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The Problem with the Mental Illness Narrative

Dale Johnson: Once again for the month of May I have with me Dr. Sam Stephens, who is the Director of Training Center Certification here at ACBC. Sam, this topic is an area of interest for both you and I—to study the world of secular psychology and try to understand some of the vain philosophies that have been impacting the church, both from a modern perspective and also a historical perspective. May is Mental Health Awareness Month and our last two weeks on the podcast, we’ve been discussing ideas and topics within this realm. This week we turn our attention specifically to the definition of mental illness. This term is used quite frequently when talking about diagnoses from the Diagnostic and Statistical Manual of Mental Disorders (DSM). The term mental disorder is also used frequently.

I really want us this week to hone in on those terms, to understand how misconstrued those terms are, what misconceptions we have especially among the common culture. I want to see what we can do to expose what reality is relative to the definition. To start, I’m going to read the definition from the DSM (this is the what we’ve been talking about previously on the podcast: the “Bible of Psychiatry”). I’m going to read to you the definition.

Now, it’s interesting that the definition is of “mental disorder,” which is what’s categorized throughout the whole of the DSM. It uses the term mental disorder and not mental illness. The writers of the DSM recognize that there is not enough evidence to use the term illness, even in its own description. Instead the DSM uses the term mental disorder. The reason is because we’re in an era of what’s called descriptive psychiatry, or criteria-based psychiatry, which means we try and lump together certain criteria sets or symptoms that allow us to categorize the problems people have.

Here’s the definition from the DSM. A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social and occupational activities. Culturally appropriate reactions to stressors are not considered mental disorders. Socially deviant behavior and conflicts between the individual and society are also not considered mental disorders unless they result from a dysfunction in the individual as described above.

Now, that was a mouthful. I understand that, but I want you to hear it exactly from the DSM—how they define this idea of mental disorder. Our common concept of mental disorder is that we’re talking about identifiers and illnesses that that people have. We say things like, “I have depression,” or “I have anxiety,” identifying it with something like “I have cancer.” Those are two different things, categorically. Sam, help us understand, how are we to think about these terms mental illness and mental disorder?

Sam Stephens: These two terms, especially as it relates to disease, are conflated together. For most of history, the idea of disease was actually pretty clearly outlined. You can think of this in three different generations of disease. This first is what comes to mind first, and that’s the idea of traditional medicine, where there’s a physiological, organic problem in the body has an identifiable cause and identifiable pathology. There’s a link between what is manifested in the body and the cause, or the etiology, of the problem. Yet, we’ve seen psychiatry move under this umbrella into the realm of traditional medicine, where the concept of disease has expanded to include things like disorders.

We’ve moved from a traditional medical understanding of disease into psychological problems that are manifested emotionally, and then even into behaviors that most people would commonly refer to as addictions. The DSM has everything from Major Depressive Disorder and Bipolar Disorder—which are linked to emotional manifestations—to things including Internet Use Disorder or Gambling Disorder. We’re going to see that continue to balloon. It’s going to encompass everything—not just what we would think of as traditional diseases like cancer or diabetes.

Dale Johnson: When we think about the idea of mental illness, it’s interesting to me that what we see commonly in literature in psychiatry right now, is people decrying the idea that we have a definition. We do not have a definition of mental illness. In fact, many of the leading psychiatrists are saying we don’t know how to define it. It’s an undefinable concept. The idea that you can take something immaterial and put it in the category of disease, where it has a pathology, is not a valid definition.

This is why we still use the term mental disorder. From that definition, it’s heavily laden upon the term “syndromes.” Now, what in the world are syndromes? Syndromes are collections of symptoms. This is the underlying base of the DSM. This primary definition is what builds the structure of the DSM—in the division of diagnoses, in the division of criterias, and the labels that people receive. It’s simply a collection of symptoms.

Now, this is not to say that we don’t have symptoms. My goodness, we all experience all sorts of symptoms with the difficulties and troubles of life. But the Bible has a lot to say about that. For us to give credence to the DSM, as if they have the market on categorizing and defining these collections of symptoms together, and that they have an answer as to how and why and the way in which we should treat these types of human maladies, I think is quite a misnomer. We’ve bought into the thinking that this is scientifically based, when in reality, it’s simply collections of descriptions.

Sam Stephens: I think part of the reason why this has become such a dominant way of thinking in the broader culture is because psychiatry as a field has been very concerted in their efforts to communicate this. But as we’ve noted in just reading the DSM, in between the lines, you see that they have to be honest about the fact that this is always evolving.

Let me read this brief sentence from the introduction of the DSM-5. I want you to listen very closely, because you’re going to see this contradiction actually in the text. It says this: “While DSM has been the cornerstone of substantial progress in reliability, it has been well recognized by both the American Psychiatric Association and the broad scientific community working on mental disorders that past science was not mature enough to yield fully validated diagnoses—that is, to provide consistent, strong, and objective scientific validators of individual DSM disorders. The science of mental disorders continues to evolve.”

They provide themselves a lot of wiggle room there. It’s always evolving. They’re saying, “We recognize that past science really couldn’t validate these, but we’re moving forward.” And that opens the door for future iterations of the DSM.

Dale Johnson: That’s exactly right. Whenever criticism is laid against the APA, especially as it relates to the collection of the DSM, the common answer is, “We’re still a young science. We still have a lot to learn.” What you just read is a demonstration of that. It doesn’t remove the point that the basis we rest on now, in our secular understanding of these types of disorders, is not a scientific basis that’s pathological, that deems the term illness, and that should carry with it labels that become identifiers for people.

I think the DSM is clear on that. It’s a collection of symptoms. I think that’s important for us as we discuss these terms mental disorder and mental illness. Is there is there really a difference between the idea of disease and the idea of disorder?

Sam Stephens: That’s a great question. This goes back to our podcast last week about biological psychiatry. This has been the dominant framework and perspective of the field of psychiatry for over a hundred years now (with a brief blip in there for psychoanalysis). The whole thrust of biological psychiatry is moving concepts of mental trouble or mental anguish under the disease model. That’s been the definite approach.

There’s an attempt to conflate disorder, again not ignoring that there are symptoms and that there may be physical manifestations, but we are assuming that the collection of those symptoms equals what the APA says is an illness. That’s not the same as a traditional, historical medical disease as we’ve understood it.

Dale Johnson: That’s right. Part of the reason is because what we’re doing now is taking philosophical dispositions and philosophical leanings, and putting them under the umbrella of scientific fact. Sam, that’s dangerous when you think about it. I hope our listeners are able to understand the difference.

What is the detriment of something like this? Part of the issue here, that I think is so paramount, is as we look at the terms disease and disorder, we’re talking about two distinct things, but culturally people have conflated these ideas. They put them together. Part of the problem is psychiatry has borrowed from the the natural, good advancements of the medical world. I fear that the detriment has become that over the last 70 years the medical model has become diluted to some degree, by borrowing from the scientism of psychiatry. The basis that they build on is philosophy, approaching things without pathological knowledge, but with a philosophical approach. That’s the detriment I think we see in trying to conflate the idea of legitimate, pathological disease, which we clearly see in medical science, versus this collection of symptoms that we’ve used in biological psychiatry in the term of disorder. We’ve conflated those two things, unfortunately.

I want to read something from Gary Greenberg, who is the author of the Book of Woe, which is a book that talks specifically about the DSM. Greenberg is a longtime psychologist. He’s been involved in psychiatry and psychology with the APA. He’s friends with a lot of top level psychiatrists. In the Book of Woe, he writes, “But descriptive psychiatry also has a major problem: Its diagnoses are nothing more than groupings of symptoms. If, during a two-week period, you have five of the nine symptoms of depression listed in the DSM, then you have “major depression,” no matter your circumstances or your own perception of your troubles. ‘No one should be proud that we have a descriptive system,’ [Allen] Frances tells me. ‘The fact that we do only reveals our limitations.’ Instead of curing the profession’s own malady, descriptive psychiatry has just covered it up.”

How is it covered it up? I think this is evident when we look at the progression from the DSM-1 to the DSM-5. The change of the definitions that have happened even within it. Erin Biba says, “From the DSM-1 to the DSM-5, definitions of mental illness have evolved with the culture.” Here are a few examples: think of autism, ADD, ADHD, or depression—the ever-changing, ebbing, and flowing of this definition of depression. The idea of bipolar—if you look historically—has ebbed, and flowed, and changed, and not with medical advancement, just with philosophical expressions.

What about homosexuality? This idea that used to be considered a disorder in 1973, but all of a sudden it was miraculously removed out of the DSM. Now, I’m not arguing for homosexuality as being a disorder, but this is the way the secular culture allowed this to continue. They just take the definition out. It demonstrates that what we’re dealing with here is not hard science. It’s not finding pathology and searching for a medical cure. This is something altogether a different category and that’s what we need to be wary of.

...the whole system that we've bought into we need to be cautious about, because it's built on a philosophical narrative that is contrary to the Scriptures and the way we understand man and man's problems. [1]Click To Tweet [1]

Can I just make one caveat before we continue? When Sam and I talk about these things, we are not giving blanket statements about psychiatrists. There are some well-meaning, loved brothers and sisters in the field of psychiatry, whose desire is to help people. What we’re talking about is the whole system that we’ve bought into that we need to be cautious about, because it’s built on a philosophical narrative that is contrary to the Scriptures and the way we understand man from the Scriptures and the way we understand man’s problems. I wanted to make that caveat because I think it’s important, our goal is not to decry human beings who are seeking to help. We’re talking about a system that our whole culture has bought into.

I want to finish with one final question. This is a question I end up with a lot. How in the world did we get here? How did we get to this modern concept of mental disorder and mental illness? How did that happen?

Sam Stephens: This is a philosophical shift. This is well-meaning people attempting to understand and explain things that didn’t have an explanation in their naturalistic framework. When we take God out of the picture and abandon a God-centered worldview, now we have to fill in the hole that’s left there and try to explain the problems that people are facing. It makes complete sense in a naturalistic worldview—one that’s focused on things that we can see, measure, taste, and feel, that’s bound in the here-and-now—to explain those things biologically. That is essentially, in brief, the history of modern psychiatry and even psychology in some sense. These different approaches to understanding what plagues people, because we can’t ignore that people have problems. Some things that we can’t easily explain, some things that we can. Psychiatry has always promoted these brain illness theories. From the very early years of what we know today as psychiatry, that’s been the predominant explanation as we’ve already discussed at length.

It’s interesting that you don’t see psychiatry really act like a medical practice. You see both pharmaceutical interventions—obviously the more of the medical side of things—but right with that and you see articles and books aplenty that discuss talk therapies and psychotherapies as addressing these problems. How do you see traditional diseases, as we understand them, addressed that way? You don’t. It speaks to the fact that mental illnesses and mental disorders are not diseases, as they should be understood.

Dale Johnson: If you take a look at the history of psychiatry, it was a discipline that was in struggle. There was a lot of scrutiny, with practices like phrenology and some of the barbaric actions of psychiatric medicine historically in the asylums. Psychiatry had quite a bad name, as if they were some sort of modern shaman trying to make their way into the medical advancements of the world. It was a discipline in chaos, and it was a discipline that was certainly frowned upon in the medical community.

But now they have built this philosophical narrative. They have what many people historically have called “magic bullets” that treat these symptoms. Their narrative has been built borrowing from the advancements of the true medical model, with penicillin and other examples of the medical community fighting true diseases. Now psychiatry appears as though it has arrived with all of its scientific vigor. I think the problem when you study the history of it is it doesn’t bear that story out. In fact, it’s become, in my opinion, one of the ways in which we have bought into something that’s an anti-philosophical narrative. We’ve bought into this idea of disease as something that we have, when it’s a collection of symptoms that we’re actually experiencing.

There’s much more that we could say about this, Sam. This has been the most difficult, I think, for us to get into a short period of time, but next week we’re also going to discuss rethinking depression and rethinking anxiety as we continue on in Mental Health Awareness Month. We do pray that this is helpful to you as you think about some of the hindrances to biblical counseling and why people in the culture don’t seem to want to engage biblical counseling. Part of the reason is because we’ve bought into this narrative, and so we pray that our discussions have been helpful to you in that way.

Recommended Resources

JBC Volume 15:1 PDF – Christian Counseling & Educational Foundation [2] (FREE from 5/17-5/23)

Mental Health Month Podcast Series:
The Bible of Psychiatry [3]
Biological Psychiatry [4]

Bibliography of Critical Psychology [5]