Description, Explanation, and the Problem with the DSM
I deliberately use the phrase “living under the description of manic depression (or bipolar disorder)” to refer to people who have received this medical diagnosis. The phrase is meant to reflect the social fact that they have been given a diagnosis. At the same time, it calls attention to another social fact: the diagnosis is only one description of a person among many.
THE FIELD OF MENTAL HEALTH IS HIGHLY CONTESTED. PEOPLE HAVE DESCRIBED, categorized, and responded to unconventional mental health experiences in a multitude of ways and have elicited a wide range of responses. At any given historical or cultural moment, particular descriptions of the experience and explanations for its occurrence—that it is caused by demons, the subconscious, chemical imbalances, genetics, neurology—become elevated to the status of the “standard account.” This account is assumed to provide the interpretative framework used by a majority of people to explain unconventional thoughts, experiences, and actions. Each generation thinks that its descriptions should be the “standard accounts,” and each generation assumes that its descriptions are more accurate than previous descriptions. The current emphasis within Western cultures on describing mental health challenges in biological terms is relatively new but nonetheless powerful. Genes, neurology, and chemical imbalances all can easily serve as conversation-closing explanations for mental health challenges. Yet, while biology is an important factor, it is not the only one. Running alongside this account are other important ways of describing such challenges, even if people do not necessarily give them the same social or scientific weight as the standard account. People still believe in demons, psychoanalysis, behaviorism, and many other descriptions. This book gives voice to some of these other forms of describing and understanding what is going on in people’s lives.
But first, we must ask: What does it mean to describe something?
In the epigraph to this chapter, the anthropologist Emily Martin refers to people living with bipolar disorder as living under a description, meaning that the diagnostic description “bipolar disorder” is only one way to describe an individual. “Bipolar disorder” is a powerful clinical description, one with a profound impact on a person’s life not only in how the person’s experiences are described and explained but also in how the person is perceived in the light of the professional and social interpretations of that particular diagnosis. Martin, however, reminds us that the clinical description “bipolar disorder,” important as it may be, is only one description among many that apply to the life of any given person. Human beings do not live according to a single description. We live under multiple descriptions, some of them accurate, some of them not, but all of them significant in their potential to affect our identity (who we are, who we think we are, who others think we are), our perception (how we and others perceive ourselves), and our actions in relation to others and toward ourselves.
The conflict over terms occurs because culture, medicine, religion, personality, and the zeitgeist all shape and form particular descriptions and explanations of mental health phenomena and then offer ways of naming, controlling, and responding to people’s experiences. Of course, more than one description can apply to any given experience. It is quite possible, for example, to argue that factors in mental health challenges are biological and cultural and spiritual—all at the same time. Nevertheless, we give certain descriptions more social and clinical power than others. At least part of the theological task of this book is to peel away those descriptions that are false, distracting, unfaithful, and damaging and replace them with ones that more accurately capture the nuances of people’s experience.
Descriptions are thus identity forming, action oriented, and action determining. To repeat, the ways in which we describe the world determine what we think we see. What we think we see determines how we respond to what we see. How we respond determines the faithfulness of our actions. Descriptions matter because descriptions change things.
In her work on the nature of intention, the philosopher Elizabeth Anscombe highlights the way in which description (the way we describe something) and intentionality (our ability to act deliberately toward something in the light of that description) are deeply interwoven. In Anscombe’s view, intentional actions, that is, actions that are about something as opposed to, for example, unintentional reflexes, are inevitably and irreducibly “actions under a description.”2 Descriptions define and confine the possible options open to us for comprehending and responding to any given situation. As Ian Hacking has put it: “All our acts are under descriptions, and the acts that are open to us depend, in a purely formal way, on the descriptions available to us.”3 Without a description there can be no intentional action. There is thus a dynamic interaction between describing something and the impact the description has on our responses to the things described. To suggest that descriptions shape our practices is not to suggest that the structure of the world is physically determined by our descriptions of it. Our descriptions do not have ontological power—meaning that things in the world do not actually come into existence because we describe them in particular ways. The universe will remain the universe regardless of my description of it. Nevertheless, my perception of and response to the universe are, to a greater or lesser extent, determined by how I choose to describe it.
Descriptions may not have ontological impact, but they do have epistemological power—meaning they shape and form the ways in which we come to know and respond to things in the world. This epistemological power of description is inseparably bound to practice: “Descriptions are embedded in our practices and lives. But if a description is not there, then intentional actions under that description cannot be there either…. What is curious about human action is that by and large what I am deliberately doing depends on the possibilities of description…. Hence if new modes of description come into being, new possibilities for action come into being as a consequence.”4 Much of the world around us exists for most of the time as nothing other than unnoticed background noise. Like the invisibility of water to the swimming fish, a good deal of our life in the world is lived unintentionally; it just hums along under the hood. When we bring certain things to the fore and choose to describe them, we bring them to attention. The nature of our descriptions determines the kind of attention we pay to those things. Once these things are described, we can act intentionally toward them. The same phenomenon can be described in many ways, and each description brings with it new sets of possibilities for intentional action. Different descriptions provide different modes of awareness, levels of intentionality, and possibilities for different forms of meaningful action.
There are different kinds of descriptions, depending on the angle from which one looks at a phenomenon, but there are also different types of descriptions. In his book The Interpretation of Cultures, the anthropologist Clifford Geertz presents us with the idea of thick and thin descriptions.5 A thin description provides us with the minimum amount of information necessary to describe a situation or context. A survey, for example, provides a thin account of a phenomenon insofar as it captures only certain statistical aspects and provides no contextual, relational, experiential, or cultural information. Statistics also provide thin descriptions. So, for example, we might note that one in four people will experience mental health challenges over a lifetime. This emphasizes at a general level the fact that mental health challenges are a significant issue in the population. However, this statistic tells us very little about the particularities of either the one or the four. Thin descriptions provide us with high-level insights but no low-level details. Another example might be Google Translate, a web-based program that translates typed words into a different language. Through this process, you do get a rough understanding of what words mean in other languages, but that understanding is extremely limited and can even be quite badly skewed. It is an understanding of language stripped of culture, experience, history, or linguistic subtleties and idioms. It is too thin to provide more than a very basic level of insight into the language.
As we enter the world of mental health, it will quickly become clear that thin descriptions abound, both within public conceptions of people’s experiences and within the mental health professions. In what follows, I examine four key areas where thin descriptions have become particularly problematic:
2 The DSM diagnostic system
3 The turn to biology
4 The field of spirituality in mental health care
We find a particularly powerful and devastating example of a thin description and its dangers in the phenomenon of stigma. Stigma is one of the most destructive aspects of living with unconventional mental health experiences and one of the most painful experiences that people have to endure. Stigma occurs when a person is reduced from being a whole to being a mere part; from being a full human being to being the sum of a single part. The sociologist Erving Goffman informs us that the concept of stigma originated in the Greek slave trade. After a slave was purchased, the slave was branded and, in branding, was reduced (or thinned down) to the size of the brand. The slave was no longer described as a person, a citizen, a friend, or a family member but was now simply property. Stigma functions in the area of mental health in a very similar way. Stigma reduces people living with unconventional mental health problems to the shape and form of their diagnosis, or more accurately, to people’s perceptions and caricatures of the implications of their diagnosis. In this way, stigma thins down or reduces people’s descriptions to impersonal caricatures based on the connotations of their diagnoses. People cease to be perceived as persons and become “schizophrenics,” “depressives,” “neurotics,” or any other thin diagnostic facade that people choose to project when they don’t want to engage with real individuals.
Goffman describes stigma as a phenomenon that occurs when an individual with an attribute deeply discredited by his or her society is rejected as a result of that attribute: “While a stranger is present before us, evidence can arise of his possessing an attribute that makes him different from others in the category of persons available for him to be, and of a less desirable kind—in the extreme, a person who is quite thoroughly bad, or dangerous, or weak. He is thus reduced in our minds from a whole and usual person to a tainted, discounted one. Such an attribute is a stigma, especially when its discrediting effect is very extensive.”6 Stigma is most powerful when it urges us to “reclassify an individual from one socially anticipated category to a different but equally well-anticipated one, and the kind that causes us to alter our estimation of the individual downward.”7 Such a powerful stigma redescribes individuals in negative ways that move them from one socially anticipated category to a different and lesser social category.8 Stigma is thus a malignant mode of social description that is very often aimed at some of the most vulnerable people within society.
One of the problems with mental health diagnoses is that they are highly stigmatized categories that take their meaning not only from their clinical descriptions but also and sometimes primarily from the negative cultural accretions that accompany such descriptions. This is particularly true in the Western world, which has a preoccupation with intellect, reason, and clarity of thinking. In such a cultural milieu, mental health challenges can easily be perceived as challenging each of these socially valued attributes and, in so doing, challenging our conceptions of what it means to be fully human.
Tanya Luhrmann notices this particularly in the diagnosis of schizophrenia in America: “One of the challenges of living with schizophrenia in the United States is the clear identity conferred by the diagnostic label itself. To receive care in a society so acutely aware of individual rights is to receive an explicit diagnosis. A patient has the right to know. But the label ‘schizophrenia’ is often toxic for those who acquire it. It creates not only what Erving Goffman called a ‘spoiled identity,’ but an identity framed in opposition to the nonlabelled social world.”9 Describing someone as having schizophrenia or being a “schizophrenic” has significant social and relational consequences, at least in Western cultures. As Esmé Weijun Wang put it in relation to her personal experience of living with schizoaffective disorder: “Giving someone a diagnosis of schizophrenia will impact how they see themselves. It will change how they interact with friends and family. The diagnosis will affect how they are seen by the medical community, the legal system, the Transportation Security Administration, and so on.”10
Importantly, this “spoiled identity” stands in direct opposition to those claiming to bear witness to “normality.” This is why schizophrenia can be so alienating. Built into the description is an assumption of distance and presumed Otherness. However, this is not true in all cultures, as we will see. Indeed, in certain cultures it is not possible to be “a schizophrenic”; constructing people in this way is just not what such cultures do. A question we will explore in various ways as we move on is this: What is it about Western culture that constructs schizophrenia (and other forms of mental health challenge) in such a way as to make it so dehumanizingly stigmatic?
It is clear that thin stigmatized descriptions produce spoiled identities and force expectations downward. Stigma is thus pathogenic (it causes pathology) in that once it is named, the stigmatic description actively causes harm. Stigma dehumanizes people living with mental health challenges. But it also dehumanizes the stigmatizers, who are trained to see only parts of other people without caring for the whole of them (like the doctor in my opening vignette). Stigma thins our vision and hardens out hearts. It is destructive for all concerned.
The issue of stigma will come up throughout this book. For now, we just need to notice its devastating impact and the ways it thins people out and hurts them.
Psychiatry is a hermeneutical and descriptive discipline. It describes and interprets unconventional mental health experiences and responds in ways that bring hope, healing, and relief. We will focus on the issue of interpretation later. Here we concentrate on the descriptive dimensions of psychiatry. Historically via psychiatrists such as Karl Jaspers,11 and in contemporary times through the detailed work of Andrew Sims,12 an approach to description has emerged known as descriptive psychopathology. This phenomenological tradition provides rich and deep descriptions of psychopathology so that psychiatrists can gain insight and create rich and thick descriptions that help them develop deep and therapeutic understandings that lead to effective clinical intervention. Andrew Sims lays out this approach as follows:
The study of individual personal experience is fundamental to psychiatry. Descriptive psychopathology is the precise description and categorization of abnormal experiences as recounted by the patient and observed in his behavior. There are two components to this: careful and informed observation of the patient, and phenomenology, which implies, according to Karl Jaspers, the study of subjective experience. The descriptive psychopathologist is trying to hear what the patient is saying without any theoretical, literary or artistic gloss of interpretation, and without the mechanistic explanations of science used inappropriately. In order to achieve understanding, phenomenology uses empathy as a precise clinical tool.13
The purpose of such a phenomenological approach is not to explain what is going on but to try to understand it: “In Jaspers’ usage, understanding is contrasted with explanation. Understanding, in this sense, involves the use of empathy, subjective evaluation of experience by the ‘understander’ using his or her own qualities of observation as a human being: feeling inside. Explanation is the normal work of natural science involving the observation of phenomena from outside, and objective assessment. Both are required of the practicing doctor but whereas the method of observation in science is carefully and comprehensively taught, teaching the method of empathy to give subjective understanding is frequently neglected.”14 Sims draws attention to this phenomenological tradition but acknowledges that it does not get the recognition it deserves either in medical education or in practice.
One of the reasons this phenomenological tradition has been “lost” relates to the systems currently in place through which we make diagnoses and describe mental health challenges. These systems prefer thin descriptions to the richness and thickness of the phenomenological look. Part of the issue, as we have seen, relates to time. If you have only fifteen minutes with a patient, gathering rich phenomenological detail is not going to be high on your list of priorities. But lack of time is not the only reason for the thinness of psychiatric descriptions.
The practice of psychiatric description (diagnosis) is organized according to the groupings and categorizations that compose diagnostic manuals such as the World Health Organization’s International Classification of Diseases (ICD)15 and the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM).16 These manuals contain the criterion used to redescribe persons’ experiences in terms of commonly observed symptoms and to develop the formal names for mental health conditions. By “redescribing,” I refer to the process whereby a person brings a set of experiences to the attention of the psychiatrist, who then redescribes them in terms of signs and symptoms of some kind of underlying pathological process.
The World Health Organization (WHO) claims that the “ICD is the foundation for the identification of health trends and statistics globally, and the international standard for reporting diseases and health conditions. It is the diagnostic classification standard for all clinical and research purposes. ICD defines the universe of diseases, disorders, injuries and other related health conditions, listed in a comprehensive, hierarchical fashion.”17 Defining the universe is a pretty impressive claim, even for an organization as esteemed as the World Health Organization! Nevertheless, the ICD criteria have been deeply influential in diagnosing mental and physical conditions and have been adopted in Europe, North America, China, Korea, Sweden, and Thailand.18 The ICD and the DSM are closely connected:19 “Although the [DSM] manual is American, it is much used elsewhere, despite the fact that the International Classification of Diseases, drawn up under the auspices of the World Health Organisation in Geneva, is usually seen as the official manual, if there is one. DSM-5 gives ICD codes when they match, and there is a project aimed at harmonising the two rulebooks.”20 While recognizing the importance of the ICD system, we will focus on the DSM, which is the main classification system used in the United States and is highly influential throughout the world.21
The most recent incarnation of the DSM, DSM-5, was published in May 2013 by the American Psychiatric Association and claims to offer standard criteria for the classification of mental disorders. The DSM-5 provides a series of descriptions of mental health phenomena, which are clustered together to form various diagnostic categories. Each category is given a number: schizophrenia is 295.90, schizoaffective disorder is 295.70[F25.0], and so forth. In this way, a statistical system is merged with the self-narrated qualitative experiences of mental health, as numbers are assigned to people’s experiences. The manual is statistical because “its classifications can be used for studying the prevalence of various types of illness. For that one requires a standardised classification. In a sense, the manual has its origins in 1844, when the American Psychiatric Association, in the year of its founding, produced a statistical classification of patients in asylums. It was soon incorporated into the decennial US census. During the First World War it was used for assessing army recruits, perhaps the first time it was put to diagnostic use.”22
This manual is used by a wide variety of persons and groups: researchers, clinicians, drug regulation agencies, pharmaceutical companies, and health insurers. The presence of a DSM diagnosis is necessary, not only in terms of accurate diagnosis, but also (at least in the United States and parts of Canada) to access Medicare and insurance plans provided in Canadian provinces.23 Its influence can be seen in the fact that the majority of English-language journals insist that the language of DSM be used to characterize any research published. The DSM is a purely descriptive document and offers no recommendations for treatment, although those who use it might argue that accurate diagnosis leads to the most appropriate treatment. In determining the kinds of areas that are fundable and not fundable for research, the descriptions contained in DSM-5 are seen to serve bureaucratic as well as medical intentions. In short, DSM-5 has a good deal of clinical, political, and financial power.
The process for determining diagnostic categories begins when groups of psychiatrists meet in various hotels across America to discuss which mental health experiences should fit within the various diagnostic categories. After a lot of discussing, arguing, categorizing, and recategorizing, the psychiatrists judge which classifications, names, and criteria are appropriate descriptions to guide clinical practice. Thus is born the DSM.
Any given diagnostic category—schizophrenia, bipolar disorder, obsessive-compulsive disorder—comes into existence as it is constituted by the DSM criteria. The DSM has the power to establish, or at least to give formal, organized existence to, mental health experiences. As such, it is not only descriptive but also formative. Diagnoses are shorthand descriptions of complex human behavior. In descriptive mode, DSM-5 provides clinicians with concepts and forms of language that can be used to make sense of clusters of unusual human experiences. However, such descriptions also form the ways psychiatrists (and others) see and describe the person before them. Once you accept the DSM as the basis for your diagnostic practices, that becomes the way you see people. Diagnoses will help you to see some things very clearly, but they will inevitably occlude other things. The DSM thus propagates a certain type of clinical gaze that is bounded by the parameters of the knowledge and expectations of the clinician. The expectations of the clinician are not free-floating. Clinicians are deeply aware of the expectations of the system and the limitations of time. Shorthand descriptions are very helpful within a system that is bounded and limited by the pressures of time.
There is thus a complicated dialectic between the consensus-based formation of diagnoses by clinicians and the pressures of the system clinicians have to use. A system like the DSM fits well into a pragmatic and instrumental system where therapeutic explanation and “getting things done” may be perceived as primary goals. There is little room here for thick descriptions that require more than fifteen minutes with a patient. This is why many people don’t recognize themselves in the descriptions that emerge from the DSM. As Esmé Weijun Wang puts it: “To read the DSM-5 definition of my felt experience is to be cast far from the horror of psychosis and an unbridled mood; it shrink-wraps the bloody circumstance with objectivity until the words are colorless.”24 This is clearly a problem. However, there are other, perhaps greater problems with the thin descriptions that we encounter in the DSM. It is descriptive and formative, but it is also a mode of creation: it brings mental health conditions into existence and takes some out of existence.
The philosopher Ian Hacking opens his paper “Making Up People” with a quite startling assertion:
Were there any perverts before the late nineteenth century? According to Arnold Davidson, “The answer is NO…. Perversion was not a disease that lurked about in nature, waiting for a psychiatrist with especially acute powers of observation to discover it hiding everywhere. It was a disease created by a new (functional) understanding of disease.” Davidson is not denying that there have been odd people at all times. He is asserting that perversion, as a disease, and the pervert, as a diseased person, were created in the late nineteenth century. Davidson’s claim, one of many now in circulation, illustrates what I call making up people.25
The description of someone as a “pervert” wasn’t available before the late nineteenth century. It was only when law and medicine created a category and described those who fit that category as “perverts” that being a pervert became possible. Similarly, prior to formal categorization, again in the late nineteenth century, it was not possible to be either a homosexual or a heterosexual. There has been same-sex activity in all eras, but it was not until the legislative categories became available that one could be named “homosexual” or “heterosexual.” Once these categories (kinds of people) came into existence, a variety of responses became possible: a position for or against homosexuality, heterosexuality, gay rights, homophobia, and so forth. Once these categories were created, it was possible to be these kinds of people.
However, the existence of such persons is fragile, determined by the shifting will of society and the transitive nature of the legislative system, which can in principle take them out of existence as well. For many people, it is not who they are as unique individuals that gives their existence substance and durability but the way society chooses to describe them at any moment in time. They remain in existence only as long as the category continues to be given social, political, and legal validation. It would be legislatively possible to eradicate homosexuality, heterosexuality, or perversion simply by changing the legal categories. We may find it difficult to imagine a society where people are forced to be homosexual. We may have less trouble imagining a society where people are forced to be heterosexual, as there are recent and even contemporary precedents to indicate that some would be quite comfortable with such a suggestion.26 We would have no difficulty at all imagining a society where Jewish people were legislatively considered to be less than human. Europe has a dark history that makes this point tragically. Recognizing how and why we make up people is of the ultimate importance.27
What Hacking observes about the ways we make up people resonates with the people-making power of the DSM. It is possible for a particular form of mental health challenge to come into existence only if psychiatry continues to name the set of experiences that make up such a diagnosis in the same way it always has. The problem is that the DSM keeps changing its mind. Unlike the scientific process that goes into the development of the diagnosis of physical illnesses, a committee decides the presence or absence of particular forms of mental health challenges. One reason why the DSM has to be continually revised, updated, and rereleased is that the various committees vote to add, take out, or modify particular diagnoses or aspects of diagnoses. At the end of this process of discussing, arguing, and categorizing, these committees present the categories and criteria that, in their opinion, form the basis for classifying people’s mental health experiences. The DSM has the power to create and establish, or at least to give formal, organized existence to, mental health experiences that are considered to be unconventional. These committees make up or invent mentally ill people, but they also reverse that process.
A good example of this de-creative process can be found in the response of psychiatry to homosexuality. In 1972, homosexuality was considered a treatable form of mental illness.28 In 1973, the American Psychiatric Association decided it was no longer to be described in this way. The change came about not because of any new scientific evidence but because of pressure from gay rights activists who felt the designation was unjust and unfair and that psychiatry was acting more in moral judgment than in the cause of clinical necessity. The description of homosexuality as a mental health issue was eliminated by the votes of the committee.
More recently, Asperger’s syndrome has been taken out of existence. Prior to DSM-5, it was possible to have Asperger’s syndrome. Now it’s not. Asperger’s has been subsumed into a broader category of autism. The National Autistic Society describes Asperger’s syndrome in this way: “People with Asperger syndrome see, hear, and feel the world differently to other people. If you have Asperger syndrome, you have it for life—it is not an illness or disease and cannot be ‘cured.’ Often people feel that Asperger syndrome is a fundamental aspect of their identity.”29 Although some people choose to retain the term “Aspie,” technically this way of being a person is no longer available. For many people, having Asperger’s syndrome was important. It was not, and still is not, a problem to be solved but is more a way of life that provides an important source of identity:
The news that the term “Asperger’s syndrome” will soon cease to exist has some parents concerned—especially parents raising “Aspie” children. Starting May 2013, the American Psychiatric Association’s new diagnostic manual, known as the DSM-5, will go into effect, stripping the well-known condition—a condition sometimes associated with loner geniuses like Albert Einstein and Andy Warhol—of its name. Instead, Asperger’s syndrome will simply be known as ASD-Level 1 (mild), a top rung in the ladder of autism spectrum disorders. For those who viewed an Asperger’s diagnosis as light-years away from clinical autism, this new classification may feel like a fall from grace.30
This change is problematic for some. Timothy Bumpus, who lives with autism, points out that “some of the most brilliant people had Asperger Syndrome, and you just can’t put that under the title of Autism…. This disability, which is ironically not at all a disability, causes the recipient to be antisocial, physically weak…. However, it is so much more. It allows a person to think in whole different ways, to see things in a different light than others.”31
I met a young man at a conference in Atlanta a couple of years ago. At that time, he proudly proclaimed himself to be an Aspie! The next time I met him, something had changed. He said to me: “The last time I met you I had Asperger’s syndrome. I was a wild, wild Aspie!! Now a committee has healed me of that, but they have given me autism … again!” We laughed. It was funny, but it was also telling. When something central to your identity can be changed by a committee without consulting you or others with similar experiences, you are forced to recognize that the fullness of your experience of mental health challenges is clearly not being incorporated into the diagnostic process.
Not all DSM diagnoses are as politically charged as same-sex relationships and Asperger’s syndrome, but they all involve the same process of being created, modified, rejected, or incorporated according to committee votes. The potential difficulties and the inevitable thinness of the descriptions that emerge from this process need to be recognized. Diagnoses are more like social kinds than natural kinds;32 they have a certain form of social existence in that at particular times society accepts them as useful explanatory concepts and acts accordingly. Diagnoses have an epistemology but no ontology. They are pencil sketches of human experiences that are frequently being erased and altered. On their own they tell us some potentially important things, but their descriptions are too thin to do all the work required for understanding mental health issues.
The third area in which thin descriptions are given power is within the ongoing conversation around whether mental health challenges can be adequately explained by biology. On April 29, 2013 (just prior to publication of the fifth edition of the DSM), the director of the National Institute of Mental Health (NIMH), Thomas Insel, shook the world of psychiatry by stating that the diagnoses laid out in the DSM did not describe authentic disorders. They were constructs without any empirical basis. Because there are no biomarkers attached to the conditions the DSM describes as “mental disorders,” they could not be empirically verified and were therefore invalid as criteria for defining mental disorder. That being so, the DSM could not justifiably be considered clinically relevant. The NIMH is the leading federal agency for research on mental disorder in the United States. Insel said the NIMH would no longer fund research projects that rely exclusively on DSM criteria. The problem he highlights is that while the DSM criteria offer a measure of reliability, they are lacking in validity:
The goal of this new manual [DSM-5], as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability”—each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment. Patients with mental disorders deserve better.33
Insel urged the field to leave behind the descriptive approach of the DSM and to develop a new diagnostic scheme based on solid, verifiable scientific research that focused on finding the biological roots of mental disorders.
Insel is correct to suggest that there is a need for a more rigorous and thick process of diagnosis than the DSM can provide on its own. There is an obvious weakness in a system where decisions are made and diagnoses are constructed on the basis of consensus around flexible concepts and constructions, without evidence that stretches beyond the particularities of committee votes. But is his alternative really better or even possible? As Gary Greenberg noted recently in the New Yorker: “Doctors in most medical specialties have only gotten better at sorting our suffering according to its biochemical causes … [but] psychiatrists still cannot meet this demand. A detailed understanding of the brain, with its hundred billion neurons and trillions of synapses, remains elusive, leaving psychiatry dependent on outward manifestations for its taxonomy of mental illnesses.”34 The evidence that Insel wants is, at least at the moment, simply not available. It may become available in the future, but for now, in general terms, the biological evidence for the root causes of all mental health disorders is at best speculative and at worst simply absent.35 Insel may well be correct that patients deserve better, but will a shift from describing symptoms to describing biology really produce better descriptions?
At a personal level, making such a claim without evidence must be deeply troubling for people living with mental health challenges who have been treated under the “old regime.” As Sarah Kamens has pointed out: “It’s … akin to telling patients that we made a huge mistake.”36 If the DSM has interrater reliability—that is, all psychiatrists are using the same set of criteria—but no validity (no empirical evidence to indicate the truth of a given diagnosis), then people have been diagnosed by a set of criteria that is reliable across the sector but lacking empirical verification. This leaves people living with mental disorders in a difficult situation. It is possible that their current diagnosis could be redescribed in the future, and they would have to rebuild their lives and sense of identity accordingly.
It is true that the biological quest is intended to find better treatments and to eradicate symptoms. However, what if your symptoms are meaningful for you? If the only description of your situation is that you have a mental illness that is basically the same as a physical illness with symptoms that are meaningless, then your personal experience of your mental health challenges will be discounted as irrelevant. Critical as I have been of the DSM, at least it holds open the possibility that symptoms are more than mere biological malfunctioning. Such a suggestion—that symptoms are meaningful and should be responded to as such—is counterintuitive. For now, I urge the reader to remain open to the possibility. When we look more closely at the lived experience of mental health challenges, we will see the importance of recognizing the meaningfulness of symptoms and the dangers in trying to merge them into a single biological description. Insel is right: patients deserve better. The problem is that within a universe of multiple descriptions, his solution may not be as helpful as he assumes.
It’s not that biological descriptions are not relevant or important. The problem is that they can easily become reductive. In his work on the nature of explanation, the sociologist Alan Garfinkel points out the reductive tendencies of explanation. When people think they have explained something, they tend to exclude other explanations, thus reducing understanding of the situation to a single explanation. “The reductionist claims that one class of phenomena, more or less well explained by some body of theory, is really explainable by some other theory, which is thought of as deeper or more basic; this, we say, reduces the apparent complexity of the world.”37 Such explanations reduce the complexity of multifaceted situations and experiences to a single explanation. Explanations become hegemonic when they insist on explaining unconventional mental health experiences without reference to other possible explanations. Garfinkel suggests that we
pay more attention to what exactly is being explained by a given explanation. Too often, theories talk as if they are addressing some problem, though they are really addressing different problems or different aspects, interpretations, or readings of the problem. For when a theory talks about a phenomenon, it inevitably does so in terms of its own representation of it. The phenomenon gets incorporated into the theory in a particular way, structured by a definite set of assumptions and presuppositions about its nature. This makes it very important that we recognize those presuppositions and discover how the theory has represented a particular object of explanation.38
For current purposes, it is important that we recognize the kinds of presuppositions that lie behind reductive biological explanations of mental health challenges and the dangers of uncritically accepting such explanations.
Take, for example, the common strategy of equating mental illness with physical illness. One reason people are keen on this way of thinking is that it destigmatizes mental disorder. It draws it out of the messiness of society, politics, and stigmatizing views and places it on par with forms of physical illness that tend not to attract stigma. In his book Surviving Schizophrenia, the psychiatrist E. Fuller Torey explains what he thinks mental illness is (in this case, schizophrenia): “Schizophrenia is a brain disease, now definitely known to be such. It is a real scientific and biological entity as clearly as diabetes, multiple sclerosis, and cancer are scientific and biological entities. It exhibits symptoms of a brain disease, symptoms which include impairment in thinking, delusions, hallucinations, changes in emotions, and changes in behavior. And, like cancer, [it] probably has more than one cause.”39
Putting to one side the fact that the evidence for the biological roots of schizophrenia is not clear-cut,40 let’s think through how this explanation works. It claims to give us a plausible explanation of the various experiences that bring people under the description of schizophrenia. People experience symptoms because of an underlying biological condition. The primary task for mental health care is to adjust the person’s biology in ways that will bring about relief from suffering. There may be other aspects to the patient and her care, but the central focus is on biology, because that is where the problems are fundamentally located. Schizophrenia is a malignant biological process similar to cancer, over which no one has total control. Within such an explanatory framework, people’s mental health experiences are explained as the result of such things as chemical imbalances, genetic predispositions, neurological pathology, viruses, and so forth. The assertion “Mental illness is like any other medical illness” implies, as Insel suggested, that mental illness can be fully explained according to its biological basis.
Positively, as mentioned, one of the intentions of this kind of approach in general and Fuller Torrey’s approach in particular is to destigmatize mental ill health. When Fuller Torrey wrote his book in 1982, there had been a strong tradition of blaming parents (often mothers) for the formation of schizophrenia. This blaming of family and mother had caused a lot of unnecessary grief for parents.41 Recognizing this, Fuller Torrey had become a strong advocate for families. Surviving Schizophrenia was the first handbook designed specifically to help not patients but families “survive” schizophrenia. His strong emphasis on the importance of the biological had significant social and political as well as medical origins and intent.42
The ascription of biological explanations has also been used in an attempt to destigmatize the experiences of people living with mental health challenges. The suggestion that the causes of such challenges are similar to the causes of physical illnesses such as cancer, diabetes, and influenza is intended to reduce the stigma that surrounds mental disorders. The compassion behind this approach is clear, and the sentiment is laudable. The problem is, it doesn’t seem to work.
Malla, Joober, and Garcia note that “Several well-conducted studies have concluded, almost uniformly, that this strategy—destigmatization by emphasizing the biological aspects of mental health challenges—has not only not worked, but also may have worsened public attitudes and behavior toward those with mental illnesses. Investigations of stigma have shown that those who consider mental disorders as primarily attributable to biological forces, just like other medical disorders, while absolving the mentally ill person of responsibility for their behavior and actions, tend to feel less optimistic about their ability to get better and function well, are less accepting of them and feel less positively toward them.”43 The problem seems to be that in using biology as an explanation for mental disorders, within the minds of the public and for the individual who lives with the experiences, the disorder becomes ontologized and totally defining of the person. People no longer have an illness; now they are an illness. The DSM offers descriptions that function epistemologically rather than ontologically. Biological explanation does the exact opposite. A biological explanation is much deeper, much more personal, much more tied in with the “is-ness” of who and what a person is. Biological explanations are thus seen to have unfortunate side effects.
In his book How to Become a Schizophrenic, John Modrow, a psychiatrist who lives with schizophrenia, offers a powerful insider’s critique of biological explanations and points out a hidden danger:
I cannot think of anything more destructive of one’s sense of worth as a human being than to believe that the inner core of one’s being is sick—that one’s thoughts, values, feelings, and beliefs are merely the meaningless symptoms of a sick mind. Undoubtedly the single most important causal factor behind my mental breakdown was a sense of worth so badly shaken that not even the most florid delusions of grandeur could save it. What the concept of “mental illness” offered me was “scientific proof” that I was utterly worthless, and would always be worthless. It was just the nature of my genes, chemistry and brain processes—something I could do nothing about.44
Schizophrenia is not like measles. One can have measles, but one becomes schizophrenia. Sally Clay addressed the First National Forum on Recovery from Mental Illness as follows: “Those of us who have had the experience called ‘mental illness’ know in our hearts that something profound is missing in these diagnoses. They do not take into account what we have actually endured. Even if the ‘bad’ chemical or the ‘defective’ gene is someday found, madness has its own reality that demands attention.”45 Stigma is a way of stealing someone’s story and forcing the person to accept a false, negative identity. It needs to be fought against. Biological explanations may provide a helpful and nonstigmatizing version of disturbing experiences. However, such explanations can have a shadow side that we miss at our peril.
The point is not that biology may not be formative of mental challenges. We do not yet have the evidence to make such a case across the board, but in time it may emerge. The problem is that biological explanations on their own can be highly reductive, closing down aspects of our experiences and forcing us to interpret them in a very narrow and confined way. In the end, such attempts at destigmatizing “the mental” actually end up reinforcing the idea that there is a problem with that aspect of our humanness, rather than addressing the key issue—that there is no need to stigmatize issues of the mind dualistically. A psychological description is no different from a biological one; it simply addresses different aspects of our humanness—shifting the problem from the mind to the body is nothing more than another manifestation of Cartesian dualism. The unhealthy and inauthentic anthropology that underpins this way of thinking remains fully intact. Biological descriptions are simply too thin to do the work of realigning and clarifying that is necessary for the tasks of destigmatizing and healing.
The final area of thin description emerges from a rather surprising source: the ongoing conversation around the role of spirituality in mental health care. If systems of categorization such as the DSM tend to create diagnoses that can have thinning and objectifying effects, and if biological approaches risk turning people into bodies without persons, then conversations around spirituality reveal that even in the realm of the apparently holistic and spiritual dimensions of care, thin descriptions abound and hold hidden dangers. This may at first sound rather odd. We’re tempted to say: “Surely, spirituality has to do with whole-person care and holistic ways of viewing people.” Well, one might be forgiven for thinking that. However, closer scrutiny of what is actually going on in the realm of the spiritual as it is articulated within mental health care reveals something quite different.
I have been a part of the conversations around spirituality and mental health care for many years. In 2001, I wrote a book titled Spirituality and Mental Health Care: Rediscovering a “Forgotten” Dimension.46 Among other things, that book pointed out the lack of research and practical attention being paid to spirituality within mental health care. It suggested that the “forgotten dimension” of spirituality was in fact crucial for good mental health care and indicated ways in which mental health professionals could be encouraged to remember it and, in remembering, become people who care for the spirit as well as minds and bodies.
Since then, the situation has changed significantly. What appeared to have been “forgotten” in 2001 is well and truly remembered today! The literature emerging from the mental health-care professions reveals a burgeoning and vibrant interdisciplinary conversation that explores a variety of issues around spirituality, religion, and mental health. Religious spirituality has been positively associated with the alleviation of depression, anxiety, PTSD (posttraumatic stress disorder), schizophrenia, anorexia, and personality disorder.47 The more generic forms of spirituality are not so closely tied to measurable outcomes, but they are assumed to be fundamental to genuinely person-centered care.48 Some authors even suggest it is essential to our humanness.49 This latter claim is probably not very wise, because highlighting any capacity or desire as fundamental to what it means to be human inevitably means that those who do not have that capacity or share that desire can be viewed as less than human. Nevertheless, the universality of spirituality is certainly a frequently made claim.50 The presence of spirituality is recognized even at the level of policy, with governments insisting that all mental health professionals and indeed all health-care professionals take spirituality seriously.51
At first glance, this seems to be very good news! We may not be clear on what mental disorders are, but we do know what human beings are and what human beings need: they need spiritual care. Alongside the necessary care for mind and body, we also need to care for people’s spirits. One might ask the question: “What could possibly be wrong with this?” Surely this puts things like religion and theology back on the map of professional credibility and offers important new possibilities for care. To an extent this is true, however, as useful as a focus on people’s spiritual dimensions is, there are significant problems with this approach.
The basic understandings of spirituality in the relevant literature focus on the central features of what people assume spirituality to be: meaning, purpose, hope, value, respect, love, dignity, and (for some people) God.52 Few of these definitions offer a strong philosophical or theological rationale for what spirituality actually is, and why it should be understood in such ways. Instead, many researchers simply create their own definitions of spirituality, which tend to focus on those things the researcher assumes to be most valuable in and, importantly, most absent from current caring practices. Their general assumption is that the content of spirituality emerges from the personal choice of the individual. Some people choose to express their essential spirituality in terms of religion, but others choose different ways of engaging with their spirituality (through nature, art, relationships, sport, and so forth).
Researchers think about spirituality in this way in order to ensure that it is inclusive. Put slightly differently, this is a spirituality designed to cater to people of “all faiths and none.” It is nondenominational, open to the religious and the secular, and above all, individualistic and personal. Spirituality is thus perceived to relate to a series of personal choices that everyone should be given the freedom to develop on their own terms and in their own image. Spirituality relates to my meaning, my purpose, my value, and my choice about whether I believe in God. Viewed in this way, spirituality becomes a mode of self-actualization, a way of meeting personal needs and goals quite apart from others or God. This mode of spirituality fits neatly within the goals of modernity and the expectations of a culture that is deeply individualistic and fundamentally oriented toward personal choice as the moral arbiter.
What we end up with is a very thin mode of spirituality that is terrified of offending anyone. No longer do we have deep, thick descriptions of spirituality, richly narrated spiritual encounters with God, angels, or demons. We have prayer, worship, and sometimes a loose affiliation to religion, but involvement with what God is doing in the world is optional, if it is included at all. Instead, spirituality is thinned down and renarrated in terms of personal choices and practical psychological utility (does it make you feel better?). The efficacy and acceptance of spirituality are gauged by the effect of particular behaviors—prayer, meditation, church attendance—on a person’s well-being, with “well-being,” once again, being viewed primarily in relation to an individual’s hopes and desires. One can choose the God who created the universe and who flung the stars into space, or one can choose a walk in the park. Both are assumed to be pretty much the same thing in terms of spiritual worth.
Practical utility is key. “Does it work?” “What benefits can it bring to people?” “How can it help us feel healthier?” This kind of spirituality is a spirituality from below—a spirituality that may include transcendence, but only as one option among many others. It makes little difference whether God is real. What matters is whether we choose God as a lifestyle option. Rather than introducing something that is radical and new, this mode of spirituality is designed to help certain culturally bound conceptions of spirituality fit in with current practices and assumptions. Instead of transforming mental health-care practices into something radically different from what is available currently, it is deeply shaped and formed by what is already going on in health-care institutions. It is a spirituality from below that takes its shape not from the urgings of the Spirit of God but from the nature and spirituality of health-care institutions.
An examination of the National Health Service (NHS) in the United Kingdom will illustrate this point. The NHS was launched in 1948. It is a system that assumes that good health care should be available to all people regardless of wealth. Health care is thus free at the point of use for all UK residents and is based on clinical need, not ability to pay.
The system is also designed to meet the needs of everyone; this is necessary for it to function effectively and fairly according to its expressed intentions. However, this universality inevitably problematizes and narrows the possible options for the kind of spirituality that might be acceptable within the system. In terms of spirituality, this ensures that the NHS is inevitably secular, because it cannot be connected directly with any one religion. It deals with a very broad range of people, and as such it must meet the needs of people of “all faiths and none.” The particularity of religious traditions becomes problematic within a context that requires generalities in order to function. A general, generic definition of spirituality may be thin, but it is easy to implement.
Health and social care systems such as the NHS require generalities to function effectively. At a pragmatic level, it makes sense to deprioritize the particularities of religion and to develop a general mode of spirituality to which everyone can relate. Treatments—chemotherapy, medication, physiotherapy, pain control—must be universal and applicable across the whole system. You can’t have an antibiotic that works only for one person! So, too, you can’t have a spirituality that works for only one group of people. A system would not work well if each doctor had his or her own way of doing things that might conflict with how other doctors conducted their practice. So, while there is obviously diversity within the system, the principle of generalization is necessary and established.
Within this context, people may think they are acting counterculturally and taking spirituality into the system. However, a deeper reflection indicates that the system itself shapes and forms the spirituality that is acceptable; it silently places boundaries, parameters, and brakes on the activities of spiritual care and our articulations of spirituality and compels us to work with a thin model of spirituality that dovetails neatly with what is already there.
This model of spirituality seems to resonate with the idea of a universal spirituality that everyone shares, something that abounds in the literature. However, when one runs a critical eye across the ways in which people formulate spirituality, it becomes clear that, far from being universal, it is a very Western cultural model, which assumes the primacy of Western values such as individualism, freedom, autonomy, choice, and the right of people to create their own destiny. This is clearly a cultural model of spirituality rather than a universal one. It may raise our consciousness to certain important but overlooked aspects of health care, but by claiming that “everyone has a spirituality” and seeking to make a culturally bound model appear to be universal, we risk “baptizing people behind their backs,” forcing them to accept thin, culturally bound models of spirituality and humanness that may satisfy certain desires and needs but in the end fail to meet those needs that can be discovered only as we engage with thicker descriptions. When this happens, we subliminally engage in precisely the kind of proselytizing behaviors that some consider a central danger of allowing religion to be a part of health care. There is clearly a need for a richer and thicker conversation around spirituality and mental health than is provided by current culturally bound models and approaches. The question is: What might that look like? And how might we go about achieving such a goal?
1. Emily Martin, Bipolar Expeditions: Mania and Depression in American Culture (Princeton: Princeton University Press, 2007), 10.
2. G. E. M. Anscombe, Intention, 2nd ed. (Oxford: Basil Blackwell, 1957).
3. Ian Hacking, The Social Construction of What? (Cambridge, MA: Harvard University Press, 1999), 31.
4. Thomas C. Heller, Morton Sosna, and David E. Welbery, eds., Reconstructing Individualism (Stanford, CA: Stanford University Press, 1986), 230.
5. Clifford Geertz, The Interpretation of Cultures (New York: Basic Books, 1973), 33–55.
6. Erving Goffman, Stigma: Notes on the Management of Spoiled Identity (Englewood Cliffs, NJ: Prentice-Hall, 1963), 3.
7. Goffman, Stigma, 3.
8. Goffman, Stigma, 3.
9. T. M. Luhrmann and Jocelyn Marrow, eds., Our Most Troubling Madness: Case Studies in Schizophrenia across Cultures (Berkeley: University of California Press, 2016), 27.
10. Wang, The Collected Schizophrenias, Kindle locations 225–227.
11. Karl Jaspers, General Psychopathology, trans. J. Hoenig and M. W. Hamilton, 7th ed. (Manchester: Manchester University Press, 1963).
12. A. Sims, Symptoms in the Mind: An Introduction to Descriptive Psychopathology, 3rd ed. (Edinburgh: Saunders, 2003).
13. Andrew Sims, “Is Faith Delusion?,” 2007, accessed October 28, 2019, https://www.rcpsych.ac.uk/docs/default-source/members/sigs/spirituality-spsig/is-faith-delusion-andrew-sims-editedx.pdf?sfvrsn=59a019c0_2.
14. A. C. P. Sims, “Symptoms and Beliefs,” Journal of the Royal Society of Health 112, no. 1 (1992): 42–46.
15. World Health Organization, “The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines,” accessed October 28, 2019, https://www.who.int/classifications/icd/en/bluebook.pdf?ua=1.
16. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) (American Psychiatric Publishing, 2013).
17. World Health Organization, “International Classification of Diseases (ICD) Information Sheet,” accessed October 28, 2019, https://www.who.int/classifications/icd/en/.
18. World Health Organization, “The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research” (Geneva: World Health Organization, 1993), https://www.who.int/classifications/icd/en/GRNBOOK.pdf?ua=1.
19. M. First, “Harmonisation of ICD-11 and DSM-V: Opportunities and Challenges,” British Journal of Psychiatry 195, no. 5 (1999): 382–90.
20. Ian Hacking, “Lost in the Forest,” London Review of Books 35, no. 15 (August 8, 2013): 7–8, https://www.lrb.co.uk/v35/n15/ian-hacking/lost-in-the-forest.
21. For a fascinating insight into how this way of interpreting mental health issues is becoming globalized, see Ethan Watters, Crazy like Us: The Globalization of the Western Mind (New York: Little, Brown, 2011).
22. Hacking, “Lost in the Forest,” 2.
23. Hacking, “Lost in the Forest,” 1.
24. Wang, The Collected Schizophrenias, Kindle locations 183–184.
25. Ian Hacking, “Making Up People,” in Reconstructing Individualism: Autonomy, Individuality, and the Self in Western Thought, ed. T. Heller (Stanford, CA: Stanford University Press, 1986), 99–114 (emphasis added). The interior quotation is from Arnold Davidson, “Closing Up the Corpses,” in Meaning and Method, ed. G. Boolos (Cambridge: Cambridge University Press, 2001), 24.
26. D. C. Haldeman, “Gay Rights, Patient Rights: The Implications of Sexual Orientation Conversion Therapy,” Professional Psychology: Research and Practice 33, no. 3 (2002): 260–64.
27. I am aware and a little concerned that my usage of the term “homosexuality” may be problematic. The LGBTQ community tends to avoid the term “homosexuality,” preferring to use the description “those attracted to the same sex.” I acknowledge the importance of this linguistic change while also noting that this is a useful example of the way we create and re-create people in line with the politics and expectations of the moment.
28. Sarah Baughey-Gill, “When Gay Was Not Okay with the APA: A Historical Overview of Homosexuality and Its Status as Mental Disorder,” Occam’s Razor 1, no. 2 (2002): 5–16.
29. “Asperger Syndrome,” National Autistic Society, accessed October 28, 2018, https://www.autism.org.uk/about/what-is/asperger.aspx.
30. Linda Federico-O’Murchu, “Farewell to Aspies: Some Families Reluctant to Let Go of Asperger’s Diagnosis,” Today, January 4, 2013, https://www.today.com/parents/farewell-aspies-some-families-reluctant-let-go-aspergers-diagnosis-1B7821891.
31. Federico-O’Murchu, “Farewell to Aspies.”
32. Nick O. Haslam, “Natural Kinds, Human Kinds, and Essentialism,” Social Research 65, no. 2 (Summer 1998): 291–314.
33. Thomas Insel, “Transforming Diagnosis,” National Institute of Mental Health, April 29, 2013, https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml.
34. Gary Greenberg, “Does Psychiatry Need Science?,” New Yorker, April 23, 2013, https://www.newyorker.com/tech/annals-of-technology/does-psychiatry-need-science#.
35. My point here relates to biological explanations for all mental health challenges. It is not that there is no evidence for some. It is the assumption that all problems are based in biology that is problematic.
36. Sarah Kamens, “Dr. Insel, or: How Psychiatry Learned to Stop Worrying and Love the Biomarker; A Response to RDoC” (unpublished conference paper, May 2013).
37. Alan Garfinkel, Forms of Explanation: Rethinking the Questions in Social Theory (New Haven: Yale University Press, 1981), 14.
38. Garfinkel, Forms of Explanation, 12.
39. E. Fuller Torrey, Surviving Schizophrenia: A Family Manual, 6th ed. (San Francisco: Harper, 2013).
40. Richard P. Bentall, Madness Explained: Psychosis and Human Nature (London: Penguin Books, 2004).
41. Denise Sommerfeld, “The Origins of Mother Blaming: Historical Perspectives on Childhood and Motherhood,” Infant Mental Health Journal 10, no. 1 (Spring 1989): 14–24.
42. For a further development of this point and on the history of family blaming, see chap. 5 in Anne Harrington, Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness (New York: Norton, 2019).
43. A. Malla, R. Joober, and A. Garcia, “‘Mental Illness Is like Any Other Medical Illness’: A Critical Examination of the Statement and Its Impact on Patient Care and Society,” Journal of Psychiatry and Neuroscience 40, no. 3 (2015): 147–50. See also S. Peerforck, G. Schomerus, and S. Pruess, “Different Biogenetic Causal Explanations and Attitudes towards Persons with Major Depression, Schizophrenia and Alcohol Dependence: Is the Concept of a Chemical Imbalance Beneficial?,” Journal of Affective Disorders 168 (2014): 224–28; J. Read, N. Haslam, and N. L. Sayce, “Prejudice and Schizophrenia: A Review of the ‘Mental Illness Is an Illness like Any Other’ Approach,” Acta Psychiatrica Scandinavica 114 (2006): 303–18; and N. Rüsch, A. R. Todd, and G. V. Bodenhausen, “Biogenetic Models of Psychopathology, Implicit Guilt, and Mental Illness Stigma,” Psychiatry Research 179 (2010): 328–32.
44. John Modrow, How to Become a Schizophrenic: The Case against Biological Psychiatry (Everett, WA: Apollyon, 1992), 147.
45. Sally Clay, “The Wounded Prophet” (unpublished paper presented at the First National Forum on Recovery from Mental Illness, National Institute of Mental Health and Ohio Department of Mental Health, April 1994).
46. John Swinton, Spirituality and Mental Health Care: Rediscovering a “Forgotten” Dimension (London: Jessica Kingsley, 2001).
47. On depression, S. Vasegh et al., “Religious and Spiritual Factors in Depression,” Depression Research and Treatment, 2012; on anxiety, L. M. Steiner et al., “Spiritual Factors Predict State and Trait Anxiety,” Journal of Religion and Health 56, no. 6 (2017): 1937–55; on PTSD, J. M. Currier, J. M. Holland, and K. D. Drescher, “Spirituality Factors in the Prediction of Outcomes of PTSD Treatment for US Military Veterans,” Journal of Traumatic Stress 28, no. 1 (2015): 57–64; on schizophrenia, S. Grover, T. Davuluri, and S. Chakrabarti, “Religion, Spirituality, and Schizophrenia: A Review,” Indian Journal of Psychological Medicine 36, no. 2 (2014): 119–24; on anorexia, Patricia Marsden, Efthalia Karagianni, and John F. Morgan, “Spirituality and Clinical Care in Eating Disorders: A Qualitative Study,” International Journal of Eating Disorders 1, no. 1 (2006): 7–12; on personality disorder, K. Bennett, K. J. Shepherd, and A. Janca, “Personality Disorders and Spirituality,” Current Opinion in Psychiatry 26, no. 1 (2013): 79–83.
48. Christina Puchalski, “Integrating Spirituality into Patient Care: An Essential Element of Person-Centered Care,” Polskie Archiwum Medycyny Wewnetrznej 123 (2013): 491–97.
49. Pamela Reed, “An Emerging Paradigm for the Investigation of Spirituality in Nursing,” Research in Nursing and Health 15 (1992): 349–57.
50. David Hay, with Rebecca Nye, The Spirit of the Child (London: HarperCollins, 1998).
51. NHS, Education for Scotland, Spiritual Care Matters: An Introductory Resource for All NHS Scotland Staff (Edinburgh: Scottish Government, 2009).
52. For a useful review of this literature, see Deborah Cornah, The Impact of Spirituality on Mental Health: A Review of the Literature (London: Mental Health Foundation, 2006).