Dr. Thomas Szasz and Psychiatric Name Calling

Post author By Dr. Jeffrey Rubin
Post date November 17, 2014
1 Comment on Dr. Thomas Szasz and Psychiatric Name Calling

On this blog, one of the main topics of discussion is name calling. And, from time to time, some people have asked me what I think of the types of names psychiatrists use to talk about their patients.

In response, I wrote a post titled Name Calling by Psychiatrists: Is it Time to Put a Stop to it? It stirred up a great deal of interest, and the various comments led me to write several follow-up posts. While all of this was going on, several people asked what I thought of the psychiatrist, Thomas Szasz. And so, today’s post at least begins my reply.

It was 45 years ago when I first heard of Dr. Szasz. I was about 19 years old, it was the late 1960s, and I was taking an Abnormal Psychology course as an undergraduate student at Brooklyn College. Professor Meyers presented a whole class on Dr. Szasz’s recent book, The Myth of Mental Illness. It was a time when many of us were raging against the Vietnam War. Questioning all authority went right along with that, and so Szasz’s position, for me, fell right into that general mindset.

Labeling a child as mentally ill is stigmatization, not diagnosis. Giving a child a psychiatric drug is poisoning, not treatment.--Dr. Thomas Szasz. — Labeling a child as mentally ill is stigmatization, not diagnosis. Giving a child a psychiatric drug is poisoning, not treatment.–Dr. Thomas Szasz.

After the course had ended, I really didn’t think much about Szasz’s ideas again until about 15 years later. I was working with youth in the Corning, New York area, when I began to notice a dramatic increase in the number of young children and teenagers being prescribed psychiatric drugs. At one point, five straight foster children that were brought to me for counseling not only were taking a psychiatric drug, but were taking several of them. Those students typically were unhappy about this, complained about serious side effects, and when I went to the library to check out the various risks associated with their use, I became very concerned.

To address my concern, I began to organize a debate on the use of these drugs, and the first person I thought to call was Dr. Szasz. He was very helpful, agreed to debate the topic, and the debate created so much interest that other people began to ask me to help organize similar debates in their communities. In the end, that single debate turned into a series of seven debates.

I learned a great deal from all of the participants, but it was Dr. Szasz who most challenged my thinking. Although I disagree with some of his ideas, I admire his guts for standing up for what he believed, his humor, and his extraordinary intelligence.

Thomas Szasz passed away a couple of years ago at the age of 92.

A great deal of Szasz’s writings and ideas are readily available on line (see for example the article on Wikipedia). Nevertheless, to give my readers a little sense of his ideas, I am providing below a little snippet of his opening remarks from one of the debates that I helped to organize. It is slightly edited because he was not the first speaker during the debate and some of his comments alluded to remarks that someone else had said earlier during the proceedings. Without having heard these other remarks, Szasz’s comments would be hard to follow, so I edited them out. This gives his comments a slight disconnected feel at times, so I ask that you not blame him for that.

And so, without any further ado, I give you, Dr. Thomas Szasz:

Portrait of Dr. Szasz that hangs in the medical library at the SUNY Upstate Medical University

Ladies and gentlemen…. I would like to take this time to present my views of psychiatry ….

I believe…ideas have consequences. Words only mean what we do about them. They do not have abstract meaning. So the question is what do we mean when we say something is a disease?

Now to me, psychiatry doesn’t have to do with diseases at all. Just like, to me, communism doesn’t have to do with ideas.

Communism was symbolized by a bunch of stones called the Berlin Wall. But what it actually meant is that if you lived in a communist country, you can come in, everything was fine and you were told everything was wonderful for you, but if you tried to leave you found that they shot you, that you couldn’t get out. This is what happens in a mental hospital. You can get in, but you can’t get out….

Psychiatry is a branch of the law, it has alway been, and always will be… To me, psychiatry is coercion. I have always said, I support psychiatry between consenting adults… I am only interested in involuntary aspects of psychiatry.

For the sake of the argument, I don’t believe this, but for the sake of the argument, to make my argument clear, let’s say schizophrenia is a brain disease, just like cirrhosis is a disease of the liver. If we accept this and treat it like other diseases, then psychiatry disappears. It would then be treated by a brain doctor. The insanity defense disappears. Involuntary psychiatry disappears. If somebody kills somebody they are tried like everyone else. There are no psychiatrists lining up to testify to say Prozac causes murder, or mental illness causes murder, or everything causes murder except free will.

Ok,… let me give you two English sentences. The statement Jones is bleeding, is a statement about his body. The statement that Jones is boasting is a statement about Jones. They sound like the same type of statement, but they are not. The question, what do we mean by schizophrenia. Do we mean that they are a type of lesion, or do we mean, behavior. How does someone first diagnose someone with schizophrenia—from his body, or his behavior?

Let’s assume the person has a disease. The person is still behaving, the person is still a moral agent. Patients, from a moral, legal point of view, are exactly like non-patients. If I have asthma, Parkinson, etc., I can still behave. When people have Parkinson and they shoot somebody, they are responsible, if they are nice to their wives, they get along, if they are not so nice they get a divorce and so on.

Now we come to some more issues. Supposing someone claims that someone has a disease. On whose authority do we take this? In my lifetime, great authorities have maintained homosexuality was a disease. When I was in the US Navy 30 years ago, that was one of the major ideas of the service was to single out homosexuals, who were then given diagnoses by psychiatrists. This was viewed as a serious disease. Now, on the cover of Time we find that they are entitled to civil rights. What happened to their disease?

Not only was homosexuality a disease, so was being black according to an early psychiatrist, Benjamin Rush. According to him, blacks were blacks because they had a form of leprosy. On whose authority did he claim this? On the authority that he is a doctor?

Now we are shown pictures of brains and told that they prove that schizophrenia is a disease. On whose authority? The fact is that no pathologists diagnose anyone as schizophrenic based on any pictures of someone’s brain, or any other medical test. Even on postmortem, when the patient said to be schizophrenic dies the pathologist says no disease was found. The same thing with depression…

The discussion of who has a mental illness is based on judgements of a person’s behavior. So this idea that you can have a brain disease, like schizophrenia, is a little strange. Let me just give you a few questions to stimulate you. What would asymptomatic depression look like. Now we know what asymptomatic hypertension is, or asymptomatic leukemia,… but what is asyptomatic depression? Better yet, what is asyptomatic schizophrenia? What would that be. Or asymptomatic Judaism, or Christianity. These are behaviors. If the behavior is not there it is not here….

My time is nearly up, so let me leave you with a couple of questions. Please listen carefully because this is a question and a joke. If somebody has a delusion of having cancer, then he has a mental illness, right, because he doesn’t have cancer? What would it mean if he has a delusion of being mentally ill?

Okay, now to the issue of saying someone has a mental illness which is due to some biological basis. This is nonsense because everything we do has a biological basis… The most ordinary things are biological bases, namely eating and sex, called hunger and lust. These are not diseases. And just because they have a biological basis that doesn’t mean that you have to act. Urination and defecation have a biological basis. These are powerful impulses that have a biological basis but that doesn’t mean we have to do it in the middle of the living room…. Life begins with responsibility and ends with responsibility…. Psychiatry is a discipline that undermines responsibility. Thank you.

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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 free social intelligence and emotional intelligence curriculum, insults, mental disorders, mental illness, name calling, negative criticism, psychiatry, Thomas Szasz

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ADHD and the Wisdom of William James

Post author By Dr. Jeffrey Rubin
Post date November 10, 2014
6 Comments on ADHD and the Wisdom of William James

Last week’s post, titled ADHD and Psychiatric Name Calling, criticized the prevalent practice of converting concerns about a person’s ability to pay attention into medical lingo. There was a great deal of interest in the post so I decided to present another for your consideration.

As I began to craft this, my thoughts went back to my most popular post, Teaching Children How to Deal with Criticism. Since the major reason for its great success is that its ideas largely relied on those of William James, I went back to the great philosopher’s writings to see what he had to say on the ADHD subject.

There is unquestionably a great native variety among individuals in the type of their attention. Some of us are naturally scatterbrained, and others follow easily a train of connected thoughts without temptation to swerve aside to other subjects. This seems to depend on a difference between individuals in the type of their field of consciousness. In some persons this is highly focalized and concentrated, and the focal ideas predominate in determining association. In others we must suppose the margin to be brighter, and to be filled with something like meteoric showers of images, which strike into it at random, displacing the focal ideas, and carrying association in their own direction. Persons of the latter type find their attention wandering every minute, and must bring it back by a voluntary pull. The others sink into a subject of meditation deeply, and, when interrupted, are ‘lost’ for a moment before they come back to the outer world.

The possession of such a steady faculty of attention is unquestionably a great boon. Those who have it can work more rapidly, and with less nervous wear and tear. I am inclined to think that no one who is without it naturally can by any amount of drill or discipline attain it in a very high degree. Its amount is probably a fixed characteristic of the individual. But I wish to make a remark here which I shall have occasion to make again in other connections. It is that no one need deplore unduly the inferiority in himself of any one elementary faculty. This concentrated type of attention is an elementary faculty: it is one of the things that might be ascertained and measured by exercises in the laboratory. But, having ascertained it in a number of persons, we could never rank them in a scale of actual and practical mental efficiency based on its degrees. The total mental efficiency of a man is the resultant of the working together of all his faculties. He is too complex a being for any one of them to have the casting vote. If any one of them do have a casting vote, it is more likely to be the strength of his desire and passion, the strength of interest he takes in what is proposed. Concentration, memory, reasoning power, inventiveness, excellence of the senses,–all are subsidiary to this. No matter how scatter-brained the type of a man’s successive fields of consciousness may be, if he really care for a subject, he will return to it incessantly from his incessant wanderings, and first and last do more with it, and get more results from it, than another person whose attention may be more continuous during a given interval, but whose passion for the subject is of a more languid and less permanent sort. Some of the most efficient workers I know are of the ultra-scatterbrained type. One friend, who does a prodigious quantity of work, has in fact confessed to me that, if he wants to get ideas on a subject, he sits down to work at something else, his best results coming through his mind-wanderings. This is perhaps an epigrammatic exaggeration on his part; but I seriously think that no one of us need be too much distressed at his own shortcomings in this regard. Our minds may enjoy but little comfort, may be restless and feel confused; but it may be extremely efficient all the same. (quote from William James’s Talks To Teachers)

Here we see a true master at work. His sublime summary of the concern, placed in the context of other faculties working together, always lead me to vivid images of the many students I worked with over the years who had little ability to sustain their attention on school work and yet far outperformed outstanding students in such areas as music, athletics, art, computer technology, business, etc. Rather than framing the concern as a disabling mental disorder, James paints a vision that inspires the hope of finding a way to create a life filled with substantial value.

The one assertion that I tentatively disagree with James is that a person’s attention span is probably a fixed characteristic of the individual.

I have regualarly seen children who had a below average ability to attend to school work who, as they grew older did much better. Some of them got over a particularly stressful period in their life. Others learned the value of more physical activity which tired them out, and they began to sleep more soundly. Others seemed to improve for no other apparent reason than becoming more mature.

From my own experience, I found that when I learned to meditate, my ability to sustain my attention on a number of subjects distinctly improved. There are some excellent research studies that back up my own personal experience. For an example, that also reviews several of the other available studies, check out “Intensive Meditation Training Improves Perceptual Discrimination and Sustained Attention” (Psychological Science, Jun 2010; 21(6): 829–839.) Readers of my blog can find a simple to learn, absolutely free, form of meditation in my post “Anger, Rumination and Meditation.”

Let me add here, that in our society there is a push by the pharmaceutical companies to get people viewed as having ADHD to take stimulant drugs like Ritalin or Adderall. These have a number of negative side effects, and in a fairly short period of about a month or two the initial positive effects wane, and those using these drugs are left with the illusion that the drug continues to be helpful. The illusion occurs because once the positive effects wane after a few month of regular use, when the stimulant users don’t take the drug, they begin to have a withdrawal reaction that is uncomfortable and reduces their ability to pay attention. When they then again take the drug, the relief they experience from the withdrawal reaction convinces them that the drug is helping them. Instead, they are left with no better ability to pay attention while experiencing the various side effects of the drug.

Okay, so there are a few more ideas about concerns that come up about someone’s attention. I hope you find them to be helpful.

As always, I encourage readers to join the conversation by making comments in the “Comment” box at the very bottom of this page.

My very best,

Jeff

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Tags A.D.H.D., ability to pay attention, ADHD, meditation, William James, wisdom

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ADHD and Psychiatric Name Calling

Post author By Dr. Jeffrey Rubin
Post date November 3, 2014
13 Comments on ADHD and Psychiatric Name Calling

Recently I published a 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 soon followed with a post titled “Psychiatric Name Calling: Is it Helpful?” Having thus raised some questions concerning the whole range of psychiatric labeling practices, today I’ve decided to focus in on just one of its most popular so called diagnosis–ADHD.

ADHD: A Huge Loss to Society

Gambling institutions well know that it is not hard to disguise losses as wins. For example, it is common in modern video slot machines that players are encouraged to bet on multiple play lines and follow any winning combination with flashing lights and high-fidelity audio, even when the amount won is less than the amount wagered. There are, of course, some who catch on to this gimmick. As one man noted, “I eventually realized that if I kept on winning, I was going to go broke.” A similar disguise is occurring with the ADHD situation.

In the spring issue of The Journal of Mind and Behavior, I found a relevant article by Lincoln Stoller titled “ADHD as Emergent Institutional Exploitation.” It documents that an estimated $3.6 billion was spent annually on ADHD drug treatements with the hope that this would help those students with an ADHD label do better in school. The drugs do create some flashing lights and audio sounds of delight from short-term effects of the drugs. And yet in terms of real life important outcomes for the students who are being placed at risk of a number of serious side effects, in the long term the drugs lead to more losses than gains. I well understand that many fine, well-meaning and intelligent people strongly disagree with me on this. Let’s look at the research.

The NIMH Multimodel ADHD Treatment Study (see HERE) is the largest study ever carried out, involving 6 study sites, millions of dollars, nearly 600 elementary school children, ages 7-9, randomly assigned to one of four treatment modes: (1) medication alone; (2) psychosocial/behavioral treatment alone; (3) a combination of both; or (4) routine community care. The results were initially written up as a big success for the ADHD drugs because in the short term, those taking the drugs did appear to do somewhat better on some outcome measures. But by the end of 14 months of treatment, no significant differences were found between those who had taken the drugs and a similar group who did not take them in terms of improved behavior and academic achievement.

In a recent Canadian study, those who took the drugs actually did significantly worse than those who didn’t. And other studies (see this article for review) indicate that by the time ADHD-labelled students reach the age that most students graduate high school, they do no better if they had taken ADHD drugs than a similar set of students who had not taken the drugs. High school average, high school graduation rates and performance on achievement tests were the same for both groups. But for each student taking the drugs, side-effects were endured and thousands of dollars spent on prescriptions.

And so, at some point it makes sense to start asking if a temporary improvement in school, which washes away by 14 months, is worth $3.6 billion? The pharmaceutical industry, like gambling institutions, well know that it is not hard to disguise losses as wins.

A Recent New York Times Article

Not long ago in the New York Times an article by Dr. Richard A. Friedman appeared titled “A Natural Fix for A.D.H.D.” There, the author states, “people with A.D.H.D. may not have a disease, so much as a set of behavioral traits that don’t match the expectations of our contemporary culture.” To defend his position, Dr. Friedman points to the fact that in schools, which tend to be regimented, require a great deal of sitting time, and lack much choice at what someone wants to be doing at any given time, the attention problems are far more prevalent than with adults who often have some choice at what career they go into.

For example, a patient of his, a 28-year-old man,

was having a lot of trouble at his desk job in an advertising firm. Having to sit at a desk for long hours and focus his attention on one task was nearly impossible. He would multitask, listening to music and texting, while “working” to prevent activities from becoming routine.

Eventually he quit his job and threw himself into a start-up company, which has him on the road in constantly changing environments. He is much happier and — little surprise — has lost his symptoms of A.D.H.D.

My patient “treated” his A.D.H.D simply by changing the conditions of his work environment from one that was highly routine to one that was varied and unpredictable. All of a sudden, his greatest liabilities — his impatience, short attention span and restlessness — became assets. And this, I think, gets to the heart of what is happening in A.D.H.D.

Although Dr. Friedman does a good job questioning the value of viewing ADHD as a mental disorder, he does throw in a plug for using ADHD drugs on children. Thus he says:

What are the implications of this new research for how we think about and treat kids with A.D.H.D.? Of course, I am not suggesting that we take our kids out of school and head for the savanna. Nor am I saying that we should not use stimulant medications like Adderall and Ritalin, which are safe and effective and very helpful to many kids with A.D.H.D.

In actuality, the effectiveness of these types of medications are very much in question because, as I have already pointed out, their effects soon wash away as tolerance to them develops. Meanwhile a great deal of money has been wasted.

As far as his statement that these drugs are safe, among the common side effects are high blood pressure, chronic trouble sleeping, feelings like throwing up, upper abdominal pain, and head pain. Moreover, there are a number of far more serious problems that, although rare for any individual child, nevertheless, because of the current policies that lead to several million children being placed on these drugs, thousands of our youth end up experiencing awful tragedies.

The world benefits from having people with a variety of interests, skills and talents. Schools tend to push people into too limited an environment despite the diversity of people who come through its doors.

Additional Research

There is research that demonstrates that many students who are given the ADHD label do far better if they are given opportunities to run around a few extra times during the school day, but most schools are cutting out more and more recess time to squeeze in more seat time for learning. Many kids given the ADHD label tend to be the youngest in their class. Because everyone in a class is expected to do the same level of school work in any given class, the youngest begin to stand out, and are identified more as “ADHD” kids.

Other research indicates a strong association between an ADHD label and sleep problems. These problems occur in part because some people are not morning people and like it or not, school begins early.

Should being a person who doesn’t function as well in the morning be considered a disease? In some settings, the fact that there are people who would prefer to work a later shift is an enormous plus, but for those in school, name calling and drugging is viewed by the authorities as making sense.

Some people who have sleeping problems have other real problems that contribute to their sleeping woes such as parents fighting, stress from community violence, bullying, serious financial problems, and on and on. In such cases, doesn’t it make sense to view the students as having difficulty coping with difficult environmental conditions rather than having a mental disorder?

Are Genetics the Cause?

The pharmaceutical companies love to promote genetic studies that appear to demonstrate that ADHD is a real disease. Since they fund so much of the media’s advertisement business they greatly influence what gets coverage in newspapers, TV and internet stories. Results are initially exaggerated and splashed all over the headlines. Then, when the real facts start to appear, you have to dig into the bowels of research libraries to find them.

A great example of this occurred when a 2010 study was heralded as being the first to find direct evidence that ADHD is a genetic disorder. As Lincoln Stoller tells the story:

Thapar, who is one of the authors, is cited in a press release preceding publication of the article as saying: “Now we can say with confidence that ADHD is a genetic disease and that the brains of children with this condition develop differently to those of other children” (Walsh, 2010)…. Thapar implies that those who differ from the norm are necessarily inferior.

Once the study was actually published it showed that 85 percent of those labelled as having ADHD had no discernible genetic difference from those without ADHD. Shortly after the study was published, it was found that it did not control for differences in IQ. By removing from the study students who had IQs below 70, the results indicated that about 90 percent of students with ADHD in the study had no discernible genetic difference. Finally, in a subsequent paper, two of the original authors of the study stated, “gene variants still explain only a small percentage of the inherited component of ADHD.”

Although the original press released got a great deal of attention in the media, the press was silent as the more accurate information surfaced.

Conclusion

Because people have differences, whether genetic or otherwise, this does not mean they have a disease. For example, if great singers have a genetic difference than the rest of us, this doesn’t mean they have some sort of disease. And for those of us who perhaps have some genetics that has led us to sing less than average, we need not view ourselves as diseased. We can, instead, seek to find other situations in which we can make ourselves useful. The same holds true for those who find that in some situations their minds wander more than others.

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Tags A.D.H.D., Adderall, ADHD, ADHD Treatment, mental disorders, mental illness, psychiatric disorders, Ritalin

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Exaggerating the Benefits of Anger

Post author By Dr. Jeffrey Rubin
Post date October 29, 2014
7 Comments on Exaggerating the Benefits of Anger

“Are you going to vote for the new school facility plan, Marc?”

“No, Phil. It calls for combining the two high schools in our town so that there will be nearly 2,000 students in the combined school. I prefer small schools. I say, keep them small, keep them personal.”

Turning red and glaring into Marc’s eyes, Phil begins to holler, “What are you, stupid? We can’t afford two high schools in this town. You’re nuts!”

The next day. “Hi Marc, you still going to vote against the combining the two high school plan?”

“You know, Phil, I’m hesitant to discuss anything with you. You get angry and you begin to put me down and you start with the glares….”

“Oh, don’t be a baby, Marc. Don’t you know that anger is a good thing. Research shows it can make us push on towards our goals in the face of problems and barriers. And hiding anger in relationships can be detrimental. When you hide your anger, your partner doesn’t know they’ve done something wrong, so they keep doing it. That doesn’t do your relationship any good. There’s also some evidence that anger can be useful as a negotiation strategy. If people see that you are angry, studies show that the other party will make more concessions.”

Now, it is not hard to understand why Phil, and others, might make such statements about anger. After all, if you go on the internet and glance at some of the articles that come up in search engines when we insert in the search box the words, “benefits of anger,” people can get a similar impression as Phil. There is, for example, “The Upside of Anger: 6 Benefits of Getting Mad,” or “When Anger is a Plus,” etc. However, a careful reading of the actual research studies lead one to dramatically different conclusions.

The two biggest mistakes that people make when interpreting the research on this topic is, 1. not taking a good look at what the expression of anger is being compared with, and, 2. not noticing how broadly the term anger is defined. Let’s focus quickly on these two types of mistakes.

Not Taking a Good Look at What the Expression of Anger is Being Compared With

If people only told their partners in their relationship what they feel he or she did wrong when they become angry, then there probably are times when the expression of anger might do more good than never saying anything. In such studies, comparing the expression of anger with saying nothing is, in my opinion, potentially misleading. People can learn to provide negative criticism in a far more helpful way than what we typically call anger (see my post titled “Providing Negative Criticism: Five Levels of Maturity“).

For the negotiation studies that found that people who became angry did fairly well compared to some other subjects who did not become angry, again let’s look at what “becoming angry” was compared to. Those who didn’t become angry really didn’t care all that much about whether or not they obtained the reward. They did make some halfhearted effort to achieve it, but then quickly gave in. Those folks who were confronted with someone who was angry and ended up settling for something that was less than what they would have settled for if they were confronted by someone who was not angry, also had little of real value at stake. They were also given extremely few options to use in the negotiation. Under these types of situations, a person might prefer to give the other party, if he or she becomes angry, a little more than they might otherwise do rather than to put up any longer with what felt to them like abuse.

What would have happened if the study would have compared not only a group of people who portrayed anger during the negotiation process with a group who didn’t, but also looked at a group of individuals who were well trained to respond to negotiation situations with “challenge?”

Challenge allows you to accomplish all of what anger positively does without anger’s negative consequences.

In brief, challenge has us:

Working up a heightened sense of determination to achieve our desire
Meanwhile, we consider the twin beliefs that the stress we have been experiencing is normal and fulfillment is not found in easy comfort, security, and routine, but rather in the continual growth in wisdom through what is learned from negative and positive experiences of an active, changing life[1]
Then, we take a deep breath and resolve to get down to the task at hand—carrying out a two-step process.

Step 1. Consider if the most obvious resolution is sufficient.

In such cases in which you become convinced that the resolution that you came up with poses no serious risks, it makes sense to you, and you feel comfortable with it, the only job you have left is to carry out your plan with charm, courage, and determination. However, if the most obvious solution does pose a serious risk, or you just don’t feel comfortable with it for any reason, it’s time to go to Step 2.

Step 2. Carrying out a more complete decision process.

There are numerous benefits that occur when we learn how to transform anger into challenge. Just becoming angry is, of course, far easier in the short term, but excellent studies demonstrate that those who learn to respond to difficult situations with challenge, in the long run do far better than either just becoming angry or making halfhearted efforts.

Learning to respond to anger-arousing situations with challenge takes some practice, but it can be achieved with practice. You can find free practice sessions HERE, and HERE, and HERE.

Moreover, a great way to learn how to transform anger into challenge is to read the “Cool Steve” trilogy, a series of three novels that portrays a coming of age tale that takes psychological suspense to new heights and sophisticated humor to new lows. Struggling to find respect, our hero faces many of the same struggles we all faced while growing up, and a few not so typical ones as well. Mistakes are made, but in the end, the value of challenge is portrayed in a manner you will long remember.

And so, either to respond with anger or not to respond with anger are not really our only two choices. Not responding with anger actually involves many different choices and one of them, transforming anger to challenge, is one of them, and a distinctly better choice than giving free range to anger.

Not Noticing How Broadly the Term Anger is Defined

In seeking to understand studies that seem to suggest that anger can be beneficial, it helps to look at how anger is defined in those studies. In one study that seems to suggest anger is helpful, the authors make a distinction between constructive anger and destructive anger. They then explain that it is constructive anger that can be beneficial. What they call constructive anger is responding to frustration without name calling or shouting, but with determination to achieve a goal. This sound to me more like challenge than anger.

In another study that talks about the benefits of anger, it was actually mild frustration that was beneficial in increasing motivation to achieve a goal. Despite this, as the authors wrote up the study results they claimed that frustration was a lot like anger, and therefore the results may suggest that anger is beneficial. A quick glance at this study’s results can mislead people because some people who become frustrated don’t begin to yell at people around them, nor do they start to throw insults and threats at them. They may, instead, feel challenged to vigorously respond in a constructive, problem solving manner, and it is these people who may be the ones responding in a more beneficial way than those who act in a manner that is clearly anger. Calling anger, frustration, and challenge all forms of anger, can confuse people into thinking all expressions of anger are beneficial. It would be far better to use words that clearly distinguishes these experiences so that people would be less likely to end up exaggerating the benefits of anger.

OK, so those are some thoughts to ponder for this week. I hope you’ll join us again sometime next week for another presentation on dealing with anger, conflict and respect.

[1] The value of this attitude is discussed in: S. R. Maddi, D. M. Khoshaba, R. H. Harvey, M Fazel, & N Resurreccion, 2011, “The Personality Construct of Hardiness, V: Relationships with the Construction of Existential Meaning in Life,” Journal of Humanistic Psychology, 51(3), 369-388.

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Tags anger, challenge, conflict management, free social intelligence and emotional intelligence curriculum, frustration, insults, negotiation, threats

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Suicide, Perfectionism, and Criticism

Post author By Dr. Jeffrey Rubin
Post date October 20, 2014
7 Comments on Suicide, Perfectionism, and Criticism

Sometimes I’m asked why I write so much about dealing with criticism. The answer mostly has to do with the types of concerns that have been expressed to me over the years. Some involve the desire to be liked and respected. Others have to do with seeking to gain control over anger. And still others come from parents who find that how they go about disciplining their children has been a serious source of stress in their lives. Providing and responding to criticism in a pleasant, thoughtful manner involves skills that can be learned fairly quickly, and are clearly helpful when addressing these types of concerns.

Additionally, conflicts that bring forth negative criticism, if handled in an immature manner, can escalate and result in a destructive relationship between parent and child, the parting of a relationship between two valued friends, the loss of a job, serious injury, and prison time. And then there is the relationship between certain ways that people handle criticism and suicide.

In an earlier post, titled “Teenage Suicide and Cyberbullying: A Case Study,” I wrote about 12-year-old Rebecca Sedwick who had leaped to her death after more than a year of being incessantly criticized by a coterie of 15 middle-school children. Today, once again I take up the subject of the relationship between criticism and suicide because of an article I just read in this September’s Review of General Psychology by Gordon L. Flett, Paul L. Hewitt, and Marnin J Heisel titled, “The Destructiveness of Perfectionism Revisited: Implications for the Assessment of Suicide Risk and the Prevention of Suicide.” It’s written for research-minded people and has far more nuanced information than I can share in a single blog post designed for the general reader. Nevertheless, I’m going to summarize a few of its key points for I think they are very much worth considering as we move forward in our quest to become masters at dealing with name calling, insults and teasing.

Suicide and Criticism

The media is filled with stories about the Ebola virus, which has so far killed close to 4,000 people worldwide, and one person in North America. In contrast, it is estimated that over one million people worldwide, including 40,000 people in North America, kill themselves on an annual basis. Recent U.S. data indicate that suicide is the second leading cause of death among people who are under 40 years of age. For every person who commits suicide, several more attempt it, resulting in anguish for family and friends, and financial costs from emergency room and aftercare services that are estimated to be several billion dollars.

Of course, there are a number of reasons why people kill themselves, but the article I just read makes the following argument:

Chronic exposure to situations and contexts that place excessive pressure (or percieved pressure) on the individual to be perfect can have a destructive effect on most individuals and this is heightened among those people who are vulnerable and hypersensitive to criticism and social comparison feedback. Consider, for instance, the vulnerable perfectionist exposed regularly to a hypercritical parent, (boss/supervisor) or romantic partner who is ever-present and seemingly impossible to please. Alternatively, the vulnerable perfectionist may have a work environment where mistakes are simply not allowed and excessive standards are required by a tyrannical boss.

Now, I hasten to point out that most parents, bosses and supervisors who encourage quality performance don’t cause anyone to commit suicide. Moreover, the vast majority of people who may view themselves as perfectionists, even those who see themselves as particularly sensitive to criticism, don’t end up killing themselves. Nevertheless, the consistent evidence from studies that link suicide behavior with chronic exposure to external pressure to be perfect and the relationship between perfectionistic characteristics and an increased risk of lethal suicide behavior leads one to pause. Perhaps there may be some ways to encourage quality performance without increasing suicide risks.

Ideas about Prevention

Many people who view themselves as perfectionists tend to remain silent about any despair that they may experience. And those who demand that their children or workers be perfect don’t see anything wrong with this. So these people are unlikely to show up and ask to learn some skills to improve their behavior. Prevention programs, therefore, must be designed proactively and implemented broadly to reach these people. Schools, colleges and business organizations, if they are to impact people at risk, must provide education about these issues to their entire population. Thus, Flett and his colleagues recommend the following key themes be incorporated into school-based programs:

(a) fostering self-acceptance and compassion instead of experiencing shame and self-criticism; (b) promoting appropriate goal-setting and goal appraisal versus setting and maintaining impossible standards; (c) combating ambivalence about giving up the need to be perfect since the distressed perfectionist must be highly motivated to change; and (d) developing resilience to feelings of shame and ability to cope with interpersonal conflict and feelings of being rejected by others.

For the work environment, Flett and his colleagues state:

Prevention efforts should include an organizational focus on reducing pressures to be perfect. When perfectionism prevails as part of the culture and values of the workplace, it tends to promote poorer performance rather than superior performance (Gillett & Stenfert-Kroese, 2003) and it is linked with job dissatisfaction, poorer communication quality, role conflict, reduced likelihood of staying, and a poorer perceived fit between the person and the work environment (Balthazard, Cooke, & Potter, 2006; Rousseau, 1990).

Although, as a general statement, these ideas are worthwhile to think about, a far more detailed process is necessary to foster the goals of these researchers. For those who can afford counseling services designed to teach self compassion, along with addressing each individual’s concerns, I recommend working with either of the two counselors described HERE. For those who can’t access counseling services because of the financial costs, although not as ideal as direct one to one counseling, there is available for free a curriculum that teaches the necessary skills at this blog site (see below).

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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 Assessment of Suicide Risk, conflict management, conflict resolution, criticism, free social intelligence and emotional intelligence curriculum, Gordon L. Flett, insults, negative criticism, perfectionism, relationship, suicide, violence

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Providing Negative Criticism: The Newest Guidelines

Post author By Dr. Jeffrey Rubin
Post date October 13, 2014
No Comments on Providing Negative Criticism: The Newest Guidelines

Readers of this blog well know that I often discuss immature and mature ways to provide negative criticism. Originally, I presented a post titled PROVIDING NEGATIVE CRITICISM: FIVE LEVELS OF MATURITY. There, in addition to providing an outline of what I believed was a good starting point to think about this topic, I asked readers for suggestions on how the outline could be improved. Many readers were not at all shy. While this was going on, I continued my own reading, and from time to time, I shared what I had learned. And now, just this week on the internet, I came upon an article that provided a new set of guidelines. I kind of like them, and therefore, decided to see what kind of reaction they might lead to. But first let’s quickly review what we already covered.

THE ORIGINAL FIVE LEVELS OF MATURITY FOR PROVIDING NEGATIVE CRITICISM

Below you will find preliminary descriptions of how people at five developmental levels of maturity provide negative criticism, that is, criticism that points out what we don’t like about someone’s actions, beliefs, or appearance. Level one is the most immature and uses observations of babies as its starting point. Each successive level is more mature:

This level requires displaying one or more of the following:

Cries without stating what the crying is about
Physically attacks the person being criticized
Damages property

Although these three descriptors may not sound like providing criticism, in some situations we can see that it is the very beginning of the development of this skill. Let’s say Jill takes baby Bob’s crayon away believing he is done with it. Bob begins to cry and takes a swipe at Jill. She manages, by moving away, to avoid Bob’s swipe. Bob now looks even angrier and crumbles up a piece of paper and flings it on the floor. An observer to this may conclude that Bob, in a sense, is criticizing Jill for taking the crayon.

2. This level requires displaying one or both of the following:

The criticizer does not explain what the offending behavior is, but instead expresses displeasure with glares, insults, shouting, silence, or threats that do not involve bodily harm. (For example, someone might be making too much noise and the criticizer might turn to the noise maker and glare, or cry out, “Jerk!”)
Threatens bodily harm regardless of what else is said.

3. The criticizer clearly states the criticism with enough detail so the criticized person, if he or she wills, can improve the behavior, idea, or appearance, but couples it with glares, insults, shouts, or threats that are not about bodily harm.

4. The criticizer states the criticism without bodily attacks, damaging property, glares, insults, threats, or shouts, and with enough details so that the criticized person, if he or she wills, can improve the behavior, idea, or appearance. If the person receiving the criticism becomes defensive or angry, the criticizer empathizes without returning glares, insults, threats, or shouts.

5. When the criticizer provides criticism, he or she does so in a manner very similar to a level four response, but beforehand, the criticizer considers the person who is the target of the criticism and the situation that he or she is in. As a result of such considerations, the criticizer may decide to alter the criticism.

IDEAS THAT FOLLOWED

After proposing the five levels of maturity, several additional ideas came my way. One person suggested:

Hey there. One thing that potentially could be even better than a level 5 way to provide criticism would be to ask the person permission to offer them a criticism. You could say like, “hey, would it be alright if I make an observation about the way you handled that situation” or “do you mind if I offer you a couple constructive criticisms about your song” or whatever. Then, if the person says yes, they won’t feel like they are being attacked because they’ve given consent. Or they’ll have the opportunity to say “you know what? I’m really sort of feeling on edge so maybe another time would be better for us to talk.” That way, instead of gauging for yourself whether or not the person is in a state to tolerate the criticism, you can let them decide for themselves. What do you think about this idea?

I responded:

I like your idea. It goes along with considering person variables. For me, personally, I’m almost always up to hearing criticism, even if it may sting. Therefore, always asking me for permission would eventually become tiresome. But until you know someone well, starting off the relationship as you suggest, makes sense. And if, in time, you learn the person is very sensitive about criticism, continuing asking for permission would be the wise course of action.

Others argued that unless you are invited to provide criticism, you should keep your mouth shut. And others argued that even if you are invited to provide criticism, if you don’t have anything nice to say, don’t say anything at all. I address these issues in a post titled, UNSOLICITED CRITICISM: GOOD OR BAD? Very briefly, I agreed that these ideas were worthwhile to consider before providing criticism, but after this consideration there were times when providing uninvited criticism makes sense.

In a post titled “PROVIDING NEGATIVE CRITICISM: A LESSON FROM THOMAS JEFFERSON” I explained that recently I had been reading an excellent biography of Jefferson by Jon Meacham. There, I learned that early in a relationship Jefferson typically avoided mentioning any fault in his new companion. He felt that later, once the relationship was well developed, was a better time to discuss differences of opinion. As Meacham describes Jefferson’s style, “people often talk too much and listen too little, which can be self-defeating, for in many instances the surer route to winning a friend is not to convince them that you are right but that you care what they think. Everyone wants to believe that what they have to say is fascinating, illuminating, and possibly even epochal.” In that line of thinking, Jefferson advised a daughter: “Much better…if our companion views a thing in a light different from what we do, to leave him in quiet possession of his view. What is the use of rectifying him if the thing be unimportant; and if important let it pass for the present, and wait a softer moment and more conciliatory occasion of revising the subject together.” Now Jefferson clearly recognized there was exceptions to this general rule, but nevertheless it makes a great deal of sense that whenever we are tempted to provide negative criticism careful consideration of this idea makes sense.

Another set of comments came from a few parents who argued that although the five levels of maturity made sense when adults were interacting with other adults, when parents provided negative criticism to their children, yelling, and even hitting were perfectly permissible. I responded to this in a post titled, PROVIDING NEGATIVE CRITICISM: DEFENDING THE FIVE LEVELS. The issues this raises are simply too complicated to summarize here, so I’ll just refer interested readers to that post.

Finally, someone on Facebook presented the idea that it is helpful to use the sandwich approach to providing negative criticism. Here you begin with a slice of some positive comment, then you put on top of that the negative criticism, and then, on top of that, you provide another slice of positive criticism.

OK! So, basically, in a very abbreviated manner, those are some ideas we have already discussed. Now, to a new set of guidelines.

Philosopher Daniel Dennett’s Approach to Providing Negative Criticism

Recently on the internet I came upon a post by Maria Popova titled, “How to Criticize with Kindness: Philosopher Daniel Dennett on the Four Steps to Arguing Intelligently.” There I learned that Mr. Dennett has provided the following guidelines for composing a successful critical commentary:

You should attempt to re-express your target’s position so clearly, vividly, and fairly that your target says, “Thanks, I wish I’d thought of putting it that way.
You should list any points of agreement (especially if they are not matters of general or widespread agreement).
You should mention anything you have learned from your target.
Only then are you permitted to say so much as a word of rebuttal or criticism.

I kind of like this. Whereas it is not inconsistent with the original five levels of providing negative criticism, it provides some additional ideas to consider.

Over the course of a week or two I’ll come up with some specific examples that demonstrate Dennett’s approach. Until then, my best wishes to you all,

Jeff

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Tags conflict management, conflict resolution, criticism, Daniel Dennett, dispute management, feedback, free social intelligence and emotional intelligence curriculum, negative criticism, providing criticism, psychological maturity, respect, Thomas Jefferson

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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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Women and Criticism

On this blog, I often discuss immature and mature ways to deal with criticism. The advice that I offer is designed to be helpful to males and females alike. But recently, in an Op-Ed piece in the New York Times, Tara Mohr argues that when it comes to criticism, women can benefit from advice specifically targeted to the unique cultural situation that they find themselves in.

The New York Times Article

Ms Mohr, in her thoughtful article titled “Learning to Love Criticism,” tells us:

Criticism stings for all of us, but women have been socialized to not rock the boat, to be, above all else, likable. By the time a girl reaches adolescence, she’ll most likely have watched hundreds of films, television shows and advertisements in which a woman’s destiny is determined not by her own choices but by how she is perceived by others. In those hundreds of stories, we get the message: What other people think and say about us matters, a lot.

In addition to these messages in the media, for centuries women have had less rights than men. Being likable, or at least acceptable to stronger, more powerful men, became a primary survival strategy. For many women around the world, this is still the reality.

Given this history, we might think that women have mastered the skills to insure that they are liked, but in the business world there is some evidence that problems exist.

A Recent Survey

In a recent survey that looked at 248 performance reviews from 28 different companies, both men and women gave more negative feedback to the women being reviewed. Here are a few examples:

“You can come across as abrasive sometimes. I know you don’t mean to, but you need to pay attention to your tone.”

“Your peers sometimes feel that you don’t leave them enough room. Sometimes you need to step back to let others shine.”

“The presentation ultimately went well. But along the way, we discovered many areas for improvement. You would have had an easier time if you had been less judgmental about R—‘s contributions from the beginning.”

This kind of negative criticism showed up twice in the 83 critical reviews received by men. It showed up in 71 of the 94 critical reviews received by women.

There are three possibilities that present themselves here:

1. The women received more negative criticism despite not acting in any distinctively different way than the men because of distinctively different expectations of how women “should” act;

2. The women who received more negative reviews actually acted distinctly different in certain ways than the men and it is these differences that led to the additional negative criticism;

3. It is a little of both.

An Informal Survey

Interestingly, from my perspective, are the results of an informal survey of someone I know who was intimately involved in evaluating and promoting personnel. Here, early criticism was about equal between men and women, but more women took the negative criticism they received to heart and made changes prior to their following evaluation. This ultimately led to their promotions. The majority of the men who got negative feedback seemed uninterested in making any changes and subsequently lost their opportunity for promotion.

From this, I think that it is not only possible, but perhaps even probable, that despite the pattern suggested in the more thorough survey, there is great variability across settings.

Some bosses may have an archtype that a great leader is a tough, no nonsense person who only projects a demanding sense of profits. Such an attitude will provoke a very different style of criticism around the office than one that supports the idea working for profits doesn’t have to mean that we must abandon basic principles of human dignity.

Let me just add that the person involved in providing and promoting personnel in the informal survey happened to be a master at providing very specific feedback. Consider the example provided above in which someone stated in a review:

“You can come across as abrasive sometimes. I know you don’t mean to, but you need to pay attention to your tone.”

Such a statement potentially can be helpful as one looks within and seeks to come up with a less abrasive way to respond in situations. However, the feedback would be far better if a supervisor, let’s call him Bill, invited a subordinate, let’s call her Mary, to a one-on-one meeting shortly after an abrasive incident occurred. At that meeting, Bill does several things. He gently explains that he is about to imitate how Mary had acted, using her tone of voice and what was said. Then, after imitating for her how she acted, he displays for her in a role-play how he would prefer she act when a similar incident arises. He then proceeds to ask Mary to imitate what he just acted out. Then he goes through this process with Mary until she can actually copy the less abrasive style to his satisfaction. If Bill provided this level of specific feedback, it would be potentially far more helpful then the two-sentence feedback that was actually provided.

Advice

I very much support the recommendations that Ms Mohr provides in her New York Times piece. For example, at one point she writes,

If a woman wants to do substantive work of any kind, she’s going to be criticized — with comments not just about her work but also about herself. She must develop a way of experiencing criticism that allows her to persevere in the face of it.

How can this be done? “A woman,” says Ms Mohr, “can identify another woman whose response to criticism she admires. In challenging situations, she can imagine how the admired woman might respond, and thereby see some new possible responses for herself.”

I won’t go into all of the recommendations of Ms Mohr, suffice it to say her article is well worth reading. But I do think it is essential to point out that a single article will not do the trick for most of us, women or men, who want to learn to become a master at dealing with criticism. It takes several months of regularly bringing before our minds examples of criticism, followed by a discussion of how to transform each specific example into something better. My blog provides one way to go about doing just this. Readers can begin with the introduction to this blog, and move forward at their own pace by clicking on the next newer entry post. Additionally, by reading the trilogy of novels that I’ve written, people become immersed for a few months in adventures that illustrate the struggle to seek respect even under the most trying circumstances.

Well, that’s this week’s edition of From Insults to Respect. Here’s to hoping you’ll join us again real soon.

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

Tags conflict, conflict management, criticism, dispute management, disrespectful, insults, negative criticism, negative feedback, New York Times Op Ed, psychological maturity, respect, Tara Mohr, types of criticism, women and criticism

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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

conflict resolution DSM psychiatrists psychiatry The Diagnostic and Statistical Manual of Mental Disorders

Psychiatric Name Calling: Are the Insurance Companies to Blame?

Post author By Dr. Jeffrey Rubin
Post date September 16, 2014
5 Comments on Psychiatric Name Calling: Are the Insurance Companies to Blame?

Last week, I posted an article titled “Name Calling by Psychiatrists: Is it Time to Put a Stop to it?” It created quite a stir and it’s currently challenging my two previous most popular posts—“Teaching Children How to to Deal with Criticism” and “Is it Wise to be Assertive?”—for the number one spot.

The article points out that by using the term “diagnosis” in psychiatric terminology it misleads people in a variety of ways. For example, when psychiatrists provide their patients a so-called diagnosis many people believe there is now a valid explanation for why they are struggling with their personal difficulties. Instead, all that has really happened is that the psychiatrist has converted the expressed concern of the patient into pathologizing language.

The manual that psychiatrists use when deciding which words to use when converting concerns to “diagnoses” is called The Diagnostic and Statistical Manual of Mental Disorders (DSM). Of course as this manual was developed there was a huge financial interest to utilize language that encourages the perception that an expressed concern is a very, very serious life-long condition that requires medical treatment for a lifetime. Consequently, when patients express a concern about being depressed, the psychiatrist informs them that they have “major depressive disorder,” and often couple this with statements such as, “This is a serious lifetime condition that must be managed for a lifetime.” Any language that suggests that there is substantial evidence that most people recover even without treatment runs counter to the psychiatric business plan.

Among the many comments that I received about the name calling article are those that point out that most of the doctors who are using the psychiatric terminology provided in the DSM are not psychiatrists. Pediatricians, general practitioners, internists, psychologists, and neurologists daily call people these names. Other comments present the argument that it is the pharmaceutical companies that promote the pathologizing of human concerns in order to convince people to ingest their drugs.

I’ll be exploring these issues in coming weeks. But today, let’s focus in on the argument that the real group of people at fault for this type of name-calling is the third party payers such as insurance companies, Medicaid, Medicare, and Social Security. After all, by far, the DSM terms are used most by these types of entities.

The DSM and Third Party Payers

Most people in the United States who seek mental health services don’t directly pay for them. Instead, they have insurance policies that cover some, or all, of the fees; or they qualify for Medicaid, Medicare, or Social Security benefits. Insurance companies and these other agencies are called third party payers.

Third party payers currently have a form that must be filled out whenever someone seeks mental health services under their plan. That form has boxes for the name of the person seeking services, his or her contact information, policy number, some information about who is being asked to provide services, and then, imbedded in all of this, is a little box that currently says, “Diagnosis.” In that box, mental health professionals must fill in the DSM code that corresponds to their “diagnosis” of the person seeking services.

Third party payers initially developed their form for people who were seeking medical services for physical complaints. Physicians would fill in the diagnosis box with a code that corresponded to a list of diagnoses in their pathology manuals based on a visual inspection of a tissue tear, the results of x-rays, blood test, or a pathologist examining a tissue sample of a tumor under a microscope. Sometimes it was based on a report from a toxicologist because it was theorized that the patient had been exposed to some toxic substance. In each of these cases, the diagnosis that was provided actually did provide some understanding for why patients were struggling with their expressed physical complaints.

However, I hasten to point out that in many cases physicians were unable to uncover the reason for the physical complaint. At such times they often did pretty much what psychiatrists do today—they converted the physical complaint into medical jargon, typically using Latin derived syllables, and then stuck them into the third party payer’s “diagnosis” box on the third party payer forms, prescribed some treatment, and low and behold, third party payers paid the doctors just like they did when a real diagnosis was provided.

A physician once confided in me that for the majority of his cases he was unable to identify the reason for the physical complaint but he nevertheless provided some diagnosis and a prescription for a pill. “If I didn’t,” he said, “my patients would feel that they wasted their money by coming to see me.” I then asked him how he felt about misleading his patients in this way. “Well,” he replied, “if my patients feel that I have made a real diagnosis and prescribed some pills, they feel a sense of being reassured and the pills can have a placebo effect which may be very curative in its own way.”

“The pills that you prescribe,” I replied, “are not simply substances with no physical effects beside the placebo effect, they have a number of real serious side effects associated with their use. Is that really ethical?”

“Well, the physical side effects often help the placebo effect because the patient feels something is really physically happening. It is part of what reassures them that what was prescribed has a powerful effect. When weighing the risk of serious side effects versus the minor side effects that can be helpful, I make my decisions on what to prescribe.”

And so, that’s a little of my understanding of the reasoning behind this type of misleading name-calling and prescribing practices of physicians dealing with physical complaints. I prefer honesty. However, for those who prefer this fatherly treatment that is mixed with huge financial interests, I’m advocating that they continue to get what they want.

Now, once third party payers began to provide coverage for mental health services, their administrative forms didn’t have to be changed. There was already a precedent for placing in the “diagnosis” box on the form fake diagnoses, and psychiatrists seeing that this business model was a source of a great deal of money created the DSM.

What would be a Reasonable Alternative to the DSM?

For those who prefer to be treated honestly, can an alternative to the DSM be developed?

The alternative I’ve been working on is called The Classification and Statistical Manual of Mental Health Concerns, or, for short, the CSM. With this approach, no individuals would be classified, only their expressed concerns.

With the CSM proposal, all that we would be asking insurance companies to do differently in order to add value to their customers, is to slightly change that little box that currently requires a diagnosis or a word pretending to be a diagnosis. Instead of just saying “Diagnosis” as it currently says, that box would just 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.

The cost and efforts for insurance companies would be minimal, and we would have numerous testimonials from customers that documents that this change would be viewed as a significant improvement.

Now, some of the insurance company executives might pause and say, “Wait a minute. You’re asking us to permit the use of the CSM as an alternative to the DSM. Just wait a minute. The DSM has been developed by mental health experts and is backed by a major mental health professional organization—the American Psychiatric Association. Does the CSM have that type of authority to back it up?”

If we prepared for this, we will be able to answer that the CSM was also developed by mental health experts and does have several mental health professional organizations backing up its use as an alternative to the DSM. I believe this can be achieved. We have in our alternatives group several people who would qualify as mental health experts, and I think we can get some more involved as well. And when the latest edition of the DSM was released several professional organizations expressed a strong desire that an alternative to the DSM be developed. I think it’s reasonable to assume that at least some of them would agree to back this alternative, especially if we involve them in its development.

In short, the creation of the CSM would permit us to present to insurance company executives and other third party payer administrators a real alternative to the DSM. It would be virtually cost free for them to permit its use, it would have the authority of being developed by experts in the mental health field, the backing of mental health professional organizations, and it adds value for a significant number of their customers.

The CSM Would also Help Mental Health Service Providers

Now, besides the insurance companies and other third party payers, the other big group of people in America that is currently using the DSM is mental health services providers. How would they react to being given the choice to replace the DSM code with the CSM code on third party payer forms when they felt in their professional judgment that it was appropriate? Well, we get a little sense of what their reaction would be from a survey Paula Caplan tells us about in her book, They Say You’re Crazy. According to this survey, over 70 percent of those practitioners who responded to the survey said that the only way they use the DSM is to fill out the insurance form. Other than that, it doesn’t help them at all.

To those who believe that the use of the current DSM terminology helps to enhance the placebo effect of treatment, keep in mind that this is a testable theory. We can arrange for studies that compare the outcomes of service providers that utilize the DSM coding system with service providers that employ the CSM coding system. But that would be an approach that employs basic principles of science, rather than unsupported claims backed by enormous financial interests.

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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, insults, insurance companies, mental disorders, mental health, mental health services, mental illness, name calling, psychiatric disorders, psychiatry