Tag Archives: IF THEY’RE NOT ILLNESSES WHAT ARE THEY?

The Concept of Mental Illness: Spurious or Valid?

On January 17, 2013, Peter Kinderman, PhD, Professor of Clinical Psychology at the University of Liverpool, wrote an article titled Grief and Anxiety are not mental illnesses.

On February 4, 2013, Steven Novella, MD, wrote a critique of Dr. Kinderman’s article.

On February 20, I wrote a critique of Dr. Novella’s article.

And finally, on September 17, Dr. Novella wrote More On Mental Illness Denial and How Not to Argue, a critique of my critique.

There are a number of fundamental issues involved, and I feel I should try to address at least some of these.

THE CONCEPT OF MENTAL ILLNESS

In his critique of Dr. Kinderman’s article, Dr. Novella stated:

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

Apart from the word “symptom,” I am in complete agreement.  The essential question, the central issue at the core of this entire debate is:  how can we best conceptualize problems of mood, thought, and behavior.

I would prefer to say problems of feeling, thinking, and behaving (i.e. verbs rather than nouns) because in my view, this better reflects the fact that these are activities rather than entities.  But this is not crucial to the central issue.

However, the use of the word “symptom” rather than “problem” is central.  Dr. Novella is saying that the essential question is: how do we conceptualize problems of mood, thought, and behavior – but rather than address this question, he anticipates the answer – they are symptoms, which, I suggest, entails the clear implication that “behind” these “symptoms” there are “illnesses.”

Dr. Novella goes on to express the belief that the best approach (to problems of thinking, feeling, and behaving) is something that recognizes “… the relative roles of biology, situation, and culture (and their interactions) in forming a person’s mental state.”  And if by “mental state” he means thinking, feeling and behaving, then I would agree.

Next Dr. Novella points out that the brain is an organ which can malfunction.  I don’t think anyone would disagree with that.  But he goes on:

“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.”

And this, of course, is where we have to part company.  Assuming, as I said earlier, that by “mental state” he means a kind of composite snapshot of an individual’s thinking, feeling and behaving, then in my view a mental state can be neither healthy nor sick, in any conventional sense of these terms.

But, as is clear from his definition of “unhealthy” quoted above, Dr. Novella is not using these terms in their conventional sense.  Let’s take a look at his definition:

  • 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

This is clearly not a definition of sickness in the normal medical sense.

Now I will certainly concede that in common speech, the words sick and unhealthy have been considerably extended in recent decades.  People routinely talk about an unhealthy lifestyle, for instance, when what they mean is an unwholesome lifestyle; and behavior that is crude or offensive is often referred to as sick.  But in formal speech and writing, and certainly within general medical practice, the words sick and unhealthy mean something wrong with the anatomy or physiology of the organism.  One can speak of a sick person or a healthy person, or, for that matter, of a sick horse or a healthy horse.  But one can’t validly speak of thinking, feeling, and/or behaving as being sick or healthy.  The activity of thinking can legitimately attract adjectives such as cogent, muddled, inconsequential, bizarre, etc…  The activity of feeling could be described as painful, joyous, etc… The activity of behaving could be described as productive, counterproductive, relaxed, frenetic, etc…  But one can’t attribute sickness or health to thoughts, feelings, or behaviors any more than one can attribute the quality of color to concepts.

I can’t, of course, dictate to Dr. Novella how to use or not use words, but what has to be acknowledged is that when he uses the term “unhealthy mental state,” he is very emphatically not using the word unhealthy in the conventional, formal medical sense.  The adjectives sick and healthy simply don’t apply to the activities of thinking, feeling, and behaving in the same way that they apply to organisms.  And this is true even if the thoughts, feelings, and behaviors are “outside the range of most people,” and/or “result in definable harm.”

It is noteworthy that Dr. Novella expressed the belief that “unhealthy” is a better choice of word than “abnormal” without giving any reasons or arguments to support this position.  In my view, the choice of words like unhealthy, sick, ill, etc., in this context has no special value or advantage, and is, in fact, misleading.  The words also beg what Dr. Novella concedes is the fundamental question:  i.e. how best to conceptualize problems of thinking, feeling, and behaving; for Dr. Novella they are to be conceptualized as illnesses.

If Dr. Novella had stated that “…even a biologically healthy brain can be pushed beyond tolerance limits resulting in…” problematic thoughts, feelings, and or behavior, then we would be in general agreement.  But by arbitrarily labeling problematic thoughts, feelings, and/or behavior as unhealthy mental states (i.e. as mental illnesses), he is assuming the answer to the very question that he himself concedes is critical and essential to the whole issue.  For Dr. Novella (and indeed for psychiatry generally), problematic thoughts, feelings, and or behavior are mental illnesses.  This is not something they discover; rather, it is contained within their definition.  It is how psychiatry has decided to conceptualize these problems, and it is a decision that has profound implications in psychiatric practice.

STANDARD PSYCHIATRIC PRACTICE

All of this leads fairly naturally into a second point of dispute between Dr. Novella and myself.  It is my contention that it has become standard practice in American psychiatry to tell clients that their presenting problem, whether it be depression, anger, worry, paranoid thoughts, misbehavior, etc., is the result of a mental illness which is a real illness “just like diabetes” and needs to be “treated” with drugs.  Dr. Novella suggests that this is a caricature that he has never encountered in practice.

He expresses the belief that the standards and philosophy that underpin a profession can be gleaned from official publications, academics, and published standards rather than from the “average private practitioner in the field.”

To which I can only say that I disagree.  As a case in point, would the official publications, published standards, etc., of, say, ten years ago have alerted a naïve outsider to the extent to which psychiatric research and psychiatric prescribing had been corrupted by pharmaceutical money.  But even setting aside those kinds of unethical matters, it seems almost self-evident to me that the best way to find out what psychiatrists are doing is to interact with psychiatrists.  And in my experience, psychiatrists routinely say to their clients things like:  depression is an illness, just like diabetes; and just as a diabetic has to take insulin to treat his illness, so a person with depression must take his antidepressants.  This has never been any kind of secret.  I have often heard psychiatrists make these kinds of statements, and I have heard literally dozens (perhaps hundreds) of clients repeating these kinds of statements and attributing them to psychiatrists that they had seen.  In addition, this kind of message was a mainstay component of a good deal of psycho-pharmaceutical advertizing for years.  If this was not psychiatry’s philosophy, why did they not take steps to stop the ads or at the very least publish counter-information in appropriate places?

Now obviously, I haven’t conducted any kind of formal study of psychiatrists’ behavior, and my observations are limited by my experiences.  It’s possible that my interactions with psychiatrists and with clients have not been representative of American psychiatry generally.

However, I have just Googled the phrase “mental illness just like diabetes” and got 1.3 million hits!  So somebody has been saying that mental illnesses are real illnesses “just like diabetes” and the notion is generating a great deal of discussion.  I have also Googled the term “chemical imbalance” and got 960,000 hits.  Here again, it was psychiatry that promoted this concept, and it is still being discussed actively, and in my experience, is still widely believed.

In his September 17 article, Dr. Novella contends that the general practice of psychiatry is not based on the simplistic formula: mental illnesses are real illnesses just like diabetes, and are treated with drugs.  Rather, he states that psychiatric practice recognizes that problems of thinking, feeling, and behaving:

” …are caused by the full spectrum of influences from biology to social and environmental.”

It is certainly possible that Dr. Novella is accurately portraying psychiatric practice as he has experienced it.  But it is difficult to reconcile his portrayal with the fact that most psychiatric practice has degenerated into 15-minute “med checks” every two or three months.  How much attention can one give to social and environmental considerations in 15 minutes, given that at least some of this time is already budgeted for discussion of drug side effects?

From the tenor of his earlier writings, it occurs to me that Dr. Novella might dispute my contention that 15-minute “med checks” have become the norm, so I spent five minutes on the ‘net and found two articles.  The first is by Douglas Mossman, MD, Director of the Institute of Law and Psychiatry, University of Cincinnati.  It’s called Successfully navigating the 15-minute-‘med check’.  Here’s a quote:

“Even psychiatrists who deplore 15-minute med checks recognize that they have become standard care in psychiatry.”

The second article was published on Psychiatric Times in September 2009.  It’s called Deconstructing the “Med Check,” and was written by Glen Gabbard, MD.  Here’s a quote:

“There can be little doubt in our current era that the brief ‘med check’ is becoming standard practice in psychiatry.”

Even Jeffrey Lieberman, MD, President of the APA, has gone on record lamenting the practice of “…hurriedly written prescriptions…” which, incidentally, he attributes to changes in reimbursement systems.

BRAIN DISORDERS CAN CAUSE BEHAVIOR PROBLEMS

There are many specific points of contention between Dr. Novella and myself.  Attempting to pick up and unravel all of these would, I suggest, be tedious and repetitious.  But I would like to pick up just one which I think is representative.  Towards the end of his September article, he states:

“Hickey further explains his position toward the end of his post:

‘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.’

Wait – but I thought that brain disorders can cause behavior problems? Wouldn’t such a case that Hickey acknowledges exists be considered a ‘mental illness?’ I’m trying to be fair, but such comments certainly sound like mental illness denial to me.”

I had made the point in my earlier critique that brain problems can cause behavioral problems.  I have also stated that there are no mental illnesses; that the concept of mental illness is spurious.

Dr. Novella picks up my statement that brain problems can cause behavior problems and then claims to have caught me in a contradiction – because a brain problem that causes a behavior problem is a mental illness.  Therefore, mental illnesses must exist.

The flaw in the argument, however, goes back to the earlier discussion about the meaning of the term “mental illness.”  For Dr. Novella, any significant problem of thinking, feeling or behaving that entails harm is a mental illness.  My position is that mental illness is simply the label that psychiatrists give to significant problems of thinking, feeling, and/or behaving, and of course, that’s their prerogative.  They can call things by any name they wish.  A problem arises in this case, however, because the word “illness” already has an established meaning in the English language.  And labeling problems of thinking, feeling, and behaving as mental illnesses implies that they are illnesses in the conventional sense of the term.  Dr. Novella does indeed make it clear elsewhere that for him the “illness” in “mental illness” is being used in a special sense.  But this is fraught with potential for misunderstanding.  To maintain clarity under these conditions one would need to add the rider “(the word illness is not being used in its conventional sense)” every time one used the term “mental illness.”

But to get back to the point of contention, Dr. Novella has not caught me in an inconsistency.  Brain problems can indeed cause behavioral problems.  Late stage syphilis (when the germ attacks neural tissue) can cause a person to behave in a “crazy” manner.  What’s involved here is a brain illness (a real brain illness), of which the “crazy” behavior is a symptom (a real symptom).  That, for me, is the reality of the matter.  Dr. Novella, however, adds an additional component – that the “crazy” behavior is also a mental illness.  This is not some kind of additional fact or discovery.  It is simply Dr. Novella’s (and psychiatry’s) label being added arbitrarily and pointlessly to a perfectly clear medical phenomenon.  The fact is that the syphilis germ attacks the brain and causes “crazy” thinking and “crazy” behavior.  Dr. Novella, if I understand him correctly, would reword this as:  the syphilis germ attacks the brain, causing a mental illness, which causes crazy thinking and behavior.  Perhaps he doesn’t mean to impute causative significance to the “mental illness,” but that raises the question as to why one would introduce the concept at all?

So to answer his question:  “Wouldn’t such a case that Hickey acknowledges exists be considered a ‘mental illness?’ the simple answer is “no.”  The concept of “mental illness” adds nothing to our understanding of late stage syphilis or to our understanding of the crazy behavior.  It is simply the label that psychiatrists apply, arbitrarily and misleadingly, to all significant problems of thinking, feeling, and behaving, apparently even to problems of thinking that are caused by late-stage syphilis!

THERE ARE NO MENTAL ILLNESSES

In his final paragraph in the September article, Dr. Novella states:

“If there is a reasonable position to be made against the concept of mental illness, I have yet to hear it. So far I have only encountered the level of argument similar to or worse than Hickey’s unfair and confused article. I am open to any reasonable argument to be made against my current position.”

Obviously this is a huge subject, and this post is already fairly lengthy.  But I will try to provide a brief summary of the case against the concept of mental illness.

1.  Psychiatry defines “mental illness” as any significant problem of thinking, feeling, and/or behaving.
2.  Psychiatry identifies a large number of specific “mental illnesses” to reflect specific problems of thinking, feeling and/or behaving.
3.  Psychiatry presents these specific “mental illnesses” as the proximate causes of the problems.
4.  The logic, however, is flawed, as is evident from the following hypothetical conversation.

Client’s daughter:  Why is my mother so sad; why is she so inactive?
Psychiatrist:  Because she has a mental illness called major depressive disorder.
Client’s daughter:  How do you know she has this illness?
Psychiatrist:  Because she is so sad and inactive.

The only evidence for the putative illness is the very behavior it purports to explain.

5.  When we, on this side of the debate, say that there are no mental illnesses, what’s meant is that the concept of mental illness is spurious conceptually, and has no explanatory value – it adds nothing to our understanding of problems of thinking, feeling and/or behaving.  It is misleading, in that it appears to offer an explanation.  It is also destructive, in that it serves to legitimize the widespread and ever-increasing use of drugs, increases the level of stigma attached to people who are experiencing these problems (Angermeyer, M.C. et al, 2011), and communicates the false message that people are powerless to deal with their problems without psychiatric intervention (i.e. drugs).

I have written extensively on these matters throughout the website (e.g. here and here), and the above summary is just that – a summary.

It is my guess that Dr. Novella would dispute much of this summary.  In particular, I suspect that he would object to the notion that “mental illness diagnoses” are presented by psychiatry as the proximate causes of the problems.  My contention is that assertions of this sort are routine in psychiatric practice; Dr. Novella states that this is not so and bases his position on “official publications” and other formal sources.

So let’s take a look at one “official publication” – the APA’s DSM.  This is psychiatry’s Diagnostic and Statistical Manual.

In general medical circles the diagnosis is the cause of the symptoms.  If one is very tired and is coughing up dreadful-looking stuff, and goes to see a physician, he will probably run some tests and may discover that the cause of these problems is pneumonia.  This is the diagnosis.  This is a real illness that causes real symptoms.  If you asked the physician for a diagnosis, he would understand clearly that you were asking for the cause of the presenting problems.

So when the APA produces a book called the Diagnostic and Statistical Manual, there is, I suggest, an implicit assumption that it will present lists of diagnoses (i.e. real illnesses) and the symptoms which these illnesses cause.  And in fact, when one opens the book this is what seems to be the case – lists of diagnoses with their respective symptoms.

Some psychiatrists respond to this point by contending that the book doesn’t actually say that the diagnoses are the causes of the symptoms, and that the diagnoses are really just labels of convenience for clusters of problems.  If this is the case, then I suggest that the title of the book is very misleading.  It ought to be called something like:  A listing of significant problems of thinking, feeling and behaving, together with their labels of convenience as used by psychiatrists.

 But the use of the terms “diagnosis” and “symptoms” is not the only issueThe notion that the “diagnoses” are being presented as the proximate cause of the symptoms permeates the text.  I haven’t yet had an opportunity to study DSM-5, but a careful reading of DSM-IV and DSM-III-R reveals a great many passages which imply that the symptoms are caused by the putative underlying mental disorders.  For example, many of the symptom lists contain the phrase “the symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder…),” or “the disturbance is not better accounted for by another mental disorder  (e.g.…).”  The term “better accounted for” implies a causal relationship between the putative disorder (the diagnosis) and the symptoms or problems.  The statements:  “The mental disorder accounts for the symptoms” means substantially the same as “the mental disorder is the cause of the symptoms.”

In DSM-III-R, the V codes were described as conditions “…not attributable to a mental disorder.”  The term “attributable to” is, I suggest, essentially synonymous with “caused by,” the implication being that the non-V diagnoses are, in fact, the causes of their respective symptoms.  In DSM-IV, the phrase was dropped, but the concept was retained, embedded in several of the textual descriptions.  For instance, V71.01 Adult Antisocial Behavior “…the focus of clinical attention is antisocial behavior that is not due to a mental disorder (e.g. Conduct Disorder…).”  Similarly, V15.81 Non-Compliance with Treatment:  “The reasons for non-compliance may include…the presence of a mental disorder.”  The terms “attributable to,” “due to,” and “reasons for” imply a causal relationship, and it is clear that the mental disorders are conceptualized and presented as the causes of the problems of thinking, feeling, and behavior.  And this is how the DSM taxonomy is interpreted and used in the field, and is perceived by the general public.

The DSM is not the only “official” publication that promotes the notion that “mental disorders” are the proximate causes of the “symptoms.”  I happen to have on my desk at the present time an APA document titled Five Things Physicians and Patients Should Question.  The general theme of the document, which consists of five recommendations, is that practitioners should exercise more caution in prescribing neuroleptic drugs.  The fourth recommendation is:

“Don’t routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.

There is inadequate evidence for the efficacy of antipsychotic medications to treat insomnia (primary or due to another psychiatric or medical condition), with the few studies that do exist showing mixed results.” [emphasis added]

It is clear from the wording of this item that according to the APA, insomnia (a common criterion item in the DSM) can be caused by (“due to”) a psychiatric condition (i.e., a mental illness/disorder).

Another example of this kind of circular reasoning can be found in theJAMA summary that Dr. Novella adduced to support his claim that the condition labeled ADHD is a brain illness.  On page 2 of this document, under the heading Diagnosis, you’ll find the following:

“To be significant, a symptom must have started before age 7 years, be present for at least 6 months, and not be due to another cause.” [emphasis added]

This clearly implies that the “mental illness” called ADHD causes the symptoms.

Another example:  in the NIMH’s education publication Attention Deficit Hyperactivity Disorder, under the heading How is ADHD diagnosed in adults? they write:

“For some adults, a diagnosis of ADHD can bring a sense of relief. Adults who have had the disorder since childhood, but who have not been diagnosed, may have developed negative feelings about themselves over the years. Receiving a diagnosis allows them to understand the reasons for their problems, and treatment will allow them to deal with their problems more effectively.” [emphasis added]

Again, the clear implication is that the “mental illness” called ADHD is being conceptualized and presented as the cause of (the reason for) the symptoms.

The Mayo Clinic has a Health Information pamphlet on Insomnia.  Under the heading “Common Causes of Insomnia” it states:

“Everyday anxieties as well as more serious anxiety disorders may disrupt your asleep.” [emphasis added]

It’s very clear that what’s being presented here is the notion that mental disorders cause insomnia.

 The American Academy of Sleep Medicine actually has a publication called Insomnia Due to Mental Disorder.  Here are some quotes:

“This insomnia is caused by a mental health disorder.” [emphasis added]

“Depression and other mood disorders often will result in a degree of insomnia.” [emphasis added]

The University of Maryland has an In-depth Patent Education Report on insomnia.  Here’s a quote:

“The disorders that most often cause insomnia are: [emphasis added]

    • Anxiety
    • Depression
    • Bipolar disorder
    • Attention-deficit hyperactivity disorder
    • Post-traumatic stress disorder”

As explanatory concepts, however, the “diagnoses” are entirely circular, and hence valueless.  Essentially, what’s being asserted is that problems of thinking, feeling and behaving are caused by problems of thinking, feeling, and behaving.  The explanation in fact is not an explanation at all.  It adds nothing to our knowledge.  Rather, by discouraging further inquiry, it acts as a barrier to genuine exploration and understanding, which, incidentally, was one of the points Dr. Kinderman made in his original article back in January, and to which Dr. Novella took such exception.

But let us be clear.  If it were proven that a particular “mental illness” were in fact the direct result of a brain malfunction, then the circularity would be broken, and we would be dealing with a genuine brain illness.  But despite decades of highly motivated research and the spurious claims of psychiatry in this regard, such proof is not available.  For the record, the DSM entries Mental Disorders due to a General Medical Condition are for obvious reasons excluded from these considerations.  The General Medical Condition category, however, does suggest an obvious question:  If the condition known as ADHD is indeed a brain illness as Dr. Novella asserts, then why is it not included in the General Medical Condition category?  After all, a brain illness is a general medical condition.

ADHD

In his response to my critique, Dr. Novella states that only some mental illnesses are brain illnesses, and takes me to task for confusing some with all.  This is a fair point, though I still maintain that the use of the term mental illness conveys the impression that one is talking about a real illness, and that the likely focus of this is the brain.  But we’ve already discussed that matter, and let’s set it aside for now.

As an example of a “mental illness” that he claims is indeed a brain illness, Dr. Novella points to the condition known as ADHD.  He says that there is

“…decades of research which clearly show that ADHD is a genetic disorder characterized by hypofunctioning of the frontal lobes leading to a relative deficit of executive function. This part of the brain serves as a “resource allocator” – allocating brain resources to various tasks. Relative lack of this function results in a reduced ability to pay attention to the things we should be paying attention to.”

Dr. Novella goes on to state that it’s “… difficult to provide a single reference to reflect all this research…” and instead provides a JAMA summary, authored by Denise M. Goodman, MD and Edward H. Livingston, MD.  I opened the JAMA article expecting to find a summary of research findings with citations.  Instead, I found a simplistic JAMA “patient page” that simply asserts that “…ADHD is a biological condition…”

By contrast, I suggest that Dr. Novella take a look at Debunking the Science Behind ADHD as a “Brain Disorder by Albert Galves, PhD, and David D. Walker, PhD.  Dr. Novella might also review Transforming Diagnosis by Thomas Insel, MD, Director of NIMH.  In this paper, dated April 29, 2013, Dr. Insel was critical of DSM diagnoses generally.  He wrote:

“While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each.”

“The strength of each of the editions…has been ‘reliability’…The weakness is its lack of validity.” [A lack of validity in this context means that the ‘diagnoses’ do not actually refer to, or mirror, anything in the real world.]

“…The DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.”

For the record, I do not agree with other positions taken by Dr. Insel, but his comments concerning DSM’s “diagnoses” are unambiguous.  In the present context, it is noteworthy that he did not exempt the ADHD “diagnosis” (or indeed, any DSM label) from his criticisms.

If there were clear and compelling evidence that the condition known as ADHD is in fact a brain illness along the lines that Dr. Novella asserts, wouldn’t Dr. Insel, the Director of NIMH, have known this, and excluded it from his comments?

In addition, if the condition known as ADHD is a real brain illness, wouldn’t it make sense to diagnose it by brain examination, thereby increasing the Kappa scores from their present value (0.5-0.6) to something approaching 1.0 (i.e. almost perfect reliability).

THE ESSENTIAL QUESTION

Dr. Novella and I are in complete agreement that the essential question in this entire debate is how best to conceptualize significant problems of thinking, feeling, and/or behaving.  Dr. Novella conceptualizes these problems as mental illnesses, which is not surprising because he defines a mental illness as any significant problem of thinking, feeling and/or behaving.

I, on the other hand, conceptualize significant problems of thinking, feeling and/or behaving as – significant problems of thinking, feeling, and/or behaving.

In the now distant days when I was practicing, I sat with my clients and, through unhurried dialogue and discussion, we identified and clarified the problems for which they were seeking help.  Also through unhurried dialogue and discussion, we explored how these problems might have developed, and what circumstances/pressures might be maintaining them.

If my clients said they were depressed, or worried, or angry, I asked them why, and I listened to their responses without interrupting.  In almost all cases, individuals could give perfectly coherent and plausible explanations for their problems without any reference to extraneous, spurious concepts such as “mental illness.”

I conceptualized (and still conceptualize) problems of thinking, feeling, and behaving as so individualized with regard to genesis and development as to defy any kind of simplistic categorization or classification.  I did not see my clients as ADHD’s or MDD’s or OCD’s or Conduct Disorders or Personality Disorders or any other DSM label.  I did not see them as patients who needed to have something done to them – but rather as complex and competent human beings, fellow travelers on life’s journey, who had hit speed bumps, or taken wrong turnings, or run out of fuel, or been battered, figuratively or literally, by the vicissitudes and cruelties of life.

We discussed the importance of habits: how some are productive and others counterproductive.  We discussed how habits are formed and how they can be broken.

We discussed what kind of remedial strategies might be effective, and how best they might be implemented in each particular case.  I took pains to help my clients identify their strengths, and we discussed how these strengths might be mobilized in coping with the present difficulty.

We also tried to identify what social connections the clients might have that might be helpful in the present circumstances.

It was very much not a matter of me, the “expert,” healing people or solving their problems.  Rather, my role was validating people’s experiences and their reactions to those experiences, and helping them mobilize, develop, and use their own resources to move their lives in directions they found more fulfilling.

This is a fundamentally client-centered approach in which there is no place or need for the concept of “mental illness.”

Dr. Novella clearly believes that his “mental illness” model is a better approach.  Perhaps ultimately we’ll just have to agree to differ.

What Is Mental Illness?

BACKGROUND

I recently received the following question from Disparity, on Twitter.

“I’m interested in all your posts, but they’re always telling us what mental illness ‘isn’t.’  Do you have many on what it ‘is’?

I referred him/her to the post There are No Mental Illnesses and received the following reply:

“I have read it a few times.  I largely agree with it.  But ‘something’ happens to people.  Whatever the label.”

Questions of this sort arise fairly frequently, and I thought it might be helpful to write a post.

WHAT HAPPENS TO PEOPLE?

I suspect that underlying Disparity’s question is the notion that “mentally ill” means “crazy,” and that there really are people who seem to be “crazy.”  This is, I think, a widely accepted notion.  But in the present context, it leads naturally to another question:  if they’re not ill, if they haven’t actually contracted an illness, then what has happened to them?

SOME FACTS

For several years now, it has been confidently stated by government agencies and by psychiatrists that approximately 50% of the population will experience a “mental illness” in their lifetime.  That’s half the population!  So if we are to believe this, then clearly the individuals embraced by the term “mental illness” are actually very ordinary and unremarkable.  It’s you, me, the man next door, the milkman, Auntie Betty, etc., etc.

What has happened to all these people is life.  Bad things happen to all of us.  Sometimes we don’t cope too well with these challenges, and if we are brought to the attention of the mental health system, we get a “diagnosis” and enter the ranks of the “mentally ill.”

Psychiatry – especially in recent months – claims that they only assign “diagnoses” when the individual’s actions or feelings are extreme.  In practice, I suggest that this is not the case.  If you go to a psychiatrist and tell him/her that you’ve been feeling very down, that your mother used to feel this way, that she has been doing very well since she started taking an antidepressant, there’s a very good chance that you will be assigned a “diagnosis” and given a prescription – especially if you throw in that you don’t feel like getting up in the morning and that your appetite is poor.  And you are now a “mentally ill” person.  So what happened?  You got to feeling down.

“What happened,” of course, varies from person to person, and from situation to situation.  A person who has experienced a truly horrendous situation and has persistent distressing memories may be assigned a “diagnosis” of posttraumatic stress disorder.  A misbehaved child may get a “diagnosis” of oppositional defiant disorder.  A juvenile delinquent might get a “diagnosis” of conduct disorder.  And so on.

Even very young children are fair game for the “diagnostic” net.  Children as young as 3 or 4 are being “diagnosed” with bipolar disorder if they display frequent temper tantrums!

THERE ARE NO MENTAL ILLNESSES

When I say that there are no mental illnesses, what I mean is that behavioral and emotional problems are not illnesses.  It is frequently suggested that by saying this I am minimizing the significance of these problems.  Nothing could be further from the truth.  Human problems can be mild, moderate, severe, devastating, and every level of significance in between.  But they’re not illnesses.

Psychiatry has promoted the falsehood that they are illnesses (“just like diabetes”) to justify their promotion of pharmaceutical products.

The matter is complicated by the fact that sometimes behavioral and emotional problems do indeed stem from real illnesses.  For instance, hypothyroidism can occasionally cause delusions and hallucinations.  However, these cases are dealt with by treating the hypothyroidism.

But behavioral and emotional problems can – and I suggest, usually do – arise in the absence of any underlying physical illnesses.

I discuss these general ideas in more detail in the posts on the individual “diagnoses.”

Mental Distress Is Not An Illness

BACKGROUND

Sam Thompson (University of Liverpool) posted the following tweet on April 27:

Can anyone point me to a good, succinct summary of the case for equating mental distress with illness?  (serious, non-sarcastic question)

On the face of it, this looks like a straightforward question, and one might think that a straightforward answer could be found.  But this is not the case, because ultimately it boils down to a matter of definition.  And psychiatry is a field where definitions are notoriously fuzzy.

MENTAL DISORDER

Contrary to widespread belief, the APA’s Diagnostic and Statistical Manual is not a listing of “mental illnesses,” but rather of “mental disorders.”  However, for the last 20 years or so, almost all psychiatrists have conceptualized the problems they treat as illnesses (specifically, chemical imbalances in the brain) and have routinely expounded this untruth to their clients.

It is noteworthy that the APA has never issued any kind of clarificatory statement on this matter, and in practice the terms are used interchangeably.  But the confusion is no accident.  By interchanging these terms, the psychiatrists have allowed the medicalization of the identified problems by implication rather than by fiat, which makes it easier for them to extricate themselves should the medical model ever come under serious scrutiny – which, incidentally, is what’s happening at present.

The protest against the spurious medicalization of virtually every life problem is loud, focused, and growing.  And, predictably, the psychiatrists are beginning their extrication process.

Ronald Pies, MD, is a well-known US psychiatrist who blogs on Psychiatric Times.  On the illness terminology, he had this to say on July 11, 2011:

“In truth, the ‘chemical imbalance’ notion was always a kind of urban legend- – never a theory seriously propounded by well-informed psychiatrists.” (link)

And on April 18, 2013:

“But on the whole, I believe the medicalization narrative is philosophically naive and clinically unhelpful.” (link)

He blames the “chemical imbalance” notion on pharma:

“And, yes—the ‘chemical imbalance’ image has been vigorously promoted by some pharmaceutical companies, often to the detriment of our patients’ understanding.” (link) ( 7/11/2011)

So the spurious medicalization of clients’ problems is in no way the responsibility of psychiatrists.  It’s the fault of pharma.

But like most psychiatrists, Dr. Pies is experiencing some inner conflict in this general area.  Here’s another quote from the April 18 paper:

“So long as the patient is experiencing a substantial or enduring state of suffering and incapacity, the patient has disease…”

And there you have it.  For Dr. Pies, suffering + incapacity = disease, which presumably is synonymous with illness.  Dr. Pies quotes a reference in support of this position.  It’s an essay he wrote in January 2013.  You can see Part 1 here, and Part 2 here.  In these papers he doesn’t actually produce arguments in support of this position, but simply asserts it to be so.  For instance:

“Regardless of context, once a certain threshold of suffering and incapacity is crossed, physicians justifiably apply the term ‘disease’ (or ‘disorder’) to the person’s condition. (For purposes of this discussion, I am using the terms ‘disease’ and ‘disorder’ more or less synonymously, although the medical literature is remarkably inconsistent in how these terms are applied.

There it is:  once a “…certain threshold of suffering and incapacity is crossed…” a sub-optimal behavior or feeling becomes a disease/illness.  And also notice that “disorder” and “disease” have become synonymous.

I mention Dr. Pies’ work in this context not because of any intrinsic value, but because he managed to put into words many of the unspoken assumptions inherent in modern psychiatry.  What’s particularly striking in Dr. Pies’ writing is the notion that one can consider a condition an illness even in the absence of any demonstrable physical pathology.

This is echoed in the APA’s definition of a mental illness/disorder:

“…a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress… or disability … or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.” (DSM-IV-TR, p xxxi)

There are a number of noteworthy features to this definition.

–  a behavioral or psychological pattern (i.e. any kind of human activity)
–  that occurs in an individual (as opposed, say, to in a family or in society)
–  that is associated with (not necessarily causally associated)
–  distress or disability or significantly increased risk
–  of death or pain or disability or loss of freedom

Note the multiplicity of “ors”, so only one of the factors listed is needed for a condition to be a mental illness/disorder.

It is truly difficult to think of any sub-optimal human activity that would not be embraced by this definition.  Habitually wearing shoes that are too tight, for instance, is a behavior pattern; it occurs in an individual; and is associated with pain.  Playing one’s car radio too loud is associated with disability (hearing loss).  Any kind of criminal activity is clearly embraced by the definition on the grounds that it entails the risk of incarceration.  Mountain climbing is associated with increased risk of death.  Etc., etc., etc…  The definition is so broad that it can embrace any activity that the APA chooses to include in the DSM.

As with Dr. Pies’ writing, there is no requirement of physical pathology for a condition to be called a mental disorder/illness.

Over the past 30 years or so, various attempts have been made to prove that the conditions listed in DSM are illnesses. These proofs usually involve showing that the activity in question has a characteristic neural underpinning, and “therefore” the activity is an illness.  Most of the attempts have foundered under scrutiny.  For instance, the brain damage theory of “schizophrenia” collapsed when it was demonstrated that the characteristic damage was actually caused by neuroleptics.  But even if characteristic neural or hormonal or genetic correlates were accurately and reliably identified, this will never be the full story.

Consider the case of violent behavior.  Let’s say person X kicks person Y in the head quite viciously, and the question arises:  why did X kick Y?  An explanation might be offered along the following lines:

The muscle fibers in X’s thigh contracted and rapidly released; this muscular activity was caused by the organized firing of various neurons, coupled with the presence of adequate reserves of potassium ions in the blood stream.  The neuronal activity was initiated by synaptic activity in the cerebral cortex which in turn was influenced by sensory input signals.  And all of this activity was made possible by the fact that the digestive tract was primed and functioning and was providing energy to various bodily systems via the blood stream.  The adrenal glands had secreted adrenaline … etc..

This kind of account if developed in detail might easily run to a million words; could be 100% true, and would indeed constitute an explanation of the act of kicking.  Behavioral patterns are indeed underpinned and driven by corresponding physiological patterns.  This is true whether the behavior is functional or dysfunctional; productive or counterproductive, helpful or unhelpful.  The fact that a behavior can be explained in physiological terms does not make the behavior an illness.    All behavior can be explained in physiological terms.  One could, for instance, conduct a physiological analysis (similar to the one above) for the activity of riding a bicycle.  This would not prove that bike-riding is an illness.  Nor would it be the full story or even the main story.

Another way of explaining the kicking incident, for instance, might go like this:

X grew up in very violent surroundings, and he acquired the habit of responding violently to anything or anybody who seemed threatening.  Y was speaking loudly and aggressively and had begun to assault X, so X knocked him down and kicked him in the head.

I suggest that while the physiological explanation would have a great deal of interest for physiologists, the latter (behavioral) explanation has more usefulness and relevance for people working in the human service field, and indeed for people generally who are trying to understand human behavior, feelings, conflict, etc…

A complication in this area is the fact that biological malfunctions can and do occur, and occasionally these malfunctions can cause psychological/behavioral problems.  A number of such conditions are known, and the underlying biological damage/malfunction has been identified with various degrees of precision.

But, and this is the critical point, the vast majority of behavior that meets the APA’s criteria for a mental disorder is not associated with known biological pathology.

But then there’s yet another complication, which stems from the fact that people can learn.  We can acquire new skills and behaviors.  This process has been studied extensively by psychologists and others, but the underlying physiology/neurology is not well understood.

However, it is obvious that there is some neurological basis to every item of new learning.  If I take a walk in some place where I’ve never been before, and afterwards I can recall details of the area or even draw a map of the place, clearly there is something inside my brain that has changed.  Similarly newly acquired skills and habits, whether they are functional or dysfunctional, are underlain with some kind of neural “program”.  And this fact, though seldom articulated, is the basis for the psychiatric medicalization of all human problems.

Suppose I have, for instance, an extreme fear of public speaking.  This is an acquired fear (i.e. I wasn’t born with it), and it is likely that I have acquired this fear in the same general way that people acquire other fears (i.e. through social conditioning).  But there is something in my brain that corresponds to, and indeed causes, physiologically, this particular fear response.

Getting rid of this fear is generally not difficult.  I could design a program of systematically increasing exposure; I could ask a psychologist to help me; or I could join Toastmasters.  Assuming that the retraining is successful, then the neural underlay will also be removed, or disabled, or modified in some way.

Psychiatry’s approach, however, is to get rid of the fear by directly targeting the neurological basis, and they apply this approach to all human problems – not just fears.  The methods they use are drugs, electric shock, and scalpels.  It is a central theme of this website that their efforts in this regard are not only unsuccessful, but also do a great deal of harm.  But for now, let’s continue to explore the conceptual issues.

I have a picture “in my head” of a school I attended as a child.  Let’s say I have truly horrendous memories of this school, and let’s say that the neurological trace of this building is confined to one minute spot in my brain.  A neurosurgeon might conceivably be able to go in with a tiny electrode and burn out the offending tissue, and I would never again be troubled by this memory.

I’m not suggesting that anything of this sort is, or ever will be, possible (if for no other reason than that the bad memories are probably not confined to one tiny neural location).  But this is the essential reasoning behind the illness theory: that painful memories, bouts of depression, counterproductive habits, etc., are all best understood in terms of their neural underpinnings, which have to be removed, damped down, rebalanced, adjusted, burned out, or whatever, even though they are not in themselves pathological, either with regards to genesis or functioning.  My horrendous memories of the school are actually adaptive, and might conceivably help me avoid aversive situations of this sort in the future.

At the present time, and I suggest in the foreseeable future, the tools used by psychiatrists in their efforts to effect these adjustments are more analogous to soup spoons, or even jackhammers, than tiny electrodes.

Some of these issues can be clarified with a computer analogy.  I can take a photograph of my house and put it into my computer.  (Well, to be honest, I would have to ask my wife to do this.)  But the picture is in the computer in the form of a string of on or off magnetic fields.  If I decide to delete this picture, I (or Nancy) can press the various keys and the picture is gone.  In other words, I remove the picture using essentially the same technology that was used to store it in the first place.  This is analogous to helping people free themselves from fears, negative feelings, counterproductive habits, etc., by means of human contact, dialogue, support, etc…

Alternatively, I might in theory be able – if I knew a great deal about hardware – to go inside the physical apparatus with tiny drills, etc., find where the picture was stored, and physically obliterate the 1’s and 0’s, so that the picture would be destroyed.  Inevitably I will damage a good deal of the surrounding hardware and, of course, other information stored on this hardware.  Again, I’m not suggesting that any of this is even possible.  It would probably just destroy the computer!  But the point is that this tactic is analogous to the psychiatric/biological approach: tampering with the brain in a misguided attempt to get rid of unhappy thoughts or counterproductive habits, even though there is nothing wrong with the brain.  A person with a perfectly ok brain can acquire an extreme fear.  Remember Little Albert (here).

So finally, let’s get back to Sam’s question:  What proof is there that mental distress is illness?  The question can be rephrased as follows:  If a person’s behavior or feelings are causing him distress, should the neural underpinnings of these behaviors/feelings be considered an illness?  And it is immediately clear that this is not something that admits of proof; rather it is a matter of semantics.  Not long ago the International Astronomical Union decided that Pluto is no longer to be considered a planet.  It is now a dwarf planet.  This was not something that had to be proven.  It was a decision about the use of the terms.  If someone were to ask the astronomers to prove that Pluto was not a planet, the only possible way to respond would be to elucidate the meanings of the various terms.

Psychiatrists choose to call all human problems illnesses (“just like diabetes”).  Normally, like Dr. Pies, they make no attempt to justify this position.  They simply state it to be so.

When psychiatrists do try to rationalize their practice of calling human problems illnesses, it is always along the lines of “correcting” brain structure, physiology, or programming, even though there is no evidence of a neural pathology.  If the neural entities are causing distress or pain or disability or the risk of incarceration, then by definition, they are illnesses.

And that’s all there is to it.  Human problems are illnesses because the APA say so.

The common usage of the term “illness,” however, implies physical pathology, i.e. something wrong with the structure or functioning of the organism.  Psychiatrists implicitly endorse this notion when they tell their clients that depression (or ADHD, or anxiety, etc.) is a real illness “just like diabetes.”  What does the phrase “just like diabetes” mean in this context?  I suggest it means real physical pathology.  And psychiatrists routinely push this notion even though it is false, and even though there is no requirement of physical pathology in their definition of a mental illness.  Within the APA’s conceptual framework, human problems are illnesses because the APA say so.  There really is nothing more to it than that.

 

 

 

 

 

There are No Mental Illnesses

I have been writing this blog for the past three years.  The primary concepts are scattered throughout the blog, and I thought it might be helpful to draw together the essential underlying concepts in one post.  Some of this repeats material covered under the individual “diagnoses,” and for this I apologize to my regular readers, but the notion that there are no mental illnesses (which I repeat regularly) is unorthodox and warrants clarification.

Until relatively recent times, man’s understanding of biology was minimal to zero.  Even as science began to unravel the secrets of nature in the inanimate sphere, the biological arena remained largely a closed book

Now, as we know, the human brain is a pattern-seeking machine.  It craves explanations in the same way that an empty stomach craves food.  So when a person is confronted with a situation or phenomenon that he doesn’t understand, there is a strong temptation to invent an explanation, and then – unfortunately – to cling to that theory even as better explanations become available.

So, with regard to biology, to the ancients just about everything concerning life was a mystery.  But they were particularly baffled by cognitive phenomena.  How can a person carry inside himself a picture of another person?  How can a person sleeping in his bed somehow “visit” other places in his dreams and “see” people who are far away or even dead?  And so on.

The state of science at this time was rudimentary in the extreme, and even the best thinkers had not the slightest inkling as to how these kinds of activities are possible.  So in the best human tradition, they invented explanations.  Man can see, hear, etc., because he has the faculty of sensation.  Man can think because he has a mind. Man can make decisions because he has a will.  And so on.

Now as an explanatory system, this kind of faculty psychology is useless.  Imagine the following conversation between one of the ancient Greek teachers and a student.

Student:  Why can man think?
Teacher:  Because he has a mind.
Student:  How do you know he has a mind?
Teacher:  Because he can think!

The concept of mind is a spurious artifact created to allay man’s anxiety with regards to his ignorance, but providing nothing in the way of genuine explanation.  There are no minds!  What we think of as our minds are actually activities, such as thinking, deciding, hoping, perceiving, analyzing, etc..  When we introspect, what we encounter is the content of these activities.  If, for instance, I’m thinking about a triangle – I “see” a triangle.  If I’m thinking about the house I grew up in, what I “see” is a “picture” or “pictures” of that house.  One of the mental abilities that we’ve got is the ability to generate “pictures” in our heads, and most of our thinking involves examining and manipulating these pictures,  usually with the help of silent speech.

But even though there are no minds, the concept persists.  Some of this is due to language.  Expressions like “changing one’s mind,” “speaking one’s mind,” etc., are deeply ingrained, and create the impression in growing children that the mind is an entity within us, ontologically equivalent to the heart or liver.

There are numerous examples in history of spurious explanatory concepts that have been supplanted by valid science.  Many of these ideas persisted even after better explanations had been developed.  Perhaps the most celebrated example is phlogiston.  From earliest times man has wondered about the nature of fire, and various speculative notions were developed.  The ancient Greeks regarded fire as one of the basic “elements.”  In the 1600’s, however, a concerted effort was made by a number of scientists to develop a coherent, scientifically validated theory of combustion, the result of which was the phlogiston theory.  The hypothesis here was that combustible material contained a substance called phlogiston.  When the object was heated, the phlogiston began to be released.  This created more heat which in turn released more phlogiston, and so on, until all the phlogiston in the object was consumed.   Objects that contained no phlogiston were non-flammable.

The theory had some superficial plausibility, but there were numerous problems.  Initially scientists tried to prop up the phlogiston theory in ways reminiscent of Ptolemy’s epicycles.  But eventually the modern theory of combustion (by oxidation) was developed, and the phlogiston theory was discarded.  Many older scientists, however, (including the eminent Joseph Priestly, the discoverer of oxygen!) clung stubbornly to the older theory.

Witchcraft is another example of a spurious explanatory concept.  The presenting issue here was the fact that bad things happen.  People get sick; babies die; crops fail, etc..  Today most of these occurrences can be explained satisfactorily as the result of invasion by germs, fungi, etc.., but in former times these concepts were unknown. The “hungry” brains, however, obligingly invented an explanation:  Witchcraft!  The idea was that certain individuals in the area (usually unpopular women) had established a pact with the devil and were able to effect the various mischiefs in question by channeling the latter gentleman’s power more or less at will.  The notion is nonsense, of course.  There are no witches, and there are no devils – but the concept was used for hundreds of years as an excuse for murdering women.  Incredible as it seems, remnants of witchcraft thinking can be found even today!

In the same way, the spurious concept of mind persists to this day, enshrined in speech and routinely adduced to explain people’s behavior.  One can readily recognize conversations like the following:

Q.  Why did he do it?
A:  His mind just snapped.
Q:  Why didn’t he get married?
A:  He just changed his mind.

The spurious nature of these answers can be readily unmasked by applying the circularity acid test – how do you know his mind snapped? And how do you know he just changed his mind?

The concept of mind adds nothing to our understanding of human existence.  There are no minds.  Mind is an outdated concept invented by primitive pre-scientific people in an attempt to explain cognitive phenomena.

In medieval times, little distinction was drawn between people who today would be called retarded and those who today would be called crazy or psychotic.  Also, little distinction was made between those who are born with intellectual deficits and those who acquire cognitive/behavioral problems as a result of post-developmental brain injury.  All of these individuals were considered to be “out of their minds” or demented.

In primitive agrarian societies these individuals, if they survived infancy, were cared for by family and neighbors, but as the Industrial Revolution lured increasing numbers of people into the growing towns and cities, this simple kind of family/village care became more problematic.  The practice of housing these individuals in jails and institutions became common, and the conditions were often truly appalling.

The various reform movements of the 1800’s resulted in the construction of large asylums.  The idea was to provide care for these people in clean, well-designed buildings under medical supervision, in the hope that this would help the inmates develop their potential, or at the very least provide a more humane environment in which they could live.

As the decades passed, however, it became clear that the dreams of the reformers were not being realized, and in particular the notion that medical supervision would significantly “humanize” treatment became increasingly tenuous.

In the 50’s and 60’s there arose a great push to discharge people from the asylums and help them integrate into mainstream society.

Meanwhile concepts were being developed, the most notable of which was the idea of “mental illness.”  It was recognized that broadly speaking there were two distinct groups of inmates:  those whose intelligence was clearly restricted (whom today are called retarded) and the rest.  Because the asylums had been placed under medical supervision, the latter group came to be thought of as “mentally ill.”  Of course there are no minds and there are no sicknesses of the mind, but the term caught on and in practice it meant:  a person who is in a mental asylum and who isn’t retarded.

Just as the witchcraft business spawned “research” into the causes, varieties, and indicators of this phenomenon, so the “mental illness” enterprise attracted its share of students.  At first the findings were rudimentary and global.  It was noticed, for instance, that there were three kinds of “mental illness:” depression, mania, and craziness, but as the twentieth century advanced, these categorizations became increasingly complex and detailed.

And today we have DSM-IV, with the promise of DSM 5 just around the corner.  The proliferation of these so-called illnesses and the avid promotion of these “diagnoses” by pharmaceutical companies and by the psychiatric profession have led us to the point where it is widely claimed that 46% of the population has or has had a mental illness, and mood-altering drugs are being routinely prescribed to more and more people for an ever-increasing range of ordinary human problems.

The fact is that there are no mental illnesses.  The notion is as senseless as the concept of witchcraft, and yet through the miracles of modern marketing, it has become the foundation of a multi-billion dollar world-wide business.  Now when I say there are no mental illnesses, I’m not saying that people don’t have behavioral/emotional problems.  It’s obvious that many people do, and that these are sometimes very serious.  But they are best conceptualized – not as some kind of poorly-defined illness – but simply as dysfunctional, counter-productive habits.

Genuine understanding of human behavior requires so much more than assigning a spurious label.  I have developed this concept at length in the posts on the individual “diagnoses.”

The use of the DSM “diagnoses” is not only logically spurious, it is also destructive, in that the application of the label provides subtle encouragement for people to act in accordance with the “requirements” of the label.  (“What more can you expect of me; I have schizophrenia.”).  The labels also discourage attempts to find genuine explanations for dysfunctional behavior.

Mental Illness: The History of a Mistake

The human brain is a pattern-seeking machine.  Because of his brain, man strives to understand the world around him and uses this understanding to improve his lot.  The brain looks for patterns and explanations.  Our ancestors, for instance, discovered that certain rocks, through processing in certain ways, could be shaped to make sharp tools which they used to great advantage.  Later it was discovered that other rocks when heated in certain ways produced iron. And so on.

The brain’s pattern-seeking activity is not confined to great discoveries.  People use their brains every day to navigate through their environment and to find the procedures and practices that work to their best advantage.  Commuters learn which routes have the fewest delays.  Shoppers learn where they can find the best bargains.  Politicians learn what to say to increase their chances of getting elected.  Gardeners learn when is the best time to plant.  And so on.  In all aspects of daily life – great and small – the brain is storing and analyzing data, identifying patterns and explanations, seeking endlessly to optimize results.

It is likely that our ancestors of a few thousand years ago were pretty much as bright as we are in terms of raw intellectual ability.  But their store of valid knowledge was a great deal less.  The ancients lacked our knowledge of electricity, atoms, sub-atomic particles, germs, cells, neurons, periodic table, gravity, galaxies, etc., etc.. They had no understanding of why people got sick, why crops failed, why the moon and sun stayed up in the sky, or why some substances burned and others did not.  They didn’t even understand the true nature of fire – knowledge that is well within the scope of any high school student of today.  But this lack of knowledge didn’t prevent their brains from working on these various questions. The drive to make sense of their environment was as strong in them as it is in us today.  So they invented explanations – explanations that today seem primitive and naïve, but that made sense to them and helped them organize and systematize their experiences.  So they said that the moon and sun manage to stay up in the sky because they are gods (or goddesses), and gods can stay up in the sky.  Readers of this blog will readily recognize the fallacy in this reasoning.

  • Why does the sun stay up in the sky?
  • Because it is a god.
  • How do you know it’s a god”?
  • Because it stays up in the sky.

And, of course, this kind of simplistic logic can be found in psychiatric circles to this day.

But to get back to the main point:  people in virtually every ancient culture invented explanations for phenomena that they didn’t understand.  They then ignored data that contradicted their explanations and highlighted data that supported them.

One of their more significant errors of this kind was, of course, the anthropomorphic god.

  • Thunderstorms:  god is angry.
  • Fine weather:  god is happy.
  • Famine:  god is punishing
  • Etc..

But where the ancient civilizations really erred is in the nature and workings of life.  Today we know that all living organisms consist of cells, and these cells remain alive and multiply through complex microscopic processes involving nutrition, mitosis, etc.. We also know that death occurs when the cells’ DNA – through aging – is no longer able to split reliably and hence no longer able to replenish depleted material.

But the ancients knew nothing of this.  So to explain the phenomenon of life, they invented the soul or mind.  This explained a great deal.  A dead body was one that the soul had left.  In dreams the soul left the body temporarily and travelled to distant places, faint memories of which remained after the soul had returned and the body reawakened.  If you dream about your dead father, it’s because the travelling soul has visited the spirit world and seen him.

This is noteworthy in that we today in the computer age are very familiar with the notion of stored data and even stored images.  But the idea that all of our memories were somehow stored in our brains was foreign and incredible to the ancients.  The storing of data of this sort, which we call memory, was completely baffling to them.  And they “explained” it by the simple expedient of declaring it to be a spiritual activity and therefore, of course, the province of the soul or mind.

Historians of philosophy call this “faculty psychology.”  It goes like this.  Different parts (faculties) of the organism have specialized functions.  The function emanates from the faculty.  So people can think because they have a faculty called mind.  People can feel because they have hearts, etc.. Today it sounds simplistic and naïve, but back then people found it helpful.   Activities such as thinking, remembering, planning, hoping, believing, etc., were most baffling to our ancestors, and they explained these activities by asserting that the faculty from which they emanated (the mind) was a kind of nebulous, ephemeral or “spiritual” entity, which in the hands of many religious leaders became equated with the “soul.”  So all was explained.  The mind (or soul or anima) was inside the otherwise inanimate, insensitive body.  Experience was channeled to the mind through various body parts (touch, sight, etc..), and the mind organized all this data and did the thinking, deciding, etc.. Today, of course, we recognize this as spurious, but for centuries it was central to all Western thinking.

In reality, the concept of mind was an error – an error prompted by an ignorance of the anatomy and physiology of the brain.  This ignorance was prolonged by an establishment, steeped in dogmatism and certainty, and resistant to any form of genuine scientific enquiry.

Today we realize that “mind” is essentially a metaphor for “self.”  When we say: “I changed my mind,” what we mean is:  “I, myself, reversed my earlier decision.”  And so on.  But in former times people thought of “the mind” as a real “faculty” residing somewhere (?) within the body.  And this kind of spurious psychology held sway throughout the Western world for centuries and is indeed current in some circles to this day.

The notion of madness or craziness has also been around for centuries and was conceptualized largely as an irremediable defect of “the mind.”  Crazy people were cared for by their families and communities and sometimes by religious houses.  Then came the industrial revolution.  People were no longer needed to work the land, so they flocked to the cities, where they found unmitigated poverty and squalor.  Individuals who weren’t productive were often abandoned. This included the “crazy” people, who begged in the streets and ended up in jails.

From this context a number of reformers, driven by humanitarian motives, started a movement to have these individuals housed in specialized institutions.  The buildings would be clean and properly run, and to lend respectability to these places, they would be placed under the jurisdiction of a physician.  From there it was a short leap to the notion that these places were hospitals (which they weren’t) and that the residents were sick (which they weren’t).  And so was born the notion of mental illness. An illness of a non-existent faculty!

The sickness idea was deemed progressive.  Prior to that, the current notion was that these individuals’ “minds” were defective in some way and this defect was regarded more as a morality issue than anything else.  Great shame was attached to the person’s family. Many (perhaps most) of the individuals considered crazy were what today we would call retarded or intellectually handicapped  – but this distinction was not clearly grasped even 200 years ago.  So locking these people away in enormous buildings managed by medical superintendents was considered charitable.  (It also got them off the streets, which was considered desirable).

The more recent history is well-known.  From being a relatively small number of asylum superintendents, American psychiatry has burgeoned to the 45,500 strong that it is today. Mental illness (the spurious disease of the spurious faculty) has been creatively expanded by an increasingly rapacious APA to the point where it can embrace virtually anyone.

So we have institutionalized this error and turned it into a vast drug-pushing enterprise in which human welfare and human dignity are routinely sacrificed to the all-consuming maw of pharmaceutical psychiatry.  There are no minds.  And there are no mental illnesses.  There are people and we people live in a complex world.  And we have problems – sometimes little, sometimes large. And sometimes we lose our way and our thinking becomes distorted.  But conceptualizing these problems of human existence as illnesses to be “treated” by self-styled experts has been a colossal historical error – an error fuelled and maintained by career-building and corporate greed.  The most pressing need in this area today is the de-medicalization of these problems and the provision of concrete help, guidance, and support to the individuals concerned.

The So-Called Mental Illnesses Are Not Illnesses

The central theme of this blog is that mental illness is a spurious and invalid concept, which is promoted and developed by the American Psychiatric Association to legitimize the use of mood-altering drugs.

It is certainly true that people display various problems in their daily lives and particularly in their interpersonal relationships.  The American Psychiatric Association claims that all such problems are caused by mental illness and their list of these so-called illnesses is so long that virtually anybody can be embraced within their coils.

It is also true that problem behavior can be the direct result of an illness.  The paradigm example of this is general paresis.  This illness, which is in fact an advanced stage of syphilis, often generates psychotic symptoms and at one time accounted for 10-20% of mental hospital admissions.  But psychotic behavior and other behavioral problems can and do occur in the absence of any underlying illness.  Indeed it is my main task in these posts to show how these kinds of behaviors can be explained in terms of the ordinary constraints of daily living.

The vast majority of mental health workers subscribe to the APA’s philosophy.  There have been voices of dissent, however.  The late George Albee, PhD, wrote this in 1999:

“Most mental/emotional problems are learned patterns of maladaptive behavior resulting from the stresses of poverty, anxiety, exploitation and abuse or neglect!”  (Sarasota Herald-Tribune June 27, 1999)

William Glasser, MD, a renowned psychiatrist, was the top speaker at the 2006 national conference of the American Psychotherapy Association.  The National Psychologist (Nov-Dec 2006) quotes him as follows:

“I’ve never identified anyone as having a DSM disorder.  …All of these are phony diagnostic categories.  The DSM was not written to help people; it was developed to help psychiatrists – to help them make money.”

The point is this:  mental illness is an explanatory concept.  It purports to explain unusual, aberrant, or troublesome behavior. So that if a person were to ask:  Why does my mother say these crazy things?  Why doesn’t she take care of herself and let us help her?”  The answer from the mental health establishment is:  “Because she has a mental illness called schizophrenia.”  We’ve discussed the circular nature of this so-called explanation in an earlier post.   And the fact is that it’s not an explanation at all.  It’s a soothing form of words – a mantra, if you will – that legitimizes medical involvement in the “treatment” of people who are experiencing problems with living.  The history of medical involvement in these kinds of problems is not edifying, and the present-day exploitation of these individuals by pharmaceutical and medical drug pushers is no exception.

Three books I’ve come across recently on these topics are well worth the read:

Shyness: How Normal Behavior Became a Sickness

Christopher Lane, PhD, Yale University Press, 2007
Mad In America

Robert Whitaker, Perseus Publishing, 2002
The Myth of the Chemical Cure (Revised Edition)

Joanna Moncrieff, MD, palgrave macmillan, 2008

 

 

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