Lack of Cooperation Disorder
Let’s talk frankly. Are you really very interested in reducing your emotional distress? Do you really want to feel better? What if feeling better requires that you change your daily habits, change your habits of mind, change your circumstances, upgrade your personality, and work like the Dickens? I mean, seriously—are you up for that?
You say that you don’t want pills—well, do you want all this responsibility instead?
You say that you don’t want to talk endlessly in therapy—well, do you want all this responsibility instead?
You say that you don’t want to live like this any longer—well, do you truly want to live differently?
See if this is you. You are suffering and you seek out a helping professional whom you hire to help you relieve your emotional distress. Unfortunately for both of you, you have certain powerful reasons for not cooperating with this person you have hired.
Maybe you don’t want your drinking, smoking, or eating habits tampered with. Maybe you don’t want to change—you want other people to change. Maybe you can’t reveal what’s going on because you’re embarrassed by your thoughts or your actions. Maybe there would be repercussions—say, if your mate found out about your affairs. Maybe you’re very comfortable with your formed personality and your habits of mind, even though they bathe you in sadness or anxiety.
This would make you entirely human and not very unusual. In fact, virtually all people prefer being who they are to being helped or reducing their emotional distress—if being helped and reducing their distress makes work for them, requires that they change, or forces them to look in the mirror.
It is an artifact of evolution that our “selfish genes” are not very smart. They cause us to defend ourselves even against self-help. It might prove in your best interests to make certain admissions and take responsibility for healing and for changing, but most human natures rebel against such brutal honesty.
This reality surely doesn’t much help the helping relationship.
These are “your issues”—but they also become the issues of the helping professionals you hire. You are forcing them to deal with human nature and they get very tired of human nature. The whole current thrust of mental health services provision in the direction of “diagnosing and treating mental disorders” and “medicating patients” is rooted in exactly this failed transaction.
What modern psychiatrist isn’t happier acting like you “have something” and writing you a prescription than trying to arm-wrestle you out of your personality, your habits of mind, and your ways of being? Wouldn’t you be rather likely to do the same in his position? And aren’t you just a little glad that he is telling you that you “have something”? Doesn’t it serve your ends to “have depression,” rather than look at your sadness, or “have an attention deficit disorder,” rather than manage your anxiety and pay attention?
Aren’t the two of you in this together?
Maybe you are more unwilling to cooperate, say because you have secrets to keep, or maybe you are more unable to cooperate, say because your chronic sadness has you so down that you have no energy to use in your own support. These are different situations but from a helper’s point of view they amount to a similar problem: you aren’t helping. And that has consequences for you, because your lack of cooperation must get factored into the diagnostic label you get and, in turn, into your prognosis and your treatment plan.
How could it not?
And what if you are not only uncooperative but also up front and adamant about it? Say, for example, that you make a point of being uncooperative and make a further point of doubting your helper’s expertise, methods, and even his good intentions? Isn’t that going to count against you? Of course it must!
Picture a psychiatrist, a psychologist, or a psychotherapist of some other stripe. If you disagree with him, if you mock his expertise, if you see him as an agent of society and not as an actual helper, he will almost certainly provide you with a harsher diagnosis than if you are pleasant and act cooperative. Isn’t that just natural?
If you are uncooperative and loud about it, you are less likely to get some adjustment disorder diagnosis or some mood disorder diagnosis and more likely to get a personality disorder diagnosis. Just as a judge has a remedy for “difficult and unpleasant” in his arena—contempt of court—a therapist-as-judge has his particular remedy. He has the ability to diagnose you with a “borderline personality disorder” or an “oppositional defiant personality disorder” or something else that translates as, “Boy, are you difficult!”
This is all covert, of course. A psychiatrist would never say, “Because you are being uncooperative I am giving you a harsher label.” He might say, “Your lack of cooperation is a symptom of your personality disorder”—that he might just say. But that is a very different sort of sentence.
He might provide you with this harsher diagnosis for two different reasons: because he is annoyed with you but also because once he gives you that precise label he is relatively off the hook as far as treating you goes, since it is “well known” that folks with personality disorders are by-and-large unreachable and untreatable.
You get the label because you are a pain in the neck but you also get it because it reduces his responsibility dramatically, since “nobody can reach someone with a borderline personality.” You, by virtue of being difficult (and you are), and he, by way of preferring an easier ride, collude in providing you with a label that completely obscures the failed nature of the transaction.
A person’s general unwillingness to participate in reducing his own emotional distress because it is too much work to do so, coupled with a therapist’s wish to take it easy on himself when dealing with uncooperative clients, leads us to this exact moment in the history of mental health helping, with drugs running rampant and everyone acting as if human beings have caught this or that version of some craziness flu.
The scandal that is the DSM-V is a professional scandal. But it is also the completely predictable result of two agendas colliding: the collision of the client’s wish to remain the same and the helper’s wish to make it through the day.
We in critical psychiatry who are looking at alternatives to the DSM and to our current diagnosing madness must somehow factor this reality in. How good can any new system be if it doesn’t take into account that human beings are only mildly interested in reducing their emotional distress? In medicine, the issue is compliance: will a patient take his meds or stop eating fried foods? Our issue is an even more intractable version of the same problem.
Maybe every new client should start out with a “lack of cooperation disorder” diagnosis—maybe with refinements like “mild,” “moderate,” or “severe”—until he proves that he is actually interested in cooperating. No—we certainly do not need another disorder label! What we need is a new education system that alerts children from the beginning of life that if they want a certain outcome like emotional health they will need to work for it.
It is actually easy enough to imagine what that education might look like—if only anyone wanted it.