Handbook of positive psychology
2
Stopping the “Madness”
Positive Psychology and the Deconstruction
of the Illness Ideology and the DSM
James E. Maddux
come easily. The field began with the founding
of the first “psychological clinic” in 1896 at the
University of Pennsylvania by Lightner Witmer
(Reisman, 1991). Witmer and the other early
clinical psychologists worked primarily with
children who had learning or school problems—
not with “patients” with “mental disorders”
(Reisman, 1991; Routh, 2000). Thus, they were
influenced more by psychometric theory and its
attendant emphasis on careful measurement
than by psychoanalytic theory and its emphasis
on psychopathology. Following Freud’s visit to
Clark University in 1909, however, psycho-
analysis and its derivatives soon came to dom-
inate not only psychiatry but also clinical psy-
chology (Barone, Maddux, & Snyder, 1997;
Korchin, 1976).
Several other factors encouraged clinical psy-
chologists to devote their attention to psycho-
pathology and to view people through the lens
of the disease model. First, although clinical
psychologists’ academic training took place in
universities, their practitioner training occurred
primarily in psychiatric hospitals and clinics
(Morrow, 1946, cited in Routh, 2000). In these
settings, clinical psychologists worked primarily
as psychodiagnosticians under the direction of
The ancient roots of the term clinical psychol-
ogy continue to influence our thinking about
the discipline long after these roots have been
forgotten. Clinic derives from the Greek kli-
nike, or “medical practice at the sickbed,” and
psychology derives from the Greek psyche,
meaning “soul” or “mind” (Webster’s Seventh
New Collegiate Dictionary, 1976). How little
things have changed since the time of Hippoc-
rates. Although few clinical psychologists today
literally practice at the bedsides of their pa-
tients, too many of its practitioners (“clini-
cians”) and most of the public still view clinical
psychology as a kind of “medical practice” for
people with “sick souls” or “sick minds.” It is
time to change clinical psychology’s view of it-
self and the way it is viewed by the public.
Positive psychology, as represented in this
handbook, provides a long-overdue opportunity
for making this change.
How Clinical Psychology
Became “Pathological”
The short history of clinical psychology sug-
gests, however, that any such change will not
1314
PART II. IDENTIFYING STRENGTHS
psychiatrists trained in medicine and psycho-
analysis. Second, after World War II (1946), the
Veterans Administration (VA) was founded and
soon joined the American Psychological Asso-
ciation in developing training centers and stan-
dards for clinical psychologists. Because these
early centers were located in VA hospitals, the
training of clinical psychologists continued to
occur primarily in psychiatric settings. Third,
the National Institute of Mental Health was
founded in 1947, and “thousands of psycholo-
gists found out that they could make a living
treating mental illness” (Seligman & Csik-
szentmihalyi, 2000, p. 6).
By the 1950s, therefore, clinical psychologists
had come “to see themselves as part of a mere
subfield of the health professions” (Seligman &
Csikszentmihalyi, 2000, p. 6). By this time, the
practice of clinical psychology was characterized
by four basic assumptions about its scope and
about the nature of psychological adjustment
and maladjustment (Barone, Maddux, & Sny-
der, 1997). First, clinical psychology is con-
cerned with psychopathology—deviant, abnor-
mal, and maladaptive behavioral and emotional
conditions. Second, psychopathology, clinical
problems, and clinical populations differ in kind,
not just in degree, from normal problems in liv-
ing, nonclinical problems and nonclinical pop-
ulations. Third, psychological disorders are
analogous to biological or medical diseases and
reside somewhere inside the individual. Fourth,
the clinician’s task is to identify (diagnose) the
disorder (disease) inside the person (patient) and
to prescribe an intervention (treatment) that
will eliminate (cure) the internal disorder (dis-
ease).
Clinical Psychology Today:
The Illness Ideology and the DSM
Once clinical psychology became “pathologi-
zed,” there was no turning back. Albee (2000)
suggests that “the uncritical acceptance of the
medical model, the organic explanation of men-
tal disorders, with psychiatric hegemony, med-
ical concepts, and language” (p. 247), was the
“fatal flaw” of the standards for clinical psy-
chology training that were established at the
1950 Boulder Conference. He argues that this
fatal flaw “has distorted and damaged the de-
velopment of clinical psychology ever since”
(p. 247). Indeed, things have changed little since
1950. These basic assumptions about clinical
psychology and psychological health described
previously continue to serve as implicit guides
to clinical psychologists’ activities. In addition,
the language of clinical psychology remains the
language of medicine and pathology—what
may be called the language of the illness ide-
ology. Terms such as symptom, disorder, pa-
thology, illness, diagnosis, treatment, doctor,
patient, clinic, clinical, and clinician are all con-
sistent with the four assumptions noted previ-
ously. These terms emphasize abnormality over
normality, maladjustment over adjustment, and
sickness over health. They promote the dichot-
omy between normal and abnormal behaviors,
clinical and nonclinical problems, and clinical
and nonclinical populations. They situate the lo-
cus of human adjustment and maladjustment
inside the person rather than in the person’s
interactions with the environment or in socio-
cultural values and sociocultural forces such as
prejudice and oppression. Finally, these terms
portray the people who are seeking help as pas-
sive victims of intrapsychic and biological forces
beyond their direct control who therefore
should be the passive recipients of an expert’s
“care and cure.” This illness ideology and its
medicalizing and pathologizing language are in-
consistent with positive psychology’s view that
“psychology is not just a branch of medicine
concerned with illness or health; it is much
larger. It is about work, education, insight, love,
growth, and play” (Seligman & Csikszentmi-
halyi, 2000, p. 7).
This pathology-oriented and medically ori-
ented clinical psychology has outlived its use-
fulness. Decades ago the field of medicine began
to shift its emphasis from the treatment of ill-
ness to the prevention of illness and later from
the prevention of illness to the enhancement of
health (Snyder, Feldman, Taylor, Schroeder, &
Adams, 2000). Health psychologists acknowl-
edged this shift over two decades ago (e.g.,
Stone, Cohen, & Adler, 1979) and have been
influential ever since in facilitating it. Clinical
psychology needs to make a similar shift, or it
will soon find itself struggling for identity and
purpose, much as psychiatry has for the last two
or three decades (Wilson, 1993). The way to
modernize is not to move even closer to
pathology-focused psychiatry but to move
closer to mainstream psychology, with its focus
on understanding human behavior in the
broader sense, and to join the positive psychol-
ogy movement to build a more positive clinical
psychology. Clinical psychologists always have
CHAPTER 2. DECONSTRUCTION OF THE ILLNESS IDEOLOGY AND
THE DSM
been “more heavily invested in intricate theo-
ries of failure than in theories of success” (Ban-
dura, 1998, p. 3). They need to acknowledge
that “much of the best work that they already
do in the counseling room is to amplify
strengths rather than repair the weaknesses of
their clients” (Seligman & Csikszentmihalyi,
2000).
Building a more positive clinical psychology
will be impossible without abandoning the lan-
guage of the illness ideology and adopting a lan-
guage from positive psychology that offers a
new way of thinking about human behavior. In
this new language, ineffective patterns of be-
haviors, cognitions, and emotions are problems
in living, not disorders or diseases. These prob-
lems in living are located not inside individuals
but in the interactions between the individual
and other people, including the culture at large.
People seeking assistance in enhancing the qual-
ity of their lives are clients or students, not
patients. Professionals who specialize in facili-
tating psychological health are teachers, coun-
selors, consultants, coaches, or even social activ-
ists, not clinicians or doctors. Strategies and
techniques for enhancing the quality of lives are
educational, relational, social, and political in-
terventions, not medical treatments. Finally, the
facilities to which people will go for assistance
with problems in living are centers, schools, or
resorts, not clinics or hospitals. Such assistance
might even take place in community centers,
public and private schools, churches, and peo-
ple’s homes rather than in specialized facilities.
Efforts to change our language and our ide-
ology will meet with resistance. Perhaps the pri-
mary barrier to abandoning the language of the
illness ideology and adopting the language of
positive psychology is that the illness ideology
is enshrined in the most powerful book in psy-
chiatry and clinical psychology—the Diagnostic
and Statistical Manual of Mental Disorders, or,
more simply, the DSM. First published in the
early 1950s (American Psychiatric Association
[APA], 1952) and now in either its fourth or
sixth edition (APA, 2000) (depending on
whether or not one counts the revisions of the
third and fourth editions as “editions”), the
DSM provides the organizational structure for
virtually every textbook and course on abnor-
mal psychology and psychopathology for un-
dergraduate and graduate students, as well as
almost every professional book on the assess-
ment and treatment of psychological problems.
So revered is the DSM that in many clinical
15
programs (including mine), students are re-
quired to memorize parts of it line by line, as
if it were a book of mathematical formulae or a
sacred text.
The DSM’s categorizing and pathologizing of
human experience is the antithesis of positive
psychology. Although most of the previously
noted assumptions of the illness ideology are
explicitly disavowed in the DSM-IV’s introduc-
tion (APA, 1994), practically every word
thereafter is inconsistent with this disavowal.
For example, in the DSM-IV (APA, 1994),
“mental disorder” is defined as “a clinically sig-
nificant behavioral or psychological syndrome
or pattern that occurs in an individual” (p. xxi,
emphasis added), and numerous common prob-
lems in living are viewed as “mental disorders.”
So steeped in the illness ideology is the DSM-
IV that affiliation, anticipation, altruism, and
humor are described as “defense mechanisms”
(p. 752).
As long as clinical psychology worships at
this icon of the illness ideology, change toward
an ideology emphasizing human strengths will
be impossible. What is needed, therefore, is a
kind of iconoclasm, and the icon in need of shat-
tering is the DSM. This iconoclasm would be
figurative, not literal. Its goal is not DSM’s de-
struction but its deconstruction—an examina-
tion of the social forces that serve as its power
base and of the implicit intellectual assumptions
that provide it with a pseudoscientific legiti-
macy. This deconstruction will be the first stage
of a reconstruction of our view of human be-
havior and problems in living.
The Social Deconstruction of the DSM
As with all icons, powerful sociocultural, polit-
ical, professional, and economic forces built the
illness ideology and the DSM and continue to
sustain them. Thus, to begin this iconoclasm,
we must realize that our conceptions of psycho-
logical normality and abnormality, along with
our specific diagnostic labels and categories, are
not facts about people but social constructions—
abstract concepts that were developed collabor-
atively by the members of society (individuals
and institutions) over time and that represent a
shared view of the world. As Widiger and Trull
(1991) have said, the DSM “is not a scientific
document. . . . It is a social document” (p. 111,
emphasis added). The illness ideology and the
conception of mental disorder that have guided16
PART II. IDENTIFYING STRENGTHS
the evolution of the DSM were constructed
through the implicit and explicit collaborations
of theorists, researchers, professionals, their cli-
ents, and the culture in which all are embedded.
For this reason, “mental disorder” and the nu-
merous diagnostic categories of the DSM were
not “discovered” in the same manner that an
archaeologist discovers a buried artifact or a
medical researcher discovers a virus. Instead,
they were invented. By describing mental dis-
orders as inventions, however, I do not mean
that they are “myths” (Szasz, 1974) or that the
distress of people who are labeled as mentally
disordered is not real. Instead, I mean that these
disorders do not “exist” and “have properties”
in the same manner that artifacts and viruses
do. For these reasons, a taxonomy of mental
disorders such as the DSM “does not simply
describe and classify characteristics of groups of
individuals, but . . . actively constructs a version
of both normal and abnormal . . . which is then
applied to individuals who end up being classi-
fied as normal or abnormal” (Parker, Georgaca,
Harper, McLaughlin, & Stowell-Smith, 1995,
p. 93).
The illness ideology’s conception of “mental
disorder” and the various specific DSM catego-
ries of mental disorders are not reflections and
mappings of psychological facts about people.
Instead, they are social artifacts that serve the
same sociocultural goals as our constructions of
race, gender, social class, and sexual orienta-
tion—that of maintaining and expanding the
power of certain individuals and institutions and
maintaining social order, as defined by those in
power (Beall, 1993; Parker et al., 1995; Rosen-
blum & Travis, 1996). Like these other social
constructions, our concepts of psychological
normality and abnormality are tied ultimately
to social values—in particular, the values of so-
ciety’s most powerful individuals, groups, and
institutions—and the contextual rules for be-
havior derived from these values (Becker, 1963;
Parker et al., 1995; Rosenblum & Travis, 1996).
As McNamee and Gergen (1992) state: “The
mental health profession is not politically, mor-
ally, or valuationally neutral. Their practices
typically operate to sustain certain values, po-
litical arrangements, and hierarchies or privi-
lege” (p. 2). Thus, the debate over the definition
of “mental disorder,” the struggle over who
gets to define it, and the continual revisions of
the DSM are not searches for truth. Rather,
they are debates over the definition of a set of
abstractions and struggles for the personal, po-
litical, and economic power that derives from
the authority to define these abstractions and
thus to determine what and whom society views
as normal and abnormal.
Medical philosopher Lawrie Resnek (1987)
has demonstrated that even our definition of
physical disease “is a normative or evaluative
concept” (p. 211) because to call a condition a
disease “is to judge that the person with that
condition is less able to lead a good or worth-
while life” (p. 211). If this is true of physical
disease, it is certainly also true of psychological
“disease.” Because they are social constructions
that serve sociocultural goals and values, our
notions of psychological normality-abnormality
and health-illness are linked to our assumptions
about how people should live their lives and
about what makes life worth living. This truth
is illustrated clearly in the American Psychiatric
Association’s 1952 decision to include homosex-
uality in the first edition of the DSM and its
1973 decision to revoke homosexuality’s disease
status (Kutchins & Kirk, 1997; Shorter, 1997).
As stated by psychiatrist Mitchell Wilson
(1993), “The homosexuality controversy
seemed to show that psychiatric diagnoses were
clearly wrapped up in social constructions of de-
viance” (p. 404). This issue also was in the fore-
front of the controversies over post-traumatic
stress disorder, paraphilic rapism, and maso-
chistic personality disorder (Kutchins & Kirk,
1997), as well as caffeine dependence, sexual
compulsivity, low-intensity orgasm, sibling ri-
valry, self-defeating personality, jet lag, patho-
logical spending, and impaired sleep-related
painful erections, all of which were proposed for
inclusion in DSM-IV (Widiger & Trull, 1991).
Others have argued convincingly that “schizo-
phrenia” (Gilman, 1988), “addiction” (Peele,
1995), and “personality disorder” (Alarcon,
Foulks, & Vakkur, 1998) also are socially con-
structed categories rather than disease entities.
Therefore, Widiger and Sankis (2000) missed
the mark when they stated that “social and po-
litical concerns might be hindering a recognition
of a more realistic and accurate estimate of the
true rate of psychopathology” (p. 379, emphasis
added). A “true rate” of psychopathology does
not exist apart from the social and political con-
cerns involved in the construction of the defi-
nition of psychopathology in general and spe-
cific psychopathologies in particular. Lopez and
Guarnaccia (2000) got closer to the truth by
CHAPTER 2. DECONSTRUCTION OF THE ILLNESS IDEOLOGY AND
THE DSM
stating that “psychopathology is as much pa-
thology of the social world as pathology of the
mind or body” (p. 578).
With each revision, the DSM has had more
to say about how people should live their lives
and about what makes life worth living. The
number of pages has increased from 86 in 1952
to almost 900 in 1994, and the number of men-
tal disorders has increased from 106 to 297. As
the boundaries of “mental disorder” have ex-
panded with each DSM revision, life has become
increasingly pathologized, and the sheer num-
bers of people with diagnosable mental disor-
ders has continued to grow. Moreover, we men-
tal health professionals have not been content
to label only obviously and blatantly dysfunc-
tional patterns of behaving, thinking, and feel-
ing as “mental disorders.” Instead, we gradually
have been pathologizing almost every conceiv-
able human problem in living.
Consider some of the “mental disorders”
found in the DSM-IV. Premenstrual emotional
change is now premenstrual dysphoric disorder.
Cigarette smokers have nicotine dependence. If
you drink large quantities of coffee, you may
develop caffeine intoxication or caffeine-induced
sleep disorder. Being drunk is alcohol intoxica-
tion. If you have “a preoccupation with a defect
in appearance” that causes “significant distress
or impairment in . . . functioning” (p. 466), you
have a body dysmorphic disorder. A child
whose academic achievement is “substantially
below that expected for age, schooling, and level
of intelligence” (p. 46) has a learning disorder.
Toddlers who throw tantrums have oppositional
defiant disorder. Even sibling relational prob-
lems, the bane of parents everywhere, have
found a place in DSM-IV, although not yet as
an official mental disorder.
Human sexual behavior comes in such vari-
ety that determining what is “normal” and
“adaptive” is a daunting task. Nonetheless, sex-
ual behavior has been ripe for pathologization
in the DSM-IV. Not wanting sex often enough
is hypoactive sexual desire disorder. Not want-
ing sex at all is sexual aversion disorder. Having
sex but not having orgasms or having them too
late or too soon is considered an orgasmic dis-
order. Failure (for men) to maintain “an ade-
quate erection . . . that causes marked distress or
interpersonal difficulty” (p. 504) is a male erec-
tile disorder. Failure (for women) to attain or
maintain “an adequate lubrication or swelling
response of sexual excitement” (p. 502) accom-
17
panied by distress is female sexual arousal dis-
order. Excessive masturbation used to be con-
sidered a sign of a mental disorder (Gilman,
1988). Perhaps in DSM-V not masturbating at
all, if accompanied by “marked distress or in-
terpersonal difficulty,” will become a mental
disorder (“autoerotic aversion disorder”).
Most recently we have been inundated with
media reports of epidemics of Internet addiction,
road rage, and pathological stockmarket day
trading. Discussions of these new disorders have
turned up at scientific meetings and are likely
to find a home in the DSM-V if the media and
mental health professions continue to collabo-
rate in their construction, and if treating them
and writing books about them becomes lucra-
tive.
The trend is clear. First we see a pattern of
behaving, thinking, feeling, or desiring that de-
viates from some fictional social norm or ideal;
or we identify a common complaint that, as
expected, is displayed with greater frequency
or severity by some people than others; or
we decide that a certain behavior is undesir-
able, inconvenient, or disruptive. We then
give the pattern a medical-sounding name, pref-
erably of Greek or Latin origin. Eventually,
the new term may be reduced to an acronym,
such as OCD (obsessive-compulsive disorder),
ADHD (attention-deficit/hyperactive disorder),
and BDD (body dysmorphic disorder). The new
disorder then takes on a life of its own and be-
comes a diseaselike entity. As news about “it”
spreads, people begin thinking they have “it”;
medical and mental health professionals begin
diagnosing and treating “it”; and clinicians and
clients begin demanding that health insurance
policies cover the “treatment” of “it.”
Over the years, my university has con-
structed something called a “foreign-language
learning disability.” Our training clinic gets five
or six requests each year for evaluations of this
“disorder,” usually from seniors seeking an ex-
emption from the university’s foreign-language
requirement. These referrals are usually
prompted by a well-meaning foreign-language
instructor and our center for student disability
services. Of course, our psychology program
has assisted in the construction of this “disor-
der” by the mere act of accepting these referrals
and, on occasion, finding “evidence” for this so-
called disorder. Alan Ross (1980) referred to this
process as the reification of the disorder. In light
of the awe with which mental health profes-18
PART II. IDENTIFYING STRENGTHS
sionals view their diagnostic terms and the
power that such terms exert over both profes-
sional and client, a better term for this process
may be the deification of the disorder.
We are fast approaching the point at which
everything that human beings think, feel, do,
and desire that is not perfectly logical, adaptive,
or efficient will be labeled a mental disorder.
Not only does each new category of mental dis-
order trivialize the suffering of people with se-
vere psychological difficulties, but each new cat-
egory also becomes an opportunity for in-
dividuals to evade moral and legal responsibility
for their behavior (Resnek, 1997). It is time to
stop the “madness.”
The Intellectual Deconstruction
of the DSM: An Examination of
Faulty Assumptions
The DSM and the illness ideology it represents
remain powerful because they serve certain so-
cial, political, and professional interests. Yet the
DSM also has an intellectual foundation, albeit
an erroneous one, that warrants our examina-
tion. The developers of the DSM have made a
number of assumptions about human behavior
and how to understand it that do not hold up
very well to logical scrutiny.
Faulty Assumption I:
Categories Are Facts About the World
The basic assumption of the DSM is that a sys-
tem of socially constructed categories is a set of
facts about the world. At issue here is not the
reliability of classifications in general or of the
DSM in particular—that is, the degree to which
we can define categories in a way that leads to
consensus in the assignment of things to cate-
gories. Instead, the issue is the validity of such
categories. As noted previously, the validity of
a classification system refers not to the extent
to which it provides an accurate “map” of re-
ality but, instead, to the extent to which it
serves the goals of those who developed it. For
this reason, all systems of classification are ar-
bitrary. This is not to say that all classifications
are capricious or thoughtless but that, as noted
earlier, they are constructed to serve the goals
of those who develop them. Alan Watts (1951)
once asked whether it is better to classify rabbits
according to the characteristics of their fur or
according to the characteristics of their meat. He
answered by saying that it depends on whether
you are a furrier or a butcher. How you choose
to classify rabbits depends on what you want to
do with them. Neither classification system is
more valid or “true” than the other. We can say
the same of all classification systems. They are
not “valid” (true) or “invalid” (false).
Instead,
they are social constructions that are only more
or less useful. Thus, we can evaluate the “valid-
ity” of a system of representing reality only by
evaluating its utility, and its utility can be eval-
uated only in reference to a set of chosen goals,
which in turn are based on values. Therefore,
instead of asking, “How true is this system of
classification?” we have to ask, “What do we
value? What goals do we want to accomplish?
How well does this system help us accomplish
them?” Thus, we cannot talk about “diagnostic
validity and utility” (Nathan & Langenbucher,
1999, p. 88, emphasis added) as if they are dif-
ferent constructs. They are one and the same.
Most proponents of traditional classification
of psychological disorders justify their efforts
with the assumption that “classification is the
heart of any science” (Barlow, 1991, p. 243).
Categorical thinking is not the only means,
however, for making sense of the world, al-
though it is a characteristically Western means
for doing so. Western thinkers always have ex-
pended considerable energy and ingenuity di-
viding the world into sets of separate “things,”
dissecting reality into discrete categories and
constructing either-or and black-or-white di-
chotomies. Westerners seem to believe that the
world is held together by the categories of hu-
man thought (Watts, 1951) and that “making
sense out of life is impossible unless the flow of
events can somehow be fitted into a framework
of rigid forms” (Watts, 1951, pp. 43–44). Un-
fortunately, once we construct our categories,
we see them as representing “things,” and we
confuse them with the real world. We come to
believe that, as Gregory Kimble (1995) said, “If
there is a word for it, there must be a corre-
sponding item of reality. If there are two words,
there must be two realities and they must be
different” (p. 70). What we fail to realize is that,
as the philosopher Alan Watts (1966) said,
“However much we divide, count, sort, or clas-
sify [the world] into particular things and
events, this is no more than a way of thinking
about the world. It is never actually divided”
(p. 54). Also, as a result of confusing our cate-
gories with the real world, we too often confuse
classifying with understanding, and labeling
CHAPTER 2. DECONSTRUCTION OF THE ILLNESS IDEOLOGY AND
THE DSM
with explaining (Ross, 1980; Watts, 1951). We
forget that agreeing on the names of things does
not mean that we understand and can explain
the things named.
Faulty Assumption II:
We Can Distinguish Between
Normal and Abnormal
The second faulty assumption made by the de-
velopers of the DSM is that we can establish
clear criteria for distinguishing between normal
and abnormal thinking, feeling, and behaving
and between healthy and unhealthy psycholog-
ical functioning. Although the DSM-IV’s de-
velopers claim that “there is no assumption that
each category of mental disorder is a completely
discrete entity with absolute boundaries divid-
ing it from other mental disorders or from no
mental disorder” (APA, 1994, p. xxii), the sub-
sequent 800 pages that are devoted to descrip-
tions of categories undermine the credibility of
this claim. This discontinuity assumption is
mistaken for at least three reasons. First, it ig-
nores the legions of essentially healthy people
who seek professional help before their prob-
lems get out of hand (and who have good health
insurance coverage), as well as the vast numbers
of people who experience problems that are sim-
ilar or identical to those experienced by those
relatively few people who appear in places called
clinics, yet who never seek professional help
(Wills & DePaulo, 1991). As Bandura (1978)
stated, “No one has ever undertaken the chal-
lenging task of studying how the tiny sample
of clinic patrons differs from the huge popula-
tion of troubled nonpatrons” (p. 94).
The normal-abnormal and clinical-nonclinical
dichotomies are encouraged by our service de-
livery system. Having places called “clinics” en-
courages us to divide the world into clinical and
nonclinical settings, to differentiate psycholog-
ical problems into clinical (abnormal) problems
and nonclinical (normal) problems, and to cat-
egorize people into clinical (abnormal) and non-
clinical (normal) populations. Yet, just as the
existence of organized religions and their
churches cannot be taken as proof of the exis-
tence of God, the existence of the mental health
professions and their clinics is not proof of the
existence of clinical disorders and clinical pop-
ulations. The presence of a person in a facility
called a “clinic” is not sufficient reason for as-
suming that residing within that person is a
psychological pathology that differs in either
19
kind or degree from the problems experienced
by most people in the courses of their lives.
Second, this discontinuity assumption runs
counter to an assumption made by virtually
every major personality theorist—that adaptive
and maladaptive psychological phenomena dif-
fer not in kind but in degree and that continuity
exists between normal and abnormal and be-
tween adaptive and maladaptive functioning. A
fundamental assumption made in behavioral
and social cognitive approaches to personality
and psychopathology is that the adaptiveness or
maladaptiveness of a behavior rests not in the
nature of the behavior itself but in the effect-
iveness of that behavior in the context of the
person’s goals and situational norms, expecta-
tions, and demands (Barone et al., 1997). Exis-
tential theorists reject the dichotomy between
mental health and mental illness, as do most of
the theoreticians in the emerging constructivist
psychotherapy movement (e.g., Neimeyer &
Mahoney, 1994; Neimeyer & Raskin, 1999).
Even the psychoanalytic approaches, the most
pathologizing of all theories, assume that psy-
chopathology is characterized not by the pres-
ence of underlying unconscious conflicts and
defense mechanisms but by the degree to which
such conflicts and defenses interfere with func-
tioning in everyday life (Brenner, 1973).
Third, the normal-abnormal dichotomy runs
counter to yet another basic assumption made
by most contemporary theorists and researchers
in personality, social, and clinical psychology—
that the processes by which maladaptive be-
havior is acquired and maintained are the same
as those that explain the acquisition and main-
tenance of adaptive behavior. No one has yet
demonstrated that the psychological processes
that explain the problems of people who present
themselves to mental health professionals
(“clinical populations”) and those who do not
(“nonclinical populations”) differ from each
other. That is to say, there are no reasons to
assume that behaviors judged to be “normal”
and behaviors that violate social norms and are
judged to be “pathological” are governed by dif-
ferent processes (Leary & Maddux, 1987).
Fourth, the assumption runs counter to the
growing body of empirical evidence that nor-
mality and abnormality, as well as effective and
ineffective psychological functioning, lie along a
continuum, and that so-called psychological dis-
orders are simply extreme variants of normal
psychological phenomena and ordinary prob-
lems in living (Keyes & Lopez, this volume).20
PART II. IDENTIFYING STRENGTHS
This dimensional approach is concerned not
with classifying people or disorders but with
identifying and measuring individual differ-
ences in psychological phenomena such as emo-
tion, mood, intelligence, and personality styles
(e.g., Lubinski, 2000). Great differences among
individuals on the dimensions of interest are ex-
pected, such as the differences we find on formal
tests of intelligence. As with intelligence, any
divisions made between normality and abnor-
mality are socially constructed for convenience
or efficiency but are not to be viewed as indic-
ative of true discontinuity among “types” of
phenomena or “types” of people. Also, statis-
tical deviation is not viewed as necessarily
pathological, although extreme variants on ei-
ther end of a dimension (e.g., introversion-
extraversion, neuroticism, intelligence) may be
maladaptive if they signify inflexibility in func-
tioning.
Empirical evidence for the validity of a di-
mensional approach to psychological adjustment
is strongest in the area of personality and per-
sonality disorders. Factor analytic studies of
personality problems among the general popu-
lation and a population with “personality dis-
orders” demonstrate striking similarity between
the two groups. In addition, these factor struc-
tures are not consistent with the DSM’s system
of classifying disorders of personality into cat-
egories (Maddux & Mundell, 1999). The dimen-
sional view of personality disorders also is sup-
ported by cross-cultural research (Alarcon et al.,
1998).
Research on other problems supports the di-
mensional view. Studies of the varieties of nor-
mal emotional experiences (e.g., Oatley & Jen-
kins, 1992) indicate that “clinical” emotional
disorders are not discrete classes of emotional
experience that are discontinuous from every-
day emotional upsets and problems. Research
on adult attachment patterns in relationships
strongly suggests that dimensions are more
useful descriptions of such patterns than are
categories (Fraley & Waller, 1998). Research on
self-defeating behaviors has shown that they
are extremely common and are not by them-
selves signs of abnormality or symptoms of
“disorders” (Baumeister & Scher, 1988). Re-
search on children’s reading problems indicates
that “dyslexia” is not an all-or-none condition
that children either have or do not have but oc-
curs in degrees without a natural break between
“dyslexic” and “nondyslexic” children (Shaw-
itz, Escobar, Shaywitz, Fletcher, & Makuch,
1992). Research on attention deficit/hyperactiv-
ity disorder (Barkley, 1997) and post-traumatic
stress disorder (Anthony, Lonigan, & Hecht,
1999) demonstrates this same dimensionality.
Research on depression and schizophrenia in-
dicates that these “disorders” are best viewed as
loosely related clusters of dimensions of indi-
vidual differences, not as diseaselike syndromes
(Claridge, 1995; Costello, 1993a, 1993b; Per-
sons, 1986). Finally, biological researchers
continue to discover continuities between so-
called normal and abnormal (or pathological)
psychological conditions (Claridge, 1995; Lives-
ley, Jang, & Vernon, 1998).
Faulty Assumption III:
Categories Facilitate Clinical Judgment
To be most useful, diagnostic categories should
facilitate sound clinical judgment and decision
making. In many ways, however, diagnostic cat-
egories can cloud professional judgments by
helping set into motion a vicious circle in which
error and bias are encouraged and maintained
despite the professional’s good intentions.
This vicious circle begins with four beliefs
that the professional brings to the initial en-
counter with a client: first, that there is a di-
chotomy between normal and abnormal psy-
chological functioning; second, that distinct
syndromes called mental disorders actually exist
and have real properties; third, that the people
who come to “clinics” must have a “clinical
problem” and that problem must fit one of these
syndromes; and fourth, that he or she is an ac-
curate perceiver of others, an unbiased and ob-
jective gatherer and processor of information
about others, and an objective decision maker.
These beliefs lead to a biased and error-prone
style of interacting with, thinking about, and
gathering information about the client. One of
the biggest myths about clinical psychology
training is that professionals with graduate ed-
ucations are more accurate, less error-prone,
and less biased in gathering information about
and forming impressions of other people than
are persons without such training. Research
suggests otherwise (Garb, 1998). Especially per-
nicious is a bias toward confirmatory hypothesis
testing in which the professional seeks infor-
mation supportive of the assumption that the
client has a clinically significant dysfunction or
mental disorder. The use of this strategy in-
creases the probability of error and bias in per-
ception and judgment. Furthermore, the criteriaCHAPTER
2. DECONSTRUCTION OF THE ILLNESS IDEOLOGY AND THE DSM
for normality and abnormality (or health and
pathology) and for specific mental disorders are
so vague that they almost guarantee the com-
mission of the errors and biases in perception
and judgment that have been demonstrated by
research on decision making under uncertainty
(Dawes, 1998). Finally, because the DSM de-
scribes only categories of disordered or un-
healthy functioning, it offers little encourage-
ment to search for evidence of healthy
functioning. Thus, a fundamental negative bias
is likely to develop in which the professional
pays close attention to evidence of pathology
and ignores evidence of health (Wright & Lo-
pez, this volume). From the standpoint of pos-
itive psychology, this is one of the greatest
flaws of the DSM and the illness ideology for
which it stands.
Next, these errors and biases lead the profes-
sional to gather information about and form
impressions of the client that, although not
highly accurate, are consistent with the profes-
sional’s hypotheses. Accordingly, the profes-
sional gains a false sense of confidence in her
social perception and judgment abilities. In turn,
she comes to believe that she knows pathology
when she sees it and that people indeed do fit
the categories described by the DSM. Because
clients readily agree with the professional’s as-
sessments and pronouncements (Snyder, Shen-
kel, & Lowery, 1977), the professional’s confi-
dence is bolstered by this “evidence” that she is
correct. Thus, together they construct a “collab-
orative illusion.”
Finally, because of this false feedback and
subsequent false sense of accuracy and confi-
dence, over time the professional becomes in-
creasingly confident and yet increasingly error-
prone, as suggested by research showing a
positive correlation between professional expe-
rience and error and bias in perceiving and
thinking about clients (e.g., Garb, 1998). Thus,
the professional plunges confidently into the
next clinical encounter even more likely to re-
peat the error-prone process.
Faulty Assumption IV:
Categories Facilitate Treatment
As noted previously, the validity of classifica-
tion schemes is best evaluated by considering
their utility or “how successful they are at
achieving their specified goals” (Follete &
Houts, 1996, p. 1120). The ultimate goal of a
system for organizing and understanding hu-
21
man behavior and its “disorders” is the devel-
opment of methods for relieving suffering
and, in the spirit of positive psychology, en-
hancing well-being. Therefore, to determine the
validity of a system for classifying “mental dis-
orders,” we need to ask not “How true is it?”
but “How well does it facilitate the design of
effective ways to help people live more satis-
fying lives?” As Gergen and McNamee (2000)
have stated, “The discourse of ‘disease’ and
‘cure’ is itself optional. . . . If the goal of the
profession is to aid the client . . . then the door
is open to the more pragmatic questions. In
what senses is the client assisted and injured by
the demand for classification?” (pp. 336–337).
As Raskin and Lewandowski (2000) state, “If
people cannot reach the objective truth about
what disorder really is, then viable construc-
tions of disorder must compete with one an-
other on the basis of their use and meaningful-
ness in particular clinical situations” (p. 26).
Because effective interventions must be
guided by theories and concepts, designing ef-
fective interventions requires a conceptualiza-
tion of human functioning that is firmly
grounded in a theory of how patterns of behav-
ior, thought, and emotion develop and how they
are maintained despite their maladaptiveness.
By design, the DSM is purely descriptive and
atheoretical. Because it is atheoretical, it does
not deal with the etiology of the disorders it
describes. Thus, it cannot provide theory-based
conceptualizations of the development and
maintenance of adjustment problems that might
lead to intervention strategies. Because a system
of descriptive categories includes only lists of
generic problematic behaviors (“symptoms”), it
may suggest somewhat vaguely what needs to
be changed, but it cannot provide guidelines for
how to facilitate change.
Beyond the Illness Ideology and the DSM
The deconstruction of the illness ideology and
the DSM leaves us with the question, But what
will replace them? The positive psychology de-
scribed in the rest of this handbook offers a re-
placement for the illness ideology. Positive psy-
chology emphasizes well-being, satisfaction,
happiness, interpersonal skills, perseverance,
talent, wisdom, and personal responsibility. It is
concerned with understanding what makes life
worth living, with helping people become more
self-organizing and self-directed, and with rec-22
PART II. IDENTIFYING STRENGTHS
ognizing that “people and experiences are em-
bedded in a social context” (Seligman & Csik-
szentmihalyi, 2000, p. 8). Unlike the illness
ideology, which is grounded in certain social
values that implicitly and explicitly tell people
how to live their lives, positive psychology
“would inform individuals’ choices along the
course of their lives, but would take no stand
on the desirability of life courses” (Seligman &
Csikszentmihalyi, 2000, p. 12).
What will replace the DSM is more difficult
to predict, although three contenders have been
on the scene for some time. The dimensional
approach noted previously is concerned with
describing and measuring continua of individual
differences rather than constructing categories.
It assumes that people will display considerable
statistical deviation in behavioral, cognitive, and
emotional phenomena and does not assume that
such deviation is, per se, maladaptive or path-
ological.
Interpersonal approaches begin with the as-
sumption that “maladjusted behavior resides in
a person’s recurrent transactions with others . . .
[and] results from . . . an individual’s failure to
attend to and correct the self-defeating, inter-
personally unsuccessful aspects of his or her in-
terpersonal acts” (Kiesler, 1991, pp. 443–444).
These approaches focus not on the behavior of
individuals but on the behavior of individuals
interacting in a system with others (Benjamin,
1996; Kiesler, 1991). For example, relational di-
agnosis is concerned with “understanding the
structure function and interactional patterns of
couples and families” (Kaslow, 1996, p. v). De-
spite its sometimes excessive concern for devel-
oping typologies of relationship patterns, its as-
sumption that “theoretical formulations and
clinical interventions must be informed by an
understanding of ethnicity, culture, religion,
gender, [and] sexual preference” (Kaslow, 1996,
p. v) is nonetheless a stark contrast to the
DSM’s assumption that mental disorders exist
inside the individual.
The case formulation approach posits that
the most useful way to understand psycholog-
ical and behavioral problems is not to assign
people and their problems to categories but to
formulate hypotheses “about the causes, precip-
itants, and maintaining influences of a person’s
psychological, interpersonal, and behavioral
problems” (Eells, 1997, p. 1). Because case for-
mulations are guided by theory, they are the
antithesis of the DSM’s atheoretical, descriptive
approach. Case formulation has been given the
most attention by behavioral and cognitive the-
orists, but it also has advocates from psycho-
analytic, time-limited psychodynamic, interper-
sonal, and experiential perspectives (Eells,
1997). Despite their diversity, case formulation
approaches share an avoidance of diagnostic cat-
egories and labels; a concern with understand-
ing not what the person is or what the person
has but with what the person does, thinks, and
feels; and an emphasis on developing theory-
guided interventions tailored to the individual’s
specific needs and goals.
Despite their differences, these three ap-
proaches share a rejection of the illness ideol-
ogy’s emphasis on pathology, its assumption
that pathology resides inside of people, and its
rigid system of categorization and classification.
Also, because they set the stage for an exami-
nation of both adaptive and maladaptive func-
tioning, they share a basic compatibility with
the principles and goals of positive psychology.
Conclusions
The illness ideology has outlived its usefulness.
It is time for a change in the way that clinical
psychologists view their discipline and in the
way the discipline and its subject matter are
viewed by the public. The positive psychology
movement offers a rare opportunity for a re-
orientation and reconstruction of our views of
clinical psychology through a reconstruction of
our views of psychological health and human
adaptation and adjustment. We need a clinical
psychology that is grounded not in the illness
ideology but in a positive psychology ideology
that rejects: (a) the categorization and pathol-
ogization of humans and human experience; (b)
the assumption that so-called mental disorders
exist in individuals rather than in the relation-
ships between the individual and other individ-
uals and the culture at large; and (c) the notion
that understanding what is worst and weakest
about us is more important than understanding
what is best and bravest.
This change in ideology must begin with a
change in the language we use to talk about hu-
man behavior and the problems that human be-
ings experience in navigating the courses of
their lives—a change from the language of the
illness ideology to the language of positive psy-
chology. Because the language of the illness ide-
ology is enshrined in the DSM, this reconstruc-
tion must begin with a deconstruction of this
CHAPTER 2. DECONSTRUCTION OF THE ILLNESS IDEOLOGY AND
THE DSM
icon of the illness ideology. As long as we re-
vere the DSM, a change in the way we talk
about people and problems in living will come
slowly, if at all.
The illness ideology and the DSM were con-
structed to serve and continue to serve the so-
cial, political, and economic goals of those of us
who shared in their construction. They are sus-
tained not only by the individuals and institu-
tions whose goals they serve but also by an im-
plicit set of logically flawed and empirically
unsupported assumptions about how best to un-
derstand human behavior—both the adaptive
and the maladaptive. Psychologists need to be-
come aware of both the socially constructed na-
ture of the assumptions about psychological dis-
orders that guide their professional activities
and the logical and empirical weaknesses of
these assumptions. We need to continue to
question the often unquestioned sociocultural
forces and philosophical assumptions that pro-
vide the foundation for the illness ideology, the
DSM, and our “distorted and damaged” clinical
psychology. Finally, we need to encourage our
students, the public, and our policy makers to
do the same.
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