Diagnosis Dilemma

Alice Keys, MD
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Not long ago I had a conversation with a psychiatrist. He told me about a diagnostic dilemma he’d run up against at work.

It’s not that he didn’t know how to create an accurate diagnostic label for a patient according to the book. The DSM works a bit like a Chinese menu. One from column A and two from column B for at least two weeks equals diagnosis C. He’s quite good at this.

In a way, being accurate and by the book is one part of the problem he’s run into.

His diagnostic dilemma doesn’t come from problems with the criteria being used to make the diagnoses or with psychiatric diagnoses per se. Rather, his diagnostic dilemma arises from the purposes for which these labels are used.

Specific types of psychiatric diagnoses are used as magic keys that unlock funding gates for psychiatric services, medical insurance and some types of government support payments.

If the psychiatrist doesn’t provide a “payable” type of psychiatric diagnosis from a specific list, the provider organization he works for will not get paid. And provider organizations can’t afford to give away free patient care. When the psychiatrist doesn’t create a “payable” psychiatric diagnosis, this blocks the patient’s access to mental health services. Not making one of these “payable” diagnoses can also block the patient’s access to insurance for medical care and some kinds of public assistance money.

This psychiatrist was unwilling to use one of these “payable” labels for a certain person. He said it just wasn’t accurate based on his evaluation. He’d been criticized by co-workers on the grounds that he had denied the patient access to needed care.

A tangled web of ethical, legal and human issues arise within a system that requires a specific coded psychiatric diagnosis before a poor person can receive counseling, access to medical care and money to live on.

And it’s fraud if the doctor creates a false diagnosis for payment or benefit purposes.

So the psychiatrist is caught between the legal and ethical issues of fraud on the one hand and a desire to help his patient access resources on the other. This is a rock and a hard place for everyone concerned.

But there’s more to this conundrum.

Some of these unfunded patients arrive at the psychiatrist’s office through legal mandates to treatment. A judge can order a person to get into mental health treatment. The consequences of disobeying this legal mandate can include loss of children and incarceration.

This legal situation leaves both the psychiatrist and the unfunded patient with the need to produce a “payable” diagnosis so that the patient can access money to pay for the court-mandated treatment. When a judge makes an unfunded treatment mandate as part of her judgment, she pressures the doctor to make a “payable” psychiatric diagnosis.

The American Psychiatric Association’s professional practice guidelines recommend daily drugging for many “payable” psychiatric diagnoses. Once this “payable” diagnosis is in place, drugs generally follow.

If the psychiatrist decides against giving the diagnosis-driven drugs spelled out by the A.P.A. guidelines, he places himself at risk. No matter what goes wrong in that patient’s life, the doctor can be held liable for not providing drugs according to the “practice guidelines”. Neither the doctor’s employer nor his professional liability insurance will stand behind him if he chooses his own judgment over “practice guidelines”.

The doctor who makes a correct diagnosis but does not label a person with a “payable” psychiatric diagnosis can be denying his patient money to live on, counseling and access to medical care. Not labeling a patient who’s been mandated to treatment by a judge can result in the patient going to prison.

If the doctor stretches the truth out of sympathy and provides an inaccurate but payable diagnosis so that his patient can have access to medical care and money to live on, he is committing fraud that can mean heavy fines and incarceration for himself.

It seems there is no right thing for the doctor to do. Every choice he can make is wrong. He can commit fraud to get resources for a poor person and risk his self or remain diagnostically correct and leave the patient without money and care.

* * * * * * *

Thanks or reading, thinking and writing.

Alice Keys MD

 

 

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Alice Keys, MD
Necessary Phoenix: Can one physician help heal the practice of medicine? After two and a half decades of work as a psychiatrist in private practice, community clinics and inpatient units, Dr. Keys shares her personal perspectives on the devolution of medical care and the needed resurrection.

109 COMMENTS

    • Hi
      May I ask why a personalty disorder is a stigma?

      In Scandinavia we can treatment and disability pension .
      And why do we seldom read about personality disorders on this site.

      Somehow I feel it is stigmatized here as well.

      I read how one person after an other tell us they do not have any illness. Well I can tell you with personalty disorders you can get terribly terribly sick and it smashes your life to pieces even after years in therapy .

      Why the stigma? It is nothing else than ignorance,lack of knowledge and evil.

      Sorry for the hard word,but it is my honest feelings about this.

      Reading this website I also wonder what is wrong with healthcare ,attitudes and knowledge in the American society.
      And by the way, a diagnoses is not an insult . The problem is the lack of knowledge.
      Sincerely Licinia

      • Licinia,

        I think part of the issue in the US in the payment system. Axis I disorders are considered potentially treatable (even when we have no evidence of specific, helpful treatment), while Axis II disorders (personality disorders mostly), are considered untreatable or not worth treatment. Because of that, providers don’t often like to diagnose them, as insurance won’t pay for treatment that they don’t think can be helpful, and people don’t like to be labled with them because it undercuts credibility, sense of self, and future accesss to treatment and sometimes just basic rights (parenting/custody, parole, licensure for certain professions). Despite this, personality disorders, when diagnosed, are often done as a punitive or defensive measure. Patients who don’t get along with their providers or respond well to their chosen treatments are often labeled with a personality disorder to explain why their treatment isn’t helpful. It also can be used to cover mistakes/errors, and make patients seem less credible if professionals fear litigation. Basically, the diagnoses basically label people bad patients and bad people, despite their distress or past history, and it does so with sense of permanence and depth that makes seeking change seem hopeless.

  1. That’s why all of my clients got an “Adjustment Disorder” if I could in any way justify it. Almost anyone has current or recent stressors they are having a hard time dealing with, and “Adjustment Disorder” implies the need for therapy rather than drugs.

    But it really does emphasize how ridiculous DSM diagnosis is. The truth is, the doctor probably doesn’t have to worry about it, since no one on earth can ever prove you’re right or wrong about a psychiatric diagnosis. It’s really a beautiful scheme, if your desire is to make money without the slightest accountability.

    The DSM’s a sham, and anyone not religiously committed to psychiatric precepts knows it. The shame is that we continue to go along with it, mostly for the reasons you mention. The only real answer is to scrap the whole idea of “medical” diagnoses for mental/emotional/spiritual issues. But I’m not holding my breath on that one…

    —- Steve

  2. Fantastic essay Alice, you really nail the “objective” dilemma here, where in reality “objects” ie, money is more important than “humanity.” How have we gotten our own reality so “backwards” in our thinking that objects like money and property are more valued than the precious vitality affects to human health, like a heartfelt smile?

    One suspects that this conundrum comes from a taken for granted subject – object orientation of the Western mind in which, rather than “being” with another and using the full capacity of our sensory nature, we sit in defense of our objectified sense of self and diagnose an “object” before use.

    Of coarse we make the right “lip-service” noises of an assumed empathy yet do so more in “simulation” technique, than the spontaneous flow of our sensitive nature. Perhaps after your hiatus you may re-kindle your love for the healing professions with an embrace of a paradigm shift in psychotherapy which is taking back to Freud’s “unconscious” realm, albeit with aid of technology. Please consider;

    “RIGHT BRAIN NONVERBAL ATTACHMENT COMMUNICATION: THE INTERSUBJECTIVE ORIGINS OF THE IMPLICIT SELF

    A. Schore has described how the emotion-processing limbic circuits of the infant’s developing right brain, which are dominant for the emotional sense of self, are influenced by implicit intersubjective affective transactions embedded in the attachment relationship with the mother (Schore, 1994, 2005). Implicit processing underlies the quick and automatic handling of nonverbal affective cues in infancy, and “is repetitive, automatic, provides quick categorization and decision-making, and operates outside the realm of focal attention and verbalized experience” (Lyons-Ruth 1999, p. 576). Trevarthen (1990) described how prosodic vocalizations, coordinated visual eye-to-eye messages, and tactile and body gestures, serve as channels of communicative signals in the proto dialogues between infant and mother, which induce instant emotional effects. Bowlby (1969) also described “facial expression, posture, and tone of voice” as the essential vehicles of attachment communications between the emerging self and the primary object (Schore, 2001a).

    The dyadic implicit processing of these nonverbal attachment communications are the product of the operations of the infant’s right hemisphere interacting with the mother’s right hemisphere. Attachment experiences are thus imprinted in an internal working model that encodes strategies of affect regulation acting at implicit nonconscious levels. Neuroscientists have documented that visual input to the right (and not left) hemisphere during infancy is essential for the development of the capacity to efficiently process information from faces (Le Grand, Lucci, Mazzatenta, & Tommasi, 2003). These findings support earlier speculations in the psychoanalytic literature that “The most significant relevant basic interactions between mother and child usually lie in the visual area: the child’s bodily display is responded to by the gleam in the mother’s eye” (Kohut, 1971, p. 117); that early mental representations are specifically visually oriented (Giovacchini, 1981); and that historical visual imagery is derivative of events of early phases of development (Anthi, 1983).

    It is important to note that these early experiences may be regulated or dysregulated, imprinting either secure or insecure attachments. Watt (2003, p. 109) observes, “If children grow up with dominant experiences of separation, distress, fear and rage, then they will go down a bad pathogenic developmental pathway, and it’s not just a bad psychological pathway but a bad neurological pathway.” This is due to the fact that during early critical periods organized and disorganized insecure attachment histories are “affectively burnt in” the infant’s rapidly developing right brain (Schore, 2001a, 2003a). These stressful relational experiences are encoded in unconscious internal working models in the right, and not left, brain. In a study of hemispheric lateralization of avoidant attachment, Cohen and Shaver (2004) conclude, “Emotional negativity and withdrawal motivation have been connected in psychophysiological studies with the right frontal lobe of the brain” (p. 801), and that avoidant individuals show “a right hemisphere advantage for processing negative emotion and attachment-related words” (p. 807).

    It is now accepted that the “non-verbal, prerational stream of expression that binds the infant to its parent continues throughout life to be a primary medium of intuitively felt affective-relational communication between persons” (Orlinsky & Howard, 1986, p. 343).

    Most relational transactions rely heavily on a substrate of affective cues that give an evaluative valence or direction to each relational communication. These occur at an implicit level of rapid cueing and response that occurs too rapidly for simultaneous verbal transaction and conscious reflection. (pp. 91– 92)  

    Scaer (2005) describes essential implicit communications embedded within the therapist– client relationship:   Many features of social interaction are nonverbal, consisting of subtle variations of facial expression that set the tone for the content of the interaction. Body postures and movement patterns of the therapist … also may reflect emotions such as disapproval, support, humor, and fear. Tone and volume of voice, patterns and speed of verbal communication, and eye contact also contain elements of subliminal communication and contribute to the unconscious establishment of a safe, healing environment. (pp. 167– 168)

    A fundamental question of treatment is how we work with what is being communicated but not symbolized with words. In discussing subsymbolic processing, Bucci (2002) observes, “We recognize changes in emotional states of others based on perception of subtle shifts in their facial expression or posture, and recognize changes in our own states based on somatic or kinesthetic experience” (p. 194). These implicit communications are expressed within the therapeutic alliance between the client’s and therapist’s right brain systems.  

    Human beings rely extensively on nonverbal channels of communication in their day-to-day emotional as well as interpersonal exchanges. The verbal channel, language, is a relatively poor medium for expressing the quality, intensity and nuancing of emotion and affect in different social situations … the face is thought to have primacy in signaling affective information. (Mandal & Ambady, 2004, p. 23)

    In the developmental attachment context, right brain– to– right brain auditory prosodic communications also act as an essential vehicle of implicit communications within the therapeutic relationship. The right hemisphere is important in the processing of the “music” behind our words. When listening to speech, we rely upon a range of cues on which to base our inference as to the communicative intent of others. To interpret the meaning of speech, how something is said is as important as what is actually said. Prosody conveys different shades of meaning by means of variations in stress and pitch— irrespective of the words and grammatical construction (Mitchell, Elliott, Barry, Crittenden, & Woodruff, 2003). These data support suggestions that the preverbal elements of language— intonation, tone, force, and rhythm— stir up reactions derived from the early mother– child relationships (Greenson, 1978).

    During heightened affective moments, these right brain dialogues between the relational unconscious of both the patient and the therapist (like the attachment communications of the infant and mother) are examples of “primary process communication” (Dorpat, 2001). According to this author, “The primary process system analyzes, regulates, and communicates an individual’s relations with the environment”:  

    [A] ffective and object-relational information is transmitted predominantly by primary process communication. Nonverbal communication includes body movements (kinesics), posture, gesture, facial expression, voice inflection, and the sequence, rhythm, and pitch of the spoken words. (Dorpat, 2001, p. 451)

    It is important to stress that all of these implicit nonconscious right brain– mind– body nonverbal communications are bidirectional and thereby intersubjective (see Schore 2003b for a right hemisphere– to– right hemisphere model of projective identification, a fundamental process of implicit communication within the therapeutic alliance). Meares (2005) describes,   Not only is the therapist being unconsciously influenced by a series of slight and, in some cases, subliminal signals, so also is the patient. Details of the therapist’s posture, gaze, tone of voice, even respiration, are recorded and processed. A sophisticated therapist may use this processing in a beneficial way, potentiating a change in the patient’s state without, or in addition to, the use of words. (p. 124)  

    Implicit right brain– to– right brain intersubjective transactions lie at the core of the therapeutic relationship. They mediate what Sander (1992) calls “moments of meeting” between patient and therapist. Current neurobiological data suggest that “While the left hemisphere mediates most linguistic behaviors, the right hemisphere is important for broader aspects of communication” (van Lancker & Cummings, 1999). In light of this, A. Schore (2003b) has proposed that just as the left brain communicates its states to other left brains via conscious linguistic behaviors, so the right brain nonverbally communicates its unconscious states to other right brains that are tuned to receive these communications. Regulation theory thus describes how implicit systems of the therapist interact with implicit systems of the patient; psychotherapy is not the “talking” but the “communicating” cure.

    The neuroscience literature holds that “The left hemisphere is more involved in the foreground-analytic (conscious) processing of information, whereas the right hemisphere is more involved in the background-holistic (subconscious) processing of information” (Prodan, Orbelo, Testa, & Ross, 2001, p. 211). Indeed, the right hemisphere uses an expansive attention mechanism that focuses on global features, whereas the left uses a restricted mode that focuses on local detail (Derryberry & Tucker, 1994). In contrast to the left hemisphere’s activation of “narrow semantic fields,” the right hemisphere’s “coarse semantic coding is useful for noting and integrating distantly related semantic information” (Beeman, 1998), a function that allows for the process of free association. Bucci (1993) has described free association as following the tracks of nonverbal schemata by loosening the hold of the verbal system on the associative process and giving the nonverbal mode the chance to drive the representational and expressive systems, that is, by shifting dominance from a left to a right hemispheric state. These nonverbal affective and thereby mind– body communications are expressions of the right brain, which is centrally involved in the analysis of direct kinesthetic information received by the subject from his own body, an essential implicit process. This hemisphere, and not the linguistic, analytic left, contains the most comprehensive and integrated map of the body state available to the brain (Damasio, 1994). The therapist’s right hemisphere allows him or her to know the patient “from the inside out” (Bromberg, 1991, p. 399). (This was my DIY self-therapy challenge, to understand my fearful emotional dysfunction from the inside-out.)

    To do this the clinician must access his or her own bodily based intuitive responses to the patient’s communications. In an elegant description, Mathew (1998) evocatively portrays this omnipresent implicit process of bodily communications:  

    The body is clearly an instrument of physical processes, an instrument that can hear, see, touch and smell the world around us. This sensitive instrument also has the ability to tune in to the psyche: to listen to its subtle voice, hear its silent music and search into its darkness for meaning. (p. 17)  

    Intersubjectivity is thus more than a match or communication of explicit cognitions. The intersubjective field co-constructed by two individuals includes not just two minds but two bodies (Schore, 1994, 2003a, 2003b). At the psychobiological core of the intersubjective field is the attachment bond of emotional communication and interactive regulation. Recall Pipp and Harmon’s (1987) assertion that the fundamental role of nonconscious attachment dynamics is interactive regulation. Implicit unconscious intersubjective communications are interactively communicated and regulated and dysregulated psychobiological somatic processes that mediate shared conscious and unconscious emotional states, not just mental contents. The essential biological purpose of intersubjective communications in all human interactions, including those embedded in the psychobiological core of the therapeutic alliance, is the regulation of right brain– mind– body states. These ideas resonate with Shaw’s (2004) conclusion:  

    Psychotherapy is an inherently embodied process. If psychotherapy is an investigation into the intersubjective space between client and therapist, then as a profession we need to take our bodily reactions much more seriously than we have so far because … the body is “the very basis of human subjectivity.” (p. 271)”

    Excerpts from “The Science of the Art of Psychotherapy” by Allan N. Schore.

    It will be interesting to note how you reply to this articulation of an “explicit & implicit” sense of self? I know you love the world of words and I’m curious to witness your response to this dual process that Schore describes. In my own journey it was a trauma conditioned block in my ability to “be” with my clients that drove me to explore the foundations of my “explicit” sense of self more deeply. A journey that has brought me face to face with the foundational denial of my human mind, “I’m not an animal and I have no “instinctual” motivation, for my intellectual rationalizations.”

    Again, a brilliant essay Alice, you really nail the “objective” illusions at the heart of our human denial.

    Best wishes,

    David Bates.

  3. Hi
    When I took my first degree it the university in 1972 the textbooks described schizophrenia exactly the same was!
    Lifelong, and untreatable.
    And look at “open dialog” today.

    The experts simply lack knowledge.

    Unfortunately it is health workers and journalist that keep the myths alive in my country.

    I like website,and learn a lot but I wish also could open up for some debate about these problems.

    It can be hard to cure cancer patients as well,but do we call cancer patients bad because they have not yet found good cures. We do not.

    It makes me sad.
    No emotional health problems have more “honor” than others. They are only different way to express pain.

    And did Masha Linehan have to lie about her diagnoses.
    “Something is rotten inthe state of America,”. Even more so than here in Scandinavia.

    • I think they are in danger of losing their jobs if they speak out. Look at Loren Mosher’s experience. There is definitely a “code” amongst even fairly radical critics that must always be followed: we have to say, “We acknowledge that many people are helped by psychiatric medications…” Anyone who comes out and says, “This whole system makes no sense, and appears to be damaging clients far more often than it helps” is quickly ostracized, and if s/he has enough power to be of influence, s/he is attacked as an “antipsychiatrist” or “Scientologist” and loses any position or authority s/he had.

      The rulers of the profession don’t tolerate dissent.

      — Steve

    • I think there are many reasons why more psychiatrists and their subordinates don’t speak, social-psychological, economic, ideological, careeristic, situational and institutional in character.

      Social-psychological and institutional pressure can never be discounted. Although it cannot be said that they operate under external compulsion (they might lose their job, but that hardly qualifies as external compulsion), or that they do so at pain of death, there is nevertheless great pressure to conform. Psychiatrists and their subordinates are essentially members of a group whose membership is contingent upon the espousal of the official doctrine.

      Latitudinarianism is alien to the institutional environment of psychiatry, just look at how Mosher and Szasz were treated. Their dissension only served to ensure their eternal place in the profession’s demonology, along with heretical patients. Therefore, the social-psychological pressure to conform must be great in such an oppressive, intolerant institutional environ, though I say this without the intention of exculpating the perpetrators of psychiatric crimes, after all, the same could be said of people who worked in Nazi death camps. There is a moral imperative to speak out against these crimes, and no situational factors can literally deprive you of the capacity to make important moral decisions and responsibility for your behaviour.

      In some cases this peer pressure may be sufficiently oppressive enough to shape the decisions and thinking of the few whose moral principles and sense of decency hasn’t been entirely corroded by ideology, but social-psychological reasons perhaps have only limited explanatory capacity in this context, because such social- psychological pressure wouldn’t exist if most people possessed principled objections to orthodox psychiatric practice.

      This is where we come to the role of institutional pressure. Much like in the film industry and the print media industry individuals have very little latitude for self-expression (for example, all Hollywood films are edited in the same way, have the same narrative structure etc., betokening the lack of creative freedom of the so-called artist, who is really just an assembly-line worker taking orders from above), the same phenomenon is to be found in institutional psychiatry.

      The institution is structured in such a way as to filter out individualism. This is partially done through the imposition of an ideology and rules from above, so that the advancement or security of your career depends in such an environment on a willingness to observe the rules of the institutional game, so that careerists and apparatchiks are favoured in such an environment, and such people will think whatever way they are told to think. It is these people who put the pressure on the more principled to conform, these people who will believe whatever in furtherance of their own interests, those who unthinkingly obey authority.

      As Steve and Alice rightly point out, one of the ways in which this intolerance of deviationism and peer pressure manifests itself is through the use of certain rhetorical devices. This is a very effective means of subtly enforcing and extorting conformity.

      In the preceding paragraphs, I have also alluded to some of the psychological and instinctual preconditions of a general willful blindness and refusal to say that 2+2=4. Important in this regards is the herd instinct; in their desire to be liked, to gain the approbation of the herd of which he/she is a unit, there are no limits to what man will believe or how he will behave in pursuit of the sanctuary of popular approval, and all its concomitant psychological gains.

      Another explanation for this conspiracy of silence is that most psychiatrists and their subordinates, or at least a large percentage, have long since crossed the moral and psychological rubicon, they have gone past the point of moral and psychological return. Having committed themselves to their morally dubious path, they have little option but to spin webs, woven of casuistries and sophistries, around their conscience, their perpetrations and the morally dubious elements of their past.

      Last, but certainly not least, these people need to think well of themselves. When defending psychiatric orthodoxies, many psychiatrists and their subordinates are defending their need to think of themselves as decent people, as healers and carers, as saviours. If reality doesn’t accomodate these needs, then you turn your back on reality.

      Far too many people are psychologically invested in the continuation of this delusion and tyranny to expect anything else than what we are seeing. In many respects it represents the self-preservation instinct at its basest.

  4. Somewhat reminds me of an experience I had in my early 20’s when trying to seek services that would help get me off SSI. Supported employment, education, subsidized housing — all of these things existed, but only to the “treatment compliant” group of patients. It was because of my seeking of services that I wound up back in the psychiatric system and for the first time as an adult, including two involuntary commitments in my mid-20’s. If I knew back then what I did now, I would had just stayed quiet and under the radar.

  5. Alice

    “I can blame no one who declines to speakup.”

    I’ll give you a chance to rethink your above comment.

    Biological Psychiatry is destroying people’s lives everyday; people are dying, brains are being destroyed, human resilience crushed with each label and brain numbing chemical cocktail. This situation demands that people speak up, especially those who are aware of some of these truths. TO NOT SPEAK UP IS TO BE COMPLICIT IN THESE CRIMES!!! After all we do not want become today’s “Good Germans.”

    Like Steve, who also writes on this site, I work in community mental health as a therapist. I speak out all the time and I look for ways to challenge this complete take over of the medical model in any way I can; I plan to do even more of this in the future. Yes, this has been risky and will become more so as Biological Psychiarty becomes more defensive with the growth of our movement. But I couldn’t live with myself if I wasn’t prepared to take risks. “THERE IS NO VICTORY WITHOUT RISK!”

    Two years ago I attended an educational presentation on “psychopharmacology” for CEUS. There were 300 clinicians attending this training. I had Whitaker’s book with me and was prepared to raise serious challenges during the question and answer period. The only trouble was that the speaker eliminated question and answers due to a time shortage. The presention repeated the whole mythical “chemical Imbalance Theory.” I could not sleep for weeks after this training because I was beating myself up for not standing tall and interrupting this speaker during his lies and distortions of the truth; lies that harm millions of people everyday. For me this will never happen again! I can’t wait for the next opportunity to strategically (with careful thought and preparation)interrupt such a presentation.

    Alice, a well organized small group of psychiatrists could wreak havoc in the APA if they dared to take the risks; DOESN’T HISTORY DEMAND THIS OF US!. Dropping out and retreating to our families is certainly seductive given the difficulty of challenging the status quo, but it is not the road forward in this movement. The leaders of Biological Psychiatry want nothing more than for disenters to drop out or quit; that allows them the freedom to continue there crimes.

    LET’S ALL BECOME BIOLOGICAL PSYCHIATRY’S WORST NIGHTMARE!!!

    A SINGLE SPARK CAN START A PRAIRIE FIRE!

    Richard

    • Hey, thanks, Richard! Good to know another rabble rouser is out there. I agree, there are times I can barely live with myself for not speaking up louder. But there are limits what one person can do without completely destroying his/her credibility. I work on trying to get facts out and get people to think. Not everyone sees that as a noble effort, but I guess if we don’t, we’re yielding the field to the enemy.

      Keep up the good fight! If enough of us join together, they can’t fire us all!

      — Steve

      • I’m all for rabble rousing but usually it takes a group of committed people who want to support each other to continue doing this over time. As an individual it can be draining and disheartening.

        I think Alice is doing a great job raising awarness of the difficulties professionals will have in challenging the present system but I’m also in favour of people organising in a more rabble rousing way. Different people will indeed do different things and all efforts should be encouraged but I really miss seeing a bit of rabble rousing on this issue.

        I wrote a paper about this for Mr Kermt but he hasn’t published it so far. If you want a copy contact me on facebook via speakout against psychiatry

  6. Alice,

    IMO, the Mental Health Parity and Addiction Recovery Act(2008)was a mistake. This requires insurance companies (through group plans of 50 or more who were *already* providing insurance) to cover mental health “treatment” as they would any other condition.

    If we had *real* treatment, there might be a case to be made. But carriers are required to pay for psychiatric drugs that easily may cost $1,000 per month for each drug (much more, in the case of cocktails). NAMI pushed for this act for years. Do the math.

    One of the *major* reasons healthcare has become increasingly unaffordable is due to this mandate. These expenditures are passed through to every person on the plan. Do the math.

    Now the federal government will require *all* employers (50 employees or more) to provide full coverage, including psychiatric “care* (drugs, drug and more drugs). This will cost the employer approximately $20,000 per year for each employee with a family. Or the employer may choose to pay a $2,000 per year fine and simply bow-out. Estimates are that *millions* of employees will be dropped in the first year ObamaCare goes into effect. $20,000 to cover employees or $2,000 for an IRS fine. Do the math.

    Private health care insurance will soon be *very rare*.

    Which brings us to the public sector.

    A solution:

    The federal government needs to stop paying for drugs that have been illegally researched and/or marketed – in Medicaid, Medicare Part-D and Veterans Affairs. It also needs to stop paying for drugs in Medicaid and foster programs that are not safe for children (*all* psychiatric drugs and *many* others).

    Once private insurance is run out of the health care market (and that day is coming soon, unless Obamacare is quickly repealed), the same rules need to continue.

    The Pharmaceutical Research and Marketing Association (PhRMA)pushed for ObamaCare for a *reason*. As did NAMI. Once again, do the math.

    Duane
    discoverandrecover.wordpress.com/freedom

  7. Hi Richard
    Excuse my typos!
    What I tried to write was that must RESPECT
    and never push persons on the barricades or those like Alice that has a healthy knowledge about how far she can go personally.

    We,living outside the The US look at your health care system with horror. No offense,but this is the truth. We simply can not belIve what we see,read and hear.And you all have our deepest sympathy.
    A society as large as the US is hard to change partly because of it’s size. It is so much easier to change things in smaller countries like mine with 6 million inhabitants only.
    Human nature is the same but our circumstances differ.

    I wish Alice the best of luck and hope she will not burn out.
    If she comes here I will be on her list as a patient. Lots of persons here can have an English speaking therapist.
    I like this woman.

    Smiles from Licinia

    • Richard,

      Just because Alice isn’t willing to go as far out on the limb as you want her to, doesn’t mean she is a hypocrite. Unlike other psychiatrists who talk out of both sides of their mouths regarding the issue of meds, she clearly gets it that less is alot better.

      I applaud any psychiatrist who blogs on this board and who is willing to challenge their long time beliefs.

  8. AA

    I did not call Alice a hypocrite. In previous postings I have supported Alice’s writing on this blog and also above gave her kudos for her critique of the current medical system.

    What I have questioned is her statements that pretend that she is not (in her own way) telling people what to do. If you read her blogs there is a clear theme regarding what she believes is necessary and possible to do as an activist at this time. I believe it is appropriate to challenge that in a respectful way. We all can do more and perhaps when I write this way I am also challenging myself at the same time.

    Richard

  9. Perhaps I a only a cycnical old behaviorist, and cant help but look for reinforcements. But I think It takes a buyer to sell and vice versa. No matter what a person, (or even a dog or cat) does over and over, the habit must function in some way. Something is relieved by doing it. With personality disorders it is usally a combination of “attention, control, revenge, or to display inadequacy”.
    Always a touchy subject, especially to those who “accept their illness”

  10. Obviouly I need to learn more here and I suspect things are slightly different in the UK than in the USA. However I agree it is laregly capitalist corporations that keep drug based psychiatry so powerful. A Uk gov minister said this week something about how the armamants companies and big pharma were leading the way in the economic recovery (what recovery I hear you ask). So if the UK government is relying on corrupt, lying and dangerous drugs companies to generate wealth it is not very likely to go against them.

    On the other hand I went to a UK Soteria Conference a year or so ago and went to a presentation where a Dutch practitioner had set up a Soteria style unit in a Dutch hospital using economic arguments to prize the funding from the service commisioners. It seemed a slightly corrupted Soteria house which used much more medication than many of the audience were happy with, but the guy did get it passed on economic grounds.

    The way services are commissioned will be different in the USA from the UK and they are just about to change here but well organised economic arguments could be useful.

    These arguments about how health provision in general and psychiatry in perticular is dominated by multi-national companies may allow us to make allies in other anti-captitalist struggles. Indeed, at Occupy London, outside St Paul’s Cathedral, some members of the Critial Psychiatry movment, some who have blogged on MIA, spoke.

    I organised a training for speak out against psychiatry and anti-capitalists came along and also lead the training. It seems that a lot of them get this struggle much more easily than the general public, though at Occupy London the proffessionals who volunteered in the Welfare group were most offended by the Speak Out Against Psychiatry flyers I spammed their e-mail list with. I guess proffessional pride got in the way again.

    Finally, a few blogs by Corpwatch, or people who know their work would be very welcome. One interpretation of the piece above is that it is partly the logical outcome of Big Pharma domination of healthcare. http://www.corpwatch.org/section.php?id=122

  11. Hi Alice

    I know little about the situation in the US.
    But I read this website and here is some questions:

    1:
    What happens in your Universities? After all they educate your psychologists and psychiatrists .
    2:
    In Norway psychologist can not prescribe drugs or medicines .

    On this websites so many writes about psychiatrists . Few mention psychologists .

    Are you not free to visit a psychologist when you feel need for help?

    Personally I have tried both,and stayed with the one that understood what was going on with me. He is a psychiatrist and he never,never asked me to take medicines.

    Instead he told me to call him day or night when in deep crises. This offer also when he was on vacation.
    I never called him during the night or when he was on vacation. The fact that he told me I could was enough to make me feel secure enough to go through the changes I need to.

    But back to my first question. What happens in your universities?
    You have some of the best in the worlds,or am I wrong?

    • Licinia,

      Psychologists can’t prescribe drugs here, yet. A number of them are lobbying for the privilege of doing so. In most American medical schools psychiatrists are no longer taught to do talk therapy but are only taught about the so-called “medications.” They are not taught much about how to help people titrate down and get off the drugs either.

      I work in a state hospital and one of our units is a “teaching” unit where young student doctors do a tour in psychiatry in their process of trying to choose a specialty. One of the problems for the patients placed in these student doctors’ care is that they try out all of the medicines on people. We can always tell when they’re doing what I call “experimentation” because the unit is always in an uproar because people are suffering from being jerked off of one of the toxic drugs and zapped with another. Many of the patients are on a merry-go-round of seven or eight drugs, which are being constantly tinkered and played with by these young doctors. I feel that it’s unethical to allow them to do this but my voice as a peer worker is totally ignored. I’ve observed the unit psychiatrist who supervises these young doctors during his teaching moments and the things displayed on the screen that he talks about are always pharmacology and not psychotherapy. The students don’t know how to talk with the patients and they never listen to them and that’s also another cause for uproar on the unit. As staff, we dread a new batch of student doctors because it just makes more work for staff and more heartach for the residents.

      It is the rare psychiatrist today who practices in the system and does any kind of talk therapy. In fact, these psychiatrists often can’t and don’t last in the system because they take too much time in dealing with their patients and this is looked down on. Some in private practice do psychotherapy but it’s very expensive and many times insurance companies don’t want to pay for it. It sounds like you truly have a real gem of a psychiatrist.

      Hope you don’t mind my jumping in to add my answer to your question.

      • No not at all.
        The fact is that I can not belIve what I hear here. And how can this go on and on.

        And all this also cost society a lot of money. Maybe they think they save money by giving patients medicines and not therapy. But what happens after that. Can they go back to school,work,their families and take care of themselves and others after this “treatment “.

        For us looking at this from the outside it is like reading news from the a thirld world country. Like when we read about the horror stories from Congo. Or worse in fact. As we already know persons diagnosed with schizofrenia has higher rates of recovery in other parts of the world .also in the South as we say here.

        I feel so sorry for you.
        And I am glad nobody with a masters degree had the right to give me my diagnoses,because they would not be qualified to understand me.

        It sounds like Americans treat persons in emotional distress worse than all their beloved pets.
        You begin to sound more like Russia.

  12. The main problem with the diagnostic dilemma that you mention in your post is that the DSM is fundamentally flawed. See my blog post and essay on “Fear is Not a Mental Disorder.” A complete reworking of the DSM following a new theoretical construct is necessary to solve its many problems. As a practicing clinical psychologist I see every day the problems with these ethical and diagnostic dilemmas, yet the problems of misdiagnosing, stigmatizing clients and the “medicalization” of behavioral health conditions are easily solved if you read my essay and my book “Pack Leader Psychology.” http://www.PackLeaderPsychology.com

  13. The legal system might offer a proper forum for the national discussion we are trying to provoke. The arguments to support the current paradigm are hard to expose within the medical model, precisely because the diagnosis cant be tested for or against. Possibly if we look at the assumptions through a different lens (ie, legal) it can reveal the corruption. It also allows people who have been harmed to act toward restitutions. Of course the financial incentives are just as present in the legal system as psychiatry and counseling. I work in a large hospital network in Eastern PA and it seems very obvious that the people who attend treatment longer, and have the most access to care are much more likely to end up on disability. We make more money on people who dont get better, and the only outcomes we measure are financial (attendance, staff to client ratios, etc). We try not to consider how many we help wind up disabled within a few years. We ignore completely the people who get better and stop taking pills. There is no profit in it.
    Im outspoken and will be fired pretty soon for telling people that recovery is possible. Im angry about what is happening, especially to the adolescents. Most of my co workers, will conceed that they see the same things I do, but feel like they cant say anything because they need the jobs.

  14. Hi Alice,

    Thanks for taking on this important issue.

    How often is it though that a diagnosis is challenged in psychiatry as a potential fraud of the system? It seems that it would be quite easy to give a patient a diagnosis without it being easily challenged, since the whole process of psychiatric diagnosis is subjective. For example, some patients have five or ten different diagnoses in their records given by different doctors – but no would accuse the doctors of fraud or incompetence for not agreeing. (Although it would certainly raise red flags in other medical specialties where there are objective tests like blood work, biopsies, MRIs etc. to rule on these things.)

    I can appreciate the potential ethical issue of giving a patient a particular diagnosis to allow them to receive benefits (or the clinic to be paid). The difference ultimately comes down to whether your ethical system is deontological (believing you have an ethical duty to uphold certain rules or standards, even if they produce bad outcomes) or if you are teleological (believing a good end justifies the means, even if it requires bending the truth or breaking some rules.) Neither system is necessarily more moral than the other from an objective standpoint.

    As I’m sure you are aware, patients also face similar ethical dilemmas when interacting with providers and others in the mental health system, due to the complexity of the requirements. I use to attend a patient support group that served as a forum where patients got together to share experiences on what to say (and not to say!) in all kinds of situations – when talking to SSDI and other benefits administrators, in ER evaluations to ensure you would (or would not) be admitted, what to say to get a doctor to discharge you from a hospital, a judge to release you during a commitment hearing, or to a college administrator to be allowed to re-enroll in classes after a medical leave.

    Interestingly, those in the group who were actually somewhat functioning, were the purest teleological thinkers – they were clever, learned the rules of the game, and had no qualms when it came to manipulating the system to get what they wanted out of it. The purest deontological thinkers – the ones that had a strong commitment to honest communication and were unwilling to change their stories to fit the requirements set by the system– were the ones who were revolving in and out of treatment, on and off their benefits, and ultimately falling through the cracks.

    The system is clearly broken on both sides. There has got to be an easier way that allows the treatment, payment, safety net and recovery process to work in a more straightforward way while still protecting against legitimate cases of fraud and abuse.

  15. I was emboldened by Reading Anatomy of an Epidemic, and inspired to speak out by the many contributers here, especially Dr Keys, Dr Foster, and Corinna West. After Im fired I will be even more outspoken. Over the past 10 years Ive developed an alternative to the current system (using CBT, DBT, and Positive psychology) which I am currently using at the hospital. They wont allow me to test for outcomes, and insist on containing the ideas that recovery is possible.

  16. I want to correct a few false premises.
    First of all I will identify myself. I am a renegade psychologist. I became unemployable in the public mental health system in 1988 as soon
    as I (successfully) encouraged clients to wean themselves off of psychiatric drugs. I did not expect to be fired. I naively thought as the system became less Freudian (as was happening in the 80’s) it would become more pluralistic. And I thought I had freedom because in earlier phases of my training in psychology there was not pressure to put ALL clients on drugs. In the late 70s I could give clients
    a less toxic “diagnosis” and save them from a life-time of being drugged.

    Second people posting here have referred to the dilemma of psychiatrists who are reluctant to drug people. There was even suggestion that they could fight back. My question is: Both of them? I live in NYC. In 20 years I was only able to locate 2 psychiatrists who were willing to help non wealthy “schizophrenic” (completely harmless) patients get off of psych drugs. By this I mean a shrink who would take Medicaid…

    This leads me to point to another false premise. The system does not exist to help people–that is not even a tertiary goal. Its whole purpose is to market and to sell drugs. Please read Toxic Psychiatry. Read the chapter on the psychiatric-pharmaceutical industrial complex. Breggin has a slightly different name foe the PPIC but he nailed the dynamics. This started in the late 70’s when the APA voted to change their laws so they could accept drug company money. People on this website who think they can persuade colleagues the system is not working are deluded. The system works. 20 % of youth are psychiatric drugs. This is growing.One of psychiatrists’ roles is to provide a facade of scientific legitimacy for drugs that make people worse. There is an alternative––but it’s based on self-help. One successful model was the Hearing Voices Network. Professionals who resist drugging are like military officers who are against war. So far unlike the military whistleblowers will not be prosecuted like Bradley Manning–they won’t face a life time in prison. But they will not find jobs within the system.Unless they write a blockbuster book like Breggin their influence will be limited. They cannot expect to retain jobs within the PPIC. There are exceptions––outside of the US or in Vermont.

    Finally the premise of the article is wrong–that there is pressure to misdiagnose. What sense does that make? It is wrong because every diagnosis is a misdiagnosis. It’s impossible to “diagnose” someone accurately using the DSM. Read Thomas Szasz
    That said I used to help persons get access to resources by labeling them with an “anxiety disorder.” If a client can get way with taking a benzo, it is one of the lesser evils. But as David Healy points out, that is rare. The pressure of the drug companies is to sell their blockbuster drugs–those are SSRIs and neuroleptics, drugs which destroy the body and brain and soul. The goal is to get clients on them for life. THe role of psychiatrists is to help doing this–for which they are well-rewarded. They take their families to the Bahamas on long holidays while their clients die of cardiovascular disorders, obesity,tardive dyskinesia, diabetes and suicide. The labels warn of these “side effects” but patients don’t read the labels and psychiatrists don’t care. Well they care somewhat–enough to avoid the drugs and keep their families off them.
    Seth Farber, Ph.D., author of http://www.amazon.com/The-Spiritual-Gift-Madness-Psychiatry/dp/159477448X/ref=sr_1_1?ie=UTF8&qid=1362598238&sr=8-1&keywords=farber+gift

  17. Hi Alice,
    Thank you
    I don’t quite under quite understand your arithmetic but let me make a few points.
    First as to arithmetic. The APA made the decision because it was financially lucrative-to the APA and presumably its members. Tell then you reject the contract.
    Most shrinks after a few years set up private practice and get away from the riff raff. At this point at least half’
    are making consultation fees from the drug companies.

    Second I don’t see the danger––not for the professional. You are worrying about a chimera. As Steve said “The truth is, the doctor probably doesn’t have to worry about it, since no one on earth can ever prove you’re right or wrong about a psychiatric diagnosis.” It is purely subjective. Since there are no objective tests and there is hardly any reliability there is no way to be wrong. If this were the Rosenhan experiment would have generated more anxiety within the profession.

    I would argue the diagnoses are wrong –because they don’t have any construct validity. These days the “meds” confirm the putative existence of the illness and vice versa.

    Thomas Szasz wrote the Foreword to my first book, Madness, Heresy and the Rumor of Angels (1993) but I’ve actually been more influenced by Laing. One cannot bracket the issue of the DSM.
    The premise is that those who are not adjusted are mentally ill and thus society is normative, as Laing pointed out. I maintain that every diagnosis is a misdiagnosis––and a self-fulfilling prophecy. If the professionals realizes they are not valid then and only then will they not become detrimental to the client. If you doubt this Alice I suggest you take a look at Sarbin and Mancuso’s book Schizophrenia: Medical Diagnosis or Moral Verdict. It’s not as dated as it may seem. They went through 20 years of studies and experiments from 1960-80.They are all methodologically flawed. In my books I tried to show that diagnoses are based upon anthropological and ontological premises–as well the premise of the normative status of normal society. For example “I m unhappy” or “I have a problem” or “She is acting very weird” becomes translated into “There is something wrong with Mary.” But the latter does not follow from any of the former.
    The therapist has made an interpretation based upon her ontology.
    \
    Although Tom Szasz hated R D Laing they both came to the conclusion that the DSM was comparable to the Malleus Mallifacorum–the authoritative manual for diagnosing the witch. The DSM has the appearance of being scientific. Science is supposed to be value-neutral. But there are no value-neutral diagnoses. Once you reject the premise: “There is something wrong with you” you must reject the DSM––which is a catalogue of alleged mental disorders. So by the late 1980s I would put down a diagnosis but I would always tell the client: “There is nothing wrong with you.” I would say That’s why I say “every diagnosis is misdiagnosis.” And thus so called schizophrenics (I did not alwys get to chose the label) got better. I am not a secularist. I assert the soul is holy, the psyche is holy, the mind is holy. It could be desecrated or self-desecrated, but its ground is holy. The task of the therapist is to convey that fact. There is no mental illness.

    .BTW I did post-doc training with Minuchin and Jay Haley respectively in tthe 1980s. Thus I would accept a “diagnosis” of an eg “enmeshed family.”
    Here’s a paragraph from an article I wrote on this 20 years ago– but it’s still valid This was originally published in the special issue of The Journal of Mind and Behavior–1990 edited by David Cohen. It has essays by Szasz, Sarbin, Gergen–– Laing had died. http://www.academyanalyticarts.org/far
    ber.htm

    “The medical model, the model of the social control agent, exemplifies an “objectivist” approach, to borrow Gadamer’s (1976) term. It is based on the premise that patients are objects who are not influenced by the way in which they are understood and interpreted by Institutional Mental Health. Today, psychology, fueled by positivist aspirations, apes the natural sciences in a futile attempt to delineate transhistorical laws of human behavior that it imagines will allow it to achieve the ideal of total predictability. This is ultimately the project of Reason, which seeks to escape from its historical moorings by totally objectifying history – and by objectifying persons.
    The hermeneutic approach provides the tools for exposing the limitations of objectivism. Hermeneutics recovers history. The observer is implicated in the act of observation, what he or she observes is not independent of this act. This is the fundamental hermeneutical insight. Gadamer wrote, “In this objectivism the understander is seen.., not in relationship to the hermeneutical situation and the constant operativeness of history in his own consciousness, but in such a way as to imply that his own understanding does not enter into the event” (p. 28).
    Institutional Mental Health acts as if its own understanding does not enter into the event. It focuses its lenses upon the Others, the deviants, and professes to possess objective knowledge about their situation and their destinies. It fails to see how its own way of understanding the Other enters into the event. It is as if its particular way of understanding has no historical or social ramifications. It is as if psychiatrically labeled individuals are deaf to the discourse that Institutional Mental Health articulates through a variety of media, institutions, groups and individuals. Mental illness is a cultural artifact, the end result of a particular kind of highly structured dialogue between socially empowered experts and socially disenfranchised, psychiatrically stigmatized individuals. ”

    Every diagnosis is subjective. For that reason the mental health worker can write down anything without risk. The only risk you take—which could redound upon you– is of participating in the destruction of the patient’s
    soul.
    Seth
    http://www.sethHfarber.com