All psychotherapies move as directly, swiftly, and effectively to the heart of a problem as the validity of their explanations enables them to do. The manner of treating patients has always been derived from what made sense according to some understanding of the ailment. Most therapies, however, had blindly groped for solutions to problems that were partially or dimly illuminated, if at all, in their theoretical framework. A few therapies have developed from serendipitous discovery of something that seems to help people--without persuasive explanation of why or how it helped (as in eye movement desensitization). For these a rationale attempting to explain the process was usually developed later.Each school of psychology has devised treatment strategies relying largely on whatever they have posited as the key factors in the illness. The current major groups are listed below in a simplified outline:
1. Biological psychiatry supposes that psychological troubles have their source in brain chemistry
2. Psychoanalysis considers all psychological illness as based in origins of personality development (with exceptions such as inborn deficits)
3. Cognitive theory postulates the key element to be faulty thinking (although in that school, workers appear to concentrate more on attitudes than on idea)
4. Behaviorism postulates the key element in pathology to be faulty or unfortunate conditioning
5. Popular psychologies consider key issues to be such matters as stored emotion, faulty self-attitudes such as inferiority complex, or temperamental difficulties such as "over" or "under" assertiveness
In fact, all those suppositions are imperfect. The treatment results for the classic neuroses, by the approaches of each school, corroborate the impression of weaknesses and deficiencies entailed in those theories. This suggests we are at an early stage in the development of the science. It needs more work. Although some treatment approaches for psychological disorders had been presented with little theoretic basis, even in those atheoretic psychologies the techniques fit with some defined principle (such as the hopeful, religiously based, somewhat mystical but persuasive "built-in drive for health" posited earlier in the nondirective therapies and visible again more recently in Kohutian "self" theory). Occasionally specific techniques have been offered without substantial supporting theory, but by the influence of an authority declaring them to be of value, have acquired undeserved credence. Overall, however, therapy techniques are usually carefully delineated applications of elaborate theoretical formulations of mental process, psychological development, symptom formation, illness, or health. Let us make comparisons as we consider treatment processes. In the course of our examination, we will find that a new approach offers not only more efficient and effective treatment, but also the possibility of actual cure of the illness rather than of the episode.
четверг, 29 октября 2009 г.
Should We Treat the Peripheral or Central Aspects of Psychological Illness?
Once one notices the mental processes of emotion and observes the occurrences of emotion storms, one recognizes those as the major participant processes of psychological symptom disorders. With access to that information, we view a sequence within the disorder processes--(first) the conditions or situations that trigger an illness, (next) the dynamic mental processes that are the central aspect of the illness, and (then) the various manifestations that are the consequences of the illness. Those of us who discern symptom disorders as a coherent group of psychological disorders based in emotion storms, and are able to observe the steps in the sequence just described, find the most effective treatment comes by dealing directly with the illness processes. In contrast, none of the four mainstream schools that currently dominate the treatment market for these illnesses view the illnesses in terms of central psychological process. Instead they each focus on other elements they regard as vital aspects of illness. Three of these schools focus on conditions that trigger illness--one (Behavioral) on external and two (Cognitive and Psychoanalytic) on internal conditions that trigger the illness. The fourth view (Biological psychiatry) focuses instead on some consequences of the illness.
We can see that the four mainstream approaches resolutely work with elements in proximity to the illness, but not with the emotion storm itself. The Behavioral, Cognitive, and Psychoanalytic approaches, each in its own way, focuses on the trigger condition as the important factor. Behaviorism works with external conditions in an attempt to dull response to the trigger by wearing it out--while it ignores the psychological process of inner experience. This attempt to wear down the triggering response is comparable to the current approach in treatment of allergies, in which we have insufficient knowledge to enable us to modify the underlying process. It is comparably weak in success. Cognitive approaches work with the internal response to external conditions in an attempt to rationally persuade or teach patients that the response to the trigger is illogical, not a sensible reaction, and not something worth the excitement. However, most symptom disorder patients react as they do to trigger conditions even though they are typically conscious of the illogicality of doing so. It is rare that they are unaware that they are making mountains out of molehills. Psychoanalysis also focuses on the inner response to conditions that trigger the illness in an attempt to change the basis of reaction so that the trigger loses its effect. In contrast to those three, the biological-psychiatry approach, needing to categorize symptom disorders as brain disorders, brings an aim to chemically suppress signs or symptoms because such consequences of the psychological illness are taken for the illness. That focus on the consequences of the illness is comparable to a pediatrician ignoring chickenpox while concentrating on a child's pimples as if that is the whole of the illness.
We can see that the four mainstream approaches resolutely work with elements in proximity to the illness, but not with the emotion storm itself. The Behavioral, Cognitive, and Psychoanalytic approaches, each in its own way, focuses on the trigger condition as the important factor. Behaviorism works with external conditions in an attempt to dull response to the trigger by wearing it out--while it ignores the psychological process of inner experience. This attempt to wear down the triggering response is comparable to the current approach in treatment of allergies, in which we have insufficient knowledge to enable us to modify the underlying process. It is comparably weak in success. Cognitive approaches work with the internal response to external conditions in an attempt to rationally persuade or teach patients that the response to the trigger is illogical, not a sensible reaction, and not something worth the excitement. However, most symptom disorder patients react as they do to trigger conditions even though they are typically conscious of the illogicality of doing so. It is rare that they are unaware that they are making mountains out of molehills. Psychoanalysis also focuses on the inner response to conditions that trigger the illness in an attempt to change the basis of reaction so that the trigger loses its effect. In contrast to those three, the biological-psychiatry approach, needing to categorize symptom disorders as brain disorders, brings an aim to chemically suppress signs or symptoms because such consequences of the psychological illness are taken for the illness. That focus on the consequences of the illness is comparable to a pediatrician ignoring chickenpox while concentrating on a child's pimples as if that is the whole of the illness.
Mental Health
The mental health field has continued to work with impaired theories of health and illness. Instead of continuing to consider mind processes as brain dysfunction, as if they were physiological troubles, we need to consider these in psychological terms to obtain useful answers. Our mental processes comprise subsets of emotion and cognition processes. Probably the theories about emotion have been the more seriously handicapped of the two basic psychological theory areas.
Two emotion theories were quite influential in the history of mental health studies. From our current view we see them as scientific blunders. Freud's theory of anxiety set the stage for a long continuing emphasis on anxiety as the fundamental emotion. Although other emotions were studied and considered in psychoanalysis, anxiety remained the major focus as the significant emotion. Later, efforts by Tomkins used ideas derivative of Darwin and James to put the basic function of emotion in the arena of communication, thus not considering its significance as a central mental process. Emotion, along with cognition, should have been considered a central issue. Instead, healthy growth of emotion theory was stunted by the powerful influence of the affect theory viewpoints of Freud and Tomkins and, astonishingly, the effective omission of affect from behavioral and cognitive theories. It is because the twin processes of emotion and cognition are so important to a theory of health and illness that the consequences of the use of impaired theories are so unfortunate.
Thus, failure to comprehend the healthy processes and functional utility of emotion, or the pathological processes of muting, emotion potentiation, and storm--all unnoticed decade after decade--meant that they unfortunately were unavailable for understanding and helping people. These psychological processes, discernible to some people and invisible to others, are not generally noticed even decades after their discovery and are not yet generally absorbed into the thinking of theorists or practitioners. A theoretical contribution encompassing the dual mind, which now enables the field to answer old questions more ably and to raise and answer new questions, must first catch the attention of sufficient workers to be studied and recognized for what it is.
Various special theories had been devised to deal with small portions of emotion process, such as discharge or signal, or some particular emotion such as anxiety or anger. Special theories were constructed relating to diagnostic entities as if they were specific emotions, as with depression and phobia. The differing premises of these several special theories precluded assembling and integrating them to construct a general theory of affect or illness. The incompatibility of the various premises in efforts at such combinations assured that no matter how complex the aggregation of special and partial theories became, they provided little helpful information about human life. No extended dialectic could be persuasive.
Two emotion theories were quite influential in the history of mental health studies. From our current view we see them as scientific blunders. Freud's theory of anxiety set the stage for a long continuing emphasis on anxiety as the fundamental emotion. Although other emotions were studied and considered in psychoanalysis, anxiety remained the major focus as the significant emotion. Later, efforts by Tomkins used ideas derivative of Darwin and James to put the basic function of emotion in the arena of communication, thus not considering its significance as a central mental process. Emotion, along with cognition, should have been considered a central issue. Instead, healthy growth of emotion theory was stunted by the powerful influence of the affect theory viewpoints of Freud and Tomkins and, astonishingly, the effective omission of affect from behavioral and cognitive theories. It is because the twin processes of emotion and cognition are so important to a theory of health and illness that the consequences of the use of impaired theories are so unfortunate.
Thus, failure to comprehend the healthy processes and functional utility of emotion, or the pathological processes of muting, emotion potentiation, and storm--all unnoticed decade after decade--meant that they unfortunately were unavailable for understanding and helping people. These psychological processes, discernible to some people and invisible to others, are not generally noticed even decades after their discovery and are not yet generally absorbed into the thinking of theorists or practitioners. A theoretical contribution encompassing the dual mind, which now enables the field to answer old questions more ably and to raise and answer new questions, must first catch the attention of sufficient workers to be studied and recognized for what it is.
Various special theories had been devised to deal with small portions of emotion process, such as discharge or signal, or some particular emotion such as anxiety or anger. Special theories were constructed relating to diagnostic entities as if they were specific emotions, as with depression and phobia. The differing premises of these several special theories precluded assembling and integrating them to construct a general theory of affect or illness. The incompatibility of the various premises in efforts at such combinations assured that no matter how complex the aggregation of special and partial theories became, they provided little helpful information about human life. No extended dialectic could be persuasive.
Mental Illness as Deviation from Natural Processes
The more clearly we can specify aspects of health, the more clearly we can describe illnesses in their deviations from our view of healthy processes. Where do we place the boundaries between health and illness? How do we decide what makes a boundary between health and illness? In a health-centered approach, we tend to concentrate more on elements of process--both healthy and pathological--than on signs and symptoms of health and sickness. From a pathology-centered approach, we consider any suspiciousness a possible sign of paranoia and then evaluate how severe that piece of paranoia is. From a health-centered focus, we consider suspiciousness a healthy, functional, self-protective watchfulness, possibly appropriate for the circumstances of that person and not necessarily a sign of paranoia, even if intense. We recognize sadness as a useful emotion, not as a piece of depression. We consider a rush of ideas to be a manifestation of excitement, enthusiasm, or interest, rather than a sign of hypomania. Thus the currently commonplace attempts to cure rapid or slow thinking, excitement, grief, anger, loneliness, fear, sadness, guilt, shame, and other discomfiting but useful healthy responses become recognizably improper.
This is not so much a difference among schools of thought as it is a difference in ways of using the knowledge within each school. Health, no longer considered the reduced presence of noticeable elements of pathology, comes to be seen as the existence of functional utility of the endowed mental processes. In the past, most professionals aimed to rid patients of what those professionals regarded as pathologies, rather than aiming to enhance their processes of health. Their view has been that the absence of noticeable pathognomonic symptom aspects of pathologies is what confirms health.
We could define psychological health in a more complex but more useful way as the functional utility of many natural useful processes of mind that serve to guide lives and enable people to be and do what they want to be and do, in ways that are not harmful to themselves and others. Actuating this view will take many years, but will finally define an ideal of mental health based on use of function rather than absence of dysfunction. That may finally eliminate the preposterous attempts to cure people of elements of their health.
The failure to work from a basis of health is part of the reason we have therapies aiming to cure natural healthy reactions, as if they were illnesses. They mistakenly treat as pathology such natural and useful (although unpleasant) feelings or states as grief, loneliness, anger, sadness, shame and guilt. They seek to cure such natural and useful (even if unpleasant) conditions as perceived low self-esteem, inferiority, superiority, inadequacy, passivity, and shyness. None of these conditions ordinarily calls for interferences with the natural processes that are occurring in them. Attempts to cure health frequently risk transforming health into long-term illness. It can waste lives, as exemplified in the account in the previous article of a patient suffering from tension phobia. I know of many such instances.
This is not so much a difference among schools of thought as it is a difference in ways of using the knowledge within each school. Health, no longer considered the reduced presence of noticeable elements of pathology, comes to be seen as the existence of functional utility of the endowed mental processes. In the past, most professionals aimed to rid patients of what those professionals regarded as pathologies, rather than aiming to enhance their processes of health. Their view has been that the absence of noticeable pathognomonic symptom aspects of pathologies is what confirms health.
We could define psychological health in a more complex but more useful way as the functional utility of many natural useful processes of mind that serve to guide lives and enable people to be and do what they want to be and do, in ways that are not harmful to themselves and others. Actuating this view will take many years, but will finally define an ideal of mental health based on use of function rather than absence of dysfunction. That may finally eliminate the preposterous attempts to cure people of elements of their health.
The failure to work from a basis of health is part of the reason we have therapies aiming to cure natural healthy reactions, as if they were illnesses. They mistakenly treat as pathology such natural and useful (although unpleasant) feelings or states as grief, loneliness, anger, sadness, shame and guilt. They seek to cure such natural and useful (even if unpleasant) conditions as perceived low self-esteem, inferiority, superiority, inadequacy, passivity, and shyness. None of these conditions ordinarily calls for interferences with the natural processes that are occurring in them. Attempts to cure health frequently risk transforming health into long-term illness. It can waste lives, as exemplified in the account in the previous article of a patient suffering from tension phobia. I know of many such instances.
Theories of Mental Health and Mental Illness
By emphasizing pathology, we had tacitly accepted health as the absence of signs of pathology. If instead we emphasize normal development and healthy functioning, we adopt the view that pathology is deviation from health as nonfunction, dysfunction, or malfunction of natural processes. The pathology-centered approach brought an increasing tendency to consider all human mental function as essentially pathology, in greater or lesser degree, which often led us to spend a great deal of effort in working to cure aspects of healthy function. That is a terrible error. Instead, we can view mental health as a complicated but definitive functioning condition, discernible as having many elements of normal processes functioning well, with mental elements and factors that serve purposes we can understand. We then view health as those processes aiding us to adapt and function in personal and interpersonal life. This vantage promises to be increasingly fruitful and more useful than pathology-oriented study. The work presented in this blog has already brought knowledge for cure and prevention. Extension of the theory of health beyond the scope of emotion health may bring far more knowledge.
The "everyone is ill" belief leads to an industrial approach to mental health issues and all too frequently to a smug, condescending attitude toward patients. As one psychiatrist observed, "Every child should have a course of psychotherapy during adolescence." His belief that everyone is ill in some degree meant that he should treat everyone who came to him, to prevent catastrophic developments, or at least to make their lives healthier in some degree by removing pathology. From his illness-oriented approach, any least characteristic or element of any illness that he could note he declared to be sufficient basis for necessity of treatment.
From several of his former patients who eventually came to me, those elements of illness he detected would often have been better understood if they had been considered along a range of variation within healthy mental functioning. His approach had made healthy children into patients. Then they needed psychotherapy--to free them from being patients! His practice involved thousands of adolescents over at least three decades. His belief in the universal necessity for treatment gave him what could look like an uncanny diagnostic talent. He needed only to hear the name of an adolescent to know sincerely that the youngster should be under his care, usually in a hospital for thirty to sixty days, isolated from communication with parents (to break the parent-child bond and foster a healthy relationship with the therapist), all the while medicated with one or another psychotropic drug. Supposedly the child then could start anew to form good relationships with parents and family. The problems in that are obvious.
The "everyone is ill" belief leads to an industrial approach to mental health issues and all too frequently to a smug, condescending attitude toward patients. As one psychiatrist observed, "Every child should have a course of psychotherapy during adolescence." His belief that everyone is ill in some degree meant that he should treat everyone who came to him, to prevent catastrophic developments, or at least to make their lives healthier in some degree by removing pathology. From his illness-oriented approach, any least characteristic or element of any illness that he could note he declared to be sufficient basis for necessity of treatment.
From several of his former patients who eventually came to me, those elements of illness he detected would often have been better understood if they had been considered along a range of variation within healthy mental functioning. His approach had made healthy children into patients. Then they needed psychotherapy--to free them from being patients! His practice involved thousands of adolescents over at least three decades. His belief in the universal necessity for treatment gave him what could look like an uncanny diagnostic talent. He needed only to hear the name of an adolescent to know sincerely that the youngster should be under his care, usually in a hospital for thirty to sixty days, isolated from communication with parents (to break the parent-child bond and foster a healthy relationship with the therapist), all the while medicated with one or another psychotropic drug. Supposedly the child then could start anew to form good relationships with parents and family. The problems in that are obvious.
Shifting the Focus to Natural Processes
A major shift in thinking about theory would occur with a move from pathology-centered pathognomonic approaches to a functional health-centered approach. Prevention approaches, having definitions of health and how to maintain it, would give us great advantage in helping people to productive and creative lives, would improve interpersonal and intrapersonal relations, and would change our understanding of diagnosis and psychotherapy. Not only is it just as possible to consider usable diagnoses in terms of deviations from healthy processes as it is from diagnosing pathologies from presence of signs or symptoms, it would offer significant advantages over the common current system.
At first blush this may seem to be a distinction where there is no difference, as if this is only a matter of starting at different ends of the same continuum, but when you begin exploring the possibilities, the differences become recognizable. Once understood, we see it as two different journeys, starting from different locations and heading for different destinations. In the current system, health is considered as a residual condition in the absence of illness or what exists after signs and symptoms of illnesses are cured or removed. In the other, health is a definitive state with built-in natural processes performing adaptive tasks within an optimal range. This allows for variation of function within and between individuals. In the health definition, the manifestations are considered first as natural variations in useful functioning. Using the illness definition, we seek any aspect of mental function that shows tainted attributes (signs and symptoms) of illness. If no pathognomonic taint is found, the person is considered healthy. The more signs and symptoms that are found and cured or removed, the healthier the person is considered to have become. In contrast, using the health centered orientation, we work to strengthen the natural, built-in mental functions to enhance healthy processes and so prevent illness or free people from illness. The same processes guide our lives and either cure or decrease the vulnerability of each person to psychological illnesses. Because most people occasionally manifest some declared signs or symptoms, some pessimistic professionals are led by strained logic to the view that everyone adapts by using considerable effort to hold psychotic chaos at bay. To them, health is a successful fight against illness.
Those without knowledge of the dynamics of mental processes resort to manifestations of signs and symptoms to identify a disorder process. That is the current approach in both behaviorism and biopsychiatry. Pathognomonic reading can lead to a quick diagnosis, but too often it is a quick erroneous diagnosis. The pathognomonic diagnosis is speedy. If we can check the list and there is the sign "fatigue" and the sign "insomnia" plus symptoms of apprehension and sadness, that unquestionably is the illness "depression." But following that diagnostic approach glosses over an underlying process that may have any of several surface manifestations, and the same surface manifestations may stem from any of several underlying processes. Is the problem a drug reaction or depression?
At first blush this may seem to be a distinction where there is no difference, as if this is only a matter of starting at different ends of the same continuum, but when you begin exploring the possibilities, the differences become recognizable. Once understood, we see it as two different journeys, starting from different locations and heading for different destinations. In the current system, health is considered as a residual condition in the absence of illness or what exists after signs and symptoms of illnesses are cured or removed. In the other, health is a definitive state with built-in natural processes performing adaptive tasks within an optimal range. This allows for variation of function within and between individuals. In the health definition, the manifestations are considered first as natural variations in useful functioning. Using the illness definition, we seek any aspect of mental function that shows tainted attributes (signs and symptoms) of illness. If no pathognomonic taint is found, the person is considered healthy. The more signs and symptoms that are found and cured or removed, the healthier the person is considered to have become. In contrast, using the health centered orientation, we work to strengthen the natural, built-in mental functions to enhance healthy processes and so prevent illness or free people from illness. The same processes guide our lives and either cure or decrease the vulnerability of each person to psychological illnesses. Because most people occasionally manifest some declared signs or symptoms, some pessimistic professionals are led by strained logic to the view that everyone adapts by using considerable effort to hold psychotic chaos at bay. To them, health is a successful fight against illness.
Those without knowledge of the dynamics of mental processes resort to manifestations of signs and symptoms to identify a disorder process. That is the current approach in both behaviorism and biopsychiatry. Pathognomonic reading can lead to a quick diagnosis, but too often it is a quick erroneous diagnosis. The pathognomonic diagnosis is speedy. If we can check the list and there is the sign "fatigue" and the sign "insomnia" plus symptoms of apprehension and sadness, that unquestionably is the illness "depression." But following that diagnostic approach glosses over an underlying process that may have any of several surface manifestations, and the same surface manifestations may stem from any of several underlying processes. Is the problem a drug reaction or depression?
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