The Challenge and Risk of Seeing Problems as Clinical Disorders
When is a psychological or social problem a disorder, and when is it, well, just a problem? How our society answers this question has been changing in complex ways because we see both problems and disorders differently today than we did just a few decades ago. Let’s start with how we view psychological disorders.
A key development in clinical psychology in the past half century is the evolution and widespread acceptance of the medical model. The medical model of mental illness refers to the idea that, like diabetes and tuberculosis, depression and schizophrenia are diseases. These and other clinical disorders are presumed to have a physiological basis in the body and the brain that can be treated with drugs. So, the medical model views a clinical disorder as an illness to be treated rather than as a sign of personal weakness in the person experiencing the disorder.
Instead of encouraging people to blame the person for his or her problem, the medical model nudges us toward empathy and understanding and reduces patient shaming. Prior to the medical model, and for much of human history, people who experienced mental illness were highly stigmatized. Even today, the widely-shared attitude that mental illness is a sign of personal weakness is probably one of the reasons why men seek treatment for clinical disorders less often than women do.
Yet, despite the strengths of the medical model, it does raise some tough practical and ethical questions. For example, is being a poorly behaved, angry, and disobedient child a clinical disorder that is best treated with drugs? That might seem an odd question. But the medical document that defines clinical disorders – the Diagnostic and Statistical Manual for Mental Disorders or DSM-5 – includes oppositional defiant disorder as an official clinical disorder for children.
According to the DSM-5, this disorder is characterized by: a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from a list of categories, and exhibited during interaction with at least one individual who is not a sibling. Some of the symptoms of oppositional defiant disorder include anger problems or irritable mood, being defiant, and having been hateful (spiteful or vindictive) to an adult or non-sibling at least twice in the past six months.
Social psychologist Nick Haslam might raise questions about the inclusion of this disorder in the DSM-5, and this brings us to how we see problems differently as well. Haslam recently argued that in the past few decades, our efforts to understand human problems have caused parents, educators, and psychologists to engage in “concept creep.” To paraphrase Haslam, concept creep is a process by which definitions of harmful behaviors are expanded so that criteria for labeling social problems or diagnosing clinical disorders become looser. Ponder this definition as you consider the description of oppositional defiant disorder – which includes characteristics of bullying. In the past, definitions of bullying were narrower, and behaviors that people now define as bullying were considered a normal childhood experience.
But Haslam suggests that recent concept creep regarding bullying has created both beneficial and harmful consequences. For example, it is obviously good to be aware of and to reduce bullying. But it is also possible to broaden the definition of bullying so much that the concept loses much of its original meaning. If almost any negative behavior qualifies as bullying, cases of highly abusive bullying may be lumped together with good-natured teasing. In keeping with this idea, Haslam suggested that although concept creep “is inevitable and often well motivated,” it also “runs the risk of pathologizing everyday experience.”
Along similar lines, the clinical psychologist, Ofer Zur, has been critical of the DSM as a guide to clinical diagnosis. As Zur puts it, the DSM, while useful, “is a document that has been developed to some extent in service to the psychopharmacological and psychiatric industries. It pathologizes many normal behaviors so that medications can be prescribed.”
The distinction between clinical depression and normal grieving after the loss of a loved one is a compelling example, underscoring the concerns raised by Zur. Whereas the previous edition of the DSM contained an explicit exclusion highlighting the differences between normal grieving and clinical depression, the DSM-5 removed that exclusion. This opened the door for diagnosing normal grieving as depression and then treating it with drugs. Although the American Psychiatric Association attempted to explain the reasons for removing the exclusion, we find their explanations lacking. Normal grief and a major depressive episode differ in many important ways, and the dangers (and tragedy) of labelling someone’s normal grieving as clinical depression are manifold. Though we cannot speak for Zur and Haslam, their concerns raise many tough questions.
To be sure, the DSM remains an important diagnostic tool. However, therapists and mental health providers who use it must exercise some degree of caution – and recognize the possibility of concept creep. A normal response to the loss of a loved one, for example, should not be turned into a disease to be treated with chemical interventions. Walking the tightrope between increased sensitivity to clinical and social problems and falling prey to extreme versions of concept creep is not an easy balancing act.
For Further Reading
Haslam, N. (2016). Concept creep: Psychology's expanding concepts of harm and pathology. Psychological Inquiry, 27(1), 1-17.
Noone, J. H. and Stephens, C. (2008), Men, masculine identities, and health care utilisation. Sociology of Health &Illness, 30, 711-725.
Valenstein-Mah, H., Kehle-Forbes, S., Nelson, D., Danan, E. R., Vogt, D., & Spoont, M. (2019). Gender differences in rates and predictors of individual psychotherapy initiation and completion among Veterans Health Administration users recently diagnosed with PTSD. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.
Note. This blog is adapted from Brett Pelham and David Boninger’s forthcoming introductory psychology textbook. See Pelham, B. W. & Boninger, D.S. (2020). Psychology in Modules: Understanding Heads, Hearts, and Hands. London, UK: Routledge Publishing.
David Boninger is a social psychologist who has studied attitudes, social cognition, and counterfactual thinking. David also teaches a course on the grieving process. Brett Pelham is a social psychologist who studies judgmental heuristics, social cognition, the self, gender, health, and culture. Brett is also an associate editor at Character and Context.