I agree with your article, but less of it coheres with my experience. A Colorado medical school professor as recently as 2022 told me that I have a "chemical imbalance" inside of my brain during a video consult. She is now tenured. A more recent interaction with a PMHNP also stated I have "too much dopamine" and that I could "literally die if you don't take vraylar". (I'm still waiting to spontaneously "die" months later; any day now, sigh).
I believe what fuels much of the disillusionment is that these categories are taught as if they're A). homogeneous, B). static, C). a-contextual, D). overdeterministic or unidirectional. And it's because all of science holds the same assumptions with everything they theorize. E.g. Physicists demand spacetime is perfectly homogeneous, that all "laws" are deterministic, static, and a-contextual and hence generalizable. And when philosophers point out these are instead "first assumptions" the scientist responds with "Well that sounds too philosophical for me so it's not my problem!". Whereas biologists will unapologetically claim nothing living is ever homogeneous, not even "identical" twins, nor are evolutionary processes "purely" deterministic, nor are mutations unidirectional nor a-contextual. Living bodies are also not static (aging is real, circadian rhythms change, values change, habits too etc). And no metabolic process follows a straight line. So why hasn't institutional psychiatry banned these words (homogeneity, static, a-contextual, overdeterministc/unidirectional) yet? What kinds of brains are rising to the ranks of professor to regurgitate these specific assumptions? I disagree it's the general public causing them. Rather, the first time i ever learned of the word homogeneity was in a psychometrics class about "crisply measuring mental disorders", as it were, "carving nature at it's joints".
Unfortunately there are many clinicians who are not only poorly informed but even worse at communicating with patients. I completely understand what you are saying. I am not blaming the public. I think the bulk of the blame lies with professionals. I’m criticizing the “medical model” framing of this critique.
"What kinds of brains are rising to the ranks of professor to regurgitate these specific assumptions?" Exactly. Yes. What they told you is appalling.
It does often seem that psychologists as a group are particularly irrational. I've come to believe it's because to actually study and truly see human beings for what we are, to grok what we do to each other and why we do it and the harm that we inflict on each other--it's just too much for most people, for most psychologists. So they flee into some absurdly untrue, distorted theories so they don't have to deal with the reality.
Thank you for this brilliant discussion. I have become more attracted to psychosocial approaches to mental health problems (e.g., housing, counseling, social supports) over the years and have even seen my daughter benefit from such programs as provided by family members and a local non-profit organization. If my daughter had a place to live in peace with access to food and medical care under a biopsychosocial model, and daily activities to give her life meaning, with friends and acquaintances who accept rather than judge or punish behavioral symptoms by interpersonal rejection or through a carceral system, without guns or other weapons (including those introduced by police officers as first responders), then we might have something approaching a utopian solution for persons with serious mental illnesses. But politicians and members of the public who complain about an over-reliance on medications would reject initiatives to bring such psychosocial supports to scale when they found out they cost far more than pills.
Thank you, Awais, for a very thoughtful discussion of this much maligned concept of "the medical model." You are spot-on in identifying a misplaced "essentialism" as the chief culprit in the misguided arguments against the "medical model." (Please note that Ludwig Wittgenstein warned us of this trap in his Philosophical Investigations).
In a piece I wrote over 7 years ago regarding "hearing voices" [1], I noted that there is no single, written-in-stone, "essential" definition of the "medical model." Nevertheless, to the extent the term is useful in clinical psychiatry, we can identify its six central features:
1) In so far as human emotion, cognition, and behavior are mediated by brain function, there is
always an inherent biological foundation to dysfunctional states, such as clinical depression,
psychosis, etc
2) Valid psychosocial and cultural explanations of human experiences do not nullify (or contradict)
the biological foundations of these experiences
3) Conversely, biological explanations of human experiences do not negate (and often complement)
valid psychosocial and cultural explanations and formulations
4) Biological factors are always part of a comprehensive differential diagnosis of serious emotional,
cognitive, and behavioral disturbances—even if, upon careful analysis, psychosocial or cultural
explanations prove more relevant or informative
5) That certain human experiences or perceptions (e.g., “hearing voices”) have a discernible “meaning,”
symbolism, or psychological significance for the patient does not mean they have no
neuropathological etiology
6) All somatic and psychological treatment modalities—whether medication or “talk therapy”—have
meaningful (and sometimes measurable) effects on brain function and structure
It should be clear that there is nothing "reductive" in this understanding of the "medical model", and I believe these features--while not defining an "essence"--are useful, heuristic starting points for the understanding of how psychiatrists think about illness, disease, etc.
Hi Awais, I think you make many important points about medicine and the scope of its practice. There is a presupposition here, though—one that is almost unquestionable these days, for fear of being labeled pseudoscientific or the like. It's that significant mental or emotional suffering (thresholds being defined by the DSM) **is** an 'illness'. The idea of 'mental illness' seems to be a literal oxymoron to me. One way to conceptualise our mind is that it is a result of what 'our brains does'. Walking is one of the things our legs do. However, we don't have 'walking illnesses'. It's a selectional restriction in linguistics to talk about walking being 'ill'. We obviously can have leg injuries, cardiovascular illnesses, neurological illnesses, etc., but we don't talk about 'walking illnesses'. And yet, we frame psychological suffering as a 'mental illness' and not a 'neurological illness'. I can understand this from the point of view that psychological suffering is poorly characterised as a 'neurological illness'. But that doesn't mean that the frame of 'illness' is the most useful or accurate for psychological suffering. To me, this is the most powerfully and implicit 'medical model' involved here. It's the idea that psychological suffering is a medical issue. I'm curious—what do you think is the best argument that the framing of psychological or emotional suffering as 'illnesses' is well conceived, rather than just being *one* possible metaphor amongst other alternatives? Thanks so much.
That aside, I think it's easy to get hung up on the "illness" concept. In medicine one can debate whether obesity or hypertension are "illnesses"... they are quite far from the prototype of being ill that many people have in their minds, and if the term sounds unsatisfactory, we can easily call them "physical health problems" or "medical conditions" without much practical difference. In a similar kind of way, we can easily call mental illnesses "mental health problems" or "psychiatric conditions," with little practical difference. The main point is that these are problems that either can be addressed, in part, through medical interventions, or can be productively conceptualized through the tools of medicine (e.g. diagnosis). (We can also call them "disorders" instead of "illnesses," and "disorder" is a term currently shared by both medicine and psychology)
How can we justify the medical approach to psychopathology or psychiatric distress/impairment?
1) We know that many neurological and physiological disorders present with psychiatric symptoms, at times in a manner that is indistinguishable from usual presentations of mental illness. They used to be called "organic mental disorders" (and sometimes still are).
2) Severe form of paradigmatic mental disorders share many features with physiological disorders. Consider chronic, recurrent psychosis. Distortions of perception, delusions, restricted emotional expression, presence of nonspecific neurological signs, at times cognitive impairment, decline in functioning. Or consider severe depression: psychomotor retardation, fatigue, changes in appetite and sleep. Symptoms are protracted, involuntary, causing severe disability, and often associated with increased risk of poor outcomes and mortality. As Peter Kramer once put it, "What do you call an experience that is chronic or recurrent, that is associated with adverse changes in your brain, bones, endocrine glands, heart, and blood elements, and that is likely to shorten your life? Even a culture that had no concept of mental illness might well call that condition a disease." https://www.psychologytoday.com/us/blog/freud-fluoxetine/202103/peter-d-kramer-depression-placebo-and-psychotherapy
3) We know that medical interventions such as medications and neurostimulation are effective in many cases of mental disorders. We have convincing evidence from numerous clinical trials.
Thank you for this thorough reply. I appreciate it. I will number my points for clarity.
1. Thank you for reminding me of ‘gait disorders’. I had overlooked that. Obviously, we can apply words in all kinds of ways. Economies can be said to be ‘sick’, for example. I think that, as you point out, the term ‘disorder’ is more reasonably applicable to emergent properties (such as walking and mental activity) than the term ‘illness’. It probably would be strange to talk about ‘walking illnesses’.
2. Framing is one of the most powerful forces in human psychology, and so it has dramatic effects on mental and emotional issues. If I remember correctly, Randolph Nesse once mentioned how many people with ‘Panic Disorder’ his ‘Smoke Detector Principle’ helped. This certainly matches my experience where SOME people with years of ‘panic disorder’ almost instantly cease to have any problems—without doing anything at all, but just hearing the new framing (even when medication hadn’t been able to achieve the same result).
The ‘illness’ and ‘disorder’ frames carry 'psychological' consequences. As Brett Deacon has shown, biological explanations—which are presupposed by the term illness for most people, despite the nuance you have—can make people more pessimistic about their chances of recovery and bias perceived 'treatment' possibilities towards medication.
3. The frame ‘mental health’ is really the same frame--the other side of the ‘mental illness’ coin. The idea of ‘mental health’ doesn't make any sense without the implied opposite of ‘mental illness’.
‘Psychiatric conditions’ imply that a Psychiatrist is required for a ‘cure’ or ‘treatment’. One can sympathetically understand how the field of Psychiatry would want this framing, as it’s a human tendency to want to stake claim to one’s authority and dominion over lucrative domains.
I can also understand Psychologists preferring the term ‘Psychological / Mental Disorder’ for similar reasons—a framing that is more likely to equality of status, rather than being perceived as lower on the rung than a Psychiatrist.
And yet, then, both of these framings miss the fact that people often get the best help outside the ‘mental health’ realm. Is a skilled, compassionate, wise Clergy member really less well positioned to help someone with ‘Major Depressive Disorder’ than a Psychiatrist or Psychologist? Or how about a ‘Self-Help Guru’? This study of Tony Robbins’ Date With Destiny seminar makes one think that he is probably vastly more effective than the vast majority of Psychiatrists or Psychologists, at least with depression.
However, if one accepts the medical framing of such conditions, Tony Robbins *must* be a charlatan. After all, he has no license or qualifications to 'treat' such 'conditions', and 'practicing medicine' without a license is obviously unethical. And yet, if we are serious about the scientific method, the results don’t seem to support such a conclusion with Robbins.
Motivated reasoning is something we all fall victim to, and so I think we have to be very careful with confusing philosophical positions as being objective scientific truths. While the Robbins’ study isn’t perfect, and replication and better controls would be wonderful, it *is* a dramatic result.
4. Even a more plausible framing of ‘disorders’ has consequences. For example, a focus on what’s wrong. There are almost always strengths inside of mental or emotional problems that can be utilised. Milton Erickson’s work is stacked full of examples of this. In one example, with phantom limb pain, Erickson taught a patient to feel phantom pleasure in the missing limb. It is a strength, presupposed in phantom limb pain, that our subjective experience is constructed (predicted, with constraints, of course). Erickson utilised the same phenomena that caused the problem as the solution. This is not something most clinicians would think about. I believe a framing of 'disorder' and 'pathology' makes the missed opportunities, that Erickson would have easily taken advantage of, very understandable.
5. Your points that ‘paradigmatic mental disorders share many features with physiological disorders’ are spot on. There is no mind-body split. It’s all one system. Research on placebos shows this best, perhaps. Someone with asthma being triggered by an artificial plant demonstrates this. People tasting more lemon in soft drinks with more yellow on the tin, too. I think that it’s not about whether everything humans experience is grounded in biology—it is. For me, it’s more about what lens is most useful to approach the situation from. Social interventions ARE biological interventions. So are IDEAS (such as that ‘panic attacks’ are not really attacks but well-intentioned false alarms given an evolutionary heritage of better-safe-than-sorry solutions that are OPTIMAL in a world where signal detection isn’t always easy).
6. In response to Peter Kramer’s point, when pattern matching one must also include counterexamples. Social isolation and pollution both can be ‘chronic or recurrent’, ‘associated with adverse changes in your brain, bones, endocrine glands, heart, and blood elements, and that is likely to shorten your life’. And yet, only if we really employ concept-creep in an aggressive way, could social isolation and pollution be considered ‘illnesses’ or ‘diseases’. They are non-diseases that have physiological effects, which may meet the criteria for a disease in certain people over time.
Imagine someone whose parents somehow indoctrinated them into believing that exercise was a waste of time and beneath them. That idea, if accepted by an innocent child who then grows into an adult, would meet all of Kramer’s criteria—having adverse effects on brain, bones, endocrine glands, heart, blood elements, and likely shorten a person’s life. And yet, are we going to call ‘ideas’ diseases? If so, sign me up—because ideas are the heart of most ‘Psychiatric Conditions’, interacting with biology and life experiences.
7. You said ‘We know that medical interventions such as medications and neurostimulation are effective in many cases of mental disorders. We have convincing evidence from numerous clinical trials.’ I agree (without getting into the controversies about the degree of placebo effect—Kirsch and others—which I think is irrelevant to this point).
However, does the efficacy of a Psychiatric Medication necessarily imply that the illness hypothesis is accurate? One alternative model is The Drug-Centered Model, proposed by Joanna Moncrieff.
Thank you, Awais, for challenging me and stimulating my own thought processes. Maybe I’m wrong. However, the only way to know is to test my beliefs and so I deeply value conversations with intelligent people, like you, who think differently.
1. We don't insist on calling every condition in medicine an "illness"... we recognize that the concept has a certain prototype, and the farther we go from that prototype, we reach for other words... disorder, syndrome, condition, health problem, etc. But the application of the medical framework doesn't depend on calling *every* condition an illness. It's the same in psychiatry, where the term mental illness applies better to some condition, but we use a patchwork of other terms to describe the whole domain.
2. I've told many people with anxiety disorders about the smoke detector principle over the years but I've yet to see that kind of response. I'm sure it happens sometimes, but it's also unlikely to resolve the most severe and entrenched set of problems. An overactive "threat" (anxiety/panic) system is like an overactive immune system. If someone is having a mild case of allergic rhinitis, they might be reassured by the explanation that the immune system by design over-reacts to benign things such as pollen, but someone with more severe symptoms will need symptom relief. For most people with severe anxiety, an explanation of the evolutionary role of anxiety is not enough.
And if we do wanna bring up Nesse's work, I think it's fair to point out that Nesse's evolutionary approach recognizes the existence of psychological conditions which result from failures of evolutionary design. For Nesse, psychological dysfunction is an evolutionary reality, responsible for conditions such as schizophrenia and severe mood disorders. Or do you want to simply acknowledge the existence of evolved mental functions without recognizing dysfunctions of evolved mental functions?
Framing matters, sure. I think much of literature on putative negative effects relies on problematic biological explanations. I'd also be very curious about the psychological consequences of telling people with severe distress and disability that they are NOT suffering from an illness, disorder, or even a "health problem." I imagine many will react quite negatively to that.
3. I honestly don't think that it makes sense to deny or reject that there is no such thing as "mental health." I think there is no satisfactory definition of health that doesn't extend to the psychological domain. And yes, once we recognize that there is such a thing as good mental health, we can recognize that there is also poor mental health and mental health problems.
The framings cannot be understood as being exclusive. Yes, people can get help outside the "mental health" realm, but if mental health problems were indeed so easily treatable by non-clinicians, we'd be operating in a very different landscape. It is still the case that many people do not find any relief from thing such as talking to friends, or elders, or clergy members, and for such people, there remains a role for professional help. I'd like to see an experiment in which we put "skilled, compassionate, wise Clergy member" in charge of people seeking help at a Mood Disorders Clinic, and let's see how well it turns out. While some people might indeed benefit more from a priest than a physician/psychotherapist, most people with chronic, recurrent, and severe problems will have better luck with a trained professional. At least that's what I think.
"we have to be very careful with confusing philosophical positions as being objective scientific truths." I agree, which is why I don't think that illness status, or disorder status, is an objective scientific truth, and I have written extensively on that. https://www.psychiatrymargins.com/p/the-social-construction-of-disease
4. There is nothing about a disorder concept that forces us to focus only on what's wrong. The focus on what's wrong is a bias introduced in clinical settings because of the nature of the work, and it is a bias that ought to be pointed out and addressed (which is being done by movements such as Positive Psychiatry). This also applies to all of medicine, not just psychiatry.
5. "For me, it’s more about what lens is most useful to approach the situation from." I think medical framing has a pretty good case when it comes to utility. I work with people every day who find this framing helpful. It's not the most helpful for everyone, but it is the most helpful for enough people that it has a claim to legitimacy based on utility alone.
6. Social isolation and pollution are indeed medically relevant phenomena. They are public health concerns. Pollution is not an individual characteristic at all, so it cannot be considered a dysfunction/disorder *in a person* or *of a person*. A person can be socially isolated, but given the interpersonal and contextual nature of isolation as a phenomenon, and its nonspecific health effects, arguably it is better considered a risk factor. Social isolation is also better addressed via non-medical means at present. But conceivably it could become a medical condition some day. (These are not quite gotcha issues, once you start looking into discussions around the status of aging, infertility, grief, etc.)
7. Illness is not an empirical hypothesis and I think it is a mistake to treat it as a hypothesis.
I’ve enjoyed a couple of videos of you on YouTube so far, with more to watch. You come across as a great guy; balanced, fair, empathetic, and passionate — and I find myself agreeing with you excessively ;)
I’m continually reminded how limited text-based conversations can be, lacking in the non-verbal dimension that is so important in relating to another person.
Given we agree on so much, I wonder if there are perhaps just two related points of difference:
1. I am totally on board with the Prototype Theory of categories. My question is how do you assess when a particular example is best considered to be a peripheral category member, vs being better served by placing it in an entirely different category, vs creating a fresh brand new category?
As you know, prototypes tend to play a dominant role in influencing the meaning of a concept. The concept of illness, for most people, is prototypically represented by what I might artificially call ‘physical illnesses’* (the common cold, flu, diabetes, cancer, multiple sclerosis, heart disease, etc.) (*Just a way of talking here as I can’t think of a better framing: biology obviously grounds every human experience.)
To the general public, and I’m sure also with most clinicians, I would bet that the frame of ‘mental illnesses’ inherits much of its implicit meaning from these prototypical ‘physical illnesses’.
What do we do about the fact that there is a dramatic difference between most ‘physical’ and ‘mental’ illnesses?
If, for example, someone closes their eyes and just listens to someone else talk, and their problem automatically vanishes, was their problem really best described by the term ‘illness’?
I’m reminded of the work of Michael Yapko who has several patients with depression (that medication hadn’t helped), on video, having their life utterly transformed just by one session with 20 or 30 minute of hypnosis. People's depression can often vanish when people get new perspectives, learn new skills, learn how to make better decisions, have a positive change in the social life, etc.
If someone learns a new social skill-set, and their ‘social anxiety disorder’ vanishes, is it best described as a disorder, or a lack of psychological and social skills, strategies, and understandings (i.e. a learning phenomenon)?
Do conditions that CAN—not always—vanish with powerful changes in ideas (about oneself, life, situations, etc) really belong in the same category as heart-disease, cancer, or diabetes? You’re sophisticated and so you understand that categories can have peripheral examples. But when is the phenomenon so different that it shouldn’t be in the same category with something else?
Tomatoes 'should' be vegetables. They look and taste like vegetables. Botanically, they’re not. One criteria can disqualify something from belong to a category.
Something like Schizophrenia, I presume, almost never vanishes just by mere talking. Is it, therefore, better conceptualised in a different category to a very painful problem that does change with a ‘mere’ change of ideas, in a supportive social context?
We could include Schizophrenia in the same category as most depression, albeit very distinct members. Or, maybe we could have a new category for ‘conditions’ that do readily change via the right learning processes (conditioning, changes in beliefs, thought processes, the development of new skills and capabilities, etc.) or social situations (e.g. financial relief, leaving an abusive relationship, etc.)
Then presents a problem though…
How does one assess whether a problem is solvable through mere ‘ideas’ in social context? We can’t say for certain that a specific person’s mental problem requires biological intervention, because the scientific literature can’t falsify such an idea. Inductive reasoning isn't proof (much like we knew all swans are white, until people travelled to Australia and found black swans).
My point is: Surely, if someone’s ‘mental illness’ vanishes through just listening and talking, without any conscious effort on their part, surely that belongs in a different category than diabetes, heart-disease or cancer? It’s not a quantitative difference, it’s a qualitative difference. That result isn't possible with most cancers (rare potential placebo cases excluded--I don't know the literature on whether or how often that happens with cancer).
This is not just about semantics for me. If the ideas of disease—for most people—precludes an appreciation that a particular mental problem could very well likely vanish by a change in ideas, I would think that the illness frame is highly distorting the territory that is being described.
NOTE: some ideas may only be able to be changed with biological intervention. Maybe the ideas involved in a certain psychosis are changeable by a social interaction, like therapy. Or maybe they will be best solved by precise biological intervention in the decades and centuries to come (e.g. AI and ultra precise neurological modification techniques. The same could be done though, with things we'd never want to call diseases. For example, one could imagine futuristic neurological interventions to help someone fall out of love with an abuser, or become more extraverted).
I think the map-territory distinction is so important. If people said ‘What you’re suffering could be thought of in many useful ways. Thinking of it as an illness is one way. Thinking of it as a disorder is another. Thinking of it as a sign that your life will likely improve dramatically when you learn certain, key psychological skills, is another.” Etc.
My concern is that a ‘illness’ lens presents a highly impoverished conceptualisation of the actual underlying territory.
‘Psychological problems’ is a much more neutral lens. ‘Psychiatric problems’ less so, because it implies the requirement of medical help, which is not always true.
Medicine, as you rightly state, CAN include it all. However, much of the time, when we frame something as belonging to one category, it implies a preclusion of other categories. Framing suffering as ‘Psychiatric conditions’ implicitly out-frames psychological, social, learning, societal, etc. etc. approaches (Not for you, but for most people I’d bet.)
I think that just as Psychiatrists may be fearful of losing their role if the frame of illness ceased to be used, I think other equally valid lenses are under threat when ‘illness’ is used.
We don’t need an illness frame to explain highly aversive, involuntary, suffering. There are other maps that explain this equally as well. Conditioning isn’t best conceptualised under an illness frame. It’s more usefully conceptualised under a learning frame. And yet involuntary conditioned responses are often core to most ‘mental illnesses’ (e.g. panic and interoceptive cues being conditioned to fear). And, conditioning responses are influenced by genetics and the rest of biology. So a learning frame could fit equally well to medicine (‘Medication could help your brain learn you’re safe more quickly, in addition to exposure’—an empirically testable claim, that some research suggests—e.g. by David Barlow— is not true, but used just as an example).
Back to the study of Tony Robbins’ seminar. Amazing results if that study is to be believed. Tremendous skills at helping people (based on empirical results), and yet he is dismissed by many in mainstream—who would learn so much from him, if open-minded—because he is ‘practicing without a licence’ or even a university degree. However, with a more balanced conceptualisation of the underlying phenomena—which we both care most about—Tony Robbins has an equally valid place in addition to all the other experts because of results (empirical data).
Meditation was once naively mocked as pseudoscience in many parts of academia. And yet how fast that has changed! This kind of narrow definition of what’s valid vs not, based on the current dominant model, doesn’t seem to serve anyone well as far as I can tell.
If we care about the territory most—which I think you do—then we want to make sure our maps don’t implicitly bias us to ignore important parts of that territory, bias who has a right to navigate through that territory, or get us lost etc. because only experts understand the right nuance to read the said map correctly.
Am I making any sense? Thank you. I appreciate you.
Thanks Michael. You bring up a lot of excellent and important points. There is a lot to discuss here, but I'll briefly say a few things.
You are right that different terms can bias people as well as clinicians in different ways. It is important to be mindful of that and to take that into account. We can also recognize that no single term will necessarily be suitable for all contexts, and we will have to be flexible in how we use them, and we may have to switch back and forth between different terms. In general, I think "mental health problems" and "mental disorders" are suitable for most purposes, and "mental illness" is fine in many contexts (provided it is not misunderstood).
I'm inclined to be rather deflationary about the emphasis on the terms. Here is what I think suitable candidate terms should be able to do:
a) Recognize the suffering, distress, disability, or harm associated with a condition
b) Recognize that clinical assessment is warranted
c) Recognize that many interventions are available that can help a person in such a state, and that these interventions include interventions typically used in medicine.
d) Despite all the differences, there are many important similarities between problems in mental health as well as problems in physical health
f) It is appropriate for healthcare resources to be used for the purposes of assessing and treating these problems.
I think terms such as “problems in living” and “mental distress” fare poorly in performing the above tasks. “Mental health problems,” “mental disorders,” and “mental illness” are much better. I think it is fine to prioritize “mental health problems” or “mental disorders” over “mental illness” due to association connotations, but it starts becoming a problem when people start insisting that mental health problems are *not* illnesses. It also starts becoming a problem when people take the view that whether we call a condition an "illness" or not *determines* whether some form of medical intervention is appropriate and whether healthcare resources can be used for that purpose.
“Mental illnesses” are indeed different than diabetes, heart-disease or cancer… which is why they have a category of their own, don’t they? We recognize that there are different types of illnesses and disorders, and we categorize them to facilitate the recognition of their differences.
Now for mental disorders, things like behavioral learning, personality development/personality traits, and life story are extremely important, way more than they are for most other areas of medicine. (Referring to McHugh and Slavney’s figure in the post above). Any account of mental illnesses/disorders/health problems that doesn’t recognize this is extremely problematic and indeed quite impoverished.
“This is not just about semantics for me. If the ideas of disease—for most people—precludes an appreciation that a particular mental problem could very well likely vanish by a change in ideas, I would think that the illness frame is highly distorting the territory that is being described.”
Well, that’s kind of the whole point of psychotherapy and other psychological interventions, that we can bring about change, at times powerful change, with psychological tools. Even in the case of things like psychedelics, it seems as if the experiential content of the experience – a change in ideas, so to speak – is an important driver of therapeutic benefit. So it is absolutely essential to convey this to people. Mental illnesses are illnesses that respond to psychological and behavioral interventions. And if conveying this point requires using other terms preferentially, then so be it.
Thank you Awais. You're a great role model for how controversial topics should be discussed. I admire your balance, fairness, and ability to talk about this topic so rationally!
Yes, people aren’t very rational, are they? But why aren’t they? For one thing, it’s difficult for everybody to hold complex, multi-causal ideas in their heads. It certainly is for me! I think people learn some complex ideas in school, but in real life, everything inevitably gets simplified.
Besides that, there are all the influences on our thinking. For instance, the pharmaceutical companies are still a giant magnet distorting ideas about brain chemistry and such.
Another thing: I heard in a podcast someone say that in her coursework she was taught that “parents are never to blame.” A shockingly, obviously wrong statement—we all know that parents are often one of the causes of their children’s psychological problems. But from a practical standpoint—especially if you’re working with young people—you risk getting embroiled in family power dynamics if you start talking about abusive or neglectful parents. Better just ignore the facts.
Or take the reality of incest and other sexual abuse. It’s been denied for a long time. Even now, it seems nearly impossible for most people, including therapists, to talk about it. Most (many?) books on therapy don’t even mention it, even though it’s very common and everyone knows how damaging it is. Or sibling abuse. Who takes that seriously? Or dissociation of various kinds. How many therapists are taught about dissociation in depth? These matters are just too disturbing for most people to handle, and psychologists are just people.
And if psychologists don’t get it right, how can you expect patients to develop sophisticated ideas of the multi-causal nature of reality?
“Would she be disappointed when she learns that the psychedelic revolution means jack shit for those who experience “financial deprivation, poor education, racial discrimination”?”
This! I live in the bay area and I don’t know many people who can afford psychedelic therapy with a licensed clinician at the rates people charge here unless they work in tech or are wealthy. It has horrified me to watch people go to these retreats, not integrate properly with licensed professionals, and come out with huge grandiose egos. An example of this is the recent OSU commencement speech by Chris Pan. My commencement speaker was Dan Rather and thankfully he was not high on Aya when he wrote it.
I agree with your article, but less of it coheres with my experience. A Colorado medical school professor as recently as 2022 told me that I have a "chemical imbalance" inside of my brain during a video consult. She is now tenured. A more recent interaction with a PMHNP also stated I have "too much dopamine" and that I could "literally die if you don't take vraylar". (I'm still waiting to spontaneously "die" months later; any day now, sigh).
I believe what fuels much of the disillusionment is that these categories are taught as if they're A). homogeneous, B). static, C). a-contextual, D). overdeterministic or unidirectional. And it's because all of science holds the same assumptions with everything they theorize. E.g. Physicists demand spacetime is perfectly homogeneous, that all "laws" are deterministic, static, and a-contextual and hence generalizable. And when philosophers point out these are instead "first assumptions" the scientist responds with "Well that sounds too philosophical for me so it's not my problem!". Whereas biologists will unapologetically claim nothing living is ever homogeneous, not even "identical" twins, nor are evolutionary processes "purely" deterministic, nor are mutations unidirectional nor a-contextual. Living bodies are also not static (aging is real, circadian rhythms change, values change, habits too etc). And no metabolic process follows a straight line. So why hasn't institutional psychiatry banned these words (homogeneity, static, a-contextual, overdeterministc/unidirectional) yet? What kinds of brains are rising to the ranks of professor to regurgitate these specific assumptions? I disagree it's the general public causing them. Rather, the first time i ever learned of the word homogeneity was in a psychometrics class about "crisply measuring mental disorders", as it were, "carving nature at it's joints".
Unfortunately there are many clinicians who are not only poorly informed but even worse at communicating with patients. I completely understand what you are saying. I am not blaming the public. I think the bulk of the blame lies with professionals. I’m criticizing the “medical model” framing of this critique.
"What kinds of brains are rising to the ranks of professor to regurgitate these specific assumptions?" Exactly. Yes. What they told you is appalling.
It does often seem that psychologists as a group are particularly irrational. I've come to believe it's because to actually study and truly see human beings for what we are, to grok what we do to each other and why we do it and the harm that we inflict on each other--it's just too much for most people, for most psychologists. So they flee into some absurdly untrue, distorted theories so they don't have to deal with the reality.
Thank you for this brilliant discussion. I have become more attracted to psychosocial approaches to mental health problems (e.g., housing, counseling, social supports) over the years and have even seen my daughter benefit from such programs as provided by family members and a local non-profit organization. If my daughter had a place to live in peace with access to food and medical care under a biopsychosocial model, and daily activities to give her life meaning, with friends and acquaintances who accept rather than judge or punish behavioral symptoms by interpersonal rejection or through a carceral system, without guns or other weapons (including those introduced by police officers as first responders), then we might have something approaching a utopian solution for persons with serious mental illnesses. But politicians and members of the public who complain about an over-reliance on medications would reject initiatives to bring such psychosocial supports to scale when they found out they cost far more than pills.
Thank you, Awais, for a very thoughtful discussion of this much maligned concept of "the medical model." You are spot-on in identifying a misplaced "essentialism" as the chief culprit in the misguided arguments against the "medical model." (Please note that Ludwig Wittgenstein warned us of this trap in his Philosophical Investigations).
In a piece I wrote over 7 years ago regarding "hearing voices" [1], I noted that there is no single, written-in-stone, "essential" definition of the "medical model." Nevertheless, to the extent the term is useful in clinical psychiatry, we can identify its six central features:
1) In so far as human emotion, cognition, and behavior are mediated by brain function, there is
always an inherent biological foundation to dysfunctional states, such as clinical depression,
psychosis, etc
2) Valid psychosocial and cultural explanations of human experiences do not nullify (or contradict)
the biological foundations of these experiences
3) Conversely, biological explanations of human experiences do not negate (and often complement)
valid psychosocial and cultural explanations and formulations
4) Biological factors are always part of a comprehensive differential diagnosis of serious emotional,
cognitive, and behavioral disturbances—even if, upon careful analysis, psychosocial or cultural
explanations prove more relevant or informative
5) That certain human experiences or perceptions (e.g., “hearing voices”) have a discernible “meaning,”
symbolism, or psychological significance for the patient does not mean they have no
neuropathological etiology
6) All somatic and psychological treatment modalities—whether medication or “talk therapy”—have
meaningful (and sometimes measurable) effects on brain function and structure
It should be clear that there is nothing "reductive" in this understanding of the "medical model", and I believe these features--while not defining an "essence"--are useful, heuristic starting points for the understanding of how psychiatrists think about illness, disease, etc.
Regards,
Ron
Ronald W. Pies, MD
1. https://www.academia.edu/79032733/Hearing_Voices_and_Psychiatry_s_Real_Medical_Model?uc-sb-sw=38597480
https://www.psychiatrictimes.com/view/hearing-voices-and-psychiatrys-real-medical-model
Also see: Shah P, Mountain D. The medical model is dead – long live the medical model. Br J Psychiatry. 2007; 191:375-377.
Hi Awais, I think you make many important points about medicine and the scope of its practice. There is a presupposition here, though—one that is almost unquestionable these days, for fear of being labeled pseudoscientific or the like. It's that significant mental or emotional suffering (thresholds being defined by the DSM) **is** an 'illness'. The idea of 'mental illness' seems to be a literal oxymoron to me. One way to conceptualise our mind is that it is a result of what 'our brains does'. Walking is one of the things our legs do. However, we don't have 'walking illnesses'. It's a selectional restriction in linguistics to talk about walking being 'ill'. We obviously can have leg injuries, cardiovascular illnesses, neurological illnesses, etc., but we don't talk about 'walking illnesses'. And yet, we frame psychological suffering as a 'mental illness' and not a 'neurological illness'. I can understand this from the point of view that psychological suffering is poorly characterised as a 'neurological illness'. But that doesn't mean that the frame of 'illness' is the most useful or accurate for psychological suffering. To me, this is the most powerfully and implicit 'medical model' involved here. It's the idea that psychological suffering is a medical issue. I'm curious—what do you think is the best argument that the framing of psychological or emotional suffering as 'illnesses' is well conceived, rather than just being *one* possible metaphor amongst other alternatives? Thanks so much.
Hi Michael. Thank you for this comment.
Well, in some ways we do talk about "walking illnesses"... we call them "gait disorders" https://www.sciencedirect.com/science/article/pii/S0002934317312950
That aside, I think it's easy to get hung up on the "illness" concept. In medicine one can debate whether obesity or hypertension are "illnesses"... they are quite far from the prototype of being ill that many people have in their minds, and if the term sounds unsatisfactory, we can easily call them "physical health problems" or "medical conditions" without much practical difference. In a similar kind of way, we can easily call mental illnesses "mental health problems" or "psychiatric conditions," with little practical difference. The main point is that these are problems that either can be addressed, in part, through medical interventions, or can be productively conceptualized through the tools of medicine (e.g. diagnosis). (We can also call them "disorders" instead of "illnesses," and "disorder" is a term currently shared by both medicine and psychology)
How can we justify the medical approach to psychopathology or psychiatric distress/impairment?
1) We know that many neurological and physiological disorders present with psychiatric symptoms, at times in a manner that is indistinguishable from usual presentations of mental illness. They used to be called "organic mental disorders" (and sometimes still are).
2) Severe form of paradigmatic mental disorders share many features with physiological disorders. Consider chronic, recurrent psychosis. Distortions of perception, delusions, restricted emotional expression, presence of nonspecific neurological signs, at times cognitive impairment, decline in functioning. Or consider severe depression: psychomotor retardation, fatigue, changes in appetite and sleep. Symptoms are protracted, involuntary, causing severe disability, and often associated with increased risk of poor outcomes and mortality. As Peter Kramer once put it, "What do you call an experience that is chronic or recurrent, that is associated with adverse changes in your brain, bones, endocrine glands, heart, and blood elements, and that is likely to shorten your life? Even a culture that had no concept of mental illness might well call that condition a disease." https://www.psychologytoday.com/us/blog/freud-fluoxetine/202103/peter-d-kramer-depression-placebo-and-psychotherapy
3) We know that medical interventions such as medications and neurostimulation are effective in many cases of mental disorders. We have convincing evidence from numerous clinical trials.
Hi Awais,
Thank you for this thorough reply. I appreciate it. I will number my points for clarity.
1. Thank you for reminding me of ‘gait disorders’. I had overlooked that. Obviously, we can apply words in all kinds of ways. Economies can be said to be ‘sick’, for example. I think that, as you point out, the term ‘disorder’ is more reasonably applicable to emergent properties (such as walking and mental activity) than the term ‘illness’. It probably would be strange to talk about ‘walking illnesses’.
2. Framing is one of the most powerful forces in human psychology, and so it has dramatic effects on mental and emotional issues. If I remember correctly, Randolph Nesse once mentioned how many people with ‘Panic Disorder’ his ‘Smoke Detector Principle’ helped. This certainly matches my experience where SOME people with years of ‘panic disorder’ almost instantly cease to have any problems—without doing anything at all, but just hearing the new framing (even when medication hadn’t been able to achieve the same result).
The ‘illness’ and ‘disorder’ frames carry 'psychological' consequences. As Brett Deacon has shown, biological explanations—which are presupposed by the term illness for most people, despite the nuance you have—can make people more pessimistic about their chances of recovery and bias perceived 'treatment' possibilities towards medication.
https://www.sciencedirect.com/science/article/abs/pii/S0005796714000308
3. The frame ‘mental health’ is really the same frame--the other side of the ‘mental illness’ coin. The idea of ‘mental health’ doesn't make any sense without the implied opposite of ‘mental illness’.
‘Psychiatric conditions’ imply that a Psychiatrist is required for a ‘cure’ or ‘treatment’. One can sympathetically understand how the field of Psychiatry would want this framing, as it’s a human tendency to want to stake claim to one’s authority and dominion over lucrative domains.
I can also understand Psychologists preferring the term ‘Psychological / Mental Disorder’ for similar reasons—a framing that is more likely to equality of status, rather than being perceived as lower on the rung than a Psychiatrist.
And yet, then, both of these framings miss the fact that people often get the best help outside the ‘mental health’ realm. Is a skilled, compassionate, wise Clergy member really less well positioned to help someone with ‘Major Depressive Disorder’ than a Psychiatrist or Psychologist? Or how about a ‘Self-Help Guru’? This study of Tony Robbins’ Date With Destiny seminar makes one think that he is probably vastly more effective than the vast majority of Psychiatrists or Psychologists, at least with depression.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9107501/
However, if one accepts the medical framing of such conditions, Tony Robbins *must* be a charlatan. After all, he has no license or qualifications to 'treat' such 'conditions', and 'practicing medicine' without a license is obviously unethical. And yet, if we are serious about the scientific method, the results don’t seem to support such a conclusion with Robbins.
Motivated reasoning is something we all fall victim to, and so I think we have to be very careful with confusing philosophical positions as being objective scientific truths. While the Robbins’ study isn’t perfect, and replication and better controls would be wonderful, it *is* a dramatic result.
4. Even a more plausible framing of ‘disorders’ has consequences. For example, a focus on what’s wrong. There are almost always strengths inside of mental or emotional problems that can be utilised. Milton Erickson’s work is stacked full of examples of this. In one example, with phantom limb pain, Erickson taught a patient to feel phantom pleasure in the missing limb. It is a strength, presupposed in phantom limb pain, that our subjective experience is constructed (predicted, with constraints, of course). Erickson utilised the same phenomena that caused the problem as the solution. This is not something most clinicians would think about. I believe a framing of 'disorder' and 'pathology' makes the missed opportunities, that Erickson would have easily taken advantage of, very understandable.
5. Your points that ‘paradigmatic mental disorders share many features with physiological disorders’ are spot on. There is no mind-body split. It’s all one system. Research on placebos shows this best, perhaps. Someone with asthma being triggered by an artificial plant demonstrates this. People tasting more lemon in soft drinks with more yellow on the tin, too. I think that it’s not about whether everything humans experience is grounded in biology—it is. For me, it’s more about what lens is most useful to approach the situation from. Social interventions ARE biological interventions. So are IDEAS (such as that ‘panic attacks’ are not really attacks but well-intentioned false alarms given an evolutionary heritage of better-safe-than-sorry solutions that are OPTIMAL in a world where signal detection isn’t always easy).
6. In response to Peter Kramer’s point, when pattern matching one must also include counterexamples. Social isolation and pollution both can be ‘chronic or recurrent’, ‘associated with adverse changes in your brain, bones, endocrine glands, heart, and blood elements, and that is likely to shorten your life’. And yet, only if we really employ concept-creep in an aggressive way, could social isolation and pollution be considered ‘illnesses’ or ‘diseases’. They are non-diseases that have physiological effects, which may meet the criteria for a disease in certain people over time.
Imagine someone whose parents somehow indoctrinated them into believing that exercise was a waste of time and beneath them. That idea, if accepted by an innocent child who then grows into an adult, would meet all of Kramer’s criteria—having adverse effects on brain, bones, endocrine glands, heart, blood elements, and likely shorten a person’s life. And yet, are we going to call ‘ideas’ diseases? If so, sign me up—because ideas are the heart of most ‘Psychiatric Conditions’, interacting with biology and life experiences.
7. You said ‘We know that medical interventions such as medications and neurostimulation are effective in many cases of mental disorders. We have convincing evidence from numerous clinical trials.’ I agree (without getting into the controversies about the degree of placebo effect—Kirsch and others—which I think is irrelevant to this point).
However, does the efficacy of a Psychiatric Medication necessarily imply that the illness hypothesis is accurate? One alternative model is The Drug-Centered Model, proposed by Joanna Moncrieff.
Thank you, Awais, for challenging me and stimulating my own thought processes. Maybe I’m wrong. However, the only way to know is to test my beliefs and so I deeply value conversations with intelligent people, like you, who think differently.
1. We don't insist on calling every condition in medicine an "illness"... we recognize that the concept has a certain prototype, and the farther we go from that prototype, we reach for other words... disorder, syndrome, condition, health problem, etc. But the application of the medical framework doesn't depend on calling *every* condition an illness. It's the same in psychiatry, where the term mental illness applies better to some condition, but we use a patchwork of other terms to describe the whole domain.
2. I've told many people with anxiety disorders about the smoke detector principle over the years but I've yet to see that kind of response. I'm sure it happens sometimes, but it's also unlikely to resolve the most severe and entrenched set of problems. An overactive "threat" (anxiety/panic) system is like an overactive immune system. If someone is having a mild case of allergic rhinitis, they might be reassured by the explanation that the immune system by design over-reacts to benign things such as pollen, but someone with more severe symptoms will need symptom relief. For most people with severe anxiety, an explanation of the evolutionary role of anxiety is not enough.
And if we do wanna bring up Nesse's work, I think it's fair to point out that Nesse's evolutionary approach recognizes the existence of psychological conditions which result from failures of evolutionary design. For Nesse, psychological dysfunction is an evolutionary reality, responsible for conditions such as schizophrenia and severe mood disorders. Or do you want to simply acknowledge the existence of evolved mental functions without recognizing dysfunctions of evolved mental functions?
Framing matters, sure. I think much of literature on putative negative effects relies on problematic biological explanations. I'd also be very curious about the psychological consequences of telling people with severe distress and disability that they are NOT suffering from an illness, disorder, or even a "health problem." I imagine many will react quite negatively to that.
3. I honestly don't think that it makes sense to deny or reject that there is no such thing as "mental health." I think there is no satisfactory definition of health that doesn't extend to the psychological domain. And yes, once we recognize that there is such a thing as good mental health, we can recognize that there is also poor mental health and mental health problems.
The framings cannot be understood as being exclusive. Yes, people can get help outside the "mental health" realm, but if mental health problems were indeed so easily treatable by non-clinicians, we'd be operating in a very different landscape. It is still the case that many people do not find any relief from thing such as talking to friends, or elders, or clergy members, and for such people, there remains a role for professional help. I'd like to see an experiment in which we put "skilled, compassionate, wise Clergy member" in charge of people seeking help at a Mood Disorders Clinic, and let's see how well it turns out. While some people might indeed benefit more from a priest than a physician/psychotherapist, most people with chronic, recurrent, and severe problems will have better luck with a trained professional. At least that's what I think.
"we have to be very careful with confusing philosophical positions as being objective scientific truths." I agree, which is why I don't think that illness status, or disorder status, is an objective scientific truth, and I have written extensively on that. https://www.psychiatrymargins.com/p/the-social-construction-of-disease
4. There is nothing about a disorder concept that forces us to focus only on what's wrong. The focus on what's wrong is a bias introduced in clinical settings because of the nature of the work, and it is a bias that ought to be pointed out and addressed (which is being done by movements such as Positive Psychiatry). This also applies to all of medicine, not just psychiatry.
5. "For me, it’s more about what lens is most useful to approach the situation from." I think medical framing has a pretty good case when it comes to utility. I work with people every day who find this framing helpful. It's not the most helpful for everyone, but it is the most helpful for enough people that it has a claim to legitimacy based on utility alone.
6. Social isolation and pollution are indeed medically relevant phenomena. They are public health concerns. Pollution is not an individual characteristic at all, so it cannot be considered a dysfunction/disorder *in a person* or *of a person*. A person can be socially isolated, but given the interpersonal and contextual nature of isolation as a phenomenon, and its nonspecific health effects, arguably it is better considered a risk factor. Social isolation is also better addressed via non-medical means at present. But conceivably it could become a medical condition some day. (These are not quite gotcha issues, once you start looking into discussions around the status of aging, infertility, grief, etc.)
7. Illness is not an empirical hypothesis and I think it is a mistake to treat it as a hypothesis.
I also have many issues with Moncrieff's drug-centered model. https://www.psychiatrymargins.com/p/drug-centered-model-of-psychopharmacology
Hi Awais,
I’ve enjoyed a couple of videos of you on YouTube so far, with more to watch. You come across as a great guy; balanced, fair, empathetic, and passionate — and I find myself agreeing with you excessively ;)
I’m continually reminded how limited text-based conversations can be, lacking in the non-verbal dimension that is so important in relating to another person.
Given we agree on so much, I wonder if there are perhaps just two related points of difference:
1. I am totally on board with the Prototype Theory of categories. My question is how do you assess when a particular example is best considered to be a peripheral category member, vs being better served by placing it in an entirely different category, vs creating a fresh brand new category?
As you know, prototypes tend to play a dominant role in influencing the meaning of a concept. The concept of illness, for most people, is prototypically represented by what I might artificially call ‘physical illnesses’* (the common cold, flu, diabetes, cancer, multiple sclerosis, heart disease, etc.) (*Just a way of talking here as I can’t think of a better framing: biology obviously grounds every human experience.)
To the general public, and I’m sure also with most clinicians, I would bet that the frame of ‘mental illnesses’ inherits much of its implicit meaning from these prototypical ‘physical illnesses’.
What do we do about the fact that there is a dramatic difference between most ‘physical’ and ‘mental’ illnesses?
If, for example, someone closes their eyes and just listens to someone else talk, and their problem automatically vanishes, was their problem really best described by the term ‘illness’?
I’m reminded of the work of Michael Yapko who has several patients with depression (that medication hadn’t helped), on video, having their life utterly transformed just by one session with 20 or 30 minute of hypnosis. People's depression can often vanish when people get new perspectives, learn new skills, learn how to make better decisions, have a positive change in the social life, etc.
If someone learns a new social skill-set, and their ‘social anxiety disorder’ vanishes, is it best described as a disorder, or a lack of psychological and social skills, strategies, and understandings (i.e. a learning phenomenon)?
Do conditions that CAN—not always—vanish with powerful changes in ideas (about oneself, life, situations, etc) really belong in the same category as heart-disease, cancer, or diabetes? You’re sophisticated and so you understand that categories can have peripheral examples. But when is the phenomenon so different that it shouldn’t be in the same category with something else?
Tomatoes 'should' be vegetables. They look and taste like vegetables. Botanically, they’re not. One criteria can disqualify something from belong to a category.
Something like Schizophrenia, I presume, almost never vanishes just by mere talking. Is it, therefore, better conceptualised in a different category to a very painful problem that does change with a ‘mere’ change of ideas, in a supportive social context?
We could include Schizophrenia in the same category as most depression, albeit very distinct members. Or, maybe we could have a new category for ‘conditions’ that do readily change via the right learning processes (conditioning, changes in beliefs, thought processes, the development of new skills and capabilities, etc.) or social situations (e.g. financial relief, leaving an abusive relationship, etc.)
Then presents a problem though…
How does one assess whether a problem is solvable through mere ‘ideas’ in social context? We can’t say for certain that a specific person’s mental problem requires biological intervention, because the scientific literature can’t falsify such an idea. Inductive reasoning isn't proof (much like we knew all swans are white, until people travelled to Australia and found black swans).
My point is: Surely, if someone’s ‘mental illness’ vanishes through just listening and talking, without any conscious effort on their part, surely that belongs in a different category than diabetes, heart-disease or cancer? It’s not a quantitative difference, it’s a qualitative difference. That result isn't possible with most cancers (rare potential placebo cases excluded--I don't know the literature on whether or how often that happens with cancer).
This is not just about semantics for me. If the ideas of disease—for most people—precludes an appreciation that a particular mental problem could very well likely vanish by a change in ideas, I would think that the illness frame is highly distorting the territory that is being described.
NOTE: some ideas may only be able to be changed with biological intervention. Maybe the ideas involved in a certain psychosis are changeable by a social interaction, like therapy. Or maybe they will be best solved by precise biological intervention in the decades and centuries to come (e.g. AI and ultra precise neurological modification techniques. The same could be done though, with things we'd never want to call diseases. For example, one could imagine futuristic neurological interventions to help someone fall out of love with an abuser, or become more extraverted).
I think the map-territory distinction is so important. If people said ‘What you’re suffering could be thought of in many useful ways. Thinking of it as an illness is one way. Thinking of it as a disorder is another. Thinking of it as a sign that your life will likely improve dramatically when you learn certain, key psychological skills, is another.” Etc.
My concern is that a ‘illness’ lens presents a highly impoverished conceptualisation of the actual underlying territory.
‘Psychological problems’ is a much more neutral lens. ‘Psychiatric problems’ less so, because it implies the requirement of medical help, which is not always true.
Medicine, as you rightly state, CAN include it all. However, much of the time, when we frame something as belonging to one category, it implies a preclusion of other categories. Framing suffering as ‘Psychiatric conditions’ implicitly out-frames psychological, social, learning, societal, etc. etc. approaches (Not for you, but for most people I’d bet.)
I think that just as Psychiatrists may be fearful of losing their role if the frame of illness ceased to be used, I think other equally valid lenses are under threat when ‘illness’ is used.
We don’t need an illness frame to explain highly aversive, involuntary, suffering. There are other maps that explain this equally as well. Conditioning isn’t best conceptualised under an illness frame. It’s more usefully conceptualised under a learning frame. And yet involuntary conditioned responses are often core to most ‘mental illnesses’ (e.g. panic and interoceptive cues being conditioned to fear). And, conditioning responses are influenced by genetics and the rest of biology. So a learning frame could fit equally well to medicine (‘Medication could help your brain learn you’re safe more quickly, in addition to exposure’—an empirically testable claim, that some research suggests—e.g. by David Barlow— is not true, but used just as an example).
Back to the study of Tony Robbins’ seminar. Amazing results if that study is to be believed. Tremendous skills at helping people (based on empirical results), and yet he is dismissed by many in mainstream—who would learn so much from him, if open-minded—because he is ‘practicing without a licence’ or even a university degree. However, with a more balanced conceptualisation of the underlying phenomena—which we both care most about—Tony Robbins has an equally valid place in addition to all the other experts because of results (empirical data).
Meditation was once naively mocked as pseudoscience in many parts of academia. And yet how fast that has changed! This kind of narrow definition of what’s valid vs not, based on the current dominant model, doesn’t seem to serve anyone well as far as I can tell.
If we care about the territory most—which I think you do—then we want to make sure our maps don’t implicitly bias us to ignore important parts of that territory, bias who has a right to navigate through that territory, or get us lost etc. because only experts understand the right nuance to read the said map correctly.
Am I making any sense? Thank you. I appreciate you.
Thanks Michael. You bring up a lot of excellent and important points. There is a lot to discuss here, but I'll briefly say a few things.
You are right that different terms can bias people as well as clinicians in different ways. It is important to be mindful of that and to take that into account. We can also recognize that no single term will necessarily be suitable for all contexts, and we will have to be flexible in how we use them, and we may have to switch back and forth between different terms. In general, I think "mental health problems" and "mental disorders" are suitable for most purposes, and "mental illness" is fine in many contexts (provided it is not misunderstood).
I'm inclined to be rather deflationary about the emphasis on the terms. Here is what I think suitable candidate terms should be able to do:
a) Recognize the suffering, distress, disability, or harm associated with a condition
b) Recognize that clinical assessment is warranted
c) Recognize that many interventions are available that can help a person in such a state, and that these interventions include interventions typically used in medicine.
d) Despite all the differences, there are many important similarities between problems in mental health as well as problems in physical health
f) It is appropriate for healthcare resources to be used for the purposes of assessing and treating these problems.
I think terms such as “problems in living” and “mental distress” fare poorly in performing the above tasks. “Mental health problems,” “mental disorders,” and “mental illness” are much better. I think it is fine to prioritize “mental health problems” or “mental disorders” over “mental illness” due to association connotations, but it starts becoming a problem when people start insisting that mental health problems are *not* illnesses. It also starts becoming a problem when people take the view that whether we call a condition an "illness" or not *determines* whether some form of medical intervention is appropriate and whether healthcare resources can be used for that purpose.
“Mental illnesses” are indeed different than diabetes, heart-disease or cancer… which is why they have a category of their own, don’t they? We recognize that there are different types of illnesses and disorders, and we categorize them to facilitate the recognition of their differences.
Now for mental disorders, things like behavioral learning, personality development/personality traits, and life story are extremely important, way more than they are for most other areas of medicine. (Referring to McHugh and Slavney’s figure in the post above). Any account of mental illnesses/disorders/health problems that doesn’t recognize this is extremely problematic and indeed quite impoverished.
“This is not just about semantics for me. If the ideas of disease—for most people—precludes an appreciation that a particular mental problem could very well likely vanish by a change in ideas, I would think that the illness frame is highly distorting the territory that is being described.”
Well, that’s kind of the whole point of psychotherapy and other psychological interventions, that we can bring about change, at times powerful change, with psychological tools. Even in the case of things like psychedelics, it seems as if the experiential content of the experience – a change in ideas, so to speak – is an important driver of therapeutic benefit. So it is absolutely essential to convey this to people. Mental illnesses are illnesses that respond to psychological and behavioral interventions. And if conveying this point requires using other terms preferentially, then so be it.
P.S. This may also be of interest: https://www.psychiatrictimes.com/view/psychiatric-disorders-imperfect-community-peter-zachar-phd
Thank you Awais. You're a great role model for how controversial topics should be discussed. I admire your balance, fairness, and ability to talk about this topic so rationally!
Thank you for a thought provoking response Awais. You make some good points here that have got me thinking. Thanks again!
Yes, people aren’t very rational, are they? But why aren’t they? For one thing, it’s difficult for everybody to hold complex, multi-causal ideas in their heads. It certainly is for me! I think people learn some complex ideas in school, but in real life, everything inevitably gets simplified.
Besides that, there are all the influences on our thinking. For instance, the pharmaceutical companies are still a giant magnet distorting ideas about brain chemistry and such.
Another thing: I heard in a podcast someone say that in her coursework she was taught that “parents are never to blame.” A shockingly, obviously wrong statement—we all know that parents are often one of the causes of their children’s psychological problems. But from a practical standpoint—especially if you’re working with young people—you risk getting embroiled in family power dynamics if you start talking about abusive or neglectful parents. Better just ignore the facts.
Or take the reality of incest and other sexual abuse. It’s been denied for a long time. Even now, it seems nearly impossible for most people, including therapists, to talk about it. Most (many?) books on therapy don’t even mention it, even though it’s very common and everyone knows how damaging it is. Or sibling abuse. Who takes that seriously? Or dissociation of various kinds. How many therapists are taught about dissociation in depth? These matters are just too disturbing for most people to handle, and psychologists are just people.
And if psychologists don’t get it right, how can you expect patients to develop sophisticated ideas of the multi-causal nature of reality?
“Would she be disappointed when she learns that the psychedelic revolution means jack shit for those who experience “financial deprivation, poor education, racial discrimination”?”
This! I live in the bay area and I don’t know many people who can afford psychedelic therapy with a licensed clinician at the rates people charge here unless they work in tech or are wealthy. It has horrified me to watch people go to these retreats, not integrate properly with licensed professionals, and come out with huge grandiose egos. An example of this is the recent OSU commencement speech by Chris Pan. My commencement speaker was Dan Rather and thankfully he was not high on Aya when he wrote it.