A couple of weeks ago I raised the question, “Name Calling by Psychiatrists: Is it Time to Put a Stop to it?” In response, some blamed the insurance companies and other third party payers for the name calling. Because it is true that these payers do require the pathologizing of people seeking mental health services, in last week’s article, I took a close look at this issue.
Others responding to my question argued that diagnosing mental illness is based on the principles of science. So, let’s look at this line of thought.
The Nature of Science
Science enquires what is the nature of something? what is its constitution, origin, and history? Human beings also make enquires of a different sort, What is the object’s importance, meaning, significance, or value now that it is once here? Neither judgment can be deduced immediately from the other. They proceed from diverse intellectual preoccupations, and the mind combines them only by making them first separately and then adding them together.
As Steven Jay Gould, professor of zoology and geology at Harvard University, explains it:
“The net of science covers the empirical realm: what is the universe made of (fact) and why does it work this way (theory). The net of religion extends over questions of moral meaning and value. These two magisteria do not overlap, nor do they encompass all inquiry (consider, for starters, the magisterium of art and the meaning of beauty). To cite the usual clichés, we get the age of rocks, and religion retains the rock of ages; we study how the heavens go, and they determine how to go to heaven.”
In the natural sciences there is a branch called pathology that classifies tumors, lesions, bone fractures, tissue tears and microbe infections. Pathologists have reliable ways of identifying and categorizing these naturally occurring entities. When we take a science view of each of these entities of interest to pathologists, it is not a value judgment if they exist or not. If ten pathologists look at a tumor, they can all see it, describe its color, density, weight and what each of the tumor’s cells look like under a microscope.
Pathologists, as scientists, have been studying these entities and sometimes they found that some of them are associated with certain physical complaints. For example, some people complain about headaches and vision problems. When they died, autopsies were carried out and often a tumor was present that was pressing against the optic nerve.
This finding led to a theory that for people who expressed this type of physical complaint, if an operation was carried out while the patients were still alive and this type of tumor was indeed pressing on the optic nerve, perhaps removing it would alleviate the complaint. Studies were carried out and it led eventually to a valued treatment.
The connections between the research findings of pathologists gave doctors some understanding of what was causing some of the physical complaints of their patients. But often doctors could not find evidence that any of the entities of interest to pathologists were the cause of the complaint. When this occurred, most doctors merely changed the expressed complaint into some medical jargon that sounded somewhat like those concerns that had been shown to be due to a pathological condition. In such cases, they offered some treatment that was often based more on the commercial art of medicine rather than science.
These doctors usually called both types of physical complaints (those with pathological findings and those without) “illnesses” or “disorders.” By doing so, the science of medicine and the art of medicine became blurred. And then, business interests became wrapped up in the various treatment options and principles of science began to become more and more murky when applied to the medical world.
Disorders and Psychiatry
In a book titled Psychiatric Persuasion by Elizabeth Lunbeck, there is considerable documentation that back at the turn of the 20th century when the main job of psychiatrists was running insane asylums their professional organization decided to expand their market by doing two things. 1. Persuade the public that more and more normal behaviors are pathologies that require psychiatric treatment, and 2. Develop a category system that converts all psychological concerns that a person might want to get help for into a language that sounds like a pathological condition. This would legitimize the treatment of anyone who came to their office, thus the argument that the current psychiatric “diagnosis” system has become a business tool while being promoted as science.
Now, it is certainly possible to create a categorical system consistent with science for the problems that come to the attention of psychiatrists and other mental health service providers that don’t confuse conditions that are associated with pathological findings and those that are not. Such a system would classify “mental health concerns,” rather than calling people names. A mental health concern occurs when a person seeking mental health services expresses to a mental health service provider a concern about any of the following topics: behavior, emotion, mood, meaning of life, managing chronic pain, work, relationships, education, eating, cognition and sleep. Two classes of mental health concerns are concerns expressed about oneself and concerns expressed about someone else.
One benefit of classifying “mental health concerns” rather than “mental disorders” has to do with inter-rater reliability. Consider being in a room with 100 psychologists, or even 100 average Joes and Jills, and a person in front of the room says she has been feeling depressed. A questioner asks the client, “Are you concerned about feeling depressed?” and the person says, “Yes.” If you asked for a survey of how many people in the room thinks the person has expressed a concern about being depressed, you would get, I believe, 100 percent agreement. Expressing a mental health concern is a specific action that people do, and therefore it is clearly observable.
Research on the inter-rater reliability of the mental disorders classification system has demonstrated that its inter-rater reliability is very problematic.
Science is Not to Blame
It is not science that is to blame for psychiatric name calling; it is the psychiatric business tool that is cleverly designed to capitalize on the public’s respect for science.
When we begin to use a classification system that does not clearly separate principles of science from values involved in business interests, other values start to slip into the classification process as well. Early on when the pathologizing of human experience was just getting underway, William James made a number of relevant comments about this.
James argued that experiences that are commonly viewed as unhealthy or morbid are really “an essential part of every character” and give life “a truer sense of values.” To support his contention, James first provided three examples of famous individuals who expressed concerns about melancholy. Such experiences today, if expressed to a psychiatrist, would probably be converted into a so-called “diagnosis” of “major depressive disorder.” St. Paul, the religious figure of the New Testament, Cesare Lombrosa, a late 19th-century Italian criminologist, and Immanual Kant, the 18th-century German philosopher, became, according to their biographies, better as a result of their troubling experiences.
Although hallucinations can mean madness to some, James presented the case of Socrates who “once stood motionless for many hours in the cold and spoke of having a guiding demon.” Attempting to counter the association between pathologies and hallucinations, James stated, “Even if this demon [of Socrates] were really meant hallucinations of hearing, we know now that one in eight or ten of the population has had such an experience and that for insanity we must resort to other tests than these.”
James stated that there is no end to the possible types of obsessions that we see all around us. What benefit can such experiences have? James wrote about Henry Borg, founder of the American Society for the Prevention of Cruelty to Animals in 1866; Charles Henry Parkhurst, a Presbyterian clergyman and reformer who held a New York City pastorate from 1880 to 1918 and who launched a furious attack on organized crime in state government that led to an official investigation; Dorothea Dix, a mid-19th-century humanitarian who visited the insane asylums and successfully advocated for legislation to improve the care for those labeled mentally ill.
Later, James stated, “Individuals are types of themselves and enslavement to conventional names and their associations is only too apt to blind the student to the facts before him.”
James concluded that,
“Any peculiarity that is of use to a man is a point of soundness in him, and what makes a man sound for one function may make him unsound for another. Moreover we are all instruments for social use, and if sensibilities, obsessions and other… peculiarities can so combine with the rest of our constitution as to make us the more useful to our kind, why, then, we should not call them in that context points of unhealthiness, but rather the reverse . . . The trouble is that such writers [pathologizers]. . . use the descriptive names of symptoms merely as an artifice for giving objective authority to their personal dislikes. The medical terms become mere appreciative clubs to knock a man down with. . . . The only sort of being, in fact, who can remain as the typical normal man, after all the individuals with degenerative symptoms have been rejected, must be a perfect nullity… Who shall absolutely say that the morbid has no revelations about the meaning of life? That the healthy minded view so-called is all?”
To illustrate what James means here, consider an article in the American Journal of Psychiatry (May, 2004), titled “Virginia Woolf (1882-1941).” Although she is described by psychiatrists as having bipolar disorder, her diaries and letters, document movingly, her emotional extremes and her capacity to savor the “ordinary rhythms of life.” At times Woolf railed against her distressing emotional experiences, felt frustrated and impeded by them, and at other times she felt it was essential to her. In diaries and letters, she returned to the question repeatedly without reaching a resolution: were her emotional experiences a terrible obstacle to her art, or were they the necessary condition for it?
For those trying to sell psychiatric drugs, a simplistic answer to this question is eagerly promoted. Science has not provided a definitive answer to this question as far as I am concerned, and throwing around phrases such as “the brain is malfunctioning in depression,” or “the brain has a chemical imbalance in depression” goes way beyond the available evidence.
Psychiatric labels are like masks held on by rubberband straps. They hide some of the characteristics of an individual. Wearing such masks may serve some purposes, but after a while they start to get uncomfortable for many, particularly around the ears. Let those who want to wear these masks be free to do so. But let those who want to meet us face to face, also be free to do so.
Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional and social intelligence. To begin at the very first post you can click HERE.