Archive for the ‘Boy Meets Brain’ Category

Prelude

The following essay was started about three years ago and finally finished only recently. As you might notice, it is permeated with a certain feeling of anger regarding my chosen profession of applied psychology, a feeling that was originally sparked over the course of my university training (which is when I first sat down to write this essay). The reason for this feeling, which has mainly to do with what I perceive as rampant lack of skepticism within the field of psychology, is acknowledged and elaborated upon in the body of the text. Given I have had the opportunity to work, since graduating and obtaining my license to practice psychology, with colleagues who do not treat ideas in our field as hard-and-fast truths, but as objects open to discussion (which may or may not invalidate them), that feeling of anger has, in time, largely subsided. Although I finished writing this essay in another emotional state of mind than when I started writing it, I have chosen to leave intact whichever angry feelings seeped through my words when I first typed them—for the most part, to avoid invalidating my past self, but also to avoid invalidating my future self, which I am sure is not immune to a resurgence of frustration regarding his well-loved (another, complimentary feeling I hope comes through in my essay) profession.

Introduction

A Heck of a Kerfuffle.com recently celebrated its fourth birthday. On January 14, 2015, to be precise. During our first four years of “operation,” more than 35 short- to full-length articles exploring a variety of subjects were published. Further, we played host to more than 2,000 views per year from online travelers. In honor of this milestone, I thought I would share a little bit about what I learned on my first literary venture into cyberspace.

I would have loved to tell you that this blog was born out of sugar cups and rainbows. Alas, its origins are a tad more somber. The idea to develop my own blog, you see, was actually the product of frustration. Two years into my doctoral program in clinical psychology, I was exasperated. I had begrudgingly realized that the mandatory courses I was made to take embodied, at best, a forum for only a limited number of ideas and narrow discussion. Further, it appeared that fellow students were all too content feeding on the particular brand of knowledge professors were choosing to dish up. Likewise, professors seemed to have done the same during their own education, since none of them could explain to me how they had come to their conclusions, as if conclusions did not flow from underlying premises, instead spontaneously materializing out of la vérité itself.

Intent on compensating by fashioning my own education, I started to read. A lot. Books on the history of psychology and psychological theories, to find out how we got to where we are and if we happened to miss or leave behind important insights into human behavior. Books on alternate kinds of psychotherapy, because the training offered to me was either too esoteric (i.e., psychodynamic therapy) or too rigid and presumptuous (i.e., traditional cognitive-behavioral therapy). And books putting into question the very state of clinical psychology, to highlight the limits of knowledge we have come to consider absolute. Before long, my brain predictably began to writhe with ideas. But what to do with all of them? Instead of keeping my thoughts all to myself, I decided I would start writing them down, maybe even organize them into cohesive essays and share them with others. And such is how A Heck of a Kerfuffle was conceived. (Because I am not only passionate about psychology, I decided to broaden the scope of my new blog to cover other areas of interest, such as gastronomy and cinema. For the purposes of this essay, however, I choose to focus only on the process of writing about ideas in psychology.)

Before I go into the essays themselves and what writing them taught me about myself, I would like to recount to you how they came to find a permanent home on the Internet in the first place. Those of you who know me know that I am not particularly proficient at computers, and so learning to build my very own website represented a daunting task. Upon consulting, I was instructed to: find a web host, purchase a domain name, download web software to create my website, and design it to my liking. While all this makes sense to me now, getting there took some work. Going through the process, I have come to understand it in the following, less technical terms: purchase yourself a plot of Internet land, name your new domain, have builders erect your house, and furnish it to your liking. And voilà! You have got yourself a brand new home in Cyber City for everyone around the globe to visit. While I’m at it, I would like to thank Web Hosting Hub for helping pop my digi-cherry, and for providing consistently stellar service!

As you may have gathered from reading my first essays on my experiences as a clinical psychologist in training, I am skeptically inclined. Because I have elected to become a “mental health specialist,” this questioning attitude primarily manifests itself around the subjects of human behavior (or how to best understand it) and the modification of human behavior (or how to best go about it). In fact, some of my favorite insights from the past five years of clinical training and practice as a psychologist concern these particular issues. While I would describe my relationship with my chosen profession as marked with caution, even downright suspicion, do not get me wrong: I love what I do. I just refuse to let that affection dull my critical faculties and intellectually blind me.

I should specify at this point I do not advocate fanatical skepticism, or disbelief for the sake of disbelief. On this point, I am in agreement with mathematician Henri Poincaré (1901), who noted: “To doubt everything or to believe everything are two equally convenient solutions; both dispense with the necessity of reflection” (p. xxii). That being said, I believe skepticism encourages reflection more so than other attitudes: in fact, thinking that something might likely not be true incites one to consider the evidence for why it might actually be true, more so, at least, than thinking that that something is very probably true in the first place. This, of course, presupposes that the skeptic is interested, to begin with, in knowing the truth, regardless of whether or not it accords with his own expectations. To reiterate, from an experiential standpoint, the sense that “This might not be true but I want to know if it is” provides, in its underlying tension, impetus toward reflection, more so than the “tension-less” sense that “This is probably true but I want to know if it is.” To be sure, some of us may adopt a skeptical stance because we do not want something to be true, in which case we might not be motivated to consider the evidence against it. This, however, is an example of skepticism misused, in that its purpose is to service our own biases, not the search for Truth. Thus, skepticism, to be epistemologically fruitful, must always be coupled with a desire to expose reality.

Writing in 1925, the father of psychoanalysis, Sigmund Freud noted: “When instructing our own disciples in the theory of psychoanalysis, we always observe how little impression we make on them in the beginning. They accept the analytical teachings with just as much equanimity as any other abstractions which have been fed to them. Some of them may have the earnest desire to be convinced, but there is no trace that they ever really are convinced” (p. 64). It appears times have changed. In contrast to Freud’s observations, I noticed, over the course of my training as a therapist, that many of my classmates wholeheartedly accepted all that modern clinical psychology is and has to offer: clinical psychology, they implicitly insisted, is an infallible science, so why think twice about it? It is, specifically, just like medicine, and so should command the same sort of deference. Psychologist Gary Greenberg observed a similar trend, only from a professor’s point-of-view, and identifies a “top-down” process of misguided attitude transmission: “[Most] students seem oblivious to the crucial epistemological problems that haunt their discipline. Their education continues to consist of largely technical training based on the assumption that they are “doing science”” (1997, p. 257).

I, for one, refuse to take part is such unrestrained naïveté. I understand we want to feel like what we do is important—and it can sometimes be—but I cannot merrily ride along the medical bandwagon. However much we may couch clinical psychology in the language of science, clinical psychology is just not medicine. Namely, what we refer to as “mental illness” has very little to do with actual, physical illness. Likewise, what we refer to as “psychological treatment” has very little to do with actual, medical intervention. Indeed, in both instances, any similarities can best be described as specious. As such, the usage of medical terms like “illness” or “treatment” to describe the problematic behaviors we seek to change in our clients, and the conversations we use to help our clients change, is simply misleading. As critics have leveled against us for decades, our brand of science is decidedly “soft,” whereas medicine’s is anything but.

Psychologist Jeffrey Kottler (2010) tells of “writers who believe that therapy, as a profession, could quite legitimately be housed in an academy of dramatic arts instead of a school of education, health, social work, medicine, or liberal arts. In this setting, therapists would speak of their craft as professional conversation, strategic rhetoric, or even a genre of interactional theater” (p. 297). I am inclined to agree: psychological treatment is actually reflective, didactic conversation about mainly moral issues, and thus very unlike actual, medical treatment (to find out more on the difference between mental and physical cures, see Szasz, 1987). On the subject of psychotherapy, the philosopher Jean Paul Sartre even went so far as to claim that “[there] is philosophy, but there is no psychology. Psychology does not exist; either it is idle talk or it is an effort to establish what man is, starting from philosophical notions” (cited in Rybalka, 2002, p. 245).

I understand it is hard to enter a helping relationship when so much of what we do is so, for lack of a better word, fuzzy. But I believe it is imperative that we acknowledge this in order to do good work; otherwise, we are just being pretentious, when humility—my own values tell me—should drive us as responsible and effective vocational helpers. Renowned therapists themselves identify lack of humility as not only inimical to successful therapy, but also responsible for their worst therapeutic failures (Kottler & Carlson, 2002). Indeed, thinking of ourselves as purveyors of steadfast truths about life and how to best live it can have catastrophic circumstances: for instance, when we deny, ignore, or invalidate our clients’ own truths, we risk threatening the integrity of their very selves (Rowe, 1994). Thus, because so much of what we do is so (let us settle on) nebulous, I believe it is imperative that we continually, actively reflect on our profession’s professed tenets, never blindly following them, while always keeping in mind the limitations of those tenets we have settled on and chosen to abide by.

In the introduction to his no-hold-barred book on the evils of psychotherapy, aptly titled Against Therapy, ex-psychoanalyst Jeffrey Masson (1994) specifies: “The fact that some psychotherapists are decent, warm, compassionate human beings, who sometimes help the people who come to them, does not shelter the profession itself or the practice of that profession from the criticism I make in this book. It only means that they function in this manner in spite of being psychotherapists, and not because of it” (p. 41). While I do not share many of Masson’s conclusions regarding the ethics of psychotherapy, I do agree with him on one point: that those psychologists best suited to help clients are probably those who do not take their profession—in its current state, at least—all that seriously. Some authors (e.g., Engelhardt, 2004) have even gone so far as to suggest that psychologists should, for their clients’ sake and benefit, pretend as if what they know to be true about human behavior (and, more precisely, misbehavior) is not true at all!

While I do not believe that clinical psychology ultimately amounts to a science (although particular helping strategies can certainly be studied scientifically), but more of a philosophically flavored art, many of my colleagues would respectfully disagree. However, even if we were to agree to call what we do science, the philosophy underlying what we do could still not be denied. As philosopher Daniel Dennett (1995) reminds (actual) men and women of science, “[scientists] sometimes deceive themselves into thinking that philosophical ideas are only, at best, decorations or parasitic commentaries on the hard, objective triumphs of science, and that they themselves are immune to the confusions that philosophers devote their lives to dissolving. But there is no such thing as philosophy-free science; there is only science whose philosophical baggage is taken on board without examination” (p. 21; emphasis added). And so, regardless of whether we believe we are “mental health scientists” or simply life coaches, the philosophy of psychology cannot be denied. In fact, it is essential it be ascertained.

But, why bother thinking about the philosophy underlying clinical psychology (or any other human endeavor, for that matter)? Since I could not possibly say it any better if I tried even really hard, I call upon philosopher Bertrand Russell to tell us why:

Because “[the] man who has no tincture of philosophy goes through life imprisoned in the prejudices derived from common sense, from the habitual beliefs of his age or his nation, and from convictions which have grown up in his mind without the cooperation or consent of his deliberate reason. To such a man the world tends to become definite, finite, obvious; common objects rouse no questions, and unfamiliar possibilities are contemptuously rejected. As soon as we begin to philosophize, on the contrary, we find […] that even the most everyday things lead to problems to which only very incomplete answers can be given. Philosophy, though unable to tell us with certainty what is the true answer to the doubts which it raises, is able to suggest many possibilities which enlarge our thoughts and free them from the tyranny of custom. Thus, while diminishing our feeling of certainty as to what things are, it greatly increases our knowledge as to what they may be; it removes the somewhat arrogant dogmatism of those who have never travelled into the region of liberating doubt, and it keeps alive our sense of wonder by showing familiar things in an unfamiliar aspect.” (1912, p. 91)

Psychotherapy is one such “common object,” which, once prodded with the rod of philosophy, quickly reveals itself (for many, at least) to be something somewhat different from what it is normally made out to be. I will later discuss how the common object of “mental illness” meets a similar fate as psychotherapy when handled using philosophy.

The psychoanalytically minded among you will no doubt attempt to discount my cantankerous attitude toward clinical psychology by postulating potential biographical causes that may have brought it about in the first place. Perhaps I have time and again been hurt and disappointed by objects I thought I could count on, I can no longer trust those that presently inspire affection in me. Even if that interpretation were true, the “etiology” of a belief system, as psychologist William James (1901) takes great care to explain in his seminal qualitative study of the religious experience, has absolutely no bearing on its accuracy. After all, what belief claims no psycho-historical causes or reasons whatsoever as precursors (beyond a probable epistemic desire “to know,” that is)? For instance, some historians have, according to astronomer Carl Sagan, said of Isaac Newton that he “rejected the philosophical position of Descartes because it might challenge conventional religion and lead to social chaos and atheism” (1996, p. 258). But how “Newton was buffeted by intellectual currents of his time […] has little bearing on the truth of his propositions.” Sagan goes on to describe a similar attempt to discredit aimed at Charles Darwin, one that commits the added mistake of confusing cause and effect. Having said all of this, there is some validity in the hypothesis that my suspicions are at least partly grounded in my past. As a child, I was asked to assume the truth behind countless religious postulates regarding how the world works and how to best direct human behavior; when I started to think, I noticed none of them—to my satisfaction, at least—did the explanatory or regulatory job they were specifically fashioned to do. This left a sour taste in my mouth: I felt misled by authority figures I trusted.

It is then that I learned the power of independent, critical thinking in shaping my own understanding of the world. (I appreciate the value of suspending thought and just having faith, but I cannot endorse faith as a standalone life philosophy. Since any belief can be accepted as true based on faith alone, all faith-based beliefs are consequently equally true. In other words, faith alone cannot make the probably true rise above the probably not true. You need reason for that.) Historically, no knowledge (except when resting on faith) has ever deserved the qualifier of “ultimate.” After all, knowledge builds upon itself away from non-adequate accounts, arguably ad infinitum (an observation made by the philosopher of science Thomas Kuhn, in his seminal book on the titular structure of scientific revolutions.). In fact, during my very first year of university, my History of Psychology professor likened the idea of “facts” to a modern fiction, in so far as facts are final and should not technically evolve. And so, I do not see the value in assuming that what I hold to be true now will necessarily be true 50 or 100 years from now.

Some of you may be thinking at this point: “Why believe in anything if it is just a stopover on our way to Truth?” First of all, what we currently hold to be true may not necessarily be a stopover at all, but actually the final destination. However, only time will be able to tell us this (not in a decisive sense, to be sure, but in a probabilistic sense, i.e., in the progressive accumulation of evidential weight). In fact, all knowledge, be it in Science (or Philosophy), is tentative to some degree, being only one body of counter-evidence (or counter-arguments) away from modification or downright withdrawal. Second, there are presumably units of knowledge that stand closer to the final destination than others, or at least stand a better chance of leading us toward it as opposed to some epistemological dead-end. Thus, I am not advocating that we not hold on to present-day knowledge. After all, without intellectual markers to situate us, we would flounder about the world directionless. What I mean to say is: we should simply hold on to this knowledge with a loose grip (a move which can also make it easier to reach for the next epistemic monkey bar). (For simplicity’s sake, I will continue to use the terms “fact” and “truth” [and all variants thereof], but in the tentative, “as can presently best be understood” sense of the words. With one exception: when “truth” is capitalized, it is meant to evoke ultimate Truth, that which scientific revolutions rotate toward.)

Chapter I – In the Company of Ideas

In writing about ideas, I have continued to learn more about my receptivity toward them. As briefly mentioned above, however, my reluctance to accept everything I am told as automatically true is a part of me I have already been aware of for some time now. What has been more of a revelation is how I as an individual engage with immaterial (but still very real) perceptions like ideas. I have to admit: relationships with ideas can be tricky. You may fall immediately in love with one or it may grow on you in time. Once you have selected a suitable idea for possible “appropriation,” you give yourself to it completely: it is yours, you are its. Eventually, you may reluctantly come to think you can somehow make it better, only to find out it stubbornly resists change. Frustrated, you may begin to seek out or simply let yourself be seduced by a more attractive idea. However heart-breaking the thought, you may decide to ditch your previous idea, because—as you repeatedly tell yourself as if to assuage some kind of doubt—“This new one is it.” Come to think of it, idea selection bears a striking resemblance to mate selection!

For this reason, I have learned to be more cautious when considering adopting ideas. That is not to say I have not also had to learn how to be more tolerant of uncertainty when ideas are being considered (or dated, if you will). Greenberg (2010) counsels: “[When] it comes to important and complex questions, the best approach is to leave yourself in doubt for as long as possible, to live with inner conflict rather than to end it, to withstand yourself rather than to become someone different, to understand you arrived at an important juncture rather than strike out down a road simply for the sake of getting on with life” (p. 7). Adopting a hopeful view of this emotionally arduous fact-finding process, physicists Laurence Krauss even predicts “[lack] of comfort means we are on the threshold of new insights” (2012, p. xv). And so, I never abandon an ostensibly sound idea that has managed past my skeptical defenses without giving my relationship with it every chance it deserves, however trying what lies ahead. I remain attuned to counter-arguments opposed to my idea. I evaluate their cogency. I revise my own arguments in support of my idea to address the counter-arguments. If an idea repeatedly fails to stand its own during challenges or keeps resisting improvement, I (I must admit, halfheartedly) abandon it, perhaps even for the very idea that brought about its downfall.

An example: my earliest memory of me participating in a college class—Introduction to Sociology—sees me arguing against the idea of ethnocentrism by appealing to a universal moral standard. However much I enjoyed the thought of absolute moral judgments, I eventually came to question their existence. (While it may sound contradictory, I do not, in any way, advocate normative moral relativism, whereby any behavior should be tolerated simply because there exist no objective behavioral standards in Nature.)

While learning to live and getting acquainted with ideas, I have also learned a great many things about them. First off, just because an idea sounds counterintuitive does not mean that it is somehow going against Truth. On the subject of moral behavior, Russell once commented: “[Conscience] is a most fallacious guide, since it consists of vague reminiscences of precepts heard in early youth, so that it is never wiser than its possessor’s nurse or mother” (1901, p. 74). Likewise, intuition is no more informative in guiding beliefs. Because intuition rests on knowledge of what Truth should be, as perhaps outlined by prior education, it does not necessarily orient us toward that which is definitely True. Experience is, in turn, no more reliable a guide. Speaking of clinical experience, self-avowed Freud basher Frederick Crews (1995) concludes: “Standing alone, [it] is not a probative tool but an inducement to complacency and tunnel vision” (p. 7). Moreover, I have learned that while I will not assume the truth of the status quo, I will always remain open to it being true (or at the very least a right step toward True).

However demanding thinking about ideas may be, writing about them poses different sets of challenges. Whereas there is no end to thinking (you can keep doing it for as long as you want or possibly can), there is one to writing (provided you want to share your writings at some point). Since I rarely write about ideas I am completely done thinking about, this final quality to writing can be problematic. Further, the very attempt to translate shapeless ideas into definite symbols may change one’s understanding of them. Screenwriter Charlie Kauffman, in a 2008 interview for the Writers Guild of America, explains: “Part of the thing that happens when you’re writing, especially when you’re writing one piece over an extended period of time, is that you have an evolving understanding of the world and an evolving understanding of the piece. And so, if you’re trying to be truthful, you start out with one idea, and as you become more familiar with it, or explore different aspects of the idea, different things become revealed to you, and you have to incorporate that. That becomes a bit of a hindrance when you’re writing, but I guess that’s the way I like to write.” And that is the way I like it too.

Chapter II – In the Company of Ideas that are (Probably) True

I have thus far discussed Truth with no mention of its nature, and so will say a little bit about it now. Jeff Winger, the self-assured protagonist from the television series Community, puts it this way: “The biggest truths aren’t original. The truth is ketchup. It’s Jim Belushi. Its job isn’t to blow our minds. It’s to be within reach” (2010, E14/S1). I agree with Winger’s first statement: many observations are self-evident (i.e., very unlikely of ever being discounted by any new evidence), truisms that barely need stating. That being said, I disagree with his subsequent statement: truths are not always necessarily easily discernable. As Algernon replies to Jack in The Importance of Being Earnest, “[the] truth is rarely pure and never simple” (Wilde, 1899/1990, p. 6). Presuming that Truth exists independently of human perception, it may then not always be easily apprehensible by the mind. Because Truth does not exist for us, its job cannot possibly be to exist in such a way as to always be ascertainable, as if tailored for our intellect. In fact, Truth holds no purpose; it just is, and what it is cannot, unfortunately, always be within reach. Discerning Truth, instead, oftentimes requires painstaking effort. It is us that must adapt ourselves to it, not vice-versa. As Krauss remarks, it is sometimes necessary that “we expand our horizons because nature is more imaginative than we are” (2012, p. 77). Miss Giddens, in The Innocents, is even warned by her employer that the “truth is seldom understood by any but imaginative persons” (Clayton, 1961).

Presuming there are things to know about our universe, what are the best ways to discern them? I have talked about how I prefer not to rely on potential indicators like authority, intuition or experience. Other classic aids are Science, Reason, and Faith. (I make a distinction between Science and Reason for reasons that will become clear shortly.)

As many of you already know, Science only concerns itself with that which can be falsified (i.e., determined to be untrue via observation or experimental testing). For example, Science can readily assess the statement “tortoises are faster than hares,” because its opposite can easily be measured. In this way, the investigative scope of Science is fairly limited. Although Reason is inherently part of the scientific process, Reason can also be used on its own to assess statements that cannot be falsified. For example, although the statement “Life is actually a dream” cannot possibly be proven to be untrue, Reason can show it to be very improbable (for a compelling argument, see Russell, 1912). (The latter statement is presumably either True or False; it is just that we cannot “know” the answer scientifically, but merely approximate it logically.) In fact, Reason is the primary tool of Philosophy, and so is used to answer questions stemming from every one of its branches, questions that Reason via Science oftentimes cannot touch (or touch as persuasively) because of its strict falsifiability requirement (see Klemke, Kline, & Hollinger, 1994 for more on the difference between questions “fit for Science” and questions “fit for Philosophy”). For example, while Science can effectively judge secondary religious beliefs (e.g., “The Earth is 6,000 years old”), only Philosophy can unrestrictedly tackle the primary belief in a deity itself (Piggliucci, 2009). In this way, the investigative scope of Reason is fairly large, if not unlimited. Like Reason, Faith can technically assess any variety of statements, falsifiable or not. For example, one could take it on Faith that tortoises are faster (or slower) than hares, or that life is actually (or not actually) a dream. In this way, the investigative scope of Faith is as large and potentially unlimited as that of Reason. (One might even say that Faith is superior to Reason when trying to find out what is true: whereas Reason can only show an un-falsifiable statement to be probably true or false, Faith can claim it to be conclusively True or False. Unfortunately, as we shall see, Faith can also show it to be both True and False, which most of us do not consider a helpful conclusion, or a conclusion at all…)

While both Reason and Faith boast equally impressive scopes of enquiry, they are by no means equal aids when it comes to actually making out Truth. Reason (whether applied within the realm of Science or Philosophy) remains most helpful because it can show certain statements to be very probably false or truer than others. In other words, it may organize statements alongside a continuum of Truth. Faith, on the other hand, can accept anything as definitively True. For example, one person could take it on faith that “God created the universe,” and another could take it on faith that “A giant, impossibly pink and fluffy bunny-rabbit created the universe.” From a Faith-based perspective, both people would be right, which is unlikely given both aforementioned beliefs cannot be true at the same time (unless, I suppose, God is an enormous, colorfully furred rodent). Statistically speaking, then, Faith is too liberal; in other words, it is associated with too great a risk of false positives. To be fair, some claim that Faith’s purpose is not to know Truth. Nevertheless, those who adopt beliefs based on Faith assume it has oriented them toward an accurate belief. Funnily enough, even people who insist Faith is sufficient when selecting beliefs (e.g., “God created the universe”) will admit that some faith-based beliefs (e.g., “A giant, impossibly pink and fluffy bunny-rabbit created the universe”) just do not make sense. Thus, while they ultimately do value Reason, they just do not think Reason is necessary to support their own beliefs. That is why the smarter among those who initially adopt a belief based on Faith alone ultimately succumb and resort to Reason to validate these. Take, for example, the numerous logical arguments (e.g., Rachels, 2002) for the existence of God, usually taken on Faith alone. The battle over whether these arguments are cogent is here waged in the realm of Reason, because Faith is, as we have seen, always insufficient, and Science is, in this particular case, out of its element (“God exists” is a non-falsifiable statement). (Note, however, that if one appends “and can interact with the physical world” to “God exists,” the latter statement suddenly becomes falsifiable, and, thus, amenable to scientific enquiry; see Stenger, 2009.)

For this very reason are common religious arguments against the trustworthiness of Science—postulating, say, that “Science can be wrong”—embody not a criticism at all, but merely a restatement of its strength, of the reason why it can be so useful. Because Science can reject hypotheses as being inadequate, but never accept any of them as definitively true, Science naturally promotes progress and movement toward Truth. Reason outside of Science, as in Philosophy, can also evolve by way of argumentation. Faith, on the other hand, is inert, deprived of any inbuilt mechanism allowing it to advance away from Error toward Knowledge. To illustrate my point, compare the number of times Science has revised its understanding of nature in the last few centuries to the number of times Religion has revised its understanding of nature in the last two millennia. Close to 2,000 years after the birth of their religion, Christians have only recently begun to seriously consider the possibility that hell, a major element of their belief system, does not exist (Bell, 2011). Science, on the other hand, has not only questioned but also revised its conceptualization of light, one of its own conceptual obsessions, at least three times in the last 350 years: first came particle theory, then wave theory, followed by wave-particle duality (Hawking & Mlodinow, 2010). (Although one can certainly substitute, without resorting to Reason, one faith-based belief with another faith-based belief, it remains impossible to tell, based on Faith alone, whether the new belief is any truer or “falser” than the old one. In other words, trying to understand the world using Faith alone is akin to running a marathon on a treadmill. Whatever you do, you are never behind, never ahead; or at the very least, there is no possible way to know.)

As you may have guessed, I favor Reason (in the form of Science or Philosophy) when attempting to understand the world around me. I will now discuss some of the products of my reasoning over the last few years, in regards, specifically, to psychology.

Chapter III – In the Company of Ideas in Psychology (Part I)

We saw earlier that “etiology” can never determine the accuracy of a belief, because every belief has causes. I argue that in some cases, neither do its consequences. (Note that James, an ardent pragmatist, would have disagreed with this.) When determining whether a belief is true or not, I believe the effects of maintaining that belief have absolutely no bearing on its truth-value, since some truths presumably exist independently of the effects of believing in them. For example, it is not unreasonable to assume that dogs probably exist regardless of whether believing in dogs is helpful or harmful to humans. Now, that may sound silly, but many people express beliefs that, when translated using canines, sound a little bit like this: dogs must exist because dogs make humans less lonely. For example, some defend the existence of God by claiming that without belief in Him, society as we know it would crumble into chaos. But the effect of not believing in God has absolutely no bearing on whether He actually exists. Such people are confounding two debates: the existence of God, and the effects of believing in someone like Him. In short, there is a difference between the veracity and the utility of an idea, two characteristics that are often confused when attempting to demonstrate the former.

Many psychologists commit such a logical mistake when defending their own ideological beliefs (namely, their preferred therapeutic approach). To be precise, they commonly interpret the proven efficacy of a given therapeutic technique as indicating the truth of its underlying premises and postulated entities. If their brand of therapy happens to have more positive outcomes then other brands of therapy, then that must mean their approach is based on fact, and that they are justified in using it when helping clients. In doing so, many therapists “draw hasty conclusions between symptom abatement and interpretation” (Crews, 1995, p. 117). As we have seen, that habit is misguided.

Other psychologists commit a similar mistake when interpreting the finding that all therapeutic approaches are actually equally effective in relieving life difficulties (dubbed the Dodo-Bird Verdict), and that therapeutic approach actually plays only a small role in achieving this outcome, as indicating that all approaches are equally (or unequally) valid. In other words, psychotherapy is really a free for all: simply pick the one you happen to like best or borrow from here and there. To be sure, the Dodo-Bird Verdict has been the mark of much debate, but let us assume for a moment that this is in fact true, that all forms of therapy are equally effective in relieving life difficulties. Does that mean that we, as professional helpers, are warranted in using or sampling from any one of them to help our clients? Provided one values Truth over Deception, not at all. The Dodo Bird Verdict only extends to therapeutic outcome (or value), not therapeutic veracity. (I regret to inform those of you who advocate therapeutic eclecticism so as to avoid thinking about the philosophy underlying each and all therapeutic approaches, that the best eclectic therapists will only borrow from approaches that share the same core philosophical assumptions, but who suggest different strategies based on these [Neimeyer, 1995].)

As I alluded to earlier, an idea should ideally be evaluated via itself, and not via ourselves; otherwise, we are simply evaluating the effect of believing in this idea, as opposed to the idea itself. That is what the Dodo Bird Verdict amounts to: a conclusion as to the effect of an idea, as embodied by a particular approach, not a conclusion as to the legitimacy of this idea, or the approach itself. Even Wampold and his colleagues (1997), who assessed and confirmed the Dodo Bird Verdict, take care to mention in the title to their article that “all must have prizes” only “empirically.” (By empirically, I interpret the authors as meaning, “as far as observable effects are concerned.”) That is, from a wider truth-seeking perspective, all do not necessarily get to take those prizes home. Thus, the actual soundness of a given therapeutic technique cannot be determined via its efficacy, but via the accuracy of its premises and the entities that those premises engage.

Now, whether Efficacy should trump Truth in therapeutic settings is for you to decide. To be sure, therapy is meant to be helpful, but it is also expected to be truthful (i.e., based on the best knowledge available). To help me demonstrate, consider the following: if a given lie-spewing cult helps make people happy, does that make it a reasonable way of helping people? If you have answered in the negative, then you have no business conducting whichever brand of therapy you favor based solely on the fact that it has been proven to or may possibly be effective. You are only justified in conducting it if you have critically assessed the theory behind your approach to see if it stands up to Reason. For example, if you are a psychodynamic therapist, you must believe in and be able to defend the statement: “nothing in reality is ever what it seems.” (You would think that, as a skeptic, I would admire psychodynamic theory; unfortunately, such theory advocates a fanatical sort of skepticism, where no clear paths toward reliable insights are laid out except those paved by “experts.”) Further, one should be able to explain why, despite the fact that no “distinctly psychoanalytic notion has received independent experimental or epidemiological support—not repression, not the Oedipal or castration complex, not the theory of compromise formation, nor any other concept or hypothesis” (Crews, 1995, p. 298), one is still justified in speaking of these as if they were real. Cognitive psychotherapy may enjoy a better reputation nowadays and put forth and into play self-evident truths like the existence of thoughts, but that by no means exempts it from critical philosophical consideration. Likewise, if you are a second-wave cognitive-behavioral (CB) therapist, you must believe in and be able to defend the statement: “reality exists and has been decisively and irrevocably quantified.” After all, without a discernable (and already discerned) reality, there can be no such things as cognitive distortions of said-reality, and there remains nothing with which to realign a client’s mistaken subjectivity. (Third-wave CB therapists overcome this philosophical hurdle by embracing human subjectivity, even its unpleasant manifestations, without seeking to modify it.) If you cannot defend either of these arguments via non-fallacious means, yet are still conducting either brand of therapy, then fortunately for you: you have some thinking to do!

Arguing against a pragmatic view of religion, Russell (1901) confessed: “I can respect the men who argue that religion is true and therefore ought to be believed, but I can only feel profound moral reprobation for those who say that religion ought to be believed because it is useful, and that to ask whether it is true is a waste of time” (p. 197). Likewise, I can respect the men (and women) who argue that their brand of psychotherapy rests on sound philosophical premises and therefore ought to be practiced, but I can only feel profound moral reprobation for those who say that their brand of psychotherapy ought to be administered simply because it is useful.

Chapter IV – In the Company of Ideas in Psychology (Part II)

Another idea I have become quite infatuated with is the idea that mental illness does not exist. I am not going to concern myself here with the reasons why I believe this idea to be cogent, but with a common mistake people make when trying to prove me wrong. People often tell me mental illness must exist since diagnoses give people comfort. That is yet another example of mistaking value for veracity. I am not concerned with the effects of believing in mental illness, but whether it actually exists or not. Because I have concluded, by weighing the arguments I have come across until now, that it does not, I believe it would be irresponsible—not to mention disingenuous—for me to pretend as if it does, simply to assuage my clients’ distress. (Should you be curious, the effects of labeling are both positive [e.g., Angermeyer & Matschinger, 2005; Deacon & Baird, 2009; Hayne, 2003; Laegsgaard, 2010; Murrie, 2005; Murrie et al., 2007; Wright et al., 2007] and negative [e.g., Angermeyer & Matschinger, 2003, 2005; Deacon & Baird, 2009; Hayne, 2003; Kleim et al., 2008; Lloyd et al., 2010; Schomerus et al., 2010].)

Let us say I were to conclude that mental illness does, in fact, exist. Should, then, I resort to psychiatric diagnoses when explaining my clients’ experiences to them? I should think so. Unlike me, however, many of my clinical colleagues have actually come to the conclusion (or simply accept) that mental illness is real, yet somehow still debate whether to communicate their diagnoses to their clients. That is, to put it bluntly, pure hypocrisy. (A laughable type of hypocrisy, since many of those same people will tell me I am being irresponsible for not telling my clients that they have a given mental illness, an illness that I, unlike them, do not even believe in!) Currently, the debate surrounding diagnostic labels concerns whether we should use them, not whether they embody something real. Under the pretense that diagnoses of mental illness may cause stigma, some clinicians decide not to report them to patients, opting for less reductionist, more humanistic terms instead. This anxiety surrounding labels has led to many psychologists becoming two-faced, speaking the language of humanism with clients, while thinking about and discussing clients with their colleagues using the language of psychiatric reductionism.

This is all plain silly. If mental illness exists, it follows that patients should always be diagnosed with whichever illness they appear to suffer from! If mental illness is just like any other illness, then it does not matter in the least bit whether learning that one is mentally ill will impose emotional hardships. After all, have you ever heard of a doctor debate whether he should label his patient as having HIV, because he may be discriminated against on account of his infection? Of course not! Diagnoses of physical illness may be hard to take, but we still give them, because they accurately represent what is happening to a patient. And so, if psychiatric diagnoses are the same as medical diagnoses, it follows we should always give them to patients, even if learning that one is mentally ill will hurt.

Chapter V – In the Company of Ideas in Psychology (Part III)

I have argued that psychotherapy should be based on fact. Yet, at the same time, I implied earlier that psychotherapy is a predominantly value-based endeavor (compared, that is, to medical intervention, which, to be sure, also involves value-based decisions, but not to the central extent found in psychotherapy) that rallies rhetorical, relational, and experiential processes (as opposed to medicine’s use of basic speech and physical instruments*) in service of its moral aims, which center around existential-humanistic matters like “what people do” and “what people ought to do” (as opposed to physicalist matters like “what the body has,” in the case of medicine). Values, of course, are not scientific entities, nature being morally uniform. This begs the question: if we are willing to tolerate the application of values in psychotherapy, why not also enlist other fictional constructions, such as psychodynamic or psychiatric entities like the unconscious or mental illness? More succinctly, can psychotherapy ever truly be based only on fact?

The goal of psychotherapy is typically to increase psychological wellbeing. (I use the term “wellbeing” here instead of “health,” so as to avoid any unnecessary confusion between the two, broad concepts of “optimal behavior” and “optimal body.”) This goal involves the following value-statement: wellbeing is more desirable than its opposite. This statement, however, is not grounded in science and thus should not be considered formal fact. As evinced by the existence of natural disasters and the mere potential for violent behavior, nature does not always have our best interest at heart: it could not care less whether we survive and thrive within its confines, or simply suffer our way through life, only to die a meaningless death in the end. Values come into play not only in regards to the goal of psychotherapy, but also in regards to the pursuit of that goal. A correctional psychologist attempting to rehabilitate a violent offender who is quick to anger, for example, might encourage him to learn to cope with his anger without resorting to violence, because doing so will help him lead a more satisfying life, by, say, not scaring away potential resources. But nature, again, does not care whether we better ourselves or not, whether we behave in such a way as to foster or undermine our wellbeing.

The decision, in therapy, that we ought to behave in certain ways, and that we ought to replace certain behaviors with others, will forever be determined by fictional entities (i.e., values). That is, and will forever remain, the nature of therapy. We cannot do anything about that. That being said, it remains possible to favor certain behaviors over others, and to replace those behaviors we do not favor with behaviors we do consider favorable, in ways that are based in objective reality, i.e., in observable phenomena. (Indeed, although “normative judgments cannot properly be regarded as either true or false [,] accepting or rejecting an evaluative judgment [can] depend on judgments that are themselves straightforwardly nonnormative”; Frankfurt, 2006, p. 28-29, italics in original.)

For example, if we wish to help a client increase his wellbeing, we can use observation to tell us which behaviors generally increase wellbeing, and do so consistently, lastingly, and with the least number of harmful consequences. We can also rely on observation to determine the best strategies to use when replacing behaviors that decrease wellbeing with others that increase it. Note here that nowhere in nature is it prescribed that life should be pleasant, but science can still be helpful in telling us how to best accomplish this goal. (On a related note: although the selection of adaptive behaviors, and the elimination of maladaptive in favor of adaptive behaviors, can be based on scientific inquiry, the recommendation that clients live and that therapists practice according to empirically derived knowledge will always be value-based. In the words of philosopher David Hume, 1739, just because a behavior is related to increased wellbeing, or just because a therapeutic strategy is helpful in replacing behaviors that decrease wellbeing with behaviors that increase wellbeing, does not mean that it ought to be enacted.)

Thus, we would be warranted in urging a habitual substance abuser to consider substituting his behavior with another, more happiness-friendly behavior, not because this is what nature intends for that individual to do, but because objective observation tells us that using certain quantities of drugs and alcohol, while creating legitimately pleasant states of mind in an of themselves, increases wellbeing with only relative efficacy (pleasant emotions may be interrupted by unpleasant physical symptoms, or other sources of pleasure may be compromised, like one’s profession), reliability (unpleasant emotional experiences may sometimes, inadvertently and unexpectedly, become more salient), durability (pleasant emotions are fleeting), and sustainability (pleasant emotions may become hollow or require more intense consumption to come about at the same level of potency). Using certain quantities of drugs and alcohol also entails potentially detrimental consequences to others (like family and friends). Moreover, we would be warranted in suggesting to the habitual substance abuser certain change strategies over others, because observation tells us that some strategies neutralize cravings better than others.

Further, misbehaviors targeted for substitution in psychotherapy can always be described and explained in factual, or at very least parsimonious and transparent, ways. Thus we would be mistaken to describe habitual substance misuse as an id-motivated regression to the oral stage of psychosexual development, or as a chronic mental illness, because these concepts, while accurately reflecting the existence of particular behaviors, rely heavily on allegory (which often entails the creation of extraneous entities) to describe and explain these behaviors, and also fail to wear their moral loading on their sleeve (unlike, say, the expression “life difficulty,” which openly acknowledges its value-based underpinnings).

Conclusion

I have discussed en long et en large what I have learned about myself over the past fours years contributing to A Heck of a Kerfuffle.com, while focusing specifically on the topic of ideas in the field of psychology. I have, however, purposefully omitted one particular detail surrounding ideas that I now wish to consider with you: ideas are meaningless if they cannot be (and have not been) shared. We have now set foot upon the final, most agonizing step of the writing process: bidding one’s work farewell. Allowing a work to venture into a public sphere is, for two reasons, quite unnerving. First, writers no longer exert power over their creation for it does not belong to them anymore; it is out there, in the reader’s mind, becoming something “more,” a mix of the writer’s associations and the associations they, in turn, trigger in the reader. Second, allowing others to read our work demands we open ourselves up to criticism, make ourselves vulnerable in a way. However nerve-racking it is at times to conceive of and raise an idea, helping it grow into a full-fledged and freestanding essay, then free it into the world to fend for itself, it remains an exciting, stimulating process. I would go so far as to say it is addictive. In this spirit, many thanks to those of you who have taken the time to visit and rummage your way through my blog in the past four years. I am also grateful for the constructive feedback some of you have sent me via electronic mail. And on this note, to one more Kerfuffle of a year!

Footnote

* To be sure, clinical psychologists boast an arsenal of instruments at their disposal, mainly for diagnostic purposes. However, diagnostic tests in psychology do not allow psychologists to “diagnose” in the typical, medical sense of the word.

For the most part, diagnostic tests in psychology (e.g., the Beck Depression Inventory; BDI) identify a series of behaviors that are statistically correlated with one other; dub these behaviors “symptoms” individually and “disease” collectively; determine whether any of the testee’s behaviors match any of the behaviors defined as symptoms; and, given a pre-determined number of positive responses, allow the tester to conclude that the testee suffers from a disease. “To logicians,” Greenberg quips while discussing the flaws inherent in such a system of diagnosis, “this is known as assuming your conclusion as your premise, or begging the question” (2010, p. 129). Conversely, diagnostic tests in medicine, which do not involve circular logic, find evidence of disease independently of symptoms: “A good doctor would never conclude that a person with a sore throat and fever necessarily has a streptococcal infection, and a good scientist would not say that the disease of strep throat is constituted solely by a sore throat and fever. Both would insist that a bacteria must be present to complete the diagnosis” (p. 63). At present, the bacteria equivalent of depression (i.e., a definition of depression that does not include a description of what it is like to experience depression) does not exist, to say nothing of a diagnostic test that can accurately tell if a person has fallen ill with this entity.

As hinted by Greenberg, underlying, for instance, the BDI’s circular logic is confusion regarding the difference between disease and symptoms. In medicine, “the symptoms of the disease are only the signs of the disease, not the disease itself. In psychiatry, the symptoms constitute the disease and the disease comprises the symptoms” (Greenberg, 2010, p. 63-64). This confusion was earlier echoed by psychiatrist Thomas Szasz, who pointed out: “The term pneumococcal pneumonia identifies the organ affected, the lungs, and the cause of the illness, infection with the pneumococcus. Pneumococcal pneumonia is an example of pathology-driven diagnosis. Diagnoses driven by other motives [Szasz here refers to the diagnoses and motives of psychiatrists] generate different diagnostic constructions, and lead to different conceptions of disease” (1974/2010, p. 277). Tellingly, the problem surrounding the proper usage of the terms “disease” and “symptoms” in mental health is even acknowledged by the authors of the Research Agenda for the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V; Kupfer, First, & Regier, 2002): having conceded that “the field of psychiatry has thus far failed to identify a single neurobiological phenotypic marker or gene that is useful in making a diagnosis of a major psychiatric disorder” (p. 33), the authors go on to predict that “[once] it is possible to define a mental disorder based on the identification of its underlying pathology [a prediction that is based on the convenient reasoning that “proof must be coming,” which, incidentally, also begs the question: why are we speaking as if the proof already existed?], then it would surely make sense to follow the course of other medical conditions and have the presence of disorder be based solely on pathology and not on the effect this pathology exerts on the individual’s functioning” (p. 208).

On top of rendering diagnostic tests in psychology (not to mention the DSM itself) utterly useless by reducing them to complicated labeling machines (as opposed to the explanatory instruments these tests are modeled after), the confounding of disease and symptom in psychology often leads to improper use of language (which Szasz would likely qualify, depending on the speaker’s intentions, as base rhetoric). For instance, psychologists will often utter nonsensical diagnostic statements like “Martha is delusional because she has schizophrenia.” Given schizophrenia includes delusional beliefs in its definition, this statement amounts to a tautology, redundantly stating the same idea twice, only in different words. Conversely, a similarly structured statement in medicine makes perfect sense: “Martha has a throbbing headache because she has a tumor lodged in her brain.” A tumor is not a headache, and so it is acceptable to say that one is responsible for Mary’s headache.

References

Coming soon.

I was recently invited to address, as a guest speaker, a graduate seminar on clinical issues in forensic psychology. The aim of my lecture, I was informed by the inviting professor, would be to familiarize her students with the principles and practices underlying sexual offender rehabilitation. I agreed with a mix of excitement and reluctance. Excitement at the prospect of sharing with students my passion for my area of practice. Reluctance because reactions often tend to be disapproving: typical responses have ranged from, “All sexual offenders deserve is a bullet to the head,” to the comparatively more moderate (but only comparatively), “How about we just throw away the keys?” A particularly memorable response by a student of social work (a field typically attuned, much more so than psychology at least, to the needs of social outcasts) was: “Fine. Go ahead and be the Robin Hood of sexual offenders if you want to. They’re not worth my time.” (To this day, I still struggle to grasp what exactly this student meant by “Robin Hood of sexual offenders.” I understand the sentiment: in choosing to offer psychotherapy to sexual offenders, I am upholding their right to such services. But what exactly am I stealing from the law-abiding community and giving to sexual offenders?)

Students from the seminar I would be addressing were asked to provide me, in writing and in advance, with some of their questions regarding sexual offender rehabilitation. This would mainly help me gage where in their reflection students were at, but also give me time to come up with replies to any “out-of-left-field” comments. It would, additionally, provide a springboard for discussion during class. In case there would not be enough time, over the course of my lecture, to address all the questions sent to me, I prepared a document, which I handed to students at the end of class, providing answers to each of their questions. Following are the questions—in the end, all of them thoughtful—students posed to me, along with my answers. I reproduce them here as a resource for anyone curious to learn more about the “whys” and “hows” of providing psychotherapeutic services to sexual offender clients.

Q1: It seems that many sexual offenders deny any responsibility for their actions, or confidently justify them. How does a clinician work with that kind of person?

Sexual offenders display varying degrees of resistance* to change and to attempts from others to bring about change in them. In my experience, many individuals convicted of a sexual offense understand they have committed a destructive act and are motivated to behave in such a way as to reduce their risk of re-offending. When resistance is present, however, it can manifest itself in different forms: for instance, a) individuals can altogether deny** they committed a sexual offense, b) individuals can acknowledge some aspects of the allegations made against them, yet contest others, c) individuals can fully accept their guilt, but still hesitate or refuse to find ways to reduce their risk of re-offense.

In working with sexual offenders (or any type of client, really), it is important to remember that resistance is an expected part of the change process, which can be divided into five general stages: precontemplation, contemplation, preparation, action, and maintenance (Miller & Rollnick, 2013; Mitchell, 2012). Individuals in earlier stages of change are more likely to demonstrate resistance (in the form, for example, of denial), and with greater intensity, than individuals in later stages. Since resistance is as much a relational matter as it is an internal one, it is important, in order to avoid sparking or compounding resistance in clients, to tailor one’s interventions to the stage of change they currently are at: namely, individuals at earlier stages of change will benefit from interventions that seek to instigate change (by, namely, shifting their focus from stated problems to possible solutions), whereas individuals at later stages of change will benefit from interventions that help them maintain their commitment to change.

Regarding, specifically, denial in sexual offenders, it is important to remember that this cognitive stance does not generally increase risk of sexual recidivism (Hanson & Bussière, 1998; Hanson & Morton-Bourgon, 2004). (Note, however, that this finding does not apply to individuals who committed intra-familial offenses; Nunes, Hanson, Firestone, & Moulden, 2007.) As such, it is not necessary to target denial in the context of sexual offender therapy. (Even when denial is associated with an increased risk of recidivism, it could prove counterproductive to work toward getting a client to admit to his crimes, especially at the onset of therapy. This will likely serve to increase initial resistance and effectively limit any possibility of progress, not only in regards to taking responsibility, but also to other possibly worthwhile targets.) To put it another way, even though denial may spring from an inner resistance to the idea of pro-social change, it does not necessarily need to be eliminated for actual pro-social change to come about.

It is possible to work on many criminogenic needs (i.e., experiences that can change over time and that are, unlike “non-criminogenic needs,” related to re-offending) without getting clients to admit to their crimes (Marshall, Marshall, Serran, & Fernandez, 2006). With deniers, it is recommended practice for therapists to help clients find which (cognitive, emotional, behavioral, situational) experiences led to their alleged false accusations, with the intention of avoiding these experiences (and any false accusations these may lead to) in the future. Generally, clients will, in the midst of such an exploration, identify experiences that happen to be (if they truly are guilty) criminogenic: for example, “We agreed on a safe word. She says we didn’t, but we did. I wasn’t raping her for real. I’m no sicko. Whatever she says, that’s the God’s honest truth.” In this example, working on diversifying the client’s sexual interests (or, in instances where preferred sexual stimuli are problematic and exclusive, on mourning one’s sexuality) will be worthwhile for the client, whether his innocence is factual or not. Should the client really be innocent, avoiding situations where misunderstandings about consent are more likely to occur (e.g., S&M play) will help him reduce his risk of once again falling victim to false allegations. Should he really be guilty, avoiding situations where another person willingly hands power over to him (thinking he is worthy of his or her trust) will help him reduce the risk of once again mishandling that power over the course of such a situation.

Q2: Does sexual offending have a strong biological component similar to other forms of psychopathology such as bipolar disorder or schizophrenia? For example, if someone is a sexual offender, are their children more likely to engage in the same behavior when they get older? If so, what is the treatment prognosis?

This is an interesting question, one I believe will be best answered by acknowledging and addressing the different assumptions that seem to underlie the question.

Assumption #1: Sexual offending is a form of psychopathology.

Assuming that psychological processes can be pathological (see Assumption #5), sexual offending may or may not involve mental illness. The tendency to commit sexual offences is not, in and of itself, considered a mental illness. In this sense, sexual offending cannot be considered (again, in and of itself) a form of psychopathology. One could say, however, that the tendency to commit sexual offences involves psychopathological processes, in the form, namely, of deviant sexual interests (e.g., pedophilia). It is important to keep in mind, however, that not all sexual offenses are motivated by unusual sexual interests (Langevin, Lang, & Curnoe, 1998).*** (Likewise, not all individuals who exhibit unusual sexual interests commit sexual offenses; Hall, Hirschman, & Oliver, 1995; Williams, Cooper, Howell, Yuille, & Paulhus, 2009.)

Assumption #2: Sexual offending and other behaviors generally considered to be inappropriate (e.g., bipolar and schizophrenic modes of behavior) are more biologically determined than behaviors generally considered to be appropriate (e.g., prosocial, “unipolar,” and “uni-phrenic” modes of behavior).

It is important to keep in mind that all modes of behaving, whether considered appropriate or inappropriate by society, are founded in biology. While there is a tendency in the literature to only summon biological explanations when discussing inappropriate behavior, and to assume that appropriate behaviors come about spontaneously, as if materializing out of God’s breath itself, there is no reason to believe that appropriate behaviors are not similarly governed by biological rules and processes. For this reason, I find the following question equally fascinating: “Does non-criminal behavior have a strong biological component similar to other forms of psychological functioning, such as bipolar or schizophrenic behavior?” It is also important to remind ourselves that the exact role of biology (to say nothing of whether the processes involved can best be described as “disordered” or “pathological”) in behaviors commonly referred to as mental illness has been greatly overstated. The American Psychiatric Association itself, in its research agenda for the fifth and latest edition of the Diagnostic and Statistical Manual of Mental Disorders, rather candidly admitted that “the field of psychiatry has thus far failed to identify a single neurobiological phenotypic marker or gene that is useful in making a diagnosis of a major psychiatric disorder” (Kupfer, First, & Regier, 2002, p. 33). So premature are, namely, neuropsychologists’ conclusions regarding the neurological underpinnings of behaviors referred to as mental illness, that certain critics of psychology (e.g., Bentall, 2004; Greenberg, 2010) have likened modern neuropsychology to phrenology.

Assumption #3: The level to which a behavior is biologically determined will determine the likelihood at which it can be altered.

This is an interesting assumption that I am not certain science, in its current state, can corroborate. There is, however, a variation that can be addressed: biologically determined behaviors are necessarily resistant to intervention. This assumption starts crumbling to pieces if we conceptualize all human behavior as being (at least in part) biologically determined. Yes, behaviors like heterosexuality and religious belief, both of which presumably involve some biological processes, are very resistant to change. Yet, other behaviors, like vocational interests and emotional infatuations, both of which also presumably involve some biological processes, are known to be amenable to change (often without intervention).

Practically speaking, clinical psychologists working with sexual offenders do not ask, “How much is my client’s behavior due to biology?” when attempting to assess their amenability to change. Rather, they ask, “How likely is my client to re-offend in the future?” Indeed, amenability to change appears related to sexual offenders’ risk of sexual recidivism. (That is not to say, of course, that one’s level of risk is not, to some extent, rooted in biology.) More precisely, higher-risk offenders will benefit from rehabilitation more so than lower risk offenders; for low-risk offenders, rehabilitation may even increase risk of recidivism. (Although these findings are generally discussed in regards to “general” offenders [Andrews & Bonta, 2010], they seem to extend to sexual offenders as well [Lovins, Lowenkamp, & Latessa, 2009].) Regarding those sexual offenders who express inappropriate sexual interests, some behavioral methods exist (e.g., covert association, directed masturbation, masturbatory reconditioning, verbal satiation) to extinguish such interests and to reinforce more appropriate ones. These methods, however, possess varying degrees of empirical support (Marshall, Anderson, & Fernandez, 1999).

Assumption #4: Sexual offending behavior can be passed down from one generation to the next via genetic transmission.

In actuality, many dispositional and environmental factors (not to mention social norms) combine to create a moment between two individuals that comes to be described as sexual offending. While certain traits or tendencies involved in sexual offending (e.g., sexual interest in children) can be believed to be passed down from generation to generation, it is hard to conceptualize how sexual offending as a whole could be transmitted from one generation to the next, as if constituting some unique physical entity singly represented in one’s biology by a specific set of genes. Regarding inadequate sexual interest specifically, research suggests that sexual interest in children is mainly determined by one’s environment (Alanko, Salo, Mokros, & Santtila, 2013), a finding similar to that for adequate sexual interest (e.g., homosexuality; Santtila, Sandnabba, Harlaar, Varjonen, Alanko, & von der Pahlen, 2007). That is not to say, of course, that biology (simply in a form other than genetics) is not involved somehow, or that sexual offenders with pedophilic interests experience any sense of choice in their desire to engage in sexual activity with children (similarly to individuals with teleiophilic interests).

Assumption #5: Behavior can be “pathological.”

The idea that mental illness is real represents the most commonly made assumption in the entire field of clinical psychology, not to mention psychiatry. While it may appear to be self-evident, there are a number of philosophical and scientific objections to the notion that mental illness exists. (That is not to say, of course, that the behaviors referred to as mental illness do not exist [although the means via which these behaviors are categorized may be flawed] or that they are necessarily the product of human volition.) Interestingly, most of these objections, leveled by psychologists and psychiatrists alike, have and continue to come from within our field. (Arguments range from “mental illness is a metaphor” to “unlike physical illness categories, mental illness categories circularly mistake description for explanation.”) Entire books have been filled with these objections, and so I cannot hope to do justice to any of them in the space of a few short paragraphs. For those interested in finding out more on the subject, I have taken care to list a few seminal titles in the “Suggested Readings” section of this document, books that have greatly influenced my philosophy as a professional helper. Mainly, my philosophy manifests itself linguistically: I make special efforts to avoid using medical language when describing and explaining human misbehavior, preferring instead to use humanistic language, which possesses the dual advantages of a) being more parsimonious than its alternatives (i.e., not only medical, but also religious and romantic language) and of b) acknowledging the human experiences that exist behind many of the behaviors psychiatry dismisses as symptoms.

Assumption #6: Inappropriate behaviors can be “cured” with “treatment,” and have different “prognoses.”

This assumption flows from the previous one. If misbehaviors can be diseases, then they can also be “cured” with “treatment,” and have different “prognoses.” If misbehaviors are simply misbehaviors, however, medical terminology like “cured,” “treatment, and “prognosis” is inappropriate to describe the actions of those who seek to alter the misbehaviors in question, as well as to describe the course these misbehaviors adopt across time (with or without the influence of the actions of those who seek to alter them). Let me elaborate: Much in the same way what we refer to as mental illness has very little to do with physical illness, what we refer to as psychological treatment has very little to do with medical treatment (rendering the usage of the term “illness” or “treatment” in both instances misleading). What we describe as treatment in psychology is, in actuality, a relational enterprise (Szasz, 1988) that shares more in common with conventional forms of communication than it does with medical intervention: words and other symbols, combined with our ability to reason and reflect, are harnessed in the service of deciphering life challenges and developing the skills needed to overcome them.

How effective are psychological interventions at getting individuals to stop committing sexual offenses? Research has shown that psychological interventions are able to effectively reduce risk of sexual recidivism. To be effective, however, interventions must be based on what is known as the Risk-Need-Responsivity (R-N-R; Andrews & Bonta, 2010) model of offender rehabilitation: in other words, level of risk, criminogenic needs, and level of receptivity to intervention must all be taken into account when attempting to help sexual offender clients commit to a pro-social lifestyle (Hanson, Bourgon, Helmus, & Hodgson, 2009). Interventions should also abide by contemporary, empirically supported (e.g. cognitive-behavioral) principles (Andrews & Bonta, 2010; Hanson, Gordon, Harris, Marques, Murphy, Quinsey, & Seto, 2002).

Q3: Based on your experience, what do you feel are the greatest barriers to successful treatment for sexual offenders? Are the barriers related more so to external factors such as stigma and lack of access to adequate resources or are they related more so to factors involving the offender’s personality/mental health?

There are many forces, internal and external, that conspire to thwart a sexual offender’s efforts to lead a pro-social life, even when the person in question is highly motivated to do so. Fear and anger from the community (e.g., strangers, family, policy-makers, case management team members), compounded by poor knowledge of the literature on sexual offending (embodied in the form of the uniquely American notion of the mythical sexual predator), often lead to measures being taken that poorly balance a) the community’s legitimate needs for protection from harm and for revenge with b) the offender’s need to live a pro-social life (and, thus, become less of a danger to the community). In fact, while many of these measures successfully satisfy our needs as a community, they do so at the expense of offenders’ rehabilitative process, by self-defeatingly limiting these individuals’ ability to access pro-social experiences and even exacerbating particular risk factors (e.g., social rejection). In sum, we owe it to ourselves and to the sexual offenders in our communities to find a middle ground, one that takes into account our needs for protection from harm and for revenge, without producing the very circumstances we wish to avoid (i.e., by thwarting sexual offenders’ efforts to become pro-social).

Permit me a brief tangent. Certainly, fear and anger are legitimate responses to sexual offending. It is essential to our humanity, however, that we do not debase ourselves in moments of despair by acquiescing to our basest instincts and by letting these animalistic drives guide our behavior as we attempt to regain control over the situation. To summon compassion for sexual offenders is a challenging endeavor, I concede. If we are to pride ourselves as compassionate beings, however, we owe it to ourselves to attempt to offer compassion to those who ignite our ire. To put it bluntly, if we are only able to feel compassionate toward starving orphans or three-legged dogs, then the very concept of compassion becomes rather hollow and meaningless, to say nothing of our impression of ourselves as benevolent individuals.****

To those who can never see themselves mustering any compassion whatsoever for rapists or child molesters, it is important to remember that, even if we harden our hearts to the personal challenges of sexual offenders, the cost of overly restrictive offender management initiatives to the rest of us “law-abiding folks” remains potentially damaging (as mentioned previously) and should still be opposed, if only for our own sake.

A more internal barrier to change in sexual offenders is shame. Most sexual offenders understand that they have committed a destructive act, a realization that naturally produces shameful feelings in them. Some individuals seek to protect themselves from this uncomfortable emotional experience by resorting to less-than-ideal strategies, like “cognitive distortions” or, more appropriately and less presumptuously, problem thoughts (e.g., minimization, victim-blaming). While it may be tempting (especially to the strict cognitive-behavioral therapist) to immediately seek to replace problem thoughts with less damaging alternatives, this can be a mistake. It is important to understand that problem thoughts often represent defenses, and that defenses are, by their nature, protective. As such, it will often prove quite fruitless to try to eliminate problem thoughts when the experiences clients are seeking to defend themselves against (via these thoughts) remain threatening to them. For this reason, when problem thoughts are defensive, it is best to focus on, say, emotion management, before attempting “cognitive restructuring.”

While some problem thoughts are meant to protect us from feelings stemming mainly from our past, others are meant to protect us from feelings stemming from our future (or, more accurately, what we imagine our future to be). “It is perfectly acceptable for adults to have sexual relationships with children” may represent one such thought. Given the inflammatory nature of such a statement, many therapists would be quick to attack it. Again, while it may be tempting to immediately argue with an offender about the legitimacy of his belief, such a conversation might be less than productive if the subjective purpose of his belief is to permit (in the face of doubts as to the feasibility of having a satisfactory relationship with an adult) for the possibility of having one’s needs for intimacy met in the future. In this instance, only once the offender becomes confident in his ability to meet his intimacy needs within the context of an adult relationship will he become open to replacing his problem thought with a more constructive one.

Even when an offender has learned how to “navigate” his shame without feeling threatened and defensive, shame can still weigh heavily on him and limit his ability to commit to a new, pro-social lifestyle: “Look at what I’ve done. I’m a piece of shit. Scum like me doesn’t deserve friends.” One way to render shame less incapacitating is to interpret such feelings as painful indicators of clients’ humanity, of the intactness of their moral compass. (After all, they wouldn’t be feeling shameful if they thought what they did was right.) This “re-framing” of shame can be transformative for clients, bringing into perspective a moral foundation upon which to build their new life. (Once a given client has made this realization, he would also be encouraged to think about what caused him to disregard his moral compass at the time of his offense, so as to help him prevent any further deviations from his moral center in the future.) In sum, even if shame is not, in and of itself, criminogenic, it is crucial that it be recognized and addressed in therapy with sexual offenders, in that it can give rise to and maintain behaviors that are criminogenic, not to mention keep pro-social behaviors at bay.

Q4: My question is in relation to the process of treatment. Is it particular personality traits that guide you to determine treatment? Do you begin treatment focusing on the urge/impulsivity issues and work your way from there? What factors determine your treatment method?

The first part of the rehabilitative process is to assess the sexual offender’s risk of re-offense. This process highlights a number of factors that serve to increase the individual’s risk of committing a new sexual offense over the course of several, pre-determined periods in the future. Some of these factors are considered static (or historical, and thus mostly unalterable through intervention; Hanson & Thornton, 2000), whereas others are considered dynamic (or changing in time, and thus alterable through intervention; Hanson, Harris, Scott, & Helmus, 2007). Rehabilitation targets those risk factors that are considered dynamic. (Since dynamic risk factors are synonymous with criminogenic needs, this approach at rehabilitation is known as the need model). There are two types of dynamic risk factors: acute dynamic factors change rapidly across time and risk bringing about a sexual re-offense in the immediate short term (e.g., access to potential victims), whereas stable dynamic factors change slowly across time and risk bringing about a sexual offense in the longer short term (e.g., hostility toward women). Unless acute dynamic risk factors are present, rehabilitation will focus on eliminating, or a the very least decreasing, the influence of stable dynamic risk factors.

It can also be helpful, during the course of therapy, to identify, along with the client, the positive experiences (e.g., autonomy, intimacy, belonging) he was attempting to create for himself prior to and during his sexual offence. (This approach is known as the Good Lives model; Yates, Prescott, & Ward, 2010.) These valued experiences are known as “primary goods.” After validating the innate legitimacy of these experiences, the therapist should help the client (among other objectives regarding what is known as the “Good Lives plan”) find methods of achieving these same experiences in the future, this time without moving toward or engaging in sexual offending. These methods (whether constructive or not) are known as “secondary goods.” Because dynamic risk factors promote the use of inappropriate secondary goods (in the form of sexual offending), can themselves represent inappropriate secondary goods (by virtue of their risk properties), and can prevent clients from meeting primary goods not already embedded in their offense chain (up to and during their sexual offense), work on primary and secondary goods is complimentary to work on dynamic risk factors.

Finally, the therapist should help the client identify the goals, in regard to future offending, that he set for himself prior to actually committing his offense, as well as the manner in which he went about achieving these goals. (This approach is known as the self-regulation model; Yates, Prescott, & Ward, 2010.) There are several goal-manner combinations, also known as “pathways” to sexual offending. Prior to his offense, the client may have a) wished to avoid offending, but failed to implement any strategies to accomplish this (“avoidant-passive pathway”), b) wished to avoid offending, but implemented ineffective strategies to accomplish this (“avoidant-active pathway”), c) wished to offend and done so impulsively (“approach-automatic pathway”), or d) wished to offend and done so in an involved and strategic manner (“approach-explicit pathway”). Notice that, in each of these scenarios, the client either regulated improperly (by not at all attempting to control his behavior, or by attempting to do so, but ineffectively) or regulated properly (by attempting to control his behavior, and doing so effectively) toward his stated goal, which was either pro- or anti-social. Thus, the nature of the therapeutic conversation will vary depending on where exactly the problem lies: the problem may lie in the client’s goals or in his ability to regulate toward these (or in both). If the client’s stated goals are problematic, then the therapist will want to gear the therapeutic conversation toward replacing the client’s intentions with less problematic ones. Likewise, if the client’s ability to regulate toward his goals is problematic, then the therapist will want to gear the therapeutic conversation toward improving self-regulation (by curbing passive or automatic tendencies, and/or by developing goal-directed decision-making). Because dynamic risk factors and primary/secondary goods interact with sexual offenders’ goals regarding future offending and with the manner in which they accomplish these goals, work on goal-selection and self-regulation is complimentary to work on dynamic risk factors and primary/secondary goods.

Q5: How does building a strong therapeutic alliance with sexual offenders differ from the average non-sexual offender and from the general population?

Psychotherapy with sexual offenders poses particular challenges to therapeutic alliance that are generally absent or less intensely present in therapy with non-sexual offenders or the general population. Challenges to therapeutic alliance in the context of sexual offender therapy usually originate in the following order, first from within the therapist, then from within the context inside which the therapeutic relationship must unfold, and subsequently from within the client: (1) Sexual offenders have committed crimes that can sometimes elicit intense emotions like disgust or anger in the therapist, emotions that, while entirely appropriate, can easily thwart one’s ability to relate (both internally and externally) constructively with clients. (2) While some sexual offenders volunteer for psychotherapy, therapy is most often mandated. Also, the same level of confidentiality afforded to clients in non-correctional therapy cannot, for security purposes, be afforded to clients in correctional therapy. As such, sexual offenders’ motivation to invest in therapy (and any component thereof) can be very low. (3) Given the shameful nature of their crimes, sexual offenders are likely to erect various defenses within therapy, to protect themselves from the therapist’s judgment, and, ultimately, their own. This defensive tendency is compounded by sexual offenders’ common inability to interact with others in constructive ways. (Interestingly, some practitioners conceive of sexual offending as mainly a relational problem, as opposed to a sexual one.) Since all of the aforementioned experiences tend to materialize at the onset of therapy, it is important to intervene, from the very first session on, in such a way as to prevent these states of mind from crystallizing and impacting, in counterproductive fashion, the course of therapy.

To develop therapeutic alliance with sexual offenders, it can be helpful to: a) trigger one’s ability to empathize by focusing not on the client’s crime, but on the person who committed the crime, their regrets, their fears and their hopes (however suppressed or otherwise protected these may be), all of which can be rallied in service of rehabilitation, b) earn the client’s collaboration by recognizing the fact that they must attend therapy, by being forthright about the limits imposed on confidentiality, by acknowledging their (possible) reluctance to attend therapy as a function of these contextual issues, and by together finding ways to make the therapeutic hour, despite its mandatory nature and its limited confidentiality, helpful to the client, c) validate the positive experiences (e.g., connection) the client was attempting to create for himself when he engaged toward a sexual offence, and explain that, while the manner in which he sought to achieve these experiences was less than ideal, the desired experiences themselves were wholly legitimate, d) adapt one’s interventions to the stage of change the client is currently at (i.e., precontemplation, contemplation, preparation, action, or maintenance). By instilling a humane climate endowed with patience, understanding, and non-judgment, most often these methods will help to strengthen the therapeutic alliance, and to increase clients’ motivation to commit toward change through therapy.

Q6: According to Conroy (2003), “females who perpetrate against children constitute a very small percentage of sex offender population” (p. 475). What types of sexual offenses are women most likely to commit? Has research identified why women sexually offend less, especially against children? What makes them different than men? How do their special needs that differ from the needs of male sexual offenders impact treatment?

My clinical experience is limited to working with male sexual offenders, and so I am not very familiar with the literature on female sexual offending. What I do know, however, is that there is very little research available, at present, on the subject of women who perpetrate sexual crimes. For this reason, there are very few guidelines regarding how to properly assess and reduce the risk of re-offense in female sexual offenders. Regarding differences between female and male sexual offenders, it appears that female sexual offenders re-offend less often (Cortoni, Hanson, & Coache, 2010), and that the factors involved in their re-offending are different (Sandler & Freeman, 2007). On a practical note, until more is known on the causes (or, at the very least, the correlates) of sexual offending in women, I would suggest using what is currently known about male sexual offending as a template when working with female sexual offenders, while, of course, carefully keeping in mind the empirical limitations of this template.

Notes

* I use the term “resistance” not in a psychoanalytically dismissive way, but to describe that aspect of consciousness that is opposed to change—an aspect that may exist on its own, or that may be counterbalanced with openness to change. (The experiential blend of opposition and openness to change is typically referred to as “ambivalence.”)

** For the purposes of this answer, I am using the term “denial” (or any derivative of the term, e.g., deny, denier) in its categorical, all-or-nothing sense. (Certain definitions of the term will accommodate partial acknowledgement of the subject of denial.)

*** This is also implied by the possibility of assigning a given sexual offender a score of “0” on the “Deviant Sexual Preference” row of the STABLE-2007, a measure of sex-offender specific criminogenic needs (see Fernandez, Harris, Hanson, & Sparks, 2012, for coding rules).

**** This tangent was brought to you by the philosophies of Viktor Frankl, psychiatrist and author of Man’s Search for Meaning (1946), and of Paul Gilbert, psychologist and founder of Compassion Focused Therapy (see Gilbert, 2009, for an outline of the approach).

References

Alanko, K., Salo, B., Mokros, A., & Santtila, P. (2013). Evidence for heritability of adult men’s sexual interest in youth under age 16 from a population-based extended twin design. The Journal of Sexual Medicine, 10, 1090–1099.

Andrews, D. A., & Bonta, J. (2010). The psychology of criminal conduct (5th edition). New Providence, NJ: LexisNexis.

Bentall, R. (2004). Madness explained: Psychosis and human nature. Toronto, ON: Penguin Books.

Conroy, M. A. (2003). Evaluation of sexual predators. In A. M. Goldstein & I. B. Weiner (Eds.), Handbook of Psychology, Volume 11: Forensic Psychology (pp. 463–484). Hoboken, NJ: John Wiley & Sons, Inc.

Cortoni, F., Hanson, R. K., & Coache, M.-E. (2010). The recidivism rates of female sexual offenders are low: A meta-analysis. Sexual Abuse: A Journal of Research and Treatment, 22, 387–401.

Fernandez, Y., Harris, A. J. R., Hanson, R. K., & Sparks, J. (2012). STABLE-2007 coding manual (revised 2012). Ottawa, ON: Public Safety Canada.

Frankl, V. E. (2006). The search for meaning. Boston, MA: Beacon Press. (Original work published 1946)

Gilbert, P. (2009). The compassionate mind: A new approach to life’s challenges. Oakland, CA: New Harbinger Publications.

Greenberg, G. (2010). Manufacturing depression: The secret history of a modern disease. Toronto, ON: Simon & Schuster.

Hall, G. C. N., Hirschman R., & Oliver, L. L. (1995). Sexual arousal and arousability to pedophilic stimuli in a community sample of normal men. Behavior Therapy, 26, 681–694.

Hanson, R. K., Bourgon, G., Helmus, L., & Hodgson S. (2009). A meta-analysis of the effectiveness of treatment for sexual offenders: Risk, need, and responsivity. Ottawa, ON: Corrections Research, Public Safety Canada.

Hanson, R. K., & Bussière, M. T. (1998). Predicting relapse: A meta-analysis of sexual offender recidivism studies. Journal of Consulting and Clinical Psychology, 66, 348–362.

Hanson, R. K., Gordon, A., Harris, A. J. R., Marques, J. K., Murphy, W., Quinsey, V. L., & Seto, M. C. (2002). First report of the collaborative outcome data project on the effectiveness of psychological treatment for sex offenders. Sexual Abuse: A Journal of Research and Treatment, 14, 169–194.

Hanson, K. R., Harris, A. J. R., Scott, T.-L., & Helmus, L. (2007). Assessing the risk of sexual offenders on community supervision: The Dynamic Supervision Project. Ottawa, ON: Corrections Research, Public Safety Canada.

Hanson, K. R., & Morton-Bourgon, K. (2004). Predictors of sexual recidivism: An updated meta-analysis. Ottawa, ON: Public Safety and Emergency Preparedness Canada.

Hanson, R. K., & Thornton, D. (2000). Improving risk assessments for sex offenders: A comparison of three actuarial scales. Law and Human Behavior, 24, 119–136.

Kupfer, D. J., First, M. B., & Regier, D. A. (Eds.) (2002). A research agenda for DSM-V. Washington, DC: American Psychiatric Association.

Langevin, R., Lang, R. A., & Curnoe, S. (1998). The prevalence of sex offenders with deviant fantasies. Journal of Interpersonal Violence, 13, 315–327.

Lovins, B., Lowenkamp, C. T., & Latessa, E. J. (2009). Applying the risk principle to sex offenders: Can treatment make some sex offenders worse? The Prison Journal, 89, 344–357.

Marshall, W. L., Anderson, D., & Fernandez, Y. (1999). Cognitive behavioural treatment of sexual offenders. Toronto, ON: John Wiley & Sons, Ltd.

Marshall, W. L., Marshall, L. E., Serran, G. A., & Fernandez, Y. M (2006). Treating sexual offenders: An integrated approach. New York, NY: Routledge.

Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd edition). New York, NY: The Guilford Press.

Mitchell, C. W. (2012). Effective techniques for dealing with highly resistant clients (2nd edition). Publisher: Author.

Nunes, K. L., Hanson, R. K., Firestone, P., Moulden, H. M., Greenberg, D. M., & Bradford, J. M. (2007). Denial predicts recidivism for some sexual offenders. Sexual Abuse: A Journal of Research and Treatment, 19, 91–105.

Sandler, J. C., & Freeman, N. J. (2009). Female sex offender recidivism: A large-scale empirical analysis. Sexual Abuse: A Journal of Research and Treatment, 21, 455–473.

Santtila, P., Sandnabba, N. K., Harlaar, N., Varjonen, M., Alanko, K., & von der Pahlen, B (2007). Potential for homosexual response is prevalent and genetic. Biological Psychology, 77, 102–105.

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

Williams, K. M., Cooper, B. S., Howell, T. M., Yuille, J. C., & Paulhus, D. L. (2009). Inferring sexually deviant behavior from corresponding fantasies: The role of personality and pornography consumption. Criminal Justice and Behavior, 36, 198–222.

Yates, P. M., Prescott, D., & Ward, T. (2010). Applying the Good Lives and Self-Regulation models to sex offender treatment: A practical guide for clinicians. Brandon, VT: The Safer Society Press.

Suggested Readings

Note: This section appeared as an appendix to the Q&A handout.

i) General readings in offender psychology

Making Good: How Ex-Convicts Reform and Rebuild Their Lives (Maruna, 2000)
The Psychology of Criminal Conduct (Andrews & Bonta, 2010)
Rehabilitation (Ward & Maruna, 2007)
The Criminal Recidivism Process (Zamble & Quinsey, 2001)

ii) Sexual offender assessment and rehabilitation

Applying the Good Lives and Self-Regulation Models to Sex Offender Treatment: A
Practical Guide for Clinicians (Yates, Prescott, & Ward, 2010)
Cognitive-Behavioral Treatment of Sex Offenders (Marshall, Anderson, & Fernandez, 2006)
Desistance from Sexual Offending: Alternatives to Throwing Away the Keys (Laws & Ward, 2011)
Rehabilitating Sexual Offenders: A Strength-Based Approach (Marshall, Marshall, & Serran, 2011)
Sexual Deviance: Issues and Controversies (Ward, Laws, & Hudson, 2002)
Sexual Deviance: Theory, Assessment, and Treatment (Laws & O’Donohue, 2008)
Treating Sex Offenders: An Integrated Approach (Marshall, Marshall, Serran, & Fernandez, 2006)

iii) Issues in clinical psychology

This is only a sample of titles from a wide and varied body of literature critically evaluating some of psychology and psychiatry’s most popular assumptions:

The Cult of Personality Testing: How Personality Tests Are Leading Us to Miseducate Our Children, Mismanage Our Companies, and Misunderstand Ourselves (Paul, 2004)
Doctoring the Mind: Why Psychiatric Treatments Fail (Bentall, 2010)
House of Cards: Psychology and Psychotherapy Built on Myth (Dawes, 1996)
Madness Explained: Psychosis and Human Nature (Bentall, 2004)
Manufacturing Depression: The Secret History of a Modern Disease (Greenberg, 2010)
The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (Szasz, 1974)
The Myth of Psychotherapy: Mental Healing as Religion, Rhetoric, and Repression (Szasz, 1988)

iv) General readings in clinical psychology

Effective Techniques for Dealing with Highly Resistant Clients (Mitchell, 2012)
Motivational Interviewing: Helping People Change (Miller & Rollnick, 2013)

Philosopher Daniel Dennett lamented: “There’s nothing I like less than bad arguments for a view that I hold dear” (cited in Martin, 2004, p. 222). To some, Peter Shaffer’s controversial play Equus (1973) may be guilty of such a crime: disenchanted with Psychiatry’s view of human behavior, Equus adopts an alternate perspective that unfortunately commits the same mistakes as the target of its criticism. At the same time, however, “[a] philosopher who prefers a good argument for a bad cause to a bad argument for a good cause is an immoral or amoral philosopher and a bad person” (Szasz, 2004, p. 114). In this way, Equus should be commended: although it stumbles while making its point, the zeal with which it sets out to slaughter a modern behemoth ripe for criticism elevates it above those endeavors that mindlessly defend Psychiatry.

In Equus, Alan Strang, a 17-year old stable boy, has gouged the eyes of six horses under his care. Thanks to a well-intended, but misguided, court magistrate, Strang is spared from prison and instead committed to a psychiatric hospital, an often worse fate. He is appointed to psychiatrist Martin Dysart, who attempts to deconstruct his patient to remake him into a “proper” member of society. During therapy, Dysart visits Strang’s memories, from childhood to the recent past. We find out that horses have special meaning to Strang: all that is equine is also…erotic. Enamored by Strang’s passion, Dysart comes to doubt not his ability to rid his patient of his deviant sexual interest, but his moral right to do so. Psychiatry, he uneasily realizes, is a cruel and merciless executioner, whose ordained mandate is to sacrifice all those who are different at the altar of its king and sovereign, Normality. Shaffer’s play pointedly asks: as professionals in “Mental Health,” are we willing to commit the sort of moral crimes required to sustain our hungry profession?

My boyfriend and I saw Equus on stage during the Segal Center for the Performing Arts’ past season in Montreal. Impressed with the Center’s previous productions of Arthur Miller’s A View from the Bridge (1955) and Martin McDonagh’s The Lieutenant of Inishmore (2001), we had high hopes for the production that were not disappointed. In fact, my boyfriend claimed it rivaled the recent Broadway revival, featuring Richard Griffiths and Daniel Radcliffe. The set design was a visual treat, mixing sleek, modern curves with organic elements. I was mesmerized by the tall, thin beams sprouting from the floors of the psychiatric hospital: smooth and clinical metal at the base, crude and natural wood at the tip. Background video-projections of Strang’s memories also hovered above the hospital floors, serving as a bridge of sorts between the static space and the animated actors. These visual details served to evoke a sense of infiltration: either Strang’s memories of the earthy horse stables are replenishing the stark psychiatric hospital with life, or alternatively, the hospital walls are slowly closing in on and restricting his roving mind. Despite various levels of stage experience, actors performed their roles with both skill and resonance. Some of their British accents seemed to come and go, but that is a minor quibble since the lines were delivered with intent and honesty.

As suggested by the stage design, there are two disparate worlds at the center of Equus. When the psychiatrist and patient’s worlds converge, however, there is little overt conflict. Rather, something in Strang incapacitates Dysart. He cannot bring himself to impose his medical worldview on Strang, something he has probably done with countless other patients. There is an unmistakable humanity to Strang’s predicament, despite his victims being a different animal. This contradiction provokes a philosophical shift in Dysart: when the cold, clinical touch of Psychiatry can no longer relieve the suffering mind without compromising the mind’s spiritual integrity, what is a psychiatrist to do?

As a clinical psychologist in training, I identified with Dysart’s struggle. Because my educational development has been so influenced by Psychiatry’s view of human (mis)behavior, disposing of psychiatric shorthands when attempting to understand others remains a challenge. In a powerful speech, Dysart eloquently articulates his crushing realization:

“The Normal is the good smile in a child’s eye—all right. It is also the dead stare in a million adults. It both sustains and kills—like a God. It is the Ordinary made beautiful; it is also the Average made lethal. The Normal is the indispensable, murderous God of Health, and I am his Priest. My tools are very difficult. My compassion is honest. I have honestly assisted children in this room. I have talked away terrors and relieved many agonies. But also—beyond question—I have cut from them parts of individuality repugnant to this God, in both his aspects. Parts sacred to rarer and more wonderful Gods. And at what length … Sacrifices to Zeus took at the most, surely, sixty seconds each. Sacrifices to the Normal can take as long as six months.” (Shaffer, 1973, p. 65)

In Aldous Huxley’s Brave New World (1932/1994), The World State has confounded language so that its citizens have come to mistake being controlled for being free (see Bernard Marx and Lenina Crowne’s conversation on freedom; p. 81-82). They have become happy slaves. Psychiatry has achieved a similar feat in our own society: we have come to mistake being abnormal for being sick. Many of us even welcome diagnoses of mental illness! This is regrettable, but not surprising: as existential psychologist Ernest Keen remarks, “[the] possibility that a person might be reassured by medicalizing her distress […] testifies to the extent to which our culture has trained its members that human stresses and distress can be solved by expert scientific attention and that people and their problems need not be taken seriously in their own terms” (2011, p. 67). Since we use language to describe our experience, language matters. It is a testament to Psychiatry’s unique power that by simply labeling a behavior and publishing its definition in a manual, it is able to transform a challenging human experience into a disorder requiring professional attention.

Thus, we voluntarily flock to Mental Health Care facilities, seeking treatment for our so-called “conditions.” But, could it be—at least, in some situations—our “mental health” needs no “care” at all? In a 2010 article, Allen Frances, the psychiatrist who chaired the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) task force, admitted with regret: “Our net was cast too wide and captured many “patients” who might have been far better off never entering the mental health system.” Frances and Dysart are, then, in agreement: when psychiatrists choose to—and are encouraged to—overstep certain boundaries, their actions can be devastating. Still, the net has landed firmly: mental health professionals proudly defend the authenticity of their psychiatric categories, while clients voluntarily submit themselves to these classifications. Happy slaves are very hard to free…

Frances predicts that the upcoming DSM-V will only serve to “extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal.” To satisfy the Normal’s insatiable appetite, we must eventually begin to transform more and more behaviors into deviant behaviors. As mentioned, this is achieved through language. Ironically, though, the more “normal-turned-abnormal” behaviors we sacrifice to the Normal, the less “normal-to-begin-with” behaviors are left. In this way, Normality may consume itself out of existence: I can imagine a future where Normal has become a mere hypothetical, an ideal to strive for that no longer aptly describes any part of reality.

As Frances observes, we are conceptualizing an increasing number of traditionally normal behaviors as abnormal. Of course, there is inherent subjectivity in these terms, normal and abnormal. In fact, there may exist no such things at all. Think, for example, about the exercise that psychologist-philosopher William James (1901-1902/2002) proposes:

“Conceive yourself, if possible, suddenly stripped of all emotion with which your world now inspires you, and try to imagine it as it exists, purely by itself, without your favorable or unfavorable, hopeful or apprehensive comment. It will be almost impossible for you to realize such a condition of negativity and deadness. No one portion of the universe would then have importance beyond another; and the whole collection of things and series of its events would be without significance, character, expression, or perspective. Whatever of value, interest, or meaning our respective worlds may appear endued with are thus pure gifts of the spectator’s mind.” (p. 168; italics in original)

In other words, nature is neutral, uniform. But while we may view everything through our spectator’s mind, that is not to say we are wrong to conclude that some ways of living are more limiting than others or possess features that deserve careful attention. Introducing his now famous study “On being sane in insane places,” psychologist David Rosenhan (1973) assures us: “To raise questions regarding normality and abnormality is in no way to question the fact that some behaviors are deviant or odd. […] Nor does raising such questions deny the existence of the personal anguish that is often associated with “mental illness.” […] But normality and abnormality, sanity and insanity, and the diagnoses that flow from them may be less substantive than many believe them to be” (p. 250-251).

The tension between our desire to describe the world objectively and the inevitable fact that some subjectivity will always leak into any such attempt underlies a pair of comments by philosopher Bertrand Russell. On the one hand, “[what] we think good, what we should like, has no bearing upon what is.” At the same time, however, “we cannot be forbidden to value this or that on the ground that the nonhuman world does not value it” (1957, p. 54).

Thus, while normality and abnormality may not actually exist in nature itself, that does not mean we cannot divide reality into “that which is normal” and “that which is abnormal.” However, it is important to realize that if normality and abnormality indeed do not exist, it follows that how behaviors are divided is determined by systems that are artificial (some of which are, presumably, superior to others). Psychiatry embodies one such system, unique in that any behavior it defines as abnormal is also considered “sick.” Also, because there may not exist a physical boundary between normality and abnormality, it is only sensible that we investigate and acknowledge the value system that leads us to draw a clear-cut line between the two. That is, we must confess our positive and negative attitudes toward various ways of living.

What is Normal?

Dysart worries that ridding his patients of their abnormal behaviors entails stripping from them parts of their individuality, all in the name of Normality. But, there are many ways to be normal. Thus, contrary to what Dysart may believe, humans do not bow to one single God of Normal, but to a host of deities. Taking this into account, a close reading of the play suggests that the tormented psychiatrist is, in reality, only worried about sacrificing a) one particular subgroup of patients to b) one particular God of Normal.

Who are the Gods of Normal? To determine exactly which deities Psychiatry answers to, let us peruse the DSM-IV-Text Revision (TR; American Psychiatric Association [APA], 2000), a previous edition of which likely adorned Dysart’s bookshelf. I would argue that one can distill the behaviors listed in Psychiatry’s nosological compendium into three qualitatively distinct, but sometimes overlapping, categories. Each of these categories includes behaviors that offend (at least) one particular God of Normal.

One of the principle reasons why some are considered mentally ill is that they appear to be exceedingly miserable. Thus, one criterion for what counts as abnormal is the presence of suffering. I here refer mainly to psychic suffering (e.g., anxiety, fear, sadness), which I consider distinct from strictly physical suffering (e.g., a stinging wound). That is not to say, of course, that psychic suffering does not possess physiological qualities, nor that it may not arise in response to predominately physical suffering.

That being said, it is important to keep in mind that there exists no one-to-one connection between mental illness and internal suffering; as we shall see, many mental disorders entail no such thing at all. It is nonetheless true that some disorders refer entirely to behaviors that involve the experience of pain: for example, the depressive and anxiety disorders. But is it truly fair to characterize suffering as pathological? This belief suggests an indiscriminately positive outlook on life. Indeed, excessive sadness and anxiety can only be disordered if we accept that nature does not “mean” for us to ever be so emotionally incapacitated. I wonder, though: is not misery an integral part of life, right alongside pleasure? Arguing against a happy, optimistic outlook on life, which he refers to as healthy-mindedness, James (1901-1902/2002) reminds us:

“[There] is no doubt that healthy-mindedness is inadequate as a philosophical doctrine, because the evil facts which it refuses positively to account for are a genuine portion of reality; and they may after all be the best key to life’s significance, and possibly the only openers of our eyes to the deepest levels of truth. The normal process of life contains moments as bad as any of those which insane melancholy is filled with, moments in which radical evil gets its innings and takes its solid turn. The lunatic’s visions of horror are all drawn from the material of daily fact. Our civilization is founded on the shambles, and every individual existence goes out in a lonely spasm of helpless agony. If you protest, my friend, wait till you arrive there yourself!” (p. 182-183)

Following this passage, James goes on to describe in evocative detail several instances of natural horrors—for example, predators tearing the flesh off of a living victim—as evidence of the “evil facts” we must contend with in our world. To James, the widespread existence of meaningless suffering demonstrates that pain is an intrinsic part of nature, rendering any perspective that does not acknowledge this facet of reality inadequate.

You may be thinking: well, if pain is so integral to life, should then what we call “physical disease” not be referred to as pathological? It is true that many if not most physical disorders involve physical suffering. In the case of physical disorders, however, pain is merely a symptom of disease; it is not the disease itself. Take, for example, sexually transmitted infections, which are often asymptomatic: the infection continues to exist whether the infected person experiences discomfort or not. Thus, when pain occurs, it is a messenger; it signals the presence of a disruption in the regular functioning of the body.

Conversely, in the case of psychological disorders, suffering, when present, is often the disease itself. For example, there is no such thing as asymptomatic generalized anxiety disorder. If there is no anxiety, there is no disorder. Thus, when it comes to mental illness, without symptoms, there is no disease. Psychologist Gary Greenberg (2010b) explains: in medicine, “the symptoms of the disease are only the signs of the disease, not the disease itself. Except in psychiatry, where the symptoms constitute the disease and the disease comprises the symptoms” (p. 63-64). In other words, while in medicine disease and suffering remain separate (albeit related) phenomena, in psychiatry the two are one and the same. It is with this equation of suffering and disease that I object to: suffering can be a sign of disease, but not a disease in its own right, as Psychiatry insists.

But, could it be extreme psychic suffering (e.g., overwhelming anxiety or sadness) is actually a symptom of some as of yet undiscovered physical disease? At present, evidence for underlying pathology is not nearly as conclusive as some would have you believe. The APA itself rather candidly admits that “the field of psychiatry has thus far failed to identify a single neurobiological phenotypic marker or gene that is useful in making a diagnosis of a major psychiatric disorder” (Kupfer, First, & Regier, 2002, p. 33). Even were we to identify such an entity, there would still remain the problem of demonstrating that it is morbid, preferably independently of the negative qualities we assign to its behavioral product. After all, even behaviors not considered psychiatric disorders involve neurobiogenetic processes.

There are, on a fundamental level, many problems in likening psychological pain to physical disease. Should we assume psychic and physical suffering belong to the same category of human experience, that deep sadness about one’s self-worth is no different from an exercise-induced muscle cramp, and that the two are thus subject to similar modes of explanation? Can it be psychic suffering, like its physical variety, is existentially meaningless, that it has nothing whatsoever to do with our experience of a sometimes cruel world, and that it is merely an artificial product of brain chemistry gone awry? Are we to believe we were never meant to suffer that much at all, that humans have evolved in such a way that demands contentment be our status quo? To put it bluntly, to accept the idea that psychic suffering can ever be reduced to aberrant biology is to accept a “felicitous coincidence,” that we are “an organism designed for happiness in a land dedicated to its pursuit” (Greenberg, 2010b, p. 314).

It is true that there are instances of psychic suffering being caused by physical disorders. For example, Kottler (2000) relates the case of a client presenting with panic spells. No improvement came from psychotherapy, though not for lack of effort on either the therapist or the client’s part. It was later revealed that the client did not suffer from an “emotional coping skill-deficiency,” but from gas intoxication due to a furnace leak in his house. Situations such as these, though, only serve to show that behavior is grounded in biology, not that a given behavioral symptom amounts to a psychiatric disorder under ordinary, non-disease-induced circumstances. In essence, upon discovering the true cause of his panic spells, the client ceased to have a psychological disorder and was correctly diagnosed as having a physical disorder. This begs the question: in the case where behavioral patterns are explained entirely by a physiologically pathological cause, what value does Psychiatry provide? In fact, to discover a brain disease underlying all instances of, say, Panic Disorder would serve to discover a medical disorder, not validate a mental one. The disorder would exit the domain of Psychiatry, and enter that of Neurology (Szasz, 2007).

The poet Yevgeny Yevtushenko counseled his readers to reject “the vulgar, insultingly patronizing fairy tale that has been hammered into your heads since childhood that the main meaning of life is to be happy” (cited in Dawes, 1995, p. 277). Using science to make a similar point, psychologist Richard Bentall published in 1992 “A proposal to classify happiness as a psychiatric disorder.” The abstract to his article announces: “[The following review of the literature will show] that happiness is statistically abnormal, consists of a discrete cluster of symptoms, is associated with a range of cognitive abnormalities, and probably reflects the abnormal functioning of the central nervous system” (p. 94). While Bentall’s tongue rests comfortably in cheek, his writing remains straight and scholarly. This is a clever choice, leaving it up to the reader to decide whether happiness should be classified as a psychiatric disorder, or unhappiness declassified.

When we suffer, rarely do we do so for no reason at all. Often, suffering is a normal reaction (e.g., persistent nightmares) to an abnormal situation (e.g., a wartime experience). Simply, life has gotten the better of us. In fact, I would be worried if a client came to me having survived a brutal victimization, yet appeared completely unfazed.

Take, for example, the nameless, almost hidden disorder, numbered 302.9.3, which ends the DSM-IV-TR’s Sexual and Gender Identity Disorders chapter. Should the lure of the subsequent Eating Disorders chapter prove too great, you might just miss it. It is a disorder meant strictly for those upset by their sexual orientation. (In fact, before it became nameless, it was listed in a previous edition as “Ego-Dystonic Homosexuality.”) In this way, the DSM continues to pathologize same-sex sexual interest, despite having removed general Homosexuality from its pages in 1973. After all, it is certainly not heterosexual men and women that psychiatrists had in mind when inventing this modern variant of the retired disease. Let me be clear on this: those who suffer on account of their sexual orientation are not sick; the problem does not reside within them but within the environment continually taking aim at them. Since Psychiatry is so fond of labeling abstract entities, it should instead try its hand at society.

Suffering often arises from lack of skills. For example, depression may stem from rigid negative thinking. In fact, therapy seeks to impart clients with the type of abilities that allow them to overcome life’s challenges and participate in life actively, in the hopes that this will assuage their suffering. Sometimes, however, lack of skills itself is labeled a mental illness: for example, Attention-Deficit/Hyperactivity Disorder, or any learning disability. Thus, another criterion for what counts as abnormal is incompetence.

Is it fair to characterize incompetence as pathological? After all, “[we] do not expect everyone to be a competent swimmer, golfer, chess player, or marksman; nor do we regard those who play games poorly as “sick.” The activities that comprise being a student, parent, worker, etc. are, in many ways similar to the activities that comprise being a golfer or chess player. Yet, we act as if we expected everyone to play his own life games competently; and we regard those who play poorly—at being husband or wife, mother or father—as sick, “mentally ill”” (Szasz, 1973, p. 90). Further, lack of skills (e.g., poor math ability or bad hygiene) is rarely a problem in and of itself, but only becomes one when a person lacking certain skills finds themselves in a situation requiring these skills (e.g., at the bank or on a date). In other words, the problem lies not in the individual, but in the relation between individual and society.

To summarize, the DSM-IV-TR defines suffering and incompetence as abnormal. We have thus successfully discerned the first two Gods of Normal: Happiness and Competency. I have argued that while neither suffering nor incompetence is an ideal behavior, neither deserves to be considered diseased. This does not mean, of course, that we should not attempt to overcome unhappiness (without forgetting there is more to life than pleasure) or master the skills we happen to lack. Because I doubt Dysart is uncomfortable helping clients become more satisfied with and more proficient at life, it is unlikely he wishes to deprive the two aforementioned Gods of nourishment.

Rather, I think Dysart’s problem is exclusively with the third category of abnormality: social deviance. To clarify, the DSM-IV-TR does not officially recognize social deviance as abnormal: “Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual” (2000, p. xxxi). Despite this statement, many of the behaviors included within the manual’s pages are just that: deviant. Besides, as Moser and Kleinplatz (2005) rightfully point out, the “unless” clause—a major clinical cop-out—allows psychiatrists to disregard what came before and interpret “deviance or conflict” as sickness.

Is it fair, however, to characterize social deviance as pathological? After all, many socially deviant behaviors, while offensive to some (including those exhibiting them), are not inherently harmful to the self or others. Some men and women, for example, so identify with the opposite gender that they wish to be the other gender. While same-sex sexual interest is no longer considered disordered, psychiatrists nevertheless continue to stigmatize gender variance (Lev, 2006). Incidentally, the British Broadcasting Corporation (2011) reports that the Australian government has recently added a third gender category on its citizens’ passports: “indeterminate.” Thus, while the DSM-V Sexual and Gender Identity Disorders Work Group is hard at work on the new Gender Dysphoria disorder, the rest of society is busy normalizing it!

Likewise, many of us consider delusions and hallucinations as signs of pathology. In fact, the term “crazy” is often used to refer to those of us who have lost touch with agreed-upon reality. Yet, reviewing the literature on psychosis-like experiences within the general population, Bentall (2003, 2004) found that a considerable number of people not only report experiencing hallucinations and delusions during their lifetimes, but also living fairly happy lives without treatment. Thus, although unshared sensory experiences and unusual beliefs are more rare—but not as rare as we thought—than common, these deviant behaviors results in no harm to the self or others for many of those who exhibit them. Relatedly, social psychiatrist Marius Romme and researcher Sandra Escher (1993; see p. 7-10), who together instigated The Hearing Voices Movement, have suggested that there is nothing inherently problematic in, say, hearing a voice that reminds you of your failings as a person; the difficulty, instead, lies in one’s ability to cope with self-conversation (or what Szasz, 2002, calls minding) that involves not only silent, but also audible thoughts (for differences between copers and non-copers’ strategies, see Romme & Escher, 1989, and Romme, Honig, Noorthoorn, & Escher, 1992).

But, what of socially deviant behaviors that entail purposefully harming the self or others? Should we not consider those pathological? Back when the DSM-IV was being revised, Moser and Kleinplatz (2005) published an article pleading for the removal of the paraphilias (e.g., Exhibitionism, Frotteurism, Pedophilia, Sexual Masochism and Sadism) from the update. In it, the authors argue that while sexual behavior can certainly qualify as antisocial, it can never be sick. In other words, social deviance is never pathological, no matter how much harm it may pose on the self or society.

The Substance-Related Disorders chapter of the DSM-IV-TR represents one of the most glaring examples of the diseasing of antisocial behavior. (It is thus probably not surprising that it also represents the manual’s longest section; Greenberg, 2000b.) Let me state clearly: excessively and narrowly partaking in any single activity is not a sign of a balanced lifestyle. However, neither is this a sign of illness.

There is evidence that addiction, despite everything we know about “addictive substances” and their effects on the brain, may be more of a choice than we think (for a review of research negating the “irresistible impulse” hypothesis, see Fingarette, 1989, and Schaler, 2000). But even that is beside the point. The problem—and a particularly damning one at that—is that what counts as addiction in the first place is not a question of biology, but social values. The APA’s own values become more apparent when we consider that the following disorder is omitted from its manual’s pages: “psychotropic medication-related disorders.” I am not talking here about those of us who illegally consume mind-altering drugs, but those of us who are prescribed them by our family doctors or psychiatrists. After all, psychotropic drugs alter experience in the same way illicit varieties do. Why, then, does abusing the former render one “in treatment,” the latter “sick”? When we strip away the clinicized façade (i.e., state-endorsed, ritualized drug-intake), the prolonged consumption of psychotropic drugs becomes one more form of misuse, right alongside other less recognized, less supervised forms of misuse. It is only social values that make us decide whether one or both categories of excessive drug intake amount to mental disorders. Simply, we prefer the nature and consequences of one drug “addiction,” but not the other.

To reiterate, the DSM-IV-TR defines social deviance as abnormal. We have thus successfully discerned the third God of Normal: Social Convention. In so doing, we have also come across different subgroups of social deviants that offend this deity: those who cause neither harm to themselves nor others (e.g., transgendered individuals), those who voluntarily withstand harm or only cause harm to consenting others (e.g., drug misusers and sexual sadists), and those who cause no harm to themselves and harm to non-consenting others (e.g., child molesters). While I do not believe that any of these suffer from any sort of sickness, the third group strikes me as metaphorically sick: concerned with only their own needs and desires, at the expense of others’ welfare, members of this group are selfish and inconsiderate. However, they are only “sick” the way an economy can be “sick”: they represent the reality that egocentric and careless behavior will, more often than not, lead to harmful consequences.

Because I doubt Dysart is uncomfortable protecting society from harm, this leads me to conclude that he is most worried about a) sacrificing members of the first two groups of social deviants to b) the God of Social Convention. As we shall see next, Dysart’s worries are, in Strang’s case, unwarranted, because he has mistakenly categorized him.

Some of you will argue that I have been unfair in my treatment of the DSM-IV-TR, that many of the disorders I have mentioned cannot be diagnosed without the presence of distress or impairment in interpersonal, social or occupational areas of functioning. In other words, perhaps it is not the behavior itself that is the problem, but the fact that it causes negative consequences.

That is very considerate, but somewhat misguided. A host of behaviors can cause both distress and impairment but have not made it into the manual: engaging in extreme sports, being a social activist, living with parents as an adult, immigrating to a new country, eating fast-food every day, being in a relationship, starting a business, vowing celibacy. The only difference is that these behaviors are generally approved, or at least considered part of the “human experience,” and so the associated distress and impairment are considered acceptable fallout. Thus, it is not distress or impairment that signals psychopathology and warrants a given behavior’s initial inclusion into the DSM, but distress or impairment arising from behaviors we consider undesirable to begin with. Further, some disorders—for example, Delusional or Brief Psychotic Disorder—do not even include distress or impairment in their diagnostic criteria. Even when they do, and a given behavior refers to internal events (e.g., voyeuristic sexual fantasies), sometimes merely acting upon these can take diagnostic precedence (Moser & Kleinplatz, 2006). And so, it is no longer the distressing or impairing consequences that are the problem (since there might not even be any), but the behavior itself.

What of the many behaviors that involve suffering, incompetence or social deviance, yet are not considered disordered? I suspect psychiatrists shy away from applying their very own principles consistently, because carrying their conceptualization of abnormality to its logical conclusion would mean the end of their profession. Psychiatry would become the laughing stock of the Sciences, ultimately loosing its “franchise on our psychic suffering, the naming rights to our pain” (Greenberg, 2010a).

Dysart’s Mistake

Dysart is worried about sacrificing social deviants who cause no harm to others to the God of Social Convention. While his worries are legitimate, they do not apply to Strang. Dysart has committed a category error: he has incorrectly assigned his new patient to the former group, when he truly belongs to the group of social deviants who harm others.

I agree with Dysart: social deviants are not sick. Appropriately, the psychiatrist avoids medicalizing his patient’s behavior. For example, while Strang is tormented by his attraction toward horses, Dysart does not interpret Strang’s distress as a symptom of his “sexual disease.” After all, who among us has never been tormented by love? Whether or not love is directed toward an appropriate subject has absolutely no bearing on the authenticity of our distress when that love disappoints us. Unwilling to rely on psychiatric terminology to conceptualize Strang’s presenting difficulties, Dysart is thus faced with a challenge: how, then, should he describe Strang’s strange sexual obsession?

While searching for an alternate way of conceptualizing Strang’s difficulties, Dysart commits a common mistake: he romanticizes the difficulties instead. He idealizes Strang to the point of jealousy: he confesses he wishes he could know the passion his patient has felt. Strang’s sexual attraction toward animals, however, is not worthy of admiration. It is, after all, comparable to attraction toward children, in that in both cases the object of attraction is incapable of consenting to sexual activity. While most child molesters are probably quite passionate about children, I cannot say I would ever be jealous of such passion, even if I could somehow tease apart the feeling from the source.

In romanticizing Strang’s sexual interest, Dysart inadvertently transforms social deviance into its very own God (of Ab-Normal), describing Him as rare and beautiful. However, neither acceptable nor deplorable behaviors should be revered, for the simple reason that they merely constitute humans’ attempts to master life with the innate and learned tools at their disposal. As such, adding unnecessary levels of meaning to these behaviors, be they psychiatric or romantic, is simply foolish, not to mention un-parsimonious.

When seeking to make sense of his patient, Dysart had at his linguistic disposal a third option, favored by psychiatrist Thomas Szasz (1973): the type of plain language spoken by the educated layman, or secular humanistic language. The behaviors of those who choose to engage in sexual intercourse with children or animals are not sick, but terribly misguided and destructive. Their behaviors are not pathological, but illegal and immoral, since they do not involve relationships between consenting adults (of the same species). Child and animal molesters have no respect for the objects of their attraction, manipulating them to satisfy their own wants. I understand it must be terribly hard to curb one’s sexual interest, especially when there is no socially acceptable outlet for one’s particular brand of impulses. Nonetheless, there is no reason to believe that deviant impulses are, in and of themselves, any harder to regulate than normal ones (Szasz, 2007).

Of course, those entities espoused by speakers of humanistic language (e.g., “good” or “bad”) no more exist in nature than those espoused by speakers of psychiatric or romantic (or religious) language. Humanistic language is arguably superior to these alternatives, however, because it conceptualizes behaviors and relationships in terms of human needs, relying on a framework of secular morals that specifies what hurts us is bad and should thus be spoken of using derogatory terms, and what does not hurt us is good and should thus be spoken of using favorable terms. This approach would flip a medicalized statement such as “Eating disorders are highly comorbid with mood and anxiety disorders, and require intensive treatment” into “Those of us who over- or under-indulge in food are likely struggling with overwhelming emotions at the same time; one should strive to resolve these difficulties, since they distract from participating fully in life.”

Humanistic language is primarily practical: because our core concern as humans is to survive and thrive within reality, it is helpful to define the behaviors we use to orient ourselves within reality according to these needs. Such language is also parsimonious, avoiding any reliance on metaphors, which often taint our observations with superfluous (medical, quixotic or superstitious) content that distracts from what we really mean to say. (Of course, medical and quixotic language is warranted under certain circumstances; namely, when dealing with objects under the jurisdiction of medicine and the arts, like human bodies or bodies of art.) Another benefit of humanistic language is that it acknowledges human subjectivity: as its name implies, humanistic language is based upon our own subjectively human experience of the universe. No less, no more.

Dysart worries he will cause undue harm onto his patient’s individuality if he seeks to “cure” him of his sexual attraction to horses; and this, simply because he is different from the majority. This is honorable. Yet, as we have seen, there are at least three different types of social deviants. Dysart does not realize that his particular patient happens to fall into the group that constitutes a menace to others’ safety. When deviance harms, I believe it is our responsibility to help those acting upon their destructive brand of impulses to fulfill in pro-social ways whichever needs their actions are meant to fulfill (for a model of life change, or “rehabilitation,” based on such a principle, see Ward & Maruna, 2007). If we insist, we could even describe therapy whose aim it is to convince such individuals to adopt this same goal, and to teach them how to do so, as a necessary evil: necessary because it is the least restrictive strategy we have to protect vulnerable others, yet evil because it still restricts the freedom and autonomy of the harmful deviant.

Final Thoughts

At the beginning of Equus’ second act, Dysart asks himself: “[What] am I doing here? I don’t mean clinically doing or socially doing—I mean fundamentally! These questions, these Whys, are fundamental—yet they have no place in a consulting room” (Shaffer, 1973, p. 76; italics in original). It is essential to the integrity of our craft, professional helping, that we think long and hard about a) how we describe our clients’ behaviors, b) whether these behaviors deserve to be considered abnormal in the first place, c) whether, when reasonably deserving of the descriptor, these behaviors should also be considered pathological, and d) which of these “pathological” behaviors should be altered or downright eradicated. Ideally, these issues should be clarified before we even step into the consulting room. Psychiatry has weighed in, but has it painted humanity for what it is? While Equus may add a few unnecessary brush strokes of its own, it answers with a resounding No.

References

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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.

In a recent Wired Magazine article titled Inside the Battle for Mental Illness (2010), psychotherapist Gary Greenberg, author of Manufacturing Depression: The Secret History of a Modern Disease (2010), addresses the controversy surrounding the imminent release of the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-V). As indicated in a previous post, Allen Frances, the psychiatrist who chaired the task force that developed the previous edition (DSM-IV), fanned the flames of discord when he expressed a number of worries regarding the future manual. In his article, Greenberg explores Frances’ arguments, as well as other psychiatrists’ responses to them.

Greenberg forecasts that if the DSM-V is a critical failure, the mental health profession may never recover: “It could cause the [American Psychiatric Association] to lose its franchise on our psychic suffering, the naming rights to our pain.”

But, why all this pessimism? After all, the DSM-V heralds the much-touted debut of a dimensional approach to diagnosis. Rather than the more simplistic Is his personality disordered, or is it not? question, diagnosing professionals will now be able to address the more complex Where does he fall on a spectrum of disordered personality? question. Unfortunately, the excitement over this new approach appears to be unwarranted. In any case, its addition is ultimately obscured by the decision to retain the long-standing, but decidedly outdated tradition of descriptive diagnosis. Although medical diagnosis has long been about finding causes beneath effects (i.e., symptoms), psychiatric diagnosis has long been about describing effects without attention to causes.

In fact, the DSM is really nothing more than a compendium of checklists. This leads to circular reasoning: why does a person have depression? Because he has depressive symptoms. Why does he have depressive symptoms? Because he has depression.

The purpose of descriptive and etiology-based diagnosis is the same: use objective criteria to separate mental pathology from mental health. Promoting the potential within the new dimensional approach to diagnosis, Darrel Regier, the vice-chair of the DSM-V task force, envisions the discovery of what Greenberg calls the holy grail of psychiatry: “statistically valid cut-points between normal and pathological.” This vision of a more ideal future betrays the sad truth that our current understanding of where mental health ends and mental pathology begins is rather “fuzzy.”

Arguably, if psychiatry is to be taken seriously, it needs to become about more than effects; it must become about causes. Medicine has its diagnostic tests: blood tests, x-rays, etc. Apart from further checklists (i.e., questionnaires), psychiatry unfortunately boasts no such tests. However, this does not mean it is not rising to the challenge…

According to Greenberg, a new movement of research “has launched an effort to transform psychiatry into […] clinical neuroscience. This project will focus on observable ways that brain circuitry affects the functional aspects of mental illness—symptoms, such as anger or anxiety or disordered thinking, that figure in our current diagnoses.”

The bottom line of this movement of research: if we can pinpoint the neurological causes of mental disorders, we can establish what Regier believes to be the “absolute threshold” between mental illness and mental health. Thus, as Greenberg puts it, we will know for sure: is he ill or simply miserable?

Greenberg, however, appears skeptical that such a threshold will ever be discovered: “[A] new manual based entirely on neuroscience—with biomarkers for every diagnosis, grave or mild—seems decades away, and perhaps impossible to achieve at all. To account for mental suffering entirely through neuroscience is probably tantamount to explaining the brain in toto, a task to which our scientific tools may never be matched.”

While the thought sends shivers down my spine, I wonder if Greenberg is incorrect and the underlying biology of all human behavior will in fact eventually be mapped out. Let us pretend for a moment that this is achieved and that we find the biological causes of mental illness. Even then, would that truly prove the existence of mental illness? After all, psychiatrists are quick to say that attention-deficit/hyperactivity disorder is a real disease because the brains of those who suffer from it supposedly “work” differently (e.g., see Vincent’s Mon cerveau a encore besoin de lunettes: Le TDAH chez les adultes [My brain still needs glasses: ADHD in adults], 2009). But, this is interesting, because so do the brains of homosexuals (for a review, see Gulia & Mallick, 2010). Does that make them ill as well? Should we resuscitate the retired disorder of homosexuality?

Likewise, it is not unreasonable to assume that many other “unhealthy” behaviors (not considered mental illnesses) are biologically-based as well: excessive smoking, promiscuity, extramarital infidelity, racism, homophobia, murder, and so on. Should, then, these behaviors also be considered mental illnesses?

Let’s go a step further: what if individuals who engage in generally approved behaviors also show brain differences? Would they become ill should our approval vanish? Thomas Szasz wondered this in The Second Sin (1973): “Psychiatrists look for twisted molecules and defective genes as the causes of schizophrenia, because schizophrenia is the name of a disease. If Christianity or Communism were called diseases, would they then look for the chemical and genetic “causes” of these “conditions”?” (p. 102). Indeed, in recent decades, they have been and we did.

In God’s Brain (2010), anthropologist Lionel Tiger and neuroscientist Michael McGuire set out to uncover the evolutionary and biological underpinnings of religious belief. In fact, some studies have suggested that believers and non-believers’ brains “work” differently (e.g., Inzlicht & Tullett, 2010). These authors do not attempt to pathologize religion, but crossing that line is easy to do. In The End of Faith: Religion, Terror, and the Future of Reason (2004), author Sam Harris writes: “[It] is difficult to imagine a set of beliefs more suggestive of mental illness than those that lie at the heart of many of our religious traditions.” Similarly, in the conclusion to the documentary Religulous (2008), comedian Bill Maher calls religious belief a neurological disorder. Since these statements are backed up by “hard” biological neuroscience, I guess that settles it: religious belief is a mental illness.

Not so fast: religious belief (or atheism for that matter) is no more a mental illness than adolescent misconduct, depression, psychosis, pedophilia or borderline personality. In fact, none of these are illnesses at all; they are categories of behaviors. Whether we choose to call some “illnesses” and not others depends on whether the behaviors are regarded positively or negatively.

Back in 1973, Szasz quipped that “[we] will discover the chemical cause of schizophrenia when we discover the chemical cause of Judaism, Christianity, and Communism. No sooner or later” (p. 102). As we have seen, Szasz appears to have been wrong: we have begun and will continue to find the biological causes of all sorts of behaviors.

The point is: the mere presence of biological causes is not enough to support the presence of mental illness. After all, we are not made of fairy pixie dust. We are biological creatures, and so all of our behaviors, be they the source of pain or pleasure, have biological causes. Where there are behavioral differences, biology (always interacting with environment, of course) is necessarily at play; since brain and behavior are tied, differences in behavior can certainly be linked back to differences in the brain.

Several decades before the advent of neuroscience, in The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (1961), Szasz reasoned: “Pathological changes in the body, especially in the nervous system, cause abnormal behaviors. Hence, it is not unreasonable to assume that abnormal behaviors are due to pathological changes in the body. As we know, medical research has lent some support to this assumption—for example, in cases where “mental disorders” can be shown to be the consequences of infections, metabolic disorders, or nutritional deficiencies. However, the criteria for what behaviors count as abnormal are cultural, ethical, religious, and legal, not medical or scientific” (p. 296).

A further complication: if we say that brain pathology underlies mental pathology (and find proof for this), then the term mental disorder becomes obsolete. Psychopathology ceases to exist, and instead becomes neuropathology: “If mental illnesses are diseases of the central nervous system (for example, paresis), then they are diseases of the brain, not the mind; and if mental illnesses are the names of (mis)behaviors (for example, fear and avoidance of narrow spaces, called “claustrophobia”), then they are behaviors, not diseases. A screwdriver may be a drink or an implement. No amount of research on orange juice and vodka can establish that it is a hitherto unrecognized form of a carpenter’s tool” (from Szasz’s The Medicalization of Everyday Life: Selected Essays, 2007, p. 28). In other words, we cannot have it both ways: either mental disorders are really brain disorders, or else they are simply behaviors and thus not disorders at all.

Which is it then? As mentioned previously, while behaviors are biologically determined, they remain just that: behaviors. And which behaviors are considered to be abnormal (and thus which brain processes are considered to have gone awry) is entirely the product of social consensus.

Despite the numerous shortcomings, Greenberg does not deny it is useful to label certain behaviors as disorders. These labels mobilize social awareness and encourage developing resources to alleviate our human difficulties. At the same time, however, the patholigization of behavior increases “psychiatry’s intrusion into everyday life,” giving us “tidy names for our eternally messy problems.”

Personally, what worries me is that this intrusion is theoretically limitless, because the jurisdiction of psychiatry includes everything that we do, think, and feel. Indeed, everything that we are. In his article on the DSM-V, titled It’s Not Too Late to Save ‘Normal’ (2010), Frances expresses fears that the new manual will “extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal.” To be sure, psychiatry’s conceptualization of what constitutes abnormality is evermore taking over what most of us still consider to be normal. In The Myth of Mental Illness (1961), Szasz argues that while medicine discovers diseases, psychiatry invents them. This trend could prove disastrous, leading to the uncritical acceptance of all of our hardships as disorders. Let us then, both helping professionals and clients alike, finally assert ourselves and put a stop to psychiatry’s shameful attempt at medicalizing our everyday life… before it is, in fact, too late.

Additional references:

Gulia, K. K., & Mallick, H. N. (2009). Homosexuality: A dilemma in discourse! Indian Journal of Physiology and Pharmacology, 54, 5–20.

Inzlicht, M., & Tullett, A. M. (2010). Reflecting on God: Religious primes can reduce neurophysiological response to errors. Psychological Science, 21, 1184­­–1190.

Most are familiar with the story of the original sin. According to psychiatrist Thomas Szasz’s interpretation, Adam and Eve, in their infinite innocence, sampled critical thinking from the Tree of Knowledge. Preferring His creatures to be foolish and subservient, God promptly evicted them from His heavenly Garden. Szasz, however, identifies a second sin committed by humanity later in its history: having become critical thinkers, humans began to accumulate more and more knowledge, elevating themselves, along with their Tower of Babel, to godly altitudes. Jealous of this, God sabotaged humans’ intellectual ascent by confounding the one language they spoke at the time: the language of critical thinking. As a result of God’s interference, language was muddied and humans forgot how to speak clearly.

In The Second Sin (1973), Szasz reclaims the type of plain language that God and other authority figures—religious leaders, psychiatrists, politicians—so despise, by dedicating an entire book to the clear and simple discussion of a wide variety of human-related topics. Divided into thirty-four sections, The Second Sin features a collection of razor-sharp and often humorous aphorisms regarding subjects such as marriage, ethics, emotions, law, psychiatry and mental illness. Its sequel, Heresies, was released in 1976. Defining “heresy” as “being right when the right thing to do is to be wrong” (p. 1), Szasz continues to expose the truth behind topics historically distorted by so-called authorities.

In a way, The Second Sin is less about what is said, and more about the way it is conveyed. Indeed, the book is an experiment, an exercise in plain writing. To be sure, its goal is not to simplify, but to not complicate.

There are many advantages to speaking clearly. Szasz quotes 1984 author George Orwell, who explained: “If you simplify your English, you are freed from the worst follies of orthodoxy. You cannot speak any of the necessary dialects, and when you make a stupid remark its stupidity will be obvious, even to yourself” (1973, p.  xxi). However, Szasz adds, “[when] a person speaks or writes in political, psychiatric, or sociological jargon, he expresses himself with a certain indirectness and ambiguity; and like the hysteric, he dramatizes what he says as something profound, although it may be trivial” (p. 24).

This inappropriate use of language is dangerous, as the more language is used improperly, the more confusion ensues. And therein lies its power, for as confusion arises, so does the opportunity to dominate, since confusion incapacitates defenses. Indeed, “[in] the animal kingdom, the rule is, eat or be eaten; in the human kingdom, define or be defined” (Szasz, 1973, p. 20). In life, the opportunity to define embodies a rare commodity. Unfortunately, the most powerful among us have the ability to force the rest of us to adopt their definitions (even if these are one of many possible working definitions). In fact, “[those] whose social defenses are weak […] are most likely to contract invidious definitions of themselves” (p. 23).

This is not to say that there cannot be advantages to choosing to not speak clearly. The misuse of language can appease uncomfortable states, such as the angst inherent within the difficult questions of existence. For example, the concept of mental illness is often used to explain troublesome and seemingly incomprehensible breakdowns in individual and social human behavior. Indeed, “[mental] illness is a myth whose function is to disguise and thus render more palatable the bitter pill of moral conflicts in human relations” (Szasz, 1973, p. 98). Since mental illness is simply a metaphor meant to help us make sense of behavior, it is crucial that we do not confuse the metaphor with reality. However, the metaphor does confuse and distract: “[It] is precisely the technical idiom of medicine and psychiatry that stands in the way of recognizing and remedying these moral problems” (p. 30-31). (For more details on Szasz’ views regarding mental illness, see The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, 1961).

If the rhetoric of medicine and psychiatry is not appropriately suited for the task of describing humans and their experiences in accurate and constructive ways, which type of language should we favor? It is interesting to note that Szasz uses religious terminology to title both books: The Second Sin and Heresies. This begs the question: could we use the language of religion? On the contrary, psychiatry merely perpetuates the mistakes of religion: the former medicalizes (unacceptable behavior becomes mental illness) whereas the latter mystifies (unacceptable behavior becomes sin).

Indeed, in many of his books (e.g., The Myth of Psychotherapy: Mental Healing as Religion, Rhetoric, and Repression, 1978), Szasz observes that psychiatry appears to have replaced religion in modern society: we no longer kneel at the altar of God, but at the altar of Mental Health. (Some of us, of course, hedge our bets on both sides of the God/Mental Health spectrum.) Both concepts, incidentally, are symbolic representations of the same thing: the ideal human situation. In other words, religion presents a picture of ideal moral behavior, whereas the mental health system presents a picture of ideal healthy behavior. Yet, for some reason, we prefer to avoid labeling these behaviors simply as “ideals,” preferring instead to couch them beneath extraneous layers of meaning.

If not the language of religion, should psychiatrists simply adopt the language of their clients? Szasz counsels against this, arguing that either party’s attempts to impose his image of the world on the other is ultimately fraudulent because of their underlying motivations. In fact, a client’s claim that he will not venture outside his house because the world is a cruel place is no more accurate a description of his predicament than his psychiatrist’s contention that he suffers from something called agoraphobia.

Alternately, we could use anti-psychiatric language. Ironically, language that romanticizes mental illness (e.g., viewing “schizophrenia” as a transformative journey leading to untold insights) is as equally misleading as its psychiatric counterpart. Still, the romanticization of deviant experiences dates back centuries. In The 120 Days of Sodom (1785), for example, the Marquis de Sade details the sexual adventures of four libertine men, explicitly describing a wide variety of sexual crimes committed on a quest for hedonistic bliss. The resulting text is a narrative survey of different types and varieties of sexual behaviors, normal and deviant, in which people engage. By glorifying all that is sex, and doing so indiscriminately, De Sade infused sexual activity with meaning it does not inherently own.

Unfortunately, De Sade’s romantic take on sexual deviance was replaced 100 years later with psychiatrist Richard von Krafft-Ebing’s medicalized approach. In Psychopathia Sexualis (1886), Krafft-Ebing approached sexually deviant behaviors from a scientific point-of-view, attempting to survey, categorize, and explain them. By sanitizing and clinicizing all that is sex, Krafft-Ebing committed the same kind of crime against meaning that De Sade did. Approximately 80 years later, the anti-psychiatry movement, with psychiatrist R. D. Laing as its poster-child, attempted to reverse the tables on psychiatry by elevating the mentally ill to idealistic heights, much in the same way De Sade did with the sexually deviant. Resenting the suggestion that he is associated with this movement, Szasz rather affectionately titled his book on the subject: Antipsychiatry: Quackery Squared (2009).

In sum, the languages of religion, psychiatry and anti-psychiatry are equally unsuited for the task of describing humans and their experiences, adding extra layers of meaning that are not warranted and are potentially misleading. In regards to anti-psychiatric romanticization, however, I am inclined to think that its impact is less damaging than religious mystification and psychiatric medicalization: romanticization strips power away from the oppressor (i.e., the righteous, mentally healthy) and confers power upon the oppressed (i.e., the sinful, mentally ill), however misguided the exchange might be. While not perfect, at least this system of thought flips everything on its head.

Sadly, helping professions are wrought with misusers of language. This is not surprising, as modern psychotherapy is, to put it bluntly, the bastard offspring of the religious and medical schools of thought; as such, it is inevitable that its linguistic development suffered. Psychoanalysis is, in my experience, perhaps the biggest culprit, with its inscrutable layers of symbols upon symbols. Psychoanalytic language is also terribly conceited: when a client does not cooperate, we call it “resistance,” and when the client responds to the therapist the way he would to someone else, we call it “transference.” While not exempt from blame (think of the laughable term “cognitive restructuring”), cognitive-behavioral therapy fares somewhat better, limiting its range of terms to basic and more salient facets of human experience: cognitions, emotions, physiological reactions, and behaviors.

In his diminutive On Bullshit (2005), philosopher Harry G. Frankfurt explores the philosophy of bullshit in a suitably tongue-in-cheek fashion. According to Frankfurt, bullshitting is marked by an absence of concern for truth. The bullshitter, he explains, uses words to describe concepts without bothering to submit to rules of enquiry that may increase the accuracy of his descriptions. “[His] fault is not that [he] fails to get things right, but that [he] is not even trying. [The bullshitter]’s statement is unconnected to a concern with the truth” (p. 32-33). In this sense, the bullshitter stands apart from the liar because the latter is (at least) familiar with the truth; he merely chooses to misrepresent it. Indeed, bullshit may be objectively truthful; its supplier simply does not care.

Here’s a personal example: during a conversation with a colleague, she stated an argument as agreed-upon fact. When I asked if any research supported this perspective, she replied: “There must be.” That, readers, is bullshit epitomized. This is not to say that my colleague was wrong. In fact, she could very well have been right. Her argument was bullshit, however, because she did not care if her statements represented reality. What was more important to her in that particular moment was making her point.

Frankfurt identifies advertisers and politicians as bullshitters. But how about psychiatrists? If they have looked into the veracity of their truths (especially the extent to which they stem from and involve the proper use of language) and are convinced of them, they are neither liars nor bullshitters. I submit, however, that those who have never bothered to investigate and instead mindlessly adopted their so-called truths during their training qualify as bullshitters. Indeed, such psychiatrists are probably not concerned with truth to begin with, for “[the] bullshitter does not care whether the things that he says describe reality correctly. He just picks them out, or makes them up, to suit his purpose” (Frankfurt, 2005, p. 56). In the case of bullshitting psychiatrists, I suspect that purpose to be existential: they are unable to accept the drama of life, and wish to thwart its finality by elevating their life work (i.e., helping others overcome the drama of life) to the level of medicine, perhaps society’s most respected profession.

Following is an example of psychiatric nonsense: a psychiatrist teaching a course on psychopharmacology I completed during my own training once warned the class that psychotherapy, like medication, has its own side-effects. While this is metaphorically true, he said this without an ounce of lightness. He was, in fact, dead serious. That, to me, is bullshit. If that man had taken the time to think twice about what he was trying to say, he would have probably realized that beneath his metaphor laid a basic truth about relationships, such as the one between a therapist and his client: while some may prove helpful in overcoming difficulties, complexities inherent to relationship development may still obstruct the helping process.

If psychiatrists are full of (bull)shit, and clients’ own accounts of their experiences are potentially unreliable, how are we to describe clients and their experiences? Szasz (1973) proposes that “[a] dignified and humane understanding of man—his experiences and conflicts, his strengths and weaknesses, his saintliness and his bestiality—all this requires a rejection of the languages of both madness and mad-doctoring, and a fresh commitment to the conventional, disciplined, and artistic use of the language of the educated layman” (p. xx).

Thus, if I may be so bold to present my helping philosophy: when attempting to understand my clients and represent their experiences in my mind, I try to resort to the simplest terms possible. In addition to helping me better appreciate all that my clients are and want to be, refusing to add unnecessary levels of meaning helps me avoid confusing both myself and my clients. If my clients are not assaulted and incapacitated with deceitful language, they can correct me should my understanding be mistaken, affording them power and ownership in the process of reaching their personal goals. In the end, I believe my clients and I are better able to work together toward overcoming whichever difficulties trouble them. Of course, I am not immune to misuses of language, but I find it helpful to at least consciously strive to avoid committing semantic crimes. When one treads a thin line between sense and nonsense, he is often told: “choose your words carefully.” In an age when medicalized jargon has become the default, this maxim could not come more recommended.

As if the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) wasn’t enough of a travesty, psychiatrists are already hard at work on its successor. Although the DSM-V is still a few years away from publication, controversy over the next incarnation of the psychiatric bible has already arisen. Stricken with an apparent change of heart, Allen Frances, the psychiatrist who chaired the task force that developed the DSM-IV, has revealed that he is severely worried about the societal repercussions that the DSM-V may have come its release atop psychiatrists’ desks nationwide.

Frances rather candidly admits that the DSM-IV has done a disservice to society, by misleadingly labeling certain difficulties in living as mental illnesses, thus giving psychiatrists free reign over those “suffering” from these so-called illnesses. Should the recently released draft of the DSM-V be any indication of the final product, there is a serious risk that it may just end up doing the exact same sort of harm its predecessor has done… So watch out people: what is normal today might be pathological tomorrow. Come the advent of the DSM-V, we might suddenly find ourselves struggling with a mental illness we didn’t have the day before its publication!

For more details on Frances’ arguments, check out his recent article in the Los Angeles Times.

For a preview of the next DSM, head over to the American Psychiatric Association’s The Future of Diagnosis website.

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