Who in the world would say such a thing? Who in the world would want to be sick? Surprisingly, many people would. It’s not that they actually want to be sick. Rather, they want to have a reason for why they feel so bad. Having a reason why your stomach hurts answers the questions, “What’s wrong with me?” So when your stomach hurts (or your leg, or your chest, or your back), you want to know what is wrong. That seems reasonable, but the reason part of reasonable gets lost when it encounters our present healthcare system that focuses on what is wrong rather than focusing on what is right. I frequently have people tell me that they have some sort of back problem, usually described as a “herniated disc” or a “slipped disc” or some kind of twist in their spine. Unfortunately, they don’t feel any better physically, but somehow knowing what is wrong helps them understand why they hurt so much. Remarkably, it is very possible for two people to have the very same spinal abnormalities with one of these people having intense pain and the other one having no pain whatsoever. Why is that? The answer to that question is yet very illusive.
I felt compelled to write this blog because of an experience I had a few days ago. A man came to see me in my office who has been suffering from what he described as “OCD” (obsessive compulsive disorder), and has been in intensive hospital-based treatment for this alleged disorder for months. Furthermore, he has probably suffered from OCD-like symptoms and other symptoms for years. He told me that he had been making some headway with this very challenging difficulty under this intensive treatment. More recently, however, he said that his wife and he had come across the diagnosis of Asperger’s Disorder (AD), read about it extensively, and began to think that he may really be suffering from AD, either primarily or in addition to his OCD. He asked me if I could test him for AD to determine whether this diagnosis would be an answer for what was “wrong” with him. In fact, Jack (I’ll call him Jack) was quite hopeful that I would diagnose him with AD, thinking that such a diagnosis would lead to some kind of effective treatment. In a sense, he wanted to have Asperger’s Disorder, odd as that sounds. But it isn’t really odd because he just wants an answer to his distress. Can’t blame him for that. Unfortunately, finding a diagnosis like AD does not give him an answer. He might find symptoms consistent with AD, but that doesn’t mean that he has this disorder. Furthermore, many people who have AD-like symptoms are not suffering from Asperger’s just the same as how people can have the very same physical condition with one person suffering immensely while another person with the exact same condition does not suffer. Why is that?
The reason one person with a very specific physical difficulty has great pain compared to another person with the same difficulty with no pain is…we don’t know. In fact there is certainly more that we don’t know than we actually do know. We don’t know, for instance, how cancer starts. We know where it starts, like in the liver or the colon. We know what seems to be some of the reason it started in the first place. We know, for instance, cigarette smoking tends to lead to lung cancer. But what about those people who smoke for 75 years and never have cancer? We don’t know why they seem to be immune to it. We know a lot of things about physical illnesses in the way they progress, like liver cancer tends to progress fast, while lung cancer progresses at a slower pace. But we don’t know why cancer starts in the first place. And we don’t know why cancer starts because we don’t really know why a cell grows and multiplies into two cells. If we really understood why cells tend to multiply, we would know why cancer cells grow too fast and create too many cells. We know a lot about the physical body and how it functions, but we still don’t know everything. In fact, we really don’t know much about how the body functions. Thank God we know enough to correct some of the diseases that infect humankind. Yet, even though we don’t know much about the cause, the course, and the cure for many of these diseases, people still rely on their doctors to tell them what is wrong, why it is wrong, how long it will be wrong, and what can be done about it. Most of us have heard our good doctors say something like, “I am not sure” as an answer to these questions. Physical problems are just too complex to give exact answers to these questions.
We know even less about psychological difficulties, and as a result, there are even fewer answers to the why, how, and when questions although we have a few answers about the what questions. We know for instance what depression is. For instance, we know that depression has certain symptoms, namely disturbances of sleep, appetite/eating, and energy. When people are depressed they usually have sleep problems in the form of insomnia or hypersomnia (sleeping too much). Even more importantly, depressed people have low energy or motivation that we call anhedonia. We also know what anxiety is, but perhaps a bit less. We know, for instance, that people who suffer anxiety worry about the future in a variety of ways, that they can’t overcome this worry with rational thinking, and that they suffer some kind of physical symptom of anxiety, usually chest pains or shortness of breath. There is some neurological evidence that suggests that the brain operates differently with depressed and anxious people as compared to people who don’t suffer these maladies.
We know a bit about the symptoms of depression and anxiety, but we don’t really know why people get depressed or seriously anxious, how they suffer these problems, or when they start to suffer. There is a good deal of theorizing about the causes of depression and anxiety leading physicians and others to talk about a “chemical imbalance” in the brain that can theoretically be corrected with one or more medications. Unfortunately, these so-called chemical imbalances are not well understood in themselves, not universally agreed upon, and only rarely corrected with medication. Certainly, there are brain changes when someone suffers from anxiety or depression, but this is not the magic bullet people want it to be. Informed physicians will say that antidepressant medication helps about half the people who suffer from depression, but we also know that a placebo will help nearly a third of that same group. The difficulty with the medical-cure theory of depression and anxiety is that it certainly does not cure these ailments. Medications help treat the symptoms of such difficulties, but not the problem. Most people know friends and family members who have gone from one medication to another, and sometimes from one on top of another, all with minimal assistance, and certainly with no cure. And on this matter of cure there is fierce debate.
The oddity of this matter of the what, when, why, and how of so-called mental health difficulties leads people to find the magic bullet even though there is no magic in this vastly diverse field of psychology. I have previously written about the magic associated with mental health treatment: magical diagnosis, magical treatment, and magical cure. There is no such thing. There is no magic in what effective therapists do in their offices, and sadly there are not too many effective therapists in the first place. There are many therapists who are very good people, and very often well trained and intelligent as well as truly compassionate. But we often find that therapists these days are more familiar with identifying what is supposedly wrong with people than they are in finding out what is right with these people. There is even a burgeoning subcategory of psychology called “positive psychology” that purports to examine the right things about people. We have studied much of this positive psychology literature and find it valuable, if quite incomplete. And very few therapists of any stripe and degree are even familiar with any sort of positive psychology. Helping people overcome the difficulties in their lives, requires a depth understanding of psychology, certainly the mental health difficulties like depression and anxiety, but more importantly, the strengths and abilities that people have. It is these strengths and abilities that get us into trouble, much more than the so-called diagnoses.
After hearing from Jack who “wanted” to have Asperger’s Disorder, I told him (with his wife present, by the way), that I thought there may be a different way of looking at what was wrong without thinking that there was something wrong with him. This, by the way, is a statement I say to patients on a daily basis and sometimes on an hourly basis:
“There is nothing wrong with you. Furthermore, there is nothing wrong with the people you work with or the people you live with. And there is nothing wrong with the world. There is something wrong with the interface between you and people, work, and the world. For some reason, you don’t seem to fit. So you have concluded, unfortunately that there must be something wrong with you, work, people, or the world. There is nothing wrong with anyone.”
There are, however, grave difficulties between people just as there are between countries, denominations, and political parties. There are even greater difficulties between tribes of countries that are more tribal than America. It is hard for Americans to grasp the profound differences between Sunni Muslims and Shitte Muslims that has been violent for centuries and has led to the creation of ISIS and other fundamentalist groups in the world. ISIS and its cousins have taken the stand that their philosophy or theology is right…for everyone. So we have these terrible atrocities that ISIS commits in the name of Allah because they know that they are right and everyone else is wrong. Believing that nothing wrong with someone is very different from thinking that there is nothing wrong with what that person does or says.
It is easier to believe that I am right in what I believe than it is to consider that there is nothing wrong with me. Importantly, no one is always right all the time. But you can believe that there is nothing wrong with you as a person while also seeing that you say and do things that are wrong. It is easier to believe that there is something wrong with me or something wrong with the world than it is to admit that I might be wrong with what I said or did. But this is not a distinction that most people make, and it is a distinction that is the hallmark of personal maturity. The more one firmly believes that he or she is not a wrong person or a bad person, the more one can admit to errors of words or actions. Believing that you are a good person at heart, truly believing that, gives you the opportunity to see mistakes you make, misspoken words you uttered, and misunderstandings you created. And then apologize. But you are not apologizing for being a bad person. You are apologizing for failing to communicate, for hurting someone unintentionally, or for neglecting to gather all the facts before you shot your mouth off.
How does all this philosophizing help Jack who came to my office “wanting” to have Asperger’s Disorder? I needed to be quite careful with Jack because he had found some important hope that he could conquer the difficulties in his life by finding an exact diagnosis like Asperger’s. I explained what I do and how I do it, namely finding people’s strengths first and then finding the limitations and excesses of these strengths that cause problems. Within a couple of hours, we were able to come to an understanding of a different way for Jack to look at himself, one that looked at these strengths and limitations that led to his life’s problems. This is a beginning, a new beginning, a way that looks for hope in the positive and healthy rather than the negative and unhealthy. Now comes the hard work of helping Jack sees both his strengths and limitations and find ways to enhance these strengths and acknowledge his limitations in order to make a life for himself. But this is hard for Jack as it is for everyone. If I seek to replace the magic bullet of some kind of mental health diagnosis and replace it with a strengths-based “diagnosis,” I then have to help the person face the limitations of these strengths in order face the even harder task of seeing the opportunities of making the world a better place. For the moment at least Jack is excited about finding and enhancing these strengths than in finding a way to cure him of some magical disorder with some kind of magical treatment.
Further Reading
My previous blog, The Magic of Psychotherapy
Our current book, The Positive Power of Sadness (Brock and Johnson), Praeger Press.
Articles and books written on Positive Psychology (Seligmann and others)