No, You Don’t Have a Disorder. You Have Feelings

The London Times recently carried a story about an avalanche of self-harm among British school children. According to the article, “school nurses are dealing with panic attacks, self-cutting, overdoses and eating disorders rather than the nose bleeds and minor accidents of a decade ago.” The government is responding with calls for additional resources for mental health in schools, but will this address the problem? Writing in the British Medical Journal’s blog earlier this year, UK psychiatrist Derek Summerfield noted that anti-depressant prescriptions have increased from around 9 million in the 1990s to 64.7 million in 2016—without any convincing improvement in mental well-being.

Summerfield deftly characterizes the self-reinforcing tendency that comes with the medicalization of emotional pain:

When the medicalization of everyday life and the commodification of “mind” is professionally endorsed and taken up by wider culture, the language of psychological deficit is inserted into the public imagination. People come to see themselves not as normally stressed, but as “ill,” with negative emotion recast as a mental health problem. As more resources for mental health services are called for and provided, more are perceived to be needed, an apparently circular process, a dog chasing its tail.

Summerfield is not the only one. In his 2012 book Psychology’s Ghosts: The Crisis in the Profession and the Way Back, eminent Harvard psychologist Jerome Kagan deplores the explosion in psychiatric diagnosis, and our tendency to conceptualize normal human suffering as disease. Kagan contends that the misapplication of the biological model of disease has led us to pathologize ordinary emotions. “A mental illness is assumed to be analogous to malaria. If, however, most humans experience at least one serious, although temporary, bout of depression or anxiety during their lifetime, it is not obvious that these states reflect abnormal brain profiles produced by deviant genes.” He quotes a line from Beckett’s play Endgame: “You’re on earth, there’s no cure for that.”

When we construe normal feeling as illness, we offer people an understanding of themselves as disordered. This has the unintended consequence of encouraging people to be stuck in a limiting narrative. A young woman in my practice has had to take several leaves of absence from college due to what she terms “anxiety and depression.” She had been working toward completing several credits this semester, culminating recently in final exams. Reporting on her finals, she told me that she had had “a panic attack” during the first exam. Based on this experience, she had been extremely anxious about attempting the second exam and had asked for an incomplete instead.

When patients come in with pat summaries of their inner landscape couched in psychiatric waffle, it is usually an indication that they are stuck in their story. I asked this young patient of mine what in fact had happened during the first exam? She responded again, I had a panic attack. I lightly pressed her to move beyond the jargon and tell me about her actual experience as she took the exam. Eventually, she was able to tell me that, as the papers were being handed out, she become flushed and light-headed. Her heart was pounding, and her hands felt clammy. What happened then? I asked. She felt like running out of the room, but she was able to calm herself down enough to take the test. Though she successfully completed the first exam—and did okay on it—the fear that she might have another “panic attack” had prevented her from attempting the second exam.

What had happened here? One way of understanding this young person’s experience is indeed that she had had a limited-symptom panic attack. According to the diagnostic criteria for panic attacks in the Diagnostic and Statistical Manual of Mental Disorders (DSM), a limited-symptom panic attack can be diagnosed based on a pounding heart, sweating, and shaking. Of course, as anyone knows who has ever taken an exam, performed in front of an audience, or asked someone they like out on a date, these are in fact utterly normal reactions to feeling nervous. I gently attempted to reflect this back to my young patient. “So you were nervous about taking the exam, but you didn’t run out of the room. You did it. You pushed through the fear feelings.” I wanted her to see this as a success, one that she could build on, that could help alter her stuck story that tells her she is too anxious to function adequately. Her response to my positive reframing was telling. She looked up at me from under her brows and held my gaze. “Yes,” she responded firmly. “But I had a panic attack.”

Her relative triumph in finishing the semester and taking the one exam was undone by her firm commitment to the narrative that she had had a panic attack. The belief given to her by the psychiatric establishment and our culture’s enthusiasm for reductive diagnosis made her construe what happened to her in the first exam not as the success that it was, but as confirmation that she was, in fact, ill. Here was a case in which the process of diagnosis and treatment had concretized the story, arguably making transformation less likely. As of this writing, it remains to be seen whether she will be able to finish the incomplete and get the credits she worked for all semester.

I found myself wondering where she had learned that she ought not to be expected to tolerate ordinary distress or discomfort. How have we come to the point where we believe that emotional disquiet will cause harm, that we ought to be soothed and tranquil at all times? In fact, we know that children raised by parents who engage them in challenging experiences suffer from less anxiety, not more.

I was reminded of King Theoden and the insidious council of Grima Wormtongue in Tolkien’s Lord of the Rings. Grima has been acting as advisor to the king, but, in reality, he is in league with the forces of corruption and decay. As Theoden’s councilor, he whispers fear and distrust into the King’s ear, encouraging him to shun bold action and to stay safe inside his great hall. He appropriates the King’s sword and conspires to have the King lock up his devoted son. Whereas Gandalf calls Theoden to rise up and face the growing threat to his kingdom, Grima encourages Theoden to rest and play it safe. Grima Wormtongue seems to me to be a perfect metaphor for our own fears, and the ways in which treatment that lacks a broader imagination can actually make us more infirm.

Michael Pollan’s research into psychedelics and their potential use in the treatment of emotional distress provides a fresh perspective. In his recent podcast with Sam Harris, on his new book How to Change Your Mind, Pollan makes a remarkable statement. Psychedelics seem to provide the most benefit for those illnesses in which people are trapped in unhelpful narratives. “The ego is stuck in these stories,” says Pollan. Substances like psilocybin seem to work because “they dope slap people out of their stories.”

Pollan’s observations may provide a clue as to why traditional conceptualizations of mental illness tend to be self-reinforcing and create more illness. Much mental suffering results from being stuck in a story about ourselves. When we take the story at face value, we risk reifying and reinforcing it, when what heals and transforms is anything that allows us to shift our perspective and transcend the narrow, ego-bound experience of ourselves.

Psilocybin and other psychedelics appear to offer such experiences, but there are other ways to access this perspectival shift, and I suspect that taking psychedelics is not in and of itself a guaranteed way to attain this. The ego cannot manufacture such an experience. It cannot be forced by another, and it is not available in pill form—at least not yet. What is required is a degree of receptivity to that which is other-than-ego.

Such an attitude can be cultivated. Travel has a way of altering our sense of ourselves and the world, especially when we travel alone, or in a way that thrusts us out of our comfort zone. The perspectival shift afforded by travel has long been recognized intuitively, and is now being validated by research. The ability to relate to something larger than oneself cultivated by religious practice may be responsible for the apparent mental health benefits of adhering to a faith. Reading novels allows us to inhabit the emotional landscape of a fictional other and can therefore aid us in perspective taking. Dreams offer a nightly opportunity to engage a radically other-than-ego perspective.

Finding this perspectival shift can move us beyond the tired, oft-rehearsed stories about ourselves that our egos know so well, and into the realm of the implicit and not yet known. Philosopher Eugene Gendlin discovered that positive outcomes in therapy can be predicted by a single variable—the degree to which the patient struggled to find words. Patients who got better in therapy were more likely to pause and grope for words or images. According to my understanding, these behaviors are an indication that the patient is not stuck in the ego’s story, which is well-known and does not require any effort to formulate. She who pauses and reaches uncomfortably for new words is working at the edge of the known, toward the larger, unspoken tale that lies beneath our conscious understanding.

Simply being able to access this larger-than ego perspective can transform seemingly intractable problems, as Jung knew. “All the greatest and most important problems of life are fundamentally insoluble … They can never be solved, but only outgrown.” The implications of this statement are profound. Jung is saying that life’s greatest problems can never be solved on their own terms. They can only be resolved by broadening our perspective—that is, by changing our relationship to them.

Conversely, when life problems are addressed only from within the impoverished terms set by a medicalized approach to distress, difficulties become concretized. We become locked in the narrow perspective of the story and cannot escape. Any treatment that takes a too literal approach is likely to strengthen that story, validating our own belief in our sickness and keeping us stuck. An overly concrete attitude toward our inner life causes petrification—as in a fairy tale, things harden and turn to stone.

Much of our current approach to distress and dysfunction does precisely this. It fixes our understanding of our suffering as having a concretized, biological basis, a brain disease for which medication is the answer. Hence my young patient is asking herself whether she needs to up her dose of anti-anxiety medication, although she is already taking enough to experience uncomfortable and even potentially debilitating side effects. Confirmed in the belief that she is quite ill, she has begun questioning whether finishing her degree is a realistic goal. Becoming attached to a narrative of victimhood or illness closes off an imagination of who she might be.

Those of us in the mental health profession ought to be in the business of helping people to see themselves as having the potential to be well and whole. We should help them understand themselves as resilient, rather than infirm and frail. We ought to help people imagine larger, richer, more complex stories for themselves, rather than simplistic narratives of illness and victimhood.

The clinical vignette has been substantially altered to protect privacy.