Post-DSM: Reinventing old models of ‘mental health’ behaviours

Having deconstructed the DSM into constituent behaviours (some in previous blog), where does this lead us?  I have three initial suggestions, which are not very satisfactory or original but which are useful when a lot more effort is put into observing and documenting the contexts for people’s behaviour, and allowing any amount of idiosyncrasy.  The suggestions are not much use on their own—they do not constitute any sort of useful theory, for example (if that is even something you want anymore).  What they do is to push practitioners and researchers towards getting more of the story in individual cases (but which might be family or community stories) and not focus on clustering the behaviours into ‘diseases’ like the DSM does.  Any clustering will be idiosyncratic and arise from the contexts and the strategies in those contexts.

The three initial broad suggestions:

  • ‘mental health’ behaviours arise from attempts to deal with difficult situations which cause suffering, distress, and misery
  • which behaviours occur depends only on the actual contexts and strategies of that context
  • like any behaviours in life, they can become ‘locked’ into the person’s contexts and ‘lifestyle’ and be difficult to change, for good and bad

Hardly original but I will spell this out more now by drawing on the deconstruction of the DSM in this chapter:

  • life is full of difficult situations (Table 4.1)
  • we each have very different contexts even for similar-looking difficult situations
  • we can respond in functional ways to those difficulties if our training or the context allows this; we do this all the time
  • if there are no functional strategies known or able to be enacted then a range of options can still be done, such as the myriad of escape strategies, but they can have short- or long-term negative effects
  • most of our attempts to cope with difficult situations succeed or we can get help from friends and communities, financial advisors, social workers, lifestyle coaches, bank loans, religious or spiritual leaders, etc.
  • there is no special category of ‘mental behaviour’ in all our attempts to cope with difficult situations, only in the sense that behaviours which have difficult-to-observe contexts (we cannot easily see where they arose from) have been labelled that for around 200 years (previous blogs) and given to a new set of ‘experts’ in the last 100 years (so-called ‘mental health’ experts)
  • from these difficult-to-observe contexts one person might engage in more ‘psychotic’ looking behaviours to cope and another in more ‘depressive’ looking behaviours (Table 4.2), but which of these happens will depend on the contexts they arise in (Table 4.5), not any predetermined clustering from a purely metaphorical disease
  • so there should be, and is, considerable overlap in ‘mental health’ behaviours; so in the previous example there can be both psychotic-looking and depressive-looking behaviours engaged, perhaps at different times as the person tries new ‘solutions’ to their difficulties
  • one broad characterization of these other strategic options when suffering was the one we saw earlier of Horney (1949):
    • move towards people (loyalty)
    • move against people (voice)
    • move away from people (exit)
  • but a better option is to explore every context as if it will be different since these broad and simplistic strategies give no real information and are clustering  using topographical features which is unsatisfactory
  • similar looking ‘mental health’ behaviours can therefore arise from very different ‘difficult situations’ and…
  • similar ‘difficult situations’ can produce very different ‘mental health’ behaviours
  • every ‘mental health’ behaviour will depend on the exact possibilities in those contexts and the range of skills the person already had to deal in certain ways

This covers, therefore, these extra points as well:

  • a lot of the ‘mental health’ behaviours will start at a younger age when a child is coping with many new difficult situations but without many of the skills that might be necessary
  • when a person faces a very new context in life (perhaps sudden and traumatic), new ‘difficult situations’ are likely to arise
  • many dysfunctional attempts to cope with difficult situations fail but the difficult situations disappear over time anyway and there are no further issues
  • learning more and more skills, and flexible skills, probably helps overall (DBT)
  • the typical (Table 4.4) problem behaviours seen need to be checked for idiosyncratic contexts and strategies for that person and their situation alone
  • most of those difficult contexts will be also be difficult to observe, however, which is the only reason why they are referred to as ‘mental’ in the first place
  • any clustering of ‘mental health’ behaviours (Table 4.2) arises from similar functional patterns in their contexts and strategies (Tables 4.3, 4.5) rather than from centres of disease
  • we will also see in Chapter 5 (and previous blogs) that modernity has exacerbated these problems
    • modernity has new and complex difficulties, especially through the effects of capitalism and the large percentage of strangers involved in our lives (work, bureaucracies, etc.)
    • new difficulties also means there are few tried and tested skills that can help to cope
    • there is weakening of family ties through capitalism so less skills are taught (relegated to schools) and less assistance in dealing with difficulties that occur
    • having to strategize with strangers 90% of the time rather than people who might be more responsible or have some obligations towards you is problematic and with little human history for guidance
    • because there are few interdependencies and little personal history, difficult situations with all of the strangers involved in our lives will now commonly arise from context that are inherently difficult-to-observe, hence more problem behaviours are getting referred to as ‘mental health’ now


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