A month ago, I published a critique of specific terminology of DSM-5. Like countless others, I have serious concerns about the overpathologizing of normal behaviors that appears to be occurring over the past few decades. The potential consequences of this trend have been widely articulated in many circles, and have raised a serious question, “What is normal?”
But while this has been occurring in both psychiatric and lay arenas, another movement has been gaining significant support. It is the idea that mental illness (or disease) is a fabrication, and as Sera Davidow quoted E. Fuller Torrey, in her recent moving article, “Mental illness does not exist, and neither does mental health.”
There is a sense that psychological experiences exist as part of a natural progression from internal or external circumstances, and in themselves, are not disordered or abnormal. While DSM-5 has been rightly accused of overpathologizing, some may characterize this movement as underpathologizing. Ironically, both movements are left with the same fundamental question, i.e.; “Then, what is normal?”
In the practice of physical medicine, this is not necessarily a common question. No one questions whether a person with a punctured lung, broken leg, diabetes, lung cancer, or influenza is normal. Why? Because these conditions (or illnesses) cause discomfort and/or significant impairment of normal functioning. Some are self-inflicted, some are environmentally caused, but many result from a combination of both. If not addressed (personally or professionally), they can get worse.
If we use this analogy, many “mental illnesses” are not much different. They cause discomfort and/or significant impairment of normal functioning. If not addressed (personally and professionally), they can get worse. If I have debilitating anxiety (whether or not from a traumatic experience), and it results in insomnia, headaches, weight loss, chronically being on edge, and irritability that does not resolve within a reasonable time frame, then it seems safe to say that this is a not a normal state of being. Whether or not we choose to label it as mental illness may be up for debate. But just like physical conditions, it is clear that most true mental conditions (illnesses) follow a natural law — in mind, body, and relationships. When this natural law is disrupted to a significant degree, it threatens to take the normal variability of the human experience into an abnormal, unhealthy realm.
Many argue that the perceived medical model of detached, clinical identification of a diagnosis and subsequent treatment can do a disservice in addressing psychological difficulties. In many ways, I agree. Our psychological difficulties, whether of normal variability or of significant degree, are a complex interface of our social, psychological, biological, and spiritual dimensions. One of the worst things that happens when the medical model is applied is that it diminishes or invalidates the truly experiential, interactive way in which we all experience our own humanity. But this oversight, or misuse, should not overshadow the fact that we are one human being with many dimensions, who can experience a headache whether from paint fumes or screaming children or a failing marriage. It isn’t a matter of treating emotional experiences as if they are the same as physical experiences, but it is a matter of recognizing that they rise in the same person from different triggers, and may signify that something is seriously wrong, mentally or physically, in a manner that is not desired by the person.
I have six kids. Recently, a neighbor’s dog followed them onto our side porch. For a few days, they were reluctant to go outside, or, at best, hung out in the dogwood tree that hugs our front stoop. The first question we asked was “What happened to you?” We processed the experience, validated their anxiety, and discussed ways in which we could both talk to the neighbor about making sure the dog didn’t get loose, and also what they could do if it happened again.
A few days went by after talking to the neighbor, and discussing further, and they still were reluctant to go outside. We again processed their fears, which at this point I would not have labeled as a “mental illness,” but which were starting to cause problems with typical functioning. Finally, after another discussion with the neighbor, and further conversations about how we have to “challenge our fears” so they don’t guide us in directions that are not desired or healthy, our kids returned to their normal play routine.
But, regrettably, millions of people live in a chronic, phobic state of another canine-like encounter, confined to their homes and limited routines, in a way that is anything but healthy or normal, especially by their own report. My wife and I don’t want my kids to find themselves there.
For us, this was just one of thousands of experiences we have had and will have with our children, which requires us to define the parameters of human functioning on a normal and abnormal scale. If we do not, I am not sure how they will come to know when they need to take steps to address an imbalance, of whatever kind, especially since their frontal lobes will not be fully developed until they leave our household. If we allow them to believe that anxiety-induced insomnia or depression-induced irritability or inattention is normal, it sets them up for a really difficult life. Ultimately, failure on our part to clearly label “healthy” versus “unhealthy” leaves them in an increasingly confusing position about how to live the rest of their life.
Let me be clear. Both as a parent and pediatric psychologist, I take the categorization of “mental illness” very seriously. I avoid it unless it is clearly warranted, and if in doubt, I prefer to “rule out” rather than “rule in”. I speak to parents, patients, and my own kids in terms of “strengths and weakness”, “challenges and obstacles”, and “developmental variability” much more fervently than I do about “disorders” and “conditions.”
But I worry that just like the overpathologizing of typical variation can create huge setbacks, I feel that the normalizing of unhealthy behaviors could have serious consequences on a personal and societal scale. It risks leaving us with no base, no framework, no reality from which to judge whether we are living a psychologically healthy life, which must occur so that we can teach our kids critical, basic skills of self-awareness and self-evaluation that lead to the steps needed to address whatever psychological issue may be occurring (illness or not).
Normalizing unhealthy behavior leaves our society with the difficult task of knowing just who needs help, and how this will happen. Again, for my kids, and I think I speak for the population as a whole, we just want them to be able to pursue their calling — mindfully, heart-fully, soulfully aware of when they go astray.
As I have tried to understand the push to eradicate “mental illness,” I wonder if this movement is about the labeling of “mental illness” at all. What many people seem to desire is that the unhealthy response to a label of “mental illness,” whether of an internal or external manifestation, be eliminated. Not the actual understanding that “I” am struggling with a serious issue, however it is defined. If I am correct – and many may argue that I am not – I worry that the proverbial baby is being thrown out with the bathwater.
In regards to internal reactions, we desire to remove shame or guilt that immobilizes a healthy response to any unhealthy situation, although at times shame and guilt are necessary for change to occur. We despise stigma that drives people to not seek help or solace, and discrimination or unempathetic responding that is directed towards those with a mental condition. We are infuriated when diagnoses result in treatments (often forced and undesired) that leave people in a worse state than when they started. We are saddened when people are defined by their illnesses (e.g., “He is schizophrenic”) instead of as someone who suffers with a psychological condition. But I really don’t think that any of us want to live in a state of disarray not knowing that there could be another way.
Honestly, it is an interesting time in the world of mental/psychological ________. Studies are increasingly showing that psychological distress and dysfunction are on the rise over the past few generations, which can’t simply be accounted for by increased diagnoses and openness in discussing these issues. (e.g., in 2010, Twenge and colleagues published the following study in Clinical Psychology Review (30, 145-154) Birth cohort increases in psychopathology among young Americans, 1938-2007: A cross-temporal meta-analysis of the MMPI). Although a good case can be made that part of the cause is iatrogenic in nature, it is becoming increasingly clear that many other factors, both within our general society and those intrinsic to us, are at play. Recently, many in the medical field have labeled “overweight” as the new normal, as upwards of ¾ of our men and elderly are overweight or obese in this country. I worry that “debilitating anxiety” (in our highly charged society), of whatever name, may be quickly becoming the new normal just as “normal anxiety” is becoming the new abnormal.
If this is the case, it doesn’t matter what we call it. Either way, generations to come are going to suffer the consequences as we traverse the slippery slopes of life.