Why isn’t there a specific chapter on diagnosis and treatment of severe psychiatric illnesses such as psychosis, paranoia, depression, character disorders and phobias from an interpersonal point of view?

The theory behind current systems of psychiatric diagnosis that delineate what is considered mental illness and its treatment was originally developed by Emil Kraepelin, in the late 19th Century. It is in opposition to more psychodynamic theories (Freud, Sullivan, etc.) and relies on treatment by classification, prediction of outcome of classified patterns and biological determinism. This theory lends itself to the idea that since the various diagnostic categories are biologically determined, they can be best treated by physiological means, like medication or ECT. There is no detailed explanation of the biological or neurological process of how these patterns could come about. Kraepelin’s notions of treatment began to be questioned in the mid 20th century, especially as they involved eugenics or the backward notion of inherited degeneracy and racial inferiority and superiority that could be bred into or out of groupings of people. The assignment of inherited characteristics to a pattern of behavior easily lends itself to the notion that a pattern or characteristic is inevitable and unchangeable and has no connection to experience. That produces a sense of helplessness and adds to despair. Politically, it supports reactionary notions of “inevitable” social superiority of one grouping over another.

There has also been criticism of the categories that were labelled as mentally ill, such as “homosexuality.” There is an assumption of the superiority of certain accepted morality that does not recognize variation from it as legitimate or even sane. Most importantly, there is no attempt within Kraepelin’s theory or even later DSM diagnostic theory to understand how social experience might impact behavior.

The “illnesses” listed above are symptoms that can be displayed by any human being at a particular point in time and not a complete description of any human being. They are aspects of human behavior and experience. While they may occur more strenuously in one person’s life, and more often than in others’, they do so in the context of the developmental trajectory of a person’s life and in reaction to the person’s constant struggle to satisfy their needs versus their security apparatus or defenses that attempt to limit satisfaction of those needs. Should the circumstances radically change, the behavior might also radically change.

To label or diagnose a person implies they can’t change. It is better to describe a person, especially to themselves, in terms of their “presenting problem,” that is, in terms of what developmental task they are trying to accomplish, what needs they are trying to meet and how they are blocked from meeting those needs by their own security operations, as well as what it would take to diminish the effects of those security operations. Establishment of a presenting problem requires a certain amount of investigation of a person’s life history and current situation before it can be done.

How does the theory understand and treat the psychopath?

It is more useful to treat a person’s psychopathic behaviors than to treat a person as if they are a psychopath, for the same reasons as described above. It is usually not helpful to treat someone as if they were a diagnostic category. Psychopathic behavior, however, is quite real, and can be described as deliberately hurtful and destructive behavior that substitutes for tenderness and involves pleasure in the other’s discomfort. While it doesn’t provide suggestions for treatment, some fairly clear examples of psychopathic behavior can be found in Hervey Cleckley’s Mask of Sanity. Work with people who demonstrate such behavior is the same as with any other person. It involves taking a client’s history,  identifying their needs and clarifying how they limit the satisfaction of those needs.

How does the theory understand and treat substance abusers and people with eating disorders?

In the same way the theory views the “psychopath” and other diagnostic categories, substance abusers and people with eating disorders are human beings who are at varying levels of development with security systems that take many forms, notably in this case, compulsive eating and substance abuse. In such cases, it would be important to determine what interpersonal strengths are available to the client, since it has been found that utilizing a peer group can be very helpful and it’s advisable to conduct therapy in conjunction with a peer group that provides the support and validation to reduce the compulsions. 

There are also people who make use of legal, medical substitutes for drugs or alcohol who control their habit that way. However, despite removal via medication of the dilemmas caused by substance abuse or eating disorders, there are still dissociated needs pushing for expression and new security operations may arise to limit the person’s growth. The question is, what is the next step in the client’s interpersonal growth and how to identify the unsatisfied needs and get around the client’s security system to meet those needs, which still are pushing for satisfaction.


Is psychotropic medication not an option in interpersonal treatment?

Psychotropic medication may be helpful, especially in situations where a client’s symptoms are so severe that they are not able to function or relate to the therapist or anyone else without medication. However, medication is usually related to symptom reduction and not the quality of the relationships the client has with others. For that, it will be necessary to examine the client’s relationships and the history of their relationships to determine their level of development and what their most pressing needs are. Psychotropic medication is not a cure and can’t provide the insight for a person to learn how to relate to other people. Medication, in the right dose, however, can sometimes help make a person more available to listen and communicate in therapy. 

The theory seems to blame mothers or “parenting ones” for all people’s problems in living. Aren’t people also born with specific inclinations, character traits? Some are more passive or more impatient than others, for example, even from birth.

The basic assumption of interpersonal theory, that we become human by being raised by people does, not contain the concept of blame. A person’s growth and development, as well as their limitations, are initially formed by those closest to that person. However, the particular people, be they parents or a series of caretakers who raise the person, have been raised by other people who have in turn raised them and so on. In addition, every mother or “parenting one” is impacted by the larger culture or society around them that determines the ability to push for satisfaction of their needs as well as the limitations to their ability to satisfy those needs. To the extent that the initial significant other(s), or primary caretaker(s) allows the growing offspring to interact with a wider range of people, there will be a greater possibility for the offspring to grow beyond certain limitations in the parent(s). That’s because there is validation from a wider range of people.

Clients will often ask why their parents hated them so much since they “caused” their problems in living. It usually helps to point out that the same parents validated many productive functions that are clearly present. The problem was that, because of their own upbringing they reached a limit, probably shared by many people in their social circle, or even in the wider society, that prevented them from moving beyond that level of relating. That doesn’t mean the client has to respect that limitation now that they are older. They can find alternate validation. Also, it doesn’t mean that their parent(s) still feels as limited as they did when the client was younger. The parent(s) may have done their own growing.

As to the variation in temperament of infants having an effect on parenting, that may have some influence, but overall mood and temperament in an infant is highly dependent on the overall mood of the primary parenting one(s), which may change at different points in the life of the parent(s) as well as the social and material surroundings into which the infant was born.


Can children benefit from this approach to therapy?

Working with a child is different in many ways. The child does not have authority over its own choices, is still developing within the purview of the primary caretaker(s) and is materially and emotionally dependent on them. The therapist who works with a child within a family or an institutional structure becomes an important alternate validator of emerging new needs and functions, whether or not the primary caretaker(s) or institution can conceive of or approve them. At the same time, the child may or may not be able to act on the new insights the therapist may provide. A lot depends on the cooperation of the parenting one(s). There will be a need for conferences with the caretaker(s) in which the therapist may suggest changes in the child’s environment and routines. At the same time, it is important for the therapist not to betray the child’s trust by divulging what the child is saying or doing in the sessions.

Also, the child may not be able to make use of the therapeutic experience in the moment but may store the memory away for use at some future date. The alternate experience may be relegated to the dissociated, unless the primary validator(s) can accept it in some form.

In addition, the child is brought to therapy. With some rare exceptions, the child does not ask for therapy, and may often see therapy as a punishment for bad behavior. Part of the therapist’s task is to make therapy activity fun. In addition to simply talking about whatever the child wants to talk about, the therapist organizes play activities that help the therapist and the child understand the child’s interpersonal milieu (for example, using dolls); the sessions can include projects and games that build the child’s self-esteem. Overall, in building a trusting relationship with an adult who is not a primary caretaker, the therapist aims to validate the child’s curiosity and push to grow. As when working with an adult, the therapist’s alliance is always with the person’s integral personality, their unmet needs pushing for recognition.

However, once a person moves into late adolescence, validation by their peers begins to be more important than parental validation; the need to develop one’s own ability to become independent is paramount. The therapist recognizes and validates that need. Now therapy is more of a choice, even if the person is still financially dependent on the parenting one(s). They do have more of a choice about the sources of validation. In the therapeutic alliance, the sessions are now the same as with an adult.

Given how crucial good parenting is, I’m afraid to be a parent. So much at stake at every turn. How can I be a parent when I need so much therapy myself before I can have a child, and my biological “clock” is running out.

Everybody has limitations in functioning. That is not a reason not to have children. The real question is whether you want to take on the long-term project and how it will change your life. What are the other life projects you are engaged in? How will the project of raising a child fit in or conflict with them? If you are parenting with one or more other people, are they able to form a team with you to take on this project? Do you have or can you develop a social network to help? Are you comfortable allowing your child to interact with other people who may have social/emotional skills that you are still working on? Having a baby is a project. It needs to be planned for and organized. Primarily, you need to want a child and delight in their growth and development.

More questions and answers on the book launch page

We welcome your comments below. When submitting a comment, you will be asked to provide a name and email address. Your name will appear alongside your comment, but your email address will not be publicly visible.

1 Comment

  1. Bradley Williams

    As a person with very little experience in therapy, I gotta say, I’m intrigued. I read all the FAQ’s and responses and they gave me lots to think about.


Submit a Comment

Your email address will not be published. Required fields are marked *