As originally posted on Examiner.com
Recently, a friend asked me about my psychotherapy practice.
“You don’t work with people with mental illness, right?”
“I’m not sure I understand,” I replied.
“You work with people who want counseling, but not people with mental illness, right?”
I still didn’t quite understand what my friend, who is an intelligent and well-read professional outside the field of mental health, was asking. We went back and forth about it for a few minutes until the subject changed to something else.
This brief exchange got me thinking about terms like mental health and mental illness. As a clinician, I sometimes take these words for granted and forget that they can be quite loaded for people who may have had little to no exposure to the world of psychology.
We have been trained by sensational media representations and horror movies to imagine the most severe end of the mental health spectrum when using terms like mental illness. "Mental illness" may evoke images of actively psychotic people or people who need to be heavily medicated in order to lessen the danger they present to themselves or others. In recent years, as issues like clinical depression have gained more visibility, perhaps images of extreme depression and suicidality also come to mind.
For most psychology professionals, mental health and mental illness exist on a spectrum – a continuum with very high functioning on one end and very low functioning on the other. In fact, the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision), published by the American Psychiatric Association, uses a scale called the General Assessment of Functioning (GAF for short) that goes from 0 (very low functioning) to 100 (very high functioning). Danger to self or others would place someone at the lower end of the scale, while the ability to maintain satisfying relationships might place someone at the higher end of the scale. Although some may take issue with technical aspects of the DSM, most would agree that the GAF is a useful way to describe the severity of illness.
I prefer to think about mental illness as continuous (i.e. existing on a spectrum with high, middle, and low points) rather than dichotomous (i.e. you either are mentally healthy or mentally ill). Most of us have areas of our lives in which we are relatively high functioning (such as work, art, or personal relationships). I have treated a number of high-functioning professionals in therapy who nevertheless struggle with chronic depression, anxiety, or self-esteem issues. Some high functioning men and women have personality disorders or even struggle with psychosis. And, of course, substance abuse is a common issue among many otherwise high functioning people.
While there are certainly people who fall into the far extremes of general functioning, most fall somewhere in the middle. We all have some areas in which we feel confident, secure, and satisfied; and some areas in which we could use some improvement. Diagnostic labels are far less important than taking an inventory of these areas in our lives. I didn’t understand my friend’s question because I don’t think about mental illness as an either/or issue. To me, it is a both/and issue. I see most people as having both aspects of mental health and mental illness.
Mental illness is nothing to be ashamed of, but stigma and bias shame us all.”
– Bill Clinton