Below, I present a fictitious conversation between a client and therapist. This dialogue is inspired by discussions with my clients about their experiences in the mental health system. It highlights a number of problems that are described at the end of this post.
Therapist: How are you?
Client: My house is on fire!
Therapist: I’m sorry to hear that. How are you feeling?
Client: I’m terrified! My dog is trapped inside! All my possessions are burning! What am I going to do?
Therapist: I understand that you’re upset. What’s going through your mind?
Client: I can’t believe this is happening! It doesn’t seem real. It’s like I’m dreaming or something.
Therapist: Do you also feel detached from yourself or your surroundings?
Client: Yeah, I feel like I’m in a daze. You hear about this happening to people but never think it can happen to you.
Therapist: I understand. These are common symptoms of Acute Stress Disorder. It’s a mental illness some people experience in response to a traumatic event.
Client: What do you mean mental illness? My house is on fire! My dog is trapped inside!
Therapist: I’m not saying you have a mental illness, only that you might have one. We’ll have to wait two more days and see if your symptoms continue before we know for certain.
Client: What symptoms?
Therapist: Symptoms like feeling unreal and being in a daze, and other symptoms like having upsetting memories and nightmares about the fire.
Client: Aren’t those to be expected?
Therapist: It’s normal to feel upset when something bad happens. But if you have a variety of symptoms that last for at least three days, and they bother you, then you may be suffering from a mental illness.
Client: Uh, okay. But what am I supposed to do? My house is on fire! My dog is trapped inside!
Therapist: Let me teach you some skills for coping with your negative thoughts and feelings. If you are feeling upset, breathe slowly and count to ten while thinking "relax." You can also tense and relax your muscles. Negative thoughts can be replaced by positive thoughts, like memories of funny movies or times when you were happy. You can also imagine your negative thoughts floating past you like clouds in a sky.
Client: Ok. But what am I supposed to DO?
Therapist: Practice your coping skills like we discussed. And come back and see me for another session as soon as possible.
Two weeks later...
Therapist: How are you?
Client: I’m devastated. My house burned to the ground. My dog died. I lost everything.
Therapist: Have you been feeling depressed?
Client: Of course.
Therapist: Have you felt depressed most of the day, nearly every day for the past two weeks?
Client: Since the fire, yes.
Therapist: Have you lost interest in things you used to enjoy?
Client: I guess so. I used to enjoy hanging out with my dog, watching movies, and surfing the internet. But my dog died and all my stuff was destroyed in the fire.
Therapist: How have you been sleeping?
Client: Terrible. I’m staying at a friend’s house on the sofa and their baby cries all night long.
Therapist: Have you felt fatigued or had low energy?
Client: Yeah, I’m tired all the time.
Therapist: Have you been thinking about death a lot?
Client: I can’t stop thinking about my dog. It must have been horrible for him to die in the fire. I miss him so much and can’t believe he is gone. He was my best friend.
Therapist: Have these symptoms been bothering you a lot?
Client: What symptoms?
Therapist: Feeling depressed, losing interest in things you usually enjoy, not sleeping well, loss of energy, and recurrent thoughts of death.
Client: I guess. I’m just really upset and don’t know what to do. I lost my whole life in the fire.
Therapist: I think I understand the problem.
Client: What do you mean?
Therapist: You’re suffering from a mental illness called Major Depressive Disorder, also known as clinical depression. You reported having five symptoms that have persisted for two weeks, and the symptoms are producing significant distress.
Client: Wait a minute. I’m feeling depressed because of the fire. I’ve lost interest in doing things I used to enjoy because I can’t do them anymore because of the fire. I can’t sleep because the baby screams all night long. I feel fatigued because I’m not sleeping. I’m thinking about death a lot because I just lost my best friend.
Therapist: It’s normal to feel sad when something bad happens, like a fire or the death of a loved one. But when symptoms of depression persist and become distressing or interfere with your life, that’s when we know a mental illness is to blame. But don’t worry, you’re not alone. Depression is the most common mental illness. It afflicts millions of people every year. And it’s not your fault: it’s not a sign of weakness or poor character. Depression is a brain-based illness caused by a chemical imbalance. It’s a real medical condition, no different than diabetes or cancer.
Client: I’m confused. Isn’t it normal to feel depressed after what happened? Why are you saying I’m mentally ill?
Therapist: Because your symptoms meet diagnostic criteria for Major Depressive Disorder in the DSM-5, our diagnostic manual. Good mental health literacy involves recognizing the symptoms of mental illness. In your case, that means understanding that things like depressed mood, difficulty sleeping, and recurrent thoughts about death are symptoms of clinical depression.
Client: So, you’re saying that thinking I am depressed because of the fire instead of a chemical imbalance in my brain means I have low mental health literacy?
Therapist: That’s right. It’s important to understand that mental illness is real, serious, and treatable. Understanding the facts about mental illness reduces stigma.
Client: It reduces stigma to say I’m mentally ill with a chemical imbalance in my brain?
Therapist: Yes. The best way to combat stigma is by having good mental health literacy. Understanding that depression is a real, treatable illness caused by a broken brain reduces stigma.
Client: But it makes me feel worse about myself to think my brain is defective.
Therapist: Would you look down on someone for having cancer? Would you blame them for being sick?
Client: No, I guess not.
Therapist: When people understand that you’re sick with a real medical condition, and that it can be treated, they will have less stigma toward you.
Client: Wouldn’t it be less stigmatizing to say I feel depressed because my house burned down and my dog died?
Therapist: But that shows low mental health literacy. Remember, depression is a biologically-based mental illness. And the good news is that we have effective treatments for it.
Client: What kind of treatments?
Therapist: Both medication and therapy can help. Antidepressant medications help correct the chemical imbalance that causes depression. Therapy provides emotional support and helps you learn coping skills for managing depressive symptoms.
Client: How do you know I have a chemical imbalance in my brain? Don’t I need to take a test or something?
Therapist: No, that’s not necessary. We can tell your brain has a chemical imbalance because your symptoms meet DSM-5 diagnostic criteria for Major Depressive Disorder. Although antidepressant medications are effective, they are only part of the picture. Many people respond best to a combination of medication and therapy.
Client: What does therapy involve?
Therapist: Therapy provides a safe space for you to talk about what’s on your mind each week. I will listen with empathy and no judgment and provide emotional support. I can also teach you skills for coping with your depressive symptoms. These include skills for reducing negative feelings, like slow breathing and muscle relaxation. You can also learn skills for reducing negative thoughts, like replacing negative thoughts with positive thoughts and watching your thoughts pass through your mind like clouds in the sky. Having a good relationship with a trusted therapist is the key to success.
Client: What do you mean by success?
Therapist: Having fewer symptoms of depression.
Client: How am I supposed to have fewer negative thoughts and feelings? My house just burned down and my dog died!
Therapist: That’s where the coping skills come in.
Client: But I lost everything. I don’t know where to go from here. What am I supposed to DO?
Therapist: I will refer you to a psychiatrist for a medication consultation. Let’s meet again next week for another treatment session. You can book it with the receptionist when you pay for today’s session.
The dialogue above highlights a number of problematic views and practices commonly encountered by clients in the mental health system:
1. Understandable psychological reactions to stressful events, even catastrophic traumas, are viewed as “symptoms.” In other words, they are seen as indications of disease. If enough “symptoms” are present for a sufficient period of time, which can be as brief as a few days or weeks, and they are distressing to a person, that person is pronounced “mentally ill.” Although some psychological distress in response to stressful life events is allowed, it becomes “mental illness” at the point where it meets DSM diagnostic criteria for a "mental disorder."
2. Once a DSM-defined “mental illness” has been diagnosed, the cause of the problem is located inside the client, more specifically in the client’s brain. An obvious environmental cause, like the fire described above, becomes largely if not entirely irrelevant. The problem is seen as a brain disease caused by a chemical imbalance. Notably, this chemical imbalance is not actually tested, nor does a valid test for it even exist. Indeed, the chemical imbalance theory is a scientific myth. But brain pathology is simply assumed to exist when a client’s “symptoms” meet DSM criteria for a psychiatric diagnosis. This is achieved by the reductionist argument that because the mind is what the brain does, a psychological problem is by definition a brain problem. This argument allows psychological “illnesses” to be diagnosed through the use of logic rather than objective tests as with medical illnesses.
3. Clients and their family members are encouraged to have good “mental health literacy.” This means adopting a biomedical model view of psychological experience. To have good "mental health literacy," the following beliefs are encouraged (among others):
4. High “mental health literacy” is promoted to reduce stigma. The goal is to reduce blame by reframing psychological problems as brain illnesses over which the sufferer has no control. Unfortunately, blaming the brain to reduce one type of stigma worsens other kinds of stigma. Consistent research findings show that blaming psychological problems on brain disease, faulty genes, or a chemical imbalance makes people more pessimistic about overcoming the problem, makes others less inclined to socialize with the “mentally ill” person, increases concerns that the person is unpredictable and dangerous, and fosters the view that the “mentally ill” person is fundamentally different from "normal" people. Strangely, “mental health literacy” advocates and organizations seem not to know, or care, about this research.
5. Psychotherapy that offers no structure or focus, teaches clients that negative thoughts and feelings are “symptoms” that need to be controlled with superficial “coping skills,” equates success with “symptom reduction,” fails to directly address pressing issues in a client’s life, ignores behavior, and is founded on the notion that a good relationship between therapist and client is all that is necessary for an optimal outcome, is routinely offered to clients and presented as “evidence-based.”
I frequently encounter clients whose journey through the mental health system involved exposure to all five of these troubling views and practices. Indeed, problems 1-4 reflect current best practice according to many professionals and organizations who promote "mental health literacy" and the DSM-focused biomedical approach to mental health “treatment.”
At the heart of this approach is the belief that DSM diagnoses are valid biological diseases. Although this belief is not scientifically supported, and is acknowledged as such at the highest levels of the scientific community (e.g., by the psychiatrist in charge of DSM-5), it nonetheless governs the mental health system and makes ridiculous client-therapist conversations like the one presented above possible. I deliberately chose a "house on fire" to underscore the absurdity of the dialogue. But I contend a conversation like this is no less absurd if one replaces a fire with an acrimonious divorce, the death of a loved one, sexual abuse, combat trauma, financial ruin, unemployment, or other stressors and life circumstances that prompt many clients to seek mental health services.
Problem 5 speaks to a pervasive quality control problem in psychotherapy. Many therapists are trained in a model of care that views unstructured, supportive talk therapy as "evidence-based" for most any psychological problem. Although many science-based therapies have been developed and rigorously tested for specific psychological problems, and are considered best practice for the delivery of psychological services, most therapists do not provide them and most clients do not receive them.
Although they may not "blame the brain" as often as psychiatrists, many psychologists and other therapists have also adopted the DSM-based biomedical framework in their work. They discuss their clients experiences as "symptoms," attribute them to diagnoses that are implicitly or explicitly understood to be valid "disorders" that clients "have," frame the goal of therapy as "symptom reduction," and to the extent their work has a particular focus, emphasize the use of "coping skills" to control or eliminate negative thoughts and feelings.
The underlying philosophy of this framework is healthy normality, which says that humans are by nature happy and content, and that psychological suffering is therefore abnormal and indicative of an underlying illness. Psychological "symptoms" (e.g., negative thoughts and feelings) are treated like physical symptoms (e.g., fever, sore throat): both indicate the sufferer is sick, and both are meant to be eliminated. Therapists teach their clients "coping skills" for reducing "symptoms" with the goal of achieving good "mental health." Within this approach, the paragon of psychological health is a person with no negative internal experiences. Personally, I find it difficult to imagine that such a person could exist. If such a person did exist, I imagine he or she would be extraordinarily sheltered, naive, and boring.
I hope this post raises awareness about problems in the mental health system and encourages efforts to fix them. Any such efforts must begin with critical analysis of the widely accepted but scientifically unsubstantiated notion that DSM diagnoses are brain diseases. Our society and mental health system desperately needs an alternative approach to understanding human psychology and addressing psychological problems that is founded on rigorous science rather than the potentially harmful pseudoscientific ideas and practices described above. The reason why is simple: mental health outcomes have dramatically worsened as the DSM-based biomedical paradigm has come to dominate how we approach psychological problems, and compelling scientific evidence suggests the paradigm itself is worsening our psychological well-being.
Note: This blog was also posted at Mad in America.
Analysis of mental health practice, research, theory, and policy from the perspective of an American scientist-practitioner clinical psychologist in Australia.