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Key points
- Health insurance often requires a diagnosis of a mental health condition for therapy coverage.
- It can be difficult to determine what is related to a condition like depression versus a reaction to life.
- Interpersonal and family therapies focus on relationships to improve mental health symptoms.
Therapists often have the honor of being invited into a window peering into some of the darkest moments of our clients' lives. And, of course, we are also humans ourselves, who experience our life's pain. One difficult element in therapy is diagnosis.
For health insurance to cover psychotherapy, there typically must be a diagnosis of a mental health condition such as generalized anxiety disorder or major depression. Yet, often, what leads people to therapy is not mental illness but the challenges of life. Challenges such as grief, relationship difficulties, abandonment, a diagnosis of physical health illness, or caring for a loved one with an illness are common reasons for seeking therapy.
The Diagnostic and Statistical Manual for Mental Disorders does allow for a diagnosis code of "adjustment disorder" for individuals struggling with life changes, yet, according to the criteria, the response to the change must be "out of proportion" to the stressor (American Psychiatric Association, 2013). Who is to say what is out of proportion? It can be difficult to draw a line between recognizing needs and pathologizing normal.
Sometimes Both
What is even more tricky is when a person living with a mental health condition encounters a significant life event. The event can trigger a natural response, as well as mental health symptoms. For example, after a breakup, someone with depression might feel the heartbreak anyone would, and the breakup could also trigger or worsen a depressive episode.
To make matters even more blurry, according to the stress-diathesis model of mental disorders, it seems that when struck with enough stress, any person who had been at risk for a mental health condition through genetics or similar could be at higher risk of illness onset. Research targeting psychosis and schizophrenia has suggested that interactions between stress and associated pituitary, inflammatory, and neurobiological reactions may play a role in the initial onset of psychosis (Pruessner et al., 2017).
Similar findings have been made regarding depression, with research discovering an interplay between polygenic risk scores (a person's known genetic vulnerability to depression based on genetic markers) and life events in whether a person develops depression (Colodro-Conde et al., 2018).
Evidence supports a model of mental health conditions as complex conditions with biological, psychological, and social dimensions. Further, it is critical that the mental health field not minimize the emotions felt in the process of life by those with mental illness, even when it is difficult to determine what role, if any, one's mental health condition might have in their suffering.
How can we deal with this?
Interpersonal Therapy
Most psychotherapy takes an individual-based approach, focusing on things as one's own beliefs, thoughts, and emotions. Yet, individuals exist within systems wherein relationships are central. Feeling connected is an important part of mental health for almost everyone.
Interpersonal therapies take an approach that openly acknowledges the ways that mental health and social health affect each other. In interpersonal therapy, a person is given a space to explore things like grief, role transitions, and conflicts that might be affecting their mental health. If someone's social system is lacking or they are struggling with how to go about specific social tasks like making friends or assertiveness, interpersonal therapy can also work on skills development.
While interpersonal therapy is usually done in individual settings, a person's relationships are a central area of exploration.
Family Therapy
Family interventions can directly target a person's relationships in the therapy room, with the family becoming the client. When a person is living with a mental health condition, it can affect the entire family, and the stress of the family can affect both the individual diagnosed with the condition and the course of their condition.
Even in schizophrenia, a condition believed to be at least, in part, neurological in nature, research has shown that high levels of expressed emotion can hurt the illness and that family therapy can often make a meaningful difference in outcomes (Girhar et al., 2024). Research has also shown the positive results of family therapy in the treatment of a multitude of other conditions, including adolescent depression (Jiuju et al., 2022).
Still, family therapy is not routinely offered in mental health care.
In Conclusion
It can be difficult to untangle the web between our internal experiences and the alterations made by life and relationships. Diagnosis of a mental health condition makes this even more complex. Interpersonal and family therapies, which focus on relationships and mental health, may be underutilized interventions to improve these areas of well-being.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Colodro-Conde, L., Couvy-Duchesne, B., Zhu, G., Coventry, W. L., Byrne, E. M., Gordon, S., ... & Martin, N. G. (2018). A direct test of the diathesis–stress model for depression. Molecular Psychiatry, 23(7), 1590–1596.
Girdhar, A., Patil, R., & Bezalwar, A. (2024). Understanding the Dynamics: A Comprehensive Review of Family Therapy’s Impact on Expressed Emotions in Schizophrenia Patients. Cureus, 16(5).
Jiuju, L. I., Shuping, T. A. N., Yanli, Z. H. A. O., Yin, Q. I., ZHANG, F., Huaqing, L. I. U., & Lina, L. I. (2022). The effect of mentalization-based family therapy on adolescents with depressive disorder and its related brain regions. Chinese Journal of Behavioral Medicine and Brain Science, 43–49.
Pruessner, M., Cullen, A. E., Aas, M., & Walker, E. F. (2017). The neural diathesis-stress model of schizophrenia revisited: An update on recent findings considering illness stage and neurobiological and methodological complexities. Neuroscience & Biobehavioral Reviews, 73, 191–218.
