Conventions

Key concepts - you will be responsible for knowing a number of definitions of key concepts. You may be asked to give an accurate definition and example of any of the key concepts. Key concepts are in italics, bolded and colored red throughout the notes.

Discussion questions - the lecture notes contain three discussion questions. These are to be answered on Blackboard at the times given in the syllabus.

Critical points - there are some points that require extra emphasis because they are fundamental to the example or concept being discussed. Critical points are bolded, in italics and colored orange.

Course learning objective questions - These are the questions given in the learning objectives document.

What is Mental Illness

What did Thomas Szasz say about the concept of mental illness? Discuss his view and how it differs from the current view in psychology today. In your answer be sure to be clear to distinguish between cause, criteria and symptoms of disease.

 

In this lecture we deal with perhaps the most important critical issue in modern psychology.

 

The Nature of Mental Illness

As your text says many times throughout, it's important to understand that schools of thought in psychology have always had opponents. Even at the height of the behaviorist era, for example, there were opponents to behaviorism. Earlier in the course, we read a paper written by William McDougall in which he vigorously disagreed with Watsonian behaviorism and correctly predicted that the school of behaviorism would fail.

Current schools of thought in psychology are no different. Today, for instance, there exists opposition to the tendency to view mental phenomena as brain phenomena. As has always been the case, however, much of the boisterous disagreement is kept out of mainstream psychology and psychology undergraduate programs. As a course in our history, however, we must at least make ourselves aware that dissension does exist. We should also at least consider the reason for this dissension so that we do not repeat history and adopt new ways of thinking without taking existing objections seriously.

I'd like you to watch 2 short videos before looking carefully at the problem of mental illness. The videos are rather scathing attacks on the current trend to view psychological disorders as illnesses. This trend is supported by people like Patricia Churchland (recall the Churchland video from earlier in the course) who thinks that since the brain is all that exists, psychological disorders are merely brain illnesses.

Now, these videos are tough. The attacks are pretty strong. We will go over them both carefully because I want you to understand exactly where the disagreements come from historically and methodologically. When you see the historical and methodological reasons for the disagreement, I think it will help you understand the issues much better.

The first video is of a Dr called Thomas Szasz. Szasz is a very famous psychiatrist that is mentioned in a large number of psychology text books. It's unlikely you will go through an undergraduate degree in psychology today without hearing about Szasz. Let's watch....

 

 

 

I told you they were tough! Now lets sort this out.

What are the videos saying?

1) ADHD and all other mental disorders are not illnesses.

2) The result of calling them illnesses is the inappropriate prescription and use of drugs such as Ritalin or Prozac.

3) This practice is a fraud/lie perpetuated by psychiatrists and drug companies on their patients and society.

Let's look at each point in turn.

Point 1: The point here is that mental disorders are behavioral or psychological problems and diagnosed on the basis of behavioral criteria. A person that has been diagnosed as having ADHD has been identified as having a behavioral problem not a physiological problem. How do we know this? Because no physiological test for ADHD is ever done. Why? Because ADHD is not, in fact, a physiological/biological condition.

So this seems reasonable, why don't all academics think this?

Because:

what you think ADHD is

depends on

which method of determining what ADHD is,

that you think is correct.

Let's go through each of the four methods of determining what something is that we have seen in the course:

1) Aristotle's method: The true nature or essence of ADHD is given by the particular metaphysical theory one holds about the nature of psychological phenomena. If one theorizes that psychological phenomena are brain phenomena, then it appears ADHD must be a brain phenomena of some kind. Now, since ADHD is undesirable, it makes sense to suggest that the brain phenomena that ADHD is, is a disease or illness of some kind.

2) Operationism: What ADHD is, is given by the operational definition of ADHD. The operational definition of ADHD is given in DSM V. DSM V defines ADHD as:

i) A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development

The symptoms of inattention are:

a) Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
b) Often has trouble holding attention on tasks or play activities.
c) Often does not seem to listen when spoken to directly.
d) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
e) Often has trouble organizing tasks and activities.
f) Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
g) Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
h) Is often easily distracted
i) Is often forgetful in daily activities.

The symptoms of hyperactivity are:

a) Often fidgets with or taps hands or feet, or squirms in seat.
b) Often leaves seat in situations when remaining seated is expected.
c) Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
d) Often unable to play or take part in leisure activities quietly.
e) Is often "on the go" acting as if "driven by a motor".
f) Often talks excessively.
g) Often blurts out an answer before a question has been completed.
h) Often has trouble waiting his/her turn.
i) Often interrupts or intrudes on others (e.g., butts into conversations or games)

ii) Six or more of the symptoms have persisted for at least six months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities. Please note: The symptoms are not solely a manifestation of oppositional behaviour, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), five or more symptoms are required

iii) Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years

iv) Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g. at home, school, or work; with friends or relatives; in other activities)

v) There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic or occupational functioning

vi) The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal)

Since none of the criteria for ADHD given in DSM V are illnesses or diseases (they are behavioural and psychological, not pathological or physiological), ADHD is not an illness or disease.

3) Construct Validity Theory: What ADHD is, is given by the network of empirical findings related to the construct of ADHD. We know that:

a) Chemical manipulations of the brain through the administration of medications (for example, amphetamines) reduces the symptoms of ADHD in some cases. This is EVIDENCE that ADHD is physiological...it is a physiological abnormality of the brain.

b) Studies suggest that there are differences in brain structure an function between GROUPS of children with ADHD and GROUPS of children without ADHD. This is evidence that ADHD is a structural brain defect.

Results like these give empirical support to our THEORY that ADHD is a disease or illness.

4) The Ordinary Language View

ADHD is an operational definition of psychological and behavioural states/conditions that are denoted by the existing ordinary language terms: impulsive and hyperactive. In the English language impulsivity and hyperactivity denote behavioural and psychological states/conditions and so are not biological and/or pathological conditions. Since, in the English language, the concepts of disease and illness denote pathological abnormalities of the body (unless they are used figuratively, metaphorically, in slang, etc.), impulsivity and hyperactivity are not diseases or illnesses. It follows then that ADHD is not a disease or illness either.

So, which method is Szasz using?

The Ordinary Language View.

It's also interesting to note that, in the second video, Dr Fred Baughman is also using the OLV when he says that psychiatrists:

start CALLING the things they have voted on diseases.

When psychiatrists voted in the DSM committee, they voted on lists of criteria/symptoms and definitions they would use in the DSM manual. They did what the IAU did when they voted on the definition of a planet. This is not the problem.

The problem is that psychiatrists then called the behaviours and psychological conditions they voted on diseases.

According to the OLV, such maneuvers are misuses of language that cause us to become confused about the phenomena denoted by the language we use.

Are you confused about what the DSM manual contains? Are you confused about what is and is not a mental illness? Watch as one of the most prominent depression researchers in the world opens her guest lecture at Yale by suggesting that many students ARE confused about what mental illnesses are....about what the DSM manual contains.

 

 

So:

1) DSM contains no biological or pathological tests/criteria of any kind for mental disorders

2) Whether someone has a mental disorder is subjective judgment

3) The subjective judgment is based on the assessment of behaviour and self-reported feelings and thinking NOT physical pathology

These confusions about what is actually denoted by the phrase mental illness come, in large part from the use of the word illness in this phrase. Notice that Dr Hoeksema did NOT say:

"mental illness"

notice that she DID say:

mental disorder

That matters!

Why? because the use of the word illness makes the ordinary language user think that the problem is a kind of illness. And what are illnesses in the ordinary language? They are physical things.

Let's quickly go back to a video we saw earlier. This is the video of the IAU deciding on the definition of a planet. Just look at what this astronomer says about the possibility for confusion in the use of the phrase:

"DWARF PLANET"

He suggests that the inverted comas (meaning quotation marks) around the phrase read correctly but do not speak correctly. When one says the phrase....dwarf planet.... it seems as if one is talking about a kind of planet. But, according to the definition of planet upon which the IAU is voting,

a "dwarf planet" is NOT a kind of planet.

The astronomer suggests that this will cause confusion for schoolmasters, students, linguists, grammarians, etc. Watch...

 

 

 

Lack of clarity about whether or not mental disorders are physical, biological, pathological abnormalities of the brain can and has caused a great deal of confusion.

This is point "2" of the argument given by Szasz and others above....

Point 2: The result of calling mental disorders like depression illnesses is the inappropriate prescription and use of drugs such as Ritalin or Prozac. Consider the following conversations a doctor might have with the mother of a young boy who is depressed.

Dr: Joan, your son has depression.

Joan: What is that Dr?

Dr: Depression is a kind of illness. A kind of brain abnormality. There is evidence of chemical imbalance and other kinds of brain abnormalities in children with depression.

Joan: Ok Dr, what should I do?

Dr: We have various kinds of medications that seem to help some young people with depression. Would you like me to prescribe your son a medication that my help him?

Joan: What is Joan likely to say here? What would you say?

Or, it could be said this way...

Dr: Joan, your son IS depressed.

Joan: What do you mean, he is depressed, Dr?

Dr: I mean that he is sad, has a low mood, and is not feeling as happy and positive as he might.

Joan: Have you looked at my son's brain to determine if there is anything wrong with it?

Dr: No Joan, we have not looked. We have no idea what, if anything, is wrong with your son's brain.

Joan: Oh, okay, what should I do Dr?

Dr: We have various kinds of DRUGS that seem to make sad people happier. Would you like me to give your son DRUGS that might make your son feel happier?

Joan: NOW what is Joan likely to say?

Now read THIS debate carefully.....

Point 3: The psychiatric profession is actively involved in defrauding it's patients because they know that mental disorders are not illnesses and that they have no definitive cures for illnesses.

In the end, this may well not be a fraud. It may simply be a consequence of whether one holds an operationist, CV Theory, or OLV of how to determine what things are.

But the really interesting question is why Szasz thinks this is a fraud. Recall that Szasz has medical training and recall that medicine has its roots in the physical sciences that are mostly operationist and positivist. So this means that Szasz was trained as an operationist/positivist. He wants a clear definition and clear objective tests, and he can't understand anyone who would want otherwise. So since the practice of theorizing about the nature of ADHD is so obviously logically flawed to Szasz, he thinks it must be obviously logically flawed to any scientist and therefore must be a fraud.

So here, the disagreement is ACTAULLY about the logic of construct validation. It's about whether or not it makes sense to theorize about what things are. It actually comes down to whether or not Aristotle was right that it makes sense to theorize about the nature of the soul. Some people think it does make sense to theorize about what things are, others don't. Typically, social scientists and philosophers think it makes sense to theorize about what things are and physical scientists do not.

This is why knowing your philosophy and history matters. It allows you to understand what the disagreements, arguments and unrest are actually all about. If you don't understand your philosophy, you don't understand your science.

In the remainder of this lecture I would just like you to watch some recent videos and listen to an audio of two very important people in psychology/psychiatry discussing issues relating to the way mental illness is defined. The first thing you should watch is an interview with Dr Szasz on the nature on mental illness.

Listen to the interview first HERE.

Now go ahead and watch a video of Dr Szasz discussing the social functions of psychiatry. Watch HERE.

As we discussed earlier in the course, it is common for people to misrepresent a case when thy disagree with it. It is then also common for the person to argue against the misrepresentation and conclude from this that the original case was flawed. I would like you now to read a published criticism of Szasz (and a response written by me from the OLV) that takes exactly this form. Read it HERE.

It's important to understand that it is not only Dr Szasz that makes such criticisms. Many such criticisms have been made. The following is a criticism written by The British Psychological Society about the approach taken to psychological disorders in DSM-V. Read the criticism HERE.

Now go ahead and watch an incredible talk on over-diagnosis by Dr Iona Heath. In this talk, Dr Heath recognizes the possible consequences of misusing language in medical settings on the lives and health of patients. By the way, the person that introduces Dr Heath is the editor of the most powerful medical journal in Great Britain...the British Medical Journal. Watch the video HERE.

Finally, go ahead and read the first chapter of a recent book arguing about the consequences of linguistic misuses and confusion on research in mental health. Read HERE.