What is Mental Health and Mental Illness?
As a clinician, I will regularly hear statements like “he or she has real clinical depression.” “They were diagnosed with an official anxiety disorder.” “I’ve thought for a long time that I actually have ADHD.” These are natural statements connected to natural questions. But, opposed to other areas of practice and expertise, the answers in the mental health field are a bit more complicated.
We could think of diagnostics in the lens of a mechanic fixing a car. To understand the problem the mechanic would ‘look under the hood.’ But unlike “diagnosing,” a broken transmission, in mental health it is not so easy. Mental health concerns can also be strengths. Diagnostics cut to the heart of an important philosophical question: what is mental health and what is mental illness?
The history of diagnostics goes back to the beginning of studying modern anatomy and the brain in the Middle Ages (Kendler et. al, 2022). At the same time philosophical authors such as Descartes and Locke advanced the notions of a thinking as definitive of identity and being, and a “moral,” rather than spiritual, version of insanity, respectively.
We can assume that our fields of understanding have progressed considerably since the Middle Ages or even the 17’th century. But, in diagnosis in mental health, that isn’t exactly so easy to say.
The esteemed psychodynamic diagnostician, Nancy McWilliams, has noted that to this day, the DSM, the diagnostic manual for many practitioners, lacks a definition of mental/emotional health (McWilliams, 2011). This creates a quandary in discussing mental illness.
The Problems with Diagnostics
Beachaine and Hinman (2008) recognized a number of inadequacies related to diagnostics based on the growing field of neurology. Some of their identified challenges included: lacking construct validity (knowing it is this diagnosis and not that one), equifinality and multifinality (meaning a blurring of the lines between the trajectory to a disorder and ending up at that specific disorder), failed nosology and taxonomy (distinctions between disorders and ‘not’ disorders), and misrepresentations of development and cultural impacts.
Taken at a glance, these issues with diagnoses pronounce that fundamentally, the field at large does not know how diseases start, does not have a map of their impacts in the brain, can’t adequately describe the differences between existing diagnoses, can’t predict where a system of inputs will lead, or describe how inputs led to a present reality and don’t describe developmental variance or cultural influence.
These are serious and foundational concerns. The kinds of concerns in microbiology that were being addressed when Louis Pasteur (a contemporary of Freud) was discovering bacteria. One issue is that in mental health, diagnosis is in the ‘eye of the beholder.’ Interrater reliability of diagnoses (agreement between practitioners), for a number of reasons, is very small. A preeminent large-scale study of interrater reliability found agreement in the .2-.4 range (Lieblich et. al, 2015). This would mean 20-40% overlap out of possible options. This means that even among qualified clinicians, the agreement on what a client has is very, very low.
Isn’t this a pivotal concern? If clinicians only agree of diagnostics roughly a third of the time, wouldn’t that mean that they are unable to help their patients?
There is evidence to suggest that the lack of consistency in diagnosis is not that important for treatment.
Dear et al (2016) collated a very large study of treatments that are geared specifically to a diagnosis and those that are ‘transdiagnostic,’ or not geared towards any diagnosis in particular. The findings identified no meaningful difference between either option. There is parity among camps on this and other issues, but in general, treatments specifically geared to treat diagnoses don’t seem to do meaningfully better than treatments that are not.
Diagnosis can be held under scrutiny in the field of health care at large. Rosenberg (2002) argued that diagnostic labeling is a means by which to establish a market and funding for research and medical practice. Rosenberg argued that this had created “disorders,” from normative conditions, and medicalized the lives of those who had them.
The Impact of Labels and Systems
Insurance companies require formal diagnoses for reimbursement, but they also reserve the right consider those diagnoses as preexisting conditions. Other agencies can also take part in judging psychological and psychiatric diagnoses. The U.S armed forces consider diagnoses to impact professional and career decision-making. Other fields, such as law enforcement, or work as a lawyer require the sharing of this confidential health information.
This becomes a large, monied, medical system which reifies questionable diagnostics and then requires a diagnostic label for any care.
This requisite creates barriers to both treatment and life success. And so, what does this mean for the consumer of mental health care, or just human beings in general? Diagnoses have throughout history been a marker of expert knowledge and skill. Those able to pronounce them have also reserved the right to pronounce themselves as able to cure them. But in the world of mental health, the concept of diagnosis becomes subjective. The way anyone identifies their life, memory, mind and experience is their own subjective view and that is not determined by an external judge of what is “healthy.”
Passion may be viewed as the very thin line between wellness and illness, beauty and obsession. One can see this dichotomy in the single-minded pursuit of excellence demonstrated in the famous photo of the athlete Kobe Bryant. Kobe clutched a world title in his hands and sat with his head sadly draped between his knees in a bathroom after winning his second championship. Or his famous answer to a reporter asking why he wasn’t happy going up 2-0 in his fifth championship series – “job’s not finished.”
Yet for many of his fans, Kobe can be almost defined by his dedication and desire. Was he sick, was he well, did he make it in spite of himself or was his ‘depressed state’ the price of true glory? While any number of mental health practitioners might diagnose him with a disorder, but Kobe seemed to willingly exchange happiness and peace for a tireless pursuit of greatness. Who can objectively say that is the wrong choice, or unhealthy?
This paper strives to outline that the very labels of diagnoses are mapped out much as the earliest world maps were, with vital information but questionable precision.
Therapy has yet to define mental health and has focused more on ever increasing definitions of mental illness. We know what it is to be a bacterium, or to be bleeding, we don’t really know what it is to be a person – much less a “healthy person.” Disorders shift and change over time, society’s values impact what is pathologized and not. The scientific harmony behind cause, trajectory and outcome has still evaded the light of modern research; all the more because we cannot define that basic label, what is mental health.
What Is Mental Health?
This naturally means practitioners hold little agreement about what a patient may have as it is impacted by each practitioner’s subjective view of ‘bad.’ All the more, diagnostics has become a financial and civic tool that is governed by law, insurance and bureaucracy. Each practitioner navigates those constraints differently, and with different subjective values.
At the bottom of all this is a very well-meaning public that desires to understand itself and nearly half a millennium of medical tradition has guided them to do so via diagnosis. So, what is the public to do, throw up their collective hands?
The constructs, measurements and formal labels of therapy are highly questionable. But the real heart of “therapy,” has been significant in almost all of human history. Art, knowledge, faith and philosophy, and loving relationships are certainly important. These are the purpose of therapy, and it is not determined by diagnosis. Good therapy strives to help people find their own version of health.
Questioning the hold of diagnostic “sickness and health,” over therapy does not jeopardize the process of therapy. Much more important and much more meaningful than diagnosis and cure is the therapeutic relationship and process. That process can evolve in the spaces between those formal words, titles and processes. That is the real heart of therapy, and something relatively unchanged by the vicissitudes of formal diagnostics.
Citations
Beauchaine, T. P., & Hinshaw, S. P. (Eds.). (2008). Child and adolescent psychopathology. John Wiley & Sons, Inc..
Dear, B. F., Staples, L. G., Terides, M. D., Fogliati, V. J., Sheehan, J., Johnston, L., Kayrouz, R., Dear, R., McEvoy, P. M., & Titov, N. (2016). Transdiagnostic versus disorder-specific and clinician-guided versus self-guided internet-delivered treatment for Social Anxiety Disorder and comorbid disorders: A randomized controlled trial. Journal of anxiety disorders, 42, 30–44. https://doi.org/10.1016/j.janxdis.2016.05.004
Kendler, K. S., Tabb, K., & Wright, J. (2022). The Emergence of Psychiatry: 1650–1850. American Journal of Psychiatry, 179(5), 329–335. https://doi.org/10.1176/appi.ajp.21060614
Lieblich, S. M., Castle, D. J., Pantelis, C., Hopwood, M., Young, A. H., & Everall, I. P. (2015). High heterogeneity and low reliability in the diagnosis of major depression will impair the development of new drugs. BJPsych open, 1(2), e5–e7. https://doi.org/10.1192/bjpo.bp.115.000786
McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process (2nd ed.). Guilford Press.
Rosenberg C. E. (2002). The tyranny of diagnosis: specific entities and individual experience. The Milbank quarterly, 80(2), 237–260. https://doi.org/10.1111/1468-0009.t01-1-00003