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DSM Creates Phony Illness

Chapter 4 of PBM, “Probing the Boss Text: The DSM—What? Whither? How? Which?” is devoted to discrediting the DSM, in terms of the process used to create it, allusions to scientific foundations that are sketchy at best, various political and financial conflicts of interests attached to its creators, and more questioning about the “validity” of mental illness as a whole.

As I have discussed previously, I agree there are serious flaws in the DSM along the lines which BB suggests, leaving the question of how exactly “mental illness” is carved up into these individual disorders somewhat sketchy.

The Argument

Starting with the section “Activating the Text,” BB then proceeds to make the case that diagnosis is the primary, if not sole, driver of all that follows in the psychiatric system. You see a psychiatrist, you get a diagnosis, you are necessarily treated, which is done solely on the basis of that diagnosis, etc.

If the initial diagnosis (from the flawed DSM) is meaningless, the argument would go, all that follows is flawed.

Again, sounds logical enough. Let’s probe deeper.

The Necessity of Diagnosis

To quote from PBM:

While hypothetically, the practitioner separates those allegedly with “mental disorders” from those without, in point of fact, that is neither what happens nor what the system mandates. The practitioner rather is tasked with the job of assigning a diagnosis… A veritable diagnostic imperative is at work… The question then is not whether or not someone seeing a psychiatrist or psychologist will be assigned a “disorder.” The question is which disorder.

It’s true in one sense that if you see a psychiatrist, there will be a diagnosis assigned. For doctors to get paid by insurance companies (e.g. HMO’s etc. in the USA, provincial government health insurance plans in Canada) they need to provide along with your personal identifying information a “procedure code” (i.e. what they did for you) and a diagnosis code. This is incidentally true for all types of doctors, and all types of illnesses. It’s not restricted to mental disorders or psychiatrists.

Is the sole goal of an interview to arrive at diagnosis? Again, quoting from PBM:

[Tools like the Structured Clinical Interview for DSM perform] the all-important function of helping practitioners fill the empty shell of one the criteria sets with details of the patient’s life. The purpose of clinical interview per se is to arrive at the diagnosis… While the patient telling his story may be under the impression that a normal or quasi-normal conversation is going on, essentially behind his back a complex text-act sequence is under way.

While a diagnosis will indeed be found in every psychiatric assessment/consultation report, these multi-page reports also include far more information than what is strictly required to arrive at a diagnosis. More on this shortly.

Symptom Threshold

So far we’ve agreed with BB that a diagnosis will exist, even for pro forma reasons, e.g. billing.

But BB would like to distract us from the fact that diagnostic criteria require a certain threshold to be met, essentially that the behaviour/problem/stressor has to be clinically significant. The DSM makes some attempt at codifying this, and the five years of psychiatry training every psychiatrist receives provides further positive and negative examples of meeting criteria. There are grey areas and some amount of subjectivity to be certain, but overall there is general agreement about what it means to meet each criteria.

But an important criterion for being diagnosed with any mental illness is the following:

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Again, clinically significant is not as flimsy as BB would have the reader believe. Moreover, if you ask most people seeking help for mental health problems if their symptoms are getting in the way of different aspects of their life, they would be able to provide an answer.

So yes, your doctor may bill your insurance saying you have a catch-all diagnosis like “Mood Disorder Not Otherwise Specified,” but that is far different from saying you have an actual mental health diagnosis that is significantly impairing your life.

The Treatment Imperative

Which in turn brings us to the next point. The argument in PBM implies that you receive a diagnosis, and on the sole basis of that diagnosis necessarily receive treatment. This is patently false.

While a diagnosis might suggest what treatment options might be appropriate for people with that disorder who are seeking treatment, it does not determine if and how you are treated. This is determined by your individual symptoms and their severity, and in almost all cases, your own choices.

If I sprain my ankle, would I automatically get it treated? For a mild sprain that isn’t affecting me much, it’s very unlikely, and I doubt I’d even go to a doctor. For something a bit more severe, I might see the doctor, who might well tell me to just give it a rest, i.e. not treat. Or they might propose some noninvasive treatment such as a support or brace of various sorts, or something more invasive like surgery. Am I compelled to agree? No.

In all these cases, both my doctor and I would be weighing the costs and benefits of the treatment against the costs and benefits of leaving it untreated. Severity of the illness is a definite factor in this process, not just the actual diagnosis. Mental illness is no different.

For a reinforcement of this discussion, I’d refer you to an excellent blog post by Natasha Tracy entitled Mental Illness is Only a Problem When Mental Illness is a Problem.

More Arbitrariness

Some other smaller arguments are made to discredit the construction of diagnoses in the DSM.

I’d mentioned previously the “Not Otherwise Specified” notion, which PBM ridicules:

[NOS]… undermines the very concept of “criteria.” By these maneuvers, note, something qualifies as a disorder either if it meets or fails to meet stated criteria.

As noted previously, one “use” for such diagnoses is purely for billing purposes, where the physician doesn’t think the patient actually has a mental illness. Someone will see a physician because they are concerned about their mood. After hearing their story, the physician will conclude that what they are experiencing is a normal emotion, part of normal human experience, and that they don’t have an illness. This happens quite often, despite BB’s claims to the contrary.

Alternatively, while the arbitrariness of the criteria (and for example, needing five of seven symptoms to meet criteria) is criticized, “Not Otherwise Specified” is also used to specify an illness that may not fit into one of the standard boxes, yet is still severe enough that it is causing “clinically significant distress or impairment” to the patient. In other words, patients won’t need to be left to suffer with severe illness just because the categorization doesn’t quite fit.

Another criticism of the DSM is that mental illnesses are classified in such a way that:

… it is possible for two people who have no symptoms in common to receive the diagnosis of [a specific mental illness]

Again, we’d find that many “medical” illnesses exhibit similar patterns (Crohn’s disease, which can present in a multitude of different ways in different people, springs to mind).

Reconceptualizing the DSM

With the above in mind, let us reconsider the role of the DSM in actual practice.

Does it create illnesses ex nihilo (Latin for “out of nothing”; doesn’t fancy terminology give me credibility and make my argument stronger?) which are then necessarily applied to all patients, who then automatically proceed forward to treatment based on their diagnosis alone? Plainly, the answer is no.

The illness already exists in the patient, as a set of symptoms, severities, and impacts on their life. What the DSM does is take that illness and attempts to classify it. This is for several reasons. First are for mundane, administrative purposes such as billing.

Second, this serves (imperfectly) as a means to suggest treatments. As noted in an earlier section, it is for this purpose that the DSM is most-often abused by those with vested interests in applying particular treatments to as large a range of patients as possible.

Finally, as all classification tools provide, it serves as a way to decompose a larger problem (“mental illness”) into something more manageable so as to more easily conceptualize, understand and problem solve. This property also allows it to more effectively serve as a communications tool between different practitioners, a shorthand or placeholder (but not a replacement) for describing a whole range of symptoms, behaviours and effects.

Oddly, BB’s rigorous institutional ethnography did not reveal to us this common and important use of the DSM in actual practice.

From this new vantage point, the multiple iterations, changing perspectives, and differing conceptualizations of illnesses between versions can be seen not in terms of a changing understanding of some underlying physical process, but as (ideally) improvements in their effectiveness for allowing clinicians to conceptualize and communicate about mental illness.

Mental illness exists. It’s not the (at times arbitrary, or politically influenced) divisions in the DSM that make it exist.

Conclusions

As the introduction of PBM so clearly states, “much like a lawyer in a courtroom, this book in essence ‘makes a case’.” But for those sincerely seeking to learn the truth, PBM cannot stand on its own. To carry forward the analogy, we need to add, at a minimum, opposing council, rebuttal, and a judge or jury to weigh the testimony.

Patients who have been victimized or harmed in the past by psychiatric practice, whether rooted in malice, manipulation, ignorance or bad luck, have done an invaluable service and have helped overturn unjust and abusive practices of the past. Those courageous people who continue to do so to this day constantly remind us that we are still too far away from where we want to be.

Patients, families, advocates, journalists, and others who have brought these stories forward, identified structural flaws and promoted changes, who critically but openly have engaged with the broader mental health community, have similarly helped move practice forward, to open the eyes of those who need them opened, and have thereby improved the lives of other patients. As have those who have told other stories about mental health and treatment, the impact on their lives of these very real illnesses, how their lives have sometimes been improved, sometimes imperfectly, with treatment. As have those who have fought to reduce stigma, make it easier for people to come forward, and to raise the level of public conversation on this topic to unprecedented levels.

Those in the antipsychiatry movement are not to be counted amongst those who have helped. They seek not to improve psychiatric practice, but destroy it. They deny the very nature of mental illness, dissuading people from coming forward and obtaining treatment that could improve their lives. They do not engage with the broader community, but reject criticism, and retreat within an echo chamber of their own making, recycling the same examples and arguments ad nauseum.

In PBM, we have a holistic, broadly-based representative of the antipsychiatry genre. It carries the trappings of rigorous knowledge: the language, references, methodologies, and ostensible blessing of an esteemed university. Yet beneath this carefully constructed façade lies a one-sided, overzealous polemic.

Not content to advocate for change, more oversight, etc., PBM takes the audacious step of claiming with absolute logical certainty that psychiatry is without any redeeming quality and must be annihilated. The ludicrousness of this overreaching attempt is revealed in its reliance on numerous overly-simplistic and fallacious arguments.

Yet, irresponsibly but predictably, no viable alternative, no concrete solution, nothing with the slightest chance of actually happening is offered instead. We are left only with a simplistic “good vs. evil” paradigm intended only to deliver recruits to an extremist movement.

Drugs Cause Abnormal Brain Changes

Chapter 7 of PBM is entitled “Marching to ‘Pharmageddon’: Psychopharmacy Unmasked” and argues that psychiatric drugs, the “kingpin itself,” are inherently dangerous, and can only damage, not help.

We’ll pass over the sections describing the flaws in the drug creation and approval process (selectively referenced of course) and proceed to the primary argument intended to demonize psychiatric medications en masse.

The Argument

Here we’re going to be relying on the idea that mental illness has to do with imbalances (too much, too little) of several different neurotransmitters. To summarize, again from PBM:

… these substances alter brain chemistry, and given that the people being treated for “mental illnesses” in point of fact have “normal” brain chemistry, it stands to reason that these substances themselves create imbalances. [italics in original]

Sounds logical enough, leading us to the next question of whether or not people being treated for mental illnesses do have “normal” brain chemistry.

To address that, PBM leads us through an exceedingly lengthy description of neurotransmitters, how larger or smaller amounts of each can affect us behaviourally (e.g. stimulating, relaxing). The main point that she makes with respect to the argument in question is that the brain has mechanisms which automatically adjust the level of neurotransmitters to bring things back into equilibrium, to correct levels when things are too off-balance.

Because the brain does that as a normal part of its functioning, this is normal brain chemistry.

Anything that alters it is therefore abnormal brain chemistry. The drugs alter this normal functioning of the brain and its chemistry, ergo they are creating abnormal brain chemistry.

Normal

Stated that way, a lot seems to rest on this “normal” vs. “abnormal” distinction. If you’re getting a sense of deja vu, you should be, because as with the argument “mental illness has no known physical cause so it’s not real”, you have to buy the validity of this particular definition of “normal” for the argument to work.

Can we look at this another way, that is perhaps, more person-centered?

Assume that without medications, our neurotransmitters do their thing as “normal”, and our brain’s corrective mechanisms do their “normal” thing to keep everything in equilibrium. Yet oddly, for no apparent reason we’re still curled up in the fetal position on the floor in a dark room, crying and screaming 18 hours a day, like we’ve been doing for the last week.

Our spouse drags us to the doctor, who suggests a medication trial. Some psychotropic medications are added, which disrupt our brain’s “normal” way of balancing out all the neurotransmitters. We are making an “abnormal” change. Yet, we’re now able to rise, speak, eat, think, communicate with our friends and family, feel positive and negative emotions, and participate in life.

If that’s what “normal” and “abnormal” were to look like for me, sign me up.

Again, relying on a dubious definition, even when surrounding it with as many examples as you’d like of bad things that psychiatric medications have done, does not make for a convincing argument.

Treating symptoms

A slight variation of the argument is also used, namely that psychotropics are inherently flawed because there is no underlying cause for mental illness, and as such there is nothing for them to work on. We’ve addressed the physical cause issue in the “Mental Illness Isn’t Real” section already.

I will just add at this point that there are hundreds if not thousands of diseases in other areas of medicine that are treated partially, primarily or solely via treating the symptoms, and not an underlying physical pathology. Those diseases with no known etiology are just a tiny fraction of that.

Are they effective?

Once we dismiss this notion that the drugs are inherently damaging, we can discuss whether or not they are effective, cause problems, how often this occurs, etc.

PBM provides all kinds of studies and examples, many from patients directly, where harms were caused (or allegedly caused, depending on the example).

The psychiatry community can bring studies and examples, many from patients directly, where the medications were helpful to them.

This is a great situation! Let’s all actually look at all the evidence, and judge it on its strengths and weaknesses. Where we’re missing evidence, or the evidence we have isn’t compelling, let’s get more. Let’s actually address this issue through evidence.

The alternative is throwing up our hands, dismissing everything as hopelessly biased as a result of the government-pharmaceutical-industrial complex, and tossing around conspiracy theories and “logical” arguments based on ridiculous premises.

Chemical Imbalance

A quick note on the whole idea of chemical imbalances as a theory for how psychotropic medications work. While the idea of “too much serotonin” or what not may have been at one time suggested by some overzealous academic looking for tenure, it’s a gross oversimplification of our current understanding of neurobiology.

It is, however, useful as a fairly easy to comprehend model for explaining the basic idea to people. It’s the same way that we’ll still refer to Newtonian mechanics and think about things through that lens, even though we know that quantum mechanics is a more accurate depiction of physics. So don’t get too caught up in arguments resting on the existence of chemical imbalances.

Summary

Having dispatched with the ridiculous notion that all psychiatric medications are inherently flawed as a concept, we are left being able to think of them as we would other medications. What are the benefits and risks, and how do they compare with the benefits and risks of either other treatments, or doing nothing?

For most people who choose to use them, psychiatric medications represent the “least bad alternative.” Just like medications for other illnesses. They may be overused in certain circumstances for all kinds of reasons (e.g., cost, “quick fix”), but are either highly recommended, or an option that should be seriously considered, in many situations for many people.

Persuasion or Information?

PBM makes a very long, detailed and strong-sounding case about the dangers of psychiatry and the necessity of its dissolution.

Were the purpose of the book to critique psychiatric practice for the purposes of improving it, lobbying for safeguards, different standards, etc. a series of carefully documented anecdotes, thematically joined, would suffice.

Yet, the goal is far more audacious—to logically prove that psychiatry is fundamentally and irrevocably flawed. This is a tall order, impossible perhaps. Why take that step? The only conclusion I can draw is that it’s less about the noble pursuit of truth, and more about gaining converts to the antipsychiatry movement. The more the better, and especially those who are the most militant in their convictions that psychiatry is inherently wrong and must be defeated. People reading a mountain of evidence may be persuaded, yet open to the idea that there might be another side to things. But if it’s logically proven—well, there’s no room for doubt!

Let me highlight four manipulative techniques that are used to great persuasive effect in PBM: veneer of credibility, suppressed evidence, appeal to conspiracy theories, and obscuring logical fallacies within volumes of examples.

Veneer of credibility

PBM is a large academic book. It adopts a generally appropriate academic tone, though the neutral stance is frequently supplanted by the unmistakeable passionate activist trying to restrain herself. It strings together what appear at first glance to be logical and coherent arguments. There are lots and lots of references.

The investigation into psychiatry proceeds via a formal mechanism, the institutional ethnography (and who could criticize the work if they are not familiar with that methodology?) that separates observations from bias. It relies on multiple other theories drawn from feminism, political science, social justice, phenomenology, discourse analysis, indigenous and environmental schools of thought, etc. Jargon from these disciplines is sprinkled liberally throughout.

Odd choices for a book that’s designed to appeal to the masses. But really, just the existence of the book, having the form of serious academic research, is enough. After all, if you’re reading a book or paper, do you really follow up and read the references, to see what they actually say? They sound credible; good enough.

Suppressed evidence

There are a lot of references, but almost all to the same group of works and authors you’ll find in many antipsychiatry books. Despite the dozens if not hundreds of mental health and neuroscience journals with hundreds of articles each, thousands of books, etc., you will find very few references to them here. The supporting material is specifically selected to reinforce the author’s viewpoint.

That’s not necessarily a bad thing if you’re building up a set of examples to advocate for change in a discipline. But if you’re looking to eradicate an entire discipline, a higher standard, and certainly greater attention to alternative points of view, would be in order.

Cherry-picking references in this matter, from the antipsychiatry “echo chamber” provides a nicely encapsulated, closed circle of information that appeals to the intended readers’ confirmation biases (i.e. they think psychiatry is bad, and this just confirms it). It’s one sided, and it’s used to persuade, and to remove the possibility of doubt, not to inform.

Critics are neutralized and dismissed in a pro forma manner. Practitioners are automatons so enmeshed within the dominant system that they cannot see beyond the next drug company kickback in front of them. Patients who claim they have received benefit from medications have simply been “subdued” by their medications.

This, from a book that identifies its specific contribution is that “it elucidates and ‘maps’ the institution as a whole” [italics added].

Appeal to conspiracy theories

A reasonable argument can be made (and at times is made) for various biases of psychiatrists, researchers, pharmaceutical companies. There are documented examples where psychiatry has been used as a means of punishment or coercion by state or other actors. Yet, the extent to which this appears to actually occur according to PBM is truly breathtaking (again, using specific examples, but lacking evidence of the extent to which it occurs). The terminology throughout, e.g. “regime,” or “madness industry,” only emphasizes this.

When most actors are assumed to be motivated by malicious and nefarious reasons, we’ve gone past a healthy concern for bias and into the realm of serious broad-based conspiracy theories, which of course appeals to those who are most fanatical and tend to traffic in conspiracy theories. It also weakens any doubt or resistance in terms of accepting arguments and evidence that are presented.

It’s hyperbole at best, blatant manipulation at worst. What it certainly is not is a massive all-encompassing government and/or Big Pharma conspiracy.

Logical fallacies, obscured by examples

The most obvious evidence of departure from rigorous academic work is the blatant reliance on logical fallacies to “prove” the rather more extreme positions. Or to put it another way, key arguments, intended to show the inherent flaws of psychiatry as an entire discipline, are completely bogus.

Suppressed evidence is one example of a type of fallacy carried throughout the book. The fallacies of composition and overgeneralization (i.e. one part is bad so the whole thing is bad) are frequently encountered as well, including with respect to conspiracy theories. Several rather incongruous definitions of terms form the foundation for other arguments. There are a multitude of others. The next sections will detail the flaws and fallacies of several of the key arguments, highlighting the ways in which arguments are incorrectly constructed.

It’s not surprising of course to find significant logical fallacies at the heart of claims that an entire discipline is logically flawed.

If these logical flaws stood alone, they would perhaps be more obvious. They are, however, presented in a way that is intended to obscure their simplicity. First, the incorrect logical argument is made, as a “preliminary” step, though the full intended conclusion is already contained. Then, a large number of examples, references, and explanations are appended, thematically related to the argument, to highlight the horrible practices, abuses, biases, violations, and so on (and yes, the Nazi comparison’s come quickly).

While the examples do not provide additional logical support to the argument already made, they do their best to portray psychiatry and its practitioners as horrible people committing horrible acts, to the point that the reader would believe there is no level they would not stoop to, and so have no doubts as to the veracity of the earlier argument.

Yet, painting psychiatry as “the bad guy” via a seemingly endless stream of selective examples (in effect, “induction by attrition”) does not meet the standard of logical proof that PBM has inexplicably set for itself.

Summary

If PBM, and antipsychiatry writing in general, were merely meant to inform the public about abuses and violations, it could do so without resort to the manipulative techniques I’ve outlined here. In fact, there are legitimate critics of psychiatry who stick to actual facts, do not overstate their conclusions, and are open to differing arguments, opinions, and evidence. These reasonable voices contribute to a valuable and important conversation. But that is not the antipsychiatry movement.

That such an activist movement as antipsychiatry exists I can understand, and though I disagree with it and feel it is very harmful, they have the right to express their opinions, unless they descend into e.g. hate speech. I can even (at times) understand such a movement that would not consider authentically engaging with any of its critics.

What I have great difficulty with is the notion that an extreme activist movement, spewing grandiose arguments that would embarrass a first year philosophy student, apparently unwilling to entertain open dialog and criticism, appears to have pockets well-entrenched within serious academia. That such poor scholarship (in my opinion) might gain credibility from the stature of an environment known for openness and reason is truly disappointing.

With that said, let’s move on to look at some of the arguments in detail.

Exploring an Antipsychiatry ‘End Game’

Having addressed the veracity of some of the key arguments, we probably have a healthy skepticism of this claim at the start of PBM’s last chapter, “Dusting Ourselves Off and Starting Anew”:

One conclusion that has already been reached is that the institution of psychiatry must go.

Again, while many critics of psychiatry propose what PBM calls “tinkering,” this notion here, as is typical with antipsychiatry, is rejected wholesale.

A frequent criticism of the movement is that no viable solution is offered to replace what we are throwing out, the theory being that at least removing all this harm is a massive improvement over the current situation.

PBM differs in that it offers us a solution, admittedly preliminary in nature.

Solution revealed

Here’s the starting point:

One obvious direction that has surfaced is freeing ourselves from our frightening over-belief in and fetishization of science-the privileging of positivism, evidence-based research, and instrumental reason. What goes along with this and is likewise pivotal, we need to free ourselves from rule by “experts.”

It shortly continues:

That noted, cutting back on experts hardly suffices. Nor is insertion of peer workers into the current system. Such measures cannot simply by add-ons to an inherently injurious system. Moreover, even if we rid ourselves of psychiatry and even if we dispensed with mental health services as now know them—indeed, even if we drastically reduced our reliance on all associated workers—we would not have gone far enough.

The point is, you cannot simply separate out a part of a gestalt, part of a discourse—and our entire society is penetrated/constructed by regimes of ruling.

What follows is a remarkable vision of a society, a “eutopia” (“a good place”) that in its very structure provides a less competitive, more communal vision for how we all live with each other. Specifically related to mental distress, it posits a realm that values and thrives on diversity, peer support, local decisions that better respect autonomy and differences, without the centralized power structures that exist today. Some of it actually sounds quite lovely in many respects, though may be a bit too close to a “socialist paradise” for the comfort of many.

This eutopia would necessitate a few changes. In particular, it requires overturning every single cultural, legal, social, political, environmental, artistic, communal and economic foundation of our current society.

I therefore feel on safe footing if I take issue with the second part of this statement:

This chapter is necessarily both highly visionary and highly practical

From here to there

This sort of visioning exercise has its place in thinking about what kind of society would we ideally want, if we were able to start from scratch. Typically you’ll see this in university classes on political philosophy. Fresh from studying Rousseau, Locke, and Hobbes, our eager students imagine the creation of a new society, arising from a “state of nature” where life is “solitary, poor, nasty, brutish, and short.”

Yet, given that we’re rather further down the road in a different direction already, how do we make it happen?

Acknowledging that due to vested interests, big government nor big business will make these changes, this can only be accomplished by working outside the system.

There are some concrete suggestions for specific groups, mostly involving talking and starting to think about things a little bit differently, which sounds slow, incremental and unreliable. Mind you, PBM explicitly condemns incremental approaches as ineffectual and insufficient.

Perhaps greater hopes are pinned on a Kuhn-ian paradigm shift, where a rising tide of ideas finally overwhelms and replaces our existing systems and institutions en masse. This would be spurred on by activist movements akin to what we’ve seen during the antiglobalization protests, the environmental movement, or Idle No More. (The reader is presumably being asked to suspend disbelief that any such movement would be capable of coming to any shared understanding on even matters of terminology, let alone multiple substantive, highly-interconnected, complex organizational systems, and to say nothing of an implementation plan).

Extremism revisited

I’ve remarked since the beginning of this article that a concerted effort to logically “disprove,” at a fundamental level, an entire discipline seems distinctly like overkill. If the goal was to shed light on negative practices, to argue for substantial changes to practice, this could proceed without heavily relying on deeply flawed arguments. An openness to engage with critics and practitioners would presumably be warranted, rather than eschewed.

The deceptive cloak of objective scholarship and academia notwithstanding, the movement’s writings appear designed to persuade the reader, not inform them. To what end?

In light of the proposed “solution” suggested above, we perhaps gain new insight into the extremist “all or nothing” nature of the antipsychiatry movement.

The movement appears to literally be looking to recruit activists, the more engaged the better. Effective activist discourse is inherently one-sided, and often (as here) with a goal of not influencing the status quo, but overpowering and replacing it. The best chance to achieve a radical new vision of society, with a complete reconceptualization of mental health, can only possibly proceed through the mobilization of a vast army of unquestioning supporters.

Evidence, discussion, collaboration and compromise all lessen the chances of that happening. Black and white, good and evil, and not shades of grey must carry the day. As we have seen public discourse elsewhere fracture into “us vs. them,” “you’re with us or against us,” etc., the true message for antipsychiatry, despite the high-sounding rhetoric, is good humanity vs. evil psychiatry.

The worst thing that can happen for antipsychiatrists is legitimate progress continues to be made in psychiatry—in science, law, practice and culture. The opposite, an uptick in verifiable human suffering and abuses, though likely to be taken advantage of by the movement, is wisely left unstated.

And just as they have accused the “madness industry” itself of doing, they are preying on the weak and vulnerable, at times when they are most in need of real help.

To be clear, antipsychiatrists feel the best hope of replacing psychiatry, to improve the lives of people suffering from great anguish and distress, lies not in improving what we have. It is proposed instead that we replace almost every aspect of our entire society within a short time period, most likely to be accomplished by a (successful) activist revolution and mass uprising on a scale never before seen.

The Seven Deadly Sins of Psychiatrists

What makes a good psychiatrist?

If you ask patients to talk about their bad experiences with psychiatrists (or just ask psychiatrists who have taken over care of a patient from a bad psychiatrist), you’ll certainly get an earful!

Herewith, a highly unscientific list of “sins” that can arise in psychiatric care.

Selective Attention

“You didn’t hear a word I said!!!”

Whether due to unreasonably short appointments, or quickly focusing on only one small aspect of the problem(s), there’s nothing more infuriating than feeling like you haven’t been heard, or your concerns not taken seriously. If the sole response to a half hour of tearfully recounting your struggles in work and relationships is “you should drink less coffee”, you’d have a legitimate right to wonder why you waited six months for this appointment.

Good psychiatrists: Take the time to listen and acknowledge patient concerns. Even if they can only help with a small part of those concerns today, they’ll put small changes into a larger plan or context, and set overall expectations for moving forward.

Dehumanization

Are you a person or just a diagnosis? While a specific diagnosis can be helpful to help narrow down appropriate treatments to consider, ultimately the bigger question is how your symptoms are impacting your overall quality of life. Not everything needs to be treated, and the success or failure of any treatment needs to be measured against that. It’s great if a medication can help with anxiety, but if it causes an athlete to gain 50 pounds or a writer to be unable to concentrate, is that really fixing the problem? This might be the equivalent of a surgeon’s “the operation was a success, but the patient died”.

Good psychiatrists: Look at the whole person. They don’t believe in “one size fits all” treatments, and are cognizant of potential side effects. Their goal is to help improve overall quality of life, as seen by the patient, not themselves.

Polypharmacy

For some psychiatrists, it’s too easy to just add medications to deal with every new problem, or every side effect of the previous medication that was added. It doesn’t take long before someone ends up on four different benzos, a few antidepressants, a couple antipsychotics, a mood stabilizer, and several other drugs to deal with akathisia, insomnia, etc.

Unfortunately, taking people off medications and trying others takes more time and has the potential of destabilizing them for short periods of time. And cleaning up an overly complicated medication regime can be a long-term process. Just adding something else to an existing mix is an easier way out.

Good psychiatrists: Don’t turn patients into walking pharmacies. They realize finding the right combination of medications for a patient, taking into account efficacy and side effects, is worth it in the long term, and will find ways to make sure that happens.

Short Sightedness

If someone has a broken limb it may be well enough to cast them up and send them on their way, but if it happens every few months because they have a habit of jumping off their roof, you might want to look at that. Similarly, prescribing something to control a panic attack may be useful in the short term, but it may be more helpful in the long run to also address the cause of those panic attacks.

Good psychiatrists: Consider root causes and context. They understand that learning better coping strategies or engaging in therapy (even if they aren’t the ones providing it) can help solve many problems in the long term. Medications can be part of the solution, and often are needed to get people to the point they can benefit from other techniques.

Overspecialization

The old chestnut about “if all you have is a hammer, everything looks like a nail” can apply here too. A psychiatrist who specializes in mood may see everything in those terms, and overlook an obvious PTSD. More generally, some psychiatrists may assume every problem they see is as a result of a mental health cause, and try to solve it using psychotropic medications. Psychiatrists who forget they are physicians first may try a patient suffering from poor concentration and energy on five different antidepressants and give up when none of them work, but not bother to find out if their iron levels are in their boots. A psychopharmacology specialist may ignore therapy even when it may be more appropriate to the problem.

Good psychiatrists: Recognize other problems that can present with psychiatric symptoms. They understand that psychiatry makes up only one part in an overall health team, along with a variety of other professionals.

Discontinuity

Some patients who see a psychiatrist regularly can walk out of the office each time with a different diagnosis and a different medication. If their psychiatrist only looks at the symptom of the day, and ignores the patient’s overall history, patterns and changing circumstances, they’ll end up on a never-ending medication roller-coaster.

Good psychiatrists: Take a thorough history and work in the context of an overall treatment plan. They often have frighteningly good memories of seemingly trivial statements or incidents from previous sessions. They differentiate between regular behaviour patterns for each individual, normal human reactions to external circumstances, and unexplained mental status changes requiring further investigation.

Narcissism

Beware the psychiatrist who knows everything, has no need of opinions or help from others, and prides themselves on knowing exactly how to solve a patient’s every problem within two minutes of meeting them. They see themselves on high, separate and better than their patients, dispensing wisdom to those patients who should feel fortunate enough to be seen. They are quick to dismiss advice or treatments you may have received from others in the past, as those people don’t know what they’re talking about.

Good psychiatrists: Become partners with their patients and other caregivers. They demonstrate empathy, not hubris. They recognize the limitations of their own knowledge and skills, and how much time it takes to really understand another human being. They value rather than shun other opinions and perspectives.

Consequences

In the health care system, many people fall through the cracks. A lot of people shrug and say “that’s just the way it is”. Sometimes the consequences aren’t too severe. Sometimes though, they are.

Mental health writer Natasha Tracy vividly shared the story of her own suicide attempt (trigger warning). If you’re able to, read it.

If you’re one of the people working in mental health who goes out of their way to help people in need, know that it can make a difference.

If you’re one of the people in mental health who sometimes lets people slip through the cracks because “it’s not my problem” this should hit you like a punch in the gut.

If you’re a politician, health ministry worker, etc. in any position to influence how the system functions, understand that this one incident encapsulates what it means to have a mental health system in crisis.

Now multiply that by the hundreds and thousands in comparably dire circumstances.

Now multiply that by the hundreds of thousands who are suffering because they can’t get mental health help.

Okay, intellectually that may be useful to think about the scope of the problem, but it makes it too abstract. It takes the feeling out of it. Focus back on that one person, that one story.

Now focus on you.

One person can’t fix the system, and nobody should get trapped into thinking that they need to personally make up for all the flaws in the system.

But one person can make a difference.

And a lot of people pushing in the same direction can change a system.

Alberta Mental Health Review

First off, my apologies for the lengthy delay since my last posting. We relocated from Alberta to Victoria, BC at the start of May, and the period before and after that has been chaotic to say the least.

As it happens, I’d like to talk about Alberta today. It’s certainly been politically interesting there the last few months, to say the least. If you didn’t see it, I want to draw your attention to a recently announced review of the province’s mental health system, which the premier accurately acknowledges “has failed too many Albertans.” (Kudos also for getting Dr. Swann, a Liberal, involved).

I’d like to chime in on exactly how Alberta’s mental health system has failed Alberta. I’ll focus mostly on the outpatient side, but first…

Too Few (Treatment) Beds

I’m sure this will be the item that gets the most coverage. There aren’t enough mental health beds, and too many are for crisis patients only. If people need acute inpatient treatment, but are passed the point where they are certifiable, there are not enough resources around. Which of course leads to the revolving door of crisis admission, streeted, relapse.

Too Few (Unlocked) Entrances

It’s hard to access the mental health system if you’re not in crisis. There are a number of entry points (help lines, community clinics, family doctors, etc.), and efforts at stigma reduction are helping. Yet, too often these entrances are “locked”.

What I mean by that is people get turned away, either because they don’t meet criteria for whatever program they’ve approached, or they’re told by someone, often their family doctor, that they’re fine and don’t need any help. As I’ve said before, too often after working up the nerve to talk to someone in the first place, they get shut down when they first try. Particularly when its a medical professional telling you you’re fine, what are you supposed to think? How often do you try again?

Too Many Exits

Even if you are getting help from someone, if you reach the limit (for whatever reason) of what they can provide, too often you’ll get a “sorry that’s all I can do for you” and not get directed towards further help. There’s not someone following behind to make sure you get the care you need. It’s very easy to end up in what I like to call mental health limbo.

Poorly Coordinated Programming

There are lots of different providers, ranging from individual psychiatrists, counsellors, community mental health clinics, crisis teams, mental health workers associated with Primary Care Networks, etc. Again, beyond crisis work, there isn’t a lot of coordination even when it comes to the mandate of each group. Local decision making can be good, but if a PCN is deciding what services it offers, it doesn’t mean there still aren’t a lot of important services that aren’t being provided anywhere in the community. Most often actual evidence-based, effective treatment.

Wrong People, Wrong Treatments

There are lots of different mental health providers, in many professions. They all can do different things. Many of them are excellent at what they do. Many others are not.

Sending someone with an illness that responds best to treatment A (whether meds, a certain type of therapy, etc.) to a provider who only offers treatment B is not helpful. And rarely is there oversight from anyone to intercept or abort a poor match, leaving the responsibility up to the patient and/or provider.

And poor providers (or charitably, poor fit between patient and provider) are legendary.  We had one group of completely unrelated providers that offered such a horrible experience to so many patients (a psychiatrist, a community clinic, and a therapy program) that we referred to the patients who had unluckily found their way to see all three in the past as “winning the trifecta”.

(To say nothing of being sent to what you think is a psychiatrist, and finding out that they aren’t actually qualified in Alberta as a psychiatrist!)

This is all made worse because people generally have a poor understanding of mental health treatment and providers, and so will have a difficult time identifying a poor treatment or treatment provider. They’re counting on the system to ensure they’re getting the right care.

Their trust is misplaced.

No Results Accountability

What measurement occurs in the system usually revolves around capacity in one form or another. Number of beds, number of therapists, number of patients seen, number of contact hours, etc.

If someone gets seen ten times, that’s what the system tracks. Nobody is tracking whether that person is better afterwards.

We may feel good saying we’ve added X number of beds or therapists or whatever, but if they’re not actually helping people get better, are we any further ahead?

No Escalation

People get stuck going around in circles in the system for years on end. Every few years they might get sent to another psychiatrist for a consultation and another set of recommendations. But even if they’re not getting better, the cycle continues. It’s rare that someone stands up and says:

Wait a minute. Why do we keep doing the same thing again and again and expect different results?

Nobody is keeping track of how many years of someone’s life is wasted in mental health limbo. As long as they’re still seeing a treatment provider, the system is happy. Shouldn’t there be a mechanism that catches people in these situations and escalates them to a higher level of care, e.g. a psychiatrist who will spend more than half an hour with them? Or any kind of mechanism to look at what care this person should be receiving?

Not a System

The root cause of all of this is that there really isn’t a coherent system underlying mental health, just a disparate network of providers.

And navigating that network of providers is not easy, particularly when very few people have the necessary knowledge to understand both their individual needs and the providers. Often there is nobody, not even their family doctor, who can effectively help them.

The concept of patient navigation comes up a lot in other areas of medicine, e.g. cancer care. It’s not perfect, but it helps people find their way through a system, and know where to turn when they get lost.

When it comes to mental health, we could use a little less thinking in terms of episodic care, and a little more thinking in terms of patient’s long term navigation within a coordinated system.

I wish for the best out of this review, and I hope it can escape the well-meaning platitudes and vague yearning to provide more resources. I don’t think fixing the system is easy. I do think identifying what is not working should be expressed in a way that is simple, straightforward and bluntly to the point.

I Talked. Now What?

Let’s talk about mental illness.

Good advice, and if you’re ready to take this step (or have already), congratulations! That in itself is a very big and scary accomplishment.

But sometimes you don’t know what to say, or how to say it. Or are too scared and overwhelmed to get it out clearly.

Or maybe you’ve tried to talk with your doctor or another care provider, but it didn’t go as well as you wanted. Maybe you didn’t feel you were heard, or your cares were dismissed. Or you weren’t talking to the right person.

Download, print and fill out this free worksheet. It will help you collect your thoughts and the information you need to have a useful and productive conversation with your care provider.

Download: Your Mental Health Worksheet (PDF)

(If you find this helpful, please sign up for my newsletter via the form at the bottom right of this page. You’ll be informed of more helpful resources like this worksheet in the future).

You’ve come this far. Don’t stop now.

Keep talking, until you get the answers (and help!) you need.

Let’s Talk, Don’t Stop!

January 28th is Bell Let’s Talk Day. Kudos to Bell and all the people who participate in this event for the work they’re doing to help reduce the stigma of mental illness.

Working up the courage to step forward and admit to someone else that you’re worried you may have a mental health problem is one of the toughest things to do for many people. With continued efforts to reduce stigma, hopefully asking for help will be easier.

But what if you work up the nerve and ask for help, and get completely shut down?

Too often, that is exactly what happens. And if your concerns get dismissed out of hand, what then? It’s likely going to be a long time before you try to ask for help anywhere again. And that is a tragedy.

Things you Don’t Want to Hear

Below are some of the many things that have been said to people worried about their mental health, looking for help for the first time. And these are all coming from health providers, mostly physicians or in some cases mental health professionals.

“Don’t be silly, you’re fine”

This is likely to come from friends and family members, often parents, worried about the stigma of mental health and how being labelled might affect you (and them). But it can come from health providers too, whether they’re too busy, think you just worry about everything (helloooo…), or are themselves stigmatized or biased against dealing with mental health issues.

Of course, some times it is true that you’re fine. Most people aren’t experts at differentiating between emotions that are a normal part of human experience and those suggestive of mental illness. You’re asking for their expertise, and at the very least a conversation about whether or not your feelings are causing you problems is warranted. In fact, using that opening to probe deeper is prudent, as many people have a hard time talking about these things, and will downplay or minimize their symptoms.

If you’re approaching someone for the first time about mental health concerns, they should at the very least take you seriously. Most people don’t do this as a joke.

(Ok, some people may do it in a humorous manner, but that’s usually nervousness. And people who have been receiving mental health treatment for some time often develop a very biting sense of humour. But it’s certainly not there at first.)

“Psychiatrists are only for people with schizophrenia”

Yes, a family doctor actually said that to someone asking if it would make sense to speak with someone about a problem they were having.

Yes, many family doctors treat mental health issues, as do many other professionals. And yes, some psychiatrists are very specialized, and may see only people with certain types of disorders. But to suggest that psychiatrists in general don’t see people with more common mood and anxiety disorders is ludicrous.

“Here’s a prescription”

You unburden yourself after feeling for months that your life is falling apart, and that’s your doctor’s answer? Take a pill?

This is worth exploring in more detail another time, but that’s no way to respond to someone. Medications may well be the right answer, but they definitely need to be placed in a larger context. If that’s all you heard, you’re certainly not going to feel like you were taken seriously or listened to. And most people, rightly so, are probably hesitant to jump into mind-altering drugs without some education.

Yes, family doctors are busy. But really? You deserve better than that kind of response.

“Go see a counsellor”

Again, this needs to be put in context. As I’ve talked about before, there are lots of different types of mental health professionals, but knowing which one is right for you, and being able to financially or otherwise access them is often difficult or impossible.

Without any context, and some pointers in a particular direction, you’re probably going to get stuck, and feel about as good as you did if a prescription was shoved in your face.

“Well at least you don’t have cancer”

Possibly one of the most ignorant and dismissive things you could say to someone struggling with mental health issues.

“Get some more exercise and you’ll feel better”

This may well be true for some people, but certainly not for most. If that (or any other “quick fix”) is the answer given when you first approach someone, they haven’t been listening to you.

It’s true that exercise can be helpful for many people with mild-moderate depression. I know personally it delayed me needing to start antidepressants for a year or two, and keeps the dose I need lower than I would need without exercise.  But that’s several steps down the road, after some basic things like investigating the exact nature of your problems, and perhaps trying to find out what may be causing them.

“You should go to church”

Yes, some people take comfort in religion (for the record, I’m not one of them). And while I won’t downplay that, it has its limitations. Mental illness is a health issue. And to turn a previous question around, “would you go pray as the only thing you do if you have cancer?” And yet, some people still do.

Speaking to a religious or spiritual leader may be helpful, but like any other type of counsellor, you have to understand their background and training. While many clergy are getting better at recognizing legitimate mental health concerns and redirecting people appropriately, many have absolutely no knowledge or training in this area whatsoever. I’d rather not take my health on faith. And if the words “sometimes exorcisms are appropriate…” cross their lips, run.

“You must have done something wrong”

Otherwise known as “it’s all your fault.”

It’s truly amazing how often people get confronted with this, again often from family and friends, but there are even some health providers who will respond to certain types of mental health issues (e.g. some personality disorders) in this way.

Blaming people is not the answer, and shows just how far we still need to go in terms of education. Or how many people make themselves feel good by putting other people down. Mental health blogger Natasha Tracy describes this far better than I could.

“It’s all just in your head”

Technically, this may be mostly true (though you’d be amazed how much serotonin you can find in the intestines). But what people are really saying is that you’re imagining things, and that you don’t have a real health issue.

This is an obstacle for a lot of people, in the sense that there’s no blood test or diagnostic imaging investigation that will provide a mental health diagnosis. Without such “objective” evidence, it can’t be real, can it?

Yes it can. Very, very real.

“Just suck it up, you’re not even trying”

This often comes from people (including some doctors) who think that you’re consciously choosing to feel the way you’re feeling, and that if you just decided to, you could “snap out of it.” Again, this is one of the things that separates normal fluctuations in mood from mental illness.

In lieu of rebutting this, I’ll share one of my favourite cartoons on the matter (see original source):

2013-11-21-Helpful Advice

Don’t Stop Talking

Talking about your mental health concerns is the first step.

But sadly, you’re not always going to get a respectful and helpful response.

If that is the case, remember that you’re not alone. There are still too many barriers to accessing good mental health advice and care, and it’s too easy to get discouraged. It may not be easy, but try again. Keep asking for help.

You may or may not have a diagnosable mental illness. But there are trained professionals out there that can help you determine that, and what to do next.

Remember, whatever your mental health symptoms get labelled, if they are affecting your quality of life, it’s a problem.

Keep talking.

Don’t stop.