Who is mentally ill?

Sometimes as the group leader in my psychoeducational groups, I’d start my standard rap on psychopathology by writing two words on the board: sad and depressed. Then I’d ask, “Do these two words mean the same thing?” After listening to responses from group members, I’d proceed in this manner: Yes and no. On the street they’re synonymous, but to a psycho-diagnostician they can be very different things. Sadness is a universal human experience. Sometimes we can identify the reason or reasons for our sadness, other times not. When a person says, “I’m depressed because my friend is moving away,” they’re likely describing “normal” sadness that will probably diminish over time.

Sadness is a mood, and moods come and go. If a sad mood becomes persistent and affects your functioning, depression may be a better description for the experience. This persistent mood may also be due to an identifiable cause, such as a romantic breakup, or it may be unrelated to life circumstances. The former is referred to by some  clinicians as “functional” (caused by some external circumstance), the latter as “endogenous” (caused by internal, biologic factors). This isn’t an absolute distinction in all cases, but it has its utility.

There’s a deeper level of depression that isn’t a universal experience. Even at the lowest points of my life, I’ve never been as sad as the clinically depressed people I’ve known personally and professionally. People living with this kind of depression may experience hopelessness, despair, and suicidal ruminations. I’ve never been there, and I have great compassion for those who have.

One way of classifying psychopathology is assigning people to distinct diagnostic categories. You either do or don’t meet the diagnostic criteria for depression, or schizophrenia, or bipolar disorder, or antisocial personality disorder. If you don’t have the disorder, you may have traits associated with it. Another way of classifying pathological traits is to view them along continuua: straight lines with opposite poles. Everybody can be placed somewhere on a continuum between happy to be alive and suicidal, gentle and violent, honest and dishonest, paranoid and trusting, and other traits and tendencies.

If I’m extremely unconventional but functional, some people may refer to me as “crazy,”  but to others I’m merely eccentric. If I’m unconventional to the point I can’t function in society and may endanger myself or others, I could be mentally ill. In my graduate program in humanistic psychology, we didn’t even have a course titled “Abnormal Psychology”; that was considered too pejorative. Our course was titled “Unconventional Modes of Experience,” lest we apply unnecessary or judgmental labels to people.

Psychopathology is characterized by impairment or disability. I have obsessive-compulsive traits, but I don’t think of them as pathological, because I’ve been able to recognize, control and channel them. I’ve had doctors and lawyers tell me that they never could have made it through medical school or law school if not for obsessive-compulsive traits. You too may have traits of a mental disorder, but not meet the diagnostic criteria, because you’re not impaired by them. For instance, you might have some symptoms of depression, but not be pathologically depressed. Or you might have paranoid traits,  but not be diagnosable as having a paranoid disorder. The hyper- vigilance characteristic of a truly paranoid person might even be desirable, if you’re a spy.

Even if you have a diagnosed mental illness or engage in crazy behavior, you can’t be involuntarily committed to a treatment facility without a Probate Court hearing. (I only refer to behaviors as “crazy,” not people.) In most states you must be interviewed before the hearing by two Designated Examiners (DEs), one of them an MD, and have court-appointed legal counsel to represent you at the hearing. In order for you to be involuntarily committed, both DEs must agree – and convince the court – that you are of danger to yourself or others, due to a diagnosable mental illness. I’ve had the privilege and responsibility of being a DE for most of my career, and in my experience the system works most of the time to prevent people from being “railroaded” onto locked wards against their will.

Mentally ill people are often shunned, and even blamed for their symptoms. With good treatment most mentally ill people can function in society, although some are too disabled to hold a steady job. All people with mental and emotional illnesses deserve good treatment, regardless of income. But unfortunately, state mental health systems all over the country are terribly under-funded, and many folks don’t get the treatment they need to remain functional. A significant portion of homeless people have mental illnesses. Hospital ERs, jails, and prisons have become major mental health service providers. I’ll describe how we got to this sorry state of affairs in a later post.

The model muddle

I’ve already written posts on several therapy models (gestalt, Rogerian, Transactional Analysis, Freudian psychoanalytic), so it’s time I examine what models are: their utility, their strengths, and their limitations. First off, models are ways of organizing and framing ideas in a way that serve as a guide. A good model is like a good map: it helps you accomplish something you set out to do, to get where you wanted to go.

But the map is not the territory; it’s merely a helpful representation. I’ve known people who were so dedicated to a model that they couldn’t see its limitations, and were blind to alternative formulations, viewing everything through the lens of their fixed beliefs. No model is perfect and complete. Each one has its flaws and limitations.

I first started thinking about models as a young mental health professional, when I read Miriam Siegler and Humphrey Osmond’s Models of Madness, Models of Medicine, in which they compared the medical model to eight other models related to the care of mentally ill persons. After examining each model (moral, impaired, psychoanalytic, social,  family interaction, etc.), the authors – both MDs – conclude that psychiatry is the only way to go. Holistic, shmolistic..

Psychiatry is the medical model’s approach to treating mental illness, usually with medications. The medical model is a scientific model. In a nutshell, the model starts with the identification of symptoms, which leads to an appropriate diagnosis, which in turn leads to a specific treatment. The medical model is very good at what it’s good at, such as mending broken bones, and doing surgery, and treating many physical ailments. But its self-promotion as the only game in town for the care of the mentally ill has been challenged by many, notably Dr. Thomas Szasz and R.D. Laing.

No model is a perfect fit for all occasions, and many MDs have come around to believing in the benefits of a holistic approach to health care. Although I still believe that psychiatric treatment has its place and can be of benefit to many people with what are known as “psychiatric disorders,” like all models the medical model has its limitations. There are other valid approaches to health care that don’t rely on symptoms > diagnosis > treatment as their primary focus. The medical model is mostly focused on what to do after you exhibit symptoms, not so much on how you got there. Some medical traditions are more focused on wellness than on treating (sometimes preventable) illnesses. No model has all of the answers.

One of the limitations of the medical model as regards the care of mentally ill people is that the criteria for a differential diagnosis were determined by a committee of psychiatrists, to be applied to a unique individual. Unlike most physical disorders, there are no identifiable biological markers to distinguish what we call “schizophrenia” from “schizoaffective disorder” or “bipolar, manic.” Psycho-diagnosis is not rocket science, because mental illness isn’t precisely measurable. At best it’s educated guesses, and many people with an extensive history of psychiatric treatment have been diagnosed with – and treated for – a variety of diagnoses.

A model I’ll be writing about in a future post is the Recovery Model. A lot of mental health professionals initially scoffed at the idea of people “in recovery” from chronic psychiatric disorders. Recovery made sense as a helpful model for “recovering” chronic substance abusers, but did it apply to the chronically mentally ill? I think (hope) that many or most mental health professionals have come to recognize the merits of the recovery model, and there are now recovery centers in some cities that aren’t run on the medical model. You might want to check out <madinamerica.com> to learn more.

Treatment models compete in the marketplace, and there’s money to be made. For instance, the Pentagon has paid millions for training in Positive Psychology. With modern marketing in the mix, we find ourselves in the midst of a model muddle. More about this down the road.

First blog post

You don’t have to be sick to get better


My psychology graduate program at West Georgia College (now the University of West Georgia) was the only program in the Southeast, in the grad school catalogs I studied, to promote itself as a “humanistic psychology” program. For a while humanistic psychology was anathema to many fundamentalist Christians, some of whom saw it as having Satanic origins and goals. All I’ll say about that is that there was nothing in the humanistic psychology movement that was dissonant with the Christian values I was raised with, and some of my classmates were Christians.

Humanistic psychology was practically synonymous with the “human potential movement” in psychology, and was referred to as the Third Force in psychology – the first being Freudian psychodynamic theory and the second being Behaviorism. It was an umbrella term for new theories and therapies that didn’t fit neatly into either psychodynamic or behavioral theory or practice, and wasn’t grounded in remediation of psychopathology. Many or most humanistic psychologists were interested in psychologically healthy persons, as well as therapies that didn’t rely on psychodynamic interpretations or behavior modification techniques.

Among the theories and therapies in the movement were Carl Rogers’ client-centered therapy, gestalt theory and therapy, Transactional Analysis, William Glasser’s Reality Therapy, as well as various movement therapies (Feldenkreis, Alexander Technique, structural integration), encounter groups, systems theory, Eriksonian hypnosis, and neuro-linguistic programming. I’ll have more to say about some of these theories and therapies in later posts. It was an exciting time to study psychotherapy, and I couldn’t have chosen a better Masters program to prepare me for my career.

Abraham Maslow’s “hierarchy of needs” was an important part of the foundation of the human potential movement. Like all models it has its flaws, but it’s a model that explains how potentials for growth are limited by identifiable life circumstances. It isn’t grounded in psychopathology; everyone can be located somewhere in the model. Maslow described a universal hierarchy of needs, generally depicted as a pyramid. The most basic human needs are physiological, such as the need for air, food, water and shelter. According to Maslow, if these basic survival needs aren’t being met, you stay stuck in survival mode and can’t grow, or meet higher-level goals. Once these needs are met, you have the potential to grow.

Next up on the pyramid are safety needs. If you aren’t safe or secure in your life, you have to devote your efforts to security issues before you can move on and try to live up to your potentials. The third level of needs according to Maslow is social needs – healthy relating with family and friends. Our relationships are an integral part of who we are, and without them we’re incomplete. Maslow suggested that once we’ve met our essential needs up to this level, we can work on esteem needs: self-esteem, confidence, competence and achievement. Those who’ve reached this level in meeting their hierarchal needs have the potential to rise to the highest level: self-actualization.

Self-actualization is a process, not a goal. People who have their physiological, safety, social and esteem needs adequately met can devote their energies to personal growth – which may involve helping others and/or developing new competencies. Self-actualizing people can be authentic and spontaneous in relationships, and can follow their creative impulses, doing what they most want to do to the best of their ability. Of course life circumstances and obligations can limit what self-actualizing people are able to accomplish in terms of self-expression and achievement, but they can continue to grow and learn until they either lose their capacities or die.

Just because you’re grown up doesn’t mean you have to stop growing. Growth can be a life-long process if you cultivate the garden of your unique life. My next few posts will be about factors – including thoughts and beliefs – that can either facilitate or impede personal growth.