The Well Person

What does it mean to be “normal”?  We’re all unique, aren’t we?  We differ from each other in so many ways.  So what does it mean to say someone is “normal,” while someone else has a “disorder”?

This is, of course, the age-old question of psychiatric diagnosis.  The authors of the DSM-5, in fact, are grappling with this very question right now.  Take grieving, for example.  As I and others have written, grieving is “normal,” although its duration and intensity vary from person to person.  At some point, a line may be crossed, beyond which a person’s grief is no longer adaptive but dangerous.  Where that line falls, however, cannot be determined by a book or by a committee.

Psychiatrists ought to know who’s healthy and who’s not.  After all, we call ourselves experts in “mental health,” don’t we?  Surprisingly, I don’t think we’re very good at this.  We are acutely sensitive to disorder but have trouble identifying wellness.  We can recognize patients’ difficulties in dealing with other people but are hard-pressed to describe healthy interpersonal skills.  We admit that someone might be able to live with auditory hallucinations but we still feel an urge to increase the antipsychotic dose when a patient says she still hears “those voices.”   We are quick to point out how a patient’s alcohol or marijuana use might be a problem, but we can’t describe how he might use these substances in moderation.  I could go on and on.

Part of the reason for this might lie in how we’re trained.  In medical school we learn basic psychopathology and drug mechanisms (and, by the way, there are no drugs whose mechanism “maintains normality”—they all fix something that’s broken).  We learn how to do a mental status exam, complete with full descriptions of the behavior of manic, psychotic, depressed, and anxious people—but not “normals.”  Then, in our postgraduate training, our early years are spent with the most ill patients—those in hospitals, locked facilities, or emergency settings.  It’s not until much later in one’s training that a psychiatrist gets to see relatively more functional individuals in an office or clinic.  But by that time, we’re already tuned in to deficits and symptoms, and not to personal strengths, abilities, or resilience-promoting factors.

In a recent discussion with a colleague about how psychiatrists might best serve a large population of patients (e.g., in a “medical home” model), I suggested  that perhaps each psychiatrist could be responsible for a handful of people (say, 300 or 400 individuals).  Our job would be to see each of these 300-400 people at least once in a year, regardless of whether they have psychiatric diagnosis or not.  Those who have emotional or psychiatric complaints or who have a clear mental illness could be seen more frequently; the others would get their annual checkup and their clean bill of (mental) health.  It would be sort of like your annual medical visit or a “well-baby visit” in pediatrics:  a way for a person to be seen by a doctor, implement preventive measures,  and undergo screening to make sure no significant problems go unaddressed.

Alas, this would never fly in psychiatry.  Why not?  Because we’re too accustomed to seeing illness.  We’re too quick to interpret “sadness” as “depression”; to interpret “anxiety” or “nerves” as a cue for a benzodiazepine prescription; or to interpret “inattention” or poor work/school performance as ADHD.  I’ve even experienced this myself.  It is difficult to tell a person “you’re really doing just fine; there’s no need for you to see me, but if you want to come back, just call.”  For one thing, in many settings, I wouldn’t get paid for the visit if I said this.  But another concern, of course, is the fear of missing something:  Maybe this person really is bipolar [or whatever] and if I don’t keep seeing him, there will be a bad outcome and I’ll be responsible.

There’s also the fact that psychiatry is not a primary care specialty:  insurance plans don’t pay for an annual “well-person visit” with the a psychiatrist.  Patients who come to a psychiatrist’s office are usually there for a reason.  Maybe the patient deliberately sought out the psychiatrist to ask for help.  Maybe their primary care provider saw something wrong and wanted the psychiatrist’s input.  In the former, telling the person he or she is “okay” risks losing their trust (“but I just know something’s wrong, doc!“).  In the latter, it risks losing a referral source or professional relationship.

So how do we fix this?  I think we psychiatrists need to spend more time learning what “normal” really is.  There are no classes or textbooks on “Normal Adults.”  For starters, we can remind ourselves that the “normal” people around whom we’ve been living our lives may in fact have features that we might otherwise see as a disorder.  Learning to accept these quirks, foibles, and idiosyncrasies may help us to accept them in our patients.

In terms of using the DSM, we need to become more willing to use the V71.09 code, which means, essentially, “No diagnosis or condition.”  Many psychiatrists don’t even know this code exists.  Instead, we give “NOS” diagnoses (“not otherwise specified”) or “rule-outs,” which eventually become de facto diagnoses because we never actually take the time to rule them out!  A V71.09 should be seen as a perfectly valid (and reimbursable) diagnosis—a statement that a person has, in fact, a clean bill of mental health.  Now we just need to figure out what that means.

It is said that when Pope Julius II asked Michelangelo how he sculpted David out of a marble slab, he replied: “I just removed the parts that weren’t David.”  In psychiatry, we spend too much time thinking about what’s not David and relentlessly chipping away.  We spend too little time thinking about the healthy figure that may already be standing right in front of our eyes.

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19 Responses to The Well Person

  1. Mindy Schwartz-Brown says:

    This is one area where social work education used to have it all
    over psychaiatry. Sadly, too many social workers have bought into the medical model.

  2. Nathan says:

    I agree, Mindy. It’s one of the reason why I left social work school. I find it really intriguing that doctors like to talk about biopsychosocial perspectives now, and that is still kind of radical to do so. However, because they are doctors, they are really most trained and focused on “bio” parts and still privilege it. For social workers, I feel like the adaptation of the the biopsychosocial model (joining with bio) is the acquiescence of authority to bio-focused doctors and a joining into a larger biomedical model. It really is the price social workers paid to be able to be reimbursable providers, and that bargain has really stunted the extent the most unique and helpful aspects social work has on framing health, wellness, community, pathology, power, policy, context, judgement, and treatment. I find “biopyschosocial” is thrown around now by all providers more as a distracting agent to hide the specifics of what they do, primarily allowing for biomedical perspectives of mental health to continue to be primary.

    As for what is good health, my favorite definition, though still problematic, is as follows: Being in good health is being in position to take risks with your health. For mental health, perhaps wellness visits might include discussion how “well” people are growing/thriving and the risks they are willing to take to do so, and perhaps how to minimize those risks or recover from negative effects of risk taking.

  3. Duane Sherry says:

    Dr. Balt,

    IMO, the best any mental health professional can do is to help an individual begin to recognize and bring out the wholeness that already exists inside them.

    If a doctor or therapist is searching for the opposite, they will find it… in anyone. On the other hand, if they are searching for wellness, and helping the patient do the same, they will find it as well.

    To quote a song from the band, America: “Oz never did give nothin’ to the Tin Man, that he didn’t already have.”

    Duane

  4. dotdos says:

    When we discuss “mental illness” and “mental health” I know a patient who says: “Normal is what the psychiatrist says it’s normal”.

    Smart guy!

  5. AJ says:

    “Just give an adjustment disorder diagnosis to everybody until you figure things out”… brilliant! Too bad this is shooting ourselves in the foot.

    And what about the good ol’ “neurosis”? Aren’t we all touched by mental pathology according to Freud?

  6. “(and, by the way, there are no drugs whose mechanism “maintains normality”—they all fix something that’s broken).”

    Name one psychiatric drug that fixes, corrects or even ‘treats’ an identified pathology or dysfunction in a significant percentage the people with the particular diagnosis the drug is prescribed for… It is plain such a drug does not exist…

    Why claim all of the drugs ‘fix’ something—when that is not accurate in any scientific or medical sense? It would at least be accurate to say the drugs can be helpful to a particular patient…and acknowledge that professionals have NO CLUE why the drug helps that particular patient. Because as you know—The very same drug may cause irreversible harm to another patient with the same diagnosis. In the case of the neuroleptic drugs, which alter normally functioning physiological processes causing dysfunction, disease and permanent iatrogenic injuries more often than not—it is patently false to claim these neuro-toxins are “fixing something that’s broken.”

    • stevebMD says:

      Becky:

      “Name one psychiatric drug that fixes, corrects or even ‘treats’ an identified pathology or dysfunction…”

      I have to admit, when I wrote the sentence in question, that exact same thought crossed my mind. The truth is, as you accurately point out, we have no idea why (or even whether, quite often) drugs help. The fact that I, as a practicing psychiatrist, am reluctant to state this so bluntly in a public forum means either (a) I’m scared of being labeled a fool, or (b) I’m not willing to put my career on the line for the sake of honesty and openness. [I'm not too concerned, though; after all, Steve Stahl even told me, one-on-one, that everything he says is probably all wrong, too, after one of his flashy pharma lectures.]

      The point I was making is that we (allegedly) use medications to correct abnormalities– to eliminate symptoms. And sometimes patients say that the medications do just that. What medications don’t do is to maintain a state of normalcy (and we’ve never said they do, except when the Abilify folks tried to sell their drug as a “dopamine system stabilizer,” or, as Stahl put it, a “Goldilocks” drug because the level of dopamine signalling it provides is “just right”… I haven’t heard that sales pitch in quite a while, though).

  7. hiro says:

    I personally have defined wellness as being able to manage stress, acceptance of how stress affects our lives, take appropriate precautions quickly.

    The other part of wellness is the pursuit of long term goals. I don’t have my handouts handy but I recall the areas to focus on are family of origin, parenting, intimacy, education, work, health, spirituality, community, hobby/ recreation, friends. I would say each goal should be more about the pursuit of reinforcing our positive values or are to create a positive self image. At any given time (within a month) a person should have pursued 3-4 goals by just taking the next step toward that goal. Within any year we should be pursuing lets just say 7-9 areas.

    We have in the end being proud of ourselves because we are pursuing multiple goals that are consistent with our values, which is more important than being happy, and lastly being able to appropriately recognize and manage daily stressors.

    There is many smaller elements that need to be included but I find the above to be a good starting point for discussion with clients.

  8. Tom says:

    Freud said it best: Mental health is the capacity to love and work. Period.

  9. Anonymouus says:

    Loved the reference to David, I am an old decrpit piece of garbage, but have a body like a15 year old,….”It;s not how you feel, but how you look” gag! There is great work being done and with the science to back it in a number of places. We can clearly see, how antifepressants work neurolgically. (Never get me started on the animals sacrificed) And of course, any one with a brain, can see “follow thru” if it works for their patient. I am no scientist, and can hardly get change for a dollar, but triust me, I am a disaster, when non-compliant. Antidepressants work for some of us, and I guess, certainynot all and should be monitored, Best

  10. Jaen Wirefly says:

    The truth is: many people who enter into the mental health field start off as patients. They have lived their whole lives battling mental illness in themselves and in their family. They aren’t familiar with normal behavior.

    • stevebMD says:

      On the other hand, if what you say is true, then people who are familiar with mental illness might be more accepting of “abnormal behavior” in others.

      • Jaen Wirefly says:

        Perhaps, or less accepting, people tend to dislike in others what they see in themselves, at least in western culture.

  11. meatheadshrink says:

    I’m a military psychiatrist, and I probably diagnose “No Axis or Condition on Axis I” at least a few times per week. There’s this push to medicalize every unpleasant human emotion, to find an underlying “disorder” to explain away unwelcome behavior. It has to stop, and I’m doing my best–one patient at a time–to restore some sanity to this field.

  12. As a patient with multiple diagnosis including DID, I can tell you it is my experience that I have been able to function “normally” when supported by psychiatrists who treat me from a place of wholeness, from a place of what can we do to maximize your functioning right now focusing on my ABILITIES….and not focus on my disabilities.

  13. sdsddbj says:

    Reading this article gave me the impression that the author posseses a very nebulous and poorly defined definition of (what I shall refer to as) both “mental illness” and “mental wellness.”

    Some of the many disparate terms used to refer to these mental states included “normal”, “disorder”, “healthy”, “adaptive”, “dangerous”, “wellness”, “broken”, “functional.” I have only just found this blog and I get the impression that the tone is one of skepticism and known/admitted ignorance (which I appreciate)so my comments may be an endorsement of the authors views, not an undermining of them.

    Surely, if one is to attempt deal with a phenomena in a rigorous, scientific and exacting manner, one would be aided by rigorous, scientific and exacting terminology(this may be a “caual” blog, not a peer-reviewed paper, but the wandering nebulous terminology strongly implies a corresponding mindset.)

  14. sdsddbj says:

    “Average”, “standard” and “typical” are examples of some (currently) less loaded and more value-neutral words than “normal”, and thus may be preferable in some contexts when describing individuals’ mental characteristics in comparison to a population/larger group.

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