Category: DSM

Psychiatric Name Calling: What Do People Say About It?

Post author By Dr. Jeffrey Rubin
Post date May 10, 2015
13 Comments on Psychiatric Name Calling: What Do People Say About It?

In recent weeks, I have been providing a series of blog posts on psychiatric name calling (see here, here, here, and here). In these posts, I have expressed some negative opinions about the Diagnostic and Statistical Manual of Mental Disorders (DSM).

The DSM provides the names for the various mental health concerns that mental health service providers are often required to use if they want to be paid for their services or if they want to have their research published in professional journals.The language of the DSM places its terminology under the umbrella concepts of “mental illness,” “mental disorder,” and “psychopathology.” In my blog series, I have argued that the pathologizing of human experiences in this way does far more harm than good.

As part of my discussions on this topic, I quoted the opinions of some who agreed, and some who disagreed, with my opinions. The quotes that I used were selected from my own personal readings. Therefore, they may not have been characteristic of how a wider range of different people may think and feel about the DSM approach to labeling the various mental health concerns.

A few years ago, two teams of researchers have sought to obtain a broader range of views on this topic by carrying out surveys. Jonathan D. Raskin and Michael C. Gayle surveyed psychologists who regularly use the DSM, and published their findings in the Journal of Humanistic Psychology (DSM-5: Do Psychologists Really Want an Alternative? 2015, pages 1-18). Lois Holzman and her team surveyed people in some New York City communities, and published her findings on the DxSummit.org website (A Report on Community Outreach: Lay Opinions on Emotional Distress and Diagnosis, http://dxsummit.org/archives/2249). Let’s take a look at their findings.

What the Psychologists Had to Say

Here’s a summary of the survey data by Jonathan D. Raskin and Michael C. Gayle:

Only two published studies, both from the early 1980s, have specifically examined psychologist attitudes toward the Diagnostic and Statistical Manual of Mental Disorders (DSM). The current article rectifies this by presenting the results of a recent survey of attitudes toward the DSM-IV-TR and DSM-5. Though the DSM has changed over the years, psychologist attitudes toward it have remained remarkably consistent. 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 the above summary, the number 5 after the letters DSM, refers to the fact that the DSM has undergone five major revisions. Since the 1980s, there have been three such revisions. Ideally, users of the DSM would see clear improvement for each revision.

When a survey was done in the early 1980s, psychologists were clearly skeptical of the DSM-2. As described by Raskin and Gayle,

More than 40% felt it (a) distorted clinician perceptions of clients, (b) applied medical labels to psychosocial problems, (c) was not reliable and valid, (d) emphasized diagnosis over treatment, (e) obscured individual differences, and (f) overemphasized pathology. Almost 60% were dissatisfied or somewhat dissatisfied with the DSM-2 with only 17% satisfied or somewhat satisfied.

When the DSM-3 came out in 1983, Smith and Kraft carried out an updated survey on this revision of the DSM-2. The findings indicated that psychologists at that time (a) preferred social–interpersonal diagnosis, nondiagnosis, and behavioral analysis over DSM-3—in that order; (b) felt that most conditions in DSM-3 were best seen as nonmedical problems in living; (c) believed too little had been done to develop scientific alternatives to the DSM; and (d) thought that client welfare and integrity would be better served by abandoning the medical model. Eighty-five percent disagreed that mental disorders are a subset of medical disorders.

In the latest survey that was carried out by Raskin and Gayle, 128 anonymous psychologists participated. Among the questions that were asked was, “How satisfied are you with the changes being proposed for DSM-5?” Their answers indicated that they were significantly more negative about it than neutral. The general attitude about the latest version of the DSM were very similar to what was found three decades ago, namely, that a significant number of psychologists are unhappy with the DSM.

What Community Folks Had to Say

In the community outreach survey of lay opinions on emotional distress and diagnosis carried out by Lois Holzman and her colleagues, people were asked questions at two annual NYC street fairs attended by millions of people. Conversations lasted from five to over ten minutes each. In all, 143 people participated in the survey in the first of these two surveys, which occurred in 2013. The second one had 149 people who participated, which occurred in 2014.

In the 2013 survey, the focus was on how psychiatric diagnosis affected kids. Forty percent felt that psychiatric diagnosis was not valuable. For the 60% that felt that psychiatric diagnoses can be valuable, 90% of them had reservations. That is, they said that it was only sometimes helpful, there was a danger of misdiagnosis, there was racism involved in diagnosis, and it leads to stigma and over-medication.

Ten percent were completely against diagnosis under any circumstance, some sharing their experiences pertaining to children. Examples of comments from this group follow:

“Medication makes you act out. My grandson was hyperactive, not ADHD and they wanted to put him on Ritalin – I told them no. Drugs at an early age can lead to hard core drugs later in life.”

“I worked with kids who had wrong diagnosis, and this is prevalent.”

“Kids get told in 1^st grade they’re crazy—then it becomes a self-fulfilling prophecy.”

In the 2014 survey, the researchers:

“tried to go a little deeper and see if we could help people explore the apparent conflict around diagnosis, i.e., its value and its dangers. We also wanted to learn what they thought about the necessity and mandate of diagnosis.

We all know people who have gotten very depressed when they’ve lost a loved one, or children who cannot sit still in school, lots of folks who are angry and demoralized about not finding a job. Do you think any of these people need to get a diagnosis in order to get help with their emotional pain?

(IF THEY SAY YES, ASK THE NEXT 2 QUESTIONS):

Do we need to relate to them as having brain disorders? Or chemical imbalances?

Right now, in most settings, if you want to get help with ANY kind of emotional pain from a mental health professional, they are required to give you a diagnosis. Do you agree with that?

Are there other ways to support people emotionally? What do you think could help them?

Like me, you probably know people in your family, church, or at work who have serious emotional problems, who may have been diagnosed with major depression, bipolar or schizophrenia. Obviously people deserve and need top quality mental health care including access to medication. Do you think that even in these situations a diagnosis can limit the person, label them, and stigmatize them? If so, how?

From our past surveys we have found that people are conflicted about diagnosis and labels. They find it relieving to get a diagnosis and at the same time feel like the diagnosis can stigmatize or label them. Why do you think that so many of us are conflicted about this, feel it can be both helpful and harmful?

Here’s a brief summary of the finding, as described by Dr. Holzman:

Diagnosis Needed: 60% of respondents said no, people did not need a diagnosis to get help with their emotional pain. The majority of the 40% who said diagnosis was needed told us that that was the only way to get to talk to someone.

Only those who said yes, diagnosis was needed (40%), were asked the next two questions.

1a. Biological Basis: 89% of those who said diagnosis was needed said we shouldn’t consider such people as having a brain disorder or chemical imbalance.

1b. Diagnosis Required: 75% of those who said diagnosis was needed did not agree that it should be required.

Other Ways to Support (alternative types of treatment):

Everyone offered an alternative, with most people suggesting more than one. The most frequent responses involved talking to people—therapy, counseling, group therapy being the most common (including, “A center they can go to without getting diagnosed”), followed by family, friends, self-help and support groups.

A wide variety of social activities and life style changes were recommended—volunteering, hobbies, music, dance, writing, meditation, exercise, yoga, diet, prayer and creating community (“Have events that bring people out, like this fair”).

& 4. Concerns about Diagnosis: 90% (including those who thought it was needed) expressed concerns about the stigma of diagnosis, the dangers of misdiagnosis, and/or the over-medication that too often accompanies a diagnosis.

Once you have that label it doesn’t stay at the clinic. You carry it with you for a long time.

People start calling you crazy. It can be a shame for the family.

I had to fight to get counseling for my kid. They just wanted to give him drugs.

Getting a diagnosis limits life experience, you’re treated differently, you feel like an outcast.

It’s helpful to the clinic but not in everyday life.

It’s good to know what’s wrong, but it might make them feel worse about themselves and put them in a box.

It pigeon-holes people and the diagnosis becomes all that I am.

It stagnates them. It keeps them on one path with only one destination.

They think something’s wrong with them.

There is too much use of medication. It is a quick fix to avoid a real understanding.

Against it – children are still growing. Against medication.

So there you have it, some views other than mine about psychiatric name calling. In interpreting these findings, I think it’s important to bear in mind that the views of the people surveyed developed in the context of a multibillion dollar advertisement campaign by the pharmaceutical companies over many years that is designed to convince them that emotional concerns are diagnosable illnesses requiring medication treatment. How might the views of those surveyed been different without this high finance selling of the illness model?

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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 intelligence. To begin at the very first post you can click HERE.

Tags DSM, mental disorders, mental illness, psychology

Bob Dylan conflict resolution crazy criticism DSM insults madness meditation mental disorders Mental Illness Name calling negative criticism psychiatry psychopathology The Diagnostic and Statistical Manual of Mental Disorders

Bob Dylan on Madness

As some of you may know, Bob Dylan has a show called “Theme Time Radio Hour.” As the title suggests, each episode is centered on a theme. He begins his episode on madness as follows:

“Let me ask you a few questions, friends. Are you disinterested in work or family life? Do you suffer from sleep disruption? Have you had significant changes in appetite? Have you had paranoid thoughts? Thoughts of grandeur or invincibility? Any feelings of persistent anxiety or perhaps panic attacks? Are you hearing voices or seeing people who are not there? Do you have thoughts of dying? Do you exhibit strong or violent anger? Do you have the inability to pursue a normal life, normal activities or normal relationships? Well, I’m no doctor, but perhaps you’re mad as a hatter; crazy as a loon. Have you lost your morals? Are your bats in the belfry? Maybe you’re nutty as a fruitcake? Crazy as a coot? Taxed in the head? Bunkers? Bananas? Deranged? Are you crackers or daffy? Unhinged or loco? Not all there or all around the bend? Maybe you’re cuckoo or buggy or simply non compos mentis? Do you talk to yourself? Do you ever binge out on food? Do you swing suddenly from one mood to another? Do vague acquaintances treat you as though they know you far better than you would expect?

Allan Ginsberg

“Allan Ginsberg once said that he had seen the best minds of his generation destroyed by madness. Now for the next hour we’ll be providing the sound track. We’re going to look at madness, insanity, and craziness.”

Introducing his theme in this way may seem like quite a mouthful for Bob, but he manages to carry it off rather well. There is deep, dungeon-like music in the background, and he varies his voice in a manner that is full of concern and dramatic interest. Besides, if you think Bob’s description of his theme is lengthy, take a gander at the latest American Psychiatric Association’s description of a related topic. In its book titled Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, over 900 pages are consumed describing various “mental disorders.”

The theme of “madness” is relevant to this blog’s theme because when people seek to insult others, we commonly hear words like, “You’re mad,” “You’re crazy,” “You have a mental disorder,” and “You’re mentally ill.” Negative consequences often flow from such name calling. Individuals flinging these efforts to insult often become less respected by those who are their targets. Those who are their targets sometimes end up having less respect for themselves. From here, conflicts can escalate, leading to losing friends, problems at work, and even violence.

Dylan’s First Madness Song

Bob introduces the first song for his show on madness as follows:

“If craziness was a country, this would be the national anthem. Here’s Patsy Cline in a little number written by Willie Nelson–“Crazy.”

Patsy’s beautiful voice, accompanied by gentle piano riffs, drifts into its melancholy words–“I’m crazy, I’m crazy, for being so lonely. I’m crazy, I’m crazy for being so blue.”

The song goes on from here to weave the sad story of a woman calling herself crazy for loving a man whom she knows will soon be leaving her. She feels she’s crazy for worrying when he’ll leave, and crazy for trying, and crazy for crying, and crazy for loving this man.

Here we learn of just one type of experience that falls under the enormous umbrella of madness.

Connecting Madness With Genius

As the song phases out, Bob begins to tell us that according to Aristotle, “No excellent mind is without a tincture of madness,” a position with which Bob heartily agrees. He declares that “There is a thin line between genius and madness.” Defending this, he introduces us to several individuals who had been declared mad by some, and yet achieved at impressive levels in many valued fields. Thus, he tells us about the brilliant writer, Ernest Hemingway:

Earnest Hemingway

“Ernest Hemingway, for example, was convinced that people were out to assassinate him. His wife, Mary, tricked him into a mental hospital by telling him it was to treat his high blood pressure. He got shock therapy and maybe a dozen other treatments. It didn’t help. It left him more paranoid, delusional and depressed. He was afraid that his wife would put him away again, which many people believe is what led him to take his own life with a shotgun in July of ’61.”

Bob then tells us about the great jazz musician, Charlie Mingus:

Charlie Mingus

“Charlie Mingus spent some time away, although he later claimed he only had gone in to get papers declaring he was incompetent to get out of a contract with the gangster, Joey Gallo. Whatever the reason, he spent some time in Bellevue and was diagnosed as a paranoid schizophrenic.”

After this, Bob tells us the story of two more jazz greats–Bud Powell and Charlie Parker. Both at times were troubled by demons.

Then there was a comic writer:

One man that was no stranger to madness was Bill Gates. He was the editor of E. C. Comics. He had a series of horror comics in the ’50s, but then he was targeted by the government who said that his comics were ruining the morals of America’s young people. He was supposed to water down all of his books. He had one humor comic he called “Mad.” He changed it to a magazine so it wouldn’t be subjected to the comics’ code of authority. It became a huge hit and generations of kids got their first lessons on comedy from the usual gang of idiots that he assembled. He never sold advertising in the magazine while he was alive and there were no sacred cows. Bill Gates, madman of free speech.”

Bob soon moves on to the story of a hell of a fine baseball player:

“One guy that was accused of cracking up was Jimmy Piersall. He became a professional baseball player at 18, signing with the Boston Red Sox in ’48. On May 24, 1952, just before the game against the New York Yankees, he got into a fist fight with Yankee infielder, Billy Martin. After that, he scuffled with his teammate, Mickey McDermott. The final straw came when Jimmy Piersall spanked the four-year old son of his teammate, Burnt Stevens during a game in the Red Sox clubhouse. The four-year old had tried to tweek his nose and poured lemonade down his shirt. You can see Jimmy’s position–Boy, you need a spanking. There were a number of incidences like this and he was sent down to the minor leagues. He got into a lot of trouble down in the minor leagues, and spent some time in the West Borough State Hospital. He was diagnosed with manic depression, but he still returned to baseball by the opening of the ’53 season. And get this, he finished ninth in the voting for the MVP award, and the next year he was the Sox’s regular center fielder.”

Feeling That We Are Crazy Is A Common Experience

In addition to describing these individuals who were thought to be mad by some and yet achieved greatness in various valued arenas, Bob provides diverse examples of regular Joes and Jills who displayed behaviors that were viewed as crazy by either themselves or others. These examples touch a chord in the listener because they illustrate experiences that are pretty close to what we have all experienced at different points in our lives.

Thus, the show’s take away lesson, as I see it, is that if you catch yourself calling yourself names such as “crazy” note that many of the most talented people have had similar experiences. Note, as well, that such criticism is too vague to be helpful. Learn to become more aware of these thoughts, to stand back and simply observe them passing through your mind–“Oh, there I go again calling myself mad.’ In time, you will come to a point at which you will formulate some more specific approach to make improvements in your life. The practice of meditation can help you to learn this skill.

If you are tempted to call someone else these types of names, remember that such names are way too vague, encompassing thousands of unusual and usual experiences. For criticism to be truly helpful, it is usually best to craft a statement that avoids name calling and statements about what someone did wrong, and instead provides specific suggestions for what the target of the criticism can do to improve. If you can not come up with such a statement right away, perhaps it would be best to delay the criticism until you have some time for your creative impulses to come up with something better than “You’re a crazy, mentally ill fool!”

Although these are my take away lessons for today’s post, let’s end with how the more poetic Bob Dylan ends his madness show:

“Time flies when you’re talking crazy, and we gotta get out of here. But before we do I want to leave you with the words of the man who is the voice of the barroom, poet of the gutter, and Shakespeare of the alleyway. Here’s a poem by Charles Bukowski called “Some People.”

some people never go crazy.
me, sometimes I’ll lie down behind the couch
for 3 or 4 days.
they’ll find me there.
it’s Cherub, they’ll say, and
they pour wine down my throat
rub my chest
sprinkle me with oils.
then, I’ll rise with a roar,
rant, rage –
curse them and the universe
as I send them scattering over the
lawn.
I’ll feel much better,
sit down to toast and eggs,
hum a little tune,
suddenly become as lovable as a
pink
overfed whale.
some people never go crazy.
what truly horrible lives
they must lead.”

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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 intelligence. To begin at the very first post you can click HERE.

Tags Bob Dylan, conflict management, conflict resolution, criticism, insults, intrapersonal conflicts, madness, mental disorders, name calling, respect

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From Psychiatric Name Calling to Plain, Humane English

Post author By Dr. Jeffrey Rubin
Post date March 14, 2015
4 Comments on From Psychiatric Name Calling to Plain, Humane English

Many mental health service providers well know that there are serious problems with the jargon that is used in their profession. In a recent post titled “Psychiatric Name Calling: Is It Time To Put A Stop To It?” I outline some of the most glaring ones. In a subsequent post titled “Psychiatric Name Calling: Is There An Alternative?” I describe a plan for professionals who have an interest in eliminating the problems inherent in the current psychiatric pathologizing approach. This plan would allow professionals to replace the old model with one that would be practical, more consistent with principles of science, and far less stigmatizing.

As I have been seeking ways to promote these ideas, it has become more and more apparent that the gears of the mental health service provider professional organizations grind slowly. Until the necessary changes occur, what can the average English speaking person do when faced with terms like mental illness, major depressive disorder, psychosis, schizophrenia, etc.?

Three Principles That Can Be Used When Psychiatric Pathology Terms Are Employed by Others So That The Negative Effects Associated With Their Usage Can Be Reduced

Even people who are not mental health service providers will regularly use psychiatric jargon. Thus, a French writer once wrote:

My sadness was without limit, and having got possession of me, it filled my life from the most indifferent external acts to the most secret thoughts, and corrupted at their source my feelings, my judgment, and my happiness. It was then that I saw that to expect to put a stop to this disorder by my reason and by my will, which were themselves diseased, would be to act like a blind man who should pretend to correct one of his eyes by the aid of the other equally blind one.

In this quote, the French writer, to describe some concerns he had about his sad mood and how it was affecting his feelings, judgments, and happiness, uses the words “disorder” and “disease.” This is the type of language most mental health service providers throw around. What is the writer attempting to convey by their use?

Sometimes when these words will be employed, their context will make it clear what meaning the author intends. In this example, the author does provide some context. He clearly indicates he was much sadder than he wished to be, and he believed he was unable to do anything about it. He also expressed a concern about his feelings, judgments, and happiness, but he was less clear about what he meant by this.

When someone begins to use pathologizing language and we simply don’t know what is intended, we might end up with misleading, simplistic associations. And so, here are three principles that can be used when psychiatric pathology terms are employed so that we can avoid unnecessary confusion.

Each Time Someone Uses A Psychopathologizing Term, Ask The User Of The Term For A More Specific Description Of What Is Meant By It

In the example that I provided above, there was some lack of clarity about what the French writer meant about his judgments. We know that he felt that it was disordered and diseased. That really tells us nothing more than he was dissatisfied with his judgments. To clarify, we could ask for some specific examples of when his judgment proved to him unsatisfactory.

As another example, suppose you hear Alice saying that John Doe is “mentally ill.” If you want to use this first principle, you would ask Alice what, specifically, does “mentally ill” mean to her and what has John done specifically that led to her calling John this name. These questions typically lead to further constructive discussions and ends up clarifying the nature of many fascinating experiences.

When Psychopathologizing Terms Are Employed, Express A Concern That This Terminology Simplistically Devalues An Experience

Terms like “mental disorders,” “mental illness” and “psychosis,” even when used by professionals, implies that there is something wrong with the person being described. However, as I described in my post “Are Mental Illnesses Really Potentially Helpful Tools?” there are numerous examples of the types of experiences that tend to be labelled mental disorders that end up being enormously helpful. Moreover, in cultures that recognize this possibility the outcomes for those people undergoing these challenging experiences are distinctly better.

And so, as you begin to use the first principle, asking for the user of pathologizing terminology for more specifics, if he or she seems to be suggesting that the experience is bad, you might wish to point out this well documented observation. At such times, I often say, “Many people with artistic temperaments have these types of experiences. Such people have given the world some of its most valued achievements.”

Instead Of Using The Concept of “Disease” And “Illness” To Encourage Humane Responding Toward Individuals Undergoing Challenging Experiences, Emphasize Rights, Kindness, And Practical Reasons

In seeking to encourage people who are using pathologizing terminology to be more specific, it is not uncommon to find that one reason they use these terms is that they hope it will encourage people to be more humane toward those who have certain challenging experiences. They usually mean well by this, but this approach has been used for centuries and history documents that despite such efforts, people who are being given these labels have often ended up in some of the most horrible, degrading treatment facilities.

Instead of using the concept of “disease” to encourage humane responding toward individuals undergoing the experiences that get labelled with pathological terms, an alternative is to emphasize human rights, kindness, and practical reasons.

Note that when people in a town are hit with a hurricane, we don’t have to resort to calling them ill to encourage some help. Instead, we have set up laws that entitle people to certain rights from the government when emergencies occur. Moreover, as word gets out about what is occurring to those who are suffering, out of kindness, people make donations or join their hands to provide direct assistance in a variety of ways. And lest we forget, there are practical reasons to lend a hand. By doing so, we model for people just what kindness is all about.

Any of us can find ourselves in an emergency situation. The more we promote acts of kindness, the more likely we may find that others will treat us with kindness if we are ever to find ourselves in a very unfortunate set of circumstances.

Using the Three Principles

William James, in his grand book, The Varieties of Religious Experience, tells us of some people who have mystical experiences that tend to be called “mental disorders.” James begins to use the three principles when he seeks out descriptions of the various mystical experiences that go well beyond the simplistic psychopathological descriptions. He then states that these mystical states have the right to be absolutely authoritative over the individuals to whom they come.

It is vain for rationalism to grumble about this. If the mystical truth that comes to a man proves to be a force that he can live by, what mandate have we of the majority to order him to live in another way? We can throw him into a prison or a madhouse, but we cannot change his mind-we commonly attach it only the more stubbornly to its beliefs.

It mocks our utmost efforts, as a matter of fact, and in point of logic it absolutely escapes our jurisdiction. Our own more “rational” beliefs are based on evidence exactly similar in nature to that which mystics quote for theirs. Our senses, namely, have assured us of certain states of fact; but mystical experiences are as direct perceptions of fact for those who have them as any sensations ever were for us…. The mystic is, in short, invulnerable, and must be left, whether we relish it or not, in undisturbed enjoyment of his creed.

In this quote, we find no plea from James that we should treat mystics humanely because they have a mental disease. Instead, James puts forth “rights” and “pragmatic” considerations. He argues that just like we in the majority would not like to be ordered to live in a particular way, these mystics have the right to live their way. And pragmatically, if we do use heavy-handed approaches to try to change them, such as throwing them in a madhouse, they will become more stubborn in their beliefs.

James proceeds from here to state that mystics have no right to claim that “we ought to accept the deliverance of their peculiar experiences, if we are ourselves outsiders, and feel no private call thereto.” His theme is tolerance for both the majority toward the minority and vice versa.

Returning to pragmatic arguments, James tells us in his chapter on mysticism that some have found that their mystical experiences have led to wonderful fruits that they highly valued. Some, for example, suffered for a great period of time and after their mystical experience felt wondrously free from their pain and found in its place increased energy and happiness.

James well realizes that the fruits from mystical experiences are not always positive, but he asks us, at the very least, to realize that they have the potential to “be indispensable stages in our approach to the final fullness of the truth.” Thus, we see that “rights” and “pragmatic arguments” can be used instead of a disease concept to promote humane, kind responses toward those who have the types of experiences that tend to be called mental disorders.

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Tags insults, mental disorders, mental health concerns, mental illness, name calling, William James

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Psychiatric Name Calling: Is There An Alternative?

Post author By Dr. Jeffrey Rubin
Post date February 24, 2015
5 Comments on Psychiatric Name Calling: Is There An Alternative?

The publishers of The Diagnostic and Statistical Manual of Mental Disorders (DSM) currently hold a monopoly for classifying the concerns that lead people to seek mental health services. Recently on this blog, in a series of articles, I have been pointing out numerous faults of the DSM. To check out some examples of these, see my posts titled Name Calling by Psychiatrists: Is it Time to Put a Stop to it? and Are “Mental Illnesses” Really Potentially Helpful Tools?

In these critical posts, I have touched upon what I believe would be a distinctly better alternative to the DSM and argued that its creation, in breaking up this monopoly, would stimulate through creative competition, improved mental health services. Today, let’s take a closer look at this.

The Classification and Statistical Manual of Mental Health Concerns (CSM)

I called this proposed alternative manual, the CSM, and you can find a much fuller description of it in a peer reviewed journal HERE. In brief, its first chapter would begin by stating that the developed 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.

The CSM begins from the perspective of the person seeking services. Because the expression of a mental health concern is a clearly observable event, by making it the event being classified in the CSM it solves the reliability problems that have been plaguing the DSM’s far more abstract concept of “mental disorders.”

After this statement, the CSM would clearly define its main construct:

A mental health concern occurs when a person seeking mental health services expresses to a mental health service provider a concern about any of these topics: behavior, emotion, mood, meaning of life, managing chronic pain, work, relationships, education, eating, cognition, sleep and challenging life situations.

Each of these topics would have separate major sections in the second chapter, and under each section would be a list of more specific concerns.

This second chapter would be devoted to listing all of the concerns that professionals tend to hear from those seeking their services. Each concern would be given a code that would be used for various administrative purposes such as insurance forms and computer filing systems. And then there would be, for each concern, a list of related search terms that can be used to assist people who want to utilize a search engine to find all the relevant literature regarding that particular concern.

The list of concerns would be identified by two types of surveys. First, a large sample of mental health service providers would be asked to list the various concerns that they are asked to address in their practice without couching them in pathological language and to stick as closely as possible to the language used by those seeking their services. So, a concern about feeling blue might simply be classified “feeling blue,” rather than the DSM’s “Major Depressive Disorder;” a concern about a child’s above average activity level might simply be classified as “above average activity level” rather than the DSM’s “Attention Deficit Hyperactivity Disorder.” The second type of survey that would be used to generate the list of concerns that would appear in the CSM, would ask the membership of mental health service user organizations to list the various concerns that led them to seek mental health services. They, too, would be asked to avoid pathological terminology. For a number of practical reasons, a maximum of four words would be used for classifying each expressed concern in this chapter.

The final chapter of the CSM would be devoted to describing good practice guidelines for the use of psychological formulation, which is an assessment approach that is consistent with the CSM’s philosophy of not pathologizing individuals. Psychological formulation provides an approach that expands on the brief expressed concerns of individuals by developing a narrative of several paragraphs. It can be defined as the process involving a mental health service user and a mental health service provider co-constructing a hypothesis or ‘best guess’ about the origins of the mental health service user’s concerns in the context of his or her relationships, social circumstances, life events, and the sense that he or she has made of them. Once it has been established what the concerns are, the immediate next question is, ‘How do we jointly understand these experiences, why they arose, and how we might be able to address them?’

Unlike diagnosis, this type of psychological formulation is not about making an expert judgement, but about working closely with the individual to develop a shared understanding which will evolve over time. And, unlike diagnosis, it draws attention to the service user’s resources and strengths in surviving what are nearly always very challenging life situations.

Defending the CSM Approach

Now, some believe that the psychological formulation is all that is needed as an alternative to the DSM and that there is no need to join it with any classification manual such as the CSM. But keep in mind that currently the DSM is used by insurance companies and other third party payers such as Medicaid, Medicare, and Social Security. Insurance companies and these other third party payers have a form that must be filled out whenever someone seeks mental health services under their plan. This form has a little box that currently says, “Diagnosis.” In that box, mental health professionals must fill in the DSM code that corresponds to their so-called diagnosis of the person seeking services.

With the CSM proposal, all that we would be asking insurance companies to do differently in order to add value for their customers, is to slightly change that little box. Instead of just saying “Diagnosis” as it currently says, that box would add two little words, so it would end up saying “Diagnosis or Concern.” Then, when mental health professionals fill in the box, they would be given the choice to either write in the letters “DSM” and its code number that corresponds to its so-called diagnosis, or they would write the letters CSM and its code number that corresponds to the expressed concern. Mental health consumers would be given the choice to go to pathologizing mental health service providers or those using the CSM approach.

That’s all the change that would be required in order to increase value for insurance customers as well as other third party payers. And a major goal that all third party payers have is to increase value for their customers. The cost and effort for these payers would be minimum and we would have numerous testimonials from customers that documents that this change would be viewed as a significant improvement.

A psychological formulation approach, which requires several paragraphs to be completed, would be far too cumbersome for these payers to incorporate into their bureaucratic system. Moreover, a short word or phrase that could replace terms like “Major Depressive Disorder” or “Attention Deficit Hyperactivity Disorder” is necessary for other practical forms of communication. For example, if I want to write a title for a research article, it would not be practical to insert into it several paragraphs. The psychological formulation approach would become far more widely used if it has some practical way of providing some short terms that are consistent with its non-pathologizing approach to conceptualizing an individual’s mental health concerns.

Some may argue that if everyone could go to a mental health professional merely to have their concerns addressed, then the system would soon be overloaded with clients and insurance policy costs would soar. Since insurance companies only cover people with more serious conditions known as “mental disorders,” so the argument goes, this limits the amount of people who can get to see a mental health professional.

Insurance and other third party payer executives are not stupid. They would readily understand, with a little explaining, that mental health service providers now using the current DSM do not turn anyone with a mental health insurance policy away who comes to their office expressing what I refer to as a mental health concern. Professionals are in the business of increasing their clients. Let’s be honest here; there are “close enough” matches throughout the DSM for anyone with mental health insurance coverage who currently wants mental health services to get it.

Here’s another reason why the CSM would improve the psychological formulation approach. In pretty much any of the advanced countries in the world, there is a rather large segment of the population that believes science has been an enormous help advancing our knowledge. The CSM, as already mentioned, is even more consistent with principles of science than the DSM because it solves the problem of reliability that has been a mess with the DSM. And for science minded people, each branch of science must have a system of classification that helps to organize concepts, to retrieve relevant research, and to be useful in formulating programs of research. In my view, the pairing of psychological formulation with the CSM’s list of brief descriptors of mental health concerns will fit well with this worldview.

And so, these are some of my arguments for uniting in the CSM proposal a classification system and the psychological formulation proposal. Together, both can clearly improve value for consumers of mental health services by providing a new choice, but only if consumers of mental health services role up their sleeves, organize, and effectively advocate for this type of change.

In summary then, the CSM is more consistent with principles of science. It is close enough to the worldview and administrative requirements of all of the stakeholders in the mental health field, thus reducing resistance that often comes with proposed changes. And the creation of the CSM would break up the DSM monopoly, thereby spurring creative approaches for understanding the nature of anguish, sadness and tears.

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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.

Tags CSM, DSM, mental disorders, mental health, mental health concerns, mental health service, mental health services, mental illness, name calling, negative criticism, psychiatry, The Classification and Statistical Manual of Mental Health Concerns

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Are “Mental Illnesses” Really Potentially Helpful Tools?

Post author By Dr. Jeffrey Rubin
Post date February 17, 2015
6 Comments on Are “Mental Illnesses” Really Potentially Helpful Tools?

If your behavior, thoughts, or feelings become a concern, for a fee, many psychiatrists, psychologists, and social workers are eager to translate your experiences into a language of symptoms, diagnoses, psychopathology, and mental illness. In an earlier post I provided negative criticism about this type of name-calling (see here). Today, we focus in on an additional problem with the pathologizing approach.

Psychiatric Name-Calling Simplistically Devalues What William James Referred to as “Exceptional Experiences”

Tools can be used for good or evil. A hammer can be used to drive in nails in the construction of a life-preserving shelter or to bludgeon an innocent person to death. A car can be used to rush a child to an emergency room so that life-preserving treatment can be administered, or it can be used to tragically end a prom night. Are experiences that are oftentimes referred to as pathological really tools, and is it up to each one of us to use them either for good or evil?

The first time I came across this question occurred while reading about William James’s 1896 series of lectures on “Exceptional Mental States.” Harvard psychologist, Eugene Taylor, had reconstructed these lectures from James’s original handwritten lecture notes, newspaper reports, letters, and a variety of other sources.

At the very beginning of the lectures, James argues that experiences that are commonly viewed as unhealthy or morbid are really “an essential part of every character,” and give life “a truer sense of values.” To support his contention, James first provides three examples of famous individuals who suffered from melancholy, a term that corresponds closely with what modern pathologizers call “major depressive disorder.” St. Paul, the religious figure of the New Testament, Cesare Lombrosa, a late 19th-century Italian criminologist, and Immanual Kant, the 18th-century German philosopher, became, according to their histories, better as a result of their troubling experiences.

Not only is melancholy far more normal and potentially beneficial than the pathologizers would like us to believe, so too, James argues, are delusions and hallucinations. James tells us that the belief in the possession by demons, which is often viewed as a delusion by pathologizers, is remarkably common. “[It] is the one most articulately expressed doctrine of both Testaments, and . . . reined for seventeen hundred years, hardly challenged in churches.”

James then goes on to tell his audience about Buddhist sects in Japan that have priests who believe they can put themselves into a trance so that a god can speak through them. These people seek to cultivate these experiences, apparently believing that they provide some benefits to their sect.

Although hallucinations can be construed as a symptom of mental illness to some, James presents the case of Socrates who “once stood motionless for many hours in the cold and spoke of having a guiding demon.” Attempting to counter the association between pathologies and hallucinations, James states,

Even if this demon [of Socrates] were really meant hallucinations of hearing, we know now that one in eight or ten of the population has had such an experience and that for insanity we must resort to other tests than these.

Like melancholy, delusions, and hallucinations, the “symptoms” of obsessions and manias are treated in James’s lectures as experiences that are normal and potentially beneficial. Thus, James states that there is no end to the possible types of obsessions that we see all around us. And what about “the anti-slavery mania?” Is this to be viewed as pathological? What benefit can such experiences have? James tells his audience about Henry Borg, founder of the American Society for the Prevention of Cruelty to Animals; Charles Henry Parkhurst, a Presbyterian clergyman and reformer who launched a furious attack on organized crime in state government that led to an official investigation; Dorothea Dix, a mid-19th-century humanitarian who visited the insane asylums and successfully advocated for legislation to improve the care for those now labeled mentally ill; General Booth, founder of the Salvation Army; Frances Willard, a suffragette; and others. “These persons,” said James, “are not insane, not maniacs, not melancholics, not deluded.”

Later, he states, “Individuals are types of themselves and enslavement to conventional names and their associations is only too apt to blind the student to the facts before him.”

As Taylor (1984) closes his reconstruction of the lecture series, he quotes James as follows:

There is a strong tendency among these pathological writers I have cited… to represent the line of mental health as a very narrow crack, which one must tread with bated breath, between foul friends on the one side and gulfs of despair on the other. Now health is a term of subjective appreciation, not of objective description….There is no purely objective standard of sound health. Any peculiarity that is of use to a man is a point of soundness in him, and what makes a man sound for one function may make him unsound for another…. The trouble is that such writers . . . use the descriptive names of symptoms merely as an artifice for giving objective authority to their personal dislikes. The medical terms become mere appreciative clubs to knock a man down with. . . . The only sort of being, in fact, who can remain as the typical normal man, after all the individuals with degenerative symptoms have been rejected, must be a perfect nullity . . . Who shall absolutely say that the morbid has no revelations about the meaning of life? That the healthy minded view so-called is all?

The Review of the Evidence

It may seem a fanciful theory that the experiences now referred to as mental illnesses can be potentially helpful. However, in 2010, Robert Whitaker published a book titled Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness. To write the book, he pored through the scientific literature for the past 50 years and found a dramatic increase in the number of people who are pathologized, which led to an astonishing increase in psychiatric drug consumption. And more people then ever before became disabled for longer and longer periods of time.

Here is just one of many such studies that Whitaker describes.

In the 1980s, Martin Harrow, a psychologist at the University of Illinois, began a long-term study of 64 newly diagnosed schizophrenia patients. Every few years, he assessed how they were doing. Were they symptomatic? In recovery? Employed? Were they taking antipsychotic medications? The collective fate of the off-med and medicated patients began to diverge after two years, and by the end of 4.5 years, it was the off-medication group that was doing much better. Nearly 40% of the off-med group were “in recovery” and more than 60% were working, whereas only 6% of the medicated patients were “in recovery” and few were working. This divergence in outcomes remained throughout the next ten years, such that at the 15-year follow-up, 40% of those off drugs were in recovery, versus 5% of the medicated group.

Whitaker also found studies that compared cultures, like our own, that employed the pathologizing model with cultures that framed exceptional experiences as potentially beneficial. Countries infected with the pathologizing approach had outcomes significantly poorer.

These findings lead me to conclude that it is time to have a reasonable discussion about embracing other models of care.

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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.

Tags Anatomy of an Epidemic: Magic Bullets, and the Astonishing Rise of Mental Illness, hallucinations, insults, Leo Tolstoy, melancholy, mental disorders, mental illness, name calling, pathologizing, psychiatric disorders, psychiatric drug treatment, Psychiatric Drugs, psychiatric medication treatment, Robert Whitaker, William James

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The Myth of Ritalin’s Effectiveness

Post author By Dr. Jeffrey Rubin
Post date December 21, 2014
25 Comments on The Myth of Ritalin’s Effectiveness

In a recent post titled ADHD and Psychiatric Name Calling, I reviewed studies documenting how much is currently being spent annually on ADHD drug treatments. Here are some new numbers provided by Healthline: What are we getting for this? In this post I hope to clarify this issue. As you read it, you will see phrases in blue. By clicking on each, you will be taken to the actual research article that documents my statement.

For students placed on Ritalin or other stimulant drugs, in short term studies teachers and parents report some improvement in behavior. However, even in the short term, the vast majority of research indicates that there is no improvement on academic functioning. At the end of 14 months, drug treatment was not superior than no-drug treatment on the following measures: classroom observed behaviour, parent- and teacher-rated social skills, parent-rated parent–child relationships, peer sociometric ratings, and academic achievement. By the end of three years there was no significant effects of the drugs on any measure. stomach and head pain And yet, parents who undeniably care about their children, regularly expose their children to the side effects of these drugs, as well as potential long term risks. Why? Because they are convinced that the helpfulness of the drugs outweigh those negatives.

What is it about these drugs that create the myth that the drugs are really helping their children? To understand how this myth is created, it will help if we first take a quick look at how people come to believe smoking cigarettes helps them to deal with stress, and drinking caffeinated coffee helps them to be more productive.

The Myth that Cigarette Smoking Reduces Stress.

In a study published in the American Psychologist, researchers found the following:

Smokers often report that cigarettes help relieve feelings of stress. However, the stress levels of adult smokers are slightly higher than those of nonsmokers, adolescent smokers report increasing levels of stress as they develop regular patterns of smoking, and smoking cessation leads to reduced stress. Far from acting as an aid for mood control, nicotine dependency seems to exacerbate stress. This is confirmed in the daily mood patterns described by smokers, with normal moods during smoking and worsening moods between cigarettes. Thus, the apparent relaxant effect of smoking only reflects the reversal of the tension and irritability that develop during nicotine depletion. Dependent smokers need nicotine to remain feeling normal. The message that tobacco use does not alleviate stress but actually increases it needs to be far more widely known.

This paragraph just provides a summary of the research article that leads to its conclusion. In my view, the whole article lays out a very convincing argument that the relief from a drug withdrawal reaction that occurs each time a person ingests the drug can create the illusion that a drug is helpful. Moreover, I believe that this same argument can also be used to explain how a stimulant such as Ritalin can appear to be helpful even when it is not. Before we get to Ritalin, however, let’s first turn our attention to America’s favorite stimulant, caffeine.

My Personal Experience with Caffeine

When I was 18, I started college. My first class began at 8 a.m. Ugh! That meant waking up around 6 a.m. so I could wash up, have breakfast, and take the hour train ride.

Sitting down for breakfast, I decided to have my first cup of coffee. Both my parents drank coffee in the morning and throughout the day, too. I had heard that it gave you a boost when you were tired, and man, I was tired.

My first sip tasted rather bitter, so I dumped a couple of teaspoons of sugar in. Much better. Then came a little pleasant “up” sensation, but it was accompanied with a little stomach distress. Oh, well. Off I went and it wasn’t long after that I was drinking coffee regularly.

coffee3 As I entered into my twenties, I began to notice that in the morning before I got my first cup, I was irritable and struggling with sleepiness. With the first sips, ahhhh, relief.

In addition to my morning cups, I’d have a cup typically around 10 a.m., a cola with lunch, which has some caffeine in it, and a couple of cups after supper with dessert.

During my thirties, I began to develop headaches. I attributed them to stress.

coffee2 By the time I was forty, the headaches became so bad that I went to a physician who prescribed some pills. I don’t like taking pills, but the headaches were so bad that I thought maybe I should give them a try.

Before filling the prescription, I looked up information about it and found the prescribed pills were made entirely of caffeine. Then, I looked at the side effects and found that one of them was headaches. This surprised me.

Since I was already consuming caffeine throughout the day, and a side effect of caffeine was headaches, I thought maybe instead of taking the pills, the first thing I should try was to stop consuming caffeine.

Wow! Giving up coffee was not easy. For several days I went through a very rough period of headaches, feelings of depression, difficulty sleeping, and my brain seemed to be meandering through thick mud.

In retrospect, perhaps I should have tried tapering off coffee, reducing each week one cup at a time. But I did make it through the morass, and in a couple of weeks I was fine. And ever since, I no longer get any headaches.

More surprising is that when I wake up in the morning, by the time I wash up and sit down for breakfast, I’m every bit as awake as I used to become when I had finished my morning coffee. It is now clear to me that the exhausted, irritable feelings that I used to have before I gave up coffee was due to a caffeine withdrawal effect from going a whole night without having any. Throughout the day, I now find that I have a smoother ride and I am every bit as productive as I used to be when I was a coffee drinker.

The Myth of Ritalin’s Effectiveness

Ritalin, and most other drug treatments for “ADHD” are stimulants. And just as I came to mistakenly believe coffee helped me to be more productive, I think Ritalin’s effects lead to the same mistaken conclusion. And just like I didn’t attribute the side effects of caffeine to my coffee drinking, I think parents don’t realize how much of their child’s sleeping problems, headaches, late afternoon miseries are due to the drugs. And when parents try to withdraw their children from the drugs to see if it is really helping, as the withdrawal effects begin to become worse and worse, parents come to think that this is how their children naturally are when they don’t take the drugs.

Now, there is more to this story than I can reveal in a single post. For example, other factors that lead to parents thinking these drugs are more effective than they actually are is the clever advertisement of the drug companies. Moreover, in some cases, children, as they become older, typically mature at a certain pace. Thus, some children viewed as having ADHD problems completely grow out of these problems without any drug treatment. If this growth in maturity occurs shortly after a child begins to take the drugs, the improvement from natural maturity growth can be easily attributed to the effects of the drugs. When this happens, parents rave to their family members and friends that Ritalin saved their child, and they push other parents to do what they did–get their children on Ritalin.

And so, this is how I think the myth of Ritalin’s effectiveness is created. An initial improvement in behavior once the drug treatment begins; a slow tolerance develops to the drug so it becomes less and less effective, but this occurs over a period of time during which the child is naturally maturing. As a result, some parents don’t notice that the drug is becoming less effective. When parents do notice the decreased effectiveness of the drug, they often take the child to the doctor to get an increased dose. Again there is a boost in apparent improvement. As tolerance to the drug once again begins to occur, more time goes by, and of course there is more growth in the child’s natural maturity. This may lead to less attention problems, but the improvement is attributed to the drugs, rather than improved maturity. Whenever parents try to see if their child can do just as well without the drugs, the withdrawal reactions convince them that their child really needs the drug. Negative side effects of the drugs are attributed to other causes. Couple all of this with the clever advertisement campaign of drug companies, and we end up with a pretty impressive myth.

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Tags Adderall, ADHD, ADHD Treatment, caffeine's side effects, Coffee's side effects, drug treatment, DSM, mental illness, Myths, parenting, psychiatry, Ritalin

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ADHD or Attention Priority Difference?

Post author By Dr. Jeffrey Rubin
Post date December 8, 2014
14 Comments on ADHD or Attention Priority Difference?

A few years ago I worked as a school psychologist. One day the mother of a 12-year old boy, who we’ll call Pete, explained to me that upon the urging of one of his teachers, she took him to his pediatrician to be evaluated for ADHD. The pediatrician asked this mother a few questions, diagnosed Pete as having ADHD, and then wrote him a prescription for Ritalin. After reading the possible side effects of the drug, the mother became concerned and spoke to Pete’s father.

Pete’s father and mother were divorced. Pete lived with his father on weekends, and the rest of the time he lived with his mother. Upon hearing about the prescription for Ritalin, Pete’s father was very much opposed to his son taking any drug for treating this concern. And so, now the mother wanted to know what I thought should be done.

I explained that before I could make any recommendations, I would have to carry out an evaluation. As a student in the district that I served, there would be no cost to the family. Pete’s mother agreed to the evaluation.

First, I requested that the mother, father and each of Pete’s teachers fill out standardized questionnaires. The results indicated that Pete’s physical education teacher, art teacher and his father viewed his activity level and ability to pay attention as falling within the average range. Pete’s mother and academic class teachers generally saw him as having some problems paying attention. His math teacher, who had been the one to urge Pete’s mother to take him to the pediatrician, rated Pete’s ability to attend to his assignments as being way below average.

After looking at the results of the standardized questionnaire, I spoke to Pete’s father. He confirmed that it was his impression that Pete had no difficulty with either his activity level or paying attention.

“Do you mind describing a typical day that you have with your son?” I asked.

“Well, let’s see. Last Saturday, when we woke up, we went to play golf.”

“Do you walk the course, or ride in a cart?”

“We walk.”

“Pete doesn’t mind?”

“Not at all. He loves doing physical stuff like that.”

“After golf, then what did you do?”

“We went back to my place, I made some sandwiches, and then I read the newspaper while Pete worked on his drawing. He loves to draw, and he’s pretty good. Then we went in the backyard. I have a basketball hoop set up there and we shot around for a while. Then we started to get supper together.”

“Does Pete help you with that?”

“Yes.”

“Does he get distracted in any way when you two work on supper?”

“Not at all. He’s very helpful. Then we ate supper, went down to the basement and played ping pong for maybe an hour. Then we went upstairs and watched a movie.”

“When he watches a movie with you, does he appear to have difficulty sitting through it?”

“Not usually. Occasionally, the movie strikes him as boring. After the movie, he went to bed.”

“Does he have any trouble sleeping when he stays with you?”

“No. We do a lot of physical stuff that tuckers him out, and he ends up sleeping soundly.”

I then spoke with Pete’s mom. Consistent with how she filled out the standardized questionnaire, she confirmed that it was her impression that Pete did have difficulty paying attention.

“Do you mind describing a typical day that you have with your son?” I asked her.

“Well, yesterday, I got him up at 7 so he could catch the school bus on time. He complained the whole time he got ready. He hates the ride to school.”

“How long a ride is it?”

“An hour, and he says he doesn’t get along with the kids he rides with.”

“I see. He has to sit on the bus for an hour with kids he doesn’t like, then he’s in school sitting most of the time doing school work. Then he takes the bus home, sitting for another hour with kids he doesn’t like. For a boy his age who loves to do physical activity stuff, I could see how this could be hard for him.”

“Yeah, but other kids do it.”

“Most do. Please tell me what happened when he got home.”

“Well, I got home a little after he did. I started preparing supper, and that’s when I have him doing his homework. I sit him at the kitchen table where I can keep an eye on him while I prepare the meal. And he gets very distracted. He starts an assignment one minute, and I look over and I catch him doodling. Over and over again he gets distracted.”

“I see. After sitting most of the day, you have him sit and do his homework?”

“Yes. That’s when I can best keep my eyes on him.”

“How about the rest of the evening?”

“He’s fine then. Besides doing his homework, the only other time I have trouble with him is when I try to get him to clean up his room. He starts to do it, but when I look in a few minutes later, he has become distracted with something else.”

Next, I interviewed Pete. After some pleasant discussion I said, “Your math teacher says you have trouble paying attention in class. What’s up with that?”

“Aaaaa, he makes us fill out these worksheets doing the same problems over and over again. If I know how to do it, why do I have to keep doing 20 more of them? It’s so boring.”

“I see. Say, I hear that you like to draw. Would you mind drawing something for me.?”

Pete’s eyes light up. “Sure. What do you want me to draw?”

“Anything you like.”

Pete begins, and I notice he appears to become completely absorbed in the task. I start to try to distract him by making some extraneous sounds. He glances up to see what the commotion is all about, sees it’s nothing serious, and resumes work on his drawing.

A half hour later, he shows me what he has created. It’s an imaginative otherworldly drawing with spaceships and fascinating creatures. There is an excellent sense of shadowing. It’s far superior to anything I can create in the drawing department.

When I finished my evaluation, I informed the parents that in my opinion it is not in Pete’s best interest to view the concern that has been expressed about his attention as due to ADHD. A more apt description is to view Pete as having an “Attention Priority Difference.” School work was not a huge priority for him. He much preferred to draw and do more physically active tasks than is currently provided at school. These preferences may turn out to be his greatest values. He may someday find work that he truly loves in a field where his artistic interest and talent are crucial. And his interest in physical activity may keep him far more healthier than the many sedentary Americans who are at an increased risk of a number of real illnesses.

“Well,” said the mother, “will Ritalin help Pete with his Attention Priority Difference?”

To which I replied, “Consider an analogous situation. Suppose we identified a group of children who are not doing as well as most kids in physical education. Would it make sense to make up a pathological sounding term for these low-performing students, such as “Muscular Deficit Disorder” and then have doctors prescribe steroids for them?

“In my view, people have different interests and talents. This is a wonderful thing, not something that should be pathologized. We don’t just need every person in America sitting in ivory towers. We need, as well, artists, computer experts, magnificent athletes, hairdressers, and on and on.

“When I hear of a child placed on Ritalin, I become concerned about the child’s stomach, nerves, and brain. Drugs that have been said to be safe have turned out to be far more toxic than anyone ever dreamed of. I become concerned about the social misery that goes along with being singled out as a child that must take a pill to fix him. More than a few kids have told me that this became a dreaded experience.

“I believe that teaching children to turn to drugs when they are dissatisfied with their behavior or mood runs counter to a healthy lifestyle.

“I prefer to put forth a view that encourages us to teach our youth about the blessings of keeping our bodies in lifelong possession of its full youthful state by keeping their blood free of stimulants and narcotics. I wish to teach our kids that it is possible that the morning sun, air and dew can be sufficient powerful intoxicants. Doing something that puts a smile on the lips of a loved one, accomplishing a valued challenging task, providing assistance to another human being—these are the directions I wish we would point to when we guide a child toward a more fulfilling life.”

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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.

Tags ADHD, ADHD Treatment, Attention Priority Difference, attention problems, DSM, paying attention, pediatrician, Ritalin

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Crazy, Mentally Ill, and Meshuga

Post author By Dr. Jeffrey Rubin
Post date November 24, 2014
7 Comments on Crazy, Mentally Ill, and Meshuga

Followers of this blog seek to become experts in a branch of personal interactions referred to as name-calling. Among the words and phrases used in these interactions are “crazy,” “mentally ill,” and “meshuga.” In today’s post, I hope to weave a little narrative around their use in a manner that might take the sting out of them.

The Broad Use of These Words

These terms are often used so broadly that they mean the same thing as other words and phrases thrown at someone, such as “jerk,” “piece of trash,” “stupid idiot,” etc. When used like this, they all mean nothing more than the angry party strongly doesn’t like what the other party did. They serve as a type of exclamation point.

“I don’t like what you did,” is not as emotionally packed as, “Listen, you crazy idiot, I don’t like what you did!” Nor is it as emotionally packed as, “You must be mentally ill to do something like that, you jerk!” Nor is it as emotionally packed as, “Oy veh, you putz, you got to be meshuga to do something like that!!”

Of course, it is perfectly possible to convey emotionally packed exclamations without the use of these words. My mother was a master at this. Her abilities to clearly define what she objected to and to vary her tone of voice were all the tools she required to amply communicate to people where she stood on an issue.

The Special Similarities of Crazy, Mentally Ill, and Meshuga

Now, in addition to being used as general insults, “crazy,” “mentally ill,” and “meshuga” can also be viewed as falling into a group of ideas that have more similarities than most of the other insults that might be picked at random. That is, I would guess that “crazy” and “mentally ill” are viewed by most people as being more alike than “crazy” and “jerk,” even though each could be used as general insults.

It is important to note that there are people in our communities that have adopted a particular narrow use of the term “mentally ill.” To illustrate this, Margaret believes she has a mental illness and values that she has come to accept that about herself. For her, conflicts spring up when she hears someone use the term, “mentally ill” in its more broad, general insult manner. For example, let’s say Margaret is sitting in her backyard, and she hears that her neighbor, Tim, has gotten into a conflict with Ron. Suddenly she hears Tim shouting at Ron that he is a no good mentally ill idiot!!! Even though the conflict has, in a sense, nothing to do with Margaret, she becomes angry with Tim for using the term “mentally ill” in this broad, general insult manner. There is actually no law requiring that Tim adopt the narrower meaning that Margaret uses, but she is still outraged at him.

Who Should Get to Decide When it is Proper to use Terms Such as Crazy, Mentally Ill or Meshuga as a general Insult or in Some Particular Narrow Sense?

The actress, Marlene Dietrich, when asked if she believed in God, replied, “If there is a supreme being, he’s crazy.” In some religious communities, she would have been viewed as crazy for saying this. Meanwhile, Dr. Sigmund Freud, who is thought of by many as having been a great expert on mental illness, believed that all religious people suffer from a mental illness. Dr. Carl Jung, an equally great expert on the subject, disagreed with Freud, believing instead that religious people, even people today viewed as psychotic, may be in touch with deep and ancient truths.

When I was a young boy growing up in the Brooklyn neighborhood of Brighton Beach, I heard people from time to time being called a “meshugana,” which I was told means in Yiddish, “a crazy person.” What was unique about how the Yiddish term was used in Brighton Beach, is that as soon as someone was said to be a meshugana, it was very common to have someone stick up for that person with the words, “Hey, everyone has their own mishegas.” Loosely translated, this means that we all have a little craziness within us, so let’s not pretend to be so high and mighty by putting someone down like this.

Now, for people who want to know if they are really mentally ill, they can get the latest version of the DSM (Diagnostic and Statistical Manual of Mental Disorders), which was developed by the American Psychiatric Association. I happen to have a copy of it, and as I’ve been studying its pages, it has become apparent that with little imagination we can all be viewed as having some mental illness. That works out pretty good for psychiatrists because this way they never have to turn away any customers who come to their office seeking to become their patients.

But what if we really want to find out if we really, truly are crazy? Fortunately, there is now an alternative to the DSM, which can finally set us straight. It’s called the Diagnostic Manual of Mishegas (DMOM), and as the ad for it explains, the authors divide

all mental disorders into two realms: mishegas major and mishegas minor. And for each of the sub-categories it analyzes… yenta, kvetch, alter kocker, shnorrer, dementia-with-benefits, etc…THE DMOM will enable readers to transform ordinary tsuris and mishegas—the glooms, blues, angsts, and general chazzerie of their lives—into transcendent and easy-to-understand categories. It will turn kvetching into kvelling and guilt into gelt, so that readers will learn to live at peace with their inner mishegas and to treasure its precious and life-giving absurdities.

Well, I have nothing that can top that, so until we meet again, don’t let the insults get to you.

My Best,

Jeff

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Tags Carl Jung, crazy, DSM, mental illness, Mentally ill, Meshugana, Mishegas, sigmund freud, The Diagnostic Manual of Mishegas

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Psychiatric Name Calling: Is it Helpful?

Post author By Dr. Jeffrey Rubin
Post date October 6, 2014
14 Comments on Psychiatric Name Calling: Is it Helpful?

Today I offer a follow-up to my earlier post titled “Name Calling by Psychiatrists: Is it Time to Put a Stop to it?” Among the points that I had tried to make is that psychiatrists falsely claim that the names they use to describe patients are “diagnoses.” In actuality, all that they do is convert someone’s expressed concerns into medical jargon.

I received a great deal of positive and negative comments about the post from readers, but my focus today is on the negative ones. Most of them argue that in contrast to my position, they had personally found their psychiatric diagnosis very helpful.

Those who Found the Psychiatric Pathologizing Helpful

I just finished an excellent book on this topic by Lucy Johnstone titled, A Straight Talking Introduction to Psychiatric Diagnosis. There we find several quotes from people who received a so-called diagnosis from psychiatrists and spoke of its positive personal impact. For example, some felt that it provided relief at knowing “what was wrong.”

I had something that I could firmly grasp, and, you know, I could find out more and try to resolve it…[I] felt relief that this whole jungle was going to be sorted out.

Another person wrote,

It gave me the comfort of explanation…. When I was told I was depressed it gave me a framework of understanding and a first grip on what was happening.

Some felt that it gave them hope for treatment and support.

Illness meant treatment and the possibility of cure.

Acceptance of my illness was a turning point…. By accepting treatment I could actively seek the right medication, access support, and turn my life around.

I think I prefer my illness having a name because it makes me feel less lonely, and I know that there are other people experiencing my kind of misery.

Then there were those who felt it provided them freedom from blame and guilt.

Diagnosis implied that this was an illness and not my fault—important for someone whose depression has always been riddled with guilt.

Commentary

Although there are many, many people who feel this way, Ms. Johnstone points out that the relief that these people experience is based on their assumption that the diagnosis itself is valid. If it isn’t, they are simply being offered a circular explanation—“Why are my moods so up and down?” “Because you have bipolar disorder.” “How do you know I have bipolar disorder?” “Because your moods are so up and down.”

Keep in mind, as well, that these people came to view their so-called diagnosis as helpful without ever having an opportunity to compare the pathologizing approach to any alternative approaches. For example, what would be the reactions of these same people whom I have just quoted if they were provided an option that avoided simplistic, misleading terminology, while professional mental health providers and peer support groups assisted the person to find their own stories and provided a choice of treatment options?

Moreover, finding freedom from blame and guilt by playing the blaming-the-brain game may not be anywhere as helpful as the pharmaceutical companies would have us believe. Many of us have learned that we all, from time to time, do things that violate our image of our ideal self and spend some time suffering the consequences. We come to realize that we not only violated the image of the ideal self in the past, but we’ll no doubt do so again and again in the future. The experience of suffering over these lapses is the spur that, after a period of difficult reflection, eventually gets us off our butts, learn new skills and seek out the type of support that moves us to make improvements. It can take time for this to happen. It can take more time than we in our modern pressure pot world may feel we have any right to take, and our loved ones may lose their patience. However, in the long run, drugging these feelings away have always produced more harm than good.

Those who Found the Psychiatric Pathologizing Unhelpful

In contrast to those who tell of some positive reactions to psychiatric name calling, there are other people who tell a dramatically different story.

For a number of years, I accepted the medical model as a framework of understanding…. But I gradually came to appreciate drawbacks to the framework. My reading suggested the model might not stand up scientifically…. By the time I was entering my second decade of service use, the medical model, which I had initially found reassuring, seemed increasingly unsatisfactory, without the capacity to encompass the complexity of my interior or exterior life and give it positive value. As a result, I began to actively explore frameworks that better met my needs.

I already knew something was wrong with me. Now I knew I was mad…. The diagnosis becomes a burden… you are an outcast in society…. It took me years to feel OK about myself again.

My diagnosis label promoted despair and threatened to become a self-fulfilling prophecy.

I have been diagnosed with dysthymic disorder since I was thirteen. One kind of harm I suffered from receiving a diagnosis, in and of itself, was that it seemed so final and despairing to receive as a teenager. For me, having a diagnosis seemed so final. Like it wasn’t just a tempory issue that I was having, adjustment or adolescence or something, but this disorder that I was going to have for the rest of my life no matter what I did.

But the worse part of this, which I have only been able to shake within the last year…is the defectiveness I felt. Just kind of in some core way. Like I’m totally different.

I was so offended. I was really offended. I thought well, ‘F*** you! You’re attacking my personality; you’re attacking me. You’re attacking the very soul of me, you know; who I am, and what I am, that’s a disorder.

I no longer identify with my previous role as a severely ill psychiatric patient but a human being that is experiencing and surviving life in my own unique way… just like every other human being on this planet.

Commentary

In her book, Ms. Johnstone summarizes what she has learned from these quotes:

It is understandable that service users, reaching desperately for an escape from anguish, confusion, guilt and blame, might see diagnosis (at least initially) as ‘salvation’. However, these benefits may be bought at the high price of taking on profoundly destructive messages of defect, dangerousness, damage and despair.

In my view, we can come up with a much better approach to the psychiatric pathologizing of people, an approach that doesn’t label anyone, but rather, classifies mental health concerns. For those who found the pathologizing approach helpful, this alternative approach would provide the professional and peer support that they value without misleading name calling. Psychiatric terms confuse questions of fact with questions of value, and superficially declare that a person’s experience is bad when it may have some pluses and minuses.

Undoubtedly, there are kind and decent folk who have a very different position than I on this subject. In no way do I mean to suggest that those who hold a different opinion are stupid, for I have met many who are as bright as a cloudless summer day. If they want to continue to use the DSM approach, it will continue to be available. All that I seek, all that I hope for, is that those who are uncomfortable with the DSM approach, can still assess mental health services using an alternative. All that I seek is that we all take some time to think more deeply about the nature of melancholy, sadness and tears.

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Tags A Straight Talking Guide to Psychiatric Diagnosis, conflict management, conflict resolution, criticism, dispute management, DSM, Lucy Johnstone, mental disorders, mental health, mental health concerns, mental illness

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Psychiatric Name Calling: Is Science to Blame?

Post author By Dr. Jeffrey Rubin
Post date September 22, 2014
14 Comments on Psychiatric Name Calling: Is Science to Blame?

A couple of weeks ago I raised the question, “Name Calling by Psychiatrists: Is it Time to Put a Stop to it?” In response, some blamed the insurance companies and other third party payers for the name calling. Because it is true that these payers do require the pathologizing of people seeking mental health services, in last week’s article, I took a close look at that issue.

Others responding to my question argued that diagnosing mental illness is based on the principles of science. So, let’s look at this line of thought.

The Nature of Science

Science enquires what is the nature of something? what is its constitution, origin, and history? Human beings also make enquires of a different sort, What is the object’s importance, meaning, significance, or value now that it is once here? Neither judgment can be deduced immediately from the other. They proceed from diverse intellectual preoccupations, and the mind combines them only by making them first separately and then adding them together.

As Steven Jay Gould, professor of zoology and geology at Harvard University, explains it:

“The net of science covers the empirical realm: what is the universe made of (fact) and why does it work this way (theory). The net of religion extends over questions of moral meaning and value. These two magisteria do not overlap, nor do they encompass all inquiry (consider, for starters, the magisterium of art and the meaning of beauty). To cite the usual clichés, we get the age of rocks, and religion retains the rock of ages; we study how the heavens go, and they determine how to go to heaven.”

In the natural sciences there is a branch called pathology that classifies tumors, lesions, bone fractures, tissue tears, toxic reaction to a chemical, blockage of blood flow within the circulation system, blockage within or to an organ, and microbe infections. Pathologists have reliable ways of identifying and categorizing these naturally occurring entities. When we take a science view of each of these entities of interest to pathologists, it is not a value judgment if they exist or not. If ten pathologists look at a tumor, they can all see it, describe its color, density, weight and what each of the tumor’s cells look like under a microscope.

Pathologists, as scientists, have been studying these entities and sometimes they found that some of them are associated with certain physical complaints. For example, some people complain about headaches and vision problems. When they died, autopsies were carried out and often a tumor was present that was pressing against the optic nerve.

This finding led to a theory that for people who expressed this type of physical complaint, if an operation was carried out while the patients were still alive and this type of tumor was indeed pressing on the optic nerve, perhaps removing it would alleviate the complaint. Studies were carried out and it led eventually to a valued treatment.

The connections between the research findings of pathologists gave doctors some understanding of what was causing some of the physical complaints of their patients. But often doctors could not find evidence that any of the entities of interest to pathologists were the cause of the complaint. When this occurred, most doctors merely changed the expressed complaint into some medical jargon that sounded somewhat like those concerns that had been shown to be due to a pathological condition. In such cases, they offered some treatment that was often based more on the commercial art of medicine rather than science.

These doctors usually called both types of physical complaints (those with pathological findings and those without) “illnesses” or “disorders.” By doing so, the science of medicine and the art of medicine became blurred. And then, business interests became wrapped up in the various treatment options and principles of science began to become more and more murky when applied to the medical world.

Disorders and Psychiatry

In a book titled Psychiatric Persuasion by Elizabeth Lunbeck, there is considerable documentation that back at the turn of the 20th century when the main job of psychiatrists was running insane asylums their professional organization decided to expand their market by doing two things. 1. Persuade the public that more and more normal behaviors are pathologies that require psychiatric treatment, and 2. Develop a category system that converts all psychological concerns that a person might want to get help for into a language that sounds like a pathological condition. This would legitimize the treatment of anyone who came to their office, thus the argument that the current psychiatric “diagnosis” system has become a business tool while being promoted as science.

Now, it is certainly possible to create a categorical system consistent with science for the problems that come to the attention of psychiatrists and other mental health service providers that don’t confuse conditions that are associated with pathological findings and those that are not. Such a system would classify “mental health concerns,” rather than calling people names. A mental health concern occurs when a person seeking mental health services expresses to a mental health service provider a concern about any of the following topics: behavior, emotion, mood, meaning of life, managing chronic pain, work, relationships, education, eating, cognition and sleep. Two classes of mental health concerns are concerns expressed about oneself and concerns expressed about someone else.

One benefit of classifying “mental health concerns” rather than “mental disorders” has to do with inter-rater reliability. Consider being in a room with 100 psychologists, or even 100 average Joes and Jills, and a person in front of the room says she has been feeling depressed. A questioner asks the client, “Are you concerned about feeling depressed?” and the person says, “Yes.” If you asked for a survey of how many people in the room thinks the person has expressed a concern about being depressed, you would get, I believe, 100 percent agreement. Expressing a mental health concern is a specific action that people do, and therefore it is clearly observable.

Research on the inter-rater reliability of the mental disorders classification system has demonstrated that its inter-rater reliability is very problematic.

Science is Not to Blame

It is not science that is to blame for psychiatric name calling; it is the psychiatric business tool that is cleverly designed to capitalize on the public’s respect for science.

When we begin to use a classification system that does not clearly separate principles of science from values involved in business interests, other values start to slip into the classification process as well. Early on when the pathologizing of human experience was just getting underway, William James made a number of relevant comments about this.

James argued that experiences that are commonly viewed as unhealthy or morbid are really “an essential part of every character” and give life “a truer sense of values.” To support his contention, James first provided three examples of famous individuals who expressed concerns about melancholy. Such experiences today, if expressed to a psychiatrist, would probably be converted into a so-called “diagnosis” of “major depressive disorder.” St. Paul, the religious figure of the New Testament, Cesare Lombrosa, a late 19th-century Italian criminologist, and Immanual Kant, the 18th-century German philosopher, became, according to their biographies, better as a result of their troubling experiences.

Although hallucinations can mean madness to some, James presented the case of Socrates who “once stood motionless for many hours in the cold and spoke of having a guiding demon.” Attempting to counter the association between pathologies and hallucinations, James stated, “Even if this demon [of Socrates] were really meant hallucinations of hearing, we know now that one in eight or ten of the population has had such an experience and that for insanity we must resort to other tests than these.”

James stated that there is no end to the possible types of obsessions that we see all around us. What benefit can such experiences have? James wrote about Henry Borg, founder of the American Society for the Prevention of Cruelty to Animals in 1866; Charles Henry Parkhurst, a Presbyterian clergyman and reformer who held a New York City pastorate from 1880 to 1918 and who launched a furious attack on organized crime in state government that led to an official investigation; Dorothea Dix, a mid-19th-century humanitarian who visited the insane asylums and successfully advocated for legislation to improve the care for those labeled mentally ill.

Later, James stated, “Individuals are types of themselves and enslavement to conventional names and their associations is only too apt to blind the student to the facts before him.”

James concluded that,

“Any peculiarity that is of use to a man is a point of soundness in him, and what makes a man sound for one function may make him unsound for another. Moreover we are all instruments for social use, and if sensibilities, obsessions and other… peculiarities can so combine with the rest of our constitution as to make us the more useful to our kind, why, then, we should not call them in that context points of unhealthiness, but rather the reverse . . . The trouble is that such writers [pathologizers]. . . use the descriptive names of symptoms merely as an artifice for giving objective authority to their personal dislikes. The medical terms become mere appreciative clubs to knock a man down with. . . . The only sort of being, in fact, who can remain as the typical normal man, after all the individuals with degenerative symptoms have been rejected, must be a perfect nullity… Who shall absolutely say that the morbid has no revelations about the meaning of life? That the healthy minded view so-called is all?”

To illustrate what James means here, consider an article in the American Journal of Psychiatry (May, 2004), titled “Virginia Woolf (1882-1941).” Although she is described by psychiatrists as having bipolar disorder, her diaries and letters, document movingly, her emotional extremes and her capacity to savor the “ordinary rhythms of life.” At times Woolf railed against her distressing emotional experiences, felt frustrated and impeded by them, and at other times she felt it was essential to her. In diaries and letters, she returned to the question repeatedly without reaching a resolution: were her emotional experiences a terrible obstacle to her art, or were they the necessary condition for it?

For those trying to sell psychiatric drugs, a simplistic answer to this question is eagerly promoted. Science has not provided a definitive answer to this question as far as I am concerned, and throwing around phrases such as “the brain is malfunctioning in depression,” or “the brain has a chemical imbalance in depression” goes way beyond the available evidence.

Psychiatric labels are like masks held on by rubberband straps. They hide some of the characteristics of an individual. Wearing such masks may serve some purposes, but after a while they start to get uncomfortable for many, particularly around the ears. Let those who want to wear these masks be free to do so. But let those who want to meet us face to face, also be free to do so.

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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.

Tags disrespectful, DSM, free social intelligence and emotional intelligence curriculum, insults, mental disorders, mental health, mental health concerns, mental health services, mental illness, name calling, psychiatry, science, Steven Jay Gould, William James