned, of impartial onlookers, what are we to say of this quarrel? It seems to me that we are bound to say that morbid-mindedness ranges over the wider scale of experience, and that its survey is the one that overlaps. The method of averting one’s attention from evil, and living in the light of good is splendid as long as it will work. It will work with many persons; it will work far more generally than most of us are ready to suppose; and within the sphere of its successful operation there is nothing to be said against it as a religious solution. But it breaks down importantly as soon as melancholy comes; and even though one be quite free from melancholy one’s self, there is no doubt that healthy-mindedness is inadequate as a philosophical doctrine, because the evil facts which it refuses positively to account for are a genuine portion of reality; and may after all be the best key to life’s significance, and possibly the only openers of our eyes to the deepest levels of truth.
To James, people confront events daily that create feelings of helplessness, pain, sadness, horror, and dread. James argued that the feelings that go along with these kinds of events can lead toward truth. Thus, he counteracts any tendency to assume that those referred to as morbid-minded are automatically inferior to those referred to as “mentally healthy.”
The Development of James’s Views About Mental Health Concerns
And so, starting from James’s own bout with a challenging experience, we see that his views develop over the years. Initially, mental health concerns are “mental disorders” which require a physical basis. He then changes his mind, coming to believe these experiences are not completely controlled by one’s physiology, and therefore they could be dealt with through philosophical and poetic means.
It then occurs to him that in contrast to the benefits that his new perspective had for him, others prefer, even crave, to believe they are helpless in the face of these types of experiences. Finally, James comes to believe that some people can derive benefits from the kinds of challenging experiences that, to many, are properly viewed as symptoms of a diseased mind.
Like James, I have undergone a similar developmental trajectory. As I have dealt with my own challenging experiences, I have, over a good many years, learned to greet them as old friends who have valuable messages to share with me. Sometimes they stay a little longer than I would like, and I may find it frustrating that they don’t always come right out and tell me what these messages are. But my patience, through meditation and the maturity that sometimes comes in the course of passing years, has been steadily improving.
Well, I hope this discussion has deepened the reader’s views of the nature of experiences that lead to people expressing concerns to mental health professionals. Until next time, may all of your concerns be addressed with wisdom, love, and kindness.
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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional intelligence. To begin at the very first post you can click HERE.
If your behavior, thoughts, or feelings become a concern, for a fee, many psychiatrists, psychologists, and social workers are eager to translate your experiences into a language of symptoms, diagnoses, psychopathology, and mental illness. In an earlier post I provided negative criticism about this type of name-calling (see here). Today, we focus in on an additional problem with the pathologizing approach.
Psychiatric Name-Calling Simplistically Devalues What William James Referred to as “Exceptional Experiences”
Tools can be used for good or evil. A hammer can be used to drive in nails in the construction of a life-preserving shelter or to bludgeon an innocent person to death. A car can be used to rush a child to an emergency room so that life-preserving treatment can be administered, or it can be used to tragically end a prom night. Are experiences that are oftentimes referred to as pathological really tools, and is it up to each one of us to use them either for good or evil?
William James
The first time I came across this question occurred while reading about William James’s 1896 series of lectures on “Exceptional Mental States.” Harvard psychologist, Eugene Taylor, had reconstructed these lectures from James’s original handwritten lecture notes, newspaper reports, letters, and a variety of other sources.
At the very beginning of the lectures, James argues that experiences that are commonly viewed as unhealthy or morbid are really “an essential part of every character,” and give life “a truer sense of values.” To support his contention, James first provides three examples of famous individuals who suffered from melancholy, a term that corresponds closely with what modern pathologizers call “major depressive disorder.” St. Paul, the religious figure of the New Testament, Cesare Lombrosa, a late 19th-century Italian criminologist, and Immanual Kant, the 18th-century German philosopher, became, according to their histories, better as a result of their troubling experiences.
Not only is melancholy far more normal and potentially beneficial than the pathologizers would like us to believe, so too, James argues, are delusions and hallucinations. James tells us that the belief in the possession by demons, which is often viewed as a delusion by pathologizers, is remarkably common. “[It] is the one most articulately expressed doctrine of both Testaments, and . . . reined for seventeen hundred years, hardly challenged in churches.”
James then goes on to tell his audience about Buddhist sects in Japan that have priests who believe they can put themselves into a trance so that a god can speak through them. These people seek to cultivate these experiences, apparently believing that they provide some benefits to their sect.
Although hallucinations can be construed as a symptom of mental illness to some, James presents the case of Socrates who “once stood motionless for many hours in the cold and spoke of having a guiding demon.” Attempting to counter the association between pathologies and hallucinations, James states,
Even if this demon [of Socrates] were really meant hallucinations of hearing, we know now that one in eight or ten of the population has had such an experience and that for insanity we must resort to other tests than these.
Like melancholy, delusions, and hallucinations, the “symptoms” of obsessions and manias are treated in James’s lectures as experiences that are normal and potentially beneficial. Thus, James states that there is no end to the possible types of obsessions that we see all around us. And what about “the anti-slavery mania?” Is this to be viewed as pathological? What benefit can such experiences have? James tells his audience about Henry Borg, founder of the American Society for the Prevention of Cruelty to Animals; Charles Henry Parkhurst, a Presbyterian clergyman and reformer who launched a furious attack on organized crime in state government that led to an official investigation; Dorothea Dix, a mid-19th-century humanitarian who visited the insane asylums and successfully advocated for legislation to improve the care for those now labeled mentally ill; General Booth, founder of the Salvation Army; Frances Willard, a suffragette; and others. “These persons,” said James, “are not insane, not maniacs, not melancholics, not deluded.”
Later, he states, “Individuals are types of themselves and enslavement to conventional names and their associations is only too apt to blind the student to the facts before him.”
As Taylor (1984) closes his reconstruction of the lecture series, he quotes James as follows:
There is a strong tendency among these pathological writers I have cited… to represent the line of mental health as a very narrow crack, which one must tread with bated breath, between foul friends on the one side and gulfs of despair on the other. Now health is a term of subjective appreciation, not of objective description….There is no purely objective standard of sound health. Any peculiarity that is of use to a man is a point of soundness in him, and what makes a man sound for one function may make him unsound for another…. The trouble is that such writers . . . use the descriptive names of symptoms merely as an artifice for giving objective authority to their personal dislikes. The medical terms become mere appreciative clubs to knock a man down with. . . . The only sort of being, in fact, who can remain as the typical normal man, after all the individuals with degenerative symptoms have been rejected, must be a perfect nullity . . . Who shall absolutely say that the morbid has no revelations about the meaning of life? That the healthy minded view so-called is all?
The Review of the Evidence
Robert Whitaker
It may seem a fanciful theory that the experiences now referred to as mental illnesses can be potentially helpful. However, in 2010, Robert Whitaker published a book titled Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness. To write the book, he pored through the scientific literature for the past 50 years and found a dramatic increase in the number of people who are pathologized, which led to an astonishing increase in psychiatric drug consumption. And more people then ever before became disabled for longer and longer periods of time.
Here is just one of many such studies that Whitaker describes.
In the 1980s, Martin Harrow, a psychologist at the University of Illinois, began a long-term study of 64 newly diagnosed schizophrenia patients. Every few years, he assessed how they were doing. Were they symptomatic? In recovery? Employed? Were they taking antipsychotic medications? The collective fate of the off-med and medicated patients began to diverge after two years, and by the end of 4.5 years, it was the off-medication group that was doing much better. Nearly 40% of the off-med group were “in recovery” and more than 60% were working, whereas only 6% of the medicated patients were “in recovery” and few were working. This divergence in outcomes remained throughout the next ten years, such that at the 15-year follow-up, 40% of those off drugs were in recovery, versus 5% of the medicated group.
Whitaker also found studies that compared cultures, like our own, that employed the pathologizing model with cultures that framed exceptional experiences as potentially beneficial. Countries infected with the pathologizing approach had outcomes significantly poorer.
These findings lead me to conclude that it is time to have a reasonable discussion about embracing other models of care.
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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.
On this blog, one of the main topics of discussion is name calling. And, from time to time, some people have asked me what I think of the types of names psychiatrists use to talk about their patients.
In response, I wrote a post titled Name Calling by Psychiatrists: Is it Time to Put a Stop to it? It stirred up a great deal of interest, and the various comments led me to write several follow-up posts. While all of this was going on, several people asked what I thought of the psychiatrist, Thomas Szasz. And so, today’s post at least begins my reply.
Thomas Szasz, MD
It was 45 years ago when I first heard of Dr. Szasz. I was about 19 years old, it was the late 1960s, and I was taking an Abnormal Psychology course as an undergraduate student at Brooklyn College. Professor Meyers presented a whole class on Dr. Szasz’s recent book, The Myth of Mental Illness. It was a time when many of us were raging against the Vietnam War. Questioning all authority went right along with that, and so Szasz’s position, for me, fell right into that general mindset.
Labeling a child as mentally ill is stigmatization, not diagnosis. Giving a child a psychiatric drug is poisoning, not treatment.–Dr. Thomas Szasz.
After the course had ended, I really didn’t think much about Szasz’s ideas again until about 15 years later. I was working with youth in the Corning, New York area, when I began to notice a dramatic increase in the number of young children and teenagers being prescribed psychiatric drugs. At one point, five straight foster children that were brought to me for counseling not only were taking a psychiatric drug, but were taking several of them. Those students typically were unhappy about this, complained about serious side effects, and when I went to the library to check out the various risks associated with their use, I became very concerned.
To address my concern, I began to organize a debate on the use of these drugs, and the first person I thought to call was Dr. Szasz. He was very helpful, agreed to debate the topic, and the debate created so much interest that other people began to ask me to help organize similar debates in their communities. In the end, that single debate turned into a series of seven debates.
I learned a great deal from all of the participants, but it was Dr. Szasz who most challenged my thinking. Although I disagree with some of his ideas, I admire his guts for standing up for what he believed, his humor, and his extraordinary intelligence.
Thomas Szasz passed away a couple of years ago at the age of 92.
A great deal of Szasz’s writings and ideas are readily available on line (see for example the article on Wikipedia). Nevertheless, to give my readers a little sense of his ideas, I am providing below a little snippet of his opening remarks from one of the debates that I helped to organize. It is slightly edited because he was not the first speaker during the debate and some of his comments alluded to remarks that someone else had said earlier during the proceedings. Without having heard these other remarks, Szasz’s comments would be hard to follow, so I edited them out. This gives his comments a slight disconnected feel at times, so I ask that you not blame him for that.
And so, without any further ado, I give you, Dr. Thomas Szasz:
Portrait of Dr. Szasz that hangs in the medical library at the SUNY Upstate Medical University
Ladies and gentlemen…. I would like to take this time to present my views of psychiatry ….
I believe…ideas have consequences. Words only mean what we do about them. They do not have abstract meaning. So the question is what do we mean when we say something is a disease?
Now to me, psychiatry doesn’t have to do with diseases at all. Just like, to me, communism doesn’t have to do with ideas.
Berlin Wall
Communism was symbolized by a bunch of stones called the Berlin Wall. But what it actually meant is that if you lived in a communist country, you can come in, everything was fine and you were told everything was wonderful for you, but if you tried to leave you found that they shot you, that you couldn’t get out. This is what happens in a mental hospital. You can get in, but you can’t get out….
Psychiatry is a branch of the law, it has alway been, and always will be… To me, psychiatry is coercion. I have always said, I support psychiatry between consenting adults… I am only interested in involuntary aspects of psychiatry.
For the sake of the argument, I don’t believe this, but for the sake of the argument, to make my argument clear, let’s say schizophrenia is a brain disease, just like cirrhosis is a disease of the liver. If we accept this and treat it like other diseases, then psychiatry disappears. It would then be treated by a brain doctor. The insanity defense disappears. Involuntary psychiatry disappears. If somebody kills somebody they are tried like everyone else. There are no psychiatrists lining up to testify to say Prozac causes murder, or mental illness causes murder, or everything causes murder except free will.
Ok,… let me give you two English sentences. The statement Jones is bleeding, is a statement about his body. The statement that Jones is boasting is a statement about Jones. They sound like the same type of statement, but they are not. The question, what do we mean by schizophrenia. Do we mean that they are a type of lesion, or do we mean, behavior. How does someone first diagnose someone with schizophrenia—from his body, or his behavior?
Let’s assume the person has a disease. The person is still behaving, the person is still a moral agent. Patients, from a moral, legal point of view, are exactly like non-patients. If I have asthma, Parkinson, etc., I can still behave. When people have Parkinson and they shoot somebody, they are responsible, if they are nice to their wives, they get along, if they are not so nice they get a divorce and so on.
Now we come to some more issues. Supposing someone claims that someone has a disease. On whose authority do we take this? In my lifetime, great authorities have maintained homosexuality was a disease. When I was in the US Navy 30 years ago, that was one of the major ideas of the service was to single out homosexuals, who were then given diagnoses by psychiatrists. This was viewed as a serious disease. Now, on the cover of Time we find that they are entitled to civil rights. What happened to their disease?
Not only was homosexuality a disease, so was being black according to an early psychiatrist, Benjamin Rush. According to him, blacks were blacks because they had a form of leprosy. On whose authority did he claim this? On the authority that he is a doctor?
Now we are shown pictures of brains and told that they prove that schizophrenia is a disease. On whose authority? The fact is that no pathologists diagnose anyone as schizophrenic based on any pictures of someone’s brain, or any other medical test. Even on postmortem, when the patient said to be schizophrenic dies the pathologist says no disease was found. The same thing with depression…
The discussion of who has a mental illness is based on judgements of a person’s behavior. So this idea that you can have a brain disease, like schizophrenia, is a little strange. Let me just give you a few questions to stimulate you. What would asymptomatic depression look like. Now we know what asymptomatic hypertension is, or asymptomatic leukemia,… but what is asyptomatic depression? Better yet, what is asyptomatic schizophrenia? What would that be. Or asymptomatic Judaism, or Christianity. These are behaviors. If the behavior is not there it is not here….
My time is nearly up, so let me leave you with a couple of questions. Please listen carefully because this is a question and a joke. If somebody has a delusion of having cancer, then he has a mental illness, right, because he doesn’t have cancer? What would it mean if he has a delusion of being mentally ill?
Okay, now to the issue of saying someone has a mental illness which is due to some biological basis. This is nonsense because everything we do has a biological basis… The most ordinary things are biological bases, namely eating and sex, called hunger and lust. These are not diseases. And just because they have a biological basis that doesn’t mean that you have to act. Urination and defecation have a biological basis. These are powerful impulses that have a biological basis but that doesn’t mean we have to do it in the middle of the living room…. Life begins with responsibility and ends with responsibility…. Psychiatry is a discipline that undermines responsibility. Thank you.
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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.
It’s easy for me to empathize because I regularly have bouts of what I refer to as melancholy. A deep anguish comes over me, and during this period I often begin to think about how I went through my father’s death when I was twelve, how I’m getting older and can no longer do the many athletic things that thrilled me when I was younger, and on and on. Sometimes these dark melancholy experiences come about because something clearly happened that upset me, and sometimes they seem to come out of the blue.
You see, as people experience depression, or other concerns that often lead to a classification of having a mental disorder, some people go about their lives functioning as they typically were doing before the concern arose, while some find that in some areas they begin to function below the levels that are typical for them, while some find that their functioning increases in one or more areas. For example, some sleep about the same amount, some less, and some more. I have met people who, when they are depressed, start cleaning every inch of their home, while others find it difficult to get out of bed.
Also of interest when exploring a person’s expressed concern is to look at how the person had been functioning before the onset of the presenting concern. If some important relationships had begun to function below average, or if the person had been sleeping less than average to keep up with work demands, these facts can be insightful when seeking ways to address the presenting concern.
There are those who embrace this mental illness/disorder labeling. One reason is the pharmaceutical industry’s promotion of this idea to sell people on the idea that they need certain drugs to live a more normal, healthier life.
Those who are uncomfortable about the use of “mental illness” terminology point out they are stigmatizing because they are used as put downs in our society. Moreover, the media associates the most heinous crimes with those referred to as the mentally ill even though the vast majority of those classified in this manner are not violent.
Among the most articulate individuals to voice objections to the mental disorder labeling was Harvard psychologist and philosopher William James. Over one hundred years ago he wrote a book titled, The Varieties of Religious Experience (1902). At that time many medical doctors argued that people who were religious were all mentally ill. In response, Professor James wrote:Medical materialism seems indeed a good appellation for the too simple-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.
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. (p. 30)
James points out that in the natural sciences and the arts it never occurs to anyone to refute opinions, beliefs and experiences by putting down their author’s neurological constitution. Value is determined by “judgments based on our own immediate feelings primarily; and secondarily on what we can ascertain of their experiential relations to our moral needs and to the rest of what we hold as true” (p. 33).
To this, I respond that in point of fact there is currently a renewed respect for the extraordinary complexity
When individuals express a concern, exploring how they are functioning in the main areas of their life can be enormously helpful. Someone who reports a concern about experiencing depression, whom, by some gentle questioning, we find out has been functioning below average in the areas of sleep, interpersonal relationships, and exercise may benefit enormously if we work together on getting these areas of functioning in a more optimal range. This is true for those who report other types of concerns such as experiencing anxiety, hearing voices, below average range of attention, obsessive thoughts, and on and on. With a model that includes addressing concerns and exploring ways to improve functioning, labeling someone as having a mental disorder becomes unnecessary and may actually interfere with the aims of a counseling/psychotheraputic relationship.
But for those who desire to have their concerns addressed by well trained mental health professionals without being referred to as having a mental illness or disorder, I do propose that we do provide a reasonable option for them to access mental health services. In my view, mental health professionals, once we hear our clients’ concerns and how they are functioning in the various areas of their lives, we have the basics to formulate, in full cooperation with our clients, a plan for addressing these concerns. I hope you give this some thought.
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 says, “Diagnosis.” In that box, mental health professionals are required to fill in the DSM code that corresponds to their so-called diagnosis of the person seeking services.
homosexuality a disease, so was being black according to an early psychiatrist, Benjamin Rush. According to him, blacks were blacks because they had a form of leprosy. On whose authority did he claim this? On the authority that he is a doctor?
ation have a biological basis. These are powerful impulses that have a biological basis but that doesn’t mean we have to do it in the middle of the living room…. Life begins with responsibility and ends with responsibility…. Psychiatry is a discipline that undermines responsibility. Thank you.