Killer or Cure-all? -- Surviving Psychiatric Treatment
Jan 5, 2013
For today's post, I wish to re-visit "the past", the past of a few years ago, and about a month ago.
Topics I wish to briefly discuss today include
(i) changes and finalisation of changes to the American Psychiatric Association's Diagnostic and Statistical Manual -5th Edition DSM 5;
(ii) treatments for "Depression" (whatever that is!); and related to this --
(iii) Electro Convulsive Therapy ECT -- especially current practices in New Zealand's Southland District Health Board region; and lastly, for now
(iv) alternative conceptions of mental illness and treatment for mental illness -- especially Critical Psychiatry.
To begin with, I'd like to draw your attention to a recent post by Dr Allen Francis on his blog for Psychology Today DSM 5 in Distress:
DSM 5 Is Guide Not Bible—Ignore Its Ten Worst Changes [LINK]
I've discussed Dr Frances views on changes in DSM 5 before in my post
May 10, 2012 -- Psychiatric Mislabeling Is Bad For Your Mental Health [LINK]
based on Dr Frances own blog post on Psychology Today [LINK]
Recalling, Dr Frances was chair of the taskforce for the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV) and in his previous post was commenting on the results of field trials of the reliability of diagnostic criteria for DSM 5, which showed that even criteria for "well-accepted" diagnoses such as Major Depressive Disorder have resulting in their performing well below acceptable standards.
In his most recent post, using language I would never have associated with a psychiatrist before, Dr Frances states that news of the finalization of proposals for DSM 5 has resulted in "the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry."
I shall not go into detail listing the arguments Dr Frances does, I direct you to his post, but note that he considers the following "mistakes":
- New diagnosis: Disruptive Mood Dysregulation Disorder
- Normal grief will become Major Depressive Disorder
- The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder
- DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder
- new diagnosis -- Binge Eating Disorder
- Feared reduction in needed school services for those with Autism due to changes in diagnostic criteria
- First time substance abusers will be lumped in definitionally in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause.
- DSM 5 has created a slippery slope by introducing the concept of Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot
- DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life
- DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings
In conclusion, Dr Frances states:
"People with real psychiatric problems that can be reliably diagnosed and effectively treated are already badly shortchanged. DSM 5 will make this worse by diverting attention and scarce resources away from the really ill and toward people with the everyday problems of life who will be harmed, not helped, when they are mislabeled as mentally ill. Our patients deserve better, society deserves better, and the mental health professions deserve better. Caring for the mentally ill is a noble and effective profession. But we have to know our limits and stay within them. DSM 5 violates the most sacred (and most frequently ignored) tenet in medicine- First Do No Harm! That's why this is such a sad moment."
In my view, these are fairly conservative opinions, understandably perhaps, as they come from a psychiatrist. In my view, the DSM 5 changes fail to address the need for better, more inclusive, treatments for perhaps the majority of the "worried well" most in need of better services -- those with histories of childhood abuse, trauma, and neglect. It is particularly deficient in the areas of need for treatments that are more "insightful", by more sensitive therapists, for depression and anxiety. Frances limits his discussion to Grief: Normal grief, under DSM 5, he argues, will become Major Depressive Disorder, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life. Elsewhere on my site I have noted the importance of providing "titrated" pharmacotherapy for depression, with drugs being reduced from initial doses with improvements in patients' conditions, and gradual "supplementation" with and replacement by adjunctive psychotherapy, moving finally to psychotherapy and other non-biological therapies. Of course, these therapy changes must be part of an effective, collaborative therapist-patient relationship -- in my view, the evidence supports this above all other forms of therapy regimen.
One form of therapy for depression (or other disorders!) with a controversial history, that is no longer evidence-supported is Electroconvulsive Therapy -- ECT. What "re-ignited" my interest in this form of therapy was a recent issue of the Summer edition of the newsletter of the Otago Mental Health Support Trust, which commented on the high, and increasing levels of usage of ECT in my local District Health Board Region. I have previously written of the difficulties of getting appropriate, and adequate, non-drug treatments for the depression and anxiety I suffer. I attach firstly, an article by John Read, Professor of Psychology at the University of Auckland, examining outcome studies for ECT [LINK], and secondly, the text of an email I received from Professor Read, with his responses to several of the "questions" I have had over the years [LINK]. In my view these materials speak for themselves, and speak strongly AGAINST the practices of the Southland District Health Board.
Looking at the diagnostic categories and criteria for "mental disorders" contained in DSM 5, one would think the APA thinks it has the "cure all" answers for all the problems of modern living. Unfortunately, given the yawning gulf between what even Dr Frances has written, conservatively, about modern psychiatric practices, and the actual practices of psychiatrists, particularly in my local area, the potential, and likely actual, harm being perpetrated, one has to conclude that it is far more likely to be doing substantial harm rather than good.
What's the alternative?
Unfortunately, for people in my local area, very little. Locally, Psychiatry's practices go unquestioned, compared to what happens overseas, in such countries as Australia, England, Canada, and Western Europe. There seems to be a relative "Mexican standoff" in the United States -- Psychiatry is not well regarded, going by comments I see made on US-dominant email discussion lists I subscribe to. New Zealand psychologists are, by and large, the handmaidens of Psychiatry in this country, a shameful position to be in, in my opinion, acting in their own self-interest as individuals -- financially they are in a VERY good position, compared to the great bulk of the rest of New Zealand society -- certainly not acting in the best interests of the profession, and certainly not in the best interests of the New Zealand Public. Indeed, it was on one of these American lists today that I read of Viktor Frankl's lack of respect for Psychiatry.
Frankl -- a survivor of Nazi death camps during the Second World War -- was an interesting man. His first degree was from the medical school of the University of Vienna, the specialty training was in neurology, the second in neurosurgery, and the third was from the psychology institute where he earned a doctorate degree in psychology. He also was the creator of the first anti-anxiety drug ever. He developed a support group for youth after World War I for the treatment of severely depressed teenagers. Reading his autobiography is an adventure. His first wife, a nurse, became pregnant after the Anschluss. The child found the fate of abortion. The Jewish community by that time knew what lay ahead of them. His wife was deported to Auschwitz and quickly transferred to Berkinau where she died under a shower of Zyklon B.The US psychologist commented: "He told me in a private conversation that he didn’t trust psychiatrists but he did trust psychologists. All psychiatrists who practiced under National Socialism were party members. They had to be in order to be paid for their services. Is there nothing new under the sun?" That Psychiatry is still an instrument of the government is evident from readings available from sites I discuss next. I note that even Frankl had to make known his opinion of Psychiatry in private, fearing its power even in a "democratic" society.
The "alternative" is available, my readers, from Psychologists NOT trained in New Zealand, mostly those from Australia, the United States, South Africa and England, here for reasons of culture, climate and lifestyle, not for professional reasons. And you can learn about alternatives to the traditional "medical model" from sites talking about "Critical Psychiatry", such as [LINK], from the UK, and [LINK] the international group. Links to readings / articles, and to groups for "survivors of psychiatry" are also accessible from these sites.