Adam Blatner, M.D.

(Revised, September 14, 2006)   (See related papers, The Art of Case FormulationThe Art of Case PresentationFactors in Development )

The revised fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV) presents the several score categories of different types of mental disorders; yet naming these is really more an act of classification, "nosology," rather than understanding. In only a few of the diagnoses does this activity of classification really direct the treatment; mostly it is used for communications with other professionals, research, or billing purposes.

The term, "diagnosis," means "knowing through," in the sense of understanding. I have found that four general categories are particularly helpful as indicating the variables which are most relevant to prognosis and the problems which may be encountered in therapy:
 (1) Voluntariness: In what ways is the patient willing to change?
 (2) Psychological Mindedness: To what extent does the patient have the capacity to recognize and work with his or her own attitudinal system?
 (3) Coping Skills": What strengths does the patient have which can be drawn upon in treatment?... And...
 (4) Socio-Economic Resources: What can the family, community, or financial situation make available for treatment and adjunctive activities?  (The components of these four categories will be discussed in greater detail below.)

Each of these four categories may involve a number of sub-categories, and knowing about these issues can be most useful in any rational and comprehensive approach to treatment planning. Also, any dynamic and multidimensional formulation of the case is incomplete without the inclusion of these essential issues.

Moreover, prognosis is most closely associated to the relative strength or weakness of these variables, rather than to the nature of the formal diagnostic category itself. Thus, an individual with a rather severe case of acute schizophreniform disorder may in fact have a better prognosis than another person with a mere adjustment disorder, because the former might be extraordinarily gifted and highly motivated to change while the latter might be deeply entrenched in passive and subtly narcissistic attitudes and living in a culturally deprived environment.

Let us consider these variables more closely then:

1. Voluntariness.

Does the patient think there is a problem at all? It may be denied, the symptoms being "ego-syntonic," and the real complainants are the patient's family, the police, or local social agencies.

Indeed, the patient may be in the mental health system under duress, unwilling, involuntary. There is an unwillingness to take the sick role, to accept help, or to cooperate in even the most minimal fashion.

There are patients who will passively come without a struggle, and at least seem willing to attend therapy (at the encouragement of family, etc.), but they are nevertheless unclear regarding the nature of the process, or consciously or unconsciously resistant and closed to the process.

Another sub-category includes those who admit there's a problem, but immediately blame others and deny any personal responsibility. They may participate in family therapy, but are resistant to any redefining of the problem as even partially their own.

The idea of being voluntary can be blurred in more subtle ways, as can the concept of "resistance." A patient may accept therapy as a general mode of getting help, but be quite unsophisticated or immature in knowing that therapy requires a degree of activity and taking of responsibility. These patients have a magical expectation that the therapist can just "fix" them, as if there were a simple antibiotic "pill" which remedies their often multi-dimensional situation.

More subtle resistances involve an overall acceptance of the therapeutic process, but an unwillingness to go along with a particular procedure, a particular line of questioning, or even a particular therapist. These should not be thought of by the therapist as mere transferential reactions. They may involve a lack of information, a lack of "warm-up" or being introduced to the meaning of the proposed direction in therapy. Problems in the therapist's own style and possible lack of finesse, or just a lack of "goodness of fit" are not unusual and must be kept in mind.

Also, the therapist may be mistaken in thinking that a specific technique, type of confrontation, or pursuit of a certain line of questioning is what's needed. Resistance in such cases may express the client's deeper wisdom about what he can handle!

These varying degrees of voluntariness may be expressed directly and overtly or indirectly and covertly. Passive-aggressive and non-compliant behaviors are common modes of expression, but the common denominator is the underlying theme, "I don't want to do this."

Therapy may proceed fairly well to a certain point, but beyond that the variable of voluntariness becomes acute. For example, a depressed alcoholic may seek the nurturance of the helping relationship, but when the need to stop drinking becomes apparent, the therapeutic process founders.

(2) Psychological Mindedness:

This variable relates to a group of attitudes which are essential to general psychotherapeutic progress. They may operate to a greater or lesser degree, and essentially deal with a capacity for self-reflection.

Most basically, such a shift of consciousness involves a certain mixture of awareness of self as a willing and choosing self, with the possibility that certain choices are optional. This involves the process of development from a childish mode of thinking to a more adult mode, and we should not assume that teenagers or adults who are competent in a variety of ways have made this shift.  It's possible that a seemingly "together" adult may harbor profoundly immature basic personality structures in some respects. Most children through the age of twelve and many adults have not made this transition, living their lives as if there was no such thing as choice, will, decision, and, for every decision, a price to be paid. In psychological terms, this is called "self as locus of control."

Another key point of psychological mindedness is the awareness that one's beliefs and attitudes may not correspond to reality; this is the awareness of the possibility of being in error, of intellectual humility. A small step beyond this is having some active curiosity about learning more.

A related yet in some ways distinct idea is the concept of self-deception. Many people who have achieved intellectual growth in the two aforementioned ways are nevertheless blind to this possibility. "May I have been kidding myself?" "Might this belief have been functioning to save my pride?" Such questions are another step in psychological mindedness.

A psychopathological variable often present in at least a small degree in most people is a subtle dynamic of narcissism, egocentricity, an entrenched need for and habit of construing the world in terms of what supports the indivual's beliefs about himself and the world. Eric Berne called this the person's "script," and Alfred Adler used the term "style of life" to describe the same attitudinal set. To the extent this operates in the psyche, to that extent there is interference with the capacity for empathy, for looking at a situation from a point of view which might not be consistent with one's own world-view.

Thus, we're talking about introspection. Admittedly, there may be some variance in a person's actual capacity for this, a type of intra-personal intelligence, and as such this overlaps with the basic repertoire of strengths to be discussed in the next section. There are some people with the ability and even inclination to be receptive to their own feelings, intuitions, and awarenesses about the subtleties of interpersonal relationships. Others are rather dense. In some cases it's a matter of their basic temperament and capacity, while in others it's a matter of having never been exposed to or reinforced in thinking on this level.

(3) Coping Skills:

This category addresses the individual's overall level of adaptive functioning, including such sub-variables as intelligence, initiative, activity, aspirations, etc. The best single correlate of prognosis I've found in my clinical practice is the patient's level of actual achievement: What grades, awards, ranks, memberships, and other signs of meaningful accomplishment or even participation has the person acquired. Many patients should be noted more for their overall lack of involvement in life than for their particular mode of expressing psychopathology.

All sorts of scales of "ego strength" may be applied in assessing this general area of functioning. Can the person play? Are they overly fixated on just one or a narrow range of sources of pleasure?  Bellak (1973) notes fourteen types of ego functions:
    1. Reality Testing: This can range from  Disorientation to Distortion to Accurate Perception. Lots of seemingly normal people don't really check out their impressions of reality and operate with mild to moderate levels of distortion!
     2. Judgment. This can range from "Infantile Omnipotence"--that sense that if I want to do it, I can-- to a more sophisticated Degree of Appraisal of Consequences.  Even political leaders can lack this. Again, many of these variables are not always at the top end for many adults.
     3. Sense of Reality.  Most people sense their objective reality and can differentiate it from dream.
     4. Regulation/Control Affects/Impulses:  This can go in either the directions of being too impulsive or on the other hand, too over-controlled.  With maturity and health, people learn to vary the degrees of control, allowing spontaneity in some settings, being more low-key in others, and making the transitions smoothly, but few adults still do this very well, enjoying full spontaneity; many are all too habitually self-controlled. A few allow themselves to be excessively impulsive regarding anger, or shopping, or in dealing with sexual temptation, etc..
     5. Object Relations: What is the person's capacity to engage in a caring or close relationship, with a romantic partner, a good friend, family members, or close co-workers. Does the person tend to be excessively detached or, again, going to the other extreme, overdependent?  Do they shift among these positions, playing a lot of what Eric Berne would call interpersonal "games"?  (i.e., what used to be called "neurotic.") Or can they engage with mutuality and flexibility?
    6. Thought Processes. This variable includes not just intelligence, but also psychological states that avoid the anxiety of thinking, so they fail to engage in abstract reasoning. Or can they, instead, manage conceptual thinking?  Many people are in the middle on this one.
      7. Adaptive Regression in Service of Ego (ARISE): This is a fancy psychoanalytic term to explain the capacity to enjoy imaginativeness, the innocence of daydreaming, the freedom of the best of childhood's pretending and playfulness.  The lack of this can itself add a good deal of  rigidity to the personality.
     8. Defensive Functioning:   Some people use more mature defenses, humor, sublimation, suppression, and the like. Others tend to use more habitual, automatic, and immature defenses, sometimes even fairly primitive ones that waver on the edge (or go over the edge) of mental illness.
     9. Stimulus Barrier:  Some folks are hypersensitive, others too dense. To the extent that one is over-sensitive, what coping maneuvers are they capable of to compensate for this sensitivity?
    10. Autonomous Functioning. Aside from any emotional issues in life, how competent is the person, or free of pervasive inner conflicts, so that they're able to perform daily tasks regarding personal hygiene, communicating with others, being able to do simple or more complex work roles. Many people are pretty functional, but sometimes blocked if they're upset. Some have developed healthy--and occasionally unhealthy--abilities to resist any intrusion of personal issues on their hobbies or work skills.
   11. Synthetic-Integrative Functioning.  Some folks are fairly good in one area and terrible in other areas. How well can they manage to integrate all the other variables being spoken about here?
   12. Mastery-Competence:  Some people have  low initiative and are under-achievers. Others may have significant emotional wounds, but yet able to perform remarkably well in work, sports, and so forth.
   13. Superego Adaptation. Again, this can be too much, or too little, strongly blaming oneself, or shockingly lacking in guilt or shame, tending toward the puritan or happy-go-lucky type. More mature people are able to acknowledge errors and seek to rectify them, moving toward a more balanced type of social conscience.
    14. Strength of Drives:  Some people are more sexual than others, and in some cases this may be more extreme in either direction, from the asexual to the hyper-sexual or driven. This can be affected by hormones, overstimulation, and other factors.
          Another drive is the aggressive, which can be diverted into hostility, grumpiness, or more focused as competition and work. Other people are less driven, and at the extreme, "un-motivated."  (In the old South, such "shiftless" folks were not infrequently so because of severe anemia secondary to hookworm infection, so that they were out of breath climbing the front steps of their home!)
You don't have to remember or use all these categories, but it gives you a sense of the complexity of what is worth thinking about and evaluating in assessing an individual's overall ego strength in considering prognosis.

One of the clinical values of this assessment is that achievement in even one area may be utilized as a vehicle for thinking about how those skills could be transferred into aspects of life which are more problematical. Patients also need recognition for those roles in which they are competent, and rewards in developing their preferred activities can gradually be helped to expand into other dimensions of living.

(4) Socio-Economic Resources:

The last major category is obvious, yet it is often ignored because of the profession's tradition on focusing on individual psychodynamics. What good is all this cleverness if the patient can't arrange transportation, baby-sitting, or other circumstances so they can even get in to see the therapist?

What is the extent of the family network, and how supportive are they of the patient's needs? This includes extended family. How understanding are they, or are they willing to be educated about the nature of the patient's problems and needs?

How much money is in the patient's family system? Is there anyone who can or, more to the point, is willing to pay for therapy, adjunctive rehabilitative experiences, vocational training or school, or "tools" for seeking work, developing a social life, etc.? By "tools" I mean car or access to transportation, adequate clothing, monies for self-maintenance--nutrition, hygiene, etc.  Finally, I want to note recent shifts in the rationing of  community mental health resources so that they are only supporting a certain group of major mental illnesses, and other types, equally disabling, are being turned away!  So the economic issues in treatment may be the most significant!  Alas, the actual process of after-care is all too easily neglected or handled casually.

Are there any social agencies involved in the case? Does the person live in a remote rural area? In a "rough" urban area? Will anyone be available to help the patient become involved in a community club experience, a summer camp, a sheltered workshop?

Is the family so busy, economically stressed, or in other ways "drained" that the patient is left to fend for himself? Are there actual exacerbating issues in the family, such as parental conflict, violence, bullying by an older sibling, exposure to sexual or physical or emotional abuse, etc.?


Consider, then, these four categories of voluntariness, psychological mindedness, ego strength, and socio- economic resources when working out a formulation. This is the basis of a more comprehensive and realistic "diagnosis," beyond the classification of the patient's particular form of expressing pathology.

Bellak, Leopold, et al. (1973). The Ego Functions in Schizophrenics, Neurotics & Normals. New York: John Wiley.

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