We often view the world through the lens of our biases.
We bring cultural, professional, educational, and social baggage to our thoughts, decisions, and beliefs.
As mental health professionals, we carry these preconceptions to our meetings with clients, influencing our diagnoses. Therefore, we can be guilty of refusing to accept divergent behavior as normal or incorrectly seeing a symptom as an indicator of mental illness.
This article explores bias and the risks and problems associated with pathologizing normal behavior as a mental disorder.
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What Does Pathologizing Mean?
We are all guilty of bias; our knowledge and thinking (even when false) influence the choices we make. When we hold unfounded or incorrect beliefs, our decisions are most likely inferior, and we harm ourselves and others.
The bias of science
Our education, experience, knowledge, and profession may be actively limiting how we approach problems.
“If all you have is a hammer, everything looks like a nail.”
The quote is from Abraham Maslow’s renowned book The Psychology of Science published in 1966, but the original idea has a rich history. The message has remained even though the words have changed. It is variously known as (Law of the instrument, 2020):
- Law of the instrument
- Law of the hammer
- Maslow’s hammer
- Golden hammer
The law of the instrument warns that cognitive bias can lead to over-reliance on a familiar tool.
But what does this mean in the context of psychology?
The American philosopher Abraham Kaplan first used the hammer and nail analogy at a UCLA conference in 1962. He was referring to the impact that bias within science has on the choice of research methods. Described as the law of instrument in a 1964 article, Kaplan said, “give a boy a hammer, and he will find that everything he encounters needs pounding.”
He urged scientists to be cautious in their approach to selecting techniques and methodology. The method may be readily available, backed up by recent training, and yet not appropriate for the problem at hand.
And so it was in 1960s psychiatry.
For Maslow at the time, the law of the instrument referred to the limited number of antipsychotic drugs available (stelazine and thorazine). Aberrant behavior was overpathologized and treated as psychosis even when the sufferer could discern what was and was not real (Law of the instrument, 2020).
The effects of the law of instrument
The law of the instrument refers to the inability to see beyond a limited viewpoint and has parallels in the cognitive psychology term functional fixedness.
Research into perception and problem solving has repeatedly confirmed that based on prior experience, we sometimes see an object as having only one use.
For example, in the classic 1945 experiment, German gestalt psychologist Karl Duncker asked participants to attach a candle to a wall. They were given a book of matches and a box of thumbtacks. Most tried and failed to directly fix the candle to the vertical surface using melted wax or thumbtacks.
They were unable to reframe the utility of the objects. The solution came when participants recognized that the thumbtack box could hold the candle and be nailed to the wall using the tacks (Eysenck & Keane, 2015).
Sometimes we only see things in a particular way, unable to change our representation.
And this is true for the law of the instrument; it not only limits our outlook, but also negatively affects our thinking and decision making.
As a result, we (Law of the instrument – Biases & Heuristics, 2020):
- Become more inefficient
We fixate on the idea of using a particular tool and skill because we are familiar with it. Unable to let go, a task takes much longer than if we stop, think, and choose the best approach for the job.
- Attempt a one-size-fits-all approach in education
All children learn differently and at varying speeds, with a range of strengths and weaknesses. Using one system is likely to mean that for every child who excels, there will be another who fails because they do not match the style or stage of the teaching.
But why does this happen?
The following two overlapping biases can heavily influence our judgment (Law of the instrument – Biases & Heuristics, 2020):
Our professional background greatly influences our beliefs and approach to solving problems.
For example, if I am both a nutritionist and a therapist, and someone arrives with anxiety problems, I may be biased toward checking their diet. This may not be a bad thing, but it could lead us down a line of reasoning not appropriate to the problems as they present themselves.
Prior problem-solving experience can lead us to associate new problems with ones we have previously resolved. When a client arrives and exhibits similar challenges to a recent case, we are tempted to conclude they have the same issues and use a similar problem-solving approach.
Bias can be helpful; it can allow us to respond more quickly. But, like functional fixedness, it may also mean we cannot see the real problem in front of us.
Why is this a problem in psychology?
Human psychology is vastly complex, with many internal and external influences impacting how we behave (Eysenck & Keane, 2015).
Making a quick judgment as a mental health professional based on a simple presentation of what appears wrong may miss the underlying issue. We may prolong our client’s treatment through an incorrect diagnosis, waste their time, and cause further mental distress.
We are also likely to focus solely on the problems rather than the individual’s growth, development, and wish to lead a complete and fulfilling life.
As Wakefield writes in 2007, who is to say that the behavior we observe “is not merely a form of normal, albeit undesirable and painful, human functioning, but indicative of psychiatric disorder?”
Are we potentially pathologizing everyday life? Possibly.
4 Examples of Pathologizing
In mental health, we pathologize.
Much of the time, it is probably justified.
After all, we have years of experience and education under our belt. Right?
But the letters after our name do not stop us from seeing normal behavior – perhaps different from our own – as indicative of an underlying mental health issue.
The following four examples highlight how we see a symptom (either through witnessing behavior or interpreting what someone has told us) as an indicator of a mental illness.
Billieux, Schimmenti, Khazaal, Maurage, & Heeren (2015) suggest that a “ridiculous” amount of research has claimed “innovative yet absurd addictive disorders.”
So much research, in fact, that there is now a journal specifically for articles related to the creation of new disorders based on old behaviors.
For example, the unlikely Argentinian tango addiction can be reframed as an individual excessively attending dance sessions. After all, it is ultimately context dependent, and recovery (if you can recover from the tango) is most likely swift. Is this really an addiction?
While the concept of video game addiction has gained traction, it remains controversial. It is uncertain whether such an addiction is a stable construct. After all, based on observation, “clinical impairment is low,” and there are no clear diagnostic criteria (Bean, Nielsen, van Rooij, & Ferguson, 2017).
With such a large and growing list of addictions being created, with unclear guidance on what constitutes a clinical problem, it becomes easier and easier to pathologize most of us with some form of addiction.
Throughout the 19th and 20th centuries, “sexual preferences, desires, and behaviors have been pathologized and depathologized at will,” even forming part of the weighty Diagnostic and Statistical Manual of Mental Disorders (De Block & Adriaens, 2013).
Over time, the definition of a disorder relating to sexual deviance has been heavily influenced by current ethical and political thinking. Therefore, the diagnosis of sexual deviance may rely more on the sociocultural backdrop than the existence of a genuine disorder.
Concerns have been raised regarding “how behaviors become pathologized and problematized in long-term care settings.” Meaning is often assigned to behaviors through the “lens of pathology” (Dupuis, Wiersma, & Loiselle, 2012). However, applying a violent or inappropriate label may ignore the underlying reasons or causes of that behavior, to the person’s detriment.
Viewing behavior from the perspective of disease and sickness – as the direct result of dementia or another brain disease – can lead to inappropriate treatment and failure to see the person as an individual rather than a diagnosis. Labeling the patient as wandering or agitated can also cause unnecessary suffering resulting from how they view themselves.
Instead, staff needs better, more multi-dimensional frameworks to recognize the complexity of behavior and the underlying causes and offer more appropriate treatment (Dupuis et al., 2012).
“Defiance is sometimes treated as behavior that needs to be punished or even diagnosed” and yet can be seen as a virtue and contributing to the good life (Potter, 2011).
In particular, defiance among members of oppressed groups is often considered a sign of mental ill health, with individuals being treated as having a mental disorder.
It may be that defiance is a requirement for survival in groups that are oppressed rather than being associated with “bad, and even mad, behavior” (Potter, 2011). We must, therefore, remain cautious regarding the treatment of defiance as a mental disorder.
Do We Pathologize ‘Normal’ Behavior?
There is an old saying that dates back at least as far as the 18th century (Gardner, 2019):
Doctors differ, and their patients die.
As doctors (or in this case, psychologists and therapists), we look at the same client and see a different underlying cause for the behavior they exhibit. Our past experiences and our education shape our reasoning.
While our genetics are fundamental to who we are, so is our upbringing and the culture in which we grew up.
Westernization of psychology
Individuals and populations don’t all think and behave in the same way. They can differ in their feelings, emotions, reasoning, and how they make moral judgments (Henrich, 2020).
Therefore, we must be cautious when applying psychological doctrine created by and tested on Westerners to people from other cultures and backgrounds.
In Crazy Like Us, Ethan Watters (2011) claims that our Western view of mental wellness is replacing those of other cultures with disastrous results. He says we are in the process of homogenizing what it means to be mentally unwell and thereby pathologizing what in other cultures may not be atypical behavior.
When someone walks into our office, we should consider their cultural background before making judgments, or we will pathologize what is deemed to be normal – at least in certain groups.
Medicalizing mental health
Everyday life can be tough. When something awful happens – a death, breakup, illness, or job loss – we typically find it difficult to cope.
But at what point does mental distress cease being normal and instead become a mental health problem (Wasserman, 2018)?
We could be over-medicalizing normal mental health.
We apply medical knowledge and perspective to the way humans live and the problems they face, and they become “increasingly defined and treated as medical conditions” (Wasserman, 2018).
Over time, we are widening the boundaries of what defines an illness. While it can be innocent, there could be more immoral reasons such as expanding pharmaceutical markets to increase sales (Wasserman, 2018).
A Look at Problematic Overpathologizing
The line between pathologizing and overpathologizing is not well defined and may depend on our personal and professional perspective.
While the answer may be unclear, the question must be asked: Are we overpathologizing?
Increasing mental health disorders
There are increasing numbers of mental illnesses being defined and, as a result, more cases of mental health problems (Wasserman, 2018).
The handbook used by healthcare professionals in the U.S. (and beyond) to diagnose mental health disorders is the Diagnostic and Statistical Manual of Mental Disorders (DSM).
The DSM was originally published in 1952, with only 106 disorders. The American Psychiatric Association has continued to revise and expand the DSM ever since, as we learn more about mental health. There were 297 disorders listed in the fourth edition, and a further 15 were added for the fifth.
The increasing number of disorders naturally results in significantly more people reaching the criteria for diagnosis. A recent study found that according to current definitions of mental health disorders, 25% of the American public can be identified as having a mental illness (Wasserman, 2018; Mental Health Disorder Statistics, 2020).
Perhaps the American public has a lot of mental health problems, or the criteria for diagnosing is too loose, or more likely, it’s a combination of both.
Must we define something as broken to fix it?
Wasserman (2018) asks whether “it is necessary to conceptualize all of these issues of everyday life as reflective of an illness in order to devise effective treatment approaches.” His answer is a resounding “no.”
Are one in four Americans really suffering from a mental health disorder, or are we incorrectly defining everyday stress and upset as reflective of mental illness (Wasserman, 2018)?
Is everyone mentally ill? | Accurate diagnosis or overpathologizing
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A Take-Home Message
We carry a host of biases based on culture, background, training, and our profession. While such expertise is valuable, it can lead to conclusions that may not always be appropriate.
While bias may once have offered evolutionary value, it can now lead to incorrect, unhelpful, and even damaging decisions. In the case of mental health practitioners, it can lead to potential misdiagnosis and inappropriate or unnecessary treatments.
Our bias can lead us to overpathologize.
After all, “we are still far removed from a universally accepted definition of mental disorder,” and therefore, it’s unclear whether a bunch of behavioral attributes warrant such a label (De Block & Adriaens, 2013).
And while the DSM and other such psychiatric textbooks and diagnostic publications are crucial to formalizing, identifying, and treating mental disorders, there is also an inherent risk.
Once disorders are identified, defined, and documented, it can be too easy to attribute mental health problems to large sectors of the general public. The consequences may be not only misrepresenting the state of public mental health, but also promoting costly, unnecessary, and even detrimental interventions.
Try out some of our tools and worksheets to identify your clients’ problems. Try to define the scope of the issue, organize the information, and get to the root cause of what is making your clients’ lives difficult before drawing a conclusion – hopefully avoiding over-reliance on tried and tested interventions that do not fit the problem.
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- Bean, A. M., Nielsen, R. K. L., van Rooij, A. J., & Ferguson, C. J. (2017). Video game addiction: The push to pathologize video games. Professional Psychology: Research and Practice, 48(5), 378–389.
- Billieux, J., Schimmenti, A., Khazaal, Y., Maurage, P., & Heeren, A. (2015). Are we overpathologizing everyday life? A tenable blueprint for behavioral addiction research. Journal of Behavioral Addictions, 4(3), 119–123.
- De Block, A., & Adriaens, P. R. (2013). Pathologizing sexual deviance: A history. Journal of Sex Research, 50(3–4), 276–298.
- Duncker, K. (1945). On problem-solving. Psychological Monographs, 58(5), i–113.
- Dupuis, S. L., Wiersma, E., & Loiselle, L. (2012). Pathologizing behavior: Meanings of behaviors in dementia care. Journal of Aging Studies, 26(2), 162–173.
- Eysenck, M. W., & Keane, M. T. (2015). Cognitive psychology: A student’s handbook. New York, NY: Psychology Press.
- Gardner, J. (2019). Doctors differ. Drawing Blood: Comics and Medicine. Retrieved October 23, 2020, from http://drawing-blood.org/pre-modern-medicine/doctors-differ/
- Henrich, J. P. (2020). The weirdest people in the world: How the West became psychologically peculiar and particularly prosperous. London, UK: Penguin Books.
- Kaplan, A. (1964). The conduct of inquiry: Methodology for behavioral science. San Francisco, CA: Chandler Publishing.
- Law of the instrument. (2020). Retrieved October 22, 2020, from https://en.wikipedia.org/wiki/Law_of_the_instrument
- Law of the instrument – Biases & Heuristics. (2020). Retrieved October 22, 2020, from https://thedecisionlab.com/biases/law-of-the-instrument/
- Maslow, A. (1966). The psychology of science: A reconnaissance. South Bend, IN: Gateway Editions.
- Mental Health Disorder Statistics. (2020). Retrieved October 23, 2020, from https://www.hopkinsmedicine.org/health/wellness-and-prevention/mental-health-disorder-statistics
- Potter, N. N. (2011). Mad, bad, or virtuous? The moral, cultural, and pathologizing features of defiance. Theory & Psychology, 22(1), 23–45.
- Wakefield, J. (2007). The concept of mental disorder: Diagnostic implications of the harmful dysfunction analysis. World Psychiatry. 6(3), 149–156.
- Wasserman, T. (2018). Depathologizing psychopathology: The neuroscience of mental illness and its Treatment. SAM Ficher.
- Watters, E. (2011). Crazy like us: The globalization of the American psyche. New York, NY: Free Press.