Plutophilia – a proposed diagnosis

Psycho-diagnostics are culture-bound. The “Bible” of psychodiagnosis in this country is the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM), and from time to time a committee of psychiatrists updates it. The current edition is DSM 5. In DSM 2, homosexuality was classified as a mental disorder, but this error was corrected in the next edition. The DSM 3 also eliminated the “neurotic disorders” listed in the prior editions. What used to be called Multiple Personality Disorder is now called Dissociative Identity Disorder. Some diagnoses have a limited lifespan.

Each diagnosis establishes multiple criteria (e.g.descriptions of symptoms), a certain number of which have to be met in order to establish the diagnosis as accurate. Psycho-diagnostics isn’t rocket science. It’s often imprecise, and relies more on theories than on verifiable data. Unlike most physical disorders, there are no biological markers to distinguish (for instance) Schizophrenia from Schizoaffective Disorder or Bipolar Disorder, manic. Much psychodiagnosis is educated guessing. The criteria for what’s considered psychopathology are values- and culture-bound, and sometimes arbitrary.

Mental illnesses exist in other cultures that aren’t found in the DSM.  Amok  is a mental disorder that occurs in Malaysia, Indonesia, and Polynesia, where people (mostly men) go berserk and assault anyone in their path. Koro is a persistent anxiety state that manifests in some men in Southeast Asia, based on their belief that their penis is shrinking, or retracting into the body, and that this can lead to death. Susto is a belief in “soul-loss” in some Hispanic cultures, which is believed to cause vulnerability to a variety of illnesses. A lot of people around the world believe in illnesses caused by voodoo/obeah/root magic hexes or spells, or the “evil eye.”

Having stated that psychodiagnosis is somewhat arbitrary and culture-bound, I’ll try to make the case for a new diagnosis that is bound, not to an ethnic or national culture, but to the multinational corporate culture. Only the very rich can develop this pathology. I believe  that there are cultural, economic, and political reasons why Plutophilia – excessive love of wealth –  isn’t a recognized  “paraphilia,” alongside necrophilia and  pedophilia. (Plutophobia – fear of wealth or money – is believed by some clinicians to be  a treatable psychopathology.) According to the Bible, it’s not money, but the love of money that’s the root of all evil.

Here are my suggested diagnostic criteria for a diagnosis of Plutophilia: (1) Obsession with the endless accumulation of wealth, far beyond what is needed or will be spent in a lifetime; and persistent or compulsive behaviors in the service of wealth accumulation. (2) Compulsive competition with other plutophiles in amassing the greater/greatest fortune. (3) Unconcern with the negative economic, social, and ecological consequences of their exploitation of workers and/or other resources, and of their obsessive profiteering. (4) Delusional belief in their (social Darwinistic) superiority as human beings, and in having “earned every dollar.” (5) Insatiability. No matter how much wealth is accumulated, it’s never enough. (6) The belief that their psychopathology  is a virtue. I’d say that meeting five of these six criteria would suffice to establish the diagnosis.

Plutophilia is responsible for the vast gap between the wealthiest few and the masses that live in, or on the edge of, poverty. It harms society as surely as an unending drug abuse epidemic. However, having the disorder can’t be the grounds for involuntary commitment and/or court-ordered treatment. Sadly, there is no known treatment or cure.

Models of Madness

In prior posts I’ve written about the pros and cons of the medical model (psychiatry) as the predominant model for the treatment of mental illness, and about what I call “the model muddle.” Models are ways of organizing and framing ideas in a way that serves as a guide. A good model is like a good map: it helps you to get where you want to go. The map is not the territory, but merely a helpful representation. No model is perfect and complete, or demonstrably superior to all other models, in all situations. Each one has its flaws and limitations.

Psychiatry is the medical model’s methodology for treating mental illnesses – primarily with medications. In a nutshell, the model starts with the identification of symptoms, which leads to an appropriate diagnosis, which in turn leads to an appropriate treatment.  The medical model is very good at what it’s good at, such as mending broken bones, doing surgery, and treating many physical ailments. But psychiatry is built more on theory than on scientific evidence.

One limitation of the medical model is that it’s mainly focused on what you do after you have symptoms, not so much on wellness and prevention. A distinct limitation of the medical model as regards mental disorders is that, unlike most common physical disorders, there are no identifiable biological markers to distinguish (for instance) what we call “schizophrenia” from “schizoaffective disorder” or “bipolar, manic.” Psychodiagnosis is not rocket science, because mental illness isn’t measurable in the way that many physical illnesses are (i.e. medical science can distinguish between asthma and pneumonia). At best it’s educated guesses, and many people with an extensive history of psychiatric treatment have been diagnosed with – and treated for – a variety of diagnoses.

Critics of psychiatry have argued that mental illness is a social construct and not a medical condition, and that psychiatry is a process of coercive social control. The negative side effects of some psychotropic medications and mood stabilizers outweigh the benefits for many patients. The term iatrogenic effects refers to treatments that do harm. Unfortunately, contemporary psychiatry is wedded to the pharmaceutical industry. That having been said, psychopharmacology has its place in the treatment of what we call mental illnesses. I believe that in some instances there’s no effective substitute for the right dose of the right medication at the right time. But I also believe that other interventions can mitigate the need for primary reliance on drugs as the default treatment for psychopathologies.

The biopsychosocial model takes into account such factors as physical health, heredity, stress, social stigma, social support system, mental habits, chemical dependency,  economic status, nutrition, and homelessness. We need to embrace a more holistic treatment model for what we call mental illness, and to provide a range of services that gives people who’ve been labeled as mentally ill more autonomy and more options for resolving problems related to their mental health. Unfortunately, the national mental health system is severely underfunded, and many people in need of help are underserved. This is a national disgrace.

The recovery model is an alternative to the medical model. A lot of mental health professionals initially scoffed at the idea of people “in recovery” from chronic psychiatric disorders. Recovery made sense as a helpful model for “recovering” substance abusers, but did it apply to the mentally ill? Many mental health professionals have come to recognize the merits of the recovery model, and there are now recovery centers/programs in some cities, that aren’t run on the medical model. Such programs don’t necessarily preclude psychiatric interventions, but also offer educational resources to empower patients, professional and peer support, and access to community resources, to reduce the stressors that exacerbate symptoms of mental illness.. The concept of recovery from mental illness doesn’t mean full and permanent remission of symptoms, but suggests that psychiatric treatment isn’t the only route to symptom remission and control of one’s life. To find out more about the recovery movement and alternatives to traditional psychiatric treatment, check out madinamerica.com.

Psychotherapy in movies

In this post I’ll write about realistic depictions of psychotherapy in movies. Not many get it right. Barbra Streisand’s portrayal of a psychiatrist  in The Prince of Tides comes to mind. Her approach to therapy relies on the inaccurate cliché that when the client recovers the repressed memory of his trauma, he will be cured. More often than not movies about psychotherapy (i.e. Analyze This and Anger Management) treat it as a joke  – probably because the idea of being in therapy makes a lot of people nervous. Therapists routinely hear nervous jokes about their profession when they’re introduced to people as a psychotherapist. I can’t tell you how many times I’ve heard comments along the lines of, “I’d better watch what I say around you.” or “My wife really needs to talk to you.”

One of the most realistic depictions of psychotherapy I’ve ever seen in a movie was Ordinary People (1980), the first movie directed by Robert Redford. It depicts the dissolution of a family after the elder son of a loving couple dies in a boating accident. Timothy Hutton won an Oscar for his portrayal of the younger son, who feels guilty for surviving, when his brother died. Mary Tyler Moore distinguished herself as a dramatic actor in her role as the devastated mother, Donald Sutherland was totally convincing as the grieving father, and Judd Hirsch was perfect as a skilled and caring therapist who has to win the trust of his grieving, suicidal client. It’s a sad, beautiful movie, for which Robert Redford won an Oscar.

Good Will Hunting (1997) is another movie that portrays psychotherapy realistically. Matt Damon plays Will, an alienated, self-taught mathematical genius, orphaned and raised in foster homes. He’s grown a hard shell, to keep people out, and trusts nobody other than – to some degree – his best friend, played by Ben Affleck. Robin Williams portrays the therapist, who is willing to try to connect with this tormented genius. Will has to go to therapy in order to stay out of jail, but that’s his only motivation. He does everything he can to provoke and alienate his therapist, and to sabotage therapy. Robin Williams convincingly portrays a therapist who immediately sets boundaries when Will disparages his deceased wife. He’s briefly unprofessional, physically accosting and threatening Will; but this scene reveals that psychotherapists are also flawed human beings.

He clearly sees the sarcasm and hostility that he encounters as weapons that Will uses to push people away. He knows not to take the attacks personally, and works with patience and good humor to win Will’s trust, and to “disarm” him. I’ve dealt with well-defended clients like Will, working to get to the place where they were ready to hear something like this: “Look, we both know that your armor works. It makes you feel safe. The thing is, the only way you can learn that it’s safe – at least sometimes – to go out into the world without your armor is to take it off and venture out into the world.” The final therapy session in Good Will Hunting is riveting, and rings true to me as a therapeutic breakthrough.

Although it takes place in a “mental institution,” there’s not much psychotherapy in Girl, Interrupted (1999). Winona Ryder plays a young woman diagnosed with Borderline Personality Disorder and Angelina Jolie plays an antisocial manipulator. Parts of the movie are melodramatic and implausible, but the acting is good. One thing that the primary therapist in the movie – played by Vanessa Redgrave – says has stayed in my memory, because it’s point I’ve made in therapy about the meaning of the word ambivalence. Ambivalence doesn’t just mean, “Oh, I really don’t know if I want to do this or do that.” or “I don’t care if it goes this way or that way,” serving to deflect or minimize an issue. It can also mean being deeply conflicted regarding two opposing courses of action. An addict can both really want to quit using, but also really want to get high. Suicidal people can be ambivalent about living. Part of them wants to live, but another part wants to die.

The most realistic portrayal I’ve seen of therapy on TV was HBO’s series, In Treatment, with Gabriel Byrne as a therapist with, let us say, an extremely challenging caseload. He’s an excellent therapist, but his own life is something of a mess. One thing I liked about the series was that it not only depicted therapy sessions with a variety of clients and issues realistically, but it also showed us the therapist’s weekly sessions with his own therapist and clinical supervisor, played by Diane Wiest. Healers often need healing, themselves.

 

Hatred is not a mental illness

For the most part I’ve avoided political topics in this blog, and I don’t intend to change that. However, our President has crossed a line that I can’t, as an advocate for mentally ill folks, ignore. This week he distanced himself from his promises to do something meaningful about advocating for tougher gun laws when he described mass murderers as “mentally ill” and suggested  that improved care for the mentally ill would prevent mass shootings. We may be sickened by the violence of these hateful acts, but that doesn’t mean that the perpetrators are sick, in the sense of being mentally ill. It’s an insult to all mentally ill people to conflate hatred with psychopathology. People with diagnoses of mental illnesses are  no more likely to be dangerous to others than people without mental illnesses, and are more likely to be of danger to themselves than to others.

I know what I’m talking about. Throughout most of my career in the mental health system, I was certified as a Designated Examiner in the Probate Court. That meant that I routinely assessed people and testified in the Probate Court as to whether they met the criteria for involuntary commitment to psychiatric facilities. The two primary criteria are that the person is credibly diagnosed with a mental illness, and that he or she is at risk for harm to self or others. I was proud to play a part in a system that protects the civil rights of mentally ill persons, and assures that their right to due process is honored.

Xenophobia and race hatred aren’t symptoms of mental illness. They are learned prejudices, not psychopathologies. The President would have us believe that lethal hatred is a symptom of mental illness, not a product of hatred for “the Other.” Our national mental health system is a disgrace and needs to be adequately funded. But even if we had a system that provided adequate treatment for all of our mentally ill citizens, the impact on our national crisis of mass shootings would be negligible. It’s domestic terrorists that we need to worry about, not mentally ill people.

I was raised with guns. My father, an Army officer, was a world class expert on small arms and an avid NRA member. He saw to it that his sons learned to shoot at an early age, in NRA gun clubs – first with bb guns, then with .22 caliber rifles. I own guns, and I taught my wife to shoot them. A reasonable interpretation of the Second Amendment would protect the right of most citizens to own handguns, hunting and target rifles, and shotguns; but we’ve got to draw the line somewhere. You can’t buy or own hand grenades, flame throwers, bombs, or tanks – and that’s how it should be. We need to re-instate the ban on military-style semi-automatic assault weapons, such as the M-16 (AR-15). We also need to ban clips and magazines that hold ten or more rounds. Until we do this, the body count from mass shootings will continue to rise.

The signers of the Constitution couldn’t have envisioned our modern military weapons, or the mass shootings we see all too often these days, The rifles of the eighteenth century weren’t as accurate as modern rifles, and had to be re-loaded after every shot fired. Today we have semi-automatic rifles, which fire one round each time the trigger is pulled. Fully automatic rifles, which fire rapidly as long as the trigger is held down, are rightfully banned; but some semi-automatic rifles can be easily modified to be fully automatic. With clips that hold from a dozen to a hundred rounds, such rifles are weapons of war, designed for rapid slaughter. They should not be for sale to civilians.

A ban on the manufacture and sale of assault weapons won’t completely solve the problem, as there are already millions of them out there. However, the overwhelming majority are in the hands of responsible gun owners, who will never use them for mass murder. As long as they’re not allowed to be traded or sold, most of them don’t present a threat  to public safety. But an absolute ban on sales would make it harder for people who decide they want to kill people to acquire an assault rifle. A massive public relations campaign promoting a national, voluntary buy-back program would gradually reduce the number of assault weapons over time.

We also need to have a national dialogue about the “Otherizing” of racial and ethnic minorities by hate groups – the “Us vs. Them”mentality. School children need to be educated about the stereotypes that are being used to indoctrinate people to fear and hate people who don’t look like them or believe in all the things they believe in. They need to be able to recognize the lies that are told to recruit domestic terrorists. Part of the reform of our mental health system needs to be a public education program, to try to end the stigma about mental illness that is so prevalent in our society. Mentally ill people have enough problems with stigma as it is, without being blamed for mass murder.

 

 

Exposure Therapy

Most everybody knows what you’re supposed to do if you’re thrown by a horse. If you want to keep on riding, you get back up on horseback right away, to overcome your fear of being thrown again. The only way to get over your fear of drowning, if you swim in the deep end of the swimming pool, is to leave the shallow end and swim in water over your head.

The clinical term for this principle in psychology is exposure. Exposure is the antidote to avoidance, our very human tendency to reduce anxiety by avoiding activities and situations that tend to trigger anxiety. Avoidance is like a drug that immediately and reliably reduces anxiety or fear. For example, Tom is attracted to his high school classmate Jane, and wants to ask her out. He’s told himself that today’s the day he’ll get up his nerve and approach her, but he avoids doing it as the day goes by. As the end of the school day nears, he gets more and more anxious. But the moment he decides to postpone it until tomorrow, his anxiety dissipates. Avoiding and postponing work in the short-term, but serve to entrench our anxieties and fears in the long-term. Avoidance is one of the defense mechanisms  identified by Freud.

According to Dr. Marsha Linehan,  whose Dialectical Behavior Therapy (DBT) treatment of Borderline Personality Disorder has been empirically shown to be highly effective,, exposure is a necessary component of all effective cognitive behavior therapies. Two of the skills training modules in DBT, emotion regulation and distress tolerance, help to prepare clients for exposure to things they typically avoid.

Exposure therapy can be effective in treating Generalized Anxiety  Disorder, Social Anxiety Disorder, Obsessive-Compulsive Disorder (OCD), Post Traumatic Stress Disorder (PTSD), and phobias – irrational fears. It involves habituation to the feared stimulus/situation. Imagining exposure to successive approximations of the stimulus/situation (imaginal exposure) and teaching heightened awareness of physiological responses such as heartrate and muscle tension (interoceptive exposure) can be accomplished in the therapist’s office. Exposure to the actual stimulus/situation “out in the world” (in vivo exposure) is often the third step of exposure therapy. Being aware of the thoughts, emotions, and physiological responses involved prepares the client for in vivo exposure. Gradually working your way from the shallow end of the pool to the deep end involves exposure to “successive approximations” of the thing most feared. Jumping – or being thrown – into the deep end is an example of “flooding.”

The therapeutic method known as systematic desensitization was pioneered by South African psychologist Joseph Wolpe. After doing a behavior analysis of thoughts, feelings and physiological responses involved in a phobic reaction, he did relaxation training until the client felt some degree of control over his typical responses. Then he worked with the client to develop a hierarchy of fears, from the least fear-inducing to the most fear-inducing thoughts/experiences. Using this hierarchy, he would work with the client on relaxing as they went through successive approximations, leading up to the thing most feared.

Here’s an example of how I might use this method with a client who had never flown in an airplane, due to her phobia about flying. (Because flying is statistically much safer than driving, fear of flying is considered  an irrational fear, or phobia.) Having assessed Louise’s typical thoughts, feelings, and physiological responses/anxiety symptoms, and having trained her to relax, I might start a session with a relaxation induction, leading to a guided fantasy based on her hierarchy of fears. Louise has been instructed to close her eyes, to raise her right index finger whenever she felt an increase of anxiety, and to lower it when the anxiety decreased.

“You’re in your apartment and you’re packing for your flight . . . . Now you have your bags packed and you’re waiting for a taxi to the airport . . . . And now you’re at the airport and you hear the boarding call . . . . Now you’ve stashed your carry-on and are seated, buckling your seatbelt, etc.” Whenever Louise would raise her finger, I’d switch from the guided fantasy to the relaxation induction: “And as you breathe slowly and deeply, you can feel your muscles relaxing, and your anxiety is replaced by a calm feeling . . . . ” When the finger went down, I’d pick up where I left off on the guided fantasy.

Over time, Louise learns that she has increased control over her response to fearful thoughts, getting gradually closer and closer to the thing she fears most. Once she can imagine herself staying in control as the airplane takes to the skies, we might go on to in vivo exposure therapy, which might involve me accompanying her – at least at first. Some private practice therapists specializing in the treatment of phobias might even accompany his client on his first flight, coaching and encouraging him.

People with severe OCD often engage in compulsive rituals to reduce their anxiety. Exposure therapy can help them to learn that they don’t have to rely on these rituals to reduce their anxiety. People with anxiety disorders can use the principles of successive approximation to gradually desensitize themselves to stimuli/situations that used to trigger anxiety. Exposure therapy can similarly help people with PTSD to control physiological arousal in response to stimuli/situations that used to trigger fear. But in order to overcome an irrational fear, you have to eventually face it.

Psychiatry: pro and con

I write this as someone who had a career as a psychologist in the mental health system, working within the scientific/medical model of psychiatric treatment. So, I’m not writing to reject psychiatry outright, but to examine its efficacy. I’ve written about the value and limitations of models in previous posts, and about what I call the “model muddle.” Models are just maps, helpful only to the degree that they’re accurate. No one model is demonstrably superior to all other models, in all situations. Every model has its limitations.

First, I’d like to distinguish between psychology, psychiatry and psychoanalysis. Psychology is the study of human behavior, and provides the basic theoretical structure for psychotherapy. Sigmund Freud came up with the concept of “the talking cure,” the notion that dialogue with a caring professional could help to resolve symptoms and treat psychopathology. Psychiatry is a branch of medical science, based on the concept that the accurate assessment of symptoms of mental illness can lead to an accurate diagnosis, which will result in an appropriate treatment. Psychiatrists are medical doctors who specialize in the treatment of mental illness. Freud was a psychiatrist, and psychiatrists who are trained in the system of Freudian psychotherapy are called psychoanalysts.

While I believe that psychiatric (medical model) treatment has helped a lot of people with debilitating metal and emotional symptoms, like any model, it has its limitations. Since the 1960s, the efficacy of psychiatric treatment has been questioned – with good reason. A primary critic was psychiatrist Thomas Szasz, who wrote The Myth of Mental Illness. Another psychiatric rebel was R.D. Laing, and yet another psychiatrist, David Cooper, coined the term “antipsychiatry.” Critics of psychiatry argue that mental illness/madness is a social construct and not a medical condition, and that psychiatry is a process of coercive social control. This core of criticism has led to the current antipsychiatry (alt. recovery) movement.

A primary criticism of psychiatry is that psycho-diagnosis isn’t rocket science. It’s imprecise relative to the diagnostic precision for most common physical medical conditions, and can be selective and subjective in its diagnostic criteria. Unlike with physical medical conditions that can be diagnosed by tests and procedures that reveal “markers” of a specific condition (i.e. pneumonia vs. tuberculosis), there are no such markers that distinguish schizophrenia from schizoaffective disorder or bipolar disorder. I’ve known many people with chronic mental and emotional disorders who have gotten a wide range of psychiatric diagnoses, over years of treatment. Ideally in the medical model, an accurate diagnosis results in appropriate and effective treatment. This is less often the case in psychiatry, because there’s more “educated guesswork” involved.

Proponents of the antipsychiatry movement contend that psychiatric treatment is all too often more damaging than helpful to patients. Extreme treatments such as prefrontal lobotomies haven’t proven to be effective; and the negative side effects of some psychotropic medications and mood stabilizers seem to outweigh the benefits for some patients. The term “iatrogenic effects” refers to treatments that do harm.

Another valid criticism of psychiatry is that it’s over-reliant on pharmaceuticals, and that the psychiatric profession has had incestuous ties to Big Pharma. I believe that, as a culture, we’re too dependent on medications as a panacea for health problems related to bad lifestyle choices. Drug company ads suggest that we can eat whatever we want and take pills to control any gastro-intestinal symptoms that result from a poor diet.

Having said that, psychopharmacology has its place in the treatment of what we call mental illnesses. I believe that in some instances there’s no effective substitute for the right dose of the right medication at the right time. But I also believe that other interventions can mitigate the need to rely primarily on drugs as the default treatment for psychopathologies.

The concept of recovery from mental illness doesn’t necessarily mean full and permanent remission of symptoms, but suggests that psychiatric treatment isn’t the only route to symptom control or remission. There are recovery centers in cities around the country that offer alternatives to traditional psychiatric treatment, recognizing that community and peer support can be important components of treatment. Such programs don’t preclude psychiatric interventions, but don’t rely on them as the default mode.

Factors such as physical health, stress, social stigma, chemical dependency, poverty, homelessness and nutrition can all play a role in mental health and mental illness. We need to embrace a more holistic treatment model for what we call mental illness, and to provide a range of services that give people who have been labeled as mentally ill more autonomy and more options for resolving their problems.

You can find out more about the antipsychiatry movement, the recovery model, and alternatives to traditional psychiatric treatment at <madinamerica.com>.