On January 17, 2013, Peter Kinderman, PhD, Professor of Clinical Psychology at the University of Liverpool, wrote an article titled Grief and Anxiety are not mental illnesses.
On February 4, 2013, Steven Novella, MD, wrote a critique of Dr. Kinderman’s article.
On February 20, I wrote a critique of Dr. Novella’s article.
And finally, on September 17, Dr. Novella wrote More On Mental Illness Denial and How Not to Argue, a critique of my critique.
There are a number of fundamental issues involved, and I feel I should try to address at least some of these.
THE CONCEPT OF MENTAL ILLNESS
In his critique of Dr. Kinderman’s article, Dr. Novella stated:
“The question is essentially how we should think about symptoms of mood, thought, and behavior.”
Apart from the word “symptom,” I am in complete agreement. The essential question, the central issue at the core of this entire debate is: how can we best conceptualize problems of mood, thought, and behavior.
I would prefer to say problems of feeling, thinking, and behaving (i.e. verbs rather than nouns) because in my view, this better reflects the fact that these are activities rather than entities. But this is not crucial to the central issue.
However, the use of the word “symptom” rather than “problem” is central. Dr. Novella is saying that the essential question is: how do we conceptualize problems of mood, thought, and behavior – but rather than address this question, he anticipates the answer – they are symptoms, which, I suggest, entails the clear implication that “behind” these “symptoms” there are “illnesses.”
Dr. Novella goes on to express the belief that the best approach (to problems of thinking, feeling, and behaving) is something that recognizes “… the relative roles of biology, situation, and culture (and their interactions) in forming a person’s mental state.” And if by “mental state” he means thinking, feeling and behaving, then I would agree.
Next Dr. Novella points out that the brain is an organ which can malfunction. I don’t think anyone would disagree with that. But he goes on:
“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.”
And this, of course, is where we have to part company. Assuming, as I said earlier, that by “mental state” he means a kind of composite snapshot of an individual’s thinking, feeling and behaving, then in my view a mental state can be neither healthy nor sick, in any conventional sense of these terms.
But, as is clear from his definition of “unhealthy” quoted above, Dr. Novella is not using these terms in their conventional sense. Let’s take a look at his definition:
- 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
This is clearly not a definition of sickness in the normal medical sense.
Now I will certainly concede that in common speech, the words sick and unhealthy have been considerably extended in recent decades. People routinely talk about an unhealthy lifestyle, for instance, when what they mean is an unwholesome lifestyle; and behavior that is crude or offensive is often referred to as sick. But in formal speech and writing, and certainly within general medical practice, the words sick and unhealthy mean something wrong with the anatomy or physiology of the organism. One can speak of a sick person or a healthy person, or, for that matter, of a sick horse or a healthy horse. But one can’t validly speak of thinking, feeling, and/or behaving as being sick or healthy. The activity of thinking can legitimately attract adjectives such as cogent, muddled, inconsequential, bizarre, etc… The activity of feeling could be described as painful, joyous, etc… The activity of behaving could be described as productive, counterproductive, relaxed, frenetic, etc… But one can’t attribute sickness or health to thoughts, feelings, or behaviors any more than one can attribute the quality of color to concepts.
I can’t, of course, dictate to Dr. Novella how to use or not use words, but what has to be acknowledged is that when he uses the term “unhealthy mental state,” he is very emphatically not using the word unhealthy in the conventional, formal medical sense. The adjectives sick and healthy simply don’t apply to the activities of thinking, feeling, and behaving in the same way that they apply to organisms. And this is true even if the thoughts, feelings, and behaviors are “outside the range of most people,” and/or “result in definable harm.”
It is noteworthy that Dr. Novella expressed the belief that “unhealthy” is a better choice of word than “abnormal” without giving any reasons or arguments to support this position. In my view, the choice of words like unhealthy, sick, ill, etc., in this context has no special value or advantage, and is, in fact, misleading. The words also beg what Dr. Novella concedes is the fundamental question: i.e. how best to conceptualize problems of thinking, feeling, and behaving; for Dr. Novella they are to be conceptualized as illnesses.
If Dr. Novella had stated that “…even a biologically healthy brain can be pushed beyond tolerance limits resulting in…” problematic thoughts, feelings, and or behavior, then we would be in general agreement. But by arbitrarily labeling problematic thoughts, feelings, and/or behavior as unhealthy mental states (i.e. as mental illnesses), he is assuming the answer to the very question that he himself concedes is critical and essential to the whole issue. For Dr. Novella (and indeed for psychiatry generally), problematic thoughts, feelings, and or behavior are mental illnesses. This is not something they discover; rather, it is contained within their definition. It is how psychiatry has decided to conceptualize these problems, and it is a decision that has profound implications in psychiatric practice.
STANDARD PSYCHIATRIC PRACTICE
All of this leads fairly naturally into a second point of dispute between Dr. Novella and myself. It is my contention that it has become standard practice in American psychiatry to tell clients that their presenting problem, whether it be depression, anger, worry, paranoid thoughts, misbehavior, etc., is the result of a mental illness which is a real illness “just like diabetes” and needs to be “treated” with drugs. Dr. Novella suggests that this is a caricature that he has never encountered in practice.
He expresses the belief that the standards and philosophy that underpin a profession can be gleaned from official publications, academics, and published standards rather than from the “average private practitioner in the field.”
To which I can only say that I disagree. As a case in point, would the official publications, published standards, etc., of, say, ten years ago have alerted a naïve outsider to the extent to which psychiatric research and psychiatric prescribing had been corrupted by pharmaceutical money. But even setting aside those kinds of unethical matters, it seems almost self-evident to me that the best way to find out what psychiatrists are doing is to interact with psychiatrists. And in my experience, psychiatrists routinely say to their clients things like: depression is an illness, just like diabetes; and just as a diabetic has to take insulin to treat his illness, so a person with depression must take his antidepressants. This has never been any kind of secret. I have often heard psychiatrists make these kinds of statements, and I have heard literally dozens (perhaps hundreds) of clients repeating these kinds of statements and attributing them to psychiatrists that they had seen. In addition, this kind of message was a mainstay component of a good deal of psycho-pharmaceutical advertizing for years. If this was not psychiatry’s philosophy, why did they not take steps to stop the ads or at the very least publish counter-information in appropriate places?
Now obviously, I haven’t conducted any kind of formal study of psychiatrists’ behavior, and my observations are limited by my experiences. It’s possible that my interactions with psychiatrists and with clients have not been representative of American psychiatry generally.
However, I have just Googled the phrase “mental illness just like diabetes” and got 1.3 million hits! So somebody has been saying that mental illnesses are real illnesses “just like diabetes” and the notion is generating a great deal of discussion. I have also Googled the term “chemical imbalance” and got 960,000 hits. Here again, it was psychiatry that promoted this concept, and it is still being discussed actively, and in my experience, is still widely believed.
In his September 17 article, Dr. Novella contends that the general practice of psychiatry is not based on the simplistic formula: mental illnesses are real illnesses just like diabetes, and are treated with drugs. Rather, he states that psychiatric practice recognizes that problems of thinking, feeling, and behaving:
” …are caused by the full spectrum of influences from biology to social and environmental.”
It is certainly possible that Dr. Novella is accurately portraying psychiatric practice as he has experienced it. But it is difficult to reconcile his portrayal with the fact that most psychiatric practice has degenerated into 15-minute “med checks” every two or three months. How much attention can one give to social and environmental considerations in 15 minutes, given that at least some of this time is already budgeted for discussion of drug side effects?
From the tenor of his earlier writings, it occurs to me that Dr. Novella might dispute my contention that 15-minute “med checks” have become the norm, so I spent five minutes on the ‘net and found two articles. The first is by Douglas Mossman, MD, Director of the Institute of Law and Psychiatry, University of Cincinnati. It’s called Successfully navigating the 15-minute-‘med check’. Here’s a quote:
“Even psychiatrists who deplore 15-minute med checks recognize that they have become standard care in psychiatry.”
The second article was published on Psychiatric Times in September 2009. It’s called Deconstructing the “Med Check,” and was written by Glen Gabbard, MD. Here’s a quote:
“There can be little doubt in our current era that the brief ‘med check’ is becoming standard practice in psychiatry.”
Even Jeffrey Lieberman, MD, President of the APA, has gone on record lamenting the practice of “…hurriedly written prescriptions…” which, incidentally, he attributes to changes in reimbursement systems.
BRAIN DISORDERS CAN CAUSE BEHAVIOR PROBLEMS
There are many specific points of contention between Dr. Novella and myself. Attempting to pick up and unravel all of these would, I suggest, be tedious and repetitious. But I would like to pick up just one which I think is representative. Towards the end of his September article, he states:
“Hickey further explains his position toward the end of his post:
‘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.’
Wait – but I thought that brain disorders can cause behavior problems? Wouldn’t such a case that Hickey acknowledges exists be considered a ‘mental illness?’ I’m trying to be fair, but such comments certainly sound like mental illness denial to me.”
I had made the point in my earlier critique that brain problems can cause behavioral problems. I have also stated that there are no mental illnesses; that the concept of mental illness is spurious.
Dr. Novella picks up my statement that brain problems can cause behavior problems and then claims to have caught me in a contradiction – because a brain problem that causes a behavior problem is a mental illness. Therefore, mental illnesses must exist.
The flaw in the argument, however, goes back to the earlier discussion about the meaning of the term “mental illness.” For Dr. Novella, any significant problem of thinking, feeling or behaving that entails harm is a mental illness. My position is that mental illness is simply the label that psychiatrists give to significant problems of thinking, feeling, and/or behaving, and of course, that’s their prerogative. They can call things by any name they wish. A problem arises in this case, however, because the word “illness” already has an established meaning in the English language. And labeling problems of thinking, feeling, and behaving as mental illnesses implies that they are illnesses in the conventional sense of the term. Dr. Novella does indeed make it clear elsewhere that for him the “illness” in “mental illness” is being used in a special sense. But this is fraught with potential for misunderstanding. To maintain clarity under these conditions one would need to add the rider “(the word illness is not being used in its conventional sense)” every time one used the term “mental illness.”
But to get back to the point of contention, Dr. Novella has not caught me in an inconsistency. Brain problems can indeed cause behavioral problems. Late stage syphilis (when the germ attacks neural tissue) can cause a person to behave in a “crazy” manner. What’s involved here is a brain illness (a real brain illness), of which the “crazy” behavior is a symptom (a real symptom). That, for me, is the reality of the matter. Dr. Novella, however, adds an additional component – that the “crazy” behavior is also a mental illness. This is not some kind of additional fact or discovery. It is simply Dr. Novella’s (and psychiatry’s) label being added arbitrarily and pointlessly to a perfectly clear medical phenomenon. The fact is that the syphilis germ attacks the brain and causes “crazy” thinking and “crazy” behavior. Dr. Novella, if I understand him correctly, would reword this as: the syphilis germ attacks the brain, causing a mental illness, which causes crazy thinking and behavior. Perhaps he doesn’t mean to impute causative significance to the “mental illness,” but that raises the question as to why one would introduce the concept at all?
So to answer his question: “Wouldn’t such a case that Hickey acknowledges exists be considered a ‘mental illness?’ the simple answer is “no.” The concept of “mental illness” adds nothing to our understanding of late stage syphilis or to our understanding of the crazy behavior. It is simply the label that psychiatrists apply, arbitrarily and misleadingly, to all significant problems of thinking, feeling, and behaving, apparently even to problems of thinking that are caused by late-stage syphilis!
THERE ARE NO MENTAL ILLNESSES
In his final paragraph in the September article, Dr. Novella states:
“If there is a reasonable position to be made against the concept of mental illness, I have yet to hear it. So far I have only encountered the level of argument similar to or worse than Hickey’s unfair and confused article. I am open to any reasonable argument to be made against my current position.”
Obviously this is a huge subject, and this post is already fairly lengthy. But I will try to provide a brief summary of the case against the concept of mental illness.
1. Psychiatry defines “mental illness” as any significant problem of thinking, feeling, and/or behaving.
2. Psychiatry identifies a large number of specific “mental illnesses” to reflect specific problems of thinking, feeling and/or behaving.
3. Psychiatry presents these specific “mental illnesses” as the proximate causes of the problems.
4. The logic, however, is flawed, as is evident from the following hypothetical conversation.
Client’s daughter: Why is my mother so sad; why is she so inactive?
Psychiatrist: Because she has a mental illness called major depressive disorder.
Client’s daughter: How do you know she has this illness?
Psychiatrist: Because she is so sad and inactive.
The only evidence for the putative illness is the very behavior it purports to explain.
5. When we, on this side of the debate, say that there are no mental illnesses, what’s meant is that the concept of mental illness is spurious conceptually, and has no explanatory value – it adds nothing to our understanding of problems of thinking, feeling and/or behaving. It is misleading, in that it appears to offer an explanation. It is also destructive, in that it serves to legitimize the widespread and ever-increasing use of drugs, increases the level of stigma attached to people who are experiencing these problems (Angermeyer, M.C. et al, 2011), and communicates the false message that people are powerless to deal with their problems without psychiatric intervention (i.e. drugs).
It is my guess that Dr. Novella would dispute much of this summary. In particular, I suspect that he would object to the notion that “mental illness diagnoses” are presented by psychiatry as the proximate causes of the problems. My contention is that assertions of this sort are routine in psychiatric practice; Dr. Novella states that this is not so and bases his position on “official publications” and other formal sources.
So let’s take a look at one “official publication” – the APA’s DSM. This is psychiatry’s Diagnostic and Statistical Manual.
In general medical circles the diagnosis is the cause of the symptoms. If one is very tired and is coughing up dreadful-looking stuff, and goes to see a physician, he will probably run some tests and may discover that the cause of these problems is pneumonia. This is the diagnosis. This is a real illness that causes real symptoms. If you asked the physician for a diagnosis, he would understand clearly that you were asking for the cause of the presenting problems.
So when the APA produces a book called the Diagnostic and Statistical Manual, there is, I suggest, an implicit assumption that it will present lists of diagnoses (i.e. real illnesses) and the symptoms which these illnesses cause. And in fact, when one opens the book this is what seems to be the case – lists of diagnoses with their respective symptoms.
Some psychiatrists respond to this point by contending that the book doesn’t actually say that the diagnoses are the causes of the symptoms, and that the diagnoses are really just labels of convenience for clusters of problems. If this is the case, then I suggest that the title of the book is very misleading. It ought to be called something like: A listing of significant problems of thinking, feeling and behaving, together with their labels of convenience as used by psychiatrists.
But the use of the terms “diagnosis” and “symptoms” is not the only issue. The notion that the “diagnoses” are being presented as the proximate cause of the symptoms permeates the text. I haven’t yet had an opportunity to study DSM-5, but a careful reading of DSM-IV and DSM-III-R reveals a great many passages which imply that the symptoms are caused by the putative underlying mental disorders. For example, many of the symptom lists contain the phrase “the symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder…),” or “the disturbance is not better accounted for by another mental disorder (e.g.…).” The term “better accounted for” implies a causal relationship between the putative disorder (the diagnosis) and the symptoms or problems. The statements: “The mental disorder accounts for the symptoms” means substantially the same as “the mental disorder is the cause of the symptoms.”
In DSM-III-R, the V codes were described as conditions “…not attributable to a mental disorder.” The term “attributable to” is, I suggest, essentially synonymous with “caused by,” the implication being that the non-V diagnoses are, in fact, the causes of their respective symptoms. In DSM-IV, the phrase was dropped, but the concept was retained, embedded in several of the textual descriptions. For instance, V71.01 Adult Antisocial Behavior “…the focus of clinical attention is antisocial behavior that is not due to a mental disorder (e.g. Conduct Disorder…).” Similarly, V15.81 Non-Compliance with Treatment: “The reasons for non-compliance may include…the presence of a mental disorder.” The terms “attributable to,” “due to,” and “reasons for” imply a causal relationship, and it is clear that the mental disorders are conceptualized and presented as the causes of the problems of thinking, feeling, and behavior. And this is how the DSM taxonomy is interpreted and used in the field, and is perceived by the general public.
The DSM is not the only “official” publication that promotes the notion that “mental disorders” are the proximate causes of the “symptoms.” I happen to have on my desk at the present time an APA document titled Five Things Physicians and Patients Should Question. The general theme of the document, which consists of five recommendations, is that practitioners should exercise more caution in prescribing neuroleptic drugs. The fourth recommendation is:
“Don’t routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.
There is inadequate evidence for the efficacy of antipsychotic medications to treat insomnia (primary or due to another psychiatric or medical condition), with the few studies that do exist showing mixed results.” [emphasis added]
It is clear from the wording of this item that according to the APA, insomnia (a common criterion item in the DSM) can be caused by (“due to”) a psychiatric condition (i.e., a mental illness/disorder).
Another example of this kind of circular reasoning can be found in theJAMA summary that Dr. Novella adduced to support his claim that the condition labeled ADHD is a brain illness. On page 2 of this document, under the heading Diagnosis, you’ll find the following:
“To be significant, a symptom must have started before age 7 years, be present for at least 6 months, and not be due to another cause.” [emphasis added]
This clearly implies that the “mental illness” called ADHD causes the symptoms.
Another example: in the NIMH’s education publication Attention Deficit Hyperactivity Disorder, under the heading How is ADHD diagnosed in adults? they write:
“For some adults, a diagnosis of ADHD can bring a sense of relief. Adults who have had the disorder since childhood, but who have not been diagnosed, may have developed negative feelings about themselves over the years. Receiving a diagnosis allows them to understand the reasons for their problems, and treatment will allow them to deal with their problems more effectively.” [emphasis added]
Again, the clear implication is that the “mental illness” called ADHD is being conceptualized and presented as the cause of (the reason for) the symptoms.
The Mayo Clinic has a Health Information pamphlet on Insomnia. Under the heading “Common Causes of Insomnia” it states:
“Everyday anxieties as well as more serious anxiety disorders may disrupt your asleep.” [emphasis added]
It’s very clear that what’s being presented here is the notion that mental disorders cause insomnia.
The American Academy of Sleep Medicine actually has a publication called Insomnia Due to Mental Disorder. Here are some quotes:
“This insomnia is caused by a mental health disorder.” [emphasis added]
“Depression and other mood disorders often will result in a degree of insomnia.” [emphasis added]
The University of Maryland has an In-depth Patent Education Report on insomnia. Here’s a quote:
“The disorders that most often cause insomnia are: [emphasis added]
- Bipolar disorder
- Attention-deficit hyperactivity disorder
- Post-traumatic stress disorder”
As explanatory concepts, however, the “diagnoses” are entirely circular, and hence valueless. Essentially, what’s being asserted is that problems of thinking, feeling and behaving are caused by problems of thinking, feeling, and behaving. The explanation in fact is not an explanation at all. It adds nothing to our knowledge. Rather, by discouraging further inquiry, it acts as a barrier to genuine exploration and understanding, which, incidentally, was one of the points Dr. Kinderman made in his original article back in January, and to which Dr. Novella took such exception.
But let us be clear. If it were proven that a particular “mental illness” were in fact the direct result of a brain malfunction, then the circularity would be broken, and we would be dealing with a genuine brain illness. But despite decades of highly motivated research and the spurious claims of psychiatry in this regard, such proof is not available. For the record, the DSM entries Mental Disorders due to a General Medical Condition are for obvious reasons excluded from these considerations. The General Medical Condition category, however, does suggest an obvious question: If the condition known as ADHD is indeed a brain illness as Dr. Novella asserts, then why is it not included in the General Medical Condition category? After all, a brain illness is a general medical condition.
In his response to my critique, Dr. Novella states that only some mental illnesses are brain illnesses, and takes me to task for confusing some with all. This is a fair point, though I still maintain that the use of the term mental illness conveys the impression that one is talking about a real illness, and that the likely focus of this is the brain. But we’ve already discussed that matter, and let’s set it aside for now.
As an example of a “mental illness” that he claims is indeed a brain illness, Dr. Novella points to the condition known as ADHD. He says that there is
“…decades of research which clearly show that ADHD is a genetic disorder characterized by hypofunctioning of the frontal lobes leading to a relative deficit of executive function. This part of the brain serves as a “resource allocator” – allocating brain resources to various tasks. Relative lack of this function results in a reduced ability to pay attention to the things we should be paying attention to.”
Dr. Novella goes on to state that it’s “… difficult to provide a single reference to reflect all this research…” and instead provides a JAMA summary, authored by Denise M. Goodman, MD and Edward H. Livingston, MD. I opened the JAMA article expecting to find a summary of research findings with citations. Instead, I found a simplistic JAMA “patient page” that simply asserts that “…ADHD is a biological condition…”
By contrast, I suggest that Dr. Novella take a look at Debunking the Science Behind ADHD as a “Brain Disorder by Albert Galves, PhD, and David D. Walker, PhD. Dr. Novella might also review Transforming Diagnosis by Thomas Insel, MD, Director of NIMH. In this paper, dated April 29, 2013, Dr. Insel was critical of DSM diagnoses generally. He wrote:
“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…has been ‘reliability’…The weakness is its lack of validity.” [A lack of validity in this context means that the 'diagnoses' do not actually refer to, or mirror, anything in the real world.]
“…The DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.”
For the record, I do not agree with other positions taken by Dr. Insel, but his comments concerning DSM’s “diagnoses” are unambiguous. In the present context, it is noteworthy that he did not exempt the ADHD “diagnosis” (or indeed, any DSM label) from his criticisms.
If there were clear and compelling evidence that the condition known as ADHD is in fact a brain illness along the lines that Dr. Novella asserts, wouldn’t Dr. Insel, the Director of NIMH, have known this, and excluded it from his comments?
In addition, if the condition known as ADHD is a real brain illness, wouldn’t it make sense to diagnose it by brain examination, thereby increasing the Kappa scores from their present value (0.5-0.6) to something approaching 1.0 (i.e. almost perfect reliability).
THE ESSENTIAL QUESTION
Dr. Novella and I are in complete agreement that the essential question in this entire debate is how best to conceptualize significant problems of thinking, feeling, and/or behaving. Dr. Novella conceptualizes these problems as mental illnesses, which is not surprising because he defines a mental illness as any significant problem of thinking, feeling and/or behaving.
I, on the other hand, conceptualize significant problems of thinking, feeling and/or behaving as – significant problems of thinking, feeling, and/or behaving.
In the now distant days when I was practicing, I sat with my clients and, through unhurried dialogue and discussion, we identified and clarified the problems for which they were seeking help. Also through unhurried dialogue and discussion, we explored how these problems might have developed, and what circumstances/pressures might be maintaining them.
If my clients said they were depressed, or worried, or angry, I asked them why, and I listened to their responses without interrupting. In almost all cases, individuals could give perfectly coherent and plausible explanations for their problems without any reference to extraneous, spurious concepts such as “mental illness.”
I conceptualized (and still conceptualize) problems of thinking, feeling, and behaving as so individualized with regard to genesis and development as to defy any kind of simplistic categorization or classification. I did not see my clients as ADHD’s or MDD’s or OCD’s or Conduct Disorders or Personality Disorders or any other DSM label. I did not see them as patients who needed to have something done to them – but rather as complex and competent human beings, fellow travelers on life’s journey, who had hit speed bumps, or taken wrong turnings, or run out of fuel, or been battered, figuratively or literally, by the vicissitudes and cruelties of life.
We discussed the importance of habits: how some are productive and others counterproductive. We discussed how habits are formed and how they can be broken.
We discussed what kind of remedial strategies might be effective, and how best they might be implemented in each particular case. I took pains to help my clients identify their strengths, and we discussed how these strengths might be mobilized in coping with the present difficulty.
We also tried to identify what social connections the clients might have that might be helpful in the present circumstances.
It was very much not a matter of me, the “expert,” healing people or solving their problems. Rather, my role was validating people’s experiences and their reactions to those experiences, and helping them mobilize, develop, and use their own resources to move their lives in directions they found more fulfilling.
This is a fundamentally client-centered approach in which there is no place or need for the concept of “mental illness.”
Dr. Novella clearly believes that his “mental illness” model is a better approach. Perhaps ultimately we’ll just have to agree to differ.