“Good morning, Barbara,” I say, as my first counseling case walks into my office. I notice she looks a little angry. Upon sitting down, she declares, “I’m terribly frustrated. I’ve been depressed now for over two weeks, and I just can’t shake it!”
It’s easy for me to empathize because I regularly have bouts of what I refer to as melancholy. A deep anguish comes over me, and during this period I often begin to think about how I went through my father’s death when I was twelve, how I’m getting older and can no longer do the many athletic things that thrilled me when I was younger, and on and on. Sometimes these dark melancholy experiences come about because something clearly happened that upset me, and sometimes they seem to come out of the blue.
Beyond Listening in a Caring Manner
After listening in a caring way to Barbara for a few minutes, I ask her if something specifically happened that led her into her current emotional experience. Then I explore with her a question about how often she has these experiences and if she feels she has them more frequently than most people, about as often as most, or less than most. Then, I ask her about how she has been functioning in other areas of her life–sleep, eating, exercise, interpersonal relationships, work/school, household responsibilities.
You see, as people experience depression, or other concerns that often lead to a classification of having a mental disorder, some people go about their lives functioning as they typically were doing before the concern arose, while some find that in some areas they begin to function below the levels that are typical for them, while some find that their functioning increases in one or more areas. For example, some sleep about the same amount, some less, and some more. I have met people who, when they are depressed, start cleaning every inch of their home, while others find it difficult to get out of bed.
Also of interest when exploring a person’s expressed concern is to look at how the person had been functioning before the onset of the presenting concern. If some important relationships had begun to function below average, or if the person had been sleeping less than average to keep up with work demands, these facts can be insightful when seeking ways to address the presenting concern.
Now, once I found out what Barbara was concerned about, what might have precipitated the concern, and how she had been functioning in various areas of her life, I had a pretty good idea as to how to proceed in addressing her concern. I had no need to decide whether or not she had a mental disorder. However, many mental health practitioners are required to declare that the person seeking mental health services has a mental disorder if they want to get paid. Is this mental illness labeling really necessary?
Mental Illness Labeling Versus an Addressing Concern Approach
There are those who embrace this mental illness/disorder labeling. One reason is the pharmaceutical industry’s promotion of this idea to sell people on the idea that they need certain drugs to live a more normal, healthier life.
Beyond that, another major reason for this is that these individuals have a group of people in their lives that blame them for the way that they have been feeling or acting. When a doctor has declared, for example, that John Smith has a mental disorder, he may feel vindicated. “You see, there really is something wrong with me!” he may cry out in his defense.
In actuality, those who are doing the blaming may continue their blaming despite the doctor’s opinion. Moreover, many of us don’t blame people whenever they find some concern has arisen in their lives even if they are going through a non-illness experience. I know I’m not blaming myself when I experience melancholy, and I was not at all blaming Barbara for what she was going through.
Those who are uncomfortable about the use of “mental illness” terminology point out they are stigmatizing because they are used as put downs in our society. Moreover, the media associates the most heinous crimes with those referred to as the mentally ill even though the vast majority of those classified in this manner are not violent.
Among the most articulate individuals to voice objections to the mental disorder labeling was Harvard psychologist and philosopher William James. Over one hundred years ago he wrote a book titled, The Varieties of Religious Experience (1902). At that time many medical doctors argued that people who were religious were all mentally ill. In response, Professor James wrote:
Medical materialism seems indeed a good appellation for the too simple-mindedsystem of thought which we are considering. Medical materialism finishesup Saint Paul by calling his vision on the road to Damascus a discharginglesion of the occipital cortex, he being an epileptic.
Girl (6-8) praying, profile, close-up
It snuffs out Saint Teresa as an hysteric, Saint Francis of Assisi as an hereditary degenerate.George Fox’s discontent with the shams of his age, and his pining for spiritualveracity, it treats as a symptom of a disordered colon. Carlyle’s organ-tonesof misery it accounts for by a gastro-duodenal catarrh. All such mentalovertensions, it says, are, when you come to the bottom of the matter,mere affairs of diathesis (auto-intoxications most probably), due to theperverted action of various glands which physiology will yet discover.(p. 29)
James goes on from here to point out that it is true, of course, that psychology has found that there are definite psycho-physical connections that “hold good” (p. 30). Psychology, therefore:
assumes as a convenient hypothesis that the dependence of mental stateson bodily conditions must be thoroughgoing and complete. If we adopt theassumption, then of course what medical materialism insists on must betrue in a general way, if not every detail…. But now, I ask you, howcan such an existential account of facts of mental history decide in oneway or another on their spiritual significance? According to the generalpostulate of psychology just referred to, there is not a single one ofour states of mind, high or low, healthy or morbid, that has not some organic process as its condition. Scientific theories are organically conditionedjust as much as religious emotions are; and if we only knew the facts intimatelyenough, we should doubtless see “the liver” determining the dicta of thesturdy atheist as decisively as it does those of the Methodist under convictionanxious about his soul. When it alters one way the blood that percolatesit, we get the Methodist, when in another way, we get the atheist formof mind. So of all our raptures and our drynesses, our longings and pantings,our questions and beliefs. They are equally organically founded, be theyreligious or of non-religious content. (p. 30)
James points out that in the natural sciences and the arts it never occurs to anyone to refute opinions, beliefs and experiences by putting down their author’s neurological constitution. Value is determined by “judgments based on our own immediate feelings primarily; and secondarily on what we can ascertain of their experiential relations to our moral needs and to the rest of what we hold as true” (p. 33).
James was additionally concerned that medical materialism greatly overgeneralizes its knowledge of the connections between physiological variables and mind states. In James’s day, the pathology writers would take the few psychophysical correlations that they obtained under highly specialized conditions and then vaguely generalize their findings to discredit, to their satisfaction, all of the states of mind that they disliked.
The Modern Day View
Now, modern day psychiatrists sometimes respond,
“Well, certainly in James’s day we indeed knew almost nothing about such matters, but today our knowledge has vastly increased! Thus, James’s position is no longervalid because we can now make sound statements about the connections betweenphysiological states and mind states.”
To this, I respond that in point of fact there is currently a renewed respect for the extraordinary complexity
that exists during the integration process between mind, physiology, behavior, and environmental variables. Whereas it is true that there have been large gains in our knowledge, these gains are best likened to moving from a few drops of knowledge to a glass almost full; yet, to really understand the integration process, we would need oceans and oceans of knowledge. Trillions and trillions of interactions are involved.
It is for these reasons that the mental illness/disorder terminology is misleading. As Dr. Thomas Insel, the former director of the National Institute of Mental Health, recently said about the psychiatric labeling process known as the DSM.
The weakness [of the DSM] is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half-century as we have understood that symptoms alone rarely indicate the best choice of treatment.
To hear and view other leading scientists further make this point, I highly recommend the following free video:
When individuals express a concern, exploring how they are functioning in the main areas of their life can be enormously helpful. Someone who reports a concern about experiencing depression, whom, by some gentle questioning, we find out has been functioning below average in the areas of sleep, interpersonal relationships, and exercise may benefit enormously if we work together on getting these areas of functioning in a more optimal range. This is true for those who report other types of concerns such as experiencing anxiety, hearing voices, below average range of attention, obsessive thoughts, and on and on. With a model that includes addressing concerns and exploring ways to improve functioning, labeling someone as having a mental disorder becomes unnecessary and may actually interfere with the aims of a counseling/psychotheraputic relationship.
For those who desire, for whatever reason, to be labeled as having a mental disorder, I am not proposing that we interfere with this. But for those who desire to have their concerns addressed by well trained mental health professionals without being referred to as having a mental illness or disorder, I do propose that we do provide a reasonable option for them to access mental health services. In my view, mental health professionals, once we hear our clients’ concerns and how they are functioning in the various areas of their lives, we have the basics to formulate, in full cooperation with our clients, a plan for addressing these concerns. I hope you give this some thought.
For those of you who would like to learn more about how an addressing concern approach would work and be consistent with science if adopted by mental health providers, you can access my peer reviewed article for free by clicking HERE.
Until next week, may you find some kindness out there in this fascinating world of ours.
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.
In recent weeks, I have been providing a series of blog posts on psychiatric name calling (see here, here, here, and here). In these posts, I have expressed some negative opinions about the Diagnostic and Statistical Manual of Mental Disorders (DSM).
The DSM provides the names for the various mental health concerns that mental health service providers are often required to use if they want to be paid for their services or if they want to have their research published in professional journals.The language of the DSM places its terminology under the umbrella concepts of “mental illness,” “mental disorder,” and “psychopathology.” In my blog series, I have argued that the pathologizing of human experiences in this way does far more harm than good.
As part of my discussions on this topic, I quoted the opinions of some who agreed, and some who disagreed, with my opinions. The quotes that I used were selected from my own personal readings. Therefore, they may not have been characteristic of how a wider range of different people may think and feel about the DSM approach to labeling the various mental health concerns.
A few years ago, two teams of researchers have sought to obtain a broader range of views on this topic by carrying out surveys. Jonathan D. Raskin and Michael C. Gayle surveyed psychologists who regularly use the DSM, and published their findings in the Journal of Humanistic Psychology (DSM-5: Do Psychologists Really Want an Alternative? 2015, pages 1-18). Lois Holzman and her team surveyed people in some New York City communities, and published her findings on the DxSummit.org website (A Report on Community Outreach: Lay Opinions on Emotional Distress and Diagnosis, http://dxsummit.org/archives/2249). Let’s take a look at their findings.
What the Psychologists Had to Say
Here’s a summary of the survey data by Jonathan D. Raskin and Michael C. Gayle:
Only two published studies, both from the early 1980s, have specifically examined psychologist attitudes toward the Diagnostic and Statistical Manual of Mental Disorders (DSM). The current article rectifies this by presenting the results of a recent survey of attitudes toward the DSM-IV-TR and DSM-5. Though the DSM has changed over the years, psychologist attitudes toward it have remained remarkably consistent. Although more than 90% of psychologists report using the DSM, they are dissatisfied with numerous aspects of it and support developing alternatives to it—something that psychologists over 30 years ago supported, as well. The finding that almost all psychologists use the DSM despite serious concerns about it raises ethical issues because professionals are ethically bound to only use instruments in which they are scientifically confident.
In the above summary, the number 5 after the letters DSM, refers to the fact that the DSM has undergone five major revisions. Since the 1980s, there have been three such revisions. Ideally, users of the DSM would see clear improvement for each revision.
When a survey was done in the early 1980s, psychologists were clearly skeptical of the DSM-2. As described by Raskin and Gayle,
More than 40% felt it (a) distorted clinician perceptions of clients, (b) applied medical labels to psychosocial problems, (c) was not reliable and valid, (d) emphasized diagnosis over treatment, (e) obscured individual differences, and (f) overemphasized pathology. Almost 60% were dissatisfied or somewhat dissatisfied with the DSM-2 with only 17% satisfied or somewhat satisfied.
When the DSM-3 came out in 1983, Smith and Kraft carried out an updated survey on this revision of the DSM-2. The findings indicated that psychologists at that time (a) preferred social–interpersonal diagnosis, nondiagnosis, and behavioral analysis over DSM-3—in that order; (b) felt that most conditions in DSM-3 were best seen as nonmedical problems in living; (c) believed too little had been done to develop scientific alternatives to the DSM; and (d) thought that client welfare and integrity would be better served by abandoning the medical model. Eighty-five percent disagreed that mental disorders are a subset of medical disorders.
In the latest survey that was carried out by Raskin and Gayle, 128 anonymous psychologists participated. Among the questions that were asked was, “How satisfied are you with the changes being proposed for DSM-5?” Their answers indicated that they were significantly more negative about it than neutral. The general attitude about the latest version of the DSM were very similar to what was found three decades ago, namely, that a significant number of psychologists are unhappy with the DSM.
What Community Folks Had to Say
In the community outreach survey of lay opinions on emotional distress and diagnosis carried out by Lois Holzman and her colleagues, people were asked questions at two annual NYC street fairs attended by millions of people. Conversations lasted from five to over ten minutes each. In all, 143 people participated in the survey in the first of these two surveys, which occurred in 2013. The second one had 149 people who participated, which occurred in 2014.
In the 2013 survey, the focus was on how psychiatric diagnosis affected kids. Forty percent felt that psychiatric diagnosis was not valuable. For the 60% that felt that psychiatric diagnoses can be valuable, 90% of them had reservations. That is, they said that it was only sometimes helpful, there was a danger of misdiagnosis, there was racism involved in diagnosis, and it leads to stigma and over-medication.
Ten percent were completely against diagnosis under any circumstance, some sharing their experiences pertaining to children. Examples of comments from this group follow:
“Medication makes you act out. My grandson was hyperactive, not ADHD and they wanted to put him on Ritalin – I told them no. Drugs at an early age can lead to hard core drugs later in life.”
“I worked with kids who had wrong diagnosis, and this is prevalent.”
“Kids get told in 1st grade they’re crazy—then it becomes a self-fulfilling prophecy.”
In the 2014 survey, the researchers:
“tried to go a little deeper and see if we could help people explore the apparent conflict around diagnosis, i.e., its value and its dangers. We also wanted to learn what they thought about the necessity and mandate of diagnosis.
We all know people who have gotten very depressed when they’ve lost a loved one, or children who cannot sit still in school, lots of folks who are angry and demoralized about not finding a job. Do you think any of these people need to get a diagnosis in order to get help with their emotional pain?
(IF THEY SAY YES, ASK THE NEXT 2 QUESTIONS):
Do we need to relate to them as having brain disorders? Or chemical imbalances?
Right now, in most settings, if you want to get help with ANY kind of emotional pain from a mental health professional, they are required to give you a diagnosis. Do you agree with that?
Are there other ways to support people emotionally? What do you think could help them?
Like me, you probably know people in your family, church, or at work who have serious emotional problems, who may have been diagnosed with major depression, bipolar or schizophrenia. Obviously people deserve and need top quality mental health care including access to medication. Do you think that even in these situations a diagnosis can limit the person, label them, and stigmatize them? If so, how?
From our past surveys we have found that people are conflicted about diagnosis and labels. They find it relieving to get a diagnosis and at the same time feel like the diagnosis can stigmatize or label them. Why do you think that so many of us are conflicted about this, feel it can be both helpful and harmful?
Here’s a brief summary of the finding, as described by Dr. Holzman:
Diagnosis Needed: 60% of respondents said no, people did not need a diagnosis to get help with their emotional pain. The majority of the 40% who said diagnosis was needed told us that that was the only way to get to talk to someone.
Only those who said yes, diagnosis was needed (40%), were asked the next two questions.
1a. Biological Basis: 89% of those who said diagnosis was needed said we shouldn’t consider such people as having a brain disorder or chemical imbalance.
1b. Diagnosis Required: 75% of those who said diagnosis was needed did not agree that it should be required.
Other Ways to Support (alternative types of treatment):
Everyone offered an alternative, with most people suggesting more than one. The most frequent responses involved talking to people—therapy, counseling, group therapy being the most common (including, “A center they can go to without getting diagnosed”), followed by family, friends, self-help and support groups.
A wide variety of social activities and life style changes were recommended—volunteering, hobbies, music, dance, writing, meditation, exercise, yoga, diet, prayer and creating community (“Have events that bring people out, like this fair”).
& 4. Concerns about Diagnosis: 90% (including those who thought it was needed) expressed concerns about the stigma of diagnosis, the dangers of misdiagnosis, and/or the over-medication that too often accompanies a diagnosis.
Once you have that label it doesn’t stay at the clinic. You carry it with you for a long time.
People start calling you crazy. It can be a shame for the family.
I had to fight to get counseling for my kid. They just wanted to give him drugs.
Getting a diagnosis limits life experience, you’re treated differently, you feel like an outcast.
It’s helpful to the clinic but not in everyday life.
It’s good to know what’s wrong, but it might make them feel worse about themselves and put them in a box.
It pigeon-holes people and the diagnosis becomes all that I am.
It stagnates them. It keeps them on one path with only one destination.
They think something’s wrong with them.
There is too much use of medication. It is a quick fix to avoid a real understanding.
Against it – children are still growing. Against medication.
So there you have it, some views other than mine about psychiatric name calling. In interpreting these findings, I think it’s important to bear in mind that the views of the people surveyed developed in the context of a multibillion dollar advertisement campaign by the pharmaceutical companies over many years that is designed to convince them that emotional concerns are diagnosable illnesses requiring medication treatment. How might the views of those surveyed been different without this high finance selling of the illness model?
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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional intelligence. To begin at the very first post you can click HERE.
Many mental health service providers well know that there are serious problems with the jargon that is used in their profession. In a recent post titled “Psychiatric Name Calling: Is It Time To Put A Stop To It?” I outline some of the most glaring ones. In a subsequent post titled “Psychiatric Name Calling: Is There An Alternative?” I describe a plan for professionals who have an interest in eliminating the problems inherent in the current psychiatric pathologizing approach. This plan would allow professionals to replace the old model with one that would be practical, more consistent with principles of science, and far less stigmatizing.
As I have been seeking ways to promote these ideas, it has become more and more apparent that the gears of the mental health service provider professional organizations grind slowly. Until the necessary changes occur, what can the average English speaking person do when faced with terms like mental illness, major depressive disorder, psychosis, schizophrenia, etc.?
Three Principles That Can Be Used When Psychiatric Pathology Terms Are Employed by Others So That The Negative Effects Associated With Their Usage Can Be Reduced
Even people who are not mental health service providers will regularly use psychiatric jargon. Thus, a French writer once wrote:
My sadness was without limit, and having got possession of me, it filled my life from the most indifferent external acts to the most secret thoughts, and corrupted at their source my feelings, my judgment, and my happiness. It was then that I saw that to expect to put a stop to this disorder by my reason and by my will, which were themselves diseased, would be to act like a blind man who should pretend to correct one of his eyes by the aid of the other equally blind one.
In this quote, the French writer, to describe some concerns he had about his sad mood and how it was affecting his feelings, judgments, and happiness, uses the words “disorder” and “disease.” This is the type of language most mental health service providers throw around. What is the writer attempting to convey by their use?
Sometimes when these words will be employed, their context will make it clear what meaning the author intends. In this example, the author does provide some context. He clearly indicates he was much sadder than he wished to be, and he believed he was unable to do anything about it. He also expressed a concern about his feelings, judgments, and happiness, but he was less clear about what he meant by this.
When someone begins to use pathologizing language and we simply don’t know what is intended, we might end up with misleading, simplistic associations. And so, here are three principles that can be used when psychiatric pathology terms are employed so that we can avoid unnecessary confusion.
Each Time Someone Uses A Psychopathologizing Term, Ask The User Of The Term For A More Specific Description Of What Is Meant By It
In the example that I provided above, there was some lack of clarity about what the French writer meant about his judgments. We know that he felt that it was disordered and diseased. That really tells us nothing more than he was dissatisfied with his judgments. To clarify, we could ask for some specific examples of when his judgment proved to him unsatisfactory.
As another example, suppose you hear Alice saying that John Doe is “mentally ill.” If you want to use this first principle, you would ask Alice what, specifically, does “mentally ill” mean to her and what has John done specifically that led to her calling John this name. These questions typically lead to further constructive discussions and ends up clarifying the nature of many fascinating experiences.
When Psychopathologizing Terms Are Employed, Express A Concern That This Terminology Simplistically Devalues An Experience
Terms like “mental disorders,” “mental illness” and “psychosis,” even when used by professionals, implies that there is something wrong with the person being described. However, as I described in my post “Are Mental Illnesses Really Potentially Helpful Tools?” there are numerous examples of the types of experiences that tend to be labelled mental disorders that end up being enormously helpful. Moreover, in cultures that recognize this possibility the outcomes for those people undergoing these challenging experiences are distinctly better.
And so, as you begin to use the first principle, asking for the user of pathologizing terminology for more specifics, if he or she seems to be suggesting that the experience is bad, you might wish to point out this well documented observation. At such times, I often say, “Many people with artistic temperaments have these types of experiences. Such people have given the world some of its most valued achievements.”
Instead Of Using The Concept of “Disease” And “Illness” To Encourage Humane Responding Toward Individuals Undergoing Challenging Experiences, Emphasize Rights, Kindness, And Practical Reasons
In seeking to encourage people who are using pathologizing terminology to be more specific, it is not uncommon to find that one reason they use these terms is that they hope it will encourage people to be more humane toward those who have certain challenging experiences. They usually mean well by this, but this approach has been used for centuries and history documents that despite such efforts, people who are being given these labels have often ended up in some of the most horrible, degrading treatment facilities.
Instead of using the concept of “disease” to encourage humane responding toward individuals undergoing the experiences that get labelled with pathological terms, an alternative is to emphasize human rights, kindness, and practical reasons.
Note that when people in a town are hit with a hurricane, we don’t have to resort to calling them ill to encourage some help. Instead, we have set up laws that entitle people to certain rights from the government when emergencies occur. Moreover, as word gets out about what is occurring to those who are suffering, out of kindness, people make donations or join their hands to provide direct assistance in a variety of ways. And lest we forget, there are practical reasons to lend a hand. By doing so, we model for people just what kindness is all about.
Any of us can find ourselves in an emergency situation. The more we promote acts of kindness, the more likely we may find that others will treat us with kindness if we are ever to find ourselves in a very unfortunate set of circumstances.
Using the Three Principles
William James, in his grand book, The Varieties of Religious Experience, tellsus ofsome people who have mystical experiences that tend to be called “mental disorders.” James begins to use the three principles when he seeks out descriptions of the various mystical experiences that go well beyond the simplistic psychopathological descriptions. He then states that these mystical states have the right to be absolutely authoritative over the individuals to whom they come.
It is vain for rationalism to grumble about this. If the mystical truth that comes to a man proves to be a force that he can live by, what mandate have we of the majority to order him to live in another way? We can throw him into a prison or a madhouse, but we cannot change his mind-we commonly attach it only the more stubbornly to its beliefs.
It mocks our utmost efforts, as a matter of fact, and in point of logicit absolutely escapes our jurisdiction. Our own more “rational” beliefs are based on evidence exactly similar in nature to that which mystics quote for theirs. Our senses, namely, have assured us of certain states of fact; but mystical experiences are as direct perceptions of fact for those who have them as any sensations ever were for us…. The mystic is, in short, invulnerable, and must be left, whether we relish it or not, in undisturbed enjoyment of his creed.
In this quote, we find no plea from James that we should treat mystics humanely because they have a mental disease. Instead, James puts forth “rights” and “pragmatic” considerations. He argues that just like we in the majority would not like to be ordered to live in a particular way, these mystics have the right to live their way. And pragmatically, if we do use heavy-handed approaches to try to change them, such as throwing them in a madhouse, they will become more stubborn in their beliefs.
James proceeds from here to state that mystics have no right to claim that “we ought to accept the deliverance of their peculiar experiences, if we are ourselves outsiders, and feel no private call thereto.” His theme is tolerance for both the majority toward the minority and vice versa.
Returning to pragmatic arguments, James tells us in his chapter on mysticism that some have found that their mystical experiences have led to wonderful fruits that they highly valued. Some, for example, suffered for a great period of time and after their mystical experience felt wondrously free from their pain and found in its place increased energy and happiness.
James well realizes that the fruits from mystical experiences are not always positive, but he asks us, at the very least, to realize that they have the potential to “be indispensable stages in our approach to the final fullness of the truth.” Thus, we see that “rights” and “pragmatic arguments” can be used instead of a disease concept to promote humane, kind responses toward those who have the types of experiences that tend to be called mental disorders.
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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.
In these critical posts, I have touched upon what I believe would be a distinctly better alternative to the DSM and argued that its creation, in breaking up this monopoly, would stimulate through creative competition, improved mental health services. Today, let’s take a closer look at this.
The Classification and Statistical Manual of Mental Health Concerns (CSM)
I called this proposed alternative manual, the CSM, and you can find a much fuller description of it in a peer reviewed journal HERE. In brief, its first chapter would begin by stating that the developed of the CSM fully recognize that individuality outruns any classification system. It is for this reason that the CSM does not seek to classify anyone. Instead, it classifies the expressed concerns of individuals seeking to have their concerns addressed by a mental health service provider.
The CSM begins from the perspective of the person seeking services. Because the expression of a mental health concern is a clearly observable event, by making it the event being classified in the CSM it solves the reliability problems that have been plaguing the DSM’s far more abstract concept of “mental disorders.”
After this statement, the CSM would clearly define its main construct:
A mental health concern occurs when a person seeking mental health services expresses to a mental health service provider a concern about any of these topics: behavior, emotion, mood, meaning of life, managing chronic pain, work, relationships, education, eating, cognition, sleep and challenging life situations.
Each of these topics would have separate major sections in the second chapter, and under each section would be a list of more specific concerns.
This second chapter would be devoted to listing all of the concerns that professionals tend to hear from those seeking their services. Each concern would be given a code that would be used for various administrative purposes such as insurance forms and computer filing systems. And then there would be, for each concern, a list of related search terms that can be used to assist people who want to utilize a search engine to find all the relevant literature regarding that particular concern.
The list of concerns would be identified by two types of surveys. First, a large sample of mental health service providers would be asked to list the various concerns that they are asked to address in their practice without couching them in pathological language and to stick as closely as possible to the language used by those seeking their services. So, a concern about feeling blue might simply be classified “feeling blue,” rather than the DSM’s “Major Depressive Disorder;” a concern about a child’s above average activity level might simply be classified as “above average activity level” rather than the DSM’s “Attention Deficit Hyperactivity Disorder.” The second type of survey that would be used to generate the list of concerns that would appear in the CSM, would ask the membership of mental health service user organizations to list the various concerns that led them to seek mental health services. They, too, would be asked to avoid pathological terminology. For a number of practical reasons, a maximum of four words would be used for classifying each expressed concern in this chapter.
The final chapter of the CSM would be devoted to describing good practice guidelines for the use of psychological formulation, which is an assessment approach that is consistent with the CSM’s philosophy of not pathologizing individuals. Psychological formulation provides an approach that expands on the brief expressed concerns of individuals by developing a narrative of several paragraphs. It can be defined as the process involving a mental health service user and a mental health service provider co-constructing a hypothesis or ‘best guess’ about the origins of the mental health service user’s concerns in the context of his or her relationships, social circumstances, life events, and the sense that he or she has made of them. Once it has been established what the concerns are, the immediate next question is, ‘How do we jointly understand these experiences, why they arose, and how we might be able to address them?’
Unlike diagnosis, this type of psychological formulation is not about making an expert judgement, but about working closely with the individual to develop a shared understanding which will evolve over time. And, unlike diagnosis, it draws attention to the service user’s resources and strengths in surviving what are nearly always very challenging life situations.
Defending the CSM Approach
Now, some believe that the psychological formulation is all that is needed as an alternative to the DSM and that there is no need to join it with any classification manual such as the CSM. But keep in mind that currently the DSM is used by insurance companies and other third party payers such as Medicaid, Medicare, and Social Security. Insurance companies and these other third party payers have a form that must be filled out whenever someone seeks mental health services under their plan. This form has a little box that currently says, “Diagnosis.” In that box, mental health professionals must fill in the DSM code that corresponds to their so-called diagnosis of the person seeking services.
With the CSM proposal, all that we would be asking insurance companies to do differently in order to add value for their customers, is to slightly change that little box. Instead of just saying “Diagnosis” as it currently says, that box would add two little words, so it would end up saying “Diagnosis or Concern.” Then, when mental health professionals fill in the box, they would be given the choice to either write in the letters “DSM” and its code number that corresponds to its so-called diagnosis, or they would write the letters CSM and its code number that corresponds to the expressed concern. Mental health consumers would be given the choice to go to pathologizing mental health service providers or those using the CSM approach.
That’s all the change that would be required in order to increase value for insurance customers as well as other third party payers. And a major goal that all third party payers have is to increase value for their customers. The cost and effort for these payers would be minimum and we would have numerous testimonials from customers that documents that this change would be viewed as a significant improvement.
A psychological formulation approach, which requires several paragraphs to be completed, would be far too cumbersome for these payers to incorporate into their bureaucratic system. Moreover, a short word or phrase that could replace terms like “Major Depressive Disorder” or “Attention Deficit Hyperactivity Disorder” is necessary for other practical forms of communication. For example, if I want to write a title for a research article, it would not be practical to insert into it several paragraphs. The psychological formulation approach would become far more widely used if it has some practical way of providing some short terms that are consistent with its non-pathologizing approach to conceptualizing an individual’s mental health concerns.
Some may argue that if everyone could go to a mental health professional merely to have their concerns addressed, then the system would soon be overloaded with clients and insurance policy costs would soar. Since insurance companies only cover people with more serious conditions known as “mental disorders,” so the argument goes, this limits the amount of people who can get to see a mental health professional.
Insurance and other third party payer executives are not stupid. They would readily understand, with a little explaining, that mental health service providers now using the current DSM do not turn anyone with a mental health insurance policy away who comes to their office expressing what I refer to as a mental health concern. Professionals are in the business of increasing their clients. Let’s be honest here; there are “close enough” matches throughout the DSM for anyone with mental health insurance coverage who currently wants mental health services to get it.
Here’s another reason why the CSM would improve the psychological formulation approach. In pretty much any of the advanced countries in the world, there is a rather large segment of the population that believes science has been an enormous help advancing our knowledge. The CSM, as already mentioned, is even more consistent with principles of science than the DSM because it solves the problem of reliability that has been a mess with the DSM. And for science minded people, each branch of science must have a system of classification that helps to organize concepts, to retrieve relevant research, and to be useful in formulating programs of research. In my view, the pairing of psychological formulation with the CSM’s list of brief descriptors of mental health concerns will fit well with this worldview.
And so, these are some of my arguments for uniting in the CSM proposal a classification system and the psychological formulation proposal. Together, both can clearly improve value for consumers of mental health services by providing a new choice, but only if consumers of mental health services role up their sleeves, organize, and effectively advocate for this type of change.
In summary then, the CSM is more consistent with principles of science. It is close enough to the worldview and administrative requirements of all of the stakeholders in the mental health field, thus reducing resistance that often comes with proposed changes. And the creation of the CSM would break up the DSM monopoly, thereby spurring creative approaches for understanding the nature of anguish, sadness and tears.
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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional and social intelligence. To begin at the very first post you can click HERE.
If your behavior, thoughts, or feelings become a concern, for a fee, many psychiatrists, psychologists, and social workers are eager to translate your experiences into a language of symptoms, diagnoses, psychopathology, and mental illness. In an earlier post I provided negative criticism about this type of name-calling (see here). Today, we focus in on an additional problem with the pathologizing approach.
Psychiatric Name-Calling Simplistically Devalues What William James Referred to as “Exceptional Experiences”
Tools can be used for good or evil. A hammer can be used to drive in nails in the construction of a life-preserving shelter or to bludgeon an innocent person to death. A car can be used to rush a child to an emergency room so that life-preserving treatment can be administered, or it can be used to tragically end a prom night. Are experiences that are oftentimes referred to as pathological really tools, and is it up to each one of us to use them either for good or evil?
William James
The first time I came across this question occurred while reading about William James’s 1896 series of lectures on “Exceptional Mental States.” Harvard psychologist, Eugene Taylor, had reconstructed these lectures from James’s original handwritten lecture notes, newspaper reports, letters, and a variety of other sources.
At the very beginning of the lectures, James argues that experiences that are commonly viewed as unhealthy or morbid are really “an essential part of every character,” and give life “a truer sense of values.” To support his contention, James first provides three examples of famous individuals who suffered from melancholy, a term that corresponds closely with what modern pathologizers call “major depressive disorder.” St. Paul, the religious figure of the New Testament, Cesare Lombrosa, a late 19th-century Italian criminologist, and Immanual Kant, the 18th-century German philosopher, became, according to their histories, better as a result of their troubling experiences.
Not only is melancholy far more normal and potentially beneficial than the pathologizers would like us to believe, so too, James argues, are delusions and hallucinations. James tells us that the belief in the possession by demons, which is often viewed as a delusion by pathologizers, is remarkably common. “[It] is the one most articulately expressed doctrine of both Testaments, and . . . reined for seventeen hundred years, hardly challenged in churches.”
James then goes on to tell his audience about Buddhist sects in Japan that have priests who believe they can put themselves into a trance so that a god can speak through them. These people seek to cultivate these experiences, apparently believing that they provide some benefits to their sect.
Although hallucinations can be construed as a symptom of mental illness to some, James presents the case of Socrates who “once stood motionless for many hours in the cold and spoke of having a guiding demon.” Attempting to counter the association between pathologies and hallucinations, James states,
Even if this demon [of Socrates] were really meant hallucinations of hearing, we know now that one in eight or ten of the population has had such an experience and that for insanity we must resort to other tests than these.
Like melancholy, delusions, and hallucinations, the “symptoms” of obsessions and manias are treated in James’s lectures as experiences that are normal and potentially beneficial. Thus, James states that there is no end to the possible types of obsessions that we see all around us. And what about “the anti-slavery mania?” Is this to be viewed as pathological? What benefit can such experiences have? James tells his audience about Henry Borg, founder of the American Society for the Prevention of Cruelty to Animals; Charles Henry Parkhurst, a Presbyterian clergyman and reformer who launched a furious attack on organized crime in state government that led to an official investigation; Dorothea Dix, a mid-19th-century humanitarian who visited the insane asylums and successfully advocated for legislation to improve the care for those now labeled mentally ill; General Booth, founder of the Salvation Army; Frances Willard, a suffragette; and others. “These persons,” said James, “are not insane, not maniacs, not melancholics, not deluded.”
Later, he states, “Individuals are types of themselves and enslavement to conventional names and their associations is only too apt to blind the student to the facts before him.”
As Taylor (1984) closes his reconstruction of the lecture series, he quotes James as follows:
There is a strong tendency among these pathological writers I have cited… to represent the line of mental health as a very narrow crack, which one must tread with bated breath, between foul friends on the one side and gulfs of despair on the other. Now health is a term of subjective appreciation, not of objective description….There is no purely objective standard of sound health. Any peculiarity that is of use to a man is a point of soundness in him, and what makes a man sound for one function may make him unsound for another…. The trouble is that such writers . . . use the descriptive names of symptoms merely as an artifice for giving objective authority to their personal dislikes. The medical terms become mere appreciative clubs to knock a man down with. . . . The only sort of being, in fact, who can remain as the typical normal man, after all the individuals with degenerative symptoms have been rejected, must be a perfect nullity . . . Who shall absolutely say that the morbid has no revelations about the meaning of life? That the healthy minded view so-called is all?
The Review of the Evidence
Robert Whitaker
It may seem a fanciful theory that the experiences now referred to as mental illnesses can be potentially helpful. However, in 2010, Robert Whitaker published a book titled Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness. To write the book, he pored through the scientific literature for the past 50 years and found a dramatic increase in the number of people who are pathologized, which led to an astonishing increase in psychiatric drug consumption. And more people then ever before became disabled for longer and longer periods of time.
Here is just one of many such studies that Whitaker describes.
In the 1980s, Martin Harrow, a psychologist at the University of Illinois, began a long-term study of 64 newly diagnosed schizophrenia patients. Every few years, he assessed how they were doing. Were they symptomatic? In recovery? Employed? Were they taking antipsychotic medications? The collective fate of the off-med and medicated patients began to diverge after two years, and by the end of 4.5 years, it was the off-medication group that was doing much better. Nearly 40% of the off-med group were “in recovery” and more than 60% were working, whereas only 6% of the medicated patients were “in recovery” and few were working. This divergence in outcomes remained throughout the next ten years, such that at the 15-year follow-up, 40% of those off drugs were in recovery, versus 5% of the medicated group.
Whitaker also found studies that compared cultures, like our own, that employed the pathologizing model with cultures that framed exceptional experiences as potentially beneficial. Countries infected with the pathologizing approach had outcomes significantly poorer.
These findings lead me to conclude that it is time to have a reasonable discussion about embracing other models of care.
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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on. This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional and social intelligence. To begin at the very first post you can click HERE.
In a recent post titled ADHD and Psychiatric Name Calling, I reviewed studies documenting how much is currently being spent annually on ADHD drug treatments. Here are some new numbers provided by Healthline: What are we getting for this? In this post I hope to clarify this issue. As you read it, you will see phrases in blue. By clicking on each, you will be taken to the actual research article that documents my statement.
For students placed on Ritalin or other stimulant drugs, in short term studies teachers and parents report some improvement in behavior. However, even in the short term, the vast majority of research indicates that there isno improvement on academic functioning. At the end of 14 months, drug treatment was not superior than no-drug treatmenton the following measures: classroom observed behaviour, parent- and teacher-rated social skills, parent-rated parent–child relationships, peer sociometric ratings, and academic achievement. By the end of three years there was no significant effects of the drugs on any measure. And yet, parents who undeniably care about their children, regularly expose their children to the side effects of these drugs, as well as potential long term risks. Why? Because they are convinced that the helpfulness of the drugs outweigh those negatives.
What is it about these drugs that create the myth that the drugs are really helping their children? To understand how this myth is created, it will help if we first take a quick look at how people come to believe smoking cigarettes helps them to deal with stress, and drinking caffeinated coffee helps them to be more productive.
The Myth that Cigarette Smoking Reduces Stress.
In a study published in the American Psychologist, researchers found the following:
Smokers often report that cigarettes help relieve feelings of stress. However, the stress levels of adult smokers are slightly higher than those of nonsmokers, adolescent smokers report increasing levels of stress as they develop regular patterns of smoking, and smoking cessation leads to reduced stress. Far from acting as an aid for mood control, nicotine dependency seems to exacerbate stress. This is confirmed in the daily mood patterns described by smokers, with normal moods during smoking and worsening moods between cigarettes. Thus, the apparent relaxant effect of smoking only reflects the reversal of the tension and irritability that develop during nicotine depletion. Dependent smokers need nicotine to remain feeling normal. The message that tobacco use does not alleviate stress but actually increases it needs to be far more widely known.
This paragraph just provides a summary of the research article that leads to its conclusion. In my view, the whole article lays out a very convincing argument that the relief from a drug withdrawal reaction that occurs each time a person ingests the drug can create the illusion that a drug is helpful. Moreover, I believe that this same argument can also be used to explain how a stimulant such as Ritalin can appear to be helpful even when it is not. Before we get to Ritalin, however, let’s first turn our attention to America’s favorite stimulant, caffeine.
My Personal Experience with Caffeine
When I was 18, I started college. My first class began at 8 a.m. Ugh! That meant waking up around 6 a.m. so I could wash up, have breakfast, and take the hour train ride.
Sitting down for breakfast, I decided to have my first cup of coffee. Both my parents drank coffee in the morning and throughout the day, too. I had heard that it gave you a boost when you were tired, and man, I was tired.
My first sip tasted rather bitter, so I dumped a couple of teaspoons of sugar in. Much better. Then came a little pleasant “up” sensation, but it was accompanied with a little stomach distress. Oh, well. Off I went and it wasn’t long after that I was drinking coffee regularly.
As I entered into my twenties, I began to notice that in the morning before I got my first cup, I was irritable and struggling with sleepiness. With the first sips, ahhhh, relief.
In addition to my morning cups, I’d have a cup typically around 10 a.m., a cola with lunch, which has some caffeine in it, and a couple of cups after supper with dessert.
During my thirties, I began to develop headaches. I attributed them to stress.
By the time I was forty, the headaches became so bad that I went to a physician who prescribed some pills. I don’t like taking pills, but the headaches were so bad that I thought maybe I should give them a try.
Before filling the prescription, I looked up information about it and found the prescribed pills were made entirely of caffeine. Then, I looked at the side effects and found that one of them was headaches. This surprised me.
Since I was already consuming caffeine throughout the day, and a side effect of caffeine was headaches, I thought maybe instead of taking the pills, the first thing I should try was to stop consuming caffeine.
Wow! Giving up coffee was not easy. For several days I went through a very rough period of headaches, feelings of depression, difficulty sleeping, and my brain seemed to be meandering through thick mud.
In retrospect, perhaps I should have tried tapering off coffee, reducing each week one cup at a time. But I did make it through the morass, and in a couple of weeks I was fine. And ever since, I no longer get any headaches.
More surprising is that when I wake up in the morning, by the time I wash up and sit down for breakfast, I’m every bit as awake as I used to become when I had finished my morning coffee. It is now clear to me that the exhausted, irritable feelings that I used to have before I gave up coffee was due to a caffeine withdrawal effect from going a whole night without having any. Throughout the day, I now find that I have a smoother ride and I am every bit as productive as I used to be when I was a coffee drinker.
The Myth of Ritalin’s Effectiveness
Ritalin, and most other drug treatments for “ADHD” are stimulants. And just as I came to mistakenly believe coffee helped me to be more productive, I think Ritalin’s effects lead to the same mistaken conclusion. And just like I didn’t attribute the side effects of caffeine to my coffee drinking, I think parents don’t realize how much of their child’s sleeping problems, headaches, late afternoon miseries are due to the drugs. And when parents try to withdraw their children from the drugs to see if it is really helping, as the withdrawal effects begin to become worse and worse, parents come to think that this is how their children naturally are when they don’t take the drugs.
Now, there is more to this story than I can reveal in a single post. For example, other factors that lead to parents thinking these drugs are more effective than they actually are is the clever advertisement of the drug companies. Moreover, in some cases, children, as they become older, typically mature at a certain pace. Thus, some children viewed as having ADHD problems completely grow out of these problems without any drug treatment. If this growth in maturity occurs shortly after a child begins to take the drugs, the improvement from natural maturity growth can be easily attributed to the effects of the drugs. When this happens, parents rave to their family members and friends that Ritalin saved their child, and they push other parents to do what they did–get their children on Ritalin.
And so, this is how I think the myth of Ritalin’s effectiveness is created. An initial improvement in behavior once the drug treatment begins; a slow tolerance develops to the drug so it becomes less and less effective, but this occurs over a period of time during which the child is naturally maturing. As a result, some parents don’t notice that the drug is becoming less effective. When parents do notice the decreased effectiveness of the drug, they often take the child to the doctor to get an increased dose. Again there is a boost in apparent improvement. As tolerance to the drug once again begins to occur, more time goes by, and of course there is more growth in the child’s natural maturity. This may lead to less attention problems, but the improvement is attributed to the drugs, rather than improved maturity. Whenever parents try to see if their child can do just as well without the drugs, the withdrawal reactions convince them that their child really needs the drug. Negative side effects of the drugs are attributed to other causes. Couple all of this with the clever advertisement campaign of drug companies, and we end up with a pretty impressive myth.
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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.
Followers of this blog seek to become experts in a branch of personal interactions referred to as name-calling. Among the words and phrases used in these interactions are “crazy,” “mentally ill,” and “meshuga.” In today’s post, I hope to weave a little narrative around their use in a manner that might take the sting out of them.
The Broad Use of These Words
These terms are often used so broadly that they mean the same thing as other words and phrases thrown at someone, such as “jerk,” “piece of trash,” “stupid idiot,” etc. When used like this, they all mean nothing more than the angry party strongly doesn’t like what the other party did. They serve as a type of exclamation point.
“I don’t like what you did,” is not as emotionally packed as, “Listen, you crazy idiot, I don’t like what you did!” Nor is it as emotionally packed as, “You must be mentally ill to do something like that, you jerk!” Nor is it as emotionally packed as, “Oy veh, you putz, you got to be meshuga to do something like that!!”
Of course, it is perfectly possible to convey emotionally packed exclamations without the use of these words. My mother was a master at this. Her abilities to clearly define what she objected to and to vary her tone of voice were all the tools she required to amply communicate to people where she stood on an issue.
The Special Similarities of Crazy, Mentally Ill, and Meshuga
Now, in addition to being used as general insults, “crazy,” “mentally ill,” and “meshuga” can also be viewed as falling into a group of ideas that have more similarities than most of the other insults that might be picked at random. That is, I would guess that “crazy” and “mentally ill” are viewed by most people as being more alike than “crazy” and “jerk,” even though each could be used as general insults.
It is important to note that there are people in our communities that have adopted a particular narrow use of the term “mentally ill.” To illustrate this, Margaret believes she has a mental illness and values that she has come to accept that about herself. For her, conflicts spring up when she hears someone use the term, “mentally ill” in its more broad, general insult manner. For example, let’s say Margaret is sitting in her backyard, and she hears that her neighbor, Tim, has gotten into a conflict with Ron. Suddenly she hears Tim shouting at Ron that he is a no good mentally ill idiot!!! Even though the conflict has, in a sense, nothing to do with Margaret, she becomes angry with Tim for using the term “mentally ill” in this broad, general insult manner. There is actually no law requiring that Tim adopt the narrower meaning that Margaret uses, but she is still outraged at him.
Who Should Get to Decide When it is Proper to use Terms Such as Crazy, Mentally Ill or Meshuga as a general Insult or in Some Particular Narrow Sense?
The actress, Marlene Dietrich, when asked if she believed in God, replied, “If there is a supreme being, he’s crazy.” In some religious communities, she would have been viewed as crazy for saying this. Meanwhile, Dr. Sigmund Freud, who is thought of by many as having been a great expert on mental illness, believed that all religious people suffer from a mental illness. Dr. Carl Jung, an equally great expert on the subject, disagreed with Freud, believing instead that religious people, even people today viewed as psychotic, may be in touch with deep and ancient truths.
When I was a young boy growing up in the Brooklyn neighborhood of Brighton Beach, I heard people from time to time being called a “meshugana,” which I was told means in Yiddish, “a crazy person.” What was unique about how the Yiddish term was used in Brighton Beach, is that as soon as someone was said to be a meshugana, it was very common to have someone stick up for that person with the words, “Hey, everyone has their own mishegas.” Loosely translated, this means that we all have a little craziness within us, so let’s not pretend to be so high and mighty by putting someone down like this.
Now, for people who want to know if they are really mentally ill, they can get the latest version of the DSM (Diagnostic and Statistical Manual of Mental Disorders), which was developed by the American Psychiatric Association. I happen to have a copy of it, and as I’ve been studying its pages, it has become apparent that with little imagination we can all be viewed as having some mental illness. That works out pretty good for psychiatrists because this way they never have to turn away any customers who come to their office seeking to become their patients.
But what if we really want to find out if we really, truly are crazy? Fortunately, there is now an alternative to the DSM, which can finally set us straight. It’s called the Diagnostic Manual of Mishegas (DMOM), and as the ad for it explains, the authors divide
all mental disorders into two realms: mishegas major and mishegas minor. And for each of the sub-categories it analyzes… yenta, kvetch, alter kocker, shnorrer, dementia-with-benefits, etc…THE DMOM will enable readers to transform ordinary tsuris and mishegas—the glooms, blues, angsts, and general chazzerie of their lives—into transcendent and easy-to-understand categories. It will turn kvetching into kvelling and guilt into gelt, so that readers will learn to live at peace with their inner mishegas and to treasure its precious and life-giving absurdities.
Well, I have nothing that can top that, so until we meet again, don’t let the insults get to you.
My Best,
Jeff
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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.
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.
Thomas Szasz, MD
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.
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.
Berlin Wall
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.
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 byLincoln 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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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.
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 activelyexplore 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:
Lucy Johnstone
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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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.
It’s easy for me to empathize because I regularly have bouts of what I refer to as melancholy. A deep anguish comes over me, and during this period I often begin to think about how I went through my father’s death when I was twelve, how I’m getting older and can no longer do the many athletic things that thrilled me when I was younger, and on and on. Sometimes these dark melancholy experiences come about because something clearly happened that upset me, and sometimes they seem to come out of the blue.
You see, as people experience depression, or other concerns that often lead to a classification of having a mental disorder, some people go about their lives functioning as they typically were doing before the concern arose, while some find that in some areas they begin to function below the levels that are typical for them, while some find that their functioning increases in one or more areas. For example, some sleep about the same amount, some less, and some more. I have met people who, when they are depressed, start cleaning every inch of their home, while others find it difficult to get out of bed.
Also of interest when exploring a person’s expressed concern is to look at how the person had been functioning before the onset of the presenting concern. If some important relationships had begun to function below average, or if the person had been sleeping less than average to keep up with work demands, these facts can be insightful when seeking ways to address the presenting concern.
There are those who embrace this mental illness/disorder labeling. One reason is the pharmaceutical industry’s promotion of this idea to sell people on the idea that they need certain drugs to live a more normal, healthier life.
Those who are uncomfortable about the use of “mental illness” terminology point out they are stigmatizing because they are used as put downs in our society. Moreover, the media associates the most heinous crimes with those referred to as the mentally ill even though the vast majority of those classified in this manner are not violent.
Among the most articulate individuals to voice objections to the mental disorder labeling was Harvard psychologist and philosopher William James. Over one hundred years ago he wrote a book titled, The Varieties of Religious Experience (1902). At that time many medical doctors argued that people who were religious were all mentally ill. In response, Professor James wrote:Medical materialism seems indeed a good appellation for the too simple-minded system of thought which we are considering. Medical materialism finishes up Saint Paul by calling his vision on the road to Damascus a discharging lesion of the occipital cortex, he being an epileptic.
assumes as a convenient hypothesis that the dependence of mental states on bodily conditions must be thoroughgoing and complete. If we adopt the assumption, then of course what medical materialism insists on must be true in a general way, if not every detail…. But now, I ask you, how can such an existential account of facts of mental history decide in one way or another on their spiritual significance? According to the general postulate of psychology just referred to, there is not a single one of our states of mind, high or low, healthy or morbid, that has not some organic process as its condition. Scientific theories are organically conditioned just as much as religious emotions are; and if we only knew the facts intimately enough, we should doubtless see “the liver” determining the dicta of the sturdy atheist as decisively as it does those of the Methodist under conviction anxious about his soul. When it alters one way the blood that percolates it, we get the Methodist, when in another way, we get the atheist form of mind. So of all our raptures and our drynesses, our longings and pantings, our questions and beliefs. They are equally organically founded, be they religious or of non-religious content. (p. 30)
James points out that in the natural sciences and the arts it never occurs to anyone to refute opinions, beliefs and experiences by putting down their author’s neurological constitution. Value is determined by “judgments based on our own immediate feelings primarily; and secondarily on what we can ascertain of their experiential relations to our moral needs and to the rest of what we hold as true” (p. 33).
To this, I respond that in point of fact there is currently a renewed respect for the extraordinary complexity
When individuals express a concern, exploring how they are functioning in the main areas of their life can be enormously helpful. Someone who reports a concern about experiencing depression, whom, by some gentle questioning, we find out has been functioning below average in the areas of sleep, interpersonal relationships, and exercise may benefit enormously if we work together on getting these areas of functioning in a more optimal range. This is true for those who report other types of concerns such as experiencing anxiety, hearing voices, below average range of attention, obsessive thoughts, and on and on. With a model that includes addressing concerns and exploring ways to improve functioning, labeling someone as having a mental disorder becomes unnecessary and may actually interfere with the aims of a counseling/psychotheraputic relationship.
But for those who desire to have their concerns addressed by well trained mental health professionals without being referred to as having a mental illness or disorder, I do propose that we do provide a reasonable option for them to access mental health services. In my view, mental health professionals, once we hear our clients’ concerns and how they are functioning in the various areas of their lives, we have the basics to formulate, in full cooperation with our clients, a plan for addressing these concerns. I hope you give this some thought.
And yet, parents who undeniably care about their children, regularly expose their children to the side effects of these drugs, as well as potential long term risks. Why? Because they are convinced that the helpfulness of the drugs outweigh those negatives.
As I entered into my twenties, I began to notice that in the morning before I got my first cup, I was irritable and struggling with sleepiness. With the first sips, ahhhh, relief.
By the time I was forty, the headaches became so bad that I went to a physician who prescribed some pills. I don’t like taking pills, but the headaches were so bad that I thought maybe I should give them a try.
“I don’t like what you did,” is not as emotionally packed as, “Listen, you crazy idiot, I don’t like what you did!” Nor is it as emotionally packed as, “You must be mentally ill to do something like that, you jerk!” Nor is it as emotionally packed as, “Oy veh, you putz, you got to be meshuga to do something like that!!”
The actress, Marlene Dietrich, when asked if she believed in God, replied, “If there is a supreme being, he’s crazy.” In some religious communities, she would have been viewed as crazy for saying this. 
can top that, so until we meet again, don’t let the insults get to you.
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?
ation 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.
