Adam Blatner

Things have changed: Different types of “mental illness” need to be discerned. Certainly the history of medicine includes as a them the recognition that, for example, some diseases that seemed to be infectious were actually due to nutritional deficiency—such as pellagra. Similarly, a number of major mental illnesses such as “dementia paralytica” that was a major problem in the first third of the last century turned out to be due to a chronic infection by the germ that caused syphilis.

In the mid-20th century, under the domination of Freudian psychoanalysis, schizophrenia, manic-depressive disorder, and other major mental illnesses came to be viewed as just more intense forms of neurosis. What was found to be so in treating mild neuroses in outpatient private practices was imagined to apply also to the more seriously disturbed in hospitals. This was a great error, and many other than myself have felt this to be so. Reading Gerald N. Grob’s history of America’s mentally ill, titled “The Mad Among Us” (New York: The Free Press, 1994) (but only recently acquired by our local public library and discovered by me, I found this to be disturbing: I was trained in the thick of it, almost, at the mid-end of the psychoanalytic phase, so there are vague roots of allegiance that are being stretched. (This is not logical, but emotional.)

Yet I have done a goodly amount of reading in the history of psychiatry as well as thought about the various types of patients I’ve seen. It seems to me that the controversy involves not two but three to five (at least) sub-populations.

To begin with, I think there’s still a widespread sentiment among non-medical psychotherapists that all kinds of mental illness can be significantly treated without medicines. I confess that what we have today in the way of medical treatments is far from optimal—many have undesirable side effects. It’s just that on the whole they’re much better than a generation ago, and even those a generation ago were much better than the era when no medicines helped very much. But the point is that psychotherapy in my opinion is variably helpful for the more seriously mentally disordered. (Part of the problem is that many of these people suffer from anosognosia, a deep kind of denial, and so they are inclined to not take their medicine when left alone.)

On the other hand there are a good many conditions that perhaps should not be prescribed medication. This may vary with the patient, who’s complaining, how much they’re complaining, and so forth. I would prefer that physicians (who prescribe far more psychotropic medicines than psychiatrists) would be more cautious about resorting to medical treatments and work more closely with local psychotherapists to treat these problems through talk-action therapy. (I mean by action the use of certain role playing techniques.)

For many patients of all types there are very real issues of attitudes, over-learning of certain beliefs, the lack of exposure to other sources that would promote resilience, and these formulations, un-learnings and new learnings need to happen to effect true change and not just variations of numbing-out. While not core to the treatment of the major psychoses, addressing these kinds of themes plays an important role in helping to prevent relapse.

Mixed Categories

A number of psychiatric disorders are the result of behaviors that change the functioning of the brain somewhat, but these changes derive mainly from the dynamics of trauma or addiction—a mixture of habit-building, anxiety avoidance, narrow repertoire, and often one feeds the other. That is to say, some drug or alcohol or sexual addictions mask the anxiety developed in the course of living with trauma or secondary to the behaviors associated with the addiction. In turn, as hinted above, addiction leads sometimes to negative behavior, fights, and further trauma. So vicious cycles of mutual reinforcement are common parts of both PTSD and addiction.

There are scores of near-addictions, subtle addictions, problem-causing habituations, that affect health as well as life-style. Lately, obesity and its associated metabolic disorders such as secondary diabetes is being looked at as an addiction to junk food. So all of these may overlap with and compound other behavioral syndromes.

These in-between types are mixtures of psycho-social disorders and primary or secondary neuro-physiological changes. Both physical and psychological interventions are needed.

Related to all these are those who have various extremes or variants of temperament and abilities (or disabilities) and yet they’ve not been able to adjust their lives to these qualities of individuality. Rather, they’ve tried to adjust themselves to the average socio-cultural sets of demands, and it doesn’t work. These, too, need a combination of physical adjustment or medicines and education for living realistically with their temperament and abilities.

Grob’s book addresses the politics of the care of people who tended to be more chronically and severely disturbed—especially with schizophrenia or debilitating manic-depressive illness. The senile, the severely mentally retarded, the severely retarded, those, in short, with problems that need a lot of care, should not be lumped theoretically, psychologically, with those who can work and afford to attend and pay for psychotherapy sessions. But let’s not forget the intermediate forms—people who tend to be diagnosed as healthier than they are, or who tend(ed) to be imagined to be more fixed and “sicker” than they actually were. So it requires careful diagnosis in a field in which the issues as well as implications associated with the diagnostic process is murky.

In summary, then, it’s critically important to identify the unique nature of people’s problems. Merely identifying diagnostic categories is as weak as treating people according to height or weight. A much finer system of discrimination is needed. This of course relates to the realistic near-impossibility of assessing treatments for broad categories of people (based, for example, on general diagnosis). Some are more intrinsically motivated, resilient, have more to offer than others, and this also speaks to their social surroundings. The desire for simplicity needs to be confronted.