What is mental illness?

What is mental illness? This is a difficult question to answer. Recent debate about this has come to a head with the new Diagnostic and Statistical Manual of Mental Disorders (the DSM-V). Criticisms have been widely expressed ostensibly because of this very question.

The authors of the DSM-V had a nearly impossible task: to reduce the irreducible complexity of psychological suffering into distinct behavioral categories. This is a lofty goal, but a very understandable one. If we, as psychotherapists, could remove complexity, distill mental illness to its fundamental elements, then the daunting task of helping those who are in distress seems more surmountable.

However, I think a more tenable solution is not to reduce complexity, but instead to use it as an essential component to our understanding. Rather than define mental illness as a series of check-boxes, we as clinicians, must acknowledge the intricacy of psychological pain and strive to understand the nature of our patient’s difficulties. I feel that it is only in doing so, that we can truly join our patients and endeavor to help them.

It is with this, and a recent blog post by Dr. Marilyn Wedge about ADHD rates in France, that I am reminded of a former professor’s conceptualization of mental illness.


He defined mental illness as:

  1. A-cultural (i.e. occurring outside of cultural norms)
  2. Causing distress and/or suffering to the person
  3. Causing difficulties in social, academic, vocational, or family situations
  4. And it cannot be attributed to biological factors/illness


I think this definition allows for the complexity of psychological illness, and feel that it is a clinically useful. It lessens the emphasis on discrete symptoms and instead offers a framework for understanding when a person’s problems rise to the level of needing professional intervention.

Ideas of what constitutes mental illness are, of course, constructed within a context, and a study of any culture will reveal unique symptomology. For instance, in South Africa among the Batu peoples (Zulu, Xhosa, etc.) “Brain Fag” is a common conceptualization of mental illness, in which sufferers experience anxiety, forgetfulness and poor concentration (Yen & Wilbraham, 2003). It is believed to be caused by ‘bewitchment’. Central American people of African descent may similarly blame cognitive, emotional, or psychological difficulties on brujeria, or witchcraft.

This is not unique to non-western cultures, as Dr. Wedge’s post makes clear. She gives data that suggests that attention deficit/hyperactivity disorder (ADHD) is diagnosed in children at a much lower rate in France than compared to the U.S. She speculates that this may be largely a socio-cultural difference. Her argument is that the French see less of a biological basis for ADHD than American psychiatrists and may even feel that medication is prescribed to treat normal behavior which U.S. doctors label as ADHD.

It would be very easy to argue that Dr. Wedge is right or is wrong and give many supporting data to make the case, however I think this misses the point. Claiming one perspective or another would be the same impossible task of making the complex simple. Rather than reducing our understanding to that the American system over-pathologizes ‘normal’ behavior, or to dismissing French or Central American conceptualizations of mental health as ‘primitive’, clinicians (and by turn their patients) may do better to consider my professor’s definition.

Often dogmatic camps arise in which clinicians may espouse the best approach or the most evidence-based treatments for reducing symptoms or lessening suffering. Unfortunately, I think this ultimately decreases one’s ability to be truly helpful and may even be harmful. Melanie Klein, a British psychoanalyst, spoke about a defense called splitting in which humans try to simplify their world by seeing people, actions, etc. as simply as possible: as either all good or all bad. When psychologists and other medical professionals ardently defend one approach, or treatment, I fear they may be doing something similar.

I work with a diverse population of people, and in trying to care for and bring peace of mind to my patients I draw from many sources of clinical wisdom. These include evidence-based treatments, academic and clinical research studies, the clinical experience of both my colleagues and myself, and the definition of mental illness that my professor gave me.

Other clinicians may also pull from diverse bodies of clinical knowledge, but often overlook this last piece: socio-cultural context. I think this is shortcoming in our thinking and fear that patients will suffer as a result. By including an understanding of cultural factors in the definition of what mental illness is, I believe that I, and other therapists are able to offer better care, understanding, and outcomes. Doing so allows us to transcend the dogma and instead focus on the most important thing: our patient.

Blog Teens

Should you talk to your teen about drugs?

Should you talk to your teen about drugs? Yes. How? That’s more complicated.

According to recent research in the Journal of Adolescent Health by Chaplin, T. M., Hansen, A., Simmons, J., Mayes, L. C., Hommer, R. E., & Crowley, M. J. (2014) the way parents speak to their children may have a significant effect on later drug use.

These researchers asked 58 teens and their caregivers to speak to about alcohol and drug use for 10 minutes, while the teens where hooked-up to sensors to measure blood pressure, heart-rate, and stress-hormone cortisol levels. When the caregivers were rule-based, threatening, or negative and critical adolescents showed greater levels of arousal and a greater likelihood of later substance abuse.   In contrast, discussions that were warm, information-based, and educational tended to be related to lower levels of stress in the teens and correlated with reduced chances of substance use later on.

This stands in the face of “Scared Straight” style drug education efforts. Instead, empathy and access to information appear to be more effective.

Though the researchers do not offer an explanation as to why this might be the case, one might speculate that as greater levels of stress (i.e., higher blood pressure, more cortisol, faster heart rate) may be quite overwhelming and attempts to decrease this stress might come in the form of drugs or alcohol.

If you’re worried about your son or daughter using drugs and want help, contact me. I can help.


Low Self Esteem and Depression

Low Self Esteem and Depression: The Relationship

Low self esteem and depression are related. The simplest way to think about the link between the two is that low self-esteem can be a symptom of depression, but low self esteem does not necessarily indicate depression.


Are Low Self Esteem and Depression the Same Thing?

Low self esteem and depression are not the same thing, though low self-esteem is almost always a symptom of depression.

To understand, some definitions are needed. By depression I am referring to a specific set of cognitive, emotional, and physical symptoms which you feel are problematic and interfere with your ability to work, go to school, and form and maintain relationships. Symptoms like excessive eating or sleeping, poor hygiene, difficulty getting out of bed, and missed work or school are examples.

Low self esteem in depression can be seen in thoughts like “I’m worthless,” “I don’t matter to anyone,” “My work is meaningless”.

Low self esteem, on the other hand, is a cognitive and emotional relationship to yourself. Low self esteem can be seen in depression, but also can be seen in those that are shy or anxious. The cognitive signs of low self esteem often include thoughts like “I don’t have anything to offer,” “No one cares what my opinion is,” or “That idea will be shot down”.


What are the causes of low self esteem and depression?

There are many elements that can lead to low self esteem and/or depression. Generally these factors can be divided into environmental and biological factors.

For depression biological factors include: family history of depression, low levels of serotonin and dopamine neurotransmitters. Environmental factors include exposure to trauma, neglect, or trauma.

Low self esteem is primarily viewed as environmental, with experiences of rejection, failure, embarrassment, shame, and anxiety underlying most feelings of low self esteem.


Contact me

If you are interested in getting therapy, consultation, or have questions that you would like to ask, please feel free to call or email me.

I will return your call or email as quickly as I can.



Dating Skills Group for Men

Dating Skills Group for Men

10-week skills group to build the relationship you want


Are you a man who…

Gets intimidated, or feels shy around attractive women
Is lonely, but doesn’t know how to get the love that you want
Can’t settle down or meet the ‘one’
Stuck in the ‘friend’ zone
Has given up on Internet dating


You will you learn to

Overcome shyness, and nervousness in dating situations
Build fulfilling relationships
Start conversations with women
Confidently ask for dates
Develop Internet dating success


Location & Time

10 Thursdays starting June 6th from 5:30 to 7
(No group on 5 July)
North Berkeley (call for address)


$50 per person per meeting
$450 up-front ($50 savings)


510-788-0005 for an interview


Click here to download a flier


I am therapist, but not like the ones on TV

Reading Dr. Paul H. Ting’s blog post about the differences between Anesthesiologists in reality and the ones portrayed on television, made me think about the similar problems that this creates for therapists.

In my practice, when I see adolescents for teen therapy or couples for couples counseling, I have to explain that therapy isn’t like how it is dramatized on TV. I  am repeatedly confronted with patients in pain looking for solutions to their problems, who I must unfortunately tell there are no quick solutions. I feel TV has done a disservice to my patients. Popular culture paints psychotherapy in a somewhat Oracle of Delphi light where clinicians mysteriously offer solutions and advice. Patient come in expecting to be told to do something simple to solve their issues.

Anyone who has seen a Dr. Phil episode can attest to this. The appeal of this type of sage-like advice-giving is clear. It is a powerful idea to think that with very little effort one can consult with a psychotherapist, be given some piece of vital missing  information about how to live one’s life, and be ‘cured’.

Now, I think TV isn’t solely to blame here: psychology as a profession must take some responsibility too. The recent article by the New York Times about the branding problem of psychotherapy points out how out of desperation to make a living as a therapist many counselors are marketing themselves as coaches. Along with this rebranding comes promises of ‘quick fixes’. Statements like “overcome anxiety in three sessions” or “beat the blues guaranteed” are indeed alluring, but misleading. These coaches do not provide therapy, they provide advice. The problem is advice is easy to come by. Anyone with friends or family knows this. People are eager to offer solutions to the problems of others. So why pay a professional for advice if one can get it anywhere? Advice doesn’t reduce the suffering people feel, but the thought is that the advice from a professional would be superior.

This is partially true. Psychologists spend many years learning how to help others. They have expert knowledge about the most effective ways to improve one’s life, and can cite empirical evidence for this. However this is not the thing that make psychotherapy curative. As Jared DeFife, Ph.D puts it “[what makes therapy effective is] …two people sitting down and working together to explore and find effective ways of coping with mental anguish, troubled lives, broken relationships, and physical effects of emotional ailments.” In other words, it is the therapy relationship that is the curative element. Just as any relationship needs time to develop so does the clinical one.

Evidence has shown that the therapy relationship is the number one predictor of favorable treatment outcomes. This means reduced symptoms that are sustained over time.

I am a therapist, but not like the ones on TV. I take the time to build real relationships with my patients, and work with them to develop long-term solutions to their problems.

Enhanced by Zemanta