Having worked at a campus affiliate counselling center (Glebe Center, Wilfrid Laurier University) and still having a number of clients who are students, it has brought to light a trend that seems to be prevalent in mental health these days: that sadness is an illness. The same can be said for stress. Instead of talking about chronic stress, or nervousness, or worrying, for many people (and I see this predominantly in the younger culture) this has now become simply “anxiety”.
I believe that in all the push to take mental health seriously, and the importance of considering these to be legitimate concerns, we have overcompensated and created a space where the label of mental illness is used as a less-than-useful name tag that defends against criticism, prevents critical thought, and actually resists change. After all, if you are sad, then there is likely a reason for it – and there might be something to look at. But if you have a mental illness, then you could use this as an excuse to waive responsibility, reduce curiosity, or become identified with the label. There is a dangerous tendency to use ‘mental illness’ as a protective layer against change, which can allow a person and a culture to get even more stuck in the unhealthy patterns of the mental illness itself.
There are two parts to this problem. First is the way that this perspective removes moods from its rightful place in a healthy, emotionally complex human being. The other is the rigidity and subsequent assumptions that can come out of the diagnostic model.
To start with, let’s look at the problem of making stress a disease. When we do that, we then create a culture and a perspective where it is not ok to have emotions. Sadness, anxiety, anger – these are all very appropriate and healthy reactions to certain life conditions, and to reject them, tell yourself that they are wrong or bad, creates internal conflict that leads to greater suffering, and is likely the root of structural dissociation. Again and again we see clinical evidence that anxiety and depression are vastly, significantly lessened simply by their acceptance. Moods are not an illness – they are complex messages from our incredible psyche that we must get curious with. To not regard them as such, is to perpetuate the ‘myth of happiness’ that is central to Acceptance and Commitment Therapy – which is that the idea that we are ‘supposed to be happy all the time’ itself is a cause of suffering. It is just not true. And it does not need to be true. (I have written more about happiness here).
This is a complex issue. For one thing, psychotherapy works precisely because there are factors in our psyche that can change, and that we can learn to approach differently. So even when a diagnosis is truly valid (inasmuch as it meets all criteria, which itself may be questioned, as we will do soon) it still means that it is not static, and not necessarily permanent. It is crucial to know that all of this can change. That does not mean that it will, but if a person doesn’t believe that it can, then, as the saying goes “whether you believe you can, or believe you can’t, you are right”.
I need to be clear that I am not saying that we should never use a formal diagnosis of a mood disorder like depression or anxiety. We can err the other way too – there may be times when a diagnosis is useful for various reasons. But outside of a hospital environment, my experience is that this is not most of the time. And I am not saying that clinical depression cannot be a valid medical illness. I just want to clearly differentiate between it and negative moods.
The act of labelling an illness is a powerful thing.
Part of the reason why we are quick to pathologize moods is that it reduces it to a disease model label that then becomes easier to understand. If we conveniently choose to ignore the personal complexity of the problem, sure, it is easier to look at. Harder to solve – but easier to be with. And though this is not the majority of cases, I have certainly had clients before who hide behind their diagnosis, and find what we call ‘secondary gains’ in holding their maladaptions tightly. In this case, secondary gains are subtle and certainly not conscious ways that we can hold onto negative patterns. The prime example of this is someone who becomes identified as a victim, and uses this to get sympathy, attention, or emotional leverage of other kinds.
I was shocked, personally, to see that part of the depression that I used to feel was actually an imploded cry for help. I had learned to use this when I was young to get some of my needs met, and the pattern persisted (as they do, when they work). I was fortunate to have good therapy and honest critical thought to question these things and thus undo them. It has taught me that even the most pernicious mental health conditions have ideas and beliefs at their root. Working with EMDR in trauma has taught me this again and again – that the parts of us that we thought were unchangeable aspects of self, the parts that “are just the way that I am”, are themselves just patterns of being, and ideas about the world and the self that are so fundamentally held, that they cannot be seen easily. It is like asking the fish to talk about water.
Another really important aspect of this discussion is that we forget that even when it is helpful to consider mental health issues as a veritable disease, it is crucial that we remember that this may not be the same as a more biologically clear disease – it is a mental one, an illness of the psyche. They do not have precise, concrete biological correlates that we can test and say, “this is cancer” or “this is diabetes”. Depression shows a lack of serotonin, but is that a cause or a symptom? There are biological symptoms of mental health disorders, but those symptoms vary according to person, and even in the person, those symptoms vary according the day, moment, and idea that they are holding. Though it is true that a drug that changes a person’s brain chemistry by altering its use of serotonin can make a person feel better, it is also true that a person’s ideas and behaviours and attitude also – moment to moment – change the serotonin activity of the brain. There is a relationship here but we absolutely have no evidence of the direction of causation. The current medical model of psychiatry is so enamored with its medical tradition that it fails to consider the evidence that suggests that the other direction could me simply more useful to work with – that thoughts and emotions are directly causal of the molecules in the brain. There is a fabulous called the “Molecules of Emotion” by Candace Pert that shows some decent science behind all this.
The truth is that we don’t need to have a direction of causation to argue about. I believe that the greater insight is to simply know that it is not a question of what comes first. It is the acknowledgement that thoughts and emotions are simultaneous to – are the same things as – chemicals or phenomena in our nervous system. Isn’t that what the science shows anyway? Ideas are electric firings, themselves full of chemicals and neurons and all that fun stuff that can be influenced by drugs, be they SSRI’s or a good glass of wine. I do not believe that we are first biological, with our psyche as secondary result. In fact, intelligent inquiry might suggest the opposite could be true. But we don’t even need to go that far. It is sufficient to say that mind is body, and body is mind. It does not behove us to separate them, for to do so belies our capacity to heal and change, and strips us of the power to do so.
The next piece of this discussion is about the whole tricky issue of the diagnostic labels themselves. Every week I talk with clients who are worried about their diagnosis – what it means about them and why. In another reductionist failing, the medical system often slaps a label on someone, often (and I have seen this far too often) based on fifteen minute emergency room interviews, or questionnaires on the back of a drug company leaflet (that one was my own personal experience!). That is how we understand a human being? Bam! Suddenly “I am borderline” instead of “I am this personal, complicated set of traumas, behaviours, ideas, feelings, patterns”.
It is essential that we use mental health diagnosis with a light grasp.
They are loose models and suggestions – not perfect and absolute definitions. And certainly not permanent. It may be helpful to point out that what we in the western world use as our basis for diagnosis, the DSM 5, is full of man-made ideas that we use only as ways to put bunches of symptoms into boxes that are easier to handle that way. Every label is entirely abstract, and all of these labels have changed over time. Earlier editions of the DSM had different diseases in it, and the same diseases with different criteria. As our understanding of all of this changes, so too do the labels, and what they mean. A good example to remember is that earlier versions of the DSM listed homosexuality as a disease. What might the DSM in the next generation look like? Or the next one? I suspect that increasingly, we will yearn for greater cohesion and simplicity in our mental health modeling, just as we do medically. And as we do so, it will be inevitable that we start using common factors like trauma, and markers more of a mental kind than symptomatic. Certainly, there is enormous room for improvement in our approach here, and I personally welcome constructive criticism and debate about the current system.
The DSM, and the entire mental health model that we use, is not a perfect, or even particularly scientific tool. It is simply a model. And other models exist! The World Health Organization, for example, doesn’t even use the DSM, but a different model, the ICM, and there are many others out there that have been proposed and debated. In the DSM, we say that a person is clinically depressed if they meet 5 of 9 symptoms. It is laughably unprecise.
“That’s an arbitrary classification. Somebody with four symptoms of depression could be experiencing as much if not more impairment than someone who meets the five criteria. Yet five gets the diagnosis and four does not. You see this throughout DSM-5.”
So why get so hung up on the label? It is, in many ways, just a way to help the medical system make at least general sense of what is going on. If you go to the hospital, they need a diagnosis for you to get treatment. Or else, why are you there? If you go to the emergency room, they need to have a reason on the file to keep you overnight – is it a broken leg? Appendicitis? Bipolar disorder? Let’s just keep that in perspective.
As a therapist, I am not overly interested in diagnoses, though they can be helpful guidelines. It is more helpful to consider each person as a complex set of ideas, traumas, experiences – that manifest in a particular way. Some of it is more deeply stuck in the body, it seems. Older, and more entrenched. If these things can shift by talking, by new understanding, by emotional release, then either we need to re-think our medical model, or not insist that mental illness – especially mood disorders – fit in the same book as schizophrenia. Treatment comes out of the personal complexity, NOT from the label. Sure, this can suggest directions to our clinical work. But in the end, it is the same work.
Clearly, this whole system needs a vast – and probably fundamental – reworking. Yes, it has some use, but let’s not pretend for a minute that it is anywhere close to being as useful a model as the treatment of bacterial infections or Diabetes. Eventually we must see that there are connections of mind and body that are much more profound than all of our sciences want, thus far, to admit. And when we allow for that, it will make all of our systems fall into place.
Until then, let’s try to hold all of this lightly. A diagnosis doesn’t define a person any more than your name does. Let’s treat each other as human beings first, not just clinically but socially.