Last month (May 31), National Public Radio (NPR) ran an interview on Science Friday with Thomas Insel, MD, Director of NIMH, Jeffrey Lieberman, MD, President of the APA, and Gary Greenberg, PhD, practicing psychotherapist.
I didn’t hear the interview, but I have read the transcript. Doctors Insel and Lieberman were spinning the barrage of criticism directed at psychiatry in recent months, while at the same time clinging desperately to the notion that the problems that psychiatrists “treat” are real illnesses. It’s become a familiar theme, and there was nothing new.
What interested me, however, was a remark by Dr. Greenberg. Here’s the quote:
“I think, you know, one of the things to consider here is we’re dealing with the clinical reality of a need to be able to understand what people bring to us and to make clinical decisions. Some of us are old enough to remember what psychiatry was like or what clinical care was like for mental illness before we had a DSM-III, before there was a dictionary, and it was chaos. And I don’t think anybody wants to go back to that. I don’t think anybody right now has an alternative for clinical use…”
I was surprised to read these words, because I had always had the impression that Dr. Greenberg was opposed to the widespread spurious medicalization of human problems.
Let’s take a closer look at what he said.
“…the clinical reality of a need to be able to understand what people bring to us and to make clinical decisions.”
As an example here, let’s consider the case of a young man who goes to a therapist and says: “I worry a lot about germs, and I wash my hands about 100 times a day.”
To my way of thinking, this is perfectly clear and perfectly understandable. Gary seems to be suggesting that assigning this man a “diagnosis” of obsessive compulsive disorder somehow enables the therapist to understand the presenting problem. In other words, the preoccupation with germs and the frequent hand-washing are explained by the “diagnosis” of obsessive compulsive disorder. The reality, however, is that the “diagnosis” (unlike real medical diagnoses) has no explanatory content.
Let’s apply the acid test:
Client: Why do I worry about germs and wash my hands so much?
Therapist: Because you have a mental illness called obsessive compulsive disorder.
Client: How do you know I have obsessive compulsive disorder?
Therapist: Because you worry about germs and wash your hands so much.
The “diagnosis” explains nothing.
Back to Dr. Greenberg:
“…And to make clinical decisions.”
I can’t even imagine how replacing the client’s very clear, very specific problem statement with a more general statement, which has no explanatory value, can help in making clinical decisions.
Dr. Greenberg continues:
“Some of us are old enough to remember what psychiatry was like or what clinical care was like for mental illness before we had a DSM-III, before there was a dictionary, and it was chaos.”
Well I can remember back then, and it didn’t seem like chaos to me. We asked the client what was troubling him or her; sought clarification and details as necessary; listened as carefully as we could for nuances; and worked collaboratively with the client towards solutions. In the hypothetical case mentioned above, the help provided would be along the general lines of stimuli identification, and graduated exposure adapted creatively to the individual needs and concerns of the client.
Also, we didn’t call these kinds of problems mental illnesses.
“I don’t think anybody right now has an alternative for clinical use beyond what the DSM is providing.”
Behavior therapy since at least the 60’s has used the client’s own statement as the treatment “target,” not as a result of any great insight or study, but simply because it made sense.
In addition, Peter Kinderman, PhD, on May 15 posted So…What happens next? on DxSummit.org. In this article he proposes the use of a client problem list and psychosocial formulations as a rational substitute for a DSM “diagnosis.”
Psychiatric “diagnoses” were invented by psychiatrists to promote the pretense that they are real doctors, and to legitimize the prescribing of mood and behavior altering drugs. These “diagnoses” not only don’t help, they are a hindrance. They have no advantage over the client’s own statement.
I know the advantage to psychiatrists: without a “diagnosis” they can’t prescribe their drugs. But why would a therapist find these spurious “diagnoses” useful?
Dr. Greenberg continues:
“So it’s easy to criticize this and to say it’s not a perfect document.”
We have been hearing this a lot from psychiatrists lately. They say, in effect: we know the DSM isn’t perfect, but it’s the best we’ve got and we’re working hard to improve it. This whole line of reasoning misses the point of what the anti-DSM contingent is saying. We’re not saying that the DSM is an imperfect document in need of tweaking. We’re saying that it’s rubbish! It has no validity and serves no useful purpose. And, in that it legitimizes the pushing of dangerous pharmaceutical products for an increasingly wide range of human problems, it is very destructive rubbish.
The purpose of this post is not to attack Gary Greenberg. But I have commented favorably on Gary’s writing in the past, and I didn’t want there to be any perception that I was in harmony with some of the positions he took on the NPR interview.