Clinicians Have Always Been Reminded

Clinicians have always been reminded or expected to perform examinations of mental disorders and draw diagnoses from objective factors, such as symptoms. But recent studies showed that, despite this traditional outlook and persistent reminders, clinicians still rely or choose to use their personal theories in examining and diagnosing patients with mental disorders. Among the personal theories in popular use are Alfred Adler's and the Existential Theory. Adler's theory draws from an inherent motivation to self-perfection and social interest, while the Existential Theory restores patients' lost, damaged or unrecognized autonomy, freedom and responsibility for their own actions, lives and destinies.

Introduction

The influence of clinicians' personal theories over their diagnosis of mental disorders was the subject of a recent study conducted by two experts on 35 clinicians and 25 clinical trainees (Holmes 2002). The experts, Dr. Woo-kyoung Ahn of Vanderbilt University and Nancy Kim of Wesleyan University, asked the subjects to perform four basic tasks, namely, draw the relationship between the symptoms of certain disorders; identify the relative importance of these symptoms with the disorders; diagnose some hypothetical cases; and then test the participants' recall of the symptoms several hours after diagnosis. The study showed that, despite considerable efforts placed by leaders in the field of clinical psychology to keep diagnosis objective, clinicians' theoretical beliefs still exert major influence on diagnosis. The findings of the study were published in the December 2002 issue of the Journal of Experimental Psychology General (Holmes)..

Clinical psychologists have always been expected to base their diagnosis on a checklist of symptoms, but the findings revealed that clinicians' diagnosis draws heavily from their individual theories (Holmes 2002). They are likelier to make a diagnosis of mental disorder when the person displays symptoms central to the clinician's own theory of the disorder than if the patient's symptoms were peripheral to those of the clinician's theory. Furthermore, all the subjects of the study, who were practicing clinicians and graduate students, held different and complicated theories about mental disorders, from schizophrenia, major depression and anorexia to diverse kinds of personality disorders and that individual theories did not have many things in common. There was no basic understanding or agreement on the causes and the clinicians' theorizing can be erratic or lead to conflicting diagnoses. In addition, clinicians' recall of the symptoms was influenced by the theories they held. If the symptoms were peripheral, clinicians tended to forget them more (Holmes).

Among the personal theories used by clinicians are those of Alfred Adler and existentialism.

Personal Theories: Adler and Existentialism

Adler. - Adler was born in Vienna, Austria on February 7, 1870 (Boeree 1997). He could not walk until he was four years old because of rickets and also nearly died of pneumonia at five. His physical condition impelled him to acquire a medical degree from the University of Vienna in 1895. He began working as an ophthalmologist and then switched to general practice in the lower-class part of Vienna.. Most of his patients were circus performers who suffered from organ inferiorities and this led to an interest in organ deformities and compensation, clearly also because of his own experience of deformity and disability as a child. He later shifted to psychiatry and joined the discussion group led by Sigmund Freud. Adler wrote papers on organic inferiority, an aggression instinct and children's feeling of inferiority.

Adler suggested that the single motivating force or drive behind human behavior and experience is the striving for perfection (Boeree 1997). It is the desire to fulfill one's potential or come closer to one's ideal, similar to or the progenitor of the modern concept of self-actualization. Initially, he referred to this as an aggression drive, which is the reaction when other drives are thwarted or frustrated, among these the need to eat, get sexual satisfaction, get something done or the need to be loved.

Adler also referred to this basic motivation as compensation or the striving to overcome (Boeree 1997). He believed that our personalities would be so structured as to compensate or overcome problems, shortcomings or inferiorities of any kind. One of his earliest phases was masculine protest, whereby boys were expected to be strong, aggressive and in control, rather than weak, passive or dependent, which girls were expected to be. Boys and men were viewed as basically better than or superior to girls and women, so that boys and men were accorded with power, education, talent and motivation to accomplish great things not expected of girls and women. But Adler did not view boys and men as inherently superior or better, but only encouraged to be assertive, while girls and women are discouraged. He saw that both boys and girls possess the same capacity for protest.

His last phase before changing to striving for perfection was the striving for superiority (Boeree 1997, Stein 1991), which compares with the philosophy of Friedrich Nietzsche on the will to power as the basic motive in human life. Adler believed that this striving was not only for superiority but also to be better than others. He used this in connection with unhealthy or neurotic striving. Rather than adopt Freud's reductionistic view that breaks a person down to smaller concepts of superego, ego and id, Adler adhered more to the theory of Jan Smuts, a South African philosopher and statesman, who saw man as a unified whole and within the context of his physical and social environment. This was the holistic approach, which Adler adopted. He saw people as wholes instead of parts, as did Freud, and labeled his approach as individual psychology. And rather than perceiving personality as a complex of internal traits, structures, dynamics and conflicts, he referred to life style or the way one lives life, how he handles problems and relationships. In Adler's eyes, individuality expresses and molds itself in its own environment and against a background of other and different environments. It has its own life pattern and is not a merely mechanical reaction to the environment (Boeree).

Next to the striving for perfection, the human person naturally pursues social interest (Boeree 1997, Stein 1991). Under his holistic approach, a man pursues that perfection within a community or out of a community feeling. Man does not only exist and strive alone. His social interest is both inborn and learned but parents and culture must teach a person to empathize. He interpreted this social interest as a broad sense of caring for family, community, society, humanity and for all life. It means being useful for others. A lack of concern for others he perceived as the cause and definition of mental ill health. He traced all failures as deriving from that lack - neurotics, psychotics, criminals, drunks, problem children, suicides, perverts and prostitutes. In Adler's view, these individuals suffer precisely because of a lack of social interest and their pursuit of personal superiority is blocked and whatever seeming triumphs they may have are meaningful only to themselves. He enumerated four psychological types of person, namely, ruling, learning, avoiding and the socially useful. The ruling is aggressive and dominant and bullies and sadists come under this type. The learning type is sensitive, with low energy level and dependent. He easily develops phobias, obsessions and compulsions, general anxiety, hysteria, amnesia, depending upon his life style. The avoiding type has the lowest energy level who survives only by avoiding life itself, especially other people. When pushed to the limit, he can turn psychotic and retreat to his own personal world. And the socially useful is healthy and whose life style is characterized by social interest and vast energy.

Childhood plays a large role in Adler's theory. It sets forth three basic childhood situations that can lead to a faulty lifestyle (Boeree 1997, Stein 1991). These are organ inferiorities, pampering and neglect. A person with organ inferiorities is often overburdened and has a strong sense of inferiority. He may also compensate through superiority complex. Pampering is self-defeating because the person does not learn to do things for himself and does not learn how to deal with others. And neglect breeds a sense of inferiority as well as selfishness. The person's birth order is another factor. The only child is often pampered and assertive. The first child is similar to an only child until another or other siblings are born. The second child and other middle children are more passive than the first or oldest and youngest children.

In diagnosing mental disorder, Adler's approach will seek out the patient's birth order, his serious illnesses from childhood, childhood habits, dreams and self-expression (Boeree 1997, Stein 1991). His approach to therapy differs from Freuds. Adler would have everyone sitting up and talking among themselves face-to-face. It would recognize a patient's resistance as another sign of a lack of courage to give up his neurotic lifestyle. The patient must be made to understand how his lifestyle and his self-centered fictions account for his mental condition. The objective of the therapy should be to bring him to that state of feeling where he will like to listen and want to understand. He can then be influenced to live what he now understands but has yet to do. The therapist or doctor must encourage the patient or awaken his social interest and raise his level of energy along with it. By developing a genuine human relationship with the patient, the therapist or doctor can re-establish the basic form of social interest, which the patient can use in transferring it to others. Both therapist and patient must realize that the latter's ultimate cure can come only from him.

Adler's approach has similarities with that of Socrates (Stein 1991). Socrates exhorted others to "know thyself," while Adler urged that people should think for themselves (Meyer 1980 as qtd in Stein 1991). Like Socrates, he would lead the person or patient through a series of questions to a contradiction within himself as revealed by his own answers. Both philosophers were committed to the search for truth through reason. Both helped the troubled person or patient understand his own values and beliefs. Both philosophers practiced tact, wisdom, humility, eloquence and patience. They both valued freedom, courage, responsibility and inner integrity (Stein).

Adler's theory seems less interesting than Freud's and Carl Jung's, but it is the most sensible and acceptable (Boeree 1997). Its clear description of complaints, his straightforward and common-sense interpretation of problems, his simple theoretical structure, trust and affection for the common person make it acceptable, comfortable and very influential (Stein).

Adler's therapy encourages a patient to overcome his feelings of insecurity, develop deeper feelings of connectedness and redirect his striving for significance into more socially acceptable and satisfying directions or goals (Adler 1932). Through carefully planned dialogue, he is led and challenged to correct mistaken assumptions or perceptions, attitudes, behaviors and feelings about himself, others and the world. Through constant encouragements, the patient becomes stimulated to do what he always thought he could not. The outcome would consist of growth of self-confidence, pride and gratification, which can lead to a greater desire to cooperate with the therapist. The goal of therapy is to replace exaggerated, false and damaging self-protective attitude patterns, self-enhancement, and self-indulgence with courage and balanced or healthy social interest (Adler).

Adler believed that treatment should not focus on a symptom or a single expression but on the mistake made in the entire life style of the patient and in the way his mind interpreted his experiences, in the meaning he gave to life in the past and in his actions through which he answered the impressions his body received from the environment (1932). These are the data that tell the therapist something about the patient's psychology in so far as these provide evidence of the life style. Life styles are the proper subject of psychology as well as the proper material for investigation. This is the area of study for those who investigate stimuli and reactions and those who trace the effect of trauma or a shocking experience. Individual psychology deals with the psyche itself, the unified human mind and examines the meanings that the patient has given himself and its world, his goals, the directions and quality of his strivings and the approaches or means he has used to solve or deal with problems (Adler).

Existentialist Theory. - Existentialism derived from the works of Arthur Schopenhauer, Soren Kiergaard and the German philosophers Friedrich Niezsche, Edmund Husserl and Martin Heidegger (Wikipedia 2005). It was particularly popular during the 20th century because f the works of French writer-philosophers Jean Paul Sartre and Simone de Beauvoir. Its tenet was popularly structured and expressed by Sartre's dictum, "existence precedes essence," which suggests that the meaning or purpose of a person's life or existence is not something that is already established but that he chooses that meaning or purpose. Each person defines his own life. Because there is no pre-existing or ultimate evaluation beyond what he projects into the world, he can therefore be judged or defined only by his actions and choices. It makes human choices the ultimate evaluator of that existence or life. Its progenitor was Nietzsche's concept of eternal return, or that "things lose their value because they cease to exist." If all things exist all at the same time, people would be burdened with too many levels of importance. But because things are transient, they lose their value. This condition makes the only conceivable reality as the sole judge of good or evil. If only things currently in existence have meaning, without rules, limitations, laws and purpose, then truth or essence is only the projection of that which is the product of existence or collective experiences. Truth must exist before it so that it is not only the predecessor but also the ruler of its own objectivity (Wikipedia).

Because man has complete freedom to make his own decisions and possesses the responsibility for the outcome of his decisions, he develops a kind of anxiety or angst about these choices (Wikipedia 2005). Therapists use existential philosophy to explain the anxiety experienced by patients out of the belief that patients can confront that anxiety and use it positively or constructively. In confronting and taking that anxiety as something inevitable, the patient or person can use it to pursue and attain their fullest life potential. Irvin Yalom (1980 as qtd in Center for Existential Depth Psychology 2004) offered an organizational structure in attempting to understand existential theory through four main themes of death, freedom, isolation and meaninglessness. His existential psychotherapy should, however, not be taken as a comprehensive overview as it is too broad to summarize. It appears better to take several individual theories.

One major distinction between existential theorists us their view as to whether they can answer questions of existence and, in general, theorists agree that such questions cannot be answered while they are in finite form (Center for Existential Depth Psychology 2004). Some philosophers and psychologists believe that there are no final or ultimate answers to these questions. John Paul Sartre and Irvin Yalom are among them. Many have come to believe that existentialism is inherently atheistic, nihilistic and pessimistic. But this is not true about many existential thinkers and those who think so do not have a good grasp and understanding of the breadth and foundation of existentialist thought. Existentialists hold and offer a very optimistic viewpoint on the potential for good and growth, which is intrinsic in human nature and the human condition. Some of them would point to a spiritual or religious basis for the optimism, but even when existential thinkers take on the positive stance, they would not deny the reality of the challenges and horrifying consequences of being human. Among those who expressed the horror were the philosopher Soren Kierkegaard, Christian theologian and philosopher Paul Tillich, Jewish theologian and philosopher Martin Buber and psychologist Rollo May. These two groups represent the split between a spiritual existential approach and an atheistic or non-spiritual existential approach. The spiritual existential approach is not necessarily a religious one in the sense of acknowledging in God, although it can be so interpreted. But it offers a kind of transcendent or embodied answer to the major existential questions. In contrast, the non-spiritualist existential approach covers those who believe that there are no answers to those questions (Center for Existential Depth Psychology).

The existential theory emphasizes a deep respect for the individual person (Park). It holds that human beings are in a state of constant transition and evolution. It allows total and independent choice, freedoms, personal responsibility and self-determination. A man controls his own life and, therefore, must take responsibility for his own actions. Under the theory, loneliness is a natural experience and condition. It is he alone who creates meanings in his life when he answers questions on who he is, where he has been and where he is going. He knows that, sooner or later, he must face death or a state of non-being (Park).

The key concepts behind the existential theory are the capacity for self-awareness, freedom and responsibility, the striving for identity and relationship with others, the search for meaning, anxiety as a condition of living and awareness of death and non-being (Park). Clients or patients with mental disorders have that built-in capacity for self-awareness and it becomes their sole choice to expand it. It is they who choose to live freely and fully or they can choose to restrict themselves.

Every man is a free being who must accept that reality and responsibility for his actions (Park). He is responsible for the choice of his own destiny and this he does when he freely chooses from among alternatives or options. The responsibility for his own acts, therefore, lies within him and not outside or with other persons. A client or patient also has the intrinsic concern to preserve his uniqueness and identity. He learns about himself in his relationships and interactions with others. He strives to develop his personal identity or self, although this requires much courage, struggle and a huge price. Loneliness is built-in into his existence and he gains strength from the experience. He also depends on his relationships with others and his ability to relate with them is impossible unless he can stand alone and this presents itself as a paradox.

The fourth key concept is the search for meaning (Park), wherein a person's existence is something that is never complete or final, but changes through goals. Life's meaning can be found only by engaging in activities, such as commitment to creating, loving, working and building. That search for meaning in life is a never-ending struggle. A state of meaninglessness can lead to an existential vacuum, which is a hollow and empty feeling. There is such a thing in this theory as existential guilt, which is the concept of meaninglessness progressing from a sense of incompleteness. This condition is treated by logotherapy, which searches the meaning of life.

The existential theory proposes that anxiety is an integral part of the human condition but a potential growth source (Park). It is neurotic anxiety that handicaps, but normal anxiety occurs when a person confronts a situation or reality and is the consequence of an experience of freedom and of the acceptance or rejection of one's choices. And it teaches that death is an eminent part of living and an awareness of death precisely gives life that significance. The theory does not view death as something negative. Rather, it is considered a motivating factor for the living. A person who commits himself to live a full life can be at peace when he approaches the end of his life (Park).

Existential therapy differs from other approaches or personal theories in the way by which they are not living full and authentic lives (Park). It helps the person make choices that can lead to his cure and realization of what he is able to become or overcome. The existential therapist shares his reactions with the patient or client in a condition of genuine empathy. The sharing can be confrontational, but the therapist must keep in touch with her own world as she tries to cultivate in the patient or client that essential awareness of death so that she can help him make free choices in his life (Park).