Therapy Might Be Pathologizing Ordinary Experiences

In the wake of prolonged grief disorder entering the Diagnostic and Statistical Manual of Disorders, debates over pathologizing–classifying as disorders requiring specialized treatment what we might think of as typical life experiences, like grief—have reignited.

Psychiatry has long featured in these debates, most obviously in the case of homosexuality which was classified as a mental disorder until the 1970s. There has been considerably less attention devoted to psychiatry's close cousin, psychotherapy.

There's good reason to suspect that therapy might also contribute to pathologization. After all, many schools of therapy began as a treatment for specific disorders, but have since then extended their reach to more ordinary problems, For example, Cognitive Behavioral Therapy (CBT), was originally developed as a treatment for severe depression, but is now widely available and applied to everything from dieting to productivity. As the target of therapy has shifted from clear-cut cases of mental illness to more ordinary problems, we might wonder whether our understanding of these ordinary problems has also shifted.

In a recent paper, I show that CBT's understanding of mental illness–The Cognitive Model of Mental Illness–contributes to the pathologization of experiences like grief, heartbreak, and misfortune. CBT argues that mental illnesses are related to certain patterns of thoughts, referred to as negative automatic thoughts or cognitive distortions. These distorted thoughts are hypothesized to give rise to the negative emotions and behavior symptomatic of mental illnesses such as depression. Many of CBT's therapeutic techniques focus on addressing these distorted thoughts with the aim of addressing the negative behavior and emotions.

Unfortunately, typical experiences such as grief, heartbreak, and misfortune, also involve the same patterns of distorted thoughts. It is not unusual, for instance, to find oneself thinking overly dramatic thoughts, such as "I will never love anyone like that again" in the wake of a breakup. Most likely such a thought will turn out to be false (or "catastrophizing" as CBT texts tend to put it) but it is surely not disordered. We find it perfectly normal that people think such things when they are upset at the breakdown of a relationship. We also find the accompanying negative emotions and the unproductive behavior (for example, obsessively checking their ex's social media) to be fairly typical of a breakup.

Other negative experiences are similar. For example, in light of a bereavement, we may chastise ourselves by thinking that we should have spent more time with the loved one prior to their death. Or some sort of misfortune, for example, missing out on a long-desired career goal, might result in bitterly wondering whether the decision-making procedure was entirely fair — these thoughts correspond to the cognitive distortions of "the shoulds" and "blaming," respectively. However, such thoughts and the negative behavior and emotions that may accompany them are part and parcel of what it means to undergo these experiences.

When a "Pathological" Experience is Valuable

We might wonder whether it matters that ordinary experiences fall under CBT's cognitive model of mental illness. After all, they are distressing and some people might prefer to work through them with the benefit of a therapist.

However, this shift towards seeing ordinary experiences on par with more obvious mental disorders is likely to have unintended cultural consequences. Perhaps we are less patient with ourselves and others as we undergo these experiences. We may expect people to 'get over' a loss quickly and return to their daily routines more immediately.

Seeing these experiences as pathological is also a failure to see them for what they are–not just a typical or inevitable part of life, but also valuable. Both grief and heartbreak indicate that one has lost a significant relationship or a treasured person. Misfortune similarly indicates that one had something worth losing, or aspired towards something that one values, such as an ambitious career. These experiences indicate that one has had a life worth living.

No doubt, not all therapies pathologize. But CBT's blurring of the line between mental disorder and ordinary experiences in its classification of mental illness shows that we must examine psychotherapy as well as psychiatry, when worrying about pathologizing a range of human experiences.

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