The Nuance
The Drawbacks of ‘Harm Inflation’
Expanding our definitions of harm, trauma, and mental disorder may be a “mixed blessing,” experts say
Several years ago, in 2013, the American Psychiatric Association made a controversial change to its Diagnostic and Statistical Manual of Mental Disorders (DSM).
For years, the DSM’s criteria for diagnosing depression had included what was known as the “bereavement exclusion.” In a nutshell, the exclusion stated that people who had recently lost a loved one should not be diagnosed with major depressive disorder because sorrow and other depression-like symptoms are normal and appropriate following a loss.
In other words, there’s nothing “disordered” about feeling sad or distraught when someone you love has died.
But in the new (and still current) DSM, the APA dropped the bereavement clause. Even among people who are grieving the loss of a loved one, the DSM now considers depression a valid diagnosis if certain criteria are satisfied, such as an “inability to anticipate happiness” or “difficulty being consoled.”
Experts in favor of the change argued that although it might stigmatize some people who are grieving it could also help those in need gain access to therapy, medications, and other helpful resources. Proponents also pointed out that bereavement-related depression can be “genetically influenced,” and so likely to recur.
Meanwhile, some opponents viewed the change as part of a larger trend in psychology — and, for that matter, in Western society — that is ongoing today. Their view is that, slowly but surely, the APA and other authorities are broadening their lexicons and diagnostic criteria in ways that pathologize or medicalize an increasingly wide swath of human experience.
The Australian psychologist Nick Haslam is one of the leading voices in this group.
“In psychology, we know that expectations and self-classifications and beliefs and identities really matter.”
Haslam, PhD, is a professor of psychology at the University of Melbourne. In 2016, he published an analysis of what he referred to as the “concept creep” pervading both his profession and popular culture.
“Concepts that refer to the negative aspects of human experience and behavior have expanded their meanings so that they now encompass a much broader range of phenomena than before,” he wrote.
Along with psychology’s ballooning definitions of mental disorder, he highlighted the language of abuse, bullying, trauma, addiction, and prejudice as salient examples. “In each case, the concept’s boundary has stretched and its meaning has dilated,” he wrote.
Both in his 2016 paper and in his subsequent work, Haslam has emphasized that he isn’t weighing in on the rightness or wrongness of concept creep. Rather, he’s concerned with the effects of what he calls “harm inflation.” If society defines an ever wider range of experiences as disordered or harmful, this may have negative repercussions for our mental health.
“In psychology, we know that expectations and self-classifications and beliefs and identities really matter,” he says. “If because of these expanding definitions and concepts you identify yourself as a victim of bullying or trauma, or as having a disabling mental health condition, I think that can have both advantages and disadvantages.”
One of the advantages, he says, is that people who might once have felt isolated or stigmatized may now have better access to supportive communities, helpful treatments, and other resources. Especially in the near-term, the benefits of broadening our concepts of harm and mental pathology often seem to outweigh any potential detriments.
But as time passes, the effects of concept creep may be more deleterious. “One of the downsides is that if your identity centers around suffering or trauma or inability, that can be very limiting,” he says.
In support of this take, he references a 2016 study in the Journal of Affective Disorders. The study found that people with depression who perceive their condition as central to their identity experience lower psychological well-being and are also more likely to “conform” to the norms of depressed people, which leads to worse outcomes.
“The evidence suggests that getting a mental health diagnosis is a bit of a mixed blessing,” says Tegan Cruwys, PhD, first author of that study and a clinical psychologist at the Australian National University.
“On the one hand, it can be a relief to have an explanation for what is happening to you, and to know that there are treatments that can help with your symptoms,” she says. “On the other hand, people can also feel stuck and less optimistic about their prognosis for the future — especially if they have a model of mental illness that is very biological or genetic, in which case a diagnosis can feel like a life sentence.”
McNally and Jones found that broadening people’s concept of trauma increased their “vulnerability” to a gruesome movie clip.
Some psychologists who specialize in trauma disorders see similar issues lurking in the weeds.
“[It] does not bode well for people to see themselves as trauma survivors suffering from an allegedly chronic and relapsing disorder” — that is, post-traumatic stress disorder — “when the stressors are relatively mild,” says Richard McNally, PhD, a professor of psychology at Harvard University.
Some of McNally’s work has posited that, in relatively safe and affluent communities, even mildly traumatic experiences may be sufficiently jarring or incongruous to induce symptoms of PTSD. But he also says that catastrophizing the ongoing harms of traumatic experiences can produce a sort of nocebo effect, meaning people’s negative expectations help fuel negative outcomes.
In a recent study, he and one of his doctoral students, Payton Jones, found that broadening people’s concepts of trauma increased their “vulnerability” to a gruesome movie clip. The people in the study experienced more intense negative emotion and more distress.
“Regarding an aversive experience as a trauma could also function as a nocebo if people believe that the best way to cope is to avoid triggers that could prompt intrusive, distressing recollections of the experience,” he says.
While research has found that avoiding sources of fear, anxiety, or other unpleasant emotions can in some instances be helpful — particularly if avoidance enhances one’s sense of control — avoidance has more often been shown to maintain or worsen unpleasant emotions. This is why “exposure” exercises — when people confront the source of their fear or distress — are now a mainstay of many forms of psychotherapy. “Mastery of one’s fears can be an especially potent means of acquiring a sense of control,” McNally says.
The takeaway from much of this work is that we are all, to a degree, suggestible. And so the “creep” of harm-related concepts and diagnostic criteria may produce beliefs that induce, prolong, or worsen our mental suffering.
This presents a conundrum: It may be true that, to improve our societies and our institutions, we need to expand our view of what constitutes harassment, prejudice, aggression, violence, and trauma. At the same time, it may also be true that this expansion, if too tightly coupled to notions of harm, could hurt our well-being.
“Given what we know, it wouldn’t be surprising if broadening our concepts of harm or disorder is contributing to making people less well,” Haslam says.