Psychopathology

When we use pathology as a concept and apply it to the mind, we are in fact using a metaphor.  Pathology is either the study of the diseases of the body or a description of the whole range of diseases to which the human body is subject. Are we then saying that the mind is invaded by disease in the same way that, say, that the body is invaded by disease? Clearly not, since there are no counterparts to the body’s pathogens such as viruses, bacteria and poisons, which we could combat in order to restore the mind. And a mental disease is not a brain disease.

The mind has a function to direct the life of the individual and when this function breaks down, we are entitled to say that the mind is malfunctioning. If organic disease is ruled out, we may even go so far as to say that the mind is ill. The difference between the illness of the body and that of the mind is that the latter is the work of the mind itself.

Alfred Adler gives us a very clear yardstick by which we can measure how mentally unwell a person is. That yardstick is the sense of the self in connectedness with humanity and is expressed in the degree of courage or commitment to socially significant contributions to life. This is made visible in the actions of the individual and in the extent to which he tackles the problems of life to the mutual benefit of himself and his fellow mensub specie aeternitatis. Thus it is not in reference to what mankind maynormallydo but in a sense to what mankindwoulddo if the sense of self were not held back by ego-centeredness and anxiety for its own protection and advancement at the expense of others. Fritz Künkel, writing in the ’20s and ‘30s called this theWe.

Our history and our daily life deliver damning evidence of how far humanity is from this level of mental health or optimal functioning. We are all, it seems, flawed. But some are more flawed than others. We range on a continuum from what we may call normal, through neurotic, to psychotic. The differences can be both quantitative and qualitative. The kinds of mental malfunction can be different but also the degree to which a particular difficulty operates within us. The neurotic, though discouraged, is still operating in the world, having to admit his obligation to social interest. His approach is affirmative but with reservations. A case ofYes, but. Likewise his private logic has to be denied in the face of common sense. The psychotic has given up on operating in the real world and is content to live in his own fantasy, where he attempts to cut himself off from common sense entirely.

Our difficulties lie in our lifestyles, which could be expressed as self-imposed limitations that we have created to deal with our early discouragements. Feeling less than equal to the challenge of our environment we have learned in various ways to hold ourselves back from full participation in life. This feeling less than equal is the sense of inferiority or a sense of discouragement. The Adlerian, Erwin Wexberg, the first systematizer of Individual psychology, pointed out that every inferiority feeling is an anxiety. And just as Adlerians have produced schemes of typical inferiority feelings and the compensatory strivings of the individual trying to master them, so it must be also possible to produce a typology of the basic anxieties.

Fritz Riemann did exactly that in his bookGrundformen der Angst. He saw that there were four fundamental anxieties:

1. Schizoid Anxiety in the face of connecting or belonging to others, merging with  others, threatening one’s identity, independence and existence: Self-protecting distance
2. Depressive Anxiety in the face of being independent and separate from others: Self-protecting attachment
3. Compulsive Anxiety in the face of change, threatening insecurity, dissolution and death of the self: Self-protecting stasis
4. Hysterical Anxiety in the face of unalterable necessity, experienced as finality, compulsion and extinction of freedom: Self-protecting flight into novelty, change and action

It can be seen that the first two anxieties form a pair of opposites along the axis of distance-attachment. The  remaining two anxieties form a pair of opposites along the axis of stasis-change. In and of themselves they are none of them pathological and are shared by people we would consider to be functioning well. The problem of distance versus attachment is common to us all, since life requires that we assert our own separate existence as well as attach in mutuality to others. The problem of change versus stasis is also common to us all, since life is based on the conservation or maintenance of our selves as well as the change and development of our selves. The healthy individual works to combine the seeming opposites in a creative way.  When we feel unequal to the tasks of life, we cling grimly to one pole as our salvation and see the other as our downfall.

Thus I share both the general position of depth psychology and in particular the psychogenetic assumptions of Alfred Adler, in which, however, acknowledgment is made that organic influences may also play a part. Ailments of the body affect the mind and sometimes a physical cure alone can restore the mind to normal functioning.

However, I am suspicious of the readiness of many to find or assume physical causes. It is very easy to say that such and such is genetic. We often hear this without the slightest shred of evidence. But we must be prepared to accept such causes when they are proven or seem likely. I have myself witnessed how a doctor was able to see that a client’s problem was not a mind problem at all but physically mediated. The client exhibited strange, convulsive movements, which appearedmadto non medics. The doctor surmised that these were caused by the client’s nervous habit of over-breathing when stressed. When the client learned this he was able to relax and break the habit and rapidly those strange symptoms disappeared. Given that humanity is a mind-body unity, full or partial physical determination can never be ruled out.

But even in the cases of physical malfunction impacting on mental function, psychotherapy has often been able to help the individual to overcome or manage his difficulties.

Taxonomies of psychopathology such as DSM-IV differ greatly from Adlerian diagnoses in which an attempt is made to ascertain the psychic movement towards personal goals and away from personal felt minuses. Instead of Adler’s dynamic approach, which incorporates the development and destined crises of the lifestyle, DSM-IV is like a sorting box with subdivisions for isolated types. Like every classification system built that way it poses difficulties at the borders of the subdivisions, separates lifestyles that may have much in common, and treats these as static.  We have not really understood a person or her difficulties if all we have done is to find a general category in which they can be fit. She shares  that category with millions if not billions of others. This applies to both the DSM-IV approach and also to our own Adlerian approach if we merely assign a priority such as pleasing or controlling to her.

An approach such as DSM-IV offers a check list of symptoms for the determination of drug and medical treatment regimes. From our point of view the symptoms are not the problem. A person has selected her symptoms for her own mostly unconscious purposes. However it is useful for psychotherapists in helping to determine the degree of severity.

The psychotherapist and counsellor are dealing with only one side of the mind-body unity and the DSM-IV represents the medico-psychiatric field with which we need to cooperate in order to serve our clients well. We need access to the medical knowledge of our colleagues in the other field to guide us, especially in working with personality disorder, psychosis and clients subject to suicidal ideation. We have to be prepared to acknowledge our limits and pass on the severe and dangerous cases where institutional support and cooperation are required. Even in simpler cases we should be working with GPs so that organic aspects of the clients’ problems are not missed or misinterpreted.

Adlerians and other depth psychologists need to be able to communicate with professionals and clinicians in other disciplines. The DSM-IV categories  enable us all to use a common language and they do after all incorporate the traditional idea of a continuum from neurotic to psychotic. Furthermore the categories do remind us that psychotics such as schizophrenics, being at the the more severe end of the spectrum are likely to be more difficult to treat than the mildly schizoid neurotics.

In my experience so far it has been helpful to know that a client has been diagnosed by a psychiatrist or by his CMHT. But it should not become a distraction. We need to be able to put the diagnosis to one side while we make our own assessment, based on our own approach.

As a psychotherapist sometimes the people I see come with definite diagnoses and sometimes with rather vague ones. It has always proved better for me to put to one side the diagnosis and just first listen. The stories that I hear also remind me that a condition like personality disorder is not a box but a stage in a personal history. And the story gives us clues as to how that history could be rewritten.

Cases

Adrian is almost 40. he is a client of an alcohol service and also a patient of a CMHT. He is a problem to both. He seems to make no progress with his evident but not fully diagnosed personality disorder. And his impulsive drinking has never been brought under control. The CMHT is frustrated by his drinking and the alcohol service can never get him to commit successfully to controlled drinking or abstinence, despite his expressed willingness tobe a good boy. CBT sessions fail to make an impact on his behaviour and periods of apparent stability are violently interrupted by impulsive drinking sessions with public order offences on the streets. When he is in subdued mood he is able to acknowledge that drink gives him courage. he is also able to sustain apparently stable and quiet periods, complying with both clinical services but they never last. How did he come to be like this? The files are incomplete but the scraps of evidence point to a birth family of considerable instability, neglect and violence. As a baby he suffered broken ribs, was separated from his mother, herself with severe mental problems and adopted. He was adopted by a couple who had been unsuccessful in producing children but who had a child of their own immediately after. Adrian has a growing conviction that he is not wanted and becomes the naughty child and a foreign body in the family.  The father of the family inflicts physical and humiliating punishments frequently, reserved for him alone. “My life was hell; it still is.” Adrian now has frequent nightmares of death, humiliation, blood and violence. He frequently cuts himself and at least once this has brought him close to accidental suicide. He is impulsive and acts without continuity, easily led by others and by his own moods. Before this phase of personality disorder appeared he had made a brave effort to to be normal and successful. This collapsed shortly after his wedding about 10 years ago when he fled from the strain of his new obligations.

Bob is a drinker with a drug problem. For the past three years he ha s suffered from agoraphobia. He has a jovial, matey approach to people and before the descent into problem drug and alcohol use worked as a care-worker in an old people’s home. He looks back fondly on that time, having felt useful and having enjoyed the company of those he looked after. He traces his collapse to loss of his job and the breakdown of a relationship with a woman, leading him into a short career of drifting, drug use and drinking. He feels that the early loss of his father undermined his confidence at school and made him feel inferior to others. Recently he has worked out some of the lifestyle aspects which have shaped his life and has taken the first steps to overcoming his agoraphobia. At the same time he has reduced his drug and alcohol use.

Inge is an Austrian woman living in the UK. She traces her lack of confidence to her mother’s tendency always to find fault. She was never good enough, it seems, and anything she did would be criticized. Habitually and pointedly her mother would praise the daughters of other families in her presence. Feeling where here lack of confidence originated has helped to lead her to a more positive orientation.

Adler, AlfredDer Sinn des LebensFrankfurt am Main, Fischer: 1973

Antoch, Robert FBeziehung und seelische GesundheitFrankfurt am Main, Fischer: 1994

Künkel, FritzEinführung in die Charakterkunde12e Stuttgart, Hirzel: 1959

Riemann, FritzGrundformen der AngstMünich, Reinhardt: 1990

Sperry & Carlson (ed)Psychopathology & psychotherapy2e Philadelphia, Accelerated Development, 1996