the nuance

Is Modern Psychiatry Turning Us All Into Patients?

A discussion of trauma, resilience, and mental illness with psychologist Nick Haslam.

One out of four American adults now has a diagnosable mental health disorder. About the same proportion — roughly 27% of adults — is currently taking a prescription psychiatric drug.

These figures are at all-time highs. Nevertheless, most analyses find that mental disorders are likely under-diagnosed and under-treated. Based on current conceptions of what it means to be mentally ill, that is surely true. But that truth is dependent on how you answer two questions:

What is a mental disorder and who has one?

These two questions are fundamental to psychiatry, which is the branch of medicine that diagnoses and treats mental illness. And yet the answers to these bedrock questions are far from straightforward. In fact, they’re changing all the time.

I didn’t quite grasp the slipperiness of these concepts until I discovered the work of Nick Haslam.

Haslam earned both his master’s and PhD at the University of Pennsylvania. He’s now a professor of psychology at the University of Melbourne in Australia.

A lot of his recent writing and research has examined how psychiatry’s definitions of mental illness have gradually stretched and expanded to encompass a wider and milder range of psychological phenomena. He argues that while this expansion is in some ways correct and helpful, it is also problematic.

Normally I don’t publish Q&As, but in this case I felt that letting Haslam dissect these topics in his own words would be best.

We discuss the issue of “concept creep” in psychiatry’s definitions of mental disorder, the broadening of society’s notions of trauma and harm, and the problem of confusing well-being with mental health.

Markham Heid: A lot of your work has examined “concept creep” in the fields of psychiatry and psychology. What are you talking about when you use that term?

Nick Haslam: I use it to describe a gradual process whereby psychological concepts that refer to forms of harm have broadened their meanings.

An example I use a lot is bullying. Back in the 1970s when the concept was introduced to psychology, bullying referred to a particular kind of peer aggression among kids. Specifically, it was peer aggression that was repeated, intentional, and carried out downwards in some kind of power hierarchy — for example, by a bigger kid toward a smaller kid. Over time, we’ve come to use bullying in a much broader way. Now it includes interactions among adults, and many people use it when the aggression is not intentional, there is no repetition, and the aggression is directed sideways or upward in a hierarchy. For example, in theory I could be bullied by one of my PhD students if they insist on getting feedback on a dissertation draft in an unpleasant way.

A whole raft of concepts to do with harm have undergone this same transformation. Trauma is another example. That term is now used to refer to a lot of commonplace events that are well within the range of normal experience, whereas before trauma only referred to really unusual events that threatened life and limb.

MH: Why is any of this a problem?

Haslam: I think people often regard these changes as entirely a good thing, and I agree that there are positive aspects to it. With trauma, for example, the dilution was in part a recognition of the fact that people sometimes experience PTSD symptoms in response to less-severe events. We don’t want to exclude people from treatment just because the adversity they experienced doesn’t meet a threshold that might be set too high. So I fully agree that concept creep has benefits.

However, I think the downsides are various. Within psychiatry, concept creep has led to widespread diagnostic inflation. So we pathologize more and more things — we treat more and more phenomena as signs of mental illness — and that doesn’t necessarily benefit people. If you call things mental health problems that are just ordinary kinds of sufferings or normal, transient responses to adversity, that draws attention and resources away from people who are suffering from more severe problems. It also leads more people to feel in some way broken or damaged.

Taking on-board a diagnostic label can create a self-fulfilling illness-based identity. For example, going back to trauma, there are a lot more instances now where people identify an experience as trauma and they assume that they are permanently or at least lastingly damaged by it. There’s this perception of trauma as almost a break in one’s soul, and in some cases people build an identity around this belief.

I think it’s also true that when people are diagnosed with a mental illness, they often believe that either they have little chance of recovery or that recovery will be very long and arduous and require medication and therapy. But we know from research on PTSD that the vast majority of people who experience trauma recover from it quickly without intervention. One major study found that about 90% of Americans had experienced what the DSM-5 considers to be a trauma in their lifetime, but only 8% had ever met the diagnostic criteria for PTSD.

I think another way of looking at this is we’re increasing our sensitivity to harm, which could also be termed a loss of resilience. We’re using these powerful psychiatric words like trauma to create greater sensitivity to a wider range of experiences, and this is leading us to interpret more and more normal experiences as signs of a disturbance or illness.

Again, I think parts of this historical change are good. We’re recognizing and acknowledging harms we used to ignore, but at the same time I think we’re sometimes catastrophizing the damage these things cause, and this is leading some of us into treatment we don’t need or self-diagnoses that can be self-limiting.

MH: It might be helpful here to talk about placebo and nocebo effects in psychiatry, and how labelling something a mental disorder can change how a person interprets what they’re experiencing.

Haslam: Placebo and nocebo effects are really powerful in mental illness. Research shows that just about every mental illness exists on a continuum. And when you have a continuum, deciding where to place the threshold between normal and abnormal is really tricky, and in some ways quite arbitrary. With a tumor, you pretty much have one or you don’t. Mental illness is fundamentally not like that. Even psychosis exists on a continuum. Some people hear voices and are not troubled by them at all, and so it doesn’t rise to the level of mental illness.

So one of the important points here is that, with mental illness, the frame you put around the experience changes it. Let’s say I’m troubled by intense distress and interpersonal difficulties: is that because I’m traumatized, or is it a personality disorder, or do I have some kind of depression? A lot of people cycle through many different diagnoses. Part of that is because there’s so much overlap in the diagnostic criteria, and part of it is that our diagnostic systems don’t map cleanly onto the messy reality of human suffering. Also, these experiences can evolve over time.

These diagnostic terms trigger different psychiatric responses from a mental health professional, and they also lead to different forms of self-understanding. All these narratives about what people with certain conditions “are like” shape how people think about and interpret their own experiences, and this isn’t always helpful.

For example, if you believe the nature of a mental illness is biological in origin — like a chemical imbalance in the brain — you’ll tend to see talk therapy as less helpful and you’re more likely to opt for a medical treatment like a prescription drug. You’re also less likely to believe you can do very much to deal with the problem or that you’re likely to ever recover from it.

So beliefs about mental illness have real effects on how we experience psychological phenomena, how we seek help for them, and how, or if, we overcome them.

MH: I know you’ve also written about concept creep in the context of societal and interpersonal conflict.

Haslam: With bullying, prejudice, trauma, or other concepts of harm, if you lower the threshold for what counts by identifying less severe phenomena as examples, you get a whole lot more conflict.

Lowering the threshold increases the number of victims, and as you increase the number of victims you correspondingly increase the number of perpetrators. A lot more people become bullies or bigots or traumatizers, and other people tend to react punitively towards them, even when the harm they have caused may be relatively minor or even quite ambiguous.

So concept creep can increase the amount of conflict and moral outrage in society, especially when people disagree — as they do — about the meaning of those concepts. What one person sees as bullying others may see as straight-talking and accurate performance feedback.

MH: I’ve read some of your work on well-being and how it’s increasingly used as a synonym for mental health. Why is that an issue?

Haslam: Yes, there’s been this conflation of mental health with well-being. People often treat them as the same thing, so that if you’re lacking well-being you’re likely to be experiencing a mental illness. But we know from research that there’s only a moderate negative correlation between the two. There are plenty of people who have a mental illness but are reasonably happy and functional, and there are also many people who are the reverse — who have no sort of diagnosable mental illness but are pretty unhappy.

I think certainly things are going in a troubling direction with self-diagnosis. At one point psychiatry used to have a much broader and more inclusive concept of mental illness than laypeople. Critics would attack psychiatry for pathologizing everyday experience, or for what they’d call “diagnostic inflation.” I think that’s flipped now. Many laypeople have a broader and more inclusive definition of mental illness than psychiatry’s diagnostic system, and they use these labels more loosely than that system would suggest. One reason for this is that we’ve smushed together well-being and mental health. Wanting to be happier is fine, but not achieving that doesn’t mean you have a mental illness.

MH: What advice would you offer people when it comes to navigating this terrain and properly caring for themselves?

Haslam: I don’t have any glib suggestions. I think often it’s a good idea not to jump to a diagnostic label without seeing a mental health professional first. Self-diagnoses are unreliable. I also think a first step if you are feeling distressed should involve some kind of talk therapy, rather than medication being a first resort. I don’t have any bias against medication, but I think starting with the least intrusive response is the one you want to go with. Of course, that doesn’t mean you should avoid medical attention or treatment if you’re in extreme distress.

Also, I will say that one downside of the enormous attention mental health is getting right now — the fact that we’re paying so much more attention to the many forms of psychological distress and disability, and we’re constantly being told that mental illness is everywhere — is I think it can lead to unhelpful self-scrutiny and rumination. It’s tricky because you want people to be psychologically literate and to seek appropriate help, and you want them to have the tools to make sense of their troubles. But often the tendency to direct attention inward, especially through the lens of mental illness, becomes rumination. And we know that’s a real source of unhappiness for people.

Thanks for reading. I hope you found this conversation helpful. If these topics interest you, please check out my prior work on the happiness paradox, the shaky science of prescription antidepressants, and drugmaker attempts to influence our beliefs about mental illness.