Thursday 16 February 2012

Criticism of the DSM-5, and why the "middle way" is dangerous

If you're a mental health professional, or in any other way interested in the matter, and you don't want to be regarded backward, if you haven't yet, you better hurry to join in on the criticism of the forthcoming edition of the DSM!

These days, the internet is teeming with DSM-5 criticism, not least by professionals, and to judge from the vast majority of it,  the stance to take is that, this time (as in: opposed to last time), the proposals for new DSM categories are going too far. If the new categories are accepted as valid diagnoses, making their way into DSM-5, this will threaten, and might indeed erode psychiatry's credibility. After all, the proposed new categories aren't sufficiently supported by science, and we don't want anything unscientific in the DSM, do we? No, certainly not. Especially since the initiative for the forthcoming edition of the DSM was taken out of concerns about the lack of science behind the current edition... Oh, wait, that means what's in the current edition, DSM-IV-TR, isn't really backed by science, then? Exactly, that's what it means. And that then means that we protest new categories to go into the DSM, because we don't want them to -- yeah, what? Further add to the load of categories not backed by any science?...

Confused? Well, that's probably because you're still caught up in what commonly is thought of as "logic". Know that psychiatric logic is different . It may seem twisted at first glance, but, if you take a step back, and look at the big picture, it's actually quite simple: we have a number of behavior patterns, recognized by psychiatry as treatable (though not curable), medical conditions, a definition that, for several reasons but scientific ones, has been widely accepted by the public to be scientific -- just like the public once upon a time, for several reasons but scientific ones, accepted as the one and only truth that there is such a thing as spirit possession -- and now the worst we could do is to push our luck, and have this acceptance shaken to its foundation. 

Imagine, if the public started to question the validity of categories like "bipolar", "depression", or "ADHD"! Not to mention that of "psychosis"/"schizophrenia", psychiatry's "holy cow", the category that represents "insanity" in its purest form, and without which psychiatry might just as well pack up, because if the purest form of "insanity" isn't a medical condition, then none of psychiatry's categories is, and there is nothing left for psychiatry to label and treat (but not cure). Imagine, if psychiatry had to pack up, if we no longer could call people for "psychotic killers", with the psychiatric profession's seal of approval, that, miraculously, without any science to back it up, turns ordinary name-calling into, er, evidence-based diagnosis, if we had to acknowledge that we all are just human beings, reacting to life, some more extremely than others, due to more extreme life experiences than others', but still human beings! Imagine, if we couldn't scapegoat at least a certain number of people anymore, if we couldn't blame their faulty genes and brains anymore for our own insufficiencies, as parents, as a society, or as professionals! What a cruel world it would be!

So, if you want to save psychiatry, the "middle way" is the way to choose! Join the American Psychological Association, and "experts" like Allen Frances, Ronald Pies, and all the other hot-shots, including, well, Doug Bremner, and criticise the new categories proposed for the DSM-5, while you, by doing so, additionally confirm the already in the DSM, current edition, listed categories' scientific validity. By all means, don't go too far (!), like the British Psychological Society unfortunately does -- take for instance B 00, Schizophrenia, in their statement: "normal individual variation", "relational context of problems and the undeniable social causation of many such problems", "invalidity of this diagnosis", ... yeah, they're talking about schizophrenia, these guys must have lost it! Or as this and this petition wants you to go!

Certainly, a lot of harm is done to those who are misdiagnosed, and the new categories proposed for DSM-5 open up for more of such harm to be done to more people in the future, but how on earth can a diagnosis harm the person so diagnosed, if the diagnosis turns the person into a non-person? So, "psychosis", "schizophrenia", or whatever else from the DSM-IV: no harm done! Unless you were misdiagnosed, that is...

Sarcasm aside, the current discussion about DSM-5 and the validity of psych labels in general led my thoughts 1 1/2 year back in time, to a comment I received on this post, because it illustrates very nicely what the "middle way" actually looks like. A comment I back then decided not to publish.

The reason I didn't publish the comment in question back then was that I had no doubt that it was written in a state of pain and distress, emotional distress (as in "mental illness", exactly), so I thought, I'd "protect" the author of the comment against himself. This kind of reasoning, of course, is exactly the reasoning the mh system employs to justify its bad habit of regularly depriving labelled people of responsibility for themselves, their actions, their choices, and of their right to be heard. I put myself into the position of the one who knew what was good for the author of the comment, and although I still think the choice I made back then on behalf of the author was a wise one, I also think I was compromising myself by thinking I was in a position to choose on his behalf. I was infantilizing the author, "parenting" him, just like mh professionals usually do with those they've labelled "insane". "Do not parent. Parenting keeps kids alive and adults insane." -Peter Bullimore. "Insanity" means not having been given the chance to make one's own choices and take responsibility for them. No one can grow up and become "sane", as long as they're continuously denied the chance to make their own choices and take responsibility for them. So, I'm going to publish the comment below, as a sceen shot of the email notification I received back in 2010, since I, unfortunately, have deleted it from my comments folder at Blogger.

I am aware that the comment can be damaging to its author. It is for instance clearly a violation of the APA's Principles of Medical Ethics, section 7, item 3, and since it would have been possible for its author to remove it any time from the comment section at the post, while it is not possible for him to remove the screen shot here, I will of course do so, if asked to (in a commonly polite manner, any further abuse will be ignored, thank you!).

Anyway, this is what the "middle way" looks like:

Thursday 29 December 2011

Robert Whitaker at Gothenburg

So, I went to Gothenburg, Sweden, last month where Robert Whitaker was giving a talk about his latest book Anatomy of an Epidemic, a lecture arranged by the Family Care Foundation.

The point of departure in his book is Whitaker's puzzlement about, that despite the claim that pharmacological treatments have improved treatment options within psychiatry, and therefore the lives of “mentally ill” people, an increasing number of these “mentally ill” people become chronic, on disability pay, suffering through more and more serious “side”-effects, and exposed to a greater and greater risk of early death.

To find answers to his questions, Whitaker conducts a thorough review of the research in the field of psychopharmacology in its entirety, and concludes that the picture painted by this research is somewhat different than the one psychiatry has delivered to the general public.

Whitaker's book, like its predecessor Mad in America , is a disturbing read. One thing is to see how the actual science in the field clearly and unmistakably proves psychiatry's storytelling about biological brain diseases and the superiority of psych drugs in their "treatment" to the public over the past decades to be just that: storytelling, with no basis whatsoever in any scientific evidence. This is what everyone familiar with the scientific research has known for a long time. Another thing still is to see the suspicion, which even many critics will not dare to covet: that psychiatry – almost from the outset – has understood that its own tales of the wonders of  psychopharmacology are lies equal to the stories of biological brain illnesses, so unmistakably confirmed in Whitaker's book by quote after quote of “expert” statements about the matter.

Like most other critics, Whitaker ended his lecture with the inevitable, politically correct: "I do know, that many people feel they are being helped by psychiatric medications, so there is a place for these drugs in treatment."

In the discussion that followed, I asked him why, after just presenting the scientific data - which all state one thing: that if people feel helped by psych drugs, then this must be attributed to either a placebo effect, and/or simply the fact that their judgment is impaired due to the drugs' influence, so in actual fact, there is no place for the drugs in "treatment",  in as far as this "treatment" is meant to truly help people in crisis - he still decided to end his presentation with what could be described as an apology for said presentation.

In the last chapter of Anatomy of an Epidemic, Whitaker takes a thorough look at the Finnish Open Dialogue approach, which, with its well-documented effecacy, is an alternative to the current biomedical approach to emotional crisis. Yet even Open Dialogue uses psych drugs -- in a very limited capacity, especially when it comes to "anti"-psychotics, and only as a "last resort". In answer to my question, Whitaker said he would like to see projects like Open Dialogue initiated, but with just one difference: no use of psych drugs at all. I would really like to see that, too! Like  Whitaker says, mankind has survived for thousands of years on this planet, without these drugs, so…


 The slides for Whitaker's presentation are here.

Thanks to Paul Englar for his huge help with the translation of this blog post.

Monday 21 February 2011

Healing Homes. A new film by Daniel Mackler

Yesterday morning, Daniel Mackler's new film Healing Homes. An Alternative, Swedish Model for Healing Psychosis was in my mailbox. I've watched it four times since then.

If you know Daniel's previous film, Take These Broken Wings, this one is different. Healing Homes is an informal, often contemplative, and also raw, and at the same time very intimate and personal film.

Instead of the carefully staged interviews we saw in Take These Broken Wings, in Healing Homes Daniel Mackler takes a step back as a director, and leaves the scene almost entirely to the participants in the film, joining them only as just one more participant himself. This allows him to capture the essence of what Familjevårdsstiftelsen, the Family Care Foundation, in Gothenburg, Sweden, is all about: fearless openness and authenticity. Take These Broken Wings showed us, in a very professional way, how full recovery from "psychosis"/"schizophrenia" without drugs is possible, even likely, with the help of a professional therapist. Healing Homes goes further, not only explicitly revealing a truth about the human being Carina Håkansson, founder of the Family Care Foundation, but indeed revealing the truth about crisis to be a state of being human to an extreme extent that can be understood and overcome with the help of other human beings who are not afraid to be extremely human themselves. This is what this film is about. The healing power of being oneself, genuinely, uncompromizingly. And not just behind the closed door of a therapist's office, but in all life situations, which is what the family home, "det utvidgade terapirummet", the extended therapy room, invites to.

Just like Daniel Mackler himself, I'm quite suspicious of professionalism in the field. As the Norwegian psychologist Christian Moltu wrote in his article "Det konkrete, mellommenneskelige" (The actual, interpersonal) in 2009, all too often therapists make use of therapy techniques, of their professionalism, as a kind of shield they can hide behind whenever they don't manage to stay present, and truly meet their clients where these are at. Healing Homes nevertheless has convinced me that professionalism can be of great value if it is used as a means to prevent exactly this distancing, alienating, the other dehumanizing use of itself, if it is used to help the therapist, and whoever else interacts with a person in crisis, stay present with the person in any given situation by being "professionally" human, conscious about and self-aware of one's own as well as the person in crisis' humanness.

"It's about people, and... people. Giving love to people", Therése says in the film about the Family Care Foundation. And it is what the film not only is about, but what it actually does, fearlessly and uncompromizingly with great respect and love allowing people to be who they are. I've watched Healing Homes four times now, each time discovering new, fascinating details. It's a film I'll watch again and again. For the details, but first and foremost for its love for people that is the magic behind the success of the Family Care Foundation as well as the magic of this film.

Order the film here:, and watch it, again and again.

Wednesday 2 February 2011

Emotional disturbances vs. "psychosis" - A valid distinction?

Yeah, I'm still alive. Just had to find a new place to stay for myself, Calvin the cat, and my two horses, and, while one has to make major changes in one area of life, why not take the plunge, and make them in others too, and find a new job as well? Especially when you can't help but sense that your current boss doesn't really need you to work for her full-time anymore, and you've thought of trying something completely different anyway? As of today, I've found a new place to stay, and a new, completely different job.

Anyhow, the reason why I thought I'd write a new post is this post on Rossa Forbes' blog Holistic Recovery from Schizophrenia about the latest of Mark Foster's letters to Robert Whitaker, that had me remember another of his letters, this one, and my comment to it, originally posted at a Facebook thread. Since not everybody is on Facebook, and can go and read it there, here it is:

A very insightful piece, yes. Anyhow, some critical thoughts:

- "Some of my patients are very complicated with severe emotional or even psychotic disturbances, but those are rare."

What I read between the lines here is that emotional "disturbances" are different from "psychotic" ones. In how far? I went to a talk about "psychosis", given by a psychiatrist, back in November last year. According to this psychiatrist, and also according to what I've been reading virtually everywhere where "psychosis" is defined, fear is one of the main "symptoms" of "psychosis". Fear, and anger (with anger being the emotional response to fear). Fear and anger are emotions. Now, the list of "symptoms" for "psychosis" also includes so-called "thought disorders", "hallucinations", "delusions", etc., so you might say, there are other than emotional "disturbances" involved in "psychosis". However, my personal experience is that at the core of all these other "disturbances" are fear and anger. These emotions are what creates all other "disturbances". Just like sadness, grieving a loss, usually creates other than emotional "disturbances" ( inability to concentrate, withdrawal from social contexts, etc.). So, my take on this is that "psychotic disturbances", too, are emotional "disturbances".

- "What I mean is that most patients do not show signs of a pathological disturbance in their mental functioning. Rather, they are sad, lonely, anxious, frustrated, disillusioned, confused, scared--all in all, they seem very human, suffering from some of the mood changes that are endemic to the human experience. In the vast majority of these cases, major social and environmental factors are the clear precipitants of their symptoms: death in the family, job loss, marital struggles, substance abuse."

Basically, the same applies to this quote, and my question here would be, exactly where do we draw the line between what Mark Foster calls a "pathological disturbance" on the one hand, and existential, to human nature very natural, emotional suffering, "endemic to the human experience", as Mark Foster says? Or, to maybe push it to extremes, but nevertheless, where do we draw the line between naturally suffering human being, and sick-in-the-head lesser-than--human being? And who has the power to draw this line, on what basis? Towards the end of the article Mark Foster writes: "Some diseases, some mental illnesses, are severe, debilitating, life-threatening." He doesn't name which diseases he refers to, but when "mental illness" is talked about there's always one specific label that, if no other of all the labels in the DSM, seems to simply have to be a true disease: schizophrenia. Because if a reaction to life as extreme as what is labelled "schizophrenia" is just that, a reaction to life, and not a true disease, then no label in the DSM is a true disease. Psychiatry as a medical speciality stands and falls with "schizophrenia", and how we define the experience labelled as "schizophrenia". Or "psychosis".

Even among the people, who have successfully overcome what psychiatry calls "schizophrenia", there are many who would agree with Mark Foster. Joanne Greenberg and Norwegian Arnhild Lauveng are just a couple of them, referring to themselves as having been sick, having suffered from "schizophrenia". Anyhow, there are also quite a few people, and I am one of them, who do not define themselves as having been sick, as having suffered from this "severe mental illness" called "schizophrenia", although they've perfectly fitted the criteria for the label. Because they don't agree that it is sick to react to life. And here Mark Foster omits to mention an important item on his list about adverse life events: childhood trauma (that comes in all imaginable shapes, not just as physical, or sexual abuse). Only if this item is omitted, "schizophrenia" (and other "severe mental illness" such as "bipolar disorder", or "major depressive disorder", for that sake) can be explained away as being true illnesses, the manifestation of an individual flaw, be it genetic, biological (biological psychiatry), or developmental (Freud), and not understood as an actually life-saving (sic) response to life-threatening circumstances. And this leads me to Mark Foster calling these responses "debilitating" and "life-threatening". I know a lot of people, and as mentioed I am one of them myself, who would answer him to this statement that they developed "symptoms" because they had no other choice if they wanted to survive in a for them life-threatening situation, that their ability to develop "symptoms", to react in the life-threatening situation they found themselves in, actually saved their life, and that therefor they don't see this ability as "debilitating", a weakness, an illness, or anything along those lines, but actually as a strength. And indeed, life that doesn't react to its environment isn't fit to survive in it. If we're talking a single cell, or a complex organism such as a human being. Fact is, people do not die from "mental illness". They survive thanks to it, and if they die, they do so because their experience, their life story, they themselves, are explained away as "diseased", and not understood. It is not "mental illness" itself that is life-threatening. It is the fear and lack of understanding that people who react in an extreme way to extreme circumstances are met with.

Given these very different definitions of "severe mental illness", and given the fact that we do not have scientific evidence to prove one definition more true than the other, while we do have "anecdotal" evidence that may well be interpreted to support a view of the latter definition as more true than the illness-definition (cf. that most people do not refer to themselves as "diseased" but after they've been in contact with psychiatry, and that they actually often resist being defined as "diseased", and need a whole lot of "treatment" before they're ready to submit to this definition), I wonder how Mark Foster justifies his statement.

This is a complex matter, and there would be a lot more to say to it, too much for a comment on facebook...

One last thing: Mark Foster writes that the motivation to become a medical professional for most people is that they want to help others. I don't doubt that. But what I find a far more interesting question is what is the motivation behind wanting to help others? Is it imaginable that it, at least in some cases, is a profound feeling of being helpless oneself?...

Oh and, why I mention the talk by the psychiatrist: the way fear was presented by her, not fear of something, but simply fear, a meaningless symptom of a meaningless illness, turned fear, almost magically you might say, from being a natural human emotion into something completely alien (as in alienation... ) to human nature. Fear was no longer an emotion. It was a symptom, and as such it had to be feared... This is how we alienate people from the labelled, and the labelled from themselves. This is what the "stigma", the discrimination and prejudice is made of. Us and them. Human beings and "psychotics"/"schizophrenics". Sad.

Sunday 19 December 2010

David M. Allen - Making fun of child abuse

Back in April this year, I wrote in a post on this blog: "Visiting David M. Allan, M.D.'s blog, your first impression might be a rather positive one. He seems to have got at least something. And yes, he has got something." Today, reading this entry on his blog, I take back my words from April. David M. Allen hasn't got anything. Not a thing. Or he wouldn't make fun of child abuse.