Psychology Matter

Your Adult Relationship With Your Parents Could Be Your Most Consequential Adult Challenge

2011-12-17T15:56:00.000-08:00

     Time passes; you get older andbecome an adult. You have gone to college or not, you have a job, you makemoney, perhaps you are very successful, you get married and have children. Youstill have parents. They are, if this is the case, the toxic parents you grewup with. They have changed little if at all as you grew from childhood toadulthood. You have a life of your own as an adult, but your parents are stillpart of your life, still in your life. How they are in your life, I suggest,may be the most important determinant of your adult life.

     You’d like to thinkthis isn’t true. You’d like to think you are able to endure the oldrelationship with them now that you are an adult without being too negativelyaffected by the maintenance of the old relationship in your adult life. Youthink as an adult you can put a fence around the relationship you have withyour parents and mostly segregate it from how you feel and what you do as anadult. In a way you know this isn’t really true, but you feel there is nothingyou can do as a practical matter to further reduce the contact you have withyour parents and the impact your parents have on you as an adult. You lovethem, or at least feel obliged to have a relationship with them. You care abouttheir feelings and feel severe guilt about hurting them or disappointing them.You say to yourself they did their best as parents while you were growing upand you shouldn’t blame them for having personal problems and being human.Their own growing up experience hurt them, you tell yourself. You are trapped,but still you tell yourself that you can and should enjoy your life. Except youdon’t.

In my view the child’s attachment to the parent (not theother way around) is the strongest emotional force in human life. Parents canand do reject their children (to say nothing of battering and killing them),but the emotional bond and depth of feeling on the part of the child for theparent endures practically anything. I routinely hear stories about growing upwith their parents from adult clients that would lead a naïve listener toconfidently expect that the speaker has not contacted his/her parents for manyyears. This is hardly ever the case. Growing up with even blatant cruelty,hostility, neglect, etc. on the part of a parent does not in fact (as far as Ican tell) usually lead to the child forsaking the parent once the child hasbecome an adult. Far from it. Instead of rejection on the abused child’s partas an adult there is often a kind of bondage. The now adult child still wantswhat he/she did not get as a child. In addition, the adult child now displays solicitudetoward the parent that he/she never received growing up.

I routinely discuss and work on thepsychological legacy of growing up with noxious parents with clients (selfhatred, poor self esteem, etc.); here I focus on the consequences ofmaintaining the old relationship during adult life, albeit in somewhat alteredform because the client is no longer a child living with his/her parents andfinancially dependent on them. I emphasize I am talking about a parent-childrelationship that is hardly emotionally altered by the fact that the child hasbecome an adult, has his/her own income, residence, etc. The now adult childmay recognize rather well, as I mentioned, that contact with the parent isemotionally harmful, but feels powerless to alter the relationship in astrongly self protective manner.

It is one thing to talk in therapyabout the events and influence of what occurred during childhood, another tofully recognize the influence of the adult relationship with the parent on thecourse of adult life. The book on noxious parental influence is not closedbecause the child is now an adult and in many ways has assumed adultresponsibilities. Here are some examples from my clinical experience: a womansays she drinks in large part because she feels obliged to call her motherevery week, gets upset, hates her mother but feels overwhelmingly guilty abouthating her; another woman says she never had children because she could notbear to share her children with her parents; a third woman says she can neverlose the extra 100 lbs. weighing her down because the weight is a silent accusationand condemnation of her mother, but all the same she is in regular contact withher mother and cannot hurt her feelings; a man silently resents regular contactwith his mother and giving her money, meanwhile he is in his fourth marriageand has maintained a frantic pace of extramarital seductions and cruelabandonments since the start of his first marriage. When his wife discovers hisaffairs his marriage and family life crashes, to be followed by the samepattern with a new wife.

In the above examples as well asmany others, it is not only the influence of the formative years that preventsthe person from fully having a life of his/her own; in addition to the burdenof the past, the relationship with the parent (s) in the adult present powerfullyconstrains the person’s life and perpetuates unhappiness in both obvious andinsidious ways. The feeling on the part of an adult that he/she must accept aharmful and hurtful presence in his/her life forever (until the parent dies,that is) is frequently so taken for granted that its impact on the feeling ofbeing alive and what is possible in life escapes being fully appreciated.

The insidious effects of the adultrelationship with a noxious parent can be brought to light in therapy. Oncethey are brought to light, via conversation between client and therapist, theymay then appear rather obvious, but this is only in retrospect, once a certainamount of explication and clarification has occurred. I daresay just abouteveryone has had the experience of coming to realize something throughconversation that prior to conversation, or a series of conversations, was farfrom obvious no matter how personally important and consequential it appearedonce it came into focus. Therapy provides an opportunity, for most people aunique opportunity that cannot be replicated outside of the therapy setting, toas it were discover what in a sense was there to see all along but could not beclearly seen in the absence of a certain kind of conversation.

It is of course easy for atherapist to advise a client to have less contact with toxic parents. If it wasthat easy no doubt the client would have already spared him/herself the anguishthat goes along with having an adult relationship with toxic parents. I havealready suggested that the emotional bond on the part of the child towardparents is the most powerful emotional force in human life. I now suggest thatsubstantially changing the adult relationship with parents in a more selfprotective direction may be the hardest emotional work a person undertakes inlife.

The emotional capacity to alter theadult relationship with parents develops gradually, when therapy is successful,as part of the overall process in therapy of developing greater self caring,love, and respect. Self respect, self love and self care are incompatible withaccepting a noxious relationship as a permanent condition of life. Nonetheless,attachment, guilt, obligation and other sentiments concerning parents aretypically so powerful that a prolonged uphill struggle is to be expected. Themotivation to engage in the struggle is precisely the growing realization intherapy (when this occurs) that the adult relationship with parents does indeedhave a serious deleterious effect on living life as an adult---on living theone and only life you get. As suggested, the struggle to alter the adultrelationship with parents may be the most difficult emotional struggle a personfaces in life.

For most people, the goal withrespect to altering the relationship with parents is harm reduction rather thancut off. I emphasize again that I am talking about adult relationships withparents that are quite deleterious for the adult child. Harm reduction aims atreducing harm, not eliminating all harm. The preferred model for most is harm reductionbecause even if a person’s parents are manifestly harmful to him/her in thepresent, most people it seems do not find cut off a realistic option.Practically speaking, harm reduction generally means less contact with parents,something I think can only be done if the adult child actually comes to feelmore entitled to a life of his/her own, which in turn requires more self love,care, and respect. Perhaps the adult child will first have to make furtherefforts to demand or persuade his/her parents to change how they treat him/her.I will not say this is hopeless, but the truth is that the adult child has beentrying to accomplish this for many years or even his/her whole life. The hardlesson is that trying to change another person who has no interest in beingchanged is usually fruitless. The point, the work of therapy, is to accentuatethe client’s respect for his/her own life, not to continue to try to bringabout change in his/her parents.

What's the matter? (Diagnosis)

2011-12-11T05:36:00.001-08:00

     Basedon persistent distress and so on, people ask about themselves or others “What’sthe matter?”

      Over the past 31 years (that is, since the 1980 publication of theAmerican Psychiatric Association’s third edition of its Diagnostic andStatistical Manual, the DSM for short), American psychiatry has trained notonly the mental health industry but also the public at large to think and speakin the language of DSM disorder categories. This is an important topic becausethinking and speaking about personal problems in the terms laid out in the DSMleads away from understanding what actually is the matter. I am tempted toremark that like the comic strip character Mandrake the Magician (I’m datingmyself), the DSM and the “educational” efforts of the American PsychiatricAssociation “have the power to cloud men’s minds” (and women’s, too).

Statedas succinctly as I can, the purpose of DSM-III (published in 1980) andsubsequent editions was/is to assert that distressing or impairing features ofa person’s mental life are really only symptoms of an underlying althoughunfortunately for the moment unknown biological pathology. The unfortunatelyunknown causes of mental disorders would soon enough, it was claimed, yield tosustained biological research. The more immediate good news, it was claimed,was that more or less serendipitously (I am recalling the view from the 1970s)a variety of drugs had already been discovered that significantly reduced thesuffering and impairment associated with a variety of psychiatric conditions.The future would bring more and better drugs as well as major discoveriesconcerning the underlying biological causes of mental disorders.

Thereis no doubt that the American Psychiatric Association has been massivelysuccessful in training the public at large to think of personal difficulties asgenuine medical illnesses that can be treated effectively and safely withdrugs. Just about every client I meet in my office is taking severalpsychiatric drugs and has been for some time (with indifferent results, topoint out the obvious). From 1980 to the present ordinary psychiatric practicehas shifted from primarily doing psychotherapy to primarily prescribing drugs.The result, as I have already suggested, does not look anything like what isseen when effective drugs are employed in conventional medical practice (forexample, contrast antibiotics to antidepressants). The causal biologicaldiscoveries concerning mental disorder that were confidently expected in the1970s have not materialized. There is a lot of confusing hype about thismatter, but the truth is easy to see: as has been the case since DSM-IIIwas published in 1980, DSM-V (to be published in 2012 or 2013) is expected tocontinue the unbroken tradition of making psychiatric disorder diagnosesexclusively on behavioral grounds, in other words no biological information ofany sort will enter into psychiatric diagnosis (no biological information ofany sort can be used to “confirm” a psychiatric diagnosis; contrast this tomedical practice). Needless to say, the complete absence of biologicalinformation of any kind that is needed or relevant in any way for the purposeof making a psychiatric diagnosis is hard to reconcile with the claim thatpsychiatry is a medical specialty, or that psychiatric disorders are actuallymedical disorders.

In 1994 DSM-IVwent so far as to completely rule out the existence of “functional” disorders,meaning it denied that what it referred to as mental disorders (e.g., being ina depressed mood) could be brought into being on the basis of what had occurredor was occurring in a person’s life (relationships, occupation, and so on).This was based purely on ideology, since DSM-IV, as usual, based diagnosisexclusively on patient complaints and observed behavior---no relevantbiological discoveries had been made that would support the claim that what theDSM called mental disorders were caused by biological pathology. As mentionedabove, this state of affairs has not changed from 1994 to the present, and DSM-Vwhen it is published in 2012 or 2013 will draw upon no relevant biologicaldiscoveries regarding mental disorder (because there are no relevant biologicaldiscoveries).

Thepronouncement that “functional” disorders do not exist, in other words thedenial that “clinically significant” distress or suffering could be broughtabout by the vicissitudes of life, means that no matter how clear a person isabout the adversity he/she endured in the past or is facing in the present, theofficial view of American psychiatry is that the person is suffering from acause unknown medical illness. This why psychiatrists focus on eliciting“symptoms” and are basically uninterested in the nature and quality of thepersonal environment in which the individual lived in the past and in which theindividual is living in the present. The “symptoms of a specific illness”perspective has no more use for getting to know and understand the individual’spersonal lived environment than in medicine in general. For example, you havean eye infection. Diagnosing it and treating it is completely independent ofwhat is happening between you and your wife, or your boss, or what life waslike for you growing up in your family. American psychiatry has decided thatyour depression, anxiety, or whatever likewise has nothing to do with thepersonal environment in which you live. Your depression (your “clinical”depression) and so forth is simply a disorder of unknown cause that you have,to be treated practically speaking by trying out one combination of drugs afteranother.

The“symptoms” perspective, as I suggested above, leads away from a serious andrealistic inquiry of “What is the matter?” Noting, for example, that you are ina depressed mood does not by itself reveal and make explicit why your mood isdepressed. Perhaps your mood is depressed because you feel very threatened, orbecause you are bitterly disappointed about something, or your dignity has beenassaulted by some development, and so on. If depressed mood is the outcome,understanding and assisting you to feel better realistically requiresclarifying what has brought the outcome about. This cannot be accomplished byfocusing on the outcome itself. Actually diagnosis in psychiatry is adistortion of diagnosis in medicine. A physician does not treat your eye withantibiotics unless there is physical evidence indicating that you have abacterial infection in your eye. It is pointless, perhaps harmful, and improperto expose you to a medication in the absence of physical evidence concerningwhat has caused your symptoms. By contrast in psychiatry the “symptoms”themselves are the basis for prescribing drugs, since it is widely acknowledgedthat conceived as a medical disorder the cause of your disorder is unknown(there is, for example, no evidence that a person diagnosed with what the DSM callsa mental disorder is suffering from a “chemical imbalance” of any kind, andindeed there is a good deal of evidence indicating that this is not in fact thecase). Is there solid evidence that psychiatric medications, despite beingprescribed for “cause unknown” conditions, actually are effective and safe? Thepublic (meaning people who are not scholars in this area) is largely unaware ofhow contentious this issue is in the scientific literature considered as awhole (I am one of many who has written critically on this matter; please seethe publications section of my website. As I suggested above, it is commonplaceto meet clients who have gone from one drug regimen to another and are stillseeking help).

Forthe purpose of making the point that treatment must inquire into what hasbrought about the clinical outcome of interest, I probably gave a misleadingimpression about how straightforward this is (e.g., depression caused by adisappointment). It is in fact rarely the case that the clinical outcome ofinterest can be succinctly described (I could call this the DSM-created myth ofclear-cut, easy to describe, specific, and autonomous disorders) andstraightforwardly attributed to one equally clear-cut, discrete, time-limitedevent or incident in a person’s life. Persistent, long-standing distress and/orimpairment implicate a long and complex history and course of development. Thiscan only be made explicit on the basis of protracted discussion between clientand therapist. It is usually the case that a client does not realize how muchhe/she knows about the origins and reasons for his/her troubles until asuitable speaking and discussion (back and forth) situation is provided (i.e.,the therapy relationship). Both the question what is the matter and why what isthe matter has been brought about can be answered if a suitable dialoguesituation is provided. In therapy both questions are integrated with the issueof positive progress.

Addiction as a "marker" of the problem rather than the problem

2011-11-30T05:31:00.000-08:00

The title refers to a perennialdisagreement among people who treat addictions of all sorts, namely whether tothink of addiction (to alcohol or sex or anything else) as the problem(disease, disorder…) itself, or whether to think of addiction as one sign (andnot the only one) of a problem that actually generates the addiction (as wellas other signs, if one looks carefully).

First a caveat: addiction is aloose term that cannot be precisely defined. People (lay and professional)speak of addiction when an individual displays sufficiently troubling behaviorconcerning a substance or activity (e.g., gambling) to attract concern forhis/her safety and welfare on the part of other people who know and care aboutthe course of his/her life. Such a definition, correctly in my view, cannot bereconciled with a strictly biological view of addiction.

The immediate stimulation for me towrite this piece on addiction was reading a remarkable article about obesity byFelitti et al., 2010 (Obesity: Problem, solution, or both? The PermanenteJournal, 14, 24-30). The authors report on their clinical and researchexperience treating (morbid) obesity via absolute fasting supported bynutritional supplements and group therapy. Absolute fasting supported bynutritional supplements (they say hunger is not a problem) is quite safe andtakes off a lot of weight quickly if people actually refrain from eating, butin the early years of the program they observed two complications: 1. peoplewho refrained from eating and lost a lot of weight frequently could nottolerate the emotional consequences of (presumably necessary and highlydesirable) weight loss, and 2. people who did not lose weight were obviouslyeating and lying about it, but they none the less wanted to stay in the programfor the social and emotional support they received from the group.

The above complications inspiredthe clinicians to conduct a detailed exploration of the life histories of theirpatients (a sample of 286 consecutive patients, to be exact). The originalsample grew to 2000 over the years (these were Kaiser Permanents patients in San Diego). They weresurprised to discover (I should say as physicians who thought about obesity inmedical and biological terms they were surprised to discover) frequenthistories of sexual abuse and other features of growing up in “markedlydysfunctional households” in the lives of their patients. Their findings ledthem to revise their treatment plan: from thinking about supplemented fastingand education about “how to eat right’ as the treatment to recognizing thatdeeply personal revelations and efforts to face and resolve old injuries in thegroup setting was actually the treatment. As the authors say in their article:“…we have seen that obesity is not the core problem. Obesity is the marker forthe problem and sometimes is a solution. This is a profoundly importantrealization because none of us expects to cure a problem by treating itssymptoms” (p. 26). They make the same point concerning all addictions. Theyhave a revealing saying about a person’s insatiable desire for his/heraddictive substance or activity: “it’s hard to get enough of something thatalmost works.” (p. 28).

What is the relationship between aperson’s life history and obesity? Sometimes it seems straightforward, e.g., awoman sexually abused as a child reasons that obesity is good protection frommale sexual interest (the authors point out that women in their groups---Iassume they are referring to women---answer the question “What are theadvantages of being overweight?” based on some variation of the following: itis sexually protective, it is physically protective, and/or it is sociallyprotective in that people expect less from you). Obviously all children whoexperience sexual abuse or otherwise grow up in a dysfunctional household donot become morbidly obese as adults. Notice I am not suggesting that suchchildren simply shrug off what they have experienced growing up when they getolder.

What Stands Out about Addicts

2011-11-10T05:36:00.000-08:00

Firstthe usual caveat about “addiction”: It does not lend itself to precisedefinition. It really is a term indicating use (substance or activity) on thepart of someone that has come to stand out to others or the user him/herself asdamaging well-being and which resists efforts to eliminate or modulate.

It isconsequential for treatment if the person using does not really (as opposed tolip service) see his/her use as “over the line” in terms of self-harm.

Thefollowing features stand out about the person using drugs or activities in anaddictive manner (in my experience, of course):

1.The person using (whatever) addictivelydoes not regard other people as effective and reliable sources of comfort,soothing, reassurance, and so on. In short, the person using addictively doesnot deeply trust anyone. This is the frequently overlooked other side to thecommon observation that the person using addictively regards the substance ashis/her friend, is having a love affair with the bottle, and so on. There is areason based on life experience growing up that the person using addictively isdisinclined to deeply trust and rely on a person as opposed to asubstance (or activity).

2.The person using addictively is driven from within to alter his/her “backgroundfeeling state.” I use the foregoing term to bring to attention how a personfeels in the absence of strong distraction or absorption in a task. I haveheard clients say that boredom is a predictable precursor to using so oftenthat I began to ask if it was not more accurate to say “empty.” Virtually noone seems inclined to deny that empty is a more accurate descriptor. The ideaof “background feeling state” is not very esoteric once it is stated andexplained, but it does not seem to be a routine feature of professionaldiscourse concerning addiction. I think it is quite revealing. If a person’sbackground feeling state is unbearable, some remedy must be sought. Rememberthat reliance on others is not an option.

3.It more or less goes without saying that lying, disguise, subterfuge, cover-up,and the like are functional imperatives of addictive use. The person usingaddictively is well aware that other people will regard the extent of his/heruse with dismay, horror, disapproval, etc. Eventually the person usingaddictively tends to use alone/privately (as much as this is possible given thesubstance or activity; if the addictive activity requires other people, e.g.,gambling, sex with a living person, etc., there is simultaneously effort toseclude as much information as possible from people who matter). Thefeelings of shame and guilt that accompany hiding and lying add to the person’sdysphoric background feeling state, and serve (paradoxically it might seem) toaugment the need to seek excitement and soothing via the addictive substance oractivity. Using addictively locks the person into using addictively.

4.It is obvious that self-harming use is incompatible with self-care/love. Thepoint to emphasize here is that there must be a prior injury to self-care/lovefor sustained self-harming use to develop. In the absence of a prior injury toself-care/love a person will not persist in a self-damaging course of action.Self-care/love is not to be confused with narcissism (usually meant to indicateselfishness and over-inflated, unrealistic but quite fragile self-esteem) andis not a pejorative term. Self-care/love is meant to convey the idea that theindividual values him/herself and his/her life. It is the opposite ofself-hatred or self-contempt. Self-care/love develops as a derivative ofreceiving genuine care and love growing up; it goes along with being able tocare for and love others. Self-care/love is self- preservative, that is it isincompatible with sustained self-harming activity. The person using addictivelyacts like a person who does not care about his/her own welfare.

5.It is apparent that the person using addictively is not just getting high(intoxicated…) because use continues long past the point of getting high. Asimplied above, use continues beyond intoxication into danger and harm. Peoplewho do not use addictively find themselves wondering why the person usingaddictively uses so aggressively, that is so much. Why three bottles of wine anight, why not a couple of glasses to get pleasantly intoxicated? I think partof the answer is that the person using addictively is trying to get as far awayfrom his/her background feelings as possible, therefore just getting high will notdo the trick (remember I am referring to a person who engages in high volumeuse over and over again). Caution or concern for well-being is not aninhibiting influence because self-care/love is damaged. Seeking comfort fromothers is not a viable option because basic trust is damaged.

6.The person using addictively is often said to be in denial, that is distortingthe reality of how much damage he/she is doing to him/herself in a variety ofways. This is a complicated thought because it is usually the case that aperson---any and all persons---does not see him/herself as others do. It couldeven be said that a person is not able to see him/herself from a 3^rdperson perspective (only a 1^st person perspective). In this senseeveryone is in “denial” to some extent. The idea of denial implies that aperson’s reality-testing ability is impaired. But a person’s inner reality isonly fully accessible to the person him/herself. Thus only the user knows justhow desperate he/she is to banish dysphoric background feelings and so on. In short, the reality of the user’spredicament from the inside is not visible just by noticing the addictivebehavior and its consequences. A cost-benefit analysis from an external pointof view is unlikely to overlap perfectly with a cost-benefit analysis from theuser’s own point of view. This point was made quite forcefully for me in apaper by Leon Wermser, a psychoanalyst with many years experience treating drugaddiction. He quoted one of his patients as follows: “If it wasn’t for heroin Iwould have killed myself years ago.” The point again is that cost-benefit fromthe perspective of the user is not likely to overlap perfectly withcost-benefit from a 3^rd person perspective. Sustained sobriety, Ithink, requires more than suffering the consequences of addiction. It requireshope that life is livable without the addictive substance or activity (notice Isaid sustained sobriety; many developments and influences can bring abouttemporary abstinence).

Why Change is so Difficult

2011-10-01T09:20:00.000-07:00

Perhaps therapists see a biasedsample. Perhaps there are people who recognize a need to change somethingimportant about the way they live and execute change in a timely manner.But I must admit that what stands out to me as a therapist as well as throughinformal (non-therapy) relationships is how hard most people find it to changeany well-entrenched aspect of how they face the world or live in the world dayto day, regardless of how desirable it might seem to let us say “upgrade” howthey go about living life.

If people are thought of primarilyfrom the perspective of rational actors, or let us say primarily in cognitive(as contrasted to emotional) terms, then clinging to what appear to bedecidedly sub-optimal strategies for living life seems quite mysterious. Ithink it is far more realistic to emphasize emotions and feelings than toemphasize thought in trying to understand why people conduct themselves as theydo in living. The question of who is the master, feelings or thought, is avenerable one in psychology and philosophy and other fields. In my view you canhardly do wrong by focusing on the emotional side of life. Only feelings everanimate or push anybody to do anything; thought stripped of emotion lacksmotivating force. If you have ever tried to persuade a person to do anythingthey are really disinclined to do via (what you consider to be) rationalargument you no doubt know what I am talking about.

Regulating feeling life so thatfeeling life stays within tolerable limits is the primary imperative in living,I propose. If a person resists what seems to be desirable change as he/she seesthe matter (never mind how desirable it seems to others), the most likelyreason is fear or anxiety---fear or anxiety that deviating from what is knownand familiar will result in even greater emotional difficulty than what ispresently being experienced. I am inclined to call this the devil you knowphenomenon. It is very potent.

The therapist of course realizesthat if the client does not modify his/her way of living there is no goodreason to expect the future to be any better than the past, but what to do? Alltheories of therapy take for granted that the client must modify his /her wayof living (this is a deliberately elastic term that includes the client’s wayof perceiving and reacting), but there is substantial disagreement about whatthe therapist should do to help the client to change. I think it is essential tounderstand why change is so difficult. In conventional therapy parlanceclinging to the old rather than advancing towards the new is called“resistance.”

“Resistance” is an evaluation fromthe outside, from the therapist’s side, not from the client’s side (a 3rdperson term, not a 1st person term; as such, resistance called be called a“deformation professionelle”---a French term suggesting that a distortion hasbeen produced by the professional’s framework of thought). From the client’sside nothing that makes sense, is desirable, and is unthreatening in any way isever resisted. The therapist can never lose sight of the fact that his/her ownevaluation of how threatening something is is a strictly external, onlookerperspective. To bring this point into focus, it may help to think of somethingthat deeply frightens you but does not frighten a specific other person thatyou know nearly as much as it frightens you (if you can’t think of anything youreally should try harder). I make this point because it is too easy from anonlooker perspective to minimize the severity of someone else’s fear. From theclient’s side there are compelling reasons not to change (it is the client thathas “skin in the game”).

If a client resists something thatseems clearly desirable and advantageous to the therapist this (the client’sresistance, that is) is a sign that the therapist does not fully grasp what isat stake as far as the client is concerned. People do not resist things thatmake sense, are desirable, and are not threatening in some way, to repeat. Theclient may not be able to state clearly and convincingly why he/she is hangingon to the old rather than embracing the new, but the client’s reluctance itselfreveals that there are felt reasons, even if not yet articulated. The client’sbodily reactions---feelings----show that there are subjective reasons not tomove ahead, although the reasons may be far from clear to the clienthim/herself. The only thing the therapist knows with certainty is that theclient has reasons not to move ahead. The reasons may be quite complicated andtake a long time---via the process of prolonged dialogue, that is prolongedback and forth---to unearth and explicate.

Explicating the reasons formaintaining the status quo does not automatically banish fear and bring aboutchange (the fear, again, is that giving up the old will make matters evenworse). The only way to move ahead is on the basis of a feeling shift, i.e.,that moving ahead is not a certain disaster. Where does the feeling shift comefrom? This is a complicated issue. The answer I favor brings to mind theongoing debate within the therapy community concerning whether therapistintervention strategies primarily bring about change (when change does occur)or whether change occurs (when it does) on the basis of the relationship thathas developed between the client and the therapist (Bruce Wampold, an academicpsychologist, has referred to this as “The Great Psychotherapy Debate”; see his2001 book bearing this title). My answer is that a feeling shift occurs (whenand if it does occur) because the relationship with the therapist has becomeimportant to the client, thereby altering the client’s feelings of alonenessand distrust, as well as altering the client’s negative and hostileself-feelings and background dysphoria. If the therapeutic relationship becomesimportant to the client that is already a feeling shift, and it lowersobstacles to changes in the direction of more self-care, positive self-regard,and positive social connections. The bad news, I think, is that to the extentthat a person is too guarded to allow the relationship to become important, theless likely it is that significant and enduring positive change will occur. Theonus is on the therapist to do all he/she can do to foster a positiverelationship.

If the client’s background were such as to make iteasy and natural to develop trusting personal relationships, I submit, then thetherapist would not be making the client’s acquaintance as a client seeking therapyat all. If positive change depends on the establishment and development of animportant and trusting relationship, establishing and developing an importantand trusting relationship is going to be challenging, effortful, and, let ussay, little by little for the client (given his/her formative background). In asense the task is to alter the legacy of the formative years and experiences oflife. This cannot be accomplished through argument, only through experience.The experiences that really matter in life are usually intimately connected toactual relationships, actual interactions with specific people. Suchexperiences stick, that is shape self-regarding attitudes as well as a certainstyle of being involved with people. Altering self-feelings and feelings aboutothers is not like changing a shirt. It is more like coming to feel at home ina new language that you only start learning as an adult. It’s hard workand takes substantial time.

The Importance of Desire for Change and Therapy

2011-08-01T09:01:00.000-07:00

The issue of how therapy can help aperson move away from excessive, self-harming use of a substance or activitycannot be discussed meaningfully without attention to the actual intention ofthe person entering therapy.
To use learning a foreign language as an adult asa useful analogy, if the person being instructed does not actually want tolearn the language and does not make a real effort to pay attention,concentrate, study, practice, etc., he/she is unlikely to benefit much frominstruction. The degree to which the person genuinely opens to the subjectmatter and the instruction cannot realistically be overlooked (I draw upon myown foreign language instruction experience in high school and college, inwhich I engaged minimally, resentfully, and inattentively, with predictableresults).

In my experience virtually no onebegins treatment for addiction on the basis of privately reflecting about theirdrug use or some activity like internet porn and coming to the conclusion thatprofessional help is needed. On the contrary, there is almost invariably somedramatic development involving other people (spouse, business partner, police…)that throws a stark, unfavorable spotlight on the severity of a person’s use.In the aftermath of the dramatic development the exposed individual is notreally free to resume his/her old ways without substantial negativeconsequences. None the less, what is of great importance is whether or not thedramatic development actually instigates a feeling shift such that the individualhim/herself sees and feels the need to figure out how to live in a differentmanner. Again, in my experience such a feeling shift rarely if ever occurswithout concomitant ambivalence, reservation, inner hedging, magical thinkingabout the possibility of being able to control level of use, etc., but theimportant point is the person is not just saying he/she wants treatment oragrees to treatment to placate others, lie low for awhile, and so on. Like astudent who won’t pay attention and won’t study, beneficial therapy alsodepends on there being two cooperative, engaged parties.

The person who has come to see thattheir drug or activity use is not sustainable, that is has come to see thatcontinuing on the same path is disastrous, none the less faces a veryformidable problem. The problem in a nutshell is that the person had and stillhas reasons for using as he/she did, compelling reasons that involve thechallenge of facing life day to day. The person’s pattern of use, in otherwords, was far from haphazard or simply excessively self-indulgent, it wasrather the person’s attempted solution to make life livable. It was notperfect, but it sort of worked. Even if it didn’t work that well, it was atleast the devil he/she knew (less threatening than the alternative).

The therapist must get to know thereasons excessive substance or activity use seemed better than any alternativethe client could see and work with that. This cannot be done, once again,without the client’s cooperation. I think it is possible to identify somecommon reasons for addiction-as-a-solution, but whether and exactly how commonreasons apply to a specific individual requires in-depth acquaintance with thespecific person. There is no getting around this, which is why I think it isunrealistic to believe that any individual’s path to addictive behavior can beknown prior to in-depth acquaintance with the individual as such (in otherwords, talk about “the addict” in the abstract cannot substitute for getting toknow the individual).

It is useful in understandingaddiction to think about the emotional, interpersonal, and social challengesthat everyone must face in living day to day. For example, real friendship andlove require trust. If a person cannot bring him/herself to trust anotherperson at a deep level, friendship and love will of necessity be superficial,not something to really count on, not something to really turn to for comfortetc., and in consequence the person who is unable to trust at a deep level islikely to feel lonely despite the appearance of friendship and the formalstatus of marriage. If real people cannot be trusted, cannot be turned to forcomfort, etc., there are alternatives: alcohol, drugs, food, the internet,other activities…No one can contrive to simply excuse him/herself from thechallenges of living. What varies from person to person, and what leads somepeople into serious trouble eventually, is how the challenges of living arenegotiated. Every person does the best he/she can, but for some people thelegacy of their personal history growing up poorly equips them to negotiate thechallenges of living in a manner that does not eventually become conspicuouslyself-harming.

Therapy must endeavor to ameliorateways of coping with living that have proven self-harmful. This is the task oftherapy generally, none the less so applied to addictive substance use oractivities. The therapy, treatment, or remedy for a problem must suit theproblem (e.g., there is no use treating a viral infection with antibiotics).This is a way of saying that psychotherapy is the correct treatment forexcessive, harmful substance or activity use because the problem is being badlyequipped to negotiate some (not all) of the important and inescapablechallenges in living and not some other problem (bad genes, a from of medicaldisease, etc.).

Is There Really Mental Disorder?

2011-07-01T00:00:00.000-07:00

Published in The Humanistic Psychologist, Volume 38, Issue 4, 2010
Link to published article
Abstract

Proponents of the reality of mental disorder claim that mental disorder is ontologically real in the same sense that the variola virus and smallpox are ontologically real. The chief architect of the DSM-III revolution, Robert Spitzer (Zimmerman & Spitzer, 2005), candidly admits that a diagnosis of primary mental disorder present must be arbitrary because the distress or social impairment under consideration could well be a normal-range reaction to stressful events.
Based on Jerome Wakefield's harmful dysfunction thesis, Spitzer hopes that research in evolutionary psychology can solve the perennial “false positive” problem in psychiatric diagnosis. Interestingly, in 1988 Wakefield argued that the study of meaning (i.e., human behavior and the products of human behavior, such as art and literature) could not be assimilated to empiricism (science), but evidently he subsequently changed his mind. The present paper sides with the 1988 Wakefield. It is an illusion to hope that research in evolutionary psychology will reveal how people are supposed to react to stressful events and thereby rescue psychiatric diagnosis from the false positive problem. The identification of mental disorder will remain akin to the identification of pornography, i.e., a case of reification based on interpretation and moral reasoning. The fiction that mental disorder is real turns attention away from past and present conditions of living. This may serve some interests, but it is not likely to serve the patient's interests.

The title of this article is adapted from the title of a 1984 paper by Luc Ciompi: “Is there really a Schizophrenia?” Ciopmi drew upon his own research group's longitudinal findings and the long-term findings presented by Manfred Bleuler (1978) to argue that a “nosological entity of schizophrenia,” or even a “group of schizophrenias,” does not actually exist (p. 636). He noted that in 1984, Manfred Bleuler, the son of the author of the schizophrenia concept, unequivocally rejected the concept of a nosological entity of schizophrenia. Obviously Ciompi's paper did not terminate psychiatry's use of the concept of schizophrenia as a distinct clinical entity, although as Jacobs and Cohen (2003) have pointed out, it seems that the “Limitations of the Categorical Approach” section of the Diagnostic and Statistical Manual (DSM; American Psychiatric Association [APA], 2000; from III to IV-TR) admits that the primary mental disorders (nosological entities) listed in the manual are nothing more than convenient fictions. This clearly has had little or no effect on research and practice.

The point of Ciompi's (1984) paper was not to question the reality of psychosis, but I note the following comment:

Under increasing stress, nearly everybody presents symptoms of tension, anxiety, irritation, confusion, and ambivalence which can eventually progress to authentic psychotic phenomena of depersonalization and derealization, and even to delusions and hallucinations. (p. 638)

In my view, Ciompi (1984) might have more usefully observed (as Zimmerman and Spitzer appear to in a 2005 publication, discussed below) that it is a mistake to think that a person's psychological condition can be depicted and evaluated sui generis, that is independently of circumstances, situation, context, etc. Indeed, my thesis is that a diagnosis of mental disorder (the person has or suffers from or is the host of a mental disorder) divorces the individual in question from his or her history, thus creating a fabulous beast to be evaluated out of context on the basis of “distress” or “social impairment” (history includes the present moment). When history and context are included, what conspicuously emerges with regard to deciding if mental disorder is or is not present is a task of moral reasoning, not unlike deciding if a text is or is not pornographic. In short, mental disorder is an example of reification, that is, a way of speaking and judging is falsely presented as an external, objective reality that is independently there. Familiar examples in addition to pornography are intelligence, mental retardation, homosexuality…and all the primary mental disorders listed in DSM-IV-TR. I think there is no doubt that people committed to the reality of mental disorder believe they are referring to something that independently exists in the same spirit that it can be said that the variola virus and smallpox independently exist. It is only because Robert Spitzer (see following sections) believes that mental disorder exists that he is so concerned about the (apparently insoluble) false positive problem in psychiatric diagnosis.

In this article, I closely examine articles by Zimmerman and Spitzer (2005) and by Wakefield (1998). Robert Spitzer was the chief architect of the DSM-III (APA, 1980) revolution and the conceptualization of mental disorder that the APA endorses up to the present. His 2005 paper with Zimmerman frankly discusses the intractable existence of a false positive problem in psychiatric diagnosis—intractable because there is no way to decide on the basis of objective evidence if a diagnosis of primary mental disorder in any specific case is a true or false positive. Spitzer hopes that research in evolutionary psychology can remedy this. He and Zimmerman spend a great deal of time discussing the harmful dysfunction thesis that Jerome Wakefield has developed in a series of publications, especially as explicated in Wakefield's 1998 paper. The harmful dysfunction thesis postulates that research into regulatory mental mechanisms designed by evolution will produce objective evidence that will end the current obligation to arbitrarily decide if the case at hand is or is not really a case of mental disorder. Interestingly, in 1988, Wakefield published a very convincing paper, to my mind, arguing that the study (the understanding, that is) of what people say and do could not be assimilated to empiricism (science) (Wakefield, 1988). I examine Zimmerman and Spitzer's 2005 paper and Wakefield's 1998 paper in light of Wakefield's 1988 paper. I conjecture that Spitzer has, over the decades, grown desperate to solve the false positive problem because, contrary to what was confidently expected leading up to DSM-III (APA, 1980), biological research has failed to transform a single primary mental disorder into a “Mental Disorder Due to a General Medical Condition.” Unfortunately, I am not in a position to even guess why Wakefield has so profoundly changed his mind concerning the unbridgeable chasm between meaning and empiricism (science).

The issue of whether mental disorder is or is not real is not merely an academic and philosophical question. The fate of real people, especially children, is importantly impacted by the decision that the problem at hand is mental disorder as opposed to reaction to a noxious social environment (usually the family). A physician (or mental health professional) can diagnose mental disorder, but it is much more difficult for anyone to diagnose reaction to a noxious social environment in the same ex cathedra manner. My position in this article is similar to Kempe et al.'s 1962 paper in Journal of the American Medical Association (JAMA)—“The Battered Child Syndrome”—in which he and emergency room colleagues implored emergency room physicians across the country to stop diagnosing occult medical illness in cases in which injuries to infants and young children were clearly the result of parental violence. In DSM terminology, occult medical illness would be called primary, meaning idiopathic, medical illness. Primary mental disorders are occult medical illnesses:

[The former differentiation] of “organic” mental disorders as a separate class implied that “nonorganic” or “functional” mental disorders were somehow unrelated to physical or biological factors or processes. DSM-IV eliminates the term organic and distinguishes those mental disorders that are due to a general medical condition [that can be objectively demonstrated] from those that have no specified [my emphasis] etiology. The term primary mental disorder is used as a shorthand to indicate those mental disorders that are not due to a general medical condition [a medical condition that can be objectively demonstrated] and that are not substance induced. (APA, 2000, p. 181)

Spitzer (Zimmerman & Spitzer, 2005) recognizes that the false positive problem regarding psychiatric diagnosis continues to be insoluble. A diagnosis of mental disorder present that may or may not be true and that cannot be settled one way or the other on the basis of objective evidence, and that, in addition, is the perennial state of affairs in psychiatry with no remedy in sight, would seem to have little to recommend it. This is, I suppose, a conclusion as unacceptable to those committed to the idea of mental disorder as admitting that pornography is nothing more than a way of rendering a moral judgment is to those committed to the idea of pornography. A moral judgment is based on values, for example prizing conformity in the classroom and condemning resistance to authority, or prizing subtle depictions of sexual desire in a text and condemning explicit depictions of sexual desire and activity. Values are, of course, basic to human life, but the identification of something as objectively real, as having an existence of its own independent of human naming and judging (e.g., the variola virus), cannot be demonstrated if no method of identification exists that does not basically depend on the exercise of values.

THE FALSE POSITIVE PROBLEM AND THE HOPE IT CAN BE SOLVED BY DISCOVERING EVOLUTIONARILY DESIGNED REGULATORY MENTAL MECHANISMS

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In a thoughtful and candid article prepared for the 2005 edition of Comprehensive Textbook of Psychiatry, Robert Spitzer (Zimmerman & Spitzer, 2005), the chief architect of DSM-III (APA, 2000), including the formulation of mental disorder that the APA has endorsed up to the present, admits that it is not possible to make a valid (true, correct…) diagnosis of mental disorder present because what is presumably disordered, an underlying psychological mechanism, is unknown, as are normal variations of the operation of the underlying mechanism. It must be assumed he is referring to the realm of primary mental disorders, that is, to named and described clinical entities that, as far as anyone can tell, are not brought about by biopathology (speculations notwithstanding). It is definitely not sufficient to diagnose mental disorder present on the basis of distress or impairment alone (he argues), notwithstanding the fact that this is commonly done (his observation), because distress or impairment may represent a normal reaction to stressful events. He calls this the false-positive problem. He acknowledges it is possible that many people are falsely diagnosed as having a mental disorder despite DSM (APQ, 2000) guidelines being correctly followed because the existence, nature, and operation of the mental mechanism that is presumably dysfunctioning is unknown.

Spitzer (Zimmerman & Spitzer, 2005) recognizes that a real person is always in, and reacting to, circumstances, situation, context, etc., and it is therefore illegitimate to evaluate the mental status of a person as if a person existed or could exist outside of context (history…). To say the same thing in a somewhat different form, Spitzer recognizes that is meaningless to evaluate a person's mental status on the basis of current distress or impairment by itself, devoid of context. Context is a term that can only apply to a person, not a person's organs, neurotransmitters, etc. (e.g., a child is chronically belittled and rejected at home). Spitzer appears to be saying that a disorder-dysfunction framework of explanation can only be brought to bear after it is established that the person's circumstances do not warrant the distress or impairment that has come to clinical attention. At the same time, however, he postulates that a normal reaction to stressful events is based on the successful operation of an “underlying regulatory mechanism” (Zimmerman & Spitzer, 2005, p. 1006). Based on the harmful dysfunction thesis developed by Jerome Wakefield in numerous publications (e.g., 1998), Spitzer believes that mental regulatory mechanisms exist and can be discovered by research in evolutionary psychology, although he admits (this part is overfamiliar to critics of biopsychiatry) that such mental regulatory mechanisms are as yet unknown.

I think it is clear that Spitzer (and Wakefield, and evolutionary psychology) is using the word mechanism to refer to a process that is independent of anything an agent can be credited with (like how blood clots). Spitzer thinks a person reacts abnormally to, for example, a loss, because an underlying regulatory mechanism has dysfunctioned. A mental mechanism, then, is responsible for a person's reaction to loss. At the same time (I am drawing on the 1998 paper by Wakefield that Zimmerman & Spitzer, 2005, discuss at great length) there is no impersonally described loss to be found, only an individual's view of what has occurred and his or her corresponding evaluation and feelings about what has occurred. Wakefield (1998) points out that it can be a challenging task for a clinician to discover the (this is my term, but I believe it captures what Wakefield means) deep background that shapes the patient's reaction to a loss. He makes this point to correct any false impression that the clinician can decide on the basis of no background story or only a skeleton story whether the patient's reaction to loss is sufficiently disproportionate to justify a mental disorder diagnosis.

I cannot see how the patient's reaction to loss could be out of proportion to what the loss means to the patient, however obscure or mysterious this may appear to a clinician who is not privy to why the loss means what it does to the patient (a point Wakefield himself, argues in the 1998 paper). It is commonplace to find a person's reaction to something “disproportionate” until it is established via conversation what “bigger picture” or “deeper background” considerations were at play for the person. It is hardly a deep psychological insight to realize that the significance of an event occurring now may extend beyond the present moment. It is not even clear what the present moment means psychologically (is today's social interaction with x psychologically part of, or separate from, yesterday's social interaction with x?). In any event, Wakefield thinks the clinician can decide if the patient's reaction to a loss indicates that an underlying mechanism has dysfunctioned. How, exactly, does Wakefield think the clinician can determine this? At least twice in the 1998 paper, Wakefield asserts that the heart of the clinician's judgment that someone has a mental disorder is the judgment that the individual's “loss response” (a term Wakefield made up so as to speak of a hypothetical, innate, evolutionarily designed “loss response mechanism”; 1998, p. 46) is significantly disproportionate to the actual loss. But I must reiterate that Wakefield, himself, argues that there is no actual loss independent of the patient's own view of the matter. There is no abstract, impersonal “loss of a romantic relationship” to draw on one of the vignettes Wakefield presents to make exactly this point), there is only this individual's loss of a specific romantic relationship with a real person and what that means to him or her. Nonetheless, Wakefield continues to assert that the clinician decides if the person's reaction to loss is proportional to the actual loss. This is unabashed moral reasoning, no different in kind, I think, than someone deciding if Lady Chatterley's Lover is literature or pornography. Moral reasoning cannot be the basis for determining if a mechanism whose existence and purpose is unknown is dysfunctioning. Indeed, Wakefield makes this point explicitly by pointing out that dysfunction of the loss response mechanism must be judged on the basis of how the loss response mechanism was designed by evolution to function, and not on the basis of the clinician's ideas about rationality. He then refers (in principle, no references actually cited) to research in evolutionary psychology. In short, even if a clinician endorses the plausibility of research in evolutionary psychology (not to be confused with research in evolutionary biology), there is currently no firm basis for distinguishing between mental disorder present or not present. The plausibility of research in evolutionary psychology has attracted a great deal of critical thought along various lines, the most straightforward of which is the observation that there simply is no way to obtain information concerning selective social and other pressures on the mental life of our remote human ancestors (Davies, 2001; Richardson, 2007). For a range of critiques of the conventional neo-Darwinian model that (I emphasize) evolutionary psychology takes for granted, see Fodor and Piatelli-Palmarini (2010), Gould (2000), Ingold (2000), Lewontin (2000), Martin (2003), and Odling-SmeeLaland, and Feldman (2003).

CRITIQUE OF THE IDEA OF A “NORMAL RANGE” REACTION TO AN “EVENT”

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Spitzer (Zimmerman & Spitzer, 2005) remarks that the “clinical significance” requirement for diagnosing the presence of a mental disorder does not address “the issue of labeling normal reactions to stressful events as disorders” (p. 1005). Spitzer's (and Wakefield's 1998) repeated reference to a normal range psychological reaction to an event must be read/understood as endorsing a certain view of the subject matter and appropriate methodology. It is the view that the study of persons can be assimilated to the study of impersonal events—as in, for example, empirically establishing common and rare biological reactions to a certain drug, a procedure that permits sensible, empirically based talk of a normal (most frequent, expected) biological reaction to the drug. In familiar philosophical parlance, they (Spitzer and Wakefield) are, in effect, endorsing the view that mental life belongs in the realm of Naturwissenshaften (I use Toulmin's, 1985, translation: “the explanatory sciences of Nature,” p. 4). This is, of course, the hegemonic view of psychology as a scientific discipline presented in universities, psychology textbooks and journals, etc.

In the same spirit of observing, there is no impersonally described actual loss to be found, it can likewise be observed that there is no impersonally described event to be found (contrast to a drug-induced rash). Compiling statistics regarding reactions to an event takes for granted that, like a drug-induced rash, everyone is referring to the same thing. But as soon as the event is specified, like loss of a romantic relationship, it becomes apparent that what is being referred to is an abstract category that can encompass limitless variation (e.g., the category science fiction encompasses Dune, A Christmas Carol, On the Beach, and so on). The abstract category does not actually refer to anything in particular, and any and all efforts to define the essential meaning of the abstract category has the effect of reifying it and excluding or problematizing examples that would otherwise be included except for the imposed essential definition (no doubt I have been influenced to think in this manner by Wittgenstein's (e.g., 1958) now famous discussion of “family resemblance” terms like “game.” The problem for social scientists seeking to study instances of the same thing is critically discussed in Winch (1958). It is hopeless to study reactions to an event when the event is an abstract category that does not refer to anything in particular. Categorizing Dune, A Christmas Carol, and On the Beach as science fiction could be an organizational convenience for a library or bookstore, or it could make sense in the context of a specific conversation, but it would be a bad mistake to suppose there is some essence to be found that naturally joins the three novels.

Reference to an event in the DSM (APA, 2000) definition of mental disorder, and by Spitzer and by Wakefield, create the impression that psychological reactions to the same thing can be studied for purpose of establishing a normal-range reaction to a stressful event. It's not at all clear what event Wakefield is referring to in the vignette entitled “Ending of a Passionate Romantic Relationship” in his 1998 paper (pp. 56–57). Let us say it was the moment when the protagonist, a male professor in the social sciences, realized that his married lover had truly and irrevocably ended their five-year affair. A clinician is in the position of deciding if the protagonist's reaction is inside or outside a normal-range reaction. The only way this could be done on the basis of empirical evidence, as opposed to moral reasoning, is to compare the protagonist's reaction to the event with the reaction of other people to the same event (as in the biological reaction of a large sample of people to the same drug). But the event under consideration here is what his lover's rejection after their five-year affair meant to the protagonist, so it is idle to suppose it is possible to study the reaction of others to the same event. I take for granted that readers of this article realize that a clinician would need a lot more than a half-page vignette to come to a more or less adequate grasp of what the ending of the relationship meant to the protagonist (the term deep background comes to mind once again). Wakefield clearly recognizes that the ending of the protagonist's relationship must be understood in terms of its meaning to the protagonist, but he continues to insist that a clinician can discriminate between a normal and abnormal reaction. As far as I can tell, he thinks a clinician (any clinician?) can correctly discriminate between a normal and abnormal reaction on the basis of “circumstantial evidence and commonsense knowledge of human functioning” (Wakefield, 1998, p. 45). I think Wakefield is saying that the clinician makes a judgment of normal or abnormal based on the clinician's ability to empathize with the story the protagonist tells (I use empathy here to mean a person's ability to “feel into” the story and put him/herself into the protagonist's place, see Katz, 1963). However, much as I may be inclined to say that empathy is the basis for an intimate understanding of another person (Franck, 1986), I can hardly agree that x's ability to empathize with y should be the definitive method for determining if y has a mental disorder. This seems no different than holding that a critic's feeling about grasping the writer's intent can serve as the definitive method for validly discriminating between literature and pornography. I think it is obvious that different critics will have different intuitions about a writer's intent, unless critics have been carefully trained to see things similarly (of course I am analogizing to obtaining relatively respectable reliability statistics in studies of psychiatric diagnosis), but this is a minor point. The core issue is the assumption that there is a real boundary (as opposed to a made up boundary) separating literature from pornography. The basic mistake, as I see it, is reification. Contrast with deciding if this is really a case of smallpox or not. The difference is that smallpox is not simply/merely a descriptive conversational option. It is diagnosed definitively on the basis of presence or not of the variola virus (Breman & Henderson, 2002). Diagnosing a case of smallpox on the basis of the presence of the variola virus is not an instance of reification, but deciding what science fiction or pornography or mental disorder essentially/really means and then judging what is in or out is reification. Wakefield and Spitzer hope that research in evolutionary psychology will change this. The future is always promising for those who think that the real/essential meaning of a descriptive word can be pinned down by empirical research and thereby transformed into a context-independent technical term (intelligence, depression…contrast to ampere, variola virus).

WAKEFIELD WAS CORRECT IN 1988: MEANING CANNOT BE A SCIENTIFIC TOPIC

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Wakefield (1998) presents eight (presumably made up) loss vignettes for the purpose of arguing/illustrating the DSM's (APA, 2000) false positive problem. He argues these may all be examples of normal functioning of the loss response mechanism. Apparently he thinks evolution has designed a quite general loss response mechanism that covers all possible losses a person may experience in life. Reading the array of vignettes Wakefield provides, I am struck by his ability to construe each vignette as essentially a case of loss, rather than other descriptors or even as cases of loss, as well as other descriptors. He is clearly trapped into depicting all the vignettes as essentially cases of loss to argue for the existence of a quite general loss response mechanism. The question is whether the protagonist in each vignette would characterize his or her situation exclusively or primarily in terms of loss. The protagonist of “Vignette 3: Ending of a Passionate Romantic Relationship,” for example, might well feel that what occurred included being led on and abandoned, being lied to, betrayed, being ultimately found inadequate and rejected, and so on. It is not that clear what loss Wakefield is referring to in “Vignette 6: Stagnation in Work Life.” The protagonist here is a 42-year-old college professor who felt his career was on hold. Perhaps the loss Wakefield has in mind is the loss of the fantasy of continuous upward mobility and acclaim. Wakefield is, I think, inadvertently showing that the idea of a loss of some kind can be formulated in a manner that will cover practically any adverse situation. But this only shows that language can be used flexibly and creatively, not that an impersonal, quite general loss response mechanism is plausible or possible. He is also showing, as Spence (1982) has persuasively pointed out concerning psychoanalytic case histories, that the clinician-author has enormous leeway to smooth the clinical summary so that it neatly fits into and nicely illustrates the conceptual framework to which the author is committed. The patient's or client's view of the problem he/she brought to therapy (or emerged during the course of therapy) does not have a conceptual space in this (literary) genre.

Spitzer (Zimmerman & Spitzer, 2005) seems to recognize that endogenous medical conditions do not provide a useful/realistic model for understanding a person's reaction to stressful events. He likewise recognizes that it is commonplace for psychiatrists to disregard the existence of stressful events and the question of whether the person's reaction to the stressful event is inside or outside the normal range when making a diagnosis of mental disorder present (the false positive problem). He does not specifically discuss whose prerogative it is to identify whether or not a person is or has reacted to a stressful event and how to depict/describe the index stressful event. He believes that a person's reaction to a stressful event is regulated by some kind of psychological mechanism designed by evolution, but he admits that the existence and nature of such hypothesized mechanisms are unknown. In my reading, he seems to think all the relevant considerations can be assimilated to objective empirical study.

Wakefield (1998) specifically discusses the meaning of an event to an individual. More to the point, he seems to recognize that there is no event to talk about outside of or apart from the individual's own identification and description of the event. This part is consistent with his 1988 paper denying the study of meaning to empiricism on the grounds that there is no objectively described text or text analogue to study, only interpretations of the text or text analogue (the letters and words that constitute a text are objectively present, but the meaning is not. Similarly, what Rodney King and the police officers did on that day was not objectively present, although the police cars and so on were objectively present. See Goodwin and Goodwin, 1997, for an enlightening analysis of how expert witnesses for the defense managed to convince the jury that Rodney King, although unarmed and lying on the ground being beaten by a group of police officers with metal clubs, was actually in control of the situation). For some reason, Wakefield thinks that evolution has designed psychological mechanisms that not only regulate reactions to loss but (I assume) likewise do the conceptual-linguistic work of generating an appropriately nuanced description of what has occurred. I can only see this as creating a classic, thus futile, homunculus problem. Because the regulatory mental mechanisms are unknown (as suggested previously, there are good reasons to think that evolutionarily designed mental mechanisms, even if they exist, cannot be a topic of empirical study due to the vagaries of reverse engineering), it is up to the individual clinician on the scene to evaluate whether or not the patient's tale of what occurred warrants the patient's psychological reaction to what occurred. This would appear to be an interpretive–evaluative task based on empathy and moral reasoning. Characterizing the task as such would not be a problem for the 1988 Wakefield, who argued that hermeneutics cannot be assimilated by empiricism (science, that is), but the 1998 Wakefield abandoned this line to argue that mental disorder is a real thing that science can study. Science can only study what is ontologically real; science cannot study what only exists by convention, e.g., a literary genre like science fiction. (I think the really interesting philosophical question is whether it is possible to, in effect, establish a view from nowhere—no intellectual frame of reference that guides the identification, collection, and interpretation of data. Without such a place to stand, it is not clear if the thing itself can ever be apprehended. In this regard see Fleck's, 1935/1979, still contemporary thesis.).

In the 1998 paper, Wakefield presents eight vignettes in the spirit, it seems to me, of displaying specimens found in the wild. Of course, these are made up vignettes—rhetorical devices—to advance his thesis, but the way he presents them entirely obscures that a clinician's summary of a real person's distress and the background to the distress is based on conversation(s) between the clinician-author and a specific patient. A clinician's summary of a patient's distress and its background, therefore, is nothing at all like a found specimen of something that has become available for study. The clinician does not obtain the patient's account as a naturalist might obtain an insect specimen; the clinician must engage the patient in a conversation-social interaction. The clinician is thus an active and intrinsic component of the conversation-social interaction that was the basis for the clinician's eventual summary/depiction of the patient's distress and its background. There is no specimen to be studied that is independent of the clinician as both an interlocutor and as an author. When I say the clinician here, I mean a specific clinician, because the conversation-social interaction that took place between a specific clinician and patient, followed by that clinician's written summary, cannot be exactly duplicated by any other clinician. The patient's distress and the background to the patient's distress, therefore, does not exist as an object of study that is separate at any step along the way from the clinician's manner of conversing and interacting, ability to empathize, and written summary. None of the preceding remarks in any way contradict Wakefield's 1988 paper, in which, as I have said, he denied that meaning could be assimilated to empiricism (science), but in the 1998 paper he dropped the arguments he made in the 1988 paper without discussion so as to treat mental disorder as an ontologically real thing that fits—conceptually—into scientific study. As a practical matter, as we have seen, it is up to the clinician on the scene to discriminate between mental disorder present or not present based on his or her ability to solicit and empathize with the patient's story and on his or her (the clinician's) own moral reasoning (what warrants what).

Spitzer's (Zimmerman & Spitzer, 2005) recognition that a person's mental state cannot be evaluated noncontextually would seem to remove the evaluation of a person's mental state from objective study, because there can be no definitive, impersonal depiction of context as experienced by a specific person (contrast to an institution's definition or designation of context, for example “a classroom setting in a public school in which a teacher was presenting a lesson to his or her pupils”). The individual's own depiction of context may change importantly depending on the speech situation and the time frame of the speech situation (current, later, much later). The situation for an individual, then, is outside of the ambit of empiricism. This observation is consistent with the overall point of Wakefield's 1988 paper, which argues that ambiguity concerning meaning (a statement, an action, a gesture, and so forth) cannot be avoided in the realm of human study. In general the “solution” of experimental psychology to the problem of how to depict the situation for the experimental subject is to speak as little as possible to subjects and assume the obtained average value for the group on a designated quantified dependent variable speaks for itself. Actually, it is quite unclear how the experimental group's average response bears on any individual group member's response, much less how any individual member construes the experimental situation (see Mishler, 1996, for discussion concerning how misleading group scores are as a representation of the responses of the experimental group considered one at a time). The subjects' speech is officially avoided as much as possible because speech necessarily brings to the forefront the unavoidability of interpretation. In a 1986 article in American Psychologist, Saul Rosenzweig observed that, as early as 1933, he pointed out that ignoring the subject's own view of the experiment and the social interactions that took place in and around the experiment was not really a solution. The method he recommended in 1986 for the purpose of understanding a particular individual was hermeneutics.

Medical conditions do not have a context. If a person suffers from a mishap or condition that undermines the physical substrate of psychological life, then the usual necessity to consider context when evaluating what a person says and does is lessened or obviated. Context is a critical but slippery concept. I hope it does not sound paradoxical to say that what context refers to depends on the context in which it is used. Everything a person says or does takes place in a context and has a context, but what context actually refers to depends on the question or issue or problem under consideration. The question or issue or problem at hand creates the relevant context—of course, the question, etc., at hand does not exist in isolation, it has a context…and so on. Somehow, people figure out through talking with each other what the relevant interpersonal and consensual context is (a basic ethnomethodological insight, Garfinkel, 1967; Heritage, 1984; see also Goffman, 1974), a prosaic but nonetheless amazing feat. Although everything a person says and does has a context and is in context, it is often by no means immediately clear what the relevant context (circumstances, background, history…) is as far as the person under consideration is concerned when something a person says or does in some way seems problematic, uncalled for, puzzling, out of line, disproportionate, and so on. Call this, that is the relevant context, background, etc., the whole story. Moviegoers are familiar with seeing the main character do something mysterious or dastardly at the beginning of a film that by the end of the film, by dint of background having been filled in, is seen in a very different light.

Reading Wakefield's (1998) “Ending of a Passionate Relationship” vignette, it is clear that the protagonist has been devastated by his lover's decision, after a five-year affair, that she cannot leave her husband. But even for the limited question of whether the protagonist's reaction is or is not proportionate, the vignette can hardly be the whole story. There are many pertinent questions: why did the protagonist expect that his married lover would eventually leave her husband, why did he become so involved with a married woman and invest so much time and hope in her, etc.? Wakefield appears to contend that the half-page vignette provides sufficient information for a clinician to decide if the protagonist's reaction is or is not (as he puts it) prima facie a normal loss reaction. But this is rather like contending that a viewer does not have to see the whole movie or a reader does not have to read the whole book to make a final judgment (as to character, motive, plot, etc). This is an odd position for a person who wrote a paper explaining the difference between empiricism and hermeneutics to take (Wakefield 1988).

An important difference between a book or movie and a text analogue (i.e., behavior in real life) is that in the former case the reader or viewer is presented with a definitive story that has a definite beginning and end. In the case of real life behavior, it frequently is not clear where to draw the line as to relevant background, circumstances, where the story begins and ends, whether more of importance may be revealed if conversation continues, how much difference the specific setting and interlocutor makes, etc. Interpreting (trying to understand) behavior in real life is radically open, even compared to a book or movie. The correct comparison, I think, is the study of history, e.g., how much background is relevant to understanding the Viet Nam War? (America's interest in Viet Nam cannot be understood outside the Cold War, outside of America's perceived need for a strong ally in France in the post World War Two world, etc.; see McNamara, 1999). The half-page “End of a Romantic Relationship” vignette Wakefield (1998) presents can hardly be thought of as the whole story, but, as in the study of history, the whole story is often a chimera.

I think it is clear that Spitzer and Wakefield both realize that diagnosing mental disorder present—if mental disorder present is to be construed as equivalent to smallpox present, that is as ontologically real—cannot depend on interpretation (of speech, of stories…), on unique interlocutor-story teller dyads, and on moral reasoning (what warrants what). Mental disorder requires the objective identification of something disordered, something broken, something not functioning as it should (think of immune disorder). Thus, the desperate, in my view, appeal to evolutionary psychology to discover evolutionarily designed mental mechanisms. What is objectively real cannot be determined on the basis of interpretation (is Lady Chatterley's Lover pornography?). Thus, Spitzer (Spitzer & Zimmerman, 2005) acknowledges that, at present, any line drawn between mental disorder present and not is arbitrary, although he does not doubt that scientific research will ultimately remedy this. I conjecture that what is behind the desperate appeal to research in evolutionary psychology is the failure of biological psychiatry from 1980 to the present to find an objective biopathological basis for transferring a single primary mental disorder to the Medical Disorder Due to a General Medical Condition category (this is not expected to change in DSM-V [APA, 2000], e.g., Carpenter, 2009; First, 2008). In my view, all reference to mental mechanisms, if meant in the spirit of identifying a process that is independent of an involved agent (e.g., Wrathall & Malpas, 2000), creates a futile homunculus problem. This line of thought is not at all to the liking of those who take for granted that anything that occurs must be amenable to an impersonal, causal explanation, but the description of human action or feeling is always interpretive, and therefore always (or close to always) defeasible. This is one of a collection of reasons for maintaining (along with the 1988 Wakefield) that empiricism (science) cannot be tweaked to encompass understanding persons (or history, or literature, or politics…of course, this is the hoary Naturwissenshaften-Geisteswissenshaften distinction that derives from nineteenth century French and German thought (Franck, 1986; Grossman, 1986; Valsiner, 1986).

The belief that mental disorder is real requires a method of identification that does not depend on interpretation. There must be an objective method to distinguish between true positive and false positive. Severity of symptoms or (to draw on Wakefield's 1998 paper) prima facie outlandishness will not do because there may be a story (history, set of circumstances…) lurking behind the symptoms that could be construed as warranting the symptoms or at least rendering them comprehensible if the story was known (the person “presenting” the symptoms may be too damaged by personal experience to relate a coherent and convincing narrative). The medical tone of the DSM (APA, 2000) does not in any way suggest that horrors can be visited on real people in the course of growing up in the family (in 1962, Kempe and emergency room colleagues felt obliged to publish a paper in JAMA imploring emergency room physicians around the country to stop deliberately misdiagnosing the battered infants and young children they treated because they were too squeamish to face the consequences of the truth). Spitzer is candid enough to admit that an objective method to distinguish true from false positive mental disorder continues to elude psychiatry. As discussed, he hopes research in evolutionary psychology will prove to be the remedy. I consider this a mere delaying tactic. Medical research will, no doubt, continue to shed light on the ills of the flesh and the consequent mental ramifications, but in the absence of such discoveries it will not do to simply assume that a distressed or socially impaired person is suffering the mental consequences of biopathology—which the DSM does assume (APA, 2000). I am unsure what to call the position that distress or social impairment should be referred to as a bona fide medical disorder despite the absence of objective physical evidence. Spitzer (Zimmerman & Spitzer, 2005) cites Szasz for the purpose of refuting him, despite the fact that Spitzer makes the point in his own way that psychiatry is unable to distinguish between mental disorder really (actually, in fact…) present or not. I see no reason not to accept Szasz's position. Here is how Spitzer summarizes Szasz's position: “The term mental disorder is adopted to label behavior that deviates from social norms and to empower the medical establishment” (Zimmerman & Spitzer, 2005, p. 1007).

It is noteworthy that Spitzer (Zimmerman & Spitzer, 2005) does not conclude that the existence of a perennially insoluble false positive problem is incompatible with a diagnostic manual and progressive expansion of the mental disorders listed in the manual from one edition to the next. He does not propose (although Wakefield does) that mental disorder can be (validly, correctly…) diagnosed on prima facie grounds because, he acknowledges, no one knows what a person's reaction is supposed to be to the adversity that she or he has encountered. He concedes that an unknown percentage of people currently diagnosed with a mental disorder may be false positives. An MRI may indicate that a woman has breast cancer, but she may, in fact, not have breast cancer. A biopsy or surgery settles the matter on the basis of physical evidence. When it comes to primary mental disorders, there is no way to settle the matter. A diagnosis that may or may not be true and that cannot be settled by any means one way or the other cannot be the basis of a medical specialty. This seems clear and inescapable, but Spitzer does not see it. A person who is committed to a moral framework can detect immorality on the basis of his/her moral framework. But it would be a fundamental mistake—this is the basis of Szasz's 1961 book—to hold that evaluations arrived at via moral judgments are ontologically real in the sense that smallpox is ontologically real. There can be interesting and important arguments about what is and is not moral on the basis of a specific moral framework, but this should not be confused with scientific investigation and discovery.

CONCLUSION

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Spitzer (Zimmerman & Spitzer, 2005) begins his paper by listing a variety of reasons why mental health professionals should care about the way mental disorder is defined. In spite of the fact that he concedes that there is no way to remedy the false positive problem and that an unknown percentage of people who are currently given a mental disorder diagnosis are actually not mentally disordered, he only alludes to consequences for the person who is falsely diagnosed in a single sentence. Perhaps he thinks such a discussion is tangential to the topic of his paper. He does mention social control and stigmatization. These are obviously important topics. A person given a mental disorder diagnosis is de facto designated as “not normal like us,” frequently in circumstances (being a child, etc.) in which a diagnosis of mental disorder matters a great deal to the fate of the person diagnosed. If, as Spitzer concedes, “perhaps many” (Zimmerman & Spitzer, 2005, p. 1007) people who have been given a mental disorder diagnosis are false positives, this is hardly a matter to be taken lightly.

Obviously, I don't think there is a remedy for the false positive problem in psychiatry for the same reason I don't think a censor can provide a remedy for the false positive problem with regard to pornography: the thing being diagnosed does not exist outside the eye of the beholder (in contrast to the variola virus). Things, events, occurrences, etc. that can only be identified on the basis of interpretation and moral reasoning cannot be assimilated to objective scientific study. I draw on the Viet Nam War example again: Even identifying who was in the military and a combatant in the war theatre was contentious, to say nothing of what the war was about. There are good reasons to maintain the Naturwissenshaften-Geisteswissenshaften distinction.

A diagnosis of mental disorder (the person has a mental disorder, is the hapless host of a mental disorder…) reduces, if not eliminates, interest in understanding the person's difficulties in terms of history, context, agency, etc. Similarly, Kempe, Silverman, Steele, Droegmueller, and Silver (1962) pointed out that deciding that the infant's bruises, broken bones, etc. were due to an occult medical illness reduced or eliminated interest in the infant's home environment (Kempe et al. were imploring emergency room colleagues not to diagnose the infant's injuries as due to a primary, that is, idiopathic, medical illness, to update their plea in DSM [APA, 2000] terminology). I have argued that deciding to see the individual's troubles in terms of a primary (idiopathic) mental disorder requires deciding that the individual's history does not warrant the individual's troubles. Such a decision must be based on the belief that the whole story has emerged in its final and unmodifiable form, and the clinician's further belief that how he or she has personally understood and evaluated the story is sufficient grounds for placing the individual in question in the true positive category. As discussed, I do not think an ontologically real something can be identified in such a manner, and psychiatry cannot come up with anything more solid. A mental disorder diagnosis removes the diagnosed individual, at least with regard to the content of the diagnosis, from being thought of in terms of history, circumstances, or context. This is clearly a fateful decision because this is how we think about a person.

POSTSCRIPT: COMMENTS ON THE DEFINITION OF MENTAL DISORDER FOUND ON THE DSM5.ORG WEBSITE

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Given my thesis, namely that mental disorder is a reified form of moral reasoning like pornography, I do not expect a new formulation of mental disorder to come to grips with, much less solve, what Spitzer (Zimmerman & Spitzer, 2005) calls the false positive problem. I briefly comment on criteria C and D, the criteria that seem most relevant to the false positive issue.

Criterion C: Must Not Be Merely an Expectable Response to Common Stressors and Losses (For Example, the Loss of a Loved One) or a Culturally Sanctioned Response to a Particular Event (For Example Trance States in Religious Rituals)

This repeats the proposition, a basic mistake in my view, that individuals react to abstract categories (like loss of a loved one), with the consequence that an outside observer (a mental health professional) can evaluate the normalcy or not of an individual's reaction to an abstract category. Individuals do not react to abstract categories; they react to their own take on what is occurring or has occurred and its meaning and significance to them. The meaning (significance, impact) of someone's death as far as a specific person is concerned, for example, cannot be grasped by reference to an abstract category. If an individual's reaction to something seems unusual or excessive from the perspective of common expectations or cultural stereotypes, this only shows that real people react to specific circumstances as they see the matter. The authors of DSM-V, like their predecessors, are committed to a view of the person in society justly parodied by Garfinkel (1967) as a “judgemental dope,” i.e., bound by stereotypes and norms and blind to the particulars of the situation at hand (p. 68).

Criterion D: That Reflects an Underlying Psychobiological Dysfunction

Spitzer's (Zimmerman & Spitzer, 2005) understanding of the false positive problem in psychiatric diagnosis is that correct identification of mental disorder requires the identification of what is dysfunctioning, presumably a mental mechanism. The reality of something dysfunctioning cannot (this is Spitzer's reasoning) be correctly inferred on the basis of clinically significant distress or disability because the distress or disability may be a normal reaction to stressful events. If the mental mechanism that is presumably dysfunctioning is unknown, then the clinician on the scene is in the position of guessing how the individual under consideration was supposed to have reacted to whatever stressful events he or she faced or is supposed to react to the stressful situation he or she is currently facing. Spitzer is candid enough to admit that any decision the clinician on the scene makes on this matter must be arbitrary when it comes to normal or not.

Under the proposed new definition, the clinician on the scene is called upon to decide if the distress or disability under consideration “reflects an underlying psychobiological dysfunction.” The proposed definition provides no discussion as to what a “psychobiological dysfunction” is or means and how the clinician on the scene is supposed to decide whether the distress or disability under consideration does or does not “reflect an underlying psychobiological dysfunction.” There is no suggestion as to what would count as objective evidence on this matter for the same reason DSM-IV-TR (APA, 2000) could not suggest how a clinician on the scene was supposed to conclude that distress or disability should be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual (if it could be shown that the distress or disability was a manifestation of a biological dysfunction, then the diagnosis would not be a primary mental disorder). The same reason is: The authors are referring to something made up, or at least unknown, in exactly the same manner that Wakefield (1998) referred to evolutionarily designed regulatory mental mechanisms. Spitzer, at least, can no doubt recognize that the intractable false positive problem remains intractable under the new definition.

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Does Psychological Dysfunction Mean Anything?

2011-06-01T13:43:00.000-07:00

(connect to Journal of Humanistic Pychology)

with David Cohen, Ph.D.

Abstract

Any effort to discuss or study psychopathology (by any name) must decide how to distinguish between psychopathology and narratively comprehensible reactions to adverse circumstances of life. A pathology framework, which views the distressed individual as acted on by impersonal forces, is incompatible with an agential framework, which views the individual as the protagonist in a unique story.
Although the Diagnostic and Statistical Manual of Mental Disorders (DSM) recognizes this issue, it addresses it by postulating that “primary mental disorder” results from a “psychological dysfunction” and non—culturally sanctioned reactions to life events indicate mental disorder. In this essay, the authors examine whether the concept of “psychological dysfunction” can withstand an analogy to that of biological dysfunction. They also examine the DSM’s view that “culture” has already prepared an official evaluation of any reaction to the vicissitudes of life. They conclude that the DSM has failed to convincingly distinguish between psychopathology and reactions to life’s vicissitudes. They suggest that the DSM’s insistence on separating people’s feelings and actions from their own unique circumstances and context amounts to a moral, not scientific enterprise. The study of how people fare in living should abandon the concept of mental disorder and related terms.

Environmental Failure-Oppression is the Only Cause of Psychopathology

2011-05-01T13:25:00.000-07:00

The Journal of Mind and Behavior , Winter and Spring 1994, Volume 15, Numbers1 and 2, Pages 1-18, ISSN 0271-0137
(connect to: The Journal of Mind and Behavior)
ABSTRACT
The present paper intends to clear the way to considering all psychopathology asresponses to failures in the human environment by examining three common sourcesof error in scientific reasoning about psychopathology: (i) the false identificationof "biological considerations" with the sub-interest of organic pathology,(ii) the idea that a person could be genetically predisposed or vulnerable to psychopathology,(iii) the failure to distinguish between causal forms of explanation and explanationbased upon connections of meaning and significance.
For convenience, the omnibusterm "environmental failure-oppression" (EFO) is introduced to refer tothe totality of possible failures in the human environment.