Over-Pathologizing in Mental Health: Finding the Right Balance

As a mental health nurse, I’ve seen a lot over the years. One scenario I see far too often involves individuals with a myriad of needs—lack of employment, no occupation, financial struggles, no social support, little purpose, generally overwhelmed, and poor health habits—who are struggling with aspects of their mental health, such as low mood, stress, and anxiety. Often what can happen in these scenarios is that this person ends up, for whatever reason and with the best of intentions, being encouraged to see someone regarding their mental health.

Too often, this is what happens: they are referred to another service, get on a waitlist, diagnosis labels are applied in the absence of formal diagnosis, and they are pigeonholed into a “if only you could process your mental health problems first” mindset. This, I think, can lead to further harm, even with the most empathetic and best of intentions.

I hate to say this, but unfortunately, professionals (I include myself here) often minimise addressing the fundamental issues that may make a difference, like occupation, money, work, friends, hobbies, diet, sleep, and overall purpose. Instead, there’s a tendency to think in terms of mental health labels and getting an intervention. Often professionals are caught between a rock and a hard place as providing an intervention or adding to a waitlist for treatment is the only thing the professional feels able to do.

Just to caveat this in bold: I am not saying no one should have therapy, and I’m not referring to people with severe mental health disorders and risk. I truly believe that talking therapies should largely be reserved for those with mental health disorders where there is an evidence-based treatment approach. Think PTSD and CBT/EMDR. Think OCD, GAD, Panic Disorder, Health Anxiety, Social Anxiety, and CBT. Think Depression and IPT. Think EUPD and DBT, and so on. I also want to say I’ve met a ton of people in the mental health space who are doing a fantastic job of looking after someone’s holistic needs while reserving diagnosis and therapies for when they are needed.

The Faulty Reasoning

Most of us have heard the term Occam’s Razor, which is a problem-solving principle that suggests the simplest solution, one with the fewest assumptions, is usually the correct one. Seeing mental health using this principle illustrates part of the problem.

Let’s take a physical health example of faulty reasoning. Someone presents to their GP with fever-type symptoms. The GP is concerned and sends blood tests off and makes an urgent referral fearing a rare tropical disease. It turns out it was flu. Occam’s Razor would suggest that the GP should have first looked at the simplest reasons in the first instance, i.e., flu, as it is based on fewer assumptions. For a rare tropical disease to be true, lots of other assumptions would have to be true as well: the patient had to have travelled to certain places, been exposed to specific parasites, etc. Whereas for flu, it’s pretty common, in season, and could have been contracted anywhere. Applying some reasonable questions, the GP could have quickly concluded, “It’s probably flu,” and set up a simple plan: “If it persists or gets worse, see me again and we can look at the next steps.”

Now, let’s apply this to mental health. Here is the common fault I see: someone is referred to MH services with poor concentration, poor sleep, easily distracted, stressed, low mood, not being able to finish tasks, isolating themselves, struggling with work, and experiencing bouts of anxiety. The focus of interactions with a range of professionals has been around getting an assessment for Disorder X. X is now in the lexicon of this person’s mind. It’s basically a working diagnosis that will offer some level of meaningful explanation for the person and their difficulties, for example; ‘of course I’m struggling, I have disorder X’. Occam’s Razor was not applied. When you scratch below the surface: they are in a job they find boring and hate, their sleep rhythm is off, there may be a bit of alcohol/drug use, life is sedentary and lonely, and general stress levels are high. Apply Occam’s Razor to this: they may well have Disorder X, but let’s assume that the basics being met is addressed first. If the basics are addressed, it will lead to the best chance of improvement in that person’s life. If concerns continue, an assessment for Disorder X could be pursued.

Sadly, I have heard a lot of stories similar to this in mental health where people end up waiting years for something, to be told in the end, this is not for you, you should do the basics.

We need to help someone sweat the small stuff first. This could be finding new meaningful volunteer work or occupation, getting a hobby, being part of a group, accessing a psychoeducational course on sleep and diet, or getting a referral to a gym scheme—you name it. I don’t have any formal statistics to back this up, but think this is case in most cases.

Obviously, there are exceptions to Occam’s Razor. Sometimes people present with rare conditions. But typically, when tiers of services and processes are working well, stuff is ruled out quickly and the rarer stuff is picked up down the line.

This fault in reasoning can lead to something recently introduced to me: ‘overt diagnostic overshadowing.’ When there is an over-focus on diagnosis, it can lead to iatrogenic harm (harm caused by treatment or intervention) by neglecting the real needs of individuals and providing unnecessary waits and interventions. This can result in individuals being placed on long waiting lists for therapies or groups that may not address their actual issues. Worse still, they might be on a list for the perfect therapy for their issues, but because of all the abundant stress in their life, it will massively impair their chances of engaging meaningfully with the therapy. Then months or even years can pass, and countless opportunities to improve their lives through meaningful activity and support can be missed.

All this over-pathologizing, fixation on diagnosis and overt diagnostic overshadowing is a bit like waiting a year to get a leg operation, to be told on the day; ‘you don’t need an operation, you just needed to have done these exercise for the past year’.

Holistic Care: Let’s Return to the Basics

During my training as a nurse way back when, the term “holistic care” was often mentioned. Back then, I just wanted to be on a ward on placement, and all these terms never really meant much. But the concept is simple yet profound: consider the whole person, not just their symptoms. Think about it like this: If you’re building a house, you need a strong foundation, right? Similarly, in mental health, addressing basic needs first is crucial. Instead of rushing to diagnose and treat, we need to have the courage to tell people that they don’t need therapy or to ruminate or stew about their mental health problems. What they often need are small, actionable steps to improve their overall well-being and health.

When speaking to someone, I’ll sometimes frame a statement like this: You could spend a fortune for the best personal trainer in the world. You’ve got a plan, the best exercise regime just for you. But when you leave that weekly session, you go home, the house is a mess, you have little money, the fridge is full of junk food, you have a stressful day job from 9-5, your sleep is poor, and you’re drinking alcohol and using cannabis on weekends, you haven’t seen your friends in months and you definitely aren’t hitting the gym in the meantime. The personal trainer is a waste of time and money. Use that money to look after the small stuff first.

I might sound hyperbolic, and believe it or not, I really am pro-psychiatry. But when it comes to leading a more valued life, a mental health professional or GP should be far down the list of your go-to people. Our lives are far more nuanced and complex than a health professional can handle all the needs for. Family, friends, buddies, fellow dads, sports groups, gym communities, local signposting organisations, your priest, your solicitor, the guy at the allotment, and other pillars of the community should be your go-to initially. These social connections are the bridges that build lives that we value.

Maslow’s Hierarchy of Needs: A Guiding Framework

It sounds so cliché in healthcare to say “Maslow’s Hierarchy” out loud. But I think it’s a model that fits. Abraham Maslow’s Hierarchy of Needs, introduced in his 1943 paper “A Theory of Human Motivation,” categorises human needs into a five-tier pyramid: physiological needs, safety needs, belongingness and love needs, esteem needs, and self-actualisation. This theory remains highly relevant in healthcare today as it emphasises a holistic approach to patient care, prioritising basic needs before addressing higher-level psychological concerns. By ensuring foundational needs like adequate sleep, proper nutrition, and social connections are met first, healthcare providers can create a stable base for patients to engage more effectively in therapeutic interventions.

Building on this framework, it is crucial to recognise that strong foundations are necessary for growth. Often, addressing basic needs can alleviate mental health symptoms more effectively than jumping straight to suggestions for mental health assessments, diagnoses, and therapy. Basic needs might be just ensuring that someone gets help in navigating a PIP application or that they have social support, warmth, and a roof over their head.

Once these foundations are in place, they may be better positioned to pursue personal growth, reflecting on their minds and actions to enhance their mental well-being. This approach not only aligns with Maslow’s hierarchy but also supports a more patient-centred, effective healthcare strategy that supports someone’s overall well-being.

So, all my moaning about over pathology of mental health, what should we do about it?

Things We Need to Know and Do

This isn’t a perfect list, but it’s a start. It’s a list of things I really think we should all know. It’s for professionals, health workers, friends and family, and anyone who is going to be a source of support for someone with mental health difficulties.

Mental Health is Complex

Physical illnesses like diabetes can often be managed with cause-and-effect treatments. For example, if you have a diagnosis of type 2 diabetes, there is an existing evidence base of what works, and usually a plan to manage it. If blood sugar levels are X, do Y. Anxiety and depressive disorders frequently involve a mix of external stressors, physical health problems, faulty thinking, poor habits, and past adversities. There is never a simple “you have X so do Y.” It’s more like “you have X, Y, Z and a little of A. You probably should focus on doing B, D, C, and a bit of E in the meantime.” Start by mapping out these stressors, focusing on the most significant ones. High anxiety could be alleviated by reducing alcohol or cutting back on the half-dozen energy drinks consumed daily. Mood might improve with a couple of weeks of nice walks and easy gym sessions, or by establishing a sleep and wake routine.

Consider the Whole Person

Adopt a holistic approach that looks beyond mental health symptoms. Practical steps like encouraging people to expand their worlds and take small actions to improve their well-being can be more effective than rushing to diagnose and treat. A person isn’t just a bundle of neurons occupying the space in a head. They are everything—they are the connections with others, they are a dad, brother, friend, work colleague, someone who helps, who cares, and who lives a life full of value and potential. Treat them as such. They aren’t a mental illness that just needs a niche fix.

Promote the Basics

The basics matter: improve sleep, eat right, move more, connect with others, and find meaningful activities. Studies show that exercise can often outperform therapies. The New Economics Foundation’s “5 Ways to Wellbeing” suggests connecting, giving, learning, taking notice, and getting active, providing a common-sense and simple framework as good as any I’ve come across. Imagine a consultation where someone comes in with a host of problems, and the professional sets a plan to do a bit of each of the five ways to wellbeing with the client. I think it would work.

The Right Place for Therapy is Stability

Don’t immediately suggest someone needs a therapeutic intervention unless things are pretty dire. Therapy works best when specific disorders like PTSD, OCD, panic disorder, and social anxiety disorder are present without undue ongoing stressors. CBT, IPT, DBT, and BA are highly effective for those who are ready for them. Focus on achieving stability first. Think Maslow’s hierarchy of needs. Think of the personal trainer analogy: you aren’t going to get much out of CBT for depression if your roof has just fallen in, there’s water everywhere, and all your stuff is destroyed.

Questioning your thoughts, changing lifelong habits, and talking about and facing real hard stuff is not easy. It makes sense to be in a strong place to do this. Getting affairs and stressors in order as best as you can with what you’ve got will create a little more resilience and stability. So, when therapy comes along, you’ll be ready to engage and benefit from it.

Connect, Connect, Connect

One of the best protective factors when it comes to our health and well-being is having others as a source of support. No matter how introverted someone says they are, being part of a community and having connections is as fundamental to our health as food and water. There’s a reason we’ve populated the world and built magnificent structures and systems: it’s because we connect with others.

When we are at our lowest ebbs of well-being, it’s not usually the person struggling who reaches out and gets help. It’s the social safety net. It’s the mate who pops over a bit worried about them, it’s the family member who knows them better than they know themselves. It’s our kids, brothers, sisters, and partners. It’s the people who like you being part of their world.

If we know someone is isolated, engage with them. Extend those invitations and offer your time to help others connect. Build and support community networks. Encourage participation in local groups, activities, and events that promote social interaction and a sense of belonging. Strong community ties can provide a safety net for those struggling with mental health issues.

Encourage Self-Care Practices

Encourage individuals to develop self-care routines that include activities they enjoy and that help them relax. Simple practices like spending time in nature and mindfulness can significantly improve mental health. It might not even be something you like and can even be something you think is odd or wacky; it’s all about whatever works for that person. For someone, this could be yoga, ice baths, or meditation.

Educate About Mental Health

Think Occam’s Razor. Don’t jump to severe mental health conditions or personality disorders. Try to increase awareness and understanding of mental health issues through education. Provide information about common mental health conditions, and the importance of reducing stigma, which can encourage more people to seek the help they need (and hopefully the timely treatment they need). Furthermore, there is a lot of ‘over-awareness’ of many mental health conditions exacerbated by social media, often from suspect sources. I literally watched a video where a woman adopted ‘funny’ walks, suggesting if you walk like this you have ADHD. One walk involved her stopping to appreciate a tree, another that mimicked a T. rex. This is crude and insulting to genuine cases of ADHD where people’s quality of life has been impacted because of it and who now cannot access a diagnostic assessment due to burgeoning waiting lists.

Applying this logic of a serious disorder like ADHD being exaggerated on social media to a physical health illness illustrates its insanity. Imagine if I did a video where I was fumbling to find my keys or walking into a room and forgetting what I was looking for, and then suggesting that I have dementia.

Empower Through Skills Training

Teach coping skills and stress management techniques. These skills are great for absolutely everyone. There are a lot of services providing open-access courses where you can just turn up. Skills such as problem-solving, time management, and emotional regulation can empower individuals to handle life’s challenges more effectively.

In a professional capacity, I am always bowled over by the benefit some people get from seemingly simple concepts. Never underestimate the power of simple skills training.

Be Proactive in Follow-Up

Whether you are a friend or a professional who has seen someone, gently follow up with individuals to track their progress. For professionals, this might mean adjusting care plans as needed. For peers and friends, this might mean a bit of problem-solving and holding them gently to account or prompting them to look after their wellbeing. When we do this, relapses are spotted, and that person is a little more likely to seek out support when needed. A little bit of motivation and encouragement will go a long way.

It’s Okay to Be a Bit Prescriptive at Times

One thing I’ve had to unlearn over the years as a mental health nurse is ‘empowering people to make their own decisions.’ This sounds great and certainly has its place, but I have come to realise that dishing out a bit of advice and being prescriptive is just what a lot of people need (this is very different when it comes to more formal therapy where part of the process is empowering people to come to their own conclusions).

This is another blog article in itself, but when we are stressed and burnt out with life, our ability to find motivation within ourselves is sapped. We need motivation outside of us. Imagine this: a young man who is low in mood goes to a mental health worker in a GP surgery. The worker gives them a good spiel about looking after themselves and says, “Before we consider a referral for psychological therapy, I want you to contact person X, sign up for Y, and each morning do Z. Do this until our next review in 4 weeks’ time and tell me if it’s made a difference.” For a lot of us, this little bit of extrinsic motivation will do us a world of good. But we do have to know our crowd and when this is appropriate.

1 in 4 People Have…

Controversy alert. It’s the classic stat: 1 in 4 people experience mental health problems each year. Firstly, if 25% of people have it every year, that’s not an ‘issue.’ That’s normal human experience. That’s life.

The bulk of this 1 in 4 are experiencing very reasonable symptoms in response to often common stressors, life events, and transitions. Such as a loss, change in jobs, loss of role, time of year, self-neglect, sleep deprivation, being a new parent—the list goes on. Labelling it as a mental health issue leads to over-assessment and over-diagnosis when there are far more useful things to be considered in the short term.

Know When Help is Needed

The bottom line is that if it’s pretty clear that “sweating the small stuff” isn’t enough, it’s crucial to seek professional help. If someone’s problems persist despite making basic lifestyle changes, if they pose risks to themselves or others, if they have a history of self-harm or suicide attempts, or if they already have a diagnosed condition, don’t wait. Encourage them to see their GP or seek urgent help if needed. Be that confidant and support. It’s important to recognise when professional intervention is necessary to ensure their safety and well-being.

It’s essential to acknowledge that while addressing basic needs and making lifestyle changes can significantly improve mental health, there are situations where professional help is indispensable. If you notice persistent symptoms that don’t improve with self-care, signs of severe distress, or behaviours that pose a danger to the individual or others, it’s time to act. This includes instances of ongoing suicidal thoughts, self-harm, or existing mental health diagnoses that aren’t well-managed. Don’t hesitate to guide them towards professional resources, such as their GP, mental health services, or urgent care if the situation requires it. Your support and timely action can make a vital difference in their journey towards recovery.

Conclusion

In summary, while it’s crucial to address the basics and take practical steps to improve mental well-being, we must also recognise when professional help is necessary. Over-pathologizing mental health issues can lead to overlooking fundamental needs, but there are times when intervention is essential. Balance is key—support those around you by promoting healthy habits and strong social connections, but also know when to guide them towards professional care. By adopting a holistic approach and staying vigilant, we can better support individuals in leading valued and fulfilling lives. Let’s rethink our approach to mental health and ensure we’re providing the right support at the right time