If you happen not to be too familiar with the issues that I discuss in the following piece, please take a look at the reading list at the end. That will help orient you and catch you up.
On August 5 and August 6, 2014 about 20 folks (including myself) from various disciplines and from various parts of the world met in Washington, D.C. to chat about alternatives to current mental health service provision practices at an event billed as a global summit on diagnostic alternatives. Below are some of my thoughts on the issues raised at that meeting.
The meeting was in reaction to everything from the current DSM model to the core question of whether there are things that can properly be called mental illnesses. It was further in reaction to social injustice matters, societal coercion threats, pseudo-science activities, professional prestige matters, and the failure to make use of good helping practices that are currently marginalized. Here are some of my thoughts, organized around the question: What is it exactly that I would want from a new version of mental health service provision? What might a revolution in mental health service provision look like?
+ First, I would want the very ideas of “mental disorder” and “mental disease” questioned and a new picture painted of distress occurring as a result of being human and because of problems in living and not because of mental viruses and chemical imbalances.
+ Second, if this shift can be made from “mental disorder” to “problems of living,” then we might be able to also make a change in our thinking from “medications used to treat mental illness” to “chemicals with effects that may or may not produce an effect you want to handle one of your problems with living.” I would want fewer human beings on these chemicals, especially far fewer children.
+ Third, I would want all that we do not know much more honored, so that we can finally really get at, insofar as it is possible to do so, cause-and-effect in human matters and a better sense of what actually helps. There would also need to be a way of speaking about “all that we don’t know” that prevents the mental health establishment from retorting, “Look, you are saying you don’t know and we are saying that we do know, so we win!” One of tremendous challenges in moving forward is finding language that allows us to announce that there is a lot that we do not know without allowing that not knowing to become a decisive factor is dismissing reform initiatives.
+ Fourth, I would want us to carefully avoid a proliferation of new manuals, catalogues, lists, menus, and other systems that might be thought to be better than the DSM method but that do not do the real (and hard) work required of a truly better manual. For example, some new “manual of concerns” would prove no improvement, since the same faulty transaction as presently occurs would continue to occur. You come in and say that you are sad, I look up your concern in my manual of concerns, I find it, and I agree, “You are concerned that you are sad.” This isn’t an improved transaction. In this transaction we still do not have a hint or whisper of cause-and-effect or “what helps” on the table. I have only mirrored or parroted what you have told me. A genuinely improved manual, if it is even possible to create one, would need to do a real and sophisticated job of linking up varieties of cause-and-effect, the patterns produced by this amazing variety, and what then helps, either with regard to one particular “pattern” or generically, rather than just providing some list of “concerns” or “problems.”
+ Fifth, I would want us to think through how institutions that currently exist might be improved and how different institutions—for example, therapeutic communities of care—might be supported. The current institutional approach has mainly to do with society’s need to warehouse dangerous and difficult people and keep society safe from and segregated from folks who, for example, are hearing voices or threatening to kill themselves. In the current model (like in all prison models) the number one goal is not “treatment” (or, in prison jargon, “rehabilitation”) but difficult person management. Some or perhaps many members of the institution may actually want to help; but the institution as a whole is predicated on one commandment: “Control the inmates and keep the workers safe.” Naturally we would expect coercive methods to flourish in institutions with this mandate, just as we would expect them to flourish in prisons, and this is exactly what we see. I would want us to look at all this and make changes.
+ Sixth, I would want created a simple, easy-to-articulate, but also accurate snapshot of what is currently going on so that we might know what we want to change and where we want to go. Here is one example of what such a simple snapshot might look like. I think that it is fair to say that the current mental health establishment operates in the following five ways:
1. There is an atheoretical, profit-driven DSM-based diagnostic and treatment model that is the “thing” in contrast to which alternatives are most wanted. In this DSM model, where mental disorders are created in a room by folks sitting around a table, the putative goals are symptom relief, mood alteration, behavior change, and so on achieved primarily through chemical intervention. The sufferer’s “symptoms” are combined into a “symptom picture” and labeled as a certain “mental disorder.” Then the “appropriate medication” is prescribed as the only treatment or else with some adjunctive “talk therapy” added. There is no particular interest taken in knowing what is “causing” the distress, no particular interest taken in understanding the person’s circumstances, pressures, economic class, and so on, and no rationale offered for the treatments proposed except to say, “We are doing a sort of medicine.” This is the main thrust of current mental health service provision, backed staunchly by psychiatrists, drug companies, and anyone else able to profit from an easy-to-use catalogue of labels.
2. There are many theory-based diagnostic and treatment models. Many practitioners such as psychotherapists use this model (without however always announcing in an aboveboard way that this is indeed what they are doing). In this model a mental health professional relies on some perhaps coherent or perhaps incoherent set of ideas, loosely called a theory, that provides a rationale for naming causes and effects (diagnosing) and for proposing a set of tactics, strategies, or methods called “treatments.” All of the following are examples of one or another “theory-based diagnostic and treatment model”:
+ “Your faulty cognitions are causing your emotional distress and we are going to work on creating some thought substitutes for those faulty cognitions (cognitive theory and cognitive treatment).”
+ “Because of your early childhood experiences you failed to form a strong, healthy bond with yourself and now we are going to work on improving your self-relationship (self-psychology attachment theory and self-psychology treatment).”
+ “Because your id impulses are so strong, your punitive super-ego is working overtime and treating you very harshly. We need to replace those id impulses with a better functioning ego and we’ll begin with some dream analysis (Freudian theory and Freudian treatment).
+ “Your mind is causing your suffering and I have an ancient, time-honored seven-fold path to propose to you as a way for you to get a grip on your mind and relieve your suffering. Key to this effort is daily meditation (Buddhist theory and Buddhist treatment).”
+ “We all create stories and then not only do we live those stories but we tend to be held hostage by them. Let’s work on rewriting your story (narrative therapy and narrative treatment).
All of the many pseudo-theories and pseudo-systems extant—and there are scores of them, from Jungian theory to personality trait theory, from existential theory to occult theories—provide the helper with a picture of how to conceptualize what is wrong (e.g., faulty thinking) and what helps (e.g., daily meditation). Providing a particular form of help is then rationalized or justified on the basis of a particular picture of what causes human suffering.
3. Third is a client-centered approach, which is probably what most therapists actually do in practice. They ask a person who comes in, “What’s going on?”, they listen, and drawing from their experiences and thoughts about life they ask further questions, make suggestions, propose or co-create tactics, and so on. The essential quality of this approach is that two human beings are sitting across from one another and chatting seriously. At one extreme, the helper keeps “returning the work” to the sufferer by repeatedly asking, “What do you think about what you just said?” or “And how did that make you feel?” Most client-centered helpers, however, also offer advice, teach, suggest, and make considerable use of themselves and what they know. In this model, which, depending on how it is held and practiced, can amount to a complete “no-diagnosis” model, little or no “diagnosing” or labeling tends to go on.
4. Fourth is the “pure biology” or “pure science” approach where a hunt is conducted for “the biological bases of mental disease.” This is the current approach of, for example, the National Institute of Mental Health. There are grave problems with this approach: directionality issues (what causes what – for example, does sadness change the brain or does a brain malfunction cause the sadness?), definitional and theoretical issues (what are the diseases for which biological bases are being hunted?—if, for example, there is no such “disease” as “depression” or “schizophrenia,” what exactly is a biological researcher hunting for?), etc. Given these and many similar problems, it is not at all clear that science is actually being conducted here, even though the researchers may be trained “hard” scientists.
4. Fifth are all the institutional approaches, from out-patient group work under the auspices of a HMO to court-referred drinking driver programs to social worker case loads to locked ward for-profit mental institutions to forensic psychology and court-related pronouncements on mental health and so on.
To say this all simply, we need a sensible way of describing what currently goes on and the following is one plausible way. What currently goes on has five faces to it: 1) a psychiatric/pseudo-medical DSM approach; 2) a pseudo-theory-based psychotherapy approach; 3) a client-centered psychotherapy approach; 4) a biological hunt approach; and 5) generally coercive institutional approaches. With some additions, this is rather the whole landscape of current mental health provision practices.
+ Seventh, we would want to know what additional methods, systems, constructs, and institutions already exist in addition to the five I just described. Others do indeed currently exist—for example, a team approach with “flying teams” that come to your door, like the Finnish Open Dialogue method. Then there is the “communities of care” approach, where, for example, you as a sufferer come to work on a farm and live in a therapeutic community. Many “alternate approaches” are already out there—we should create a robust menu of these already-existing alternatives, maybe to include everything from pastoral counseling to AA to life coaching. If what we are looking at are indeed “problems in living” and not “mental disorders,” then whatever helps a sufferer better deal with his or her problems ought to have a place on this menu of already-existing resources.
+ Eighth, I would want us to dream up many new alternatives. There might be alternatives to the current diagnostic approach, alternatives to the theory-driven approach, alternatives to the client-centered approach, alternatives to the biological hunt approach, alternative institutional approaches, and other alternatives that do not fit into any of these five categories. For example, here are three alternative approaches that both resemble and are different from what is currently available:
1. A “patterns” model that might sound something like the following. “You say that you are having trouble with anxiety. There look to be some patterns in the lives of people with anxiety, both in terms of what is provoking the anxiety and in terms of what may help relieve the anxiety. I am not saying that we know what is ‘causing’ your anxiety and I am not saying that I know what can ‘cure’ your anxiety. But let me tell you a little bit about the patterns we think we see and you can tell me what seems to fit for you.”
In this model the mental health professional announces that she does indeed have a certain kind of expertise, an expertise in knowing about ‘patterns of distress formation and relief,’ so she is not so purely ‘client-centered’ as the sort of helper who returns all the work to the sufferer. One question is, would this model “creep” in the direction of a catalogue or manual of “patterns”—it seems natural that such creep would occur. A second question then becomes, is this creep perhaps legitimate and worthy or is it a slide back toward labeling and ‘diagnosing’? These are the sorts of open questions we would have to ask about any alternative proposal.
2. A wrinkle on the client-centered approach might be a “dialogue approach.” Dialogue has about it a sense of give-and-take, curiosity and engagement. If you are telling me a long, long story, we are not in dialogue. That is you in monologue. If you tell me something and I come back with a canned question, that is not dialogue. That is boilerplate. If, no matter what you say, I steer you back someplace, that is not dialogue. That is arm-wrestling. The fundamental quality of dialogue is that I am listening and that you are listening. If you are not listening, I am obliged to point that out. If I am not listening, you are obliged to point that out. It is not at all hard to picture how an alternative model of helping might grow out of the simple idea of dialogue. Nor, as we examine all possible alternatives, would we have any reason to scorn an alternative as too simple, too non-technical, or too non-medical. Let us get the alternatives on the table first and then, and only then, see what we like and what we don’t like about each one.
3. All sorts of “helping models” might emerge, for example a “skills building” model or a “new habits” model. For example, a “skills building” model might be created around an idea promoted in certain recovery circles, where the acronym CHIME (connectedness, hope, identity, meaning, and empowerment) stands for five “key recovery practices.” In this model, a sufferer would be told, “It’s likely that working on these five skills will help you.” Then work on those five skills would amount to the centerpiece focus of that model. Or a “new habits” model might be proposed, the argument being that what is most needed in the life of someone suffering are “new habits that help with the challenges of being human.” Such a practitioner might even have a “menu of new habits” at her disposal to share with the person sitting across from her.
Countless alternatives might be proposed. If we weren’t too quick to anoint any one new alternative as “the” alternative, there would prove no harm in having this list of alternatives grow really large. We might encounter new ways of thinking about psychological formulation, new models that focus on social justice and social constructivist concerns, new symptom-focused models that make clear what a symptom “is” (“That’s likely a symptom of something going on. Let’s try two things at once: let’s try to ease the symptom and also see if we can figure out what’s causing it.”), new goal-oriented, quasi-coaching models, and new models premised in ways that we have not thought of before. No approach would be quickly ratified; but a mental health practitioner could look at this array of alternatives and say to herself, “Hmm, that new dialogue method looks really interesting to me – I might just take it out for a spin!”
+ Ninth, we need to get all of these alternatives, both those that currently exist and those that might be proposed, “in one place,” maybe on a website run for the benefit of humanity. How these many alternatives could be presented “objectively” is a very difficult question to answer, since so many of the words that are currently used (like “diagnosis,” “treatment,” etc.) are completely loaded. But let us imagine that this presentation issue isn’t insurmountable. Implicit in the idea of inviting new alternatives to come forward is the idea that we would get to know about these alternatives, think about them, chat about them, and so forth, so let us make that implicit idea explicit: gathering together and sharing existing models and new models are important tasks of the revolution.
+ Tenth, we desperately need a clear picture of what actually helps. In fact, we already know about many things that help. We know that the warmth and humanness of the mental health service provider helps. There is tremendous evidence on that score. The warmer and more human the provider, the better the outcome. Doesn’t it seem likely that teaching helps, that skill-building helps, that providing useful homework helps, that holding a sufferer accountable for taking action helps, that inquiring into what’s going on helps, that providing basic information helps, that pointing the way to resources and making referrals help, that creating a spirit of cooperation and collaboration helps, that knowing something (for example, knowing what dozen tactics help reduce a person’s experience of anxiety) helps, that being calm helps, and so on?
It would be lovely for a really long list of what helps to be created—and better yet, it would be wonderful if a patient job could be done connecting up “what helps” with “when to use this helping strategy.” Don’t we need a smart, sensible “guide to helping strategies and when to use them”? Are there better times to listen, better times to inquire, better times to interrupt, better times to instruct, better times to confront? Are there excellent helping strategies to tease out of the myriad theoretical approaches to psychotherapy, pulling, for example, three useful tactics out of Freudian practice, four useful tactics out of Jungian practice, five useful tactics out of cognitive-behavioral practice, and so on? Wouldn’t such a guide, whatever its flaws and shortfalls, nevertheless go a long way to arming helpers with an arsenal of helping strategies?
+ Eleventh, we need much better thinking, much more clarity, and a much more careful use of language—overall. We need to stop using words like “normal” and “abnormal” if they mean nothing. We need to distinguish between medications and chemicals. We need to look carefully at the hideously empty definitions of “mental disorder” promulgated by the DSM-4 and now the DSM-5—definitions that have changed radically from one edition to the next for no other reason than to meet appropriate objections leveled at the definition of a “mental disorder” in the DSM-4. We need not to create super-ecumenical, completely meaningless umbrella “causes” for “mental disorders” by claiming, for example, that they are “biopsychosocial” in nature. Everything human is biopsychosocial in nature! We need more honesty and better thinking than that.
We need top thinkers, who perhaps currently rightly shy away from the world of mental health as too muddy, too soft, and too difficult a place in which to do real science, to inquire of themselves, “Yes, that would prove a truly difficult place, but isn’t having a say about the future of the emotional health of our species more important than participating in the creation of a new phone or television?” We need strong, smart people who know a thing or two about being human to help foment and manage a revolution away from the current pseudo-medical approach to mental health, where even non-medical folks like clinical psychologists are inveigling their way into prescribing “medications for mental illnesses.” We need strong, smart people to begin to really help the billions of people who experience emotional distress and who might love to have some real help offered to them.
+ Twelfth, we need a fundamental shift—nowadays typically called a “paradigm shift”—in our basic orientation away from the ideas of “mental disorder” and “mental disease” and toward a more rounded, sophisticated and truer vision of what it means to be human, how life naturally produces distress, how our formed personality works to lock in that distress, and what helps to relieve that distress.
We need a human profession for human problems—a needed change that may require that we promote a real revolution away from not only the current pseudo-medical model but away from the current helper designations of psychologist, psychiatrist, and psychotherapist. We may well need movement toward some new appellation like human experience specialist that more closely fits with who we want this helper actually to be – someone who knows a lot more than “psychology” and an awful lot about being human and negotiating life’s challenges.
We need these changes. We especially need them because our children are under siege. It is one thing for an adult to accept that his despair is a “mental disorder” that can be “treated” with a chemical. He is an adult, after all, and entitled to make that choice. It is another thing for a five-year-old to find himself on three or four psychiatric chemicals. There are many reasons why we require a mental health revolution but let’s just underline one of those many reasons: to spare the children. Do we want all of our children labeled and treated as mental patients just because a professional class is getting away with playing a very profitable game?
I hope you’ll join this revolution—if you’d like some marching orders, just drop me a line.
If the issues that I raise in this piece interest you, I suggest that you take a look at one or more of the following books:
Barber, Charles. Comfortably Numb: How Psychiatry is Medicating a Nation
Conrad, Peter. The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders
Greenberg, Gary. The Book of Woe: The DSM and the Unmaking of Psychiatry
Horwitz, Allan and Jerome Wakefield. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder
Kinderman, Peter. A Prescription for Psychiatry: Why We Need a Whole New Approach to Mental Health and Wellbeing
Maisel, Eric. Rethinking Depression: How to Shed Mental Health Labels and Create Personal Meaning
Moncrieff, Joanna. The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment
Szasz, Thomas: The Myth of Mental Illness
Watters, Ethan: Crazy Like Us: The Globalization of the American Psyche
Withaker, Robert: Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America
Whitaker, Robert. Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill
You may also want to look at some of my posts for Psychology Today and for the Global Summit on Diagnostic Alternatives:
Eric Maisel is the author of more than 40 books. His 2014 books include Settled, a novel about moving Israel, Secrets of a Creativity Coach, and Life Purpose Boot Camp. You can learn more about Dr. Maisel’s books, trainings, and services at http://www.ericmaisel.com or drop him a note at firstname.lastname@example.org