On Diagnosing Mental Disorders: Interacting with a Quote from Allen Frances, M.D.

saving normalI am in-process of reading the book Saving Normal by Allen Frances, M.D. Dr. Frances chaired the task force that produced the fourth revision of Diagnostic and Statistical Manual (DSM-IV) and has become critical of the current version, DSM-5.

It is too early to tell what my assessment of the book will be, but I can say it is definitely thought-provoking and well written. In this post I would like to make a few reflections on one extended quote from page 32.

The intent of Dr. Frances book is to “save the concept of normal human struggles” from being over-medicalized. He is not against psychiatric diagnoses or the use of psychiatric medication. Whether he draws the line at the right point in this tension is beyond my qualification to assess. But his aspiration seems like a good and needed balance to me in current Western culture.

The indented material below is from one continuous paragraph. I would encourage you to read all of the indented material first and then come back and read my reflections which are interspersed within.

Mental disorders should be diagnosed only when the presentation is clear-cut, severe, and clearly not going away on its own. The best way to deal with the everyday problems in living is to solve them directly or to wait them out, not to medicalize them with psychiatric diagnosis or treat them with a pill…

This seems to fit well with my attempts to define the concept of mental illness: impairment of functioning and duration of time without relenting of symptoms seem to be the best indicators for diagnoses that do not have a body fluid sample test. In response (unless there is concern for self-harm), the default first step should be to take the non-medical steps that have a probability of remedying or diminishing the life struggle.

… Prematurely resorting to medication short-circuits the traditional pathways of restorative healing – seeking support from family, friends, and the community; making needed life changes, off-loading excessive stress; pursuing hobbies and interests, exercise, rest, distraction, a change of pace…

I greatly appreciate this emphasis on “traditional pathways of restorative healing,” as Dr. Frances calls them. Honesty in authentic relationships is powerful. Exercise and good sleep hygiene have incredible effects on our emotional-cognitive health. Too often we try to obtain emotional health in lives that have unsustainable schedules. When we pursue tolerable emotions without pursuing these “traditional pathways,” we do ourselves a disservice even if medication helps us reach our goal. Our poor life stewardship will have to have more intense consequences before we consider the lifestyle that is creating the consequences.

This is not to say that “traditional pathways” will resolve all problems. I agree with Dr. Frances (as we will come to) that psychotropic medication can be a wonderful tool for health. But when we make these steps first, we are setting the medication up to succeed at what it can do by not asking it to offset what it cannot do.

… Overcoming problems on your own normalizes the situation, teaches new skills, and brings you closer to the people who were helpful. Taking a pill labels you as different and sick, even if you really aren’t…

This seems like a brief, but good, list of the benefits of facing life hardships through the “traditional pathways.” I am encouraged when I hear professionals skilled at alleviating suffering who can articulate the benefits of enduring suffering well. From a pastoral perspective it seems as if this is a value system we have lost. The less we collectively understand and value the benefits of suffering well, the more we isolate and add to the stigma of individuals who suffer long.

… Medication is essential when needed to reestablish homeostasis for those who are suffering from real psychiatric disorder. Medication interferes with homeostasis for those who are suffering from the problems of everyday life.

I am also encouraged to hear someone who is cautious about the over-medicalization of our culture be able to full-throatedly affirm the good use of medication. Medications (not just psychotropics) work by restoring balance to our body. This is good. This has an inverse implication, when we artificially restore balance to an emotional struggle that would have self-corrected, we impair the body’s ability self-correct in the future.

I look forward to reading the rest of Dr. Frances book. In the first chapter I have learned a great deal. More than learning, I’ve been given better questions to ask and categories to consider when thinking about mental health, how to define “normal,” and mental illness. I hope to continue to be stretched in this way.

If this post was beneficial for you, then consider reading other blogs from my “Favorite Posts on Mental Illness and Medication” post which address other facets of this subject.