Labels (Part 1)

Many educated people often talk of the wisdom of avoiding labeling people and or interpersonal dynamics. To a certain degree I can agree. I agree that sometimes labels reduce us to objects within a category, rather than the individuals that we are. However the opposition to labels also misses the utility of labels. Labels allow us to form cognitive shortcuts and form expectations.

Many of the labels that we use in fact are problematic specifically in the ways in which they act as cognitive shortcuts and framing expectations. But the use of the label is not so much the problem as the rigidity to which we stick to the expectations or associations of that label. Take the labels “gay or “straight,” for example. Both of these labels are laden with expectations and associations, which often on whole are true for the majority (if not all) of the people that would fit the label. A liberal interpretation of the label would allow for a man labeled as “straight” to enjoy shopping or watching Glee more than watching sports and for a gay man to enjoy working on his car or hunting more than Project Runway or RuPaul’s Drag Race, as well for the more stereotypical reverse.

However, knowing that a man is “gay” or “straight” also informs me of the likelihood that he will know certain people or places that are frequented by other people labeled “gay.” Most “straight” people in Houston are not familiar with the Ripcord or BRB, but most “gay” people are. Perhaps most importantly, I know how safe or appropriate it is to hit on someone who has labeled himself “gay” or “straight.”

Of course, again there is the problem that while most people can in fact be neatly sorted into categories, others are poor fits for any of the existing categories that we have. I have a client who would less identify as “gay” or “straight,” as he does “submissive;” the striving force of his sexual arousal is grounded in the dominant nature of a partner, rather than the partner’s gender. This client shies away from identifying as “bisexual” because “bisexual’ tends to be interpreted as attracted to both males and females, but this terms side-steps the notion that a partner’s gender is irrelevant, but rather it is the nature of the person—regardless of gender—that attracts him. I know other people who are honestly attracted to males and females and for whom gender is actually part of the attraction—“bisexual’ applies aptly for these clients.

Labels also give us a sense of belonging. Race or ethnicity is another area in which there is resistance to labeling. Race and ethnicity are, like sexual orientation, false categories that are socially constructed and do not reflect the diversity of people. However, through such labeling one has a sense of belonging, of having a kin-group. According to Abraham Maslow, Belongingness is one of our basic needs and is foundational to our forming a positive sense of self. Acceptance, a form of belongingness, is essential to healthy self-esteem. Humans are naturally (it seems) suspicious of out-group members and more willing to support in-group members, and so labeling ourselves helps provide us with sources of support as well

So labels simultaneously allow us some expectations and associations (which we ought to confirm for each individual occurrence of a label in order to avoid too rigid of interpretation of the label), and fail to capture the full range and nuanced differences among people. They also help give us a sense of how to behave and toward and around others. Similarly, they help us can give us a sense of community and promote mental health. Rejecting labels altogether because they do not work perfectly seems equally unwise as interpreting labels too rigidly.

Choosing a 100% Chance of Being Miserable

There are a couple of things which clients have said to me over the years that really stuck. The first one is from my very first client in training as a graduate student; the other was in the early days of my private practice. Both statements continue to resonate for me because they symbolize a recurring issue that I see in counseling, namely a refusal to leave a bad relationship after recognizing it is a bad relationship.

My first client was a volunteer from a psychology class for trainees to practice on; many of them did not think that they had problems that warranted counseling. She described to me the discomfort and difficulties she was having in her relationship, how her boyfriend would say mean things and go out with friends and “force” her to stay home, and how he had broken the windshield of her car. When I asked why she was still in a relationship that was so distressing she responded “It doesn’t hurt enough yet.”

She was able to recognize that being in the relationship “hurt,” but did not see that as a good “enough” reason to leave the relationship ”yet.” As this was my very first session with my very first client, I did not feel that I had the rapport with her to ask “how much does it have to hurt before it is okay to leave?” or challenge her on the notion that there needs to be some sort of threshold for pain at all in order to leave an emotionally abusive relationship. Note that there was no hope or expectation that this relationship was going to get better. In fact there appeared to be an expectation that the relationship would get worse. I kind of presume that she was waiting for the abuse to become physical—because breaking her windshield was not violent enough yet.

This was the basic sentiment expressed by the second client that left such an impression on me. He came to me to better deal with a relationship in which he was very unhappy. He relayed that they had been together about three years and how the relationship was unsatisfying in a variety of ways and how his boyfriend showed no signs of (or interest in) changing his behavior. The client described his boyfriend as a nice guy, but who did not want to do anything except stay home and watch TV; they had also stopped having sex. The client was clearly frustrated and did not know what to do, and then he said the words that continue to echo for me: “I wish he would just hit me.”

He went on to explain to me that he did not want to look like “the bad guy” in a break-up. Apparently, being miserable in a relationship is preferable to being “the bad guy” in a break-up. Furthermore, being miserable enough to want one’s partner to him/her is not itself a good enough reason to leave a bad relationship.

I think these clients emphasize the idea that we consider what might happen more than what is happening. I think there is this fear that something bad (e.g., loneliness, rejection, or loss of reputation) might follow a break-up. This really speaks to the importance of our desiring acceptance and belongingness—a willingness to endure being miserable over risking not being accepted by another. However, I would argue that being miserable in a relationship is a sign that the “acceptance” within the relationship is false and unsatisfying in its own right. After all, one does not have to be alone to feel lonely or rejected.

I do not mean to suggest that everyone should quit their relationships when things get tough. However, examining one’s relationship with regard to the amount of satisfaction-dissatisfaction in the relationship and the realistic hope that things will change (what reason are there to expect that things will—not just can—change?) is important in actually getting one’s belongingness and acceptance needs met. Within a bad relationship one can be 100% certain those needs will not be satisfactorily met. After a break-up there is at least an opportunity that one can get them met—in fact ending a bad relationship increases, not decreases, one’s odds of getting the positive attention one is afraid of not getting.

Psychotherapy vs. Psychopharmacology

Many patients seek medication for emotional discomfort, difficulty concentration, sleep disturbance, and somatic or physical manifestations of emotional discomfort. There is a tendency in our culture to treat illness with a pill—which drives this inclination, along with the continued stigma of being labeled with a mental illness—despite that so many people are on anti-depressants and anti-anxiety medications that their use is now “normal” to most people. Somehow being medicated for an emotional disturbance is not as stigmatizing as being in therapy for one. Additionally, there is a perspective that taking pills is easier (and cheaper) than seeking psychotherapy treatment. However, research on the effectiveness of psychotropic medication and psychotherapy show that many of these patients are doing themselves a disservice in this approach.

Overall, in early research the effectiveness of treatment of emotional disturbance (such as anxiety or depression) was shown to be roughly equal between psychotropic medication alone and psychotherapy alone for most common mental disorders. While there is a fair amount of research that has shown that combined therapy (medicine and talk therapy) is the most effective, more recent research has been suggesting that psychotherapy alone is as effective as combined therapy in the long run. Similarly, more recent research (focusing on long-term effectiveness, rather than immediate effectiveness) has shown that psychotherapy is more effective than medication with regard to long-term benefits. It turns out psychotherapy is advantageous compared to medicine in a number of ways.

Cumulatively, the research suggests that psychotherapy offers more long lasting benefits than medicine. Psychotherapy is actually shorter term. Even if one is in therapy for a number of years, people who begin antidepressants and anti-anxiety medication (without the additional benefit of psychotherapy) frequently end up on those medications for life—on account of the high relapse rates for medication alone. Ironically, studies have shown that across a lifetime, the cost of medication tends to exceed the cost of psychotherapy. Psychotherapy tends to be higher initial cost, but typically clients achieve a level of functioning that makes treatment unnecessary and the cost stops.

Psychotherapy additionally is safer. There are many dangerous drug interactions between psychotropic medicines and other medicines, while psychotherapy does not interact chemically with any medicines. Psychotherapy has few side effects—some initial increased emotional discomfort is common, but loss of sexual performance due to psychotherapy is extremely rare, for example. Likewise, sleeping disruption seems to be temporary and psychotherapy is not associated with unwanted weight gain—psychopharmacology cannot make those claims.

Ideal treatment for many emotional disturbances appears to be co-joint treatment with medication and therapy initially, with patients gradually reducing and terminating their medication as progress in psychotherapy provides symptom relief such that symptoms become tolerable in the absence of medication. However, there are some disorders, such as schizophrenia, ADHD, bipolar disorder, and dysthymia (chronic depression), for which psychotherapy is not as effective medicine. But even in these cases, there is also strong evidence that psychotherapy administered along with psychopharmacology is more effective than medication alone in treating these more severe mental disorders.
Of course, the downside is that psychotherapy is more work and requires actually looking at one’s pain (and sometimes the source of it), rather than covering it over. Psychotherapy functions with a goal of symptom removal, whereas medication frequently has the effect of symptom mediation. Of course, harder work also equals more meaningful reward though.

Mental Hygiene and Mental Health

In this country “mental health” typically refers only to the negative end of the spectrum, in other words, neutral mental health to mental illness—we too often think of “mental health” in terms of either having mental illness or not. We tend to ignore the role of mental health in terms of strength or resilience—the positive end of the spectrum. Psychologists are thought of in terms of fixing things that have gotten broken, but not thought of in terms of preventing things from getting broken in the first place. We do preventative maintenance our cars, but do not often (enough) think about preventative maintenance on our psyches.

The opposite of negative is not zero, but rather positive. Yet the role we have relegated psychologists to is to deal with the negative to zero range. We have come to equate “happiness” with the absence of being unhappy, and they really are not equivalent. Happiness is a positive, while the absence of unhappiness is actually zero. The greater happiness (in terms of contentment, rather than momentary joy) we have in our lives, the less susceptible to mental illness we are. As long as we ignore half of the spectrum, we will find ourselves more and more in the side of the spectrum to which we do attend.

We fail to recognize that many of the skills and techniques that psychologists have developed for mental remediation and repair can also be used for mental enhancement and strengthening (e.g., communication and social skills, openness to experience, stress management). Pre-marital counseling used to be valued, but now we only go to a counselor after the relationship has become problematic (and even then usually not until the resentment has gotten out of control).

When I was deciding on a graduate program I choose a Counseling Psychology program (rather than the more popular and better known Clinical Psychology) because as a sub-field it was known to emphasize mental wellness, instead of mental illness. Counseling Psychology was (and is) known for the emphasis on optimal function, not simply adequate functioning. Counseling Psychology tends to be more focused on hope, optimism, self-efficacy, emotional intelligence, wisdom, courage, and personal strengths. We are less excited about helping a client get better than we are about helping the client become a better version of himself or herself—even if that is from a position of mental illness.

I think of Counseling Psychology as aspirational, let’s not just make you better, let’s make you the best. When Counseling Psychology was first forming as a discipline within psychology, it focused on what was called “mental hygiene.” It was focused on keeping people’s minds functioning well, not on returning people’s minds to a functional state. There is a wealth of research on the benefits of psychological enrichment, above and beyond psychological remediation. However, we continue to value psychological remediation over psychological enrichment.

I have a friend who is a psychologist who claims that the reparative work he does with clients is more valuable or meaningful than the work that I strive to do with (typically higher functioning) clients to bring them to optimal functioning. In our culture we focus on deficiency rather than enhancement; we focus on what is missing in our lives rather than how to better develop and utilize what we already have. But the research shows that nation-wide, the impact of improving the lives of people who are already functional can have more of a positive impact than bringing (the minority of) people back to base functioning. People’s productivity and pro-social helping behaviors are more affected by life improvement than remediation of a disorder. Improve the lives of many slightly and there is more of a positive impact on society than remediating the problems of the few. However, even in the presence of many studies that have shown that happier people who better manage their stress—including the cost savings of mental preventative maintenance, mental hygiene is dismissed as unimportant.

I often run into people socially who tell me about how their lives are unsatisfying, even though they are adequately functional. They will even tell me they are not unhappy, but also unfulfilled (not happy). Most of these people would never consider going to a counselor, psychotherapist, or psychologist to help them improve their lives because they do not see their lives as “broken.” Instead they spend their time acquiring objects or sex to feel more fulfilled, which will never be as effective as counseling, and more expensive in the long run.