The Wellness Model of Mental Health in the 21st Century
The disease or medical model has been the approach towards mental health since the dawning of civilization. It is called the pathographic perspective. Pathography is the history of our suffering. The Wellness Model focuses, not on our disease and deficits, but on our character strengths, virtues, and achievements. A disorder, condition, or dysfunction is what used to be called a neurosis. A neurosis is a common part of natural human development. It is, simply, a condition that negatively impacts our emotional wellbeing and quality of life.
The disease or medical model of ‘mental’ health focuses “on a deficit, disease model of human behavior.” The wellness model focuses “on positive aspects of human functioning.”[i] This disease model ‘defective’ emphasis has been the overriding psychiatric perspective for well over a century.
We must move away from the disease model, which assumes that emotional distress is merely symptomatic of biological illness, and instead embrace a model of mental health and well-being that recognizes our essential and shared humanity. Our mental health is largely dependent on our understanding of the world and our thoughts about ourselves, other people, the future and the world.[ii]
In 2004, the World Health Organization began promoting the advantages of the wellness perspective, declaring health, “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”[iii] The World Psychiatric Association agrees, stating, “the promotion of well-being is among the goals of the mental health system.”[iv] As positive psychologists point out, “psychological wellbeing is viewed as not only the absence of mental disorder but also the presence of positive psychological resources.”[v]
The wellness model’s chief facilitator is positive psychology (PP), which originated with Maslow’s[vi] seminal texts on humanism, and was legitimated by Seligman as American Psychological Association president in 1998. The focus of positive psychology and other optimistic approaches, is on virtues and strengths “not only to endure and survive, but also to flourish.”[vii] PP describes recovery as people “(re-) engaging in their life on the basis of their own goals and strengths, and finding meaning and purpose through constructing and reclaiming a valued identity and valued social roles.”[viii]
Positive psychology is a relatively new field (since 1998) that ostensibly complements and supports rather than replaces traditional psychology. “Positive psychology serves as an umbrella term to accommodate research investigating positive emotions and other positive aspects such as creativity, optimism, resilience, empathy, compassion, humor, and life satisfaction.”[ix]
PP has been defined as the science of optimal functioning, its objective “to study, identify and amplify the strengths and capacities that individuals, families and society need to thrive.”[x] Cultural psychologist Levesque[xi] describes optimal functioning as the study of how individuals attempt to achieve their personal potentials and become the best that they can be.
Research has shown that positive psychology interventions “improved well-being and decreased psychological distress in mildly depressed individuals, in patients with mood and depressive disorders, [and] in patients with psychotic disorders.”[xii] Studies supports the utilization of positive psychological constructs, theories, and interventions for enhanced understanding and improvement of ‘mental’ health. “The things that allow people to experience deep happiness, wisdom, and psychological, physical and social wellbeing are the same strengths that buffer against stress and physical and mental illness.”[xiii]
A range of approaches promoting wellbeing have been tested in intervention research. A recent study found positive psychology interventions showed “significant improvements in mental well-being (from non-flourishing to flourishing mental health) while also decreasing both anxiety and depressive symptom severity.”[xiv] Continuing research suggests that a positive psychological outlook not only improves life outcomes but enhances health directly.[xv] A meta-analysis of 51 studies with 4,266 individuals utilizing therapies focusing on mindfulness, autobiography, positive writing, gratitude, forgiveness, or kindness, found PPIs “significantly enhance well-being . . . and decrease depressive symptoms.“[xvi]
The academic discipline of positive psychology continues to develop evidence-based interventions that focus on eliciting positive feelings, cognitions or behaviors.[xvii] Independent research shows PPIs “decreased psychological distress [in individuals] with mood and depressive disorders [and] patients with psychotic disorders . . . improving quality of life and well-being.”[xviii] Positive psychology offers promising interventions “to support recovery in people with common mental illness, and preliminary evidence suggests it can also be helpful for people with more severe mental illness.”[xix]
Disease, deficit and denigration
One-size-fits-all recovery programs
Doctor-client power relationship
Emerging research data
Positive language, attitude, perspective
Client strengths and abilities
Optimal human functioning
Support and enhance traditional psychology
Emphasize character strengths & attributes
Balanced, holistic perspective
Positive Psychology 2.0. One of the early challenges of positive psychology was its inattention to the negative aspects of the individual. Recognizing this imbalance, psychologists advocated a more holistic approach to embrace the dialectical opposition of human experience. Positive Psychology 2.0 (PP 2.0) evolved as a correction to this singular focus on optimism so that it could “move forward in a more inclusive and balanced matter,[xx] incorporating both positive and negative aspects of the holistic individual. As one psychologist put it, “people are not just pessimists or optimists. They have complex personality structures.”[xxi] PP 2.0 recognizes the individual achieves optimal human functioning by living a meaningful life that comes through full engagement. PP 2.0 is a balanced approach, one that “equally considers positive emotions and strengths and negative symptoms and disorders.”[xxii]
The positive psychology perspective maintains that individuals with a ‘mental’ disorder can live satisfying and fulfilling lives regardless of symptoms or impairments associated with the diagnosis.[xxiii] Positive psychology aims “to emphasize the positive while managing and transforming the negative to increase well-being.”[xxiv]
Positive psychology focuses on enhancing wellbeing and optimal functioning rather than ameliorating symptoms. By emphasizing wellness rather than dysfunction, the positive-psychology movement aims to destigmatize ‘mental’ illness. Positive psychologists believe “the constructive use of positive psychology perspective is generally needed in contemporary research to complement the long tradition of pathogen orientation.”[xxv]
[i] Mayer, C.-H., & May, M. (2019). The Positive Psychology Movement. PP1.0 and PP2.0. In C-H Mayer and Z. Kőváry (Eds.), New Trends in Psychobiography (pp. 155-172). Springer Nature Switzerland. https://doi.org/10.1007/978-3-030-916953-4_9.
[iii] Slade, M. (2010). Mental illness and well-being: the central importance of positive psychology and recovery approaches. BMC Health Service Research 10 (26), 1-17 (2010). https://doi.org/10.1186/1472-6963-10-26 10(26)
[v] Sin, N. L., & Lyubomirsky, S. (2009). Enhancing Well-Being and Alleviating Depressive Symptoms with Positive Psychology Interventions: A Practice-Friendly Meta-Analysis. Journal of Clinical Psychology: In Session, 65(5), 467–487 (2009). doi:10.1002/jclp.20593
[vi] Maslow, A.H. (1943). A theory of human motivation. Psychological Review, 50(4): 370-396 (1943). doi.org/10.1037/h0054346; Maslow, A. (1954). Motivations and Personality. New York City: Harper & Brothers; Early edition.
[xiv] Schotanus-Dijkstra, M., Drossaert, C. H. C., Pieterse, M. E., Walburg, J. A., Bohlmeijer, E. T., & Smit, F. (2018). Towards sustainable mental health promotion: trial-based health-economic evaluation of a positive psychology intervention versus usual care. BMC Psychiatry 18:265, pp. 1-11 (2018). https://doi.org/10.1186/s12888-018-1825-5
[xv] Easterbrook, G. (2001). Psychology discovers happiness. I’m OK, You’re OK. The New Republic, Article 27, 6
[xvi] Sin, N. L., & Lyubomirsky, S. (2009). Enhancing Well-Being and Alleviating Depressive Symptoms with Positive Psychology Interventions: A Practice-Friendly Meta-Analysis. Journal of Clinical Psychology: In Session, 65(5), 467–487 (2009). doi:10.1002/jclp.20593
[xvii] Schotanus-Dijkstra, M., Drossaert, C. H. C., Pieterse, M. E., Walburg, J. A., Bohlmeijer, E. T., & Smit, F. (2018). Towards sustainable mental health promotion: trial-based health-economic evaluation of a positive psychology intervention versus usual care. BMC Psychiatry 18:265, pp. 1-11 (2018). https://doi.org/10.1186/s12888-018-1825-5
[xviii] Chakhssi, F., Kraiss, J. T., Sommers-Spijkerman, M., & Bohlmeijer, E.T. (2018). The effect of positive psychology interventions on well-being and distress in clinical samples with psychiatric or somatic disorders: a systematic review and metaanalysis. BMC Psychiatry 18:211, 1-17 (2018). https://doi.org/10.1186/s12888-018-1739-2.
[xix] Schrank, B., Brownell, T., Tylee, A., & Slade, M. (2014). Psychology: An Approach to Supporting Recovery in Mental Illness. East Asian Arch Psychiatry, 24, 95-103 (2014).
[xx] Wong, P. T. P., & Roy, S. (2017). Critique of positive psychology and positive interventions. In N. J. L. Brown, T. Lomas, & F. J. Eiroa-Orosa (eds.), The Routledge International Handbook of Critical Positive Psychology, pp 142-160. London, UK: Routledge.
[xxi] Miller, A. (2008). A Critique of Positive Psychology— or ‘The New Science of Happiness.’ Journal of Philosophy of Education, 42(3-4), 591-608 (2008).
[xxii] Rashid, T., Anjum, A., Chu, R., Stevanovski, S., Zanjani, A., & Lennox, C. (2014). Strength based resilience: Integrating risk and resources towards holistic well-being. In G. A. Fava & C. Ruini (eds.), Increasing psychological well-being in clinical and educational settings (Vol. 8, pp. 153–176). Dordrecht, Netherlands: Springer.
Condition that negatively impacts your emotional wellbeing and quality of life.
Called a neurosis by DSM prior to 1980.
Facilitated by mind, body, spirit, and emotions working in concert.
Source of shame, stigma, and self-denigration.
Correctible inability to function in a ‘normal’ or satisfactory manner.
A normal facet of human development.
Language generates and supports perspective. Language influences thought and action. Not only is the word ‘mental’ inaccurate in describing a disorder, but its negative perspectives and implications promulgate perceptions of incompetence, unworthiness, and undesirability. It is the dominant source of stigma, shame, and self-denigration. Realistically, we cannot eliminate the word ‘mental’ from models of healthcare. Still, we should utilize it sparingly, and only to differentiate a disorder from a physical injury or ailment.
The first descriptions that come to mind when one utilizes the word ‘mental’ are crazy and insane.A person with a disorder is not crazy or insane. She or he is someone who has a common malfunction that negatively impacts their emotional wellbeing and quality of life. Scientific American speculates that ‘mental’ disorders are so common that almost everyone will develop at least one diagnosable disorder at some point in their life.[i] A disorder is a normal facet of human development that infects at adolescence or earlier. A person cannot be held accountable for their disorder. They did not make it happen; it happened to them.
In political correctness, the word ‘mental’ defines a person or their behavior as extreme or illogical somehow. During our schooldays, anyone unpopular or different was derisively called ‘mental’ or ‘mental’ retard. The urban dictionary defines mental as someone silly or stupid. The word was used for attention, involving nonsensical references and actions, usually involving violent or divisive behavior, resulting in the general amusement and hilarity of onlookers. Add the words illness or disorder onto the adjective, ‘mental,’ and we have the public stereotype of dangerous and unpredictable, deranged persons who cannot fend for themselves, necessitating isolation in an institution.
Dictionary definitions of the adjective ‘mental’ are: (1) of or relating to the mind or (2) of, relating to, or affected by a disorder of the mind. A disorder is not mental. It is administered and facilitated by the mind, body, spirit, and emotions working in concert.
To the early civilizations, ‘mental’ illnesses were the domain of supernatural forces and demonic possession. Hippocrates and diagnosticians of the 19th century favored the humours (bodily liquids). Lunar influence and sorcery and witchcraft are timeless culprits. In the early 20th century, it was somatogenic.[ii][iii] The biological approach argues that mental disorders are related to the brain’s physical structure and functioning.[iv] The pharmacological approach promotes it as an imbalance in brain chemistry. The first Diagnostic and Statistical Manual of Mental Disorders,[v] created to address the influx of veteran shell shock (PTSD), leaned heavily on environmental and biological causes.
Carl Roger’s study of the cooperation of human system components to maintain physiological equilibrium produced the word complementarity to define simultaneous mutual interaction. All human system components must work in concert; they cannot function alone. Integrality describes the inter-cooperation of the human system and the environment and social fields. A disorder is not biologic, hygienic, neurochemical, or psychogenic. It is a collaboration of these, and other approaches administered by the simultaneous collaboration of the mind, body, spirit, and emotions.
There is no legitimate argument against mind-body collaboration in disease and wellness. We know that emotions are reactive to the mind and body and vice versa. Spirit is not ethereal or otherworldly, but a natural component of human development. While some suggest spirit as the seat of emotions and character, the three are distinct entities. Spirit forms the definitive or typical elements in the character of a person. Emotions are the expressions of those qualities, responsive to the mind and boy.[vi]
In deference to a wellness paradigm, focusing on the word disorder (a correctable inability to function healthily or satisfactorily) and avoiding the mental description will help alleviate the healthcare system’s negativity. Changing negative and hostile language to embrace a positive dialogue of encouragement and appreciation will open the floodgates to new perspectives and positively affect the disordered person’s self-beliefs and image, leading to more disclosure, discussion, and recovery-remission. The self-denigrating aspects of shame will dissipate; mental health stigma become less threatening. The concentration on character strengths and virtues, propagated by humanism, PP2.0, and other wellness-focused alliances, will encourage client accountability and foster self-reliance, leading to a confident and energized social identity.
Transitioning from the disease model’s pathographic language to the optimistic and encouraging perspective of wellness models is everyone’s responsibility in the mental health community―its institutions, associations, practitioners, researchers, media, and clients. When ‘mental’ is essential for focus or differentiation, we recommend utilizing quotation marks (‘mental’) to diffuse its negative and harmful perspectives.
[ii] Khesht-Masjedi, M.F., Shokrgozar, S., Abdollahi, E., Golshahi, M., & Sharif-Ghaziani, Z. (2017). Exploring Social Factors of Mental Illness Stigmatization in Adolescents with Mental Disorders. Journal of Clinical and Diagnostic Research, 11(11) (2017). doi: 10.7860/JCDR/2017/27906.1083.
[iii] Pryor, J.B., Reeder, G.D., Monroe, A.E., & Patel, A. (2009). Stigmas and Prosocial Behavior Are People Reluctant to Help Stigmatized Persons in S. Stürner, M. Snyder (Eds.) The Psychology of Prosocial Behavior, (pp.59-80). New York City: John Wiley and Sons. doi:10.1002/9781444307948.ch3
[v] Knaak, S., Mantler, E., Szeto, A. (2017). Mental illness-related stigma in healthcare. Barriers to access and care and evidence-based solutions. Healthcare Management Forum, 30(2), 111-116 (2017). doi:10.1177/0840470416679413
I am always in your corner throughout the process of recovery, from your program’s inception through your core-work, your neural network restructuring, the imple-mentation, and onto your recovery for as long as it takes. Your disorder has impacted your life in varying degrees since adolescence; recovery is a long-term commitment. I am your guide, your teacher, and your companion. I am with you every step of the way.
What is a mental ‘disorder’ in the wellness model of recovery? A mental disorder is any of the many neuroses that negatively impacts your emotional wellbeing and quality of life. It is defined as the inability to function healthily or satisfactorily and it is correctible. There are nine types of depression, several anxiety disorders, nine obsessive-compulsive disorders, five types of stress response, and ten personality disorders sharing similar traits and symptomatology. Every personality, experience, and cause of onset is unique. Every individual is affected differently, in varying degrees of intensity and impact. Rather than focusing on what is wrong with you, however, the wellness model emphasizes your character strengths and abilities that facilitate your recovery. You have always had the power to change; you need to embrace it and make it work for you. In the words of Nelson Mandela, you are the master of your fate and the captain of your destiny.
There are five steps to an effective platform of recovery. The first is customizing a program that addresses your individual needs and personality. Next is the core-work of learning the techniques and mechanisms that will lead you towards recovery. Simultaneously, we will go through the process of restructuring your neural network. The fourth step is going out, together, into the community, to implement what you are learning through positive exposure. Finally, it is achieving remission or one-year recovery. But my support does not have to stop there, because recovery is a journey, not a final destination. Replacing your negative thoughts, behaviors, and self-image with positivity and empowerment holds the key to your future wellbeing and happiness and I am with you every step of the way.
One-size-fits-all approaches are inadequate to address the complexity of the individual personality. The insularity of cognitive-behavioral therapy, positive psychology, and other methods cannot comprehensively address the personality’s dynamic complexity. Recovery programs must be fluid. Addressing the complexity of the individual personality demands integrating multiple traditional and non-traditional approaches, developed through client trust, cultural assimilation, and therapeutic innovation.
Any recovery program must consider your environment, hermeneutics, history, and autobiography in conjunction with your wants, needs, and aspirations. Absent that your complexity is not valued, and the treatment inadequate. A working platform showing encouraging results for most disorders is an integration of positive psychology’s optimum human functioning with CBT’s behavior modification, neuroscience’s network restructuring, and other personalized supported and non-traditional approaches. You are not your disorder. You are an individual who is impacted by a disorder―a person unique and special, unlike any other. Your recovery must reflect that individuality.
Over the past decade, I have facilitated groups and practicums for persons with depression, anxiety, and other disorders. I have created programs to facilitate recovery. 40 countries have accessed my work, and my latest article on social anxiety disorder is due for release by Springer. As an individual who battled severe social anxiety for 30 years, I understand the value and necessity of creating a platform of recovery entirely focused on your individual needs and personality.
Currently, the COVID19 crisis makes it impossible for us to go into the community and implement all the hard work we do together, but that should not discourage your recovery efforts. We will prioritize the core-learning and neural network restructuring in preparation for the implementation phase post COVID19. You will be even better prepared and more confident.
Every challenge presents opportunity, and the platform for recovery we prepare together will be even more durable. I urge you to resist the temptation to procrastinate your recovery during this crisis. The comprehensive, personalized level of commitment I provide to my clients severely limits the number of persons I can help. If your condition is affecting your emotional wellbeing and quality of life, now is the best opportunity to do something about it. Get in touch with me as soon as possible, so we can create your individualized program and begin your recovery process. You deserve the best life possible, and nothing should hold you back. For all sad words of tongue and pen, the saddest are these, “It might have been.”
Healthy philautia is an essential element of self-esteem. It embraces the positive aspects of self-love and facilitates our positive self-qualities (i.e., self -compassion, -love, -regard, -respect, -value, -worth, and other intrinsic wholesome attributes). Aristotle argued in the Nichomachean Ethics that healthy philautia was the precondition for all other forms of love.[i]
In psychological terms, healthy philautia adjuncts to other modification programs engineered to overcome or replace maladaptive self-beliefs and behaviors that have supplanted positive self-qualities due to a disruption in our natural human development. Healthy philautia serves as a more focused revitalization tool in CBT’s self-esteem reinforcement and or positive psychology’s optimal functioning. Healthy philautia’s primary psychological application is to regenerate the self-esteem that supports us and our intrinsic goodness.
What causes a deficit of self-esteem?
Maslow’s hierarchy of needs reveals how childhood/adolescent exploitation can disrupt their human development.[ii] Healthy evolution requires satisfying fundamental physiological and psychological needs. The child/adolescent experiencing detachment, exploitation, or neglect, may be disenabled from satisfying her or his physiological and safety needs and the need to belong and experience love, which can impact their acquisition of self-esteem. Self-esteem is the recognition of our value; value is the accumulation of positive self-qualities that generate character strength and virtue.
The deprivation of any fundamental need can detrimentally impact our wellbeing. Wellness models’ psychological positivity addresses this lacuna by emphasizing our character strengths that facilitate motivation and persistence/perseverance.
To Aristotle, healthy philautia is vigorous in its orientation to self and others in its potential goodness. By contrast, its darker variant portends disastrous consequences due to its narcissism, arrogance, and egotism. Healthy philautia encourages the development of our intrinsic positive self-qualities. Positive self-qualities determine our relation to self, to others, and the world. They provide the recognition that we are of value, consequential, and worthy of love. Healthy philautia is vital in every sphere of life and can be considered a basic human need.” [iii] To the Greeks, healthy philautia “is the root of the heart of all the other loves.” [iv] Gadamer writes of healthy philautia: “Thus it is; in self-love, one becomes aware of the true ground and the condition for all possible bonds with others and commitment to oneself.” [v] Healthy philautia is the love that is within oneself. It is not, explains Jericho, “the desire for self and the root of selfishness.” [vi]
Philautia is a binary category of classical Greek love, which embraces both its healthy and unhealthy aspects. Unhealthy philautia is akin to clinical narcissism―a mental condition in which people function with an “inflated sense of their own importance [and a] deep need for excessive attention and admiration,” behind which “lies a fragile self-esteem that’s vulnerable to the slightest criticism.” [vii] Citizens of Athens could be accused of unhealthy philautia if they placed themselves above the greater good. Today, hubris has come to mean “an inflated sense of one’s status, abilities, or accomplishments, especially when accompanied by haughtiness or arrogance.” [viii]
The Greeks believed that the narcissism of unhealthy philautia could not exist without its complementary opposition of healthy philautia. Positive psychology 2.0 recognized this by emphasizing the need to focus on both our negative and positive qualities. Just like we would not recognize light without darkness, or heat without cold―to know goodness is to understand evil.
Healthy philautia is essential for a good life; it is easy to recognize how the continuous infusion of healthy philautia and its reacquisition of positive self-qualities supports self-respect, reliance, and appreciation of our potential. “One sees in self-love the defining marks of friendship, which one then extends to a man’s friendships with others.” [ix] Recognition of our inherent value generates the realization that we are “a good person who deserves to be treated with respect.” [x] A good person is spiritually, one that is loved. “To feel joy and fulfillment at being you is the experience of philautia.” [xi] It is through recognition of our positive self-qualities and their contribution to the general welfare that we rediscover our intrinsic capacity for love.
[i] Lomas, T. (2017). The flavours of love: A cross‐cultural lexical analysis. Journal for the Theory of Social Behaviour, 48(1): 134-152 (2017). doi:10.1111/jtsb.12158.
[ii] Maslow, A.H. (1943). A theory of human motivation. Psychological Review, 50(4): 370-396 (1943). doi.org/10.1037/h0054346.
[iii] Sharma, A. (2014). Self-Esteem Is the Sense of Personal Worth and Competence That Persona Associate with Their Self – Concepts. IOSR Journal of Nursing and Health Science, 3(6), Ver.4: 16-20.
[iv] Jericho, L. (2015). Inner spring: Eros, Agape, and the Six Forms of Loving. Lilipoh, 20 (79): 38-39.
[v] Gadamer, H-G. (2009). Friendship and Solidarity. Research in Phenomenology, 39: 3-12. (2009). doi:10.1163/156916408X389604
[vi] Jericho, L. (2015). Inner spring: Eros, Agape, and the Six Forms of Loving. Lilipoh, 20 (79): 38-39.
One reason why it is crucial for us to understand the causes and symptoms of our disorder is the likelihood of misdiagnoses. It is time to recognize: we know more about the impact of our condition than our doctors. Psychiatrists may have extensive knowledge of medication, and psychologists, treatment programs, but that expertise is useless if the client is misdiagnosed and mismanaged. Mental health misdiagnosis is a cautionary phenomenon. Even mainstream medical authorities have begun to “criticize the poor reliability, validity, utility and humanity of conventional psychiatric diagnosis.” [i] A recent Canadian study reported, of 289 participants in 67 clinics meeting DSM-IV criteria for social anxiety disorder, 76.4% were improperly diagnosed.[ii] The Anxiety Institute in Phoenix reports an estimated 8.2% of clients had generalized anxiety, but just 0.5% were correctly diagnosed.[iii] Experts cite the mental health community’s difficulty distinguishing different disorders or identifying specific etiological risk factors due to the DSM’s failing reliability statistics. This failure in psychological diagnosis is like being hospitalized for strep throat and losing a leg.
The DSM changes drastically from one edition to the next, even though the APA swears by its credibility. One study[iv] cites therapist Zimmerman’s[v] concern that criteria are “added, removed, and rewritten, without evidence that the new approach is better than the prior one.” [vi] A recent study points out that DSM-IV listed nine possible symptoms or traits for narcissistic personality disorder; DSM-V contains only two.[vii]
The massive number of revisions, substitutions, and changes from one DSM to the next is never universally accepted. Psychiatrists, psychologists, and researchers who specialize or survive by funding are justifiably protective of their territory. Even under the best circumstance with a knowledgeable and caring clinician, it is difficult to get a proper diagnosis. Currently there are eight or nine types of depression, four or five different anxiety disorders, five types of stress response (three of them are PTSD), nine forms of obsessive-compulsive disorders, and ten personality disorders.
Bipolar personality disorder, a psychosis, shares characteristics and symptoms with avoidant, social anxiety, obsessive-compulsive, and post-traumatic stress disorders (neuroses). Psychologists cite the “substantial discrepancies and variation in definition, epidemiology, assessment, and treatment” of social anxiety.[viii] A researcher for this BLOG paper received three different depression diagnoses (including bipolar) and ADHD. Social anxiety was never considered, although he met nine of ten criteria for the disorder.
Adding to misdiagnosis is the prevalence of disorder comorbidity, which is especially concerning if the first diagnosis is inaccurate. The Anxiety and Depression Association of America [ix] reports many disorders are related to social anxiety, including major depression, panic disorder, alcohol abuse, PTSD,[x] avoidant personality disorder, generalized anxiety disorder, substance abuse, eating disorders,[xi] schizophrenia,[xii] ADHD, and agoraphobia.[xiii] Anxiety and depression are commonly comorbid. “Some estimates show that 60% of those with anxiety will also have symptoms of depression, and the numbers are similar for those with depression also experiencing anxiety.” [xiv] Three types or clusters categorize 10 personality disorders: 3 focus on the bizarre and eccentric, 4 on the dramatic; and 3 on the anxious and fearful; each cluster shares traits and symptoms. The diagnostic criteria for one disorder are common to others. For example, dependent personality has characteristics and symptoms mirroring social anxiety, avoidant personality, and histrionic personality disorders.[xv] One misdiagnosis is bad enough, not to mention two, resulting in “in worse treatment outcomes.” [xvi]
Thomas Insel,[xvii] director of the National Institute of Mental Health, has been “re-orienting [the organization’s] research away from DSM categories,” declaring that traditional psychiatric diagnoses have outlived their usefulness, A program of recovery cannot be entertained if the problem is misdiagnosed. A recent article in Scientific American[xviii] suggests replacing traditional diagnoses with easily understandable descriptions of the issues.
A simple list of people’s problems (properly defined) would have greater scientific validity and would be more than sufficient as a basis for individual care planning and the design and planning of services. However, this BLOG balks at throwing out the baby with the bathwater, positing that the DSM could be utilized as a part of a more thorough analysis focusing on the character strengths that generate motivation and persistence/perseverance towards recovery-remission.
Etiology and diagnosis drive the disease model. Which disorder do people find most repulsive, and which poses the most threat? What behaviors contribute to the disorder? How progressive is it? How effective are treatments? It is important to recognize how these attributions affect public perception, treatment options, and self-belief and image. Imagine being treated for the wrong condition. Not only does it defeat the purpose of the treatment, but it is also potentially dangerous. Firsthand, we know the impact of our disorder on our emotional wellbeing and quality of life far better than the clinician, whose relationship is one of power over communication. Self-diagnosis is a slippery slope, but a client armed with the knowledge of the traits and characteristics of their disorder, and its impact would have a far better possibility of appropriate diagnosis and treatment. Equally important is recognizing the extent of our strengths and abilities to counter and defeat the symptoms of our disorder. The disease model of mental health tells us the problem; the wellness model emphasizes the solution.
[ii] Chapdelaine A., Carrier J-D., Fournier L., Duhoux A. Roberge P. (2018) Treatment adequacy for social anxiety disorder in primary care patients. PLoS ONE 13(11) (2018). doi.org/ 10.1371/journal.pone.0206357.
[iii] Richards, T.A. (2014). Overcoming Social Anxiety Disorder: Step by Step. [Online.] Phoenix, AZ: The Social Anxiety Institute Press.
[iv] Lynam, D. R. & Vachon, D. D. (2012). Antisocial Personality Disorder in DSM-5: Missteps and Missed Opportunities. Personality Disorders: Theory, Research, and Treatment, 3(4) 483– 495 (2012). doi:10.1037/per0000006
[v] Zimmerman, M. (2011). Is there adequate empirical justification for radically revising the personality disorders section for DSM-5? Personality Disorders: Theory, Research, and Treatment. Advance online publication. doi:10.1037/a0022108
[vii] Lynam, D. R. & Vachon, D. D. (2012). Antisocial Personality Disorder in DSM-5: Missteps and Missed Opportunities. Personality Disorders: Theory, Research, and Treatment, 3(4) 483– 495 (2012). doi:10.1037/per0000006
[viii] Nagata, T., Suzuki, F., Teo, A.R. (2015).Generalized Social Anxiety Disorder: A still‐neglected anxiety disorder 3 decades since Liebowitz’s review. Psychiatry and Clinical Neurosciences, 69(12): 724-740 (2015). doi.org/10.1111/pcn.12327.
[x] Koyuncu, A., İnce, E. , Ertekin, E., & Tükel R. (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs in Context 2019, 8. doi:10.7573/dic.212573; Lyliard, R. B. (2001). Social anxiety disorder: comorbidity and its implications. Journal of Clinical Psychiatry, 62(Suppl1): 17-24 (2001).
The fact that we are not accountable for the childhood/adolescent exploitation that led to our psychophysiological malfunction does not absolve us of the adult responsibility to do something about it.
Many of us avoid learning about the causes and symptoms of our disorder as if ignoring it will make it go away. When we see evidence that the traits and characterizations of the disorder match our own, it somehow makes it more concrete, more real. It makes us accountable. Although all the relevant data is readily available from credible sources, including the National Institute of Mental Health, Johns Hopkins, the Mayo Clinic, remaining uninformed perceptually abrogates responsibility.
When something is broken, it is deconstructed to analyze the problem. We isolate the components and acquaint ourselves with their objectives. Equal effort is required for the brokenness in us. We must study the traits and symptoms of our disorder, and recognize how they affect our thoughts and behaviors. For us to have any chance at recovery, we need to know what we are recovering from. Replacing or repairing defects is fruitless without knowing what those defects are and how they function. Before a football team faces their opponent, they watch hours of film, review stats, and practice. If an actor wishes to give a good performance, it is prudent to learn the character’s lines before getting on stage. Our disorder is our enemy; it is unhealthy, and it hurts us. Our deliberate ignorance is denial, and that is a deal-breaker. Our disorder will continue to impact our emotional wellbeing and quality of life until we recognize, accept, and confront it.
Recovery-remission is a psychological construct. The revelation we are not responsible for the disorder sets the foundation for recovery. Understanding that we alone are the agents of change begins the construct. Counselors and programs provide the blueprint, but we erect the edifice. The disease model tells us what is wrong with us. We do not need to hear that. Our disorder is not something that can be excised like a tumor, so what is the point of telling us what is wrong with us? The wellness model’s focus and by extension, positive psychology and other optimistic approaches, is on our virtues and strengths.
One group of psychologists describes recovery as “people (re-) engaging in their life on the basis of their own goals and strengths, and finding meaning and purpose through constructing and reclaiming a valued identity and valued social roles.” [i] Enduring recovery grounds itself on our knowledge of our disorder and the implementation of our character strengths and virtues to recover from it.
[i] Schrank, B., Brownell, T., Tylee, A., & Slade, M. (2014). Psychology: An Approach to Supporting Recovery in Mental Illness. East Asian Arch Psychiatry, 24, 95-103 (2014).
Establishing new parameters of wellness in mental health calls for nothing less than a reformation of thought and concept. In 2004, the World Health Organization (WHO, 2004) began promoting the advantages of a wellness over disease perspective, declaring health, “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (Slade, 2010, p. 1). The World Psychiatric Association has aligned with the wellness model, submitting that “the promotion of well-being is among the goals of the mental health system” (Schrank et al., 2014, p. 98). Wellbeing has become a central focus of international policy (Slade, 2010). Concurrently, some psychological approaches have become bellwethers for research and study of the positive character strengths that facilitate the motivation and persistence/perseverance helpful to persons with mental illness who aspire towards recovery-remission. Wellbeing must become the central focus of mental health for the simple reason that the disease model has provided grossly insufficient results. As clinical psychologist Kinderman (2014) writes in Scientific American “We need wholesale and radical change, not only in how we understand mental health problems, but also in how we design and commission mental health services” (p. 1). This radical change, however, should not be a dissolution of approaches but an intense review of their efficacy, and repudiation of the one-size-fits-all stance within the mental health community. Certain fundamentals like language, perspective, and diagnosis demand drastic adjustment.
The hurdles are formidable, beginning with a consensus definition of mental illness and its origins. The Diagnostic and Statistical Manual of Mental Disorders (DSM) abandoned the word neurosis in 1980 but it remains the go-to term in the mental health community. One only needs the American Psychological Association (APA, 2020) definition of neurosis to comprehend the pathographic focus of the disease model. Neurosis is,
any one of a variety of mental disorders characterized by significant anxiety or other distressing emotional symptoms, such as persistent and irrational fears, obsessive thoughts, compulsive acts, dissociative states, and somatic and depressive reactions. The symptoms do not involve gross personality disorganization, total lack of insight, or loss of contact with reality (compare psychosis). In psychoanalysis, neuroses are generally viewed as exaggerated, unconscious methods of coping with internal conflicts and the anxiety they produce. Most of the disorders that used to be called neuroses are now classified as anxiety disorders.
Health experts define mental illness as a “diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria” that can “result in functional impairment which substantially interferes with or limits one or more major life activities” (Salzer et al., 2018, p. 3; SAMSHA, 2017). Any disorder that results in 30 or more days of role impairment at work, home, or in social relationships seriously impacts one’s emotional wellbeing and quality of life. Congress defines serious mental illness as a “functional impairment that substantially interferes with or limits one or more major life activities.” The two mental illnesses called psychosis are borderline personality disorder and forms of schizophrenia. Everything else is a neurosis or disorder.
The pathographic or disease model of mental healthcare has been the modus operandi of society for centuries. Granted, there have been interruptions in the disease perspective philosophically and culturally. However, it has been the overriding psychological perspective for over a century, remerging with Freud and continuing through medical models with insular focuses on biological and neurological origins of mental illness. The chief propagator of the wellness model has been positive psychology which originated with Maslow’s (1943) seminal text on humanism and was legitimatized by Seligman as APA president in 1998. The study and research of the character strengths that generate the motivation and persistence/perseverance of a mentally ill individual in recovery-remission is of enormous benefit to psychology and individual mental health.
APA. (2020). Neurosis. Dictionary of Psychology. American Psychological Association. Washington, DC: American Psychological Association. https://dictionary.apa.org/neurosis Accessed 05 April 2020.
Maslow, A. (1943). A Theory of Human Motivation. Psychological Review, 50 (4), 370–396 (1943).
Salzer, M. S., Brusilovskiy, E., & Townley, G. (2018). National Estimates of Recovery-Remission from Serious Mental Illness. Psychiatric Services, 69(5) 523-528 (2018). https://doi.org/10.1176/appi.ps.201700401
Schrank, B., Brownell, T., Tylee, A., & Slade, M. (2014). Psychology: An Approach to Supporting Recovery in Mental Illness. East Asian Arch Psychiatry, 24, 95-103 (2014).
Slade, M. (2010). Mental illness and well-being: the central importance of positive psychology and recovery approaches. BMC Health Service Research 10 (26), 1-17 (2010). https://doi.org/10.1186/1472-6963-10-26 10(26)
We talk a lot about personality in this Blog as it directly impacts and is impacted by our dysfunction and recovery methods. Freud argued that our personality is formed through conflicts among the id, ego, and superego. Since then, there have been as many definitions of personality as there are psychoanalytic theories. For purposes of this Blog, let us simplify what we mean by personality.
Our personality is generated by everything and anything experienced by us in our lifetime. Our reaction to every teaching, opinion, belief, and influence develops our personality. It is our current being and our expression of that being. It reflects our self-qualities, character strengths, and weaknesses. It is formed by our core-beliefs and developed by our social, cultural, and environmental experiences. It is constant yet fluid, singular yet multiple. It is our inimitable way of thinking, feeling, and behaving. It is who we are, who we think we are, and who we are trying to become. We are our personalities.
To the early civilizations, ‘mental illnesses’ were the domain of supernatural forces and demonic possession. Hippocrates and diagnosticians of the 19th century favored the humours. Lunar influence and sorcery and witchcraft are timeless culprits. In the early 20th century, it was somatogenic.[i] The biological approach argues that “mental disorders are related to the brain’s physical structure and functioning.” [ii] The pharmacological approach promotes it as an imbalance in brain chemistry. The 1st Diagnostic and Statistical Manual of Mental Illness (1952) was produced to address the influx of veteran shell shock (PTSD) and leaned heavily on environmental and biological causes.
One only needs the American Psychological Association’s [iii] definition of neurosis to comprehend the mental health community’s pathographic focus. The 90-word overview contains the following words: distressing, irrational, obsessive, compulsive, dissociative, depressive, exaggerated, unconscious, conflicts, anxiety, disorders. The 3rd
The 3rd Diagnostic and Statistical Manual of Mental Disorders abandoned the word ‘neurosis’ in 1980, but it remains the go-to term in the mental health community. Its etymology is the Greek neuron ‘nerve’ and the modern Latin –osis ‘abnormal condition.’ Coined by a Scottish physician in 1776, neurosis was then defined as functional derangement arising from disorders of the nervous system.
U.S. government agencies define mental illness as a “diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria” that can “result in functional impairment which substantially interferes with or limits one or more major life activities.” [iv] This ‘defective’ emphasis has been the overriding psychiatric perspective for over a century. By the 1952 publication of DSM-1, the focus had drifted from pathology (the science of the causes and effects of diseases) to pathography (the delineation of a person’s psychological disorders, categorizing them to facilitate diagnosis). ‘Pathos’ is the Greek word for ‘suffering’ and the root of pathetic, and ‘graphy’ is its biographic rendering. Pathography is the history of an individual’s suffering, aka, a morbid biography. Pathography focuses “on a deficit, disease model of human behaviour,” whereas the wellness model focuses “on positive aspects of human functioning.” [v]
Realistically, most terms for mental illness cannot be eliminated from the culture. Unfortunately, the negative implications of the term and its derivatives promulgate perceptions of incompetence, ineptitude, and undesirability. It is the dominant source of stigma, shame, and self-denigration. In deference to a wellness paradigm, we choose the word ‘disorder’―defined as a correctable inability to function healthily or satisfactorily―over historical terms of pathographic influence.
There are four stages to any illness: susceptibility, onset, gestation, and manifestation. A disorder onsets (client is infected) and manifests (client is affected)―there can be no disagreement about that. Childhood/adolescent exploitation creates the susceptibility to the onset of a disorder, and the holism of the host―mind, body, spirit, and emotions―nurtures it.
Carl Roger’s study of homeodynamics, or the cooperation of human system components to maintain physiological equilibrium, produced the word ‘complementarity’ to define simultaneous mutual interaction. All human system components must work in concert; they cannot function alone. Integrality describes the inter-cooperation of the human system and the environment and social fields. A disorder is not biologic, hygienic, neurochemic, or psychogenic, but a collaboration of these and other approaches administered by the mind, body, spirit, and emotions (MBSE) working in concert.
There is no legitimate argument against mind-body collaboration in disease and wellness. Emotions are reactive to the mind and body; spirit’s participation merits explanation. First, spirit is not ‘super,’ but it is a natural component of human development. While some suggest spirit as the seat of emotions and character, the three are distinct entities. Spirit forms the definitive or typical elements in the character of a person. Emotions are the expressions of those qualities, responsive to the mind and body.[vi]
We all have disorders. They come in different intensities and affect each of us individually. There are at least nine clinical types of depression, five significant forms of anxiety, and four types of obsessive-compulsive disorder; their impacts can be mild, moderate, or severe. Some people adapt quite nicely and get on with their lives. Others incorporate it into their personalities―the cranky boss, clinging partner, temperamental neighbor. We designed this Blog for those of us whose lives are negatively impacted by their disorder.
Research shows that the onset of disorders happens, ostensibly, to adolescents or younger who have experienced detachment, exploitation, and or neglect. Childhood/adolescent susceptibility to all disorders is plausible because, statistically, 89% of onset happens during adolescence.[vii] However, because symptoms can remain dormant until they manifest in the adult, statistics are indeterminate. This paper posits that childhood/adolescent-onset or susceptibility to onset is total. Claims or ‘evidence’ that onsets occur later in life do not impact the argument that susceptibility to onset originates during childhood/adolescence.
Anything that interferes with a child’s social development is detrimental to adolescent and adult emotional health. Childhood/adolescent exploitation or abuse is a generic term to describe a broad spectrum of experiences that interfere with their optimal physical, cognitive, emotional, and social development.[viii] Any number of situations or events can trigger the susceptibility to onset; it could be hereditary, environmental, or some traumatic experience.[ix] Inheritability is rare and susceptible to other factors, and traumatic experience is environmental.
The cumulative evidence that childhood and adolescent occasions and events are the primary causal factor in lifetime emotional instability has been well-established. This exploitation interferes with the optimal physical, cognitive, emotional, and social development of the child. Most importantly, it affects our self-esteem, which administrates all our positive self-qualities (self-respect, -reliance, -compassion, -worth, and so on). These are the intangible qualities that make up our character, our goodness, our spirit. Our self-esteem is reactive to―and, in turn, impacts―our body, mind, and emotions. They all work together in concert. If one is affected, all are affected.
Despite the implication of intentionality in the words’ abuse.’ and ‘exploitation,’ much can be perceptual. A toddler who senses abandonment when a parent is preoccupied could develop emotional issues[x] Onset or susceptibility to onset should never be considered the child/adolescent’s fault and may be no one’s fault.
Undoubtedly, this sociological model conflicts with moral models that claim, “mental illness is onset controllable, and persons with mental illness are to blame for their symptoms,” [xi] or that mental illness is God’s punishment for sin or amoral behavior. Again, it is crucial to recognize we are not responsible for our disorder. Quite possibly, no one is at fault. Playing the blame game only distracts from the solution: What are we going to do about it?
[i] Bertolote, J. (2008). The roots of the concept of mental health. World Psychiatry, 7(2): 113-116 (2008). doi:10.1002/j.2051-5545.2008.tb00172.x; Farreras, I. G. (2020). History of mental illness. In R. Biswas-Diener & E. Diener (Eds), Noba textbook series: Psychology. Champaign, IL: DEF publishers. http://noba.to/65w3s7ex
[v] Mayer, C.-H., & May, M. (2019). The Positive Psychology Movement. PP1.0 and PP2.0. In C-H Mayer and Z. Kőváry (Eds.), New Trends in Psychobiography (pp. 155-172). Springer Nature Switzerland. https://doi.org/10.1007/978-3-030-916953-4_9.
[vii]Baron, M., Gruen, R., Asnis, l.,Kane, J. (1983). Age-of-onset in schizophrenia and schizotypal disorders.Clinical and genetic implications. Neuropsychobiology,10(4):199-204 (1983). doi:10.1159/000118011; Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry; 62(6):593–602 (2005). doi:10.1001/archpsyc.62.6.593; Jones, P. (2013). Adult mental health disorders and their age at onset. British Journal of Psychiatry, 202(S54), S5-S10. doi:10.1192/bjp.bp.112.119164
[viii] Steele, B.F. (1995). The Psychology of Child Abuse. Family Advocate, 17 (3). Washington, DC: American Bar Association.