Originally published 02/20/2017 10:34 pm ET @ http://www.huffingtonpost.com/entry/58abb3b0e4b0417c4066c22b
Once you know a crucial fact about what gets called mental illness, the debate about whether or not President Donald J. Trump is mentally ill disappears, and what is left is what really matters. What really matters is that President Trump apparently has no desire to change behavior that has been described as totally self-absorbed, self-referential, misogynist, racist, xenophobic, and otherwise abusive.
It’s ironic that the arguments on both sides of the debate about whether or not Trump is mentally ill are based on the one “alternative fact”: that deciding who is mentally ill is a science. That could not be farther from the truth.
Those who are arguably the world’s most powerful psychiatrists — those who periodically create and publish a new edition of the psychiatric handbook called the Diagnostic and Statistical Manual of Mental Disorders (DSM) — typically acknowledge that the foundational premise of the entire book, that it is possible to define “mental illness” in an adequate, appropriate, and useful way, is wrong. In each edition of the DSM, the new set of arbiters tries to create a definition of “mental illness,” since the book consists of hundreds of alleged categories and subcategories of mental illness and thus depends on their getting that primary definition right. Each time, they have acknowledged their failure to do so. Even Allen Frances, who oversaw creation of the DSM edition that held sway from 1994 to 2013, famously called psychiatric diagnosis “bullshit” (cited in Gary Greenberg’s excellent Book of Woe from his article in Wired based on his interview with the psychiatrist).
As far as I can tell, no one else weighing in on the debate about the President has served on a DSM Task Force...and then felt they had to withdraw because of what they had learned. I spent two years as an insider on Allen Frances’s Task Force, where I learned that — despite what is widely assumed to be true — psychiatric diagnostic categories are not scientifically derived but are constructed, made up by the handful of people with the most power in the DSM hierarchy. When Frances in various media currently gives the impression that he is uniquely qualified to judge President Trump because he wrote the criteria for Narcissistic Personality Disorder (NPD), the label that many therapists have recently applied to him, Frances neglected to note that the criteria for NPD change with every edition. Frances changed them somewhat from the DSM edition that came before his, and the NPD criteria in the edition subsequent to his — the currently in use DSM-5 — differ from his. These changes reflect the moving-target nature of this label.
The changes over time in how NPD is defined are important, because to debate about whether or not the President has NPD is to reify misguidedly and harmfully the notion that there is a scientific way to find out. I resigned from the DSM-IV Task Force because I could not participate in the creation of a book that would be marketed as scientific when I knew that it was not — and that would garner more than $100 million for its publisher, the American Psychiatric Association, and help Big Pharma earn billions of dollars for psychiatric drugs marketed as curing the ever-growing number of manufactured categories.
Some people try to prove that Trump does not have NPD on the grounds that his self-centeredness and so on do not cause him to suffer; but even that argument is irrelevant, because no version of NPD has specified that in order to “qualify” for this label, one has to be suffering because of its features.
Do people suffer and deserve help to alleviate that suffering? Of course, they do, and that is the subject of many books and other articles. But the research about how that is best done — what behavior, feelings, and/or thoughts can be changed — and what cannot is a side issue for our purposes here, because there is not a shred of evidence that President Trump wants to change. Remember that old joke: “How many therapists does it take to change a light bulb?” “One. But the lightbulb really has to want to change.”
There is great debate among therapists about whether or not any personality disorders belong in the manual of mental illnesses, since it is an arbitrary decision left to each individual therapist whether or not a particular patient’s personality is extreme enough to qualify as a disorder. To engage in the attempt to decide whether or not President Trump has NPD is to act as though that label is clearly a description of a mental illness, however one defines “mental illness.”
Some believe that if they were to prove that the President is mentally ill, it would be easier to turf him out of office. But it was morally wrong that Senator Thomas Eagleton was removed as George McGovern’s vice presidential running mate in 1972 when it became publicly known that he had suffered from bouts of depression and had been hospitalized for that reason, because what should have mattered for him and should matter for all elected officials is how well they can do their jobs. Eagleton had been a great Senator. Whether or not one believes that Trump is doing his current job well depends partly on whether or not you share his views of the world, partly on whether or not he is truthful with the people of this nation (many Presidents have not been), and partly on how he manages his various tasks.
At this crucial time in our nation’s history, the last thing we need is to let debates about whether or not the President is mentally ill divert us from deciding whether or not he is doing his job, whether or not we like what he is doing, and whether or not what he is doing is dangerous or evil.
Author’s note: I am the author of They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal, which is my insider’s description of the process of creating the book that is called the psychiatrist’s “Bible” and is used to determine who is mentally ill. I am editor of Bias in Psychiatric Diagnosis and have written many articles and book chapters about psychiatric diagnosis, which I would be happy for people to read.
Paula Joan Caplan's Authors Guild Blog
Originally published 02/20/2017 10:34 pm ET @ http://www.huffingtonpost.com/entry/58abb3b0e4b0417c4066c22b
Thanks to writer/performer/activist Eve Ensler, Valentine’s Day has become a time to advocate for women. However, what has been starkly missing from the tsunami of media stories about and petitions protesting a vast array of Trump administration actions and projected actions has been anything about violence against women. Senator Jeff Sessions, soon to become Attorney General of the United States, voted against funding for the Violence Against Women Act, and President Donald Trump reportedly plans to ignore and even punish women, men, and children who are victims of violence by eliminating the funding of the Violence Against Women Act. And in light of the combination of the President’s history of treatment of women and his continual expressions of respect for Russia, the Russian parliament’s recent, overwhelming vote to decriminalize domestic violence eerily resonates with these portents.
Media coverage of frightening budget cuts Trump plans for other programs has been generous, but media coverage of the plan to wipe out funding for services to victims of family violence has been sparse to nonexistent, reflecting the often hidden nature of the latter. It is ironic that such violence is comprised of one set of phenomena that could accurately be called a part of what Trump refers to as “American carnage.”
Chances are, domestic violence victims were disproportionately absent from the recent, remarkable Women’s Marches, because typical effects of violence on victims include impaired mobility in the world, reduced finances, and emotional paralysis due to fear of inciting the anger of the perpetrators. Few abusive men want their women victims to march for women’s rights.
Reports from reliable media reveal that President Trump has been working closely with the Heritage Foundation, a conservative think tank, and is likely to follow its proposals for budget cuts that would include eliminating — not reducing — funding for the Violence Against Women Act (VAWA), which then-Senator Joe Biden shepherded to passage in 1994. Already, what used to be the White House’s online fact sheet about the VAWA has vanished from https://www.whitehouse.gov/sites/default/files/docs/vawa_factsheet.pdf, where that URL now yields only this message: “Thank you for your interest in this subject. STAY TUNED AS WE CONTINUE TO UPDATE WHITEHOUSE.GOV.”
Eliminating VAWA funding would disproportionately deprive poor women, immigrant women, women from racialized groups — and many women who are disabled due to abuse — of ways to escape from further violence. Tragically ironic, given President Trump’s apparent focus on reducing costs, is that the VAWA has saved both the nation as a whole and individual states enormous amounts of money. According to the National Network to End Domestic Violence, “In its first six years alone, VAWA saved taxpayers at least $12.6 billion in net averted social costs,” and in a recent study of a single state, Kentucky, “civil protection orders saved an average of $85 million a year.” http://nnedv.org/policy/issues/vawa.html As for savings in human costs, within the Department of Justice, actions funded by the VAWA addressed to domestic violence, sexual assault, dating violence, and stalking have led to dramatic increases in reporting of violence by both women and men, and the numbers of deaths due to intimate partner violence has decreased since 1994 by 34% for women and 57% for men, while non-fatal domestic violence has decreased by 67%.
In spite of these gains, these kinds of violence continue at epidemic levels. In light of President Trump’s focus on saving money and saving jobs, it is important that the costs of intimate partner violence exceed $8.3 billion a year, that victims of intimate partner violence lose a total of 8 million days of paid work yearly, and between 21 and 60% of such victims lose their jobs for causes that stem from that abuse. http://psycnet.apa.org/journals/ocp/12/2/136/ And because, according to the World Health Organization, victims of abuse are more likely than other people to become addicted to alcohol, tobacco, or drugs, this increases the human and the financial costs of such violence. http://apps.who.int/iris/bitstream/10665/85239/1/9789241564625_eng.pdf?ua=1
According to the National Coalition Against Domestic Violence, http://www.ncadv.org/learn-more/statistics, intimate partner violence accounts for 15% of all violent crime. In one year, more than 10 million women and men are physically abused by an intimate partner in the U.S., 1/3 of women and 1/4 of men have been victims of some physical violence by an intimate partner, and for severe physical violence, the figures are 1/5 of women and 1/7 of men. These kinds of violence increase rates of suicidal behavior. Domestic violence hotlines receive an average of more than 20,000 phone calls a day. One-fifth of women have been raped, and 1 in 15 children are exposed to intimate partner violence annually, with 90% of those children being eyewitnesses.
Because of the physical injuries and psychological suffering from which so many of these victims of violence suffer, as well as from their intimidation into silence by their abusers, it is up to the rest of us to speak up loudly and unceasingly to stop the infliction of violence-by-budget-cuts on those who have already been harmed and those who will be in the future. A small but important Valentine gift the Trump administration could give would be to get the facts about violence against women back up on the White House’s website. A greater gift would be for the President and Congress to show real heart and publicly and proudly commit to fully funding the VAWA.
Please note: Reports from reliable media mentioned above include http://www.newsweek.com/donald-trump-violence-against-women-federal-funding-budget-cuts-544710 and to http://thehill.com/policy/finance/314991-trump-team-prepares-dramatic-cuts, among others.
Despite the fact that no one in history, not even the omnipotent American Psychiatric Association -- which produces and profits mightily from the "Bible" of mental disorders -- has come up with a halfway good definition of "mental illness," and despite the fact that the process of creating and applying the labels of mental illness is unscientific, any of those labels can be used to deprive the person so labeled of their human rights. This is terrifying. It ought to terrify those who are so labeled and those who are not, because deprivation of human rights on totally arbitrary grounds is inhumane and immoral.
The combination of the specter of terrorism and highly publicized incidents of gun violence have led rapidly to politicians, therapists, and the general public blaming "the mentally ill" for these dangers, and that is used to justify depriving not just terrorists and other killers but anyone with a label of mental disorder of their rights. They can be locked up against their will, they can be ordered to comply with just about anything that a professional calls "treatment of the mentally ill," no matter how these actions can harm the person and in the absence of scientific evidence that the "treatments" of people who have been psychiatrically labeled will prevent violence. In other words, the huge leap is often made from "This person has a psychiatric label" to "This person is therefore dangerous to themselves and others," even in the absence of any history or current indication of such dangerousness, and that leap is then used to lock people up and/or otherwise "treat" them against their will.
Now the United Nations human rights treaty called the Convention on the Rights of Persons with Disabilities includes the absolute prohibition of forced commitment and forced treatment, and the brilliant and tireless advocate Tina Minkowitz is leading a campaign to show that there is a wide base of support for these prohibitions. This is especially important in the United States, because 162 nations have ratified the CRPD, but the U.S. has not.
Minkowitz worked on drafting and negotiations for the treaty from 2002-2006 and helped ensure the incorporation in the CRPD of Article 12, which says that "states," countries and national governments bound by international law recognize that people with disabilities have the right to make their own decisions in all aspects of life and to do so free from coercion. Note that "people with disabilities" applies to anyone who has received a diagnosis of any mental disorder (in addition to other disabilities). It is important to note the CRPD's Article14, which specifies according to the text and the authoritative interpretation by the Committee on the Rights of Persons with Disabilities that the existence of disability or perceived disability cannot be used to justify deprivation of liberty, and Article 25 requires that healthcare be provided on the basis of free and informed consent. The word "perceived" is crucial, in light of the fact that the ballooning numbers of categories listed as mental disorders in the two primary handbooks used to classify people as mentally ill have made it possible, even likely, that anyone entering a therapist's or other professional's office in other than a calm and happy state will be diagnosed as psychiatrically disordered, moving just about anyone into the "perceived as disabled" category. So one crucial myth that is relevant to the CRPD is that psychiatric diagnoses are scientific and usually appropriately applied.
If no harm came from being classified as mentally ill, there would be less cause for alarm. But it is easy, even likely, for laypeople, therapists and other healthcare professionals, and judges to assume wrongly that having a disability (even a perceived disability) means that one's judgment is impaired and that one should not be allowed to make choices about their lives, their bodies, and the treatments to which they will be subjected. Frequently, the criterion of "dangerous to oneself and/or others" is used to justify forced commitment or forced treatment, and this is done despite the proven fact that people diagnosed as mentally ill are actually less likely than others to commit acts of violence and more likely to be victims of violence. The evidence for this pattern is all the more remarkable, given that for a number of reasons (e.g., defense attorneys trying to get psychiatric labels for their clients in order to obtain reduced sentences or diversion from prison to the mental health system; the skyhigh frequency of prisoners being diagnosed as mentally ill so that they can be heavily medicated and thus reduce the need for prison staff), statistics in the near future are likely to show an increasingly high correlation between psychiatric labels and violence. Thus, two other crucial myths that are relevant to the CRPD are that people who have received psychiatric labels are likely to be incompetent to make choices about their lives and that they are more likely than other people to be violent.
A fourth crucial myth is that forced commitment and forced treatment are beneficial (and, by implication, not harmful). That this is a myth is reflected in the high rates of suicide that follow inpatient treatment and the increased rates of suicide caused by many psychiatric drugs, as well as the plummeting rates of recovery and increased rates of longterm disability that have followed the introduction of various psychiatric drugs into the market and the use of electroshock.
Another myth is this: The important word "orthogonal" applies to the question of whether people diagnosed as mentally ill are able to make their own choices and whether they have good judgment. We all know people who have no psychiatric labels but who make terrible choices and poor judgment, yet those limitations are not used to deprive the of their human rights. These capacities are orthogonal to whether or not one has been diagnosed as mentally ill, meaning that knowing whether or not a person has a diagnosis is simply not a predictor of their judgment and ability to make good choices for themselves. A related myth is that if someone is diagnosed as mentally ill, all of their decision making power must be wrenched away from them, when -- as with many people who are not so diagnosed -- sometimes what the person needs is a little support of various kinds, including assistance with filling out forms or practical help with cooking or shopping or getting a service animal during times when they are struggling.
The CRPD standard is for people who have or are perceived to have disabilities must be provided the opportunity to give free and informed consent. That is very far from what happens with the vast majority of people treated by psychotherapists, not to mention those who are deprived of their human rights. Consider this: Psychiatric diagnosis is the bedrock, the first cause of everything bad that happens to people in and through the mental health system. If they do not diagnose you, they cannot treat (or "treat") you, whether or not the treatments are helpful to you. But almost no one who enters a therapist's office is ever fully informed and thus almost no one is put in a position where they even might give informed consent. Why? There are three reasons:
(1) They are almost never told, "In order for your insurance to pay my bills, I will have to give you a psychiatric diagnosis, but you have the right to know that psychiatric diagnoses are unscientific, that getting one does not help alleviate suffering, and that getting one carries a wide array of risks of harm, from plummeting self-confidence to loss of employment and of child custody and of security clearance...even to death from treatments that are justified on the basis of your label."
(2) They are almost never told, "I am recommending Treatment X, but I am going to tell you everything about the potential benefits and potential kinds of harm that can result." The reason they are almost never told this is that these days, the vast majority of treatments are with psychiatric drugs, and lawsuits have repeatedly revealed that the drug companies purposefully conceal much of the harm, so there is no way for conscientious therapists to get that information and thus no way for them to convey it to their patients. Something similar happens with electroshock and with expensive but intensively marketed programs called things like "neurobiofeedback" that have not been shown to be helpful but that are often very costly.
(3) They are almost never told, "I am recommending Treatment X, but I am also going to describe for you the huge array of approaches that have been helpful to people who are going through what you are going through ... and that often carry little or no risks of harm."
Alarmed about the lack of disclosure, which puts suffering people who seek help in the mental health system at huge risk of harm with no way even to know what questions to ask and what recommendations to challenge, I organized the filing of nine complaints to the Ethics Department of the American Psychiatric Association, because that APA publishes and hugely profits from the Diagnostic and Statistical Manual of Mental Disorders (DSM), whose categories had been used against the complaints with tragic effects. We said that if the APA had honestly disclosed the unscientific nature of its categories and the risks of harm, as well as that getting a label would be helpful largely or only in order to get insurance coverage for treatment, the complainants would not have blindly accepted their labels and the treatments that were justified to them on the basis of the labels ("You have Disorder Y, so you should accept Treatment Z, because that is what is used for people with Y"). The APA dismissed the complaints on spurious grounds and with not one iota of attention to their merits.
Five of those complainants then filed complaints with the U.S. Department of Health and Human Services's Office of Civil Rights (OCR). The complaints were filed pursuant to the Americans with Disabilities Act, according to which people can be discriminated against by being treated as though they are disabled (mentally ill in these cases) when in fact they are not. All of the complainants had been experiencing upsetting life situations but should by no means have been diagnosed as mentally ill. Yet according to the (falsely-marketed as scientific) DSM, they were mentally ill, and the treatments that were justified on the basis of their labels had had devastating consequences for them. The OCR dismissed the complaints on spurious grounds and with no attention to their merits.
The outcomes of these complaints provide a solid paper trail revealing that in the United States, the enterprise of psychiatric diagnosis is entirely unregulated. This makes it even less regulated than the major financial institutions whose unregulated actions seriously damaged the economy. The paper trail shows that both the lobby group called the APA, which earned more than $100 million from the last edition of the DSM and spent not one cent to reveal the truth about its manual or to warn of the harms they knew about, and the government entity (OCR of HHS) that by all rights ought to provide oversight and regulation, have chosen to do nothing. This makes it all the more compelling for all of us to press for the United States government to ratify the CRPD. The loss of human rights of just one of us through fraudulent advertising, cover-ups, and perpetuation of dangerous myths is the loss of human rights of us all.
As a U.S. citizen, I am embarrassed and appalled that as this country discusses whether or not to ratify the CRPD, it wants to add what are called "RUDs," reservations, understandings, and declarations created by the current federal administration and the Senate Foreign Relations Committee. According to Minkowitz, these include the claim that U.S law already fulfills or exceeds the obligations our country would have under the CRPD treaty. The above described complaints that we filed -- and the rejection of those complaints by the U.S. Department of Health and Human Services's Office of Civil Rights gives the lie to that claim, since there is simply no governmental regulation of psychiatric diagnosis, and diagnosis is the sine qua non of forced commitment and forced treatment. Read More
In the belly of the Pentagon in December, 2011, I first met Army Colonel David Sutherland, who had led a brigade during the surge in Iraq and straightforwardly told a Washington Post reporter that when more than 100 of his soldiers were killed, "I didn't like it." Knowing I had just written a book about veterans and organized a Harvard Kennedy School conference about veterans and their families, the Colonel asked if I had read the two Pentagon white papers called "The Sea of Goodwill" and "The Groundswell of Support." I had. He asked what I thought of them. Unaware that he had written them, I said with no preliminaries that I thought they were good as far as they went, that I agreed that all veterans deserve an education, employment, and health care. "However," I continued, "you can educate veterans and give them jobs and health care, but if they are isolated from their home communities, many will abuse alcohol and drugs, become homeless, and kill themselves."
I then said that I thought that the notion that there are a sea of goodwill and groundswell of support for veterans from nonveterans was lovely but largely untrue. In researching for my book, I had found few nonveterans who even wanted to think about veterans. After all, who wants to think about war? What's more, these days, veterans comprise less than 7% of the United States population, so when the small numbers combine with the social isolation of so many, the vast majority of citizens may not even know someone who served. If you don't interact -- or knowingly interact -- much with veterans, you simply don't have to think about them. I hoped against hope that I would be proven wrong about this.
Starting in the spring of 2011, I had begun blogging for Psychology Today, and in the next few years, I learned that nearly every time I wrote anything about veterans, between 30% and less than 1% as many people read those essays as read anything else I ever wrote about there. I was devastated to see the lack of support so starkly displayed in those numbers. I tried an experiment: The next time I wrote an essay about veterans, instead of telegraphing that in the headline, I called it "Healing Without Harming," and within three days it had garnered as many readers as my average essay that was unrelated to veterans.
After working with veterans and their families for more than a dozen years, I have had lengthy conversations with many people who deeply care about veterans and genuinely help through various organizations and services. At first, all of us were optimistic that once we made clear that many veterans and their families suffer because of the former's military experiences, that they suffer more when their deeply human responses are wrongly labeled signs of mental illness and this leads their communities to fear and turn away from them, and that there are many alternative approaches that help them truly come home, America would rise to the occasion and help. But through these years, I hear increasingly hear from these people that their optimism has gone. The Groundswell of Support is an emperor with no clothes.
Whispers from people on awards show red carpets go like this: "In the past couple of years, fewer celebrities even mention servicemembers, and with rare exceptions, the messages from those who do are far briefer than before." Why? Many celebrities believe that because the most recent wars are said to be over, veterans no longer need our attention. They have become invisible.
Help for veterans no longer appears on the lists of many charitable foundations that a few years ago listed it as a top priority for funding. A highly-placed expert on the military reports that CEOs that had formerly proudly trumpeted their intentions to employ veterans through such programs as Joining Forces that is supported by First Lady Michelle Obama and Dr. Jill Biden now tell him there is no need to help them, because "the wars are over."
These attitudes reflect a staggering ignorance of history. In an important sense, wars rarely completely end. The production of new veterans certainly never stops. Not only do thousands of servicemembers continue to serve in regions where we were recently explicitly at war, but also, 70 years after World War II ended, we have nearly 50,000 military personnel stationed in Germany, more than that in Japan, and 28,500 service members in Korea, all these decades after those wars ended. And now President Obama announces that he will send "50 Special Forces" troops to Syria, but history shows that what starts with a tiny number quickly swells. There will be more deaths, more horrific physical injuries, more emotional devastation.
The suicide rate among veterans is highest among the oldest, those from World War II, the Korean War, and the Vietnam War. Consider that fact in light of how long they have been home, and the low tide of the Sea of Goodwill should scare us to death. The fact that their wars officially ended decades ago has not wiped out their need for connection and other kinds of help. Related to this, another frightening fact has only recently begun to be whispered about: It is that the well-known claim that "22 veterans kill themselves every day" is a vast underestimate. That figure is based on reports from only 21 states, not including California and Texas with their high numbers of veterans. In spite of this, respected organizations and individuals continue to bruit about the figure of 22, when a very conservative estimate would place it at least at 50.
Suicide rates are also especially high among women veterans, and likely this is at least partly connected to the high likelihood of being sexually assaulted in the military if you are a woman. Many women and men who were sexually victimized have courageously told their stories in Congressional hearings, only to plunge into despair as year after year, no legislation has been passed that has significantly reduced the incidence of such assaults or increased the numbers of meaningful punishments for the perpetrators. They feel invisible.
Another ugly realm that has been too little revealed -- and largely unpunished -- has been the number of entities purported to help veterans who are in it too much in order, as what one called in an email sent to (but not intended for) me, to "get those veteran dollars." As I travel around the U.S., the organization I hear touted the most by ordinary citizens when asked who is helping veterans is Wounded Warrior Project, which is certainly the most highly publicized. The Wounded Warriors CEO and employees receive alarmingly high percentages of the WW budget -- the CEO's salary going well over $300,000 -- and the project ended up with more than $90 million in assets at the end of 2012, during which time they spent $300,000 for a parade and $50,000 for a monument, all of which could instead have gone to provide substantive help for veterans and their families. Their website includes the claim that they supported 398 veterans and their caregivers and placed 320 wounded veterans in jobs, not impressive figures for a charity that in 2013 took in close to $235 in revenue and in 2014, more than $340 million. (http://www.charitynavigator.org/index.cfm?bay=search.summary&orgid=12842#.VjbnnbTP6kQ) And despite refusing to provide any help to veterans who served before 9/11, Trace Adkins in one of their Public Service Announcements (read: commercial) sings a verse about a man who served in Vietnam. Vietnam veterans who were turned away from Wounded Warriors have told me they were crushed by the rejection and felt invisible.
In stark contrast are sterling entities that genuinely help veterans, including but by no means limited to Col. (Ret.) Sutherland's Dixon Center in Easter Seals, Vietnam veteran Shad Meshad's National Veterans Foundation, the Clowning Project for veterans that is run by Drs. Patch Adams and George Patrin, and Dr. Mary Vieten's Tohidu retreats. They and their staff members work tirelessly, without glitz and glamour, to give veterans and their families what they need. But the combination of the hush-hush tide that is covering up those needs threatens to become a tidal wave that conceals what we as a nation ignore at our peril.
©Copyright 2015 by Paula J. Caplan All rights reserved