Despatologização e psicologia positiva

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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