Learner therapist (14)……Distorted, not disordered, selves

Learner therapist (14)……Distorted, not disordered, selves
Torrey Orton
Feb 5, 2012

Most everyday therapy is work on distorted capabilities, not mental disorders.

I think of my patients as learners with a wheel off their practice vehicle(s). A few of them think of themselves as "having" ADHD, Asperger's, OCD, BPD (used to be Bi-Polar Disorder, or is that another?), PTSD… an array of afflictions which have a grip on them like the flu, cancer, and such. These self-perceptions are encouraged by the medicalization of mental health issues. Such issues are, in fact, uniformly multi-modal, multi-dimensional – in brief, multi-causal, if we dare to speak of their precipitating, predisposing and maintaining conditions.


We in the mental health sector, and some in the medical, uses the concept of biopsychosocial (often with additives like spiritual and cultural) to describe the domain of the afflictions we engage professionally. In other words, they are not simply "mental" issues, nor physical. They involve a life world – a life style, if that feels more comfortably you – not just loose cogs or a rusted neural joints. And, as is increasingly recognised in various high profile specialisations (addictions, particularly), successful treatment is a social as much as a personal event (think weight, depression, anxiety, eating 'disorders' and so on, too).


The Diagnostic and Statistical Manual delight
So, how did we get here? Here is Gary Greenberg on the DSM, diagnosis and disorders:

… "And as any psychiatrist involved in the making of the D.S.M. will freely tell
you, the disorders listed in the book are not "real diseases," at least not like measles or hepatitis. Instead, they are useful constructs that capture the ways that people commonly suffer. The manual, they go on, was primarily written to give physicians, schooled in the language of disease, a way to recognize similarities and differences among their patients and to talk to one another about them. And it has been fairly successful at that." …

That is, the constructs (PTSD, BPD, OCD…) attempt to describe symptoms systematically, not their sources, causes, underlying structures, etc. For instance, chronic panic is reasonably visible and audible; we feel the other's panic immediately as a reverberation or resonance in our own bodies. This is the leading edge of empathy in action.

 Deep traumas are not so accessible. They are implied by the panic if you know that they must be there, which you should if you know that panic is an appropriate response to a perceived death threat which the patient cannot easily report as the trigger of the most recent episode. That is, it is personal historical material, etc. The trigger is the form of our experience of that historical material – it is a symptom with an anchor in the chronic damage. We (pretty much all of us; not just therapists!), of course, have a sense of others who are damaged deeply, usually from non-verbal markers (the "symptoms") which we do not usually engage directly with those others.


Medicalization by bookkeeping
Symptoms define a 'disease' entity, which then can be subject to micro-analysis for costing purposes so that expenses can be managed, forecast and so on. Psychological services for mental health are increasingly being brought under the medical umbrella which distorts them in three directions: first, medical style item number servicing; second, manualised treatments (CBT); and, third, specialised treatment providers (clinical psychologists).


We can much more usefully think of mental health issues as distortions of the person, of the normal functioning of a person…with patterns arrayed around the emotion system which provides our daily self-regulatory input and output. These centre on expressions of pain (fear, sadness, etc.) and pleasure (happiness, joy, etc.) in a more or less discrete bi-polarity derived from their approximations to perceived life or death challenges of our presents and pasts…


That we have six to eight discrete core emotions (anger, sadness, joy, despair, love, confusion, etc. ) underpinned by a smaller number of organic status indicators (hunger, pain, desire, pleasure, numbness, , etc.) makes seeking an issue's source a viable enterprise. Patients' issues are all emotionally tagged. They show up for therapy because feelings tell them to. Their passage to a more viable personal world will be marked by changes in their actions and feelings about them, or letting feelings direct their actions for the first time – in other words, a reduction in perceived and actual (incongruence) self-distortion.


For a patient's global self-appreciation the thought that they have distorted life processes rather than an affliction, a disorder, is often helpful. It brings normalcy into the diagnostic picture from early on and helps them identify the necessary and useful functionalities they have, even though distorted. 'Disorder' sounds like a permanent injury, a lost limb. Distortion is a reparable injury; disorder a potential life sentence.


PS – it's funny how things come in bunches. Today I sighted a Guardian article on just this subject – distortion by disorders.- five months before the Greenberg article above. Like abortion/euthanasia spikes, they seem to come in waves, maybe annually? Anyone have a feel for the patterns???