Steven Novella M.D. and Mental Illness Denial

Recently Nick Stuart, a regular commenter on this website, drew my attention to Dr. Steven Novella.  Dr. Novella is a strong supporter of the standard psychiatric system, and routinely refers to those of us who challenge these concepts as “mental illness deniers.”(Mental Illness Denial Part I)

Nick referred me to some of Dr. Novella’s articles, and I published a brief response.  I have been giving these matters some thought, however, and I think the subject matter warrants more attention. This is because Dr. Novella does indeed marshal some compelling arguments in other areas, and also because he routinely condemns us “deniers” as illogical employers of “…semantic misdirection and evasion…”

For the present purpose I will discuss an article that Dr. Novella published on February 4 of this year:  “DSM-V – Mental Illness vs Normal Behavior.”

The article in question is a response to a piece by Peter Kinderman which I highlighted a few days ago, and which in my view is an excellent article.  Dr. Kinderman wrote:

“But diagnosis and the language of biological illness obscure the causal role of factors such as abuse, poverty and social deprivation. The result is often further stigma, discrimination and social exclusion.”

Now, for me, this is fairly obviously true and is borne out by the facts.  Psychiatrists who talk in terms of “diagnoses” and “chemical imbalances” etc., do in fact ignore causal factors such as abuse, poverty, and social deprivation.  They call their clients “patients” and they routinely tell these “patients” that they have “an illness just like diabetes” and that the pills will fix their brain chemistry.

But watch what Dr. Novella does with this:

“This is a healthy debate to have, as the concepts involved are tricky and there are real implications for societal perception, insurance coverage, and treatment strategies. I do not, however, share Dr. Kinderman’s position, which in my experience is fairly typical for a clinical psychologist. He is essentially saying that his profession’s approach to the question of mental illness is superior to the psychiatric profession. While the debate is legitimate and important, I can’t help feeling that there is a major component of a turf battle here also.”

Dr. Novella asserts that Dr. Kinderman’s position is fairly typical for a clinical psychologist.  There may be some validity to this as far as academic psychologists are concerned, but in my experience, clinical psychologists in the field are as wedded to standard psychiatry as the psychiatrists are.  But more importantly, notice what Dr. Novella has done.  He has diverted attention from Dr. Kinderman’s very valid criticism by calling it a turf war issue.  And this is the man who accuses us “deniers” of “semantic misdirection and evasion.”

But moving along – Dr. Novella states:

“The question is essentially how we should think about symptoms of mood, thought, and behavior.”

Note the use of the word “symptoms.”  This is clearly a medical term.  Dr. Kinderman’s essential point was that the medicalization of human problems is unhelpful.  Dr. Novella pretends to take this on board, but couches the essential issue in medical terms.  He could just as easily have used the word “problems” – a neutral word with which we “deniers” would have no difficulty.  People do indeed have problems.  But to refer to these problems as “symptoms” presupposes the main point of contention.  Perhaps this also could be described as “semantic misdirection.”

Dr. Novella delineates the two extreme responses to his essential question:

– those who consider human problems to be part of the normal spectrum

– those who medicalize all human problems

Dr. Novella then expresses the opinion that the best approach is something “in the middle:”  “…before you can recognize the abnormal you have to recognize the full spectrum of what is normal.”  He goes on: “…we need to recognize the full spectrum of human nature, accept less common and atypical forms of human mood, thought, and behavior, and also recognize the relative roles of biology, situation, and culture (and their interactions) in forming a person’s mental state.”  Now this is all fairly good stuff.  It certainly is a far cry from standard psychiatry, and you might actually be wondering if Dr. Novella is a closet “denier.”  But wait…

“On the other hand, the brain is an organ, it is biology, and it can malfunction biologically just like any other organ. Further, even a biologically healthy brain can be pushed beyond tolerance limits resulting in an unhealthy mental state. We can reasonably define “unhealthy” in this context (probably a more appropriate word than “abnormal”) as follows – a mental state that is significantly outside the range of most people, may represent the relative lack of a cognitive ability that most people have, and results in definable harm. That last bit is critical – it has to be harmful.”

Dr. Novella goes on to acknowledge that “there is an unavoidable amount of subjectivity in the above definition,” giving the impression that he is a reasonable person willing to concede that the “deniers” might have some validity in their corner.  But he evades the core issue – or at least what for me is the core issue – that although brain malfunction can and does cause problem behavior, problem behavior can and does occur in the absence of any brain malfunction.

The fallacy that Dr. Novella has fallen into is:  A has been noted to cause B.  Therefore every instance of B must have been caused by A.  A lightning strike can damage your TV.  But it would be unwarranted to assume that a lightning strike was the culprit every time your TV malfunctioned.

Nobody is denying that brain problems can cause behavioral problems.  But virtually every criterion item in the DSM is behavioral, and to assume a neurological malfunction as the underlying cause of these behaviors is illogical and unwarranted.  The fact is that people with perfectly normal brains can acquire dysfunctional, self-destructive, and counter-productive habits.

An early demonstration of this is the case of Little Albert (1920), who was taught to fear a white rat by psychology researchers, and was subsequently taught not to fear the same animal.  There was nothing wrong with his brain, even though his response to the lab rat was clearly dysfunctional.  In fact, his learning apparatus had to be intact.

There is a subtle point here that Dr. Novella does not address in this article, but does touch on elsewhere.  In Mental Illness Denial Part I (2007) he states “… if part of the brain allows us to pay attention, in some people that part of the brain must function poorly causing a deficit of attention.”

Let’s go back to Little Albert.  After he had been trained to fear the white rat, there was certainly a link of some sort in his brain between fear and white rats.  I am no expert in neurology or neural physiology, but common sense tells me that Albert’s training cemented in some kind of connection, and his untraining removed that connection.

Dr. Novella’s position, if I understand him correctly, is that this neural link (or whatever it might be called) constitutes the ontological reality behind the brain illness theory of the so-called mental illnesses.

In the quote above about paying attention, Dr. Novella is clearly referring to the condition known as ADHD.  His reasoning is as follows.  Brains and parts of brains malfunction.  Parts of brains are dedicated to paying attention.  If a child isn’t paying attention, there must be something wrong with those parts of his brain.

But the reality is more complicated.  Children (and adults) are always paying attention to something.  The point about ADHD is not that the child is inattentive, but rather that he is not paying attention to the things that he needs to attend to.  Everyone knows that playing is easier than studying.  Doing what we like is easier than working.  A child will generally not pay attention to the latter items unless he has been actively trained to do so.  Absent this training, he does whatever he likes and consequently attracts a “diagnosis” of ADHD.

But let’s be clear.  Training causes changes in brains.  This is self-evident.  So there are differences between the brain of a disciplined, well-behaved child and an inattentive, self-indulged, misbehaved child.  I certainly can’t specify what these changes are, and I’m not sure anyone else can either., but insisting that these brain changes (or lack of brain changes) are the cause of the misbehavior is tantamount to saying that a professional cyclist’s victory in a race is caused by the firing of neurons (rather than years of training, dedication, diet, tenacity, etc..).

If I were to kick you on the knee, and you asked why I had done this, would you accept it if I replied –”brain chemistry”?  That’s the essence of the brain malfunction theory of mental illness.

Every thing we do, from a single heart-beat to complex social interactions, can be traced back (in theory at least) to the electrical and chemical interplay of neurons.  The question:  why did he do that? can always be answered:  because of antecedent neural activity.  But it could, with equal accuracy, be answered:  because of the circulation of his blood, or because of energy transfer from his alimentary tract to his other organs, or because of the potassium content of his blood etc., etc… But these explanations are trite to the point of meaninglessness.

If Dr. Novella and other brain illness theorists seek to prove their position, they need to do better than that.  They need to specify the pathology (whether anatomical damage or physiological malfunction or a shortage of some chemical or a surfeit of some chemical) and demonstrate that this pathology is present in the individuals concerned, and is absent in the rest of the population.  At present, despite four or five decades of intensive and highly motivated research in this area, the hypothetical brain illnesses remain just that – hypothetical.

In the DSM-V article Dr. Novella goes on to point out how reasonable the DSM and practicing psychiatrists are.

“The DSM essentially is the practice of generating a list of problems that can be reliably and validly defined.”


“In reality psychiatrists understand that the categories, or clusters of symptoms, with labels in the DSM are partly labels of convenience… “


“Most importantly, the question as to which therapeutic approach is most effective can be completely disconnected to how we approach labeling symptoms.”

My only response is that this doesn’t sound like the blatantly expansionist and medicalized DSM agenda or like any psychiatric practice I have witnessed in the past thirty years.

Dr. Novella’s conclusions are worth quoting in full:

“The diagnosis of mental illness remains complex and challenging. I am not arguing that any profession (psychiatry, psychology) has it exactly right, but I do think that the mental professions generally take a thoughtful approach to the question of what mental illness is and how it should be approached.

I disagree with attempts to restrict the debate on mental illness using semantics (usually taking the form of objecting to the term “mental illness”). I also think there are many common straw men brought up in this debate. I was disappointed in Kinderman’s review of the issues, and found that he was largely tilting at these common straw men.

But when you get past the turf-war posturing and semantic arguments, I find there is actually widespread agreement on the important issues. Human mood, thought, and behavior are complex, there is a wide range of variation in what constitutes human mental states, and any thoughtful approach must consider circumstances, environment, culture, and biological considerations, including their complex interactions. Further, therapeutic approaches should consider the full range of potential interventions and should ultimately be evidence-based.”

The fundamental problem here is that Dr. Novella is assuming that mental illnesses exist, and simply dismisses arguments to the contrary as “semantics.”  Even though his article purports to be a refutation of Dr. Kinderman’s position, Dr. Novella never actually addresses the main issue.

The deniers’ point, however, (or at least this denier’s point) is that mental illness is an archaic, pre-scientific concept with no explanatory value, exactly analogous to phlogiston or witchcraft.  I have discussed these themes elsewhere.

Dr. Novella is being disingenuous in claiming that the diagnoses are really just lists of problem clusters that can be reliably and validly defined.  Firstly, because the problem behaviors don’t cluster to anywhere near the extent that the taxonomy implies (or at least this has never been proven); and secondly because the diagnoses are not nearly as enduring or persistent within the individual as the term “diagnosis” implies.  If you want to understand a person, it is not enough to assign him a label.  One needs to spend time getting to know him and his history, and becoming familiar with the context in which he lives.

If behavioral science has taught us anything over the past 100 years, it is that context is a major determinant of behavior.  The mental illness approach, with its assumption that the problem is “in the individual” (DSM-IV, xxxi) flies in the face of this reality.

In practice, despite Dr. Novella’s assertions to the contrary, the goal of an initial psychiatric interview is to uncover the “diagnosis,” assure the “patient” that he has an illness (“just like diabetes”), and prescribe the pill.  It is at least 35 years since I have encountered a psychiatrist who conceptualized his work otherwise.

And it is the APA’s self-serving medicalization of ordinary human problems of living that underpins and drives this spurious and destructive travesty.

  • Steven Novella
  • Falco

    “context is a major determinant of behavior. The mental illness approach, with its assumption that the problem is “in the individual” (DSM-IV, xxxi) flies in the face of this reality.”

    False positives in psychiatric diagnosis: implications for human freedom.

    Current symptom-based DSM and ICD diagnostic criteria for mental disorders are prone to yielding false positives because they ignore the context of symptoms. This is often seen as a benign flaw because problems of living and emotional suffering, even if not true disorders, may benefit from support and treatment.

    However, diagnosis of a disorder in our society has many ramifications not only for treatment choice but for broader social reactions to the diagnosed individual. In particular, mental disorders impose a sick role on individuals and place a burden upon them to change; thus, disorders decrease the level of respect and acceptance generally accorded to those with even annoying normal variations in traits and features. Thus, minimizing false positives is important to a pluralistic society.

  • cledwyn bastardo

    If an institutional psychiatrist calling you a denialist doesn’t drive you nuts, then you must be nuts.

    For anyone who doesn’t get the point I’m making with this epigram, being called a denialist by people who uphold a system that has frankly institutionalized denialism should be enough to drive any halfway decent, sane person to madness.

  • barry

    Sometimes the obvious answer is the obvious answer. Poverty, family breakdown, becoming physically disabled are obvious stressors.

  • Cledwyn Bastardo

    Novella is typical of a profession that instead of responding maturely to the criticisms
    levelled at it, as well as dealing with those aspects of the profession that need to be addressed, merely tries to drag the accuser down to its own level (as he does in accusing people like myself of denialism), projecting onto others what they find too disturbing to acknowledge about themselves, or simply as a strategy in the battle for hearts and minds the profession is perpetually engaged in. What better word than “denialism”, for example, could better sum up the profession’s response to the harm it causes, and regarding the true functions of institutional psychiatry both in its contemporary and historical manifestations?

    This reaction (that is, as a projection, not as a strategy in the battle for hearts and minds) puts one in mind of a corrupt human being who projects his own vileness onto people nicer than himself, as a means of dealing with the shameful image of himself reflected back to him through the juxtaposition of this image with that of a person whose decency allows him, as if in a mirror, to discern his vileness in the contrast between himself and this person, who either must be made to bear the weight of the other’s moral culpability so that the person displacing it can allay any feelings of guilt or shame, or must be made to seem just as corrupt so that the sense of shame dwindles. Hence the reason why corrupt people like to surround themselves with corrupt people.

    I think projection, both at an interpersonal and intergroup level, is perhaps the most common mechanism employed in dealing with negative emotions occasioned by truths about ourselves that can’t be absorbed into our sense of self without doing damage.

    This, I would surmise, is exactly what psychiatry collectively as a profession is doing, give or take the odd exception, such as people like Joanna Moncrieff, who work within the system whilst nevertheless preserving at least a small trace of the intellectual independence state psychiatrists delude themselves they possess.

    Human beings, notwithstanding the philosophical, rationalist pretensions we fatuously entertain, are ultimately creatures for whom the value of truth is relative.

    The value truth possesses for an individual or a group is inversely proportional to the extent to which they stand to profit from falsehood. As the latter increases, the former decreases.

    Psychiatry cannot rely on the truth as an ally, indeed, arbitrary power rarely can, so in its struggle for survival, and the individual struggles of those who practice it (and their struggles to evade responsibility and the “madness” that would engulf them if they had an honest reckoning with themselves, the work they do, the lives they are destroying etc.), they must of necessity use whatever means they have at their disposal without letting the truth narrow their options, and accusing others of what is most salient in themselves is a part of the heritage of man’s oppression of his fellow man, a heritage of hypocrisy the mental health movement is preserving.

    If the truth doesn’t threaten our existential and psychological interests, there will be little resistance, but when a truth threatens us personally, the self-preservation instinct takes over. The struggle for survival doesn’t admit of considerations of truth anymore than it does moral and sentimental considerations.

    For this reason (though this is more of an obiter dictum, not bearing directly on the topic under discussion here), it is the last word in pretension, and the quintessence of hubris (though sadly, this is a truth that will perhaps never be put into general circulation, at least in our generation. What can I say, I’m outnumbered by all the people determined to dive deeper into their fatuous delusions of rationality, which of course, would be fine, if such delusions weren’t sacrificial in character, if they could come into being without the stigmatization and degradation of those of us labelled “mad”), for any man to assume that he is truly rational (that is rational in his thought processes. It goes without saying that irrational thought processes often find themselves in the service of otherwise entirely rational behaviours and decisions. There is method in madness,) because even the most intelligent, self-aware individual, under situational compulsion, will withdraw into fantasy, erecting defences against some aspect of reality, if it threatens him in some way. What is irrational from the point of view of thought processes can be entirely rational when viewed from a the perspective of one’s interests.

    Coming back to my point, we are all conditioned to view psychiatrists in the light of their culturally-imparted mystique and mana, which ultimately precludes rational thought in relation to their utterances, behaviours and dealings. Because of this cult of the psychiatrist in modern societies, inter alia, people tend to assume, in accordance with their status as members of Reason’s elect and as the arbiters of sanity (a status which has, of course, gone to the head of those who practice it to a greater or lesser degree according as one moves up or down the scale of egotism and according to the measure of self-awareness possessed by the practitioner, a self-awareness which is nevertheless, mostly, I would surmise, useless in counteracting the intoxicating effects of status and power, effects that can be glimpsed in celebrity culture), that these people are mere humble servants of truth and reason, an assumption blinding us to the fact, as I see it, that the profession has long since turned its back on a truth that no longer accommodates itself to the needs and desires of its members who have unfortunately been exalted to a status at variance with the reality, and is using desperate measures, as this attempt to drag the accuser down to the level of the accused is.

  • Francesca Allan

    From one of Dr. Novella’s comments under his article: ” … psychiatry displays a thorough and nuanced view toward the various causes of mental disorders ….”

    Funny, in over a decade of tangling with our psychiatric system, I never came across a doctor who took environmental factors at all seriously. The message I got was always crystal clear in its reductionism: Your brain is diseased and you need medication just as a diabetic needs insulin. Unhappy marriage? Unhappy career? Utterly irrelevant.

    Where were all these psychiatrists with their “thorough and nuanced” views when I needed them? Has the field so radically changed since I escaped it? Or are there fundamental differences in psychiatric practice between our respective countries?

  • barry

    Psychiatrists casting spells again…….Cledwyn, your post is very erudite and thoughtful, but your’e over thinking it. Try he’s a (insert appropriate word.)

  • cledwyn bulbs

    Ha, maybe, I probably do over think some things. This is perhaps my idee fixe.

  • Bod

    “In his one example, however (responding to my position on ADHD) he takes
    a position that is not supported by evidence and seems to be an extreme
    environmental position. He is saying explicitly that ADHD results not
    from a brain disorder (a decrease in activity in that part of the brain
    which allows us to pay attention, what is called “executive function”)
    but rather an absence of training – i.e. bad parenting.”

    This quack, accused Hickey of using staw men, yet he goes onto say Hickey thinks bad parenting causes a child to not pay attention in school.

    He’s a moron. Hickey clearly stated that a child is always paying attention to something. The ADHD label is slapped on the kid that doesn’t pay attention to the things the adults want him to pay attention to. Parents just need to protect their kids from these psychiatrists like Novella. “a decrease in activity in that part of the brain which allows us to”…. become a quack like Novella.

  • all too easy

    “The fallacy that Dr. Novella has fallen into is: A has been noted to cause B. Therefore every instance of B must have been caused by A.”
    Incorrect. How did you graduate from a university? He does not say that or imply it. For you to say that is bizarre.

  • all too easy

    “Children (and adults) are always paying attention to something. The point about ADHD is not that the child is inattentive, but rather that he is not paying attention to the things that he needs to attend to.”

    Bottom line is the same. Attending to many things is the same thing as not paying attention at all. What haters don’t understand among other things is that when it is time to pay attention and ADHDers want to and need to, they cannot. It is not that hard to understand, but haters bounce all over irrelevant stuff to avoid what is a easy to comprehend.

    Even when ADHDers want to and need to PAY ATTENTION, they cannot, CONSISTENTLY. That is ADHD

  • all too easy

    ADHD kids/adults can’t pay attention to what they want to pay attention to and need to pay attention to, either. THAT IS THE DIFFERENCE. I know from experience.

  • all too easy

    Treatment of attention-deficit/hyperactivity disorder: overview of the evidence.
    Brown RT, Amler RW, Freeman WS, Perrin JM, Stein MT, Feldman HM, Pierce K, Wolraich ML; American Academy of Pediatrics Committee on Quality Improvement; American Academy of Pediatrics Subcommittee on Attention-Deficit/Hyperactivity Disorder.
    The American Academy of Pediatrics’ Committee on Quality Improvement, Subcommittee on Attention-Deficit/Hyperactivity Disorder, reviewed and analyzed the current literature for the purpose of developing an evidence-based clinical practice guideline for the treatment of the school-aged child with attention-deficit/hyperactivity disorder (ADHD). This review included several key reports, including an evidence review from the McMaster Evidence-Based Practice Center (supported by the Agency for Healthcare Research and Quality), a report from the Canadian Coordinating Office for Health Technology Assessment, the Multimodal Treatment for ADHD comparative clinical trial (supported by the National Institute of Mental Health), and supplemental reviews conducted by the subcommittee. These reviews provided substantial information about different treatments for ADHD and their efficacy in improving certain characteristics or outcomes for children with ADHD as well as adverse effects and benefits of multiple modes of treatment compared with single modes (eg, medication or behavior therapies alone). The reviews also compared the effects of different medications. Other evidence documents the long-term nature of ADHD in children and its classification as a chronic condition, meriting the application of general concepts of chronic-condition management, including an individual treatment plan with a focus on ongoing parent and child education, management, and monitoring. The evidence strongly supports the use of stimulant medications for treating the core symptoms of children with ADHD and, to a lesser degree, for improving functioning. Behavior therapy alone has only limited effect on symptoms or functioning of children with ADHD, although combining behavior therapy with medication seems to improve functioning and may decrease the amount of (stimulant) medication needed. Comparison among stimulants (mainly methylphenidate and amphetamines) did not indicate that 1 class outperformed the other.

  • all too easy

    If you had the slightest idea what you are saying. Phil has exactly no evidence that poor parenting causes ADHD. And his theory is ridiculous. The depths antis will go to keep from seeing life as it is, must be a separate illness.

  • all too easy

    You too have no idea. A diagnosis of ADHD sets the captive free. At last, there is a scientific explanation for the confounding mystery of a life unlived.

  • all too easy

    Keep the focus on your shortcomings. Novella knows what he is doing. You try to dismiss the reality of a true disorder locking others into a doomed existence of repeated, inexplicable failure.

  • all too easy

    Why did you need a psychiatrist? You dismiss them. Why tangle with them when they serve no useful purpose? 10 years?
    I don’t believe you.