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Jul 11

The Second Coming Out of Nicolas Kessous

Several years ago, I came out of the proverbial closet to my friends and family. Now is the time for me to come out yet again: “My name is Nicolas Kessous. I am a clinical psychologist in training, and I do not believe in mental illness.” This is my story.

Chapter 1: Genesis

Psychiatrist Thomas Szasz famously posited the notion that mental illness does not—in fact, cannot—exist. I remember reading my very first Szasz article in a CEGEP (a transitional institution students in Quebec must attend between high-school and university) philosophy class, and thinking: how odd, a psychiatrist who does not believe in mental illness. I did not, however, think anything more of it. Soon after, I started my B.A. in Psychology, registering with an indecent amount of glee for my very first Abnormal Psychology course, an introduction to the various disorders of the mind. By the end of the course, I had asked for the Diagnostic and Statistical Manual of Mental Disorders (DSM), the psychiatric bible, for Christmas.

2 ~ Excited to learn even more about psychopathology, I eventually registered for an advanced class on the subject. The required reading: psychological researcher Robyn Dawes’ notorious House of Cards: Psychology and Psychotherapy Built on Myth (1996), which calls into question many of today’s most cherished psychotherapeutic beliefs and practices. I thought to myself: what is up with mental health professionals? I did not want to believe that everything I was learning, indeed everything I wanted to be, was based on myth. I dismissed the professor as another anomaly and registered for another class instead. I have since obtained a M.A. in Experimental Psychology, and am now completing a doctorate in Clinical Psychology. After years of study, I have finally begun “assessing” and “treating” clients. Yet, I already find myself disillusioned with the field.

3 ~ As part of our program, one of the first courses my cohort was subjected to was Adult Psychopathology. To my dismay, the professor, an eloquent and self-assured psychiatrist, spoke of his clients with seemingly endless reserves of contempt, flinging diagnostic terms as if they were darts and his clients dartboards. His suggestion that homosexuality would still be in the DSM if it were up to him was the final straw. (Homosexuality was in part removed from the DSM in 1973, although the manual still considers those distressed by their sexual orientation to be sick.) Suffice it to say, I promptly dropped the class. Out of frustration and anger, I resolved to launch an attack on everything this monster of a man believed in.

4 ~ In an apparent fit of masochism, I was at the same time taking a course on psychological assessment. In each class, the teaching assistant, who I am convinced would passionately sleep with Hermann Rorschach were he still alive today, excitedly launched us students into the wilderness that is the human psyche. We were on the hunt for the most prized (yet apparently most common) prey of them all: the pathological personality trait. The thrill of the hunt aside, it soon became apparent to me that psychological assessment is nothing more than psychologists’ own clever, if not underhanded, way of making sure their darts stick to their boards. I was not impressed; in fact, I was piping mad. The behavior of my instructors was downright disgraceful, lacking any semblance of respect for the integrity and complexity of those who sought help from them.

5 ~ In his preface to House of Cards, Dawes (1996) confesses: “My own decision to write this book has been motivated by two factors in particular: anger, and a sense of social obligation” (p. vii). Psychologists, he claims, have traded healthy skepticism for unreserved gullibility, mindlessly adopting theories and tools in the absence of empirical support. His anger was sublimated into a book calling attention to this sad state of affairs, a professional wake-up call of sorts, so as to spare the profession he loves from falling into disrepute. I am not so much angry anymore as I am saddened and dissatisfied. I love psychology and have faith in its potential, but cannot help but feel it has lost its way. Unlike Dawes, my motivation here is not to denounce psychologists’ aversion to sound thinking and decision-making, but rather their apparent disdain for plain language and calling things for what they are.

6 ~ In pure science, the most basic level of explanation is quantum physics. In applied psychology, I believe it to be philosophy, in that all our theoretical propositions about why people behave the way they do and how to best help them are based on core metaphysical assumptions regarding the nature of reality and being. When we adopt beliefs without paying heed to their philosophical underpinnings, we are in effect playing a game without knowing the rules. Szasz (1961/2010) once quipped: “Physicians often play the medical game without self-reflection, unaware of the rules by which the game is played” (p. 42). The same can be said of psychologists: those who adopt a given conceptual framework often outnumber those who actually understand it. That is no surprise, since most clinical training programs tend to teach students the game of clinical practice, but not its rules. We are taught the newest and hottest therapeutic techniques with no mention whatsoever of the philosophical assumptions that must be accepted before the techniques are adopted. In other words, students are effectively made to purchase a product without being shown the fine print.

7 ~ Some examples might be helpful. The rule of the Game of Psychoanalysis: ironically enough, clinical-grade suspicion, where nothing in reality is ever truly what it appears to be (for more details, see Farrell, 1998). The rule of the Game of Cognitive-Behavioral Therapy: a perhaps stubborn adherence to the belief that an objective reality not only exists, but can be reliably ascertained. Given this, cognitions that do not correspond to this tangible reality can, using the right tools, be brought back in line with it (for more details, see Neimeyer, 2009). Thankfully, recent, postmodern-flavored brands of psychotherapy—for example, Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 2003) and Emotion-Focused Therapy (Greenberg, 2002)—have razed the shaky foundations beneath current theory and erected sounder beams supporting new, improved theories.

8 ~ Two core assumptions underlying current psychotherapeutic theory and practice which I have come to take particular issue with are: a) The mind can be sick in just the same way the body can, and b) Doctors of the mind can cure sick minds just the same way doctors of the body can cure sick bodies. These mistaken beliefs were initially brought to my attention by Szasz, whose article I had dismissed years ago. Angered by my instructors and intent on waging a well-informed war, I made my way through his controversial Myth of series: The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (1961/2010), followed by The Myth of Psychotherapy: Mental Healing as Religion, Rhetoric, and Repression (1988). While I initially turned to these out of anger, they ultimately changed, and continue to shape, my philosophy as a helping professional in training.

9 ~ Before I go into the books themselves, let me guide your attention to the use of the word myth in both titles. I have always found this to be an interesting choice, myth having two possible meanings: it can be a falsehood or a legend. Of course, falsehoods can be based on fact, and legends are often just that: fact-based falsehoods that are, in time, mistaken for truth. These two meanings are central to both Mental Illness and Psychotherapy, for, in each, Szasz not only demonstrates how mental illness and psychotherapy per say do not exist, but he also carefully makes his way through human history, following the individuals and events that led noble little figures of speech to eventually become unquestionable fact.

Chapter 2: Exodus

I started with Mental Illness, perusing it with an exhilarating mix of shame and pride. I recall reading the book during breaks in an elective Social Work course I was taking at the time. Knowing I was a psychology student, the professor informed me, “You know, that’s a subversive book.” I replied, “Yes I know, that’s why I’m reading it.” He continued, “I bet they don’t have you read it in your program,” to which I playfully responded, “Yes, that’s why I’m reading it.” In the end, Mental Illness proved a challenging read. Funnily enough, it was almost like reading a book in a foreign language. Although it sometimes took multiple readings to fully grasp and appreciate its message, it was not because it is ineptly communicated, but because it runs so counter to the values psychologists and psychiatrists are raised with during their academic development.

2 ~ The premise of Mental Illness is rather straightforward: mental illness is a metaphor used to describe troublesome behavior. Essentially, mental illness is the medicalization of life’s hardships. Some of these hardships are self-caused (bad decisions were made), and some are other-caused (bad things happened). But because the mind is an emergent property of the body, it cannot actually be sick in the same way the body can; it can only be sick in a way that resembles bodily sickness. (Some disorders, like Facticious Disorder by Proxy, are less individually oriented and more relational in nature. Like the mind, however, relationships cannot be sick in the same way the body can.) While it is undeniable that we humans exhibit non-adaptive behaviors, whether these are actually illnesses is highly questionable. To be sure, many so-called mental disorders appear to have biological “causes,” but so do many so-called healthy behaviors as well. Since the removal of homosexuality from the DSM, research has shown that same-sex sexual interest is partly grounded in biology; still, there are no plans to resuscitate the diagnosis. The point is: which objectionable behaviors are considered disordered is entirely the product of social consensus.

3 ~ As you can tell, Szasz’s thesis is not empirical in nature: as he himself puts it in his preface, “asserting that [mental illness is a metaphor] is asserting an analytic truth, not subject to empirical falsification” (1961/2010, p. xii). In all fairness, psychiatrists’ assertion that mental illness exists is no more provable or disprovable by science. Both claims are philosophical in nature, concerning the semantic accuracy of the term in question: “mental illness.” As such, only logic (as opposed to empirical study) can here identify the one true claim.

4 ~ Some will say that Szasz is nitpicking; “what’s in a name?” they will say. Anticipating this, Dawes (1996) cautions: “It is tempting to dismiss such questions as “merely semantic.” But given the widespread belief in this culture that “mental illness is just like any other illness,” questions such as these must be addressed rather than finessed” (p. 63). Indeed, a lot rides on the type of language—in this case, medical language—we use to describe our clients’ experiences: professionally, diagnoses (of mental illness) “enlarge the scope, and thus the power and prestige of a state-protected medical monopoly and the income of its practitioners”; legally, diagnoses “justify state-sanctioned coercive interventions outside of the criminal justice system”; politically and economically, diagnoses “justify enacting and enforcing measures aimed at promoting public health and providing funds for research and treatment on projects classified as medical”; socially, diagnoses are made “to enlist the support of public opinion, the media, and the legal system for bestowing special privileges (and impose special hardships) on persons diagnosed as (mentally) ill” (Szasz, 2007, p. 35).

5 ~ To be sure, the medicalization of behavior does not only lead to negative consequences. Personally, diagnoses can represent long-awaited answers to tormenting questions about why we suffer. Then again, I do not believe the legitimacy of a claim should be judged based strictly on its outcome (even if someone desires a diagnosis for peace of mind). While the disease model of the mind might provide some with welcome answers, I believe secular humanistic explanations of suffering better reflect clients’ reality and expand their choices to a greater degree. During times of inner turmoil, individuals may cling to the first semblance of meaning they are offered. As such, they deserve the fairest and most evocative assessment of their situation. At the very least, our clients deserve choice.

6 ~ During my training, I noticed an interesting trend amongst colleagues and professors. When we use metaphors other than psychiatric ones, we do not readily fall for them. We say of a couple that “their love has eroded,” yet we do not actually believe that love erodes in the same way rock does; we understand it to be geological metaphor. Yet, when we say of a client that he “suffers from a mental illness,” we accept it as undisputable fact; we somehow forget that it is a medical metaphor, that the mind cannot be ill in the same way the body can. It is true that there are similarities between behaviors we refer to as mental illness and actual bodily illness—that is why the metaphor works—but the two remain distinct. As we will see next, psychologists are not really doctors at all, but specialists in rhetoric (conversation) and logic. As rhetoricians and logicians by profession, it is thus essential to the integrity of our craft that we learn and understand the distinction between fact and metaphor, and not get lost in translation between the two.

7 ~ If mental illness is the medicalization of life’s difficulties, then it naturally follows that psychotherapy, the purported curing of mental illness, represents the medicalization of the means by which these difficulties are alleviated. Much in the same way the “ordinary behaviors of ordinary persons” are transformed into “awe-inspiring symptoms of mental disease”, the “ordinary behavior of professionally authenticated persons” are transformed into “extraordinary techniques of mental treatments” (Szasz, 1988, p. 194). Due perhaps to “our modern aversion to moral conflicts, human tragedy, and plain language” (p. 205), psychologists have opted to disguise their craft in medical attire. Instructional conversation effectively becomes cure, thereby cheapening the true spirit of our craft.

8 ~ In the stage musical Wicked (2003), well-liked Glinda offers to help ostracized Elphaba become “popular,” asking her to “think of it as personality dialysis” (Schwartz, track 7). Such fanciful medical metaphors are not only for fictional witches, but also very real psychologists. However, instead of reciting these metaphors playfully, psychologists take them very seriously indeed. During my training, I have come across such ludicrous semantic aberrations as “stress inoculation” and “psychological autopsy” to describe psychologists’ own behaviors in and out of therapy, and “decisional paralysis” and “atrophied sexuality” to describe that of their clients. Ward and Maruna (2007) also point out the ridiculousness inherent to the term “dosage,” a term commonly used for number of counseling sessions. Decidedly, psychologists love playing doctor! To be sure, metaphors can conceivably help highlight and convey truth, as long as they are never taken literally. In this particular case, however, the medical metaphors mislead more than they inform, because clinical psychology appears to have little to do with medicine, and more to do with art.

9 ~ As Dawes (1996) rather frankly puts it,the main problem with medicalizing what psychologists do is that “[the] analogy between medicine and psychology is not a good one. A good analogy is one in which the specific components are really similar. Except as a rhetorical device—to alleviate stigma and enhance the status of professionals dealing with distressed people—the implied similarity between medicine and psychology simply doesn’t exist in reality. Emotional distress, whose various forms do not constitute a natural category, is often quite unlike physical disease, and how professional psychologists attempt to treat it is quite different from how medical doctors treat physical illness” (p. 137–138).

10 ~ According to Szasz (1988), what we refer to as psychotherapy is truly a relational enterprise that shares more in common with conventional forms of communication than it does with genuine medical intervention: “[Psychotherapy] refers to what two or more people do with, for, and to each other, by means of verbal and non-verbal messages. It is […] a relationship comparable to friendship, marriage, religious observance, advertising, or teaching” (p. 3). Words and other symbols, combined with our ability to reason and reflect, are harnessed in the service of deciphering life’s challenges and developing the skills needed to overcome them.

11 ~ In line with this, Szasz (1988) proposes that psychotherapy be renamed iatrologic (iatro logoi is Latin for healing words), which he describes as “a branch of rhetoric and logic. Its practitioners, specialists in rhetoric and logic, would be known as iatrologicians” (p. 208). While the idea of psychotherapy as more art than science has fallen out of favor, some contemporary therapists have breathed new life into the notion. In his memoir On Being a Therapist, psychologist Jeffrey Kottler (2010) conceptualizes clinical psychology as applied philosophy: “As applied philosophers, we not only understand the intricacies of logic, ethics, metaphysics, and epistemology but are readily able to employ their methodologies in solving everyday problems” (p. 272). While clinical psychology itself may not be a science, the art of using conversation and logic to master life can certainly be studied scientifically. While thousands of studies on the subject are published yearly, most regrettably employ medical rhetoric to convey their message.

Chapter 3: Reformation

I want to remind my readers at this point that I am not waging war on psychology as we know it for the mere pleasure of being subversive, although I must admit I do derive a good deal of pleasure from it. I do it for the love of the profession, for the love of all those who choose to seek help from us. During my career as a helping professional, I want to understand all that my clients are and want to be. Medicalized language will not do the trick. The secular humanistic model of why we suffer, on the other hand, rings truer, daring to represent humans and human relationships in all their complexities. As the New Testament teaches in Galatians 6:7: “Whatsoever a man soweth, that shall he also reap.” I believe that also goes for language. Reductionist in nature, the disease model of the mind cannot help but be limiting. Holistic in nature, the secular humanistic model cannot help but fling doors open onto new opportunities. Szasz (1961/2010) thus defines the role of the iatrologician as follows: “Our goal should be to enlarge [the individual’s] choices by enhancing knowledge of himself, others, and the world about him, and his skills in dealing with persons and things. As psychiatrists and psychotherapists, whether of psychoanalytic or some other persuasion, we should thus try to enrich our world and try to help our patients to enrich theirs, not by diminishing the efforts and achievement of our fellow man, but by increasing our own” (p. 259).

2 ~ Exploring the limitations of the Borderline Personality Disorder label, Harter (1995) insists “[it] remains vital that therapists maintain a hypothetical stance toward their professional and personal constructions” (p. 381). To achieve this, I believe a humbler approach to the psychological usage of the metaphor, a construction by definition, is required. Let us take the relatively innocuous metaphor of the “cognitive schema” as an example. The concept of the schema is a popular metaphor in the cognitive-behavioral tradition, much like the tripartite unconscious is in the psychodynamic tradition. However, neither physically exists. Intuitively aware of this, Greenberg, Rice, and Elliott (1996), in the preface to their book on facilitating emotional change in clients, offer the following sensible caveat regarding their use of the term “emotion scheme,” an emotional variant of the cognitive schema: “We wish to comment here on our use of the concept of scheme and emotion schemes throughout the book. This is not meant to reify this structural construct to the status of an existing entity in the head. We have used this concept as a tool to capture our view that an internal organizing process exists. Our perspective does not stand or fall on the use of this concept. If and when schemes are replaced by another concept such as distributive processing, or neural nets, or some other complex patterning process, this will not disturb our theory which relies only on the notion of some modular internal organization of experience” (p. viii). Greenberg and his colleagues’ handling of the use of the metaphor in psychology is upstanding. It embodies exactly the sort of awareness and responsible attitude that is required of psychologists who choose to employ metaphors, especially those who insist on holding onto reductionist ones.

3 ~ Now, why has Szasz’s message resonated in me? Attempting to answer this question appears an almost impossible task, like answering the often posed: “Why did you choose to become a psychologist?” In both instances, the reasons (or causes in psychiatric lingo) feel implicit enough that I may not be completely aware of them. I am nevertheless going to attempt answering both questions, because I believe both answers, even in their most rudimentary form, to be related. I believe I chose to make psychology my profession because, as a child, people I trusted and respected used to tell me I was a good listener. It is true I did like to listen, and of course still do. The problem is: I’ve always felt, on some level or another, that the language of psychiatry makes it terribly hard for me to listen, to truly hear others. I believe that is why my helping philosophy has been so shaped by Szasz’s writings. Furthermore, as a member of two minorities (homosexuals and Jews), I cannot help but be suspicious of any system of thought that led others of my “category” to be labeled as disordered or inadequate in any sort of way. It is well known that people with same-sex sexual interest were, until recently, diagnosed with the rather uninspired disorder of Homosexuality. Likewise, African-Americans—one of the most persecuted groups, along with the Jews—living under captivity in 19th century America were said to suffer from Drapetomania if they expressed the desire to escape their masters.

4 ~ When asked in an interview about working towards undermining the rulers of mythology in society, author Edgar L. Doctorow (1999) stated: “When ideas go unexamined and unchallenged for a long time, certain things happen. They become mythological, and they become very, very powerful. They create conformity. They intimidate. They coerce…” (p. 151). I imagine that is what happened with the concept of mental illness: it evolved, unobstructed, from a creative image into an established “fact” mistaken for truth. Through their misguided usage of language, and in part due to our own apathy, psychiatrists (the rulers of mythology) have successfully come to dominate not only the People, but, most sadly, how they perceive themselves as well. “The person who says, “Wait a minute,” is going to find himself in a very uncomfortable position,” warns Doctorow. Still, I vow to continue to examine and challenge the psychiatric Zeitgeist currently looming over psychology, for its dominion over the field I love has now long, long overstayed its welcome. Doctorow goes on to quote a French author who asserted: “My job is to comfort the afflicted and afflict the comfortable.” And that is exactly for whose sake I want to do this and continue doing this. “My name is Nicolas Kessous. I am a clinical psychologist in training, and I do not believe in mental illness.” I may be queer, but I’m here to stay.

5 ~ May the bounties of plain language be reaped by all. Always.

 

References:

Dawes, R. M. (1996). House of cards: Psychology and psychotherapy built on myth. New York, NY: The Free Press.

Farrell, J. (1998). Paranoia methodized. In F. C. Crews (Ed.), Unauthorized Freud: Doubters confront a legend (pp. 228–245). New York, NY: The Viking Press.

Greenberg, L. S., Rice, L. N., & Elliott, R. (1996). Facilitating emotional change: The moment-by-moment process. New York, NY: Guilford Press.

Harter, S. L. (1995). Construing on the edge: Clinical mythology in working with borderline processes. In R. A. Neimeyer & M. J. Mahoney (Eds.), Constructivism in psychotherapy (pp. 371–383). Washington, DC: American Psychological Association.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2003). Acceptance and commitment therapy: An experiential approach to behavior change. New York, NY: The Guilford Press.

Kottler, J. A. (2010). On being a therapist (4rth ed.). San Fransisco, CA: Jossey-Bass.

Morris, C. D. (1999). Conversations with E. L. Doctorow. Jackson, MS: University Press of Mississippi.

Neimeyer, R. A. (2009). Constructivist psychotherapy. New York, NY: Routledge.

Szasz, T. S. (1988). The myth of psychotherapy: Mental healing as religion, rhetoric, and repression. Syracuse, NY: Syracuse University Press.

Szasz, T. S. (2007). The medicalization of everyday life. Syracuse, NY: Syracuse University Press.

Szasz, T. S. (2010). The myth of mental illness: Foundations of a theory of personal conduct. New York, NY: Harper Perennial. (Original work published 1961)

Ward, T., & Maruna, S. (2007). Rehabilitation. New York, NY: Routledge.

One Comment

  1. Jerusha says:

    I really enjoyed this blog post! I had different internal reactions throughout, but in the end, these are my thoughts:

    Even as the mind can be treated like a body in the way that personal challenges and behavior are reduced to “illness”, it seems like in the medical profession the body’s illnesses and diseases are reduced to the point of eliminating the mind (not to mention diet and other habits). No one, mind or body, can be reduced to an illness. And the body is nothing without the mind, nor the mind without the body. As much as eastern thought and medicine seem to be steeped in a mystical and unscientific approach, at least nothing seems to be separated from the whole. Yet integrating our view of a person into a whole and not into separate parts is only the first step. We must eventually extend that to our neighbors and our community and our entire world. If one part hurts, we all hurt with it, whether we realize it or not.

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