“Good morning, Barbara,” I say, as my first counseling case walks into my office. I notice she looks a little angry. Upon sitting down, she declares, “I’m terribly frustrated. I’ve been depressed now for over two weeks, and I just can’t shake it!”
It’s easy for me to empathize because I regularly have bouts of depression. A deep anguish comes over me, and during this period I often begin to think about how I went through my father’s death when I was twelve, how I’m getting older and can no longer do the many things that thrilled me when I was younger, the papers that I painstakingly wrote that were rejected by one publisher after another, and on and on. Sometimes these dark melancholy experiences come about because something clearly happened that upset me, and sometimes they seem to come out of the blue.
Beyond Listening in a Caring Manner
After listening in a caring way to Barbara for a few minutes, I ask her if something specifically happened that led her into her current emotional experience. Then I explore with her a question about how often she has these experiences and if she feels she has them more frequently than most people, about as often as most, or less than most. Then, I ask her about how she has been functioning in other areas of her life–sleep, eating, exercise, interpersonal relationships, work/school, household responsibilities.
You see, as people experience depression, or other concerns that often lead to a classification of having a mental disorder, some people go about their lives functioning as they typically were doing before the concern arose, while some find that in some areas they begin to function below the levels that are typical for them, while some find that their functioning increases in one or more areas. For example, some sleep about the same amount, some less, and some more. I have met people who, when they are depressed, start cleaning every inch of their home, while others find it difficult to get out of bed.
Also of interest when exploring a person’s expressed concern is to look at how the person had been functioning before the onset of the presenting concern. If some important relationships had begun to function below average, or if the person had been sleeping less than average to keep up with work demands, these facts can be insightful when seeking ways to address the presenting concern.
Now, once I found out what Barbara was concerned about, and how she had been functioning in the other areas of her life, I had a pretty good idea as to how to proceed in addressing her concern. I had no need to decide whether or not she had a mental disorder. However, many mental health practitioners are required to declare that the person seeking mental health services has a mental disorder. Is this mental illness labeling really necessary?
Mental Illness Labeling Versus an Addressing Concern Approach
There are those who embrace this mental illness/disorder labeling. A major reason for this is that these individuals have a group of people in their lives that blame them for the way that they have been feeling or acting. When a doctor has declared, for example, that John Smith has a mental disorder, he may feel vindicated. “You see, there really is something wrong with me!” he may cry out in his defense.
In actuality, those who are doing the blaming may continue their blaming despite the doctor’s opinion. Moreover, many of us don’t blame people whenever they find some concern has arisen in their lives even if they are going through a non-illness experience. I know I’m not blaming myself when I feel depressed, and I was not at all blaming Barbara for what she was going through.
Those who are uncomfortable about the use of “mental illness” terminology point out they are stigmatizing because they are used as put downs in our society. Moreover, the media associates the most heinous crimes with those referred to as the mentally ill even though the vast majority of those classified in this manner are not violent.
Among the most articulate individuals to voice objections to the mental disorder labeling was Harvard psychologist and philosopher William James. Over one hundred years ago he wrote a book titled, The Varieties of Religious Experience (1902). At that time many medical doctors argued that people who were religious were all mentally ill. In response, Professor James wrote:
Medical materialism seems indeed a good appellation for the too simple-minded system of thought which we are considering. Medical materialism finishes up Saint Paul by calling his vision on the road to Damascus a discharging lesion of the occipital cortex, he being an epileptic.
It snuffs out Saint
Teresa as an hysteric, Saint Francis of Assisi as an hereditary degenerate. George Fox’s discontent with the shams of his age, and his pining for spiritual veracity, it treats as a symptom of a disordered colon. Carlyle’s organ-tones of misery it accounts for by a gastro-duodenal catarrh. All such mental overtensions, it says, are, when you come to the bottom of the matter, mere affairs of diathesis (auto-intoxications most probably), due to the perverted action of various glands which physiology will yet discover. (p. 29)
James goes on from here to point out that it is true, of course, that psychology has found that there are definite psycho-physical connections that “hold good” (p. 30). Psychology, therefore:
assumes as a convenient hypothesis that the dependence of mental states on bodily conditions must be thoroughgoing and complete. If we adopt the assumption, then of course what medical materialism insists on must be true in a general way, if not every detail…. But now, I ask you, how can such an existential account of facts of mental history decide in one way or another on their spiritual significance? According to the general postulate of psychology just referred to, there is not a single one of our states of mind, high or low, healthy or morbid, that has not some organic process as its condition. Scientific theories are organically conditioned just as much as religious emotions are; and if we only knew the facts intimately enough, we should doubtless see “the liver” determining the dicta of the sturdy atheist as decisively as it does those of the Methodist under conviction anxious about his soul. When it alters one way the blood that percolates it, we get the Methodist, when in another way, we get the atheist form of mind. So of all our raptures and our drynesses, our longings and pantings, our questions and beliefs. They are equally organically founded, be they religious or of non-religious content. (p. 30)
James points out that in the natural sciences and the arts it never occurs to anyone to refute opinions, beliefs and experiences by putting down their author’s neurological constitution. Value is determined by “judgments based on our own immediate feelings primarily; and secondarily on what we can ascertain of their experiential relations to our moral needs and to the rest of what we hold as true” (p. 33).
James was additionally concerned that medical materialism greatly overgeneralizes its knowledge of the connections between physiological variables and mind states. In James’s day, the pathology writers would take the few psychophysical correlations that they obtained under highly specialized conditions and then vaguely generalize their findings to discredit, to their satisfaction, all of the states of mind that they disliked.
The Modern Day View
Now, modern day psychiatrists sometimes respond,
“Well, certainly in James’s day we indeed knew almost nothing about such matters, but today our knowledge has vastly increased! Thus, James’s position is no longer valid because we can now make sound statements about the connections between physiological states and mind states.”
To this, I respond that in point of fact there is currently a renewed respect for the extraordinary complexity
that exists during the integration process between mind, physiology, behavior, and environmental variables. Whereas it is true that there have been large gains in our knowledge, these gains are best likened to moving from a few drops of knowledge to a glass almost full; yet, to really understand the integration process, we would need oceans and oceans of knowledge. Trillions and trillions of interactions are involved.
It is for these reasons that the mental illness/disorder terminology is misleading. As Dr. Thomas Insel, the current director of the National Institute of Mental Health, recently said about the psychiatric labeling process known as the DSM.
The weakness [of the DSM] is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half-century as we have understood that symptoms alone rarely indicate the best choice of treatment.
To hear and view other leading scientists further make this point, I highly recommend the following free video:
When individuals express a concern, exploring how they are functioning in the main areas of their life can be enormously helpful. Someone who reports a concern about experiencing depression, whom, by some gentle questioning, we find out has been functioning below average in the areas of sleep, interpersonal relationships, and exercise may benefit enormously if we work together on getting these areas of functioning more in the average range. This is true for those who report other types of concerns such as experiencing anxiety, hearing voices, below average range of attention, obsessive thoughts, and on and on. With a model that includes addressing concerns and exploring ways to raise levels of functioning, labeling someone as having a mental disorder may actually interfere with the aims of a counseling/psychotheraputic relationship.
For those who desire, for whatever reason, to be labeled as having a mental disorder, I am not proposing that we interfere with this. But for those who desire to have their concerns addressed by well trained mental health professionals without being referred to as having a mental illness or disorder, I do propose that we do provide a reasonable option for them to access mental health services. In my view, mental health professionals, once we hear our clients’ concerns and how they are functioning in the various areas of their lives, we have the basics to formulate, in full cooperation with our clients, a plan for addressing these concerns. I hope you give this some thought.
Until next week, may you find some kindness out there in this fascinating world of ours.