Friday, 5 March 2010

A model of mental health

During these last few weeks I've been working on a model for understanding mental health and therapy. It is a way for me to make sense of, to make a map of what I'm learning in classes and what I'm exploring in my own therapy. This is my personal understanding of mental health, but I'm hopeful that it will be helpful in understanding and helping others, and curious of which clients and which diagnosises it models well.

I - Life issues
As we grow up, struggle through life, we must all find our own answers to the big questions – Things like....

Who am I?
Is the world a safe, good place?
How do I protect my self from those who would do me harm?
Do I deserve love?
How will I convey my own love?
What sources do I draw from to strengthen my self-esteem, what makes me feel good about myself?
How will I handle a neurological handicap I was born with or a brain injury I sustained mid-life?
Life demands answers to these questions. Our answers become models for handling everyday life, they shape who we are, what we think, what we feel. Without these models, life would be impossibly extorting.

There are some patterns that keep re-emerging as answers to these questions, for instance:

- People neglected by their parents as children become insecure of their self-worth, typically beccoming withdrawn or clingy and love-hungry.
- People denied their individuality and integrity and self-worth (and with the right biological sensitivity) can protect themself by displacing their guilt and shame into an accusing voice or delusions of other people controling them, becoming schizophrenic.
- People who are wrought by difficult loss (by a parent, for instance) and lack of love in their early years may come to the conclusion that it is actually they who doesn't deserve love. This is to retain the feeling they are in control of their life and protect themselves from the very frightening insight that they have to rely on people that deep down doesn't give a shit either way.

Questions resolved in a healthy fashion doesn't follow common patterns of development in the same way, perhaps because mental health is characterised by self-realisation, individuality, to become your own person – That is, to defy patterns and go your own way.
Or maybe just because there is far more research on mental illness than mental health.

Whereas some life questions are resolved in a way that leave the person vulnerable and frail in that domain, others are resolved successfully, and will be a source of strength and confidence for the person, following hir through life. Though typical models keep reappering in the care of mental health, each person, both ”normal” or ”abnormal” must be understood as made up of a unique disposition of life models.

You can understand these "life issues" as a mix of existentialism (It's up to everyone to find answers in life) and cognitive-behaviour therapy. (People live by automatic models, programs so to speak, of behaviour.)

II - Normality
Let us revisit Lucien A Buck's model of normality, placing different answers and strategies to life issues on his continuum of mental health.

Buck describes the abnormal position as a defensive one, protecting oneself from regressing, losing what one has. The schizophrenic person fears sie might disintegrated any moment, and keeps a paranoid wall against all other people. The bipolar (or manic-depressive) person goes into manic states to defend hirself from the soulcrushing darkness of depression. It's all or nothing, either you surrender to unbearable anxiety or you wall yourself off to survive. Abnormality is characterized by this all-or-nothing stance, it is rigid and without flexibility.

To have achieved normality in a life issue is to have accepted the answers provided by society as good. There is safety in this, community and efficiency, but normality is not without it's own problems: There is still a stiffness in letting a norm define you, not daring to explore your own answers. There is stress and ulcers in societies' norms, and it is difficult to change when you are dependent on other people's ready-made answers. And we all change with age, thus the age crisis.

Whereas abnormality and normality is defined by rigidity and stiffness, health is characterised by a form of softness – When you trust yourself this much, you can allow yourself to change according to situation, without losing track of who you essentially are. You can be playful, adaptive, open-minded. You can also be thoughtful and genuine - You know yourself well enough for that. You have explored yourself and found the right answers for your questions, whether they are part of norm or not.

Buck encourage us to take caution when exercising mental care, not to squish a person into a normality that sie doesn't fit into, and would feel alienated by. We should rather give security to abnormal issues and take care of and develop the healthy ones.

The model is actually a continuum and should be drawn as a line, but I like the thought of someone standing in the circle of normality/health/abnormality at a given moment.

III - Security
The difference between these positions can be explained with the words "sense of security".

At the greatest level of abnormality, security is none. Your life issue is at constant threat of regressing, desintegrating, collapsing, so you protect yourself against others fiercely.

Going from abnormality to normality is characterised by establishing outer control: Limits, borders, structure in your life that provides predictability and manageability, even protection from yourself.

At normality, the borders and norms have been internalised - They are a part of you now. Your self is secure enough to let other people near without exaggerated fear of being hurt. There is still a sense of insecurity though – There are still parts of you unknown to you, since you have just accepted the answer rather than exploring the question fully.

Going from normality to health is characterised by process depth: Exploring, understanding and taking control of your inner processes.

At health, security is greatest. Imagine you have built a very sturdy house – You then have the safety to leave it, to explore. You also feel safe going into your dark places, the parts of yourself you don't normally think of, confident you can handle any anxiety it wakes up. The house will hold together.

There are parallells to different psychological theories on security here:

Attachement theory describes how the children with a well founded sense of security are the bravest in their exploring. Safe in the knowledge that you can always return to your parents and they will provide safety, they will go explore the world, not needing to conform to other people for validation and approval. They already have an internal approval firmly placed in their hearts.

Humanist Abraham Maslow has an interesting idea of how humanity have a series of human needs (physical safety, social, self-realization etc), and just like the child can establish a sense of security in their parents, people can establish a sense of security in these different needs. For instance, if I have a sense of security in my social needs, I do not need constant confirmation from my friends that they still like me.

Maslow has also written on the subject of the self-actualizing person, the healthy person so to speak, who seeks to explore and express hirself, actualize hir inner potential, to grow. Just like in Buck's model, Maslow characterizes this person as someone who is genuine, who follows hir own way, not in a forced way but in a curious and open-minded way. Self-actualization is not a goal that can be reached, but rather a process, to be in movement, to be open-minded and fluid.

I associate this model to learning theories as well, but that's for another post.

IV - Therapy
All therapy must somehow first establish a sense of security. This is called therapeutic alliance, a sense of trust and hope between the client and the therapist. When the client feels safe in the therapeutic room, sie can let hir models of thought out into the light and examine them. Sie can, not necessarily consciously, test the therapist with them - If I expose you to what I was exposed to, will you react like I did, or is there another way you can show me? In this way, people's model are changed.

                                               Acceptance, empathy, genuinity ->   
                                                                     New mental models ->

Now, the big question is, does security lead to healthy models, or does healthy models lead to a sense of security? Like so often in psychology, you can work in either direction:

Humanistic therapy
 creates an atmosphere of acceptance, empathy and genuinity, building on the sense of security. Provide the sense of security and carefully prod the client towards processing depth, and sie will spontaneously explore hirself. Having written it down, I can see that this model implies that in humans there is a natural movement towards health, growing and development as long as safety, security and acceptance is supplied, and this is a foundation of humanistic psychology.

Cognitive-behaviour therapy works the other way around, first you assess the clients mental models and provide more healthy alternatives, and with this competence the client will gain a sense of security.

V - Soft-Hard
"Defensive" is a word which has made it's way into everyday english, but it is originally from psychodynamic theory. According to psychodynamic theory, defenses are something we must have to protect ourselves from anxiety, but when defenses are too strong, too primitive or too inflexible they may become a problem.

This points to how different people will handle issues differently: In a way I inhereted my fathers sense of guilt when he raised me, but whereas he keeps this guilt away by intellectualization, I have instead become sensitive and vulnerable to other people's disapproval and sensible to their own insecurities.

Strong defenses also illustrates the rigidity of abnormality: In the hard circle of abnormality, you can either let the problems and anxieties of life issue manifest themselves freely, or you handle it with strong defenses - throw it away completely, deny it, unable to confront it. All or nothing.

The softness and adaptivity of the healthy individual remind me of the ideals of taoism: Do not force yourself onto nature. Be fluid, like water, and you cannot hurt yourself. Be accepting, humble, genuine and happy in the way of the ever-curious and innocent child.

Coincidentally, it also reminds me of impro theatre.

One of my difficult life issues has been romantic love. I've never actually achieved a romantic relationship, which has been the source of great stress - I felt that I had to have it, I had to reach normality, and through reaching this normality I would reach a sense of self-worth. I've had problems with expectations building up - Love encounters became confrontations with the only possible outcomes a) high expectations fulfilled or b) nothing at all. As you can tell, there was a great deal of stiffness involved.

With a greater sense of security, with the safety to explore these feelings, process them deeper and understand them better, with a chance to experiment without the have-to's, love can become something playful and lustful. Something healthy. I can stay in the moment, fluid, enjoying the present rather than building up to some wishful future state.

I don't actually have to have a single relationship if it doesn't feel right - The one important thing is that I find my way to that bright and gentle circle of health.

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