Tag: psychodiagnostics

Psychiatry: pro and con

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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>.

 

 

Who is normal?

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Nobody is normal.

I think normality is one of the most misunderstood concepts in our culture, in that so many people still nervously ask the question, “Am I normal?” It seems that “normal” has come to be equated with “desirable,” is in ten-fingers-and-ten-toes-on-the-baby normal. But it ain’t necessarily so. I, for one, am unapologetically not normal, and have no wish to be seen as normal, conventional or average. I don’t dress funny or anything outwardly apparent, and my  abnormalities are benign: I don’t follow sports. I don’t own a cell phone.  I create strange art. (Check out jeffkoob.com)

“Normal” is a relatively modern social concept, and is based on a statistical idea. It isn’t found in nature, and like “Justice,” only resides in the human brain. On the street, normal correlates to  average, and abnormal has come to have negative connotations. In statistics there are three “measures of central tendency” (mean, mode and median) that produce what we call averages. But there is no values correlation between average (normal) and good, or desirable. Cigarette smoking used to be a normal adult habit when I was growing up. Obesity is normal in our society, as is divorce. Five hours or more of screen time daily seems to be the new normal. Standards of normality change over time.

There’s no such thing as a normal dog or a normal day or a normal rock, let alone a normal human being. While the average American family may have (let’s say) 1.8 children, you won’t find a single family that actually has 1.8 children. Normality is an abstraction, not a reality.

We increasingly live in a world of manufactured situations and pastimes, with a high standard of standardness.  Fashion choices may seem to set us apart, but following fashion just makes us part of the fashion parade. The mass media promote conformity and superficiality as virtues. It’s easy to see why a person who sees herself as a misfit might  long to “just be normal.” But I agree with Frank Zappa, who said that while many people think normality is grand, “normality is not grand, it is merely okay.”

If you’re conflicted or alienated, you may have an unrealistic vision of normality as a desirable destination. But balance, harmony and serenity are better destinations than normality. You are unique, and you need not be normal to live well and happily. People  who strive to be normal may not recognize or cultivate creative potentials within themselves. Original art doesn’t come from normal thinking, and “thinking outside the box” means not thinking conventionally. Extraordinary people are, by definition, not normal.

In my last post I mentioned the “Unconventional Modes of Experience” course in my humanistic psychology graduate program. It didn’t take the same approach as traditional “Abnormal Psychology” courses, as it didn’t have the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) as a textbook. Instead, the focus was on the phenomenology of madness. I won’t attempt to explain phenomenology in this post, other than to say that its focus is on subjective experience, not objective diagnosis. Crazy behaviors are often the result of unconventional experiences, such as auditory hallucinations. Scientists dismiss such phenomena as mere symptoms. Phenomenologists, like shamans, explore them for meaning.

I later took DSM-based courses and professional development classes to develop my diagnostic skills, but I’ve always appreciated my exposure to phenomenology as an alternate lens to the medical model. A belief underlying my therapeutic practice was that the better I understood each client’s unique experience of being-in-the-world, the better equipped I’d be to help him therapeutically.

I know that gay people didn’t choose to be gay any more than I chose to be straight. Being gay isn’t statistically normal, but it’s a normal variation from the heterosexual norm in every known culture on earth. I worked in therapy with a number of gay people who expressed their longing to be normal, to meet the standards of normality they were raised with in their families and communities. Some knew they’d be shunned if they were labeled abnormal. But what is considered normal is always culture-bound. Arranged marriage is normal in some cultures. That doesn’t mean it’s good or bad, just that it’s what most people do.

As long as you live your life productively and responsibly, and don’t exploit or abuse others, being normal is optional. Being abnormal isn’t necessarily a bad thing, if it’s an authentic expression of who you are. There’s no objective and timeless standard for what’s normal, anyway; so you should feel free to be your unique self. Other people’s judgments may be their problem, and may not have to be yours.

 

Who is mentally ill?

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Sometimes as the group leader in my psychoeducational groups, I’d start my standard rap on psychopathology by writing two words on the board: sad and depressed. Then I’d ask, “Do these two words mean the same thing?” After listening to responses from group members, I’d proceed in this manner: Yes and no. On the street they’re synonymous, but to a psycho-diagnostician they can be very different things. Sadness is a universal human experience. Sometimes we can identify the reason or reasons for our sadness, other times not. When a person says, “I’m depressed because my friend is moving away,” they’re likely describing “normal” sadness that will probably diminish over time.

Sadness is a mood, and moods come and go. If a sad mood becomes persistent and affects your functioning, depression may be a better description for the experience. This persistent mood may also be due to an identifiable cause, such as a romantic breakup, or it may be unrelated to life circumstances. The former is referred to by some  clinicians as “functional” (caused by some external circumstance), the latter as “endogenous” (caused by internal, biologic factors). This isn’t an absolute distinction in all cases, but it has its utility.

There’s a deeper level of depression that isn’t a universal experience. Even at the lowest points of my life, I’ve never been as sad as the clinically depressed people I’ve known personally and professionally. People living with this kind of depression may experience hopelessness, despair, and suicidal ruminations. I’ve never been there, and I have great compassion for those who have.

One way of classifying psychopathology is assigning people to distinct diagnostic categories. You either do or don’t meet the diagnostic criteria for depression, or schizophrenia, or bipolar disorder, or antisocial personality disorder. If you don’t have the disorder, you may have traits associated with it. Another way of classifying pathological traits is to view them along continuua: straight lines with opposite poles. Everybody can be placed somewhere on a continuum between happy to be alive and suicidal, gentle and violent, honest and dishonest, paranoid and trusting, and other traits and tendencies.

If I’m extremely unconventional but functional, some people may refer to me as “crazy,”  but to others I’m merely eccentric. If I’m unconventional to the point I can’t function in society and may endanger myself or others, I could be mentally ill. In my graduate program in humanistic psychology, we didn’t even have a course titled “Abnormal Psychology”; that was considered too pejorative. Our course was titled “Unconventional Modes of Experience,” lest we apply unnecessary or judgmental labels to people.

Psychopathology is characterized by impairment or disability. I have obsessive-compulsive traits, but I don’t think of them as pathological, because I’ve been able to recognize, control and channel them. I’ve had doctors and lawyers tell me that they never could have made it through medical school or law school if not for obsessive-compulsive traits. You too may have traits of a mental disorder, but not meet the diagnostic criteria, because you’re not impaired by them. For instance, you might have some symptoms of depression, but not be pathologically depressed. Or you might have paranoid traits,  but not be diagnosable as having a paranoid disorder. The hyper- vigilance characteristic of a truly paranoid person might even be desirable, if you’re a spy.

Even if you have a diagnosed mental illness or engage in crazy behavior, you can’t be involuntarily committed to a treatment facility without a Probate Court hearing. (I only refer to behaviors as “crazy,” not people.) In most states you must be interviewed before the hearing by two Designated Examiners (DEs), one of them an MD, and have court-appointed legal counsel to represent you at the hearing. In order for you to be involuntarily committed, both DEs must agree – and convince the court – that you are of danger to yourself or others, due to a diagnosable mental illness. I’ve had the privilege and responsibility of being a DE for most of my career, and in my experience the system works most of the time to prevent people from being “railroaded” onto locked wards against their will.

Mentally ill people are often shunned, and even blamed for their symptoms. With good treatment most mentally ill people can function in society, although some are too disabled to hold a steady job. All people with mental and emotional illnesses deserve good treatment, regardless of income. But unfortunately, state mental health systems all over the country are terribly under-funded, and many folks don’t get the treatment they need to remain functional. A significant portion of homeless people have mental illnesses. Hospital ERs, jails, and prisons have become major mental health service providers. I’ll describe how we got to this sorry state of affairs in a later post.

Freud’s legacy

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Freudian psychoanalytic theory was the basis of the whole notion of  “the talking cure” – what we now know as psychotherapy. But many of Freud’s ideas have been discredited and none (to my knowledge) have stood up under the lens of scientific scrutiny. This doesn’t necessarily mean that they have no utility, just that they can’t be proven. I’m not suggesting that nobody has benefitted from psychoanalytic therapy, but its techniques and benefits haven’t been empirically validated.

The first two editions of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) were largely written by psychoanalysts, and analyzed mental illnesses through Freud’s theoretical lens. (Both editions labeled homosexuality as a mental disorder, a grave error corrected in the third edition.) Subsequent DSM editorial committees saw fit to question the utility of Freudian concepts such as neurosis and hysteria, and to focus instead on identified symptoms in establishing diagnostic criteria. Most of Freud’s psychoanalytic concepts have proven superfluous to our understanding of the pathologies, or unfounded.

Freud attributed most psychopathy to unconscious and unresolved infantile or early childhood issues and conflicts, especially those conditions he characterized as “hysterical” or “neurotic.” He posited that the Oedipus Complex was a universal experience for little boys: the unconscious wish to kill Dad and have sex with Mom. The Electra Complex was the female analogue of this Freudian notion, which no longer seems to have any utility. The concept of female “penis envy” also appears to tell us more about Freud’s psyche than about the human condition.

While there may be some metaphoric validity to the idea that some people are “accident prone” or have a “death wish” due to unresolved unconscious conflicts, there’s no real evidence for these propositions. Conversion disorders – the loss of some physical or sensory capability for psychogenic reasons – are still in the DSM, but calling them “hysterical” in origin contributes nothing to our understanding of the condition.

There’s been a steady decline over the years in people who undergo the rigorous training required to become a psychoanalyst, and its theory and techniques haven’t been validated by research. The technique of “free association” (saying the first thing that comes to mind, in response to serial stimulus words) can reveal interesting mental associations, but there’s no scientific evidence of its effectiveness as a therapeutic technique. Dream analysis can be fascinating, but it’s not a magical key to insight.

I’ve already written a post in which I presented Freud’s concept of defense mechanisms as a useful tool in psychotherapy. But what other Freudian notions have stood the test of time? In my opinion, his popularization of the concept of unconscious motivations has contributed significantly to our understanding of human behavior. Sometimes people do things for reasons they don’t consciously understand. This idea has taken root in modern life.

The personality structure of superego, ego and id still has some metaphoric validity, and was revived in Transactional Analysis as parent, adult and child. The way I used the metaphor in therapy went something like this: “It’s as if we had three aspects to our personalities, the parent, the adult and the child. Children operate on the pleasure principle – I want what I want right now! One of the tasks a child needs to master on the journey to adulthood is learning to delay gratification, to be willing to do needful things now, in anticipation of future reward.”

Another Freudian concept that still makes sense to me is that of transference and countertransference. It describes emotional dynamics within a therapeutic relationship. Freud said that patients tend to unconsciously transfer feelings for significant others (like Dad , or a lover) onto their therapist. A therapist who is aware of this dynamic in the therapeutic relationship, and who isn’t unconsciously affected by countertransference (her feelings for the patient), can use transference to the patient’s benefit in therapy. A client falling in love with his therapist or a therapist falling in love with her  client (it happens) can also be understood through this Freudian lens.

But it seems to me that Freud’s most enduring legacy (influenced by his mentor, Joseph Breuer) was his concept of “the talking cure,” the idea that talking about your problems with an attentive and caring therapist can be healing. This may seem obvious to many of us today, but without Freud’s contribution, contemporary psychotherapy as we know it wouldn’t exist.

Bonus recommendation: If you want to read an excellent novel about the genesis of “the talking cure,” I highly recommend Irvin Yalom’s When Nietzche Wept. Freud isn’t the main character, but the novel imagines a friendship between Joseph Breuer and Friederich Nietzche, and how it affects the lives of both men. Don’t waste your time on the movie adaptation.