Monthly Archives: March 2009

Attention Deficit/Hyperactivity Disorder

Attention Deficit/Hyperactivity Disorder is defined as “a persistent pattern of inattention and/or hyperimpulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development.” There is a requirement that the problem existed before age seven and that some of the problems are present in at least two settings. There also must be clear evidence that the inappropriate activity interferes with the individual’s social, academic, or occupational functioning. With regards to the actual diagnostic procedure, the APA lists eighteen behavioral indicators, nine under the heading “inattention,” six under “hyperactivity,” and three under “impulsivity.” For the diagnosis to be considered positive, the child must exhibit at least six problems from either the inattention list or the hyperimpulsivity lists.

DSM-IV-TR (2000) cites a prevalence rate of three to five percent for school-aged children, but even the most cursory familiarity with the reality makes it clear that at least in the U.S., the diagnosis is being assigned with increasing frequency with the passing of years. A CDC study from 2003, for instance, reports a 7.5% nationwide prevalence, the highest rate being in Alabama (11%) and the lowest in Colorado (5%).

Diagnostic Criteria
Attention Deficit/Hyperactivity Disorder is one of the most blatantly abused mental disorder diagnoses and is having an extraordinarily destructive effect within our society. To enable the reader to readily appreciate this matter, and facilitate a discussion, the APA’s eighteen criteria for this fictitious illness are set out below:
a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
b) often has difficulty sustaining attention in tasks or play activities
c) often does not seem to listen when spoken to directly
d) often does not follow through on instructions, and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
e) often has difficulty organizing tasks and activities
f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
h) is often easily distracted by extraneous stimuli
i) is often forgetful in daily activities
a) often fidgets with hands or feet, or squirms in seat
b) often leaves seat in classroom or in other situations in which remaining seated is expected
c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults may be limited to subjective feelings of restlessness)
d) often has difficulty playing or engaging in leisure activities quietly
e) is often “on the go” or often acts as if “driven by a motor”
f) often talks excessively
g) often blurts out answers before questions have been completed
h) often has difficulty awaiting turn
i) often interrupts or intrudes on others (e.g., butts into conversations or games)

Not A Chemical Imbalance
As with most of the DSM diagnoses, no physical damage or etiology is required for a diagnosis to be assigned. Indeed, with regards to ADHD, DSM acknowledges that there “are no lab tests that have been established as diagnostic in the clinical assessment of” this disorder, nor are there any “specific physical features” associated with it. This is particularly noteworthy in that the notion that ADHD is caused by a malfunction in the brain is widely and actively promoted by psychiatrists and other mental health professionals. Parents, teachers, and other professionals, as well as the general public, are being told that the child can’t pay attention or sit still because of “a chemical imbalance” in the brain. The fact, however, is that there is no evidence to support such contentions, and it is just as reasonable, and far more plausible, to conceptualize the matter as plain, old-fashioned misbehavior. Certainly no one could dispute that problems in brain structure and chemistry can lead to problems in behavior, e.g. Hatfield-McCoy (or Von Hippel-Lindau) disease, but it is equally obvious that problems in behavior can and do occur in the absence of neurological problems. To infer neurological problems purely on the evidence of misbehavior is illogical, unwarranted, and even reckless.

Children who display the misbehaviors listed in the DSM criteria are clearly difficult to manage, and present problems in the classroom and possibly other settings. Parents and teachers are frequently all too relieved to refer these children to a psychiatrist and to accept the chemical imbalance explanation. The psychiatrist prescribes a pill, which by and large keeps the worst of the misbehavior under control. Once again, everybody is off the hook, and the psychiatrists and the pharmaceutical companies are making money.

At the risk of stating the obvious, just because a child doesn’t pay attention, does not mean that he can’t learn to pay attention. There is hardly a child in the world who would not prefer to be outside playing, rather than doing homework or sitting in class learning multiplication tables. Previous generations saw this clearly, and our parents and grandparents accepted the task of teaching their children the necessary skill of applying oneself to difficult and boring tasks and paying attention respectfully to authority figures. Today, tragically, if this training has been neglected, and the child reaches the age of six or seven without this skill, the entirely unwarranted assumption is made that he has a brain problem which prevents him from developing appropriately in this area. The far more likely assumption, that his training and discipline have been blatantly neglected in the home, is almost never even considered.

Former Times
Almost all of the so-called diagnostic criteria listed earlier can be conceptualized as disobedience, laziness, defiance, and misbehavior, and the fact that the misbehaviors are not routinely seen as such is an indication of how far standards have been allowed to slip. The notion that a child of normal intelligence who leaves his seat in the classroom and wanders about the room at will, or climbs or talks excessively, or refuses to wait his turn, or interrupts or intrudes on others, is displaying symptoms of a mental disorder, borders on the bizarre. In former generations expectations were higher. Children who had the temerity to engage in such activity were quickly corrected (usually within the first few weeks of starting school) and readily acquired the appropriate level of self-discipline and control for an academic setting. As the child progressed through the successive grades, expectations were raised, and appropriate correction was provided for problems such as careless mistakes, not listening, not following through on instructions, and avoiding difficult tasks. It might be argued that classrooms in former times were over-regulated and regimented, but there certainly were not large numbers of children routinely misbehaving in the ways listed in the DSM criteria. So either some incredible change has occurred in the brain chemistry of our nation’s children across the last generation or two (which seems unlikely), or else the widespread and highly profitable prescription of psychoactive drugs to control this misbehavior is unwarranted. Nevertheless, these prescriptions have become the standard treatment for this so-called mental disorder.

Circular Explanation

The parent bringing a child to a psychiatrist and asking why he is so restless, why can’t he pay attention, etc., is told “because he has a mental disorder, a chemical imbalance in his brain that prevents him from functioning appropriately in these areas.” If the parent were to push the matter and ask “how do you know he has this disorder, this imbalance?” the only possible response is: “because he is so restless and inattentive.” The “explanation” is entirely circular, and in fact explains nothing. The problem behavior that the APA refer to as ADHD is not something a child has, but rather something he does. It is voluntary behavior which can be trained and modified using the normal methods of parental discipline and control. Parents of children who have been assigned this diagnosis, when confronted with this reality, usually protest that they “have tried everything,” but that their child is simply unamenable to any kind of normal training and correction. In fact, however, what is usually the case with parents in this kind of situation is that they have tried little or nothing in the way of creative discipline and correction, and routinely afford very little time and energy to the task of monitoring and directing their children’s activities. They tend to be extremely unconfident in parenting matters, want to “give” their children as much as possible, routinely fail to say “no” and to enforce sanctions even in situations where this is clearly needed. The mental disorder explanation actively promoted by the psychiatrists and pharmaceutical companies eases their consciences, and the drugs control the worst of the misbehavior. Tragically the child is given the expectation that he is damaged and that he can’t acquire the normal developmental skills in these areas without psychoactive drugs. He is also exposed to an array of side effects that sometimes make the original problem look fairly benign.

Although most parents of these children fit the profile outlined above, there are a few who do not want their children on drugs, and who resist the referral to psychiatric services. The Elementary and Secondary Education Reauthorization Bill, debated in the U.S. Senate and House in October 2001, contained provisions whereby schools could refer children to psychiatrists for mental health treatment only with parental permission. On their website at that time, the APA was actively encouraging readers to contact their political representatives and lobby for the deletion of that particular section of the bill. The question naturally arises as to why the APA would want to see these children without their parents’ permission. The psychiatrists say it’s to ensure that the parents’ resistance does not cause the child to miss out on needed services, but their track record in the marketing and lobbying area, and their ever-vigilant search for ways to expand their services, suggest that their agenda may also have had a more self-centered aspect.

Adult ADHD: A Marketing Success
In the context of marketing, it is worth noting that Attention Deficit/Hyperactivity Disorder is no longer considered exclusively a childhood condition. In recent years adults who exhibit these dysfunctional behaviors are being given the ADHD diagnosis by mental health practitioners, and are being encouraged to think of themselves as having a chemical imbalance in their brain. They are also, of course, being prescribed psychoactive drugs. Like their childhood counterparts, these adults are given the false message that their laziness, inconsideration, and lack of attention are perfectly acceptable, and that problems of this sort can be resolved pharmaceutically without any effort or difficulty on their part.

Success Through Effort
The notion of success through effort and perseverance has been fairly fundamental in western culture. Throughout most of our history successive generations have been encouraged to strive towards high standards in various areas, and there has always been the recognition that this is not easy. Habits of work and application have been encouraged formally and informally throughout our history. The ADHD diagnosis is a direct attack on the notion of success through effort and hard work. The fact is that most parents still take their responsibilities seriously, and teach their children to sit still, pay attention, etc.. Attributing the dysfunctional behavior of the children who do not receive this training to a mental disorder essentially belittles the efforts of the parents who have been successful in this area. It is noteworthy that the phrase “has difficulty” is used four times in the ADHD criteria: “often has difficulty sustaining attention…”; “often has difficulty organizing tasks and activities…”; “often has difficulty playing…quietly”; and “often has difficulty awaiting turn.” The assumption being made here is that the child who is misbehaving somehow has more difficulty acquiring the appropriate habits of discipline and self-control than the child who is behaving appropriately. This assumption is entirely unwarranted. The well-behaved child may, in fact, be experiencing enormous difficulty staying on track, but he continues to do so because he has received appropriate training, discipline, correction, etc., from his parents. The chronically misbehaved child, on the other hand, usually has never been exposed to the notion of success through personal effort, and has never received systematic discipline and training in these areas. He does not, in fact, experience any more difficulty waiting his turn than other children. He has simply never been required to make the effort in this or other areas.

ADHD and DisabilityIn 2006, more than half a million children in the US were receiving disability SSI from the Social Security Administration for mental disorders other than retardation. This was 49% of the total number of children receiving benefits for all disabilities. In other words, of all the children receiving disability benefits, 49% were awarded disability status on the basis of mental disorders other than retardation! In 2003, the percentage was 40%. This increase is part of a trend dating back to 1990, when new criteria for establishing childhood disability were put in place. The new criteria focussed on the child’s functioning, where the previous criteria were based more on proven etiology. The SSA website describes these trends in detail and offers this comment:

“A significant portion of the increase in awards involved mental disorders rather than mental retardation, with much attention directed at awards based on attention deficit hyperactivity disorder (ADHD) and various mental disorders manifesting themselves in maladaptive behaviors.”

An interesting sidebar in this area is that the welfare reform legislation passed in 1996 was expected to reduce the number of childhood disability awards. In fact, the number of awards continued to increase after 1997. It is clear both from the figures and from my personal knowledge of the system at the time, that Social Services departments were routinely referring their problem families to the mental health services, where the children could receive a “diagnosis” and be declared disabled. So they came off the welfare roles and went onto the disability roles. It is also my impression from this period that at least some parents were actively coaching their children in the ADHD symptoms to increase the likelihood of a disability determination. If the reader will glance back to the ADHD criteria listed earlier, it will be apparent that coaching of this sort would present no great challenge. What’s particularly interesting here is that a child who was successfully coached and encouraged to display these misbehaviors would really have ADHD. He would not be faking ADHD. The only requirement for a diagnosis is that the child misbehaves in the ways stated. If the child does these things, then he has ADHD, and if the misbehaviors are severe enough, then he will qualify for disability payments. Why he is behaving this way – or how he got to this position – is of no concern. SSI payments vary from state to state, but are usually about $500 per month per child ($640 in California; $476 in Alaska as of 2006.)

The abuse of these so-called diagnoses is a logical outcome of the APA’s spurious taxonomy. The APA’s position is that these misbehaviors are really symptoms of an illness, and that no other evidence is required to establish the diagnosis. Once this notion gains currency, it can be only a matter of time before someone says: “If my child is sick then why can’t he qualify for disability benefits?”

Next Post:  Conduct Disorder and Oppositional Defiant Disorder

How Can They Just Invent Illnesses?

The notion of a professional group such as the APA sitting in their councils and committees inventing illnesses for themselves to treat seems so preposterous that a measure of disbelief on the part of the reader is understandable.  In its historical context, however, the development is not so surprising.  The original 1952 DSM was very simple and unpretentious, and whilst part of the APA’s motivation in drafting the document was undoubtedly to draw some credibility and respectability to their profession, there is at the same time nothing to suggest any great drive at that time towards aggrandizement or service expansion.  However, having agreed in 1952 that neurosis was a form of mental disorder, it was inevitable that subsequent revisions of the manual would attempt to define this feature further and look for subdivisions of the general category.  This, of course, is exactly what has happened, and the current version of DSM lists literally dozens of disorders of this sort, although the general term neurosis is no longer used.  (For an interesting discussion of this matter, see Karen Franklin’s post at In The News.)

Trichotillomania is a case in point.  DSM-IV describes trichotillomania as a mental disorder in which the victim, usually a female child, twists, tangles, and pulls out her hair in a compulsive, habitual manner.

The reality is that children play with their hair, and children also frequently develop dysfunctional and counterproductive habits, such as picking their noses, putting their fingers in their mouths, etc..  It is likely that children have displayed hair-tangling and hair-pulling tendencies since before people lived in caves.  Parents from generation to generation have dealt with these kinds of problems as a matter of course, as an integral part of the normal parental responsibilities.

Functional, effective parents intuitively use the normal systems of coaching, teaching, rewards, punishments, etc., in a more or less systematic attempt to instill productive habits in their children and eliminate dysfunctional ones.  This includes hair-pulling.  Certainly up till a generation or so ago, no parents would have conceptualized this as anything other than a habit, and the matter would have been resolved promptly within the family using natural methods of coaching, encouraging, etc..

Today, however, thanks to the widespread “consciousness raising” of the APA and the pharmaceutical companies, a growing number of parents have accepted the notion that a child displaying this kind of behavior has a mental disorder and needs immediate professional attention.  Newspaper ads and free screenings, both paid for by pharmaceutical companies, promote these ideas and frequently suggest that failure to seek prompt treatment may result in matters becoming a good deal worse.

The treatment usually involves a psychotropic prescription, the side effects of which frequently are far more destructive to the child’s health than the original problem.  The child is also “enrolled” in the ranks of the mentally disordered, and is given the false notion that it is impossible to deal with life’s normal problems without the assistance of professionals and pills.  He or she is well on the road to customer-for-life status, which of course benefits the practitioners and the pharmaceutical companies.

In this context it is important to note that the question “is trichotillomania a mental disorder or not?” becomes meaningless, because there is no definition of a mental disorder other than the one the APA provides.  If the APA says something is a mental disorder, then it is, otherwise it is not.  There is no external reality to which their findings must conform.  By contrast, a geologist, for instance, who asserted that wood is a form of rock would be rebutted on the grounds that wood simply does not have the objective qualities and characteristics of rock, and no amount of discussion or consensus can alter that reality.  A psychiatrist, on the other hand, who suggests that road rage, for instance, is a mental disorder, merely has to persuade enough of his colleagues that this is the case, and it will become so by being included in the next edition of DSM.  It is the psychiatrists who decide what is a mental disorder, and their general philosophy in this regard for the past fifty years has been “the more the merrier.”  A recent editorial in the American Journal of Psychiatry, for instance, asserts that Internet addiction is a mental disorder and should be included in the next edition of DSM.

In general, business has been good for psychiatrists in recent decades.  Clients are indeed seeking their help for an increasingly wide range of problems, and it is likely that DSM-V, when it emerges, will list even more mental disorders than the current edition.

Calling a problem a mental disorder obviously does not change the nature of the problem, nor does it provide any special insight into the matter.  The fact is that most children play with their hair.  For a very small number the habit becomes strong, and they actually tear hair out in significant quantities.  When psychiatrists say, “This is a mental disorder,” essentially what they are saying to the parent is, “You can’t take care of this.  You must bring this child in for treatment.”  The disempowering aspect of the message is not usually articulated, but parents who succumb to these kinds of pressures do in fact become disempowered and ineffective, and usually relegate an increasing measure of their parental responsibilities to the professionals.  This, of course, is good for business, but the results in terms of the child’s general development are often far from satisfactory.  Furthermore, by defining the problem as something inherent to the child, the system is ignoring the role the parents may have played in the creation and maintenance of the problem, and in general, little or no attempt is made to empower or coach them towards more effective parenting.   (For an interesting perspective on this, see codeblog’s post about a day in the children’s psych ward.)

In the context of diagnostic proliferation, it needs to be recognized that psychiatry is a profession, and that the APA’s primary agenda – rhetoric notwithstanding – is to promote the welfare and interests of their members.  That’s why the individual psychiatrists join and pay their dues (currently $540 a year).  Like other professional groups, they window-dress their documents and their press releases with public welfare platitudes, but also like other professional groups, they protect their own interests and fight tenaciously for their turf.

It should also be acknowledged that in the turf protection area, psychiatrists have enjoyed a great deal of success and have become extraordinarily adept at lobbying legislators and other decision-making bodies in matters that affect psychiatry’s financial interests.  In this regard they have had the wholehearted assistance of the pharmaceutical companies, who have used their formidable advertising and lobbying power to full advantage in the drive to develop the mental disorder framework and to promote its acceptance by the American people.  Pharmaceutical companies routinely fund most of the “free screenings” for depression and other so-called mental disorders that one sees advertised in the newspapers and on TV.  Their funding sources are seldom acknowledged in the ads, but can usually be verified by calling the 800 number and asking where the funding comes from.  In addition the pharmaceutical companies donate large quantities of money to organizations sympathetic to their cause, for instance, the National Alliance for the Mentally Ill (NAMI), and have in recent years begun targeting ads for psychotropic drugs directly towards potential patients.

The central theme of this website is that the APA’s framework, in which an increasingly wide number of human problems are conceptualized as mental illnesses and best treated by psychotropic drugs, is spurious and counterproductive.  It is a disempowering philosophy that undermines not only the value and integrity of the individual affected, but also saps the strength, vitality, and creativity of our families and communities.  In the following posts I will discuss some of these so-called diagnoses in more detail.

Next post:  Attention Deficit and Disruptive Behavior Disorders

Psychologists, Social Workers, and Counselors in the Mental Health Field

Although psychiatrists are the primary and most influential players in the mental health business, they are not the only professionals involved. Most agencies also employ psychologists, social workers, and counselors, and it is important to recognize how the developments of recent decades have impacted their roles also.

Psychologists are licensed professionals who have obtained a psychology degree at a doctorate level.  They have no medical training. They work in a wide range of settings, including industry and education. Psychologists became involved in mental health work largely because they were instrumental in the development of psychological tests, and the numbers of psychologists employed by hospitals and out-patient agencies increased fairly steadily through the second half of the twentieth century. Despite this apparent acceptance, however, there has always been a measure of tension between the psychiatrists and the psychologists. Some of this derives from conflicting ideologies, but a good deal of it is driven by simple rivalry and competitiveness, and by considerations of “who’s in charge.” Psychiatrists have consistently attempted to relegate the psychologists to an assistant or underling role, whilst the psychologists have striven for independent status. These tensions continue to this day, and in fact have gained a measure of prominence as psychologists lobby vigorously for prescription rights against the vehement opposition of the psychiatrists.

It is particularly noteworthy, however, that despite these long-standing rivalries, most psychologists working in the mental health field accept, use, and endorse the APA’s diagnostic manual. New candidates to the profession are required to be very familiar with the manual’s content, and the national psychologist licensing examination always contains a large number of questions based directly on DSM material. Psychologists’ acceptance of DSM is driven primarily, of course, by economics. Thanks largely to intensive lobbying over many decades by the psychiatrists, the diagnostic system is recognized by Medicare and by the private insurance companies, and if psychologists want to be reimbursed for their services by these payers, they must use the same system.

Clinical social workers and counselors are in essentially the same position, and despite any ideological objections they might have to DSM, if they wish to make a living in the mental health field, they must also endorse and use the DSM labels and categories. Economics makes cowards of us all.

Many psychologists, social workers, and counselors attempt to rationalize and justify this activity as a mere bureaucratic necessity. The diagnosis, it is argued, is just something that needs to be written on the billing form, and that, within the context of treatment, they continue to follow their principles and to do what they think is right.

There is merit to this argument, of course, but it does not override the fact that when they sign their bills, they are certifying that the client has a mental disorder, and they are lending their support to the spurious notion that mental disorders are the underlying cause of human problems and have reached epidemic proportions in our society. An interesting but important point in this area is that in a great many cases, the client is not informed that he has been assigned a mental disorder diagnosis. A person might seek help from a psychologist or counselor because he is feeling overwhelmed by stress at home or work. He goes along for five or six sessions, talks out his problems, feels better, and is pleased to learn that his insurance company picked up eighty percent of the tab. What he may not realize is that his insurance company paid the bill on the basis of the assigned diagnosis, and that this mental disorder diagnosis now constitutes a part of his insurance record. He has also joined the ranks of the “one fifth of the population” cited in the earlier government statistics.

Next Post: How can they just invent illnesses?

Psychiatrists and the Pharmaceutical Companies

Psychiatrists are medical doctors who after graduation from medical school specialize in the treatment of mental disorders. In 1950 there were about 7000 psychiatrists in the United States. Most of these worked either in the state mental hospitals or in private practice, and in both settings treatment was conceptualized primarily on the lines of talking to the patients, gaining an understanding of their problems, and encouraging them in positive directions.

In the hospitals, considerations of containment and control sometimes eclipsed those of treatment, but in their private practices psychiatrists practiced the newly emerging art of psychotherapy with vigor and enthusiasm. Different schools of thought emerged, and there existed a healthy measure of dialog and debate as to the merits and demerits of various techniques. Articles were published in learned journals, and in every respect psychiatry was poised for development as a “talking” profession.

Despite the enthusiasm with which the psychotherapeutic movement was being greeted generally, it was not without its critics. Physicians generally had always been somewhat skeptical of their psychiatric cousins, but now as the other medical specialties aligned themselves increasingly with the physical sciences, and developed an array of formal tests and procedures to complement their healing arts, the psychiatrists began to feel increasingly self-conscious with regards to the somewhat nebulous and ill-defined nature of their subject matter.

At about the same time, many industrial and commercial organizations in the United States began to offer medical insurance as a fringe benefit to attract employees. Physicians quickly discovered that their bills were paid more reliably and more promptly under these schemes, and not surprisingly, the psychiatrists began to look for ways whereby they also could bill insurance companies for their services. Because of the time-consuming nature of psychotherapy, it was at that time, apart from the state hospitals, almost exclusively the province of the wealthy. Human nature being what it is, however, it is reasonable to believe that psychiatrists had as much difficulty collecting their accounts as other physicians, and their desire to improve their lot in this regard is certainly understandable.

To bill insurance companies, however, they had to specify more clearly than previously what illnesses and disease entities they were purportedly treating. An additional pressure to formalize psychiatric diagnoses arose within the armed forces, where unprecedentedly large numbers of individuals were receiving psychiatric services and where military formalities and accounting were demanding a higher level of precision and definition than psychiatrists had encountered in civilian life. For all of these reasons, the psychiatrists had to produce a formal list of diagnoses, and in 1952, the American Psychiatric Association (APA) published its Diagnostic and Statistical Manual (DSM). The work was not very precise and the diagnostic categories were not clearly defined, but it was a start, and more importantly, the formal endorsement of the APA afforded the diagnoses a respectability and perceived validity that they would not otherwise have achieved.

The first DSM listed four broad categories of mental disorder: psychosis; neurosis; character problems; and psycho-physiological problems. Psychosis embraced what a lay person might term “craziness.” Neurosis referred to worries, anxieties, and depression. Character problems meant bad habits, and psycho-physiological problems referred to mental problems which were believed to be caused primarily by physical factors.

What is especially noteworthy about this early list of mental disorders is that there is no expansionist agenda evident. It was simply an attempt on the part of a helping professional group to codify and systematize the object of their study. They were describing the problems brought to them by their current clientele, and there is nothing in the text to suggest any preoccupation with expanding the diagnostic categories to embrace large numbers of new clients.

By contrast, the current edition of the APA’s manual, DSM-IV, published in 1994, has more than three hundred diagnostic categories and sub-categories, and it is difficult to avoid the perception of expansionist marketing. In addition, the diagnostic categories are so vaguely defined that almost anybody at some time in his or her life will meet the criteria for at least one mental disorder.

To understand how such a major shift in emphasis occurred, it is necessary to examine the role of the pharmaceutical companies.

In the 1950’s, several psychotropic drugs were discovered or invented, and it was clear that further developments in this area were imminent. Psychotropic drugs are chemicals that alter people’s behavior and/or mood, and it was also clear that the sales potential in this area was enormous.

The problem for the pharmaceutical companies, however, was that they needed diseases and illnesses for which these drugs could legitimately be prescribed. In the United States the testing and marketing of drugs is regulated by the Food and Drug Administration (FDA), and part of the regulatory process requires the manufacturer to specify the illness targeted by a new drug and to conduct appropriate clinical trials. The testing procedures are not as rigorous as the public generally believes, but obviously they cannot be completely ignored.

So as the second half of the twentieth century was under way, we had the APA, on the one hand, formalizing and codifying the disorders or illnesses that their members are treating in their daily practices. On the other hand the pharmaceutical companies were looking for illnesses which would legitimize the sale and distribution of their newly discovered psychoactive products. The mutual interests were obvious. The psychiatrists and pharmaceutical companies joined hands in a collaborative venture that flourishes to the present day. The major impact of the “merger” on the psychiatrists is that the nature of their work changed from psychotherapy, which consisted essentially of talking and listening, to prescribing pills. At the present time it is extremely rare to find a psychiatrist who has ever practiced or even received training in any form of “talk” therapy. For the most part a psychiatrist’s workday consists of a succession of fifteen-minute “med checks”: routine interviews for the purpose of renewing psychoactive prescriptions.

Most psychiatrists seem comfortable with this role. They can see more clients and therefore generate more income than their colleagues of former years, and for many the pills and the codified diagnoses lend a “scientific” legitimacy to their activity that they feel was absent in the days of psychotherapy. Successive revisions of DSM have enormously expanded the potential client population to the point where psychiatric services (in other words, psychoactive drugs) are now being actively promoted and advertised for every age group and virtually every problem of human life. It is the pharmaceutical companies, of course, who drive these drug promotion campaigns, the success of which is clearly evident. In the meantime, the number of psychiatrists in the US has risen to over 45,500, a six fold increase since 1950.

Next post: The role of psychologists, social workers, counselors, etc., in the diagnosis of mental disorders.

Proliferation of Mental Disorders

In December 1999, David Satcher, MD, then Surgeon General of the United States, reported that almost one fifth of the American population will experience a mental disorder in any given year, and that fully half of the population will have such a disorder at some time in their lives. [Mental Health: A Report of the Surgeon General.]

Most Americans have understandably become somewhat skeptical with regards to government press releases and statistics, and it is unlikely that the report received total acceptance by the general population. On the other hand, the report received no major challenge. Indeed, it was endorsed wholeheartedly by several leading healthcare organizations and lobbying groups. The American Academy of Family Physicians, for instance, described mental illness as “one of the most pressing concerns we are facing” and made it their annual clinical focus for the year 2000. The National Institute of Mental Health estimates that 22% of American adults have a diagnosable mental disorder in any given year, and that four of the ten leading causes of disability in the US are mental disorders.

When repeated often enough, claims of this sort become accepted as facts, particularly when they are undisputed. Although the man in the street might not be able to cite the official government figures, there has been an increasing acceptance in our society that mental disorders are on the rise, and are much more prevalent than was once thought to be the case.

The intriguing question, however, is where are all these mentally disordered people. At any given time they supposedly constitute one in five of the population. There should be one or two of them in an average line at the store or the Post Office; two or three on the school football team; twenty or thirty in a small church congregation; and literally thousands at a large concert or sporting event. Every organization and work place in the country should be staffed by large numbers of mentally disordered people, and if we are to believe the government statistics, these disorders will infect fully half of our population at some time in our lives. This amounts to more than one person per household!

In the face of claims of this sort, the astonishing fact is that life seems so normal. People get up in the morning, eat breakfast, ride busses, go to work, go out on dates, etc., and for the most part our communities and societies continue to function in a reasonably collaborative and harmonious fashion. The reportedly vast numbers of mentally disordered individuals are not instantly conspicuous or disruptive, and the question arises as to how people carrying such stigmatizing and potentially unmanageable diagnoses can remain so anonymous and concealed.

To older people in particular, the matter is all the more puzzling. In 1950 if you had asked an intelligent, socially active adult to identify the “mentally disordered” individuals in his town or community, he would probably have been able to name a few individuals who were considered “crazy” or “out of their minds.” These would have been very few in number, however, and by no stretch of the imagination would ever have reached the proportions claimed in the government statistics cited above for the present day. In fact, an attempt to persuade our 1950 citizen that half of the population would develop a mental disorder in their lives would probably have generated within the listener a firm conviction that the speaker himself was crazy.

So what has happened? How has our open, democratic society deteriorated to the point where mental disorders are among the most prevalent conditions, almost as common as coughs and colds? Have we as individuals been making terrible mistakes in our daily lives, or has our leadership let us down in areas of social policy and community direction? Why is it that in a fifty-year period, during which enormous strides have been made in physical medicine, general technology, and civil rights, our mental health has declined to such appalling standards? And why has this decline gone largely unnoticed and unrecognized by the man in the street?

The answers to these questions are astonishingly simple. The increase in mental disorders implicit in the government statistics is fictitious. No deterioration of this magnitude in the nation’s mental health has occurred. All that has happened between 1950 and the present time is that a wide range of human problems that formerly had been considered normal challenges of the human condition, have been relabeled as mental disorders. This relabeling process has been subtle, progressive, insidious, and persistent. It has received “official” approval from governmental and other agencies at national, state, and local level, and is beginning to be accepted by the general public.

In 1950, for instance, a child who was routinely disobedient to his parents was considered to be simply a misbehaved child, – a brat – and by and large the problem was attributed to lax or indifferent discipline on the part of the parents. Remedial action was conceptualized as a need for the parents to regain an appropriate level of control and to train their child in socially accepted ways using the normal time-honored methods of dialogue, reward, punishment, etc.. Today a misbehaved child is routinely diagnosed by psychiatrists and other mental health professionals as having a mental disorder called oppositional defiance, and this putative mental disorder is presented as the underlying cause of the problem behavior. Remedial action is conceptualized in terms of intervention by paid professionals, and in particular the administration of psychotropic prescription drugs.

This extraordinary shift in conceptual framework is not confined to childhood problems. Virtually every problem that confronts individuals and families has been relabeled in this way. Fears and depressions, bad habits, poor coping skills, painful memories, and just plain old-fashioned irresponsibility have all been painstakingly and systematically relabeled as mental disorders, and the new philosophy is being promoted actively by government and by an increasingly wide range of establishment-affiliated groups and organizations. As a society, not only are we being encouraged to accept the new ideas, but to “seek help” for these alleged disorders. The Surgeon General’s report cited earlier laments the fact that most people with mental disorders “do not seek treatment” and actively encourages them to do so.

The issues at stake here are very fundamental, and it is important to ask how such a profound paradigm shift can have occurred in just the comparatively short space of two generations. Who, it needs to be asked, has managed to orchestrate this extraordinary shift in focus? Who are these people that have persuaded us that most of the normal challenges of life with which our ancestors coped adequately for thousands of years, are, in fact, mental disorders requiring professional help and drugs?

This question will be addressed in the next post.