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.

Identity and diagnosis

I’ve  written two prior posts on the paradox of identity, and now I want to return to the topic. I’ve run into different versions of the  following affirmation/mantra and I don’t know who to attribute it to, but it’s a good starting point for this brief examination of what identity is and isn’t: “I have a body. I am not my body. I am more than my body. I have emotions. I am not my emotions. I am more than my emotions. I have thoughts. I am not my thoughts. I am more than my thoughts. ” For people with identified mental illnesses I’d add: “I have a diagnosis. I am not my diagnosis. I am more than my diagnosis.”

Folks grappling with mental illnesses often find themselves stigmatized, treated as the modern equivalent of lepers, although they’re not contagious. Even within the mental health community individual patients are sometimes referred to by clinicians as “a schizophrenic” or “a borderline.” Mentally ill people often sense that others stereotype and define them by their mental illness. One of my great revelations early in my career (I already knew it intellectually, but not experientially) was that people with mental illnesses are, first, unique individuals – like the rest of us. Their mental illness is a feature of who they are, not a defining characteristic.

When I worked in a Dialectical Behavior Therapy (DBT) program, designed to help “borderlines,”  one of my individual therapy clients was a highly intelligent and assertive  woman. She let me know up front in our first therapy session that she wouldn’t abide being referred to as ” a borderline” by me or my colleagues. “I’m a person who meets the diagnostic criteria  for  Borderline Personality Disorder.” And that describes her better than any diagnostic label. (Years later she saw me at a mental health event and gave me one of the finest and most honest compliments I’ve ever gotten from a former client. She said that I was the second-best therapist she’d ever had.) She refused to let others define her by her diagnosis, and was her unique self. I’ve worked with a number of people diagnosed with Borderline Personality Disorder, and no two of them were alike. I’ve worked with many more who carried the diagnosis of schizophrenia, and no two were alike.

It’s easy to stereotype people we don’t understand, and whose behavior might confuse or threaten us. As with homophobia, fear of crazy people – the most common stereotype –  is rooted in the unconscious or conscious fear, “what if I were that way.” The idea of “losing your mind” is frightening to anyone who thinks about it. Les aliens is a French term for the insane. Many people with chronic mental illnesses feel internally alienated because of their symptoms, whether depression or hallucinations. But on top of that, mentally ill people are frequently treated as aliens by people who don’t understand, and therefore fear, them.

People struggling to cope with the symptoms of mental illness often find themselves judged or blamed for their symptoms. A person in a manic state may be told, “Just pull yourself together and stop acting crazy!” A person suffering from clinical depression or PTSD might hear, “What’s wrong with you, anyway? You should have gotten over that by now.”, as if they had a choice.

Psychodiagnosis is a necessary part of the medical model but, as discussed in a previous post, it’s based on decisions made by committees and applied to unique individuals. It’s not rocket science. Psychiatry puts the people it treats in the patient role, or sick role. There are both advantages and disadvantages to being conferred the sick role. It absolves you of responsibility for certain things you’d normally be held responsible for; but it prescribes what you must do as a patient, and often keeps you dependent on ongoing treatment. This makes sense for a kidney dialysis patient, but not necessarily for everyone with a psychiatric diagnosis.

In some circumstances, for mentally ill persons there’s no substitute for good psychiatric treatment. But all too often patients are told that medication is the only option, and that they’ll have to depend on medications with awful side effects for the rest of their lives. The recovery model is person-centered, not patient-centered. Centers run on the recovery model work with their clients to come up with a unique recovery plan that serves to empower them, encouraging autonomy and hope. The plan may include referrals for psychiatric treatment when it’s needed, but other options are explored. More about the recovery model soon.

The model muddle

I’ve already written posts on several therapy models (gestalt, Rogerian, Transactional Analysis, Freudian psychoanalytic), so it’s time I examine what models are: their utility, their strengths, and their limitations. First off, models are ways of organizing and framing ideas in a way that serve as a guide. A good model is like a good map: it helps you accomplish something you set out to do, to get where you wanted to go.

But the map is not the territory; it’s merely a helpful representation. I’ve known people who were so dedicated to a model that they couldn’t see its limitations, and were blind to alternative formulations, viewing everything through the lens of their fixed beliefs. No model is perfect and complete. Each one has its flaws and limitations.

I first started thinking about models as a young mental health professional, when I read Miriam Siegler and Humphrey Osmond’s Models of Madness, Models of Medicine, in which they compared the medical model to eight other models related to the care of mentally ill persons. After examining each model (moral, impaired, psychoanalytic, social,  family interaction, etc.), the authors – both MDs – conclude that psychiatry is the only way to go. Holistic, shmolistic..

Psychiatry is the medical model’s approach to treating mental illness, usually with medications. The medical model is a scientific model. In a nutshell, the model starts with the identification of symptoms, which leads to an appropriate diagnosis, which in turn leads to a specific treatment. The medical model is very good at what it’s good at, such as mending broken bones, and doing surgery, and treating many physical ailments. But its self-promotion as the only game in town for the care of the mentally ill has been challenged by many, notably Dr. Thomas Szasz and R.D. Laing.

No model is a perfect fit for all occasions, and many MDs have come around to believing in the benefits of a holistic approach to health care. Although I still believe that psychiatric treatment has its place and can be of benefit to many people with what are known as “psychiatric disorders,” like all models the medical model has its limitations. There are other valid approaches to health care that don’t rely on symptoms > diagnosis > treatment as their primary focus. The medical model is mostly focused on what to do after you exhibit symptoms, not so much on how you got there. Some medical traditions are more focused on wellness than on treating (sometimes preventable) illnesses. No model has all of the answers.

One of the limitations of the medical model as regards the care of mentally ill people is that the criteria for a differential diagnosis were determined by a committee of psychiatrists, to be applied to a unique individual. Unlike most physical disorders, there are no identifiable biological markers to distinguish what we call “schizophrenia” from “schizoaffective disorder” or “bipolar, manic.” Psycho-diagnosis is not rocket science, because mental illness isn’t precisely measurable. 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.

A model I’ll be writing about in a future post is the Recovery 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” chronic substance abusers, but did it apply to the chronically mentally ill? I think (hope) that many or most mental health professionals have come to recognize the merits of the recovery model, and there are now recovery centers in some cities that aren’t run on the medical model. You might want to check out <madinamerica.com> to learn more.

Treatment models compete in the marketplace, and there’s money to be made. For instance, the Pentagon has paid millions for training in Positive Psychology. With modern marketing in the mix, we find ourselves in the midst of a model muddle. More about this down the road.