Diagnosis Dilemma

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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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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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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

    • Nathan,

      Thanks for reading and commenting.

      Yes. Personality disorder diagnoses are very stigmatizing.

      In this situation I believe the correct diagnosis was “no psychiatric diagnosis”.

      Is it possible that a person can be troubled and struggling but NOT have an axis I or axis I diagnosis?

      Could a person like this still benefit from access to counseling, health insurance and financial assistance?

      I think the answer to both of these questions is “yes”.

      All the best.

      Alice

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    • 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

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      • 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.

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      • Licinia,

        Great question.
        Personality disorder diagnoses were stigmatized even before the care managers and insurance companies got into the fray and decided not to pay for treatment. This was the case when I walked into my first psychiatric training experience as a medical student in 1981.I don’t know why. A supervisor explained that this stigma was there and said she never used these diagnoses because of it. She said that once this diagnosis type was used,people stopped listening. Much later I had a teacher who always said “Don’t tell me a diagnosis, tell me about the person.” It struck me as good advise.
        Alice

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        • In the UK people with Personalit Disorder are very likley to be labelled as, “Manipulative,” and, “Attention Seeking.” Usually this means they are still displaying signs of extreme distress after the workers has given treatment. So it is a way of blaming the patient for not responding to the ministrations of the clinitian.

          Also, it hides the trauma that is usually at the root of the persons distress. The level of childhood sexual assualt and family violence that people with personality disorder diagnosis is very high yet few workers seem comfortable in talking this over wiht the people who get these diagnosis.

          Also, in the UK, treatment is patchy, in some areas you get drugs, in others you get drugs and therapy, in others good theraputic support in others it is considered a non-medical condition and therefore it is considered not appropriate to give help at all.

          So a bit of a geographical lottery – or post code lottery as we say in the UK.

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  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

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    • Steve,
      Thanks for you well considered response. I, too, have labeled a lot of people with “adjustment disorder” back in the olden days before care managers in my private practice. This would unlock the private insurance sometimes without the same stigma as Major depression and without the same push for drugs.

      But an adjustment disorder diagnosis gets an impoverished person nowhere but back out the front door unless they have cash in hand. Treatment for an “adjustment disorder” will not happen in the public sector. Neither will it get a bus pass or access to medicaid health insurance or disability payments.

      “It’s really a beautiful scheme, if your desire is to make money without the slightest accountability.”

      There’s a trouble with the “money scheme” concept you mention. This is a common misconception, that psychiatrists rake in the cash from this process. Give some thought to this arithmetic:

      With these “payable” diagnosis the only ones that make the “big bucks” are the pharmaceutical companies. The drugs amount to thousands of dollars of tax-funded insurance dollars a month if prescription coverage is won with the diagnosis.

      The second largest potential money winner on the diagnosis deal is the patient. They may receives a monthly disability check, free health insurance and a bus pass.

      The doc will see the patient one to four times a year for maybe 15 minutes each time. This is what’s allowed by the company. In my recent job search I came up with a part-time (7 hours a week), no benefits $70 an hour job which required free 24/7 coverage. That’s $20 to $70 a year payout for one patient and worked out to less than $3 an hour for my time. Creating false psychiatric diagnoses is NOT a big money maker for a psychiatrist. It’s only a big liability and fraud risk.

      Plus, if I generate more patients in the public sector, my employer double and triple books people for my same hourly rate and expects free overtime work to keep up.

      I wish more doctors had the arithmetic pointed out before spending all the years and borrowing all the money for school. The money ain’t here.

      Even the mental health agencies are money losers that barely keep the wheels on the bus from year to year.

      Thanks for giving me the opportunity to walk through this part. It could be another rant, eh?;-)

      Alice

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      • You are too right. It’s the insurance companies and the drug manufacturers who get the big bucks. I’m sorry to hear the “Adjustment Disorder” strategy doesn’t work any more. Just goes to prove my point about greed being the driving factor.

        And I believe you 100% about public vs. private healthcare – the docs aren’t making much, and neither are the therapists. A licensed MS or MSW counselor in Portland, OR often makes $30,000 or less, even in a clinical supervisor position. No wonder no one sticks around. Foster kids, in particular, get the short end of the stick, with the most inexperienced and unstable counselors handling the most complicated situations. And we wonder why a quarter or more of all foster kids are on psych drugs.

        And as for the patient being on disability, that’s a benefit in a way, but it also penalizes clients who want to get a job. So we’re encouraging disability financially.

        Thanks for providing the doc’s perspective. It’s a grim read all around.

        —– Steve

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          • I thnk this is really important. We can only dent the drug based psychiatric system by banding together and having an analysis that pulls in workers by showing that the major benficiaries of the present arrangements are the drug companies (and in the USA the insurance companies) and not the patiets or the workers is a really useful thing to do.

            I’d like to see more of this anlysis.

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      • Many psychiatrists in the US don’t accept insurance and take cash upfront just for this reason. My former psychiatrist was one of these. He specializes in panic and anxiety and once he puts people on medication, he keeps them coming back for med checks. The money rolls in every month- enough for he and his wife to take several international vacations every year. I paid him 150.00 US per month for ten to fifteen minutes of mainly listening to him talk about himself.
        Now, he would write up a slip for the patient to submit for reimbursement, and he did use specific dx codes to ensure continued payment. After all, if a patient can’t get reimbursed they are more likely to drop out of treatment.
        Not a bad gig for him, actually.

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        • Engineer,

          What you describe sounds like a money maker on the one hand and easy access to pills for folks who want them on the other.

          “Med check” may be a misnomer used for insurance billing purposes, however.

          What sort of things could possibly be “med checked” in ten minutes while typing the legally required documentation and writing prescriptions?

          Takes two to tango, I suppose. Where there’s a customer, there will be a salesman.

          Alice

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  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.

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  3. Hey David,

    I’m glad to hear from you. Thanks for your support of my writing. I appreciate your offering of well-considered thoughts.

    From your question below:

    “Perhaps after your hiatus you may re-kindle your love for the healing professions…”

    The flame of my love for the healing profession has never burned brighter. My hiatus does not reflect any loss of love for my work nor loss of love for people. If there were a venue that made sense to me, I would be there today.

    Rather, my hiatus reflects a fundamental change in the healing profession. “Irreconcilable differences” have lead to my stepping away from my work. I can no longer go along with the pretense that prescribing pills, ordering tests and typing is the same thing as medical care.

    With regard to your question of my thoughts about the Allan Shore excerpt you included:

    I may not be the best person to respond to this. Highly theoretical complexity is lost on me. It simply slips over the surface of my brain without penetrating.

    My personal stance with regard to psychotherapy and personal healing relies much on the therapeutic relationship and uses primarily a cognitive and behavioral toolkit. I like physical, interpersonal and meditative approaches. I also like understanding the cultural matrix we are all embedded in.

    Perhaps this is in the ballpark of your question.

    Thanks again. All the best.
    Alice

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    • I understand your need to defend your “cognitive” sense-of-self Alice, and your reluctance to expose your limitations here. Perhaps I can help with simpler excerpt from Schore;

      “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.”

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

      Allan Schore and others articulate a science perspective which does give great authority to what so many in this community “intuitively” know. My posting of such material against the “expected” norm of “us vs them” social-politics is in the hope that my brothers and sisters here will not simply throw out the neurscience baby with the bathwater, simply because they have been so hurt by the mismatch between science and its economically driven, clinical application.

      Best wishes,

      David.

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      • David,
        You are more of an expect on Schore’s work than I. I’ll leave explanations and analysis of his work in your capable hands.

        You hit the nail on the head with “economically driven”. Money is the power driving the steamroller masquerading as medicine that flattens so many people.

        All the best,
        Alice

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  4. 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.

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    • 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

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      • Steve,

        Thanks for answering this question so well. This is the truth. Psychiatrists are workers with kids and payments like the rest of you.

        The psychiatrist who stood up about the “no diagnosis” worried that he would lose his job over it.

        Since I’ve been speaking out about the problems in psychiatry, I have been labeled as anti-psychiatrist and anti-medicine when I am neither. I have been approached with anger and suspicion by a psychiatrist I worked with for eight years and treated as if I’ve lost all competency as a professional. Although I haven’t yet been called a Scientologist;-) No one would consider employing me once they Google my name. Professionally, I’m creamed chipped beef on toast (S.O.S.) from here on out. I can blame no one who declines to speak up.

        Alice Keys MD

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        • Qiute – and I hope people solute you for your honesty and bravery in your decision to speak out.

          I think the pressure to water down the message is not just from professinals. I recently found a group of psychiatri survivors not wanting to offend other service users by telling it as it is – sigh.

          I had a worker write to me to say she could not work with me on a voluntary project because I had written a letter that was critical of psychiatry to the local paper because I was disgusted with the way a friend was being treated by the services.

          The drug based paradigm is so central to contempory psychiatry that to criticise it is so often taken as a personal insult people employed in the industry as well as being totally against so many organisations central policies.

          At the same time in order to win we need to find workers who are open to this message, no matter how small their agreement with the central ideas of Mr Whittaker’s books or other key texts, anything that gets workers to take on a bit of this message is important.

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          • John, I find have to tip toe around friends who allow their children to be drugged. They are not asking my advise. I am not their doctor. I can express concerns and direct them to reading material. A serious rant would simply drive then out of my life. It would not get them to re-think.

            “A man convinced against his will is of the same opinion still.”

            I find that peaking up against prevailing beliefs requires great tact.

            Alice

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          • I’m certainly not faulting professionals who don’t speak out. After all, I work in a state hospital where I witness constant harm done to people by the so-called “best treatment” and I haven’t spoken out; yet. I need the money that I make there plus I realize that if I speak too soon I will also be chipped creamed beef on toast. It’s a delicate process to try and build a support base for our ideas within the very system that harms people on a daily basis. It’s like being in the belly of the beast. T go home every day feeling very guilty that I’ve not done more. I’ve been “feeling out” staff who might be open to new ways of doing things and I now know what the resistence fighters in the French Underground must have felt like. It hasn’t come to the point of having secret signs or special handshakes yet, but you never know! One false step, one uncautious word and you’re chipped beef! But, I just received a commitment from the administration to hire peer workers on every unit of the hospital over an extended period of time and I’ve been given permission to lead groups on three units of the hospital. It doesn’t seem like much but it’s taken almost two years to achieve this. So, I understand about the reluctance to speak out.

            However, I also believe that we’re spinning our wheels until more professionals, like you, begin standing up and speaking the truth about what’s going on in the system.

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    • 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.

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  5. 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.

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    • Jeffrey,

      If I had know back in 1979 what I know now, I would not have borrowed the big piles of money to go to medical school.

      So here we are today,you and I, having made choices we each made in our unchangeable pasts.

      There is only forward to go from here for each of us.

      Thanks for reading and commenting. I appreciate your support of my writing.

      Alice

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      • Hi Alice
        Why not come to us? We need you!

        Scandinavia is not a bad place to live and work .
        Many of the terrible ethical dilemmas you struggle with does not exist in warfare stats.
        We have our problems of course,but my guess is that is easier to work here as a psychiatrist or psychologist.

        I am serious.
        You are welcome and needed.

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        • Licinia, where in Scandinavia? Even a professional as diplomatic as Alice Keys wouldn’t have a chance in Denmark. Also, access to therapy is limited to certain labels only, while all that others secure you is drug “treatment”, and maybe some “psycho-education” teaching you about your “illness”. Without a label nothing goes, and social workers have the nasty habit of sending just about everyone, no matter what their problem, to a psychiatrist, because, as we all know, if you’ve lost your job and/or your home, or whatever else misfortune you’ve experienced in your life that make it necessary for you to ask for benefits, the reason must be that you are “mentally ill”. And sure the psychiatrist will find that you are, and write a prescription, which the social worker then can use to tell you that if you don’t pop the pills, you can’t get benefits…

          “Welfare” is a beautiful word, but as the saying goes, don’t hold everything as gold that shines like gold.

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          • Marian,
            Thanks for checking in here and telling us about how things are in your neck of the woods.

            Wow. In Denmark it’s like this, too? I’ve been asked to treat acute and chronic homelessness, acute and chronic unemployment, addictions, relationship breakups, house fires, divorces et cetera, with psychiatric drugs.

            And yes. “Psycho-education” is what passes for psychotherapy. This is to “educate” the patient to the illness and the need to keep taking the meds as prescribed.

            All that shines sure isn’t gold. So not to the Scandinavia for me, eh? 😉

            All the best.
            Alice

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          • Hi
            I live in Norway.
            I am not qulified to answer the questions about Alice’s possibilities here.
            Personally I have used psychiatrist and psychologist that I can use nearly for free due to the welfare state health system. But I have also used therapist that came here from America,UK . That worked outside this system. But this was in the eighthies with PrimalScream ….And other alternative forms of therapy was available in Oslo.

            And if I have money to pay I can use the psychiatrists and psychologist that have private praxis . But for me it would be very expensive to use
            them.

            But for lots of persons here the cost is not an issue. And our Universities have to turn down 25-50 students each week that ask for help. We lack professionals in this field.
            It is fight to find a person that has knowledge about what bothers me,and like me. I would never ever let anyone” mess with my head” unless I trusted he or she did not harm me in any way.

            And for that reason I have lived through my crises alone since 1987

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  6. 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

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    • Richard,

      Thanks for checking in. I appreciate your support of my writing.

      Good for you speaking up. It takes all styles and flavors of speaking up to be heard.

      I also speak up. Check under the “rant” tab of my personal blog for other things I speak out against in my writing:

      alicekeysmd.wordpress.com

      I’ve learned through a variety of “speaking up” experiences over time that I can only speak up for myself and not for others. I live with the consequences of my own speaking up.

      I can’t choose for another person.

      So I’m probably not going to join the APA in the hopes that I could create havoc.;-)

      But I will keep reading, thinking and writing. And talking to anyone who will listen to me.

      All the best.
      Alice

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      • Alice

        I DO support SOME of your writing (especially your exposure of our broken medical system) but I cannot support other key components of your writing.

        You say “I can only speak for myself…I can’t choose for another person.”

        These are COP OUT kind of statements and actually hide the fact that you do indeed speak for other people and are trying to influence people in a certain direction with your writing. And I choose to question the thrust of this part of your message.

        You are in a unique position with your credentials, knowledge, and experience to shake up this OPPRESSIVE system from within. It’s not just the fact that you choose to back away from this opportunity and responsibility that history (accident of birth together with your hard work) has afforded you, but you promote and defend this position with this “who am I to tell someone else what to do” approach.

        If we don’t DARE to develop and advocate for (and I know I could pull out of you specific ideas about a different way to organize a new medical system) some alternatives to the current madness, then this just assures the fact that the present system (and those promoting it) will continue its’ daily destruction of human life and spirit. Your writings DO tell people what to do without acknowledging that fact; they sometimes are telling people it’s not worth the struggle on a macro level, “just act locally”, write a blog, focus on your kids, and that ideas about “dismantling systems” are just too confrontational.

        It’s certainly your choice to have these views, but don’t pretend that your not, in your own way, telling people what to do.

        The fence you are walking on is rapidly becoming a razor blade; no side will escape the potential dangers of that blade. My sense from your writings and from the overall feistyness of the inner character that you project, is that you will soon be headed towards the barricades. This system has a way of doing that to many people who temporarily choose to stand near the side lines. I hope to see you stepping out in the future.

        Respectfully, Richard

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        • Hi Richard

          Respect Alice’s personal borders.
          We go on the barricades when we can. Never push or demand that another person go further than she can cope with.

          We have a deep tragedy in Norway this week. A young brilliant Muslim woman from Syria ended a mental hospital in Sweden in total collaps and suicide attempt.

          She has been alone on the barricades for lesbian Muslims, transgender persons,immigrants,Syrians. She is brilliant,received lots of prizes

          Now she write to us from the mental hospital and tells us they she gives up,and withdraws her public voice.

          And she also fled from Norway to Sweden in hope of a new start.

          Those that go on the barricades must be respelled and never pushed. To do so is to use and exploit an other human being.

          But I see you point of course.

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          • Licinia,
            Thanks for bringing this tragedy to light. I depend on people like you to keep the information channels open.

            Yes. We all speak and write as much as possible and to the best of our personal abilities. I certainly do.

            And I’m not certain where these “barricades” I’ve heard about lay or what the exact behavior I’m supposed to be demonstrating there may be.

            All the best.
            Alice

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        • Richard,
          I appreciate your personal outspokenness and your contributions.

          At the same time I am unclear where these barricades lie that I am to go to and what the expected behavior would look or sound like.

          Forgive my brief response. I lack my usual access to an internal “reply” button. I am limited by this.
          Alice

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    • 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

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      • 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

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          • well the history of the Survivor Movement talks about a occupation of the Paddington Hospital when it changed from a therputic community to more drug based treatment IN 1971 – 72. http://www.amazon.co.uk/Asylum-Action-Paddington-Therapeutic-Communities/dp/1843103486

            Some friends of mine recently climbed the chimney of a proposed gas powered electricity generating station to protest about the UK goverment energy policy and how it is influenced by large corporations and is watering down the governments climate change commitments (weak as these are).

            And I was part of a Greenpeace crew that sat on the houses of parliament prior to the Copenhagen Climate negotiations (flop though the negotiations were I’m glad I did it).

            Now there is a theory of social change which says that movements need this kind of rabble rousing to take off, becuase it gets the attention of the mainstream. This then allows reformers who work through government and bureacratic channels to get thier voice heard.

            We all choose how we use our voices. No one should be forced to take part in any activity they don’t want to do, or are not ready to do. That is a basic rule of people who engage in direct action. You writing your blogs maybe having a bigger impact than you realise and I for one am not suggesting you do anything else but write them and enter into the excellent debates in the comments below them. Sititng in cafes and discussing these issues with friends is a valid choice and also will have some impact, as is going to mental health conferences and asking awkward questions as Richard proposes doing. I’m choosing to sit at home and make apple pancakes at the moment but that doesn’t mean that this perticular bit of theory, that a bit of rabble rousing, allows social change activists to get their voices heard, is wrong, it is just a matter of whether people want to do them and if so how and with what precautions.

            A few years ago I tried to organise a sit at a psychiatric institution to protest drug company dominance and forced treatment but I couldn’t find people who wanted to join it. I did get a speak out with a quite good number in attendence and an article in a national newspaper. I tried to organise a protest group, and although it has had it’s successes it is hard to organise very confrontational protest with people who are really worried about being forced to have psychiatric treatment against their will and it is hard to organise with people who have very high levels of trauma where almost every communication is laced with minunderstanding.

            However a Yes Men type event where a fake website from a drug company apologising for all the harm they have caused and saying how actually schizophrenia is caused by trama and not bad genes is entirely possible. A friend and I disgussed it some time ago, so far no action though.

            I sometimes mix with people who have done direct action, mainly around the environment, often with an anit-capitalist edge, and I’ve done it myself. I see this type of action lacking in this struggle. Your comments below, about the dominance of capitalist corporations show the link between these struggles. Once you get your head around it the possibilities are endless both in terms of possible targets and techniques. Invading a hospital dressed as drug reps and shouting, “keep handing out the drugs, it pays my wages, marvellous job you’re all doing. Never mind the brain damage. Marvellous.” Banner drops, office invasions, disrupting conferences, die ins at pharmacies, online petitioning of CEO’s of Big Pharma after an occupation of his “anti-psychotic” manufacturing plant.

            OO, my mind gets all over excited at the prospect! But for the moment I shall make the next apple pancake batter and read a good book, because that is where I am right now and finding people who want to do these things is difficult.

            Well you asked, and I hope you find my writing enlightening. Yours is very englightening, drawing in the overall economic picture and also the individual choices which elaborate psychiatric treatment in the USA, and unfortunately the majority of the developed world.

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  7. 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

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        • Duane,
          It’s so nice to hear from you. I love it when people do the math. It does simplify understanding things a lot.

          One really must follow the dollars. To do this you have to know where they go.

          I have seen several thousand dollars (3+) a month go to one person’s drugs. Poly-pharmacy is the rule now, not the exception. During job interviews (I’ve been on a few this year) I talk about wanting to reduce and simplify drug regimens as a general approach. Providers cringe at the thought of less and fewer drugs. One woman said “I don’t want to see anyone get hit.”

          There is this idea that all the drugs are keeping people safe. If you lower the drugs the patient will hurt someone. I don’t understand it. Perhaps through the media? I don’t watch TV.

          All the best. I’m glad to hear you thoughts.You may have to start a new chain in the comment zone, though.
          Alice

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          • Alice,

            It seems we have the cart before the horse. *How* people get paid before *what* they get paid for.

            Greed is certainly a problem – with Pharma. But also is the need to control – on the part of both the government along many in the psychiatric system.

            We could do so much more, with so much less (greed and control) if we would begin to think out of the box and try something new!

            Best,

            Duane

            Report comment

          • wow, and I thought Open Dialogue was expensive! I think the economic arguments with service commissioners are ripe for being put forward for effective psycho-social alternatives if so many people are being put on such an expensive mix of drugs

            Report comment

          • John,

            I have to wonder if the federal government is concerned with spending.

            They can either borrow or print.

            For the states, it’s a different matter. Which IMO, is *why* the feds want to take on health care. It’s not about saving money, it’s about power.

            Duane

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  8. 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

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    • 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.

      Report comment

      • AA

        Thanks for your support of my writing. This means a lot to me.

        I don’t know when we got to this point where a patient can leave an acute hospital after a few days on seven new drugs. But here we are.

        This frightens me.

        And the outpatient doctors may be afraid to make reductions. Any problem, whether from reducing the drugs or not, is pinned on the drug reduction.

        I didn’t hear “hypocrite” so much as I hear someone who hopes that I can do more than I have been. I understand this desire. There’s a lot to do.

        Alice

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    • Licinia,
      No offense taken. Lot’s of us living inside the US look at our medical system in horror as well. I’ve been unable to get safe adequate medical care for my family for the past 20 years and I’m an outspoken physician with “good” insurance. Our approach is to work hard to stay healthy and avoid medical contact.

      I love to write. I can do this without burnout. My writing sometimes takes other forms but it continues unabated.

      Many smiles to you and to all readers.
      Alice

      PS I am troubled by access to “reply” here. I haven’t given up though and work around it.

      Report comment

  9. 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

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    • Richard,
      I agree. You have never called me a hypocrite. Plus I have felt supported in my writing and activism efforts by your reading and commenting here.

      Yes indeed. You have caught me in the act of writing in such a way that I tell people what I think they should do. What good is writing opinion if one cannot work to be persuasive as a writer?;-)

      One thing I’ve learned about people is that they don’t want advise unless they ask for it. And maybe not even then. People often ask what I think as an opening to argue at me.

      There is nothing I enjoy more than having people ask what I think and then listen. I think a lot about a lot of things. I have strong opinions. I’m a rather good talker.

      As far as my own personal activis,m I take daily steps against a number of horrors perpetrated in the name of progress. For example, I park my car and walk most days. Cars are the number one cause of death in the US for ages 8-34 and runs a close second in other age groups.

      I think each person has to choose their own fights. And I respect however they get there. After all, I drove a car every day for years.

      Keep writing. All of our voices are important. All of our personal efforts count.

      Alice

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  10. I had to start a new thread here. I copied this post forward so I can reply:

    Discover and Recover on March 5, 2013 at 10:59 pm said:

    Alice,

    It seems we have the cart before the horse. *How* people get paid before *what* they get paid for.

    Greed is certainly a problem – with Pharma. But also is the need to control – on the part of both the government along many in the psychiatric system.

    We could do so much more, with so much less (greed and control) if we would begin to think out of the box and try something new!

    Best,

    Duane

    Duane,

    Thanks for you hopeful and helpful voice here. Thanks for your emphasis on following the big money trail. This is crucial in any understanding of the situation we face.

    Alice

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  11. I’m stating a new thrread so there is room to respond to this writer. I have copied his comment here:
    John Hoggett on March 6, 2013 at 7:09 am said:

    wow, and I thought Open Dialogue was expensive! I think the economic arguments with service commissioners are ripe for being put forward for effective psycho-social alternatives if so many people are being put on such an expensive mix of drugs

    John,

    As you point out, it is not the expense that gets in the way of changing direction in delivery of healthcare. There are known cheaper, safer and better approaches that are not being used just as there have been safe, fuel-efficient cars for decades in Europe that never see the light of day in the US.

    Where does the power lay that keeps all this happening? Let’s see… Is it in the hands of hourly wage-slave doctors? Hmmm…

    One could almost believe that giant capitalist corporations can reach across international and political boundaries with more ease and fire power than people. One could almost believe corporations have been granted immortality and basic human rights by the courts.

    As John Steinbeck wrote in his book “Grapes of Wrath” “The monster isn’t men, but it can make men do what it wants.”

    But where to go with this…

    Alice

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  12. 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”

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    • Marcella,

      As an old cynical behaviorist myself, I can see some sense in what you say.

      One must not, however, underestimate the effects on an individual of submersion from birth in a cultural matrix put into place and maintained by the six corporations that own all information in our country.

      With this in mind, one has to step back a bit further and wonder who is selling what to whom. And by what means.

      All the best. Keep reading, thinking and writing.
      Alice

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  13. I am starting a new thread here by copying this post:
    Discover and Recover on March 6, 2013 at 9:27 pm said:

    John,

    I have to wonder if the federal government is concerned with spending.

    They can either borrow or print.

    For the states, it’s a different matter. Which IMO, is *why* the feds want to take on health care. It’s not about saving money, it’s about power.

    Duane

    Duane,

    If it doesn’t seem like government is interested in saving money, they’re probably not.

    Government is bought and owned by corps. Bottom line is more cash funneled into big pockets, not “savings” or “health care”.

    Alice

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    • I’m wondering how you realized or discovered all of these things. I’m truly interested in what it was that brought you to where you are today in your thinking? In my old age people are trying to call me a conspiracy person becasue I’m coming to some of the same conclusions that you’ve already made. What was it that helped you to remove the “veil” so you could see the reality of what the man behind th curtain is really doing in our country? It was my awful introduction to biopsychiatry and the so-called “mental health system” that began to open my eyes and now one thing leads to another.

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      • Stephen,

        No television (or other media) for 11 years. Learned another language and traveled outside the country to hear what they really thought and why. Read LOTS if non-fiction and history. Talked to people and listened. Paid off my debt so I could afford to open my eyes and ears.

        Tolerated being called names like “conspiracy theorist” 😉 and “too radical to work here”, even when they weren’t joking.

        **When things didn’t make sense, I looked where the money went.** This always leads you to the man behind the curtain.

        Thanks for asking. Really.
        Alice

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    • Alice,

      Sadly, I agree.
      It’s called ‘Crony Capitalism’.

      It’s a partnership between big business and the feds.

      The ideal model would be for the government to protect the people from harmful drugs with oversight. Along with protection against psychiatry’s obvious monopoly in what should be a free market.

      The Mediaid situation (often the largest line-item on states’ budget) is a huge problem – fraud run rampant. The drugmakers continue to pay fines back to the states, but there has been no recourse for those individuals and families who were injured.

      The feds approve the drugs.
      They let the pharma companies market them – fraudulently to the states and the people.

      Then the state AGs sue the drugmakers.
      The states recover their money.
      And the drugmakers market more drugs.
      The cycle starts all over.

      I’m not a genius.
      But something is *wrong* with this picture.
      As in, “The fox guarding the hen house.”

      Crony capitalism.
      Not good.

      Duane

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  14. 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

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    • John,
      “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.”

      Good thinking here. Always follow the cash. This also sounds like a great government marketing PR spin for arms and pharm corps.

      Is it possible that a Soteria house that “uses much more medication” may simply be named Soteria?

      Once upon a time I was hired by a clinical director who said her goal was to use psychiatrists for roles other than prescribing pills. Many months into this job I asked when those other parts of my work would begin. She laughed and said “Oh. That’s just a goal. We’re not really going to do it.”

      Go by behaviors over words every time. (I say this to the choir.)

      Thanks for reading, thinking and writing.
      Alice

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      • Lol – well I did boo the guy from Holland about how they pressured people in the unit to take the drugs after a few weeks if they were not coping and then suggested they take them for two years after they leave. Not much difference between that unit and convential psychiatry.

        But he had succesfully used the economic argument to win his case and I thought that was interesting and potentially useful. I started doing back of a risperdal packet calculations on the cost of Open Dialogue and comparing it to hospitalisation, and now to polydurgging. It comes out quite favourable. Whether people will listen to a proposal for a small volunatry secter run unit funded by an NHS commmissioning body is another matter.I don’t have the business or clinical expertise to put a serious proposal together. Also, I don’t think small units are necersarrily a big challenge to organised large power structures, nice though they are to see happen.

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  15. To John Hoggett: (Ran out of thread to reply so continued here)

    I’m delighted to hear of your exploits and of your apple pancakes. I personally bake my own bread by hand every day in protest of the awful stuff passing for bread here.;-)

    Protests here are a bit difficult as well. Our occupy movement was swept away. Many were jailed. All gone now.

    Our homeland security now collects and stores all internet data and communications. They started doing this while it was still illegal then back-dated amnesty for themselves.

    Last year our president signed into law his right to use the military to arrest American citizens on American soil and hold them indefinitely in detainment areas without legal recourse based upon vague suspicions. Our supreme court just upheld this last month.

    This puts a damper on protest movements and journalism.

    I occupy my kitchen and cook my family’s food. I occupy my feet, park the car and walk. I occupy my own words.

    Today, in the USA, writing and speaking of concerns has risks beyond simply being branded too radical to be employable for the rest of ones life.

    Yes. Each of us does do what we can.

    I rather enjoy the French and their constitutional right to public protest. It’s seen as an ordinary part of being French people. They don’t have to deal with tear gas, rubber bullets and incarceration when they speak up in public.

    Well. I have to go knead up the dough for our morning baguettes.

    Much love and peace.

    Alice

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      • John.
        I don’t know much about eggs and pudding or “incipient fascism”. It’s the law here and now. Our beloved Obama has also granted himself the personal privilege to order military executions of Americans abroad as well. Plus he’s using the WWI Espionage Act to prosecute and imprison Federal employee whistle blowers.

        Do you suppose we’ve wandered off topic? I tend to do this. Legalization of executive and military human rights violations may have nothing to do with legalization of human rights violations in psychiatry.

        Just call me crazy.;-)
        Alice

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        • Well it’s all much of a muchness. The state gets more militaristic and repressive (or icipiant facism as I put it) and the rest of society follows suite – to the monetary benefit of large corporations.

          So it is possible to see themes in these two topics. It’s ritalin and an early bed if you play up my boy – or it’s putting on a list and threats of imprisonment, solitary confinement in inhuman conditions (Bradley Manning for example) or torture or state sanctioned murder if you seriously threaten the state.

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    • There’s something very calming and peaceful about kneading dough! I was going to say theraputic but I try not to use the system’s vocabulary if I can help it. Making your own bread also keeps you from ingesting all of the additives in the commercial stuff that passes for bread. I bought a bag of onion rolls from the store and put them on top of the fridge and forgot about them. Four months later my roommate found them. There was no mould etc. and that convinced us that whatever the additive was that kept that from happening couldn’t be good for a human being to eat!

      Nutrition is so important for healing and wellness and cooking things from scratch is one way of benefiting yourself when you’re trying to remove yourself from the system and get healthy.

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      • Stephen,
        Just me and a sack of organically grown flour.Yes. I know what you mean about the bread not spoiling. A contractor threw the bread from his sandwich outside on our wood pile for the birds to eat. We found it, unchanged even by the rain, months later. The birds and all the other creatures in our wooded yard knew better than to eat it.

        The other great thing to make is vegetable soups and stews. We have “miscellaneous vegetable soup” most days. Whatever is in season. There is no better personal health and financial skill than knowing how to throw together a pot of cheap healthy fresh vegetable soup.

        Oops. Perhaps I’ve wandered off topic again. But like you say, anything that supports healing and wellness will benefit those trying to remove themselves from the system and get healthy.

        All the best. Be well.
        Alice

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  16. 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?

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    • 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.

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      • Stephen,
        Good job with your answer. I added a few other comments in my reply to Licinia but you’d already covered things well. Thanks.

        “Seven or eight drugs” changed rapidly. This horrifies me. Since we don’t know why or if any of the drugs work one at a time, there is no way to know what’s going on inside a human body when you have a chemical soup like this. “Prescribing” of this sort is unconscionable.

        I’ve seen many people released from hospitals on soups like this. Doing this in private hospitals over a few days has become the norm, not the exception.

        I’d almost have to believe drug sales people are in charge of “medical education”. Oh wait. Sorry. That’s right. They are.

        If people in charge of the purse strings can’t be led to have concern about basic human safety, perhaps they could be encouraged away from allowing these terrifying drug combinations with a financial argument?

        All the best.
        Alice

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        • My former roommate went to a private hospital a few months ago. He was on an antidepressant that wasn’t working. When he came back four days later he was on a higher dose of the antidepressant that wasn’t working AND an antipsychotic! When I asked him why he was on the antipsychotic he said that the psychiatrist said that the antipsychotic would “jump start” the antidepressant and make it “kick in” and begin working faster and better! I stood there looking at him in shock and finally asked if he believed such bull manure. He weaseled and waffled and never really gave me an answer because I don’t think he really believed it, but he continued taking the combination!

          When I was a patient in the same hospital where I now work I would listen to numerous patients talk about how badly the drugs made them feel and how they had begged their psychiatrist to stop giving them the stuff. Many were on numerous drugs. I would watch them as they could barely stand up and walk, as they jerked and shuddered and experienced uncontrollable body movements. I watched them gain weight very quickly. They looked so miserable and there was no doubt in my mind that they felt terrible. Often, the two psychiatrists on the unit just upped the doses or added more drugs. It made my heart break on a daily basis. It still makes my heart break on a daily basis. Every morning that I get up I thank my lucky stars that I’m no longer a patient there!

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          • Stephen,
            This breaks my heart as well. Even as a psychiatrist on the “inside”, I could do nothing to stop this.

            The anti-psychotics are being marketed as the “jump starters” for antidepressants. What you wrote is straight out of marketing literature.

            Alice

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      • 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.

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        • Licinia,
          Pets do get better care, even better than our children. The rates of immunizations are higher among dogs than among children.

          I apologize in advance for the language I use but can’t think of a better way to say it: Medical care and psychiatric treatment is pretty crazy here.

          Thanks for your sympathy with our struggle.

          Alice

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    • Licinia,
      Stephen has this right.

      Psychologists are not medical doctors. Psychiatrists have gone to four years of college then four years of medical school to become physicians before training an additional four years as psychiatrists.

      Alas, psychiatric training has devolved to “prescriber” training as drug companies have taken over funding for education. This is true in all branches of medical training.

      In my own training as a psychiatrist (long ago) I learned many approaches and theories of psychotherapy, human behavior and psychology. This type of training is a thing of the past in the US.

      I’ve heard that psychologists (who have no medical background or training) have been granted “prescribing privileges” in two states and in the American military so far.

      Social workers have been lobbying for prescribing rights in Oregon for years.

      In Oregon, any person with a “masters” level degree in any social related field (teaching, ministry) can make and give a psychiatric diagnosis. This used in schools to label children and force drugs on them. Pediatricians end up prescribing based on teacher recommendations.

      The schools deny education to “non-compliant” families. Without the day-care provided by schools, this can mean loss of job and home. School teachers, in effect, are prescribing drugs to children through this multi-step process of coercion.

      These policies are decided state-by-state so I can’t say how this works in the other 49 states.

      All the best.
      Alice

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  17. 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

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  18. Harper West,
    Yes. The DSM is deeply flawed. It was written by committees made of people with conflicts of interest.

    These deeply flawed diagnoses are used to grant or deny people access to basic health care, housing, and incomes. They are used to direct drugging through “standards of practice”.

    These deeply flawed diagnoses are also deeply entrenched.

    Thanks,
    Alice

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  19. 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.

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    • Marcellas,
      Thanks for reading and writing.

      How would you see the legal system being involved as a national forum? Are you thinking of law suits filed by patients who’ve been harmed?

      Certainly case law has given directives to the practice of psychiatry. The “duty to warn” required breach of confidentiality and involuntary commitment laws both came from legal mandates to protect.

      I know there are financial conflicts of interests in mental health care. It is in the best interest of clinics to get people on disability as soon as possible.

      Clinicians see this as doing the patient a good favor by making sure they get health insurance and money to live on. This also creates long-term paying customers as a side-effect.

      Getting people on disability is lucrative for drug companies. Disability comes with government health insurance to buy drugs with.

      Now that medicare has part “D”, this government insurance covers drugs for the disabled and retired. I am told that this was a hard fought battle won for beneficiaries.

      I’m sorry for your struggles at work. Yes. Speaking up puts jobs at risk no matter how gently one speaks up.

      Alice

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  20. 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.

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    • Alexa42,
      Thanks for reading and your very well considered comment. I especially like the support group your describe:

      “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.”

      This sounds like a way to level the playing field (a tiny bit). I have coached people on what to say or not say as well to prevent unwanted outcomes and to increase the possibility of desired outcomes. I don’t tell them exactly what to say, just what words tend to trigger what responses.

      People are not always functioning well enough to chose their words carefully during a crisis. I tell people to always bring a friend or family with them who they trust when seeing any doctor for anything. I do this myself.

      Thanks again for your kind words and your support of my writing.

      Alice

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  21. 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.

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    • Marcellas,
      Hang on to your job as long as you can.

      It sounds like you are doing much good there. Keep speaking up however you can. People may be hearing and be on your side but not be in a position to speak up more yet.

      Thanks for your kind words of support.
      Alice

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  22. 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

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    • Seth,
      Thanks for joining this conversation. I appreciate your support of my writing.

      Thanks for your well-written view point.

      I wrote this article from the perspective of a well-meaning professional who is doing his best within the system as it exists today. There are many layers to everything.

      I did not intend to take on the validity of the DSM in this article. I try to keep things to a circumscribed enough topic to complete my thought without writing too long. I don’t want to lose my audience by taking on too many issues at once.

      It sounds like you are well-versed in the issues inherent in the DSM. Thanks for bringing this important aspect to the discussion.

      Keep reading, thinking and writing.
      Alice

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  23. 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

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    • Seth,

      Thanks for your vibrant response. Energetic voices such as your are needed. Every voice counts.

      You may be making a couple of incorrect assumptions with regard to the APA. It sounds to me as if you think all psychiatrists are members of the APA and that it operates as a voting democracy.

      I have not been a member since I had to be for their sponsored professional liability insurance (that went belly up) many years ago.

      A psychiatrist buys APA membership with annual fees. For this he/she receives journals filled with drug-sponsored research and ads, is placed on endless junk maillists and has the opportunity for reduced rates to attend the annual meeting (and hear about drug-sponsored research). I think there may be is a political lobbyist and a polite answering service.

      If there is much more to APA for most members than this, I have no idea. I suppose some write membership it on resumes as if it means something more. There are committees and officers. I have no idea how one gets to be one of those.

      Thanks for sharing your paper.

      All the best.
      Alice

      The APA membership is not invited to vote on diagnoses.

      In this essay I did not venture into whether the diagnostic system is valid or not. I try to limit myself to one issue at a time.

      There are other lovely essays on this site that address validity well. Thanks for your own shot at this.

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    • Seth,

      I can’t speak for anyone but myself on the arithmetic. I have my own numbers well in hand.

      No drug consultation fees here. I didn’t “escape the riff raff”. Private practice wasn’t lucrative even when I did cash-up-front work. I paid everyone except myself the last two years of private practice before I closed up shop in 2003. I was going to have to add money from my husband’s job to meet the overhead.

      Alice

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