Welcome to From Insults to Respect. I hope the beauty of spring is helping to make your daily challenges more pleasant.
Regular readers know that from time to time I write a post advocating that mental health service providers change the way people access their services so that it becomes more respectful and more consistent with the principles of science. What I mean by this, is that currently those who have a health insurance policy that includes mental health services discover that when they seek to access those services they have to first be declared as a person with a mental disorder. Not everyone is happy about this, as the following parable suggests.
The Parable of Julianne and Dr. Robles
“Hi Julianne,” says Dr. Robles, as he greets his new counselee. “What can I help you with?”
“Well, Dr. Robles, I…I….” Tears begin to form in Julianne’s lovely hazel eyes. She takes out a tissue, blows her nose, wipes her eyes, and continues. “You see, I have two young children, age 3 and 5, and my husband left us a couple of months ago. I’ve been trying to keep it together, especially for the children, you know, and, well, it’s been so hard.”
“I can imagine it would be,” Dr. Robles replies gently. “Raising two kids even under the best of circumstances is quite a challenge.”
“Yes. And now I’m trying to do it all by myself, and I’ve been feeling so depressed, and if I get any worse…. I mean I thought I better come in to prevent myself from crawling into bed and not getting out. I have to think of the children. I checked and I have mental health coverage on my insurance policy.”
“Yes, my secretary looked into that, and you do have mental health service coverage.
Your insurance company requires that I must place a diagnosis on your health insurance form for you to access that service. I hear, so far, that you are concerned about….”
“Wait! What do you mean you have to place a diagnosis on my health form? You aren’t going to write in there that I have some sort of mental disorder, are you?”
“Well, I wish we didn’t have to get into this labelling issue. Personally, I think it’s best to treat each person that I provide counseling to as an individual. It is understandable that many people don’t want to be placed in a diagnosis box, especially one known to be stigmatizing. But the insurance companies do require a diagnosis.”
“That’s not fair! I’ve been paying insurance premiums for years and I never signed any agreement that to access this service I had to be labeled like this?”
“Well, I can easily see why you feel that it is unfair. I actually agree with you. Perhaps it would help if I let you know that in the vast number of cases the information in your medical records remains confidential?”
“No, it doesn’t help! Even the most confidential government records have been hacked, and my husband and I are in a legal fight over custody of the children. If he petitions the court to see my medical records, what guarantee do I have that the court won’t end up seeing them?”
“Computer hacks do occur, and I have heard about very rare instances when courts did manage to view a person’s medical records over the patient’s objections, so your concerns are reasonable. I wish I knew of some way around this labelling requirement, but for now we are stuck with this system.”
The Purpose of the Above Scenario
In today’s scenario, we see an example of both the person seeking counseling and the mental health service provider desiring that a certain requirement of accessing mental health services be eliminated.
Unlike them, some people actually find it reassuring when a doctor declares that they have a diagnosable condition, and they experience no objection when they learn that this condition is to be placed in their medical records.
For those who believe the current mental disorder classification system is helpful, I seek not to interfere with their ability to access services in the manner that they prefer. What I do seek is that for the significant number of people who do object to the current psychiatric labelling system, they nevertheless have equal access to mental health services without the mental disorder labelling requirement.
The above scenario provides readers an example of why some object to this type of labelling, but recent surveys indicate there are many others as well. In an article published in the Journal of Humanistic Psychology (Click HERE to access the article), I discuss these surveys.
For example, here’s what Jonathan D. Raskin and Michael C. Gayle wrote when they summarized their survey data of psychologists who regularly use the standard mental disorder classification system known as the DSM (DSM-5: Do Psychologists Really Want an Alternative? 2015, pages 1-18).
“Although more than 90% of psychologists report using the DSM, they are dissatisfied with numerous aspects of it and support developing alternatives to it—something that psychologists over 30 years ago supported, as well. The finding that almost all psychologists use the DSM despite serious concerns about it raises ethical issues because professionals are ethically bound to only use instruments in which they are scientifically confident.”
In my journal article, I go on to propose a practical, more scientific alternative to the DSM. I call this alternative, the Classification and Statistical Manual of Mental Health Concerns (CSM). The first words in the CSM would be: “The developers of the CSM fully recognize that individuality outruns any classification system. It is for this reason that the CSM does not seek to classify anyone. Instead, it classifies the expressed concerns of individuals seeking to have their concerns addressed by a mental health service provider.”
After publishing my journal article, I discovered at a number of forums that many people after hearing me out, expressed that the CSM approach makes a great deal of common sense. Some also readily saw that its scientific merits are enormous because the expression of a mental health concern is a clearly observable event that occurs at a specific time and place, and therefore its use would beautifully solve the reliability problems that have been plaguing the DSM’s far more abstract, vague, theoretical construct of “mental disorder.”
On the other hand, some resisted the CSM approach. As I began to question them, seeking to figure out where exactly the disconnect was, I discovered that for some, it had to do with their belief that the DSM is a classification system based on solid principles of science and nothing could possibly be better. As I questioned them further, I discovered that their understanding of what a scientific classification system is designed to do was a bit incomplete. So, in today’s post, I explain in an easy to understand manner the nature of scientific classification systems, beginning with a description of a classification system with which we are all so very familiar–birds. This will enable us to see clearly why the bird classification system is useful as a scientific instrument. We will then look at the DSM classification system in light of what we learned about the bird system, and this will reveal the DSM‘s serious scientific shortcomings. Finally, we will compare and contrast the DSM system with the proposed CSM system in a manner that can make the superior scientific merits of the latter crystal clear.
The Bird Classification System
A branch of science begins with something some people are so interested in that they want to study it carefully and share what they find with others, while at the same time learn from others what they find out. 
As it turns out, there are some people very interested in birds.
The next thing that happens in a branch of science is careful observation of the topic of interest. After some early observations, the scientists begin to put together a classification system, which is also known as developing a taxonomy. This begins with explicitly defining what that something is that they are interested in. Said in another way, they describe that something of interest in a clear and detailed manner, leaving no room for confusion or doubt. So, in our example of “birds,” scientists have decided that they are a group of endothermic vertebrates, characterized by feathers, toothless beaked jaws, the laying of hard-shelled eggs, a high metabolic rate, a four-chambered heart, and a strong yet lightweight skeleton.
Once scientists carefully define their general topic of interest, they describe different types of what they are interested in. So in our bird example, the scientist interested in them came up with a taxonomy that lists bluejays, pigeon, sparrow, and so forth as subtypes of the general category of birds, describing each subtype in a precise manner that can reliably distinguish each from the others on their list. Why bother to do this?
The main reason is that when they discuss their findings with others, they want to make sure they are using words that mean the same thing, and it is a great time saver. For example, let’s say John is a bird scientist and he says to Judy, another scientist, “I saw a bird the other day and I didn’t know what type it was; can you help me figure out what it is?” Notice that since both of these scientists know the meaning of a bird, it saves John quite a few words. Just imagine if instead every time John uses the word bird he had to say, “I saw something that had an endothermic vertebrae, characterized by feathers, toothless beaked jaws, the laying of hard-shelled eggs, a high metabolic rate, a four-chambered heart, and a strong yet lightweight skeleton.” That’s quite a mouthful to have to say each and every time you refer to a bird. In this example, just saying bird saves a scientist about 30 words each time the word bird is used.
The word bird, once explicitly defined also saves time in other ways. For example, let’s say there was no agreed upon definition of what a bird is and no classification systems at all. 
And let’s say John, the scientist, wants to find in a library some information about a particular type of bird. He would have to waste time looking at every single book in his library until he found one that seemed to be talking about what he was interested in.
As another example of the time saving value of classification systems, let’s say “bird” was vaguely defined as a flying creature. 
This would result in John having to unnecessarily wade through numerous books on flying insects, of which there are hundreds of thousands of types, bats, and some fish that sort of can fly. With the current bird classification system, anyone can go to a library and quickly find the specific section that houses information on just birds. Similarly, placing the word “bird” in a search engine enables John to more quickly retrieve relevant information than would a less explicit definition.
The DSM Classification System
The DSM‘s overarching topic of interest is something it calls “mental disorders.” Dr Ralph Slovenko was a renowned psychiatrist. Prior to his death in 2013, he authored hundreds of articles and more than 10 books, including Psychiatry in Law/Law in Psychiatry, which went into a second edition in 2009. Let’s take a look at how he described the definition of mental disorder:
“Although this manual [the DSM] provides a classification of mental disorders, it must be admitted that no definition adequately specifies precise boundaries for the concept of “mental disorder.” The concept of mental disorder…lacks a consistent operational definition that covers all situations. All medical conditions are defined on various levels of abstraction–for example, structural pathology (e.g., ulcerated colitis), symptom presentation (e.g., migraine), deviance from a physiological norm (e.g., hypertension), and etiology (e.g., pneumonoccal pneumonia). Mental disorders have also been defined as variety of concepts (e.g., distress, discontrol, disadvantage, disability, inflexibility, irrationality, syndrome pattern, etiology, and statistical deviation). Each is a useful indicator for a mental disorder, but none is equivalent to the concept, and different situations call for different definitions.”
Dr. Slovenko goes on from here to tell us what the definition was used in the edition of the DSM back in 1994.
“In the DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significant increase risk of suffering death, pain, disability, or an important loss of freedom.”
Now I ask you, does this definition meet your standard for being explicit? To me, it is like saying that the definition of a bird is, something that has feathers, or scales, or teeth, or is beaked, or is warm blooded. It is actually worse than that, because the difference between such descriptors as teeth and a beak can be determined with excellent reliability. Can we determine the difference between “clinically significant” and “not clinically significant” with the same degree of precision? Clinically significant is subjective, in contrast to being objective, and science requires objective definitions.
The latest edition of the DSM (DSM-5) is just as vague. It begins, “Although no definition can capture all aspects of all disorders in the range contained in the DSM-5, the following elements are required.” Although it says the following elements are required, it then makes it clear that the elements that it lists are not required. As I provide the rest of the definition, notice the use of the word “or” and “usually.”
“A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognitive, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expected or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”
Again, the descriptor “clinically significant” is used, as it was in the previous edition of the DSM. 
This is about as vague a descriptor as one can possibly conjure up. How about the descriptor “dysfunction?” This, too, is left to the subjective opinion of mental health providers who often have financial interests in declaring that someone has a mental disorder.
My above critique of the mental disorder definition begs the question, Can scientists reliably distinguish those with a mental disorder from those who do not?
There is a simple scientific way to determine this. It involves randomly selecting a few hundred people from the population. Then, perhaps 20 scientists familiar with the definition would interview each in the time period usually devoted to making a so-called diagnosis in clinical practice. After each interview, each scientist would separately indicate on a piece of paper his or her decision about whether or not the person has, or does not have, a mental disorder. Each decision would be made independently from the other scientists, that is, without knowledge of the other scientists’ decisions. After this data were collected, statisticians would look to see how well the different scientists agreed with each other.
Recently, I tried to retrieve this type of study using Google Scholar by putting in the search window, “Reliability of determining who has a mental disorder and who does not.” Nothing of value came up. I tried other search terms to retrieve this basic scientific information. Again, nothing.
Eventually I found some relevant information. The vast majority of mental disorders listed in the DSM were never assessed for reliability, and the few that were indicate that this is a major area of weakness for this classification system.
Relevant to this issue is a recent peer reviewed article by Barbara S. Held in the Review of General Psychology (2017) that discusses the various mental disorder categories (p. 82-94). She states that these heterogeneous categories have produced a lack of scientific progress because of their “internal incoherence, such that any given instance (diagnosed person) may share few and, in some cases, none of the category-defining features of other persons given that same categorical label.” (p. 83)
Dr. Held goes on to say:
“This is called the problem of “polytheticity” in the theoretical/philosophical clinical literature, and is seen as a primary source of obstacles to building a progressive science of mental disorder; it is also seen as related to the daunting problem of comorbidity, which calls into question the presumably discrete nature of disorder categories.”
So, boiling down the above critique of the mental disorder construct to its basics, the construct violates principles of science because its definition is neither explicit nor objective.
The CSM Versus the DSM
I, for one, am interested in a phenomenon that I, and others, call mental health concerns. Obviously there is wide interest in this. After all, there are numerous educational institutions that provide training to people so they can become credentialed to address mental health concerns. Numerous people actually voluntarily go to these educational institutions, devoting considerable time and expense. Once completing the credentialing requirements, they apply to their state credentialing board, pay a fee, and then after the board checks to see if all of its requirements have been fulfilled, it grants a license permitting the person to legally provide mental health services. That person then sets up a practice that offers mental health services. People wishing to access these services first devote some time to decide where to go. They then make an appointment, show up for the appointment, and then express their mental health concern to the mental health service provider. Aspects of all of this occur each and everyday and involves tens of thousands of people working in a coordinated fashion to have mental health concerns addressed in a professional manner.
Now, as someone interested in this mental health concern phenomenon, I have spent some time observing the phenomenon by matriculating into undergraduate and graduate programs, and then meeting all of the requirements to provide some mental health services in my state. I’m not permitted to prescribe psychiatric drugs, and if you think electroconvulsive shock treatment is a mental health service, I can’t provide that service either.
But other then those two services, people have made appointments with me for over thirty years and expressed various mental health concerns, and I did my best to work with them to address these concerns.
So, now that I carefully observed this something that I am keenly interested in, I’m ready to put together a classification system with others interested in scientifically studying the same something. To begin the process, I first proposed in a peer-reviewed format a tentative proposal which was accepted for publication (see HERE). It defines my something of interest as follows:
A mental health concern occurs when a person seeking mental health services expresses to a mental health service provider a concern that he or she wants to have addressed.
This definition of a mental health concern requires all of the following items for a mental health concern to exist:
- A person seeking mental health services
- A mental health service provider offering his or her services
- The mental health service provider had to fulfill undergraduate and graduate training that meets the standard of his or her state licensing department.
- The person seeking services expresses a concern to a mental health service provider with the desire that he or she will work to address the expressed concern
Notice that the phenomenon that I am talking about requires that all of the various items listed exist in order for a mental health concern to be present. It is therefore far more explicit about what constitutes a mental health concern than the DSM‘s set of criteria for a mental disorder which uses language indicating that a disorder can’t really be defined clearly, but sometimes this is present, or maybe this, or maybe this, unless it is this other thing….
Also notice that no one doubts that each of the 4 listed items that, taken together, make up the mental health concern concept exists. Everyone agrees that there are people who seek mental health services in our society. Everyone agrees there are people licensed to provide mental health services. If you go further down the list, there is no question whatsoever, that these other conditions also exist. So the definition, I contend, meets the scientific standard that it describes the something of interest (mental health concern) in a clear and detailed manner, leaving no room for confusion or doubt. Once the CSM classification system comes to be fully developed, people would be able to use the term “mental health concern” as a short way to indicate a phenomenon that contains all four of its defining characteristics.
With regards to the various types of concerns that mental health service providers are asked to address by those seeking their services, two major types would be, 1. concerns expressed about oneself, and 2. concerns expressed about someone else. Under the headings of each of these two major types would be concerns regarding behavior, emotion, mood, meaning of life, death, dying, managing chronic pain, addiction, work, relationships, education, eating, cognition, sleep, hearing voices others don’t hear, and challenging life situations. This, of course, is just a preliminary list of types, and through survey data that ask psychologists and mental health advocacy groups about the various mental health concerns that they are asked to address, the list would become more fully developed.
Conclusion
The above explanation was designed to clarify just one of the reasons why the proposed CSM’s mental health concern concept provides a far more solid scientific foundation on which to build a classification system than the DSM‘s mental disorder concept. Despite the fact that many people have become convinced that the DSM‘s classification system is a sound scientific instrument, its definition is far more vague than how I propose defining a mental health concern.
Many people, including professionally trained psychiatrists and psychologists, have long argued that the mental disorder concept fails to meet the very basic principles of a valid scientific concept. We can do better by using the basic scientific standard of explicitly defining core concepts in our mental health classification system, and giving people seeking mental health services a choice about whether or not their expressed mental health concerns are to be converted into pathologizing language.
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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional and social intelligence. To begin at the very first post you can click HERE.
Recently, I wrote a post titled “
“Oh, yes!” he cries enthusiastically. “He’s great!”
With little more than a public high school education, you managed to save a little money to open your own small convenience store. From your background, isn’t there anything indicating to you that Trump is not out to help people like you and those in your family and community?”
“Donald Trump, who was born rich, went to the finest private schools, was set up in the real estate business by his wealthy father, has always associated with rich people. He was over 70-years old when he began to run for president, and prior to that never showed any passion to help people like you and me. In fact, he has a long history of screwing people like us. You really think Trump cares one bit about people like you? Sure, he’ll say anything to get your vote, but we’ve seen him lie over and over again.”
His Trump University project ended up costing 30 million dollars to settle charges of fraud. You say he’s not beholden to anyone, but he and his associates are beholden to their own enormous financial interests. That’s why he has put the richest people he could find in top political positions.”
Under Obama, unemployment went from 10 percent to 5 percent, and the economy was improving steadily while he was in office. The fact that it has slightly further improved the first few months under Trump was during a time when there was not a single congressional bill passed designed to aid the economy. Despite this, you are completely convinced that the improvement, slight as it is, has to do with Trump?”
“OK, if that’s what you believe. Let’s move on to health care. Trump vaguely said when he was running for president that he had a great health plan he would enact as soon as he is elected. He said he will repeal and replace the Affordable Health Care Plan, and his own plan would be great and cover everyone. It turned out that he had no plan of his own. The plan he first supported came out of the House of Representatives, a bill that cut coverage for millions according to the Congressional Budget Office, so he plainly lied. Then, when the bill went to the Senate, they didn’t like it and so Trump ended up saying that the House bill was really mean. Then he supported the Senate bill that also cut services for millions of Americans. Nothing got passed, and he antagonized in the process the very people he has to work with if he is to get anything of his agenda through the congressional process. Why do you remain so gullible that he knows what he is doing and trust what he says?”
And people can climb over walls using rope ladders or cherry pickers. Drilling a little hole in the wall and sticking a stick of dynamite in it will blast a hole in the wall that will allow people to walk right through it. In a matter of a few years the wall will look like Swiss cheese. Maintaining the wall will cost tax payers like you and me billions and billions of dollars. His arguments for the need for the wall makes absolutely no sense.”
Now that we looked over today’s parable, let’s see if we can determine how well our Trump supporter utilized the three sets of skills that help to keep us from being gullible–Plausibility Checking, Trust Calibration, and Assessing Argumentation.
In the parable, the only evidence I can see that Bob used any plausibility checking occurs when he says Trump is a business man. Apparently that is enough for him despite the fact that the practice of business pits some business interests with other interests. When Ann points out that Trump’s business interests lie in big business and Bob’s business is a small business, this has no apparent effect on him.
The final skill set that helps to prevent people from being strongly gullible is “Assessing Argumentation.” In the parable, Bob does mention that Trump’s rhetoric appears to have led to the economy improving. But he does not explain why he is convinced that Trump’s rhetoric is the reason for the improved economy. Moreover, Bob’s support that somehow building a wall on the Mexico border makes sense is backed up with nothing more then declaring that we have to stop illegal immigration. There is not a single argument that he provides to defend that the wall would be a reasonable way to accomplish what he desires.
The scene, the offices of a large import, export business. Alice and Jill have just left their desks to go to lunch.
As examples of these skills, Mr. Mercier points out that studies demonstrate that participants find less compelling an argument from authority when the authority is not an authority in the relevant area, or if he or she has a vested interest. In an earlier post titled, “
Well, in thinking about this, I hasten to mention that Thomas Kuhn’s (1972) classic book, The Structure of Scientific Revolutions, rightly points out, for real change to occur in a branch of science, it is not enough to point out the weaknesses of a paradigm. There needs, as well, a new approach that is a distinct improvement over the old paradigm.
Regular readers know that I have, from time to time, been dealing with a conflict regarding psychiatric diagnosis. Said briefly, there are many people who immediately lose respect for anyone who questions the validity of the mental illness/mental disorder theoretical construct. On the other hand, many people have lost respect for the psychiatric profession because of its pathologizing approach of addressing concerns related to thinking, mood, behavior, or challenging life situations. Amidst this conflict, I have been trying to put forth on this blog, and in a number of other publishing outlets, an alternative approach with which the disputing parties can live in relative peace. 
Last year, I presented a paper on this topic at the American Psychological Association convention in Denver (see 
Albert Einstein created a revolution in the branch of science known as physics. Prior to the 20thcentury, physicists explained the propagation of light with the use of a theoretical construct known as the ether. There were experts in the ether who described ways to define it, along with its various characteristics. It was thought, for example, that the ether didn’t move in any direction, but it could vibrate. There was much discussion about an ether wind. And then Einstein came along and described the nature of light without resorting at all to the ether.
Criticism of the mental disorder construct began at the very beginning of American psychology when William James declared that it was nothing more than superficial medical talk. Criticism continued throughout the 20th century, and when the latest version of the DSM came out, there was a ton of media and professional articles that once again pointed out its numerous scientific shortcomings. Many throughout general psychology expressed deep concerns that psychologists utilizing the DSM approach had sold out to psychiatry and the pharmaceutical industry. Moreover, they bitterly complained that a paradigm that utilizes the mental disorder construct brings down respect for psychology as a legitimate branch of science. What can be done about this?
Well, in thinking about this I hasten to mention that Thomas Kuhn’s (1972) classic book, The Structure of Scientific Revolutions, rightly points out, for real change to occur in a branch of science, it is not enough to point out the weaknesses of a paradigm, there needs, as well, a new approach that is a distinct improvement over the old paradigm. So, is it possible to really come up with a distinct improvement over the current DSMapproach? I think our APA can do this easily if it set its mind to it, and it can do so within a year.
Let’s say Mary Doe comes to a licensed practicing psychologist and says she has been feeling a great deal of sadness much of her days. The psychologist, for verification purposes can say, “I hear you saying that you are concerned about how sad you have been feeling much of your days, and you would like us to work together to address this concern, is that correct?” If the service seeker says yes, this would verify that a mental health concern has been expressed, and what the concern is.
Well, there you have it. I only have seven minutes to present the paper, so many of the essential points that I would love to make have to be left out. There will be some time for questions and discussion, so some additional information could be shared then. And, for those who are interested, as I point out in my paper, they can now readily retrieve a far more complete presentation of my proposal by assessing the journal article I wrote that was just published last month.
Regular readers know that I have, from time to time, been dealing with a conflict regarding psychiatric diagnosis. Said briefly, there are many people who immediately lose respect for anyone who questions the validity of the mental illness/mental disorder theoretical construct. On the other hand, many people have lost respect for the psychiatric profession because of its pathologizing approach of addressing concerns related to thinking, mood, behavior, or challenging life situations. Amidst this conflict, I have been trying to put forth on this blog, and in a number of other publishing outlets, an alternative approach with which the disputing parties can live in relative peace. 
Last year, I presented a paper on this topic at the American Psychological Association convention in Denver (see 
Albert Einstein created a revolution in the branch of science known as physics. Prior to the 20th century, physicists explained the propagation of light with the use of a theoretical construct known as the ether. There were experts in the ether who described ways to define it, along with its various characteristics. It was thought, for example, that the ether didn’t move in any direction, but it could vibrate. There was much discussion about an ether wind. And then Einstein came along and described the nature of light without resorting at all to the ether.
Criticism of the mental disorder construct began at the very beginning of American psychology when William James declared that it was nothing more than superficial medical talk. Criticism continued throughout the 20th century, and when the latest version of the DSM came out, there was a ton of media and professional articles that once again pointed out its numerous scientific shortcomings. Many throughout general psychology expressed deep concerns that psychologists utilizing the DSM approach had sold out to psychiatry and the pharmaceutical industry. Moreover, they bitterly complained that a paradigm that utilizes the mental disorder construct brings down respect for psychology as a legitimate branch of science. What can be done about this?
Well, in thinking about this I hasten to mention that Thomas Kuhn’s (1972) classic book, The Structure of Scientific Revolutions, rightly points out, for real change to occur in a branch of science, it is not enough to point out the weaknesses of a paradigm, there needs, as well, a new approach that is a distinct improvement over the old paradigm. So, is it possible to really come up with a distinct improvement over the current DSM approach? I think our APA can do this easily if it set its mind to it, and it can do so within a year.
Welcome to From Insults to Respect. Today’s topic, friends.
Next, Bob tells us a little about Sister Rosetta Tharpe, the lead singer of the song he is about to play, “Don’t Take Everybody to Be Your Friend.”
Moving right along, Bob tells us about Moon Mullican, a Texan. Bob surmises the guy must be a friendly fellow from the song he sings, “Make Friends.”
Next, Bob tells us about one of the wisest guys he ever got to know, Muhammad Ali, who once said, “Friendship is the hardest thing in the world to explain. It’s not something you learn in school. But if you haven’t learned the meaning of friendship, you really haven’t learned anything at all.”
If you need a friend, here’s some things that makes a good friend: Good friends listen to each other. Good friends help each others solve problems. Friends are dependable. This one is very important, good friends never borrow money. 
Good friends never change the channel on your radio. Good friends will always tell you when you have food in your teeth. Good friends sometimes pay for dinner. And good friends sometimes let you have the last beer. And if you are doing all of those things, maybe you’ll have a friend, like Carol King sings about. Here’s Carol King. She’s going to brighten up even your darkest night. 
When you’re down and troubled,
You just call out my name
If the sky above you grows dark and full of clouds
Now, ain’t it good to know that you’ve got a friend
Tapestry, the Carol King album this song appears on, was the most popular of the early 1970s era, remaining on the charts for over 6 years. So, on that series of notes, I think we’ll begin to fade out for this week. I hope you enjoyed our little meditation on friends, and I hope you’ll join us again right here at From Insults to Respect.
According to the FDA, there has been a long-standing concern that antidepressants may have a role in inducing worsening of depression and the emergence of suicidality in certain patients during the early phases of treatment. Pooled analyses of short-term placebo-controlled trials of antidepressant drugs showed that these drugs increase the risk of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults (ages 18-24) classified as having major depressive disorder and other psychiatric disorders. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24; there was a very slight reduction with antidepressants compared to placebo in adults aged 65 and older.
This may sound somewhat encouraging for those who are thinking of taking antidepressants and are over 24-years old if they are willing to put aside concerns about the many other negative side effects associated with taking this class of drugs. However, interpreting these findings is highly problematic for a number of reasons. For example, these results were based on short-term studies, typically lasting just a few weeks, while many people used the drugs for years. Many drugs that were viewed as relatively safe when the short-term evidence became available later turned out to have serious negative effects when the long-term effects started to come in.
Other concerns have to do with the fact that the current available studies are almost always carried out by the drug companies that have a massive interest in proving that the drugs are safe. With the largest lobbyist group in Washington, DC (see 
“In a meta-analysis of the placebo-controlled trials from 2006, the FDA reported only five suicides in 52,960 patients on SSRIs (one per 10,000 patients)(3), but there were many more suicides in these trials(2). Five years earlier, in 2001, Thomas Laughren, who was responsible for the FDA’s meta-analysis, published a paper using FDA data where he reported 22 suicides in 22,062 patients randomised to antidepressants(4), which is 10 per 10,000, or 10 times as many as he reported in 2006. In Laughren’s 2001 paper, there were four times as many suicides on antidepressants as on placebo, which was statistically significant (P = 0.03, my calculation). However, Laughren did not tell his readers about this but wrote: “There is obviously no suggestion of an excess suicide risk in placebo-treated patients.” No, but there surely was in the drug-treated patients!”
In interpreting the safety of these types of drugs, there are many other types of concerns hidden in the data. For example, there is strong reason to think that the subjects in these published studies are not at all the typical people who take antidepressants. Usually when someone is depressed and is open to taking antidepressants to feel better, they go to a nearby physician and get a prescription for the actual drug. That’s not at all how the subjects in these studies go about it. They have to fill out more forms than usual, and they have to agree to be part of an experiment that has them being randomly assigned to taking either the real drug or a placebo.
Now think about that. If you are depressed and open to taking these types of drugs, why would you agree to not knowing if you are taking the real pill or the fake one? Here’s a possible clue. As it turns out, many, if not all, of the subjects who agree to this are already taking one or more psychiatric drugs, including antidepressants. They have to agree to stop taking the antidepressants that they were taking, which typically leads to very uncomfortable withdrawal reactions.
So, again, why would people who are already depressed agree to undergo such an ordeal. It seems to me that it is very possible that many of these subjects had come to feel that the drugs that they had been taking had not been helping them. Thus, they became willing to try being part of the experiment in the hope that they will be put on another experimental drug they have not tried yet and it might end up providing the relief they were seeking.
Now, add this to the picture. Those who agreed to being subjects were excluded if they had had any suicidal thoughts or attempts. So, keeping this in mind, it turns out that many in this group of subjects are those who were placed in the past on antidepressants and did not have suicidal issues when taking them. This leads one to conjecture that this is a group of people who are particularly less likely to have suicidal issues than most people when they use antidepressants. After all, many people who choose to go on antidepressants in the usual manner (going to a local doctor) do so because they have begun to have suicidal thoughts and feelings, and some may have made an attempt to end their life. These folks would be excluded from participating in the study. Thus, those who participate in these studies are a special group who tend to not have suicidal reactions before taking antidepressants and when taking antidepressants.
Given all of these problems, how can we get some additional relevant information about whether these drugs increase suicidal issues for adults? Well, here’s a recent published study that I think is worthwhile to consider.
We found that antidepressants double the risk of suicidality and violence, and it is particularly interesting that the volunteers in the studies we reviewed were healthy adults with no signs of a mental disorder….
In one of the two crossover trials we excluded because we did not have data on the first period separately, a healthy volunteer committed suicide, which was mentioned in both published articles.A14,A15 She had received duloxetine in increasing doses for 16 days, tapered off the maximum dose of 400 mg daily very quickly (in just four days according to the design of the study) and killed herself four days later while on placebo. 
The authors, several of whom were employees of Eli Lilly or owned stock in the company, judged her suicide ‘to be unrelated to study drug treatment’,A15 although it is well known that the suicide risk is high when an antidepressant is stopped abruptly.
Although only two of the 29 clinical study reports were eligible for our meta-analysis, e.g. as the studies needed to be double-blind, two researchers (AØB and PBD) read them all (2224 pages) and extracted data independently, as we wanted to explore possible selective reporting of harms in the published articles. Nineteen clinical study reports reported on the harms we investigated and nine of these were published, but less than half of the harms were reported in the articles (21 of 50 events on antidepressants and two of four events on placebo)….
There can be little doubt that we underestimated the harms of antidepressants. For 11 of our 13 trials, we only had access to the published article, and it well documented that the drug companies underreport seriously the harms of antidepressants related to suicide and violence, either by simply omitting them from the reports, by calling them something else or by committing scientific misconduct.
Psychiatrists believe that the suicide risk with antidepressants is only increased till age 24, but this misconception builds on seriously flawed trial data that the FDA has published.
They also found out that many suicide attempts must have been missing; some of the investigators responded that there were suicide attempts they had not reported in their trials, while others replied that they did not even look for them. Further, events occurring shortly after active treatment was stopped were not counted. Another 2005 meta-analysis conducted by independent researchers used UK drug regulator data and included 40,826 patients; they found a non-significant doubling in suicides or self-harm events when events occurring later than 24 hours after the randomised phase was over were included (relative risk 2.14, 95% confidence interval 0.96 to 4.75, our calculation).
Even the FDA’s 2006 meta-analysis of 100,000 patients in 372 placebo-controlled trials
Well, this is just one study that discusses the issue of suicide risks for adults choosing to take antidepressants. I chose to present it because it is the most recent study on this topic, and it seemed to me to present some additional information not usually available in the US literature.
There is something similar to this when it comes to how Americans feel about psychiatrists. There are many people who hold the belief that psychiatrists are enormously helpful to our society by relieving suffering while others believe that psychiatrists have sold out to the pharmaceutical industry, consequently leading to enormous harm.
We get to see and hear favorable positions for the psychiatric point of view from the numerous ads on TV, radio, and print media sponsored by the fabulously wealthy pharmaceutical industry, which has the biggest lobbyist group in Washington, DC (see 
Psychiatrists have become addicted to the enormous financial benefits of transforming human suffering into a language of mental illness and then convincing people that they need to spend the rest of their life on psychiatric drugs. The consequences to society of this mental illness/drug approach is an enormous increase in people becoming disabled due to the negative drug effects. There is also some recent research suggesting that when women on these drugs become pregnant, there is an increased risk of miscarriages, and if the infant is brought into this world alive, she or he is at an increased risk of serious health consequences.
In my opinion, one of the best places to obtain the arguments about the harmful approach of psychiatric drugs is at the “Mad In America” site that readers can access 
The latest version of what is viewed by psychiatrists as the most authoritative American text on mental illness is the DSM-5. It tells us that mental disorders “are usually associated with significant distress in social, occupational, or other important activities (APA, 2013, p. 20).” There is some additional vague wording here about also having a “dysfunction.” Although my focus here is on the suffering component of the definition, I will say a few words about the functioning part of the definition shortly.
n case this vague definition does not provide enough wiggle room for clinicians to label all people seeking their services as having a mental disorder and to prescribe a drug for it, the ICD tells the clinician, “When the requirements are only partially fulfilled, it is nevertheless useful to record a diagnosis for most purposes” (p. 8). This type of double talk is one of the reasons why many people view the mental illness construct as too vague for scientific purposes.
Now, lets get back to the “suffering” component of the mental disorder definition. According to Buddhist philosophy, the first Noble Truth is that to live is to suffer. According to Christian philosophers that I have read, suffering is something to make us think. It is a tool to get our attention and to accomplish the Lord’s purposes in our lives in a way that would never occur without the trial or irritation. In Judaism, the Talmud teaches us that the righteous suffer in this world in order to increase their reward in the Eternal World. Rabbi Eliezer, in the Talmud, welcomed his suffering, calling his pains ”my friends.”
If we look outside the religious teachings, we find that giving birth is accompanied by suffering, and yet it makes more sense to classify this experience as a natural part of creating new life rather than a pathological condition. When writers receive rejections from publishers, or a loved one dies, suffering often accompanies these experiences.
Add to all of this the problems one encounters when one tries to decide objectively how much suffering, beyond the “normal” amount that one experiences during life’s parade of disappointments, is required to ascribe a diagnosis. In the end, can we really determine if one’s “suffering” is really a symptom of a disorder, or just life being life.
In saying this, I am not seeking to encourage people to be disrespectful to people who choose to take psychiatric drugs. It is their life, and it is their right to make the best decision they know how to make, and I wish them well. At the same time, I believe suffering may best be served by exploring what it could potentially provide. In my own life, I have seen numerous examples of people growing from their suffering. And one of the hardest lessons I had to learn, when seeking to be of help, is that there are times when it is best to address another’s suffering not by trying to fix it, but to stand respectfully beside the person’s misery and sharing what they are going through.
It begins with Sanders turning to Kasich and asking him, “Is Trump a liar?”
Kasich, 
Then, Kasich says, “But I’m not going to go so far as to call someone a liar! That when you get, when you start using terms like that, Bernie, we saw it in Congress. You know, back in the days when we were in the majority and they were after Jim Wright and all those things and there was a lot of calling people dogs and liars. Just let the facts speak for themselves, and then we can draw a conclusion. And I’m only saying this, not because I’m trying to defend anybody. I’m worried about my country. I’m worried about getting through this.”
At this point, Sanders replies, “But when we talk about the facts, I mean Jake asked a pretty simple question. All that I’m saying is, it’s not a question of, you’re a Conservative and I don’t think you’re a liar. We disagree on everything, but that doesn’t make you a liar, and I don’t think that makes me a liar. But if you were to tell me that three to five million people voted illegally in this election, of which no Republican or Democratic official believes, what can I say? I think that it’s a lie.”
Here Kasich looks troubled, and replies, “I, I, look, I guess I’m gonna do it, I didn’t think I would, does that mean that someone who writes a campaign ad that distorts somebody’s record is a liar? I mean, we have to be careful about our terms. That’s all I’m saying, okay?” 
Regular readers of this blog well know that name calling leads to me and others to lose some respect for the name caller. Calling someone a “liar” is name calling, and we can see the loss of respect that Governor Kasich feels for those who use that term when we watch the video clip.
As Bob Dylan once said on his radio show, “According to a survey, 4 out of 5 people admit to telling white lies at least once a day, and I’m telling you that that other guy, he’s lying.”
And they love pictures of him illustrating his lying ways. This might have been the reason for the chuckling of Senator Sanders and those in the audience when Governor Kasich began to reply to the question, “Is Trump a liar?” But consider how you would feel if someone called the candidate you support a liar. 
Recall that there were people calling President Obama a liar during his administration and illustrations of what some believed were his lying tendencies. 
I think the Golden Rule applies here. Moreover, calling the president a liar stirs up his supporters to be angry, and this can produce less than ideal conditions for people to come together in mutually beneficial ways.
Now, Senator Sanders has been trying to make the case that there is something different in the type of lying that President Trump engages in compared to what most people engage in. He is seeking to see how he can best make that distinction by bringing up the liar issue. In the clip, he brings up the example of the president declaring repeatedly that between three million and five million people voted illegally, and that if just the legal votes were counted, he not only won the electoral votes, he also won the popular vote. At other times, Sanders noted that the president has repeatedly claimed that his electoral vote victory was by the largest amount in history. When the president is confronted with the facts that the previous president, Mr. Obama, had won more electoral votes then he did, that many other presidents also won by more electoral votes then he did, and that this can easily be verified by anyone really interested in the truth of the matter, he just continued to claim he won the election by the greatest margin in history. At another time, the president claimed he was against the Iraq War despite a videotape clearly showing his support of that war, and no evidence that he spoke out against the war when it was getting under way.
These, along with others that he has made, are indeed whopper-sized lies. By providing the type of specifics that I provided in the previous paragraph it makes the point clearer than calling him a liar.