peer reviewedbeware the borderline tightrope.pdfBeware .docx

peer reviewed/beware the borderline tightrope.pdf
Beware the
Borderline Tightrope
Elizabeth Root, ACSW
Ithaca, NY
I narrate the story of how I was reduced from a fully employed,
capable mother to a person
alone and destitute following extensive hospitalization.
Interactions with treatment pro-
fessionals are recounted and analyzed to provide insight into
how relationship problems
between clients and therapists can shape the vulnerable client
into a “borderline person-
ality.” The detrimental consequences of institutionalization,
medication, and electroshock
therapy are described. Therapeutic posturing more conducive to
successful outcomes is rec-
ommended as an alternative to that of the traditional medical
model.
Keywords: psychotherapy; mental health system; electroshock
therapy; alterna-
tive therapy
S
ometimes people in psychotherapy develop an illness that is
worse than their origi-
nal condition, attributable to the very treatment that was

intended to help. The hor-
rors of medication and electroconvulsive therapy are obvious.
Less obvious are
the catastrophes that can occur in relationships between clients
and their therapists. All
these contributed to my own iatrogenic process in a mental
health system that landed me
in the unenviable diagnostic category of borderline personality
disorder,1 robbing me of 10
precious years, and altering my life in many negative ways.
With the intent of minimizing
risks that therapists face in relationships with vulnerable
clients, I tell my story and ana-
lyze the interactions within the treatment setting that so
diminished me. I suggest alter-
native therapeutic postures that promote growth rather than
regression.
PERSONAL ACCOUNT OF TREATMENT THAT HURT2
My story is an insider’s view of the pitfalls often encountered
when treating people who,
for various reasons, bear the invisible “wounds” of a childhood
that lacked adequate nur-
turing. While some such children are able to manage
relationships as adults, others are left
with a deeply felt sense of neediness. The latter become clients
most likely to develop
symptoms during the relationship-building stage of
psychotherapy that make them ex-
tremely challenging and difficult. An ability to function well in
some domains may belie
that latent weakness, which remains hidden until exposed to
what is deemed a potentially
caring, nurturing relationship. Such exposure can trigger a

staggering degree of instability
and regression. The typical therapeutic relationship, intimate
yet with inherent limits, is
a setup for excruciating pain on the part of the client and for
difficult boundary issues on
the part of the therapist. Therapists’ attempts to undo the
development of boundary diffi-
culties can be disastrous. What results is the notorious love/hate
attitude of the client to-
ward the therapist. Therefore, therapists should assess for the
risk of regression and the
Ethical Human Psychology and Psychiatry, Volume 7, Number
2, Summer 2005
© 2005 Springer Publishing Company 143
05_EHPP_7(2)_Root.qxd 7/28/05 9:45 AM Page 143
development of “borderline” symptoms. Telltale signs might
include a history of unstable
relationships and crises and self-report of an unfulfilled
childhood. Yet the client might
have very good coping skills and seem to function quite well. It
is paramount that this re-
markable adjustment be maintained while assisting the person to
achieve a more satisfying
life. An evaluator unprepared to handle the risk of regression
should refer to a therapist
qualified to safely treat this vulnerable client.
MY STORY
Decades ago I began the arduous road back from my dark

journey through more than 10
years of mental health institutionalization3 followed by another
10 before I could declare
myself fully recuperated—not from the trauma that supposedly
caused “borderline” symp-
toms, but from the effects of the mental health system that
dispossessed me in the course
of treatment.
I led a checkered life until events in midlife tipped the balance
of my tightrope walk. A
rather Victorian upbringing stifled autonomy and emotional
spontaneity, but offered me
certain privileges. My intelligent father’s endless curiosity took
me to some wonderful
places of learning about the world of nature and the arts.
Fortunately, I absorbed some of
his strengths, which kept my spirit alive through the trials of
later years. I was well edu-
cated and my long-term marriage to an ambitious, highly
respected scientist and academi-
cian afforded me further opportunities to learn and grow. My
balanced trek through those
years was interspersed with tumbles into perplexing emotional
difficulties not well toler-
ated by my intellectually oriented husband. The relationship
collapsed under the strain of
these falls and the events I will mention in the following
narrative.
On a June day in the 1970s, I was plucked from my job during
my lunch hour by a coun-
selor who said the director of a local mental health agency
wanted to talk with me. She
drove me to the clinic where this psychiatrist I’d never met
before simply confronted me

in a waiting room full of people and declared that I was being
committed to a state hospital.
In a voice audible to everyone in the room, he stated he was
sure I would kill myself if this
action were not taken. A uniformed officer stood in the doorway
obstructing my path to
freedom. I knew I was in no danger of killing myself, but
realized I had been playing
brinkmanship with the counselor by repeatedly hinting at
suicide as a cry for help. At the
same time, I had a good job and was performing it well. I also
had a home and a son to
whom I had bid good-bye that morning with no inkling that
never again would I return to
that home nor to any semblance of the life I once lived and
loved. During the previous sev-
eral years I had experienced the death of two immediate family
members and the prema-
ture departure from home of a teenage daughter, followed by
separation from my husband.
Through a number of short-term hospitalizations during this
period, I was indeed walking
a borderline tightrope between being self-sufficient and giving
in to a system upon which
I was becoming more and more dependent.
That June day was the defining moment when the mental health
establishment took
over my life. After 2 weeks in the state hospital, I was
transferred to a private hospital.
Upon admission, I endured about a week of grand mal seizures
precipitated by the Elavil
that was prescribed. None of the other medicines helped either.
By the end of about 6
months, “borderline” traits emerged full blown as the
relationship with my young psychi-

atric resident became more entangled and difficult. A power
struggle ensued with him
and staff whose attempts to prohibit self-abuse were perceived
by me as rewarding, caring
144 Root
gestures. I would diabolically “up the ante” the more they tried
to stop the behaviors. This
phenomenon was common among patients on the unit,
occasionally resulting in serious in-
juries. Two fellow patients I had befriended actually completed
suicide, one in the hospi-
tal and the other shortly after discharge.
I was discharged after a year of confinement. Alienated from
home and community and
stigmatized by “mental illness,” friends shunned me and my
family members’ lives went on
as though I had died. Soon I returned to the hospital on
condition that I submit to elec-
troconvulsive therapy (ECT). Eighteen ECT treatments and
mismanaged psychotherapy
with the same resident resulted in an involuntary admission to
still another state hospital
5 months later. I was released abruptly after 2 weeks in a state
of confusion. With my mem-
ory radically affected by ECT, I was not able to recognize
streets or landmarks to find my
apartment. Readmission to the private hospital that had become
my surrogate home was
refused due to my outrageous “borderline” behavior (that did,

admittedly, put my life at
risk).
I was stymied by an inability to find sustainable work and by
lack of a support network.
I excelled at a door-to-door fund-raising job, but it was too
grueling to continue long term.
I applied to social work graduate school and was rejected.
Finally, the “home” hospital took
me back for another tumultuous year. During this stay I
received legal papers with the dis-
tressing news that I had been divorced 9 months earlier, while
in the fog of ECT. I was not
thinking clearly, either, when our home was subsequently sold.
Despite intractable de-
pression, I was again discharged, but my dependence on the
hospital and its staff persisted
for several years and I had many shorter-term readmissions.
Therapy should enhance strengths, improve self-esteem, and
build self-reliance, but in
the course of my treatment, I lost those. Rebuilding a life
seemed to be an interminable
struggle against overwhelming inertia and despair. Yet I knew I
had it in me to emerge
from this nightmare. My determination deepened when my
psychiatric resident suggested
I was hopeless so why not place me in a permanent “residential
setting.” Little did he know
of my inner spirit that never entirely yielded to the tyrannical
system he represented. The
warm embrace of a 12-step fellowship supported me for a few
years. I eventually obtained
a “real” job and gained some respectability. These factored into
a successful second bid to
graduate school to earn the master of social work degree. I

worked at my first clinical po-
sition for some years before finally obtaining employment in my
hometown. There I re-
connected with family, made new friends, and eventually bought
my own home. Eleven
years had passed since my last hospital admission.
I knew I was fully in charge of my life again when I finally
stopped seeing my one-time
resident psychiatrist, whom I had followed through his various
professional positions. I
yielded so much power to him and other hospital staff that
terminations once seemed un-
thinkable. But during the long, slow process of restoring a
healthy sense of self and my
place in community, those spurious relationships waned as
genuine ones replaced them.
Family and career regained precedence and I now live life to the
fullest, cherishing every
day as if to make up for lost time.
THE IATROGENESIS OF REGRESSION
For a long time, I saw this prolonged ordeal as of my own
making, since I fell willingly into
the institutional quagmire that replaced my real life. But
through my professional lens, I
perceive the undoing of my life as the result of unwitting
collusion between misguided
Treatment Hurts 145

mental health professionals and myself, a person vulnerable to
the misguidance that felt
like the caring I craved. Hence, the more enmeshed I became
with the treatment milieu,
the more “borderline” I acted. Hospital environments rife with
unequal power relation-
ships are anathema to people at risk of regression. My treatment
fanned a more benign
condition into the full-blown spectrum of “borderline.” That
encapsulates the iatrogenic
phenomenon. Treatment blunders affected me like replays of the
same emotional injuries
that made me a candidate for this very costly outcome.
Moreover, probing for forgotten
trauma, in the context of total immersion in the institution, was
disastrous. It is vital to
stay connected to the positive things in the present, and often
unnecessary to delve into
the past for causal factors. As the ties to my then present life
were being destroyed, my
therapists cast doubts on the value of my early life experiences
and my family of origin,
leaving me with virtually no anchor. Encouraging acceptance of
bygone errors, instead,
would have strengthened me. A critical segment of my healing
was the restoration of love
for my family, knowing they did their best and recognizing the
gifts they bestowed.
Much as I deplore the label, “borderline” is an apt description
of the road traveled by
those vulnerable to that condition. Clients can regress in the
outpatient setting as well as
in the hospital. An outstanding example was a young woman
who presented to our agency
one evening as a walk-in emergency. Initially, she appeared

fully in charge of herself and
functional. She had a good job, was well dressed and intelligent.
But when she entered my
office, she seemed to become a different person. She was in
crisis because her therapist had
shortened her sessions. Clearly, the therapist had not set
appropriate boundaries and was
now withdrawing her overindulgence in this client.
Traumatized, the young woman’s pain
was palpable and her rationality diminished to infantile
behavior. The transformation of
this woman’s persona reminded me of myself on that June day,
long ago, when I teetered
between the strong working mother and the helpless child who
craved the illusory caring
of professionals. She was walking my same borderline
tightrope, barely able to maintain her
balance and tempted to slip off into a fantasy world where her
therapist could fill up her
emptiness. This is the abyss that treatment providers must
understand in order to uphold
their professional imperative to do no harm.
BETTER ALTERNATIVES
Central to good care is a respectful, strength-based, egalitarian
approach that normalizes
instead of pathologizes the symptoms brought to the therapeutic
setting. The therapist
should focus on assets, and a collaborative rather than
hierarchical relationship between
client and therapist should be engendered to keep the therapist
out of an exalted position.
Such therapeutic posturing maintains dignity, minimizes
dependency, and encourages self-
determination on the part of the client. A level playing field

provides no latitude for power
struggles, the major pitfall of traditional medical model therapy
with the vulnerable client.
NOTES
1. Contrary to traditional medical model thinking, I believe
diagnoses are artificial. Everyone is
unique and cannot be placed in a “box.” I believe in the
psychosocial etiology of conditions that
bring people to treatment and that people at risk of being
labeled “borderline” arrive encumbered by
a variety of early life events that were experienced as trauma.
However, while this may be necessary,
146 Root
it is not always sufficient to cause the “borderline personality.”
I propose that often treatment itself
becomes the stressor that exacerbates the condition to a full-
blown “borderline” profile. The enclo-
sure of the word “borderline” by quotes throughout this paper is
mine, in contempt of the pejorative
innuendo typically denoted by the term.
2. In relating my experience, I do not suggest that the same
factors apply to all persons who have
been labeled “borderline.” We represent a disparate group. But I
do believe many share similar dy-
namics to those I experienced in my interactions with treatment
professionals.

3. My use of this word refers to the mindset caused by extensive
hospitalization and complete im-
mersion in the mental health system to the exclusion of a real
life.
Offprints. Requests for offprints should be directed to Elizabeth
Root, ACSW, 121 Hawthorn Place,
Ithaca, NY 14850. E-mail: [email protected]
Treatment Hurts 147
peer reviewed/e1.gif
peer reviewed/Journal of Health Politics, Policy and Law-1980-
Shwed-193-8.pdf
Guest Editorial
Social Policy and the Rights of the
Mentally Ill: Time for Re-examination
Harvey Shwed, Psychiatric Institute, Saint Michaels Medical
Center
Mental health experts and concerned citizens have been
frustrated in
their attempts to institute reforms in archaic systems of caring
for the
mentally ill. Hard to dislodge myths and stereotypes about

mental illness,
creaky bureaucracies, penurious legislatures, and an elusive,
commonly
accepted definition of mental illness, have conspired to
sabotage reform
attempts. Ironically, although the last decade has witnessed
sweeping
changes in mental health laws and regulations, it also has seen
hardship,
anguish and, at times, chaos for the mentally ill because of
these same
reform efforts. l
What has contributed to this seeming paradox, in which
ostensibly
far-reaching reforms often become “anti-therapeutic” when they
are
instituted?2
Clinically untutored mental health advocates
An avante-garde of young mental health advocates, trained in
law and
untutored in the realities of mental illness and emergency
psychiatric
treatment, has pressed for the passage of laws and regulations
that are
clinically naive and often too unwieldy to have practical
application.
A backdrop of civil rights and anti-war sentiment in the 196Os,
accom-
panied by a consumer “consciousness raising” ethos in the
197Os, has
created a climate ripe for the emergence of the mental health
advocate

movement.
Mental health advocacy has provided a natural niche for
socially-
minded young lawyers who have rejected traditional legal career
tracks.
The vagaries of the job market for law school graduates have
given addi-
tional impetus to this new brand of legal ombudsmanship.
However, the
Journal of Health Politics, Policy and Law, Vol. 5, no. 2,
Summer 1980. [email protected] 1980
by the Dept. of Health Administration, Duke University.
1 9 3
Journal of Health Politics, Policy and Law
Published by Duke University Press
194 Journal of Health Politics, Policy and Law
reformist zeal of this group is often in conflict with the clinical
realities of
psychiatric practice. Acute psychiatric emergencies with
suicidal, homi-
cidal or agitated psychotic potential require rapid medical-
psychiatric as-
sessment, treatment and disposition. Cumbersome regulations
protecting
the civil liberties of such acutely ill patients paralyze or
significantly
impede appropriate, swift treatment.

Although such civil libertarian safeguards may seem thoughtful
and
reasonable in the context of a law or medical school seminar,
they become
obstructive to “front line” mental health professionals working
in a busy
hospital emergency room setting with an acutely disturbed
patient and his
distraught family.
Ideological conflicts between law and psychiatry
A basic philosophic clash between law and psychiatry as to how
each
views human behavior helps to explain why these professions
are often at
odds. Essentially, our legal system must view man as a rational
organism
capable of evolving and abiding by logically conceived laws
and codes of
behavior. To do otherwise would introduce chaos into our
framework of
laws and justice. The revolutionary contribution of
psychodynamically
oriented psychiatry to the understanding of human behavior was
the
conceptualization and description of an unconscious level of
human func-
tioning, which is frequently illogical and almost totally isolated
from con-
scious awareness.
The unwitting left turn made by the driver of an automobile,
when his
destination consciously dictated a,right turn, and the inadvertent

“slip” of
the tongue may serve as clues to undercurrents of
psychologically “truer”
feelings. The driver of the car, in making a “wrong” turn, may
be express-
ing a wish to avoid what lies at the end of his trip. More than
we would
like to admit or accept, our behavior is molded and energized by
this layer
of the human mind.
Therefore, the patient in the throes of a depression, (which by
clinical
definition renders the individual’s outlook on the world as
“hopeless”), is
unable to make a rational decision about a projected treatment
plan. His
illness precludes him from seeing “light at the end of the
tunnel”-indeed,
so black is his mood, that suicide for him at this time may be
secretly held
to be his only “realistic” alternative. However, a court of law
may view
him as rational, albeit depressed, with cognitive functions
intact, and
capable, therefore, of accepting or rejecting a treatment plan.3
Criminal justice system issues
When grafted onto systems for the care and treatment of the
mentally
ill, libertarian concepts such as “due process”, and “least
restrictive

Shwed ?? Guest Editorial ?? Social Policy 195
environment, ’ ’ accompanied by increasing adversary muscle,
are at best
ill-fitting, and at worst, produce chaos for the mental health
professional.
Apprising a patient of his “rights” when he is delusional and
hallucinating,
is an act of bureaucratic madness when he lacks the capacity to
compre-
hend what is being read to him.
A mentally competent individual should have the right to refuse
treat-
ment, even when such action may be deleterious to his health,
but thera-
peutic mayhem results when we try to apply such concepts to
severely
disturbed patients whose illnesses preclude a rational decision
regarding
treatment. Neither the paranoid schizophrenic who feels that the
world
and its inhabitants are “out to kill him,” and who views the
ministrations
of physicians and nurses as harmful, nor the clinically
depressed indi-
vidual who, by textbook definition, feels helpless and hopeless
with over-
whelming guilt and unworthy of treatment, can participate
rationally in his
own treatment. The manic individual, who spends his day
“wheeling and

dealing, ’ ’ impulsively making inappropriate purchases,
reducing his life
savings on ill-conceived business ventures to the detriment and
despair of
his family, may grandiosely refuse treatment and have little or
no insight
into the fact that he is ill. By legal definition, however, many
such patients
would be judged “competent”.
Those who suffer from severe mental illness are chained and
imprisoned
by the ravages of their disease: they need to be freed. Yet
straight-faced
lawyers argue, civil libertarians lend support, judges rule, and a
charade
gets played out every day across the land in the name of patient
constitu-
tional rights. A civil libertarian mantle suited for those accused
of having
committed crimes, fits awkwardly when draped over the
country’s mental
health system.
M e d i c i n e b y fmt
Legislation which aspires to guarantee basic standards of
psychiatric
treatment and create a “cookbook” approach to the treatment of
the
mentally ill, creates procrustean beds that thwart the flexibility
inherent in
sound, mature and responsible medical judgment. Such rigid
laws place
the practitioner in an untenable legal and medical Pandora’s
box-he is

damned if he flaunts the rules in order to exercise his
medical/psychiatric
judgment, and clinically damned if he “plays it strictly by the
book.”
The legal system as the quintessential “rescue fantasy”
In psychoanalytic argot, a “rescue fantasy” is an extraordinary
desire to correct some existing injustice to make up for
“wrongs’
wish or
’ rained
upon the fantasizer or his family when he was a child. It is the
zealous and
intense personalization of the intended crusade, excluding from
psychic
view all other issues, that makes the “rescue fantasy”
potentially dan-
gerous for both the fantasizer and society.
Unquestionably, new laws and fresh interpretations of old ones
have
effected major revisions in the way man treats and relates to his
fellow
man. The author is no expert in jurisprudence, but common
sense dictates

that all human problems cannot be solved by acts of Congress.
Would that
we could “outlaw” cancer, heart disease or mental illness.
Unfortunately,
much of the sum and substance of recent mental health
legislation
operates on such an assumption. Its naivete dooms it to ultimate
failure
but havoc and pain to individuals and their families will
continue to be the
unfortunate by-product until the pendulum returns to a more
midline
position.
I share the frustration of those who have toiled arduously in the
cause
of improving the mental health delivery system only to come up
against
intransigent executive, administrative and legislative obstacles.
But a
strategy and approach which results in additional rather than
diminished
psychological pain makes no sense at all.
When “right to treatment” laws result in freeing additional
funds to
upgrade existing facilities (e.g., hiring additional staff), then
the mental
health advocacy system can point with pride to its “finest hour.”
However, too often I fear such laws result in compulsory
discharge of a
sick “nondangerous” patient from a public institution, where he
was
receiving some level of care, to a community that offers less or
even no
treatment .4 To some individuals, transferring senile, ‘

‘nonmentally ill”
older adults from inadequate psychiatric facilities to equally
inadequate
nursing homes may be viewed as God’s work. However, it is
perceived as
a cruel hoax by the patient, his family and the mental health
professionals
who have worked with him.
A fiscally harassed government and a Proposition 13-minded
public are
not likely to free funds because right-to-treatment legislation
has been
passed, any more than they were responsive to the pleadings for
such
upgrading requests over the past three decades.
We have a penchant for creating systems which, from the outset,
are
inadequate to tackle the assigned task. We then seem to take a
certain
sadistic pleasure in criticizing the agency at some later date for
failing to
reach the goal it never had the tools to achieve. This is like
entering a
legless frog in a leaping contest, and then berating it for coming
in last.
Consumer mistrust
In an age of consumerism, trusted professional groups have
come under

Shwed ?? Guest Editorial ?? Social Policy 197
suspicion. This increasing distrust has contributed to the
climate for legis-
lation placing the actions of professionals under surveillance,
replete with
rigid auditing procedures, and requirements to document and
justify stan-
dards of practice. So deep is the mistrust of professionals
among certain
segments of society that, until now, traditional mechanisms for
monitoring
standards of practice have been viewed with suspicion. Thus,
involuntary
commitment statutes are suspected as opportunities for
unscrupulous
physicians, in conspiracy with families, to “railroad and
incarcerate psy-
chologically intact persons. “5 As one state official phrased it,
allowing
professional societies to regulate the ethics and practices of
their members
is like putting the “foxes in charge of the chicken coop.”
Politics, myths, and superstitious behavior
Although we take pride in a sense of sophistication, technology
and
scientific acumen, we are not so terribly far removed from our
caveman
ancestors with regard to fears and anxieties. This “human
condition”
affects our daily interactions with fellow human beings, as well

as our
attitudes towards illness and its treatment.
With the possible exception of the current controversy
concerning the
use of laetrile as an anti-cancer agent, no other medical
treatment modali-
ties have been as politicized as those used by psychiatrists.
Since its
introduction by Italian psychiatrists in the mid-1930s
electroshock treat-
ment has been regarded by conservative, well-trained
psychiatrists as a
reasonably safe treatment for depression and other psychiatric
illnesses.
Although it is certainly not a cure-all, and is shrouded in
mystery, it has
regrettably been associated in the public mind with “snake pit”
horrors,
mind control, and alleged nefarious use by psychiatrists for
political re-
pression in authoritarian countries. It also conjures up images of
Frankensteinian proportion, not to mention the final
punishment, “the
electric chair.“6 Because of these issues, rather than solid
medical facts,
this particular form of psychiatric treatment has been subjected
to harsh,
rigid regulations which have essentially discouraged and
neutralized its
use in mental illness.’
Conclusion
In medicine, there is an aphorism that warns about cures which
ulti-

mately heap more woe on the patient than the disease for which
he seeks
help. Thus, those who seek to redress ills in our mental health
delivery
systems, would do well to re-examine the new laws which may
add to the
burdens of the mentally ill, handcuff mental health
professionals in effect-
ing treatment, or prove too rigid to have any practical value!
The time has come for a dispassionate reassessment of reform
regula-
tions and laws to see which ones make sense and which do not,
which ones
result in meaningful change, and which among them we should
scrap. The
pendulum has swung too far, and we should not passively wait
for the laws
of nature to send it on its return journey.
Notes
1, S. Rachlin, “With Liberty and Psychosis for All,“Psychiatry
Quarterly 48 (1974): 410-20;
S. Rachlin, A. Pam, and J. Milton, “Civil Liberties versus
Involuntary Hospitalization,”
American Journal of Psychiatry 132 (1975): 189-92; D. A.
Treffert, Dying with Your

Rights On. Presented at the 127th Annual Meeting of the
American Psychiatric Associa-
tion, Detroit, Michigan (May &lo, 1974); H. J. Shwed,
“Protecting the Rights of the
Mentally Ill, ’ ’ American Bar Association Journal 64 (April
1978): 564-67; Wyatt v.
Stickney, 344 F.Supp. 373 and 387 (M.D. Ala. 1972), affd. sub.
nom. Wyatt v. Aderholt,
303 F.2d 1305 (5th Circuit 1974).
2. V. Bradley and G. Clarke, eds., Paper Victories and Hard
Realities: The Implementation
of the Legal and Constitutional Rights of the Mentally Disabled
(Washington, D.C., The
Health Policy Center, Georgetown University, 1976).
3. “Position Statement on Involuntary Hospitalization of the
Mentally Ill,” American
Journal of Psychiatry 130 (1973): 392.
4. A. Becker and H. C. Schulberg, “Phasing Out State
Hospitals-A Psychiatric Dilemma,”
New England Journal of Medicine 294 (1976): 255-61; A.
Etzioni, “No Place to Go,” The
Washington Monthly 8 (1976): 42-48; K. McManus and J.
Horowitz, “Cruel and Unusual
Punishment,” New West 3 (1978): 39-48.
5. “Improper Commitments Lead to Malpractice Claims,”
Psychiatric News 11 (1976): 14.
6. J. Friedberg, Shock Treatment is Not Good for Your Brain
(San Francisco, Glide Publi-
cations, 1976).
7. “ECT Law Declared Unconstitutional,” Psychiatry News 11
(1976): 1.

8. H. J. Shwed, “Political Assertiveness is Psychiatry’s Order of
the Day,” Legal Aspects
of Medical Practice 6 (1978): 61-63.
peer reviewed/latino and elextroconvulsive therapy.pdf
Latinos and Electroconvulsive Therapy:
Implications for Treatment, Research,
and Reform in Texas and Beyond
Ken Major, MS
Our Lady of the Lake University
San Antonio, TX
No literature exists concerning the implications of using
electroconvulsive therapy (ECT)
in the treatment of Latinos. Given the large and increasing
Latino population in the
United States, the contentious history of ECT, and the possible
differences in language
and cultural vantage point between the typical ECT provider
and Latino client, this
paucity of research is worrisome. This article identifies a
number of potential problems in-
volved in multiculturally untrained service providers treating
Latinos with ECT, including
invalid diagnoses, an incomplete knowledge of the strengths and

resiliencies of the client,
and the use of ECT rather than culturally appropriate
interventions. Also discussed are
Latino cultural beliefs and practices salient to mental health
service providers, some of the
recent mandates for multiculturally informed service provision
in mental health, ideas for
the constructive modification of the diagnostic and treatment
protocols currently guiding
the use of ECT with Latinos, and needed research relevant to
the issues raised.
Keywords: electroconvulsive therapy; Latinos; cultural beliefs;
Texas; electro-
shock therapy
E
lectroconvulsive therapy (ECT, also known as electroshock
therapy) has generated
an enormous amount of controversy as a psychiatric
intervention. Throughout its 60
years of use, courts have routinely enacted guidelines for its use
(Finch, Sobin, Car-
mondy, DeWitt, & Shiwach, 1999) and the psychiatric and
psychological communities
have sustained a wide-ranging discourse on ECT’s efficacy,
mode of action, adverse effects,
and ethical underpinnings. While more than 5,000 articles have
been written on ECT
since its inception (Medline) and data are available regarding
the ethnic breakdown of
treatment in a handful of states (Reid, Keller, Leatherman, &
Mason, 1998), not a single
study (to the knowledge of this author) has explicitly attended
to the issues involved in the

treatment of Latinos with ECT (searches done in 2005 on
Medline, PsycINFO, PsychAr-
ticles, and Academic Search Premier refining search results for
“electroconvulsive ther-
apy” with “Latino,” “Hispanic” and their plurals). While this
could be the corollary of a
marked trend in the field of ECT research across all
demographics to focus on the treat-
ment itself rather than the person receiving it, it is alarming that
such a controversial treat-
ment should for any reason at this point in the development of
multicultural research,
ethics, and awareness go on essentially unchecked in this
domain.
While recent meta-analytic studies continue to advance the
position that ECT is safe
and effective (U.K. ECT Review Group, 2003), the constructs
which define efficacy re-
main imbedded in biological, reductionist views: “Success”
often depends on continued
2, Summer 2005
© 2005 Springer Publishing Company 159
07_EHPP_7(2)_Major.qxd 7/28/05 9:46 AM Page 159
maintenance ECT (Bourgon & Kellner, 2000), scientific
comparisons with psychotherapy
are rare, the client’s subjective and/or qualitative view of the
experience is even rarer, and
a multiculturally informed focus on the contexts, consequences,

and ethicality of the treat-
ment is absent. Thus, while the professions of care continue to
debate the basic practice of
ECT (with many, including this author, of the opinion that
“modern” ECT remains a prac-
tice deeply imbedded in problematic sociopolitical processes), I
contend that within such
contexts it should be beyond debate that the use of ECT with
any person of a group that is cul-
turally and linguistically distinct from the populations portrayed
by mainstream, pathology-
oriented models of human problems is neither ethical nor
scientific.
ECT USE IN TEXAS
It is important to first note that ECT is not being
disproportionately prescribed to Latinos
in Texas. Two archival studies done within the last 7 years
utilized the data generated by
the Texas law which requires that “all nonfederal clinical
facilities providing electrocon-
vulsive therapy (ECT) report every treatment to the state’s
mental health agency” (Reid
et al., 1998, p. 8). The results from both studies indicate an
underrepresentation of Lati-
nos in the treatment group. Reid and colleagues found between
1993 and 1995 ECT was
administered 15,240 times to 2,583 individuals. Only 201 (or
7.8%) were identified as
“Hispanic,” while the same group is reported in the study to
comprise 25.5% of the general
population of Texas (based on 1990 census figures). Whites
comprised 88.1% (2,267 indi-
viduals) of the treatment group, while making up 60.6% of the
population. Reid and

colleagues reported that these data dispute previous suggestions
that ECT is dispropor-
tionately applied to minority patients, and furthermore suggest
that Black and Hispanic
populations do not have adequate access to ECT as a treatment
option. Scarano and Felt-
hous (2000) reported similar findings with an even larger
amount of data. The authors
drew from 16 quarterly reports from 1993 to 1997 which
included 41,660 ECT treatments
in 5,971 patients. Scarano and colleagues found that Whites
received 87.3% of ECT
treatments, and noted that “assuming that the remaining ethnic
groups suffer from mental
illness amendable to ECT treatment, it appears that they were
underserved in this regard”
(p. 1200). While I do not challenge that ECT is proportionately
overused, I do assert that
demographic information and a purely biological perspective of
the person being treated
provide only the most superficial perspectives on ECT; there are
many other factors for
the multiculturally trained practitioner to consider when treating
an ethnically diverse
population.
LATINO CONSIDERATIONS WITHIN
THE LANDSCAPE OF ECT TREATMENT
Problematic Differences
Demographics and Language Fluency of Patients and
Practitioners. According to the
most recent U.S. Census Bureau data (2004), Latinos of all
cultural heritages numbered
39.9 million by July of 2003. This is roughly 13% of all

Americans. Data from the 2000
census show that in Texas, nearly 7 million (or 33%) of the
state’s 21 million inhabitants
are Latino (U.S. Census Bureau, 2000). This is a large (and
increasing) population in our
160 Major
country with very specific attributes and beliefs according to
particular ethnic backgrounds.
Yet the professions of psychology and psychiatry are hardly
meeting the challenges posed by
this growing population. According to a supplemental report put
out by the Office of the
Surgeon General via the Substance Abuse and Mental Health
Services (2001), data col-
lected throughout the 1990s indicated that less than half of all
Latinos did not speak Eng-
lish well or at all. Importantly, there is a great disparity
between the ratios of mental health
professionals for Latinos and Whites, 29 per 100,000 and 173
per 100,000, respectively. Fur-
thermore, less than 1% of licensed psychologists who identify
themselves as Hispanic are
members of the American Psychological Association. Other data
suggest higher rates of
Latinos in psychiatry, but with numbers still far from
representing the population as a whole.
Alarcon (1999) noted that depending on the method of
identification, Hispanic American
Psychiatric Association members number between 2,000 and
3,000.

Lack of Multicultural Training. While the above figures provide
a representation of
those individuals who may have a greater knowledge of cultural
and linguistic issues spe-
cific to Latinos, no figures are available that report the Spanish-
speaking fluency of psy-
chologists or psychiatrists, or measures of expertise in the
treatment of Latino mental
health issues (with dramatic differences depending on culture of
origin [Cuban, Puerto
Rican, South American, Mexican] migration, and other issues)
in particular. This dearth
of multicultural competency standards is complemented by
ECT’s own lack of standard-
ization or licensing process. Currently even a minimal standard
for education in ECT does
not exist. As Fink (1999) makes clear, due to the paucity of
training programs available in
postgraduate psychiatric residency ECT training is almost
exclusively done in “continuing-
medical-education programs” (p. 102). And as a consequence of
the abbreviated nature of
these courses, “practitioners are left to develop their experience
while treating their first
patients” (p. 103). When viewed in conjunction, such an utter
lack of standards is tremen-
dously concerning.
Implications of Language-Mismatch. Preciado and Henry (1997)
posit a number of
dangers associated with the provision of health services by
monolingual English practi-
tioners to monolingual Spanish or limited English-speaking
Latino patients. The most
basic information covered in an intake session, from current

complaints to health history,
may be invalid if the monolingual Spanish patient is unable to
give clear descriptions. It is
problematic to make diagnoses and treatment plans, including
the recommendations made
to the patient, under conditions of misinterpretation and poor
understanding. While that
article speaks specifically about a medical interview, a
psychiatric or psychological con-
text, arguably more culturally, personally, and linguistically
nuanced, could be understood
as even more problematic a venue for such barriers to present
themselves. Cuellar and
Arnold (1988) suggest that individuals are able to express their
emotions with greater clar-
ity and comfort in their native language, and Flaskerud and Hu
(1992) claim that inter-
views (whether psychiatric or psychological) done with
monolingual Spanish patients but
conducted in English often bias the diagnosis given.
Culture-Specific Disorders. Behavioral issues particular to the
Mexican-American and
Latino populations predominant in Texas include mal de ojo
(evil eye), ataque de nervios
(nervous attack) (Santiago-Rivera, Arredondo, & Gallardo-
Cooper, 2001), and susto (a
prolonged state of fright) (Cuellar & Gonzalez, 2000). The
authors above as well as others
Latinos and ECT 161

(Falicov, 1998) describe symptoms expressed in relation to
ataque de nervios (including
uncontrollable emotional outbursts, crying, dissociations, as
well as aggressive behaviors)
that without cultural context could easily lead a North
American-trained, English-
speaking-only mental health practitioner to an improper
diagnosis and culturally inappro-
priate treatment.
Culture-Specific Values. One of the most common themes in
Latino identity is that of
familismo, “a preference for maintaining a close connection to
family” (Santiago-Rivera et
al., 2001, p. 42). North American mental health theory and
practice has often miscon-
strued this value, interpreting family interdependence as
codependence or enmeshment.
Respeto is yet another feature common in Latino populations
that may have implications
for ECT treatment and the field of mental health in general.
Respeto entails “deference to
authority or a more hierarchal relationship orientation”
(Santiago-Rivera et al., 2001, p.
46). With a procedure as arguably serious as ECT treatment, an
examination of the role of
respeto and familismo (in addition to the concerns of language
and idiomatic pathologies
explained previously) in the agreement to treatment and the
informed consent process
seems necessary.
Possibility for the Enactment of Oppression. Oppression can be
understood as acts
that knowingly or unknowingly hinder or harm a person or
group’s ability to be self-

determining (Freire, 1970, in Utsey, Bolden, & Brown, 2001).
New trends in ECT research
that include qualitative and/or client-centered approaches, while
not explicitly examining
the issue of culture, suggest the possibility that minority clients
could experience ECT
treatment as a form of oppression. A foundational study done in
the United Kingdom by
Johnstone (1999) explored the experiences of a 20 individuals
who self-reported as having
found ECT upsetting. Johnstone’s research posited a variety of
themes shared by her par-
ticipants, including “feelings of fear, shame and humiliation,
worthlessness and helpless-
ness, and a sense of having been abused and assaulted” (p. 69).
In summary, Johnstone
advanced:
Powerlessness, control and conformity were themes that
constantly recurred in the partic-
ipants’ responses. They came for help feeling confused, helpless
and desperate. The help
they were offered was experienced as a further loss of power
and control which left them
even less able to protest and assert themselves than before.
None of them had felt able to
convey the strength of their feelings about ECT to mental health
professionals, implying
a possible hidden pool of distress that is unlikely to be picked
up by hospital-based surveys.
(p. 74)
While these findings cannot be generalized onto the population
of ECT patients as a
whole, or Latinos in particular, when viewed in conjunction
with the lack of multicultural

concern evident in the ECT literature questions about the
possible negative subjective ef-
fects of ECT on Latinos are legitimate.
At the very least, the issue of Latino perceptions of mental
health services should be
considered in relation to ECT. As Echeverry (1997) elucidates,
the belief is held within
some Latino communities that mental or emotional problems are
“a sign of weakness, lack
of strength or character, bad luck, the result of a spell or similar
supernatural event, or sim-
ply God’s will” (p. 99). It is not unreasonable to imagine that
ECT treatment might carry
162 Major
an even more negative connotation for the individual and their
familial and community
contexts than traditional psychiatric or psychological services.
Promising Alternatives
A tremendous number of practitioners, scholars, and researchers
have already laid the
foundation for a multicultural knowledge base that can inform
the constructive evaluation
and augmentation of the diagnostic and treatment protocols
currently guiding the use of
ECT with Latinos, provide potential alternatives to ECT
treatment, and guide quantita-
tive and qualitative inquiries into this subject.

Multicultural Training and Standards. The American
Psychological Association’s
“Guidelines on Multicultural Education, Training, Research,
Practice, and Organizational
Change for Psychologists” (2003), the Department of Health
and Human Services’ “Men-
tal Health: Culture, Race, Ethnicity,” (2001), and the National
Association of State Men-
tal Health Program Directors’ (NASMHPD) “Position Statement
on Culturally
Competent and Linguistically Appropriate Mental Health
Services” (2000) represent re-
cent core contributions to the field of mental health that have
dramatically expanded the
multicultural resources, knowledge bases, and ethical mandates
available to and guiding
practitioners, scholars, and researchers. The essential aim of
integrating this knowledge
into the existing corpus of paradigms in the treatment of human
emotional and relational
problems is to encourage a shift “from a culturally encapsulated
framework toward one that
embraces a multiculturally relevant framework” (Neville,
Worthington, & Spanierman,
2001). The goals attendant to this shift include but are not
limited to making multicultural
knowledge and skills a component of all phases of education
and licensure for mental
health professionals, the establishment of certification processes
for the provision of bilin-
gual mental health services, the hiring of linguistically capable
professionals in treatment
settings that serve diverse clientele, and the provision of
services and informed consent in
the preferred language of the consumer.

More Inclusive Approaches. Falicov (1998) elucidates a
multicultural, ecosystemic,
comparative approach (MECA) that provides a framework for
mental health clinicians in
relating to diverse clientele. This framework, which attends to
issues of language, belief
systems, family practices, migration history, and the friction
generated when those salient
aspects of identity encounter different and/or more powerful
cultural discourses, offers a
compelling and pragmatic complement to general multicultural
training. Such an ap-
proach is sensitive to and complements the inherent resiliencies
and ongoing practices
often sustaining Latino clientele. These resources are often
overlooked when considering
problems from purely intrapsychic or biological frameworks.
Santiago-Rivera and col-
leagues encourage practitioners “to view familismo and its
many dimensions as strengths
within families. For instance, the extended family, particularly
los compadres (the godpar-
ents), can be an important resource in providing needed support
during times of crisis” (p.
43). In a recent study following up on previous research on
linkages between ethnicity,
emotion, and schizophrenia, López, Nelson-Hipke, and Polo
(2004) found that Mexican
American families view their psychologically impaired family
members with more warmth
and less blame and criticism than the comparison Anglo group,
and that this warmth was
one of the most salient factors in protecting against the family
member’s relapse.

Latinos and ECT 163
In adhering to a professional standard of psychosocial treatment
as complement or al-
ternative to a biological viewpoint, it is also important to
include and encourage practices
of healing ongoing in the family, such as prayer, religious
service attendance, or consulta-
tion with a curandero or herbalista. As López (1997) suggests,
the integration of clients’
ideas of sickness and healing into the professional treatment
leads to greater cooperation
and improved treatment outcomes.
Better Research. The tremendous and increasing diversity of
this country’s ethnic
composition, along with ECT’s documented increase in use
(Thompson, Weiner, &
Myers, 1995) and troubling history (Breggin, 1979, 1986), make
a very strong case for the
emergence of multiculturally oriented empirical research
considering the relationship be-
tween the two. Studies comparing ECT to linguistically and
culturally appropriate psy-
chotherapy might provide data that expand operational
definitions of ECT’s efficacy and
help to examine the existing notions of the suitability (even
ethicality) of the treatment.
In response to the lack of multicultural training and standards of
care within the field, an-
other potentially helpful line of research might be to investigate
the diagnosis decision-

making processes and multicultural counseling competence of
ECT-prescribing
psychiatrists. Qualitative research exploring the personal
experiences of Latino and other
minority ECT patients and their loved ones would provide an
excellent complement to the
above research, offering a truly ecosystemic understanding of
the treatment.
CONCLUSION
As the U.S. Census Bureau (2000) has made unequivocally
clear, our country is changing.
Within 25 years, approximately 40% of adults and nearly half
the children in our country
will be from racial and ethnic minority groups; by 2050 a
quarter of the United States will
be Latino (U.S. Census Bureau, 2004). While I have chosen to
limit the explicit concerns
of this article to some of the myriad issues surrounding the use
of ECT with Latinos (pri-
marily Mexican Americans) in Texas, these concerns are
underscored by the larger prob-
lem that a gap of this magnitude could exist in the literature
about ECT at all. In spite of
the increasing popularity of ECT treatment and the proliferation
of claims of its safety and
effectiveness, much about the psychosocial implications of the
treatment within today’s
multicultural context remains unknown. This paper argues that
the corpus of ECT litera-
ture needs a more expansive, complex view of the treatment to
include the person, the
family, culture, and language.
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166 Major
peer reviewed/the electroshock forced on children and
involuntary adults.pdf
2, 2009
80 © 2009 Springer Publishing Company
DOI: 10.1891/1559-4343.11.2.80
Electroshock Forced on Children
and Involuntary Adults
Peter R. Breggin, MD
Ithaca, New York
I
n the United States involuntary adults continue to be

administered electroshock
treatment (ECT) despite strenuous legal efforts and publicity
generated by psychiatric
reformers (Oaks, 2009). In Australia psychiatrists have taken
shock treatment to a
new level of irrationality and abuse by administering ECT to
toddlers age 4 and younger
in Victoria (Hale, 2009).
The controversy over ECT for children has a long history. In
2000 before his untimely
death, Steve Baldwin, at the time a professor of psychology in
Australia, and his coauthor
Melissa Oxlad, wrote a book reviewing and condemning the
practice around the world.
The inspiration for electroshock treatment was found in a
slaughterhouse in Italy in
the 1930s. Before being killed, hogs were knocked out by a jolt
of electricity to the head
and brain. If they were not slaughtered, after a while the
animals awoke and were able
walk around on wobbly legs. Two Italian psychiatrists learned
about this phenomenon and
immediately tested electroshocks to the head of an involuntary
mental patient. The man
was not rendered unconscious by the fi rst application and
struggled from the table scream-
ing “Murder!” The doctors administered a more intensive dose,
producing a convulsion
and then unconsciousness. When he awoke, the previously
resentful and resistant man
was docile and no longer complained. Almost any form of
closed-head injury will produce
similar results.

Why were psychiatrists searching for new means to traumatize
the brain and to produce
convulsions? This was the era that originated lobotomy and
insulin coma as therapists for
institutionalized patients. It was believed that convulsions
might have an ameliorative
effect on mental disorders. But many doctors also thought that
the controlled infl iction
of brain damage was therapeutic. Until the 1950s, many
psychiatrists voiced the opinion
that brain damage was good for severely disturbed patients. It
certainly made the patients
more docile and hence easier to manage in giant state lockups.
Only in more recent times,
in response to criticism, did shock advocates begin to claim that
the treatment was harm-
less and corrected biochemical imbalances (history reviewed in
Breggin, 1979, and more
briefl y in Breggin, 2008).
Shock treatment damages the brain through a variety of
mechanisms. First, it causes
grand mal seizures that are much more intense and destructive
than those spontaneously
experienced by people with severe epilepsy. These multiple
seizures (typically three per
week for a few weeks or more) exhaust and damage neurons or
brain cells. Second, the elec-
tric current by itself damages the brain by disrupting electrical
function, overheating brain
tissue, stimulating massive hypertension inside the brain,
breaking down the blood brain
barrier, and causing tiny blood vessels to spasm shut, depriving
neurons of oxygen and nutri-
ents (reviewed in Breggin 1979, 1992, 1998, 2008). Commonly,

patients undergo several
Forced Electroshock 81
seconds after ECT in which their brain fl atlines—zero
detectable electrical activity—a sign
of permanent brain death when extended for minutes. Animal
studies have shown small
hemorrhages and cell death throughout the brain and in the
frontal lobes after exposure to
doses of ECT that are smaller than presently used in clinical
practice (e.g., Alpers, 1946;
Hartelius, 1952; studies reviewed in Breggin, 1979, 2008).
Recent human studies show that
former ECT patients suffer from persistent loss of mental
function and dementia (see Breg-
gin, 2008; Sackeim et al., 2007). Unfortunately, shock
advocates have proven impervious to
science and to public criticism alike and there has been no
abatement in the treatment.
I have not been alone in criticizing ECT as wholly ineffective
(Ross, 2006) and as danger-
ous. One heroic survivor of ECT and insulin coma, Leonard
Frank, spent decades reeducat-
ing himself and learning to live with long-term harmful effects,
devoting himself to reform
in psychiatry and to writing one of the best scientifi c critiques
of ECT (Frank, 1990).
For the fi rst time, doctors who recommend or carry out ECT
have been fi nding that
they are not immune to malpractice suits. In June 2005 in South
Carolina, I was the medi-

cal expert in the fi rst ever malpractice trial in which a jury
found a doctor negligent for
referring a patient for ECT (see breggin.com for details). Within
recent months, I was the
medical expert in a malpractice case that was settled for a very
large sum. It involved a
man who was demented by considerably more than 100
treatments over a 2-year period.
Meanwhile, ECT advocates themselves have published a long-
term follow-up of
patients treated with electroshock and found massive,
irreversible harm to a broad range
of mental functions including memory and learning (Sackeim et
al., 2007; reviewed in
Breggin, 2007). The overall condition of the patients with
persistent multiple cognitive
defi cits is consistent with a diagnosis of ECT-induced
dementia. How have advocates of
ECT responded to the latest confi rmation that their treatment
severely damages the brain
and mind? To my knowledge, not a single one has expressed any
caution following the
publication of the study, which has received no follow-up
attention in psychiatric journals
or newspapers. As we now see, advocates have been pressing
hard to enforce ECT on
children and involuntary adults.
Shock treatment has been going since 1938—more than 70
years. Let’s celebrate the
passing of its 70th anniversary by putting a stop to it, once and
for all. It is time for ethical
professionals to voice their concerns and to refuse to participate
in referring patients or
performing ECT.

REFERENCES
Alpers, B. (1946). The brain changes associated with electrical
shock treatment: A critical review.
Journal-Lancet, 66, 363–369.
Baldwin, S., & Oxlad, M. (2000). Electroshock for minors: A fi
fty-year review. West Port, CT: Green-
wood Press.
Breggin, P. (1979). Electroshock: Its brain-disabling effects.
New York: Springer Publishing.
Breggin, P. (1992). The return of ECT. Readings: A Journal of
Reviews and Commentary in Mental
Health, 3(1), 12–17.
Breggin, P. (1998). Electroshock: Scientifi c, ethical, and
political issues. International Journal of Risk &
Safety in Medicine, 11, 5– 40.
Breggin, P. (2007). ECT damages the brain: Disturbing news for
patients and shock doctors alike.
Ethical Human Psychology and Psychiatry, 9, 83–86.

82 Breggin
Breggin, P. (2008). Brain-disabling treatments in psychiatry:
Drugs, electroshock and the psychopharma-
ceutical complex. New York: Springer Publishing.
Frank, L. (1990). Electroshock: Death, brain damage, memory
loss, and brain washing. Journal of
Mind and Behavior, 11, 489–512.
Hale, E. (2009, January 25). Child shock therapy. Melbourne
Herald Sun.
Hartelius, H. (1952). Cerebral changes following electrically
induced convulsions. Acta Psychiatrica
Neurologica Scandinavica, 77(Suppl.), 1–128.
Oaks, D. (2009). Mindfreedom.
http://www.mindfreedom.org/ray
Ross, C. (2006). The sham ECT literature: Implications for
consent to ECT. Ethical Human Psychology
and Psychiatry, 8, 17–28.
Sackeim, H., Prudic, J., Fuller, R., Keilp, J., Lavori, P., &
Olfson, M. (2007). The cognitive effects of
electroconvulsive therapy in community settings.
Neuropsychopharmacology, 32, 244–254.
Correspondence regarding this article should be directed to
Peter R. Breggin, MD, 101 East State
Street, No. 112, Ithaca, NY 14850. E-mail: [email protected]

http://www.mindfreedom.org/ray
peer reviewed/the need to operationally define disease in
psychiatry and psychology.pdf
2, 2009
120 © 2009 Springer Publishing Company
DOI: 10.1891/1559-4343.11.2.120
The Need to Operationally
Defi ne “Disease” in Psychiatry
and Psychology
David B. Stein, PhD
Virginia State University
Petersburg, VA
Robert Foltz, PsyD
Chicago School of Professional Psychology,
Department of Clinical Psychology, Chicago
A universally accepted operational defi nition for the term
“disease” is not yet established
in contemporary psychiatry. In clinical psychology and
psychiatry, disease has been used
indiscriminately. The term disease has been invoked (even when
no systemic etiology or
pathology has existed) to describe addictions, a cluster of
bizarre symptoms, and to justify

crude medically based treatments (e.g., electroshock, lobotomy,
involuntary commitment,
medication prescription). More recently, sophisticated machines
such as CAT scans, PET
scans, and MRIs have been used for questionable research
conducted to try to identify
supposed diseases, to justify the overuse of psychotropic drugs.
Economic and industry
interests have superseded scientifi c concerns. To establish
scientifi c rigor in psychiatry and
clinical psychology research, an operational defi nition of
disease is proposed.
Keywords: mental disease; mental illness; psychiatric
diagnosis; mental disorders;
mental syndromes; mental symptoms
Everything should be made as simple as possible, but not more
so.
Albert Einstein
H
istorically, the disease concept has been used in psychiatry to
describe a wide range
of phenomena. The inception of the idea that abnormal behavior
was caused by
malfunctions of the body can be traced to the somatogenis
hypothesis proposed by
Hippocrates (460–357 b.c.e .). The fi rst modern disease
concept was promoted in the nine-
teenth century by the German physician, Griesinger (cited in
Davison & Neale, 1994).
Griesinger proposed that every mental condition had a specifi c
physiological etiology. This

was outright conjecture however, with no empirical support.
Kraepelin (1899) advanced
this early biomedical model with the publication of an extensive
diagnostic classifi cation
system. Kraepelin used the term syndrome to describe a cluster
of symptoms that regularly
occurred together. This implicated supposed underlying bodily
and physical causes (even
though no specifi c physical abnormalities had been clearly
identifi ed). Kraepelin (1898)
The Need to Defi ne Disease 121
had previously integrated two different ideas. The fi rst idea
was from existing knowledge
about syphilis. In 1815, the medical establishment had already
designated syphilis as a
disease and labeled it general paresis. The second idea was
borrowed from Pasteur, who
in the 1860s and 1870s had promoted the germ theory of
disease. Kraepelin (1898) also
described a syndrome with symptoms similar to the late stages
of general paresis, which
consisted of delusions, bizarre behaviors, and hallucinations. He
suggested these symptoms
should be labeled dementia praecox, thus attempting to integrate
general paresis and the
new germ theory. Kraft-Ebing (as cited in Davison & Neale,
1994) later showed that
paretic patients injected with syphilitic matter did not
subsequently develop syphilis. He
concluded (incorrectly) that these patients previously had
syphilis. Despite the lack of
support for Kraepelin’s disease theory, it was subsequently

widely accepted into the twen-
tieth century era of psychiatry.
Kraepelin’s diagnostic system dominated psychiatry until 1980.
The Diagnostic and Sta-
tistical Manual of Mental Disorders (American Psychological
Association [APA], 1957),
and the DSM–II (APA, 1968) were subsequently developed by
physicians, psychiatrists,
and other members of the American Psychiatric Association.
The DSM and DSM–II were
founded on disease-type formulations about psychosocial and
mental health disorders. The
origins of the DSM can readily be traced directly back to
Kraepelin’s diagnostic system
and associated beliefs about disease states. The biopsychiatric
aspects of the DSM however
created many critics, including Szasz (1961), Laing (1969),
Glasser (1965), and Bateson,
Jackson, Haley, and Weakland (1959). All these critics noted
the major absence of empiri-
cal support for the disease theories. Actually the absence of
conclusive data for either side
left the argument unresolved.
A second disease movement can be traced to alcohol and drug
abuse–addiction litera-
ture. In the 1940s, a group of Yale psychiatrists formed the
National Council on Alcohol-
ism (NCA) to “convince Americans that alcoholism is a disease
and the alcoholic is a sick
person who needs help and treatment” (Peele, 1989, p. 45).
Again, empirical support was
lacking. This was actually more of a public relations campaign
under the guise of science
and medicine, which seems to have succeeded, since 90% of

Americans now believe it
(Peele, 1989). Jellinek (1960) had borrowed the disease concept
and hypothesized about
fi ve types of alcoholic. In this framework, only the gamma
alcoholic was actually viewed as
the product of a disease process. In problem drinking research
however, no study has ever
confi rmed the existence of a disease in any of the categories
described by Jellinek (as cited
in Miller & Heather, 1999). A coincidental disease campaign by
the founders of Alcohol-
ics Anonymous (AA) only added more spurious credibility
(Peele, 1989). The AA only
stated, as part of their charter, that alcoholism was a disease.
No empirical support was
even attempted.
A third disease movement can be traced to the attentional
disorders literature. The
fi rst person to speculate about children who were inattentive
and highly misbehaving as
being diseased was made in 1902 as a guess by an English
pediatrician, George Still. As
a physician he was trained to see everything as medically
caused, and his interpretation
of these children’s behaviors was consistent with his medical
orientation. Unfortunately,
even though no supportive evidence existed, the disease theory
for ADD/ADHD had its
beginnings.
Around 1923 a breakout of an encephalitis epidemic left
numerous children with this
inattentive and hyperactive behavior pattern. Dr. F. G. Ebaugh
concluded that perhaps
a virus or the encephalitic virus itself caused infl ammation or

damage to the brain of
122 Stein and Foltz
children that resulted in this behavior pattern (1923). Without
proof and only as a guess,
it further fueled the disease notion.
In 1937, Dr. Charles Bradley noticed that stimulant drugs
seemed to subdue the behav-
ior of highly active and inattentive children. As stated earlier
this became known as the
paradoxical effect, because he believed that only in these hyper
children do we observe
this subduing effect. This theory remained popular until fairly
recently when researchers
began to discover that stimulant drugs produce this same effect
on almost everybody,
adults or children.
Baldessarini (1985) calls this reasoning allopathic logic ,
while Elliot Valenstein (1998)
calls this ex juvantibus reasoning, meaning that because a drug
produces an effect, then
there must be a disease. Both view this type of reasoning as
false, misleading, and invalid.
Since the same reactions are regularly observed in most
children, this idea has pretty much
faded away and few currently accept the paradoxical effect
theory.
In 1947 Strauss and Lehtinen proposed the idea that the cause
of these behaviors was
some type of minimal brain damage (MBD), but it was so

minimal that no one could fi nd
it. This notion has also mostly disappeared.
The American Psychiatric Association use of the term
hyperkinetic reaction of child-
hood was published in the DSM–II in 1968. The term
hyperkinesis was considered by
many psychologists as misleading because it sounded like or
connoted a meaning of a
disease (Seligman, 1994). During that time period psychologists
were not in favor of such
pejorative terminology (i.e., negative or implied disease), and
the term was dropped.
As Seligman (1994) stated, in the development of the 1980
version of the DSM–III ,
there was a strong current of feeling, primarily by
psychologists, to move away from both
pejorative connotations and from disease concepts that had no
support. Researcher Vir-
ginia Douglas viewed the behavior problems as resulting from a
defi cit in attention. The
term attention defi cit disorder (ADD) was settled upon.
However, the terms ADD or
ADHD are still pejorative and carry a strong connotation of an
underlying disease (Stein,
1998).
The connotative meaning of words is important, especially in
psychiatry and psychol-
ogy. Just by naming something presents the problem of reifi
cation, which is to make some-
thing concrete or real when it is not. Unfortunately, without
realizing it reifi cation may be
what is happening in too many minds within the professional
community. Many profes-

sionals are passionate that certain disorders are real diseases
without realizing that their
arguments are emotional and lack credible scientifi c support;
that is, because it sounds like
a disease, and may even look like a disease, it therefore is a
disease, is a poor substitute in
a healthy scientifi c atmosphere.
During the 1960s and 1970s psychology developed its
professional profi le in North
America and Europe. In the United States, many doctoral
programs were accredited, psy-
chologists were licensed to practice, and legislation was passed
that entitled psychologists
to third party payments. In the 1960s there was an ascent of
behavioral analysis. The radical
behaviorism of the 1970s was associated with psychologists
who were trained extensively in
scientifi c rigor and experimental methodologies. There were
several challenges to the exist-
ing orthodox methods and the ineffectiveness of
psychotherapies, especially psychoanalysis
(Eysenck, 1952). This critical climate stimulated an interest in
more scientifi c approaches
to treatment (e.g., behavior therapy and behavior modifi cation).
These approaches were
committed to data collection and outcome evaluation via
empiricism and the scientifi c
analysis of human behavior.
This renewed interest in science was overdue in psychiatry,
much of which had been

established on anecdote and reports of “what I saw in my clinic
last week.” Nonscientifi c
terms like disease were commonplace, as previously stated, in
psychiatric diagnostic systems.
Professionals had adopted different positions; generally
psychiatrists promoted prodisease
views and concepts, whereas many psychologists adopted
antidisease perspectives, based
on a psychosocial framework. The advent of DSM–III (APA,
1980) helped ensure that
disease views were abandoned. Moreover, associated terms like
psychosis and neurosis were
also removed. Coincidentally, however, at the beginning of the
1980s, many advances in
medical technology occurred. The considerable advances in
information technology were
complemented by medical and health innovations such as
computerized axial tomogra-
phy (CAT) scans, positron emission tomography (PET) scans,
magnetic resonance imaging
(MRI), electron microscopes, and computerized spectrograms
(SPECT). For biopsychia-
trists investing in physical treatments like shock and drugs,
access to such technology set
the conditions for further hypothesizing about disease-type
explanations of psychosocial
problems (e.g., depression, thought disorder). Unfortunately,
however, the claims made in
studies based on these technologies were contaminated by
inaccurate machine readings or
claims of readings irreproducible by other researchers. These
overstated claims included
inappropriate and unfounded assertions about supposed disease
theories. A statement made
by Barkley (1995) reveals how premature and inappropriate
these claims are:

Misled by research reports that lab measures have found
differences between ADHD and non-
ADHD children and by the fact that ADHD is a biologically
based disorder, many parents ask for
medical tests to confi rm the diagnosis of ADHD. At present,
there are no lab tests or measures
that are of value in making a diagnosis of ADHD, so blood
work, urinalysis, chromosome studies,
EEGs, averaged evoked responses, MRIs, and computed
tomography (CT scans) should not be
used routinely in the evaluation of ADHD children. (p. 122)
The illusory precision of PET and SPECT images prompted
some biopsychiatrists to
overstate their claims about these methodologies. For example,
Zametkin and colleagues
(Zametkin, Liebenauenauer, Gitzgerald, & King, 1993;
Zametkin, Nordahl, et al., 1993)
and Barkley (1995) have made claims about a disease etiology
for ADD or ADHD based
on PET scan fi ndings. These PET scans however are highly
inaccurate (Sedvall, 1997).
The scans do not yield suffi cient precision to justify any
conclusions about any hypotheti-
cal underlying disease, illness, or pathological state.
Introduction of these new medical technologies did improve
subsequent observation
and measurement of associated chemical changes and
physiological variances. Nonethe-
less, the apparent face validity of these medical machines and
associated technologies
when used in psychiatric research has been extremely
problematic, with unwarranted
images of precision, accuracy, and reliability, marketed and

sold to the general public
(Mayberg, 1998; Sedvall, 1997). Moreover, revival of the
disease concept by biopsychia-
trists has also been falsely linked to supposed discoveries in
biochemistry and physiology
(DeGrandpre, 1999). In addition, investment in research
programs such as the human
genome project has added more complexity to the mired disease
campaign by the recent
supposed discoveries of genes for schizophrenia, depression,
handedness, hyperactivity,
substance misuse, aggression, and gambling. Currently there is
an ongoing debate about
whether or not such supposed changes in biochemical,
physiological, genetic, or metabolic
functions constitute a true disease process or not. The
committee that reformulated the
124 Stein and Foltz
DSM–IV (APA, 1994) had never defi ned mental disease (p.
xxxi). Scientifi c challenges to
the disease concept (DeGrandpre, 1999; Stein, 1999) however
necessitate and require the
establishment of a widely accepted operational defi nition.
WHEN USING THE TERM “DISEASE ”
Accuracy, validity, reliability, and utility of operational defi
nitions should be at the
foundation of both psychology (Skinner, 1957) and psychiatry
(Clare, 1976). The term
“disease” sets the occasion for particular physical treatment
modalities (i.e., medicines,

surgery, hospitalization, electroshock). The legal profession has
only partly resolved this
dilemma. It is well known that in the United States during the
1970s and 1980s lawsuits
helped to reduce hospital populations to 10% of their previous
size (Bachrach, 1984).
Civil commitments were removed from the responsibilities of
psychiatrists. Countercon-
trols were established on many psychiatric treatments. In the
1990s however there was
a revival of many physical treatments, including more use of
drugs (Breggin, 1998) and
shock to minor clients (Baldwin & Oxlad, 2000; Baldwin &
Jones, 1996) and elderly
people (Oxlad & Baldwin, 1996).
In the 2000s use of the disease concept has been associated
with purposes of cor-
porate and personal gain. Political agendas, special interest
groups (e.g., Alcoholics
Anonymous, Narcotics Anonymous) global economic industries
(e.g., pharmaceuticals)
all threaten to further erode scientifi c standards. The term
“disease” has been manipu-
lated, marketed, and retailed to the public as a product base for
pharmaceutical drug
sales (Breggin, 1998). The incorporation of the disease
concept into the professional
territories of clinical psychology and psychiatry has been a
useful platform to launch
pharmaceutical products for supposed pathophysiological states
such as depression and
schizophrenia. Unfortunately however the scientifi c evidence
for these conditions as ill-
nesses or diseases does not exist. Since 1990, overwhelming
volumes of poorly designed

and fl awed studies have been published that claimed to have
found the disease causing
attention defi cit disorder (ADD) and attention defi cit
hyperactivity disorder (ADHD),
depression, and schizophrenia. These studies, however, have
been a camoufl age of junk
science (DeGrandpre, 1999; Schlesinger, 1998) many of which
are unethical (Stein,
1998; see Tables 1, 2, and 3) and none of which has been
accepted as valid. For example
the following statement was made in the summation about
ADHD at the NIH Consen-
sus Conference, 1998:
At this time, we do not have a diagnostic test for ADHD
(biochemical, physiological, anatomi-
cal, genetic, etc.). Therefore, the validity of the disorder
continues to be a problem. (p. 3)
The same may be said for depression, schizophrenia, obsessive-
compulsive disorder, and
so forth. Many may wholeheartedly believe that some of these
disorders are diseases, but
belief should not overzealously replace the validity of real
scientifi c fi ndings, which at
present, do not exist. As will be discussed later, if such fi
ndings were to be made, several
potential contaminations must be cleared up to make the claim
of disease. These clarifi ca-
tions will later be made clear in the development of a defi nition
of disease in psychiatry
and psychology.

TABLE 1. Representative Studies of Brain and Nervous System
Dysfunction in ADD/ADHD
Area of the Brain or Chemical
Imbalance Implicated Author/Date of Study
1. Brain stem Lahat et al. (1995)
2. Caudate nucleus Castellanos et al. (1994)
3. Corpus callosum Giedd et al. (1994)
4. Dopamine Levy (1991)
5. Folic acid Greenblatt, Huffman, & Reiss (1994)
6. Frontal lobe Heilman, Voeller, & Nadeau (1991)
7. Brain metabolism Zametkin, Libenauenauer, et al. (1993)
8. Prefrontal cortex Amen, Paldi, & Thisted (1993)
9. Serum lipid Arnold, Kleykamp, Votolato, & Gibson (1994)
10. Serotonin Halperin et al. (1997)
Dysfunction in Depression
1. Serotonin Goodwin & Jamison (1990)
2. Dopamine Depue & Iacono (1989)

3. Dopamine agonists Silverstone (1985)
4. Norepinephine Samson, Mirin, Hauser, Fenton, Schidkraut
(1992)
5. Dexamethasone Gibbons (1964)
6. Catecholamines Schildkraut (1965)
7. Cortisol Christensen, Hadzi-Pavloc, Andrews,
Mattrick (1988)
8. Melatonin Shafi i & Shafi i (1998)
What Underlies Premature Disease Claims
Pharmaceutical companies have fi nanced large research grants
to generate fi ndings that
promote disease discoveries as well as the positive qualities of
their drug products. Pharma-
ceutical products have both positive and negative effects. The
ingestion of drugs (especially
by minors) however is a serious activity. Formal drug
prescription should be predicated on
rigorous scientifi c analysis of risks and benefi ts (i.e.,
monitoring of side effects, collection
of follow-up data). Scientifi c, not economic, interests should
underpin prescription drug
use. As many modern drugs are marketed, targeted, and directed
toward children and teen-
agers, this is especially salient (Baldwin & Anderson, 2000;
Stein, 1999). The money trail
unfortunately has unduly infl uenced researchers doing so-
called scientifi c investigation.
Negative results or fi ndings by drug company researchers are

ignored, suppressed, and are
never submitted to the pharmaceutical-sponsored psychiatric
journals (Valenstein, 1998;
126 Stein and Foltz
Dysfunction in Schizophrenia
1. Dopamine Carlsson (1995)
2. Serotonin Meltzer (1992)
3. Enlarged ventricles Cannon and Marco (1994)
4. Smaller frontal lobe Gur & Pearlson (1993)
5. Smaller cortical gray matter Buchanan et al. (1998)
6. Reduced blood fl ow Zemishlany et al. (1996)
7. Viral infections before birth Torrey (1988)
8. Defi cient activity in the dorsolateral prefrontal cortex
(DLPFC)
Berman & Weinburger (1990)
9. Lack of migration of nicotinamide-adenine dinucleotide
phosphate-diaphorase (NADPH-d)

Akbarian et al. (1993)
Jackson, 2005). Hundreds of fl awed research articles about
disease fi ndings and studies
only espousing the positive qualities of drugs have been
published in psychiatric journals
funded mostly by drug companies. The sheer volume of these
papers that promote disease
and the virtues of pharmacotherapy contribute directly to the
promotion and sale of drug
products (Baldwin & Anderson, 2000; Breggin, 1998;
DeGrandpre, 1999; Stein, 1999;
Valenstein, 1998). Has volume replaced quality and integrity?
THE IMPACT OF THE DISEASE CONCEPT ON SCIENCE
At the interface of psychiatry and clinical psychology, several
related concepts intersect.
There are two major components to the disease concept. First,
there have been several
previous (unsuccessful) attempts to defi ne disease. Second,
there is also a low-level, poor-
quality research campaign to fi nd magic bullets that supposedly
cause and explain these
psychiatric conditions. In the fi eld of problem drinking, for
example, the search for a
biochemical marker, specifi c gene, or metabolic trigger has
remained elusive for more than
50 years. As yet, no conclusive scientifi c evidence for a
biochemical trigger has been estab-
lished (Miller & Heather, 1999). The same is true for other
behavioral disorders. Especially
during the 1990s, bioeconomic interests prevailed, with the
generally fruitless search for
the supposed underlying pathological conditions of thought
disorder (aka schizophrenia),

bipolar disorders, drug and alcohol problems, and ADD/ADHD
research.
Multiple Defi nitions
A literature search for a defi nition of so-called mental disease
has yielded multiple defi -
nitions (see Table 4). None of these conditions however fulfi ll
the scientifi c conditions
of clarity and precision required for an empirically anchored,
operational defi nition for
psychiatric disease.
TABLE 4. Attempts at Operationally Defi ning Disease in
Psychology and Psychiatry
1. Peele (1989)
Disease might be defi ned as an abnormality of bodily form or
function that causes an adverse or
unfavorable effect. (pp. 5–7)
2. Kaplan, H. I. and Sandock, B. J. (1995)
The social construction, or illness, involves a series of
intersecting or nested explanatory models
for the diseases, held or promulgated variously by the patient,
the family, the physician, other
health-care personnel, and the larger culture as represented, for
example, by religious authority
or the law. (pp. 351–352)
3. Lavin, M. (1985)
Disease is at once a biological event, a generation-specifi c

repertoire of verbal constructs
refl ecting medicine’s intellectual and institutional history, an
aspect of a potential legitimization
for public policy, a potentially defi ning element of social role,
a sanction for cultural norms,
and a structuring element in doctor–patient interactions. (pp.
535–543)
4. Rosenberg, K. E. (1989)
Many words have been used to refer to conditions whose defi
nitions to date have been
generally unsatisfactory; among them are abnormality, affl
iction, condition, defect, deviation,
disability, disfi gurement, disorder, disturbance, dysfunction,
impediment, illness, injury, lesion,
reaction, variant, and wound. In medical anthropology, disease
refers to whatever biological
reality underlies the disorder in question; illness refers to the
social construction of the disease
(e.g., the explanatory model that is favored by the culture). (pp.
1–15)
5. Damjanov, I. (1995)
The psychological and social aspects of disease are as important
as their biological basis. As a
result, a person does not have to be physically ill to feel sick.
(pp. 167–168)
Magic Bullets
Tables 1, 2, and 3 list samples from many studies whose
authors have claimed to have found
the magical medically based etiology, or magic bullets, of ADD
and ADHD, depression, and
schizophrenia. Examination of these studies however has
revealed a sideshow of inadequate

research. No study has yet received overall recognition within
the scientifi c community,
because every study has been seriously fl awed. In many
studies, participants were taking psy-
chotropic medications, either during the study or in the
preceding years (Breggin, 1998).
These psychotropic drugs can typically produce identical effects
improperly attributed to
a supposed disease state. They can cause the chemical and
physiological changes that are
touted as disease etiologies. Often the discussion section in
these studies has marginalized
the signifi cance of such drug contaminations and confounds.
Pharmaceutical companies have developed an almost unlimited
power to fund psychi-
atric research that produces outcomes consistent with their own
drug product marketing
needs. Researchers in universities frequently have collapsed
their ethical principles to
secure and win large drug research grants. Universities
generally do not discriminate about
the source of funding and their administrators may perceive
such large grants as presti-
gious. Researchers who accept this money may be seduced into
making untrue statements
about their work (e.g., methylphenidate is not addictive) to
appease powerful pharmaceu-
tical company sponsors. In general medical research, drugs
control (or do not control) an
identifi able disease entity. Only in psychiatric research
however, vagueness and confusion
often obscures conceptual clarity. Although behavioral control
can be achieved with psy-
chiatric drugs, this is not de facto evidence for the presence of a
disease state (Baldessarini,

128 Stein and Foltz
1985; Valenstein, 1998). It has already been established that the
sedative, tranquilizing
effects properties of antipsychotic drugs (Julien, 1998) are the
characteristics most valued
by psychiatrists and family members. There is however no clear
scientifi c evidence that
specifi c receptor site action infl uences neurotransmitter levels
to directly modify abnormal
individual thought patterns. Rather, it can also be interpreted
that the celebrated effects
of antipsychotic (more properly called antibehavioral )
medications (Julien, 1998) may be
based on their ability to exert restraint and to establish akinesis.
Scientists should protect the general public by adhering to
excellent standards. When
scientifi c standards are compromised, the general public can
suffer severe and sometimes
irreversible consequences (e.g., when a dangerous drug such as
Thalidomide is licensed).
The nature of human service provision and honest science
means that corruption is
eventually exposed, although this may take time. Tobacco
industry-type investigations
are now being applied to psychiatry, psychology, and
pharmaceutical companies, to deter-
mine confl icts of interest and insider trading. As self-
regulation by psychiatrists within
psychiatry seems impossible, stronger countercontrols clearly
are required from indepen-
dent, external monitoring agencies.

LACK OF REPLICABILITY ADDS ANOTHER
CONTAMINATION
This fl awed research based on volumes of weak nonscientifi c
reports has unduly infl uenced
the uncritical psychiatric community. The issue of the
nonreplicability of the huge volume
of disease claiming research was discussed earlier. The general
public and professional
community has been duped about the nonexistent disease
validity of concepts such as
hyperactivity, depression, obsessive-compulsive disorder, and
schizophrenia. The external
monitoring of journals, university research, and professional
organizations should be more
rigorous to prevent the hijacking of science to achieve other
goals.
DNA RESEARCH IS ALSO BEING COMPROMISED
The substitution of volume at the expense of quality has also
occurred in the DNA fi eld.
In Table 3 many different genes supposedly cause ADHD. The
identifi cation of multiple
genes to explain behavior wholly undermines the scientifi c
enterprise. Genetic research
has proved an ideal arena for unethical researchers to identify
disease states in both psy-
chiatry and clinical psychology. In the ADD and ADHD fi elds,
for example, diagnosis has
increased at a yearly rate of 400%–500% (Stein, 1999). Genetic
disease however does not
increase at such rates. Only a major environmental event (e.g., a
massive radiation leak)
could account for such an increase. In the absence of such an

event, only politics and eco-
nomic interests can explain this explosion of ADHD diagnosis
(Stein, 1999).
THE STRESS–DIATHESIS ISSUE
The stress–diathesis model (Zubin & Spring, 1979) presents
still another problem. In this
model it is assumed that there exists a genetic predisposition to
develop a disorder in the
presence of suffi cient stress levels. This model is now being
expanded to include many types
of disorders and lends to the reifi cation of these disorders into
diseases. No proof of diathe-
sis exists, and yet it seems to have taken on a life of its own
because it seems to be appearing
in more and more abnormal psychology textbooks. There is no
available evidence for the
existence of any DNA, or gene, or chromosome that produces a
state of diathesis. There
is no evidence of an anatomical, chemical, or physiological
thing called diathesis. It is a
name, a hypothesis that is taking on an unfounded and
unsubstantiated reality.
TRIGGERS: SAME DISORDER—DIFFERENT CAUSES
The disease business has involved a quest to discover and name
the biological triggers that
cause each of the disorders (i.e., conditions categorized in
DSM—IV ). A trigger is that

which initiates or causes a behavioral disorder to occur. This
quest involves the traditional
deterministic search for the discovery of cause–effect
relationships. The establishment of
such a relationship implies that prediction and control (i.e.,
treatment) is possible. The
quest for disease states is to fi nd a reductionistic trigger. This
requires a shift in the level of
explanation of causation, from the molar (environmental) level,
to the molecular (biologi-
cal) level. Even if the cause of the cause–effect relationship is
molecular or biological, then
control or treatment does not necessarily have to be biological
(i.e., medical). For example,
behavioral interventions can be highly effective to modify
action repertoires with biologi-
cal conditions such as Down’s syndrome and autism (Kazdin,
1994; Lovaas, 1987).
There is much literature about the supposed causes of many of
these disorders. Dif-
ferent authors have viewed causes, or triggers, at different
physical levels. Some authors
have argued for molar or environmental causes. These include
Seligman’s (1975) theory
of learned helplessness underlying depression. Others have
argued solely for molecular or
biological causes. These authors include Schildkraut’s (1965)
theory of catecholamine
imbalance that supposedly causes depression. Arguments about
biological or environmen-
tal causes often have become quite impassioned. There is
abundant evidence that disorders
can be triggered or caused by events at different physical levels.
Depression (i.e., affect disorder) for example can be triggered

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