Do You Still Need Your Psychiatric Diagnosis?

Lucy Johnstone, PsyD
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Do you still need your psychiatric diagnosis? The answer for practical purposes is probably ‘Yes.’ In the current system, diagnosis is essential for accessing services and benefits and, particularly in the USA, for covering your treatment costs. But do you need to believe in your diagnosis? Do you have to accept this particular attempt to explain your difficulties, and to take it on as part of your identity by becoming one of the ‘mentally ill’? In the words of the blurb for my book, one of the ‘Straight-talking introduction to….’ Series, which has just become available for pre-order in the US via Amazon.com:

A revolution is underway in mental health. If the authors of the diagnostic manuals are admitting that psychiatric diagnoses are not supported by evidence, then no one should be forced to accept them. If many mental health workers are openly questioning diagnosis and saying we need a different and better system, then service users and carers should be allowed to do so too. This book is about choice. It is about giving people the information to make up their own minds, and exploring alternatives for those who wish to do so.

—  ‘A Straight Talking Guide to Psychiatric Diagnosis,’ Ross-on-Wye, PCCS Books

As far as I am aware, this is the first book to provide a concise, accessible and reasonably affordable summary for service users, carers and others which:

  • Summarises the complex debates for and against psychiatric diagnosis
  • Looks at the impact of psychiatric diagnosis at every level from the individual upwards
  • Outlines the alternatives to diagnosis, which in essence come down to various versions of finding your own story
  • Supplies lists of reading, resources and organisations which can help you to think about alternatives to diagnosis if you decide to do so. This includes the websites and blogs of many MIA contributors, including Laura Delano, Jacqui Dillon, Rachel Waddingham and Rufus May.

In the book, I’ve been very open about my own position: I am opposed to the use of psychiatric diagnosis (with obvious exceptions for conditions such as dementia) at all. But it’s not going to go away overnight, and I recognise that many people experience it as helpful, at least in some ways. I also recognise that it is never easy to question fundamental aspects of our assumptions and identities, even if they have caused us pain. Many of the accounts I have quoted testify to this.

However, in the current state of conflict, controversy and crisis in psychiatry, I do not believe it is professionally, scientifically or ethically justifiable to present psychiatric diagnosis to service users and carers as an undisputed fact or truth. The Chair of DSM IV, Dr Allen Frances, has described the manual as ‘deeply flawed and scientifically unsound’ and the Chair of DSM 5, Dr David Kupfer, has admitted there are no biomarkers to validate the categories; a former NIMH director has described DSM as ‘totally wrong, an absolute scientific nightmare’ while the current one confirms that its categories ‘lack validity’; and NIMH has embarked on a massive project to re-write the diagnostic manuals from scratch. How can any professional think it is acceptable to conceal these vital debates from service users and carry on as before?

The first part of the book explains what we mean by diagnosis and takes the reader through some of the arguments for and against applying this model in mental distress. It tackles some common questions such as ‘So what is the role of medication if you don’t use diagnosis?’ and ‘Surely you need to categorise things somehow?’ It then moves on to discuss the personal impact, positive, negative and mixed, of receiving a diagnostic label. This is placed in the context of service responses, social consequences, and the wider role of psychiatry.

One of the most important aims is to find a midway between two polarised positions that have been described as ‘brain or blame’.1 This refers to the difficulty that we seem to have as a society in finding ‘a middle ground between “You have a physical illness, and therefore your distress is real and no one is to blame for it” and “Your difficulties are imaginary and/or your or someone else’s fault, and you ought to pull yourself together”’ (p.2.) There are descriptions of the emerging alternatives to the diagnostic tradition, including constructs, narrative approaches and psychological formulation, which can provide non-blaming and constructive ways forward.

In the second half of the book, I am indebted to a number of former service users who have given me permission to use their powerful and moving accounts of how they eventually came to discard their diagnoses, sometimes with help from within services and sometimes through outside organisations and agencies. There is a comprehensive list of strategies, reading and resources for those who may wish to pursue this path themselves. Comments from readers include: ‘The book helps me to make more sense of what happened when I was in the mental health system, while giving me a renewed sense of hope and optimism in my recovery journey. If I had a book like this 6 years ago, it would have saved me a lot of trauma and time spent in trial and error. It would have speeded up my recovery.’ There is a review by Dr Phil Hickey on his website, Behaviorism and Mental Health.


Psychiatric Diagnosis and Choice

Informed consent is expected for most medical interventions, so that people can make meaningful decisions about their healthcare; for example, whether or not they want to have a particular operation or take a particular medication. I believe it is time for people to have the chance to make an informed decision about whether to accept, or at least whether to believe, a psychiatric diagnosis with all its subsequent consequences, both useful and damaging. To pursue the drug analogy, I would also argue that services should be offering support to help psychiatrically-diagnosed people to ‘come off’ or ‘withdraw from’ their diagnosis, if they so wish. I envisage something along the lines of the survivor-led groups described by Jacqui Dillon and Rufus May in which ‘people have the opportunity of reclaiming their experience in order to take back authorship of their own stories . . . finding a space where one can tell one’s story, discover one’s truths and explore possible ways forward’.2

How near are we to achieving this state of affairs? When I and colleagues presented at the American Psychological Association Annual Conference last August, we were flattered but somewhat surprised to be told that the UK is ‘so far ahead’ in its critiques and alternatives. It certainly doesn’t always feel like that. Nevertheless, there are hopeful signs. The recent Division of Clinical Psychology (subdivision of the British Psychological Society) report ‘Understanding Psychosis’, edited by Anne Cooke and co-authored with 25 professionals and service users, has been widely welcomed – by, among others, the Rt Hon Norman Lamb, Health Minister, and psychiatrist Dr Geraldine Strathdee, the National Clinical Director for Mental Health (free download from www.understandingpsychosis.net). This is extremely encouraging, given that the theme of the report is choice about aspects of mental health care that have until now been seen as unquestionable. The executive summary states that ‘Professionals should not insist that people accept any one particular framework of understanding –for example, that their experiences are symptoms of an illness’ (p.6) and the report has a section exploring the pros and cons of seeing your difficulties in diagnostic terms (pp 17-28.) This is in keeping with the message of other Division of Clinical Psychology reports such as the one on ‘Bipolar disorder’: ‘Services should not insist that all service users see their problems as an “illness” and take medication’ p.8.

The ‘choice’ and ‘informed consent’ argument is a strong one, because it is hard to argue against it without sounding authoritarian and paternalistic. Indeed, the ‘choice’ rhetoric has shaped services  in both the UK and the US for decades. But choice about diagnosis exposes psychiatry as something fundamentally different from legitimate branches of medicine, in which it would be ridiculous to say ‘This meets the diagnostic criteria for cancer, but we can describe it as pneumonia or a stress reaction if you prefer.’ Since ‘diagnosis is the Holy Grail of psychiatry and the key to its legitimation’,3 offering choice about diagnosis strikes at the foundation of the theory and practice of traditional psychiatry, and reveals its essentially unscientific nature.

There is, of course, another way of looking at the issue – which is that since psychiatric diagnoses have been admitted to be non-valid even by the people who drew them up, professionals should not be offering people the ‘choice’ of describing their difficulties in diagnostic terms in the first place. That would still leave people with the right to adopt whatever explanation suits them as private individuals – as they are free to do in general medicine. Someone diagnosed with cancer is perfectly at liberty to believe that it is caused by negative thinking, or overuse of mobile phones, or spirit possession, or anything else that is not accepted by current research. They will not be labelled as ‘lacking in insight’, forced to undergo treatment, and assigned a devalued and stigmatised identity against their will. However, we expect doctors to abandon concepts like wandering wombs, or railway spine, or scrofula, or apoplexy, or green fever, that have not been validated by the evidence. Anything else is folklore, not science.

But that is a bigger question. At present, it is hard to disagree that offering people an informed choice whether to accept or reject a psychiatric label is the only honest and humane way forward. I hope this book will be a contribution to that process.

 * * * * *

References

  1. Boyle, M (2013) The persistence of medicalisation. In S Coles, S Keenan and B Diamond (eds) Madness Contested: Power and practice. Ross-on-Wye: PCCS Books.
  2. Dillon, J & May, R (2003) Reclaiming experience. Openmind, 120, 16–17.
  3. Kovel, J (1980) The American Mental Health industry. In D.Ingleby (ed) Critical Psychiatry: the politics of mental health pp. 72-101. Harmondsworth: Penguin

20 COMMENTS

  1. Lucy,

    You hit several nails on the head!
    A great blog piece!

    One factor to consider is disability from these conditions. This is another area that needs to be addressed for those who truly cannot work (hopefully, becoming more temporary than permanent, with a paradigm shift underway).

    How can somebody obtain and keep these benefits without a psychiatric label? We need to address this issue, particularly and ironically, for those who are disabled from conventional psychiatric treatment.

    Lastly, where did you get that smile?! Wow!

    Be well,

    Duane

  2. Lucy Johnstone wrote:
    “But choice about diagnosis exposes psychiatry as something fundamentally different from legitimate branches of medicine. . . . Since ‘diagnosis is the Holy Grail of psychiatry and the key to its legitimation’, offering choice about diagnosis strikes at the foundation of the theory and practice of traditional psychiatry, and reveals its essentially unscientific nature.”

    Lucy,

    Many thanks for your observations on problems that so rarely get such clear thinking. You remind me of my one and only worried visit to a psychiatrist. I asked him how he knew whether people were crazy or not. “By their behavior,” he said. I was surprised. I thought he had some kind of medical or scientific test that ordinary people didn’t know about. “By how they ACT?” I asked. “By their behavior,” he said firmly.

    I had planned to tell the psychiatrist about the strange thoughts that had erupted in my brain, and ask his advice on how to handle them, but his answer to my question really told me all I needed to know. I thanked him politely for his time, paid the bill for the consultation, and went home. The next few weeks were pretty rough, yes, because even I knew I was having psychotic thoughts. But I never acted them out or went to a psychiatrist again. It was too dangerous. Only crazy people had to go to psychiatrists. I wasn’t crazy as long as I stayed away and put on a good act. That’s what the psychiatrist told me.

    Later when I went to psychology graduate school, I learned that what the psychiatrist told me is quite true: diagnosis is based on the patient’s behavior (or at least reported behavior): on how the patient acts. Thus a common outcome of institutional treatment is that patients learn that to be discharged, they must “behave” (act sane) and say what the doctor and nurses need to hear. The chief difference between me and the average properly diagnosed and treated schizophrenic is that I was a quick learner.

    Best regards,
    Mary Newton, PhD

    • What I didn’t realize until after my family’s medical records were handed over by some decent nurses is that psychologists will lie through their teeth to you and your family, while misdiagnosing you and demanding you be medicated, based upon nothing other than lies from alleged child molesters … “diagnosis is based upon behavior (or at least reported behavior).”

      Why is it considered “appropriate medical care” for psychologists to run out and get a list of lies and gossip, “reported behavior,” from child abusers so they may railroad people onto massive quantities of major drug interaction laden cocktails and aid and abet in keeping child molesters on the streets?

      I’m quite certain defaming and poisoning people based upon “reported behavior” / gossip should be illegal.

    • Mary: From time to time psychiatrists would ask me if I heard voices.I never have, and because having been a participant at MIA, had I heard voices, I now surely would have told them no. When the thirty day evaluation for my release from Weston State hospital came up (30days to life sentence) I was asked if I had ever considered harming myself, and of course after the interrogation, forced medical treatment, and torture, I lied and told them no. Something inside of me told me to trust myself rather than them.

  3. Lucy,

    Thank you are expressing the material reality of being in the psychiatric system. Personally I am in the twenty-second year of my psychiatric career and the next time I see a mental health professional it is guaranteed that I will be treated as knowing absolutely nothing about my condition while sounding like an electrocuted Scotsman. Perish the thought that the ordinary person should catch on that all you have to do to never work again is to see a psychiatrist for the ten minutes that it takes to be labelled, the line-up would from Washington DC to New York City.

  4. Hi Lucy,

    Thanks for this. I am very interested in your work in this area. The iatrogenic trauma that I have witnessed with regards to specific labels has been significant, most notably with the uniquely pernicious and oft feared ‘borderline’. Despite it being invalid, unscientific, subjective, gendered, and biased – it is if anything increasing in use.
    If a label resembles little more than hate speech and is used to the same effect against an often vulnerable group of women – can it ever be justified? I would argue not.
    The greatest harm done is often the internal self stigmatisation which is a complex and painful process to undo, for even the most intellectually able person. In fact, it would seem there is nowhere to turn to counter the damage and women are left to simply cope with the aftermath alone.
    There’s a considerable body of research that clearly outlines the harm experienced by those who receive the label , but very little literature for how to recover from the trauma of that labelling.
    How is the loss of self, hopelessness and shame that many experience to be addressed?
    I think a very important question within the wider area of refuting diagnosis is, what do we do when the damage is already done?

  5. Hi Lucy,

    Yes, you’re right of course, everything would be so much easier in a community of survivors.
    The reality is I would disadvise anyone from outing themselves as having received this particular label, which sadly leaves many even more isolated.
    It has been used against women not only to invalidate their testimony in cases of sexual violence and historical child sex abuse but to deny them child custody. Dana Becker has written on this specifically.
    It’d also be career suicide in many ways, unless like Clare Shaw, you work as a trainer /activist and write professionally in the creative field.
    If I’d sat down and dreamt up a more damaging and dangerous construct for women in distress, I’m not sure I could top ‘borderline’! What’s almost comical in a black hearted sort of way is that most women who have been unfortunate enough to have received this tag have lived through what many would never survive only to be told they have difficulty ‘regulating’ themselves.
    I think the most valuable thing I could do would be to set up an online resource to support women in undiagnosing themselves and reclaiming their place in the human family.
    But maybe if you were inclined you might write a post that speaks directly to the issues I’ve addressed.
    Namely, how to begin to recover from or address living with a concealed stigmatised identity or self stigma that it’s not possible to publicly reveal. Because even if we reject the label, read critical material, accept it’s scientific invalidity – it still has the capacity to do untold harm to how we view ourselves and the choices we make. Intimate relationships are impossible places to hide trauma in but the risk of revealing a past history of psychiatric labelling of this nature, to me seem too great.
    I know many cases of women simply frozen in traumatised isolation as a result of it. Reading about online you come across these scenarios frequently.
    But, finally, I realised recently what sets this demographic of survivors apart and you’ve nailed it above.
    It attacks one’s very core, the essence of who one is. No wonder so many labelled as ‘BPD’ can’t identify with the survivor community’s focus on biopsychiatry. Many of them would only have loved to be told they had wonky brain chemisty but instead were told they were mad/bad and sad with broken ‘selves’.
    Anyway, on a brighter note, I hold out much hope for formulation. To be honest, I can’t think of anything I’ve encountered that makes more sense.

    Isis.

  6. I never has a psychiatric diagnosis before I came to the attention of the psychiatry services in your local health board area, this last year, Lucy. Now I have some spare ones that I am willing to donate as an Easter Giveaway treat to anyone who wants to share the experience!

    Most notably, I have alleged autistic spectrum traits relating to my “rigid thinking” around NICE Clinical Guidelines, and paranoid personality disorder symptoms relating to my “distrustful, combative” questioning of the psychiatrist’s (lack of) expertise, a tenacious sense of personal rights (to be treated in accordance with aforementioned NICE Guidelines….), a litigious nature (demonstrated by a formal complaint about the loss of massive amounts of my personal data) and excessive self-referential behaviour, as evidenced by the audacious way in which I talked about me and my own lived experience during an assessment of….. well, that would be me, I think. Or was it supposed to be all about him, and I missed the memo about that?

    One of the most difficult barriers for me of rejecting my unwanted diagnoses (one of the diagnoses was wanted and is helpful for treatment purposes) was the initial sense of intense shame I felt, to be in the position of needing to see a psychiatrist in the first place. Another was (and is) the fear that if I reject the unwanted labels, then I may be denied continuing access to the treatment that I do feel I need.

    Advocacy support has been massively helpful to me in helping me to throw off the straitjacket of my psychiatrist’s inexpert opinion. Mindfulness practice helps me to stay with the uncomfortable sensation of sitting under the gaze of the creepy psychiatrist, whilst retaining a sense of myself as being more than the sum total of his frantic scribblings. Access to my clinical case notes was a significant factor too! The Paranoid Personality Disorder diagnosis was not disclosed to me because the psychiatrist in question feels uncomfortable sharing his thoughts with patients, apparently. Bless him, poor love.

    Any chance of matching my Great Easter Diagnosis Giveaway by offering a couple of free copies of your book to the local psychiatry team?!

  7. Dear TenaciousMe,

    Please don’t feel ashamed. It’s probably the most corrosive, painful, and utterly futile emotion. The only thing it does in your case is indicate that you have been badly mistreated, no?
    You have nothing to be ashamed about. You write very well and you’re laugh aloud funny in parts which shows resilience. They love that word – resilience. It’s all about resilience building they tell folks!
    Well, I call bullshit on that to be honest. I think cracking up and fighting back is a legitimate response to life at times.
    But here’s the thing. Many people make the decision to totally disengage from services as to stay plugged in does more harm than good and in certain cases can be lethal. If the ‘help’ on offer is shaming, coercive, violent and pathologising then it might be in someone’s best interests to work towards putting alternative supports in place (however scarce) that enable them to move towards disengaging with a system that is abusive.
    If there are certain aspects of a service a person wants or needs then I would advocate they don’t let deliberately provocative behaviour from consultants or staff take that away from them.
    The sticky thing about shame is that it attaches to all of the worst things we think and fell about ourselves.
    But here’s the thing – even if someone has behaved in ways that they themselves would rather they hadn’t, it has happened for a reason. I think we’ve all been in a place (I know I have) where we think ‘I wish I hadn’t said/reacted/responded/like that’, but it’s important to separate bad tempered shouting at a cold caller or being less than polite to a frustrating bank teller, from distress and overwhelm.
    Distress is not a maladaptive response. It’s a valid, understandable, and logical response to life events and experiences.
    What really is pathological is the demand for people in distress seeking help to be passive in order to be helped. So, let them say you’re floridly paranoid and unnecessarily litigious. My alternative undiagnosis is that you were unnervingly articulate and assertive and they had a bit of a tantrum. Albeit through the medium of the DSM.
    Don’t le the bastards grind you down! (and maybe write a blog, folks would certainly follow it)

    Isis.

  8. Thanks, Isis. I don’t feel ashamed any more.

    One enormous way in which I feel privileged is that I have had consistent and fantastic support from my GP surgery. When I first sought help a couple of years ago, my lovely GP was generous with his time and unconditional support. When I admitted to feeling disgusted and ashamed of my depression, he repeatedly told me that my feelings were not “me”, that I was not disgusting, that I could and would recover. Each week he encouraged me to “Keep Going”.

    I started to feel shame again when I first came in contact with the mental health team, but that turned into anger (and hilarity at times) when I realised that the dysfunction was not all mine.

    I’m fucking angry (are we allowed to swear here?) about the way I am being treated but I am entirely unapologetic for that, and I am chanelling my anger into trying to make services better for others who come after me.

    As Lucy will know, our Health Board area covers some of the most economically deprived areas in the country. Many mental health patients will not have had the educational privilege that I have had, and I realise that I am unusual in my capacity to be outspoken in this particular Health Board, but I feel it is important for those of us who can speak out to do so, for the greater good.

    Aneurin Bevan came from a Welsh valley close to ours. He was a passionate and unashamedly angry campaigner for social justice and he drove forward the creation of our National Health Service with a relentless drive to challenge social and health inequalities. I asked my psychiatrist to consider whether there would even be a national health service in which he is privileged to work, if Nye Bevan had been discovered by his local psychiatry team before he was discovered by the Labour Party. The psychiatrist looked perplexed and then admitted that he wasn’t quite sure who Aneurin Bevan was….

  9. In the interests of refusing to bear shame, I will say here that my “wanted diagnosis” is of ADHD-Inattentive. I know that that diagnosis is controversial, but it fits me like a glove and gives me access to controlled drugs that are a benefit to me.

    I am seeking a referral to a specialist ADHD clinic but have been denied my request on the grounds of…. no reasonable grounds. In lieu of my right to proper treatment, I am seeing someone with a “special interest” in the condition, but without much knowledge of the latest clinical and research outcomes. (Under the heading “self-referential behaviour”, he wrote with no apparent sense of irony, “she has read more papers than me”. Ummmmm….. what can one say to that?! I actually want to reclaim that part of the diagnosis and wear t on a t-shirt.

    (Maybe I should get quotes from my case notes printed on t-shirts to wear to future reviews: “Have read more papers than you”, “feeling angry and litigious today”, “distrustful (cf: long complaint letter)”).

    I do blog, but it’s private for now, and is a means of thinking things through in a more balanced way.

  10. Yes, I think a lot of smart folks can identify with what comes under the heading of ADHD.
    I’m glad you don’t feel shamed any more and it’s lovely to hear your GP was so supportive.
    Sami Timimi makes the point that all interactions with a person have the capacity to be therapeutic and that this isn’t the preserve of one group of workers within a service. It’s comical and slightly tragic that so many consultants see their role as ‘diagnosing’ (labelling) and ‘medicating’ (drugging) and that the talky feely stuff is for the psychologist.
    Incidentally, Sami Timimi (who seems like a very nice fella) specialises in the field of what is termed ‘ADHD’ and co-edited a collection of writings on the subject. He would certainly be a good person to even meet to chat with were that possible. He seems to be based in Lincolnshire. http://www.amazon.co.uk/Rethinking-ADHD-Culture-International-Perspectives/dp/0230507123/ref=sr_1_1?ie=UTF8&qid=1427999617&sr=8-1&keywords=Rethinking+ADHD%3A+From+Brain+to+Culture

  11. Thanks for that link. He looks interesting. 🙂

    I’m absolutely OK with the ADHD diagnosis though. Yep, it’s a daft name for a condition where I don’t have any hyperactivity symptoms, and yep, the diagnosis fuels a massive pharmaceutical industry, esp in the USA. But we live in an imperfect world and accepting a label in order to obtain a prescription for a necessarily controlled substance is fine by me. I think the diagnosis will continue to evolve as the condition is better understood and I reserve the right to change my mind and withdraw from treatment at any point. I’m just OK with making the most informed decision I can right now, and playing the future by ear. And, to look on the bright side, I doubt anyone locally would mind if I chose to throw away my ADHD diagnosis any time soon – it is the “paranoid personality disorder” label that they need me to wear, in order to cast a shadow of doubt over the validity of my complaint about the psychiatry service! 😉

    TBH, I didn’t know that adult ADHD was a thing, until about 18 months ago, and I am 43 years old. No-one “sold” it to me in the way it seems to be marketed in the States. I came to the realisation of the symptoms on a meditation mat in a Mindfulness class run in my local Buddhist Centre. (My Buddhist friends cringe when I say that, as they are generally super cautious about psychiatric labels and treatments!) But, yeah, it was through a mediatation class that I came to reflect on issues that I had discussed with my GP over previous months, and to notice that there were quantitative and qualitative differences between my experiences and those of many others in the group. I did a little googling, tentatively approached my GP, and then started looking at a whole lot of non-medical approaches to managing the unwanted symptoms before I became ready to give medication a go. And medication is still only an adjunct to the non-chemical approaches I take to managing the unwanted symptoms.

    In the UK, the specialist adult ADHD clinics/professionals are quite well engaged with patient groups and the research literature is quite easily accessible and digestible so I felt as informed as I could be before beginning treatment. I don’t feel safe with my current psychiatrist and I am determined to get to a specialist one way or another because I’d like to try different medication that might suit me better in terms of some of the unwanted effects, but I am happy with the therapeutic effects of the meds. I am someone who would normally be reserved about even taking paracetamol (tylenol?) for a headache, so I have surprised myself (in a good way) by trying these.

  12. One thing I think is important to say is that I think psychological assumptions can also be harmful if they are overused. For so long, my procrastination behaviours were identified by others as being related to “perfectionism” and I was encouraged to explore where in my past, my ideas of perfectionism came from.

    That never resonated with me, although I bought ALL the self-help books that the pop psychology industry could throw at me, at great cost.

    And then one day, within around 40 minutes of taking a methylphenidate pill my “perfectionism” disappeared (for 4 hours). The cure for my psychological condition was cured by the ability to focus long enough to finish what I needed to finish, wanted to finish, and had been happy all along to finish imperfectly if necessary…. Who knew?

  13. One of the reasons I have remained on medicine for so long is I have no means of income without SSI. Now that my parents are retiring in the spring, I hope to get on SSDI which will mean I can refuse drugs.

    At 42 I have never been gainfully employed and have no real hope of ever being so because of the stigma, as well perhaps, of the iatrogenic nerve damage after 24 years of damaging my nervous system with drugs. I wish I had never gone to that evil psychiatrist when I was 18. He ruined my life with his brain drugs and diagnosis. I wish I hadn’t been obedient for once.

  14. a scientific alternative: “Problems in psychological functioning can be thought
    of as narrow or rigid repertoires of behavior, linked to
    inappropriate selection criteria, at the wrong level or
    dimension, with insufficient retention of successful
    variants that may occur given the current context.”
    See “Modern psychotherapy as a multidimensional multilevel evolutionary process”
    https://www.researchgate.net/publication/272396184_Modern_psychotherapy_as_a_multidimensional_multilevel_evolutionary_process