“Excuse my Mental Health Problems.” Why Labeling Mental Illnesses Creates Victimhood, Irresponsible Excuses, and Ineffective Help.
August 2, 2013 Lecture to the Tennessee Association of Pastoral Therapists
Dr. Ron McDonald, President of TAPT, Pastoral Counselor in Memphis, TN
A few years ago a patient asked me and a psychiatrist to evaluate him for disability. We couldn’t quite see the sense in a disabling psychiatric diagnosis, so we wrote a letter that was honest and probably wouldn’t help him with the Social Security Administration. As he was waiting for one last brief conversation with the psychiatrist, I said to him, “You’ve been seeing many doctors and getting very little support for disability. Why do you think you will get ‘disability’?” He immediately replied, “Because I’ve been working so hard for it!”
Another patient who had been denied disability and had not appealed told me that she always preferred to work anyway and had reluctantly applied for disability at the advice of a couple of doctors. She had a minimum wage job at the time, which she would lose soon just like she had every other job she’d had during her life. From time to time she had clear and disturbing symptoms of Bi-polar Disorder, Multiple Personality Disorder, Generalized Anxiety Disorder, Paranoid Personality Disorder, Borderline Personality Disorder, Major Depression, Intermittent Explosive Disorder. Even when she presented herself as “normal” she looked sick, for she smoked heavily and for years had abused drugs and alcohol. Her background was about as abusive and unstable as any I knew of. It was disturbing to me that she had been denied Disability. She was clearly mentally ill.
Tonight I want to walk a line between recognizing the reality of mental illness and the temptation to give away psychiatric diagnoses like candy to be used as an excuse for difficulties. Some diagnoses are liberating because they finally explain what’s wrong; some imprison people in a pseudo-justification for what should be manageable difficulties. What I will speak about is part of the nature vs. nurture debate. I will be more critical of “nature” because I believe we have turned so far towards a scientific explanation that we’ve weakened freedom and personal responsibility.
Recently I was asked to meet a group of teenage bicyclists at the city hospital in Memphis who were visiting one of their group who had been hit by a car that caused a massive pile-up. The group and I arrived at about the same time and I was immediately informed that they had just been told that the hospitalized girl had been pronounced dead. We went to the room and crowded around their friend. The mother of the dead child spoke courageously of her interpretation of the meaning of the death. She said, “This was all part of God’s mysterious plan, something we must accept. God called for her, and she is in a better place. Go about your lives with the faith that you must go on praising God for this mystery.”
I didn’t agree with her, but I didn’t interrupt. I wondered if some of the teenagers might think what I’ve heard many people say to such reasoning: if that’s the will of God, I’ll do without God. Later, on the way home, I searched for words that make more sense to me and realized that I believe the gift of life includes freedom, and freedom is always accompanied by risk (like the freedom to ride a bicycle on a dangerous road). For me life would be dull without risk. I prefer to live with the threat of tragedy than give away my freedom to ride my bicycle. The adventure is worth the risk, for adventure is inherent in love.
Theologian Dorothee Soelle criticizes our attempts to explain suffering by siding with a God that seems mysteriously connected to torture. She says that the better way is to side with the victim, in this case with the suffering friends and family (which is what I believe the mother was doing in her demeanor, maybe not her words). Siding with a powerful, vindictive or mysterious God who causes bike wrecks at its best encourages humility (which is what John Calvin wanted to elicit), at its worst causes apathy, which is the opposite of love. The alternative, joining with those who suffer, the victims of tragedy, must include the natural protest – No! – that raises the question that sends us inward to a basic question about life: Is love worth this pain?
Hold that question in your hearts until the end of this presentation, please. For, first, I want to challenge our profession, for we have strayed professionally just as that suffering mother had been led astray from those who need help answering questions of suffering. Despite our noble motivation, we have presented a wrong answer to this fundamental question.
Victim Psychology
About twenty years ago Charles Sykes wrote a book entitled A Nation of Victims: The Decay of American Character in which is he suggested that we have created an entitlement culture, and our therapeutic culture was partly responsible for this. We bought into the idea that “we’re not bad, we’re sick.” It became a substitute religion, with sensitivity the mark of civil society not dialog or argumentation.
Sensitivity, Sykes argues, morphs into a “rolling standard” that deems many as fragile, frail, with low self-esteem, or we might say, victims. We become hyper-sensitive, and this leads to brow-beating, intolerance, guilt, a sense of powerlessness, and the final nail in the coffin, disability. It’s no longer a dialectic of ideas and insights, it is, instead, a shift to feelings that are rooted in emotional sensitivity and accusations of guilt for those who are argumentative, who are not comfortable with medical and social complexes that they feel are a flight from responsibility. Mental illness is trivialized, and instead of civil dialog there are therapies, litigation, and victim groups.
Sykes suggested that the moral compass we need to return to is Martin Luther King’s “content of character.” Similarly, Matthias Beier, an AAPC Diplomate at Christian Theological Seminary, suggests that the supervisor’s and therapist’s main role is to lift up King’s idea of the “somebody-ness” of the supervisee or patient. King would shout, “You are somebody!”
Sykes ideas have contaminated my thinking on the prevailing diagnoses of the day for 20 years. I first noticed it when ADHD was invented – excuse me – discovered. ADHD sounded good at first, for we’ve all run across hyperactive, distracted kids who gave us fits, but it became a diagnosis for so many so fast that I couldn’t help but question its validity for many children. Not only did it appear to be a proposed solution to parents’ and teachers’ difficulties, it also gave rise to Ritalin as a very popular drug. Obviously, many were making money off the diagnosis.
Personally it challenged part of my own self-esteem. When I was in the third grade my parents took me to an audiologist to see if I had hearing problems. They were told that I didn’t. I just wasn’t listening. At the same time, I was a highly active boy: skinny, barefooted as much as possible, always wanting to go outside and play. You recognize this, don’t you? I was obviously ADHD. But partly because my parents demanded with some force that I listen, and partly because they let me go outside a lot, by the fourth grade my grades rose, and by the fifth grade I had become a very good athlete. By the 11th grade I was, when I wanted to be, an honor roll student who was interested in nearly everything, and I also had discovered that I could out-run most people. I actually became proud of my curiosity and convinced that I had the gift of endurance. What today might have been labeled my disability – flitting around from interest to interest and always moving my body (ADHD) – had become a source of my self-esteem.
I’m ADHD and proud of it. I AM somebody! Isn’t that special?
Along came Bi-polar Disorder. Hey, I’ve got ups and downs. Don’t you? Maybe we’re all disabled. Think we could get a handicapped parking sticker?
This is what Sykes did to me! It’s his fault.
No, this is what we’re doing to our society. We are part of the trivialization of mental illness. As I see it even using the terms “mental illness” or “mental health professional” is part of this trivialization. What we want is simple: find the right diagnosis, follow standard treatment plans, get the right medicine, and do okay until the next fad diagnosis comes along. In the meantime, the mental health professionals who keep up with “advances” in the profession can expect to make a good living. We’re creating our own market.
Some of the Evolution of Pastoral Counseling
Pastoral counseling used to use language that sought to describe inward processes, not just a psychiatric diagnosis. We didn’t talk so much about pathology or mental illness. We used words and images like splitting, the undiscovered self, seeking a new way of being, individuation. There was an assumption that we had to develop a relationship with patients[*] that would help us understand as a co-pilgrim with our patients. From this relationship vantage point, we garner insight, join in the suffering, and craft that new way of being: consciousness of self, soulfulness, or what Rollo May described as “intentionality” – movement towards what is obvious (intent) coupled with the acceptance of implicit, unconscious meaning.
In the 1990s along came Managed Care, which changed the foundation of pastoral counseling. Instead of insight-oriented counseling that was paid out-of-pocket by willing patients (because they believed in its value), the marketplace shifted towards symptom-relief, a results-orientation, medicines, and insurance. That automatically led to a management of competition, called quality controls, but it was really about insurance companies’ control of payments. The entry point was licensure.
About 10 years ago AAPC certification chairs began to advise aspiring pastoral counselors to seek licensure first, AAPC certification second, if at all. It was good advice for those who need first to earn a living. You just aren’t going to get insurance payments with only AAPC certification. Here in Tennessee we were forward-thinking enough to create Licensed Clinical Pastoral Therapist based on Fellow level certification, but it remains the least influential mental health license in the field. AAPC certification is little in demand anymore. And AAPC has shrunk in numbers significantly since our height in the 1980s.
Many would say that this is nothing to be alarmed about, for it’s simply a shift in the way people with emotional and relationship problems are getting help. Furthermore, they would argue, therapists are better trained than they once were, for research has made therapy more efficient. Standards of practice are clearer and higher. The science is better.
They might be right. Yet I worry that patients are treated more like customers who are understood to be seeking relief. That relief is to be found in a clinical or psychiatric explanation for their problems: “You have Generalized Anxiety Disorder”…Major Depression…Borderline Personality Disorder…or “a chemical imbalance.” What a relief to know that “It ain’t my fault!”
There a story or myth that a wealthy, successful businessman went to see the great Carl Jung for analysis. To the question “why here” the businessman replied, “I’m doing great; I just want to be analyzed by the great Carl Jung.” To his disappointment Jung dismissed him, saying that he could not help him. A few years later the man returned to Jung and confessed, “My life is miserable; nothing’s working; everything has fallen apart.” Jung replied, “Good! Now maybe we can get somewhere.”
Pastoral counseling at its best meets patients at their point of pain, the point where the immerging self, the wounded soul, shows its ugly face and pleads for recognition and grace. We offer a new way of being, and our helpfulness depends on the wisdom we have gleaned from relationships with other patients, from our personal therapy, from our supervisors and consultants – from suffering itself. Wisdom is found in making sense of suffering, not just eliminating it with a diagnosis, instructions, and medicines (which is an illusion anyway). Suffering helps us get somewhere.
I have long found that thoughtful people prefer this way of thinking. They are relieved to hear a therapist suggest that the way is difficult and the result will include wisdom. Furthermore, most people, educated and uneducated, are actually thoughtful people looking for something that makes sense. Wisdom is worth aspiring to, and to hear someone remind you that wisdom is inherent in life’s difficulties makes difficulties less difficult.
Why then would we minimize this deeply meaningful orientation towards therapy in favor of standardized mental health? I think we’ve done it because even as we yearn for wisdom, our shadows tempt us with laziness. It is easier to make a living by specializing in ADHD or Bi-polar treatments. I also think we’ve struggled to know how to articulate an alternative that makes immediate sense. Our failure to create a clear, well-articulated understanding of pastoral counseling and pastoral diagnosis has left us weak and somewhat lost. We have struggled to find the courage to face suffering that must be answered from within. It is easier to explain away the suffering by identifying with the cause (nature or God) than to join the suffering victim of and look for answers within the context of what hurts.
Diagnosis
Diagnosis is an attempt to understand, so the clinician’s primary task is to join the suffering victim. Psychiatric and neurological diagnosis, though extremely helpful in many cases, has a shadow, too. It moves us so far away from insight or nurture to where science or nature rules. Wisdom is replaced by knowledge. Logic and research dominate; intuition and the yearnings of the heart diminish in importance.
Mental health diagnosis begins with a complaint: something is wrong. Underlying the complaint are normal descriptions of what life should be like. The classical summation of normal life is from Freud: “love and work,” or good relationships and meaningful work. But diagnosis in the mental health profession is hard focused on identifying and categorizing the particular pathology of a patient. The DSM is filled with descriptions of people who are dysfunctional, and one of those descriptions is about you! Three or four are about me. It’s really not about mental health, it’s about mental illness. Once again, it ain’t my fault. The underlying normality is obscured by the search for pathology.
At its best pastoral diagnosis offers four alternatives to the mental health diagnosis. First is that we try to speak in a more common sense and less judgmental language. For example, almost all diagnoses branch off of the big two: depression and anxiety. Depression in the mental health field is often called “clinical depression,” a euphemism for a psychiatric condition that needs cognitive therapy and/or medicine. Clinical depression is “treated.” For the pastoral counselor, though, depression begins with the definition of the word: to press down. The pastoral counselor asks not what is wrong, but what are you depressing? Is there something that needs to be released from the pressure you are exerting? Is your mood a result of not expressing something important? Let’s talk about what is depressed. Note that the phrase is not, “let’s talk about the mood, about the condition.” Instead, it’s “let’s look at what is being pressed down inside of you.”
Another example is about anxiety. A mental health diagnosis seeks to identify what kind of anxiety: generalized, social, paranoia, PTSD. A pastoral counselor begins with the assumption that anxiety is part of the human condition and has to do with, as Tillich suggested, meaninglessness, guilt, and death. Each of these existential struggles is at the root of much of our anxiety and panic, so concurrent with the need to help patients manage oppressive anxiety (deep breathing, repeating comforting phrases, walking, etc.) is an interest in helping the patient find “the courage to be” (Tillich), to live fully in spite of doubts, confusion, loneliness, imperfection, pain, and death. A pastoral counselor asks “What is rattling your cage?” or “Is this anxiety pointing towards some need for revelation, for change, towards an inner conflict, or at a relationship issue?”
In essence the pastoral counseling position is that depression and anxiety are to be befriended, not overcome or stopped. When we befriend an enemy, the enemy losses its oppositional power. Pathology is transformed into the paradox of life’s riddle: how come the very thing we fight the most turns into the source of our revelation or salvation? Christians call it the glory of the cross. Bowen or Friedman might have said that when loneliness turns towards differentiation, creative solitude and intimate connection begins.
The second alternative diagnostic orientation is that pastoral counseling begins with another definition of normality, something more akin to Maslow’s self-actualized person. Not just a normal person, an average person, but a person’s true self, highest calling, uniqueness. The foundation of the more actualized self is a soulfulness or somebody-ness that is continually transformative. It is what Jung meant by individuation, and it is where abnormality is not pathological. This is the call of the true self, the definition of one’s uniqueness.
The third is that pastoral diagnosis is invitational: it invites the patient to look for answers that speak to the heart, not just the head. These answers – maybe the word “responses” is more accurate – are found within. It invites the patient into a new, different inner room, much like Jesus’ invitation: “Come to me all ye who are weary and heavy laden and I will give you rest.”
And the fourth is the confrontation inherent in community life. Because communities are filled with love and conflict, they push us to stand up straight, to rise to our full height, to be willing to speak truth to power. Communities teach character. Thus, the pastoral counselor takes an interest in the community or system the person is part of. How does one make peace with the paradox of being a part of and apart from? Any good therapist has to be a systems thinker, but the pastoral counselor expands that into the realm of the Spirit: community life. “Tell me about your friends, your support system, your confidants, your relationship sanctuary?
Pastoral Diagnostic Presuppositions and Statements
Pastoral diagnosis presupposes values, not values that point to normalcy, but values that lift up individual uniqueness and meaningful participation in community life. Pastoral diagnosis is more artistic than scientific. Here are a number of examples. The value presupposition is numbered; the pastorally diagnostic statement is in quotations.
- Soul is found in everyday life, revealing itself in images, symbols, stories, and even symptoms of dysfunction.
“Sometimes our dreams, the stories we are immersed in, even the symptoms we complain about are pointing to needs and desires we have been unaware of. If we befriend these symptoms, in the long run we may find them helpful.”
- Meaning and purpose are essential in the good life, and these are directly related to what some describe as a call, others as vocation.
“Finding meaning in life has much to do with vocation, one’s sense of call. Meaninglessness might be best confronted by looking again at what you feel called to (or what you feel like God wants from you).”
- The mature, peaceful person must learn to embrace paradox and ambivalence. We all live with essential polarities.
“Maturity has something to do with embracing paradox and accepting ambivalence.”
- Humiliation (or shame) is paralyzing. Humility is liberating. Humility is the first stage of change.
“Seeking help has already shifted you from the humiliation of not being able to solve your own problems to the humility that will help you solve them.”
- Freedom to seek adventure and endure risk needs to be combined with mature judgment and the courage to accept tragedy. Belief in predestination needs to foster humility, not apathy towards tragedy (especially when it includes identification with human perpetrators of tragedy).
“We are free to seek adventure and endure risk. One of our fundamental questions is whether or not we have the courage to accept the risk that might cause tragedy. If we do, we can enjoy adventures (all adventures include risk) and love others. If we don’t, we need to just settle down and live alone.”
- Depression is a necessary part of our journey. It is the trip down under where soulfulness resides.
“Depression means to press down, to depress. Its opposite is expression. Talking will help.”
“Depression is like a dip in the road. Some of those depressions are deep and we get stuck in them. When we do, we need to dig around in the muck, for there is a treasure buried under the mud. And if we can find it and pull it out, we’ll have something very valuable for the remainder of our journey.”
- Anxiety is God’s way of awaking us from mere existence. It sounds at first like wind and thunder, but if we are able to settle down, there is a still small voice to be heard.
“Your anxiety may be too important to get rid of too quickly. Perhaps it’s trying to open you up to something new.”
“Anxiety is normal, but even when normal, it is troublesome. Normally it is about meaninglessness (is there any meaning in my life?), guilt (can I ever be good enough?), and death (what really happens when I die?). This kind of existential anxiety can only be accepted and overcome by the courage to be true to yourself.”
- When the journey of faith is arrested, which is a common religious trap, we are often disturbed by doubts. When faith is not arrested, doubts are part of a wonderful quest for a deeper spiritual life.
“Faith is a journey from an early interest in stories, to a group faith where faith is a box of beliefs, to a questioning faith that usually begins in the late teenage years, which is also threatening to a group faith (for we are questioning beliefs). If we question long enough, we find an owned faith where faith takes on a meaning more like openness or trust and can move to a universal faith where we are appreciative of other religions and belief systems. This, finally, leads back to the richness of a story faith.
“Usually a crisis of faith happens because it’s hard to climb the mountain of questioning when the old group faith is accusing us of abandoning the unquestioned faith of our youth. Yet if we continue climbing, a new way of being is ahead.”
- Prayer is found in all expressions of our deepest yearnings and compassion.
“Your words (tears, expressions) are clearly from your heart. I think they express your deepest prayer.”
- Humor, saltiness, earthiness are part of happiness.
“The truth will set you free; but first it will make you miserable.”
- Faith is more about openness than right belief. Grace flows through open doors.
“Your openness is setting you free.”
- People need people.
“You do not have to go through this alone.”
- There are two spirits or “seeds” within each of us – good and bad, creative and destructive. We must learn to manage the bad and provide fertile ground for the good.
“Sometimes, in spite of your better nature, you lose yourself and become destructive. Our task is to turn up the volume of your better nature and turn down the volume of the other.”
- Love is the answer.
“Even though loving someone is like opening an unhealable wound, for some mysterious reason, we want to love.”
Each day I think of another value statement and diagnostic expression, reminding me that pastoral diagnosis is a creative, spontaneous process. Pastoral diagnosis is the attempt to find words that point to the creative and confident inward spirit that empowers us to be at peace with ourselves and others.
Not a Normal Life
Pastoral counseling starts with spiritual ideals that are part of the foundation of a good life. Not a “normal” life – let’s leave that to mental health consumers and professionals. A “good” life, one filled with spirit, soulful, courageous, embracing of big-letter Life, beyond mere existence – maybe even abnormal.
Dorothee Soelle, in her book, The Silent Cry: Mysticism and Resistance, suggests that we all have what I call “mystic moments” – brief experiences of Wow! (the word for “God”) or Weird! (the word for “important”). It can be when we walk outside and notice dramatic weather, when we realize we are engaged in a particularly significant conversation, when we feel deep love for another, when we see a beautiful sight, when we feel compassion, when we find fascination, when we are touched by adventure, when we hurt. These mystic moments are strung together all day long, and if we stop to recognize them we would be one of those common mystics Soelle wrote about. It is this kind of mysticism that pastoral counseling needs to be looking for. We are all about naming the spirit, which is alive and well in all lives. It’s just unnamed and unnoticed in most of us.
If it is “normal” to be living lives void of the consciousness of these mystic moments, then we are called to abnormality. Only this kind of abnormality doesn’t cotton to a DSM diagnosis. It needs a pastoral assessment that understands the spiritual diagnosis.
A Pastoral Way of Being
I have been fortunate to serve for the last few years on AAPC Certification Committees. I’ve read papers, listened to and watched work samples, discussed ideas that shed light on what goes on in the clinical setting, and learned from the sometimes brilliant ideas of our candidates. I have become thoroughly convinced that the pastoral counseling movement cannot die, despite our dwindling numbers in AAPC and small numbers in organizations like TAPT. For we lift up the uniqueness of each human spirit and the life-giving nature of community life in a special way – one that points to the divine within and its intimate connection to the unconscious self. The integration of spirituality and clinical work is part and partial of our sense of invitation and challenge, which is at the heart of pastoral diagnosis. We are called to speak the language of the soul, to name the spirit when it emerges from the chaos and confusion of our troubled existence.
We must continue to teach new pastoral counselors, for there is an inherent blessing in this work that needs to be passed along. Training in pastoral counseling may not be as practical as it once was, i.e., it’s no longer a roadmap to making a living, but as we use our licenses to earn a living, we’ll still need to settle into the arms of pastoral wisdom that is available through the mentoring process inherent in AAPC certification. It will make you a much better therapist.
Finally, let us return to that question: Is love worth the pain?
Soelle says that one of the mystic moments is compassion. This feeling stands in stark contrast to feelings associated with beauty, fun, elation, fascination, or ecstasy. Compassion hurts.
When I was still in my 20s we had an 87 year old neighbor we called Louie. Our son, Jonah, was 2 years old and loved to follow Louie around when he was puttering in his yard. Louie acted like Jonah was an annoyance, but we could tell that he loved Jonah – like Mr. Wilson and Dennis the Menace.
One Sunday morning Louie’s best friend, an elderly woman neighbor, came visiting to tell us that Louie had died that night of a sudden heart attack. She had taken care of necessities for the time being, so, with a heavy heart, I went on to my Quaker Meeting to worship. As I sat in the circle of quietness, I felt a need to speak, so I carefully crafted a short, smart message about life and death. When I felt ready I said a prayer that I doubt God ever answers in the affirmative: “God, please help me to say this without crying.”
I spoke, “Our neighbor, Louie, whom we loved, died last night.” Suddenly, I was struck dumb by those tears God was supposed to help me avoid. I sobbed, and the whole room leaned towards me, quietly, leaving me plenty of room to weep. I felt their compassion, and I also knew that my smart message was not to be. Finally, I said only seven words that would haunt me in a revelatory way: “I’m glad I let myself love him.”
Where did that come from? I’d ask myself later. Why in the middle of all that anguish would I be happy I had loved Louie?
For now, though, I settled back into a deeper silence that can be so special about Quaker unprogramed worship. Soon a Friend said, “We turn out the light when the day approaches.” Silence, then another Friend spoke: “To love someone is to open an unhealable wound.”
Over thirty years later now I still am awed by that worshipful experience, and now I think I know where those seven spontaneous words of mine came from. The freedom to love, even when it opens an unhealable wound, is far too rewarding to trade for a life without freedom. Such a life might be free of pain – O, sweet illusion! – and free of love: “a tale told by an idiot. Full of sound and fury, signifying nothing” (Shakesspeare).
Love turns mere existence into Big Letter LIFE! And Life is what pastoral counseling is all about.
Don’t excuse my mental illness. I’d rather be myself, just as I am. We’ll figure it out together.
[*] I have returned to the word patient because it literally means “to endure pain,” which encompasses courage, self-reflection, and soulfulness.