Steven Novella M.D. and Mental Illness Denial

by Phil on February 20, 2013

Recently Nick Stuart, a regular commenter on this website, drew my attention to Dr. Steven Novella.  Dr. Novella is a strong supporter of the standard psychiatric system, and routinely refers to those of us who challenge these concepts as “mental illness deniers.”(Mental Illness Denial Part I)

Nick referred me to some of Dr. Novella’s articles, and I published a brief response.  I have been giving these matters some thought, however, and I think the subject matter warrants more attention. This is because Dr. Novella does indeed marshal some compelling arguments in other areas, and also because he routinely condemns us “deniers” as illogical employers of “…semantic misdirection and evasion…”

For the present purpose I will discuss an article that Dr. Novella published on February 4 of this year:  “DSM-V – Mental Illness vs Normal Behavior.”

The article in question is a response to a piece by Peter Kinderman which I highlighted a few days ago, and which in my view is an excellent article.  Dr. Kinderman wrote:

“But diagnosis and the language of biological illness obscure the causal role of factors such as abuse, poverty and social deprivation. The result is often further stigma, discrimination and social exclusion.”

Now, for me, this is fairly obviously true and is borne out by the facts.  Psychiatrists who talk in terms of “diagnoses” and “chemical imbalances” etc., do in fact ignore causal factors such as abuse, poverty, and social deprivation.  They call their clients “patients” and they routinely tell these “patients” that they have “an illness just like diabetes” and that the pills will fix their brain chemistry.

But watch what Dr. Novella does with this:

“This is a healthy debate to have, as the concepts involved are tricky and there are real implications for societal perception, insurance coverage, and treatment strategies. I do not, however, share Dr. Kinderman’s position, which in my experience is fairly typical for a clinical psychologist. He is essentially saying that his profession’s approach to the question of mental illness is superior to the psychiatric profession. While the debate is legitimate and important, I can’t help feeling that there is a major component of a turf battle here also.”

Dr. Novella asserts that Dr. Kinderman’s position is fairly typical for a clinical psychologist.  There may be some validity to this as far as academic psychologists are concerned, but in my experience, clinical psychologists in the field are as wedded to standard psychiatry as the psychiatrists are.  But more importantly, notice what Dr. Novella has done.  He has diverted attention from Dr. Kinderman’s very valid criticism by calling it a turf war issue.  And this is the man who accuses us “deniers” of “semantic misdirection and evasion.”

But moving along – Dr. Novella states:

“The question is essentially how we should think about symptoms of mood, thought, and behavior.”

Note the use of the word “symptoms.”  This is clearly a medical term.  Dr. Kinderman’s essential point was that the medicalization of human problems is unhelpful.  Dr. Novella pretends to take this on board, but couches the essential issue in medical terms.  He could just as easily have used the word “problems” – a neutral word with which we “deniers” would have no difficulty.  People do indeed have problems.  But to refer to these problems as “symptoms” presupposes the main point of contention.  Perhaps this also could be described as “semantic misdirection.”

Dr. Novella delineates the two extreme responses to his essential question:

- those who consider human problems to be part of the normal spectrum

- those who medicalize all human problems

Dr. Novella then expresses the opinion that the best approach is something “in the middle:”  “…before you can recognize the abnormal you have to recognize the full spectrum of what is normal.”  He goes on: “…we need to recognize the full spectrum of human nature, accept less common and atypical forms of human mood, thought, and behavior, and also recognize the relative roles of biology, situation, and culture (and their interactions) in forming a person’s mental state.”  Now this is all fairly good stuff.  It certainly is a far cry from standard psychiatry, and you might actually be wondering if Dr. Novella is a closet “denier.”  But wait…

“On the other hand, the brain is an organ, it is biology, and it can malfunction biologically just like any other organ. Further, even a biologically healthy brain can be pushed beyond tolerance limits resulting in an unhealthy mental state. We can reasonably define “unhealthy” in this context (probably a more appropriate word than “abnormal”) as follows – a mental state that is significantly outside the range of most people, may represent the relative lack of a cognitive ability that most people have, and results in definable harm. That last bit is critical – it has to be harmful.”

Dr. Novella goes on to acknowledge that “there is an unavoidable amount of subjectivity in the above definition,” giving the impression that he is a reasonable person willing to concede that the “deniers” might have some validity in their corner.  But he evades the core issue – or at least what for me is the core issue – that although brain malfunction can and does cause problem behavior, problem behavior can and does occur in the absence of any brain malfunction.

The fallacy that Dr. Novella has fallen into is:  A has been noted to cause B.  Therefore every instance of B must have been caused by A.  A lightning strike can damage your TV.  But it would be unwarranted to assume that a lightning strike was the culprit every time your TV malfunctioned.

Nobody is denying that brain problems can cause behavioral problems.  But virtually every criterion item in the DSM is behavioral, and to assume a neurological malfunction as the underlying cause of these behaviors is illogical and unwarranted.  The fact is that people with perfectly normal brains can acquire dysfunctional, self-destructive, and counter-productive habits.

An early demonstration of this is the case of Little Albert (1920), who was taught to fear a white rat by psychology researchers, and was subsequently taught not to fear the same animal.  There was nothing wrong with his brain, even though his response to the lab rat was clearly dysfunctional.  In fact, his learning apparatus had to be intact.

There is a subtle point here that Dr. Novella does not address in this article, but does touch on elsewhere.  In Mental Illness Denial Part I (2007) he states “… if part of the brain allows us to pay attention, in some people that part of the brain must function poorly causing a deficit of attention.”

Let’s go back to Little Albert.  After he had been trained to fear the white rat, there was certainly a link of some sort in his brain between fear and white rats.  I am no expert in neurology or neural physiology, but common sense tells me that Albert’s training cemented in some kind of connection, and his untraining removed that connection.

Dr. Novella’s position, if I understand him correctly, is that this neural link (or whatever it might be called) constitutes the ontological reality behind the brain illness theory of the so-called mental illnesses.

In the quote above about paying attention, Dr. Novella is clearly referring to the condition known as ADHD.  His reasoning is as follows.  Brains and parts of brains malfunction.  Parts of brains are dedicated to paying attention.  If a child isn’t paying attention, there must be something wrong with those parts of his brain.

But the reality is more complicated.  Children (and adults) are always paying attention to something.  The point about ADHD is not that the child is inattentive, but rather that he is not paying attention to the things that he needs to attend to.  Everyone knows that playing is easier than studying.  Doing what we like is easier than working.  A child will generally not pay attention to the latter items unless he has been actively trained to do so.  Absent this training, he does whatever he likes and consequently attracts a “diagnosis” of ADHD.

But let’s be clear.  Training causes changes in brains.  This is self-evident.  So there are differences between the brain of a disciplined, well-behaved child and an inattentive, self-indulged, misbehaved child.  I certainly can’t specify what these changes are, and I’m not sure anyone else can either., but insisting that these brain changes (or lack of brain changes) are the cause of the misbehavior is tantamount to saying that a professional cyclist’s victory in a race is caused by the firing of neurons (rather than years of training, dedication, diet, tenacity, etc..).

If I were to kick you on the knee, and you asked why I had done this, would you accept it if I replied –”brain chemistry”?  That’s the essence of the brain malfunction theory of mental illness.

Every thing we do, from a single heart-beat to complex social interactions, can be traced back (in theory at least) to the electrical and chemical interplay of neurons.  The question:  why did he do that? can always be answered:  because of antecedent neural activity.  But it could, with equal accuracy, be answered:  because of the circulation of his blood, or because of energy transfer from his alimentary tract to his other organs, or because of the potassium content of his blood etc., etc… But these explanations are trite to the point of meaninglessness.

If Dr. Novella and other brain illness theorists seek to prove their position, they need to do better than that.  They need to specify the pathology (whether anatomical damage or physiological malfunction or a shortage of some chemical or a surfeit of some chemical) and demonstrate that this pathology is present in the individuals concerned, and is absent in the rest of the population.  At present, despite four or five decades of intensive and highly motivated research in this area, the hypothetical brain illnesses remain just that – hypothetical.

In the DSM-V article Dr. Novella goes on to point out how reasonable the DSM and practicing psychiatrists are.

“The DSM essentially is the practice of generating a list of problems that can be reliably and validly defined.”

And:

“In reality psychiatrists understand that the categories, or clusters of symptoms, with labels in the DSM are partly labels of convenience… “

And:

“Most importantly, the question as to which therapeutic approach is most effective can be completely disconnected to how we approach labeling symptoms.”

My only response is that this doesn’t sound like the blatantly expansionist and medicalized DSM agenda or like any psychiatric practice I have witnessed in the past thirty years.

Dr. Novella’s conclusions are worth quoting in full:

“The diagnosis of mental illness remains complex and challenging. I am not arguing that any profession (psychiatry, psychology) has it exactly right, but I do think that the mental professions generally take a thoughtful approach to the question of what mental illness is and how it should be approached.

I disagree with attempts to restrict the debate on mental illness using semantics (usually taking the form of objecting to the term “mental illness”). I also think there are many common straw men brought up in this debate. I was disappointed in Kinderman’s review of the issues, and found that he was largely tilting at these common straw men.

But when you get past the turf-war posturing and semantic arguments, I find there is actually widespread agreement on the important issues. Human mood, thought, and behavior are complex, there is a wide range of variation in what constitutes human mental states, and any thoughtful approach must consider circumstances, environment, culture, and biological considerations, including their complex interactions. Further, therapeutic approaches should consider the full range of potential interventions and should ultimately be evidence-based.”

The fundamental problem here is that Dr. Novella is assuming that mental illnesses exist, and simply dismisses arguments to the contrary as “semantics.”  Even though his article purports to be a refutation of Dr. Kinderman’s position, Dr. Novella never actually addresses the main issue.

The deniers’ point, however, (or at least this denier’s point) is that mental illness is an archaic, pre-scientific concept with no explanatory value, exactly analogous to phlogiston or witchcraft.  I have discussed these themes elsewhere.

Dr. Novella is being disingenuous in claiming that the diagnoses are really just lists of problem clusters that can be reliably and validly defined.  Firstly, because the problem behaviors don’t cluster to anywhere near the extent that the taxonomy implies (or at least this has never been proven); and secondly because the diagnoses are not nearly as enduring or persistent within the individual as the term “diagnosis” implies.  If you want to understand a person, it is not enough to assign him a label.  One needs to spend time getting to know him and his history, and becoming familiar with the context in which he lives.

If behavioral science has taught us anything over the past 100 years, it is that context is a major determinant of behavior.  The mental illness approach, with its assumption that the problem is “in the individual” (DSM-IV, xxxi) flies in the face of this reality.

In practice, despite Dr. Novella’s assertions to the contrary, the goal of an initial psychiatric interview is to uncover the “diagnosis,” assure the “patient” that he has an illness (“just like diabetes”), and prescribe the pill.  It is at least 35 years since I have encountered a psychiatrist who conceptualized his work otherwise.

And it is the APA’s self-serving medicalization of ordinary human problems of living that underpins and drives this spurious and destructive travesty.

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