In reading a recent article in the New York Times by L. Alan Sroufe of Minnesota’s Institute of Child Development, I had a strong sense of deja vu. Based on his literature reviews of treatment programs for ADHD symptoms, along with 30 years’ experience conducting his own longitudinal studies, Dr. Sroufe concludes that there is no evidence to support the “inborn defect” theory of attention deficit disorder and no lasting benefit to be had from taking Ritalin, Adderall and other drugs commonly prescribed for attention deficit disorder. It so reminds me of the scientific controversy around the chemical imbalance theory of depression, detailed by Robert Whitaker in his book The Anatomy of an Epidemic, and his conclusion that there is no evidence to support it, and no lasting benefit from the long-term use of anti-depressants.
According to a recent article in the New York Times, the revision to the APA’s Diagnostic and Statistical Manual currently underway will reconsider not only the personality disorders (rumor has it that Narcissistic Personality Disorder may be eliminated) but also the autistic disorders. In particular, it looks as if Asperger’s Syndrome will be eliminated as a separate diagnosis and subsumed within the more tightly focused Autism Spectrum Disorder. Read the entire article for an understanding of how the skyrocketing medical and social costs of treating autistic disorders are driving this revision, at least in part.
This change once again throws into question the validity of psychological diagnosis as a scientifically precise methodology. If Asperger’s Syndrome can be written out of the DSM by committee, one has to wonder if it was ever as distinct a disorder as many people have wanted to believe. Even though I object to the very idea of a diagnosis manual akin to the ICD-10, I’m moderately hopeful that the current revision to the DSM is a step in the right direction: the new name, at least, seems to acknowledge that there’s an entire spectrum of autistic disorders. Still, with its focus on symptoms and behaviors (rather than psychodynamic process), this new Autism Spectrum Disorder continues to reflect the kind of pseudo-scientific precision that characterizes the APA and all its efforts.
In working on my book about defense mechanisms, it has become increasingly clear to me that the problem with modern psychiatry is its renunciation of its psychodynamic roots. Whereas psychoanalytic thinking once dominated the American Psychiatric Association of 50 years ago, the continuing revision to the DSM that began in the 1970s has “re-medicalized” psychiatry — that is, made it more scientific, with identifiable diseases leading to sanctioned cures. Psychodynamic thinking has been written out of the clinical picture so that today, we talk about bipolar disorder, borderline personality disorder and post-traumatic stress disorder as if each was as consistent and identifiable a medical syndrome as diabetes, but with no understanding of their underlying psychic processes. (For more on the medicalization of psychiatry, see Robert Whitaker’s excellent book, The Anatomy of an Epidemic, which I reviewed in a series of three articles, beginning with one on the chemical imbalance theory of depression.)
An interesting study reported in Sunday’s New York Times disputes a widely-accepted belief: that will power depends largely on chemical events in the body, especially in connection with glucose, and that it’s more or less beyond our conscious control, a question of biology rather than self-discipline. This new study found that people who believe willpower actually is limited perform significantly worse on assigned tasks than people who believe it is not limited. In other words, will power and self-control are limited only if you believe they are. It’s an interesting piece, and not very long — you might want to read the whole thing.
As I was reading this article, it resonated with my familiar objections to the diagnostic labels contained in the DSM-IV, as well as to the theory holding that mental illness is the result of a chemical imbalance in the brain. The use and abuse of psychological diagnosis, to begin with, makes people believe they have a recognizable disorder, akin to a medical syndrome, and that it’s beyond their control to do anything about it. If you are told and believe you suffer from borderline personality disorder, that it’s a lifelong malady you can do little to modify, then you have no reason to struggle with it and try to gain insight. If you are told and believe you suffer from Asperger’s Syndrome, you won’t try to understand the particular nature of your defense mechanisms and to confront what lies beyond them. In my experience, providing a psychological diagnosis to people essentially deprives their suffering of its meaning, discourages them from self-exploration and encourages a sort of passivity. “I have Asperger’s Syndrome — what can I do?” I don’t mean this as a criticism. When the medical establishment, the media and just about everything in our culture supports this view, why should anyone believe otherwise?
The chemical imbalance theory is even worse. Because people are told and believe that their symptoms of depression, their panic attacks or their bipolar disorder symptoms all result from chemical irregularities in their brain chemistry, they have no reason to dig in and do the hard work of self-exploration. It’s a chemical imbalance; I was born that way and I need to take a pill to rectify it, like my doctor said. One of the beneficial side-effects of the medicalization of mental health is removing much of the stigma from mental illness, especially as celebrities such as Catherine Zeta-Jones have publicly acknowledged their struggles with bipolar disorder and other issues. But in the face of the relentless public relations push for psychiatric medication as the answer to all forms of mental illness, few people have the will power and self-control to struggle with their inner conflicts. They have been told that will power and self-control are irrelevant — it’s all about your biology — and so they believe they can do nothing to help themselves get better.
There are some bright spots in the mental health profession. Cognitive Behavioral Therapy provides depressed clients with some useful techniques for coping with their negative self-talk and self-defeating behaviors — in other words, it assumes that you can make a difference in your state of mind by exerting effort. Will power and self discipline are necessary parts of the work. Dialectical Behavioral Therapy appears to be effective in reducing suicidality, substance abuse and hospitalizations with borderline personality disorder, using a highly structured program to help clients develop a degree of self-control where impulsive behavior is concerned. Neither treatment modality explores the meaning of the client’s symptoms, however, or helps them access their unconscious dynamics. Both reduce people to a recognizable syndrome that can be treated with a uniform approach, in the process accepting severe limitations on what is possible to achieve through psychotherapy.
Assumptions by the therapist as to what is possible for any given client will naturally have a profound impact on the treatment. If therapists believe they can do little to help a borderline client, they will communicate such a conviction to that client, who will then come to believe it as well. If a therapist believes that his or her client’s depression is the result of a chemical imbalance, both therapist and client will come to share limited expectations for what their work together can accomplish. Everywhere I look within my profession, I see evidence of this acceptance of limitations, a kind of widespread learned helplessness in the face of mental illness, a rejection of the long hard work involved in psychodynamic psychotherapy. I’m not advocating a return to the era when we blamed people for their difficulties, when our culture viewed mental illness as a weakness, a lack of will power, the failure of self-discipline; but the pendulum has swung too far in the opposite direction, so that we no longer expect anyone to take responsibility for their struggles.
It’s a medically-recognized syndrome, a chemical imbalance — you can’t help it. When you accept such a belief, you’re like the subject in that study from the NYT article, who did significantly worse on assigned tasks when they believed their own will power and self control were limited.
The fees we charge for psychotherapy, as discussed in the last two posts, also link to some ethical considerations that arise when psychotherapists accept health insurance for payment. I’d like to discuss my experience in this area and invite my colleagues to share theirs. I’d also like to hear how other readers who’ve been in treatment feel about these issues.
It’s been quite a while since I’ve accepted insurance, so this first issue may now be moot. Earlier in my career, when insurance carriers offered more generous mental health benefits, it wasn’t unusual for a policy to pay 80% of the provider’s fee up to a fairly high limit. Thus if my fee were $100 per session, it would pay $80 and the client would pay $20 out-of-pocket. The maximum coverage used to be higher than what I actually charged. On several occasions, I had clients ask if I would provide them with a bill that over-stated my charges so that the insurance company would reimburse me for the full amount of my actual fee; the client would pay nothing out-of-pocket.
Thirty-five years ago, I received a phone call from my friend Lily about a car accident involving a mutual friend of ours, Terry. The three of us had just graduated from UCLA the week before. Terry, along with her sister, brother-in-law and niece, had gone on a trip to the Colorado River. En route, along a two-lane highway, another vehicle tried to pass them and the line of cars ahead. The driver mis-calculated the distance and as a result, a semi-truck coming from the opposite direction swerved to avoid the passing car, struck our friends’ car and instantly killed Terry’s sister, brother-in-law and niece. Terry survived but suffered severe and irreparable brain damage.
I had given up my apartment following graduation and was briefly staying with my parents before leaving on a long trip. When I came out of my room after the call, deeply upset and in tears, my mother immediately went to her bathroom and returned with a blue, 10 mg Valium tablet which she pressed into my hand. Her response to my grief was to offer me the same medication she used to keep her own pain sedated. I hadn’t thought about that incident in years, but recently, in considering some of the wrong reasons people take antidepressants, the memory came back to me.