Recently I had a conversation about psychological labels such as OCD, autism, and ADHD. This conversation reminded me of the work of Laura Batstra, psychologist and professor of orthopedagogics, who critically examines the use of psychological labels for behavioral and emotional problems. Batstra points out the risks of overdiagnosis, medicalization, and neglecting the broader social context in which problems arise. Below I will try to present her vision.
The difference between disease and disorder
A key point in Batstra’s approach is the distinction between diseases, such as diabetes, and disorders, such as ADHD. While diseases can be objectively diagnosed based on biological
markers, such as elevated blood sugar levels in diabetes, disorders are
usually defined by behaviors that occur in specific situations. ADHD is
not diagnosed by a biological marker, but by behaviors such as attention
problems and impulsivity. Batstra emphasizes this distinction to
illustrate that disorders are more subjective and open to
interpretation.
Overdiagnosis and medicalization
A
worrying trend within the DSM, the manual for mental disorders, is that
more and more behaviors and emotions are being labeled as disorders.
Behaviors that used to be considered normal or temporary are now more
quickly classified as a mental disorder. In addition, increasingly
milder symptoms are being included in the DSM, so that even minor
deviations can lead to a disorder. According to Batstra, this expansion
leads to overdiagnosis and medicalization of normal behavior .
Batstra
acknowledges that labels can sometimes be useful in facilitating care,
but warns that this can be a pitfall. If we continue to push the
boundaries between normal and abnormal behavior, behavior that used to
be considered “normal” can be unnecessarily pathologized. Batstra
advocates not to assign labels too quickly, especially when symptoms are
mild, and to first look at the context in which the behavior occurs.
The subjectivity of diagnosis and the role of “often”
Diagnoses
for disorders such as ADHD are often made based on criteria that leave
room for subjective interpretation. In the DSM, for example, ADHD is
defined using words like “often” and “regularly,” as in “often having
difficulty sustaining attention on tasks” or “often fidgeting.” Using
such terms makes it difficult to draw a clear line between normal and
abnormal behavior, which can lead to different interpretations depending
on the assessor.
Batstra
acknowledges that subjective criteria are sometimes unavoidable but
argues that we should only diagnose when the behavior is truly
dysfunctional and causing serious problems. By carefully assessing
whether behavior is dysfunctional in the context of a person’s life,
unnecessary diagnoses can be avoided.
Labels as false explanations for behavior
A common problem with using psychological labels is that they are often seen as explanations for behavior, when in reality they are merely descriptions. This is also known as the confusion between ‘naming’ and ‘explaining’
. For example, when someone says, “He is so restless because he has
ADHD,” a label that only describes behavior, such as restlessness and
difficulty concentrating, is incorrectly used as an explanation for that
behavior. This leads to circular reasoning, where the label merely
names the behavior without providing insight into its causes.
Reification: the reification of labels
This fallacy is often accompanied by what is called “reification”: treating abstract concepts like ADHD as if they were concrete,
tangible “things” that reside in people. This reification and the
viewing of labels as explanations creates the impression that the cause
of the behavior lies within the individual and is fixed in the brain or
personality. This narrows the perspective and detracts from other
factors, such as environmental influences, which are often at least as
important. Furthermore, this misconception can create feelings of
powerlessness, because the behavior then seems to arise from an
unchangeable “disorder.” In reality, behaviors are often complex and
influenced by a dynamic combination of personal and environmental
factors.
The ecological fallacy and its implications for brain research
Another
major concern of Batstra is how findings from brain research are often
applied in diagnostics. For example, brain research shows that there are
small differences in brain structures between groups of people with and
without diagnoses such as ADHD. These group differences are sometimes
interpreted as evidence of abnormalities in the brain in ADHD, while
these differences only exist at the group level. This is called the ecological fallacy: the incorrect application of statistical group differences to
individual cases. For example, men are on average taller than women. But
that does not mean that if someone is 6ft3 tall, we
automatically know that the person is a man (Batstra herself is 6ft3 tall, for example). Batstra emphasizes that these group differences
say little about the individual and warns against the misconception that
everyone with ADHD would have the same brain abnormality.
Stigmatization and the consequences of labels
According to Batstra, psychological labels such as ADHD and autism often lead to stigmatization. A label can make someone think that he or she is “disturbed” or
“ill”, which can undermine self-image and self-confidence. A label can
be especially harmful for young people, who are still busy developing
their identity. By assigning the label, we place the problem within
the person. In addition, the label often places the responsibility for
behavioral problems with the individual, without taking into account the
environmental factors that may have an influence.
The role of social factors and the underexposed context
Batstra
criticizes the tendency to individualize mental health problems without
taking into account the broader social context. She emphasizes that
factors such as poverty, exclusion and the pressure on the educational
system are often overlooked in diagnoses, while these social factors can
cause behavioral problems that are then wrongly labeled as mental
disorders. According to Batstra, shifting the focus to the social
context makes it possible to see children and adults not immediately as
problem cases, but as individuals in a complex social environment.
Proposal for an alternative approach: the “DSS”
To
support a more social approach to mental health problems, Batstra
proposes to develop a new diagnostic manual: the “DSS” (Diagnostic and
Statistical Manual of Societal Problems). This manual would focus on
social problems that can contribute to mental health problems, such as
poverty and social exclusion, rather than solely on individual
disorders. Batstra’s idea is that by mapping social and economic
factors, we can gain a better understanding of the causes of mental
health problems and stimulate preventive measures aimed at improving the
social context of individuals.
Less focus on medication and more support for parents and teachers
Finally,
Batstra advocates a reduction in the use of medication for behavioral
problems. Medication, such as Ritalin for ADHD, often only provides
temporary relief without addressing the underlying causes. Instead, she
proposes to provide more support to parents and teachers, who play an
essential role in the behavior and development of children. By guiding
and supporting them with strategies, behavioral problems can often be
effectively addressed without children immediately being given a
psychological label.
Conclusion: Towards a holistic and contextual approach
Laura
Batstra’s ideas underline the importance of a holistic and contextual
approach to behavioral problems. She advocates a clear distinction
between illness and disorder and warns of the risks of overdiagnosis and
medicalization of normal behavior. A diagnosis should not ignore the
context, but rather start with the social and personal environment of
the individual. Batstra’s approach strives for a world in which children
and adults are supported in a way that promotes their growth, without
being unnecessarily labeled or stigmatized. Her vision, in which nuance
and the bigger picture are central, offers valuable insights for the
future of mental health care.