What Do We Owe the Overburdened?
Doing justice to trait-demand mismatches
“Psychopathology: Persistent failure to move toward one’s psychological goals due to failure to generate effective new goals, interpretations, or strategies when existing ones prove unsuccessful.”
Colin G. DeYoung & Robert F. Krueger (2018), A Cybernetic Theory of Psychopathology
“Some clinicians might be concerned that, if they applied the harmful dysfunction concept, they may find that they are treating many of their patients or clients for nondisorders. Actually, the DSMs have always recognized that the mental health profession often can be helpful to individuals with “problems in living” that are not disorders.”
Robert L. Spitzer (1997), Brief Comments From a Psychiatric Nosologist Weary From His Own Attempts to Define Mental Disorder
In clinical practice, I routinely encounter people whose cognitive, emotional, or temperamental capacities are being overwhelmed by what their lives are demanding of them. It is a collision between who the person is and what they’re facing. These are among the most common presentations in psychiatric clinics today, yet our diagnostic vocabulary captures them poorly. And the two dominant framings on offer, namely, stress-diathesis as a model of disorder development versus a moralistic, disapproving stance of overdiagnosis and medicalizing social problems, are each inadequate in their own way.
What sort of examples do I have in mind?
A woman with high baseline neuroticism who is chronically anxious in a work environment that would be stressful but manageable for someone with average emotional reactivity. She is able to function, just about, with the support of SSRIs and psychotherapy.
A man working two jobs to support his family, chronically sleep-deprived, cognitively impaired by exhaustion, who is able to function, barely, thanks to stimulant medications for ADHD. He was diagnosed with ADHD as a child but was never treated before and never needed stimulants until now.
A student with average working memory and processing speed enrolled in a program that selects ruthlessly on the ability to perform under timed, high-stakes conditions. She is experiencing self-doubt, low worth, anxious ruminations, and pessimism about the future. She wonders if she has generalized anxiety and ADHD because most of the other smart people struggling academically whom she knows of seem to have those diagnoses.
A woman with a history of developmental trauma and insecure attachment, in an abusive marriage, refusing to even entertain the possibility of leaving the relationship, presents to the psychiatrist and therapist with worsening anxiety and depression, requesting more aggressive pharmacological and psychological treatment because she is unable to function.
What all these cases share is a mismatch between what these particular people can tolerate or sustain given their particular dispositions and what their circumstances require. Sometimes their capacities are entirely within the normal range, and sometimes they have unusually high or low values of a trait that renders them vulnerable. These are situations of temperament-environment mismatch, cognitive capacity-demand mismatch, socioeconomic entrapment, unhealthy attachments, self-defeating behavioral patterns, and, sometimes, the search for enhancement or optimization.
What they also share is that the person typically does not present to the psychiatrist saying, “I’m in an impossible situation and I need help figuring a way out of this.” They present saying, “I have anxiety” or “I can’t focus” or “I’m depressed” or “I am overwhelmed and breaking down.” They come seeking a clinical remedy for what they experience as a clinical problem. And in the contemporary healthcare system, it is very easy, almost frictionless, to confirm that framing, write a diagnosis, recommend a treatment, and move on.
There is a real temptation, especially for conscientious clinicians, to adopt a stance that goes roughly like this: “Your problem isn’t really psychiatric. There is nothing wrong with you. It’s situational. Medication won’t fix it. What you need to do is change your circumstances. Leave the job, leave the relationship, lower your expectations, accept your limitations.” In many cases it is at least partly correct, but it also leaves much to be desired and rarely offers anything meaningful to the patient.
It assumes the person has options they may not have right now, structurally or psychologically. Telling someone to change their situation when they are not in a position to do so is just an ineffective lecture. This can shade into a kind of moralism that is disguised as clinical judgment. The clinician is making a value judgment about how the patient should be living their life, and they are using their control over the prescription pad to enforce that judgment.
Also, the neat distinction between “disorder” and “mismatch” that makes this stance feel intellectually coherent does not survive contact with clinical reality. Because of the interaction between trait vulnerabilities and situational stressors, there is considerable uncertainty in real-world clinical assessments about the relative contributions of each and the existence of downstream dysfunctions arising from their interactions. Chronic stress, for example, brings its own neurobiological and psychological changes (hello, HPA axis dysregulation) that can acquire an independence of their own even if the original stressor is removed.
Finally, this ignores that the person can genuinely benefit from clinical treatment, including medications, at least to some degree, at least for some time, and withholding that treatment from an actively suffering person requires some degree of clinical indifference that makes most clinicians uncomfortable.
I find that I oscillate, case by case and sometimes within a single encounter, between positions that are hard to reconcile. Psychiatry should not be in the business of helping people endure situations that are harming them. To medicate a person so they can tolerate an intolerable job, or an abusive relationship, or chronic sleep deprivation, is to collude with the conditions that are making them sick.
On the other hand, the person in front of me is suffering now. They are not an abstraction or a case study in social determinants. They have come to me asking for something specific, and I have the ability to provide it, and it has a reasonable chance of helping them to some degree. Why should we withhold treatment from a suffering patient because we disapprove of the circumstances that produced the suffering? The structural conditions that generate these presentations are unlikely to change on any timeline that is useful to the person sitting in my office.
The standard psychiatric assessment is structured around an evaluation of symptoms and accompanying distress and impairment. Identifying demand-capacity mismatches requires the clinician to assess the person’s capacities and their environment’s demands and then evaluate the relationship between them. It requires assessing baseline capacities, asking about lifelong temperamental patterns, cognitive profiles, and stress tolerance independent of the current presentation. A person who has always been highly neurotic but managed fine in a structured, predictable job and began struggling only when moved to a chaotic one has a very different clinical story than a person whose anxiety has been debilitating across all contexts since adolescence.
Some patients have a hard time seeing the mismatch at all because they have fully internalized the idea that they are deficient or defective in some way. I struggle, others don’t, what is wrong with me? Why can’t I deal with this?
Others see the mismatch clearly but cannot change it; they are trapped by economics, obligation, or fear, and need the clinician to take their constraints seriously.
Some can see the mismatch but refuse to change it or are unwilling to take the steps needed for reasons that are irrational, puzzling, or opaque.
And some cannot see the mismatch because seeing it would require confronting something they are not psychologically ready to confront.
I find DeYoung and Krueger’s approach to psychopathology as a persistent failure to move toward one’s goals due to failure to generate effective new goals, interpretations, or strategies helpful in this context. I’m going to bypass any broader discussion of how adequate it is as a general definition of psychopathology; for now, I am more interested in the idea of “persistent failure to move toward one’s goals” as a target of clinical intervention and as a characterization of the sorts of problems we are discussing here.
Extreme trait levels are neither necessary nor sufficient for a failure to accomplish one’s goals. What matters is the failure of characteristic adaptations. A person with high neuroticism struggles when their characteristic adaptations (the specific goals, interpretations, and strategies they have developed in response to their life circumstances) fail, and they cannot generate effective replacements. The problem, in many cases, is neither purely in the trait nor purely in the environment but in the failure of the adaptive interface between them. Two people with equal neuroticism in the same demanding job may differ in their capacity to generate effective new adaptations. The one who can generate these adaptations remains functional despite the mismatch.
In other cases, there is a conflict between people’s goals, and their existing interpretations and strategies are failing in resolving that incompatibility. And sometimes, the goals are impossible given the person’s resources, and no amount of generating new strategies will make them achievable. The situation genuinely does not allow any effective adaptations within the constraints the person faces. And we know from evolutionary psychiatry that confronting inescapable and hopeless goals is particularly depressogenic.
The emphasis on characteristic adaptations and trait vulnerabilities allows us to think about effective lines of intervention.
Generating new strategies is often the most straightforward. Helping the person develop better coping mechanisms, more effective work habits, or more adaptive relational patterns is the bread and butter of psychotherapy. This is what CBT, DBT skills training, and many behavioral interventions do. In the mismatch scenarios, this corresponds to helping the person manage their situation more effectively within existing constraints.
Generating new interpretations is helpful in situations where existing interpretations are maladaptive and holding people back. Reinterpretation does not change the situation, but it can change the person’s relationship to it in ways that reduce conflict and restore some degree of effective functioning.
It is often necessary to abandon or modify goals that are unachievable (or achievable at a great cost to oneself). Giving up a goal can be difficult when the person is highly emotionally invested in it. It is useful to see negative affect as a signal, similar to bodily pain, pointing towards a change that needs to be made. Sometimes acknowledging this can sound like we are telling the person that they should want less from life because of who they are. When a clinician helps a person generate new goals, they are participating in reshaping that person’s vision of their own future, and it is important to be clear about whose values are guiding the process.
Psychiatric medications tend to target the trait level, adjusting the parameters of the cybernetic mechanisms that produce the trait. An SSRI that reduces neuroticism is, in cybernetic terms, adjusting the sensitivity of the threat-detection system so that the person registers fewer mismatches between their current state and their desired state. The person with reduced threat sensitivity may be able to tolerate the demanding job, generate new strategies that were previously blocked by anxiety, and develop characteristic adaptations that are more effective.
Whether this is a “good” outcome, in a broader ethical sense, depends on whether the continued functioning in that particular environment is conducive to a person’s overall flourishing and well-being. It also depends on how sustainable the improvement is. Sometimes a medication only buys people time, a pause before their capacities are overwhelmed again, a pause that can be valuable if it is used to develop new adaptations and reassess goals.
I am of the view that the most important things a psychiatrist can offer in these situations are an honest formulation, communicated with care, with the clinical room to explore and work through the trait-demand interactions at play, respecting a person’s autonomy and preferences, the openness to use medications in a clinically appropriate manner while being forthcoming about what they can and cannot do, avoiding medications when they will only worsen the problem (e.g. masking sleep deprivation with stimulants), guiding the person to the right psychological interventions aimed at building new strategies, interpretations, and goals, and providing space and grace for the person to come to terms with what they have been unwilling or unable to confront.
What I keep coming back to is the obligation to be honest. Honesty with the patient about what I think is happening and what I can and cannot do about it. Honesty with myself about the limits of my abilities and the values embedded in my clinical judgments. And honesty, insofar as I have a public voice, about the ways in which the profession I practice is being asked to absorb and individually manage forms of suffering that are, in part, collective in origin and that deserve collective responses. And honesty about the need for a clinical language that does justice to trait-demand mismatches and sees them as firmly and unapologetically deserving of clinical care.
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Thank you Awais for putting into words what I have been struggling with since I started practicing- ‘what can I do for the person who is in front of me right now’ is a very different to ‘what would I do for this person in a world where there are no structural, resource, or individual constraints.’ Treatment planning with someone who has stable housing, good social supports, good health, good insight and good judgement is very different to treatment planning with someone who does not have those things, yet many of our policies and guidelines assume the former. Case in point: ‘suicidal patients do better in their own home with the support of their loved ones than being in hospital’ is only true if they have a home and supportive family who are capable and willing to care for them. Gold standard care presumes gold standard funding, and gold standard environments.
Thank you again Awais for a clinically grounded piece and as always nuanced and wise! As a clinical psychologist in Sweden the dilemma of moralizing, overdiagnosing or prioritizing a ”subclinical” over someone with more severe problems is an everyday occurrence in our government sponsored health care system. I also think you make the situation so vivid in which you have somebody suffering right in front of you even if they may not be the correct level of care for the psychiatric out- patient clinic where I work. Being honest, validating of their experience and inserting some education about the complexity of mental health issues that Bob Krueger, Colin DeYoung, and you narrate so elegantly, I agree is probably the most respectful and helpful response. Thank you!