Let's be less quick to hand out psychological labels

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.