As the turmoil surrounding the construction of the DSM-5 continues (here is a recent op-ed piece by Allen Francis arguing the time might be right to allow mental health professionals other than psychiatrists to have a say in what constitutes a mental disorder), I thought it might be useful to review the broad models of mental health and illness that have been employed to understand and characterize such phenomena. Let’s start with some examples to get us thinking about the concept of mental illness.
Janice is a 42 year old woman who lives alone in a rundown inner city apartment that has no heat or running water. She hears voices telling her that the house across the street is cursed and demons live there. One day, she buys a gallon of gasoline, pours it around the house, chanting that the demons must be sent back to hell. She lights the home on fire. The home is not up to fire code, and the single mother and two children inside die in the blaze.
Tina is an 18-year-old college freshman. She grew up in a small, rural town and is a first generation college student. She did extremely well in high school and has always been very driven and conscientious. However, her first semester did not go very well. She experienced difficulty making friends, and she was uncomfortable with the drinking and party atmosphere. She focused a lot on her studies and studied several hours a day, but she struggled to get the As she expected. Now she is having problems taking tests and staying focused and is worried that she has AD/HD. She is starting to have trouble sleeping, as she can’t fall asleep because she is constantly worrying about what she needs to do the next day. She is also having nightmares about failing out of school, feels ineffective, and pessimistic about her future.
Nathan is a 40 year old Southern Baptist preacher in the 1960s who, despite their protests, takes his family (wife and four daughters) on an Evangelical mission in the Congo. Although numerous indicators point clearly to there being serious trouble, Nathan is certain that the path to reward is righteous servitude to the Lord. His wife and children become stressed and depressed. Their youngest daughter gets ill, is then bitten by a snake and dies. His wife leaves him, taking the remaining children on a dangerous journey to escape. He stays behind, blindly preaching the gospel. He is ultimately identified as a threat by the Congolese he was trying to convert and is killed.
(Note that the first two are examples of individuals I have seen in my work as a professional psychologist. The third is a character in the fictional novel The Poisonwood Bible by Barbara Kingsolver).
With these examples in mind, let’s identify the central elements that results in people being characterized as mentally ill. There are two central psychological dimensions to mental illness: 1) feeling; and 2) functionality. Feeling refers to levels of psychic distress and pain (as opposed to joy and contentment) being experienced. Functionality refers to the capacity (or lack thereof) to coordinate the flow of resources in a desired or adaptive way. Mental illness is perceived when there are high levels of distress and dysfunction at the psychological level of analysis (the behavior and experience of the individual). In contrast, mental health is when individuals effectively coordinate resources to achieve growth goals and feel good about that process.
The last point that needs to be considered is the sociocultural context of justification, and we need to consider this from two angles. First, we need to consider the sociocultural context in which the psychological processes are unfolding. If, for example, the processes are normative and observed at the population level, then mental illness is less clear/more complicated. (For example, if a woman performed a clitoridectomy on one of her daughters in America, it would be labeled as obvious psychopathology; however, it is much more complicated to label such behavior as psychopathological when it is normative for that context). Second, we need to consider the evaluator’s values and worldview (e.g., Was Hitler mentally ill? If one had a Nazi value system, then the answer would likely be different than if one has a modern view of human values).
With this backdrop grounding the elements that go into the concept of mental illness, we can now describe the five prominent frames that have been used to explain such phenomena in modern times.
The first and oldest explanatory system for mental illness is spiritual. From a traditional spiritual perspective, consciousness is seen as resulting from or deeply connected to some supernatural force. Usually, there is a religious narrative that explains that there are good and bad forces in the world, and that suffering is a function of either being possessed by the bad, or through the idea that the afflicted have fallen out of favor with the good. This generally occurs because of sin or related concept of immoral behavior that leads to some form of badness or contamination. For example, Janice’s behavior described above might be explained as the Devil possessed her soul and used it to spread suffering and pain. Or a related spiritual explanation might involve looking to Janice’s past behavior for sin, which separated her from God and thus opened up space for the demonic possession.
The second explanatory system for mental illness is moral character. The idea of moral character has been advocated by many cultural systems. Western thought can clearly locate the origin of ideas about moral character in the Greek philosophers. In a nutshell, the position of moral character is that there are virtues which one must learn, such as courage and fortitude, honesty and integrity, compassion and grace that enable on to live the admirable life. From such a perspective, one might explain the source of Tina’s problems as lacking courage and fortitude, or one might characterize Nathan as lacking compassion and grace.
Although certainly common in everyday language and conception, these two perspectives of mental illness are generally eschewed or de-emphasized by modern mental health professions, and instead the latter three are what most focus on, at least in their professional lives. Of course, in their personal lives, many mental health professionals undoubtedly adopt religious or moral character models to explain people’s behavior.
The third explanatory system for mental illness is biological and neurophysiological. Here the belief is that the human is an organism that consists of natural functions designed by nature (i.e., natural selection operating on genetics) and mental illness is the breakdown of such functions (see Jerome Wakefield’s Harmful Dysfunction Analysis for example of this model). Thus, just as a heart attack is a biological disease characterized by the breakdown of the functioning of the circulatory system, mental illness stems from malfunctioning neurophysiological processes. Janice would be probably diagnosed as having paranoid schizophrenia, and the operating belief would be that there was a breakdown in how her brain processed information. Likewise, Tina might be characterized as having an anxiety disorder that stemmed from an underlying pathophysiology of the fear and anxiety systems, such as the over- activation of her amygdala.
A fourth explanatory system for mental illness is learning and developmental (or psychological). The general model here (from Freud to Rogers to Skinner to Beck) is that the individual develops along a trajectory and attempts to adapt to their environment. However, if the individual fails to learn certain crucial elements or learns the wrong responses to new situations or adopts short term solutions that have long term maladaptive consequences, then suffering and dysfunction result. Tina, for instance, might have learned strategies for connecting in her family that did not generalize (and indeed were maladaptive) to making connections with college friends. Nathan’s rigid, authoritarian following of the Bible was a defense against feelings of guilt for events that happened during WWII. Even Janice might be conceived as having experienced real or imagined trauma, which caused her to dissociate and misattribute inner experiences to external causes.
The final explanatory system is sociological. Here the focus is on the macro structures of power and resources, the social construction of what constitutes illness and which individuals are socially sanctioned to declare who is mentally ill, labeling and the manner in which mental illnesses are distributed and treated in different cultures. At the extreme, the sociological level disavows the entire concept of mental illness. The psychiatrist Thomas Szasz famously argued that mental health professionals are secular priests and that mental illness was simply labels for deviant individuals that society deemed needed to be controlled. Similarly, feminist and other culturally sensitive philosophers emphasize how pathology is labeled and managed. Finally, at a more basic resource level, sociological analyses explore the connection between deviance, difficulty functioning, and depleted resources.
It is important that educated individuals keep in mind all five angles from which to analyze mental illness. Certainly, for some conditions one particular explanatory system might be more relevant. But each angle is important to keep in mind, and it is helpful to analyze each case from each angle.