Adam Blatner

Considering the challenges of counseling, let’s also consider the idea that there may be not just differences in the severity of illness, but rather different types of illnesses, as different as conditions caused by vitamin deficiencies and conditions caused by infectious agents (as I discuss on a webpage about the history of medicine.)

So let’s re-consider what tends to get lumped together as psychiatric disorder. First of all, of course, there are the most obvious ones, the major mental illnesses, such as schizophrenia, bipolar disorder, major depressive disorder, delirium (which is revers-able) and dementia (which is not, but it’s important to not miss a treatable delirium in elders—usually treatable by reducing their medicines!—from dementia.)

These more severe conditions are in truth still poorly understood. Certainly the treatments available are for the most part better than sixty years ago, but there are many controversies, many horror stories of overtreatment, many touted alternative treatments, some of which might be effective.

In addition, there are fuzzy boundaries among the categories which, though perhaps in some ways better than those used fifty years ago, are by no means valid in all ways. For example, some conditions are made worse by and confused with the consequences of un-diagnosed post-traumatic dynamics or the phenomena associated with illegal drug or alcohol abuse. Also, these conditions are complicated by too much or too little sensitivity or ability in various realms, and so forth.

Much of course of these disorders depends on corresponding presence or relative strength or absence of (1) degrees of voluntariness; (2) psychological mindedness; (3) the support by or undercutting of family and friends; (4) economic access to clinics, appointments, travel, time off from work or child care, etc.; and (5) aspects of ego strength—mainly, how much success has been enjoyed in life in any way, intelligence, etc.  I’ve found that people who are low on these variables are of lower prognosis are more difficult to treat. The point is that it’s not what’s wrong, it’s the proportion of variables that are healthier versus variables that reinforce illness—the vital balance, as Karl Menninger said.

The second group, a little overlapping with the first and third, are those who are moderately messed up from trauma and/or substance abuse or any other kind of addiction. The problem is that people with PTSD often numb themselves out, but this numbing in turn generates other kinds of major stress, such as jail or divorce or abandonment or loss of job, etc.

The third group also has many sub-categories. One of the main populations are those smart and relatively healthy people who want to overcome minor quirks in their personalities as part of holistic development. Most adults have such quirks and this sub-population sees “therapy” as a way to address them. Some of these folks also are therapists in training.

I would dare suggest that this type of “mental illness” is not really illness per se, considering that many clients can keep a job and pay the counselor! Is the disease model relevant here? Sure, there are a few elements in common with other psychiatric disorders, but then again one might lump together football and basketball insofar as they both involve a ball!

Again there are two sub-categories here: Those who really want to change and those who suffer, want relief, and want others to change. The second category disguises itself as the first but is far more difficult to treat.

The DSM being descriptive, in my opinion is an insufficient system of categorization, because it fails to differentiate according to the criteria of degrees and types of voluntariness, psychological mindedness, or ego strength, and I suspect that these sub-types account far more for the differences in how it all turns out (prognosis) than any criteria based on the type of expression of the symptoms. That is to say, it may not matter that much if the client is nervous (anxious) or depressed, compared to identifying what’s bothering him and his style of coping.

In summary, the problem of diagnosis in therapy is muddled, and in consequence, I am concerned that much of the literature on psychotherapy lumps together all these conditions and assumes that meaningful questions can be asked about what works. I doubt that this effort is any more meaningful than a pre-modern approach to medicine that views illness as an imbalance of humors.