Harm Reduction & the Elephant in the Room: End DSM Dependency

Jack Carney, DSW
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Introduction: The article below was originally accepted for November publication in a small British academic review for psychology students. On the heels of its acceptance, the article was rejected by a senior editor who, for unknown reasons, decided that what I wrote and what you will read below was “over the heads” of the poor benighted students. As a consequence, I’ve been allowed to salvage my status as persona non grata to academia, a dubious but proudly worn badge of honor, and been afforded, dear reader, the opportunity to provide you with a summary of the major ills ascribed to the new DSM and a brief review of alternatives to the use of DSM or any diagnoses.

The focus of the latter will be the anti-diagnosis approach being developed by the UK Division of Clinical Psychology (DCP) of the British Psychological Society (BPS). Lucy Johnstone, one of its more prominent spokespersons and an MIA blogger, has termed their approach “psychological formulation,” which, in very short order, has been incorporated into the DCP’s training curriculum for novice psychologists. It is also the approach that the Committee to Boycott the DSM-5, for which I serve as national coordinator, will be promoting when we launch our No-Diagnosis Campaign sometime this Fall. More below and to follow.

Charges vs. the DSM-5: If you’ve been paying attention the last two years, you’ve seen the new DSM-5, as well as its predecessors, taking a beating from a variety of critics pre- and post-publication. Their observations have been pretty direct.

• Most have begun by noting the work of Kirk and Kutchins and, later, Bentall, who documented the lack of construct validity of DSM’s diagnoses, dating from the landmark DSM-IIIR in 1987. All three concluded that, given the absence of scientific evidence to support their existence, these diagnoses were less likely to represent the neurobiological phenomena claimed by the DSMs’ several authors than to be products of their collective imaginations.

• The DSM-5 Task Force itself has noted the steady decline in DSM’s diagnoses’ inter-rater reliability, i.e., the degree of concurrence among clinicians and researchers about the meanings of specific diagnoses, from one edition to the next – from DSM-III in 1980, through IIIR in 1989, IV in 1994, IV TR in 2001 and DSM-5 this year.

• Numerous American and European critics have underscored that successive editions of the DSM, culminating in #5, have moved the Kraepelinian line demarcating the normative from the presumed mentally ill considerably since 1952, when DSM I was published with 94 diagnoses, to the present and DSM-5’s 300-plus diagnoses. Their similar conclusions – that the American Psychiatric Association, via its DSMs, appears intent on pathologizing the quotidian or day-to-day life experiences of ordinary individuals, exposing increasing numbers to treatment with psychoactive medications.

• Further, the above-mentioned critics, joined by many others, have emphasized that DSM diagnoses are invariably reductive, with rich and varied human experiences consigned to codes which in no way represent those experiences; which offer no explanation for them and, consequently, no remedies for the problems and distress for which prospective patients are seeking help, and no prognoses or predictability that prescribed treatment will actually work. The critics’ conclusions: DSM diagnoses bear no resemblance to medical diagnoses and are, at best, to be regarded as class- and culturally-biased guesses.

• Finally, the APA and the DSM-5 Task Force found themselves obliged to admit under the unrelenting scrutiny to which the new DSM was being subjected that the long-awaited biomarkers, i.e., the scientific evidence which would support the existence and validity of the APA’s putative biomedical model or biological etiology of mental illness, had yet to be uncovered.

An immediate adverse consequence was the very public decision made by Thomas Insel, Director of the National Institute of Mental Health (NIMH), that NIMH would no longer utilize or support research that employed DSM diagnoses; rather NIMH will spend the next ten years developing its own nosology or disease classification. In short, the primary mental health research institution in the U.S. will not surrender its belief in a biomedical model of illness but will forego the use of DSM diagnostic categories in a continued quest for the elusive biomarkers or evidence of such a model.

Life Without the DSM: So what would life be like without the DSM and its collection of diagnoses? Would clinicians know what to do? Perhaps more importantly, does the DSM help clinicians do their jobs even now?

After the barrage unleashed above, it would surprise me if clinicians were to allege that attaching a DSM diagnosis to a user of their services actually helps them be more effective with that person. I would be immediately put off by the DSM diagnoses’ reductionism, their utter disregard for the person’s life experiences, past and present, where the source and causes of the person’s distress are to be found.

To tell a bit about myself, I administered a case management program in New York City for seventeen-plus years. I oversaw the work of fifty staff members whose job was to help folks who had been given diagnoses of serious mental illnesses re-settle in their home communities after spending varied amounts of time in the State’s and City’s prisons, jails and psychiatric hospitals. Most of the women referred to us – approximately ninety percent – had long histories of physical and sexual abuse; which, if acknowledged in the “psychosocial histories” attached to their referral packets, appeared nowhere in the treatment plans developed for them by their institutional caretakers. Their usual diagnosis was “schizoaffective disorder,” to which we paid little attention since it held no meaning for us or for our clients.

Our concern was the behaviors – drug use, prostitution, petty crimes – that would get our folks re-institutionalized, and our primary strategy to help them learn more self-protective behaviors was via the relationships that they formed with the case managers working with them. Over the course of time they told the case managers their stories, enabling the latter to become less judgmental and more empathic and facilitative. Although we never designated it as such, our case managers were engaging their clients in a rudimentary form of “narrative therapy”, which is a collaborative venture designed to help the person using the service develop a more complete narrative or richer comprehension of life events previously excluded from her/his understanding of her/his problems. As per White and Epston, who originated narrative therapy, “the person is not the problem, the problem is the problem.” Bentall, in a similar vein, stated not too long thereafter, “Once these complaints [or problems] have been explained [and understood], there is no ghostly disease remaining that also requires explanation.” In short, to quote from a piece where I referenced Bentall, “… only the “ghosts” or faint memories of their presumed illnesses will remain and there will no longer be need for diagnoses.”

Psychological Formulation: We’ve got a long way to get to that point. The Division of Clinical Psychology of the BPS has taken the lead in the UK to get us there. They just issued their manifesto, “Time for a Paradigm Shift,” this past May, more on which below. Their counterparts in the U.S., Division 32 of the American Psychological Association, led by Brent Robbins, are about to initiate their “Diagnostic Summit Committee,” to discuss alternatives to the DSM nosology; our Committee to Boycott DSM-5 is planning to launch our “No-Diagnosis” Campaign this Fall, which will oblige us to investigate alternatives; and the Stop-DSM Committees in Paris and Barcelona, headed, respectively, by Patrick Landman and Carlos Rey, are planning similar ventures.

Lucy Johnstone and her colleagues of the DCP seem several steps ahead. As per Lucy’s several blogs that I’ve had the chance to read, they’ve been examining the issue of alternatives to diagnosis, DSM or otherwise, since at least 2006. To quote from one of her January, 2013, MIA posts, “[Psychological, as opposed to psychiatric] formulation can be defined as the process of co-constructing a hypothesis or ‘best guess’ about the origins of a person’s difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them … Unlike diagnosis, it is not about making an expert judgment, but about working closely with the individual to develop a shared understanding which will evolve over time.” She proceeds to address the role of the professional helper: “The central task of all … professionals is to work alongside service users to create meaning out of chaos and despair.”

Finally, in a subsequent post, she issues a stern caveat to prevent the concept of psychological formulation from being distorted or co-opted: “The most important and controversial issue is whether formulation is used as an addition to, or an alternative to, psychiatric diagnosis… It was for this reason that we wanted the [Psychology Training] Guidelines to draw a clear distinction between psychiatric formulation and psychological formulation – the former being an addition to diagnosis and the latter being an alternative.”

Johnstone and colleagues won their point. As she notes, “… the following best practice criterion was agreed [upon by the DCP membership]: psychological formulation as practiced by UK clinical psychologists ‘is not premised on a functional psychiatric diagnosis …’.” Ever the pragmatist, Johnstone understands that the treatment system within which we work will not readily allow individual psychotherapists to freely practice and implement psychological or what I would term collaborative formulation. In the U.S., the best individual practitioners could hope to achieve would be to use collaborative formulation as an add-on to the obligatory DSM or ICD diagnosis, precisely what Johnstone warns against. Accordingly, as a strategy, as well as a methodology, she suggests a team approach to promote the use of formulation and provide necessary support to those who want to employ it in their practice in lieu of diagnosis. The difficulty here, and part of the struggle to change, is to find a venue that will tolerate even that.

Final Thoughts: If you should insist on working with diagnoses, I would suggest you lobby for the incorporation into the next DSM – my guess is that there will be one – Bentall’s “proposal to classify happiness as a psychiatric disorder.” Specifically, he proposes in the abstract of the article he wrote under that title “that happiness … be included … under the new name: major affective disorder, pleasant type. In a review of the relevant literature, it is shown that happiness is statistically abnormal … and probably reflects the abnormal functioning of the central nervous system. One possible objection to this proposal remains – that happiness is not negatively valued. However, this objection is dismissed as scientifically irrelevant.”

FYI: Bentall published this in 1992. Yup, this stuff’s been going on for a long time. So remember … don’t mourn … be happy, if you’re so inclined … and organize!

References:

Bentall, R.P., “A Proposal to Classify Happiness as a Psychiatric Disorder,” Journal of Medical Ethics, Vol. 18, 1992, pp. 94-98

Bentall, R.P., Madness Explained: Psychosis and Human Nature, Penguin Books, London, 2004

Carney, J., “1984 Revisited: The New DSM,” Behavioral Health News, November 30, 2011, www.behavioral.net

Carney, J., “The DSM-5 Field Trials: Inter-Rater Reliability Ratings Take a Nose Dive,” Mad In America, March 26, 2013

Corcos, M., “How to Measure Human Distress,” 2011, www.blogs.mediaport.fr/blog/taky-varsoe/1711/lhomme-sein-le-dsm-le-nouvel-ordre-psychiatrique-essai-maurice-corcos

Division of Clinical Psychology, British Psychological Society, “Position Paper on the Classification of Behaviour and Experience in Relation to Functional Psychiatric Diagnoses: Time for a Paradigm Shift,” May, 2013,

Greenberg, Gary, The Book of Woe: The DSM and the Unmaking of Psychiatry, Blue Rider Press, New York, 2013

Johnstone, L., series of blogs re DSM diagnoses and Psychological Formulation at www.madinamerica.com/author/ljohnstone:
“Time to Abolish Psychiatric Diagnosis, January 1, 2013
“Thinking About Alternatives to Psychiatric Diagnosis,” January 7, 2013
“More Thinking About Alternatives to Psychiatric Diagnosis,” January 15, 2013
“Using Formulation to Change Team Cultures,” April 7, 2013
“UK Clinical Psychologists Call for Abandonment of Psychiatric Diagnosis and the ‘Disease’ Model,” May 13, 2013

Kirk, S.A., Kutchins, H., The Selling of DSM: The Rhetoric of Science in Psychiatry, Aldine de Gruyter, New York, 1992

Rey, C., “Otras Lecturas: Para Una Clinica Basada en la Clinica,” 2013, www.imaginarte.net/projecyts/otras-lecturas/index_v2.php

White, M., Epston, D., Narrative Means to Therapeutic Ends, W.W. Norton, New York, 1990

9 COMMENTS

  1. As a former Master’s level and state licensed Social Worker with twenty years of experience, I found this article interesting. I saw the change from less is more approach with medication too full blown full steam ahead use of drug cocktails. In the early early years of my involvement medication was not routinely used in residential centers. At times psychdocs would admit a patient for time off drugs to see if there would be a positive change in their baseline. I myself entered the patient world as a result of nonprofessioanal”friends” intervention. None, even the one social work peer they consulted behind my back had my professional experience in Mental Health and the memories of the great work of Family therapy and its subsequent demise as a solid contender. They called my husband and my mother saying a needed a pscyh evaul for psychosoical stressors that were quite beyond normal life. My error was in believing them. I became a “a good patient” and walked down the hellish path of medication which I now believe led my into psychotic states and destroyed some of my cognitive abilities. The trauma I was dealing with has eventually come to be explained and I was right on target.
    I kept on telling the professionals of my over the top stressors but they were forced into labeling me and pushed me into outpatient programs( awful) and hospitalizations (horrific) I knew about Soteria House but was never able to access any treatment program that mirrored it for myself.
    My family supports were weak and ineffectual no one did any research or advocacy so I walked the road alone. It was only Bob’s book and this site that made me sit up and take notice and have the energy to fight back.
    I found it disturbing that case managers at first looked down their clients. That’s a academic lesson of first response in Social Work – start where your clients are at. People aren’t in the gutter many times because of themselves but because of their lived childhood and lives. See Alice Miller’ work which should be on all Social Work Schools primary book lists.
    I don’t think this article was too advanced for students. I say it attacks the atatus quo and brings up memories of how Social Work use to be in the middle of last century. So many of us have quit and the new ones have no memory base to draw from. Thanks for holding the flame of Jane Addams,Dorthea Dix and Selma Fraiburg.

  2. Good work as always Jack. The journal gatekeepers and their censoriousness just show the public that what we are saying is true. An IDEOLOGY is running global ‘mental health’, common sense is certainly not running the show. Very few working in ‘mental health’ are ready to admit they are an ideologue and make a change. Facing the horror that they and the world have been taken a for a ride, a ride where many of the ideologues have been willing to use actual state sanctioned violence to force their beliefs on others, is just too much for most to handle.

  3. Of course I agree with your sentiments Jack, yet, as you point out in your final sentence;

    Yup, this stuff’s been going on for a long time. So remember … don’t mourn … be happy, if you’re so inclined … and organize!

    So why is it that mainstream society feels a need to ignore the reality of all the research and all the book publications? And is the reality of this mainstream ignorance just about the power of capitalism’s predatory nature? Will we still be making the same protests, pointing to the same research findings, and results, like the “open-dialogue” approach, in five years from now? Is there a “subconscious” need, beneath the seemingly obvious in our objective reasoning about what is actually happening in society? Does our usual understandable protesting, paradoxically maintain a mainstream status-quo?

    In the facebook Occupy Psychiatry Discussion group, I’ve asked this same question with a plea to occupy psychiatry with good sense and good science, like the science of psychophysiology I refer to in the chapter link below, which most readers will assume to be just egoic self-promotion;

    In October 2010, when I’d returned to Australia towards the end of a six week long psychosis, I’d spent an evening with my best friend from 1980, and he made this interesting comment;

    ‘That first time, back in 1980, it felt like the real you had come out, then everyone wanted you to go back into your shell again.’
    ( see: A Physiological Foundation – My New Realization?
    http://www.born2psychosis.blogspot.com.au/p/chp-6.html )

    ‘People see it as a breakdown, its so disruptive to the old personality, the personality they’ve become adjusted to, but that old personality was habitually defensive and I needed a breakthrough experience to change an unconscious pattern of avoidance behavior,’ I replied.

    Yet are we really so self-aware, about our subconscious reactions, which stimulate our mind’s sense of reason? IMO Freud’s iceberg metaphor about our human motivation, is as relevant today as it ever was and I don’t believe that we really understand the emotional dynamics involved in the mental health debate. Of course, its about human rights, yet we are treated so differently because our experience goes to the heart of what it means to be human, with the average citizen scared to death, by what people like us go through.

    As Foucault pointed out, our cultural assumption is of reason on the one hand and madness on the other, while reality testing suggests unreason and madness, on a continuum of human experience. Yet, IMO the problem is, that society at large will desperately cling to its image of reason, regardless of inconvenient truths?

    Are we in this community, guilty of the same thing, in this oh so rational, debate? We humans are exasperating and quiet paradoxical, are we not?

    Best wishes,

    David Bates.

    • I’m coming to agree with you. Even those of us who think that we’re very self-aware can be blind as bats when it comes right down to why we do the things we do and feel the way we feel. We may not be as blind as some people but our ability to see properly, especially when it comes to our own motives, is still obviously very hampered. I can only speak for myself, but I think you’re right when you offer that humans are exasperating and very paradoxical.

      My own blindness was brought to my attention just this morning by the bottle of shampoo I’d bought for a friend. Won’t go into the long details here but when I realized how blind I’ve been in my dealings with this friend it hit me between the eyes like a sledgehammer!

      Thanks for the confirmation of my experience this morning of my own blindness!

      • Hi Stephen,

        I know people here get annoyed by my references to Murray Bowen and his seminal contributions to family systems theory. But IMO there are few original thinkers, with most psychological productions being little more than a repackaged, regurgitation of the breakthrough thinkers wisdom.

        People cite the “open-dialogue” program here, and I’am amazed how much people don’t seem to realize how much its based on these seminal ideas, produced in America, in first place. Bowen predicted that a reduced level of individual self-differentiation in society would come tho head in the middle of this century. Quiet the prophet, IMO. Please consider his thoughts about our levels of intellectual/emotional functioning;

        The concept of differentiation of self is important. At the more differentiated end of the scale is the person who can “know” with his intellect, and who can also know, or be aware of, or feel the situation with his emotional system. He has reasonable ability to keep an operational differentiation between intellect and emotions and take action on the fact of intellectual reasoning, that opposes his feelings and the truth of subjectivity. Only a small percentage of the population has this level of differentiation.

        A person can have a well functioning intellect but intellect is intimately fused with his emotional system, and a relatively small part of his intellect is operationally differentiated from his emotional system. He can accurately “know” facts that are personally removed, such as mathematics and the physical sciences, but most of his intellect is under the operational control of the emotional system, and much of his total knowledge would be more accurately classified as an intellectual emotional awareness, without much differentiation between intellect and feelings.

        The person at this level of differentiation does not commonly have a clearly formed notion of fact, or differences between truth and fact, or fact and feeling, or theory and philosophy, or rights and responsibility, or other critical differentiations between intellectual and emotional functioning. Personal and social philosophy are based on the truth of subjectivity and life decisions are based more on feelings and maintaining the subjective harmony. _Murray Bowen.

        Regards,

        David.

  4. One of the problems here in Britain is that once a person suffering from psychosis has been sucked into the mental health system, that person is never given the chance of speaking to a psychologist or therapist. That is my experience anyway.

    • It’s like this in the U.S. too. When I was a patient on the unit of the hospital where I now work there was an actual therapist that the residents could talk with anytime during the day, if she was available. She made herself available to us, which is very unusual when it comes to the way staff work things. A few months after I was discharged she took a more lucrative job with another organization.

      When I started working at the hospital I found out that she had been the only therapist in the entire hospital and worked only on that unit. My assumption was that ever unit in the hospital had a therapist. Bwahahahaha…..just goes to show you how ill-informed I was about reality. I guess I was “delusional!” When I asked who they’d hired to replace her I was told that her position was never filled. Consequently, there is no one who does any talk therapy on a one on one consistent basis in the entire hospital! We are a 300 bed institution!

      The expectation is that social workers will do therapy with the “patients” but the reality is that they’re so overwhelmed with increased required paperwork. The good ones really do try to sit down and listen to the people they’re assigned to but if they do that then they don’t get the required paperwork done and then they’re in trouble with the Clinical Services Dept. It’s a huge, messy “Catch 22” situation that has no exit as far as I can see. Consequently, the “patients” don’t get to talk with anyone.

      It’s beneath the psychiatrists to even think about sitting down with one of their “patients” so that they can really listen to the person. Listening to people is not their mission nor part of their job for they already know what the “patient” obviously needs and that’s more of the wonderful, toxic drugs! Nothing the “patients” have to say is worth noting anyway since we all know that “patients” lie and manipulate and listening to them describe their “delusions” is not theraputic and responding to their voices will not be tolerated. Staff better not be caught “collaborating” with “patients” concerning their “delusional voices;” you will be shown the front door of the hospital and you won’t have a job. Not even the psychologists are allowed to talk to peoples’ voices, even they’ve been fired for doing so.

      In the end, the only people that the “patients” have to talk with are other “patients!” And really, when it boils right down to it, “patients” themselves are some of the best therapists in the world! But forget about doing any taling with the “professionals” because that will never happen.

  5. Jack,

    What I learned is true, unfortunately based upon experince, that Whitaker points out scientifically is true according to the medical evidence, seems to still not be confessed to or even comprehended by the industries, either psychiatric or US psychological. But I understand why, everything you paid good money for, and were taught in school was wrong, and that is hard to believe.

    But the antidepressants and ADHD drugs CAUSE the bipolar symptoms. And the antipsychotics CAUSE the schizophrenia symptoms. Thus, it strikes me that the psychiatric industry spent the past 50 years writing a DSM “bible” describing the serious mental illnesses their drugs CAUSE, plus of course a medicalization of normal human emotions to railroad as many onto the drugs as possible.

    My point is the DSM is TOTALLY “lacking in validity” because it is merely a description of the adverse effects of the psychiatric drugs. The DSM disorders are totally based on “pillars of sand,” bogus science.

    And it seems even Dr. Insel may have realized this, so both the psychiatric and psychological industries should get to this realization too, quickly. The DSM is garbage, based on the myoptic viewpoint of historic psychiatrists documenting the mental illnesses CAUSED by their drugs.

    The DSM disorders are merely a description of the serious mental illnesses CAUSED by the psychiatric industry’s drugs. But I understand many within the industries were deluded by big Pharma’s false advertising and theories. And most within the big Pharma complex and the FDA, probably may not have assumed the psychiatric industry’s drugs were always the CAUSE of all the serious psychiatric illnesses themselves.

    But it broke my heart to work with children who, according to the medical evidence were dealing with major drug interactions and hospitalized due to these, listen to and read psychological and medical denials of these major drug interactions. And dismiss these children’s problems as “lacking in validity” DSM disorders. As if, because a person has as doctorate, a DSM disorder, trumps concerns over proven major drug interactions.

    Maintaining the DSM as a guideline is not the answer, but I understand that is a hard pill to swallow for both the psychiatric and psychological industries.