thanks for these constructive comments
Just about any study, even an excellent one, will have flaws and/or limitations. The challenge for me is to what extent those feature still allow me to make good use of the findings. Neither patients nor providers should feel like a study has to be squeaky clean to be helpful.
I’m not here to defend psychiatry, so please don’t put me in that position.
There’s not a single thing you’ve written that suggests to me anything other than a contempt for the field, and I would not presume to try to offer you an alternative idea until or unless you displayed the slightest evidence of a view that differs from yours in the slightest.
Not all exchanges are productive, and I have no wish to persuade you that there might beg other ways to think about these issues.
I respect your views and assume they are based on what must have been horrible experiences. I don’t expect this to be any consolation, but I don’t believe they are universal.
It’s your right to respond to this, but please be aware that I don’t intend to respond again in this chain. If you re-read all the things you’ve written to me and imagine they were written to you by someone else, that might help you see what I mean.
I wish you well.
Gee, Steve, I thought you were asking me a reasonable question when you wrote “I’d also love to hear a response to my answer to your question about how to train therapists.” I gave you what I thought was a reasonable answer, but you flew right past that, as if I were some staunch defender of DSM and the current establishment. After our exchanges, you ought to know that just lumping me in with those you oppose is both unfair and guilt-by-association. From my standpoint, it seems you really didn’t want to hear what I said, but wanted another chance to make your own points. This is exactly – exactly – the kind of thing that we both ( yes both of us) deplore when it happens between those who are seeking help and those who profess to want to provide it, that someone has “THE ANSWER” and the other person just needs to acknowledge it.
Black-and-white thinking is a trap and a danger, as I’m confident you well know.
What makes it so hard to say “I don’t fully agree, but you have a point.”? You asked me a fair question, I gave you an answer, and if you re-read it, I bet you’ll say to yourself the solution is not as simple as erasing DSM and having no clear plan to replace it with something better.
If I tell a colleague who also treats the same person (like a therapist or a PCP), using DSM provides some ( not complete, don’t go there!) common ground to begin a collaborative discussion. As I said, for some diagnoses, it’s more helpful, and for others, I don’t bother and use other language.
As for training new treaters, you have to define the scope of what your program trains treaters to treat. If you opt not to call them illnesses, fair enough, but you have to somehow be able to say “we’re training people to help with problems like X or Y or Z,” using non-illness language. One could say “problems in living” a la Szasz, which is reasonable. In the world as it is, it would be a challenge to find people or institutions to fund it, don’t you think? Even most current psychology. or social work training programs can’t escape some form of DSM-type targets of treatment.
Hi Birdsong –
here’s what you wrote earlier–
“Richard, knowing the difference between cynicism and skepticism is a very useful skill to have when trying to make sense of just about anything.”
Now you’ve said that that was a kind of suggestion – I didn’t read it that way and it wasn’t written as one. I agree that there’s a difference and I’m reasonably sure that I know the difference as you clearly do.
I agree that there are many viable alternatives to establishment psychiatry. If one size fit all, there’d be just one thing everyone should do.
I’m glad that my blog has stimulated a lot of comments. It’s tempting to respond to each of them, but an ongoing give-and-take with the commenters is tough to keep up with. I’m going to say a few things here by way of acknowledging what you’ve written; I might ( not promising) to make future ones, so please don’t read anything into what future comments I don’t respond to. I promise to read them all, however.
(1) There’s lots in psychiatry and the mental health field to be critical of, and I have been one of its critics when I’ve seen us fail. I’m not writing to defend it, but, as I see it, trashing the field has limited value.
(2) We all have our biases and blind spots. I know some of mine, but I’m sure not all. That’s true for all of you, too, I bet.
(3) My experience is that most in the field are neither evil nor dupes of Big Pharma, the APA, nor worshippers of the DSM. Maybe you know some who are evil or dupes, and I would join you in saying those people shouldn’t be practicing. I have known a few myself.
(4) The DSM is not a bible. It’s a partly helpful, partly unhelpful way to talk about patients. It’s more helpful with schizophrenia and bipolar and some anxiety conditions than it is with mood or personality disorders, or ADHD. That’s an incomplete list. We are stuck with it for billing purposes until something better comes along. It’s a big moneymaker for APA, which troubles me, and it’s part of why I’ve not been an APA member for over 40 years.
(5) It’s a cliche to say that we are a polarized society in many ways, and I guess one of them includes how we all think about mental health care. Good vs evil, freedom vs totalitarianism, clear-eyed vs naive: I think it’s unhelpful to frame things so simplistically. I know that trying to stake out some common ground, disagreements included, can appear unprincipled or chickening out. I just don’t buy that.
(6) I’d be interested to know if there are things you’d like to have me write about in the future. Please understand that I’m wanting to bring some perspectives to the table that don’t already have voice on MIA. Not promising to respond to any of your suggestions, but I value my audience. Thanks.
Steve, you’re talking as if we humans don’t have anything in common. Not sure if you mean that, but the implication of that might be that if a therapist is successful with patient A, it’s random that they’ll be able to help patient B. Ditto for the unsuccessful therapist. We do know that successful therapists have some things in common.
If we have to reinvent therapy for each patient ( and in a sense I agree), it makes me wonder how and who would teach people how to be therapists. I’d be daunted to be a therapy trainee and be told I have to come up with a brand new therapy for each new person. Wouldn’t you? I’d need at least a framework, so I’d be curious to know how you might teach that.
Just for the record, I am not – never have been – an apologist for DSM. I think it, like most things, can be useful if we also acknowledge its limitations.
This problem is not limited to psychiatric diagnoses; two people with diabetes can be in wildly different states of health or disability.
Jane DRF –
thanks
I agree with you about some of the limitations of RCTs, which is why I said that science is not to be worshipped and that RCTs are one way to get information, not the only one.
I would add that it’s simply not the case that RCTs are only good for drug studies; there are some others the compare psychodynamic psychotherapy with cognitive psychotherapy for anxiety disorders, just as an example
I think we have to also say that individual factors, important as they are, help us with the person in front of us, but not so much with the next person who has a whole different set of personal situations and problems and strengths.
Personal anecdotes mean a lot, but how do we take person #1’s story and reliably use it for person #2? Maybe we can’t, other than to be reminded that #1 and #2 are different, and there’s not much else to guide us.
I’d be interested to know if you know of the kind of research you think ought to be done. If we all don’t have enough in common, we can’t be studied as a group of any kind.
thanks for these constructive comments
Just about any study, even an excellent one, will have flaws and/or limitations. The challenge for me is to what extent those feature still allow me to make good use of the findings. Neither patients nor providers should feel like a study has to be squeaky clean to be helpful.
Report comment
I’m not here to defend psychiatry, so please don’t put me in that position.
There’s not a single thing you’ve written that suggests to me anything other than a contempt for the field, and I would not presume to try to offer you an alternative idea until or unless you displayed the slightest evidence of a view that differs from yours in the slightest.
Not all exchanges are productive, and I have no wish to persuade you that there might beg other ways to think about these issues.
I respect your views and assume they are based on what must have been horrible experiences. I don’t expect this to be any consolation, but I don’t believe they are universal.
It’s your right to respond to this, but please be aware that I don’t intend to respond again in this chain. If you re-read all the things you’ve written to me and imagine they were written to you by someone else, that might help you see what I mean.
I wish you well.
Report comment
Gee, Steve, I thought you were asking me a reasonable question when you wrote “I’d also love to hear a response to my answer to your question about how to train therapists.” I gave you what I thought was a reasonable answer, but you flew right past that, as if I were some staunch defender of DSM and the current establishment. After our exchanges, you ought to know that just lumping me in with those you oppose is both unfair and guilt-by-association. From my standpoint, it seems you really didn’t want to hear what I said, but wanted another chance to make your own points. This is exactly – exactly – the kind of thing that we both ( yes both of us) deplore when it happens between those who are seeking help and those who profess to want to provide it, that someone has “THE ANSWER” and the other person just needs to acknowledge it.
Black-and-white thinking is a trap and a danger, as I’m confident you well know.
What makes it so hard to say “I don’t fully agree, but you have a point.”? You asked me a fair question, I gave you an answer, and if you re-read it, I bet you’ll say to yourself the solution is not as simple as erasing DSM and having no clear plan to replace it with something better.
Report comment
If I tell a colleague who also treats the same person (like a therapist or a PCP), using DSM provides some ( not complete, don’t go there!) common ground to begin a collaborative discussion. As I said, for some diagnoses, it’s more helpful, and for others, I don’t bother and use other language.
As for training new treaters, you have to define the scope of what your program trains treaters to treat. If you opt not to call them illnesses, fair enough, but you have to somehow be able to say “we’re training people to help with problems like X or Y or Z,” using non-illness language. One could say “problems in living” a la Szasz, which is reasonable. In the world as it is, it would be a challenge to find people or institutions to fund it, don’t you think? Even most current psychology. or social work training programs can’t escape some form of DSM-type targets of treatment.
Report comment
Hi Birdsong –
here’s what you wrote earlier–
“Richard, knowing the difference between cynicism and skepticism is a very useful skill to have when trying to make sense of just about anything.”
Now you’ve said that that was a kind of suggestion – I didn’t read it that way and it wasn’t written as one. I agree that there’s a difference and I’m reasonably sure that I know the difference as you clearly do.
I agree that there are many viable alternatives to establishment psychiatry. If one size fit all, there’d be just one thing everyone should do.
Report comment
I’m glad that my blog has stimulated a lot of comments. It’s tempting to respond to each of them, but an ongoing give-and-take with the commenters is tough to keep up with. I’m going to say a few things here by way of acknowledging what you’ve written; I might ( not promising) to make future ones, so please don’t read anything into what future comments I don’t respond to. I promise to read them all, however.
(1) There’s lots in psychiatry and the mental health field to be critical of, and I have been one of its critics when I’ve seen us fail. I’m not writing to defend it, but, as I see it, trashing the field has limited value.
(2) We all have our biases and blind spots. I know some of mine, but I’m sure not all. That’s true for all of you, too, I bet.
(3) My experience is that most in the field are neither evil nor dupes of Big Pharma, the APA, nor worshippers of the DSM. Maybe you know some who are evil or dupes, and I would join you in saying those people shouldn’t be practicing. I have known a few myself.
(4) The DSM is not a bible. It’s a partly helpful, partly unhelpful way to talk about patients. It’s more helpful with schizophrenia and bipolar and some anxiety conditions than it is with mood or personality disorders, or ADHD. That’s an incomplete list. We are stuck with it for billing purposes until something better comes along. It’s a big moneymaker for APA, which troubles me, and it’s part of why I’ve not been an APA member for over 40 years.
(5) It’s a cliche to say that we are a polarized society in many ways, and I guess one of them includes how we all think about mental health care. Good vs evil, freedom vs totalitarianism, clear-eyed vs naive: I think it’s unhelpful to frame things so simplistically. I know that trying to stake out some common ground, disagreements included, can appear unprincipled or chickening out. I just don’t buy that.
(6) I’d be interested to know if there are things you’d like to have me write about in the future. Please understand that I’m wanting to bring some perspectives to the table that don’t already have voice on MIA. Not promising to respond to any of your suggestions, but I value my audience. Thanks.
Report comment
Steve, you’re talking as if we humans don’t have anything in common. Not sure if you mean that, but the implication of that might be that if a therapist is successful with patient A, it’s random that they’ll be able to help patient B. Ditto for the unsuccessful therapist. We do know that successful therapists have some things in common.
If we have to reinvent therapy for each patient ( and in a sense I agree), it makes me wonder how and who would teach people how to be therapists. I’d be daunted to be a therapy trainee and be told I have to come up with a brand new therapy for each new person. Wouldn’t you? I’d need at least a framework, so I’d be curious to know how you might teach that.
Just for the record, I am not – never have been – an apologist for DSM. I think it, like most things, can be useful if we also acknowledge its limitations.
This problem is not limited to psychiatric diagnoses; two people with diabetes can be in wildly different states of health or disability.
Report comment
Jane DRF –
thanks
I agree with you about some of the limitations of RCTs, which is why I said that science is not to be worshipped and that RCTs are one way to get information, not the only one.
I would add that it’s simply not the case that RCTs are only good for drug studies; there are some others the compare psychodynamic psychotherapy with cognitive psychotherapy for anxiety disorders, just as an example
I think we have to also say that individual factors, important as they are, help us with the person in front of us, but not so much with the next person who has a whole different set of personal situations and problems and strengths.
Personal anecdotes mean a lot, but how do we take person #1’s story and reliably use it for person #2? Maybe we can’t, other than to be reminded that #1 and #2 are different, and there’s not much else to guide us.
I’d be interested to know if you know of the kind of research you think ought to be done. If we all don’t have enough in common, we can’t be studied as a group of any kind.
Report comment