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The Perfect Psychiatrist

On March 19, a new article was posted on Aeon Magazine.  It’s titled A Mad World,  and was written by Joseph Pierre, MD, who works in Log Angeles as a psychiatric practitioner and professor.  Dr. Pierre has authored more than fifty papers, and has received several awards.  He has lectured nationally and internationally, and would, I think, be considered an eminent psychiatrist.  I am grateful to several readers for the link to the article.

The paper is written in a collegial, reassuring manner, but there are some very profound and disturbing implications which I feel ought to be identified and elucidated.

Dr. Pierre opens his discussion with some chatty remarks concerning the reluctance of people to disclose information about themselves to psychiatrists for fear that they might be “.. labelled crazy, locked up in an asylum, medicated into oblivion, or put into a straitjacket.”  He then continues:

“Of course, such fears are the accompaniment of the very idiosyncrasies, foibles, and life struggles that keep us from unattainably perfect mental health.”

What he’s saying here, or at least what I think is implied, is that “idiosyncrasies, foibles, and life struggles” are what stands between us and “perfect mental health.”  In other words, idiosyncrasies, foibles, and life struggles are illnesses or symptoms of illnesses.  This, of course, has been psychiatry’s implied message for decades, but it is unusual to see it articulated so clearly.

Dr. Pierre continues:

“As a psychiatrist, I see this as the biggest challenge facing psychiatry today. A large part of the population – perhaps even the majority – might benefit from some form of mental health care, but too many fear that modern psychiatry is on a mission to pathologise normal individuals with some dystopian plan fuelled by the greed of the pharmaceutical industry, all in order to put the populace on mind-numbing medications.”

So the biggest challenge facing psychiatry today is to rope even more people (“the majority” of the population) into psychiatric “treatment.”  But psychiatry is thwarted in this noble and altruistic challenge because people are fearful that the psychiatric-pharma alliance is on a “mission” to pathologize normality and sell more drugs.  Wherever could we have gotten such a notion?  Perhaps from the inexorable expansion of the DSM catalog?  Perhaps from psychiatry’s long-standing corrupt relationships with pharma?  Perhaps from psychiatry’s willing and active involvement in the fraudulent research?  Perhaps from the pharmaceutical infomercials that posed as, and were avidly accepted by psychiatry as, continuing education?  Perhaps from pharma ads to the general public?  Perhaps from the ghost-writing scandals?  Perhaps from the self-serving fabrication of childhood bipolar disorder by an “eminent” psychiatrist and the consequent widespread prescribing of mind-numbing neurotoxic drugs to children as young as two years for temper tantrums?  Perhaps from the medicalization of bereavement?   Etc.?  So perhaps our fears and concerns with regards to psychiatry’s mission are founded.

Dr. Pierre then gives us a brief historical account of the expansion of psychiatry’s scope including:

“From the first DSM through to the most recent revision, inclusiveness and clinical usefulness have been guiding principles, with the profession erring on the side of capturing all of the conditions that bring people to psychiatric care in order to facilitate evaluation and treatment.”

It is clear that he approves of this widening of psychiatry’s net and of the general blurring of the distinction between psychiatric “illness” and normality.  One of the putative advantages of this development is that

“… newer medications with fewer side effects are more likely to be offered to people with less clear-cut psychiatric illnesses.”

Then:

“Viewed through the lens of the DSM, it is easy to see how extending psychiatry’s helping hand deeper into the population is often interpreted as evidence that psychiatrists think more and more people are mentally ill.”

Actually, it isn’t just interpreted as evidence, it is evidence.  Psychiatrists do indeed promote the notion that more and more people are “mentally ill.”  They have promoted this spurious notion in three ways:  firstly, by increasing the number of their so-called diagnoses, secondly, by progressively lowering the criteria thresholds, and thirdly, by routinely telling their clients that they have chemical imbalances in their brains.

“To many, the idea that it might be normal to have a mental illness sounds oxymoronic at best and conspiratorially threatening at worst. Yet the widening scope of psychiatry has been driven by a belief – on the parts of both mental health consumers and clinicians alike – that psychiatry can help with an increasingly large range of issues.”

So, there it is!  All this time we thought that psychiatry was expanding its scope for self-serving purposes like turf expansion and increased business, when in reality they were just responding dutifully and responsibly to requests for help with an “increasingly large range of issues”!

The fact is that people go to psychiatrists for an increasing range of non-medical human problems, because psychiatrists have developed and promoted the false notions that these problems are illnesses, and that these illnesses are best treated by drugs.  They have also downplayed the adverse effects.  In these endeavors they have been ably assisted by their pharmaceutical allies.  They have also promoted the notion that failure to “treat” these spurious illnesses inevitably leads to dire consequences, particularly in the case of children.  Pharma’s ad campaigns, including ads in psychiatric journals, have been a major driving force in this area for at least the last 40 years.  If psychiatrists had had any qualms about pharma’s excessive rhetoric, shouldn’t they have spoken out?  Shouldn’t they have refused to run the ads?  Is it not reasonable – given the absence of any such protest – to conclude that psychiatry approved of, and was even complicit in this promotion?

To state, at this advanced stage of the proceedings, that psychiatric expansion is simply a reflection of increased confidence on the part of the consumer is at least disingenuous and perhaps blatantly deceptive.

Dr. Pierre continues by telling us that psychiatry’s ” diagnostic creep…becomes more understandable by conceptualizing mental illness, like most things in nature, on a continuum.”  (Note in passing the phrase “like most things in nature,” which conveys the impression that the DSM catalog actually identifies real entities, in the manner, say, of the Periodic Table, when in fact the only ontological status that these “illnesses” have is the fact that they were voted into existence by the APA.)

He then uses the continuum concept to justify the “diagnosing” and drugging of almost anyone.

“For example, someone with mild depression might not be on the verge of suicide, but could really be struggling with work due to anxiety and poor concentration. Many people might experience sub-clinical conditions that fall short of the threshold for a mental disorder, but still might benefit from intervention.”

This is a level of psychiatric spin that I have not encountered before.  Psychiatry has received a good deal of criticism in recent years for expanding their “diagnoses” and for prescribing drugs to more and more people.  There have been some half-hearted and unconvincing rebuttals from psychiatry, but for the most part their response has been:  deny, deflect, and keep your head down till it blows over.  These are the standard tactics of politicians.  But Dr. Pierre has taken us to a new level:  diagnostic expansion and increased drugging are good things.  Imagine a politician confronted with a charge of taking bribes arguing that bribes are a form of economic activity and, as such, should be encouraged in a free market context!

Then Dr. Pierre points out that the DSM, with its fussy little polythetic criteria sets, isn’t really such a big deal.

“The truth is that while psychiatric diagnosis is helpful in understanding what ails a patient and formulating a treatment plan, psychiatrists don’t waste a lot of time fretting over whether a patient can be neatly categorised in DSM, or even whether or not that patient truly has a mental disorder at all. A patient comes in with a complaint of suffering, and the clinician tries to relieve that suffering independent of such exacting distinctions. If anything, such details become most important for insurance billing, where clinicians might err on the side of making a diagnosis to obtain reimbursement for a patient who might not otherwise be able to receive care.”

This is drug-pushing without even the semblance of a medical veneer.  He might as well hang out a shingle:  Whatever ails you, get your drugs here.  I also imagine that, like the street dealer, he gets a lot of repeat customers.

He concedes that he may have to fabricate something to get the insurance company to pay for his services, a practice which incidentally constitutes fraud, but he’s not going to “waste a lot of time” fretting over “such exacting distinctions.”

Then Dr. Pierre treats us to the standard psychiatry-is-just-like-general-medicine claim.

“Though many object to psychiatry’s perceived encroachment into normality, we rarely hear such complaints about the rest of medicine.”

Why, he asks, if we accept that we can have a wide range of physical illnesses during our lives, are we so reluctant to accept “…that it might also be normal to be psychiatrically ill at various points in our lives?”

And that’s a terrific question.  My answer is:  because “mental illness” is a spurious concept with no explanatory or ontological validity – that the problems embraced by the term are actually not illnesses at all, and that the various “diagnoses” listed in DSM are nothing more than rewording of the presenting problems.  If Dr. Pierre were to spend an hour browsing the anti-psychiatry websites or even reading a few books such as The Myth of The Chemical Cure  by Joanna Moncrieff or Anatomy of An Epidemic by Robert Whitaker, he would get lots of other answers.  But alas, his question was rhetorical.  He already knows the answer.

“The answer seems to be that psychiatric disorders carry a much greater degree of stigma compared with medical conditions.”

There is it – the Jeffrey Lieberman argument: people won’t accept our concepts because of the stigma.  The big, bad, stigma.  It’s got nothing to do with the conceptual flaws, or the damage caused by the “treatments.”  Just that darned stigma! – to which, incidentally, psychiatry’s medicalization drive has been a major contributor, as Angermeyer et al, 2011, have demonstrated so convincingly.

So how can we get rid of stigma?  Well, here again, I could make a few suggestions, but no need.  Dr. Pierre has it all figured out.

“To be less stigmatising, psychiatry must support a continuous model of mental health instead of maintaining an exclusive focus on the mental disorders that make up the DSM.”

In other words:  forget the DSM; forget the diagnoses (who needs them?).  Let’s just acknowledge that everyone can experience suffering and impairment, and offer psychiatric services to all.  Then there’ll be no stigma.  We’ll bump into each other socially as we come in and out of the psychiatrist’s office, and it’ll be:

“What are you in for today?”
“The grandchildren are coming up for the weekend and we thought we could use a little extra Valium.  What about you?”
“Oh, Big Phil has been a bear since we changed over to Daylight Savings Time.  I always need a little Celexa for that.  It takes the edge off, you know.”
“I haven’t been a bear!”
“Yes you have.”
“Really?  Perhaps I should go in and get a little something.”
“Yes, do.  Get some Valium.”

See – no stigma at all.

In fairness to Dr. Pierre, he sounds a note of caution in this regard.

“If the scope of psychiatry widens, will psychiatric medications be vastly overprescribed, as is already claimed with stimulants such as methylphenidate (Ritalin) for attention deficit hyperactivity disorder (ADHD)?”

(Note the word “claimed” – but let’s let that go.)

But he reassures us:

“In the end, implementing pharmacotherapy for a given condition requires solid evidence from peer-reviewed research studies. Although by definition the benefit of medications decreases at the healthier end of a mental health continuum (if one isn’t as sick, the degree of improvement will be less), we need not reject all pharmacotherapy at the healthier end of the spectrum, provided medications are safe and effective.”

So, as long as the drugs are “safe and effective,” we can confidently dish them out for “sub-clinical conditions.”  But who determines that the drugs are “safe and effective?”  The same chronically-flawed, short-term, industry-sponsored trials that we have at present.  Every psychiatric drug on the market today is “safe and effective” by that standard.

And here, dear readers, it really goes downhill.

“…the shift to medicating the healthier end of the continuum paves a path towards not only maximising wellness but enhancing normal functioning through ‘cosmetic’ intervention. Ultimately, availability of medications that enhance brain function or make us feel better than normal will be driven by consumer demand, not the Machiavellian plans of psychiatrists.”

“Maximizing wellness”; “enhancing normal functioning”; “cosmetic intervention”;  “make us feel better than normal”?

And then it goes further downhill.

“The legal use of drugs to alter our moods is already nearly ubiquitous. We take Ritalin, modafinil (Provigil), or just our daily cup of caffeine to help us focus, stay awake, and make that deadline at work; then we reach for our diazepam (Valium), alcohol, or marijuana to unwind at the end of the day. If a kind of anabolic steroid for the brain were created, say a pill that could increase IQ by an average of 10 points with a minimum of side effects, is there any question that the public would clamour for it? Cosmetic psychiatry is a very real prospect for the future, with myriad moral and ethical implications involved.”

Note the slick juxtaposition of caffeine, on the one hand, with Ritalin and diazepam on the other:  routine aids to daily living.  And what are we to make of likening a pill that could increase IQ by 10 points to the present array of psychiatric drugs?

Dr. Pierre assures us that psychiatrists are just trying to help.

“In the final analysis, psychiatrists don’t think that everyone is crazy, nor are we necessarily guilty of pathologising normal existence and foisting medications upon the populace as pawns of the drug companies. Instead, we are just doing what we can to relieve the suffering of those coming for help, rather than turning those people away.”

and

“A good psychiatrist draws upon clinical experience to gain empathic understanding of each patient’s story, and then offers a tailored range of interventions to ease the suffering, whether it represents a disorder or is part of normal life.”

On March 22, Psycritic, another psychiatrist, posted a critique of Dr. Pierre’s article.  In this article, psycritic makes some interesting points.  He/she ultimately attributes Dr. Pierre’s enthusiasm for increased drugging to misguided consumerism.  The idea is that while consumerism (sell the customer whatever he wants) is OK with regards to everyday products and services, it can create problems when applied uncritically to medicine.

There is merit to this argument, of course.  But there is another, more fundamental, issue:  that it has been pharma-psychiatry’s objective for decades to expand, without any indication of limits, the use of psychiatric drugs.  Pharma has pursued this objective through advertizing and through the distribution of largesse to psychiatrists.  Psychiatrists, meanwhile, have played their part by creating new “diagnoses,” lowering thresholds for existing diagnoses, making widespread use of their NOS categories, pretending that the drugs are medications, and through active political lobbying, such as the present drive to expand coerced administration of psychiatric drugs.

The reality is that Dr. Pierre is not just an overly-enthusiastic consumerist.  Rather, he is the perfect psychiatrist:  the flag-carrier for all that the APA stands for which is:  that every human problem is the legitimate concern of psychiatry, and for every problem there’s a pill.

 

Benzodiazepines: Disempowering and Dangerous

I recently read an article by Fredric Neuman, MD, Director of the Anxiety and Phobia Center at White Plains Hospital, NY.  The article is titled The Use of the Minor Tranquilizers: Xanax, Ativan, Klonopin, and Valium, and was published in June 2012 by Psychology Today.  Thanks to Medicalskeptic for the link.

Dr. Neuman opens by telling us that benzodiazepines are “…very commonly prescribed for any sort of discomfort.”

“They are called anxiolytics, and they are prescribed for any level of anxiety and more or less to anyone who asks for them.”

Dr. Neuman has been working at the Anxiety and Phobia Center for 41 years, first as Associate Director and then as Director.  So when he says that benzos are routinely given to “anyone who asks for them,” it’s probably safe to say that he’s being accurate.

He tells us that the benzos have a “modest tranquilizing effect” in the doses at which they are “usually prescribed.”  But –

“…I see patients all the time who feel they cannot manage ordinary situations in life without taking one of these pills.”

and

“…I think these individuals suffer a loss of self-confidence. Their ability to rely on themselves has been undermined by their reliance on these drugs.”

Dr. Neuman asserts that benzos

“…are the most commonly prescribed drugs in the world. They are for the most part safe, but even safe drugs can sometimes cause problems.”

He provides a list of those adverse effects that concern him most.

  1. They are addicting.
  2. They effect coordination, particularly in the elderly.
  3. They compound the effect of other drugs and alcohol.
  4. They interfere to some extent with memory. 

And to this list he adds the dangers of abrupt discontinuation and

“…the fact that I think something is lost, as I indicated above, when someone relies on something make-believe to get through the day.”

Dr. Neuman concludes:

“…these drugs are sometimes helpful a little, and in some ways hurtful a little.  But I don’t wish to give the impression that they are really bad. If a patient demands them, I will usually acquiesce, assuming the dose is small. I always encourage patients to take less as time goes on.  If they won’t, I don’t usually argue with them.”

and

“I know most doctors give these drugs much more readily than I do.”

 DISCUSSION

In the article Dr. Neuman comes across as a reasonable and helpful person.  He prescribes benzos, but he recognizes and articulates the disempowering aspect of relying on drugs, and I think it is reasonable to assume that in his practice he encourages people to pursue genuine resolution of fears and anxieties rather than chemical masking.  But what struck me most forcibly in the article was the sentence:

“If a patient demands them, I will usually acquiesce, assuming the dose is small.”

Dr. Neuman is to be commended for his honesty, but it is a truly amazing admission – particularly his use of the word “demand.”  It has long been my contention that there is very little essential difference between psychiatric “prescribing” of psychoactive drugs and the illegal selling of drugs on the street.  Dr. Neuman’s use of the word “demand,” his admission that he usually acquiesces, and his credible assertion that most doctors prescribe these drugs more readily than he does, lends support to this contention, at least as far as benzos are concerned.  It is difficult to reconcile his statements with the notion that these drugs, when used in a psychiatric context, are medications being prescribed to treat illnesses.

MORTALITY HAZARD

The same day that I read Dr. Neuman’s piece, I also read an article in the BMJ:  Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study, by Weich et al.  Here are the conclusions:

“In this large cohort of patients [34,727 participants and 69,418 matched controls]  attending UK primary care, anxiolytic and hypnotic drugs were associated with significantly increased risk of mortality [hazard ratio: 3.3] over a seven year period, after adjusting for a range of potential confounders. As with all observational findings, however, these results are prone to bias arising from unmeasured and residual confounding.”

The increased risk for those participants who had taken only benzodiazepines was slightly higher at 3.68.  Risk ratios were adjusted for age, gender, and the following health problems:  “arthritis, asthma, cancer, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, diabetes, epilepsy, gastrointestinal disorders, hypertension, musculoskeletal disorders, anxiety disorders, sleep disorders, other (non-anxiety), psychiatric disorders, and prescriptions for non-study drugs.”  The association followed a dose-response pattern.  Participants who had taken benzos at the highest doses had a hazard ratio of 5.1.

Even allowing for the standard disclaimer, the study raises serious doubts as to the oft-claimed safety of these products, especially as other studies have produced similar findings.  It should also prompt us to question Dr. Neuman’s somewhat cavalier approach to these products – an approach which in my experience is widespread in psychiatry.  A three-fold increase in mortality rate over seven years is not a trivial matter.

Involuntary Mental Health Commitments

The recent publicity surrounding the Justina Pelletier case has focused attention, not only on the spurious and arbitrary nature of psychiatric diagnoses, but also on the legitimacy and appropriateness of mental health commitments.  It is being widely asserted that these archaic statutes are fundamentally incompatible with current civil rights standards, and the question “should mental health commitments be abolished?” is being raised in a variety of contexts.

CRITERIA

Here in the US, each state has its own laws and procedures for pursuing a mental health commitment.  Some states allow outpatient commitment as well as inpatient.  There is wording variation from state to state, but in most jurisdictions there is provision to commit a person involuntarily for psychiatric treatment if there is convincing evidence that the person has a “mental illness” and as a result of such “mental illness” is a danger to himself or others, or is gravely disabled.  The term gravely disabled is generally defined along the lines of being unable to care for oneself or provide for one’s basic needs. In recent years some states have expanded these criteria to embrace:

  1. Individuals who have a psychiatric history and are on a “deteriorating course.”
  2. Individuals who are being cared for by a family member, and this care is about to be terminated.

SHORT-TERM EVALUATION HOLD (72 hours)

Here again, the procedures vary from place to place, but in most cases the mental health center is involved.  Typically the police bring the individual to the mental health center to be evaluated by a mental health professional.  The professional evaluates the individual to determine if the legal criteria are met.  If they are, he fills out the necessary forms, swears to their accuracy in front of a judge, who , if he agrees with the assessment, signs the hold order.  The individual is then taken to the state hospital, or an alternative approved facility, by a police officer.

THREE-MONTH HOLD

Before the expiration of the 72-hour hold, the hospital personnel decide whether to allow the individual to convert to voluntary status (which he can do by signing the appropriate forms) or pursue a longer-term commitment.  The latter usually involves a formal hearing conducted in the local courthouse, or more usually, in a room at the state hospital.  A judge presides, and both hospital and client are represented by lawyers.  The hospital calls as witnesses psychiatrists and other staff who have worked with the client.  Clients may also call witnesses, but seldom do.

DISCUSSION

The fundamental premise underlying all mental health commitment legislation is that mental illnesses exist, and that these putative illnesses cause people to think, feel, and behave in a problematic, and sometimes dangerous, manner.

It is my position that this premise is spurious.  I have developed this theme throughout the website, and the details need not be repeated here.

It is also my position that psychiatric treatments, which almost always mean psycho-pharma drugs, and/or shock treatment, are for the most part unhelpful and disempowering, and usually damaging, especially in the long term!  They generally reduce, at least somewhat, an individual’s level of agitation, aggression, and/or disruption, and this is the essential justification for their use in these situations.  The notion that they are medications and are being used to treat illnesses is false.  The stark reality is that the individuals are being forcibly drugged into quietude, and this is being done under the guise of providing “treatment” for an “illness.”

If the treatments that individuals received at state hospitals and other approved facilities were extremely beneficial, then one might be posed with an ethical dilemma.  To illustrate this, consider the case of a person who has, say, a gangrenous finger, but is refusing treatment.  The treatment would involve losing the finger, but saving his life.  Refusing treatment will result in death.  One could certainly make a case for enforced treatment, especially if his family, friends, etc., were petitioning the courts in this regard.  But in fact, in the US, the general principle is that such an individual is legally entitled to refuse treatment, and die from his illness if he so chooses.

But mental health commitments are entirely different.  Individuals get committed to state hospitals, not because they are sick in any conventional sense of the term, but because they are agitated, and/or aggressive, often as a result of conflict with family members, neighbors, local officials, etc…  Usually they are people who have been committed previously, sometimes very frequently, and their social and other abilities have been severely compromised by a history of ingesting psychiatric drugs.  Often their agitation/aggression at the time of the commitment is caused by withdrawal from psychiatric drugs that they had previously taken.  In most cases they have received large quantities of neuroleptic drugs, over extended periods, the devastating side effects of which are all too obvious, and contribute to the perception that they are “different” and need to be locked up.

Because the agitation/aggression is conceptualized as a “symptom” of the putative illness, little or no attempt is made by the police or by the mental health staff to explore the reasons for the agitated, problematic behavior, or what remedies might be available.  The individual is deemed to be “mentally ill,” and it is assumed that attempts at discussion or dialogue would be pointless.  It is also assumed that the individual has zero credibility.

So the kind of ethical dilemma that might exist in the case of the man with the gangrenous finger, doesn’t arise here.  We’re not having to choose between respecting the person’s civil rights vs. saving his life.  We’re choosing between respecting his civil rights vs. forcing him to undergo procedures that will damage him further and will likely cause further deterioration in his relationships with family and other members of the community.

“KANGAROO” COURTS

The Fifth Amendment to the US Constitution states:

“…nor shall any person…be deprived of life, liberty, or property without due process of law…”

The Fourteenth Amendment states:

“…nor shall any State deprive any person of life, liberty, or property without due process of law…”

In practice, the procedures outlined above for the 72-hour hold and for the 3-month committal are considered to be due process of law.  Strictly speaking this is true, because they reflect the law as enacted by the particular state legislature.

The more fundamental question, however, is:  do these procedures provide adequate protection for the civil rights of the individual who is being committed?  In my view, the answer to this question is no, for the following reasons.

1.  In practice, the 72-hour hold is decided by the mental health worker, often a fairly junior intake worker, who in many cases has been trained to think of involuntary commitment as the only reasonable response to a crisis.  Even in cases where a judge’s signature is required, it is extremely rare to find a judge who will attempt to second-guess the mental health professional.  The unspoken ethos here is that “crazy” people are fundamentally different from “ordinary” people; that they can only be understood by trained professionals; and that interference from non-professionals is likely to be counterproductive.  This ethos, incidentally, is actively promoted by organized psychiatry.  Indeed, I would suggest that it constitutes one of the fundamental pillars of psychiatric “treatment.”  It is also false.  People who are “crazy,” or despondent, or agitated are not fundamentally different from “ordinary” people.  Their craziness, despondency, and/or agitation are usually understandable if one is willing to listen attentively and respectfully and patiently.

2.  In practice the judge’s signature tends to be a rubber stamp, and there is no attorney present to argue for the client.  There is usually not even a requirement that the client be present at the initial meeting between the mental health worker and the judge.

3.  Although danger to self or others or grave disability is usually required by the statute, in practice a 72-hour hold can be obtained in situations that don’t actually rise to this standard.  In most cases, if a client has come off his “meds,” and is agitated, a 72-hour hold will be granted even if his agitation is for some legitimate reason and is perfectly understandable, and even if he poses no particular threat to self or others.  The tacit, and incidentally false, assumption is that his agitation/aggression will inevitably escalate unless he is sent to the state hospital for “stabilization.”

4.  Once the 72-hour hold has been activated, the process is very difficult to reverse.  The client is taken to the state hospital and is often “persuaded” to convert to voluntary status.  The persuasion usually entails the threat that if he doesn’t convert, he will be committed.  I suggest that this kind of tactic makes a mockery of the term “voluntary.”

5.  If the client refuses to convert to voluntary status, he can be brought before a formal mental health hearing.

6.  This is an improvement over the 72-hour hold procedure, but in my view, the individual’s rights are not adequately protected.  As mentioned earlier, the hearing is often (perhaps usually) held in the hospital. This confers clear advantage to the psychiatrists.  They can call all the witnesses they want.  They’re on the payroll and just a few steps away.  The client is at a marked disadvantage, in that any witnesses he might want to call are likely to be in his home area (usually hours away), and at work.  The client is often unfamiliar with the procedure, and has had little opportunity to prepare his case.  Usually he gets to meet his defending attorney for only a few minutes prior to the hearing, and, in some cases, his cognitive ability has been compromised by prior “treatments.”  I recently received an email from a woman who has been through this kind of proceeding.  She pointed out that: 

“…having a patient address her involuntary status at a Review Panel while drugged and wearing hospital pajamas does tend to work against her.  If you’ve decided that someone’s incompetent, that’s pretty much what you’ll see.”

7.  If the client expresses the belief that he is not ill, and that he doesn’t need treatment, this will be interpreted (and sworn to by the psychiatrists) as convincing evidence that he is ill, and that he does need treatment.  Imagine, in a criminal trial, if a plea of not guilty were routinely construed as evidence of guilt!

8.  There is usually a great reluctance on the part of the defending attorney to challenge the psychiatrists and other professional witnesses, and in most cases the hearing endorses the psychiatrists’ recommendation – which is usually:  keep him here until we say it’s OK to let him go.

9.  Eventually, even the most heavily-drugged client realizes that the only way he’s going to get out of the hospital is to cooperate with the psychiatrists and staff.  This entails saying things like:  “I was a fool to go off my medication;” “I realize now that you people are just trying to help me;” “I’m my own worst enemy;” “I need to stay here until you people say it’s OK for me to go.”  If he can keep this up for a week or so, he’ll probably be released.

So to get back to the original question:  should this kind of practice cease? The answer is obviously yes.  The recent Justina Pelletier case has drawn much-needed attention to the abuses inherent in the psychiatric commitment system.  In particular, this case has highlighted the fact that psychiatry is a closed system that routinely rejects, marginalizes, and even pathologizes any attempt to challenge or even question its pronouncements.  Such a system has no place in a democratic, transparent society.

THE WAY FORWARD

The most significant step forward at this juncture would be the removal of the concept and term “mental illness” from all statutes.  The term has no explanatory significance, and no clear meaning.  In the area of civil commitment, it serves merely as justification of enforced drugging for individuals who are agitated or aggressive or otherwise disruptive.  It also serves as justification for denying these individuals some very basic civil rights.

Commitment is essentially a form of imprisonment.  But it goes beyond ordinary imprisonment, in that it entails the forced administration of neurotoxic chemicals and electrically-induced seizures.  What happens in practice is that the individual takes the drugs under duress in the facility, then semi-voluntarily in the community for a few weeks or even months.  He then stops taking them, or tapers himself off, until the next bout of agitation or aggressiveness.  This precipitates another trip to the state hospital, and this revolving-door travesty continues until he is too brain-damaged to live in the community.  He then goes to a nursing home, where his “medication” is dutifully administered every day, until he succumbs to a premature death. 

If “mental illness” commitments were abolished, there would be a need for a non-psychiatric crisis response team in each county/jurisdiction.  How such a team would be structured and organized is a huge topic, beyond the scope of the present article.  From a practical perspective, it needs to be noted that any non-psychiatric crisis response system will be resisted vigorously by vested interests and will not happen overnight.  What we should focus on in the meantime are those parts of the present system that are particularly unjust or particularly destructive.  These include:

1.  Doing away with the 72-hour hold and replacing it with a formal hearing with mandatory legal representation in front of a judge. 

2.  Providing training to lawyers concerning the spuriousness of psychiatric concepts and the destructiveness of psychiatric treatments.  This training should be geared towards empowering them to challenge mental health testimony in commitment hearings with the same force and vigor that they do in criminal proceedings.  In particular, they should be knowledgeable, or have ready access to knowledge, of the adverse effects of the various psychiatric drugs in common use, and the abysmally poor long-term outcomes for individuals who have been repeatedly committed over a period of years.

3.  Recruitment and training of non-psychiatric “talk-down” teams in every county.  These could be part of the sheriff’s department or, preferably, separate departments in their own right.

4.  Continuing to expose psychiatry as the spurious, destructive, and pharmaceutically-corrupted activity that it is.  The major need in this matter is to expose the damage that psychiatry routinely perpetrates against those entrusted to its care, and the impact that this has on life expectancy. 

5.  Encouraging mental health centers to hire psychiatric survivors, especially those who don’t support the bio-medical model.  A requirement of survivor representation on governing boards would also be helpful.

6.  Requiring mental health centers to seriously review drug dosages on all clients monthly, and either reduce these dosages or explain why this can’t be done.

7.  Requiring mental health centers to provide active training in social skills to all clients who have ever been committed to a psychiatric hospital.

Drugging Our Children: A Book Review

Drugging Our Children

 

The 2012 book Drugging Our Children: How Profiteers Are Pushing Antipsychotics on Our Youngest, and What We Can Do to Stop It, is edited by Sharna Olfman PhD, and Brent Dean Robbins, PhD.  It is a collection of ten articles, plus an Introduction and an Afterword by Sharna Olfman.  Here are the chapter titles, with a quote from each:

 

Introduction, by Sharna Olfman, PhD

“…they [antipsychotics] constitute such an assault to a child’s body and brain that it is hard to fathom why they are being prescribed so widely and casually, when safer and more effective and humane treatment modalities already exist.” [p xiii]

1.  Weighing the Evidence: What Science Has to Say about Prescribing Atypical Antipsychotics to Children, by Robert Whitaker

“The drugs’ disruption of normal functioning along these various neuronal pathways causes many predictable adverse events.” [p 7]

2.  From Ice Pick Lobotomies to Antipsychotics as Sleep Aids for Children: A Historical Perspective, by Brent Dean Robbins

“The era of moral treatment teaches us that successful treatment of many forms of mental illness requires neither biological explanations nor medical specialty.” [p 24]

3.  Drugging Our Children:  A culture That Has Lost Its Compass, by Sharna Olfman

“Sadly, it appears that support for families in the United States continues to deteriorate in lockstep with the rise in psychiatric disturbances.” [p 48]

4.  The Marketing of Madness and Psychotropic Drugs to Children, by Gwen Olsen

“Children are a lucrative expansion market for any drug, particularly one that requires lifelong maintenance therapy once initiated.” [p 53]

5.  Pediatric Antipsychotics:  A Call for Ethical Care, by Jacqueline A Sparks and Barry L. Duncan

“When the evidence is explored, no reasonable scientist or practitioner would come down on the side of a favorable risk/benefit profile for pediatric use of antipsychotics.” [p 87]

6.  Legal Issues Surrounding the Psychiatric Drugging of Children and Youth, by Jim Gottstein

“The horrific use of neuroleptics on defenseless children and youth cries out for legal efforts to curtail the practice.”  [p 115]

7.  Drug-Free Mental Health Care for Children and Youth:  Lessons from Residential Treatment, by Tony Stanton

“One of the first things we observed in the records sent to us was a death of curiosity.  This was due, in part, to the rush to impose a diagnostic label.  Once the diagnosis was applied, curiosity was no longer necessary.  The goal had been reached:  the child’s behaviors and symptoms were placed in their proper category.  In the records sent to us, we saw the repeated implication that there was nothing left to describe or discover.  In particular, the child’s living connections with caretakers and their history had become irrelevant.  A logical result was that clues about the origins of symptoms like those we found for Mark or Jim, didn’t need to be pursued.” [ p 129]

8.  Strategic Family Therapy as an Alternative to Antipsychotics, by George Stone

“Psychiatry assumes that a child’s psychological issues are biological events that have no meaning and sweeps the important social and contextual information that is being conveyed under the rug of genetic malfunction.” [ p 147]

9.  How Parents Can Improve Their Children’s Developmental Trajectories, by Adena B. Meyers and Laura E. Berk

“Little attention is paid to the many risk and protective factors that may influence children’s trajectories over time.  Instead, there is a tendency to reify diagnostic labels while losing sight of their hypothetical nature.  This may create the erroneous impression that a tangible disease entity with known causes,  processes, and treatment mechanisms permanently resides within each affected child.” [p 154]

 10.  Building Healthy Minds:  It Takes a Village, by Stuart Shanker

“In order for primary care physicians to play the central role that I have outlined, they will need to make a major modality shift, away from treating symptoms with psychiatric drugs to addressing the causes.” [ p 183]

Afterword, by Sharna Olfman

“Record levels of psychiatric disturbance, violence, poverty, apathy, and despair among our children speak to our current cultural crisis.” [p 187]

This is a well-written and compelling book.  It describes, in detail, psychiatry’s shameful, destructive, and widespread drugging of our children.  But it also offers a conceptual framework and practical suggestions for breaking free from the psychiatric-pharma destruction.

I highly recommend this book for parents, mental health workers, and anyone who has an interest in the welfare of our children.

 

 

 

Life Is Bipolar

This post was submitted by a reader.

 

I am a 30 year man who finally realized a few months ago (after finding this website) that he is not mentally ill but just an adult who often acts like a child. I dabbled with some “official” drugs (meaning prescribed) in the last few years when I was first diagnosed  with depression (was put on anti deps + anti anxiety pills) and then bipolar a year later (this time it was mood stabilizers and sleeping pills).

Before that I went to the occasional therapy session when I hit some intense lowpoints but always told them that I refuse to take their drugs and usually never returned for a second visit. But throughout the years it seems my problems went from bad to worse and a few times I’ve even been on the edge of ending it all or at least wanting to not endure this suffering any longer. I also could never really afford the expensive doctors but after telling my parents what’s been going on, they agreed to pay for whatever is needed.

I also tried alternative paths like yoga, zen, veganism, raw veganism, and of course the other extreme of sex drugs and rock n roll but none of that seemed to help at all except shallowly and temporarily. It seemed that my underlying condition was something for which there was no cure. Existence itself was the disease. Or so it felt.

So in autumn 2012 I finally gave in and took the pills.

I also tried cognitive behavioral therapy after the depression diagnosis but I didn’t really like the therapist because he was spending too much time thinking and I didn’t want to pay for that.  It was just frustrating. I thought that I can do this on my own (as I had always in the past).

I felt terrible taking the pills. I was tired and had these strange anxiety symptoms when just walking on the street e.g. I felt like my jaw was suddenly locked or that my motor skills were somehow compromised. I even took anxiety medicine before going to a party to be calm. When one time I took the whole prescription with after drinking a bottle of gin, I blacked out on my floor for the next 24 hours. The doctor refused to give me more of them after I told her about that. I didn’t want them anyways as I knew I wanted to stop all of these pills.

Which I did. Against my doctors orders. I told her that I felt better and dont need them anymore so I slowly weaned myself off them and started the year of 2013 clean and quit seeing the shrinks. Although I now know I was right that I didn’t need them it turns out that my issues were far from gone. So fast forward 10 months and I’m back at the doctors office. This time the diagnosis is bipolar which for some reason didn’t fit my symptoms the previous time (a year earlier).

(I had also undergone a psychiatric evaluation earlier that year (spring 2012) where they thought I was bipolar but because apparently I didn’t fit the description, they just gave me nothing at all and told me to find a cognitive therapist. I moved to another country so I didn’t pursue this until the depression diagnosis mentioned above).

So autumn 2013. I was in a new relationship and it seemed that my issues were coming to the fore again, not that they ever really went away. The depressive episodes were bad and my girlfriend urged me to call the psychiatist I saw a year earlier. She wasn’t available but her colleague was who prescribed me the mood stabilizers “Lamictal” for bipolar (she even said I should’ve been diagnosed bipolar earlier). I started them but because they had zero affect, after about 3 months, I quit them. During this time I again saw a therapist (neuropsychologist) but I didn’t really like her style especially after learning about the behavioral approach here. I told her that this mentall illness stuff is totally spurious to which she seemed very confused. So I ended that also. I sent them both a kind email at the end of the year about my disbelief in their position (ie. the notion of mental “illness) so it was sayonara once again to the psych-pharma industry.

The big revelation for me was when I found an article on this site called “Bipolar is not an illness”, which I read sometime in november 2013. It seemed like a light switch flicked on in my mind. I realized this whole psychiatry mental illness stuff is complete nonsense. It’s also a business where it’s practitioners seem to be as blinded as the customers. And the drugs dont even work for me! I know they might make some people feel better… After reading the many comments on the various articles on this site I realized that I am in control of my behavior and I must take responsibility. The symptoms associated with the diagnosis are just human problems that I can tackle individually. At least so I hope. Besides if there is a cluster of symptoms which fit my predicament best, it is Borderline Personality Disorder. Again, these are also just human problems but
the doctors wrote that one off for some reason…

This was just before last christmas after which I haven’t been on any drugs or gone to therapy. I still have problems but I am dealing with them as I would deal with other problems. A few times I’ve made the mistake of over estimating a revelation only to find out that another depressive episode is happening once again and my not so developed coping skills are challenged. It’s not easy I admit to get out of these but somehow I do. I just can’t help but think there is an existential crisis lurking around the corner that I am distracting myself from. I am still a little apprehenisive about the question of who is in control of this thing called “me”.

I also quit smoking and drinking and coffee in the new year and plan to keep it that way. I intend to get on top of my bad habits this year. Every month I will tackle on a few new challenges to exercise my willpower and self-discipline to get back on track in life. But I am ultimately responsible for my actions.  I ordered a few books on Dialectical Behavioral Therapy (a workbook + journal) which I look forward to beginning.  Any experiences with those? Other suggestions and feedback is also welcome.

All this time I was right about one thing.  There is no cure for existence (besides death of course…) which includes highs and lows. Nor should there be as that is what makes life interesting. Yet I do want to be happy which is not easy for such a highly sensitive, extremely self-critical person such as myself.

The universe is bipolar.  There is no fixed personality. There are no absolute labels to describe because we are capable of so much change if we want.

I fully support the dessimation of the whole psychiatric industry.

Thanks for reading. Have a nice day.

In friendship,

Anon

ADHD: Are We Helping Or Harming?

In November 2013, the British Medical Journal published Attention-deficit/hyperactivity disorder: are we helping or harming? by Rae Thomas, PhD, Psychologist, Australia; Geoffrey K. Mitchell, MB BS, FRACGP, PhD, Professor of General Practice, Australia; and Laura Batstra, PhD, Psychologist, Netherlands.  The article is part of a series on the dangers of overdiagnosis.

Here are some quotes:

“Prevalence and prescribing rates for attention-deficit/hyperactivity disorder (ADHD) have risen steeply over the past decade, partly in response to concerns about underdiagnosis and undertreatment.”

“…prescribing rates for commonly used drugs such as dexamfetamine, methylphenidate, and atomoxetine for children diagnosed with ADHD have increased.”

“DSM-5 widens the definition of ADHD by expanding behavioural descriptions to include more examples and increasing the maximum age of symptom onset from 7 to 12 years.”

“Among the work group advisers of DSM-5 for ADHD and disruptive behaviour disorders, 78% disclosed links to drug companies as a potential financial conflict of interest.”

“The main medications for ADHD are methylphenidates and amfetamines, which can cause adverse reactions such as weight loss, hepatotoxicity, and suicide ideation, and in the short term may suppress pubertal growth.”

“A diagnostic label is value laden and has the potential to cause harm and, paradoxically, increase mental health problems.”

SUMMARY

This is an interesting and important article.  The authors emphasize the factors that are driving the increased “prevalence” and the consequent potential damage, particularly in what they call mild and moderate cases.

Unfortunately, although they don’t describe ADHD as an illness, they do appear to accept a medical perspective, or at least a need for medical intervention, in severe cases.  If the problems persist after “minimal intervention” with parents and some “brief …counselling,” they recommend that the child be referred to “a developmental pediatrician or psychiatrist for definite diagnosis and treatment”.

This general theme – that the condition known as ADHD is a valid medical entity that is simply being overused – is becoming quite common.  It was the primary thread in Dr. Lieberman’s latest article, and is being widely promoted in an attempt to rescue the illness concept from collapsing under its own weight.

But in reality, there is no more reason to conceptualize severe inattention/impulsivity as an illness, than mild inattention/impulsivity. 

Nevertheless, the article is useful.  It is certainly a step in the right direction, and provides a long list of references.  With regards to the illness concept, my guess is that the wording of the article represents a compromise.  Dr. Batstra is quoted elsewhere as saying that “It is a fallacy to regard ADHD as an illness.”  Dr. Thomas in Moving the diagnostic goalposts: medicalizing ADHD, states:  “I believe that attention deficit hyperactivity disorder is a real disorder; I also believe it’s too frequently diagnosed and over-treated.”  Dr. Mitchell’s position is harder to assess, but from the wording of some articles of which he was a co-author, it seems possible that he conceptualizes ADHD as an illness.

For the record, and to guard against misunderstanding, it is my position that the condition known as ADHD is a loose cluster of vaguely-defined problem behaviors, most of which can be conceptualized as a failure on the part of the child to acquire age-appropriate habits in the areas of discipline, self-control, and social interaction.  It is not an illness in any meaningful sense of the term.

 

 

 

Recovery Model: A Reader’s Story

This post was submitted by a reader.

 

 

Very interested to read some of your very clearly reasoned, explained and referenced posts. I am familiarising myself with the status of the Recovery Model of mental health for my new job and have repeatedly come across critiques of modern psychiatry and the DSM diagnosis. I am encouraged by this line of questioning because I have 7 years experience with the Grow peer support program for recovery and personal development. Like many recovery programs, it largely ignores diagnosis, seeks to recognise and draw out the strength and human potential in all of us and has helped many people to dispense with meds altogether and live a productive, peaceful and happy life. In contrast I have found it heartbreaking to see the dehumanising “flattening” of friends when they have been heavily medicated or zapped. Learning how to constructively experience, integrate and grow from the disappointments and challenges of life has been preventative for me and taken me off the slippery path of unhealthy thoughts and attitudes. Professional therapists need to see psych patients as humans first with intrinsic value and untold potential. They need to see the purpose of medication as the end of medication. Thank you.

Grower

Is Psychology Going the Way of Psychiatry?

On January 7, Maria Bradshaw, co-founder of CASPER, published an interesting article on Mad in America.  It’s called Prescribing Rights for Psychologists, and it suggests that psychology as a profession may be falling into some of the same errors that enmire psychiatry.

Maria makes some very compelling points, and focuses particularly on the fact that psychologists have won prescribing rights in a number of jurisdictions, and are engaged in an ongoing effort to expand this aspect of their work.

The article points out that the DSM-5 Task Force comprised “nearly 100 psychiatrists and 47 psychologists,” and also expresses concern that as psychologists become more heavily involved in the prescribing of drugs, they will inevitably become targets for pharma corruption.

Maria explores the possibility that psychologists may be moving closer to psychiatry’s medical model of human problems, a model that formerly they viewed as erroneous and dangerous.

This article is timely.  At present, I would guess that most psychologists are still on this side of the debate, particularly in the UK, where the medical model has always been viewed with a good measure of skepticism, and where recently the clinical division of the BPS took a major step away from this model.  But there are deep-seated and disturbing trends, especially here in America.  And these trends have been long in the making.  For decades a significant proportion of the questions on the psychologist’s licensing exam in the US have been based on the DSM.  For example, a scenario would be sketched and the examinee had to identify the “correct diagnosis” from a list of four or five.  The choice: “This is an inane question” was never listed.  The examining body is currently engaged in the process of integrating DSM-5 into the exam content.  This is logically equivalent to asking chemistry graduates to identify the correct methods for transmuting base metals to gold.

In the May 1993 issue of the Behavior Therapist I wrote:

“Today it is not unusual to find practitioners who describe themselves as behaviorists discussing these disorders [DSM “diagnoses”] as if they had the same ontological status as diabetes or pneumonia, which of course, they don’t.”

That was 20 years ago, and I don’t think the trend has slowed.

The prescribing rights movement is, in my view, a giant step in the wrong direction, but shows no signs of losing momentum.  When psychiatry’s ship finally founders in the storm of scrutiny and survivor protest, psychology, as a profession, may also be swept away, especially if it is perceived as a sister profession.

Psychology is the discipline that studies human thoughts, feelings, and behaviors, and applies its findings to helping people resolve problems and find a more fulfilling and empowered lifestyle.  Psychiatry is the non-science that treats non-illnesses.  Strictly speaking they should have very little in common, similarity in name notwithstanding.  The urgent need for psychology today is to re-find its roots, and generate distance between itself and psychiatry.  Otherwise it will inevitably be tarred with the same brush.

 

Understanding Human Behavior

A couple of months ago I wrote an article concerning ECT which generated some controversy.  One of the issues that came up was the relationship between biological explanations of human activity and more global explanations, which, for want of a better term, I’ll call person-centered explanations.

Any human activity can be viewed from different levels of abstraction.  Suppose, for instance, that I am sitting in my living room reading a book.  Then I put the book down, stand up, and go outside.  If the question were to be asked:  why did he put the book down and go outside? A wide range of perspectives and answers are possible.  One could, for instance, focus on the fact that I am a biological organism, and one could develop a detailed and comprehensive flow sheet of every muscle movement, every heartbeat, every sensory input, neural impulse etc., that had occurred from the moment that I put the book down until I was standing outside.  Such an account might be more or less detailed.  There would, of course, be physical limitations on the amount of information of this sort that is attainable, but from a theoretical point of view, one could compile a detailed, complete, and accurate biological account of the actions in question.  And such an account would be a valid response to the question:  why did he put the book down and go outside.

But there are other perspectives.  One could, for instance, ask me why I had behaved in this way.  This would be a person-centered approach.  And suppose I reply:  I had been sitting inside for too long; I wanted some fresh air.  Assuming that I’m truthfully describing my motives and feelings, this is also a valid and accurate explanation.

Of particular note is that although the two explanations appear very different, they are entirely compatible.  In fact, if the biological account is thorough and complete, one would be able to identify the neural activities that corresponded to my feelings of restlessness, my decision to move, my muscular movements, and my relief on getting outdoors.  Again, I stress that I doubt if that level of precision is, or ever will be, possible in practice, but the concept is valid.  Every element of the person-centered explanation will have a corresponding element in the biological flow-sheets.

For this reason it makes no sense to argue about which explanation is correct.  They are both correct.  I – the subject of the person-centered perspective – am also the subject of the biological perspective.

The act of stepping outside for fresh air is trivial and unremarkable, but the same plurality of perspectives can be applied to all our actions, including dysfunctional or counterproductive behavior.  The activity can be viewed as biological and can be probed and catalogued by neurologists, physiologists, etc…  Or it can be seen from a person-centered perspective and explored and formulated from that point of view.  There are also other perspectives, e.g. economic, political, social, familial, occupational, etc…  From the economic perspective, for instance, I would be considered a consumer, and my restlessness and my desire for fresh air might identify me as a marketing target for outdoor wear, wilderness vacations, bird-watching magazines, etc…  From a familial perspective, I am a husband, father, father-in-law, and brother within a fairly extended network of supportive relationships.  From a political perspective, I am a voter.  And so on.  I can be observed and studied from all of these perspectives, and although the observations will look very different, they are entirely compatible provided they are accurate.

For every thought, feeling, and behavior there is a corresponding neural event.  Some people contend that the thought/feeling causes the neural event; others say that the neural event causes the thought/feeling.  Still others contend that the cognitive/emotional activity and the neural activity are the same thing, but viewed form different perspectives.  The relative merits of these contentions have been debated by philosophers for hundreds of years, but for our present purposes, it doesn’t matter which is correct.  The point here is that there are neural events and there are thoughts/feelings/actions, and there is a correspondence between the two.  A super-neurologist with super-equipment could probe my brain and identify and catalog various patterns and clusters of neural and chemical activity.  But I experience these neural activities as thoughts and feelings.  Each perspective is valid, and each has its proper place.

A neurosurgeon, for instance, would be primarily concerned with the biological perspective, while most of our day-to-day interactions with other people are approached from a person-centered perspective.  A person asking me, for instance, why I had stepped outside is not enquiring about neural activity, inside my skull.  He’s asking about my thoughts/feelings/actions.

It is often tacitly assumed in psychiatric circles that because every thought, feeling, and/or behavior has a corresponding neural underpinning, therefore counterproductive thoughts, feelings, and/or behaviors must be the result of faulty or malfunctioning neural equipment.  But this is an unwarranted assumption.

Let’s take the example of childhood temper tantrums – and let’s look at these from a person-centered perspective.

If a child throws a tantrum in a grocery store, demanding candy or a toy or whatever, and if the parent gives in to his demands, then other things being equal, the probability of a tantrum in future store visits is increased.  This is one of the ways that we learn:  if an action brings about a favorable result, we try it again.  This is an adaptive mechanism.  It is not an instance of something going wrong in the child’s brain.  Rather it is an instance of something going right.  The child’s learning “machinery” has worked perfectly.  And from a person-centered perspective, it is an instance of the child learning to navigate his way in social relationships.

In the example above, I’ve described the scenario and outcome in very simplistic terms and have included the qualifier “other things being equal.”  But in practice other things are never equal, and the precise outcome on any given occasion is impossible to predict.  But whenever we interact with our children, we are teaching them something, and they are teaching us something.  In the above example, the child has learned:  if I want candy, I throw a tantrum.  The parent has learned:  if I want to stop his tantrum, I give him candy.  Unless something significant changes, it is likely that two things will happen.  The child will start to throw tantrums in other situations besides grocery stores, and any attempt on the part of the parent to regain control of the situation will be met initially with escalation of the tantrums.  This is not an instance of something going wrong within the child.  Instead, and apparently paradoxically, it is something going right.  The child is expanding his behavioral repertoire in accordance with the normal principles of behavior acquisition.  What has gone wrong is that the parent is teaching a response that ultimately will be problematic and counterproductive.

From a person-centered perspective, even frequent and severe temper tantrums can be understood as normal responses to suboptimal situations.  Obviously, in this context, I do not mean statistically normal.  Severe and frequent temper tantrums are not normal in the statistical sense of the term, but in the circumstances outlined above, they are normal in that they can be understood if viewed from a person-centered perspective.  There is no a priori need to invoke explanations based on neural malfunctions or pathology in the absence of compelling indications that such factors are present and causally significant.

Obviously each tantrum has a specific neural underpinning, but it is fallacious to assume neural  pathology based purely on the presence of negative or counterproductive behaviors.  Neuronal circuits and neurotransmitters that are functioning perfectly can underpin and drive destructive behavior as readily as constructive behavior.

The distinction between a person-centered perspective and a bio-neurological perspective applies to almost every facet of human existence.  We are biological organisms, but we are also thinking, feeling and self-directed persons.  For instance, I carry within me memories of the home in which I grew up and of my family of origin.  These memories are complex and intertwined, but I can bring them to the forefront of consciousness more or less at will.  Now let’s say that my super-neurologist with his super-equipment can probe around inside my skull and locate the neurons in which all these memoires are stored.  And let’s make him (or her) even more super, and imagine that he can “read” these various neuronal engrams.  There is still a fundamental qualitative difference between his readings and my memories of my childhood.  A good analogy would be that he can read the book, but I’m living the part.  Another analogy:  a person could, in theory at least, analyze a movie on a DVD and identify every pixel and sound unit.  But this is not the same as watching the movie.  A chemist can analyze every molecule of paint and canvas in the Mona Lisa, and still know absolutely nothing about the picture as a work of art or the motivation of the artist.

Our super-neurologist could analyze and catalog perfectly every sensory input and neuronal impulse in the actions of a tennis player making a spectacular backhand return.  But this is not the same kind of experience as that of the tennis player or even of the exulting fans.  And so on.

It’s tempting in this context to say that psychiatry has lost sight of the forest for the trees.  But it’s worse than that.  They’ve lost sight of the tree for the minute fibers and biological processes that sustain the tree’s growth.

There’s a quality to human experience that transcends neurons.  One can know everything that there is to be known about neurons and neurochemicals and know nothing of human life.  People are living, sentient, motivated beings, and we each have our own perspective and point of view.  We can be studied at various levels of abstraction:  atomic, molecular, bio-molecular, physiological, neuromuscular, skeletal, psychological, social, economic, political, occupational, etc… But we can also be approached and understood simply as individual people, with our individual histories, contexts, hang-ups, and aspirations.  No one perspective has any legitimate claim to being the preferred point of view.  One’s perspective has to be chosen in the light of the context.  If a person is sick (with a real sickness), then a biological perspective is probably preferable.  If he is sad or anxious, then a person-centered perspective seems the most apt.  If he is lonely and isolated, a social perspective might be most fruitful.  And so on.

In my experience virtually all the problems listed in the various editions of the DSM can be best approached, understood, and ameliorated from a person-centered perspective.  If you want to know why someone is depressed, take the time to get to know him, and then ask him.  Most people can tell you why they’re depressed or worried or nervous or scared or whatever.  But if it’s clear that your only interest is a 15-minute med check, they will tell you nothing.

If there is neural pathology then this, of course, should be addressed and alleviated to the extent possible.  But tampering crudely with the brain in the absence of confirmed pathology is dangerous and destructive.  Drugs do create altered states of consciousness, but the notion that we can provide effective help to people with problems of thinking, feeling, and/or behaving by tweaking their neurons betrays a fundamentally flawed and condescending view of humanity.

 

 

 

Schizoid Personality Disorder

There’s a new entry on the Tell Your Story section of my website.

The author, who wishes to remain anonymous, tells how during his teenage years, his social skills were poor, and he met the criteria for schizoid personality disorder, the essential features of which are social isolation and emotional detachment.

Here are two quotes:

“By the end of this project I had developed solid social skills, created an interesting circle of friends and no longer met the criteria for ‘schizoid personality disorder’. This is without any psychiatry, medication, or even the knowledge that I was ‘suffering’ from something that many consider a ‘disorder’.”

“My ‘disorder’ could accurately be described as a lack of social skills remedied by proper training in a safe environment, not much unlike an inability to speak French.”

The entry is brief and well worth reading.  Its message is positive and empowering, and stands in marked contrast to the disempowering quality of psychiatric “diagnoses.”