DSM-5; step into the straight-jacket…



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.

Economic lie number 4; inequality is good for the system…

The whole Capitalist system is dependent on aspiration, or so we are told. Our Chancellor of the Exchequer has just heralded his 2013 budget as something for an ‘aspiration nation’- seeking to help those who want to help themselves- those who want to own their own houses.

Without the wealth creators (business entrepreneurs) there can be no long term prosperity. All that you will have is stagnation- look what happened in the old soviet bloc countries.

Without greed we have bad cars, cabbage soup and bureaucrats in stone washed denim.

Except that the rich are getting richer, even WITHIN our western economies. This from The Telegraph;

The world’s rich are getting richer. The Forbes billionaire list was published this morning (there are now 1,426 of them globally in dollar terms, with 210 new entrants in the last year), and collectively they are $800bn richer than they were a year ago. Each billionaire is, on average, $100m richer than in 2011, with an average wealth of $3.7bn.

And the poor poorer; The Institute of Fiscal Studies forecasts that, as a result of UK tax and benefit policies, there will be significant increases in child poverty in the coming years. In Scotland alone forecast trends would suggest between 50,000 and 100,000 more children being pushed into poverty by 2020. (See here.)

And what is more, the argument can be questioned even by people on the inside;

There is the opposite argument too- that the more equal societies are in terms of income, the better its citizens seem to do. This from here;

In The Spirit Level Wilkinson and Pickett base their analysis on data from 23 rich countries as well as data from the 50 American states. They say that in the main this shows that the following problems are much more pronounced in countries with higher levels of income inequality.

Health inequalities: At the end of the 1990s there was an average gap of 7.3 years in mortality between rich and poor people in unequal societies. This can rise to as much as 28 years in some American states. They argue that research shows these differences cannot simply be explained by differences in health behaviours.
Mental illness: They argue that ‘inequality is  causally related to mental illness’; that rates of mental illness are five times higher in the most unequal societies compared to the least unequal.  Illegal drug taking is also higher.
Obesity: Unequal societies are more likely to have higher levels of obesity, with poor people most at risk, partly because of the attractions of ‘comfort eating’.  Indeed the rate of obesity is six times higher in the most unequal, compared to the least unequal, societies.
Divorce rates: There have been larger rises in more unequal societies. This then creates more stress for children.
Teenage pregnancy: This is more prevalent in unequal societies. Indeed in the USA the rate of teenage pregnancy is four times the EU average.
Violence: Wilkinson and Pickett argue that the strongest evidence or the negative effects of inequality is violence figures. The reasons for this are explored below.
Imprisonment: Unequal societies are more punitive. People are five times more likely to be imprisoned in the most unequal societies than the least unequal.
Social mobility: Inequality leads to less social mobility. Inequality ‘solidifies the social structure’ and also depresses educational attainment for the poor.
Women’s position: In general women are less likely to be in higher status jobs in unequal societies and they also have worse health than women in more equal societies.

Wilkinson and Pickett argue that the problem of inequality is not just for poor people: everyone suffers. The life expectancy figures even for rich people is lower in unequal societies than more equal ones. The reason they advance for this is that unequal societies have lower levels of trust than more equal societies. This lack of trust leads to more hostility, fear and lower levels of community participation. In this way everyone suffers.

In the data they present the societies which are most unequal, and have the biggest health inequalities and social problems, are the USA, the UK, Portugal, Australia and New Zealand. The least unequal are the Scandinavian countries and Japan.


Fast food, religion and politics- a marriage made in America?

I do not mean to be in any way rude to American readers, but there are lots of things that happen over on your side of the Atlantic that often seem to make little sense over here. I think this is partly because in many ways the Conservative, Christian, largely Republican middle America is so very different from the UK- even if this is just one part of your vast and wonderfully diverse country.

However, the influence that American Christian media has on certain strands of religion over here is significant- music, satellite TV, funding for ‘mission’, Evangelists, books- these are overwhelming dominated by US products.

Then I read this story in the guardian.

Here is Fox New’s take on it;

It goes something like this- CEO of fast food company (who donate millions of dollars to charities who try to ‘cure’ homosexuality) openly states his opposition to gay marriage. This causes a backlash, including from the Mayor of Chicago, and- Kermit the Frog;

However, step forward the right wing ‘Shock Jock’ Mike Huckerbee;

 …former Republican presidential candidate and current Fox News host, Mike Huckabee stepped in to defend Chick-fil-A. In order to bolster support for the company, he encouraged people to visit their local franchise on Wednesday. It was dubbedChick-fil-A Appreciation Day.

As Huckabee put it, it had the “simple” goal of affirming “a business that operates on Christian principles, and whose executives are willing to take a stand for the Godly values we espouse”.

Too often, he said, “those on the left make corporate statements to show support for same-sex marriage, abortion, or profanity, but if Christians affirm traditional values, we’re considered homophobic, fundamentalists, hate-mongers, and intolerant”.

There is so much I could say about this story. I think we have to start with an understanding of how easy it is to be influenced and controlled by our culture. Culture in this case that is mixed with religion and becomes so rigidly conservative and controlled by assumptions and normative values that make anything outside seem threatening and requiring a defensive (or even an aggressive) response.

There is also the fact that for much of Middle America, President Obama (the physical embodiment of this threat) and  is ahead in the polls, leading to great uncertainty. Mitch Romney’s blunder-ridden jaunt around Europe might make him a comedic figure this side of the Atlantic, but to many he is the hope for salvation.

Then there is that word ‘fundamentalism’- which in this context involves a literal interpretation of the Bible- even if thinking Evangelicals would admit that there are still nuances to this when we try to adopt words into our culture. I have been around this way of thinking for much of my life, and though I currently find myself at considerable divergence, it is clear to me that many people who hold to these beliefs are actually trying desperately to live a good life, according to the light of God revealed through the words of the Bible.

On this issue however, I find myself with more in common with Kermit than with Huckabee.

Partly this is because my theology sits quite comfortably with same-sex unions- I am quite happy to celebrate love and life long commitment wherever we might find it. Far from this being a threat to any kind of family values I hold dear, my hope would be for new families to thrive and grow as mine has done.

I also do not think that Christians need to engage in any kind campaign to protect their ‘rights’ to proselytise or to condemn others for what we would see as immorality. Let us raise our voices against injustice, corporate greed, globalisation, leave the rest to God, and resist the throwing of the first stone.