As of the moment, the site says that my blog was opened (read?) by over 840, and there’ve been 88 comments by many. I expected it to be met with all kinds of challenges, though the breadth of them did surprise me some. I don’t think I posed a simple question, what to do with the DSM, though some of you had easy and quick responses. Some of you don’t think any kind of classification is needed. Some think the DSM was created with malice and for purposes of power and social control, describing “mental disorders’ that some of you simply believe do not exist. Some think it’s a metaphor. Some believe that if there is no identifiable reliable biological finding for something, it therefore cannot be an illness.
And some of you think I am naive and can’t see what is so clearly obvious to you, which suggests to some of you that I am so far into the system that I can’t see its flaws, in which case my comments maybe have to tolerated but that’s about it. And you wonder why MIA would bother allowing this to be posted.
And some of you found the piece thoughtful or thought-provoking in a good way, and noticed that someone so totally under the thumb of the psychiatric-medical-pharma-socialcontrol forces probably wouldn’t write what I wrote.
I was tempted to respond individually some more to what you all have posted, but I don’t think it’s productive and would mostly lead to more heat than light. I had the same experience with my first blog in July, and at some point, the back-and-forth becomes endless. I’m sure I missed something someone wrote in my attempt to summarize what you have written, but I tried here to say ” OK, I hear you, and you have some good points, some I just disagree with, and some that took things way beyond the scope of my blog.”
I’ll make a couple of brief comments which you are, of course, welcome to respond to, but I am not planning to continue the comment-and-respond. I can’t do that with everyone, and I don’t want to pick and choose who gets a response. I have read every single word of what you all have written. Every word.
Final points:
–I don’t agree that the DSM was created to enable corruption. It may have been misused in corrupt ways by some, maybe more than some, but that’s different
–just because a drug can cause schizophrenic symptoms or mania does not mean that there isn’t a separate condition that we ( yes, using DSM) call schizophrenia or mania
–the idea of abolishing psychiatry and insurance is kind of tempting, but what comes after that is still hanging out there
–changing society probably could lower what we call mental illness, but to assume it is a big leap. many cross-cultural studies have shown the incidence of some mental illnesses ( Yes, DSM again) to be relatively stable, even though they may look different, say, in aboriginal society than in Chicago
–I Agree that the lack of firm scientific evidence (including genetics) for even bipolar is a big concern. Fair to differ, but I have seen enough of what most call bipolar to say that it’s not just a metaphor or a reaction to stress or to capitalism or communism or iatrogenic behaviors. I won’t ask you to un-see what you’ve seen. Goes both ways.
–there is something to the role of inflammation and what we’re calling mental disorders. It’s not clear yet, nor is it the case that giving anti-inflammatory treatments have been shown definitively to help. But it’s promising.
–Yes the NIMH is not thrilled with DSM, but the RDoC has not yet been shown to shed more light. Yet.
–Anosognosia! – it’s a great word which our commenter chose not to define, so I will. It reflects some neurological condition in which someone is not aware of one’s mental or neurological deficits.
Yes, many differences among individuals that lead to mania, psychotic or otherwise, and some are more stress-related than others. There is not a lot of strong data – so far – linking inflammation ( I know there is some), and there’s not much yet to support anti-inflammatory treatments for mania. Maybe that will come.
One of the big problems with DSM is that it isn;t that helpful for – nor intended to be – guiding treatment. If we agree there is something called mania – do we? – the current ( not forever and not final ) evidence is that lithium is the best treatment ( not the only one, not forever, not without downsides) so far. Emphasis on “so far.”
So if it’s the case that the vast majority are not mentally ill and don’t need medical care, they presumably need something else. Depending on what you think they need, you’d have to make the case ( and I’m not to whom – insurers? – maybe not, they’re in the medical care paying business) that someone needs to pay for that care (not sure if that would be treatment).
You write as if finding alternative payment systems are going to be easier than I think. I hope you’re right. Who would foot that bill? Would that include hospitalizations at all? That might put us back in the medical-model business.
By the way, I don’t think it’s necessary to talk about corruption in order to talk about what to do about DSM. Even if there were zero corruption, DSM is full of holes, so I’m not avoiding, as you put it, I’m focused more narrowly. Fine if you want to expand the perspective.
You have some interesting ideas there, but I’m still trying to figure out if our system ( such as it is now or might be in the future) needs some way to classify. I tend to think it’s our nature to classify things and it will be irresistible to have some way to do that.
I’m not at a point in my life or career to be a leader in that, so the MIA is a way for me to put this out there in what I hope is a constructive way.
I’m sorry about your nightmarish story.
Forgive me for not saying more about that, but with regard to DSM, you said you had PTSD in high school. I know people use that term casually, but it’s a DSM diagnosis, so you’re either using it casually, or you believe you did have that DSM diagnosis, which couldn’t have been made if we, as you said at the start, toss it out completely.
I did not say it fits the medical model. I do think it is more like a medical illness than, say, major depression because there are more commonalities in bipolars with regard to genetics, course of illness ( sorry:), and response to treatment. It’s not a perfect fit, just one of the better ones.
No, some people do have a single manic episode and they should not, in my view, be called bipolar as if it’s a lifelong condition.
We can say that massive stress is tough on everybody, but there is something about what people with mania have more in common than say PTSD
thanks
wonder if you think there should be any attempt to classify whatever we’re going to call the reasons why people seek help? Sorry to say, but if you were deciding what taxpayers or private companies should pay for, would you either just say OK to all, deny all, or have another way to make those decisions? I just don’t see a way of avoiding that question; do you?
some people hate labels, some find them reassuring; not true that labels are all bad.
I don’t want to be defending DSM, but I am explaining that there is nothing in it about how to treat, with drugs or not
What I said about bashing DSM – if I loved it, I wouldn’t have written this – is that any attempt to categorize is going to have problems, so it’s fine to bash DSM but that leaves us back with the options in my title. If we say it’s fiction, so let’s bash and trash it, tell me what’s next?
I can’t think of much that would make my head hurt more than to have even more DSM diagnoses. I think some make sense, more don’t, and I wouldn’t want to build on such a mushy foundation.
So we are agreed that DSM, for a combination of the reasons I mentioned and you expanded on, is full of flaws. Yes, you pointed out some things I didn’t cite, but I didn’t want to go on too long in my blog. Again, my challenge to myself and you and the profession and the insurance companies and the drug companies and the researchers and government and those who receive care is how to craft a better system. If we exclude any of the groups I just mentioned, I can’t figure out how that would work. Can you?
Thanks for weighing in. You covered a lot of ground.
I wrote this partly out of my longstanding awareness and concerns about the shortcomings of DSM. I also wanted to try to get a little beyond “DSM is biased and unscientific and misused” and see, as my title indicated, if there’s a way to have a better system. So far I don’t have a good answer, which is not the same as endorsing DSM as it is now, which my blog is lightyears from doing.
I’d be curious to know if you have some thoughts about whether DSM can be improved, or, as I pose to myself and readers, should it be replaced. My view is that we can’t do without some system of classification, and it doesn’t have to be one of diagnoses. But a diagnosis-free system is not going to be practical for some of the reasons I wrote about.
Birdsong and Steve– You two and I have had over a month of (to me) exchanges. Despite our differences, I have had the idea that if we were to sit down together and not be limited by the reality of the MIA site, we’d find more common ground that it sometimes appears ( at least to me). My sense is that we all have a pretty good idea where each of us stands on things.
I’ll add that I bet that there aren’t that many psychiatrists who get on this site, much less do a blog as I did. I say that to remind you that the others whom you’ve seen do bad things are not too likely to read MIA. I’m not going to be as broadly critical of the field as you might have me be, which is way different from excusing bad behavior or saying the whole field is sort of contaminated by greed, malice, or Pharma. You’ll have to trust me, if you can, when I say I have a reputation for calling out bad stuff. I have listened closely to my patients over the years and they would tell you that what you’ve seen and experienced with others doesn’t apply to me despite my flaws.
I’m contemplating another blog contribution in the next few weeks. I hope it’ll be useful even though you shouldn’t expect me to talk about how bad psychiatry can be. MIA has plenty of that already. I don’t see life or psychiatry or people in black-and-white terms; to me, that just adds to the divide between us.
Feel free, of course, to respond to this if you wish. I will read it, but after these many back-and-forths, I don’t plan to respond here again. Not at all personal. I’m going to bet that not too many bloggers here have had so many exchanges with readers.
If, as you seem to suggest, being charitable or reasonable is not called for, but contempt and condemnation are better tools, I hope that you have some ideas about how to make things better once you feel you have fully expressed that contempt and condemnation.
Even if you are 100% correct, and I know some others think you are, it seems that you might have some duty to go beyond that in hopes of improving things for people in need. Refuting each of my points as inherently invalid doesn’t make for much of an exchange. but it does give you a chance to express that contempt and condemnation. And there you stop. Since you seem to think that being charitable and reasonable are unhelpful, maybe you have some unreasonable and uncharitable proposals to offer.
Let’s agree – if we can – that there is overprescription of psychiatric meds. We both, probably, have our own sense that that’s the case. Fair?
We could say that no one, ever, should be prescribed meds unnecessarily and certainly never coerced into it. Still on the same page?
The world isn’t perfect, so bad things are going to happen, even though we wish they never did. I think it’s a fair question to ask how much overprescription goes on. So I ask respectfully, since you say there is “so much” of that, how much overprescribing is there in your view, and how do you come to that conclusion? I do not know the answer. I know we all have our experiences and hear stories of others. We can’t ignore that, but it’d be nice to have some data to work with. Do you know of some?
I’m asking because the solutions to a huge widespread problem should be different from the solutions to a problem that occurs mostly, say, in hospitals or prisons or nursing homes or foster settings, and not so much elsewhere. I’m not saying I know the extent of the problem, so I’m asking, respectfully, what you know and how you know it.
The problems of psychiatric care in institutions are serious. It’s my impression ( not data-based) that there’s way too much emphasis on behavioral control, and the pressure on docs to medicate is therefore higher, even when non-med approaches may work better and are safer. Some institution staffs are unable, unwilling, or otherwise stretched too thin to give those approaches more time. The docs who work in those places tend to have to see many kids in a short time, don’t know them too well, and are trying, sorry to say, to keep the staff happy. The docs really don’t have other tools to use in those circumstances, making it look like their framework is narrowly biological. I agree it’s not good.
I get that you have a lot of experience in those settings ( I have been a CASA, too). I don’t think that generalizing to the broader range of psychiatric practice is a step you can take without taking into account
that kind of setting. Ditto for prison and nursing home care. It’s a lot harder for docs in institutional settings to feel like those are “my patients” than in most other kinds of psych settings. It’s a much bigger issue than the biological focus alone.
Hi Eric – I’ve read your post from the other day. You’ve given me some things to consider for future blogs.
We know that MIA is aimed, as it says in its mission statement and posting guidelines, at “rethinking psychiatric care.” I take that to mean that this site is about identifying what’s good and effective, what’s bad and ineffective about psychiatric care, and how it can be improved. I get that some people think the whole system has to be dismantled and that posts on MIA are solely to be describing the bad and ineffective, and that anyone who has a more nuanced view is either naive, evil, or otherwise not worthy of being heard. That’s not consistent with the posting guidelines, nor with how I view things. I suppose that anything I write from here on in will be met with some reactions not in keeping with the spirit of MIA.
With regard to your specific suggestions-
1) my blog mentioned drugs, but most intentionally not as the core of my discussion of research, which I carefully mentioned can be used for non-drug treatments. It was not my aim to get into longterm studies, so not fair to say I “ignored” them. It’s another topic, deserving of its own discussion.
2) Not sure what evidence you have that confirmation bias -which is a problem for everyone, including many posters here – has “destroyed” objectivity. I agree it’s a concern, maybe we differ on the extent of it.
3) I can’t count how many psychiatrists I’ve known. I can’t speak to your experience, but the next one I meet who believes we are “just biologically evolved entities” will be the first. I’ve never heard anyone say or even imply that. I don’t believe that anyone teaches that, either. Doctors who seem to do ‘only meds’ may appear to think that, but I believe it’s an illusion.
4). As just said, the medical model is – I mean this sincerely – NEVER taught as the sole approacH, even if it might look that way sometimes. The organic/functional distinction still has some usefulness, but since there’s so much disagreement as to how to draw that distinction, I’d say that it’s still used when it”s helpful and not when it’s not.
Your comment about staff in institutions is interesting, though not one I know lots about.
I appreciate the exchange. You deserved a thoughtful response. Please understand that I am happy and willing ( as I have been elsewhere in my career) to point out problems in our field. Those who want to hear me only focus on what’s wrong will, in my view, simply be exercising their own confirmation bias and that won’t make things better for those do need and deserve help ( and I don’t mean meds).
I have been a fan of Dr Fava and that journal for a long time, and I’d heard the MIA podcast with him not long before I wrote my blog. As I re-read what I wrote, he and I – both clinicians – are on the same page as you two about the importance of research being clinically relevant. Controlled trials are not fully transferrable to real life, but they are not without some value.
Ditto for a single patient experience.
I’ve taken the time today to read your MIA contribution in 2022 detailing the tragedy of what your daughter and your family went through for so long. I can tell that it impacted all of those who read it back then and commented on it.
I’m sure to say that I, too, am sorry for what you went through (and still do endure) pales in comparison. But I offer my condolences and sympathies here nonetheless.
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.
As of the moment, the site says that my blog was opened (read?) by over 840, and there’ve been 88 comments by many. I expected it to be met with all kinds of challenges, though the breadth of them did surprise me some. I don’t think I posed a simple question, what to do with the DSM, though some of you had easy and quick responses. Some of you don’t think any kind of classification is needed. Some think the DSM was created with malice and for purposes of power and social control, describing “mental disorders’ that some of you simply believe do not exist. Some think it’s a metaphor. Some believe that if there is no identifiable reliable biological finding for something, it therefore cannot be an illness.
And some of you think I am naive and can’t see what is so clearly obvious to you, which suggests to some of you that I am so far into the system that I can’t see its flaws, in which case my comments maybe have to tolerated but that’s about it. And you wonder why MIA would bother allowing this to be posted.
And some of you found the piece thoughtful or thought-provoking in a good way, and noticed that someone so totally under the thumb of the psychiatric-medical-pharma-socialcontrol forces probably wouldn’t write what I wrote.
I was tempted to respond individually some more to what you all have posted, but I don’t think it’s productive and would mostly lead to more heat than light. I had the same experience with my first blog in July, and at some point, the back-and-forth becomes endless. I’m sure I missed something someone wrote in my attempt to summarize what you have written, but I tried here to say ” OK, I hear you, and you have some good points, some I just disagree with, and some that took things way beyond the scope of my blog.”
I’ll make a couple of brief comments which you are, of course, welcome to respond to, but I am not planning to continue the comment-and-respond. I can’t do that with everyone, and I don’t want to pick and choose who gets a response. I have read every single word of what you all have written. Every word.
Final points:
–I don’t agree that the DSM was created to enable corruption. It may have been misused in corrupt ways by some, maybe more than some, but that’s different
–just because a drug can cause schizophrenic symptoms or mania does not mean that there isn’t a separate condition that we ( yes, using DSM) call schizophrenia or mania
–the idea of abolishing psychiatry and insurance is kind of tempting, but what comes after that is still hanging out there
–changing society probably could lower what we call mental illness, but to assume it is a big leap. many cross-cultural studies have shown the incidence of some mental illnesses ( Yes, DSM again) to be relatively stable, even though they may look different, say, in aboriginal society than in Chicago
–I Agree that the lack of firm scientific evidence (including genetics) for even bipolar is a big concern. Fair to differ, but I have seen enough of what most call bipolar to say that it’s not just a metaphor or a reaction to stress or to capitalism or communism or iatrogenic behaviors. I won’t ask you to un-see what you’ve seen. Goes both ways.
–there is something to the role of inflammation and what we’re calling mental disorders. It’s not clear yet, nor is it the case that giving anti-inflammatory treatments have been shown definitively to help. But it’s promising.
–Yes the NIMH is not thrilled with DSM, but the RDoC has not yet been shown to shed more light. Yet.
–Anosognosia! – it’s a great word which our commenter chose not to define, so I will. It reflects some neurological condition in which someone is not aware of one’s mental or neurological deficits.
Thanks for reading this far.
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Yes, many differences among individuals that lead to mania, psychotic or otherwise, and some are more stress-related than others. There is not a lot of strong data – so far – linking inflammation ( I know there is some), and there’s not much yet to support anti-inflammatory treatments for mania. Maybe that will come.
One of the big problems with DSM is that it isn;t that helpful for – nor intended to be – guiding treatment. If we agree there is something called mania – do we? – the current ( not forever and not final ) evidence is that lithium is the best treatment ( not the only one, not forever, not without downsides) so far. Emphasis on “so far.”
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So if it’s the case that the vast majority are not mentally ill and don’t need medical care, they presumably need something else. Depending on what you think they need, you’d have to make the case ( and I’m not to whom – insurers? – maybe not, they’re in the medical care paying business) that someone needs to pay for that care (not sure if that would be treatment).
You write as if finding alternative payment systems are going to be easier than I think. I hope you’re right. Who would foot that bill? Would that include hospitalizations at all? That might put us back in the medical-model business.
By the way, I don’t think it’s necessary to talk about corruption in order to talk about what to do about DSM. Even if there were zero corruption, DSM is full of holes, so I’m not avoiding, as you put it, I’m focused more narrowly. Fine if you want to expand the perspective.
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You have some interesting ideas there, but I’m still trying to figure out if our system ( such as it is now or might be in the future) needs some way to classify. I tend to think it’s our nature to classify things and it will be irresistible to have some way to do that.
I’m not at a point in my life or career to be a leader in that, so the MIA is a way for me to put this out there in what I hope is a constructive way.
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I’m sorry about your nightmarish story.
Forgive me for not saying more about that, but with regard to DSM, you said you had PTSD in high school. I know people use that term casually, but it’s a DSM diagnosis, so you’re either using it casually, or you believe you did have that DSM diagnosis, which couldn’t have been made if we, as you said at the start, toss it out completely.
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I did not say it fits the medical model. I do think it is more like a medical illness than, say, major depression because there are more commonalities in bipolars with regard to genetics, course of illness ( sorry:), and response to treatment. It’s not a perfect fit, just one of the better ones.
No, some people do have a single manic episode and they should not, in my view, be called bipolar as if it’s a lifelong condition.
We can say that massive stress is tough on everybody, but there is something about what people with mania have more in common than say PTSD
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thanks
wonder if you think there should be any attempt to classify whatever we’re going to call the reasons why people seek help? Sorry to say, but if you were deciding what taxpayers or private companies should pay for, would you either just say OK to all, deny all, or have another way to make those decisions? I just don’t see a way of avoiding that question; do you?
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who will decide which intern, and what should be his/her qualifications? and then…?
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One might say that the Bible, among many other books, is a tool for social control.
Who’s in charge of deciding which books get banned? Want that job?
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some people hate labels, some find them reassuring; not true that labels are all bad.
I don’t want to be defending DSM, but I am explaining that there is nothing in it about how to treat, with drugs or not
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What I said about bashing DSM – if I loved it, I wouldn’t have written this – is that any attempt to categorize is going to have problems, so it’s fine to bash DSM but that leaves us back with the options in my title. If we say it’s fiction, so let’s bash and trash it, tell me what’s next?
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I can’t think of much that would make my head hurt more than to have even more DSM diagnoses. I think some make sense, more don’t, and I wouldn’t want to build on such a mushy foundation.
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So we are agreed that DSM, for a combination of the reasons I mentioned and you expanded on, is full of flaws. Yes, you pointed out some things I didn’t cite, but I didn’t want to go on too long in my blog. Again, my challenge to myself and you and the profession and the insurance companies and the drug companies and the researchers and government and those who receive care is how to craft a better system. If we exclude any of the groups I just mentioned, I can’t figure out how that would work. Can you?
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Thanks for weighing in. You covered a lot of ground.
I wrote this partly out of my longstanding awareness and concerns about the shortcomings of DSM. I also wanted to try to get a little beyond “DSM is biased and unscientific and misused” and see, as my title indicated, if there’s a way to have a better system. So far I don’t have a good answer, which is not the same as endorsing DSM as it is now, which my blog is lightyears from doing.
I’d be curious to know if you have some thoughts about whether DSM can be improved, or, as I pose to myself and readers, should it be replaced. My view is that we can’t do without some system of classification, and it doesn’t have to be one of diagnoses. But a diagnosis-free system is not going to be practical for some of the reasons I wrote about.
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Birdsong and Steve– You two and I have had over a month of (to me) exchanges. Despite our differences, I have had the idea that if we were to sit down together and not be limited by the reality of the MIA site, we’d find more common ground that it sometimes appears ( at least to me). My sense is that we all have a pretty good idea where each of us stands on things.
I’ll add that I bet that there aren’t that many psychiatrists who get on this site, much less do a blog as I did. I say that to remind you that the others whom you’ve seen do bad things are not too likely to read MIA. I’m not going to be as broadly critical of the field as you might have me be, which is way different from excusing bad behavior or saying the whole field is sort of contaminated by greed, malice, or Pharma. You’ll have to trust me, if you can, when I say I have a reputation for calling out bad stuff. I have listened closely to my patients over the years and they would tell you that what you’ve seen and experienced with others doesn’t apply to me despite my flaws.
I’m contemplating another blog contribution in the next few weeks. I hope it’ll be useful even though you shouldn’t expect me to talk about how bad psychiatry can be. MIA has plenty of that already. I don’t see life or psychiatry or people in black-and-white terms; to me, that just adds to the divide between us.
Feel free, of course, to respond to this if you wish. I will read it, but after these many back-and-forths, I don’t plan to respond here again. Not at all personal. I’m going to bet that not too many bloggers here have had so many exchanges with readers.
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If, as you seem to suggest, being charitable or reasonable is not called for, but contempt and condemnation are better tools, I hope that you have some ideas about how to make things better once you feel you have fully expressed that contempt and condemnation.
Even if you are 100% correct, and I know some others think you are, it seems that you might have some duty to go beyond that in hopes of improving things for people in need. Refuting each of my points as inherently invalid doesn’t make for much of an exchange. but it does give you a chance to express that contempt and condemnation. And there you stop. Since you seem to think that being charitable and reasonable are unhelpful, maybe you have some unreasonable and uncharitable proposals to offer.
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Let’s agree – if we can – that there is overprescription of psychiatric meds. We both, probably, have our own sense that that’s the case. Fair?
We could say that no one, ever, should be prescribed meds unnecessarily and certainly never coerced into it. Still on the same page?
The world isn’t perfect, so bad things are going to happen, even though we wish they never did. I think it’s a fair question to ask how much overprescription goes on. So I ask respectfully, since you say there is “so much” of that, how much overprescribing is there in your view, and how do you come to that conclusion? I do not know the answer. I know we all have our experiences and hear stories of others. We can’t ignore that, but it’d be nice to have some data to work with. Do you know of some?
I’m asking because the solutions to a huge widespread problem should be different from the solutions to a problem that occurs mostly, say, in hospitals or prisons or nursing homes or foster settings, and not so much elsewhere. I’m not saying I know the extent of the problem, so I’m asking, respectfully, what you know and how you know it.
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The problems of psychiatric care in institutions are serious. It’s my impression ( not data-based) that there’s way too much emphasis on behavioral control, and the pressure on docs to medicate is therefore higher, even when non-med approaches may work better and are safer. Some institution staffs are unable, unwilling, or otherwise stretched too thin to give those approaches more time. The docs who work in those places tend to have to see many kids in a short time, don’t know them too well, and are trying, sorry to say, to keep the staff happy. The docs really don’t have other tools to use in those circumstances, making it look like their framework is narrowly biological. I agree it’s not good.
I get that you have a lot of experience in those settings ( I have been a CASA, too). I don’t think that generalizing to the broader range of psychiatric practice is a step you can take without taking into account
that kind of setting. Ditto for prison and nursing home care. It’s a lot harder for docs in institutional settings to feel like those are “my patients” than in most other kinds of psych settings. It’s a much bigger issue than the biological focus alone.
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Hi Eric – I’ve read your post from the other day. You’ve given me some things to consider for future blogs.
We know that MIA is aimed, as it says in its mission statement and posting guidelines, at “rethinking psychiatric care.” I take that to mean that this site is about identifying what’s good and effective, what’s bad and ineffective about psychiatric care, and how it can be improved. I get that some people think the whole system has to be dismantled and that posts on MIA are solely to be describing the bad and ineffective, and that anyone who has a more nuanced view is either naive, evil, or otherwise not worthy of being heard. That’s not consistent with the posting guidelines, nor with how I view things. I suppose that anything I write from here on in will be met with some reactions not in keeping with the spirit of MIA.
With regard to your specific suggestions-
1) my blog mentioned drugs, but most intentionally not as the core of my discussion of research, which I carefully mentioned can be used for non-drug treatments. It was not my aim to get into longterm studies, so not fair to say I “ignored” them. It’s another topic, deserving of its own discussion.
2) Not sure what evidence you have that confirmation bias -which is a problem for everyone, including many posters here – has “destroyed” objectivity. I agree it’s a concern, maybe we differ on the extent of it.
3) I can’t count how many psychiatrists I’ve known. I can’t speak to your experience, but the next one I meet who believes we are “just biologically evolved entities” will be the first. I’ve never heard anyone say or even imply that. I don’t believe that anyone teaches that, either. Doctors who seem to do ‘only meds’ may appear to think that, but I believe it’s an illusion.
4). As just said, the medical model is – I mean this sincerely – NEVER taught as the sole approacH, even if it might look that way sometimes. The organic/functional distinction still has some usefulness, but since there’s so much disagreement as to how to draw that distinction, I’d say that it’s still used when it”s helpful and not when it’s not.
Your comment about staff in institutions is interesting, though not one I know lots about.
I appreciate the exchange. You deserved a thoughtful response. Please understand that I am happy and willing ( as I have been elsewhere in my career) to point out problems in our field. Those who want to hear me only focus on what’s wrong will, in my view, simply be exercising their own confirmation bias and that won’t make things better for those do need and deserve help ( and I don’t mean meds).
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I have been a fan of Dr Fava and that journal for a long time, and I’d heard the MIA podcast with him not long before I wrote my blog. As I re-read what I wrote, he and I – both clinicians – are on the same page as you two about the importance of research being clinically relevant. Controlled trials are not fully transferrable to real life, but they are not without some value.
Ditto for a single patient experience.
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I’ve taken the time today to read your MIA contribution in 2022 detailing the tragedy of what your daughter and your family went through for so long. I can tell that it impacted all of those who read it back then and commented on it.
I’m sure to say that I, too, am sorry for what you went through (and still do endure) pales in comparison. But I offer my condolences and sympathies here nonetheless.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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