Adam Blatner

As the American Psychiatric Association has now come out with their fifth revision of the Diagnostic and Statistical Manual—the DSM-5—a number of controversies have arisen. My critique aims at a fairly basic theme: Should we think of all psychiatric disorders as a unitary category, or might they be as different as, say, skin rashes or abdominal pain? All sorts of different conditions from mild to severe can create such problems and they are very clearly not to be thought of as all due to the same thing. That kind of thinking went out of style in Medicine with the passing of the humoral theory in the early 19th century: that all disease was caused by an imbalance of the four humors—the blood, black bile, yellow bile, and phlegm. (That was the rationale for the near universal use of bleeding—either using leeches or cutting a vein and letting some blood out!)

The relevance of all this is that for a while in the mid-20th century many diseases were all imagined to be at least theoretically responsive to “good” psychoanalysis. That theory has been pretty well debunked, but still people are being asked to justify “psychotherapy” without specifying what is being “treated.” It’s clearly a very varied field.

First of all, although we can modify the symptoms of the major mental illnesses somewhat, let me note quite clearly that the best minds in psychiatry don’t understand all that much about the major disorders, schizophrenia, bipolar (manic-depressive), some major depressions, dementias, etc. We know more than fifty years ago, but not much.

We have become aware that some people tip over into the major psychoses and others are terribly disturbed due to trauma, and yet trauma can also be compatible with high-functioning people with certain emotional scars.

We’ve become aware that many people with addictions are self-medicating to reduce the mental suffering of trauma, but also many people use that as an excuse to support their continuing addiction.

We are just beginning to recognize that there are some people who are temperamentally more sensitive and suffer more than other people, given the same stress, and that tempering their sensitivity sometimes can happen with the new classes of medications. This accounts for some forms of “depression.”

We are most familiar with conventional “neuroses” that are associated with problems in living. Some of these are manifested in “identified patients,” but when the family system is examined, the whole system is distorted and work needs to be done on all parties concerned. This conjoint family therapy is important.

It is not always clear if the individual is to be treated or the society, because some people are at the edge of a system—such as pressure to be involved in some competitive activity and not succeeding—and getting disturbed about it all—when what’s crazy is as much the pressure to play the game when the game doesn’t recognize individual differences in temperament or ability—as much as the reaction to this stress.

Diagnosis?

We need to recognize that the present diagnostic system is a spin-off of earlier efforts to modify even earlier efforts. Its roots were themselves based on what I suspect were false assumptions, such as the idea that certain diseases have the same dynamics.

For example, just maybe some people who are diagnosed with schizophrenia have a psychic sensitivity to psychic invasion, the intrusion of voices. Their personalities are not as shaky as some others who are diagnosed with schizophrenia. It may well be that people with this sensitivity, unless they are helped to cope, deteriorate from the chronic fear that this condition often generates. (Being crazy is funny in some cartoons, but in real life it’s more often hellish!)

Psychotherapy

We need to recognize that working out many aspects of the problem—including just establishing that there is a problem and what it is—is a real challenge. For some the problem is in the mind, helping people to think more rationally. (This is cognitive therapy and it applies to most people with problems insofar as most people add a layer of perhaps mistaken interpretations to whatever they’re experiencing. But that doesn’t mean that cognitive therapy gets at the roots of all problems.)

I want to remind readers that physical problems—getting a leg blown off in Iraq, having a stroke or symptoms of mild post-concussion dementia—in some football players!—requires counseling for all the side-issues generated, the family and vocational issues. Point here is that most people who have major dysfunctions have psycho-social and often vocational issues. But the counseling isn’t aiming at changing the fundamental condition—the blown-off leg—but rather in helping the patient to adapt to life with whatever problem is happening.

Alas, psychotherapy has not yet recognized that there should be as many types and sub-types of counseling as there are individuals and problems. The idea that one approach can treat all is insane—a hold-over from the era when psychoanalysis was competing with other approaches—Adlerian, Jungian, etc.—to prove who was the “best.”

I am pretty convinced that there should not be anything near the same “approach” or type of therapy for all of the aforementioned conditions. The challenge is to rationally design an individualized program that will take into consideration the strengths and weaknesses of the individual patient. Otherwise we are stuck with the problem of what A. H. Maslow observed: People who only know how to use a hammer tend to treat everything as if it were a nail.

Until folks dare to specify what they’re thinking they’re treating, I don’t buy any efforts to assess “scientifically” how well a treatment works. Some who are impatient to establish their method may find this objection frustrating, but that’s too bad.

This mini-essay began with a questioning of diagnosis, which led to a re-thinking of what folks consider “disease.” It’s essential to note different types and sub-types. They may reflect very different causative factors. Note also that many people have several different causative factors operating sometimes at different levels. Until this is cleared up, jumping to assess what “works” is quite premature.