It should be obvious to most people that there is a pervasive concern over mental health and mental illnesses in our country. While the concept of mental illness was once reserved for those who demonstrated particularly abnormal, self-destructive or otherwise inexplicable behavior, the category of “mental illness” is today is applied more broadly. Many who would have not been included within its conceptual boundaries one hundred years ago are now designated as suffering from a mental illness.
But Christians must push back against the cultural tide and ask a few basic clarifying questions like, Is “mental illness” a legitimate category? How should we assess the idea of mental illness from a Christian perspective? Are the commonly-accepted definitions of “mental illness” logically coherent? In this article, my aim is to apply some sanctified conceptual analysis to the category of mental illness in order to test its logical cogency and practical usefulness.
Defining Mental Illness: The DSM-5
A “mental illness” or “mental disorder” is defined by the latest version of the Diagnostic and Statistical Manual (DSM-5) as follows:
A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior, that reflects a dysfunction in the psychological, biological, and development processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless deviance or conflict results from a dysfunction in the individual, as described above.”DSM-5, 20.
This is a dense paragraph, so let’s break it down and make a few important observations. First, the DSM describes a mental disorder as a “syndrome.” The word syndrome is defined as “a group of signs and symptoms that occur together and characterize a particular abnormality or condition.” The classification of mental illness as a “syndrome” is significant because it tacitly concedes that the concept of “mental illness” resists traditional diagnostic procedures and conclusions.
With physical illnesses, the doctor assesses symptoms in order to correctly determine the underlying cause of the symptoms. The medical doctor would say something like, “The lab tests indicate that your symptoms of weight loss, fatigue, and constant nausea are all caused by pancreatic cancer.” In this scenario, the pancreatic cancer is not the symptoms—the weight loss, fatigue, or constant nausea are. Rather, the cancer is the cause of these three ailments, and the ailments themselves serve as evidence to lead to the identification of their principal cause.
The Logical Incoherence of the DSM’s Definition
A mental illness, however, is defined by its symptoms. Inserting the definition for “syndrome” back into the DSM definition above, we get this: “A mental disorder is a group of signs and symptoms that occur together and characterize a particular abnormality or condition.” Notice that the mental illness is the “group of signs and symptoms,” that “characterize” a specific “abnormality or condition.” It is not the condition itself. Thus, a mental illness is not diagnosed in the way physical illness are. Indeed, a mental illness isn’t diagnosed at all if by “diagnosis” one means the identification of an underlying disease that gives rise to certain symptoms.
Rather, a diagnosis of a mental illness is merely the affirmation of symptoms. This is why the various diagnoses in the DSM do not provide the reader with a clear root cause of a given disorder. Rather, most disorders discussed in the DSM are just detailed descriptions of the kind of behaviors a person may exhibit. But this is not a diagnosis in the traditional sense of the word—it is merely a verification and labeling of one’s problematic behaviors. By affirming symptoms and calling it a disorder, the DSM is guilty of a creating a tautology that appears sophisticated but yields no real knowledge about what is happening to the person in question. The symptoms are evidence of the disease and the disease itself. This is illogical.
But let us probe a little further into the DSM’s definition. What symptoms lead to the identification of a mental illness?
According to the definition above, for a person to be diagnosed with a mental illness they must display serious “disturbance” in their “cognition, emotion regulation, or behavior.” Yet, these symptoms must be “clinically significant” to classify as a mental illness. The phrase “clinically significant” usually means that a person’s symptoms have increased to such a pitch that the person is now unable to manage normal, day-to-day responsibilities and routines. That’s why the DSM includes this sentence: “Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.” Said another way: the person in question has exhibited such problematic behavior that their ability to manage daily routines and fulfill social and employment obligations has been severely hindered. Work, relationships, financial responsibilities, even attention to personal hygiene, must be curtailed to a substantial degree for a collection of symptoms to qualify as a mental illness or disorder.
This set of symptoms “reflects a dysfunction in the psychological, biological, and development processes underlying mental functioning.” With this sentence, the DSM attempts to root the mental illness in a foundational cause. There is “dysfunction”—an impairment of some kind—at the level of the person’s psychology, biology, and/or “developmental processes” that give rise to a person’s mental state.
This is a confusing sequence of terms because of the overlap of meaning between “psychological” and “mental.” Again, it is a kind of tautology or a distinction without a difference to refer to that which is psychological and that which is mental. But this is also a convoluted sentence because there is no consensus within modern psychiatry and psychology as to how to define the “psychological” in relation to the “biological;” the “mental” in relation to the “physical.” Much of modern psychological theory is built upon naturalistic assumptions concerning man’s nature—assumptions which, by definition, do not allow for the immaterial category of “mind.” Yet the distinction between “psychology” and “biology” in the DSM’s definition seems to assume material and immaterial components of the human person.
Again, however, in a great irony, because modern psychological and psychiatric science assumes naturalism, the category of “psychology” doesn’t have any real explanatory power. Indeed, in a recent academic article published in Psychological Medicine, authors Stein, Palk, and Kendler concede that the interaction between “psychological” and “biological” components of a person is a mere construct. It is a construct because, working within naturalistic foundations, there can be no psyche (i.e., soul or immaterial mind) and thus no real interaction with biology.
The Need for Body and Soul
At a popular level for well over a decade, some psychologists have been pushing against these strict naturalistic parameters, arguing that the concept of an immaterial “soul” or “spirit” or “mind” (i.e., something other than brain and biology) is a necessary category without which one cannot speak coherently of people’s mental problems. The attempt to speak of mental illness within an Enlightenment framework is, according to one psychologist, a foundational flaw within the structure of modern psychology.
Post-Cartesian rationalism holds firm, Jung [the spiritualist] is marginalized and psychology, to great dismay, is ever more firmly planted in the arena of science….Unable to bear the weight of the false, or at least incomplete, premise under which it labors, psychology—divorced from spirit—has begun to crumble under the weight of its own inauthenticity.Michael J. Formica, “The Faliure of Psychology and the Death of Psychotherapy
Formica’s mention of “post-Cartesian rationalism” here refers to the tendency after Rene Descartes (1596-1650), a mind/body dualist, to collapse mind and body into one entity. Sigmund Freud, for example, was a monist—he assumed everything could be explained by reference to one substance, not multiple substances (like an immaterial mind and a physical brain). Most psychiatrists and psychologists today believe that the “mind” is a product of the brain.
Formica sees that psychology presently suffers from a severe internal contradiction. On the one hand, the scientific component of psychological inquiry is naturalistic—mental states are reducible to biology and can be studied and assessed along such lines. On the other hand, as Formica has concluded from his own experience, there is irremediable loss in the study of human motivation and behavior when the category of “soul” or “spirit” is downgraded to a mere theory or less. We all seem to know intuitively that we are more than our biology.
I mention these internal inconsistencies within modern psychiatry and psychology to underscore the stubborn truth that mental illness does not have strong conceptual or logical footing, despite how it is portrayed in popular media and elsewhere. Even doctors who worked on the DSM’s previous iterations are voicing their concern that current attempts to define “mental illness” are tenuous at best.
A Lack of Conceptual Clarity
Take for example Dr. Allen Frances. Dr. Frances is a former professor of psychiatry who served as the chair of the DSM-IV task force in the early 1990s. In his book, Saving Normal: An Insider’s Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life, Frances laments that there are no past or present definitions of mental illness that enable one to accurately assess whether a person has such a condition. In a remarkable admission, Frances comments:
I have reviewed dozens of definitions of mental disorder (and have written one myself in DSM-IV) and find none of them the slightest bit helpful either in determining which conditions should be considered mental disorders and which not, or in deciding who is sick and who is not.Dr. Allen Francis, Saving Normal, 16-17.
Frances’ conclusion should not surprise us. Given the incoherence that afflicts modern psychiatry and psychology at their philosophical foundations, we should expect that naturalistic attempts to define mental illness do not lead to greater conceptual clarity. Actually, the question of whether “mental illness” is a legitimate category has been challenged by psychiatrists and psychologists for decades. A significant work highlighting the logical confusion that pervades modern psychiatry and psychology (recently re-released with a new preface in 2003) is Thomas Szasz’s The Myth of Mental Illness. The late Dr. Szasz was a professor of psychiatry at the State University of New York for over 50 years. In the preface Szasz comments,
The claim that “mental illnesses are diagnosable disorders of the brain” is not based on scientific research; it is a lie, an error, or a naïve revival of the somatic premise of the long-discredited humoral theory of disease….In medical school, I began to understand clearly that my interpretation was correct, that mental illness is a myth, and that it is therefore foolish to look for the causes and cures of the imaginary ailments we call “mental diseases.” Diseases of the body have causes, such as infectious agents or nutritional deficiencies, and often can be prevented or cured by dealing with these causes. Persons said to have mental diseases, on the other hand, have reasons for their actions that must be understood; they cannot be treated or cured by drugs or other medical interventions, but may be helped to helped themselves overcome the obstacles they face.Thomas S. Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, xii, xviii.
Szasz continues in his book to argue with sharp insight and refreshing logical clarity that the label mental illness did not derive from identifying actual diseases, but by changing the definition of what constitutes a disease. Szasz observes, “…to the established criterion of detectible alteration of bodily structure was now added the fresh criterion of alteration of bodily function; and, as the former was detected by observing the patient’s body, so the latter was detected by observing his behavior” (The Myth of Mental Illness, 12). This is why, modern attempts to root mental illnesses in discernible differences in brain structure notwithstanding (attempts that have thus far yielded no clear empirical evidence of a neurological cause of mental illness, only neurological involvement), a physician’s “diagnosis” of a mental illness is almost always based on the mere observation of a patient’s behavior, not on medical tests that reveal an underlying organic cause. (Physicians will sometimes have their patients submit to blood tests, but this is done to rule out any organic cause of their supposed mental illness, not to establish the mental illness in the person’s biology.)
The Takeaway for Christians
The takeaway for the Christian is this: we must be careful not to uncritically absorb modern definitions and diagnoses of so-called mental illnesses. These definitions and diagnoses are not rooted in objective science, but instead flow out of a particular anthropology that dismisses the biblical distinction between the physical body and the immaterial soul. At basic, the construct of “mental illnesses” is simply a naturalistic/materialistic way of interpreting certain problematic behaviors.
Christians cannot accept these constructs because we know, based on divine revelation, that we are body and soul: we possess an immaterial mind that is distinct from the physical brain. And what modern psychiatry and psychology call “mental illness” Scripture identifies in many cases as sinful issues of the heart (Prov 4:23), corrupt motivations/desires (Matt 15:18-20), warped thinking (Gen 6:5), demonic oppression (Mark 5:1-5), and spiritual confusion that has run amok in a person’s life and caused all kinds of trouble (Prov 22:5). Sometimes a person may be diagnosed with a mental illness because they have developed patterns of behavior and thinking that are contrary to reality as a way of coping with sins committed against them (e.g., Dissociative Identity Disorder). Furthermore, what is defined as a mental illness may not always be sinful or abnormal but simply a characteristic of a particular demographic (age, gender, etc.) or a reflection of ordinary variation among people (e.g., alleged cases of ADHD).
Importantly, a biblical worldview leads us to say that a person is responsible for their anger, anxiety, laziness, disruptive and anti-social behavior because there is an “I” that is distinct from and more than one’s biology. Biology is involved in our moral behavior, but a robust biblical anthropology would say that it does not ultimately cause it.
The good news is that in Christ, the “I” is no longer a victim of one’s biology, but is now able to, through the power of the Holy Spirit and well-informed obedience to God’s Word, begin to think, feel, and act in a way that corresponds to their design by God. They can effectively (though not perfectly) put off anger (e.g., bipolar disorder, conduct disorder), repent of laziness and selfishness, and apply diligence to every aspect of their life (ADHD). They can navigate anxiety, learning when and where such feelings are appropriate and how to trust God when they are feeling restless (anxiety disorder), control their thoughts (dissociative identity disorder) and much more.
That’s not to suggest that people never experience genuine cognitive troubles due to an underlying physical disease or structural abnormality. Those who have suffered severe brain trauma or who live with Alzheimer’s, diabetes, or thyroid troubles (or other physical maladies) may experience cognitive difficulties that manifest in behaviors similar to the behaviors listed in the DSM. A biblical anthropology provides the basis for interaction between the immaterial mind and physical body, and both can and do affect the other (see Ps 32:3; Prov 3:8).
But what Christians cannot accept is a category of “mental illness” that rests upon naturalistic foundations and dismisses sinful or otherwise bizarre behaviors as the mere result of a disease rather than fruit of the heart. In truth, all people are mentally ill in that all of us have sinful hearts and minds that are prone to embrace error, become confused, and dwell on that which is evil. But this mental illness can be healed in Christ through regeneration and renewal of the inner person (Rom 12:1-2). In Christ, we can be put in our right minds (Luke 8:35) and begin a lifelong process of renewing our minds after the image of our Creator (Col 3:10). One day we will be completely delivered from the ravages of sin and its effects on our minds when we are taken to glory to be with our Savior forever (Phil 1:21; Rev 22:1ff). This is the ultimate hope and promise of the gospel, and the only cure for mental illness.
Editor’s Note: We added the word”moral” to the sentence “Biology is involved in our moral behavior, but a robust biblical anthropology would say that it does not ultimately cause it,” because we recognize that some involuntary behaviors are caused by our biology. The aim of the article, however, is to demonstrate the logical incoherence of mental illness as a theory and argue for a biblical anthropology that places the culpability for our moral behavior in the non-material “mind,” not the material brain.