Action Without Vision
More mental health/psychology-related stuff here, so feel free to skip if that’s not your thing. I promise that’s not the only thing I’m going to talk about here, but there’s some interesting stuff happening right now and it’s been on my mind.
This ended up being quite the long one again, so I’m splitting it in two …
The truth about mental health is that the causes of all of the mental conditions you hear about are unknown, and the idea that “hidden diseases” lurk behind human suffering is an out-and-out failure.
― Steven C. Hayes, A Liberated Mind: How to Pivot Toward What Matters
We talked a bit previously about taking a “categorical” rather than “dimensional” (or transdiagnostic) view of mental health and suffering. The other day I picked up Beyond the DSM: Toward a Process-Based Alternative for Diagnosis and Mental Health Treatment, as well as Process-Based CBT: The Science and Core Clinical Competencies of Cognitive Behavioral Therapy, both edited by Steven Hayes and Stefan Hoffman, and while I haven’t fully dived into either yet, I’ve started to get what I think is a good feel for their core arguments, and I think they offer a more precise language to talk about why the disease model of mental health/illness is actually harmful, and maybe why self-identification with a diagnostic label isn’t all that helpful either.
So, I’ll get this out of the way: a few weeks back, I decided to finally check out TikTok. My thoughts are, well, mixed, to say the least, and I’ve become fairly convinced that I probably have ADHD, something I’ve wondered on and off for years but never really put a whole lot of stock in. See, TikTok—without me giving it almost any inputs in the form of likes (other than saying “no thanks” to a bunch of conservative “humorists”)—started delivering almost entirely mental health-related content to me. Which is definitely concerning, regarding what these apps must know about me through the sharing and selling of my data, but it was also interesting to watch how the mostly younger users of TikTok talk and teach about mental health. My big takeaway is that everyone on the clock app has ADHD, and most of them are on the autism spectrum, whether self-diagnosed or having gone through more formal testing by a psychologist. That’s kind of a joke and kind of not. Regardless, I am all for spaces to have these kinds of discussions and build community. But I do worry about the zeal with which some folks seem to turn these diagnostic labels into full-blown identities.
There’s a reason we do this. As someone who, in their early twenties, was diagnosed with bipolar II disorder after over a decade of responding poorly to depression treatments, I know the relief that a diagnosis can bring. I know how a correct (resisting the air quotes around that word) diagnosis can be explanatory in a way that nothing else has been so far, and how it can guide treatment that is actually helpful rather than at best doing nothing and at worst actively causing harm. And I mean, definitely thinking, oh hey, maybe I have ADHD made some things click into place for me.
There are also underlying psychological principles at play. In A Liberated Mind, Steven Hayes details six core yearnings that are inherent to all humans and which underlie nearly all human behaviors. I’m not going to go into all six, but I think there are two that really help explain our need for self-labels and identities. (The other four have a role to play here as well, but these two are the most directly implicated, I think.)
First, we yearn for coherence—we want the world and our place in it to make sense. Because of this, we impose order upon the world; when this order and meaning are violated, it causes us pain. Identities are one way of imposing this order, of saying “this is who I am, and this is how things are, and this is my place, and it makes sense.” We feel safe when we have coherence, and a diagnostic label that explains why we are the way we are (and how we fit in with the world because of it) gives us a feeling of psychological safety.
We also yearn to belong. Humans are, by our nature, social creatures. We come out of the womb wired to connect. From an evolutionary standpoint, if the children of early humans didn’t make those connections with their caregivers, they were not likely to survive. And if the adults didn’t fit in with the in-group, well, that probably wasn’t going to end very well either. And so we build identities around these in-groups (or have them imposed on us): everything from your circle of friends to subcultures to social constructs like race and gender to nation-states. Our in-groups are considerably more complicated than they were 200,000 years ago, however.
If we buy the evolutionary principles, identity-making is, by necessity, a rather inflexible process. There is no need for nuance—you are either part of Tribe A or Tribe B, and the one you’re a member of keeps you safe, and the other wants to take all your resources and doesn’t care if you end up dead because of it. For the vast majority of us, this is not the world we live in. This is a world of complexity and moral grey areas and “no ethical consumption under capitalism.” Our natural tendency toward identity-making causes us problems in a complex world, so when we find a community to belong to that helps to flatten that complexity, it feels rather like home.
An acquaintance on Facebook posted a status update a few days ago, discussing their reaction to a friend excitedly sharing the news that they were likely on the road to getting a diagnosis. My acquaintance rightly identified that sharing this reaction with their friend was probably inserting their opinion where it wasn’t appropriate and may not have been appreciated. There is a tension, of sorts, because we can see how diagnosis can be useful, but also worry that categorical approaches (which I will call “syndromal” from here on out) are constructs with which over-identification can cause problems. No one wants to tell their friend who was just diagnosed with, say, complex posttraumatic stress disorder (not a diagnosis in the DSM, for what it’s worth) or ADHD or borderline personality or whatever else that their diagnosis is a socio-medical construct based on perceived clusters of symptoms. It’s not a “disease,” certainly not in the way cancer is a disease, and, as my acquaintance put it, isn’t a metaphysical truth about oneself, either. It’s a flattening of complexity.
Elsewhere on Facebook, someone shared an article by a disability advocate called How CBT Harmed Me: The Interview That the New York Times Erased. It was a compelling read that highlights the ableism that is often present in those treating (or paying for the treatment of) chronic pain and other disabilities, and how mental health technologies (like CBT) can actually be incredibly harmful. The author discusses CBT as being “victim-blaming,” “based around gaslighting,” “all about telling a patient that the world is safe, bad feelings are temporary, and [pain] is a … distortion of thinking.” Readers, you may not be surprised to learn that I’m at least somewhat sympathetic to this view of CBT; I’ve written a bit about my problems with traditional CBT here and on Twitter.
Many of the comments on the page that shared the article were in agreement; many people discussed their own bad experiences with CBT, not just in the treatment of chronic pain, but in the treatment of depression, anxiety, trauma, and so on. And those comments had even more likes, suggesting a great number of people agreed: CBT ain’t shit.
There was a lone dissenter, however. Someone who pointed out that the article, and many of the replies to it, were flattening the complexity of treatment protocols. And, of course, he was right. He was right to say that CBT is in fact a very broad umbrella, not just one particular treatment approach; there are many CBTs, including DBT, ACT, and many others. He pointed out that what unites the various CBTs is the idea that targeting your thoughts can be useful in trying to change your emotions and your behaviors. That they don’t all frame things as “cognitive distortions” or “faulty thinking.” That the underlying model is based on the idea that thought, feeling, and behavior interact, and that addressing one can affect another.
He was right to point out that the manualized treatment protocols we are talking about when we talk about CBT don’t make up the whole of CBT. But, as I felt compelled to point out, there is a reason why so many people discuss having bad experiences with CBT. The widespread popularization of CBT as a manualized treatment protocol that (seemingly) requires little to no specialized training and which is sometimes the only thing insurance will agree to pay for has done massive harm, both to clients—who are often recipients of a CBT that victim blames, pathologizes, and assumes a “healthy normal” to which we all should aspire—as well as the wider umbrella of cognitive-behavioral therapies. The conversation then shifted into a wider discussion of why this is, implicating capitalism and for-profit healthcare, poorly trained clinicians, an overall lack of education about treatment protocols among referral sources, and so on.
But there’s something else at play here, too.
If the syndromal model of mental illness is incorrect and unhelpful, what are we supposed to be doing? What’s the way forward? Previously I talked about taking a “dimensional” (and transdiagnostic) approach that views symptoms as being on spectrums, and focusing on whether it was causing you problems rather than whether you meet the categorical definition of a syndromal diagnosis.
I was close, but missing a piece of the puzzle.
The syndromal view suggests underlying disease or disorder—each syndrome (collection of symptoms) has its own etiology. But this doesn’t actually make any sense—why do so many syndromes, then, have overlapping symptoms? Why is differential diagnosis so complicated at times? Why can it be difficult to know whether someone’s executive dysfunction is caused by autism, or ADHD, or bipolar disorder? Why are there so many that suffer from the symptoms associated with these syndromes while not meeting the criteria to actually be diagnosed with them? The APA itself wrote (in 2002, a full decade before the publication of DSM-5) that their approach of researching and refining syndromes was unlikely to ever uncover the etiology of the disorders their manual classified and helped to diagnose. Of note, DSM-5 made a rather halfhearted attempt to address this by suggesting (but not implementing) a dimensional approach to diagnosing personality disorders.
This is a big problem! And one that’s haunted psychology/psychiatry for generations. Yes, there are medical syndromes and disorders that have unknown etiologies. But this is the case for nearly all of the disorders in the DSM. Objective lab tests can’t tell the difference between one psychiatric disorder and another. There are shared neurobiological features between disorders, and the medications that treat these disorders are nonspecific (why can you treat bipolar disorder with anticonvulsants or obsessive-compulsive disorder with atypical antipsychotics?) without clear biological pathways or mechanisms for change.
This is the case for talk and behavior therapies, as well. We don’t actually know why CBT works for a wide range of psychiatric disorders. We are pretty sure that, for example, the eye movements and/or bilateral stimulation in EMDR does absolutely nothing, meaning whatever works about it is probably an element shared by other “gold standard” trauma treatments, but we can’t say with certainty what that shared element is. (It’s probably exposure.) We do know that the single most important factor in successful treatment is the therapeutic relationship, but again, we don’t actually know why.
Part of me wants to say, well, if it works, who cares why? Why does it matter? And in fact, I have said exactly this about treatments like EMDR in the past. But it matters because if we know the mechanism of change, we can create more successful treatments, ones that target the right things and ditch the extraneous and nonessential bits. Treatments that can help people more quickly, freeing up openings in previously overstuffed caseloads, getting people who are suffering off of waitlists and in front of a therapist who knows that what they’re doing is helpful, rather than adhering strictly to inflexible protocols or throwing everything at the wall and hoping something sticks.
And this is where process-based therapy comes in.
Thanks for reading! You can expect part 2 in the coming weeks. The upcoming Thanksgiving holiday here in the US is a fraught one, but please do know that I’m grateful for each and every one of you that takes the time to open these emails and give them a gander. It means a lot to me.
j.