Category: Mental Health

Categories
blame blaming guilt guilting mental disorders Mental Health responsibility

A Lesson From The Play, Next to Normal

Welcome to From Insults to Respect.

This week I happened to watch on TV the play Next to Normal. It dramatically and musically brought forth a wealth of thoughtful and emotional reactions. I can’t, in a single post, express all of these, so here, I’m going to focus on just one–the issue of blaming those given a mental disorder label and their parents for how they are acting and experiencing.

The Play’s Main Plot

A woman who had a baby that died in infancy continued to grieve after four months. A psychiatrist, therefore, has classified her as having a mental disorder and has been prescribing psychiatric drugs for depression. Because his patient also imagines that the baby is still alive, and on birthdays she sees him growing up, and she regularly has conversations with him, the doctor has been prescribing an additional cocktail of drugs. As we enter the play, we see the drugs have certainly not relieved the woman from her or her family of the anguish that has come about. The imagined baby has grown to be a teenager. Her family, made up of her husband and teenaged daughter, are deeply concerned and support the psychiatrist’s treatment recommendations. Treatment during the play changes from drugs, followed by an hypnosis approach, and finally Electroconvulsive Therapy (ECT), none of which lead to satisfactory results.

My Reaction To The Play

In my training as a psychologist, I learned to avoid blaming people who act in ways that lead to a mental disorder classification or their parents. Blame implies thinking someone is guilty of doing something wrong.

If I perceive that someone has done something wrong and I become frustrated and angry at the person and I begin to seek to punish the person, I view that person as guilty.

For example, if I make a wrong turn to go to my friend’s house and when I discover my error if I have a strong emotion of frustration that springs up in me and I cry out, “What an idiot I am for making that mistake,” I am feeling guilty that I made the mistake, and the reason I am calling myself an idiot is because it is my angry effort to punish myself.

I use that specific type of definition for “guilty” to distinguish it from how I define responsibility, which I view as a more mature response. When people act responsibly, they recognize that they did something wrong, experience a strong feeling of frustration, recognize at the same time that as long they are a human being they are going to make mistakes. They recognize that the strong feeling of frustration is a good thing because it leads them to focus on what they did wrong, and the emotionality helps spur a process that increases the possibility of fixing the error in the long term, decreasing the chance that they will make the same mistake. Part of this frustration reaction leads me to focus on what I can specifically do next time to prevent the mistake. This is a wonderful process, and I welcome the experience as I would a helpful friend. When I see guilt springing up in me, I have been getting more and more skillful at transforming it into my helpful friend.

It seems to me beneficial to keep the idea of angrily desiring punishment when someone does something wrong separate from the idea of learning from the experience of making a mistake by experiencing frustration in a friendly, non-punishing manner. If you see that your five-year old son has made a mistake when trying to add 7 plus 3 and he came up with 9, you may see that he has done something wrong, but you might experience this as somewhat different from when you feel someone is “guilty” of doing something wrong.  You may think that your son almost got the right answer, and he’s trying, and this is part of a useful learning process. You might not feel angry at him, nor think he deserves to be punished for his efforts. Perhaps you might gently correct him and give him a warm smile.

Although I am pretty good at avoiding the blaming game, from time to time I slip up and become angry at what I’m perceiving is happening with people dealing with mental health concerns. This play, so well done, has helped me to better reconnect with the habit of making the distinction between guilting and taking responsibility as I conceptualize them.

The music, singing, and dialogue blend together to avoid simplistic interpretations of events and filled me with empathy for the complexity of dealing with such challenging circumstances. I was left thinking that people embroiled in the types of situations that the play depict would do well to learn for themselves the difference between blame and responsibility. Moreover, it seems to me that it takes more than just noting the difference; it takes practice to turn this understanding into a useful habit. One useful practice is to identify five times when you found yourself employing guilting, and then see if you can write out a way to turn them into a response that better matches a responsibility response.

My Best,
Jeff

 

Categories
addiction Alternative to mental health treatment antidepressants Antidepressants effectiveness Mental Health pharmaceutical Industry psychiatric drugs psychiatric medications

Are Psychiatric “Medications”Essentially The Same As Recreational Drugs?

Welcome to From Insults to Respect. Today we shall look at a theory that is certain to fire up some mighty strong emotions.

Most advocates within the medical profession say their prescriptions for psychiatric drugs, which they refer to as “medications,” improve the health outcomes for their patients. There are some within the profession that fervently object to this claim and provide extensive research evidence for their position, but nevertheless are clearly a minority. Meanwhile, taking legal and illegal recreational drugs are mostly viewed as distinctly different not only by medical doctors, but a majority of those in the general population.

That said, I do think it is useful for us to look at the case that although there are some differences, essentially they are the same when it comes to opportunities to 1. assess side effects/toxicity as one makes decisions to partake, and 2. what keeps users to continue consuming them.

Assessing Side-Effects and Toxicity

The Food and Drug Administration provides readily available information on the internet, regarding the side effects and toxicity of these substances. Updated research on this information is regularly appearing in the press. For example, we have recently seen stories about how even one glass of an alcoholic beverage can have negative effects on some aspects of health outcomes.

Anyone who wants to delve into a more thorough assessment of health consequences of any of the legal and illegal recreational drugs and psychiatric drugs can do a literature search. I have found Google Scholar fairly easy to use for this purpose. It provides the abstract of the research for free. There is an occasional pay wall that can be modestly costly in order to read the entire paper, but anyone who wants to make a fully informed decision on the risk of partaking can obtain the available evidence at a reasonable cost. Many of the published evidence can be misleading particularly because most studies look at just short-term results, yet many folks take these drugs for much longer. But this is true for recreational and psychiatric drugs, so assessing safety is hardly perfect regardless of what drug is being considered.

The Physical and Psychological Reasons People Continue to Consume These Legal, Illegal, and Psychiatric Drugs Are Essentially the Same.

Let’s begin this theory by using nicotine as an example and by taking a close look at an impressive study in the scientific literature (see HERE).

smoking 5Our body, upon beginning the habit of consuming nicotine, at first fires its receptors more frequently than usual upon each exposure to this drug. This leads to feeling more alert, which some of us experience as rather pleasant. But your body recognizes that if you were to keep firing those receptors at the pace that occurs when you first start smoking, certain functions in your body will end up exhausted. Thus, your body starts to reduce the number of these receptors. In the scientific literature, this process is called “down regulation” or “tolerance.”

For smokers, we see evidence of tolerance in studies that indicate fewer responses than do non-smokers to the same amount of nicotine (Perkins et al. 2001b). More specifically, we see a reduction on measures of subjective stimulation that may be viewed as pleasurable, such as arousal, vigor, and a subjective experience often referred to as “head rush” or “buzz.”

Once the down regulation process is complete, you end up with enough receptors to function fairly well as long as you continue to consume using this drug. withdrawal 2However, shortly after you pause from smoking even for a few minutes, you end up not having enough of these receptors to do what they were originally designed to do. It is this shortage of receptors that occurs when there is not enough nicotine in your system to keep your receptors firing at a rate that would typically occur if you were not regularly consuming the drug that leads to the uncomfortable, sluggish, stressful feelings that lead to a craving for the next cigarette. When you light up, you feel relief because now the reduced amount of receptors are sufficient to carry out your major life functions in a less distressed manner.

The relief that smokers feel each time they give themselves another dose of nicotine creates the powerful illusion that cigarettes help them to deal with stress. Thus, in a study published in the American Psychologist, researchers found the following:

smokingSmokers 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.

drug withdrwal 1Theoretically, this same process is largely the reason why people become addicted to other substances, such as alcohol, caffeine, illegal drugs, and even the drugs that psychiatrists prescribe, such as the so called antianxiety drugs (anxiolytics), antidepressants, and ADHD stimulants such as Ritalin. They all have the potential of creating for addicted people the illusion that they are functioning better than they did before they started consuming the addictive drug.

Another major part of the addiction process is that the addictive substance often is used as part of a ceremony creating a very pleasant experience. As an example of this, listen to the actor John Cusack explaining his smoking habit:

John Cusack

John Cusack

To me, cigars are a much better situation than cigarettes. Cigarettes are compulsive and cigars are kinda, languid, luminous conversation. Like you’re gonna sit for a couple of hours and talk to somebody. If you gotta smoke, I would say, at least have a long conversation with someone you like, rather than just compulsively sucking down a cigarette. That’s how I’m gonna lie to myself so I can keep smoking cigars.

Although the cigarette habit is not John’s cup of tea, many people have fond associations of sharing a cigarette with others, and drinkers have associations of some very good times hanging out with their buddies. Of course, others have very negative associations with an addictive substance.

Can it be that the same two mechanisms–reduced receptors and pleasant ceremony– that creates the illusion for nicotine users are similar for other drugs that are the other legal, illegal, and psychiatric drugs?
Clearly, regular users of alcohol go through a withdrawal reaction when they don’t get a drink around the time they usually imbibe. We get a delightful sense of this listening to Jimmy Buffet singing about it being five o’clock somewhere and his desire for the relief he needs by taking a swig of his favorite intoxicating drink.

How intense the need can become is powerfully brought home to us during Ray Milland’s Academy Award winning portrayal of Mr. Birnam, an alcoholic in the movie, “The Lost Weekend.”

Ray“Just give me a drink,” says Mr. Birnam with exquisite anguish.
The bartender, in a disbelieving voice: “Mr. Birnam, this is the morning!”
“That’s when you need it most, in the morning,” Mr. Birnam replies with disgust. “Haven’t you learned that yet! At night, it’s a drink, in the morning, it’s medicine!”

Like nicotine, regular consumers of alcohol get a pleasant relief from the sensation of drug withdrawal reactions, and it is often associated with particularly good times.

Often, it is a combination of these drugs that work together to create the illusion that they are a type of “medicine,” relieving stress and feeling an improved sense of being.

Consider Jerry Irby who tells us in his song, One Cup of Coffee and a Cigarette:

IrbyHotlineNow when I get up in the morning
And I’m feeling mighty low
There’s just one thing that will pep me up
And I want you all to know.
Well it happens every morning
No matter where I’m at
I just gotta have a cup of coffee
And a cigarette
Coffee, coffee,
And a Cigarette
Is a habit
That you can’t forget…
There is no doubt that each of the legal, illegal. and psychiatric drugs have powerful withdrawal actions that is relieved when one once again consumes them. The ceremony that medical doctors use to encourage their patients to use psychiatric drugs involves a highly respected professional describing a process in which people often report feeling better as a result of consuming their prescription.

With so called “antidepressants” the withdrawal reaction is referred to as “Antidepressant Discontinuation Syndrome.” It causes a variety of symptoms like nausea, insomnia, fatigue and achiness. Interestingly, prescribing doctors of these drugs, when the patient reports not being helped by the first prescribed drug, often will prescribe others, and even a cocktail of others until the patient reports improvement. During this time the patient might have improved without the drug but attribute feeling better to the drug.

Different people find some drugs pleasant when they first try them while others are not. I know someone, for example, who loves his cigarettes but doesn’t like how marijuana makes him feel. The process that doctors use when trying different prescriptions until one is found that the user happens to feel better on serves this illusion creating process perfectly.

Support for the theory I am putting forth comes from several studies.

People Who Get Over Depression Without “Antidepressants” Do Better Than Those Who Had Taken Them

A recent publication in the journal American Psychologist by Professor Steven Hollon neatly summarizes what I am referring to.

Depression is an inherently temporal phenomenon. Any given episode tends to remit spontaneously even in the absence of treatment but recurrence is common (at least among people seeking treatment). There is reason to believe that depression may be an evolved adaptation (like pain or anxiety) that increases reproductive fitness (the likelihood that one’s gene line will pass on). If so, then any treatment that facilitates the functions that depression evolved to serve is likely to be preferred to one that only anesthetizes the distress.  

After this opening statement, Prof. Hollon provides a more complete description of his theory:

Depression is an adaptation that evolved because it keeps organisms focused on (ruminating about) complex social issues until they can be resolved and that medications work not so much by addressing a nonexistent deficit in neurotransmitters in the synapse as by perturbing underlying regulatory mechanisms to the point that they reassert homeostatic control over those systems. If the latter is true then medications may work to suppress symptoms in a manner that leaves the underlying episode unaddressed and patients at elevated risk of relapse whenever they are taken away. 

So, I hope you will consider this theory of the illusion regarding how helpful these drugs are and please feel free to express your reactions in the comment section below.

My Best,
Jeff
———————————
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.
Categories
Insanity Mental Health Mental Illness The Rolling Stones.

The Rolling Stones On Going Insane

Welcome to From Insults to Respect. 

Those who experience what is sometimes referred to as a nervous breakdown can receive a great many insults as their behavior begins to annoy. The Rolling Stones’s hit “19th Nervous Breakdown” insightfully explores this issue.

The lyrics begin,

You’re the kind of person you meet at certain dismal, dull affairs
Center of a crowd, talking much too loud, running up and down the stairs
Well, it seems to me that you have seen too much in too few years
And though you’ve tried you just can’t hide your eyes are edged with tears

You better stop, look around
Here it comes, here it comes, here it comes, here it comes
Here comes your nineteenth nervous breakdown

The song tells us about someone who frequently, nineteen times so far, experiences what the vocalist, Mick Jagger, refers to as a nervous breakdown. I get the sense the “talking way too loud” is annoying. Mick hazards a guess in this first stanza as to what’s causing these breakdowns–seeing too much in too few years. The character in this tale is overwhelmed.

Mick, in the next verse, provides some additional theorizing.

When you were a child you were treated kind but you were never brought up right
You were always spoiled with a thousand toys but still you cried all night
Your mother who neglected you owes a million dollars tax
And your father’s still perfecting ways of making sealing wax

Early childhood experiences, such as being spoiled, a lack of motherly attention, and family financial difficulties can be significant stresses leading to a variety of emotional concerns. Supporting this line of thinking is an abundance of research evidence (see HERE, HERE, and HERE). 

Meanwhile, the pharmaceutical industry, along with psychiatrists who sold out to it, promotes the theory that these emotional concerns are due to a chemical imbalance. The right pill prescription, they claim, is the first line of treatment.

Because doctors in the physical health arena have become so respected because of many amazingly successful treatments dealing with physical health problems, doctors in the mental health arena find it easy to convince their patients to take a variety of pills. This financially rewording model continues despite years of negative research findings (see HERE). Hans S. Schroder, clinician and researcher at the Harvard Department of Psychiatry along with his colleagues, recently wrote:

“Our findings are in line with accumulating evidence that some biogenetic beliefs, like the chemical imbalance belief, are linked with poorer expectations for improvement, especially among those with the most troubling symptoms.”  

As the Rolling Stones song continues, it begins to express the exasperation that can occur when trying to help someone going through emotionally challenging experiences:

Oh, who’s to blame
That girl’s just insane
Well, nothing I do don’t seem to work
It only seems to make the matters worse
Oh, please

You were still in school when you had that fool who really messed your mind
And after that you turned your back on treating people kind
On our first trip I tried so hard to rearrange your mind
But after awhile I realized you were disarranging mine

It’s understandable how people can lose their patience with someone viewed as insane. That’s one of the reasons some people are super quick to encourage the quick fix of psychiatric drugs. However, in another hit by the Rolling Stones, “Mother’s Little Helper,” Mick doesn’t seem too comfortable with this. The song’s lyrics deal with the popularity of prescribed drugs and the potential hazards of overdose or addiction. The early part of the song tells us,

What a drag it is getting old,

“Kids are different today”
I hear every mother say
Mother needs something today
To calm her down
And though she’s not really ill
There’s a little yellow pill

She goes running for the shelter
Of her mother’s little helper
And it helps her on her way
Gets her through her busy day

We are indeed getting older, and having anxiety about this is a common useful experience, not an illness. Anxiety, when handled skillfully, motivates us to come to mature understandings about how we can live a life worth living (see HERE for a fuller understanding regarding the nature of anxiety). But when a mother goes to a doctor and expresses concerns about her anxiety, there’s an excellent chance she will have her expressed concerns translated into mental disorder language and she will leave the office with a drug prescription. That’s how the doctors make their money. How does this sit with Mick?

“Things are different today”
I hear every mother say
Cooking fresh food for her husband’s just a drag
So she buys an instant cake
And she burns a frozen steak

And goes running for the shelter
Of her mother’s little helper
And two help her on her way
Get her through her busy day 

“Doctor, please
Some more of these”
Outside the door
She took four more
What a drag it is getting old

Life has its periods of frustration. If you were brought up in a home where feeling down was viewed as something is wrong with you, it’s easy to move from that view to pathologizing such experiences. The pharmaceutical industry promotes this way of thinking with ads that depict someone feeling down, and then, following a prescription for a pill, the sun is now shining, and everyone is all smiles. There is a serious downside that comes with this approach, as the song’s next lines begin to bring into focus.

“Men just aren’t the same today”
I hear every mother say
“They just don’t appreciate that you get tired”
They’re so hard to satisfy
You can tranquilize your mind

So go running for the shelter
Of a mother’s little helper
And four help you through the night
Help to minimize your plight

“Doctor, please
Some more of these”
Outside the door
She took four more
What a drag it is getting old

Notice that two pills are no longer sufficient for these mothers. The process of addiction is underway. In the scientific literature, this process is called “down regulation” or “tolerance.” To understand this process, let’s take the example of tobacco smokers. We see evidence of tolerance to tobacco in studies that indicate fewer responses than do non-smokers to the same amount of nicotine (Perkins et al. 2001b). More specifically, we see a reduction on measures of subjective stimulation that may be viewed as pleasurable, such as arousal, vigor, and a subjective experience often referred to as “head rush” or “buzz.”

The relief that smokers feel each time they give themselves another dose of nicotine creates the powerful illusion that cigarettes help them to deal with stress. Thus, 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. Moreover, adolescent smokers report increasing levels of stress as they develop regular patterns of smoking. For those who quit the smoking habit their stress levels are reduced. Far from acting as an aid for mood control, nicotine dependency exacerbates stress. This is confirmed in the daily mood patterns described by smokers, with above average levels of stress 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 occurring between nonsmoking intervals.

drug withdrwal 1This is largely the reason why people become addicted to other substances, such as alcohol, caffeine, illegal drugs, and the drugs that psychiatrists prescribe. They all have the potential of creating for addicted people the illusion that they are functioning better than they did before they started consuming the addictive drug. During the interval when they do not take the drug they begin to experience an uncomfortable withdrawal reaction. They don’t attribute the discomfort to a withdrawal reaction, but instead, to falsely believing it is due to the return of how they would feel if they had never taken the drug.

Another part of the addiction process is that the addictive substance often is used as part of a ceremony creating a very pleasant experience. Here’s what that process is like.

Many people, when they have more than a small dose of the drug, they begin to feel sick. This keeps their intake of the drug at moderate levels. Even at these moderate levels, regular consuming of the drug tends to increase moderately the risk of negative health consequences. Nevertheless, once tolerance has been established the relief that comes from the easing of the negative withdrawal effects each time they take the drug is perceived as pleasant. Moreover, there is pleasantness from the rest of the ceremony that often involves marking the end of the work day, putting on music they love, and joining together with friends in a pleasant shared experience. In this way, people end up feeling the resulting pleasant feelings that come with this combination–the easing of the drug withdrawal process and the ceremony– is worth the minor risk of negative health consequences from the moderate use of the drug or drugs.

Although this can be an acceptable decision for many, for others, hoping they can remain moderate users of one or more of these types of drugs is disastrous, which is brought out in the last few lines of “Mother’s Little Helper.”

“Life’s just much too hard today”
I hear every mother say
The pursuit of happiness
Just seems a bore
And if you take more of those
You will get an overdose

No more running for the shelter
Of a mother’s little helper
They just helped you on your way
Through your busy, dying day

Although Mick is singing about the kinds of pills being prescribed by doctors, within the crowd of musicians he hung out with, he was witnessing some awful consequences of addiction to street drugs.

There are a variety of skillful ways to deal in a healthy manner with anxiety and its sister experiences, depression and melancholy. There are ways to make friends with these experiences.

 

Meditating once or twice a day provides an opportunity to spend time addressing concerns with little distractions. Although as we enter into meditation, we don’t do so with the intent to address concerns, they naturally bubble up from the relatively peaceful state, and our minds spend time working through our various concerns in a natural healthy manner before we become overwhelmed. Taking a walk, particularly in a place filled with nature, journal writing about concerns, and speaking to a counselor are other healthy examples.

Well, there you have it, some of my thoughts for this week provoked by two wonderful songs of The Rolling Stones.
My Best,
Jeff

——————————-

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.

Categories
conflict resolution Dealing with insults Mental Health mental health concern model Mental Illness

A Kinder Approach to Mental Health

Welcome to From Insults to Respect. Today, we take a look at the question, Can psychologists come up with a kinder, more respectful, healthier approach for dealing with the types of concerns people seek mental health services?

The current approach, often referred to as the “medical model” or the “mental disorder model,” is promoted by the American Psychiatric Association (APA), the World Health Organization (WHO) and the pharmaceutical industry. Mental health service providers, to be reimbursed for their services by third party payers, are required to select from a variety of the “disorders” listed in the APA and WHO mental disorder manuals and then place its code on the service user’s third party form. To access mental health service in an affordable manner, most service users rely on a third party payer, such as a government universal health plan or a private health insurance program.

We begin to wrestle with this question about an alternative model with some concerns about the current medical model.

Concerns about the Medical Model

Here’s a quote from my favorite psychologist and philosopher, William James:

William James

“Individuality outruns all classification, yet we insist on classifying everyone we meet under some general head. As these heads usually suggest prejudicial associations to some hearer or other, the life of philosophy largely consists of resentments at the classing, and complaints of being misunderstood.”

The various “mental disorders,” falls under the head of “diseases” in the WHO’s International Classification of Diseases. Not everyone feels at home with this. Here is one service user expressing her discomfort:

“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.”

Note that she was looking for a framework that would give her complex life positive value. We shall return to this issue shortly. But first, I think it would be helpful if I share my own concerns about the medical model.

My Experience: My original exposure to the pathologizing medical model occurred when I took a course in Abnormal Psychology as an undergraduate at Brooklyn College. Shortly afterwards, I found that my classmates began to use the new terms that they learned in the course as insults whenever someone did something they didn’t like. One person was called a narcissist, another–a manic depressive, another–psychotic, and on and on.

This insulting behavior didn’t sit well with me. As an undergraduate I had, at various times, the typical troubling emotional experiences of teenagers that could easily be framed as various mental disorders. The stigmatizing mental disorder labels being used as insults could readily be applied to me.

Then, as a PhD graduate student, I was required to take a course titled, “Descriptive Psychopathology.” There I learned that because of a vote, mental health professionals had first declared that being what they termed “homosexuality” was a mental disorder, but recently they voted to no longer view it as a disorder. Although I’m not gay and happily married to a wonderful woman, I was glad to hear this, for I had since met some gay folks and felt the psychopathologizing of them didn’t seem right. I also thought that classifying people as having a disease based on a vote, rather than on some objective evidence of an infection, tumor, organ blockage, or tissue tear also wasn’t quite right.

Then I began to read books by William James. He had advocated that mental health service providers should not take their terminology too seriously, referring to it as superficial medical talk. This viewpoint of James began as early as 1896. In his Lowell Lectures on Exceptional Mental States (which were reconstructed by Eugene Taylor in 1984 from James’s notes), the good professor stated 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.” He went on from there to note that,

“medical writers 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…. 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?

Upon graduating and serving in various roles as a psychologist, I learned about the various shortcomings of the pathologizing approach:

  1. It is stigmatizing to mental health service users.
  2. It privileges the clinician’s perspective over that of the mental health service user.
  3. It has serious reliability and validity problems.
  4. By focusing on what’s wrong with the individual it tends to miss their strengths, the complex relational context they find themselves in, and malfunctioning social structures.
  5. By framing these concerns as mental disorders it misses the fact that the greatest advances of human being has been borne out of strife. There are numerous examples that suggest the possibility that these challenging experiences often serve an adaptive function. In framing these concerns as opportunities to expand possibilities, rather than suppress “symptoms,” we could increase self-efficacy and resilience.
  6. By pathologizing psychological concerns, it promotes the use of psychiatric drugs that in many situations worsen outcomes.

Regarding this last shortcoming, I became aware that the pharmaceutical industry has had a huge financial interest in promoting the idea that psychological concerns are real “illnesses” that require drug treatments just like physical illnesses. Cosgrove, and her team of researchers have made a compelling case that this can be seen by how the industry has been exerting a great deal of influence on psychiatric research and practice, resulting in publications and news reports that exaggerate claims of its drug treatments’ effectiveness while minimizing harms. For example, the “Clinical Practice Guidelines (CPG)” for mental health services provides the “standard of care” for health care providers. The confidence in the benefits of these drug treatments, if it were free of industry influence, would be more convincing but Cosgrove’s team found,

“Ninety percent of the authors of 3 major guidelines in psychiatry had financial ties to companies that manufacture drugs which were explicitly or implicitly identified in the guidelines as recommended therapies for the respective mental illnesses. None of the financial associations of the authors were disclosed in the CPG”.

Now, I know millions of people like taking drugs, whether they be prescribed by doctors or not. So, any alternative to the medical model that interferes with this desire is going to meet with a tsunami of resistance. So, the medical model as an option to service users is likely to continue. The best we might hope for, is that third party payers that now require a mental disorder “diagnosis” also cover services under a more kinder, respectful framework.

A Proposed Alternative

For people who have come to believe the medical model is too stigmatizing, and drugging problems away is not for them, what might a more acceptable alternative look like? One idea comes from a recent study by Schroder, et al. (2023).

“We describe the historical development of popular messages about depression and draw from the fields of evolutionary psychiatry and social cognition to describe the alternative framework that depression is a “signal” that serves a purpose. We then present data from a pre-registered, online randomized-controlled study in which participants with self-reported depression histories viewed a series of videos that explained depression as a “disease like any other” with known biopsychosocial risk factors (BPS condition), or as a signal that serves an adaptive function (Signal condition) …. The Signal condition led to less self-stigma, greater offset efficacy, and more adaptive beliefs about depression.”

As we have discussed above, the medical model conceptualization of the types of concerns that is classified under the disease heading often fails to motivate active coping beyond taking a pill. Moreover, it fails to honor the labeled person’s perspective. The above study suggests that framing these concerns as a potentially healthy functional signal can lead to less self-stigma, and perhaps greater self-efficacy in making healthy life-style improvements.

Dr. Jeff Rubin

Consistent with this suggestion, in several of my earlier posts, I provide numerous examples of people who found various experiences typically labeled as “mental disorders” as helpful. For example, Joshua Wolf Shenk in his biography of Abraham Lincoln, makes the case that his depression fueled his greatness. Similarly, the music legend, Joni Mitchell, upon discussing her frequent bouts of depression observed,

Joni Mitchell

“Depression can be the sand that makes the pearl. Most of my best work came out of it. If you get rid of the demons and the disturbing things, then the angels fly off, too. There is the possibility, in that mire, of an epiphany.”

In a paper I published in the Journal of Humanistic Psychology, I describe in detail one proposed alternative that is consistent with this way of thinking. This alternative involves creating a manual for a classification system that replaces the disease overarching concept of mental disorders with mental health concerns that potentially serve an adaptive function. Those seeking mental health services would be given a choice to have their concerns addressed utilizing the pathologizing approach or the mental health concern approach. Both types of services would be equally covered by third party payers. I argued that, in contrast to the pathologizing approach, this alternative would increase the self-efficacy of individuals struggling with these concerns. Additionally, it would be kinder, more respectful, improve outcomes, provide a new choice, stimulate fresh perspectives, and open new avenues of research.

The first chapter of the manual would explain that the mental health concern approach begins from the perspective of the person seeking services. It does not classify anyone. Instead, each person is viewed as a unique individual. What is classified is the concern expressed to a mental health service provider. Then, the manual would clearly define its main overarching 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, addictions, meaning of life, death, dying, managing chronic pain, work, relationships, education, eating, cognition, sleep, and challenging life situations.”

This is an observable event that occurs at a specific time and place, and therefore avoids the reliability and validity problems of the vague definitions provided in both the APA and WHO mental disorder manuals.

Two types of data sources would be utilized to identify the list of concerns that would appear in this alternative manual. The first would come from a large sample of mental health service providers that ask them to list the various concerns that they have been asked to address in their practice in the past year without couching them in psychopathological language and to stick as closely as possible to the language used by those seeking their services. The second source would come from another survey that 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 psychopathological terminology.

Some have argued that there is no need to have any classification system. According to this argument, a “psychological formula” approach consisting of a few paragraphs describing the case without pathological labels is sufficient to replace the medical model. But note that the vast majority of current third-party payer systems do use the mental disorder codes. The codes are used in the following manner. Third party payer systems utilize forms that must be filled out whenever someone seeks mental health services under their plan. These forms typically have a little box that reads, “Diagnosis.” In that box, mental health professionals must fill in a short code that corresponds to some specific “mental disorder.”

Utilizing just the psychological formulation approach, which involves the creation of several paragraphs as an alternative to these codes, would be far too cumbersome. The concern approach, like the medical model approach, provides a short descriptive phrase coupled with a code and is therefore far more workable.

With the concern proposal, all that third-party payer institutions would need to do differently to add value for their customers is to slightly change that little “Diagnosis” box. Instead of just reading “Diagnosis,” that box would add two simple words, so it would read, “Diagnosis or Concern.” Then, when mental health professionals fill in the box, they would be given the choice to either write in the letters “D” and the code number that corresponds to the so-called diagnosis, or they would write the letters “C” and the code number that corresponds to the specific concern. imgMental health consumers would be given the choice to go to pathologizing mental health service providers or those using the concern approach. This is all the change that would be required to increase value for a significant number of mental health service users. The cost and effort for third party payers to make both the pathologizing and concern approaches available would be minimal.

Moreover, a short word or phrase that could replace terms like “major depressive disorder” or “attention deficit hyperactivity disorder” is necessary for other practical means of communication. For example, if I want to write a title for a research article, it would not be practical to insert several of the formulation paragraphs into the title. The psychological formulation approach would be far more widely used if it had some practical way of providing some standard short terms for conceptualizing an individual’s mental health concerns arranged in a valid scientific classification manual.

Some may argue that the mental health concern approach is not practical because 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 third-party payers’ costs would soar. Because third party payers made up of insurance companies and national health services only cover people with more serious conditions known as mental disorders, so the argument goes, this limits the number of people who can get to see a mental health professional. However, how do mental health service professionals honestly determine if a person has a serious enough condition to warrant “treatment?”

The process with the pathologizing approach is suppose to be as follows. When someone who expresses a concern (which is referred to as a “symptom”) to the mental health professional, the professional is to decide if the symptom arises to the vague level of “clinical significance.” Only if it does is the symptom considered serious enough to warrant a “mental disorder diagnosis.”

I have been a PhD level psychologist for over forty years. Not once have I heard of an occasion in which an individual who made an appointment for mental health services and then showed up for it, leave the appointment without a mental disorder diagnosis. This intuitively makes perfect sense because mental health professionals are in the business of increasing the number of their clients. Given that they have over 300 vaguely described “mental disorders” to choose from, and the only way they will get paid for their services is to declare that the person seeking services has a “clinically significant” disturbance, who can doubt that no one is turned away.

The professional status of the service provider leads the public to think something more serious has been established when a diagnosis is declared. Although it is true that some expressed concerns are more serious than others, a mental disorder diagnosis is not indicative of this.

So, the alternative “Mental Health Concern” approach more honestly describes what is actually going on in easy to understand language. It is one proposal for a more kinder, respectful, and healthier way for people to have their expressed concerns addressed by a mental health provider and covered by third party payers. Criticism of this approach and suggestions for some other alternatives are highly encouraged.

My Best,
Jeff
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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.
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conflict resolution CSM Diagnostic and Statistical Manual of Mental Disorders-5 Mental Health mental health concern model

Alternatives to Psychiatric Diagnoses

Welcome to From Insults to Respect.

Dr. Jeffrey Rubin

From time to time I have written about the growing lack of respect for the current manner in which people seeking to obtain mental health services are treated. Particularly upsetting to many is the requirement that they be labeled as having a mental disorder.

This labeling process relies on descriptions provided in the Diagnostic and Statistical Manual of Mental Disorders–Fifth edition (DSM) and the International Classification of Diseases–Tenth edition (ICD). Both are manuals that are conceptually similar, utilizing as their core concept, mental disorders, and both share the same “diagnostic” codes. Because of their similarities, I will simply refer to them as the DSM/ICD approach.

Many professionals defending the use of this approach explain that it provides a common language for mental health professionals to communicate about those utilizing their services; its various classification terms, such as major depressive disorder, anxiety disorder, and so on, are short phrases that are convenient for placing into titles and search engines, and for efficient/streamlined communication in high-speed hospitals and clinics; third-party payers of mental health services have found that their coding system works well as part of a practical method for their record keeping; with the aid of these codes, people manage to access mental health services, mental health service providers manage to get paid, and for-profit health companies tend to make a profit.

Unfortunately, there are a number of serious weaknesses with this approach. It tends to be stigmatizing to mental health service users. The lack of reliability and validity of the various so called diagnoses violate basic principles of science. The process of coming up with a psychiatric label privileges the clinician’s perspective over that of the mental health service user. It ignores the fact that many people who have been labeled with these stigmatizing psychiatric terms come to realize that the experiences which led to their seeking services, rather than being an indication of a pathological condition, are really an essential element to their creative development. Many have also expressed concerns about the “mental illness” terminology which medicalizes mental health concerns, thus leading to an incredible number of people being prescribed psychiatric drugs, the use of which leads to numerous serious side effects.

Just as I was writing this post, major news outlets began to report that researchers found nearly a 50% increased odds of dementia for those taking the most popular drugs for treating depression and other mental health concerns. Although the study could not prove conclusively that these drugs caused the increased risk of developing dementia, because these same drugs had already been linked to confusion or memory issues, the new evidence is deeply troubling. The researchers expressed concerns that if this association is causal, it “would equate, for example, to around 20,000 of the 209,600 new cases of dementia per year in the United Kingdom.” With the population of the US being 6 times larger, this could mean that over 100,000 cases of dementia may be attributed to these drugs every year here in my own country.

Adding fuel to these types of concerns about negative effects of ingesting these drugs are the recent findings indicating that despite the fact that more Americans than ever are being prescribed so called antidepressants, the rate of suicide has climbed to an all-time high. Is the increased use of antidepressants causing this increased rate of suicide? Although definitive evidence is not yet available, it is a well known research finding that these drugs do increase the risk of suicidal thinking in many patients.

Meanwhile, the DSM/ICD approach has created a monolithically wealthy pharmaceutical industry, with all of the drawbacks associated with such institutions.

Given these problems, an international effort has been seeking to come up with some reasonable alternative that could provide all of the perceived practical benefits of the DSM/ICD approach, while having significantly fewer shortcomings. As part of this effort, I have come up with one alternative proposal which I discuss most extensively in a peer reviewed article published in a 2018 volume of the Journal of Humanistic Psychology (see HERE). Today, I shall summarize my approach, and then we’ll look at some of the published discussions on this topic that have come out after my article first appeared.

A Summary of My Approach

My proposed alternative to the DSM/ICD approach calls for the development of The Classification and Statistical Manual of Mental Health Concerns (CSM). In contrast to the DSM/ICD approach’s overarching concept of “mental disorders,” the CSM’s overarching concept is “mental health concerns.”

The CSM approach begins with a full recognition that individuality outruns any classification system. It is for this reason that the CSM does not classify anyone. Instead, it classifies the expressed concerns of individuals seeking to have their concerns addressed by a mental health service provider. 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, death, dying, managing chronic pain, addiction, work, relationships, education, eating, cognition, sleep, and challenging life situations.

Classifying the expressed concern would provide mental health service providers a common language that is helpful when communicating among other professionals. So, a professional might say to a colleague something like, “My 9:00 a.m. case is concerned about feeling depressed, my 10:00 case is concerned about his failing grades, my 11:00 case is concerned about how anxious she is in social situations.” Such communications are straightforward and easy to understand, not only for professionals, but for the general public as well.

Each expressed concern listed in the CSM would be a sufficiently short phrase so that it can be conveniently used in titles and search engines to retrieve valued relevant information. Along with each classified expressed concern, there would be a numerical code that would be convenient for third-party payer bureaucratic record keeping.

The CSM, in addition to coming up with a brief label for the expressed concern and a code for third party payers, describes a collaborative approach between the person expressing the concern and the mental health service provider for creating a psychological formulation narrative of a few paragraphs that eschews the DSM/ICD pathologizing jargon. This process involves 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, cultural heritage, 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?” This formulation is not something that is shared with third party payers of mental health services, but is utilized exclusively by the mental health service user and service provider.

With the CSM approach, no one is viewed as mentally ill, having a mental disorder, or having some psychopathological condition. Instead, it highlights that the progress of society is due to the fact that individuals naturally vary from the human average in all sorts of directions, that the originality is often useful, while, at the same time, being different can create a variety of concerns. Moreover, some people become concerned about how they are handling enormously stressful and traumatic experiences. Still others are living in unhealthy ways, such as making unhealthy choices in what they consume, or getting insufficient exercise. Mental health professionals, with the CSM approach, are viewed as seeking to address these types of concerns that arise from these conditions in a supportive setting while relying on a variety of wisdom traditions. Central to this approach, is an honoring of what Ralph Waldo Emerson referred to as the grand sweep of humanity.

Compared with the DSM/ICD approach, the use of the CSM would be less stigmatizing, more respectful to those seeking services, and more practical because of the ease of understanding the words and phrases that it utilizes. Moreover, it would be more consistent with principles of science because instead of using as its core concept the vaguely defined “mental disorders,” the CSM uses as its core concept “mental health concerns,” which is a clearly recognized event that occurs at a specific time and place. Finally, the CSM approach would provide a new choice to both mental health service users and providers, challenge old ideas, stimulate fresh perspectives, and open new avenues of research.

The Latest Discussions

Since my article on the CSM was published, the Journal of Humanistic Psychology (JHP), in its May 2019 issue, has several articles that discuss my approach as well as a few others. Let’s take a look at some of what was said, and as we do so, I’ll share a few thoughts about my reaction.

In an article titled, “What Might an Alternative to the DSM Suitable for Psychotherapists Look Like?” Jonathan D. Raskin notes that recent surveys of psychologists and counselors indicate they are dissatisfied with the DSM/ICD approach and are interested in coming up with alternatives better suited to their professions. Nevertheless, more that 90% said they will use the DSM/ICD; after all, that is how they get paid by third party payers.

What would be a better alternative for psychotherapists and counselors than the DSM/ICD approach? According to Dr. Raskin, it would have to be a system that allows them to contextualize psychosocial and biological aspects of human suffering in a more nuanced manner. And then he writes,

Dr. Jonathan D. Raskin

“Jeffrey Rubin (2018) has proposed that we classify concerns that clients bring to therapy, not disorders they have. Identifying concerns is very different from identifying disorders. Concerns are things such as feeling anxious about one’s job, unhappy about one’s marriage, emotionally distraught about past abuse, or unable to move past what one witnessed while fighting in a war. The current diagnosis system encourages clinicians to translate these concerns–which are clearly contextual and not reducible to biology alone–into disorders that afflict people. But therapists and counselors do not actually treat disorders. Instead, they talk to people about their concerns–some of which are quite serious and lead to extremely challenging and intransigent difficulties.”

To Dr. Raskin, any alternative to the DSM/ICD approach must be a better fit with what therapists and counselors actually do. The CSM approach admirably achieves this.

In a commentary on Dr. Raskin’s article that appears in the same JHP issue, Rachel Cooper, a senior lecturer in philosophy at the United Kingdom’s University of Lancaster, and author of Diagnosing the Diagnostic and Statistical Manual of Mental Disorders, puts in some of her own thoughts on this topic.

She begins by agreeing with Dr. Raskin that most psychologists and counselors would be keen for an alternative classification to be developed. She then reviewed research indicating that social workers should be included among the professionals unhappy with having to use the DSM/ICD approach. In surveys, most indicated they would not use it if it was not required for insurance purposes.

Despite this finding, Dr. Cooper expresses pessimism about any alternative becoming accepted for funding psychotherapy via health care insurance. Among the factors that make it particularly challenging is the marketing of psychopharmaceuticals, which heavily promotes the idea that certain drugs treat the specific conditions listed in the DSM and ICD. The sum of money being acquired with this approach, she points out, makes producing a competitor classification far beyond the reach of most organizations.

She then refers to my CSM approach, stating that I suggest that insurance companies could be persuaded to pay for “Mental Health Concerns,” as they would readily come to understand, with a little explaining, that mental health service providers now using the current DSM/ICD approach do not turn anyone away who has mental health insurance coverage and comes to their office expressing what the CSM refers to as a mental health concern. She then writes,

“I think that Rubin’s optimism is misplaced. The fact that some (but by no means all) therapists currently get away with recording DSM diagnoses to facilitate payment even in cases where a diagnostic criteria may not be met will not be news to insurance companies. It is a practice that insurers have long known about and usually try to prevent. I think it unlikely that insurers would easily agree to cover Rubin’s ‘Mental Health Concerns.'”

First of all, when Dr. Cooper says insurance companies usually try to prevent mental health providers from recording diagnoses to facilitate payment even in cases where a diagnosis criteria is not met, I strongly disagree with her. I’ve never in my entire career heard of an insurance company questioning a diagnosis, and on what basis could they possibly do so? Insurance funders are not present in the room when a so called diagnosis is made. All that they get as documentation for a given diagnosis is a code indicating the diagnosis.

Moreover, the ICD actually encourages mental health professionals to come up with a diagnosis when criteria are not met. Thus, it states, “When the requirements are only partially fulfilled, it is nevertheless useful to record a diagnosis for most purposes” (WHO, 1992, p. 8).

I do agree, however, with Dr. Cooper when she says that getting the change that I have been advocating for is not going to be easy. Nevertheless, I believe we–professionals, service users, and service users’ relatives and neighbors–have a responsibility to try. Moreover, I have been encouraged by the steady increase in the influence of mental health service user advocacy groups who are becoming more and more vocal about the need for their members to be treated respectfully. And whenever I am invited to speak to professional organizations about the CSM approach, the rousing applause that I receive at the end of my presentation, along with the positive comments from audience members afterwards, keep my hope alive.

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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.