Psychological and psychiatric practice exists, at its best, to relieve suffering. The disciplines help us understand patterns of thought, emotion and behaviour that can become profoundly disabling, and they provide ways of helping people whose quality of life has been eroded by genuine psychological disorders.
But in our efforts to see no-one gets missed out, our professions have become over enthusiastic about turning individual differences into diagnoses. Over the last few years, I have had many registered mental health professionals coming right out and argue there’s no harm in diagnosing a client with a disorder even if they don’t believe they have it, because they’ll get access to services. So, where is the harm in that? Well, I’m going to argue there’s a lot of harm in it. I’ll also argue we need to rediscover an important idea; humans vary. A lot. We’re meant to.
First of all, meet the familiar bell curve. Whatever feature you can measure in a population (height, anxiety, daily steps) you can plot on a graph and it will start to resemble a bell. Most of us are in that fat middle lump.
A bell curve is a statistical distribution where most observations cluster somewhere around the average/middle, while progressively fewer occur as we move towards either end. Look closely at the midsection of any bell curve and something important becomes obvious; the normal range has loads of wiggle room. At the most generous limits the normal range takes in nearly 70% of people on any measure. In research studies the normal range is considered to be over 95% before we can say a measurement is ‘outside’ of the normal distribution. Just about everyone of us is at the ‘normal’ party. But in fact, ‘normal’ is a statistical concept. It describes the aggregation of many data points and isn’t well suited to describing individuals any more than ‘neurotypical’ is – whatever that means. That’s why it’s easier to predict the behaviour of a million people than predict what you will do.
Individuals differ in attention, sociability, emotional intensity, organisation, sensitivity, interests, energy, temperament and their capacity to tolerate noise. Some people love parties; others would rather have a tooth pulled. Some can concentrate on a spreadsheet for six hours but can’t remember where they left their keys. Many people have unusual hobbies, unconventional ways of speaking or an intense fascination with obscure subjects. Some are naturally orderly and punctual. Others are chaotic, dreamy and will be late to their own funeral.
The vast majority of this is not pathology. It is humankind.
Human variability is not something we should tolerate or worse, correct. It is one of the strengths of our species and the reason we’ve flourished. Groups benefit from having cautious people and risk-takers, social people and people who work best alone. A population in which everyone behaved and developed identically would not be healthier. It would be less diverse, less resilient and probably quite short-lived.
There is another problem with pathologising ordinary human variation. It does a serious disservice to people with severe and debilitating psychiatric/psychological disorders.
COVID provided a sobering example. During the pandemic, mental-health advocates in the media claimed (without any evidence) that ‘about one in two’ of Australians were experiencing mental illness. Bunkum! What many Australians experienced was anxiety; and for damned good reason.
There was a novel virus spreading around the world. People feared illness or infecting their parents. Businesses closed. Jobs disappeared. Children kept home from school. Governments imposed restrictions unimaginable in most Australians’ lifetimes, and nobody knew if it was going to get better. Anyone who wasn’t anxious may have had reason to suspect a delusional disorder. OK, I exaggerate… but suffering under those circumstances was not evidence half the country had a mental disorder. Anxiety is a necessary part of the human emotional repertoire. It alerts us to danger and uncertainty. Sometimes being anxious is the psychologically appropriate response.
Why does it matter? Well, when we collapse the distinction between experiencing anxiety and having an anxiety disorder, something peculiar happens. A person whose life has been severely limited by severe panic attacks, obsessive fears or chronic avoidance tells someone they have an anxiety disorder and hears: “Oh, I’ve got anxiety too.” The intention may be sympathetic, but the effect can be hurtfully minimizing and factually misinformed. I fear the same is happening in many other areas.
Difficulty concentrating as much as you’d like to does not necessarily mean an ADHD. Being socially awkward, highly introverted, brilliant at Rubik’s cube or passionately interested in 15th century siege engines does not always denote autism. Struggling with motivation does not automatically indicate a disorder (God I hope not anyway). Neither does being emotionally intense, eccentric or poorly socialized by your childhood role models (an increasing problem now millions of kids are being anti-socialised by YouTube and Roblox).
Of course, these characteristics can form part of ADHD, autism spectrum disorder or another diagnosable condition. These are real disorders, and for some people they are significantly disabling. The point is precisely that diagnosis should mean something – and it must demonstrate why normal variability, or other likely causes are insufficient to explain the presentation. I find such differential diagnosis increasingly rare in the rush to diagnose or even invent new diagnoses ad hoc.
Clinical diagnoses should identify patterns of symptoms sufficiently persistent, pervasive and impairing to warrant being understood as disorders. If virtually every manifestation of ordinary human difficulty can be interpreted as evidence of psychopathology, then the distinction between disorder and difference eventually becomes meaningless. What we used to call coping (which is extremely tiring), we now call masking. Struggling used to be accepted as a part of life, so did the fact we don’t all struggle with the same things, but now in many cases we fail our clients and children by making emergencies of what we used to call growth.
I love the profession of psychology. I believe deeply in its capacity to help people. But I am increasingly uncomfortable with the way some forms of ‘awareness raising’ have begun to resemble demand generation.
Psychology is, after all, also an industry. Industries eventually seek to develop incentives to expand perceived need for their services and the mental illness industry is not an exception. Private practitioners need clients. Organisations need referrals. Training institutions need students. Professional groups need junkets. Before we start raging at capitalism, even if every psychologist in Australia were employed in the public sector, the profession would still have an incentive to demonstrate the need for increased funding. It seems cynical but there’s an economic imperative here. When you convince someone they’re deficient or too (unproductive, fat, sensitive, unfit, dysregulated, sad), you can sell them things like drugs, AuDHD (that’s not a real disorder by the way) ‘coaching’, therapy, fidget spinners.
But the financial motive makes intellectual restraint more important, not less. And we’re not seeing as much of it as we should be.
Of course we must improve recognition of mental disorders. False negatives (i.e. not diagnosing when you should) are damaging. People who are suffering should not be overlooked because their condition is poorly understood. But what is less well appreciated is that false positives (diagnosing when you shouldn’t) are equally dangerous; and preventing them is the other half of the mission to improve recognition of mental disorders. False positives minimize the difficulties of people who truly have a disorder, can lock people into a certain ‘tribe’ which becomes their identity, they often allow people to avoid personal accountability (i.e. suddenly diagnosed once charged with a crime), and they can keep the client from accessing the right kind of help.
Greater awareness of mental illness must not become a project of convincing every quirky, sad, worried, distractible or socially uncomfortable person that there is something clinically wrong with them. It was rare 20 years ago, but increasingly I see people for whom the biggest problem is that the media (anti-social and otherwise) has convinced them they’re broken in ways only a diagnosis can fix. It is often not the case.
People are anxious at times because life is, at times, just plain frightening.
Sometimes we get dysregulated because injustices piss us off and we can’t contain it. Why the hell shouldn’t we be angry? To be fair, sometimes I’m just overtired…
Perhaps people cannot concentrate because the task is boring, or their IPhones have ground their concentration span down to three minutes. Often they’re just asking too damned much of themselves.
People feel miserable because something awful has happened.
Humans hey? We’re are often difficult, eccentric, shy, obsessive, aggressive, temperamental, badly organised, badly behaved (guilty here) or simply weird. Wonderful critters.
Statistically your weirdness is much less likely to be a disorder than just plain difference. Our suffering is, it has to be said, usually very normal. So let your freak flag fly. You don’t need a diagnosis to be different, it’s your birthright.
