Update: How’s the ACA (“Obamacare”) doing?

There were two major objectives of the ACA: extend coverage, and reduce costs. Let’s look at some evidence-based summary articles.

The Affordable Care Act Works – Costs per family are down (obviously we’re talking averages, here).

It’s Working Despite Misinformation – The number of uninsured people has decreased.

Poorer Health of Surgery Patients on Medicaid May Alter Law’s Bottom Line – When our health care system does NOT care for everyone, and then makes health care accessible, it turns out that the poorly-cared-for are in bad shape, and cost significantly to get healthy. Moral: preventive care (there’s a big emphasis on this in the ACA) is definitely a cheaper option than neglect, in the long run.

Everyone agrees that the system needs improvement. This is NO surprise. It was expected to, from the beginning. But already, it is known that health care delivery costs are far less for Medicare than for non-Medicare patients (by about a factor of 4). Government involvement saves the entire system money. That what the data have been saying for years.

What costs us piles of money is incessant ideology that is without any real factual basis.

Let’s just work from evidence, and get it all to work, for ALL of us.

(adapted from a Facebook comment made 2014.05.17.)

Writing made simple…although perhaps not for the faint of heart

Possibly the greatest writing lesson I ever received happened one afternoon when I was at my work-study job at Oregon Health Sciences University in Portland, OR. I was a research assistant for a young Assistant Professsor in the Medical Psychology department. He was fierce in his devotion to research, and especially to writing about it. He was also having a very good start to his career. He would take on a subject about which he know little, like, say, pregnancy and smoking, and study it hard and long, and then write about it and get published in good journals. THAT is hard work, let me tell you!

So this particular afternoon, I come in at about 1PM, and he’s sitting his desk, with a single sheet of paper in front him, and a yellow legal pad. The desktop is bare, otherwise. He gives me my instructions for the day, and I ask him what he’s doing. He tells me “This is the introduction to my new article I’m about to submit. I’m trying to get it right”. That single sheet of paper contained what looked like 3 paragraphs.

I go off to the computer center (I have distinct statistical analysis skills and have had them for a long time, and that was my focus on this day). At 4 PM, three hours later, I return to his office. He’s still there, sitting, staring at what is now a legal pad with notes on it. “Having problems with the writing?” I asked helpfully. “Oh no,” he says. “What most people don’t realize is that writing isn’t easy. I have graduate students ask me ‘how do you do it – what’s the trick?’” (He wrote like an angel – it was clear and effortless to read. Simply gorgeous – and that’s not easy to do in a psychological research report!)

“There is no trick,” he explained. “It’s just hard, so you work at it.” I left him there, sitting at the desk. I’m sure his piece got published. It seemed they always did, and he did about 3 a year.

I’ve written a great deal since then, including a 300+ page Master’s thesis. It’s all proven him right, although if you keep at it, you do acquire a certain grace relative to simply starting, and to more or less getting things decent in the first draft. Beyond that…hard work.

So, there you are. “Blood, sweat, toil, and tears.” It could be worse. The silence of a blank sheet of paper is worse.

One last thought: I have observed over the years that serious writers all seem to share a common trait: We write out of necessity. We cannot not do it. It’s how we pull form out of our own chaotic minds, not to mention the collective chaos of those around us. It just has to happen. Resistance is futile. I do not object.

DSM-5 a catastrophe? Nope – just the next version of the best-we-can-do-today classification scheme we use every day

There’s been a lot of noise lately about how awful the new version of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association is going to be. Virtually none of this drive-by criticism appears to be the least bit informed as to the goals of the DSM-V, much less the process by which it has been developed.

A recent critical article: Why Many Mental Health Professionals Are Ditching the DSM-V ‘Bible’. There are SO many problems with this article, yet most will completely elude detection by readers.

1. The title asserts that “many” MHPs (Mental Health Professionals) are abandoning the DSM-V. Absolutely NO evidence is given for this assertion. A cheap shot, nothing more.

2. The title refers to the DSM as a “Bible”, which it is not. The Bible is considered to be a revelatory document (by believers) or a historical document (by non-believer scholars). The DSM is neither. It’s a data driven, clinically validated, periodically updated classification scheme, and nothing more. That’s all it’s designed to be.

3. “major players in the mental health community say the book needs more research”. Who are these “major players”? The NIMH is mentioned, but that’s now old news, and not immediately relevant, anyway (see #4 below). Unnamed academics from Columbia and Rutgers are also referenced – complaining about the DMS’s lack of epidemiological perspective, and insufficient consideration of ancillary causal factors. As usual, these non-clinician critics want the DSM to be the kind of research review it never was intended to be. It’s for working clinicians, not researchers. It USES research, in several ways, but is NOT a research report, review, or even summary. Once again we see non-clinicians simply failing to understand what we in clinical mental health are actually doing in our work.

4. NIMH director Thomas Insel is paraphrased (correctly, I think) as saying the DSM lacks validity because it classifies disorders solely by their symptoms. Pray tell, what is the alternative? The DSM, in recent iterations, derived from a desire to diagnose not according to theory (for which, by definition, there was little or no formal research support) but according to actual clinical presentation – yes, symptoms. WHAT ELSE DO WE HAVE? This isn’t a mistake, it’s a NECESSITY. We’re playing the only game we actually CAN play, at this point in the evolution of our knowledge of mental illness.

Insel’s project is a research strategy, for an agency with a very strong commitment to basic (i.e., physical science and medical) research. But don’t expect it to answer all questions; it simply can’t

There is a vast amount of research – from studies of morphology in biology to the famed “Minnesota twin studies” in psychology – which supports the idea that what one sees in the real world is about 50% derived from genetic factors and 50% derived from environmental factors. The conceit that any study of genetics+environment will allow us to account for the spectrum of depressive disorders, anxiety disorders, and most particularly trauma disorders is either phenomenally ill-informed or gratuitously over-optimistic. The further notion that the results of such a effort will properly be considered “medical” presupposes that psychology can be reduced to physiology, at the least. Yeah, and while you’re at it, let’s reduce computer programming to mere electronics. This is sort of “reductionist” logical error one is cautioned about as an undergraduate. Such decomposition of a higher order field to one or more lower order fields has never, to my best knowledge, happened – outside of the realm of theory, not is it ever going to.

For how many decades has the search been unfolding for a “gene for alcoholism”? And the results: still looking…

“Further evidence and an approximate estimate of heritability – crudely speaking how genetic a condition is – can be derived from twin studies that yield figures of 50% for males and 25% for females…” (Ball, D. (2004). “Genetic approaches to alcohol dependence”, The British Journal of Psychiatry
185: 449-451 doi: 10.1192/bjp.185.6.449)

What this should make clear is that “medical” approaches to such things will ever only get us part of the way to our goal. The rest of what it will take has to do with behavior, learning, and a causal model that will contain a number of non-physical factors. And alcoholism is EASY, compared to anxiety, depression, or trauma disorders.

It is fundamentally misguided to think that psychology can be reduced to physiology or medicine. Yet, if awareness of this thinking error is not much in the minds of the general public, it is also significantly lacking in the minds of too many mental health professionals. Insufficient awareness of this error is at the heart of much criticism of professional clinical psychology by non-clinicians outside of the field. They just don’t get it. Clinical work is NOT research any more than research is theory. Different areas of thoughtful activity – different goals – different processes – different rules – different outcomes. So shall it always be.

I appreciate that several rather subtle considerations are touched upon in my remarks above, of necessity. This is ALL about explanatory and prediction strategies, and THAT topic isn’t seriously taken up by most students until graduate school. If this were an easy topic, it’d be covered in high school.

Biology is still actively arguing about species delineation and classification (a fascinating topic, by the way). It’s hardly surprising that we are doing the same in the nosology of mental illness. It’s part of the process by which science improves itself. We’re NOT in trouble; we’re just doing our job.

[based on a 2013.05.14 post to the G+ Trauma and dissociation: education and advocacy community]

::Talking with children about incomprehensible disasters and tragedies

Most of us have been deeply affected and disturbed by events of  December 14, 2012, in Newtown, Connecticut. Sadly, we’ve been through this too many times before, in recent history. Far too many times. However, this particular disaster has multiple dimensions of horror to it. When I read the news, I was unable to work for several hours, and the distraction I felt for the rest of the day has continued today. One well-known child psychologist I know simply abandoned his work and went home to his family. I have years of training, experience, and thought invested in my twin careers as cultural anthropologist and psychotherapist, all of which induce me to see this event as profoundly complex, and well beyond the grasp of any easy explanation. For that, I will wait.

My first thought is for those who will most identify with the victims* – children who did not die on that day but who heard the news. We are social animals, and that means we care about our children. We must, for they are us, and they are our future. It is in our genes and therefore in our hearts to have concern for their welfare; it cannot be otherwise. A partial solution for my own distress has been for me to write the following. (Please note that “children” here means anyone below the age of 18. However, adults are perfectly capable of becoming functional children in time of crisis, and will also respond to much that is helpful to actual children.)

Adults must care for children because they cannot do the job themselves. “Caring for” them simply means helping them grow up to be adults, so that the cycle of nurturing can be repeated. As caretakers, our first job is to protect children from anything they cannot handle: threats to their physical or emotional health certainly are legitimately our primary concern. Such protection is certainly not all that they need from us. It’s just the first thing. Our attempts to protect them will surely fail, multiple times, as they grow up. When that happens, we must stay on the job, as it were.

So, what can we do, when all of us are impacted by incomprehensible disaster and tragedy?

First, we take a little time to compose and calm ourselves

We do this because those who seek to assist others need to be sure they are not part of the problem.

It’s often helpful to distinguish a crisis – which requires immediate action – from a problem. With the latter we have time to work things through, and stay with the problem until we arrive at a conclusion we can live with. In the overwhelming majority of situations, a child who has been witness to the incomprehensible will be mostly fearful, and that’s usually a problem, not a crisis. With problems we have the luxury of going forward slowly and deliberately. Taking a little time to compose ourselves before turning to children will help us help them better.

Second, focus on the child

Take time to do what adults can do uniquely well for children: be receptive, interested, accepting, and calm. This leaves the conversational space open for the child to occupy, which is what they need. We don’t need to talk TO them so much as talk WITH them – and most of all to listen while they talk to us.

We may surely be having problems coping with what’s happened. These problems are best taken up with other adults. Children don’t need our problems, cannot make use of them, and may become overwhelmed by them. But, do realize that most children become fairly perceptive, at an early age, of the feelings of adults upon whom they depend, so they likely do know that we’re upset. The problem is just that what we show them of our distress needs to help them, not add to their own distress. With older children, showing some of your distress, overtly and in moderation, is usually appropriate and even helpful. It’s realistic, and it’s useful for them to see that it’s alright to have feelings and to share them. They also need a good example of how to do this without making a problem for others.

The younger the child the more they must be the focus. Our concern needs to be for them, as they actually are, not as we might imagine them to be. Don’t make a problem larger than it is. We do well to let the child show us what their problem (if any) is, rather than to make suppositions about it. The question we need to answer is: Are they in trouble, and if so what kind of trouble?

Most of the time, physical threat is not the issue – although fear of such threat well may be. If it is, what needs to be done will be fairly obvious to us: block the threat, in reality and in the child’s mind. What’s left after that is, in order of priority, emotional threat, then conceptual threat.

Emotional threat simply has to do with feelings the child has but cannot handle. People of all ages have feelings in reaction to what they are seeing, in reality or in their mind. Encourage the child to tell their story and their feelings will usually show well enough. We can then visibly recognize them, without amplifying them, and show the child that we can handle their having them. We thus become a container for what may be difficult for them to manage, alone. This simple act is often the most useful thing we can do.

Conceptual threat has to do with the child’s inability to make sufficient sense of what has happened. But how can we help them when we cannot make sense of something ourselves? The first key is to remember that the child’s viewpoint is not ours – they are not adult. Their ability to “understand”, on the best of days, is limited. We can work to help them construct a story about what happened that they can be reasonably comfortable with. It needs to be their story, however, and told on their terms and in their language. They construct it, and we can help them get it right. That doesn’t mean “accurate” so much as “acceptable” to them, emotionally.

The second key is to remember what their concerns actually are. Doing this well requires adequate insight into a child’s developmental status, of course, but in general, all children need to know that we are watching them, concerned about their welfare, and that this won’t cease. Demonstrating this is more important than saying it. We are their buffer against chaos, and they need to see and feel this. More concretely, when we help them construct an age-appropriate story about what happened, we can see that it ends with the statement that we adults are working to set things right, and will continue to work to protect them from harm as much as we can. How you say this to a four year old will differ greatly from how you say it to a sixteen year old, but the core message is the same.

Finally, work to restore a sense of normalcy

Children are concrete thinkers. A child’s world is small, and it is appropriate and manageable for them to be focused on immediate things. So, see that those things are in order for them. Daily life needs to be predictable and familiar, for the most part. When it’s not, it needs to be interesting and challenging without being overwhelming. Therefore, restore daily routines they know and like. Keep from them unwanted and unneeded exposure to aspects of the disaster which can too easily continue to intrude and disturb. It’s far more useful to emphasize, when the child has questions about this, that disasters are rare, and that adults actively watch for them, to keep kids safe as much as possible.

The most crucial part of that effort is you, as their caretaker. Keep yourself functioning and they will follow after you. Do what you usually do, every day. Convey to them that life does go on, even if it’s in a new place, or with new people, and they will see that they are a part of this, and return to their task of growing up. When that is achieved, we have done our best.

And stay with it. Things take time. Children will continue to think about and react to what has happened, and talk about it with other children. Continue to pay attention to what’s going on with them and their world, as is customary for you to do. Stay on the job, and they will move on through the challenge and thrive as well as possible, all things considered. We all want that, and we can all work to achieve it.

Note

“victims” – We must acknowledge that the children are not the only living victims of this. Their families certainly come next in our concerns, and the first- responders who had to confront the awful aftermath of this disaster. Finally, let us acknowledge the family and relatives of the shooter, for they also are innocent and will be affected for the rest of their lives by all this. All need to know that we are thinking of them, and would offer willing offer them help were it possible for us to do so.

::A clear path to control of a woman’s body – by the woman involved

The “morning-after” birth control pill prevents ovulation; it does not cause abortion of an embryo. This is the news, this morning, in a New York Times editorial :  How Morning-After Pills Really Work. This fact removes one of the final blocks to access (other than cost, a problem in some cases) to a significant advance in birth control pharmacology, that block being the presumption that the pill was killing something. As the editorial points out, this belief was never more than speculation, and in fact there is NO evidence for it whatsoever.

To the contrary, as another recent article in the Times points out, “Studies have not established that emergency contraceptive pills prevent fertilized eggs from implanting in the womb…” What they do establish is that medications like “Plan B”, the most widely known “morning after pill”, delay ovulation, which essentially places a time barrier between sperm and egg. This works because, contrary to common belief, sperm and egg to do not unit at time of intercourse, but rather days later. Sperm require time to travel and position themselves, and will die in a mere few days if no egg is available to act upon.

Such a “time barrier” will still be objectionable to those conservatives who believe that all interference with what they stipulate to be the sole legitimate purpose of sex – reproduction – is immoral. I find such objections to be unreasonably arbitrary. They are made primarily by men who want to control the behavior of women.

I was a young man when the birth control pill for women became easily available. It appeared revolutionary at the time, and that appearance has been confirmed over the years. Rejection of the pill as “immoral” seemed presumptive and poorly argued at the time, and that, to me, has not changed either, with the passage of time.

The world does not need more babies, much as I love them. Nor does it need more pregnancies – which, after all, have enormous physical, financial, and social implications in each and every case. I sometimes think that the solution to human beings who think and breed like rabbits might be to provide them with a lifetime supply of rabbit feed, and a large, solitary cage. (OK, that’s absurd…but something needs to be done about the thoughtless, or witless, who just keep having large families without regard for the implications of their act.)

It’s worth recalling that the birth control movement came about because of the problem of poor women having babies they could not afford. Women were dying, from pregnancies they didn’t want which went bad, and from dangerous attempts at inducing abortions. Where affordable birth control is not available, this is still happening. I’ve never heard cultural conservatives express moral outrage about that, sadly – nor about the unfairness of being born female and being compelled by biology to become pregnant as a result of acting on ones sexuality.

There are two arguments in favor of birth control (and more in support of the birth control pill, which in some cases has clear medical benefits not at all related to birth control): one has to do with moderating human breeding, and the other with empowering women relative to whether or not they become pregnant. Both are critical considerations, but today, for me, I’m impressed mostly by the latter. Pregnancies impact women far, far more than they do men. Women should be the decision makers regarding whether or not they become pregnant.

We now need to see that “Plan B” type birth control becomes available to all who want it.

::The ongoing struggle for justice for women in Egypt

[UPDATE: Amnesty International tells Egypt to probe mob attacks on women (Question: Why do they have to be told?)]

This is hard news:

Egyptian women protesters sexually assaulted in Tahrir Square – Mob attacks small group calling for an end to sexual harassment as women continue to demand a ‘new Egypt’ post-Mubarak

Before I was a psychotherapist, I was (and still am) an anthropologist. I understand the evolutionary heritage of our particular branch of the primate family tree. I understand that our species has a social adaptation (we survive as a social unit, unlike, say orangutans), and that critical to that adaptation is that males have organized “military” power, while females have charge of rearing our highly vulnerable young. There is a power imbalance inherent in this, and one sees this in all places, at all times, in our history. Those who rail against our “patriarchy” do well to understand how deep lie its roots in our species. It is not an ideology (though ideology may be used to justify it at times), it a biologically derived social adaptation.

That said, it has long been time for change, and it surely IS happening, though hardly overnight. For example, women are becoming the majority at many institutions of higher education, throughout the “developed” world, and in many other places as well (I heard today that this is the case already in Libya). Yet there are still many issues to resolve, and many, many places where they need resolution.

Consider, in my country – the U.S., “…40 years ago doctors in America were prosecuted for providing women with birth control, and women risked jail for using it”[1] And to this day, there are very significant forces in my country who would deny women access to birth control. One of the two major US political parties regularly fields candidates who oppose any kind of public funding for birth control, and who in fact would be fine with making it illegal. Backward leap anyone?

New version of “All Your Base Are Belong to Us” – All your uterus are belong to us!

Kind of catchy, don’t you think? Certainly reflects the mindset of those guys in the US – not mention those cultural conservatives in Egypt who regularly grope women in public. Their message is clear:  women are for their control and use.

So…take note – of the ongoing struggle in Egypt, and the courageous women at its center (read the article above to learn to what I am referring). The last paragraph of that article:

“Women activists are at the core of the revolution,” said Ahmed Hawary, who attended Friday’s protest. “They are the courage of this movement. If you break them, you break the spirit of the revolution.”

I’m no authority on gender and names in Egypt, but I believe that’s a male speaking – the women are hardly alone in their struggle. And I’ll wager that those women won’t break.

Let me close by giving the highest praise to the cordon of men who put themselves between the female core of the protest march and the mob around them, and who continued to attempt protection when their cordon was shattered and they were significantly outnumbered. It must have been a fearful melee.

Real men do not assault women. Real men appreciate and protect them, and all who need protection (and that includes other men), against those who would do them harm without justification. Let us pray that the veil of ignorance obscuring the vision of the male perpetrators of the assaults reported in the article above will be lifted sooner rather than later. It is only right, and the only outcome that can be acceptable to all of us.

Note

[1] Griswold, Privacy, and the Right of Women to Religious Liberty, downloaded 2012.06.09

::Briefest post ever – we are now www.sleightmind.com!

I guess that means I’m in this for the long haul. (But that was likely already clear…)

Technical note: anyone browsing to https://sleightmind.wordpress.com will still end up here.

Non-technical note: I didn’t come here tonight to do this. WordPress.com just gave me an offer I couldn’t refuse. My real purpose is the post to follow.

::There’s coffee in your future!

Sometimes things just come together in the most marvelous way. Taking a break from my ongoing (and perpetual) study of what I do to justify my existence (and pay the rent), I discover that there’s NEWS – now bear with me, as these items seem distinctly unrelated…at first. But I won’t leave you wondering about the connection –

Coffee linked to lower risk of death – “A study finds that older adults who drink java are less likely to die than those who don’t. Subjects who averaged four or five cups per day fared best, though it’s not clear why.” A bet: the study says its not the caffeine, as those on decaf do as well as those on the livelier stuff, so, say I, it’s clearly the polyphenols in the coffee. There, wasn’t that easy?

Italian university switches to English – “…one of Italy’s leading universities – the Politecnico di Milano – is going to switch to the English language. The university has announced that from 2014 most of its degree courses – including all its graduate courses – will be taught and assessed entirely in English rather than Italian.” Well, sure. English is already the international language of science, and of business. They want their classes to address the world as it is and as it is becoming, and for their students to be ready to live and work in that world.

Whites Account for Under Half of Births in U.S. – “After years of speculation, estimates and projections, the Census Bureau has made it official: White births are no longer a majority in the United States.” I guess that means that salsa really isn’t a fad. I’m so grateful.

So…”they” are taking over our language, and “they” are taking over our country, and soon we’ll all look like what we drink – if we want to live long and prosper in this fine new world.

Maybe now (well, eventually…) we’ll all have some peace.

The main thing I worry about is whether or not there will enough coffee for all us. As greed-and-ignorance-propelled climate change causes warmer and warmer temperatures in the higher elevations where good coffee is grown, there will be less of it. We could fight about this, but when we all look the same, who will we fight? Maybe those who can afford the coffee because they haven’t been paying those who grow, harvest, transport, and market it what their labor is really worth.

Ah, but there’s a solution for that, isn’t there…

(And we’ll also need to do some clever plant breeding to build a more adaptive coffee tree. Hmm…if we can do that to the coffee tree, might we also build a more adaptive culture, so we don’t have to continue “…consuming resources at a pace that is 52 percent faster than what the Earth can renew“? Let’s get the coffee thing fixed first. We’re going to need all we can grow – to deal with that other thing, not to mention all the denial that’s keeping us from dealing with ANY of it!)

::Misdiagnosis > mistreatment > missed opportunity: Bipolar Disorder and Borderline Personality Disorder

[NOTE: This post is a work-in-progress, posted here to make it available at the earliest opportunity to a number of interested individuals. I will soon be adding more content, sources, and references. Meanwhile, the core of my argument is decently laid out, and will be, I should hope, informative. ~t.c.]

For years I have watched the psychiatric community’s increasing interest in bipolar disorder[1] (BD). Once a mysterious,  troubling, and untreatable phenomenon, it has become the ideal psychiatric illness: it’s apparently organic in origin, it responds, often well, to a variety of medications, and appropriate diagnosis and treatment often leads to highly significant restoration of functionality for afflicted individuals.

This affliction, major in its impact on an individual’s ability to live and work successfully and with the appearance of normalcy, shows us just how powerful and useful modern psychiatry has become.

During approximately the same time, one of the most perplexing and disruptive of the personality disorders[2] has also been receiving increasing attention, although not from psychiatry, which has had little to offer it: borderline personality disorder[3] (BPD). In 1993, clinical psychologist Marsha Linehan published documentation of her research validated treatment program for BPD. A first, it has since been joined by other validated approaches.

There is, however, a back-story to all this – several of them, in fact. I will focus on two: the transformation of psychiatry into a role with diminished significance in the mental illness treatment community, and one probable consequence of this: the very real problem of misdiagnosis of both bipolar disorder and borderline personality disorder.

Back-story #1: Psychiatry, once dominant in mental illness treatment, becomes second-fiddle

It is a little hard to believe, in our time, that in the recent past the application of psychology to problems of mental illness was all but non-existent. If one had a “mental illness”, and there was not an obvious and treatable organic cause, one got psychotherapy (if it could be afforded) from a psychiatrist. But there were three problems with this services delivery model, all contributing to the demotion of psychiatry as the primary source of research and treatment services in mental health:

Problem 1: Psychiatrists were (and still are) necessarily expensive. The training of a psychiatrist was and is long, arduous, and expensive: after attaining an MD or equivalent, one did a multi-year residence in psychiatry, which itself involved training in two only casually related fields: psycho-pharmacology and psychotherapy. When finished, there were training expenses to be recouped, and ostensibly valuable services to be offered, at a price which would be expected to reflect their supposed value.

Problem 2: Psychiatric psychotherapy was not grounded in science… In the 1940s, 50s, and 60s, psycho-pharmacology didn’t amount to much, which more or less eliminated one of the hurdles would-be psychiatrists had to cross. Psychotherapy itself was dominated by the psychoanalytic, psychodynamic, Jungian, and other largely European and Freudian-derivative theoretical orientations, which were all busy distinguishing themselves as bastions of theory, not science. Psychiatry of this time presents the curious picture of individuals who have received some of the best scientific training available anywhere embracing a body of learning rooted almost solely in anecdote and experience with clinical populations who representativeness of the larger population of individuals needing professional attention was unknown and of no apparent interest. Psychiatry was functioning more like religion, or philosophy, than anything resembling an empirical science.

Problem 3: …Consequently, psychiatry got modest results, at best, and with only a few disorders. However, this problem was about to addressed by a different breed of service provider. Experimental psychologists, working in the fields of learning and cognition, were busy distinguishing themselves as bastions of science, with the result that well-grounded systems-models of brain function were developed which could be fruitfully applied to multiple species, including the human one. Applications of these models began to get results where before there had been little – with prison populations, addicts, conduct-disordered adolescents, back-ward chronically mentally ill individuals, and even the ordinary “worried-well”.

This was all accomplished with new, previously unseen levels of efficiency in delivery of treatment services, and without the burden of the opaque, obfuscated psycho-analytic, -dynamic, or -whatever theory, which was still being thrust at psychiatric residents in the medical schools and hospitals as the supposed best thinking that was available in the field.

To put it as clearly as possible: in outpatient settings, and at times in inpatient ones as well, psychologists were clearly getting better results than classical psychiatry, more quickly, and at a service-delivery-hourly-cost significantly below that necessarily charged by psychiatrists. Psychiatry was in trouble, and there was no obvious solution to the threat posed by emergent clinical applications of research validated models of mental function emerging from experimental and cognitive psychology.

A national response: modern clinical psychology is born. These results psychologists were getting got noticed. After World War II ended, it was apparent to the US Government that thousands of returned servicemen and women needed help that couldn’t be provided either by physicians (because their dis-ease was not fundamentally organic), or psychiatrists (because there weren’t enough of them, and they weren’t basically affordable anyway). Clinical psychology DID exist, but the cohort of professionals was breathtakingly small.

So, the US Government did what governments do best: it initiated a system-wide response to a system-wide need, called a conference of psychology department chairmen (as they were, then), in Boulder, Colorado, in 1949, and basically told them that funds would be made available to them for the development of clinical psychology programs in their institutions. Modern clinical psychology was born, as a social institution, in the space of a few days. The solution to the post-WWII mental health services scarcity problem, if not instantly created, was nevertheless launched.

It takes a few years to train a service provider in clinical psychology, but they do not need to have a PhD to be as effective as a one, and even with one they are out the door and working far sooner than any psychiatrist could be. In addition, they are far more price-accessible to most people in need. Finally, due to the superiority of their training (being science-based, not theory-based), they are often more effective with more problems.

Clinical psychology has always been based on experimental psychology, and has never been the property of psychiatry. Because psychiatry never brought into its psychotherapy practices the scientific methods of general allopathic medicine, the psychotherapy it offered was surpassed by therapy which was based on scientific research – that of the experimental psychology community. Whether they wanted to or not, psychiatrists now played second fiddle to clinical psychology in the mental health professional community.

Backstory #2: The resurrection of psychiatry, as physician to the mentally ill, paves the way to diagnostic myopia and misdirection

Fortunately for psychiatry, there were two saving trends on the rise in the sixties: the ascendancy of biochemical biology and modern neuroscience[12], and  the emergence of truly effective psychotropic medications. These trends completely revived the notion of an effective organic approach to mental illness, an approach which Freud and his associates and students had abandoned simply because they had so very little to work with.

When new drugs made it possible to push the chronically mentally ill out of hospitals and into the community, the need for effective medical management of this population was created. Now, both psychiatrists and the drug companies, as well as politicians seeking to minimize tax dollars sunk into management of the chronically mentally ill, had a shared  interest in seeing psychiatry flourish. Chronic mental illness was largely seen as deriving from organic causes (even though the research supporting this was skimpy at best, in most cases), and thus accessible to medical management – if the drugs could be found. Soon, many of them were, and “big pharma” made sure the psychiatric community knew about them.

It has subsequently become clear that the big pharmaceutical companies have become masters of capturing the attention the professional psychiatric community. They provide the most accessible information about psychotropic medications (the Physicians’ Desk Reference), and are “..the source for most clinical research” funding in psychiatry[4]. As psychiatry had come too often to dance to the tune of big pharma, there have been problems[10]:

• The childhood bipolar disorder research and diagnosis scandal[5];
• Suppression of unfavorable drug research results[6];
• Obfuscation of authorship of pharmaceutical research reports[11];
• Complicity with price gouging by the pharmaceutical industry[7];
• Continuing controversy about the freedom of the leaders of the psychiatric community to do their own thinking[8].

It goes without saying that all of these issues were and are vigorously disputed[9], with big pharma often leading the way.

What cannot go without saying is this: in spite of problems associated with the transformation of modern psychiatry into what it is today:

1. The level of expertise in the profession, relative to management and treatment of organically based mental illness is at an all-time high. What modern psychiatry does best is not done better, or even as well, by any other profession.
2. The treatment efficacy of the profession, relative to organic disorders, while still not what is desired by all of us, is also at an all-time high, and at its best is simply exceptional. Today, psychiatry can change and  save lives in ways never before seen. We should all be grateful for this.

A consequence of the fall and rise of modern psychiatry: misdiagnosis of bipolar disorder and borderline personality disorder

This much, at least, BD and BPD have in common: both are under-diagnosed, in some circumstances, and over-diagnosed in others. This may seem odd, but there is substantial evidence of this, and there are multiple factors contributing to the problem[13].

[Note: I must stop here, today, but will return at my earliest opportunity to complete this. See my last footnote for some of the sources I’ll be using.]

NOTES

1. For reliable and well-written professional summaries of the bipolar disorder diagnosis, please see Bipolar Disorders and Bipolar Affective Disorder.

2. For reliable and well-written professional summaries of personality disorders as a class of problem, please see Personality Disorders (at the Merck Manual website), Personality Disorders (at the Medscape website), and  (at the NIMH website).

3. For reliable and well-written professional summaries of borderline personality disorder, please see Borderline personality (at the Merck Manual website), and Borderline Personality Disorder (at the Medscape website), and Borderline Personality Disorder (at the NIMH website).

4. See NIMH RDoC vs DSM, paragraph three.

5. The center of the controversy has been Harvard psychiatrist Joseph Biederman, how has been extremely active both in promoting the concept of childhood bipolar disorder and its diagnosis, and in receiving vast amounts of money from the pharmaceutical industry. In an effort to be fair, let me just say that this raises questions about self-promotion, intellectual independence, and trust, which do not benefit psychiatry, Harvard, or Dr. Bierderman.

6. A book could be (and several have been) written on this subject, the incidents are so numerous. Here’s one especially disturbing incident, involving apparent suppression of research indicating that certain types of antidepressants are not safe for children. Additional coverage of this problem is available in Drug Companies & Doctors: A Story of Corruption.

7. Again, where do I start? Well, here one interesting place – a lengthy, carefully sourced article by Marcia Angell is a Senior Lecturer in Social Medicine at Harvard Medical School and former Editor in Chief of The New England Journal of Medicine: The Truth About the Drug Companies. Here’s an interesting response to her article.

8. See Conflicts of Interest Plague the Next International Manual of Mental Disorders, Experts Argue.

9. Here’s one noteworthy exchange, between Marcia Angell (see note 7, above) and several individuals of note.

10. …and that’s an understatement. See Drug Companies & Doctors: A Story of Corruption for much more on this.

11. See Authorship Rules for Medical Journals Flouted by Pharma Industry, Experts Say, and Ghostwriting Revisited: New Perspectives but Few Solutions in Sight.

12. The decade from 1990 to 1999 was declared by President George H. W. Bush to be the “Decade of the Brain”. This was both a call for increased effort in, and focus on, neuroscience research, and a recognition of the immense promise of the field, given its current status. For more on this, see Project on Decade of the Brain.

13. Partial list of sources to be used:

• Borderline Personality Disorder and the Misdiagnosis of Bipolar Disorder
• BPD and Misdiagnosis: Why is BPD Misdiagnosed So Often?
• Borderline Personality Disorder often Misdiagnosed as Bipolar Disorder
• Personality Disorders Misdiagnosed As Bipolar

::Final call – DSM-V comments from the general public

Instead of some light summer reading, I offer you some heavy spring reading – it can’t really wait until summer.

The coming new edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (expected to be published in Spring of 2013, as the DSM-5) promises to be yet another major step forward, though not necessarily because of any dramatic reorganization in the diagnostic categories having to do with trauma and dissociation. What’s new (as I understand it) is (a) public access to the development process, due to first-time-ever use of the Internet, coupled with overt solicitation of public comment, and (b) the plan to have an online, updated edition of the DSM, which is why it’s being termed “DSM-5” and not “DSM-V”, so that there can be a “DSM-5.1”, etc. I strongly suspect that we’ll have to subscribe to keep current (or maybe access will come with purchase of the hard-copy version).

The final of three comment periods has opened – see Last Chance for Public Feedback on DSM-5 (this will give you an overview of the current status of the DSM-5 revision effort) and DSM-5 Draft Criteria Open for Final Public Comment – May 2nd through June 15th, 2012 (on the DSM-5 homepage).

Commenting is easy (but you will have to register with the DSM-5 website). However, be aware that many, if not all, of the work groups associated with various diagnostic categories have elicited research and recommendation papers from leading authorities on the relevant diagnoses, and familiarity with these papers (all that I’ve seen are available online) is a likely prerequisite for crafting of a valuable comment.

Their location is not highly visible at the DSM-5 website. Select an individual disorder, then the “rationale” tab on its page, and you’ll probably see the link. I offer two such links below. These review papers are well worth your attention, if you haven’t already seen them.

• (from the Trauma- and Stressor-Related Disorders ) – Considering PTSD for DSM-5 [PDF] (there are additional valuable references on the source page – most available online).
• (from the Dissociative Identity Disorder page) – Dissociative disorders in DSM-5 [PDF].

Finally, for a couple of  additional perspectives of central interest, consider looking at:

• Psychiatric Diagnosis: Where’s the Science? (advocates for increased attention to research on the categories into which we sort mental illness).
• A DSM alternative – The Perspectives of Psychiatry Approach to Patients; & Beyond the DSM: The Perspectives of Psychiatry Approach to Patients.

Enjoy!