The Sale of Certainty

This morning I heard health expert Dame Prof Sally Davis, on BBC radio 4, talking about the health of UK children. (It seems that cases of rickets are on the rise. She suggested the introduction of vitamin supplements for all kids).
During the interview (which you can listen to here, at approx 2h 39min), she was also called upon to comment on mental health issues in family life, and their treatment.
How disappointing it was to hear the same old line trotting out once again, like a soundbite, or one of those management-speak buzzwords that seems to be infectious in the meeting-room spreading from one employee to another. It goes something like this:
 (a lot of mental health problems) "will respond to.... Cognitive Behavioural Therapy... talking therapies..... "

The words used here are telling. They show a lack of understanding about the therapy world; its different modalities, and their potential use in the wide range of mental health issues. The words also show a willingness to endorse, publicly, a particular form of treatment.

I have previously drawn attention to this advertising of the CBT 'brand' here.

Dame Sally makes it very clear to us exactly why she wears this logo on her T-shirt. She says "I believe that we should only offer treatments that are evidence-based."
What she's saying, then, is that she only values treatments (and that includes therapies) which offer a statistical probability of "success" based on "outcome measures", and perhaps therapies which lend themselves to a widely-accessible "treatment protocol".
(For a deliciously sarcastic take on this kind of approach, see my friend Jason Mihalko's blog here).

Dame Sally is, of course, coming from her own training and heritage. She is steeped in the politics of medicine; a world of ever-increasing tension between public treatment needs and public costs. She values 'evidence-based' therapies, because, perhaps rightly, it would be hard to advocate the spending of public cash on therapies that aren't shown to be 'cost-effective'. The taxpayer deserves value for money, of course.

Evidence-based treatments are useful because, in the medical world, they offer the best assurance that a certain drug/intervention will work. The science tells us that in (n) cases, (x) show a measurable improvement compared to a control group who haven't been given this intervention. Therefore, the chances of your symptoms improving with this treatment are predictable to a certain level of probability.
Evidence-based treatments are also seductive, because they offer us a sense of safety and hope for a particular outcome that we are invested in.
We invest psychologically as patients, because we all want our symptoms to improve.
We also - as Dame Sally illustrates - invest financially. This, on a political level, has huge consequences, because government will clearly be much happier to offer therapy that offers clear, predictable outcomes.

Easy, then, to be fooled into thinking that therapies offering statistically-supported outcomes are the 'best'.
Sure, if you have the type of problem that fits neatly into the standardized diagnostic boxes that NICE and the APA prefer. But the problems of our life and our world are, to my mind, mostly in a different category than this.

How many times, for instance, have you lost a night's sleep because of a meeting, interview, or other event the next day that you are uncertain about?
We have all become stressed and irritable, maybe felt depressed, because of an ongoing issue in life that we can't control or predict.
Maybe you have thought about making a major decision in your life but have been held back for some time, because of the fear of the unknown. "If I knew I could get more work over there, I'd leave this job for good. But how do I know...?"

If only there were an assured, statistically-supported outcome, that you could be certain of....!

I don't believe I'm in the business of offering people assured or certain outcomes. Because in lots of ways, I don't believe there are many to be found. However, the selling of empirically-supported therapy is popular because it fits with an economic and medicalized model of human suffering. The natural human needs for self-exploration, mutual discovery and understanding, and psycho-spiritual development, are not necessarily part of the 'treatment plan'.....

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The Other Side of the Wafer-Thin Barrier

This week, SOAP (Speak Out Against Psychiatry) held a demonstration at the Institute of Psychiatry in London. It follows a long period of widespread criticism of the DSM and its political influence.
I'm with the SOAP people in spirit, because I think someone needs to hold up a mirror to psychiatry, and I hope that psychiatry will be smart enough to look earnestly at itself.

I've written a little about this (see here and here) but I am by no means the most vocal critic or the most prolific writer on the DSM5 and all its problems. A good distillation of the issues, which is kept up-to-date with current material, can be found on the Beyond Meds blog - the DSM update page is here.

The SOAP web page for this event is well worth a read. There, they explain their position that human suffering is more than a medical issue, and so we should not rely upon a medical treatment for wider problems. Normal human experiences, they say, are being medicalized which results in people being labelled.
I agree, and have agreed for some time.  The DSM5 threatens to turn grief into a disorder, and child tantrums into a disorder. This is a dangerous form of 'mission creep'.

My instinctive opposition to diagnostic labelling comes, I think, from what I have learned in my training and experience as a psychotherapist. I have also had some experience of the mechanisms of psychiatry and psychopharmacology, which lead me to believe that both practices have departed significantly from what I hold to be the work of healing mental illnesses.

An article shared on Twitter recently notes that "Psychiatry was not - on Freud's watch - to be swallowed by medicine". Perhaps Freud intended that psychoanalysis be practiced by people who did not go through the sheep-dipping of medical training, and who could connect in a different way to their 'patients' as a result. Clearly, Freud knew that looking at people through a medical lens could be an inherently limited approach.

It's interesting to note the boundaries getting fuzzy here, between psychiatry (which is a branch of medicine) and psychotherapy. It's true that some psychiatrists are also trained psychotherapists who have undertaken extensive personal therapy themselves. But it's true too that many psychiatrists are just doctors. Some of these doctors are working on the assumption that their medical degree and psychiatric training entitles them to carry out psychotherapeutic enterprises under the banner of psychiatry. They also work on the assumption that their medical training (and with this I include the social, cultural, and heirarchical effects of medical and psychiatric training) will not somehow infiltrate the relationship, and the treatment that they offer. As if the person that we are, and the experiences we have, can somehow be irrelevant once we are in the room with a patient.

No.

The article also quotes Robert Spitzer, who headed the development of DSM-III. In a hugely telling remark, he is reported to have said: "..looks very scientific..... It looks like they must know something". For me, this is symbolic of the eternal struggle of medicine as a science - to name, to understand, and thus to defend against the impossible anxiety of NOT knowing.

"The medical model is a wafer-thin barrier against uncertainty" - Irvin Yalom

So, I question psychiatry as it's practiced today because of its over-emphasis on naming, and understanding stuff - much of which (like grief, tantrums, and the stress of someone's death) is actually the stuff of LIFE and not really there to be understood through a medical model.
I want to be prepared to sit on the other side of that barrier, where there is chaos, confusion, or hurt, and allow that to be the stuff. Because that's what I believe people want and need from soul-healing.

Here's the article, by the way

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Something in the air......

I was interested to read, after my cynical musings last time, that I'm not the only one to be asking who is making money from the DSM-5. Crazy thought it may sound, it seems that a large proportion of the DSM team have ties with drug companies. As they say - go figure.

I'm rather happy to see that there is a growing number of individuals, groups, and organizations who are rallying to show their opposition to DSM-x, on ethical, moral and political grounds. They range from the satirical: Here, on a page called DSMSucks! there is even a link to a "new psychiatric disease generator" which is funny and has a point ...

... to the serious call-to-arms of an 'occupy' movement who are planning a protest at the APA meeting in May. It has obvious echoes to a similar protest in September, 1969.

One of the root traditions of Transactional Analysis is that of Radical Psychiatry - a movement which sought a move away from diagnostic labelling, with all its interpersonal, societal and political implications, and back to the practice of 'soul healing'. This wasn't a 60's love-in... it was a move against the rise of Big Psych, one of Big Pharma's older cousins.

These days, the arguments are familiar and just as relevant. People are being labelled, and they shouldn't be. People are making money and gaining power over others because of this. The process is mystified so the power dynamics are camouflaged. People are alienated - from themselves, each other, the medical establishment, and from any feeling of what's normal and human.

"Call out the instigators, because there's something in the air
We've got to get together, sooner or later, because the revolution's near
.... and you know it's right" (Thunderclap Newman)

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DSM 5 - it's all medicalized now

One vocal critic of the DSM-5 bereavement issue is Allen Frances, MD. He has been blogging for some time that the 'mission creep' of the DSM has slipped out of control.
He speaks from experience, as a member of the task force that worked on DSM-IV.

So, why the 'mission creep'? How come the DSM's land-grab in the world of psychic difficulty has extended so far? Here in the UK I would expect the average Daily Mail reader to voice the (reasonable) suspicion that 'someone somewhere is making money out of it'. Perhaps - after all, the production, publishing, and distribution of the DSM is a high-value business. Most successful businesses need to update their stock from time to time - keep the customers interested. Offer a 'new, improved' version of the old product, and suddenly you have a new revenue stream.... for the APA - and oh, lest we forget - for the drug companies who will no doubt profit hugely from the new avenues of prescribing that are offered.

But I don't think for a second that it's just about the money. I think it's also about power and control. In the face of human suffering or distress, the medical model usually responds with an effort to contain or remove it.... diagnose, treat, cure. One could see this as a way of defending against the (more difficult?) reality that life is tough, and sometimes awful, and not always can we do anything about it. As existential psychotherapist Irvin Yalom said, "the medical model is a wafer-thin barrier against uncertainty".
One suggestion to add, then - DSM-x (I'm adding an algebraic symbol here, as I am assuming the revisions will continue....) is revamped time after time, to give the APA further reassurance that they have the power over all these individually classified sufferings. The mission-creep into territory that is NOT mental illness, but represents genuine and normal human life, serves to add to the fantasy of control - we can even help with this horrid stuff too, you see.

The idea that we could (or should) try to map all the ups & downs of the human psyche seems a bit grandiose to me, actually. We mapped the human genome, which has had some useful implications, but we still know that there are huge complexities and gene interactions that we have yet to fathom. So it is with our internal world. Why assume that we can solve all the mysteries?

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DSM 5 - Some thoughts.....

I see that a major journal of the medical establishment has spoken out about the American Psychiatric Association's new revision of the "Bible" - the DSM.
An article in the Lancet questions the rationale for removing the 'exclusion' of bereavement.


This exclusion, at present, draws a distinction between those who are suffering grief from an understandable recent loss, and those who are clinically depressed. In my view, this is an important boundary to maintain, for two reasons:

1. People who are suffering from a normal grief reaction aren't normally helped by being told they have some kind of disorder

2. Medics need to be reminded sometimes that there is a difference between a normal emotional reaction and a 'disorder'. See my comments on this in the palliative care field


There was some reaction from the President of the APA, Dr John Oldham. I'll offer some thoughts on his statements later.

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