During my first session with clients, I often suggest to them that while they are thinking about which therapist might be a good fit for them, they ask themselves this question, “how does this therapist define what constitutes ‘mental health’?” I wonder to myself, if asked that question during an initial session or phone call with a client, and without warning about the question, would most therapists be able to answer it? I have my doubts. This, I think, is because at least for now, we seem to very stuck on the question, “what is mental illness” when it seems we should (also) be asking “what is mental health?” Isn’t the goal of therapy to get to a place of mental health? I think it should be. And you aren’t going to get there if you don’t know where “there” (mental health) is.
We all have a pretty good idea these days about what constitutes “mental illness.” We see the commercials that ask questions like, “where does depression hurt?” or suggest: “if parties make you nervous, anxious, fearful, you may suffer from ‘social anxiety disorder.” As a psychotherapist, I am required by insurance companies, and encouraged by the mental health profession, to rely on a book called the “Diagnostic and Statistical Manual of Mental Disorders, IV-TR.” That’s quite a mouthful. The shorthand name for the book is the “DSM.” And it’s a big book to boot. Its about 800 pages long, and contains groups of many different varieties of symptoms that are given names and called mental disorders. The most well-known names of disorders include depression, anxiety, Attention-Deficit Hyperactivity Disorder (ADHD), Post-Traumatic Stress Disorder (PTSD), along with lesser known names of disorders like Obsessive-Compulsive Disorder (OCD), Anorexia Nervosa, Bulimia, Schizophrenia and Borderline Personality Disorder.
What do all these names of things have in common: they all describe a set of symptoms that cause problems in the life of the person who has those symptoms. The symptoms are grouped together and given a separate name if it seems like there are patterns of symptoms that people share. For example, lots of people with depression lose interest in doing fun stuff in their lives, and they often also lose weight, can’t sleep, feel tired a lot, and become irritable. Not everyone who suffers from what the DSM calls depression suffer from all of the nine symptoms listed in the DSM for depression. In fact, to be diagnosed with “depression” according to the DSM, you only have to show five of the nine symptoms (and one of the symptoms needs to be either “depressed mood” or “lack of interest”). In the DSM, you can be diagnosed with “Depression” even if you do not feel “depressed,” as long as you have at least five of the other symptoms, and have a lack of interest in pleasurable activities. Each of these names of mental disorders has a numeric code, which therapists, doctors, psychologists and others use as a kind of shorthand for whatever diagnosis we make about a client’s mental health. For instance, depression is “296.” Generalized Anxiety Disorder is “300.02.” ADHD is 314. Don’t ask me where they came up with these numbers. I have no idea.
Now you have a little insight into how the mental health profession used the DSM to define “mental illness.” Oh, and before I move on to “mental health,” I want to mention the fluid nature of all of this. Note that the name of the DSM includes the roman numeral “IV” and the capital letters “TR.” That means that the current version of the DSM approved by the American Psychiatric Association and the American Psychological Association is in its fourth revision, and not just the fourth revision, but the fourth revision that also has had a “text revision.” That’s the “TR.” Text revision. So, the names of mental disorders, the symptoms included, the ideas about their cause and their treatment has changed many times. And version “V” will eventually take over, with different names, symptoms, causes and suggested treatment. Its all very fluid, so don’t get too stuck on what it says right now.
In my next installment on this topic, I’ll delve into what constitutes mental health for most clients, and offer some insights into the various ways to move away from an “illness” or deficit or problem concept of therapy to a “health” or strength or solution concept of therapy.