It’s surprising that so much discourse on mental illness, in published literature, in professional training and development, and in therapy itself, is vague about mental wellness, as if that were somehow just obvious. I don’t have a complete answer, but some ideas I’ve come across recently seem relevant.
Clearly, if you are the kind of therapist who wants to create dependency in your patients and hang on to them for as long as possible, then any notion of mental wellness is downright dangerous to your revenue stream. But that’s not a decent goal for any therapist, and it’s certainly not the goal of genuine CBT therapists who intend to create rapid and helpful change in their patients.
On the other hand, if you are the kind of therapist who performs set piece treatments from a manual, then any notion of mental wellness is irrelevant. Once a diagnosis sets your clockwork going, you’ll rattle on until you have played your piece. Again, that’s not an honest goal for any therapist, and it’s certainly not the goal of genuine CBT therapists who intend to work with the realities of their patient’s lives.
So in between these extremes, decent honest therapists need some solid concept of wellness so that they can determine, from moment to moment, in the course of a therapy session, what’s illness and what’s wellness, where the boundary lies.
It should be obvious that mental wellness is not the same thing as perfect happiness. Part of being mentally well is being able to feel unhappy at times, and yet in the longer term cope with the feeling. Sigmund Freud famously made this point way back in 1895, in Studies in Hysteria (p. 306):
…you will see for yourself that much has been gained if we succeed in turning your hysterical misery into common unhappiness. Having restored your inner life, you will be better able to arm yourself against that unhappiness.
In The Rorschach in Practice, the book I reviewed last week in Inky, Theodora Alcock also considers the concept of mental health (p. 104, my italics):
The preoccupation of Rorschach workers tends to be with the pathological. For this reason it is sometimes found that analysis of a [Rorschach test] record develops into a sort of witch-hunt, in which little account is taken of factors indicative of healthy control… A human being who never experiences emotional disturbance would be something less than human. It is the manner of coping with inner stress that bears witness to personality health or sickness.
The trouble with this is that accepting that it is normal to be somewhat disturbed and unhappy only makes it more difficult to define the boundary between illness and wellness.
Theodora Alcock quotes a list of attributes of normal intellectual functioning due to Kurt Goldstein (although this list appears elsewhere in slightly different forms) (ibid., p. 105):
- Power to assume a mental set voluntarily.
- Power to shift voluntarily from one aspect of a situation to another.
- Ability to keep in mind simultaneously various aspects of a situation and to grasp the essential of a given whole.
- To be able to isolate parts of a situation.
- To generalize and abstract common properties.
- To plan ahead ideationally.
- To think and act symbolically with ability to detach the ego from the outer world.
The focus of this list is on the power to think in certain ways, but to me there’s something unsatisfactory about it. These powers seem to be one step removed from emotional states.
No one, for example, seeks psychotherapy for being unable to plan ahead. It’s rather that being unable to plan ahead is a secondary effect of an emotional state like, for example, depression.
Theodora Alcock herself simplifies and recasts the list in term of freedoms (p. 106):
- Freedom to think effectively within the limits of intellectual ability.
- Freedom to act without any serious degree of compulsion or inhibition.
- Freedom to use instinctual drives and unconscious conflicts for consciously desired constructive ends. That is, to sublimate.
- Freedom to form, maintain, and enjoy human relationships.
To me this seems much cleverer. It reveals that many patients whom one might think of as very ill are in fact mostly well. The common mental illnesses only affect people in limited ways, restricting certain of their freedoms. For example, most people who seek psychotherapy are able to think effectively and form a relationship with the therapist.
This list also exposes methods of therapy that rely on suppressing instinct and conflict, trading off a restriction of freedom 3 in the list for possible gains in other areas. Therapies like this do not really promote wellness, but instead just hide the illness.
In CBT the test of wellness is much simpler. Wellness is when a person’s emotional states make sense. So, for example, if someone is unhappy, that’s normal if it makes sense to be unhappy given the person’s situation.
CBT does not concern itself with the mechanisms of a person’s inner life, the manner of coping with inner stress. This is a failing of CBT in cases where the mechanism is faulty, perhaps in some severe personality disorders. But in the common mental illnesses the mechanism only needs a gentle nudge to get back on track, and the criterion of making sense is adequate.
Such a simple test of wellness is not always easy to apply and interpret. Skill in evaluating wellness is a key element of your effectiveness as a therapist, and sometimes a difficult element that deserves consideration in supervision.
In difficult cases, Theodora Alcock’s list of freedoms can be a useful guide.