DSM-5; step into the straight-jacket…

DSM-5

 

It is out today.

Back in February, I wrote a long piece reflecting on a number of issues thrown up by the new American Psychiatric Association edition of the Dignostic and Statistical Manual of Psychiatric Disorders. I confessed to considerable skepticism and concerns into the way this hugely dominant document had been drafted. Here is some of what I said

 It matters on an individual level because all of us will be affected by mental disorder. One in four of us will be diagnosed according to one of the classifications above, so even if this is not you it will be someone you love or someone you work with. Lots of us feel a strange relief when distress is given a name – it suggests understanding, companionship, a removal of uncertainty and the possibility of treatment. However, for many these can easily become self perpetuating and destructive as they have the effect removing responsibility, ownership and eventually hope of recovery, which some never find again.

It matters too on a sociological level. Our societies are increasingly regulated by psychiatry. We medicalise, medicate and plan ‘evidence based interventions’ into all sorts of human variation. This may simply amount to the application of science and knowledge to the alleviation of mental illness, but the question is whether this is ‘healthy’? Are we seeking to make a world in which the mess and gristle of life is edited out, tidied away, chemically suppressed? And is it working?

Psychiatric classification almost always demands treatment, so step forward the drug companies, with another product to push by fair means or foul. All those countless drug rep funded lunches, gadgets, even holidays, in the name of publicity for the next wonder drug. Even if the drugs do half of what they promise there is no doubt that our population is increasingly medicated.

At the time I wrote a list of what I hoped might form the new direction within mental health care- which I am convinced will be looked back on by future generations with shame and anger;

Away from ‘illness’ towards ‘distress’

Away from ‘symptoms’ towards understanding that we develop different  means of coping with this distress.

Away from restrictive labels towards listening to individual experience.

Away from medicalised interventions, towards encouragement and support of individual recovery.

Away from simplistic distinctions between ‘psychosis’ and ‘neurosis’ towards a greater interest and understanding of the effect of trauma.

Away from segregation and ‘otherness’ towards seeing mental distress as an essential part of the human experience and as such, part of all of our experiences.

Away from ‘maintenance’ towards hope and acceptance.

I was not expecting quite so much public and professional resistance to DSM5- even to the point of questioning anew the core concepts of ‘mental illness’. This from here;

Critics claim that the American Psychiatric Association’s increasingly voluminous manual will see millions of people unnecessarily categorised as having psychiatric disorders. For example, shyness in children, temper tantrums and depression following the death of a loved one could become medical problems, treatable with drugs. So could internet addiction.

Inevitably such claims have given ammunition to psychiatry’s critics, who believe that many of the conditions are simply inventions dreamed up for the benefit of pharmaceutical giants.

A disturbing picture emerges of mutual vested interests, of a psychiatric industry in cahoots with big pharma. As the writer, Jon Ronson, only half-joked in a recent TED talk: “Is it possible that the psychiatric profession has a strong desire to label things that are essential human behaviour as a disorder?”

Psychiatry’s supporters retort that such suggestions are clumsy, misguided and unhelpful, and complain that the much-hyped publication of the manual has become an excuse to reheat tired arguments to attack their profession.

But even psychiatry’s defenders acknowledge that the manual has its problems. Allen Frances, a professor of psychiatry and the chair of the DSM-4 committee, used his blog to attack the production of the new manual as “secretive, closed and sloppy”, and claimed that it “includes new diagnoses and reductions in thresholds for old ones that expand the already stretched boundaries of psychiatry and threaten to turn diagnostic inflation into hyperinflation”.

Others in the mental health field have gone even further in their criticism. Thomas R Insel, director of the National Institute of Mental Health, the American government’s leading agency on mental illness research and prevention, recently attacked the manual’s “validity”.

And now, in a significant new attack, the very nature of disorders identified by psychiatry has been thrown into question. In an unprecedented move for a professional body, the Division of Clinical Psychology (DCP), which represents more than 10,000 practitioners and is part of the distinguished British Psychological Society, will tomorrow publish a statement calling for the abandonment of psychiatric diagnosis and the development of alternatives which do not use the language of “illness” or “disorder”.

The statement claims: “Psychiatric diagnosis is often presented as an objective statement of fact, but is, in essence, a clinical judgment based on observation and interpretation of behaviour and self-report, and thus subject to variation and bias.”

All this comes starkly to light when we hear the voices of experience;

“Strange though it may sound, you do not need a diagnosis to treat people with mental health problems,” said Dr Lucy Johnstone, a consultant clinical psychologist who helped to draw up the DCP’s statement.

“We are not denying that these people are very distressed and in need of help. However, there is no evidence that these experiences are best understood as illnesses with biological causes. On the contrary, there is now overwhelming evidence that people break down as a result of a complex mix of social and psychological circumstances – bereavement and loss, poverty and discrimination, trauma and abuse.”

Eleanor Longden, who hears voices and was told she was a schizophrenic who would be better off having cancer as “it would be easier to cure”, explains that her breakthrough came after a meeting with a psychiatrist who asked her to tell him a bit about herself. In a paper for the academic journal, Psychosis, Longden recalled: “I just looked at him and said ‘I’m Eleanor, and I’m a schizophrenic’.”

Longden writes: “And in his quiet, Irish voice he said something very powerful, ‘I don’t want to know what other people have told you about yourself, I want to know about you.’

“It was the first time that I had been given the chance to see myself as a person with a life story, not as a genetically determined schizophrenic with aberrant brain chemicals and biological flaws and deficiencies that were beyond my power to heal.”

Longden, who is pursuing a career in academia and is now a campaigner against diagnosis, views this conversation as a crucial first step in the healing process that took her off medication. “I am proud to be a voice-hearer,” she writes. “It is an incredibly special and unique experience.”

In the 1960’s the liberation battles were about race, the 1970’s gender, the 1980’s sexuality. The 1990’s we began to think we had sorted it all out and in the 2000’s we discovered that perhaps we had not.

This decade, let us take on the oppressive machine that makes madness out of the variety of human distress.

Personal growth and the rise to the top…

 

Life is for living – for drinking deep from the well of experience. That is why many of us believe that wild places are so special; they take us out of our narrow protected bubble and open up something deeper, more eternal.

A fulfilled life is a difficult thing to measure. Very soon we start to use nebulous words like ‘well being’, ‘happiness’ and ‘satisfaction’.

We may also have to acknowledge that life is a process – a journey. Some would call this journey a process of ‘maturity’, others would say ‘enlightenment’, others still would call it ‘personal growth’. All these ideas contain the idea that life, in all its joy and difficulties, should embrace transformation; movement from one state of being to another. Standing still is unlikely to be healthy and ultimately it will likely prove impossible.

For a while, many of us (particularly men) come to believe that a fulfilled life is one characterised by success. And because we are competitive creatures there has to be some means of measuring this success so we are always heading for the next achievement, the next conquest, the next acquisition.

I was reminded of this again today listening to a radio discussion about psychopathy with Jon Ronson, author of this book

The word ‘psychopath’ is one of the most overused and emotive terms employed by the media in relation to mental illness, but Ronson’s book goes far beyond the stereotype. He qualified to use the Hare Psychopathy Checklist, and became, by his own admission, something of an obsessive Psychopath spotter.

Whatever you believe about the usefulness of labels like this, the fascination with the sort of people who can commit such acts of appalling cruelty apparently guilt free is almost universal. All the more sobering then is the statistic that roughly 1% of people can be regarded as psychopathic.

Rather than getting stuck with all the high profile serial killers and despots, Ronson’s interest takes us more towards the very place of madness at the heart of our society. At the same time as vilifying psychopaths as not-human ‘others’, he argues that there is something psychopathic about our society, and that many parts of our society actually reward psychopathic tendencies.

Consider this – one of the two ‘factors’ in Hare’s checklist

Factor 1: Personality “Aggressive narcissism”

It is easy to see how an individual with these kind of characteristics could succeed in much of society. It is impossible not to start thinking of people we know, bosses we have had.

I went to hear psychologist Oliver James speak at Greenbelt Festival last year (you can download the talk here.) One of the things I remembered him saying was that in all his dealings with the rich and powerful, including several Prime Ministers, he had yet to meet many who he would regard as psychologically healthy.

However, Ronson goes further than this and suggests that the very institutions of our society can become psychopathic. Banks that loan what they know can never be repaid, therefore condemning people to financial indebtedness for the rest of their lives. Health systems that thrive on the sickness of the population. The creation of all sorts of addictions to gadgets and shiny product in order to ensure profit.

It is almost as if the process of becoming – whether we understand this as a spiritual, psychological or simply biological development – has been replaced by a process of conquest, where success at almost any cost is the only thing that matters.

But success is fickle. The journey to the top is often followed by the journey back down again.

Back to this maturity/enlightenment/personal growth thing. Most of us come to a point when we realise that success is rarely a route to any kind of lasting happiness (even if this is a legitimate aim for any of us.) A life that cuts us off from the social animal that we humans are and replaces this with narrow acquisition is a kind of madness – all the more so for the fact that it is a collective madness.

So for those of us who are climbing to the top, may we succeed. May our enterprises go from strength to strength. But may we also remember that success without ethical responsibility and without the mess of all that humanity may indeed still be success, but it may also be the cause of our own destruction – both individually and collectively.