Treatment of Mental Disorders

What Disorders Should Be Treated?

A disorder should only be treated if it is a problem. A problem is anything which causes subjective distress in someone or creates a threat of harm to anyone, including the sufferer. This thinking is a relatively recent development for the mental health community (although there are probably still some holdouts from the "old school" of "Treat everything that doesn't follow your definition of "normal"). For example, the sexual deviances such as exhibitionism, fetishes, sadism and masochism, transexuality, homosexuality, transvestism, three-on-a-match, and so on are no longer considered to require treatment. In other words, if you're comfortable with your bizarre sexual practices and they don't hurt anybody else, you don't have problem. But keep in mind that this is subject to change any time a person important to you (a "significant other" like your spouse or parents) complains (in other words, suffers distress).

Causes of Psychological Distress

There are 3 basic causes of distress: 1. Feelings of Inadequacy, 2. Guilt Feelings, and 3. Unfavorable Environmental Circumstances.

I had once had a phobic client who was afraid of her own feet. Despite heroic therapeutic effort on my part, there was little improvement. However, at the termination of therapy she said, "I didn't get over my phobia, but you did make me feel better about myself." I guess that was a partial success. (?)

All of these, the first two more than the third, contribute to a general characteristic of people seeking counseling or psychotherapy: Low self-esteem. For this reason anything that improves self esteem is therapeutically beneficial. It has been demonstrated again and again that you can endure stressful times much more easily when you feel good about yourself. Therefore one practical goal of psychotherapy is to increase self esteem.

Treatment Strategies

Biomedical Therapy

Biomedical therapy is basically administering drugs. It is the psychiatrist's lifeblood since they are the only mental health practitioner currently allowed to prescribe medicine - something psychologists have been fighting ever since I can remember. It is also the reason why mental health clinics and psychologists in private practice must have access to psychiatric services. Otherwise, problems that could be effectively treated with drugs could not be dealt with in the optimal way. Virtually all psychoses require some medication. In addition, only medical providers can commit someone to an institution. This means if you're a psychologist, social worker, or counselor and one of your clients gets so bad they need hospitalization (like, say they become suicidal), only a physician can commit them (doesn't have to be a psychiatrist, even).

"Biomedical Therapy" is often used to bring the patient to a place where psychotherapy can be effective. In other words, if you have a patient you can't talk to because they are having distracting hallucinations or disorganized thinking, sometimes administering drugs can make them rational enough so that your psychotherapy will have an effect.

The Psychotherapies

Most verbal psychotherapies have been heavily influenced by the theories of Freud and his brainchild, psychoanalysis. According to Freudian theory, psychological problems are caused by thoughts and desires which are repressed and/or disguised to keep them from becoming conscious and causing anxiety. But they do not simply lie there quietly. Instead they express themselves in disturbing symbolic forms which are not understood by the patient and which interfere with their normal functioning. They are repressed - made unconscious - because if they weren't, the person would feel uncomfortably anxious. This is the chief assumption of the psychodynamic approach: symptoms are caused by unacceptable thoughts and wishes that are disguised or repressed to protect the client from feeling anxious. Therefore, the way to "fix" the problem is to make the symptoms conscious by interpreting them so that the person can examine them and "de-fang" them with the help of the therapist. Because the goal is making the client understand his symptoms, this approach is often referred to as "insight-oriented therapy."

Despite its occasional success, this is not a very scientific approach because ferreting out the symbolic meaning in symptoms is not a very reliable process and therapists will differ enormously in their interpretations. Still, sometimes the symptoms baffle the therapist to the point where this may be his/her only option. This is exemplified in the eating disorders where the why is lost in obscurity and therapists are almost forced to conclude that the cause is hidden in psychodynamic factors (like hatred of the mother, desire to control, rebellion, etc.)

Person-Centered Therapy (formerly "Client-Centered Therapy")

Person-Centered Therapy emerged out of Humanistic Psychology. Basically, the Humanistic psychologists were fed up with theories and therapies that put us down as mindless robots unthinkingly carrying out the dictates of our antisocial unconscious or the laws of nature.

Both psychoanalysis and behaviorism preached that humans had no free will. Freud of course thought behavior was determined mostly by the unconscious which harbored socially unacceptable and irrational motives. He thought there were two basic instincts governing behavior: Sex and Aggression - and both of these were present at an early age (like from 2 on). This didn't set well with people's puritanical notions at the time. Who likes to think the only reason you do anything is because of lust or to hurt somebody? Behaviorism was also seen to belittle humans by maintaining that there was no such thing as "free will" because behavior was determined mostly by learning and external environmental factors, not human choice. B.F. Skinner, the most prominent behaviorist of our time, even wrote a book called Beyond Freedom and Dignity whose theme was that we will continue to struggle in the mess we have created until we give up the hobbling illusions that we are "special" and have free will.
After this unpopular pronouncement, he needed a bodyguard. People generally take offense when you tell them they can't help what they do (unless it's in the context of a criminal trial at which point they will stand up and shout, "I couldn't help it! I was mentally ill! Don't put me in jail!). It's hard to feel good about yourself if you believe you're only an irrational automaton.

Partly in response to this pessimistic assessment of humanity, Carl Rogers developed "Client-Centered Therapy. (Subsequently changed to "Person-Centered" Therpay") He called it "Client-Centered" to distance himself from the medical model wherein people with mental problems were called "patients." (If they're "patients" they must be "sick" and need to see a "doctor" who can give them medicine to make them "well", right?)

Rogers also stressed the basic equality of the therapist and the client. He said that calling them "patients" suggested they were in an inferior position to the "expert" therapist, when in fact, the client themselves were the most capable in solving their problems. Because of this, Rogers thought it was inappropriate for the counselor to give advice because that implied they knew more than the client about what to do. Because of this proscription, Person-Centered therapy is sometime referred to as "non-directive counseling" because you don't "direct" the client how to behave.

The underlying assumption of Person-Centered therapy is that people are inherently "good" and possess within themselves the capability to make themselves better - if only the therapist provides a setting in which those positive traits can come out.

The therapist provides this setting by being empathic, non-judgmental, and giving "unconditional positive regard."

Glossary:

1. Empathic: "Feeling the other person's pain" - seeing things from their eyes.
2. Non-judgmental: Accepting without criticism anything the client does.
3. Unconditional Positive Regard: Showing you like the client no matter what they do or have done, because they are innately "good."

Sometimes showing positive regard (making them feel you like them) gets hard to do when your client commits a really evil act like, say, Hitler killing 20 million people - or worse still, when you're not sick and your car isn't broken down and you still don't come to class. How could you say that monsters like this are "good"? To do this, you must separate their behavior from them as a person. For example, you might say, "Adolph, you're a good person and I really like you, but sometimes you kinda do some awful things - you know what I'm sayin'? Like you yourself are good, but your behavior is sorta bad."

But you might ask, "What is to stop the client from accepting all your positive regard and just going on being a monster and continuing to miss class?" The answer according to Rogers is that people won't do that because they are innately good and will act good if you just give them unconditional positive regard. A little optimistic, you say? - I agree.

Despite its logical shortcoming, Person-Centered therapy is still commonly used and almost always gives at least short term relief - sometimes more. And almost all therapies stress the Person-Centered traits of "being genuine" and "empathic." Plus, whenever a therapist doesn't know what to do or hasn't yet formulated a therapy strategy, or hasn't had much training or experience, it is not at all uncommon for them to use Person-Centered therapy until they can think of something better or get more training. In fact, if you should ever happen to be at the south pole on a scientific expedition and one of the team starts to "lose it", or if you're at a fancy restaurant and someone starts to have a panic attack, you can always fill in with Person-Centered therapy until a mental health professional can be brought in. All you have to do is reflect the person's thoughts and feelings in a non-judgmental empathic way that conveys unconditional positive regard. I'll demonstrate the technique later in class.