Psychotherapy Brown Bag

Deflating empty arguments - A defense of mental illness diagnoses

by Michael D. Anestis, M.S.

Welcome back to PBB.  It's been a chaotic couple of weeks for us and the site will be making a transition of sorts as Joye takes the lead and I begin my internship.  I'm not done writing by any means, but my posts will be much less regular for a while.

I had several topics ready for tonight's post, but everything changed when my colleague - Kelly Caron - pointed me towards this mind-boggling article written on the Huffington Post by a psychiatrist named Peter Breggin (click here to read the article).  In the article, Breggin attempts to make the case that mental illness diagnoses are harmful and based on nothing but opinion (an ironic criticism given that he bases this on his opinion).  As you might guess, I disagree wholeheartedly with his conclusions.

As I have done in the past, I will paste a comment from the original article in italics and then write my retort below it.

"In reality, psychiatric diagnosing is a kind of spiritual profiling that can destroy lives and frequently does."

I'm not even certain I understand what "spiritual profiling" means, but it certainly sounds awful.  My assumption is that Breggin is claiming that a mental illness diagnosis is a criticism of an individual's character, a critique of who they are as an individual.  This is completely untrue.  A mental illness diagnosis is a recognition that an individual is experiencing a group of systems that often cluster together and which have been shown to respond to a particular treatment or set of treatments, some of which are pharmacological and some of which are psychosocial.  No therapist should imply that a diagnosis is some sort of character flaw or a description of the sum of an individual's personality.  If they do, the problem is with the therapist, not the diagnosis.

"First, there's the obvious cookie cutter problem. People can't be easily fit into the prefabricated labels contained in the Diagnostic and Statistical Manual of Mental Disorders from whence all official diagnoses emanate. Diagnoses frequently change, often in an effort to justify this or that drug. It's not realistic, enlightening or empowering to reduce yourself or your child to one of these diagnoses. Psychiatric diagnoses are simplistic."

If Dr.Breggin's point is that diagnoses are imperfect, he's spot on.  This does not seem to be his point, however.  He seems to be saying that the diagnostic categories never properly fit individuals' presenting problems.  On what does he base this claim?  Again, nobody is saying that panic disorder, depression, borderline personality disorder, or any other diagnosis explains the depths of an individual's soul.  They are simply saying that individuals often present with a particular cluster of symptoms and that research has enabled us to learn a lot about those symptoms and how to treat them.  Sometimes, an individual meets criteria for more than one diagnosis (in fact, this is the norm).  Sometimes, an individual's symptoms do not fit the criteria well but still cause significant impairment and/or distress.  Those individuals receive a "not otherwise specified" diagnosis and are still eligible for treatment.  As time goes by, diagnoses are adjusted.  These changes are not made to justify this or that drug, but rather to fit what we have learned through research since the previous edition of the DSM was published.  This is, in fact, the very nature of science: imperfections are gradually clarified through research, then changes are made to the model in order to better reflect current knowledge.  Would it be nice if we understood diagnoses perfectly?  Absolutely.  This is, of course, true of all scientific fields, however, so if we are going to disown this component, we must do so to all (including medical diagnoses, which also change to reflect increased knowledge).

"Consider this: Psychiatric diagnoses are always negative. There are no such diagnoses as "Exceptionally Able to Face Stress" or "Remarkably Resilient" or "Courageously Independent in the Face of Abuse." That's how I like to think about the people that I try to help--as heroes or potential heroes in their own life stories. I never want them to sum up, categorize or symbolize their lives in such a demeaning fashion as a psychiatric diagnosis.

But that's only the beginning of the problem. These diagnoses imply that you or your children have a disease, especially an underlying biochemical imbalance. This can be discouraging and disempowering. Having a psychiatric diagnosis tends to make us feel helpless to transform our lives or the lives of our children for the better. It makes us feel less responsible for our own psychological and spiritual recovery and for that of our young and dependent children.

Medical diagnoses are real. When you learn you have pneumonia, diabetes or even cancer, you quickly discover that there are potential remedies. There are scientific tests and studies to diagnose the disease and to evaluate its treatment. Medical diagnoses don't demean your mind and your soul, they describe your bodily impairments."

There are a number of troubling contradictions here.  First of all, while Breggin is correct in noting that there are no mental illness diagnoses that are positive like "remarkably resilient," there are also no medical diagnoses that are positive (e.g., "super special not broken bone!").  If this is a problem for mental illness, why is it not a problem for medical illnesses?  People come in for the treatment of problems and effective clinicians recognize those problems, use science to help them identify the best treatment, and then also utilize the client's strengths in that treatment.  Providing a diagnosis of a mental illness does not prevent a therapist from working with and advertising a client's strengths.

Going a bit further here, mental illness diagnoses are not negative in nature. People are not being labeled - their symptoms are being described.  It is the job of the therapist to describe symptoms as symptoms and not as an individual's identity.  When this is done properly, data has demonstrated convincingly that clients actually respond positively.  Don't believe me?  Click here to read Dr.Jill Holm-Denoma's description of data that verifies my claim.

In the above segment, Breggin simultaneously claimed that psychiatric diagnoses are demoralizing because they imply that we have a disease or chemical imbalance (which they don't) and that medical illnesses - which include diseases and chemical imbalances - don't demean us because they describe bodily impairments.  So...mental illnesses are bad because they sound like diseases but diseases are good because they are only about our bodies.  That's not strong logic.

Breggin also noted that when you are diagnosed with a physical ailment, you feel encouraged because you can immediately learn about potential remedies through objective tests and science.  Well...when you are diagnosed with a mental illness, you can also learn about the multitude of empirically supported treatments that are available (which includes a vast array of psychosocial treatments not mentioned in Breggin's article).  Breggin is correct in noting that there is an element of error inherent in psychosocial diagnostic tools; however, there is also extensive research supporting the reliability and validity of a number of diagnostic tools, including structured diagnostic interviews and a variety of behavioral observations.  On the medical side, consider that some diagnoses are fatal, meaning there are no treatments available, some treatments are so expensive that they will bankrupt a family and ruin them financially, and some rely on diagnostic tools that heavily weigh subjective interpretations or indirect measures of the actual ailment.  Psychological diagnostics are not as sloppy (when properly utilized) as Dr.Breggin believes and medical diagnostics (when properly conducted) are not as full proof as Dr.Breggin believes.

"Psychiatric diagnoses take power and authority over your life, and the lives of your children, out of your hands. They place that power and authority in the hands of health professionals. Often it takes but a few minutes in an office to transform you or your child from a complex human being into a product on the psychiatric assembly line--and endless assembly line that can lead to a ruinous lifetime.

Perhaps worst of all, these diagnoses almost inevitably lead to the prescription of psychiatric medication to you or your child."

If you ever encounter a clinician who makes you feel this way, immediately go to another clinician - one that utilizes empirically supported treatments and proper diagnostic procedures.  When psychiatric diagnoses take over an individual's life, something has gone horribly awry in the diagnostic process and the problem lies with the therapist, not the concept of diagnostics.

Also, diagnoses do not almost inevitably lead to the prescription of psychiatric medication.  Click here to read all of our articles on empirically supported psychosocial treatments for mental illness.  I'll let that data speak for itself.

"But something more subtle occurs when we accept a psychiatric diagnosis for ourselves or a loved one. We lose empathy for ourselves and our loved one. Instead of learning about and identifying with the sources of our emotional pain and suffering, and our failures in life, we ignore our real lives and explain ourselves away with the diagnosis. To understand ourselves or anyone else, to help ourselves or anyone else, we must care about the details of the life before us."

What?  There is absolutely no logic to this argument.  None.  Empathy does not disappear when we accept the diagnosis of mental illnesses unless we have a completely distorted understanding of mental illness.  Surely Dr.Breggin knows this and got carried away with his prose.

"The destructiveness of psychiatric diagnoses could fill a book. You and your loved ones, and those you seek to help can never be understood though a psychiatric diagnosis. Psychiatric diagnosis is like looking at the world through wrong end of a spiritual telescope. Instead you have to open your heart and your mind to knowing what you have endured, and the mistakes you have made, and the right choices you have made, and the good things you have done that have led you to this moment in your life. You must be ready to appreciate your life and the life of anyone you seek to help."

The destructiveness of ignorance and empty rhetoric could fill a much larger book and that book would actually be accurate.  Dr.Breggin is right in saying that an individual can not be understood through a diagnosis of a mental illness.  You know what can be understood that way though?  Mental illness.  The point here is that mental illnesses are not who we are and any clinician who attempts to understand the entirety of a person through a mental illness diagnosis is as idiotic as a clinician who attempts to understand the entirety of a person through a diagnosis of a broken leg.  Mental illnesses are not who we are - they are what we are struggling with.  Identifying those mental illnesses helps us know which treatments to use and to understand that we are not weak, weird, or alone, but rather completely human and experiencing common emotional processes that, left untreated, often linger and become more severe.  When an individual receives a mental illness diagnosis, their strengths and experiences are not pushed out of the picture.  Those variables can absolutely be assets in treatment.  Their existence, however, does not invalidate the mental illness.

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I'm sure that Dr.Breggin has pure intentions and that he is wholly devoted to helping individuals improve their lives.  Even still, his words are disturbing and have the potential to do harm as they steer people away from proper treatments and perpetuate myths about mental illness.  It angers me to no end when individuals write harmful an factually incorrect information about mental illness - particularly when those individuals are educated enough that they should have a clear grasp on the scientific evidence that completely contradicts their point.

If you are experiencing symptoms of a mental illness, please seek help.  Click on our "EST Clinics" link or call a university in your local area and ask if they utilize evidence-based treatments.  If you have a bad experience with an individual who utilizes such approaches, try another therapist before you give up on the process.  Additionally, 1-800-273-TALK is always available if you are in a crisis.

If you would like to learn more about the topics discussed on Psychotherapy Brown Bag, please consult our online store for scientifically-based psychological resources.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University and a resident at the University of Mississippi Medical Center

Movin' on up....

Greeting PBB readers.  Just a quick heads up that the site will not likely have any new posts for a week or so, as Joye and I are beginning the process of moving to Mississippi, where I will complete my internship year.  Once we're settled in our new place and we have internet access there, things will return to normal.  In the meantime, I will continue to get notifications when you make comments on any of our articles and I will be able to publish them (although I will not be able to reply).

One thing that I think might be fun would be to leave a few open ended questions here for folks to discuss, essentially turning this into a message board for a week.  In other words, feel free to go a bit off topic on the comments as long as they are within the bounds of what we have laid out as acceptable in the past.  So, if there is something else you want to discuss/debate with fellow readers beyond these questions, go ahead and put it out there.

That being said:

(1) What do you think are the pros and cons of using iPhone apps to assist with or even perform psychotherapy?

(2) Should researchers be able to sell their measures or should the most sound measures be available for free to whoever wants to research mental health?

(3) Would it be possible to have a popular television or radio show about mental health that is rooted in science, or is it the non-scientific ideals of popular shows that make them popular in the first place?

(4) If an individual with a mental illness is informed of the data supporting (or not supporting) a particular form of therapy and tells his or her therapist that her or she prefers a treatment not shown to work (or shown not to work), is it ethical for a therapist to provide that form of therapy?

(5) Should there be multiple degrees (Ph.D, Psy.D) for people looking to perform the same job or should education be more standardized within the field?

(6) Will the Pittsburgh Pirates ever have another winning season? (sorry, that's probably only interesting to me)

Again, feel free to raise issues completely unrelated to these random questions I just put together.  Just keep things civil, remember this is a forum for education and discussion rather than a resource for therapy, and have patience if it takes me a while to see that your comment has arrived in my inbox for approval. 

Have a great week!

Mike Anestis

New research on suicide in the military

by Michael D. Anestis, M.S.

Suicide in the military has been one of the central components of my research over the past few years.  In doing this, I have been privileged to collaborate with some amazing psychologists, some of whom are members of the military and some of whom are not.  Late last year, Chad Morrow of the United States Air Force contributed a guest article about a study that several of us published examining suicide in Air Force personnel (click here to read the article).  Today, I would like to quickly discuss an article published  in the Journal of Clinical Psychology by PBB guest author Craig Bryan, PBB guest author Kelly Cukrowicz, Christopher West, and PBB guest author Chad Morrow (in press).  I'm not going to repeat all of the information about the interpersonal-psychological theory of suicidal behavior, so if you are unfamiliar with the theory, I encourage you to read our previous discussions before going further here.

In this particular study, Bryan and colleagues (in press) compiled a sample of 522 service members deployed in support of Operation Iraqi Freedom (OIF).  This, in and of itself, is a big deal, as previous research on the interpersonal-psychological theory in military samples have involved case studies or personnel not yet deployed.  151 of the participants were referred to an in-theater traumatic brain injury (TBI) clinic, 44 self-identified for routine services in an in-theater mental health clinic, and 327 took part in baseline psychological testing in case of future head injuries during deployment.  The sample was thus a mix of clinical and non-clinical cases.

The authors hypothesized that combat exposure would predict the acquired capability for suicide, but would not predict either of the components of the desire for suicide (thwarted belongingness and perceived burdensomeness). In order to be sure that any relationship between combat exposure and the theory components was not better accounted for by other variables, the authors controlled for gender, past suicidality, PTSD symptoms, and depression symptoms.

So what did they find?  Combat exposure did, in fact, significantly predict the acquired capability, although it accounted for only a small portion of the variance. In other words, combat exposure accounted for some degree of why different individuals scored differently on the acquired capability, but other variables play a bigger role.  The authors raised some interesting thoughts as to why this might be the case.  First of all, it is entirely plausible that the intensive training that takes place prior to deployment into combat could elevate the average level of the acquired capability high enough that combat exposure does not add all that much to what has already been gained.  Alternatively (or additionally), it might be that individuals who enroll in the military already have the elevated physiological pain tolerance and diminished fear of death that comprise the acquired capability.  Here again, because initial levels are already so high, it might be difficult for combat exposure to account for all that much variability.  Future research utilizing a number of time points, tracing the progress of individuals' acquired capability from the time they enter the military (or before) would help us answer this question.

Bryan and colleagues (in press) also found that, as expected, combat exposure did not predict the desire for suicide.  Keep in mind that the current state of affair, in which suicide rates in the military are higher than civilian rates, is unique in history.  Traditionally, the opposite has been true and many have explained this state of affairs to the fact that soldiers often form strong bonds with fellow soldiers (increased belongingness) and feel that they are making an important contribution to the world (decreased burdensomeness).  As a result, although soldiers develop a vastly enhanced capability for suicide, they do not necessarily ever experience the desire.  Combat exposure on its own, it seems, does not account for increases in that desire.  Instead, when solders experience suicidal ideation, this is better accounted for by depression symptoms, PTSD symptoms, and a number of other related but distinct ideas.

So what does this study tell us?  It appears that when soldiers are exposed to combat, their capability for enacting lethal self-harm increases.  Their desire for suicide, on the other hand, is unrelated to combat exposure.  Future research will tell us more about the mechanisms that drive suicidal behavior both in the military and in civilian populations, but this study marks an impressive step forward in empirical investigations on suicide in this particular segment of the population.

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If you would like to learn more about suicide or other topics discussed on Psychotherapy Brown Bag, we hope you will consult our online store for scientifically-based psychological resources.  Additionally, if you or anyone you know is experiencing thoughts of suicide, please remember that 1-800-273-TALK is a free, 24/7 service available to those in need.

Mike Anestis is a doctoral candidate in the clinical psychology department of Florida State University and an incoming resident at the University of Mississippi Medical Center.

Great conversation about the need for science in psychology training programs

I'll be adding a new post in a bit, but I wanted to call your attention to the great conversation unfolding in the comment section of our recent article on whether or not universities should be required to build their psychology training around science (Seth Gitter currently has my favorite comment of the bunch).  I don't want this conversation to stall, so my hope is that readers will continue to add their own thoughts, experiences, and opinions.  You should not feel shy about adding contrasting views. In my opinion, this conversation is remarkably important, so let's see if we can keep it going here.

To add your thoughts, click on this link, scroll down to the bottom of the article, and write your comment.  All comments are sent to me before they get published, so when you submit, it will simply disappear for a bit until I stumble upon it in my inbox and set it up to be published.