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(1) abolishing the corruption by giant drug companies of mental health institutions, research, and practice; and

(2) exhuming buried truths about the relationship between a dehumanized society and emotional suffering.

Abolishing the Corruption by Big Pharma of Mental Health Institutions, Research, and Practice

In what has become a “psychiatric-pharmaceutical industrial complex,” giant drug companies have corrupted mental health institutions, research, and practice. Most major mental health organizations and institution from which the general public and doctors receive information are financially interconnected with Big Pharma. This practice needs to be abolished by law.

The official psychiatric diagnostic bible that is published by the American Psychiatric Association (APA) is called the Diagnostic and Statistical Manual of Mental Disorders (DSM). DSM-5 was recently approved by the APA, and according to the journal PLOS Medicine, “69% of the DSM-5 task force members report having ties to the pharmaceutical industry.” The corruption of the APA by Big Pharma is nothing new. On July 12, 2008, the New York Times reported the following about APA “In 2006, the latest year for which numbers are available, the drug industry accounted for about 30 percent of the association’s $62.5 million in financing.” Congressional investigators in 2008 also discovered that then president-elect of the American Psychiatric Association (Alan Schatzberg of Stanford University) had $4.8 million stock holdings in a drug development company.

The APA’s recently approved DSM-5 is an embarrassment even for some psychiatrists who had taken seriously previous DSM editions. Psychiatrist Allen Frances, former chair of the DSM-4 taskforce and currently professor emeritus at Duke, wrote in “Last Plea To DSM-5: Save Grief From the Drug Companies, “Making grief a mental disorder will be a bonanza for drug companies, but a disaster for grievers… Psychiatry should not be mislabeling the normal.”

Most mental health professional organizations that are not on the take from Big Pharma are opposing DSM-5. The Coalition for DSM-5 Reform is comprised of over 50 organizations including the Society for Humanistic Psychology (one of several divisions of the American Psychological Association that are in the coalition), the British Psychological Society, the Danish Psychological Association, the Association of Black Psychologists, the Association for Women in Psychology, Psychologists for Social Responsibility, and the International Society for Ethical Psychology and Psychiatry.

Within the psychiatric-pharmaceutical industrial complex, there is a government-industry revolving door of employment, a staple of industrial complexes. As I detailed in 2008 in “Psycho-Pharmaceutical Industrial Complex,” there has been a revolving-door of employment between giant pharmaceutical corporations and the U.S. Food and Drug Administration (FDA), as well as with the National Institute of Mental Health (NIMH). This makes it easier for Big Pharma to create and corrupt psychiatry “thought leaders.”

Perhaps psychiatry’s most influential thought leader is Harvard psychiatrist Joseph Biederman, who “single-handedly put pediatric bipolar disorder on the map,” according to pediatrician and author Lawrence Diller. Biederman’s financial relationships with drug companies was discovered by the public in 2008, when the New York Times reported the following about him: “A world-renowned Harvard child psychiatrist whose work has helped fuel an explosion in the use of powerful antipsychotic medicines in children earned at least $1.6 million in consulting fees from drug makers from 2000 to 2007 but for years did not report much of this income to university officials.” As part of legal proceedings, Biederman was forced to provide documents about his interactions with Johnson & Johnson, the giant pharmaceutical company; the New York Times reported Biederman pitched Johnson & Johnson that his proposed research studies on its antipsychotic drug Risperdal would turn out favorably for Johnson & Johnson — and then Biederman delivered the goods.

Due in great part to Biederman’s influence, the number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003. Bloomberg News reported in 2007, “The expanded use of bipolar as a pediatric diagnosis has made children the fastest-growing part of the $11.5 billion U.S. market for antipsychotic drugs,” and today this market has grown to $18 billion.

Biedeman is not alone among psychiatrists lining their pockets with drug company money. The New York Times (“Top Psychiatrist Didn’t Report Drug Makers’ Pay”) reported this about Charles Nemeroff: “One of the nation’s most influential psychiatrists earned more than $2.8 million in consulting arrangements with drug makers from 2000 to 2007, failed to report at least $1.2 million of that income to his university and violated federal research rules, according to documents provided to Congressional investigators.”

A 2008 Congressional investigation revealed a widespread financial interconnection between Big Pharma and psychiatric institutions and thought leaders. Unfortunately, the U.S. Congress has a history of occasionally exposing the corruption of a major industrial complex but then doing nothing about it; and this has been the case with Congress and the psychiatric-pharmaceutical industrial complex.

What needs to be done? Let’s start by throwing out everything that has been created by Big Pharma corrupted mental health institutions and thought leaders. And let’s begin a “Mental Health Enlightenment” based on genuine science, which would mean an admission of exactly what psychiatrists and psychologists do and do not know.

Exhuming Buried Truths about the Relationship between a Dehumanized Society and Emotional Suffering

Big Pharma corruption of mental health institutions has also meant an ever-increasing focus on our biochemistry. We are diverted from the reality that many emotional problems are not caused by biochemical or genetic defects but are often natural human reactions to powerlessness, hopelessness, and loss of community and autonomy that have been created by public policies. Mental health is hugely political, and it is very much connected to the sanity and humanity of a society and culture.

In the United States today, Native Americans have the highest suicide rate among all ethnic groups, and suicide is the second leading cause of death among Native American adolescents. As I document in Surviving America’s Depression Epidemic, prior to colonialism and their subjugation, suicide was virtually nonexistent among young Native Americans. Social and cultural upheaval has resulted not only in depression and suicide for Native Americans but also in alcohol abuse and other destructive behaviors. Psychologist Roland Chrisjohn in The Circle Game (1997) notes: “In truth, does not the history of Jewish suicide during the holocaust, like the histories of suicide in the Arawaks, the Home Children, and the Marshallese Islanders, and countless other oppressed groups, teach us that suicide is in part a normal human reaction to conditions of prolonged, ruthless domination.”

As I described on May 6, 2013 in “What’s Behind ‘Substantial Increases’ in Suicide Rate for Middle-Aged Americans? Bad Economy Is Likely Culprit,” the Centers for Disease Control (CDC) reported on May 3, 2013 that the suicide rate among Americans aged 35–64 years increased 28.4 percent between 1999-2010, and the Lancet estimates that the three-year recessionary period from 2008 thru 2010 was a source in the United States for “4,750 excess suicide deaths.”

An exclusive focus on giant coroporations’ profits comes at the expense of important components necessary for mental health. One such component is community — face-to-face contact with emotional and economic interdependence. Another component is autonomy — the experience of some control over one’s life.

Postpartum depression occurs in 10 to 20 percent of women in the the United States but is considered rare in Fiji and some African populations, according to a 2004 BMJ article “Learning from Low Income Countries: Mental Health.” Based on a review of the literature, the authors concluded, “Structured social supports after childbirth are described in groups of women with low rates of postpartum depression.” Because of politics and public policies, many American woman lack social support before and after childbirth.

Genuine community in America is increasingly obliterated as social isolation increases. A major study reported in the American Sociological Review in 2006, “Social Isolation in America: Changes in Core Discussion Networks Over Two Decades,” examined Americans’ core network of confidants (those people in our lives we consider close enough to trust with personal information and whom we rely on as a sounding board). Authors reported that in 1985, 10 percent of Americans said that they had no confidants in their lives; but by 2004, 25 percent of Americans stated they had no confidants in their lives. This study confirmed the continuation of trends that came to public attention in sociologist Robert Putnam’s 2000 book Bowling Alone, which reported a decline in U.S. social capital (his term for social connectedness) in virtually every area people have historically found community.

Social isolation is related to depression and many other emotional problems. Increasing social isolation in America is not caused by genetics and biochemistry but by public policies that focus only on increasing the profits of giant corporations.

Large empires can enslave people, and large corporations can create standardized, assembly-line, robotic living. Until recently, it was common sense that all bigness was a threat to autonomy and freedom. Before the terms mental illness and depression entered our lexicon, it was basic common sense that if a few big guys had all the power, then the rest of us would have none, and if we had no autonomy or control over our lives, then we would more likely have emotional difficulties.

Because of corporate domination, Americans have increasingly lost community and autonomy, and have acquired instead the tyranny of institutionalization: domination by gigantic, impersonal, bureaucratic, standardized entities — visible in large corporations, the workplace, health care, schools, and much of our lives. This institutionalization has made many Americans feel small, isolated, helpless, scared, inattentive, bored, angry, alienated, and depressed.

In a Mental Health Enlightenment based on genuine science, mental health researchers and practitioners would be uncorrupted by Big Pharma. They would acknowledge what, scientifically, they do and do not know, and they would make clear to Americans how public policies affect our mental health.

Bruce E. Levine, a practicing clinical psychologist, writes and speaks about how society, culture, politics and psychology intersect. His latest book is Get Up, Stand Up: Uniting Populists, Energizing the Defeated, and Battling the Corporate Elite. His Web site is www.brucelevine.net

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For several decades, since the days when I was a patient, I have seen and heard how an obsession with questions damages psychiatry. Many of us have been asked the same questions day after day, year after year: ‘Do your thoughts seem faster than normal?’, ‘Do you ever have thoughts in your mind which are not your own?’, ‘Do you feel anxious?’, and so on.

What does this feel like? As ever, my patients describe it best. One locates it as “like a machine gun into my brain”, another “an attack, an intrusion, a knife into my body”. A socially anxious man appeals “Did I say what I was supposed too? Did I perform OK?”. A woman with a long history of childhood abuse says the questions felt like “a penis going into my body, again and again”.

These type of descriptions are the norm not the exception. For the structure of being asked questions is a specific one: it places the desire of a powerful other (the nurse, the psychiatrist, the social worker) as primary. This echoes an interactional pattern so familiar to so many who have been bullied, shouted at, beaten, tortured, sexually abused. The feelings from these past times can return in the body – anxiety, paralysis, disconnection, anger – none of which are articulated to the professional, trumped by the desperate life or death task of getting out of the room in a vaguely ‘together’ way. So the doctor gets thanked for his time and doesn’t learn any better, and it is the student nurse on the ward, or the parent at home who sees the person in bits. Hearing only what a patient says under questioning when frozen by paralysis, or subject to the hyper-arousal of anxiety, the professional misses the opportunity to hear the threads of something new, the possibility of weaving with the patient a narrative of hope and recovery.

To be with someone in real distress can be incredibly difficult, and we can perhaps empathise with the professionals unconscious desire to cling desperately to the diagnostic manual, to the crib sheet of mental state assessment questions, as someone drowning clings to a rock. Hearing a person’s real history, rather than the history of their symptoms, makes explicit the limits to what psychiatry can do – the drugs don’t often work, and they rarely get rid of what triggered the problem in the first place. As both parties have some awareness of this, they can only perform  ‘the doctor who asks questions’ and ‘the patient who answers questions’. This is deeply depersonalising and means neither party will quite be there, both alienated by a set of rules of how they should be, as Tom and Jerry are obliged to perform Cat and Mouse. Yet, it’s perfectly possible to rip up the implicit rule book, and have a real encounter. It doesn’t mean the psychiatrist can’t check in on any risk questions right at the end, it doesn’t mean no medication to dampen down the physical, but it does mean the patient gets to dictate what the space might look like for the overwhelming majority of the time.

The need to fight for space so something of one’s distress can be heard becomes ever more important as even psychotherapy spaces becoming colonised by form filling, much of which is a response to the professionals internal judge who screams ‘show you are doing something!’ as opposed to a task related to patient care. For a barrage of questions about symptoms obliterates the possibility of the joining patient and professional to explore: ‘symptom of what’.  This is especially tragic when going mad can unconsciously be a way to try to communicate something that hasn’t been put into words. Mania can be a desperate attempt to flee hopelessness, voices the still heard words of an abuser, rage an understandable response to being downtrodden, depression unspoken grief for a baby, lost. The ‘what’ here is not connected to anything that can be found in one of the heavy diagnostic manuals, or got rid of by a small change in medication dosage. Every meeting that fails to explore this ‘what’ solidifies the psyches defences – it repeats what is often a common theme in a patients life ‘you are alone with this’.

How, then, can we construct a space that isn’t dominated by colonising questions? Both parties may think anxiously of the comic blind date sketches that originate from the horror of being asked outright ‘What do you want to talk about?’ Instead, professionals need to learn how to carve out an open, space in a gentle manner. This must involve thinking about how power, emotion, and social conventions may be present in interaction. Consider the question ‘How are you?’. A health professional will often ask this before proceeding to do a mental state exam, taking a simple response as meaning its time to start on their agenda. However, in any scenario, ‘How are you?’ nearly always needs to be asked twice. For at first, we tend to give a smudged response (‘ah you know, so so’) to allow us to ask the questioner how he or she is, the rules of normal discourse. We do this so often it’s automatic, so if a professional asks it we default into the same pattern.

Yet, if we ask someone ‘how are you?’ a second time, and really mean it, something more singular always emerges. The text of the person’s response nearly always provides some clues we can pick up on. So, if someone says “I’m alright, you know, things aren’t always easy”, we can repeat “things aren’t always easy” with a questioning tone and we’ll get an elaboration on how present the voices are, how impossible it is to open the post, or whatever it may be. Or we might pick up the ‘you know’, insisting perhaps with a dollop of humour, that its actually the patient who knows. And then we hear how tough its really been. We ask one simple question and then position ourselves as subservient to the discourse of the patient, attending to the silences, and pauses, and body language. It is this which gets to direct the conversation. Questions only become useful when they are about something idiosyncratic that has slipped into the conversation – an interest in a particular band, an old dream to be a footballer. Curiosity on this can often allow new expanses of our experience to reach discourse, can remind us of things its worth getting better for.

Rather than the dominance of the voice of the most powerful person in the room, we need a psychiatric practice that privileges and gives real space to the service users voice. It is madness to expect healing to occur if a space is colonised by standard often heard psychiatric questions, with the service user only asked what they wish to talk about in the snatched last few minutes, expecting them to express their needs whilst a professional shuffles their notes and makes to leave the room. Though psychiatry brings up metaphors of the brain to justify its practices the whole time, the evidence base actually supports such an approach. The diagnostic system is being revealed left, right and centre as an unscientific system still waiting 100 years on for evidence, the promised improved wave of new atypical antipsychotics now revealed as no more effective than the ones that went before, and the talking therapy beloved of the market place, CBT, is shown to be no more effective than befriending for psychosis . In contrast, the best outcomes in the world, using the most rigorous randomised controlled trials, are from a Scandinavian programme called ‘Open Dialogue’. With this approach, when someone becomes acutely distressed, everyone involved meets within twenty four hours – the patient, their family, any neighbours or friends, and professionals. They talk about what may be happening. The professionals do not ask questions, they are more there to witness what emerges, and make sure everyone’s voice is heard. The professionals talk about the power their titles may seem to bring, and how it is is dwarfed in the face of the lived experience of those present who know what’s been happening. All the professionals do is listen for the truths, the islets of hope, the forgotten traumas and dreams, which inevitably leak out in the act of speaking.

I write “all the professionals do is listen for the truths” but the ability to do this, to stay with distress, is something that has to be cultivated through gently guiding the professionals hand away from the book, so they can actually be with the person in front of them. If the professional can stop using questioning as a way not to be there, they will be able to join with the patient to hear something new and emerging in the conversation that may be a surprise for all. It is when we have the space and safety to surprise ourselves with hidden knowledge of where we are, and where we have been, that the seeds of recovery are sown.

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I am part of a group of folks working on a new community or “peer’” bridging project in Western Massachusetts.  The bridging intended in this work is in support of people who are hospitalized and would like support transition back into the community.  The initial stages of this project, however, have had us in quite different “bridge building” situations — with hospital management — to discuss our upcoming roles.  These meetings have often been stressful and emotional experiences for reasons I will explore below.

Recently our group was asked to present a “recovery” training to employees at a local psychiatric hospital.  We were invited to talk about general ideas and our personal experiences.

After sharing our thoughts, and intimate details from our own lives we learned that our words were sought out less in earnest but more as a test of our credibility.  The small group of upper-management clinicians admitted they had asked us there on the terms of a recovery training as a way to “screen” us.  Our reputation for being potentially venomous and “anti-psychiatric” had, apparently, preceded us and it was our task to — unwittingly — prove we were credible enough to address the larger staff.  The ill feeling from this meeting stayed with me for days after.

In short, I felt exploited.  We were working from a deficit.  The five clinicians present actually seemed a bit moved by our words, although their admission that we had essentially been asked there on false pretenses only diminished one clinician’s claim that, “we actually have a lot more in common than not.”

I feel compelled to write about this experience for both Mad in America regulars and the hospital staff whom we met with this past month because I genuinely believe their underlying intent was not bad. In fact, judging by the words they chose in the meeting I could easily imagine the reasons many of these people ended up in these roles was through genuine concern for “helping” other human beings.  Meetings such as these carry stresses for us as peer advocates regardless of the intent of those with whom we meet.

If you’ve ever had to talk about difficult experiences in your life and speak about them in ways that defy the stereotypes and connotations these experiences evoke for most people — you might understand.  I imagine testifying in a courtroom and trying to state things that bring up strong and deep emotions with a delivery that tries to remain as unemotional and rational as possible is similar.

Speaking to directors of behavioral health or clinical or nursing supervisors in psychiatric hospitals has felt like that for me.  We were compelled to speak about some of the most devastating, distressing and emotional times in our lives in as credible, articulate and well-stated language as possible.  It’s like time-traveling — with all the exhausting implications for a person moving between different environments and bodily states at breakneck speed.  Oh; and there are things at stake in just how well you hold yourself in these moments too.

This brings us back to the hospital conference room and the so-called “recovery training” we were asked to provide.

Much of our presentation included such feats of time-traveling — and more specifically the ability for us to put words to some of the most devastating experiences in our lives.  It required us to explicitly and implicitly say, “And, yet; here I am speaking and living life fully, defying those expectations many people hold for those other people diagnosed with a ‘serious mental illness,’ or who suffered years of feeling suicidal, or who experienced dozens of hospitalizations.”

In many ways we as peer advocates were moving out on a limb to show such vulnerability to people whose roles remind us of the very visceral experiences of these times and the utter hopelessness we felt living in them.  A large part of our work as advocates, including sharing our ideas with those who work in the mental health system, involves this risk of vulnerability and, for me, also the challenge to relate to those people labeled “clinicians” (or psychiatrists, therapists, psych nurses, etc.) as human beings, rather than just what they might symbolize to us from the past.

When one of my colleagues asked in the middle of the training why we weren’t meeting with more of the staff, as had been our expectation, rather than just the five folks in supervisory roles, the response one clinician provided revealed that this was intentional.  In summary, she said that our reputation of being “anti-medication” preceded us and that these five folks wanted to meet with us first under the guise of a training to see if we were, in fact, as hostile and unable to listen to their viewpoints as they imagined we might be.  She admitted this and in the same breath suggested that we, in some way, defied these stereotypes in how we spoke about our lives and ideas on “recovery”.  Unfortunately, these words could not erase their original deception.

We are already used to being discredited for our psychiatric diagnoses, adding insult to how much those labels have failed to faithfully represent us in both the past and present.  Now, we are faced with overcoming a lack of credibility because honest talk of the abuses we’ve suffered, the anger we’ve felt and the changes we hope for (mixed with rumor and assumptions) sometimes seems to lead people with roles in the mental health system to believe we are obstinately “anti-them.”  It feels as if these folks are sharing some sort of case file and ‘diagnosis’ that has been applied to our whole organization, and I hope this doesn’t make me sound “symptomatically” paranoid.

Although different in some ways, reflecting on this meeting reminds me of an experience my friend encountered when visiting an acquaintance confined to a psychiatric ward.  She and her friend were trying to talk privately in a cafeteria (the designated and not very private visiting area on that particular floor) about some very traumatic and emotional experiences when a nurse came out of the nursing station, which looked more like an observation deck looming over the cafeteria than a separate room.  She addressed both of them by saying that the person locked on the ward was acting very paranoid and inquiring if she didn’t she think she could use some more medication to address that behavior.  Her response was, basically, “You keep staring out of the nurses station after whispering things to the other nurse while my friend and I are trying to talk through some distressing stuff — wouldn’t that make you paranoid, too?

The point here is not the nurse’s apparent rudeness but rather that people in roles of power in the mental health system often don’t realize how much complicity they have in actually creating the symptoms they claim are biologically-based in individuals with psychiatric labels.

I’d like to challenge the clinicians in the “recovery training” scenario I’ve outlined to think about their roles in the system and how much our interaction may have benefited without such prescriptive mistrust and increased honesty as a baseline for dialogue.  If we are going to have any chance at seeing each other’s perspectives first, we — as peer advocates — must be treated with the respect and dignity that would be afforded to anyone else without these labels (both psychiatric and anti-psychiatric).  Then we might agree to approach each other with genuine curiosity and humanness, values through which the opportunity for growth and understanding can exist.

To those with whom we met: I hope you will be open to hearing this and moving forward in a way that creates more space for us and the many people like us to share the wisdom gained as time travelers who can reach back into our histories and pull on experiences to which you do not have first-hand access.  And, with such respect acknowledged, my ears are open to learning from you, too…

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Of further interest:
Childhood ADHD linked to obesity in adulthood (Salon)

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Because I was ill, “I needed to take medication.” The fact that I didn’t want to take medication was “because I was ill.” If I wanted to get better, I “must accept my diagnosis and take medication” and then they would give me welfare benefits and a free bus pass. I wouldn’t ever recover. I would always have this illness. I wouldn’t be able to work. I didn’t know what was best for me. I lacked insight. As mental health professionals, they all knew what was best for me, because they were the experts.

As far as I am concerned, I am not mentally ill. What my abusers did to me was sick. I have had a perfectly natural, human response to devastating experiences. Living with the knowledge of what was done to me, and the way in which psychiatry has added insult to injury by blaming me, is enough to drive anyone mad. My first psychiatric admission in 1993 was my last. I knew then, and I still know now, that to be in such a desperate state in such an unsafe environment was potentially lethal. Ironically, the place that was meant to provide sanctuary for me became the place that nearly drove me over the edge once and for all.

Sadly, my experience, like many people in the psychiatric survivor movement, is still all too common. Every week across the world, intelligent people are expected to accept discredited diagnoses for fear of being labeled as `lacking in insight’ and having treatment forced on them. Every week thousands of people are coerced into taking medication that they don’t want and which frequently does more harm than good. Every week, people are incarcerated against their will, “for their own good”. Fighting for the rights of people deemed mad, many who have already suffered more than enough, is the last great civil rights movement.

The recent furore surrounding publication of the new DSM has provided a much-needed opportunity to discuss and debate crucial issues about how we make sense of, and respond to, experiences of madness and distress.  Many psychiatrists, psychologists and other mental health professionals have expressed their dismay about the dominance and inadequacy of a biomedical model of mental illness.

Whilst we share these concerns, welcome these debates and support colleagues that are willing to take a stand, The Hearing Voices Network believes that people with lived experience of diagnosis must be at the heart of any discussions about alternatives to the current system. People who use services, are the true experts on how those services could be developed and delivered; they are the ones that know exactly what they need, what works well and what improvements need to be made. This is not just an academic or professional issue – it’s one that affects our lives. That is why we have launched this debate on DSM5 and psychiatric diagnoses.

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PRESS RELEASE: Monday 20 May, 2013

HEARING VOICES NETWORK LAUNCHES DEBATE ON DSM 5 AND PSYCHIATRIC DIAGNOSES

IT’S THE BAD THINGS THAT HAPPEN TO YOU THAT CAN DRIVE YOU CRAZY!

The Hearing Voices Network in England has issued a position statement on DSM 5 and the wide issue of psychiatric diagnoses following last week’s debate on the need for a new paradigm in mental health services, reported largely as a ‘turf war’ between psychiatry and psychology. Concerned that this debate can all too easily sound ‘academic’ and miss the voices of the very people these systems impact upon – those diagnosed with mental health problems – HVN are taking the debate back to the people.

“We believe that people with lived experience of diagnosis must be at the heart of any discussions about alternatives to the current system.”

Jacqui Dillon, Hearing Voices Network, Chair.

In their statement, the Hearing Voices Network (HVN) state that psychiatric diagnoses are both scientifically unsound and can have damaging consequences. HVN suggest that asking ‘what’s happened to you?’ is more useful than ‘what’s wrong with you?’.

Concerned that essential funds are being wasted on expensive and futile genetic research, they call for the redirection of funds to address the societal problems known to lead to mental health problems and provide the holistic support necessary for recovery.

This is part of a growing, international movement by survivors of the psychiatric system who are questioning the adequacy of a biomedical model to make sense of and respond to madness and distress (see: InterVoice Online, MindFreedom, PsycDiagnosis, Mad in America, Occupy Psychiatry, The Open Paradigm Project

HVN invites people with lived experience of diagnosis and their supporters to engage in a discussion about the issues and help plan a way forwards.

“People who use services are the true experts on how those services could be developed and delivered; they are the ones that know exactly what they need, what works well and what improvements need to be made. This is not just an academic or professional issue – it’s one that affects our lives.”

Jacqui Dillon, Hearing Voices Network, Chair

Notes for editors:

• The Hearing Voices Network (England) is a national, user-led charity that supports people who hear voices, see visions or have other unusual experiences. The Hearing Voices Network is part of the rapidly expanding global Hearing Voices Movement with 26 Hearing Voices Networks operating, across 5 continents. The Hearing Voices Network’s position statement can be read, and commented on, via their website www.hearing-voices.org

• Hearing Voices Network Chair, Jacqui Dillon (07951 635 033) and Trustees Rachel Waddingham (07969 161 586) and Peter Bullimore (07950 837 694) are available for interviews.

_____

Position Statement on DSM 5 & Psychiatric Diagnosis

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Through being allowed the space to explore and thus resolve the troubling conflicts in his psyche that extended into extreme states of consciousness (often these extremes are labeled as madness and psychosis), he was able to change the limiting beliefs he had about himself, about his challenges he faced and how he related to others and the world around him. Upon his release, Jamin stopped the treatments the mental health professionals forced upon him and has been free from their psycho-active drugs for over four years now. He is studying such disciplines as psychology, NeuroLinguistic Programing, Hypnosis and more, furthering his understanding as to how our beliefs and perceptions impact the changes we see in our lives.

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It caught my eye because it started with a nod to Frieda Fromm-Reichmann, the psychoanalyst who was immortalized in Joanne Greenberg’s fictionalize memoir of her recovery from psychosis, I Never Promised You a Rose Garden.  Ms. Shulevitz goes on to describe the field of loneliness studies from a psychological to a neuroscience perspective.

I have been struggling with the notion of the medical model as it applies to human suffering as well as the ability of basic science research to inform the work we do.  There has been a lively discussion on this website about this (here, here, and here).

For me there are at least four separate questions to be addressed. The first is whether neuroscience is capable of understanding human emotion and higher level cognitive experiences.  The second is the extent to which that understanding – even if it is achievable – is critical to our being able to help people in distress.  The third is whether  it is correct to assume, as many people seem to do, that if we come to some basic understanding of brain function as it pertains to core human emotion and suffering that this will automatically translate into treatments that are commonly thought of as “biological,” such as drug treatment. The fourth relates to the limitations and relevance of studying the brain in isolation when we are constantly in interaction with our environment.

The Shulevitz article provides a good platform from which one can address these questions.  She begins with a discussion of Fromm-Reichmann’s assertion that loneliness – and by this she meant the subjective experience of want of intimacy – was “at the heart of nearly all mental illness”.  She then reviews all of the effects loneliness has not only on the psyche but the body. This is followed by a review of modern research into this field which traces the effects of loneliness in humans from a social perspective to the effects of social isolation and rejection on brain functioning.

I found the article and the studies described to be of interest but inherent in the narrative is the notion that we needed the evidence of brain changes to legitimize Fromm-Riechmanns’s initial observations. The recommended “solutions” are primarily social; the author describes studies that showed the benefits of providing enrichment to young children and their families and she reports on an ongoing study in which researchers are teaching soldiers about social cognition with the hope of reducing post-traumatic stress.  The implication, however, is that the basic science data were necessary to legitimize this area of inquiry.

For those of you who reject the notion that neuroscience research might inform our understanding of human distress, I suggest this thought experiment. I was talking recently to a colleague who studies headache. He explained how researchers in this field worked for years without being able to find biomarkers. They then decided to model a diagnostic system after the DSM. This allowed them to do research that provided preliminary data which they hope will improve their funding.  They propose that understanding the neural substrates of head-ache will yield clues on how to provide more benefit to those who suffer from what for many is a debilitating affliction.   At the same time, he understands how the experience of headache is not based entirely within the person; that the experience can be modified by external experiences.  He is not entirely wedded to finding drugs that will reduce headache; he understands that altered environments might also help. But he nevertheless, believes that this basic research will be informative.

If this seems legitimate, I would ask how in any way this differs from a similar approach to something like anxiety?  Anxiety is an experience that can range from mild and transient to persistent and debilitating. It is experienced in the subjective realm and it has correlates throughout the body.  It can sometimes be reduced dramatically with drugs but it can also be exquisitely impacted by environmental changes.  If basic neuroscience research is legitimate to further our understanding of headache, why is it less important to further our understanding of anxiety?

I find it interesting to learn of the neural correlates of core human experience. In the true spirit of science, we do not know where the research will lead.  I think it is incorrect to assume that neuroscience research will only result in treatments approaches that are “biological”; i.e., contained in a capsule. However, I am not convinced this work is required to legitimize investigation into the value of social connections on our well-being and I do not think we need to wait until we have mapped out the brain before we invest time and money into learning more about this.

That to me is the crux of the issue. I do not dismiss, a priori, that we might someday completely untwist the fundamental workings of the brain.  However, I do not think this is where all of our research dollars should go.  For me, there is ample evidence that social connections matter.  We can invest money into understanding why some of us struggle more and how those of who struggle might learn to make more connections. We can try to understand how our social system maximizes health and well being.  We can invest in understanding treatment approaches that appear to have had good outcomes even if they are not premised on the fundamental biological paradigms of the day.

At the same time, I think it benefits all of us to listen openly to as many perspectives as possible as we join together in re-imagining how best to engage with people who are struggling with extreme states.  I do not want to be privileged in my authority to speak  merely because I am a physician; my experience has taught me the profound limitations of my knowledge.  But we will not know until we know what neuroscience can and can not teach us.  I am hesitant to walk away. I think I write this in the spirit of Robert Whitaker’s work; honest and open inquiry is what should be privileged not an authority or the particular framework from where that inquiry emanates.

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Of further interest:
Why screening for depression in primary care is impractical (Commentary in Canadian Medical Association Journal)
Screening for Depression Lacks Strong Evidence (Medpage Today)

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On the 19th, Jim Gottstein of PsychRights and Matthew Morrissey of Mind Freedom International will lead a several-hours long Occupy APA rally directly across from the Moscone Center where the APA will be meeting. The several speakers who will address rally participants – Leonard Roy Frank; Ted Chabasinski; Chaya Grossberg; Michael Cornwall – will be crossing mics with former President Clinton who, sometime later that afternoon, will deliver the conference’s keynote. Rollin’ out the big dawg for the big bucks. Clinton is sure to attract lots of mainstream media coverage, which will give the APA the chance to put a favorable spin on some of the recent setbacks it’s suffered.

The biggest blow came from an unanticipated source, from the National Institute of Mental Health and its director, Dr. Thomas Insel. On April 29, less than a month before the new DSM’s release, Insel announced that “… it is critical to realize that we cannot succeed if we use DSM categories as the ‘gold standard’ … That is why NIMH will be re-orienting its research away from DSM categories …” Ironically, as Kirk and Kutchins remind us in their scathing critique of the DSM III, the disease classification that Robert Spitzer and colleagues pioneered in DSM III was designed to facilitate research into the biological causes of mental disorders. Its authors soft-soaped the lack of construct validity of their diagnoses and spot-lighted what they contended was a high degree of inter-rater reliability. According to Spitzer, if psychiatrists could agree among themselves about diagnoses and the criteria on which they rested, they would now be free to investigate the underlying, bio-medical etiology. And so the advent of “scientific psychiatry.”

Thirty years later we’re still waiting. Psychiatry has continued to search and continued to promise, in edition after edition of the DSM, that the next edition would be the charm. The decision in 1999 to develop the DSM-5, despite no apparent need for a new manual, was rooted in the APA’s illusion that the discovery of the root causes of mental illness was at hand. Given the work already done – some presumed genetic links – ten years were deemed sufficient to complete what had been started, and publication was projected for 2009. Then pushed back to 2012; and here we are, 2013, and still no root causes. Under the intense scrutiny and barrage of criticism from professionals and the general public, the APA was obliged to admit last December that the sought-for holy grail of “biomarkers” had yet to be found. Hence, Insel’s announcement that NIMH was jettisoning the DSM and any research done with it. From this point on, NIMH will only fund investigations that utilize its own “research framework,” the “Research Domain Criteria (RDoC)”; which, wonder of wonders, is at least ten years away from being operational. To quote Insel, “… we cannot design a system based on biomarkers or cognitive performance because we lack the data … RDoC is a [research] framework for collecting the data needed for a new nosology … Not a clinical tool … a decade-long project that is just beginning…”

If you can follow all this, it means that the NIMH has to collect the data to develop the research tools to do the research; and it will pay good money – some of the $100 million Obama talked about for “brain research” – to get those tools to do that research. Ah, Rube Goldberg would have loved this, circles within circles. And just so you don’t get your hopes up too high, Insel reminds us that “… mental disorders are biological disorders …” More of the same for the next ten, twenty, thirty years.

As if that weren’t enough for the APA to digest, the Division of Clinical Psychology of the British Psychological Society, one of the APA’s principal gadflies, issued a position paper on May 13 that constitutes a direct challenge to the APA and the NIMH. Entitled “Time for a Paradigm Shift,” it calls for “a conceptual system not based on a ‘disease’ model.” Largely ignored in the U.S., save for Lucy Johnstone’s May 12 post on MIA, the Division’s position paper received wide play in the British press – The Observer printed two provocative articles on May 11 and 12, respectively, “Psychiatrists Under Fire in Mental Health Battle,” and “Medicine’s New Battleground: Does Mental Illness Really Exist?” Fortunately for the APA, American professional organizations, made no public comment: “captive,” as Allen Frances would allege; or adrift, as per my telling, on that long and peculiarly American stream, Denial. In any event, the counter-spin has begun. On May 14, Insel and Jeffrey Lieberman, the APA’s president-elect, issued a joint statement, “DSM-5 and RDoC: Shared Interests.” They pledged that the two organizations will “…continue … to work together…; ” conceded that “ … what may be … feasible today for practitioners is no longer sufficient for researchers …;” and agreed that “ … Patients, families and insurers can be confident that effective treatments are available and that the DSM is the key resource …”

To which I can only echo Groucho — “Horsefeathers.”

Fortunately for those of us who can’t be with them, Jim and Matthew and the APA Occupiers will be on the scene to expose the lies and hypocrisy. I’m sure that ‘phone calls, tweets and e-mails of support to those you know will be there will provide them with a sense of our support and solidarity with them. I had been invited to speak at the rally, but, unable to attend, have substituted a statement on behalf of the Committee to Boycott the DSM-5 which will be read to those assembled by Matthew Morrisey. I’ve attached below a copy of the statement, “The APA & The NRA: Two Peas in a Pod.” It not only expresses my solidarity with the APA Occupiers but my frank contempt for two of the foremost supremacist organizations in the United States. Read it and join the Occupiers. And, don’t forget – “Don’t mourn, organize!”

(Please note that the references for Section I above are to be found at the end of Section II below.)

* * * * *

II — The APA & The NRA: Two Peas in a Pod

Jack Carney, DSW, Coordinator
Committee to Boycott the DSM-5
OCCUPY APA Action
Annual APA Convention, May 19, 2013

Greetings, comrades and occupiers. I regret we can’t be there with you, but, poor substitute, I’ve sent along this statement of support and solidarity that one of the Occupy organizers will share with you.

I’ll begin by saying that the APA deserves all the enmity you can direct its way. You’re in San Francisco to protest the American Psychiatric Association at the time and place of its annual convention – its 166th, by the APA’s count –and to occupy as best you can the time and space it has claimed as its own. Not surprisingly, the APA’s wordsmiths have devised a throat-gagging theme for the convention — Pursuing Wellness Across the Lifespan – and the conference organizers have outdone themselves by inviting as the keynote former President Bill Clinton, otherwise known as the first-husband-in-waiting.

You’ve come at an opportune time, the occasion of the publication by the APA of its new DSM, the DSM-5, the fifth in a series of diagnostic manuals issued by the APA since 1979 that the APA has claimed are rooted in scientific research. In the intervening years, the DSM has become an iconic tome, used by psychiatrists and mental health profesionals throughout the world; relied upon by Big Insurance to adjudicate claims and by Big Pharma to validate the effectiveness of its medications. It is the face of the APA, its universal identifier, its singular accomplishment. It has also attracted unwelcome attention to itself and to the APA — success has its costs.

With each successive DSM since 1979 – DSM-III & III R; DSM-IV & IV TR; and now, DSM-5 – criticism as well as skepticism has increased. With each diagnosis that’s been added, the credibility of the DSM and of the APA has diminished. More and more of us now know that none of the 300 diagnoses that have accumulated over the years and that will populate the DSM-5 has any scientific basis, that the vaunted biomedical model is a sham, a fiction. We’ve also come to see the APA as a shill for Big Pharma and the DSM’s diagnoses as a cover for the prescription of psychoactive medications that are addictive and dangerous and that have succeeded in killing and shortening the lives of thousands of the persons prescribed them.

How very much like the NRA, another organization that has sold itself to corporate interests, in this case to the large gun manufacturers. The NRA sees more guns as the antidote to gun violence. What’s its slogan – a bad guy with a gun can only be stopped by a good guy with a gun? The APA for its part hasn’t seen a psychoactive med it doesn’t like. Wayne La Pierre’s strategy to protect kids in school is to station cops with guns in every school in the country and to arm teachers. The APA has a companion strategy — ferret out potential student killers by increasing school mental health services, identify more ADD kids and prescribe them the necessary sedating medications.

Welcome to 1984 and Big Brother, with half the population somatized. Welcome to the U.S. as an armed police state.

The NRA won’t oppose prohibition of the sales of assault rifles because they’re the biggest money makers for Big Gun. It’s taken to hide its money-grubbing agenda behind two preposterous beliefs that serve it as perfect smokescreens: first, that the 2nd amendment gives citizens a right to own guns and that the Federal government wants to take that right away — nothing like a little paranoia to muddle people’s minds; and second, that only crazy people commit mass murders – if the public wants gun control legislation, do a bait and switch … pass a law increasing mental health funding to keep the crazy folks under control. To no one’s surprise – not mine, not yours, not even that of The New York Times — the mental health lobby has taken the bait and it looks like the APA and the NRA will wind up sharing the same bed.

So where does that leave us and those Americans that seem to have figured this out? It leaves us up against two nine hundred pound gorillas, with not a fraction of their resources. What can we possibly do?

Well as the old Wobbly and my guiding light, Joe Hill, would have said … “Don’t mourn [or feel sorry for yourself], ORGANIZE!” If you want to change or put an end to a system of oppression, disrupt the relationships of those entities that comprise it. The four principals of the national mental health system are Big Government, Big Pharma, Big Insurance and the APA. You’ll notice that I didn’t say BIG APA. That’s because the APA is the most vulnerable of the bunch – rooted in phony science and myths about so-called mental illness; dependent on the three other BIGS for its resources; desperate to sell the new DSM and re-coup its $25 million investment. Which is why it’s selling the new DSM for $200 a pop. Which is why it’s hired Bill Clinton as its chief huckster.

So you’ve picked the right target – a desperate and diminished APA, whose credibility is at its lowest ebb in forty years, thanks to the metaphysics it’s attempting to peddle as science. Your mission – our mission – is to continue to attack its credibility; to question how and why the BIG THREE – GOVERNMENT, INSURANCE, PHARMA – are so willing to invest so much confidence and so much money in such a flawed institution.

But that’s another story, one that we’ll see played out as the four principals and their lesser acolytes kick around next year’s political football, the ICD-10. As for the NRA … ditto. Neither the NRA nor the APA will prevent another Newtown, another Aurora, and folks with diagnoses will again be scapegoated. Putting an end to needless deaths and ruined lives will require life-long commitment and ongoing struggle. I see you all in my mind’s eye …

In the struggle, Jack Carney

* * * * *

References – Section I:

* * * * *

Division of Clinical Psychology, British Psychological Society, DCP Position Statement on Classification: “Time for a Paradigm Shift” May 13, 2013,

Doward, Jamie, “Psychiatrists Under Fire in Mental Health Battle” The Observer, May 12, 2013,

Doward, Jamie, “Medicine’s New Battleground: Does Mental Illness Really Exist?”, TheObserver, May 12, 2013,

Frances, Allen, “Does the DSM-5 Have a Captive Audience” Huffington Post, May 16, 2013,

Insel, Thomas, “Transforming Diagnosis” April 29, 2013,

Insel, Thomas, Lieberman, Jeffrey, “Joint APA & NIMH Statement – DSM-5 and RDoC: Shared Interests” May 14, 2013,

Johnstone, Lucy, “UK Clinical Psychologists Call for the Abandonment of Psychiatric Diagnosis and the ‘Disease’ Model” Mad In America, May 12, 2013,

Kirk, Stuart and Kutchins, Herb,  The Selling of DSM: The Rhetoric of Science in Psychiatry New York, Aldine, 1992

Spitzer, Robert, DSM III Casebook, American Psychiatric Publications, 1981

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Deacon, B; The biomedical model of mental disorder: A critical analysis of its validity, utility, and effects on psychotherapy research. Clinical Psychology Review. Online April 8, 2013

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Of further interest:
Military and Press “Baffled” by Suicide Facts a 12-year-old Could Discern (OpEd News)

The post Rise in Suicides Baffles Military appeared first on Mad In America.

So what this means, then, is that this inflatable giant has one particularly sensitive vulnerability—what we could call the “needle of truth.” If the mainstream population really knew and understood and were able to integrate the many truths and research studies that so many of us who are active here on the MIA forum are familiar with, I can’t imagine it would take very long at all before the “giant” succumbs to this sharp needle of truth.  Pop!

So how do we pick up this needle of truth, and how do we jab the giant with it? Well, to begin with, this forum itself (Mad in America) has naturally evolved as a hub of truly inspirational people who have been working hard at sharpening and polishing this needle. I’m enormously grateful to Robert Whitaker, Kermit Cole, and others involved in establishing this forum. It’s been meeting many of my needs in a big way, including shared reality, open-minded exploration, mutual support, and hope. It’s also strengthened my own sense of hope and inspiration, especially during those difficult times when strong waves of hopelessness and futility move through me.

To give an example of such a wave (just one example of many), just last week, a new client who came to see me in my practice as a clinical psychologist informed me that he had recently gone to a doctor to discuss his difficulty with sleeping. What kind of support did he receive? Prescriptions for Lorazepam (a benzodiazapene), a nonbenzodiazapene hypnotic (sleeping pills), and Seroquel (an antipsychotic). Upon hearing this, I was struck by yet another wave of hopelessness. Wow, has it really gotten this bad? But then I recalled the many people who are active here (on MIA) and in other similar groups I’m connected with — people who really get the absurdity and tremendous harm of all of this —and some sense of hope returned.

One particular avenue of inspiration that has developed in me is a desire to devote some of my time and energy to community outreach, and it strikes me that we — the members of this forum — are in a unique position to create some real waves in the field by supporting each other in developing new community outreach projects and strengthening already existing ones. Of course, I recognize that much of this type of work is already being done here, and yet I also recognize that there is so much more that we need to do if we really want to take down this giant. So I’d like to share some of what I’m doing and invite others so inclined to chip in and/or share their own ideas and projects that they’d like some support with (please feel free to use the COMMENT section below for this).

So far, my own personal outreach has consisted of attempts to reach out to the mainstream population at large and to other professionals and academics in the mental health care field (which was the motivation behind the publication of my book, Rethinking Madness, and my continued writing and speaking in other forums and venues). For some time now, my time and energy have been stretched a little thin, as I’m sure are many of the other members here, so my own activities in this regard have taken something of a back burner. But lately, I’ve begun exploring ways of trying to get more involved again, and in particular, ways to hone in on the groups who I believe are the most instrumental in keeping the biopsychiatric paradigm so entrenched within the mainstream culture —groups such as mental health care workers, members of the pharmaceutical industry, and family support groups such as NAMI.

In my explorations of possible outreach projects, it’s occurred to me that internet discussion forums have grown exponentially in the past few years and many of them offer really good opportunities to target some of these groups more directly. For example, I’ve discovered that NAMI has quite an active group on LinkedIn (with over 10,000 active members), and last week I decided to use my recent blog posted here on MIA as an opportunity to present an alternative paradigm to this group and invite discussion. As many members of MIA must know, NAMI members tend to be among the most impassioned “bible thumping” advocates of biopsychiatry out there, and yet there are signs that some serious doubts may be creeping into their “faith,” especially when we consider the fact that Robert Whitaker has been invited to speak at their annual conference next month.

For those of you who don’t know, the way that these discussions on LinkedIn work is that for each comment a particular discussion receives, a mention of the article is made in the “Latest Updates” column at the top of the page, and a given commenter will also be listed in the “top influencer” column (also  at the top of the main page) upon making a relatively high number of comments (I became listed here for the NAMI group after making only about 4 comments over the week). Also, each new discussion is posted at the top of the page and also emailed out to each member. In other words, it’s really not that difficult to create some significant waves and draw some attention, even within a group as large as the NAMI group. So I’d like to encourage anyone who is so inspired and who has a little time on their hands to take advantage of these ever increasing opportunities and consider jumping in on my existing discussion with the NAMI group, start new discussions in this and other similar groups, and/or share similar groups, discussions or other similar projects with the rest of us (again, feel free to use the COMMENTS section below for this).

The recent series of highly respected groups repudiating the DSM, the acknowledgment of a continued lack of evidence for the biopsychiatric model by the king drug pushers themselves (the APA), and now clumsy attempts at backpedaling all suggest that we may have some of the largest advocates and pushers of the biopsychiatric model “on the ropes.” Call me overly optimistic, but I’m pretty sure we’re seeing evidence that the “giant” is losing its balance. Right now may be one of those rare opportunities to go for the “knockout” blow. Sure, I know that it’s a David vs. Goliath battle, and I’d have a difficult time arguing with anyone who would accuse me of being naïve and even irrational in my belief that it’s possible to convert the biopsychiatric “believers.” But what have we got to lose? After all, David did take down the giant in the end.

The post Taking down the Giant: A Call for Increased Community Outreach appeared first on Mad In America.

Unfortunately, the technician on the task at WiredTree walked away from our updates with a major error still in place, leaving the site entirely inaccessible for several hours longer than expected. In the process of trying to resolve this error, I recognized another significant change to our configuration that needed to happen. At the moment the site is accessible again using some fallback software that does not perform as well as our desired setup. You may still notice slow speeds and occasional errors. Support at Wiredtree continues to work on the problem, which has now been unresolved for over six hours.

Readers, I apologize for any inconvenience. Hopefully the site will be working better than ever very soon.

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In NIMH director Thomas Insel’s late-April statement, the DSM is characterized as having poor “validity.” This means, plainly, that there is no consistent evidence that the DSM classifications of experiences deemed “mental disorders” correlate to any specific or measurable process of disorder. The diagnostic categories of the DSM are based on subjective symptoms, for which there are often no identifiable causes.

The dominating reign of the DSM has been dealt what may well be a terminal blow. There may not be a DSM-VI.  Our entire “mental health” system may need to begin considering vast revisions of coding and service. Because the DSM has been publicly declared (by a presumed authority, the NIMH) to lack validity, anyone who uses the book in practice or policy will have to think hard about the integrity of the ethics that govern their professional practice. In some ways, the NIMH announcement was a great boon to the efforts to build support for alternatives.  In other ways it is an insult, given that advocates and activists have been criticizing the DSM as unreliable, inaccurate, distorting and ultimately useless for decades.

The DSM is on its way to being history. However, with the NIMH announcement came a new set of research domains that will affect the future of sciences pertaining to the human condition, with a specific focus on identifying neurobiological markers and processes that may be linked to manifest human difficulty that is currently seen as “mental illness.”

Yet, recent reports from the American Psychiatric Association clearly state that there is not a biological marker that can be identified using neuroimaging, indicating a vast abuse and squandering of funds that could have actually supported the research and development of additional evidence-based healing practices. Research that has purportedly identified variation in genetic or neural function or structure is minimally informative, as any phenomenon of the brain is:

A) dependent upon a great number of variables

B) likely to change, given the fact that we are in a constant state of growth and response

So, where does that leave us?

There is a fear that the research directions charted by the NIMH may lead to a hypermedicalized view of the human condition, and that many more billions of dollars will be spent developing invasive technologies designed to affect our neurobiological function, possibly in ways that may be toxic.  Given the exploitative collusion that regularly happens among researchers and industry, this is a legitimate concern.

“Scientific” research has, historically, been the driving impetus for vast and insidious human rights abuses and the formal literature has contributed mightily to distortions in our conceptualizations of normative function and expression. This is not, of course, to dismiss “science” or present an “anti-intellectual” view of the existing body of literature. However, a systematic review of said literature will reveal vast reams of flawed methodology, theoretical bias, and a dearth of the simple logic that informs us that our lives are complex, messy, and dynamic, with multiple variables acting upon one another in ways that make it difficult to generalize any conclusions across large portions of the human population.

Two people (or 7 billion people) can be genetically related and be, within their subjective experiences, very different. They can go through the same tragic events and experience them uniquely.  Even people who share tendencies of experience are not the same and what might be helpful for one person may prove to be unhelpful – or even harmful – to another.

However, in spite of the barriers to generalization, there are correlational trends among people who experience struggle between themselves and their life circumstances, with potential causal links between trauma, stress, and psychosocial dynamics as these factors relate to difficulty in experience. We are all affected differently by constructs of economy, opportunities for education, and the other factors which shape the landscapes of our lives, be they plush or war torn.

There are numerous psychosocial/emotional/existential/spiritual theories about what may cause difficulty in human experience. Entire fields of science and inquiry are based on hypotheses of the mind and musings on the heart. Obviously, we are more than our neural connections. Yet, we do have brains. We do have neurons and synapses, enzymes and chemicals, areas of tissue that mysteriously hold networks of memory, others that map our anticipations.

Do we need to know the specific neurological correlates of internal conflict?

How does the fear of being alone pass between our synapses?

Does hope light up our brains, or just our hearts?

Is it even possible to know? Is it important?

Perhaps it would be more useful for us to focus on what seems to help, rather than trying to identify some elusive shared trait among those who struggle for some reason or another with their human experience. By establishing evidence of the efficacy of alternatives, the “problem” may become less important than the possible (or obvious) solutions. It doesn’t take a Ph.D to know that when we are empowered, accepted and loved for who we are we tend to feel better and enjoy our lives more.

For the sake of fairness and acknowledgement of reality, there are some instances that neurological duress or wounding can be implicated in difficulty within our human experiences. The effects of chemicals and certain elements (such as illicit and pharmaceutical “drugs” and lead, for example) can wreak havoc on the functions of our brains, as can (actual and measurable) diseases like cancers of the brain. Even in the absence of drug effects, the neurological effects of an actual disease, or environmental toxins, some people do experience some significantly difficult recurring experiences. Sensory integration issues, distinct features of processing or thought tendency, and regulation of emotion and energy are genuine and very real struggles that many people often attribute to neurological differences.

First and foremost, difference is not disease. This cannot be said enough. Difference is not disease, by definition. Some differences are caused by diseases, but difference itself is not a disease. A disease requires an evident process, with indicators and predictable outcomes. Based on those exceedingly simple criteria, the bulk of challenging human experiences cannot be attributed to anything remotely resembling a disease.

Some people do have what they have found to be characteristics of experience that can be, in part, attributed to elements of our human function that are considered to be at least somewhat neurological, such as sensory integration. These differences – some of which can be experienced as disabling depending on the expectations that establish “normal ability,” contributing to severe sensitivities and learning differences, among other struggles – are often identified through neuropsychometric testing (e.g. IQ tests) of some sort. These measures are often problematic themselves. Yet, they do measure something, and those inventories of attribute do have the capacity to inform us of some aspect of our human experience, even if it is only whether or not we “test well.”

Acknowledging neurodiversity is in no way endorsing a biomedical disease model. There is an entire movement of people who identify with concepts relating to neurodiversity, which acknowledges that some people do fall well outside of the range of statistically normative neuropsychological features and that these variances from neurotypical function are a good thing, rather than a disease. The human species is diverse by nature, and rightfully so. We encompass artists, musicians, architects, astronomers, storytellers, engineers, farmers, cartographers and healers…and we all, as humans, struggle.

Yes, for some the struggle is tremendous.

Yet, just as we all struggle, we all also, as humans, have the capacity to live our lives well to the best of our abilities, which ought not be impeded or discouraged by circumstance or belief. We grow and change. We find out, through trial and error,  who we are, what we like and what we are scared of. We learn what works for us and un-learn the belief that we can’t learn.

It ultimately may not be important for us to know the specific rate and content of exchange across neural networks. Even if we figure out how something works in one person, or even in a supposed group of people, the variables that shape our lives and experience are complex. It is difficult to conclusively generalize any broad truth about why we are human in the ways that we are and what the future may hold for any of us.

If the NIMH spent as much funding on accessible, trauma-informed, integrated, choice-driven community wellness centers and lobbying for better quality of life opportunities as they do trying to find evidence of elusive brain diseases, we would not have the “mental health” crisis that we currently have.

We would, perhaps, have more of what we deserve, not as people identified as having a “mental health disorder” or as people that could “qualify for disability” but as human beings with universal human rights.

Do we really need research to tell us that kindness and compassion are healing, that options are good and that the more perspectives we have access to the better able we are to figure out a meaning and strategy that may best work for us?

Due to the resources afforded to the pharmaceutical industry, state institutions and the military, research funding has been unequally distributed. Therefore, the ideas and theories that have been formalized as “science” are largely representative of the interests and paradigms that research institutions and grantors may ultimately profit from.  In what directions will the NIMH fervor for a new nosology drive this science devoted to answering questions that don’t need answering, or which cannot be answered by a medical test? What good comes about from looking for a disease and what will they make of what they may find? Are so they so desperate to find something that they would be willing to create disease where there is none, simply so that they may find it?

So far, they have found, for all their sophisticated techniques, surprisingly little. There are no lesions, no consistent protuberances, no void grey areas of neurological scarring. Potential variations that have been identified could have been caused by anything, and may simply be the fact of human diversity in function and expression.

So, is there anything good or useful that could come out of new NIMH research directions?

Well, some innovative researchers may be able to secure some renewable research grants to conscientiously and strategically contribute to the body of literature on alternative non-invasive evidence-based practice, perhaps relating to the neurological benefits of naturally occurring micronutrients in delicious food or the measurable effects of mindfulness, stress reduction and life enjoyment programs. Perhaps someone could conduct research on the beneficial neurochemical effects of hanging out in fields with friends, laughing.

Researchers may gain insight into the effects of stress.

They may learn more about the specific ways that neuroleptics damage our brains.

All in all, we may not need research to tell us what we most need to know about human struggle and human healing, which is simply that both phenomena are intrinsically human and, by virtue of that, we are all different in what hurts and in what may help. It is, however, fair to conclude that for most people fear can be toxic and that love/acceptance/nurturance can be healing.

I do believe in the potential for bad ideas and dysfunctional systems to destroy themselves and I am hopeful for the development of an ethical science of the human condition. At the basis of this science would be a commitment to framing the human experience in a manner which is realistic and informed, with a resolution to not call things diseases which are not diseases. I am hopeful that young scientists paid attention in their philosophy of science classes, their ethics courses.

To me, it seems that it would be far more interesting and exciting to destroy a useless and harmful paradigm than it would be to try to prove evident mistruths. It would be a lot more fun to research the neurological characteristics of a life well lived than it would to be to spend life sitting in a laboratory looking at numbers about some poor little kid’s dopamine levels as they may be affected by neuroleptics.

*Laura Delano’s excellent recent post “Mental Illness,” the DSM-5, and Dreams for a Post-Psychiatry World explores the implications of recent shifts in the direction of formal understandings of human struggle as our realities relate to misinformation, oppression, and multisystemic trauma. In the comments is a really great discussion of the body, mind, heart, environment dynamic as it relates to potential hypermedicalization of our perspectives of human experience.

Here is a poem that I wrote about scientific paradigm shifts as such things may relate to brain research and a picture that I drew during a period of involuntary outpatient commitment, while I was thinking about how strange it sometimes is to be human.

The Scientist’s Lobotomy

Did you look inside her brain

at that place

where you imagined

all those demons, that disease?

Was her skull split open

like a shell

for its soft fruit

to be examined

by the stainless tines

of your science?

What did you find, in that shimmering inside?

Was it not so dark as you thought it might be?

Did you see, there in the folds, the pits that you had pictured?

Did you find

the small empires

you expected

in a chemical rot and lesion?

Did you swim

in the swamps

tucked into the coasts between

this region and that region?

Were there valleys and layers, tangles like cities on a roadmap?

Or was it softer, smoother…perfect?

Did the gentle pink edge remind you of a shell

that you once picked up from the shallows of the ocean?

Did the salt on your lips taste like waves?

There were patterns in the sand and you traced them

as mountains.

You saw the pools, your eyes reflected against the sky reflected and…

…you knew the truth.

You found it in that shell that held the sunset.

That soft slick bruise

of grey and blue

that felt, to you,

soft like your scalpels

could never be.

For a moment, the whole world was there

and you felt

the sound inside

like music.

It’s so easy to forget

that you wanted to live

inside that place

where the ocean roared

against your ear

for you alone to hear.

When you looked at her brain did you see

the landscape of her memory?

Was it a castle

a library

a junk store

a field?

Was the universe in there?

Did it look like sand?

Or did it look like stardust?

Does stardust look like sand?

…or did you only see a small grey region, asleep

and of a certain weight

that you carved out

and placed on a scale?

Was it barely alive at all?

Did you find, in her crenellated warmth, the place

where voice is born?

You never heard it.

She never spoke.

You never listened?

It doesn’t matter now.

You’ve forgotten

what it was

that you were looking for

in that space behind her eyes.

Do you see that, even sleeping, her mouth looks like a bow?

You have no way of knowing that as a child

she sang the same song

over and over again

because it made her happy.

Tell me, when you pulled

the two halves apart

did they make

any noise at all?
Tell me, what did you see inside?
Did you find God?

Or did God find you?

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Scientific Integrity, Human Diversity, and the
Potentially Bleak Future of Psychiatry appeared first on Mad In America.

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It has been shown that persons who have experienced extreme trauma tend to be more likely to have a sense of purpose in life! ⁽¹⁾

Imagine being able to live harmoniously amongst others without fear.  I cannot.  Cannot imagine it even a little bit. What can be created for people in my camp? People who are sensitive and had so much trauma in childhood that life among others is highly stressful, scary and worrisome? I’m allowing myself sanctuary-time alone, quiet time, time to write… yet… will things ever be different? Will I ever find my niche in this world, where I feel safe and able, valued and worthwhile, loved, adored and comfortable? I have no idea. And what about all of the others like me in this regard? I know there are plenty of us and our numbers are growing. Getting older seems to make things harder; I feel less resilient (in some ways).

I know I am not alone in this feeling. I see it in many, this loneliness. I see it and know it in all kinds of escape mechanisms, I see it in our eyes, our stumblings, our yearnings and reachings out. I see it in that we are writing as there is so much to say that is hard for us to articulate vocally, aloud. Every one of us is vulnerable to this feeling as well. A partner can die at any moment, or a relationship can go sour, friends can move away; we ourselves can be called to move. It seems our best social safety net is a larger number of connections, yet any of us can feel lost in the sea of large groups, incoherent “communities,” friends who are quite different from ourselves.

From these differences and challenges comes growth, yet in order to truly grow, we must crack at the core, we must reform, we must let new light into our dark places, our soil, the seeds deep inside that were planted long ago. This process shakes us at our core if we are willing to go through it. It cracks us and can feel immensely scary, yet we have no choice whatsoever – it’s life or death, we need to let new air in.

There’s a part of me that is utterly indignant, that KNOWS I should never be told (even by myself) to open up and trust anyone after what I have gone through. There’s a part of me that hates people who had happy childhoods, or for whatever other reasons are able to trust others and live amongst them in a way that feels safe. There’s a part of me that knows those people look at me with judgment, at least some of the time, some of them do, and that part of me wants to SCREAM. And cry. Because it is that judgment that limits me more than anything — that oppression which I have now internalized that tells me I must conform. And since I know I can’t, I feel doomed to die a failure some days. I feel certain I will never succeed by their standards, yet their standards weren’t made for me.

There are many who feel this way, no doubt, and when I talk to them I know they are far from failures. Just like when I write, “I feel doomed to die a failure,” there’s a wise woman in me who bursts out belly laughing. My eyes tear and I’m also heaving and wailing at once since dying a failure isn’t an option for me. It makes me cry to know in my bones that I have already done a lot of what I came to this earth to do, and the whole “die a failure” concept needs to die. Yet I know I am not alone, I know it is alive in many of us.

I wish there were something I could do about all this. If I could move this mountain, I’d really die a success. I want to move it for each and every one of us who feels doomed to misery due to programming in our psyches that happened early on and feels insurmountable (sometimes). I want to take away every limit there is or seems to be in the way of each and every person being healthy, strong, free, and fully embodied and alive. I want to measure the distance between here and there so I’ll have a map, a time frame, a sense of something that will, of course be called senseless.

Extreme trauma turns our mind inside-out. It makes us senseless. This may get us labeled insane, but I stand behind the fact that senselessness has within it the best gifts we have to offer. The same trauma that turns our minds inside-out and makes us feel incapable of action, turns our minds around just enough to open us up to something larger. This something larger is vision, it’s prophesy, it’s being a knower and seer, it’s seeing beyond the veil of “reality” as it presents itself and seeing something others have not yet seen. This is true inspiration and if we find it in the tunnels, we have found our purpose in life, our destiny. We all have this within us, yet for some horrible reason, it can take trauma to bring it forth. The meaning in the madness, that could have never been found in the humdrum consensual reality. The consensual reality we sometimes feel we’d settle for because the alternative can be agonizing.

Let’s face it: consensual reality is straight up boring. If almost everyone experienced life the same way, we might all want to bolt. We’d be bored out of our minds (with their perfectly predictable chemical reactions and neurosynaptic responses keeping us ever stable all the time). It is only when consensus is abandoned that any individual can find something new and find true, lasting motivation.

Hence the mental health system is a paradox, and a dead end, asking people to conform AND be motivated and purposeful in that conformist state. I just want to say to everyone, including myself, REBEL!!!!! Be yourself, however unhappy you may feel! For it is only in your very own journey through your very own tunnel that you will find your very own purpose for being here. Prozac may help you find someone else’s life purpose (or rather, put money in someone else’s pocket), but that will never be a substitute for your own. True purpose leads to true motivation and the only place to find that is in the tunnels of your very own consciousness.

We are each unique and have something different to bring to the table, which is inherently non-consensual in its reality, and at its best senseless, being a little more important than “sanity.”

Note:

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In the discussion that followed several people stepped forward to defend CBT as a valuable therapeutic approach that in the right hands can be used to facilitate positive change. Some tended to exaggerate its importance and promote its use as almost some type of liberated way of thinking about the world; an approach able to solve all human emotional problems without referencing any type of moral evaluation of the material conditions of life giving rise to certain types of thoughts and behaviors in this world. So let’s take a cold hard look at what CBT really is, and what it is not.

To make this analysis, let’s imagine you are a therapist who is given the task of providing therapy for Ariel Castro (the recent accused kidnapper and rapist) to help him deal with suicidal thoughts over being universally hated and most likely condemned to a life sentence or the death penalty. Now think about the absurdity of doing CBT in this situation; that is, analyzing his negative thought patterns to help him deal with his one-sided thinking so he can better adjust himself to his (not so nice) life conditions.

Even better, imagine you’re given the task of providing therapy for Dr. Joseph Biederman (the key promoter of children’s Bipolar diagnoses) who perhaps is dealing with a severe depression related to negative public opinion regarding the enormous damage his work has done to tens of thousands of children (unfortunately his depression is a made-up scenario). Again you have the assigned responsibility to use CBT to help him see beyond the “negatives” in his thought patterns to find the “positives” in his career in order to help relieve his depression so he can get on with his work with great enthusiasm.

And even more controversial, let’s say you have the task of providing therapy using CBT for President George Bush several months after he launched the Iraq war; imagine for a moment that he has become quite depressed related to the growing mass demonstrations and the grief displayed by the parents of dead American soldiers coming home in coffins on a daily basis. Your job is to help him overcome his depression so he can get back to being The Commander In Chief.

Do you now get a clearer picture of the serious limitations and pragmatic and amoral nature of CBT? If you think like me, you would absolutely refuse the task of helping all three of these criminals attempt to solve their particular emotional problems. In my way of thinking if you had to choose, Ariel Foster would actually be the least difficult of the three to work with; after all he is in jail and can no longer harm anyone. In addition, his crimes against humanity (in my eyes), as horrible as they may be, actually fall short of his cohorts in this analogy.

As far as Biederman and Bush are concerned, I would actually hope they would become even MORE depressed NOT LESS. I would want this to become the outcome not because of hatred (although hatred is not wrong to feel towards these individuals) or revenge (I do understand why people might want these people to suffer, but I would struggle to resist those impulses) but instead for the morally justified reason that the MORE DEPRESSED they become hopefully the LESS EFFECTIVE they would be at performing their jobs, and thereby perhaps lessen the damage they can do to the masses of potential human victims. Whether or not they are nice to their own children or happen to be loving toward their dogs, this is of no relevance to my overall opinion of them or in any kind of objective analysis of their overall social role in the world at large.

Clearly I am responding from a position that Biederman’s social role as a major spokesperson for Biological Psychiatry is indeed causing great harm to thousands of children (and others) and he should be prosecuted and punished for the deaths and psychological damaged perpetrated against innocent children.

And in the case of George Bush, in the reactionary cause of imperialist empire building, he launched one of largest drive-by shootings in modern history, essentially almost killing a country by destroying its infrastructure, (including food distribution, medical services and electrical power etc.) creating the material conditions for the deaths of several hundred thousand Iraqi people (500 thousand may be an underestimate of human lives lost), and in addition, the lives of several thousand American soldiers.

It could be said that all three of these people have literally lost their humanity, but I don’t believe it is my job to spend one second attempting to restore it. My time would be much better spent exposing their crimes and organizing people to create the material conditions in the world where they (and others like them) can no longer have the ability to carry out further crimes against humanity; and in the long run help create a world where there is no longer the material or psychological basis for people to ever lose their humanity.

However, if you had a CBT therapist who was a believer in Biological Psychiatry’s Disease/Psych drug model of treatment (a completely different interpretation of the same material world that gave rise to my way of thinking) he/she might have no problem working with Biederman to help him overcome his “negative” thinking and thereby, not only justify his psychiatric work diagnosing and drugging children, but overcome his depression to rededicate himself to his “important” work “helping” his patients.

And if a backward thinking CBT therapist believed that it’s America’s moral destiny to police the world spreading “free market” capitalism and the Christian way of life throughout the entire planet by toppling any political leader standing in its way, and ultimately justifying the deaths of hundreds of thousands of innocent civilians for this cause, then he or she might jump at the chance to challenge the “negative” thought patterns of George Bush and help him overcome his depression and resurrect his “moral” courage to prosecute the war effort.

So let’s get real about CBT. At the beginning and end of the day CBT is nothing more than a pragmatic and sometimes useful tool that has serious limitations due to its’ fundamentally “idealist” philosophical origins in understanding the world. CBT comes out of the school of thought that says we are what we think we are, or if we take it a step further, “I think therefore I am.” This way of thinking implies that there is no material reality independent of our thoughts; so there can be multiple realities based on any one person’s interpretation of the world. This is in direct opposition to a “materialist” philosophical perspective that says “I am therefore I think.” The latter view postulates that thoughts, ideas, and theories come from one’s interaction with the material world. If that world is, in fact, oppressive to the humans interacting with it, this will be directly reflected in the thinking and behavior of those human beings. Of course when ideas (emerging from interaction with the material world) are subsequently put into action they can influence and change the material world in an ongoing dialectic or spiral development of change.

CBT, being part of the “idealist” school of thought, tends to sever the relationship between the specific nature of the material conditions in the environment that gives rise to a person’s thoughts, and leaves it up to the interpretation of the listener (often a therapist) to determine whether or not the environmental source of those thoughts was actually traumatic or oppressive or more positive and humane.

So in reality the pragmatic value of CBT as a therapeutic method (in the short run) can be achieved without any type of moral compass or historical barometer to determine if the end result actually advances the cause of humanity, or if it only meets the immediate selfish needs of its user in the moment. In other words, we need to ask the important question: for whom is the CBT method being used, and for what purpose?

Yes, CBT can be defined as a pragmatic tool. However, should we somehow imply that it is a liberating program and ideology? Definitely not. In the right hands, in the right circumstances, and in a micro sense, CBT can help people overcome specific problems; in the wrong hands it can actually do great harm.

We could apply the same morality that condemned psychologists who helped train and evaluate the CIA’s water boarding interrogation methods to those that would help people on the wrong side of history feel better about themselves and function better in the world by using CBT. In a macro sense, the only way this can ultimately be evaluated is by making an historical examination regarding what political and social movements (and the ideologies and ways of thinking arising out of and promoting them) are truly advancing the cause (conditions of life) for all of humanity and therefore should be supported; and those that are moving things in the opposite direction and therefore should be opposed. This is not an easy task, but one that CAN and MUST be done.

Twenty two years ago I was trained as a therapist with a specialty in addictions. I was exposed to multiple theoretical and practical approaches to helping people overcome problems. This training included Rogerian, Psychoanalytic, Object Relations, Reality Therapy, Twelve Step, Rational Emotive Behavior Therapy, Family Systems and Cognitive Behavioral Therapy, to name a few.

In my work I probably have used bits and pieces of all of these methods and theories, but it would be absolutely foolish to think that one therapy approach provides even close to all the answers to the human condition. There are clearly other liberation ideologies that have led to major advances in human social organization and morality that have more potential revolutionary content than those necessarily coming out of the field of psychology.

In fact it was my preceding 20 years of experience as a radical political activist (coming out of the late 1960’s) that actually prepared me in the best ways to be a “coach” or a so-called counselor to people experiencing problems in life. These experiences trying to change the world certainly made me want to pay very close attention to a person’s narrative and truly understand the conditions of life that gave rise to their thinking and behavior.

The critical thinking skills promoted among radical activists allowed me to very quickly migrate to the critics of the medical model and determine that Biological Psychiatry was an oppressive paradigm of treatment. In 1991 I even wrote my Masters’ thesis on the dangers of psychiatric drugs after encountering the work of Peter Breggin. However, I must say that it has been my recent exposure to the survivor movement through MIA that has taken my critique of Biological Psychiatry to a whole new level and renewed my activism and desire to radically change the world.

Working as a therapist in community mental health for 20 years I have sat with people who have experienced so much trauma and negative experiences in life that I felt as though I had absolutely nothing to offer them, other than to act as a witness to their personal horror and express my sorrow that they had to go through those terrible experiences. In those moments I have even thought to myself “if that was my life I would absolutely find it unbearable and most certainly consider ending it all.” Their resilience to survive and go on another day would literally astound my own sensibilities.

In those situations if I had somehow attempted to apply CBT to help get that person to focus on evaluating their “negative” thought patterns and look for and reframe the “positives” in their thinking, this would have been totally absurd and perhaps even harmful to that person at that moment.

In another example, I have worked several years with a woman who has experienced trauma, depression, multiple losses, and a series of dysfunctional relationships. She told me a year ago that the most profound moment in all our therapy together, after more than 6 years of work, was when she saw me shedding tears as she described the time when she had to put down her 13 year old beloved dog.

A final example might be those people I’ve seen in counseling who say that in the throes of some deep emotional crisis they actually hear my own words reverberating in their head guiding their actions. I often don’t even remember exactly what I said at that particular moment in therapy, and have to recheck the content of those words to be reminded of the power of my position in helping people in extremely vulnerable moments in their life.

It is these types of experiences in counseling that should truly humble us as we have been so privileged to share a window into the lives of people experiencing deep emotional suffering, and who are bravely attempting to solve the problems of life we ALL face on this planet, each of us learning from the other as we go. It should also force us to go through some type of continuous self-interrogation of our own beliefs and values and how they may be influencing the beliefs and actions of others. This all reminds us of our tremendous responsibility doing this kind of work.

I gladly look forward to a time in history when this type of counseling or “coaching” type of relationship between human beings will literally wither away and no longer be needed. We all have much work to do to radically transform the material world, and in the process transform ourselves and our ways of thinking, as part of the achieving true liberation.

The post Cognitive Behavioral Therapy:
The Good, The Bad, The Limitations appeared first on Mad In America.

Leonard Roy Frank, early pioneer of the Psychiatric Survivor movement, discusses his lived experience, including forced insulin shock treatment, ECT, and the relationship between non-conformity and psychiatric diagnosis.

Since 1959 Mr. Frank has resided in San Francisco, where he managed an art gallery that played host to early meetings for the Psychiatric Survivor movement. Starting in 1972 he was staff at Madness Network News, and in 1973 Frank and Wade Hudson founded Network Against Psychiatric Assault (NAPA), a patients’ and survivors’ advocacy group. Peter Lehmann called Leonard Roy Frank ‘one of the most important people who helped to develop the theory and practice of humanistic antipsychiatry.’

Join Mr. Frank and other featured speakers at the upcoming Occupy Psychiatry protest of the American Psychiatric Association’s 2013 annual conference at the Moscone Center in San Francisco on Sunday, May 19th. The Open Paradigm Project will be live streaming the protest on MadinAmerica.com – stay tuned for upcoming details.

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Activist and Pioneer appeared first on Mad In America.

Pellagra (meaning rough skin) was apparently first described in 1735 by a Spanish physician, Don Gasper Casal, and was called “mal de la rosa”, due to the characteristic red rash on the hands and feet. At the time, the cause was unknown but it was associated with poverty. Cases in the US were first reported in the early 1900s, where there was a pellagra epidemic in the southern US. Although linked to the poor person’s diet (often consisting mainly of corn products), the going wisdom at that time was that it was contagious (Pellagrans, as they were called, tended to live in close proximity) and was perhaps hereditary (sound familiar?).

The relevance of pellagra to psychiatry is that it also can present with psychosis, obsessions, mania, depression and confusion. It involves the main organs of the brain, the gut and the skin – many referred to the 4 Ds: dementia, diarrhoea, dermatitis and death.

In 1914, Joseph Goldberger, a physician and clinical epidemiologist, was invited to investigate the epidemic. Careful reviews of the literature and cases indicated to him that pellagra was a dietary disease, not an infectious one. Only poor people seemed to get it and they often had a diet that consisted of Indian corn. Cases were being reported in hospitals whereby the patients, mainly eating a monotonous corn-based diet, would get the disease whereas the nurses, despite daily contact with the patients, would not. The nurses apparently received a more nutritious diet. Outbreaks appeared in mental institutions, orphanages, and cotton mill villages where the diet was considered a monotonous 3M diet – molasses, meat and cornmeal. Similarities with European pellagra led many to conclude that the disease was caused by spoiled corn.

Following his theory that the disease was a dietary one, Goldberger began running “trials” in different orphanages by manipulating their diets: those given fresh meat and legumes experienced no recurrence of pellagra. He also conducted experiments in which he showed he could induce pellagra in healthy men (usually prisoners) by feeding them a corn-based diet. Through observation and controlled experiments, by the 1920s Goldberger had established that pellagra was a disease of a faulty diet caused mainly by extreme conditions of poverty.  These experiments convinced him that infection was not the form of transmission and in the early 1920s he began to search for the specific nutritional deficiency.

The part that we really like about this story is that Goldberger was so confident in his theory of pellagra’s etiology that he was willing to risk sacrificing his wife’s health to prove it. Despite his repeated controlled experiments using diet manipulation, many authorities did not believe his theory and people continued to hold to the prevailing wisdom that it was infectious. And so he found 16 volunteers (his wife being one of them) and exposed them all to the blood, urine, faeces, and epidermal scales of pellagrous lesions and not a single one of his volunteers developed pellagra (or else we might not be telling you this story). Goldberger spent the rest of his career and life trying to isolate the ingredient that was causing the condition. Although he died before figuring it out, it wasn’t long before another scientist, Conrad Elvehjem, determined that niacin was the essential dietary factor.

Fortification of food with niacin did not occur until 1941. It was estimated that there were over 3 million cases and over 100,000 deaths in America in the 40 years until its true cause was determined.

The impact of Goldberger’s discoveries has to be understood in terms of the incredibly high prevalence of this problem: it has been estimated that fully 1 out of 5 people admitted to mental hospitals in the 1930s were there solely because of pellagra psychosis, an easily preventable/treatable nutrient deficiency. And also, returning to our previous blog on the wisdom of our ancestors, until pellagra was essentially eradicated by fortification of foods with niacin, the Diagnostic and Statistical Manual (DSM) acknowledged that nutritional deficiencies could cause mental symptoms: “psychosis with other metabolic or nutritional disorders (including pellagra)”. It is interesting that the current edition of the DSM no longer refers to metabolic disturbances as etiological factors.

But we leave the reader with this thought:  while niacin therapy has been accepted now for the eradication of pellagra and pellagra-psychosis, is it not possible that a combination of nutrients may have had far superior effects more broadly? And if Walter Mertz was correct when he declared in 1994 that the era of one-nutrient, one-disease was over, what other mental symptoms might be eradicated with combinations of nutrients as treatment?

For those who would like to read further about this important historical discovery:

Brown TM. Pellagra: an old enemy of timeless importance. Psychosomatics. 2010;51:93-7.

Rajakumar K. Pellagra in the United States: A Historical Perspective. South Med J. 2000;93:272-7.

The post Jeopardizing Your Wife to Prove a Point:
Pellagra as an Example of Deficit appeared first on Mad In America.

Today’s launch is marked by the appearance of our first eight posts. These posts come from a variety of prominent people in the field, each offering a unique perspective on the current state of diagnosis and where we might take things as we move forward. Importantly, the goal of DxSummit is not to endorse a particular view, but to provide a space for discussion and deliberation. According to the Summit Mission Statement:

Rather than starting from a specific theory about the “right” way to define and treat psychological suffering, GSDA is a virtual arena for the expression of diverse perspectives, a space to deliberate those questions that seem most challenging and, at times, insurmountable. Our ultimate goal is to generate a transdisciplinary, international, egalitarian conversation about the possibility, feasibility, and potential implications of new means for conceptualizing mental distress.

The mission statement goes on to more fully explicate the questions the Summit wants participants to address:

• What is the basic nature and function of clinical diagnosis?

• Is diagnosis necessary for describing mental distress?

• To what extent should psychiatric diagnosis mirror diagnosis in general medicine, and why?

• What is the current status of diagnosis across the helping professions?

• Why have mental health professionals become disillusioned with the current diagnostic systems for research and practice?

• What function does diagnosis have for patients/clients?

• What are the iatrogenic risks of clinical diagnosis?

• How do diagnoses function in larger society and the public sphere?

• Is diagnosis a universal phenomenon? Can diagnostic practice be generalized across cultures?

• How can the major helping professions work together to address current issues in diagnosis?

• What do the various helping professions see as the most important dilemmas its practitioners face regarding diagnosis and what ideas do these professions have regarding directions for diagnosis in the future?

• What are possible alternatives to the DSM/ICD systems?

  • Are these alternatives feasible/practical?

  • What are the political/ethical implications?

  • Should we prioritize validity over utility, or vice versa?

  • Should interdisciplinary scholars (in the neighboring social sciences and humanities) be involved in the development of diagnostic alternatives?

How can you be involved in the summit? Check the site often, read our posts, and get involved in the discussion by leaving comments. We look forward to a generative and exciting ongoing electronic summit. Hope to see you there!

Official Press Release: DxSummit Officially Launches

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Backing Away from DSM-5 appeared first on Mad In America.

This young man, dressed neatly in Monday morning work attire, said his last goodbye and committed suicide surrounded by police officers, firemen, first responders, emergency personnel, school activity buses and hundreds of morning commuters snarled in the traffic jamb created by this very public emotional crisis.

Despite fervent attempts on the part of police officers, and to the horror of those in close proximity, he held his breath and jumped… into seemingly thin air.

I first heard about this young man’s unfolding crisis at a planning meeting for our Family Dens, our organization’s family mental health support groups. Our development director was late for our meeting and arrived in great distress. She had been stuck in traffic and saw this young man’s anguished face as he turned toward her and the police officer just a few feet away trying to negotiate with him.

“He looked just like you or I,” she shared, tears streaming down her face. “He was so handsome, and he looked, well, normal.”

We assured her he would be okay with so many people on the scene to help (not fully thinking through how completely terrifying all those lights, sirens, bull horns, and stopped cars must have been).

We finished our meeting and went home, each of us going straight to our computers to check on this young man and to reassure ourselves everything was okay.

It wasn’t.

This “unnamed man” had, in fact, jumped — a horrific act neatly described in exactly 150 words in only one local news source.

Contrast this coverage with what happened just a few hours later as reports of the Boston Marathon bombing quickly flooded local and national airwaves, news sources, social media and every conceivable conversation.

I learned about the Boston bombings from a feature writer I was talking to about our local suicide just a few hours before.

“This is not a good day,” she said and mentioned she was frantically trying to get in touch with her friend in Boston. I was puzzled until I checked the news and was confronted with images of the chaos in Boston.

Man jumps, news at ….?

It would not be until almost a week later that the second (and last) news story would appear regarding our local suicide, an act of desperation witnessed by hundreds of Ashevillians.

This time, “the unidentified man” got 165 words. And he hasn’t been heard from since.

Curious, this lack of news coverage, given the public nature of this suicide and the reality that more people die each year from suicide than from car accidents, averaging just over a 100 suicides a day, according to the Centers for Disease Control and Prevention.

This silence on the subject is curiouser still in our age of trauma-informed care where we are, theoretically, enlightened enough to recognize the importance of community support and collective healing around public tragedies. And the importance of supporting those who are left behind in trauma’s wake. And the importance of taking collective action to ensure future crises are prevented.

Yesterday, I noticed my local bank proudly displaying a window sticker proclaiming We Are Number 1 with Boston. (And yes, we are).

Meanwhile, our county has the fourth highest suicide rate in the state with five times as many suicides as homicides in 2010. When it comes to these tragedies, we aren’t number 1, we’re number 4.

But we’re not talking about it.

I called my children’s elementary school to see if Mother Bear could come in and do a presentation on mental health with the kids. A couple of classes were on an activity bus  caught in the traffic jam caused by the suicide event.

“Frankly, we’re afraid to talk about it with the kids,” whispered a well-meaning teacher who answered the phone.

As far as I know, they still haven’t.

Last month, Will Hall published an excellent blog here on Mad in America in which he suggested it was time for a new understanding of suicidal feelings.

“We need to speak openly about our suicidal feelings without fear of institutional reaction,” Will asserts.

Speaking openly about those we have lost, and how we are impacted in the aftermath, would be a good place to start. Even learning their names would be some progress.

Many of those lost to suicide remain lost and nameless because of the stigma surrounding taking one’s own life. Family grief, guilt and shame are only made worse in the deadening silence that is created when we can’t find our collective voice and then turn our backs on the suffering of the dead and those they leave behind.

It is time for a new understanding of suicidal feelings and actions.

Perhaps a more open dialogue, without fear of sirens and police and involuntary hospitalizations, would have made a difference for one young man here in Asheville last month. Perhaps more public local conversation would have saved some of the 45 lives we lost here in Buncombe County in 2010. Perhaps a more public and safe national conversation would have saved some of the 22 veterans who died from suicide every day in 2010.

And, lest we worry about what to say, an exploration of the many factors that contribute to suicidal feelings and acts would give us endless fodder for discussion. From poverty and trauma to individual and institutional abuse to existential crises and our “insane” pace of life to lethal side effects of psychiatric over- or mis-medication to lack of compassionate care.

There is so much we could talk about.

Perhaps all that talk might motivate us to actually do something to address our suicide epidemic. It might inspire us to reach out to someone who is hurting or to reach out when we ourselves are hurting. It might even stop us, as a society, from doing things that perpetuate the hurting.

We do have some examples of what can be accomplished when someone dares to talk about these matters.

MIA blogger and mother Maria Bradshaw’s wonderful organization, CASPER, has done much good work in New Zealand and beyond to support an open and healthy dialogue about the rapid rise in suicides and what we can do to prevent more of them. We are grateful to be able to refer families to CASPER when they have lost their loved ones to suicide or have concerns about suicide risks, particularly with regard to children and medications.

But we need more organizations like CASPER and many, many more conversations.

Unlike the one that started far too late and ended far too early on the morning of April 15 at approximately 9:30 a.m.

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Where does that sense of self get lost?  When does it happen?

When I was about 5, I started to turn to food.  I remember standing at a window in my childhood home, hand pressed against the cold glass pane, peering out at the driveway and watching my mother drive away and leave me alone.  The world felt like a pretty unsafe place.  I was not safe.  I needed to take care of myself.  And so I made myself some chocolate milk.  I felt a little better.  I thought I’d get in trouble if my mother knew, so I cleaned up any sign of my little indulgence before she returned.  No one was the wiser.

But all was not well.  The cycle repeated, and at the same time my sense of being wrong in the world grew.  I felt ugly, too big.  I took up too much space.  Why had my father left me and moved out?  Why didn’t I connect and make friends with the same ease that others did?  Why did I seem to think about everything so much more deeply than other kids my age?  Why did I so often feel like I was travelling around in a little bubble that kept me separate from and sometimes floating above the rest of the world?  When I was about 8 or 9, I remember playing at a neighbor’s house on his swing set and having the swing break under me.  I fell  on the ground and felt humiliated.  I took it as proof that I was too big; too much.  I mumbled some excuse and ran home before he could tell me that he now understood that I was disgusting.

When I was in Junior High I started starving myself.  School lunch was torture.  Monday through Friday, I made a charade of pretending to make important phone calls on the payphone in the hall, filling in the gaps by hiding in a bathroom stall.  I did it to stay away from the kids and the food.  The idea of having to ask for permission to take up space at some cafeteria table while displaying the food I was daring to take in was overwhelming.

And when starving would get to be too much, I would return to bingeing at home and hide the material remnants of my secrets in drawers around my room.  When I was a Freshman in high school, I remember coming home from the mall with a friend one day and rushing toward the stairs that led to my room only to have my friend and I greeted by a mountain of those remnants at the top of the stairs.  I was frozen.  My mother had been in my room; searched through my drawers.  She’d created a museum of shame for my friend to see to ‘teach me a lesson’ about my bad behavior.  I don’t even remember what I said or how I made it through that level of humiliation.  It’s a blank.

By the time I got to college, I was pretty confident in my sense that I should be apologizing to people for having to look at me.  I spent a lot of time putting on make-up every day largely because I could ease a bit of that pain in the illusion that there was something of a mask between me and the world.  At some point, I became so convinced that everyone was talking about me and saying how disgusting I was that I stopped going to classes or leaving my apartment and eventually got kicked out of school.

I could tell many parts of my story, including how I made it beyond that point to where I am today, but I won’t.  Not for now.  I’m telling this part at the moment for a reason.  This self-loathing for my own body – my most intimate ‘home’ –  that I so insistently projected onto others is not something I’ve ever completely overcome.  There are many ways in which it was seeded within me, and many experiences that helped its hold on me grow.  But I’m not so special.  My experience in this realm may have been bigger than some, but it’s not that different from many.

Our culture teaches us to hate ourselves; Women, in particular.  Should it be such a surprise that so many of us cave under its pressures in ways that leave us teetering on the brink of diagnosis or falling over the edge into its abyss?  What happened to me that led me to want so desperately not to be connected to my corporeal being is very personal and involves much more than I am sharing here.  However, had I not been directly and indirectly cheered on in my own self-hatred by television and movies and magazines and all the women in my life talking incessantly about how much they also hate themselves, I wonder if the outcome might not have been at least a little bit different.

By the time I was 5, I had also seen plenty of weight loss commercials on television advertising women in bikinis running on the beach.  (I still thought they were too fat.  Their flesh jiggled when they ran.  I didn’t want my flesh to jiggle.)  By the time I was 8, I had already heard friends and family and friends’ families complaining about their ‘too big’ stomachs or butts or arms and what they were eating to be ‘good’ or ‘bad.’  By the time I was in Junior High I was reading articles every week about how to ‘lose that ugly fat.’  By the time I was in college, I felt like I couldn’t even be near strangers without overhearing their own words of self-deprecation every day I entered the world.  And if they were saying that about themselves so freely in public, what on earth were they thinking and saying about me?

I want to plug my daughter’s ears up with cotton and cover her eyes.  I don’t want to have to bear witness to her loss of that care free sense of belonging in this world; of taking up just the right amount of space.  I don’t want to watch her begin to question if she really deserves to be loved.

We as human beings – and especially those of us who are female – need to take this up as a political issue.  We need to understand that when we disparage our own bodies we are disparaging the bodies of those around us and re-enforcing the idea that they should do the same.   We need to know that trite sentiments like, “It’s what’s inside that counts,” (no matter how earnestly stated) aren’t enough because what they’re tacitly communicating is, “You’re right that what’s on your outside is something we’re doing you the favor of looking past.”   We need to realize that when we loudly exclaim how happy we are that we lost x number of pounds after a week-long bout with the flu, that we’re essentially broadcasting the message, ‘skinny at all costs, including your health!’  In my mid-20’s, I went through a volunteer training at AIDS Care in Northampton, Massachusetts and at some point I felt safe enough with the group to share that some dark part of my mind was actually jealous.  I was jealous of people who had contracted the Human Immunodeficiency Virus because they often got to experience wasting – a no-effort, super express pass to skinny.  Holy crap.  What was wrong with me?  What is wrong with all of us?

I refuse to talk about my current-day inner dialogue about my body with anyone.  ‘They’ say that men think about sex every 7 seconds, and I’m probably still competitive with that figure when it comes to disparaging thoughts about my body.  But I won’t speak them out loud.  I will not be a part of passing along that particular societal ill.  And I will not comment on other people’s bodies, even in supposedly positive ways.  And when someone ‘compliments’ me by saying they think I look like I’ve lost weight, I will not respond or – even better – state clearly that I don’t keep track of that sort of thing or that it really doesn’t matter to me (even if not mattering is a wish more than a truth at this point).  And if I’m really feeling saucy, I might try out one of my favorite but mostly unused responses:

“Yes, tomorrow I’ll be cutting off my left leg to drop some more.  Quickest 30 pound loss EV-er!”

Or

“Yes, I’m afraid the cancer has really set in now.  They say I probably only have six months left, but I’ll surely drop at least another 10 before I go.”

That’d stop them in their tracks.

No, I’m not suggesting that weight cannot or should not ever be an issue.  Surely, pharmaceuticals pour on the pounds for people in ways that absolutely do matter.  And, ‘too much’ weight (whatever that actually means for a given person) can bring on a variety of physical issues.  But I am suggesting that teaching body hatred has the ability to make us sick, and that it does the exact opposite of creating space for us to eat and move in ways that actually feel good and support us to be healthy and to look like and be ourselves.

I realize this is a bit of a deviation from the various diatribes about language, psychiatric oppression and misguided diagnosis.  But in the end, it is all related.  It is related because anything that fosters a sense of alienation for us from ourselves and each other also fosters the same kind of pain that so often ends up becoming labeled as ‘symptom’ somewhere down the road.  It is related because the same kind of cultural force used to define what makes our bodies ‘acceptable’ comes from a very similar place as the cultural force that also judges and evaluates our behavior and minds.  And let’s be honest.  Body hatred breaks down our most basic resiliency and leaves us all the more vulnerable and susceptible to all the other pervasive negative messages – including pathologization and diagnosis and the belief that we need to be treated for how we are ‘wrong’ on the inside because of how we are impacted by all the awful things happening on the outside around us.

I hope that those of you reading this will consider how you think inwardly about yourself, but even more importantly, how you talk outwardly about yourself and others.  I urge you to give up the conversations about your latest diet or weight loss (especially in front of children!), to stop making public remarks about your own body hatred, and to stop commenting (particularly unsolicited) on other people’s bodies even when you think you’re saying something positive.

It may not change everything for you or for me, but perhaps it can be some part of cultural change on a broader scale; of teaching each other by example how to be more connected and loving to ourselves and each other.  Perhaps it can play some small role in supporting children from our next generations to avoid the paths that self-loathing can lead us down.  Perhaps teaching a little self-acceptance now can help avoid at least a few Prozac prescriptions later.

Our words really do have power.  How we talk about ourselves and each other means something.

I don’t want my daughter to experience this kind of pain.

For me, it still hurts.

The post Body Politics appeared first on Mad In America.

My name is Michael Rock.  Until now I have been participating on MadinAmerica.com as a commenter named “Marcellas”.  It is very nice to finally introduce myself to this community under my real name.  Although I only occasionally commented, I have been a regular visitor and reader of MadInAmerica.  I am especially grateful to Corinna West, Dr. Mark Foster, and Laura Delano. It was good to know I wasn’t alone.

I feel like I need to apologize for hiding behind Marcellas. Anonymity is not something I am proud of, nor was it a trivial matter to me.  When I marched with Mindfreedom in Philadelphia last May, I was reluctant to introduce myself to some of you who were harmed by an industry I continue to work for.  I am a group psychotherapist in a large hospital network in Eastern Pennsylvania. I have been working with people in groups for twenty five years.  I love my job, and believe I am helpful. I felt that “Marcellas” allowed me to continue to work quietly for change within the system.

When I read Anatomy of an Epidemic, it seemed obvious (from my admittedly limited vantage point) that the national trends in treatment outcomes closely reflect our local outcomes.  By this time I was already on record as a critic of medications and the chemical imbalance theory, and a skeptic of diagnosis.

I wrote To Mr. Whitaker in 2010 after reading Anatomy of an Epidemic to tell him that I was introducing his book to our team library and intended to discuss it. He was kind enough to write back and wish me luck.

I spent the next three years being more stubborn then loud, and I like to think I made some progress.  I developed a model of behavior chain analysis using CBT, DBT, and Positive Psychology.  I call it “Habits”. It can be presented in a very brief series of sessions (our average length of stay of 7 days).   A central theme of the technique is to assume that anyone can learn to control their thoughts, feelings, and actions. Everyone can learn to explore what they are capable of, rather then limited to.

The model is very popular with our patients.  I use a lot of humor and try to make it entertaining as well as helpful. I consistently receive the highest number of compliments from patients at discharge than any other team member, and I am very proud of this. More importantly, I’ve yet to find evidence that the model doesn’t work.

However, my message indirectly challenges the assumption that “accepting illness” along with “medication compliance” is the best path to recovery. This has made me unpopular with those invested in preserving the status quo.  Obviously there are financial incentives involved.

In January I received my “final written warning” from the hospital, and have been working under threat of immediate termination since then. I’ve been to several meetings in which it was stressed to me how serious they are about firing me, and I believe them.

I am not sure what effect leaving Marcellas will have on my career.  I don’t think there is anything I can do to prevent being fired at this point. Not only am I am small fish in a big pond (I only hold a BS degree in Psychology and work for the largest employer in the area), but I also live in a “right to work state” which translates from Orwellian into “the right to fire anyone at any moment for any reason, or no reason at all”.

Since January I have driven to work every day wondering if the ride home would include boxes of photos from my office.  Sympathetic coworkers tell me that when they fire me I’ll be escorted by security in a public walk of shame. It’s assumed they will want to make an example out of me. So I have this to look forward to.

I want the reader to understand that the people who are firing me are not bad people.  They are trapped in the same system as everyone else. I believe they respect me and like me personally, and it’s very clear to me that firing me is painful for them.  I believe also that the practices at my hospital are not unusual in the current paradigm of care.  From all I can see, my hospital is state of the art in contemporary industrial psychiatry.

I am not bitter about being fired.  I am aware that speaking publicly in this way could blacklist me, and I may never work in mainstream mental health again. I have always been very proud of my work and my reputation, and it is difficult for me to throw these away.  Naturally I am nervous about losing my income (although not as nervous as my girlfriend, who is convinced she will soon be supporting me).

I intend to use the extra time I’ll soon have to write about the narratives of disability, the people I met in the system, and to suggest an alternative to it.

I know there are more out there like myself, working under the same pressures, trying to help people. I expect you are also haunted by the people who come to us for help; trust us, do everything we suggest, and get worse.  Please know that you are not alone.

I know now that I am not alone.  I am Michael Rock.

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Psychiatrists Don’t Use the DSM

One of the fiercest criticisms of DSM-5 is that it will expand the borders of mental disorder and thus psychiatrists will wrongly diagnose and treat people as mentally ill. Allen Frances, former chair of the DSM-IV task force, most ardently voices this criticism. He comes across as a silly old man nursing a narcissistic injury (he was excluded from DSM-5), throwing his toys out of his pram. He makes the assumption that psychiatrists use the DSM to make diagnoses. It is an open secret most psychiatrists in fact do not! If most psychiatrists used the DSM constructs we would not see an epidemic of bipolar diagnoses in children as young as two. In fact, most of the patients who come to me with the label of bipolar disorder, do not meet the criteria for the DSM-IV bipolar disorder construct. Schizoaffective disorder, which is supposedly a rare diagnosis, is possibly the most common diagnosis I see in the charts of inpatients which is deeply suspicious. More systematic studies show diagnoses patients garner have little to do with the DSM. For example, one study in the Veteran’s Administration system suggest 25% of schizophrenia diagnoses did not meet DSM criteria, and psychiatrists often made up diagnoses so Veterans could get benefits. In the private systems, fraudulent diagnoses are given as diagnosis determines remuneration.

Most psychiatric diagnoses are not made by psychiatrists but in primary care. Most primary care physicians do not know the diagnostic criteria for most of the common mental disorders as described in the DSM, but that does not stop these labels being used. Even for some common mental disorders most psychiatrists do not know the diagnostic criteria off by heart, and even if they do, take no heed. Take posttraumatic stress disorder as an example. This is a common mental health diagnosis. The diagnostic criteria for the construct are many and complex. I would hedge that over 90% of psychiatrists do not know the diagnostic criteria verbatim. Even if they did, one criterion is than an individual responded to a traumatic event with “fear, helplessness, or horror.” I do not know of any psychiatrists who ask their patients whether they responded in one of these three legitimated ways of responded to severe adversity, and if they did, their patients would probably be puzzled. Having no immediate reaction, or feeling anger or shame instead of “fear, helplessness or horror” to rape will not preclude a psychiatrist making a PTSD diagnosis, but if you stayed faithful to the DSM-IV, PTSD cannot be diagnosed. For depression, the bereavement exclusion is going and there has been concern people will now be diagnosed with depression following bereavement. It is already happening and has been happening for years.

That is not to say that diagnostic assessments are never useful, but this goes beyond the DSM. Diagnosis is important when it comes to identifying whether the morbid mental state is secondary to a medical condition. For example, I have treated patients who present with ‘depressive psychosis’ but this is due to myxedema coma, or those who are behaving bizarrely but have a metabolic encephalopathy. It is also important to identify whether the individual has fried their brains with drugs such as methamphetamine, ‘bathsalts’, or ‘spice’ which can lead to florid perceptual distortions and erratic behavior.

DSM diagnoses no longer guide treatment

Perhaps diagnosis informed treatment once upon a time, but this does not seem to be the case today. This is at least partly true. Individuals have experiences of mental life that cause distress and lead them to behave in ways others feel are bizarre or un-understandable. As a result they may see a psychiatrist. The psychiatrist can engage in the semiotic act of making a diagnosis. In order to do that, he engages in a precursor semiotic act, which involves recoding individual experience and observable mental phenomena or behaviors into ‘symptoms’ and ‘signs’ respectively. If he stops there, he can, and often does ‘treat’ the patient. If those ‘symptoms’ and ‘signs’ are regarded as psychosis, he will end up on a neuroleptic. If the patient is seen as ‘depressed’, he may end up on a serotonin reuptake inhibitor. If he appears ‘anxious’, perhaps a benzodiazepine will be prescribed. If ‘mood swings’ are observed, lithium or an anticonvulsant will be the order of the day. Many patients have experiences that are recoded into a bewildering combination of depression, elation, irritability, psychosis, anxiety, and may end up on an ‘antidepressant’, anticonvulsant, neuroleptic, and benzodiazepine, and if there is no response, this experience will be interpreted as ‘treatment-resistance’ and another medication will be added! I would like to say that this is a caricature of American Psychiatry, but this appears to be the rule rather than the exception. This is not how I practice, and am fortunate to have thoughtful trainers, but outside the academic ivory tower and in the community rampant polypharmacy is the rule. This happens in spite of diagnostic constructs in the DSM, not because of them. Sometimes response to cocktails is even used to support a diagnosis in a backward logic. In this way the DSM is largely irrelevant to the practice of psychiatry. Systems of psychiatric classification are relevant in the consultation room more from their influences on cultural consciousness and experience of the self, than from use in guiding diagnosis and treatment.

Redefining Personhood

Throughout history there have always been individuals who have been regarded as mad, or as Philippe Pinel called it, suffering from ‘mental alienation.’ For Pinel, to be mad meant one’s “character, as an individual of the species is always perverted; sometimes annihilated”. Without reason, man is no different “from the beasts that perish”. It is not madness that causes one to relinquish personhood, but to be identified as such. Psychiatrists, as the moral arbiters of mental life are thus also the high priests of personhood. Psychiatric diagnoses today extend far beyond ‘mental alienation’ and include a wide array of behaviors and experiences regarded as deviant. The removal of homosexuality from the psychiatric cannon is the best example of how personhood was restored to individuals previously regarded as pathological and deranged. For DSM-5, ‘gender identity disorder’ is being replaced with ‘gender dysphoria’. This is similar to homosexuality being replaced with ego-dystonic homosexuality before being expunged altogether. So whilst transgender individuals will no longer be regarded as mentally ill, it is a mental illness if you feel shit about it. A step to reclaiming personhood perhaps, but the transperson’s response to an intolerant society is still seen as pathological.

Far away from the locked psychiatric unit and the consultation room, the DSM exists in classrooms, libraries, the internet, the popular imagination. Each diagnosis at once hijacks personhood and redefines it. With the disappearance of Asperger’s syndrome, a cohort of socially awkward computer geeks have been disenfranchised and forced to rejoin ‘neurotypicals’ or be redefined autistic. The DSM provides the script of how we should respond to trauma; the narrative of resilience replaced with vulnerability. It is a veritable ‘how-to’ for those wanting to be anorexic or bulimic and join ‘pro-ana’ communities. It conveniently rewrites the ways we can be seen as ill, seek professional help, gain compensation, or even moral exculpation for our behavior. From Portland to Port Moresby, the DSM unites us with a global template for being mentally ill. In doing so, the DSM not only seeks to describe the landscape of psychopathology, it actively shapes it. Whilst removing the bereavement exclusion for diagnosing major depression may not change the psychiatrist’s attitude, it does refashion the cultural expectations of what constitutes acceptable misery. What is pernicious about the DSM is not how it shapes psychiatric practice directly – it doesn’t. Instead, it at once erodes personhood from those seen as ‘mad’, and for everyone else creates a cultural expectation that we are all sick and in need of treatment.

The post Does DSM-5 Matter? Yes; but not for Psychiatrists appeared first on Mad In America.

As the medical director of a community mental health center, my colleagues look to me for guidance on how to approach this new edition. How many should we buy? How much time should be devoted to staff training?  Although this is a book published by psychiatrists, it has become widely used as the basis for diagnosis by many clinicians.

I have written previously about what psychiatric diagnosis does and does not tell us.  I am well aware of the many limitations of labeling something about which we have such limited understanding.  As widely publicized, Thomas Insel, the Director of the National Institute of Mental Health published an essay on the eve of the publication of DSM-5 which essentially laid out the profound limitation of this guide.

People on this particular website may deride any service offered in a community mental health center like the one which employs me, but everyday people come to us seeking help. We are embedded in the social service network and the insurance system. This is all reliant on some sort of process to allow us the get paid for our services. That process is based on diagnosis.  The scope of the need goes far beyond seeing a psychiatrist.  If someone is homeless and needs a voucher for a hotel, if someone needs a coach to help find a job, if someone wants help to stop abusing alcohol, if that person and his therapist agree to check urine samples to follow his progress, all of this requires someone – often me – to provide a diagnosis.

When I think about replacing this model, I have wondered whether it might be helpful to allow each citizen to draw from a fund at any point in her life without regard to a faulty diagnostic system.  If a young person hits a rough patch where she seems unable to focus and has trouble staying at work, she could draw on this for a period of time until she rights herself without out having someone apply a label based on a system that so many people agree is flawed and lacking in validity.  Another person might rely on this when a loved one was ill and needed care.  This might raise the bar for requiring us to label a person as disabled or anything other than someone who for whatever reason needs a time out.

That is a thought. Probably not a realistic one. So what do I do in my own world now?  My answer to my colleagues is to wait.  I do not believe the DSM-5 is anything other than a code book.  I think we will be able to find out for free how the codes have been adjusted and changed. We can look at the ICD system which is available on line. We have limited resources and it does not appear to me that they are well used in buying this book or retraining our staff.

Most importantly, we need to train our staff and talk to the people we serve about what these labels do not tell us. They do not answer what is wrong or what happened in a person’s life. These labels do not tell us who can recover. Even for those who believe that the drugs we prescribe may be helpful, the labels do not tell us much about what specific drug will be effective. So-called antidepressants, for instance, are used so broadly that the label makes little sense.  Even for those who believe that we will understand extreme states by deconstructing the fundamental workings of the brain, these labels do not inform us about  brain function or dysfunction.

On a positive note, perhaps the publication of the DSM-5 has prompted a much-needed discussion of the profound limitations of psychiatric diagnosis.

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“The DCP is of the view that it is timely and appropriate to affirm publicly that the current classification system as outlined in DSM and ICD, in respect of the functional psychiatric diagnoses, has significant conceptual and empirical limitations. Consequently, there is a need for a paradigm shift in relation to the experiences that these diagnoses refer to, towards a conceptual system not based on a ‘disease’ model.”

In brief, the argument is that the so-called ‘functional’ diagnoses – schizophrenia, bipolar disorder, personality disorder, ADHD and so on – are not scientifically valid categories and are often damaging in practice. The statement argues that we already have alternatives, such as psychological formulation, and that there is a need to work in partnership with service users and professional groups, including psychiatrists, in order to develop these further.

The story made the front page of one of the UK’s best-known broadsheets, the Observer, sister paper to the Guardian, and there was a double-page spread inside (“Medicine’s big new battleground: does mental illness really exist?“, and “Psychiatrists under fire in mental health battle“). Within hours, over 500 comments (and counting) had been posted online, and the articles were being re-tweeted round the world. The articles quoted me, Professor Mary Boyle (author of ‘Schizophrenia: a Scientific Delusion?’) Eleanor Longden, researcher, campaigner and survivor, and Oliver James, psychologist and journalist, in support of the call for a non-medical approach to mental distress.

Needless to say, there has been as much backlash as appreciation. Perhaps most predictably, Allen Frances, outspoken opponent of DSM-5, described the document (without having read it) as ‘extremist posturing by British Psychological Society, just as silly as DSM-5 and NIMH – why not a balanced biopsychosocial model’ (@AllenFrancesMD 12.5.13.) Many took advantage of a somewhat unhelpful online headline to dismiss the debate as inter-professional ‘turf wars’, while others accused the DCP of ignoring the role of biology.

The actual statement makes it absolutely clear that these are misrepresentations. The DCP specifically states that ‘This position should not be read as a denial of the role of biology in mediating and enabling all forms of human experience, behaviour and distress.’ The statement also explicitly says that the argument is about ways of thinking, not about particular professions. The ‘turf wars’ accusation is particularly wide of the mark given that the DCP statement is simply a more measured reiteration of recent comments by some of the world’s most eminent psychiatrists: Allen Frances himself described DSM-5 as ‘deeply flawed and scientifically unsound’, while Dr Thomas Insel, NIMH director, said ‘Patients…deserve better’. Former NIMH director Dr Steven Hyman, was even blunter: he called DSM-5 ‘totally wrong, an absolute scientific nightmare’ and in response, the Chair of the DSM-5 committee, Dr David Kupfer, admitted “We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting.”

The main difference – and of course it is a crucial one – between the position of these eminent psychiatrists and the DCP is that the former are determined to pursue the biomedical model at all costs. Indeed, NIMH has (as discussed on this site) announced the intention of launching a 10-year programme to pin down, once and for all, the elusive biomarkers that have evaded researchers so far. The project starts from the remarkably unscientific position of assuming what needs to be proved: in their words that ‘mental disorders are biological disorders.’ Flawed as this enterprise is, it will allow traditionalists to continue to claim that ‘We’re getting there – honestly!’ In the meantime, the overwhelming amount of evidence for psychosocial causal factors is once again relegated to a back seat.

I was a member of the DCP working party which took 2 years to arrive, painstakingly and carefully, to this consensus statement. I believe there is nothing more important that a professional body can do than speak the truth about the evidence – and that is what this statement does. Nevertheless, given the nature of the issues, it is a brave move. I hope that other organisations will take heart – as they did from the original BPS response to the DSM-5 consultations in June 2011 – and join the DCP in calling for a more humane and evidence-based approach to mental distress.

Links to BPS consultation responses on DSM-5

Society Statement on DSM-5 (12/12/2011)

The British Psychological Society Still has Concerns Over DSM-5 (6/20/2012)

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“Does Mental Illness Really Exist?” appeared first on Mad In America.

As a refresher for those not up on their Szasz, his basic argument is that “mental illness” is a nonsensical term (Szasz, 1974). Minds differ from brains. Unlike brains, minds aren’t physical and therefore cannot become biologically sick. To think otherwise is to reify a metaphor. The things that DSM-5 says are mental disorders are not diseases the same way heart disease, cancer, and diabetes are because none of them can be explained in terms of specific physiological malfunctions. Yes, some disorders in DSM-5 are likely putative diseases; that is, we suspect that they have physiological bases, even if we haven’t actually discovered them yet.

However, most of the disorders in DSM-5 probably aren’t even putative diseases. They are simply vexing life problems that warrant attention and remediation—things such as coping with divorce, experiencing social isolation, struggling with family conflict, dealing with the stress of economic pressures, and plain old general unhappiness in the face of challenging circumstances. These problems deserve attention to be sure, but those experiencing them aren’t ill in any literal sense. They are simply struggling with the trials and tribulations of everyday life. Life, after all, is often quite hard.

Despite its straightforwardness, Szasz’s contention that mental disorders are not genuine illnesses initially strikes many people as wrongheaded. This is not surprising given how often we have been told that mental illnesses are serious medical conditions afflicting a significant portion of the population—1 in 4 of us, according to the National Institute for Mental Health (NIMH, 2013). Dismissing mental disorders as hokum is often viewed as an affront to all those suffering from them because seeing people as sick allows us to stop blaming them for their problems and start treating them more humanely. This begs the question of why we wouldn’t empathize with or provide assistance to people upset over difficult life circumstances, even if we didn’t think they were ill. However, that’s a question for another day.

Recent events suggest that Szasz’s arguments remain timely. On April 29, the National Institute for Mental Health broke with the DSM, asserting that it will be “re-orienting its research away from DSM categories.” At first glance, the rationale offered sounds like something straight out of Szasz:

The weakness [of DSM] is its lack of validity Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever.

In other words, the NIMH acknowledges that mental disorders, as currently defined in DSM, are little more than descriptive conveniences. None of them are diagnosed based on biology. Szasz would have agreed. However, from a Szaszian perspective this leaves things wide open. It means that DSM categories are either (a) putative illnesses whose status as brain diseases (not metaphorical “mental disorders”) might one day be revealed, or (b) problems in living that are currently being misrepresented in medical terms.

The NIMH’s perspective is a bit narrower than Szasz’s. To them, all mental disorders fall into the putative brain diseases category. While they agree with Szasz that mental disorders cannot at present be diagnosed biologically, they remain fully committed to the idea that “mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior.” In their view, it is the DSM that is holding science back from proving that mental disorders are brain diseases. If we just chuck the DSM and redouble our efforts, the elusive biomarkers we seek will be found.

The irony is that both the DSM and the NIMH unintentionally reinforce Szasz’s basic argument when they acknowledge that mental disorders cannot be diagnosed biologically. Where they miss the boat is that they continue to hold out hope that all the problems we currently classify as mental disorders will ultimately be revealed as brain diseases. Some of them perhaps might, but it is likely others never will be. As Szasz knew, many of the problems that psychiatrists, psychologists, counselors, and social workers find themselves dealing with are not physical illnesses. They are problems in living.

Medicine, for all its virtues, will never be able to “treat” (in a literal, medical sense of the term) people who are struggling over whether to quit their jobs, end a relationship, or give up grieving a loved one because to treat such things would mean there would have to be a biological malfunction, rather than a set of life circumstances, triggering these difficulties. Being upset about something does not always—or even usually—mean that one is sick. The negative feelings that life problems evoke are not always diseases. They are usually part and parcel of being human. Most psychotherapists tend to agree with this viewpoint and see the vast majority of their clients as struggling with the emotional consequences of challenging life situations. Only once the DSM and the NIMH acknowledge Szasz’s argument in full is there likely be any progress in differentiating putative brain diseases from problems in everyday living.

References

Insel, T. (2013, April 29). Transforming diagnosis.

National Institute of Mental Health. (2013). The numbers count: Mental disorders in America.

Szasz, T. S. (1974). The myth of mental illness: Foundations of a theory of personal conduct (rev. ed.). New York, NY: Harper & Row.

The post The Myth of Mental Illness Revisited, NIMH Style appeared first on Mad In America.

Susan Salasin created this video about the role of trauma in the lives of those who are labeled seriously mentally ill. She collaborated with Andy Blanch and Joan Gillece of NCTIC (National Center for Trauma Informed Care), and with Leah Harris of the NEC (National Empowerment Center).

Thanks to Beyond Meds

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Michael Rock has been a group psychotherapist for 25 years.  Using elements of CBT, DBT, and Positive psychology, he developed a model of behavior chain analysis called “Habits”. The Model can be applied (in brief, 6-8 sessions) to a wide range of mental health issues. His areas of interests include: Promoting a national discussion on mental health, increase public awareness of the dangers of diagnosis & long term medication compliance, and the consequences of a narrative of disability: He can be reached at plantspeaks@gmail.com

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