A patient asked me a number of good questions today:
Mr. Y: We all have feelings, including negative feelings. Having feelings, even negative feelings, is to some extent [said with a tentative tone of voice] a normal state. How do I know when my feelings are more than just “normal feelings”?
Dr. P: When it feels like your feelings [depression or anxiety or anger] are out of proportion to a stressor or when there is no stressor at all but powerful feelings are present for “no good reason” that is a good reason to seek the counsel of a specialist.
Mr. Y: When there is a stressor, is there a way of knowing if my emotional response is in fact “out of proportion”?
Dr. P: When your feelings, even if justified, run you down into the ground, chance is that they are “out of proportion”. Feeling overwhelmed by a feeling is a good rule of thumb. Have you ever felt feelings at that level of intensity?
Mr. Y: Yes. I had a very painful break-up years ago. It got the best out of me. To the point of having trouble getting out of bed, taking a shower, showing up for work every single day. It took time.
Dr. P: Did you stop going to work?
Mr. Y: No, but I was almost literally dragging my feet.
Dr. P: Did you stop caring for your loved ones?
Mr. Y: Still caring but I just wanted to be alone. Didn’t care to see anyone.
Dr. P: When being overwhelmed gets to the point of affecting your ability to function across multiple area of your life (work, family, other relationship, leisure activities) most likely your feeling reached an “out of proportion” level. If you are still functioning, even though at a less than optimal level, and your reaction follows a significant stressor, it may be that things are not yet “out of proportion”.
Mr. Y: What is “significant”? Same situation: same people fall apart, some brace themselves and move on.
Dr. P: That is a good observation. Different individuals have different thresholds for falling apart.
Mr. Y: Some are strong and some are weak. Or lazy. Or look for excuses or the easy way out. Or is that mental illness?
Dr. P: You try to put yourself together but you cannot. It is not due to a lack of willingness or desire to do and feel well, but an inability to. When you try and fail and your best effort to get out of the situation only gets you to further sink down that is an indication that all might not be in order at the mental level.
Mr. Y: So that is an indication of mental dis-order? But then why was I able to deal successfully with similar situations at other times in my life?
Dr. P: As our mental “reserve” is not always the same. At times the reserve is plentiful, at times it runs dangerously low. To get “stressed-out” does not always require the same level of stress. If minimal stress stresses you out, your mental reserve is low, a potential indication of a mental dis-order, as were things to be in order, you would operate with optimal mental reserve, at a level that will protect you against stress. Do not compare yourself with others or even with your self-ability to hold it together at other times. If to the question “Am I falling apart?” at that specific moment in time you answer in the positive, that is a good reason to seek professional help.
Mr. Y: But I do have times when I feel like I am falling apart. Most times they are brief and I am then able to pull myself together. After how long of feeling “broken” should I call you?
Dr. P: Depends on how “broken” you are. So broken that you plan to get a gun and actually you start walking toward the gun store – call right away. Broken but able to bear it – wait till it becomes unbearable to the point of consistently affecting your ability to function in multiple areas of your life – remember our discussion about dysfunction. The wait period is dependent on the result of [level of dysfunction] x duration so to speak.
- The problem: excessive (rather than “negative”) feelings
- Intense feelings for no good reason are a reason of concern
- Intense feelings, while appropriate under certain circumstances, are a reason of concern if they result in consistent dysfunction across multiple areas/domains of life.
- Consistent dysfunction is a function of severity and duration
At the end of the day, while reviewing my notes, all of a sudden I was struck by the extent to which I relied on the patient’s feeling (as opposed to thinking) about his feelings in constructing a diagnosis. I was also struck by the frequent use of metaphorical speech (broken, out of proportion, falling apart), essentially a subjectively/value-loaded language, as the optimal way of conveying what should be to whatever extent possible, an objective understanding of the concept of mental disorder (in this specific context).
Interestingly, the criteria that emerged from our brief dialogue are to some extent consistent with Wakefield’s idea that “a mental disorder is a harmful mental dysfunction” – however in his definition Wakefield emphasizes the socio-cultural perspective on what is harmful – when in our dialogue the patient’s subjective perspective is the foundation of this value judgment (Wakefield 2007).
Further, the perspective that emerged from this dialogue where a patient was an equally invested partner in finding a mutually agreeable definition of the problem, is also fairly similar to the DSM dysfunction criteria for a “mental disorder”.
Was this also a therapeutic exchange?
Time will tell, but when it comes to mental disorders, somewhat paradoxically, it appears that there is a place for subjective feelings in constructing objective assessments.
How about making such collaborative exchanges a subject of empirical testing?