How benighted, that we once diagnosed schizophrenia as satanic possession. Or, later, that we blamed “frigidity” for the absence of an orgasm and “cold mothers” for their children’s mental illnesses.
Well, we still blame greed and sloth for endocrine obesity; irresponsibility for addiction that has altered the brain’s receptors; perversion for behaviors we now know come from a complex combination of genes and trauma; recklessness for impulsivity caused by impaired brain development when a child does not have a calm, safe, loving home. Until an autopsy revealed a brain tumor, we assumed the clock-tower shooter was a violent sadist. We forget that rage could be foreshadowing dementia.
Diagnosis is tricky. Laypeople and physicians alike get stuck in certain modes or limited by prevailing theories. Diagnosing mental illness is trickiest of all, and while the label does hand you an insurance billing code, it also drapes you in a cloak of shame and stigma.
But the pendulum swings.
Today, people cheerfully announce that they are “stressed out” or “socially awkward,” admit to anxiety and depression, make TikTok “diagnosis videos” about symptoms and their label. This is great, in that it dissolves stigma and encourages community, awareness, and the seeking of help. This is lousy, though, in that those lists of symptoms can make anybody feel like they have anything, and soon everyday behaviors and feelings are pathologized.
“Doctors have already seen a rise in patients, especially young women, presenting with physical tics common to Tourette syndrome patients,” writes Emily Baron Cadloff for The Walrus. “Notably, many of these patients started showing the symptoms after exposure to TikTok. While #Tourette’s now has 5.5 billion views on the platform, one study estimated that the disorder affects only about 0.05 percent of the adult population.”
Years ago, when I worked up the nerve to ask a colleague what the doctors thought caused his wife’s suffering, he gave me a rueful grin and rattled off a long list of diagnoses tossed at her over the years. Anyone who has watched the DSM (the Diagnostic and Statistical Manual of Mental Disorders) add, elaborate, or jettison categories over the years know that the labels are vaguer and far less absolute than they pretend to be.
Is it time to scrap the entire system? British psychologist Lucy Johnstone thinks so. She and psychologist Mary Boyle, professor emerita at the University of East London, created, under the auspices of the British Psychological Society, a Power Threat Meaning Framework as a way to rethink our mental state. Instead of pathologizing symptoms and blaming the individual for some flaw or deficit, the framework takes the larger societal pressures into account and explores various ways we respond to emotional distress. Patterns emerge, and often the traditional diagnoses’ symptom clusters slot smoothly into one or more of those patterns.
To me, this sounds like a wonderful way to stop pathologizing distress—but a terrible way to handle mental illness caused by genes or biochemistry. Granted, that line is tough to draw: how well loved someone is, how calm their childhood, how just and supportive their society, might well alter how a genetic predisposition plays out.
But it might not.
The brain is complicated. You can treat it with utmost tenderness and still have it go a little haywire, just as you can endure extreme stress, trauma, and deprivation and stay sturdily sane. Our pendulum swings too far, either blaming and pathologizing the individual or throwing all the emphasis on environmental and societal forces.
The PTMF wants to change the narrative from “I have a mental health problem” to “I am surviving difficult circumstances in the best way I can.” It shifts the core question from “What’s wrong with you?” to “What’s happened to you?” How did it affect you, or threaten you? How did you make sense of it; what meaning did you draw? What did you have to do to survive?
Those are great questions for certain kinds of emotional distress, but not everything is circumstantial; some mental health problems really are purely physical. My in-laws were fabulous parents, loving and steady, but by age three you could have seen that my future husband had severe ADHD (no doubt inherited from both of them, a double whammy, though their symptoms were milder and went undiagnosed). Yes, the power of social norms increased his misery, and the narrative he formed for himself in response to the threat of impulsivity was that he had to wrap himself tightly to keep control. But far from stigmatizing, it was pure relief for him to receive a diagnosis that made sense of twenty-eight years of struggle, and to be prescribed medicine that better balanced his brain’s neurochemicals. Would a “non-medical perspective” have helped explain his struggle to focus and concentrate? I doubt it.
“The PTMF argues that distress of all kinds, even the most severe, is understandable in the context of our relationships and social circumstances, and the wider structures, norms and expectations of the society and culture we live in,” Johnstone says. Maybe so, in that our society requires more focus and stillness than it used to, so ADHD is more apparent and more intrusive. Maybe it would have felt better to talk about his “distress” than his “symptoms”—though I am not sure Andrew would have preferred that.
In her new special, Douglas, comedian Hannah Gadsby says, “The day I was formally diagnosed with autism was a very good day. Because it felt like I’d been handed the keys to the city of me. Because I was able to make sense of so many things that had only ever been confusing to me.”
On the other hand, a friend of mine suffered with anorexia and bulimia and went through years of treatment with a psychiatrist later infamous for exploiting his young female patients. Her family was not supportive, her peers were competitive, and society wielded a lot of ideological power over her, dictating a certain way of winning approval. In her case, a Power Threat Meaning Framework would have helped a lot more than a label that only added shame.
The same is true, I imagine, of the rampant depression and anxiety among young people—for a few, these are lifelong neurochemical imbalances; for many, they are shaped by a stressful, bleak, uncertain world, a fear of inadequacy, and a lack of emotional anchors.
I like the PTMF’s idea of restoring “the multi-leveled layers of meaning in madness and distress that are obscured by the process of psychiatric diagnosis.” Of exploring the stories we tell about our lives, mining them for subtle clues as the now-unfashionable psychoanalysts did. Thinking in terms of patterns, not procrustean boxes. Sweeping aside notions of pathology. Acknowledging the ways the surrounding culture can constrain us. Humbling psychiatry with the reminder that “there are no consistent associations between functional psychiatric diagnoses and any biological pathology or impairment, and nor have any biomarkers been identified.”
But not every mental problem can be understood as systemic and ideological in origin. PTMF has its own limitations. “Narrative might not be any more helpful than a clinical diagnosis,” points out journalist Mark Brown, who lives with a bipolar II diagnosis. “What are you liberating me from and who gave you permission?”
We need labels—for consistent insurance reimbursement, if nothing else—and we need ways to stop thinking in terms of labels. But we get so trapped by territoriality and logistics that we never manage to integrate approaches; we insist on wiping one out in favor of the other—a tendency that does deserve a pathologizing diagnosis. Because, just as we never needed to put everybody on a Freudian velvet couch, we do not need to use only a single system to understand our minds. They are way bigger than that.
Read more by Jeannette Cooperman here.
