What is mental health: a view from the psychology / psychotherapy

    Hello, reader! My

    previous article came out somewhat “dry”, in which I was rightly reproached at several sites, so I decided to write another one, more filled with lively examples and understandable explanations. Today, I propose to talk about mental health in general - what it is, what is manifested, where the line between it and ... not quite healthy states, etc.


    tl: dr : The article addresses the issue of mental health using the example of a model proposed by Nancy McWilliams (“16 elements of mental health”). For each element, I will try to give examples of how the psyche looks “broken” in this aspect, what was done to “fix” it (in this particular case), what mistakes were made, what else could be done, etc.

    Unfortunately, the desire to simplify the material on my part has significantly reduced the accuracy and objectivity of the formulations, I warn you right away.

    As examples, I will take, first of all, my personal problems (I am quite an experienced psychiatric patient) simply because it removes a lot of ethical questions about the legality of disclosing other people's stories, and where this is impossible - the problems of those people with whom I happened to to contact under certain circumstances, of course, on conditions of complete anonymity and deletion / modification of any details that could lead to a deanon.

    DISCLAIMER: I am a clinical psychologist, not a doctor (a psychologist is not a doctor, unlike a psychiatrist, if someone does not know, even a clinical one). I do not have a license for medical activities. This means that all references to diagnoses, drugs, methods of treatment, and other medical aspects are given merely for reference: they are neither recommendations nor prescriptions. Any decisions regarding starting, changing, or stopping treatment should be made with an appropriate physician. The article in no case should not be perceived as a manual for treatment or self-treatment.

    About the boundary of the norm and pathology

    Psychiatrists and specialists in related specialties are often asked the following questions: “And who determines what is normal and what is not?”, “Why are you trying to fit everyone to the conformal majority?”, “And if it’s not me who’s ill, I’m just too brash , in order to understand me? ”and t, n.

    Without aiming to give a detailed answer to each of them, I would say that the real line between normal and pathology is not as clear as we would like, that the problem of subjectivity in the assessment of patients in psychiatry does exist that the system is imperfect (take t Only one section F21 of ICD-10).

    But this does not mean that everything is very bad. In practice, there are two thick books - ICD (International Classification of Diseases) of the tenth version and DSM (Diagnostic Manual of mental disorders) of the fifth version. These books list the currently known mental illnesses and the criteria for determining them (in order to diagnose a disease X, the patient must type N matches with the above criteria).

    The accuracy of such a diagnosis strongly depends on the performer, but I want to take this question beyond the scope of the article and talk about another problem of ICD and DSM: a huge number of cases where a person is clearly ill and he definitely doesn’t have “something wrong with the psyche” in one diagnosis. Or fit into several at once.

    For example, I personally put: anxiety disorder, obsessive-compulsive disorder, schizotypal disorder, schizophrenia, depressive episode (moderate to severe) and even suspected dissociative identity disorder. For those who are not at all familiar with psychiatry, I will explain: these are completely and completely different diseases that are very, very different from each other in etiology / pathogenesis, prognosis, treatment, etc.

    On the other hand, one girl, let's call her P., clearly shows signs that something is wrong with her (unfounded fears, inability to work, mood swings, chronic weakness, quasi-psychotic phenomena, etc.) does not have a diagnosis - neither psychiatric nor "somatic." Those. her condition clearly does not allow her to live a full life, but she does not gain enough matches for any diagnosis (according to doctors) so that it can be made.

    And this situation in which people who are actually sick are told: “you are healthy, you are just lazy / wrong / do not want enough”, in my opinion, without exaggeration, can be called a tragedy.

    No less a tragedy is the setting of some kind of diagnosis “as long as it was, it’s necessary to put something in”, accompanied by the actual absence of a normal treatment. Another girl, let's call her A., ​​in such circumstances came out of the window. Just because it did not receive normal assistance (with a formal diagnosis).

    Why am I all this? Besides, the diagnostic system based on ICD / DSM (the second one I like more) is not perfect. There are no real alternatives for them to date *, but there is a model “16 elements of mental health” proposed by Nancy McWilliams.

    * More precisely, there is a psychoanalytic diagnostic manual, but it does not have the status of an official manual.

    This model is not so specific (it will not allow to determine what is wrong with a person and assign him specific treatment), but it has much greater sensitivity: many experiencing problems, formally healthy by ICD or DSM, are successfully “caught” on one from the criteria of McWilliams.

    Consider them. I will try to give some extended interpretation and context based on personal experience and knowledge, i.e. reliability class D (or even lower, “personal expert opinion” / “description of individual cases”, not more).

    Main criteria

    1. Ability to love

    It means the love of another person. It is love, not love, that is, accepting a person as he is: without idealization and devaluation, the ability to give, without sacrificing yourself, to trust, but to preserve your boundaries. Speech here is not necessarily about sexual love, it can be love for children, parents, siblings, etc.

    An example of brokenness (mine) : after the “divorce” I was not able to trust my partner. I always expected betrayal (I have a fad on this subject), considering my contacts as temporary. Constantly pestered partners with suspicion, did not open and did not tolerate openness. Violated the boundaries, indicating what to do and what not.

    I was not capable of non-sexual forms of love: I either distanced myself from people (in most cases) or went into a mode of sacrifice and self-deprecation (I did not feel love, for example, but experienced fear in my parents).

    How it was possible, and whether it was possible to fix it : by combining romantic relationships and therapy. Yes, I know, you can't do that, but what happened was. Since my girlfriend ( stanimira ) is so good at therapy, we decided to try.

    The first few months were almost daily therapy sessions. Then psychedelic therapy was added (in order not to trigger extra services, we will assume that holotropic breathing was used).

    As a result, the basic fear of betrayal was somewhat reduced, and I was able to trust in another person. This led to the fact that I stopped making her brain with my suspicions, was able to get more emotional returns from this relationship, and I want to believe, I myself became a more comfortable partner.

    What mistakes were made : the combination of personal and therapeutic relationships. We avoided this at the very beginning (I was not her patient), but stepped on this rake later. At some point we both realized that the therapy was too contaminated by the personal, and stopped it. But I received quite a lot of emotional pain in connection with such a mixture. I think she too.

    What would be more correct to do: First go through therapy, then enter into a relationship. Or do not join. Or at least make it so that the partner and therapist are different people.

    General recommendations: pharma is usually ineffective ( hereinafter, I express only my personal opinion, specific decisions about the feasibility or inexpediency of pharmacological treatment, the patient makes with the doctor, only this way, and nothing else ). Short-term therapy, too. This is one of the few problems (Vanguay in the comments of the deniers of the fact that this is a problem at all) for which long-term therapy is really justified.

    2. Ability to play

    Here we are talking about “the game” in the broadest sense - creativity, creativity (whatever the word means), the ability to act outside the box, go beyond rigid scenarios, the ability to fool around, etc.

    An example of brokenness (not mine) : a man, a logistics specialist in a large company, quite productive (according to his colleagues). Not bad in solving non-standard tasks in work, but completely incapable of spontaneity in social situations. A single mother, who is deprived of communication (ie, this loneliness is not the most high). Close relationships are completely absent in the sense that most people put into this expression. Against this background, there is a tremendous anxiety that (surprise!) Leads to a decrease in productivity at work: it is not as effective as it could be.

    How it was possible, and whether it was possible to fix it : for now. A person receives psycho- and pharmacotherapy, came to the realization of this problem as a problem. On this at the moment - everything.

    What would be more correct to do : ask for help earlier, much earlier.

    What mistakes were made : in therapy, this problem has not been worked out for a long time (an error on the part of the therapist). Much time was lost.

    General recommendations : the effectiveness of pharma is moderate - if the problem is, for example, in asthenia, then the correct pills, by improving the overall tone of the person, can help to realize this very gaming behavior.

    But the pills are secondary here, as a rule. In therapy, the creation of a safe environment in which a person would decide to experiment with behavior. Formation of some initial skills by demonstrating a personal example. Unfortunately, this can also take a long time.

    3. Ability to work

    Here it is not only (and not so much) that it is depressing to hang around in the office from nine to six. This is more about the ability to create a product that has value not only for the creator, but also for [even a limited group] other people. This is about the case (with a capital letter) or about the ability to find some meaning in the case (with a small letter) in which a person is engaged.

    Example of brokenness (mine): I ended up in a mental hospital because I could not work. There were two problems here: firstly, asthenia and impaired thinking really prevented me from engaging in purposeful activities effectively, and, secondly, there was a strong (at the level of delirium) confidence that I could not work in principle. I can not because I can not. I was not ready to try, because this idea was so tight in my head that when I tried to make me take it and try it, I would start cutting myself or beating my head against the wall, or some other tantrum. And not at all in order to fall behind, but simply was so bad that I wanted to switch from emotional pain to physical pain — it's easier to endure.

    How was it possible and was it possible to fix it: First, therapy and “holotropic breathing” radically “reformatted” my head. I believed that if I tried, I would not die. Secondly, properly selected antidepressants gave strength to get out of bed at all and do something. Thirdly, a correctly selected neuroleptic removed multiple internal dialogues interrupting each other and filling the head with flood (I didn’t have voices, but felt like my own thoughts, only belonging to different “I”).

    What would be more correct to do : do not bring to this state, contact the specialists 15 years earlier (in adolescence). One should not blindly trust “doctors” (I cannot talk about quotation marks without these quotes, with all due respect to real specialists).

    What mistakes were made: too long and stubbornly clung to IT, denying the fact that you can still realize a lot where. Now I understand that in IT I don’t “can’t”, but I don’t want it.

    General recommendations : pharma effective. At least in the early stages, when you need to overcome asthenia, remove disturbances of thinking or restore sleep. Well, and many other problems that hinder the work, it perfectly cleans. But its possibilities are not infinite: it copes well in order to add strength or remove some restrictions, but if the problem is that the person “does not stick” what he does, nor does he find an outlet on the side, then here, most likely, you will have to disassemble the psychological problems.

    Additional criteria

    It so happens that a person is able to love, play and work, but something is still wrong with him. And under the criteria of the ICD / DSM, it may not fall. For example, a man, let's call him B., has a well-paid job, is in a romantic relationship, realizes himself in the works (in the field of machine learning), but at the same time he has huge problems with interaction with people: he adapts too much to them, dissolves in other people's expectations, subordinates their lives to them.

    In order to cover such cases, the following additional criteria were developed.

    4. Ability to form secure attachment

    The point here is, on the one hand, to be able to become attached to another person (a certain level of affection is the basis of close relationships), and, on the other, that these affections do not become a problem. Sometimes it happens that there is affection, but the subject is constantly worried about her (“Will he / she leave me?”). Or easily refuses attachment, but remains with huge gaping wounds inside (“I will give up on you, let me be worse”). Or experiencing along with attachment - anger, resentment, and shows aggressive behavior ("Just do not leave me, despite the fact that I hate you").

    Example of brokenness (not mine): girl, let's call her C., constantly provoking her partner to parting. She arranges scandals for him, she makes sure that he learns about her infidelities, she seems to be doing everything so that his patience once failed. But at the same time, any attempts to end the relationship on his part lead to powerful suicidal impulses, which she skillfully (albeit unconsciously) manipulates.

    How it was possible, and whether it was possible to repair it : at the moment, it was not possible to completely repair it, despite the fact that quite a lot of specialists from different areas worked with it, psycho- and pharmacotherapy were used.

    The current level of progress - she realized the toxicity of the relationship with this partner (he also does not meet our sixteen criteria) and was able to complete them. This greatly stabilized her condition (and also mood-stabilizers and neuroleptics, yes), but I personally do not venture to make predictions about what her next relationship will be. She is actively working to increase her own awareness and constructiveness, but ... Everything is difficult here, in general.

    What mistakes were made : at the beginning of the treatment, an inappropriate pharmacological scheme was used, which significantly worsened the girl's condition. Some experts allowed the use of destructive labels: “You are bad, you are simply not trying hard”, they did not help her for a long time to understand what was happening to her and why it was happening.

    What would be more correct to do : do not use derogatory / destructive labels, this time. I have some questions to her psychiatrists according to the pharmacological scheme, but they are doctors - they know better. From the point of view of psychotherapy, it seems to me that it would make sense to pay more attention to the level of awareness, and not to concentrate all attention on purely behavioral changes.

    General recommendations : the type of attachment that a person uses is formed in his childhood and is almost completely determined by early experience. Pharma is ineffective (unless it allows you to slightly muffle anxiety or impulsivity, but the observed behavior changes, at best, the essence of the relationship remains the same).

    Psychotherapy is also very conditional. A long, difficult and expensive work with a specialist may not succeed, even if he does everything right: simply because the pattern of attachment formation may sit too deep in the psyche. Sometimes close relationships with a mentally more stable and healthy person can be effective (the subject introjects his method of forming attachments), but according to the same McWilliams, this takes at least five years, and there is no guarantee.

    5. Autonomy / Solvency

    Here we are talking about the human understanding of the fact that he can and should manage his life, the ability to defend himself, to follow his (and not only imposed from the outside) desires (where appropriate, of course).

    Example of brokenness (mine): I didn’t believe for a very long time that I could do something “serious” (something that seems subjective to me). I did an excellent job with the university’s educational tasks and on the courses, I felt calm and confident there, but as soon as the time came to perform the same tasks in real life, I was anxious and I started to mess up. I could not make independent decisions, I had to rely on someone. Over time, this was over-compensated, but this over-compensation led me to a situation of complete emotional burnout and the need for a long, difficult and very expensive recovery.

    “You can't do that! This (business, tuning tsisok, driving a car and a lot of other things) - for big uncles, do not go there, puppy! ”- my Inner Parent told me most of my life. And I did not climb into these areas. Worse, according to the conviction that I realized later, in the process of psychotherapy, “being happy” is also included in this list of prohibitions.

    How it was possible, and whether it was possible to fix it : antidepressants with a stimulating effect (correctly selected) and a successful neuroleptic created the basis for the possibility of behavioral therapy. Before that, it was (and it is directly related to this point too) the reformatting of the brain, which was discussed above.

    Having gained a certain minimum level of confidence that “I can” and “I can” (thanks to pills), I began to try to do something in the framework of behavioral therapy, for each attempt I received a reward (the drugs provided a relatively correct work of the reward system in my brain) in the form of a huge “buzz of the first experience”: I overcame internal prohibitions one by one, and it was very cool.

    I will not say that now I meet the criterion under consideration, but the progress is obvious - some activities that I would not even have had before (including my current professional activity) are now available to me.

    What mistakes were made: first of all, parenting mistakes :) In addition, I turned too late for help, and this help was at first wrong: a psychiatrist told me how cool he is and how much better he is, which did not motivate me, rather the opposite.

    What would be more correct to do : immediately write me the correct drugs, and not “vegetable” six months in an insane asylum on useless outdated schemes.

    General recommendations: I do not believe that you can do something with one thing - pharmacy or therapy, in some complicated cases a combination is required. Pharma is the basis, if significant mistakes are made there, therapy will not help. On the other hand, without therapy, it is very difficult to translate those changes in the emotional background and mode of thinking that pharma gives into constructive forms.

    6. Constancy of self-perception and objects, identity integration

    Here, basically, it means the ability to perceive several sides of oneself or an object, even if these sides are opposite (“positive” and “negative”) characteristics. The ability to say about a person that he, of course, is a reptile, but this and that is doing the right thing. Or that he is a good and, in general, an example of everything in everything, but here it is concrete - fundamentally wrong.

    The second aspect is the understanding that “I am yesterday,” “I am today,” and “I am tomorrow” are the same subject (to some extent).

    An example of brokenness (mine) : here we can say about the classic “Kernberg test”, which is that the specialist asks the patient to describe himself / mother / father and see if he can produce a “stereoscopic” picture with positive and negative properties.

    Before the manifestation of the disease (and, accordingly, before the treatment), I idealized the father. I could not even think that he could be “bad” or at least make mistakes. Even when I saw some unpleasant facts, I dodged and thought out delusional explanations of the form “they are all bastards, they set up such a good person”.

    At some point, the assessment changed, but not to a healthy one, but stupidly to the opposite - now he was a monster, a fiend of hell, a creature, and even the embodiment of Evil. It came to the fact that when he called, I was afraid to pick up the phone because he could calculate me (how? - it does not matter), come, take him to a special torture cellar (where did he come from?), Hang him by the legs ( ) and torture until I become different: the way he needs.

    How was it possible and was it possible to fix it: Now, after a course of neuroleptics and psychotherapy, I understand that he is not a very good person (as part of my rating system), but he seems to have his own strengths.

    I still cannot perceive it, equally taking into account the positive and negative sides (and I can never, according to Kernberg), but the evaluations have become “artificial”, “false” -objective: at the level of intellectual reasoning I can grasp the fact that he, like any person, has pros and cons, but emotionally anyway throws me into one of the extremes. Important stages were neuroleptics and confrontation.

    What mistakes were made: late recourse. I denied too much that I generally had problems in this area, and psychiatrists interpreted this as nonsense and tried to remove it with outdated preparations, and not understand the situation and see that this is just one-sidedness of perception that is characteristic of my level of personality organization.

    What would be more correct to do : I have an inadequate attitude towards him since childhood (I was sure that he would kill me either because I was gay (actually not), or because I wasn’t his son ( also no)). If I had been shown to a child psychologist / or psychiatrist, perhaps he could have been fixed earlier, and life would have gone otherwise.

    General recommendations: here pharma is needed only in cases where the impossibility of simultaneous (“stereoscopic”) perception is a consequence of a serious endogenous process, which is not always the case.

    Therapy is shown, but it is not able to return this possibility completely to those who have it broken. There are no miracles to wait for, but even the results that are possible are worth making significant efforts: I have become much more objective in assessing people, processes and phenomena, they frustrate me less often (since I already see not only their negative sides) and this greatly improves the quality of life.

    7. The Power of the Ego / Ability to Endure Stress

    Here we are talking about the fact that a healthy person copes with stress constructively: not falling down in acting out, in helplessness, in aggression towards the weak and helpless, flight into alcohol or drugs, and so on. A healthy person rather quickly begins to look for ways to either remedy the situation, or, if this is not possible, adapt to it (see Criterion 16 ).

    An example of brokenness (not mine) : an elderly man, experiencing a divorce, experienced a relapse of alcohol dependence after a long period of remission.

    How was it possible and was it possible to fix it: working with automatic thoughts within the framework of the second wave CPT, visiting group therapy (AA) and raising the general level of awareness as part of the circuit therapy led to the formation of healthier copings in relation to stress, and then to a change in attitude towards the stress situation itself.

    What mistakes were made : both he and the experts did everything correctly, except for one thing: at the very beginning it was necessary to call the therapist, and not to take a glass. If not even psychotherapeutically, then pharmacologically it was possible to prevent a breakdown in relapse.

    What would be more correct to do : immediately seek help from specialists.

    General recommendations: KPT of the second, and then the third version (I personally like this sequence) can be an effective tool for the rapid formation of new skills. Properly chosen pharma is a good catalyst. Analytical therapy allows to “strengthen the ego”, i.e. not just to form mechanistic skills, but to make a person stronger.

    8. Realistic and sustained self-esteem

    The ability to see their own shortcomings, take them into account in life planning and specific behavioral acts, learn from mistakes, but not go into self-deprecation, self-accusation - and generally treat yourself well by default, regardless of the ratings of others. Understanding that even if someone from a meaningful environment treats you badly (even if there are many such people), you can ... love / accept yourself anyway.

    Example of brokenness (not mine): The aforementioned man, B. (see the beginning of the “Additional criteria” section), is so much dependent on other people's assessments that he doesn’t have any stable self-assessment at all. His mood and condition depends entirely on whether he is being praised at the moment, whether he is given to understand in feedback that he is smart. On this depends the performance, intellectual abilities, the ability to cope with stress (not related to external assessments) and a lot of everything else.

    How was it possible and was it possible to fix it: long work on raising awareness (“why do I depend so much on what they say to me?”), search for invariants in different assessments (“what my features are all”), validation (“you really are what you think of yourself” ), as well as the tireless work of the client on themselves led to the fact that self-assessment began to take shape. It is still extremely unstable, but it is there, and the person began to realize its advantages for himself (to take at least more stability in the work).

    What mistakes were made: for too long and diligently attempts were made to draw the client’s psyche into the Procrustean bed of models known to the therapist. The real progress has gone after these attempts have been abandoned, and joint work has begun with the client to develop an accurate model of what is happening in his head, and, accordingly, the formulation of goals and methods within this model.

    What would be more correct to do : not to waste time on pharma (in this particular case, it is more harmful than useful) and attempts to "shove nevpihuemoe."

    General recommendations : here I would put therapy on the first place, without diminishing the importance of a correctly chosen pharma (correctly applied antidepressants can be quite a topic).

    9. Adequate personal orientation system / superego

    The presence of some external ("moral") landmarks simultaneously with the ability to flexibly follow them. Do not go into a complete denial of the norms of social existence, but do not treat them as immutable dogmas, feel the context and applicability of each of them in this particular situation.

    An example of brokenness (mine) : I had everything OK with the presence of moral guidelines, but I did not know how to be flexible in their attitude. This led to the fact that I gave a significant part of my income to a person to whom this money was not needed either for survival or for the implementation of any significant projects.

    Roughly speaking, he spent them on Ponte. However, I considered myself his debtor, and the debt - non-repayable. This led to the fact that, having, in principle, a good salary by the standards of the region, I sometimes lived below the poverty line (according to Rosstat criteria). This was very demotivating in work (why work hard, if you still give a significant part of the income), perhaps this was one of the factors in the manifestation of the disease.

    How it was possible, and whether it was possible to fix it : stimulating antidepressants gave some feeling that I was “not a trembling creature, but I have the right”, but long (analytical) therapy led to the realization that the mentioned debt can not be paid (I rechecked this statement with several experts, all agreed).

    What mistakes were made: psychiatrists did not begin to understand the reasons, considered it nonsense (in the clinical sense) and began to feed them with heavy typical antipsychotics. It took almost a year and a half to recover after this “treatment” and about a million rubles.

    What would be more correct to do : choose the right pharma and start therapy, do not jam and do not veg.

    General recommendations : here, in my opinion, it is the psychotherapy that is primary, and pharma can only create the necessary background for it. In some cases (true antisocial personality disorder), probably, neither one nor the other will help - only isolation (for the good of society, not the patient, alas).

    But if there are at least some “gaps” in the structure of a sociopathic character, therapy is difficult but justified: it should be aimed at shaping the subject’s strategy within which he could fulfill his needs for power without harming others (for example, became a tough senior manager - soulless, but effective).

    10. Ability to transfer own emotions and thoughts / Ability to restrain affective reaction

    The ability to separate emotions from thoughts, and those and others - from automatic actions. Ability to endure experienced emotional shocks without fatal / serious consequences for yourself and others.

    An example of brokenness (not mine) : a young woman, let's call her E., is very sensitive to stress. Especially in the relationship with her young child. When a child does something “wrong”, she feels a sense of betrayal of such strength that she cannot cope with it. And breaks down on his son, calling him the last words.

    How was it possible and was it possible to fix it: unfortunately, it was not possible to connect the work of the psychiatrist (and pharma) to the process - this was contrary to E.'s convictions, and it was impossible to overcome them. On one therapy, it was possible to reduce the frequency of such episodes (from 3-5 times a week to 1-2 times a fortnight).

    It was possible to raise awareness and due to this to direct part of the anger to the primary objects (in fact, she is angry not at the child, but at those towards whom she has an internal prohibition on aggression). Coping cards and working with early maladaptive schemes made it possible to develop several alternative ways to cope with stress, which did not include the redirection of aggression.

    What mistakes were made: it was not possible to keep the client in therapy, could not be persuaded to contact a psychiatrist for pharmacy (a mood stabilizer or a small dose of a suitable neuroleptic would reduce impulsivity and greatly facilitate the work).

    What would be more correct to do : at the stage of concluding a contract for therapy, to make cooperation with a psychiatrist and medication a prerequisite.

    General recommendations: It's hard to say what will be more effective - pharma, therapy or combination. Very much depends on how and why exactly a person can not cope with stress. But if you try to derive some common denominator, I would put drugs (mood stabilizers, atypical antipsychotics, SSRIs or serotonin modulators) first, third wave CPT, in particular, circuit therapy (however, we remember that it is not so important) school, I just like their ideology).

    11. Feeling Separate / Ability to look at oneself from the side / Insight ability

    I do not know why so different things McWilliams combined into one criterion.

    Let's try to figure it out. First, it is about (first of all, emotional) the realization that the Other is the Other. That if he does something wrong, as a person wants, then it is the act of the Other, and not the mistake of the person himself (such perception occurs quite often, in fact).

    Secondly, it speaks of the opportunity to look at oneself from the outside - to step back from emotional experience and move into the position of an observer. This also includes the ability to realize the possibility of their own madness (or its presence, if it is already present). Critical attitude to experiences.

    The ability to insight as the pinnacle of cognitive activity - that “dawned on”, “eureka!” And so on.

    An example of brokenness (not mine) : a man, let's call him G., believes that he is not capable of constructive activities as a result of his serious illness. At the same time sabotage all real attempts to cure this disease - violates the medication intake scheme, uses alcohol (which is strictly contraindicated in his case). He does not realize that there are a sufficiently large number of activities that he can perform, despite the presence of this disease (especially with the correct treatment).

    How was it possible and was it possible to fix it: Against the background of the appointment of adequate doses of antipsychotics by a psychiatrist, a number of sessions were conducted according to the method of Garrett “CPT psychosis in a psychoanalytic setting”. The essence of the method, if very simplified, is to ensure that by subtle unobtrusive questions (in the complete absence of direct confrontation) to lead a person to the realization of certain contradictions in his beliefs. The breakthrough was marked by the phrase G.: “Laziness is actually hiding behind my illness.”

    What mistakes were made : there was not enough work done with relatives, who formed around G. an aggressive, disabled, invalid, and disabling environment.

    What would be more correct to do : connect to therapy (at least psycho-, and, possibly, at the discretion of the psychiatrist, and pharmaco-), relatives with whom G. lived

    General recommendations : again, pharma can be the basis for therapy (in some cases it is simply necessary so that you can even enter into some kind of contact with a person), but therapy here is the main one. The Garrett method shows itself quite well in a number of cases of violations by this criterion.

    12. Ability to mentalization and reflection

    Mentalization in this context is, on the one hand, an understanding that the Other can have its own thoughts and emotions, possibly not related to ours, and, on the other, the ability to build a certain model of these thoughts and emotions in our head.

    Reflection is the ability to analyze one’s emotional state, one’s thoughts, intentions and other phenomena of psychic life, the ability to create a sufficiently powerful and adequate model of how one’s own psyche works.

    An example of brokenness (not mine) : a woman, let's call her I., who has a strong conviction (imposed by the environment) that she needs to get married in order to be happy. However, she considers all those who are in the so-called. “Common law marriage” (cohabitation) or not at all married, unhappy, having as serious problems as hers.

    She sincerely believes that everyone treats this issue in the same way as she (inability to mentalize, simple projection instead of adequate models), believes that her only source is the lack of officially registered marriage relations, directly denying the role of social maladjustment, problem relationships with parents and other factors (inability to reflect).

    How it was possible, and whether it was possible to fix it : a long work was done to raise awareness, which brought some results: I. was able to accept the other woman’s opinion and the opposite attitude to the issue of family and marriage as valid, real, though different from her own point view.

    What mistakes were made: for a number of reasons, it was not possible to keep I. in therapy for a long time, - so long that it was possible to form a skill of reflection, and not just mentalization. There was no formal contract for therapy.

    What would be more correct to do : a formal contract for therapy should be concluded, perhaps even with a prepayment in significant amounts for I. (as an additional motivation not to interrupt therapy in the middle of the process).
    General recommendations : the pharma is secondary here and is prescribed by the doctor “symptomatically” (for example, depression should be lowered). The basis is therapy, and, as a rule, long-term (alas, I don’t know the methods of cultivating mentalization or reflection for several sessions, moreover, I don’t even have any data that hints at least that there are any such methods).

    13. Flexibility in the use of mental defenses and copings

    A mentally healthy person has a fairly large arsenal of mature mental defenses (the ways in which the psyche copes with frustration and pain), as well as copings (roughly speaking, the same thing, but at the level of behavior).

    Those. in one situation, a woman who does not have problems according to this criterion (even for definiteness, it will be a woman) will simply force out a frustrated need (“forget” about what she wanted to buy bitcoins in 2011), in the other she uses regression (look innocent children’s eyes on the boss reporting her), in the third she decides that playing cryptocurrency courses is immoral and contrary to her principles, i.e. uses moralization, etc. Those. in different situations she will apply different mental defenses.

    A person with problems according to this criterion uses the same protection (or their narrow repertoire) in the widest range of completely different situations. As a result, protection is often ineffective. The same with copings.

    An example of brokenness (not mine) : a girl, let's call her J., uses avoidance as the main coping strategy (at the slightest difficulty - quits what she started, as a result she has neither profession, nor work, nor hobby, nor relationship), but as the only (well, almost) protection - a primitive isolation (departure from real life into the world of inner fantasy experiences).

    How was it possible and was it possible to fix it: since motivational readiness (i.e., the willingness to do something to change oneself) is zero at her, all attempts to “take her to a psychiatrist / psychotherapist” have failed.

    The most convincing strategy of work is the scheme expressed by one psychotherapist in a private conversation about this case: letting J. “sink to the bottom”, wait for the emergency survival mechanisms to work, and in this state begin psychotherapeutic work.

    What mistakes were made : forced (in fact) appeal to specialists. J. was subjected to a lot of pressure, she went to different specialists several times, but she didn’t get any sense of it.

    What would be more correct to do: wait for the formation of motivational readiness under the influence of external circumstances (J. has a pretty strong Ego, so you can reasonably expect to mobilize resources in a situation where it will be a threat of frustration of primary needs - housing, food, security). Of course, it is important here not to bend or put a person in a situation of realization of a threat to life, safety, etc.

    General recommendations : a pharma here can only remove some accompanying states, the basis should be therapy aimed at teaching a person new copings and defenses.

    14. Balance between self and social orientation

    The ability to take into account their interests, recognizing their priority, and - at the same time - the interests of others / demands of society.

    An example of brokenness (mine) : some time ago I completely devoted myself to work, sincerely believing that the interests of a manager (not matters, but his own) are more important than my own. This was expressed in a huge amount of unpaid reworkings, agreement on terrible, violating all conceivable sanPiNy working conditions, which led to burnout and a decrease in efficiency, and then - to the loss of any ability to work.

    How was it possible and was it possible to fix it: Pharmacotherapy in the form of a combination of large doses of SIOsND and SIOZN forced a few to reconsider priorities in the direction of defending one's own interests. Psychotherapy with elements of direct learning - showed constructive ways of such upholding.

    What mistakes were made : and again I will say hello to the idiots in white coats (I respect the normal doctors very much, but I will call these exactly that way) who loaded me with aminazine and other rubbish.

    What would be more correct to do : assign adequate pills and send me to therapy.

    General recommendations: despite the fact that personally, in my case, pharma has played, perhaps, a decisive role, I can not say that this is a universal trend. In my opinion, this is more about therapy (first - most likely - CPT, then - at the discretion of the specialist).

    15. Feeling of vitality, ability to produce new meanings.

    A person must “feel alive”. Many authors (especially of analytical sense, for example, Winnicott) wrote that a person can function normally from the point of view of an external observer, but at the same time be “as if inanimate” (and feel accordingly).

    An example of brokenness (not mine) : stanimira often experiences a feeling of his own emotional / inner mortification. At the same time, she is fully capable of coping with her work responsibilities, generating some original ideas and being a good partner in a relationship (the very first three criteria), but not feeling alive.

    How was it possible and was it possible to fix it: neither pharma nor therapy led to the solution of this problem. In theory (referring to Ganderson), a feeling of vitality should appear after 3-5 years of therapy, but so far there is very often none.

    What mistakes were made : therapy was completed / interrupted too early.

    What would be more correct to do : go through the experts, until the one whom she can not devalue appears.

    General recommendations : sometimes antidepressants (or combinations based on them) help (in simple cases). But often this is a symptom of personality disorders, which are very poorly amenable to drug treatment, and require very long-term therapy. Again, with a non-guaranteed result.

    16. The ability to come to terms with what cannot be changed and adapt to it.

    The ability to survive the grief / tragedy / frustration, not to dwell on it and continue to live (live an active life, but not sluggishly exist).

    An example of brokenness (not mine) : a young man, let's call him L., has a currently incurable disease that significantly impairs his quality of life. Doctors say that “he is already half-dead” and “he has little time left”. For a moment, he gave up and stopped even trying to fight - he actively used alcohol, violated the rules for taking medications, spent all his time in games - trying to escape from the inevitable.

    How was it possible and was it possible to fix it: in this case - pharma. She reduced the severity of the main symptoms, allowed him to believe in modern medicine. After - long supportive therapy began (besides somatic illness L. has serious mental problems, he is not ready for more intensive types of therapy).

    As a result, it was possible to reduce the suicidal risk and form the conviction that, despite the fact that it is impossible (with the current level of development of medicine) to cure the main somatic illness, it can significantly influence its course. This became the main goal for L. for a sufficiently long period of time: he took an active position on his own treatment and began to take an active part in it, the level of compliance with the treating physicians increased significantly.

    Today L. is actively fighting for his health, he has already lived longer than some specialists gave him, he found more competent doctors in the context of the underlying disease, and together they even made some progress on this front. And L. changed the consumption of content (games) for its production, he went into the works.

    What mistakes were made : for a long time the psychological (not psychiatric, namely psychological) aspects of the L. state were ignored, which was not allowed: the psychological mood was an important component of his treatment.

    What would be more correct to do: to pay attention not only to the underlying somatic disease, but also to the psychological state of L., to conduct therapy not only with him, but also with relatives in order to create a healthier environment in the family, so that it is easier to fight / recover.

    General recommendations : it is difficult to make a general conclusion on the subject of “pharma or therapy”. Frankly speaking, even in this case I can’t say what was more important - drugs prescribed by a psychiatrist, recommendations of an endocrinologist or a change in psychological attitude L. In my opinion, all three components were necessary, and none of them was sufficient .

    Some additions

    The first thing that readers will probably notice is that the people in these examples fit in perfectly with the traditional criteria formulated in the ICD and DSM. And this is indeed the case, I tried to choose examples that were quite pronounced, so that it was clear what was going on, and this is usually the case with people who have a particular mental illness.

    However, as it was said at the very beginning of the article, it also happens that a person does not formally fit into any diagnosis, and something is wrong with him. I think that each of the readers, if he tries, recalls examples - such people who are formally healthy mentally, but in fact are maladapted.

    Secondly , what should be said: the list of criteria is not exhaustive, as indicated by McWilliams herself.

    Thirdthat, I think, everyone also noticed, - the list clearly has a rather strong attack of psychodynamic ideas. Not surprisingly: McWilliams works precisely in the direction of psychodynamics (or even classical psychoanalysis in general), but personally I like it more likely than not.

    Fourth . The criteria are just as inaccurate and subjective (and maybe even more so) than in the ICD or DSM. Just recognize this flaw (or dignity - how to look).

    The fifth . Nonspecificity, which I have already mentioned above. According to these criteria, it is impossible to write guidelines for treatment, they are not for this. They are to supplement the guides, to create some variation in therapist's behavior, on which you can build an individual approach to each client / patient.

    Sixth. Surely, many have noticed that in a number of examples I am talking about the ineffectiveness of short-term therapy. And this is not because I want the brain rights to get more money, but because it, damn it, really has its limits of applicability in such “muddy” cases (when there is no clear limited symptom complex consisting of a small number of understandable symptoms) not too effective.

    The sad truth is that often effective therapy is not affordable for a person (or another option is not suitable because it takes too much time, and the result is needed NOW or even YESTERDAY), it takes several sessions (or even several dozen with objective need in a hundred), does not achieve the desired result and stops therapy.

    The question of how to understand whether it is effective at all, and whether, having passed, for example, 50 meetings, to subscribe for another 50, is complex, ambiguous and will be covered somewhere else, not here. And yes, next is the question of how to distinguish a good specialist from a charlatan (especially for psychologists / psychotherapists, everything is incomprehensible with them), and it is also important, and will also be considered some other time: the article is not about that . Well, the question of whether, in principle, psychotherapy can be effective, is a bit highlighted in the previous article .


    If a person does not have a psychiatric diagnosis, it does not mean that he is healthy. If you personally ask me about where this notorious line between “healthy, but strange” and “mentally ill” lies, I would say that there is no clear line here. These are two intersecting sets / clusters, you can select only their centers of attraction, but not the exact boundaries.

    Phenomena that make you think about mental illness, for me, first of all, are social maladjustment and a subjective feeling of the inadequacy of myself and the world. Naturally, I do not pretend that this can be used in any serious diagnostics, but this is a simplified formulation that I am ready to give to an unprepared reader with the condition that he will not write someone on it in “healthy” or “ psychos ”and leave this job to specialists.

    Personally, I like the criteria McVilliams, they are useful in my work as a psychologist (at least as a checklist through which a client can be banished), and I would very much like psychiatrists to pay some attention to them and take they are in service in the part where they do not contradict the existing guidelines.

    And last but not least: as you can see from the examples (although individual examples are not evidence of something), in many cases working only with a psychologist / psychotherapist cannot bring the desired results: it is often necessary to include psychiatrists with pills. Not always, but often. To my great regret.

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