Letting go of hubris and learning from clients

Maddux & Winstead (2008) report that clinicians do not show better clinical judgment than a lay judge. Furthermore, although clinicians believe that their clinical experience increases their diagnostic ability, the research shows that this is not true (Maddux and Winstead, 2008). "The relation between clinical experience and judgmental accuracy has been weak in most studies of personality and psychopathology assessment” (Maddux & Winstead, 2008, p. 114).

I have noticed that a disturbing number of mental health professionals believe that their degrees and experience qualify them to diagnose people and determine all kinds of things about them without spending very much time with them or sometimes without even meeting them. Just today I had a counselor tell me that my client obviously does not need disability benefits based on very little information that I provided. I have spent hours interviewing this particular client to determine if she meets Social Security's requirements for said benefits, but this person believes she can determine this based on one sentence! I wish I could say that this is the first clinician whom I've witnessed exhibit such hubris, but that's far from the case.  

I have a theory that there is potential for clinicians to learn from experience if we stop assuming that we know so much from the beginning. As a profession, if we assume less about clients and stop trying to figure them out with increasing speed, and instead keep an open mind and listen, we can indeed learn from experience. This experience however, should never cause us to reach the point where we believe we cannot learn more from our clients. I am reminded of a quote: "Knowledge speaks. Wisdom listens."

Maddux, J.E., & Winstead, B.A. (2008). Psychopathology: Foundations for a contemporary understanding (2^nd ed.). New York, NY: Taylor and Francis Group. 

James Holmes: an example of why we need diagnosis?

Someone recently suggested to me that diagnosis is necessary because of violent individuals like James Holmes, perpetrator of the recent shooting in Aurora, CO. This person said, "We must be able to define abnormal behavior which monumentally affects the individual and poses a threat to society... [James Holmes] clearly is mentally ill and probably has an identifiable psychological disorder." This person is making the assumption that (1) James Holmes was not diagnosed and did not receive treatment prior to the shooting and (2) if only he had been diagnosed, he would have received treatment that (a) helped him and (b) would have prevented the shooting. The person is also conflating mental illness and violence. While I agree that it is part of the role of mental health counselors to address and prevent violence, I think we are treading on dangerous territory and promoting stigma when we are not careful to differentiate mental illness from violence. See my earlier post, America's Gun Problem is Not About Mental Illness. 

James Holmes saw at least three mental health professionals before his crime. Unfortunately, the right steps were not taken to help this man or prevent his crimes. I do not know whether he was taking psychiatric medications, but there is also the issue of akathisia, a side effect of some psychiatric medications that has been linked to violence and suicide by a number of professionals, including psychiatrist Peter Breggin, author of (among other things) Medication madness: The role of psychiatric drugs in cases of violence, suicide and crime. James Holmes told a classmate four months in advance that he wanted to kill people. I do not know what, if any, label James Holmes received from the mental health professionals he saw, but for me his case is not a question of his diagnosis. My question is, how can we educate society so that people such as his classmate, who knew of Holmes' plans months in advance, know what to do with such information? And much more importantly, how could the mental health system have better engaged Holmes when he was at the door, finding ways to heal him so that he could feel at peace, for his own good and that of all the lives later lost in Aurora? I don't know the answer, but I do know that it does not lie in the DSM. 

Apples and disorders

Can we define psychological disorders? Should we try?

We can never really truly define what constitutes a psychological disorder, but this hasn’t stopped us from trying. I think the trend away from categories and toward dimensions will further our understanding, but it doesn’t and cannot eliminate all barriers to clarity because a psychological disorder can never be as easily pinpointed as say, an apple. This is in part because there is not as much at stake in the definition of an apple. As David Patrick concluded, “the concept of mental disorder is of dubious scientific value but it has substantial political utility for several groups who are sane by mutual consent” (qtd. in Maddux & Winstead, 2012, p. 15). Every single person on the DSM-IV workgroups responsible for the definition of mood and psychotic disorders received funding from pharmaceutical companies (Maddux & Winstead, 2012). Although most of those people may truly believe that psychological disorders are caused by (yet to be discovered) chemical or genetic imbalances that can only be corrected with medication, this, too, is a problem, because disorders are being defined based on the limited views of one profession, with less consideration to the views and experiences of counselors, psychologists, and particularly consumers. This is by design, because “the purpose of DSM-III... was to allow psychiatry a means of marking out its professional territory” (Maddux & Winstead, 2012, p. 15). When people define disorders so that they can get in or remain in power and/or profit, our understanding remains clouded. Other obstacles to definition include vast differences in disorders between different cultures and individuals. Yet we can do our best to define psychological disorders by continuing to revisit the issue and looking at various perspectives, rather than remaining frozen in one viewpoint. We need more thinking, for example, about why third world countries have much higher rates of recovery from schizophrenia than first world countries. What can we learn that will help us better define psychotic disorders and improve worldwide rates of recovery? The Psychodynamic Diagnostic Manual (PDM Task Force, 2006) is another step toward a deeper understanding, offering a complementary (or alternative) perspective to the DSM.

A related question tugs at my mind. While we are defining disorders, why are we choosing to define them as disorders? Why must we see people with mental health challenges as broken? I see people with mental illnesses as coping as best they can with psychological, social, spiritual and biological challenges. Evidence of post-traumatic growth (Woodward & Joseph, 2010) and post-psychotic growth (Williams, 2012) indicates that what we view as disorders are often healing in and of themselves. The mere idea of disorders assumes a mechanistic rather than naturalistic viewpoint. I see therapists not as mechanics but as guides and supporters along a challenging path of healing. 

Maddux, J. & Winstead, B. (2012). Psychopathology: Foundations for a contemporary understanding (3rd ed.). New York: Routledge, Taylor & Francis Group. 

PDM Task Force. (2006). Psychodynamic diagnostic manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations. 

Williams, P. (2012). Rethinking madness: Towards a paradigm shift in our understanding and treatment of psychosis. San Rafael, CA: Sky’s Edge Publishing. 

Woodward, C. & Joseph, S. (2003, September). Positive changes and post-traumatic growth in people who have experienced childhood abuse: Understanding vehicles of change. Psychology and Psychotherapy: Theory, Research and Practice, 76(3): 267-283. doi: 10.1348/147608303322362497. Abstract retrieved from http://onlinelibrary.wiley.com

Diagnosis: Helpful yet destructive

     I am inclined to agree with therapist Daniel Mackler, who wrote, “The diagnostic categories we presently use are so often arbitrary, misleading, stigmatizing, or just downright wrong (and at times all of these) that they end up doing far more harm than good” (2011, Abandon Diagnosis and the DSM section, para. 2). Because our society would have to change much more drastically than can be expected in the near future, however, I think Mackler’s call for an abandonment of diagnosis is premature. Diagnosis plays a small, valid role in psychotherapy, but it must be “applied properly and its limitations... understood” (Frances, 2010, Afterword, para. 1).

  Diagnosis can lead to discrimination by society, the justice system, the insurance industry, and even the mental health system. (If you don’t believe the latter, ask anyone with borderline personality disorder.) 

  Mackler argues that there are three groups who benefit from DSM diagnosis: (1) the pharmaceutical industry, (2) psychiatry, and (3) some consumers. As Frances points out, “biological psychiatry has failed to produce quick, convincing explanations for any of the mental disorders” (2010, The Epistemological Game section, para. 4), yet most people believe that behind each and every disorder is a meticulous biological explanation that will direct them to a quick pharmaceutical solution. Far too much weight is placed on diagnosis and the related drug treatment. Diagnosis can also provide some relief for consumers, but in my experience this relief often seems more like resignation. Mackler articulates a similar experience: 

...the saddest group to benefit from diagnosis is a not insignificant subset of consumers themselves:  those who are so broken, both by the traumas of their childhood and the traumas they’ve suffered at the hands of psychiatry, that they have lost hope. Diagnosis gives them an excuse not to have to struggle anymore.  It tells them that their brains are hopelessly broken and that they can never recover.  And far too many find a tragic comfort in that.

  Diagnosis does not need to be associated with the myth that recovery is impossible, however. It can serve a limited, positive role that allows therapists and researchers to share a common language, points in a very general direction to treatment options, and allows people to obtain needed disability benefits and treatment. Yet far more important than the label we fix to each person is their individual story. If we can remember this,  make sure our clients understand it, and most of all listen carefully, we may be able to use diagnosis for good rather than evil. 

References

Mackler, D. (2011). Ten ways to revamp the mental health system. Retrieved from http://www.iraresoul.com/RevampMH.html

Frances, A. (2010). DSM in philosophyland: Curiouser and curiouser. Bulletin of the Association for the Advancement of Philosophy & Psychiatry , 17(10).