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Paula Joan Caplan's Authors Guild Blog

Don't Believe Everything You Read: Words Matter Desperately

Initially published January 12, 2021, at https://www.madintheuk.com/2021/01/dont-believe-everything-you-read-words-matter-desperately/

The seed for this essay is the way that the use of five words has skyrocketed in print, in media, and among both professionals and laypeople, and this is causing harm. The overuse of three of these words has especially increased during the covid-19 pandemic, leading to what I consider the unwarranted and dangerous pathologizing of feelings that should not be considered signs of "mental illness." The overuse of the other two of these words leads to the minimizing of the seriousness of behavior that is abusive and oppressive, making it hard for the targets of such conduct to feel that the degree of their upset is perfectly understandable and justified. 


Readers of this site tend to know a great deal about the harm done by psychiatric diagnostic labels. As I have said elsewhere, psychiatric diagnosis is the first cause of everything bad that happens in the mental health system. After all, if they don't diagnose you, they are not supposed to do anything to "treat" you, but once they give you any psychiatric label, they can do almost anything to you in the name of treatment, and since psychiatric diagnosis is totally unregulated, there is little or no recourse if you are harmed. Because I have written and spoken at length about these matters,1 I will not elaborate on them further here.  Instead, I will address some other harmful words that are liberally used these days and that ought to cause us alarm. 


The words on which I focus in this essay are "depression," "anxiety," "guilt," "bullying," and "microaggression." It is alarming that even people who scrupulously avoid using psychiatric labels readily use the above, apparently without concern for the ways they (1) make it harder to identify what is really happening to someone who is suffering and (2) pathologize sufferers even though the terms do not come from the Diagnostic and Statistical Manual of Mental Disorders or the psychiatric portion of the International Classification of Diseases. Often, the sufferers themselves apply these words to themselves, perhaps unaware that this can cause them trouble and get in the way of their feeling better. 


The words "depression," "anxiety," and "guilt" have in common that they are used to describe a person's feelings, and it is hard to read an article or hear a media commentator talk about the pandemic without saying that the rates of these have dramatically increased (Caplan, 2020a). "Bullying" and "microaggression" are different, because they describe behavior by others that is harmful/abusive/traumatizing to the targets of that behavior.  


"Depression," "Anxiety," and "Guilt" 
I am an actor and director, and a few years ago, I was asked by the world's best acting coach, the (now late) Eden Harman Bernardy, to speak to her students, who were increasingly being asked to audition to play characters who were described in psychiatric terms: "Chris is Bipolar" or "Marilyn is Borderline." I explained that these categories are not scientifically derived, and that for a great many reasons, two people given the same psychiatric label usually differ from each other in a wide variety of ways, so it is not helpful to try to "play Bipolar" or "play Borderline." 


I also addressed with the students what are perhaps the three most commonly used, ordinary words for emotions: "depression," "anxiety," and "guilt." Each is misleading in ways that make it hard to know what a person who ascribes it to themselves is really feeling.  


David Cohen and David Jacobs in a classic article (2007) have shown that "depression" is essentially a wastebasket term, used so variously that if no attempt is made to understand more about what a "depressed" person is feeling, it makes hard for them and for the person who wants to help. People who say they are "depressed" may be feeling loneliness, sadness, grief, hopelessness, helplessness, despair, shame, nostalgia, meaninglessness, aimlessness, lack of physical energy, or brain fog. If the sufferer and the prospective helper leave it at "depression," they will find it difficult to figure out what might be useful in alleviating the feeling. Furthermore, leaving it at "depression" is these days extremely likely to lead to the proposed "solution" being drugs marketed as "anti-depressants"; that is, if "depression" is assumed to be a clearcut, identifiable entity, then it can seem to make sense that an "anti-depressant" will fix "it." Of course, following the lead of Cohen and Jacobs, if "depression" itself is so vague, then if the people studied in research about treatments including psychiatric drugs are "depressed" people, the treatment is being tested on people whose suffering is troublingly heterogeneous. If a drug is given to people who have a certain bacterial infection, it makes sense that the drug is an antibiotic known to kill that bacterium. But giving an "antidepressant" drug to some people who are lonely, some people who have lost their religious faith and are struggling for that reason, some people who are bereaved, some people who are feeling ashamed, some who are being harassed at work but unable to leave their job because they support their children, etc., what do we think we have found when we look at the results of the drug? Indeed, how do we even begin to think about the results? If instead of calling their drugs "anti-depressants," if drug company executives were required to be truthful, they would have to name them "drugs we'd like anyone not feeling happy and fulfilled to take, in the hope that they will be helped." 


So when someone says they are "depressed," I ask them the following: "If you were not going to use that word to describe how you are feeling, what word or words would you use?" This helps that person and me to understand more about what is going on, and whether in a professional situation or speaking with a friend or family member or colleague, the road to feeling better will become clearer if the feeling or feelings are described as accurately as possible. It is unfortunate that people have been led to believe that reporting they are depressed is informative beyond conveying only "I don't feel happy." 


When someone says they are "anxious," I ask them the same question I ask someone who says they are "depressed." The reason is that having identified oneself as feeling "anxiety," one has little idea how to get to feeling better. In an acting class, a young woman performed a monologue, and afterward, Eden Harman Bernardy asked how she felt about how she had done. The woman replied, "I didn't feel good about it. You see, I have been anxious all week about doing this monologue." When I asked her what word she would use to describe how she had felt during the week if she were not going to use "anxious," she immediately replied, "afraid." She was afraid she would not do well, afraid of looking foolish, afraid it would prove she could not act.  I find that nearly always when I ask a person to use a word other than "anxiety," the word they use is "fear." In contrast to the nebulous images "anxiety" evokes, "fear" points the way to reducing suffering: Fear is always of something. Once we consider what we fear, we can ask crucial questions such as, "If the thing I fear really happens, will that be a total disaster?" and "Are there steps I can take to reduce the chances that the thing I fear will happen?" and "How do I want to handle it if the thing I fear does in fact happen?"


When we are already afraid, we paralyze ourselves emotionally if we also feel powerless, and the vagueness of "anxiety" increases not only the sense of powerlessness but our actual lack of power, because we don't know how to think clearly about moving forward. 


A parallel with the use of "depression" is that someone who reports to a professional that they feel "anxious" is very likely to light up the "anti-anxiety drug" spot in the professional's brain, so that instead of guiding the person to identify the underlying fear and ways to minimize the feared consequences or plan to cope with them, both sufferer and therapist will match the vague "anxiety" with "anxiolytic drug." Although for some people at least for awhile, drugs in that class may help suppress the physical effects of fear, they do not help the person understand the fear and learn to cope with it. 


When Dr. Nikki Gerrard wrote a paper years ago as a graduate student and called it "'Guilt' Is a Terminal Word," I was intrigued by the title. Her point was that to say, "I feel guilty" gives one nowhere to go to move beyond that feeling. Saying, "I feel guilty, because I rarely go visit my mother" does not change the situation. So in trying to help someone overcome what they are calling "guilt," that word is terminal in that it stops the person in their tracks. "Guilt" sounds like something individual and intrapsychic, but when Gerrard talked with people about what they began by calling "guilt," she found that the key factor was what she called a problem-in-relation, something about a difficulty in a connection that mattered to them, such as worry about loss of love. I thought that was a terrific insight, so I began asking people who said they felt "guilty" what word they would use to describe their feeling if they were not to use that word. Almost always, the response has been "shame." Now, that is not a terminal word! "Shame" is the emotion we have when we feel we have been seen by someone — usually someone we care about — to fail to live up  to a particular standard. Therefore, the routes to pursue are to ask "What is the standard you feel you are failing to meet?" "When you think about it, does that seem like a reasonable standard, one that you definitely want to meet?" "How did you come to accept that standard?" "Do you know who set the standard for you?" "In whose eyes do you feel you are failing to meet the standard?" "Do you agree that you are failing to meet it?" "How much do you care about that person believing you are failing to meet the standard?"  


Another important aspect about the word "guilt" is that it is easier to pathologize ("This person is just inexplicably consumed with guilt"), because it seems less understandable than worry about losing a loved or admired one's respect or care. 


"Bullying" and "Microaggression" 
These two words are causes for worry, because both of them minimize the damage done to the targets of such behavior, and that minimizing makes it easier to classify the target's upset as overreaction. 


I've never understood why the term "bullying" suddenly became popular, but each time I hear a description of behavior to which that term is applied, I am struck by the fact that the behavior is actually abuse. "Bullying" tends to evoke images of a young kid on a playground being mean to another child, and some schools have entire "anti-bullying" programs. But what possible useful distinction can be made between "bullying" and abuse? Aren't cruelty and throwing one's literal or figurative weight around in order to intimidate another person abusive? Surely nothing is to be gained by reducing such conduct to "bullying." In fact, it is damaging that the perpetrator's responsibility for causing harm is minimized.   


The history of this term is important to understand. In 1970, when condemnation of overt race-based violence had increased in some quarters, leading some people to claim that racism was behind us, Dr. Chester Pierce  (1970) coined the term "microaggression," because he recognized the importance of drawing attention to less blatant manifestations of racism. The "micro" part of the term was intended to reflect the fact that bias and oppression can take forms other than physical attacks, name-calling, and explicit rejection or humiliation.


"Microaggressions" are described as brief and/or subtle manifestations of prejudice and hatred that are "great in the power or magnitude of their consequences" (Caplan & Ford, 2014). I coordinated the Voices of Diversity Project (Caplan & Ford, 2014), in which we documented the factors on predominantly white university campuses in the United States that are manifestations of racism and sexism and that impede their targets' attempts to acquire an education. Because some overt manifestations of racism and sexism (though not sex-based assault) had declined due to laws and regulations against hate speech and to civil rights laws, most of what we heard in our one-on-one interviews with students we called "microaggression." In an irony that I did not recognize at the time we wrote the report of our research, we went to great lengths to report the students' detailed, vivid, heartbreaking descriptions of the devastating effects those manifestations had on them. Only in 2020, when I read Ibram X. Kendi's brilliant, important book, How To Be An Anti-racist (Kendi, 2019), where he criticizes the word "microaggression" as minimizing the effects that these "micro" events have did I realize how the term can make the targeted people feel that they are overreacting to "something so small." As I recently wrote elsewhere (Caplan, 2020b), "I wish I had thought to point out in [the] article [reporting our findings] that the term 'microaggression' could mistakenly imply that the effects of such acts are minor. In fact, the very nature of these acts often makes it easier for the perpetrators to claim that their targets are overly sensitive or paranoid, which can cause huge torment." I gave this example (one among a huge number) of a student's description of something that happened to him:   


An African American man said: "I have to stop and think sometimes, 'Are they being racist? Or, is that just how they act? Or, are they just not being friendly because they're having a bad day?' So I try not to let it get into my head and make me angry and things like that. I just try to think it through, like maybe there are other reasons why they're not friendly. So I try not to think about all the negative and try to think about the positive. I do speak and try to get them to speak, but if they don't want to, I just try to go on with my day. It makes me feel like I am not wanted." (Caplan, 2020b, p.5) 


Imagine if that student had been told that what had happened to him was called "microaggression." What he needed was someone to tell him that whoever told a racist "joke" or rolled their eyes when he spoke in class or turned away from him when the professor said to form work groups was being cruel and oppressive. 


I hope that readers will consider how the five words noted here cause unnecessary human suffering and in various ways impede attempts to reduce suffering. 


Caplan, P.J. (2020a). Is covid-19 making everybody crazy? https://www.madinamerica.com/2020/07/covid-19-making-everybody-crazy/ 

Caplan, P.J. (2020b). Editorial/éditorial: "Microaggression" is not micro. APORIA: La revue en sciences infirmieres/The Nursing Journal 12(1), 4-5. https://uottawa.scholarsportal.info/ottawa/index.php/aporia/issue/view/524/309 

Caplan, P.J., and Ford, J.C. (2014). The voices of diversity: What students of diverse races/ethnicities and both sexes tell us about their college experiences and their perceptions about their institutions' progress toward diversity. APORIA: The Nursing Journal 6(3), 30-69. 

Cohen, D., & Jacobs, D.H. (2007). Randomized controlled trials of antidepressants: Clinically and scientifically irrelevant. Debates in Neuroscience 1, 44–54.  

Kendi, Ibram X. (2019). How to be an Anti-racist. New York: One World. 

Pierce, C. (1970). Offensive mechanisms. In F. Barbour (Ed.), The Black Seventies. Boston: Porter Sargent, pp. 265-282. 

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When Psych Diagnosis Means Life-or-Death

Originally published at https://www.madinamerica.com/2020/10/psych-diagnosis-means-life-or-death/? October 30, 2020.


Many people know that getting a psychiatric label referring to emotions or behavior exposes the labeled individual to a wide array of kinds of harm, the ultimate harm being death. What is less widely known is that one label in the Diagnostic and Statistical Manual of Mental Disorders that applies to cognitive abilities—"Intellectual Disabilities"—is crucial in determining whether people accused of crimes in some U.S. states will be executed. This interests me as a psychologist and as a filmmaker working on a documentary about this subject, "Execution by the Numbers" (executionbythenumbers.com)


Like all psychiatric categories, "Intellectual Disabilities" (I.D.) is not scientifically derived. Decades ago, when I was a naive advocate of psychiatric diagnosis generally, I was shocked to discover that what was then called "Mental Retardation" (now called "I.D.") appeared in the handbook of psychiatric disorders, although it was about cognition, not emotions!


It's alarming and reprehensible enough that those who write and market the DSM and the International Classification of Diseases (the latter's psychiatric section is similar to the DSM) have acquired so much power to decide who is "normal" and who has a "psychiatric disorder," and many of us for decades have been warning of the harm that can result from getting any of those labels—the harm can range from plummeting self-confidence to loss of jobs, child custody, the whole variety of human rights, and even loss of life, this last usually from drug effects. But the path from diagnosis of "I.D." to execution by states that have the death penalty is direct and spelled out in the laws of those states.


What actually happens? When a person is (accurately or falsely) accused of committing a crime that is considered a capital crime in that state, that means they are eligible for the death penalty. Different states have different criteria for deciding what is a capital crime, such as the degree to which it is "heinous." But the key point for this essay is that in 2002 the U.S. Supreme Court in Atkins v. Virginia ruled that people with (what was then called) "Mental Retardation" must not be executed, such executions being cruel and unusual punishments and thus, according to the Eighth Amendment, unconstitutional.


Writing for the majority in Atkins, Justice John Paul Stevens gave as reasons for the ruling the following:

"[people with "MR"] have diminished capacities to understand and process information, to communicate, to abstract from mistakes and learn from experience, to engage in logical reasoning, to control impulses, and to understand the reactions of others…

"…they often act on impulse rather than pursuant to a premeditated plan, and that in group settings they are followers rather than leaders. Their deficiencies do not warrant an exemption from criminal sanctions, but they do diminish their personal culpability."


Justice Stevens further wrote that the two presumed aims of the death penalty—retribution (getting their "just deserts") and deterrence (preventing them from causing future harm)—do not apply to such people. Retribution should only apply to the most culpable, and he felt that they were less culpable due to their impairments. As for deterrence, he said that because such people were more likely to act on impulse than were other people, the death penalty's existence was less likely to come to their minds to inhibit them from committing capital crimes.


Death penalty retributivists (proponents for purposes of punishment) like New York Law School Emeritus Law Professor Robert Blecker argue that Stevens' reasoning treats people with limited intelligence as having less humanity than other people. He says if we credit them for good behavior for running into a burning building to save children, we cannot suddenly excuse them when they commit harmful behavior. That subject warrants extensive discussion beyond the scope of this essay but is an important one to raise.


A major problem with the Atkins ruling was that each state was left to decide how to define and determine "Mental Retardation" ("M.R."), although Atkins included a reference to the crucial I.Q. cutoff point of 70.  There causes a host of problems. One is that some people who "qualify" to be executed in a particular state would not meet the criteria in another. Further, readers of Mad in America will not be surprised that the whole business of deciding how to define and evaluate "M.R."—currently called "I.D."—is not an objective, hard-and-fast matter.


The two criteria lists most widely used appear in successive editions of the DSM and in publications of the organization that, at the time of the Atkins decision, was called the American Association for Mental Retardation and is now called the American Association on Intellectual and Developmental Disabilities (AAIDD).


Debates about how to define "intelligence" have raged for well over a century, because the concept is a construct, like "love," in that different people can define it in different ways. Both the AAIDD and the DSM descriptions list three factors—(1) intellectual functioning (conventionally measured by a standard I.Q. test), (2) deficits/limitations in adaptive functioning (such as holding a job, social judgment, making friends, finding one's way on public transportation, feeding and clothing oneself, etc.), and (3) present before age 18. The AAIDD description includes somewhat less emphasis on I.Q. test scores than does the DSM one, which latter at the time of Atkins included specifying that the I.Q. score needed to be 70 or below.


That number 70 has held great sway over the decades, as defense and prosecution attorneys have argued about whether someone with an I.Q. score of 73 "really" had I.D. because their 73 indicates a range going as low as 68 to 70 and thus they should not be executed…and whether someone with a score of 68 "really" did NOT have I.D. but was not trying their hardest when tested and thus probably qualified for execution.


Every one of the three usual criteria for "I.D." is problematic, for reasons we recount in our film-in-progress, "Execution by the Numbers," and I will address these, but first I want to highlight other compelling concerns.


First, the public generally believes that the decision to sentence someone to death is made by judges and juries. In fact, however, enormous weight is placed on what psychologists tell judges and juries, to the extent that it's not much of a stretch to say that the psychologists are making the life-or-death decisions. This granting of so much power to psychologists is done to a great extent under two fictions: (1) that psychologists are unlike other humans in that psychologists are strictly objective, and (2) that I.Q evaluations are strictly scientific and not subject to bias.


That (1) is a fiction is reflected in the facts that some psychologists are known to be hired guns for the prosecution (one in Texas was called "Dr. Death") and that even the best of psychologists, being human, likely have some conscious or unconscious attitude toward the death penalty that could affect their choice, administration, and interpretation of I.Q. evaluation instruments in either direction.


That (2) is a fiction is reflected in the very instructions of standard I.Q. tests, which reflect that the psychologist often has to judge whether a person's answers merit 2 points, 1 point, or 0 points, and sometimes those judgements are hard to make. Furthermore, it can be a matter of judgement how many adaptive functioning limitations a person has, whether they are substantial enough to be called limitations (when life itself is at stake), and whether to take into account any strengths they have in adaptive functioning.


In a recent case coming from Texas, prosecutors were using the fact that a person on trial had any strengths in adaptive functioning to claim that the person did not have "I.D." and thus could be executed. The Texas Court of Criminal Appeals cited the character Lennie in Of Mice and Men as an example of someone who should not be executed because of his limitations. However, that character represents one stereotype of people with "I.D." that many intellectually limited people fail to fit.


The Briseno Factors used in Texas included such questions as whether the person had formulated plans and carried them through and whether they responded rationally to questions. If the answer was "yes," prosecutors had an easier time arguing that the person couldn't possibly have an "I.D.," no matter how many limitations they did have. Of course, it is hard to find someone with an I.Q. score between, say, 60 and 70 who has never formulated plans and carried them through, and many people with intellectual limitations have put a lot of energy into learning how to act "rationally" or in socially acceptable ways that can mask those limitations. Fortunately, a SCOTUS ruling recently was aimed to end use of the Briseno Factors.


As for the criterion that the person had to have "I.D." before age 18, that makes no sense to me, because to the extent that I.Q. is considered relevant in death penalty cases, surely what matters is the person's cognitive capacities at the time they either committed a crime or falsely confessed to one. I think of a case a few years ago in which a man had above average intelligence and no criminal history, then suffered a brain injury when he was trimming a tree, and a chainsaw entered his skull. His test results were certainly lower than before the accident, when he was decades older than 18, and the crime was committed afterward.


In addition, although I am grateful that the Atkins decision has saved many people from execution, I think it is not ideal. Why? Because the elements of an I.Q. evaluation do not correspond for the most part to what is relevant for the court cases. What does a person's ability to answer math problems or learn a nonverbal code have to do with these questions: Did they think about the consequences when deciding to commit the crime (IF they committed a crime)?

If their Miranda rights were read to them or they were asked to read them aloud, did they understand them? Were they easily led to sign a false confession? Did they understand the confession they were asked to sign? Were they easily led into participating in a crime? Can they participate in their own defense?


(Samuel Oates, defense attorney in a case that made legal history, said in his interview for our film that at the end of the first day he spent with Jerome Bowden, he realized Jerome had no more idea what he was being asked than at the beginning, so he could not help with such things as recalling whether, months before, there was a witness to his having been somewhere other than the crime scene.)


Can they understand crucial aspects of court proceedings (such as the implications of being offered a plea bargain)? Do they understand what execution and death are? During their time in prison, have they, like many prisoners, improved their reading and vocabulary skills, so that an I.Q vocabulary test given now will not reflect what they knew at the time the crime was committed?


Until the criminal justice system and psychologists come together to come up with reliable and valid ways to answer the above kinds of questions, and unless Atkins is superseded by a later SCOTUS ruling, Atkins will hold sway. So I hope readers will educate as many people as possible about how some psychologists—and wrong beliefs about psychologists and I.Q. evaluations—literally have the power over life-and-death decisions.


As I have often felt in my decades learning about what psychologists can and cannot do, what our strengths and our limitations are, I am alarmed by the huge divide between those realities and what many people mistakenly believe, i.e., that many of us are better and have more skills and power than we do and that we are solid scientists with no biases of our own. When life itself is at stake, these myths cry out for drastic revision.


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Suicidal Thoughts, Psychiatric Diagnosis, and What Really Helps: Part Two

Originally published at https://www.madinamerica.com/2020/09/suicidal-thoughts-part-two/ on September 25, 2020


Portions of this essay are based on the Mad in America webinar, "Issues in Dealing with Suicidal People…and What Experience with Military Veterans Teaches about Nonpathologizing Approaches for All," April 2, 2019.


Part 1 of this essay was about the absurdity and dangerousness of pathologizing suicide as "mental illness" and about the ways traditional approaches either do not reduce suicide or risk actually increasing it. Now we consider some factors that tend to inhibit suicidal people from reaching out for help, and that is followed by description of what actually can be helpful.



What can get in the way of reaching out for help?
Barriers to asking for help—and there are good kinds of help—include:

(1) Fear of being called mentally ill and all that follows from that, including losing support from friends and family, who want you to confine your talk to a therapist behind closed doors, just take psychiatric drugs, and/or agree to be hospitalized.

(2) Belief that only a therapist can help—this often keeps others from reaching out to someone who is suffering, because therapists' guilds have taught the public that only therapists can help reduce human suffering, that we have special knowledge no one else has, when that is almost never, ever true

(3) Feeling unworthy of taking up the time of a family member or friend. This can differ depending on one's sex-role socialization, since traditionally, women are not supposed to ask for anything for themselves, and men are not supposed to need anything.

(4) Believing one ought to be able to manage on one's own—whereas, in contrast, in some cultures the community considers it a community responsibility to reach out to and support those who have been traumatized, those who are feeling despair.

(5) Being labeled mentally ill because of having suicidal thoughts or made attempts to kill oneself, even though these are more common than widely assumed, and the masking of many of the causes of such thoughts or attempts, because "mental illness" is assumed to explain them.


What therapists and many others can do to help
(1) Realize that it can be very hard to predict who, even among people deemed to have risk factors, will attempt suicide (https://www.ajpmonline.org/article/S0749-3797(19)30506-9/abstract). So begin by not taking responsibility for what the suffering person ultimately does.

(2) Related to (1), stop assuming therapists can prevent suicides. The truth is, we therapists don't know how to do that, certainly not based on our clinical training. In a USA Today article (https://www.usatoday.com/in-depth/news/nation/2020/02/27/suicide-prevention-therapists-rarely-trained-treat-suicidal-people/4616734002/), Dastagir wrote this: "experts say training for mental health practitioners who treat suicidal patients is dangerously inadequate….There are no national standards that require mental health professionals be trained in how to treat suicidal people, either during their education or their career." Keep in mind that therapists are not supposed to work in fields in which they have not been trained.


And too often, those that do receive training are "taught" to send people who are considering suicide to the ER, get them on psychiatric drugs, and/or have them committed to an inpatient facility.  Many clinicians spend most of their time trying to treat a patient's allegedly underlying mental illness, rather than asking the person, "What makes you want to kill yourself?


Dastagir wrote: "Stacey Freedenthal, a suicide attempt survivor and associate professor at the University of Denver Graduate School of Social Work, says a common feeling among therapists when they realize they're sitting across from a suicidal person is panic. Their reflex is to send the patient to an emergency room.


'You've got this person who has taken weeks or months or more to work up the nerve to go to a professional and the professional is saying, "I can't help you, you have to go somewhere else." And that can be very harmful,' Freedenthal said."


(3) Stop using psychiatric diagnostic terms everywhere. Instead, tell suffering people you don't consider them mentally ill. Teach them the truth about psychiatric labels, because just being told one is mentally ill can lead to despair. In a recent Mad in America essay (https://www.madinamerica.com/2020/02/pathologize-eating-problems/), Jo Watson and I mentioned a New York Times essay by a woman who had been body-shamed by her ballet teacher for years, but it was only when her therapist told her she had an "eating DISORDER" that she said she fell to the floor and was despondent.


(4) Broaden the field of what we consider might be helpful, not just therapy and/or psychiatric drugs. Over the decades, as people have told me what helps them, I have seen two categories of helpful approaches: connection and creation.


Connection can be with people other than therapists, so the suffering person will know they won't be labeled mentally ill or treated as though they are, and this can be anyone who will be a willing listener. That is why the Listen to a Veteran listentoaveteran.org (LTAV) project is so powerfully effective. A Viet Nam veteran who had become a counselor and listened to others' suffering for decades had just one session in which a nonveteran truly just listened to whatever he wanted to say, and that ended his intense wishes to die.


I have referred to "The Astonishing Power of Listening" (https://www.madinamerica.com/2020/09/suicidal-thoughts-part-two/), which cannot always prevent suicide but sometimes can. And on a recent episode of "CBS Sunday Morning," a person whose suicidal despair had been stopped because of receiving occasional, simple post cards from someone said, "It wasn't about my mental illness.  It was isolation"—having someone reach out and show they cared.


When Hom et al. asked 329 suicide attempt survivors what they wanted, they said reducing stigma of suicidality, expressing empathy and active listening, a range of treatment options, including nonmedication treatments, addressing root problems, bolstering coping skills, and using trauma-informed care (https://www.madinamerica.com/2020/09/suicidal-thoughts-part-two/). Connection with service animals and with something spiritual or religious can also be helpful. This makes sense, given the crucial roles of isolation and hopelessness in leading to thoughts of suicide.


Creation can be in the form of involvement in the arts, doing volunteer work, gardening, etc., and many forms of creating also involve connection, whether with other beings, with the earth, or something spiritual. This website has more than two dozen very brief videos of nonpathologizing approaches to reducing isolation and suffering and providing real help (they come from a conference focused on veterans but are useful for anyone).


And keep in mind that another part of destructive labeling includes not just psychiatric labels but also "art therapy," "music therapy," etc. People find meaning, connection, enrichment, and creativity through the arts, so it harmfully sets up some people as belonging to the category of Other to say "I paint a picture, but YOU need art therapy"?


(4) Reduce or get rid of psychiatric drugs whenever possible, because it is known that they increase suicidal thoughts and suicides (https://www.madinamerica.com/2020/03/open-letter-va-secretary-wilkie-deprescribing-veteran-suicides-plan/).


(5) Get rid of firearms, since they are known to increase suicide risks substantially (https://onlinelibrary.wiley.com/doi/abs/10.1521/suli.2010.40.5.421).


(6) Provide real-life help getting safe places to live, jobs, healthcare, community connections, and a sense of meaning.


(7) Without being Pollyana-ish, help the person consider the strengths within themselves and their external resources.


(8) Help the person look realistically at the structural factors that may cause their despair, such as various kinds of violence, sexism and sexual harassment, racism, classism, ageism, ableism, homophobia and transphobia. CALL THESE FORMS OF OPPRESSION AND EMOTIONAL VIOLENCE BY THEIR NAMES, say they are all forms of abuse, and tell the person they are of course upset and feeling powerless in the face of such treatment. Help them consider ways to fight against these, including but not limited to political action and use of the arts.


(9) Be careful what you wish for. Don't give up your critical thinking and think the problem has been solved when someone or some entity says it cares. For instance, the American Psychiatric Association has recently professed alarm about the lack of mental health care given to Black people. I am sure some of their members are aware of racism as a cause of suffering and would not ignore it and attribute suffering caused by racism to an alleged chemical imbalance in the brain. But given that the APA is officially a lobby group, not a service organization and not an anti-racism one, one has to wonder to what extent they are looking for new markets.


The Congressional Black Caucus rang the alarm about increasing rates of suicide by Black youth (https://watsoncoleman.house.gov/uploadedfiles/full_taskforce_report.pdf). Although this is cause for alarm, it is worrying that they attribute this to "depression" rather than to being targets of racism, and they call for more mental health research funding, reducing barriers to mental health treatment, increased use of "depression" screenings, and getting more mental health professionals into Black schools.


These recommendations are worrying, because too little traditional mental health work involves calling out racism—or other forms of oppression and violence—as a cause of deeply human responses, not of "mental illness."


(10) Try to avoid suicide hotlines. Instead, use warm lines (see below). When I asked the directors of the Army suicide program what happens when someone calls their hotline, they said they are told to get "mental health services." Those are nearly always the labeling, drugging, and hospitalization referred to above.


I investigated many high-profile hotlines and crisis lines and some that are not well-known. I want to describe the experiences I had when calling them. One of the best-known services, the one most often mentioned by colleagues whom I asked for recommendations, has toll-free numbers and several numbers with various local area codes that turn up in online searches. Over a period of several hours one evening, dialing one of those local numbers consistently elicited nothing but a busy signal. Over those same hours, another of the local numbers in a different location consistently elicited an automated message instructing the caller to dial 911 if it was an emergency and otherwise to call back.


A third local number in still another state also rang busy for hours, but a man finally answered. I asked what they do for suicidal callers. I said I hoped to find a line where people would listen, be supportive, and try to maintain a meaningful and helpful connection with the caller. He replied that what they do is send people to get "mental health care." When I asked whether they have been trained at least to offer callers information about alternative, nonpathologizing, low-risk approaches that have been shown to be helpful—such as physical exercise, meditation, volunteer work, involvement in the arts, other kinds of human connection, and having a service animal—he said that they have not and that he himself does not suggest them.


When I called the main toll-free number for that same crisis line group, the automated answering message immediately gave an option to press 2 if you are a veteran. I pressed 2, and a man answered right away. I told him about a dear friend who is a veteran who takes three psychiatric drugs and has attempted suicide several times, each precipitated by a change in the drugs. I asked what the people answering their line would say if I persuaded him to phone them. He told me that he would tell him to go straight to the VA. I expressed dismay, saying that it is well known that at the VA, veterans are often put on psychiatric drugs, even up to a huge number at once, and that even some top VA people have expressed alarm about the ways the drugs so often lead to deaths. I got nowhere.


Around the United States and in other countries, people who have themselves been through difficult times and who do not rush to recommend psychiatric diagnosis, drugs, and hospitalization are creating "warmlines" for people who are having suicidal thoughts or other kinds of upset. Many such lines have small budgets and can only provide people to respond a few hours a day, usually in the evening, but from what I learned by contacting some, they are staffed by compassionate people who respond in helpful ways. Although some do not have toll-free numbers, they can be phoned from anywhere in the U.S.


When providing someone with numbers to call, it is important not to overreact to their having mentioned thoughts of suicide. A simple and kind, "Here are some numbers for you if you continue to have thoughts about suicide. They are staffed by warm and caring people who will not rush to recommend psychiatric care, diagnosis, drugs, or hospitalization. I am providing them in case you decide you would like someone to speak to about these feelings."


The primary aims of this two-part essay are to save everyone time and worry when trying to help prevent suicides by describing the absurdity and even the harm caused by psychiatric labeling and drugging of people who are thinking of killing themselves, by providing a list of "What Not to Do" and providing concrete suggestions for "What to Do." I hope this is of use.


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Suicidal Thoughts, Psychiatric Diagnosis, and What Really Helps: Part One

Originally published at https://www.madinamerica.com/2020/09/suicidal-thoughts-part-one/


This piece is the first of a two-part essay about suicide, diagnosis, what doesn't help, and what does help. This part is about suicide, diagnosis, and some of what fails to help.

Paula J. Caplan, PhD
September 24, 2020

Portions of this essay are based on the Mad in America webinar, "Issues in Dealing with Suicidal People…and What Experience with Military Veterans Teaches about Nonpathologizing Approaches for All," April 2, 2019.


The arena of psychiatric diagnosis, "depression," and suicidal thoughts is a godawful…and dangerous…mess. And it just gets worse and worse.


Consider this development: On June 18 of this year, the American Psychiatric Association (APA) issued a news release that they were adding diagnostic codes and definitions for suicidal behavior and nonsuicidal self-injury to the upcoming revision of the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM).


It is already a serious problem that both having suicidal thoughts and killing oneself are, in a knee-jerk way, considered proof that the person has a "mental illness." When someone kills themselves, if they had a psychiatric diagnosis, the suicide is attributed to that alleged mental illness. If they had no such diagnosis, it is claimed that they had an undiagnosed mental illness.The circular logic of this is astounding. And it could not be farther from scientific thinking.

This is illogical, absurd, and dangerous, if we want to find out what really leads to suicide and how to try to prevent it. In this two-part essay, I am recommending a) intensively and sincerely validating the suffering of people who are suicidal, b) avoiding mental illness diagnosis and psychiatric drugs, and c) a great many things one can do instead of the traditional ones.


Consider what the DSM conveys about grief, which is often called "depression." When preparation started for DSM-5, the chair of the DSM-IV Task Force, Allen Frances, expressed alarm that what he called his edition's "bereavement exclusion" would be eliminated in DSM-5.This implied that in DSM-IV, he had said that Major Depression should not be diagnosed in someone who was bereaved.


In fact, however, DSM-IV includes the statement that Major Depressive Episode (MDE) should not be diagnosed if someone has been bereaved within the past two months. That is alarming enough, because bereavement does not end or, often, even diminish very much after 60 days, nor should we expect it to do so. Thus, it is hard to see what would justify the intensity of Frances' outrage about the DSM-5 authors diagnosing a depressive "disorder" immediately or after two weeks rather than two months.


But even in DSM-IV-TR, the instruction not to diagnose a disorder if the "symptoms" arose less than two months after loss of a loved one is followed by this: "unless they are associated with marked functional impairment or include morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation."


Note especially the word "or" in the foregoing. One need meet only a single criterion in that list to qualify for MDE even as soon as the first day of bereavement. It is hard to think of anyone who has lost a loved one and not met at least one of those. It is clear that even Frances' editions of the manual actually have no bereavement exclusion. To ignore that this was the case in DSM-IV is to render invisible the suffering and harm caused to grieving people whose bereavement was diagnosed as "mental illness" and often "treated" with psychiatric drugs.


What Causes Thoughts of Suicide?
The term "mental illness" is often assumed to indicate that the person isn't thinking clearly, is out of touch with reality—otherwise, suicide would not enter their mind. Those who make that assumption would do well to listen to people who have been suicidal. Many such people say that death is the only way they can think of to end intolerable emotional or physical pain.

Marsha Norman's Pulitzer prizewinning play 'night, Mother is a brilliant example of this. In the play, a middle-aged daughter tells her mother she is going to kill herself that evening. Her mother tries every way she can think of to persuade her daughter to change her mind, but the daughter explains: "I'm feeling as good as I've ever felt in my whole life." She recounts the many miseries of her life, saying she is worn out from trying to make her life better and never succeeding. She says she is "somebody I waited for who never came and never will. I didn't make it." She is at peace, because she finally feels there is something she can do that will end her misery. So, one kind of reason for wanting to kill oneself is to end what feels like unbearable suffering when there is no prospect of change.


Trauma of any kind can be a reason for wanting to die, in part because trauma by definition is a horrible experience, and sometimes suicide can feel like the only way to avoid another such experience or to escape from the effects of the trauma. In addition, trauma tends to be fragmenting and disorienting, which makes it that much harder to reach out and connect with others and with resources that can be helpful in dealing with the effects of trauma and avoiding further trauma. Trauma can come from violence, extreme poverty, and forms of oppression including sexism, racism, classism, ageism, ableism, homophobia, transphobia, and looksism.

In more than a decade of working with veterans, I have met so many who have been told they have "Post-traumatic Stress Disorder" ("PTSD"), an alleged mental illness listed in the psychiatric handbook. Elsewhere (https://www.amazon.com/When-Johnny-Jane-Come-Marching/dp/150403676X), I have extensively critiqued this term, but a major relevant point here is that it consists of a list of effects of trauma. It is a dangerous pathologizing of people's reactions to trauma.


What would be a "healthy" response to trauma, then? Not being affected at all by seeing a buddy blown to bits or being raped by one's sergeant?! Veterans often tell me that therapists have said, "You have this mental illness called PTSD and will have it all your life." Just being told that could easily lead to despair and thoughts of ending one's life.


In contrast, listening to veterans and other traumatized people when they are devastated, rather than thinking about how to label them, reveals that they variously feel grief, terror, shame, disorientation, moral anguish, loss of innocence. Do we want to say that someone who feels despondent when intensely grieving or deeply ashamed is mentally ill…and should be labeled and drugged?


As for moral anguish—the reasons servicemembers experience it are well known, but non-military people can also experience it when, for instance, a mother learns that her children's father is abusing the children, and she desperately wants to stop the abuse but is terrified that if she reports the abuse, the courts will consider her a lying troublemaker and give the children to him … as has been proven to happen 2/3 of the time in cases of child sexual abuse.

With regard to loss of innocence: Many people join the military when they are barely out of high school, maybe going from prom to basic training, and at that age to witness war or experience military sexual assault can clearly be overwhelming, causing despair and hopelessness from the shock of having such experiences while so young and unprepared (as if anyone could be prepared for war or military rape at any age).


This applies as well to nonmilitary people who experience trauma: Until the trauma, they have had a narrow view of what life is really like, and now a large proportion of their young life's experience has been horrific. Do we want to call all of this "mental illness" rather than experiences and feelings that seem intolerable and lead to thoughts of suicide?


In our death-phobic society, it is little known that many people—perhaps even most—in the course of ordinary lives think about suicide at some time. As soon as one becomes aware of life itself and of the inevitability of death, what could be more natural, more human, than to consider the possibility of choosing the time and method of one's death, whether in a philosophical way, or because one is afraid of how one might die if one doesn't take it into one's own hands, or because it makes one feel more in control? This is often common among adolescents and adults who are sensitive, artistic, and thoughtful. Then there are the people who either are desperately lonely and believe that will never change, or who have what feel like overwhelming burdens and problems for which they can see no escape.


Traditional Mental Health Approaches Don't Help Anyway
Susan Stefan, in her brilliant book (https://www.amazon.com/Rational-Suicide-Irrational-Laws-Psychology-Law/dp/0199981191) and in her lectures, urges that when we know someone is thinking of suicide, we offer to listen to whatever they want to say and ask them, "What would make your life worth living?" and then see if we can help with that. And of course, our offering to listen can help reduce their isolation. This could not be more different from traditional therapists' approaches.


Stefan has comprehensively reviewed the approaches to dealing with people who have suicidal thoughts in the traditional mental health system and has reported that these approaches tend to exacerbate the problem. That is a powerful reason for refusing to classify suicidal behavior as signs of mental illness. It does not belong in the DSM.


Does it help that the DSM staff say they plan to list it in Section II, "Other Conditions That May Be a Focus of Clinical Attention" so that it can have a numeric code? Of course that doesn't help. The book after all has "mental disorders" in the title, and its authors have zero ability to warn the world NOT to classify suicidal behavior as a "psychiatric disorder" even though it is in their book. What reason is there to give it a code to put on medical files and send to insurance companies if not to help therapists expand their territory, power, and income?


Although the rest of this section is about military servicemembers and veterans, the principle points about how traditional approaches do not help apply to people who have not served in the military as well.


In my book about veterans (https://www.amazon.com/Rational-Suicide-Irrational-Laws-Psychology-Law/dp/0199981191), I raise the question: If traditional mental health approaches are effective, why are veterans' suicide rates so high? When the book first came out in 2011, I warned about the ineffectiveness and harm from psychiatric drugs. And in two chapters called "What the Military Is Doing and Why It's Not Enough" and "What the VA Is Doing and Why It's Not Enough," primarily based on the Department of Defense and VA press releases, I found the following pattern: About every year, the DoD and the VA would issue press releases in which they expressed concern about high rates of suicide among active duty members and veterans, respectively. Each time, they would express mystification about these rates and mention ways they planned to reduce them. But that happened in each announcement, and in each subsequent one, the suicide rates had not declined. Strikingly, they tended steadfastly to avoid considering the role of war trauma and rape trauma in leading to suicides.


Concerned about this, Col. (Ret.) David Sutherland and I wrote an essay (https://www.inquirer.com/philly/blogs/phillypharma/Unseen-wounds-Psychotropic-drugs-often-intensify-the-veterans-suffering-and-isolation.html) about the four main reasons veterans kill themselves. These were:

The vileness of war (and rape, sexism, racism, homophobia, classism, and so on);
The soul-crushing isolation most experience when they return home;
Being labeled "mentally ill" instead of being told their reactions to trauma were deeply human responses…and the label often increasing the isolation; and
Psychotropic drugs, which can increase suicidal thoughts and suicides and which often dampen people's emotions, thus making it harder to form or maintain relationships.

Some years ago, I met with the two Army people (one a therapist, one an Army officer) charged with creating the Army's whole suicide prevention plan. It consisted of two things:

Persuading soldiers that the slogan "Army strong" can include "strong means asking for help"; and
Setting up a suicide hotline.


But without massive changes in military culture, the first wouldn't work. In fact, we need to look at toxic masculinity for men and the expectation for women to ask for nothing for themselves as barriers to decreasing disconnection and isolation. As for the hotline, more in a moment. But note that Jensen and Platoni (2018)(https://nationalpsychologist.com/2018/11/most-military-efforts-miss-target-on-suicide-prevention/105185.html) have written:


The military and the civilian community have missed the mark on suicide intervention and prevention. The truly intervening and healing elements are not treatment programs, not piles of pills, not being encouraged time and again to reach out…but community itself, in the context of compassionate, educated, reciprocal, PROACTIVE social support.


Suicide hotlines are often assumed to be important and effective, and that is a dangerous assumption. An Oscar-winning film about the VA's hotline, "Crisis Hotline: Veterans Press 1," illustrated (no doubt unwittingly) the massive drawbacks. The general audience with whom I watched the film gasped in horror when they saw onscreen "22 veterans kill themselves every day." (Note that that famous number is wildly inaccurate, because it was based on VA data from only 21 states, not including Texas and California, which have huge populations of veterans.)

But the audience probably wanted to believe that the hotline takes care of the problem. In the film, one sees no veterans but sees and hears what those who answer the hotline say. One of the most striking aspects was the almost total lack of warmth and connection displayed by the responders, who were described as having had "mental health training."

Tremendous focus was on keeping the veteran on the phone until the police arrived or ensuring the veteran got to an Emergency Room. It's frightening to be in a position of responsibility for people who are talking about killing themselves, so it's understandable that the responders may have been relieved to serve as little more than way stations, directing the callers to the police or ER.


Another astonishing feature of the film was the extended conversation a responder was having with a Marine whom we could not hear. Based on the responder's comments, the Marine was having flashbacks of seeing his buddy lying in a pool of blood. The responder said vigorously at one point (no doubt with good intentions, trying to forestall a suicide), "Your children NEED their Marine father!"


I would have hoped that whatever training the responders had had would have included the information that when someone is seriously suicidal, they deeply believe that the greatest favor they can do their loved ones is to kill themselves. I fear that that Marine may have felt that the responder utterly failed to understand them, perhaps increasing their sense of isolation and despair.


When I once called the VA hotline, because I had good reason to fear that a veteran I knew was going to try (again) to kill himself with the many psychiatric drugs VA personnel had prescribed, I asked the responder what they would do if I could persuade him to call them. The answer: "Get him to an ER to be committed to a psych ward where they could adjust his medications." My pointing out that the drugs were a huge part of his problem completely failed to elicit any other response.


In July of this year, the FCC approved the use of the number 988 (as of this writing, that is not a working number) which anyone thinking of suicide would be urged to call, but all callers to that number would be directed to the existing National Suicide Prevention Line, which has many of the same problems as the VA one, as do other crisis hotlines.


I have critiqued these hotlines in Chapter 6 of the paperback version of my book, When Johnny and Jane Come Marching Home (https://www.amazon.com/When-Johnny-Jane-Come-Marching/dp/150403676X), and have described the alternative: what are known as "warm lines" that are answered by people whose focus is to connect and be supportive.

Hopefully, it is now clear why it is so inappropriate to conclude that people who are considering suicide or have killed themselves are/were mentally ill. Traditional therapists' approaches simply fail to help them. In Part 2 of this two-part article, I will address some barriers that tend to prevent suicidal people from seeking help—and ways that we truly can be of help.


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How Many Times Must the "PTSD" Label's Harm Be Exposed?

First published October 7, 2020, in



A recent Wall Street Journal (WSJ) article and a recent American Psychiatric Association (APA) press release reveal the power the APA has wielded through its various DSM editions in pathologizing the effects of trauma.


What's Wrong With the "PTSD" label?
Before I examine the problems with the article and press release, it is important that readers not assume that if "PTSD" ("Post-traumatic Stress Disorder") is a harmful label, "PTS" (just removing the "D") is fine. There is little difference, because "PTSD" is so widely used—even by people who rightly criticize the use of other psychiatric labels—that it will be generations before people stop thinking "Disorder" when they hear "PTS." Instead of using either term, what is accurate and useful is to call the trauma what it is—war trauma, rape trauma, hurricane trauma, etc.—and to call trauma's effects what they are, such as terror, grief, fragmentation, moral injury, loss of ability to trust, total exhaustion, etc.


As with any psychiatric label, its application subjects the labeled person to a vast array of kinds of harm, ranging from plummeting self-confidence to loss of child custody, employment, respect, all possible human rights, and even death.


Neither the WSJ article's author, Andrea Petersen, nor the unknown author of the APA press release ever questions what "PTSD" means in the DSM, what people will assume it means, and whether there is any scientific validity to it at all.


As I found when on two DSM-IV committees, there is no scientific validity to it. Still worse, when it first went in a DSM edition as a description of (some) reactions to trauma, there was a sentence noting that these were normal responses to abnormal situations. That meant it was weird to include it in a manual of mental disorders, but the DSM authors have rarely worried about consistency in their rush to include as many labels as possible. But that sentence was useful for traumatized people to see, because sometimes it made them feel less like they were overreacting and "crazy." However, even that little bit of help vanished when Allen Frances headed DSM-IV's Task Force, for that sentence was removed.


Not only is "PTSD" not scientifically derived, but even caring therapists apply the diagnosis without ensuring that their patients even meet all the DSM's required criteria, as researcher Meadow Linder wrote in a chapter in Bias in Psychiatric Diagnosis.


In a way, that is irrelevant, because what good does it do to stick scrupulously to arbitrarily chosen criteria? But this means that, as I have written elsewhere, "PTSD" now consists of shifting sands on shifting sands—an unscientific label, unscientifically and unsystematically applied.


When a Label Has No Validity, It's Absurd to Study What Helps "It"…and Other Problems
The Wall Street Journal author starts by referring to the pandemic, wrongly assumingthat it is creating skyrocketing rates of "PTSD"—rather than NONpathological suffering, and reviewing what she says therapists have described as "new" and needed treatments for the "disorder." It is especially troubling that she mentions that the most common reports of "PTSD" during the covid-19 pandemic in a large study were about loneliness and worries about the virus. Does it make sense to call loneliness and worries about the virus signs of mental illness?


And she mentions another study, this one of frontline healthcare workers during the pandemic, in which 16.7% are said to have "PTSD." Does it make sense to claim that it is a mental illness for people constantly exposed to a mysterious, dangerous, contagious illness to be traumatized? What is the point of all that, other than to alarm people and provide more money, power, and territory for therapists?


What the author mentions only briefly in her lengthy article is how helpful self-help groups for traumatized people can be. Instead, she writes endlessly about one drug after another after another and various forms of traditional talk therapy.


The author then zooms ahead, naming the psychiatric drugs (she calls them "medications") Zoloft, Paxil, MDMA (called "Ecstasy" on the street), and ketamine, all of which have negative effects ranging from upsetting (e.g., sexual problems) to dangerous (e.g., increased violence against self or others). Acknowledging that only small percentages of people who take these drugs are helped, she asserts that "Scientists" (who?) are seeing (based on high-quality research…or not?) "early" (oops) "positive studies combining psychotherapy with certain drugs." Even so, she does note that "About 40% of people who received the MDMA treatment reported side effects including anxiety, headaches and nausea." She might also have cited this report of even more serious kinds of harm.


Petersen also reports that an unspecified "growing body of research shows that transcranial magnetic stimulation, which uses a high-powered magnet placed on the scalp to stimulate neurons in certain parts of the brain, can ease PTSD symptoms." To begin with, I know from direct experience with one of the top marketers of such devices that they often fail to warn of negative effects and fail to disclose that these devices cannot be targeted to particular neurons, so little is known about what effects they will have—good or bad—in any given individual.


Further food for thought is that leaders in the movement challenging the traditional mental health system have asked the rhetorical question, "Why should we assume that when these marketers say that their devices are safe because they send LESS current through people's brains than traditional electroshock, we should believe them?"


Petersen asserts that the best psychotherapies for "PTSD" are cognitive processing and prolonged exposure therapy. In my decade of listening to military veterans, as well as to other traumatized people, I have learned that sometimes the former—examining one's beliefs that cause them suffering—helps and sometimes not, because often the moral injury and powerful emotions caused by trauma and the painful isolation are never addressed. And I have learned from them that exposure therapy—going over and over the trauma—helps some people but is horribly retraumatizing for others, and it, too, does not in and of itself include working on the moral injury, the isolation, or the other strong emotions.


Toward the end of the article, Petersen does mention the potential effectiveness of aerobic exercise, though only combined with prolonged exposure.


In summarizing concerns about the WSJ article, it is important to note that it is always a good thing to allow people to try anything that has helped some people who are similarly suffering, but it is essential for those people to be told in advance and fully what the potential benefits and the known kinds of harm are.


APA Wants Exclusive Control Over Prescribing Drugs for Veterans with "PTSD"
In a September 24, 2020, news release, the APA's headline came across as gloating: "Successful APA Advocacy Assures Veteran Patient Safety Regarding MH Care." The piece was about the House of Representatives' Veterans' Affairs Committee removing a proposal from suicide prevention legislation that would have given psychologists the right to prescribe drugs to veterans. A major problem in the release is that they automatically assume that the veterans who killed themselves had "PTSD."


Unsurprisingly, after a lengthy description of its lobby efforts about this matter, the release included this quotation:


"We will continue our work with the VA, Congress, and partner organizations to improve the mental health and substance use care available to our veterans through the VHA and beyond," said APA CEO and Medical Director Saul Levin, M.D., M.P.A.  "We must work with policymakers on genuine solutions that promote the recruitment and retention of critically needed psychiatrists, psychologists, and other mental health providers who are in short supply within the VA system. Meanwhile, with the help of our members, we have avoided the enactment of a false solution that could have put many veterans at risk, without any improvement in access to the care they truly need."


Note that Levin acknowledges that psychologists can help veterans but that allowing them to prescribe drugs would be "a false solution that could have put many veterans at risk," as though psychiatrists prescribing drugs does not put veterans at risk. This is reprehensible in light of the well-established fact that so many psychiatric drugs increase rates of suicide. My own view is not that it is worse for psychologists than psychiatrists to prescribe these drugs but that the fewer people of any discipline who are prescribing them, the better.


What would be amusing if it were not so frightening is that Levin is also quoted as saying:

"We believe that nothing is more important than ensuring that veterans are given high quality mental and physical health care by qualified, appropriately educated, and trained medical clinicians, not more prescribers and more prescriptions…."


Nowhere in the news release is there mention of any attempts to prevent suicide except through psychiatric drugs, and all the gloating is about how impressively the APA prevented psychologists from doing this. Wouldn't it have been great if he had:

surprised everyone by saying that psychiatrists should be prescribing fewer such drugs;
said that traumatized vets should be told they are having deeply human, understandable reactions to trauma instead of pathologizing them by saying they have "PTSD," and pointed out that labeling people as "mentally ill" increases the chance they will be put on drugs;
mentioned any of the many nonpathologizing approaches to helping traumatized people (such as the many at this website: http://www.youtube.com/playlist?list=PL51E99E866B9D735E)?

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Is Covid-19 Making Everybody Crazy?

Originally published at https://www.madinamerica.com/2020/07/covid-19-making-everybody-crazy/ 


The coronavirus pandemic has provided a golden opportunity for some psychotherapists, Big Pharma-funded entities, and others, who have sounded an alarm, claiming that massive numbers of people are "mentally ill" because of fears of the virus and reactions to social distancing.


Media producers have promoted these warnings during May, which was deemed Mental Health Awareness Month. A recent Washington Post article headlined "A third of Americans now show signs of clinical anxiety or depression, Census Bureau finds amid coronavirus pandemic" made that claim. And in a recent New York Times article, psychologist Andrew Solomon, reporting data that nearly half of respondents said the pandemic harmed their "mental health," shockingly equated this with mental illness becoming "universal reality."


In a June 5 press release, the American Psychiatric Association (APA), a lobby group for psychiatrists, reported an increase in psychiatric disorders during the pandemic that it based on an anonymous, online screening tool. Screening tools that allegedly tell the test-taker whether they have a "mental illness," including this Mental Health America (MHA) tool, are usually based on a list of feelings and difficulties that most people feel sometimes, and the cutoff points they give for when you should seek professional help are not scientifically based.


This tool includes instructions to take their Depression test if you are feeling overwhelming sadness. Do we really want to call overwhelming sadness in response to the isolation, fear, and unknown future occasioned by the pandemic a mental illness? They say to take their Anxiety test if worry and fear are affecting your daily functioning. Who these days doesn't worry whether their mask is adequate, whether they have washed their hands enough times and in hot enough water, whether to stay away from a beloved, elderly relative for fear of communicating the virus and thus increase their loneliness or go see them, wearing mask and gloves and staying six feet apart but still worrying because we might find out later that six feet of distance was notenough?


Such claims promise a vast expansion of the market for therapists, but such claims carry great potential for harm, adding to the burdens of people with upsetting but understandable, deeply human feelings by informing them they have psychiatric disorders. Anyone having upsetting feelings deserves love, help, understanding, and support, whether from family and friends or, if they choose, from clergy or therapists. But people also deserve to know about the dangers of classifying all upset as mental illness.


There are two common meanings of the term "black box," and both apply here. One meaning comes from the Food and Drug Administration's black box warnings to alert potential consumers to a product's dangers, and as applied here, people should be warned not to rush to call their upset "mental illness."


When people are struggling, suffering, or responding in unusual ways, they frequently fear their feelings mean they are "mentally ill," that they should be "doing better" than they are. One of the most helpful things that therapists can do is to let them know that their feelings are deeply human reactions, not signs of illness.


A hard look at four facts makes it clear that caution is warranted before pathologizing reactions to the current pandemic:

(1) Little is known about COVID-19 or how to protect oneself from it, and its effects can be fatal, so feeling confused, frightened—even terrified, powerless, and helpless—should not be classified as psychiatric disorders but rather as a normal and understandable reaction to extremely unusual events.
(2) As poet Heather McHugh observes, in our daily lives under ordinary circumstances, we tend to avoid "our fundamental terror at our own deaths," but the pandemic's massive concentration of so many deaths at once, and the fact that our own death is now more likely to be imminent, "makes the burden of the knowledge of mortality weigh" heavily on us. McHugh cites Audre Lorde's poem, ""A Litany for Survival," which ends with the line "we were never meant to survive." Suddenly to be confronted with something so terrifying for many people that they usually drive it out of awareness is a shock and disorienting in its own way: The fleeing doesn't work as well now, so how to begin finding other ways to cope with our mortality?
(3) Physical isolation from others interrupts the participation in community that is proven to be healing; but social distancing and stay-at-home policies drastically reduce participation in community. Connections via zoom calls have skyrocketed and can be helpful but have drawbacks. Many include numerous participants, which can inhibit deep conversations about feelings and creation/maintaining of meaningful relationships. Further, there is some strain involved in monitoring who is speaking and when to jump in, and it requires extra energy to remember to stay within camera range, monitor when to mute and unmute oneself, and project enough to be heard. No zoom call can replace human touch, which promotes security, happiness, and belonging. Being unable to hug a loved one without fear of unknowingly transmitting or getting the virus seriously interferes when we want to see people with whom we do not live—grandparents, elderly parents, grandchildren, friends, neighbors.
(4) Many people are grappling with increased loneliness, alarm about losing jobs and work identity, new financial crises, and child or spousal abuse. Asians and Asian Americans have been targets of discrimination and abuse because of claims that COVID-19 originated in China. Many African Americans and Latinx people and people in nursing homes, prisons, and psychiatric hospitals know that their risk of getting the virus is higher than that of others, compounding fear, suffering, and anger about the reasons for the increased risk. Upset due to any of these causes should not be called mental illnesses. The same applies to frontline healthcare and other essential workers and people who have suddenly had to provide constant care for family of all ages and education for offspring or those grieving loved ones' deaths. As with military veterans traumatized by war, or victims of all forms of oppression and violence, the last thing such people need is to be told their reactions are proof that they are psychiatrically disordered; the message that they should be "coping better" only adds to their burden.

No wonder so many people are feeling upset!


People who are suffering emotionally from the effects of COVID-19 deserve help, but it must be real help, such as lifting their economic burdens, protecting them from violence, and increasing community support, including all of us showing we are willing to listen to what they are going through and acknowledging how common these struggles are. Importantly, we must let them know that their suffering does not warrant classifying them as mentally ill (as psychiatrist Dainius Puras, Special UN Rapporteur, notes).


An increasingly pervasive pattern is the leaping to recommend "therapy" or "mental health services" when attention is drawn to human suffering. This relates to the older meaning of "black box" as something whose inputs and outputs can be viewed but whose internal workings are unknown. The terms "therapy" and "services" are black boxes, so vague that they can include the entire range of good and bad therapists and approaches. Often, well-meaning friends and family, and certainly legislators, feel they have done their bit by sending someone to therapy or voting to increase funding for such services without ensuring that the therapists are caring and effective or that the services actually help. Some therapists are terrific, and some approaches classified as "mental health services" help some people, but some therapists cause harm.


Likewise, psychiatric drugs sometimes help but very often harm, and their use has skyrocketed early in the pandemic, perhaps due to people assuming they would need them, but has now declined to around pre-pandemic levels. Other approaches can cause harm, and some services actually increase suicides. Furthermore, as soon as a person is diagnosed as "mentally ill," their own focus and that of professionals tend to veer sharply away from nonpathologizing, low-risk and no-risk approaches that are known to be effective.


More than two dozen of the latter, such as involvement in the arts, physical exercise, meditation, having a service animal, doing volunteer work, and having a listener, can be seen here (these are from a conference about veterans but can be helpful for anyone) (see also here). But entities like the APA do not tend to mention such approaches but only focus on therapy and drugs, and the MHA screening tool they cite urges people to see a mental health professional.


Lauren Tenney, Ph.D., a psychologist with expertise in trauma and human rights violations, says that "emotional responses people are having to the unnatural and traumatic circumstances created by the pandemic are not signs of supposed 'mental illness.'" She stresses that people who are "experiencing a range of emotions outside of their comfort zone ought to see these emotional upheavals as par for the course and attempt to embrace the depths of feelings social isolation can create."  She urges those who are suffering: "Actively work to connect with others who are having similar experiences" and suggests that "People should be supported in finding resiliency in the face of environmental adversities."


Even Google is getting into the act, partnering with the National Alliance on Mental Illness (NAMI) to post an "anxiety self-assessment" tool. The announcement of the partnership included description of NAMI, which is heavily funded by Big Pharma, as a "grassroots" organization and uses a tool that is based directly on a psychiatrized description of anxiety and is titled with a psychiatric disorder's name. Furthermore, they will "provide access to resources"—there's that black-box word again, "resources," developed by NAMI.


A major source of confusion is that when the terms "mental health problems" or "mental health conditions" are used—instead of, for instance, "emotional upset" or "suffering"—it is very often taken to mean "mental illness." As a result, media reports of increases in which understandable reactions to the pandemic are described as "mental health problems" are easily assumed to indicate increases in psychiatric disorders. Compounding the confusion is that psychiatric disorders are widely—but wrongly—assumed to be scientifically validated entities, so in the face of claims of increases in mental illness, rarely is the basic question, "But isn't 'mental illness' defined unscientifically and by whoever has the power to define it?" Instead, the assumption is made that it's clear what "mental illnesses" are and that they are rising.


One example is a recent warning that the pandemic will increase "postpartum depression" and "perinatal mood and anxiety disorders." The author, a psychiatrist, comes nowhere near to questioning the validity of these categories and simply alleges that they are partly neurobiologically caused, and she pathologizes expectant mothers' totally reasonable fears the pandemic provokes, despite acknowledging that social supports (harder to get in the coronavirus era) are crucial to preventing what would more properly called postpartum isolation, fearfulness, and sadness rather than psychiatric disorders.


Curiously, the World Health Organization's Director-General Dr. Tedros Adhanom Ghebreyesus warns that the "pandemic is highlighting the need to urgently increase investment in services for mental health or risk a massive increase in mental health conditions in the coming months," despite noting that pandemic factors like "social isolation, fear of contagion, and loss of family members is [sic] compounded by the distress caused by loss of income and often employment."


The psychiatrizing of America has been so efficacious that many professionals and laypeople readily assume the traditional mental health system can and should solve all emotional problems. Evidence of the limitations of that system include high and increasing rates of suicide and death and high and increasing rates of long-term disability of people treated in that system. Good therapists—and laypeople—can help normalize feelings and explore useful ways to cope.


But therapy must not be seen as the only option or as the one that will definitely help. What has been proven helpful to suffering people has included freedom from economic pressures, poverty, violence, oppression, and inadequate physical health care; a safe place to live; and meaningful human connections. Even the authors of a recent British Medical Journal article warning of a "tsunami" of "mental health cases" note that the people most at risk are those with "precarious livelihoods" and "poorest health," and fortunately, some groups are assuring people that their upset is understandable in light of the strange, new, massively and abruptly changed circumstances and being torn from their usual communities and sources of support.


Controlled studies of approaches aimed to reduce emotional suffering are nearly impossible to create, but an interesting contrast of the effects traditional, pathologizing approach and those of nonpathologizing ones is reported in a recent articleabout two neighboring Ohio regions. Although more information is needed from similar contrasts, the report from these two is of interest.


The Richland County Mental Health Board, which has encouraged the traditional use of counseling and crisis hotlines, reports a recent increase in suicides. Nearby, Ashland Mental Health and Recovery Board executive director Steve Stone, whose Board advocates nonpathologizing approaches, or what he calls "self-care" and "natural support systems," reports that their crisis services have not increased and in some respects have slightly decreased, and there have been no suicides and no increase in new people seeking help. He cited peer support programs as crucial to keeping their numbers low, including a sewing group, in which community members made hundreds of face masks, and a writing group that will write letters to patients in state hospitals during the pandemic. Stone is quoted as saying that they rely very little on state hospital and inpatient programs, and he "thinks the need for professional mental health services will remain low based on common sense approaches of people taking care of themselves as well as each other."


It will add to the tragedies caused by the current pandemic if all hope is focused on the mental health system and is diverted from the many things that reduce suffering and that do so without calling all suffering mental illness.


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The President’s Fitness: Can Professionals Help Decide?

First published May 8, 2020, at https://www.madinamerica.com/2020/05/presidents-fitness-can-professionals-help-decide/ [new material added here is in square brackets below]


Even before Donald Trump became President of the United States, speculations about whether he was fit to serve were rampant. Although it is beside the point, much time and heated debate consisted of questions such as, "Is he mentally ill?" and "Which kindof mental illness does he have?" In our psychiatrized nation, such discussions have widely been heard as meaning: "Trump is mentally ill, and that makes him unfit to serve as President."


Most readers of Mad in America know that both the overarching category of "mental illness" and the hundreds of alleged subcategories listed in psychiatric classification systems have no scientific basis and are not useful in helping people who are suffering or stopping those who make other people suffer. I addressed this in an article I wrote fairly early in the debate, called "The Truth about Trump and Psychiatric Diagnosis."


Most readers of Mad in America also have a healthy skepticism about what—or whether—professionals have anything to contribute to the benefitting of society. So the question is whether that skepticism applies to determining whether Trump or any President is fit to serve in that office. I think that, for once, it does not, but I have a very specific reason for saying this.


The 25th Amendment to the United States Constitution was supposed to provide for the removal of an unfit President. It was "proposed by Congress and ratified by the states in the aftermath of the assassination of President John F. Kennedy" and "provides the procedures for replacing the president or vice president in the event of death, removal, resignation, or incapacitation." However,  the devil is in the details, and the Amendment turns out to be woefully inadequate. Why? Because Section 4 provides that:


Whenever the Vice President and a majority of either the principal officers of the executive departments or of such other body as Congress may by law provide, transmit to the President pro tempore of the Senate and the Speaker of the House of Representatives their written declaration that the President is unable to discharge the powers and duties of his office, the Vice President shall immediately assume the powers and duties of the office as Acting President.


However, even if that happened in Trump's case, the Amendment provides that if the President just declares in writing that "no such inability exists," he continues in his office unless the Congress determines by two-thirds vote of both Houses that the President is unable to discharge the powers and duties of the office. It's not hard to imagine that with the current Senate, that would be unlikely to happen, given the Senate's utter failure to act after the House of Representatives impeached the President.

Congressman Jamin Raskin (D-MD), a brilliant Constitutional law scholar, has tried to draft legislation that would get around the highly political nature of the process as it is described in the Amendment. He aimed to create a mechanism for determining fitness to serve by creating a Commission for that purpose. In correspondence with me (Sept. 4, 2017), he explained the further wish to avoid making the process solely "psychiatric or medical," because then, "people will say the decision has been medicalized or psychologized when it is properly a public policy question."


His idea was to constitute a Commission with a mix of public policy, medical, and psychiatric professionals. Since fitness to serve can be affected by such physical impairments as those caused by strokes and comas, it makes sense to include medical personnel who are not psychiatrists. The legislation he proposed was HR 1987 from the 115th Congress, to which 70 members of the House of Representatives signed on, all Democrats.


I sent Congressman Raskin a proposal in which I strongly argued against including mental health professionals who would likely focus on psychiatric diagnosis. I pointed out not only that such diagnoses are unscientific but also that many people who have been given such labels have done great work and done no harm.  I then pointed out that some psychologists and educators can offer information and tools that are directly relevant to fitness to serve.


In fact, it strikes me as quite simple: Determination of fitness to serve should be based on whether the office-holder can carry out the crucial elements of the job. Professionals who are trained in developing and administering reliable, valid achievement tests and tests of memory and abstract thinking—primarily some psychologists and educators—could play crucial roles in such a Commission.


Here are excerpts from what I wrote to the Congressman on January 4, 2018, and which still applies. I have added slight clarifications in square brackets.

If you have [psychiatrists] on the Commission, whatever they say will not be scientific, not empirically demonstrable, and thus open to accusations that the process is improperly political. Where there is no science (there is none in psychiatric diagnosis), there is only opinion, and opinion is always highly susceptible to bias of many kinds.
The Commission ought to include a neuropsychologist, since they are trained to give standardized memory tests, and memory is of course an essential component of fitness to serve.  The Commission should arrange to have [chosen or] constructed the relevant tests of fitness, which are in many ways achievement tests — tests of knowledge about the Constitution ([a] book being published tomorrow includes…that someone tried to discuss the Constitution with Trump and got as far as the 4th Amendment before he changed the subject, so this is a timely way to point out the usefulness of the approach I suggest), how a bill becomes a law, geography, political systems globally, and tests of memory and of the understanding of abstract concepts including but not limited to cause-effect relationships.
The tests described in (2) have a parallel in the achievement tests a person applying for U.S. citizenship needs to take. As you said, the Constitution does not include requirements as in (2), but those become relevant once the question of fitness to serve is raised.
Various people throw around the term "mental" as in "mental impairment." It is essential to distinguish between two kinds of "mental impairment": There is emotional impairment [or difference] (e.g., absence of empathy and compassion, believing oneself to be Jesus Christ [if one is not]), and there is cognitive impairment (e.g., dementia, reading disability, math disability, inability to form or comprehend abstract concepts). Just a note: Trump may be suffering from both lifelong cognitive impairment (one of his professors from Wharton called him the dumbest student he ever had) and perhaps now, some dementia. [T]he way he slurred "United States" recently is not explained by dry mouth as was suggested. He could be having small strokes. That's why a neurologist as well as a neuropsychologist would be good to have on the Commission.
If you left out Trump's name and just told anyone some things he has said and done, they would assign labels such as "bully," "whopping sense of entitlement," "power-hungry," "stunning lack of empathy and compassion" [and "thug," "criminal," or "evildoer]. These are more than adequate to explain a huge amount of what we see in him. Ask people what they think calling him "mentally ill" would add. What does it explain that is relevant to fitness to serve as President? Saying he is unfit to serve because of being mentally ill is causing huge offense to people who have psychiatric labels, and that may well come close to 1/3 of the U.S. population. Abraham Lincoln would have been diagnosed as mentally ill. A psychiatric label is orthogonal to the matter of fitness to serve.
The kinds of tests described in (2) are exquisitely specific, jargon-free, and inarguably relevant to fitness to serve.

Congressman Raskin, in a May 6, 2020 email to me, said that if he were to rewrite the legislation today, he would include Governors and a neurologist. He noted: "All of the events we are living through reconfirm for me that the critical concept under Section 4 of the 25th Amendment is 'dangerous unfitness' to discharge the powers and duties of office."


Despite all of the above, many psychiatrists and psychologists have claimed that they have "special expertise" and extensive training that qualify them to judge Trump to be mentally unfit and dangerous to this nation's "public health." Their position is that they have a "duty to warn" that justifies their ignoring of the Goldwater Rule, https://www.madinamerica.com/2020/04/muzzled-psychiatry-time-crisis/ which prohibits the giving of professional opinions of anyone the therapist has not evaluated in person.


Of course, given that psychiatric diagnoses are not valid, the Goldwater Rule by all rights should specify that no one should ever give anyone a psychiatric diagnosis. But the rule refers to more than just diagnosis, so the professionals who claim special expertise—who tend to vary among themselves, and some of whom vacillate between saying he is mentally ill and saying diagnosis is beside the point [their leader, Yale psychiatrist Bandy Lee, has been quoted in a recent article in a publication that is opposed to psychiatric diagnosis https://www.madinamerica.com/2020/04/muzzled-psychiatry-time-crisis/ as saying that diagnosis is beside the point, when in fact she sometimes says that but has vigorously promoted a book she edited and a film about the book in which her chosen authors say that he is mentally ill, and some even claim to know he should be diagnosed with specific, but various, labels] —should stop claiming that they must speak out because of that alleged expertise.


For psychiatrists, psychologists, social workers, and other therapists to claim that they are essential for warning people that Trump is dangerous is to claim special expertise and insight to which they are not entitled, and it simultaneously demeans the judgment of nonprofessionals and helps strengthen the power of their guilds.


The fact is that, as longtime expert on dangerousness Dr. James Gilligan has said, the only good predictor of dangerous behavior is past commission of dangerous acts, and as Dr. Gilligan pointed out in a press conference at the National Press Club in February, 2018, Trump himself has acknowledged his own dangerous behavior, including but by no means limited to his sexual assaults.

My middle-school grandchildren observed this with no help from any professional or anyone older than they. There is, then, a role for some professionals in trying to remove unfit officials from office, but it is not the one that some would like us to believe.

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Big Pharma meets Big Diagnosis, Big Courts, and Big Psychiatric Hospitals

First published January 31, 2020, at https://www.madinamerica.com/2020/01/zyprexa-papers/


If you think the truth can set us free, and you care about harm done to suffering souls who seek help from the traditional mental health system, only to discover too often and too late that that system exponentially adds to their burdens, Jim Gottstein's blockbuster new book, The Zyprexa Papers, is essential reading. It should be required reading for every well-meaning friend or family member of someone who suffers emotionally, as well as for legislators who genuinely want to weed out corruption and harm.


The book is focused on the neuroleptic drug Zyprexa and two cases related to it — one in which Gottstein represented a client and one in which he became the accused — but importantly, it exemplifies problems throughout the systems of not only Big Pharma but also what could be called Big Diagnosis, Big Psychiatric Hospitals, and Big Mental Health-related Courts. It's a book about how the tsunami fed by the profit motive and the vast systems involved in the politics of mental health, including the so-called justice system, swamps what ought to be primary: the alleviation of emotional pain.


Gottstein's book is The Pentagon Papers of the traditional mental health system, because he exposes a mind-blowing number and variety of cold-blooded, calculating actions on the part of Eli Lilly in trying to hide what it knew to be the devastating effects of its hugely profitable Zyprexa, from its lies of both omission and commission about relevant data to what can only be called its persecution of Gottstein himself for trying to sound the alarm. Gottstein, a courageous and brilliant lawyer and tireless activist trying through strategic litigation to prevent people from being harmed by psychiatric drugs and electroshock through his nonprofit Law Project for Psychiatric Rights (PsychRights), also takes us day by day through his attempts to prevent one particular client, Bill Bigley (to whom the book is dedicated), from being involuntarily committed to a psychiatric facility and forcibly drugged. In doing so, he exposes the staggering number of ways the court system that handles such cases amounts way too frequently to a kind of Kangaroo Court, where the odds are so stacked against the person labeled mentally ill that it's almost inevitable they will be deprived of their rights. The hurdles the client and lawyer have to jump are so numerous and various that this part of The Zyprexa Papers will be a revelation to those who have not themselves been through it.


Where does Big Diagnosis come in? Without the hundreds of psychiatric categories in the Diagnostic and Statistical Manual of Mental Disorders (DSM), none of this could have happened, because giving a person even one DSM label — even one that sounds relatively innocuous — is what enables therapists, drug companies, and judges (not to mention others) to make a wide array of recommendations and even impose courses of action that they can call "treatment." And when the "treatments," including drugs, cause harm or fail to help, the labeled person's reports are easily ignored, minimized, or used as further "proof" that they are "mentally ill." Equally appalling is that calling psychiatric drugging, electroshock, involuntary commitment, and other intrusions "treatment" allows those who suggest, impose, or enforce them to escape culpability. In a lawsuit in which I was an expert witness, three therapists who nearly destroyed someone's life were not held in the least negligent, on the grounds that they had just been following the mental health system's standard of care.


The Zyprexa Papers is a hard book to put down, and it's so worth reading, because we need to know what goes on largely in secret, and as we read, we see clearly the many points where changes for the better must be made… and how each of us can help to change them.


Gottstein had had personal experience in the mental health system. In 1982, at age 29, he had become terribly disoriented from lack of sleep and as a result had been locked up in the Alaska Psychiatric Institute (API) — the very entity that had repeatedly hospitalized and forcibly drugged Bill Bigley. At API, Gottstein reports:


"I was told I would have to take mind-numbing Thorazine-like drugs for the rest of my life. When I told them I had graduated from Harvard Law School (which I had), I was considered delusional. Those who believed I was a lawyer said I would never practice law again. However, my mother, who was the Executive Director of the Alaska Mental Health Association, steered me to a terrific psychiatrist, Robert Alberts, who said that anyone who doesn't get enough sleep will become psychotic, and I just needed to learn how to keep from getting into trouble. … was lucky not to have been made into a permanent mental patient by the mental illness system. These experiences started my advocacy for people diagnosed with serious mental illness."


Gottstein describes having been inspired by Robert Whitaker's classic investigative book, Mad in America, which he describes as both "a terrific read" and "a litigation roadmap for challenging forced psychiatric drugging on the basis that it isn't in the patient's best interest." He explains that drugs like Zyprexa "have been marketed as 'antipsychotic'" when in fact what they do is "suppress people's brain activity so much they can no longer be much trouble—at least temporarily." For this reason, he uses the term "neuroleptic," which means "seize the brain" — it was "one of the first names given to this class of drugs, and is the most accurate description." To call them "antipsychotic," he says, is "marketing hype."


Readers discover the ghastly lengths to which Lilly, aiming solely to maximize its profits, went from the outset to conceal the fact that Zyprexa caused, among many other serious problems, high rates of diabetes, rapid and enormous weight gain (in some cases, more than 100 pounds after a year on the drug), and even death. How much money was at stake? In 2005, the year before the book's saga begins, Zyprexa's reported sales were $4.2 billion, with about two million people across the world taking the drug.


Gottstein describes his triple efforts, starting in 2006, to help one person protect his right to refuse psychiatric drugs, to help in other strategic litigation, and to publicize widely the truth about Zyprexa's dangers. The incriminating evidence about those dangers had been discovered by an expert witness for a number of plaintiffs in the 8,000-person, multi-district litigation who charged they were harmed by the drug, and Gottstein obtained that evidence by subpoenaing the expert for the documents to be used for Bill Bigley's case against forced drugging. In the multi-district litigation, the large number of lawsuits had been consolidated, and the documentation about Zyprexa's concealed dangers became subject to an order that they be kept secret. Fortunately, however, the information could be produced if it was subpoenaed for another court action and if Lilly was first given "notice and a reasonable opportunity to object."


The amount of time that "reasonable opportunity to object" required was unspecified, so when Gottstein subpoenaed the documents from the expert witness, Dr. David Egilman, whom he describes as a man of conscience, Egilman sent them to Gottstein not immediately but before Lilly objected. Egilman had told Gottstein he hoped Gottstein would subpoena him and then, after receiving Egilman's documentation, would turn it over to New York Times writer Alex Berenson for his reporting about Zyprexa. However, to Gottstein's personal detriment, when Egilman only showed Gottstein part of the entire secrecy order, he acknowledges that he "motored past that red flag" and relied on Egilman to indicate when he thought a "reasonable" amount of time had passed since Egilman had notified Lilly of Gottstein's subpoena and thus Gottstein was free to send the documents to Berenson, as well as to many others who would help disseminate the truth.


The interpretation of "reasonable" became a major weapon in what can legitimately be called Lilly's persecution of Gottstein for making the information public. On December 6, 2006, Egilman notified Lilly's top attorney that Gottstein had subpoenaed him for a deposition by telephone for December 20. On December 11, Gottstein sent Egilman an amended subpoena, because the original one had included the order for the doctor to bring his documents with him, but since the deposition was going to be by telephone, Gottstein needed the documents sent to him before the deposition. He asked Egilman to notify Lilly of the amendment, but Egilman did not do so. Egilman said that five days had passed since his notification to Lilly, and he believed that that constituted "reasonable" notice, so on December 12, he went ahead and uploaded the material to an internet domain Gottstein had created for that purpose. Gottstein had received a voicemail message from a Lilly lawyer the night before and had left a voicemail for him the next morning. In the meantime, as he said, "feeling Lilly's breath on my neck," he proceeded to give the Times reporter access to the documents, and he sent them in various ways to many other people.


Gottstein's courage in doing this is stunning. He knew that he could end up going to prison, given Lilly's power and money, but "thousands upon thousands of people had already been killed by the drug, and we [he and Egilman] were hoping to keep that from happening to thousands upon thousands more."


What followed showed both Lilly and the courts at their worst. Lilly's ability to bring in judges to try to intimidate Gottstein was astonishing. Readers will be alarmed to learn in the pages of The Zyprexa Papers how vulnerable truthtellers can be, even when their aim is utterly selfless and when they try to prevent massive harm like that which had already come to huge numbers of people. Lilly demanded that Gottstein not reveal the documents to anyone and that he immediately retrieve them from everyone to whom he had sent them and take them down from anywhere he had posted them. By then, some of his recipients had sent them on to still other people, and in various ways they had been further publicized. In fact, in an article Berenson wrote around that time, the following appeared: "Mr. Gottstein said yesterday that the information in the documents should be available to patients and doctors, as well as judges who oversee the hearings that are required before people can be forced to take psychiatric drugs. 'The courts should have this information before they order this stuff injected into people's unwilling bodies,' Mr. Gottstein said."


As media coverage about the matter increased, Lilly, clearly incensed, threatened Gottstein that he would lose his law license and that it would "seek sanctions" against him for having violated the secrecy order from that case that had been settled with the 8,000 plaintiffs. A court order included the instruction to him to "Preserve all documents, voice mails, e-mails, material and information relating to Dr. Egilman or any other efforts to obtain documents produced by Lilly." I recall that around that time, I had called Jim's office about some other matter and was stunned to hear his outgoing message, in which he instructed callers not to leave a message of any kind on his answering machine. It felt Orwellian.


The ways that Lilly and the courts conspired against Gottstein must be read to be believed. And it is poignant to read Gottstein kicking himself for the very human mistakes he made when called to testify under circumstances of extreme sleep deprivation, but these errors should never have justified the outcomes. Gottstein had spent vast amounts of money trying to defend himself and was facing even more legal fees beyond the huge ones he had already incurred. In addition, threats of losing his law license and contempt of court charges were hanging over his head. The story of why and how the case ended for him makes one rail at the so-called justice system and the overwhelming power of Big Pharma, as well as how they work together.


Gottstein speculates that the judges' decisions were due to their view that Gottstein flouted their authority by sending out the material covered by the secrecy order, and it looks to this reader as though they jumped at the chance to interpret or misinterpret anything in Gottstein's favor so as to allow them to protect Lilly. This impression is strengthened by the fact that vast numbers of the documents covered by the secrecy order had always been public knowledge, including media reports, yet all were subsumed in that order.


Bending over backward to understand the court's alarm about exposure of the documents, one might ask what benefit comes to the plaintiffs in settlements like the one that included the secrecy order. Gottstein tells us that the Zyprexa settlement with 8,000 victims averaged a little less than $90,000 per victim and says:


"This doesn't seem like a lot for giving someone diabetes, but it is even worse when you consider that the lawyers took 40% and then Medicaid and Medicare were reimbursed another 30%. At that point, even the approximately $27,000 individual victims received, on average, put those who were on Medicaid and disability over the asset limit for eligibility. This meant they had to spend the money from the settlement to treat their diabetes and otherwise spend it over the course of a year or two to maintain or get back their Medicaid and disability payments"


Furthermore, Gottstein writes, "judges are supposed to allow the secrecy only if it is in the public interest, but in practice, they don't. The secrecy greases the wheels of settlement as well as litigation, and judges want to have cases resolved and off their docket. … Normally, no one is representing the public interest." He continues:

I think it is fair to say by issuing the secrecy order the … Court was complicit with Lilly in hiding the great harm being done to people as a result of Zyprexa. If this information had become public earlier, thousands of additional lives could have been saved, and hundreds of thousands of people would probably not have taken Zyprexa.


Gottstein describes where the Court erred in considering the subpoena he issued and his release of the Zyprexa Papers:


"It felt I had violated its secrecy order, and never gave serious consideration to the possibility I had not. Protecting its authority was really the court's only consideration. It did not give fair consideration to PsychRights' legitimate interest in the Zyprexa Papers. It did not give fair consideration to the fact that PsychRights followed the secrecy order's rules in obtaining the Zyprexa Papers. … I had my independent and proper reasons for subpoenaing them, including alerting the public to the great harm caused by Zyprexa. … I believed I received them under the secrecy order's rules and once I had them in that way, they lost their secrecy."


The second story in the book, interwoven throughout with the Lilly case, is about the way that Bill Bigley, whom Gottstein brings to life with warmth and respect, experienced tragic losses that understandably made him sad. His deeply human reaction was then pathologized: He was diagnosed with psychiatric labels that formed the foundation for starting him on a cycle of involuntary hospitalizations that grew to number around 70 and of forced drugging that caused him so many problems that he understandably resisted those chemicals. All of this predictably led to his deterioration in many ways, and he began sometimes to act in ways that annoyed some people, but he was never violent. Gottstein writes: "In reality, it wasn't about Bill's quality of life at all but about reducing other people's annoyance with him."


In spite of this, the mental health system destroyed this man, whose suffering, like that of so many, led to diagnosis that was then used to justify depriving him of his rights on the utterly unsupported grounds that he must have an incurable chemical imbalance and needed "treatment." As Gottstein describes trying to help Bigley so many times, he shows point by point how the system in Alaska — typical of those across the U.S. — was used to order involuntary commitment and forced drugging was rigged against him.


The very fact that someone has been given any psychiatric label is used in a staggering variety of ways to deprive them of self-respect, dignity, self-confidence, employment, custody of their children, the right to make decisions about their medical and legal affairs, and even their lives. Just as Gottstein's accurate statement that he had graduated from Harvard Law School had been construed as evidence of his "mental illness," so when Bigley accurately stated that he had been quoted in the New York Times, that was construed as proof of his "psychiatric disorder." And as so often happens, Bigley's refusal of psychiatric drugs was alleged to be proof that he was too "ill" to know how to take care of himself.


Flagrantly ignoring proof of the harm caused by psychiatric drugs, the judge ordered that Bigley could be drugged against his will. The judge's "reasoning" belongs in Alice in Wonderland rather than a court order. Try to find the logic in what the judge held, as Gottstein cites it:


"The Court is willing to assume that past medications have damaged Bigley's brain. It is further willing to assume that additional brain damage will result if API is allowed to administer more psychotropics. But that does not end the analysis.

"The Court finds that the danger of additional (but uncertain) damage is outweighed by the positive benefits of the administration of medication and the emotional and behavioral problems that will escalate if Bigley is not medicated. Even if the medication shortens Bigley's lifespan, the Court would authorize the administration of the medication because Bigley is not well now and he is getting worse."


Given that Zyprexa and similar medications such as Risperdal have been shown to cause early death, Gottstein is reasonable in concluding: "I guess judges decide who shall live and who shall die all the time, although the death penalty is not even allowed against murderers in Alaska."


Bill Bigley's hearings were usually held in a room at the Alaska Psychiatric Institute rather than in a courtroom and were usually not open to the public, as most similar court proceedings are supposed to be in order to help ensure due process and protect the person's rights. When hearings are held within such hospitals, they tend to become Kafkaesque, throwing due process and legal procedures out the window, so that coercive orders are made in the absence of evidence that the criteria for coercion (danger to self or others, gravely disabled, least restrictive alternative) are met. Bill Bigley therefore wanted his hearings to take place in a real courtroom and to be public.


Anyone in danger of losing their human rights — or their life — through a court proceeding should have someone like Gottstein advocating for them, because he is a tireless advocate, knows the law inside out, and never loses sight of what is true, what is right, and what is humane in its respect for his clients' dignity. He uses a combination of legal principles and procedures with analysis of whether those principles hold water within legal traditions but also outside of those traditions. Not feeling constrained by precedent in court and practice in the mental health system, he is consistently creative and resourceful in trying to find solutions. For instance, pursuing the principle that the "least restrictive alternative" should be tried, and knowing that court orders in cases like Bigley's were usually based on consideration of only two alternatives — drug the person or don't drug them, period — he makes this commonsense, caring proposal that includes a third option:


"…when someone is having a meltdown, they can be approached and told, 'Listen, we can't have you doing these things, because of ______________ [e.g., you annoy people or you scare people], so if you don't calm down, we are going to have to inject you with Haldol or put you in restraints or seclusion (solitary confinement). Which would you prefer?' I think some people would prefer the restraints or seclusion over the drug, but I also think there is some chance simply giving them the choice would allow them to calm down."


Of course, since this proposal is based on respect for the person and the assumption that they can use reason, consider options, and have agency, it's not the kind of thing that judges tend to accept. Their dual concerns — that they will be blamed if they don't order hospitalization and/or drugs and "something happens," and their tendency to believe the claims of the powerful, well-funded entities like Big Pharma and Big Psychiatric Hospitals — get in the way.


As for the psychiatric hospital's representatives, as Gottstein writes, what their continual pushing for forced drugging "demonstrates clearly is API was incapable of treating people without using drugs. This was and remains basically true of psychiatric 'hospitals' around the country."


Gottstein wrote this book in part to try to prescribe a roadmap for approaching these kinds of cases, which, he said in an email message to me, includes the need "to treat these cases like the big-stakes litigation they are." His compelling descriptions of his clashes with Lilly and his advocacy for Bigley make clear how high are the stakes and how dangerous to the brave souls who engage in the struggles. But as he poignantly notes, Zyprexa "is still being used on hundreds of thousands of people, including being forced on many. The same is true of the other neuroleptics." Indeed, even many who advocate for victims of the traditional mental health system in their writings and films legitimize and even valorize former DSM-IV Task Force head Allen Frances, despite knowing that he and two colleagues earned just under a million dollars for creating the fraudulent foundation that allowed Johnson & Johnson subsidiary Janssen Pharmaceuticals to deceptively market the dangerous neuroleptic drug Risperdal for an astonishing variety of "conditions" in people from childhood to old age. (For more on this, see my articles "Diagnosisgate: Conflict of Interest at the Top of the Psychiatric Apparatus" and "Diagnosisgate: A Major Media Blackout Mystery.")


Gottstein believes, finally, that:


"inadequate legal representation is the lynch pin for the massive harm being done to people through psychiatry. If people were being represented adequately the current system would be unable to lock the legions of people up and drug them against their will and would have to find some other way to deal with people diagnosed with mental illness and being disturbing. If PsychRights had the resources to employ just two or three lawyers full time in Anchorage, Alaska for such representations and funds for expert witnesses, I believe PsychRights could break the system and force provision of different approaches that have been shown to work and help people get through the problems they are having."


The book's Kindle edition is available for order starting today, January 31. The paperback is now also available for ordering on Amazon.


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A book review of "Acceptance: The Defining Voice of Validation"

First published March 13, 2020, at https://www.madinamerica.com/2020/03/acceptance-book-review/


Happily, above the flood of books about whatever the author decides to call—or accepts as defining—"mental illness," with traditional recommendations about what is helpful, usually these days amounting to psychiatric drugging, a humane, nonpathologizing, truly useful volume has appeared. It is psychologist Evelyn Sommers' book, Acceptance: The Defining Voice of Validation, whose writing is clear as a bell and whose voice is consistently of one who walks with the reader who wants to move past earlier, upsetting matters and become "unstuck" in order to get on with a more productive, forward-looking life.


As with her previous books—Voices from Within: Women Who Have Broken the Law and The Tyranny of Niceness: Unmasking the Need for Approval—the writing of Dr. Sommers, a Toronto-based clinical psychologist, is an easy pleasure to read and is deceptively simple. In her new book, she identifies a universal problem that at first glance might seem too minimal to warrant serious consideration but that in fact often causes emotional troubles ranging from transitory discomfort to an inchoate uneasiness that can last decades to major psychological paralysis and confusion about what is real.


This is no goody-goody book but one that compellingly draws our attention to what in our hurried, overburdened lives too easily gets lost, that is, the essential human need for acceptance and validation. Validation, she says, "is a joining with the distressed person to reflect or give voice to that person's feelings accurately."


Early in the book, Sommers writes that a great deal of necessary attention is being paid to the role of trauma in creating emotional suffering, but she makes a powerful case for also focusing on what may seem like minor events that in fact constitute powerful barriers to self-acceptance, self-confidence, and an ability to focus on the future and make choices rather than being stuck because of an event or a comment that the world hasn't recognized as hurtful.


Better yet, Sommers offers thoughtful solutions that are easy to understand and begin to practice. She makes us notice things we need to see, that we might have overlooked, and that, once seen, we can use to help ourselves and to avoid causing unnecessary harm to others.


Some of the examples in Sommers' book are about children, and one might be tempted at first to think that we cannot create perfect worlds in which no child ever has to navigate dealing with an incident of invalidation, but it is crucial to recognize that one of the few things that psychologists know for certain is that acceptance through validation is what helps developing human beings grow a core of strength and resilience.


Furthermore, surely few of us even as adults can say honestly that if, in a work meeting or family gathering, someone is dismissive or demeaning of our point of view, our reactions don't range from feeling unsettled and unsure of ourselves to feeling humiliated and inclined either to silence ourselves or to lash out.  And anyone who has lost a loved one or returned from a war zone can give examples of the devastating—though of course clueless—exhortations some people have offered them to "Move on with your life. You can't grieve forever." Or, as a well-meaning friend urged me about six weeks after my dear father died, when he saw that I was grief-stricken, "You're still so upset. Don't you think you should see someone professional about this (as though the grief were not normal and only a professional could help) and get a little something (psychiatric drugs, of course) to take the edge off?"


Precisely because people who speak the invalidating words are rarely aware of their harmful effects and often consider themselves to be doing something for the other person's benefit, it may never strike the person whose reality was upended that that is what has happened. The invalidated person often just feels somehow insecure, ashamed, confused, or frightened and cannot figure out why.


Sommers starts with an example from her own life that may at first strike the reader as too trivial to think about: At eight years of age, when spring had arrived but snow had fallen, she one morning resisted her mother's reminder that she put on her boots before heading to school. The child felt clumsy and confined by the galoshes and longed to don lighter shoes and run freely outdoors. When she said, "I hate the snow," her mother, whom she hastens to describe as loving and having good intentions, responded by saying, "No, the snow is pretty" and reciting a poem about it.


She doesn't take the easy and too-common way out of pathologizing or even blaming her mother, instead speculating that her mother was "trying to help me accept what couldn't be controlled." But the child not only was not comforted but felt angry at her mother, with the dual consequences of creating tension between them and doing nothing to help the child come to terms with her disappointment and go on to enjoy the day. Had her mother said, "I know you're sick of wearing those boots, but I'd hate for you to sit all day in school in wet sneakers and socks," the child would have had her feelings validated. It wouldn't have taken much to do that, but Sommers acknowledges that, as a parent and grandparent herself, she understands the various pressures of time (have to get the kid to school soon) and emotion (I don't want her to be upset) that can get in the way of stopping to think about how—quickly—to validate the child's feelings and then move on.


If that seems like a trivial example, consider that it's never pleasant to feel tension in a relationship that is the most important in one's life, and when one is a child, having the adored adult act as though one's feelings are just plain wrong can—especially if it happens more than once and perhaps even more when it is clear that the adult's intentions are good—make one start to doubt one's perceptions and consider one's emotions and thoughts to be weird or even bad… or invisible to those who matter most to them. Furthermore, children, Sommers writes, "are often unable to articulate what is happening to them, and so instead act out their suffering in ways that make no sense to adults who expect them to be rational." At worst, she says,


"Lacking validation of their basic feelings, children learn to view the world as a place dominated by denial of their reality, and they begin to see their worth as conditional on social acceptance. In reaction, they either over-comply with or resist adult demands and then grow into adults who cannot move out of those stuck ways of relating. As a result they may never feel free to make up their own minds about their lives. Still others unconsciously resign themselves to the belief that they can never have validation and give themselves over to the demands of others."


Being seen for who we are, especially by those closest to us, is essential to developing a core sense of ourselves at any age. Sommers writes that "Validation is an inferred sense of being seen." In fact, even when we feel joyful, if those around us seem not to share our joy, we can feel uneasy, "overly expressive," embarrassed about our legitimate feelings.


Importantly, Sommers broadens the view of sources of invalidation beyond parents, siblings, teachers, friends, and other individuals, writing:

"Governments that create programs and structures that fail to meet individuals' needs are guilty of invalidating people who require them. Similarly, corporations that create myths about people's needs in order to market their products effectively are also guilty of invalidating individuals. The media cannot be forgotten in this list because messages abound in "news," advertising and promotion that lead people to doubt themselves. The corporate source of invalidation is not accidental. Instead, although corporations or governments would not express it in these terms, the implicit intention is to create enough invalidation, self-loathing and insecurity to weaken people in order to then convince them that they will be better off (and validated) by following the advice, programs or pitches that each entity might propose."


Helping us to recognize the various, common forms invalidation can take, and reflecting how her approach ranges from the individual to the societal, Sommers names and discusses clichés (e.g., "She's in a better place"); trivializing of suffering ("Don't cry. You didn't fall that hard."); diminishing of the person; diversion from real problems (politicians who claim that gun violence is due to "mental illness"—my example); certain comments presented as "jokes"; established, unquestioned practices (doctors who implement "treatments" that have no proven usefulness and may even be dangerous, because that is the standard of care); and celebrating of diversity while perpetuating in-groups (dominant groups endorsing festivals to celebrate racial and ethnic diversity but being more likely to accept people who look like "the Caucasian ideal").


Because she cares about making the world a better place, Sommers packs her book with eminently do-able solutions, beginning by pointing out blind spots that make it hard for us to notice when we commit invalidation and roadblocks to validating another's experience. In that connection, she quotes a client who sent her this note about how she helped him identify his blind spots:


"One of the most striking recent discoveries I've made […] in the process of working with you, has been to realize the absolutely awesome power and responsibility a parent has to quietly validate the most microscopic of emotional wounds in their child, and to do this in real time. Critically, these wounds are healed by the child itself, not the parent—and the child possesses equally awesome power to heal itself […] All that's needed is one critical gift from the parent: to strengthen the child's emotional immune system by providing the recognition that the wound actually exists […] Wounds that are not validated by the parent […] accumulate, get infected, fester […] grow in proportion and severity, and can gather unfathomable destructive momentum as the child ages and becomes an adult. If only the parents realized that they, too, just like their children, inherently deserved to exist in a state of healing."


Once Sommers describes the common roadblocks to our validating others, it's much easier to catch ourselves committing invalidation. One roadblock is difficulty in staying present, "both physically and emotionally," and she makes useful suggestions for staying present under difficult circumstances, such as when the other person is crying or yelling.

Other roadblocks include but are by no means limited to the use of psychiatric diagnosis, which nearly always leads to the discounting of the experiences of people who are so labeled and even overlooking of their real physical problems such as terminal illnesses; sexism that leads to the dismissive treatment of women's and girls' reports of sexual harassment and assault; ageism that leads to the ignoring or minimizing of old people's suffering; and the unresolved presence of the invalidator's own "fears, preconceptions, and needs."


Throughout the book, Sommers reminds the reader that "validation, understood to be acceptance of feelings, is central to being able to progress emotionally by moving through distress," and lack of validation produces "stuckness." Her avoidance of jargon and obscuring verbiage is combined with her deep exploration of nuance and variation in how people can learn to recognize invalidating tendencies quickly and how to correct for them.


Should readers wonder whether validating someone means always agreeing with them and supporting them in their choices, she writes that "Validation is at once simple and complex, an acceptance of where someone is in the here and now" and explains that "If you believe someone is misguided you can simply and clearly express your disagreement" after you make clear that you see and understand how they feel. "If you believe someone is doing harm by acting from their beliefs you can still validate [their] being without endorsing or validating views and attitudes with which you don't agree or that cause harm," she says.


I cannot do justice here to the depth and subtlety of the insight and guidance Sommers provides, but I can say that after reading Acceptance, I have become more aware of how many times each day I notice that have many chances to validate, ignore, or invalidate the experiences of others—including people who do repairs in my building, cashiers at the grocery store who are often the butts of customers' frustration when the self checkout machines fail to work, family members and friends of all ages—and find that Sommers' suggestions about how provide validation add to my own enjoyment of life.


Near the end of her book, she writes:

"The mechanism for validating someone is rather straightforward, hinging on acceptance of the other's emotional state and allowing time for the distressed—or sometimes the happy person—to take in your words. The real challenge is to manage your own emotions and to tolerate others' beliefs or ways of seeing a situation and feelings that differ from your own."

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Why Must People Pathologize Eating Problems?

First published February 15, 2020, at https://www.madinamerica.com/2020/02/pathologize-eating-problems/


by Paula J. Caplan, Ph.D., and Jo Watson


The latest issue of the Sunday New York Times (February 9, 2020) had a full-page essay in its "Modern Love" series, in which writer Lauren Covalucci, an intelligent, self-aware woman, describes having been shamed since age three in her ballet class because her tights dug into her waist. At age 13, she writes, "my body had stretched and thinned," and her teacher said to her, "You finally look like a dancer." You might think that would be enough to convince her that such intolerable pressures – which pervade not only the ballet studio but the wider societies of many countries across the globe – are unconscionable and that something is wrong with the perpetrators of those pressures, not with those who are made to feel horribly inadequate and even to hate themselves.

Sadly, Covalucci reports that, after she began feeling better about her body thanks to being in a relationship with a man who treated her well – "Another person's comfort with you can make you forget your discomfort with yourself," she says – her therapist announced that she had an "eating disorder." The result of that diagnosis was despair: "That's when I really plummeted…. I spent mornings on the floor in a corner…, wailing because I couldn't speak in complete sentences anymore and my brain, my beautiful, Harvard-trained brain wouldn't work right." As psychologist Michael Cornwall has written, assigning someone a psychiatric diagnosis is the "infliction of what amounts to a medical curse."


Covalucci writes that eventually, she got better, and although she started taking psychiatric drugs that she says helped her it was the ongoing love and respect of her partner that made a huge difference. (She later mentions Prozac, which often causes weight gain, and reports that she has become "fat" and is trying to have a positive attitude about that.) Even when at one point her partner mentions that she has gained weight, because of his loving attitude toward her, "The words lost their venom coming from him." What would have helped, she says, is if her therapist had not told her she had an eating disorder, thus making it seem like she was "mentally ill," that there was some kind of internal, individual difficulty she had rather than that she was responding to terrible pressures from her ballet teacher and society in general.


Given that the societal factors leading girls and women to panic about their weight are crystal clear, why didn't her therapist address that with her instead of doing the most harmful thing, classifying her as mentally ill? That, too, would have been helpful, as the work of Prof. Carla Rice, former director of the Body Image Project at Women's College Hospital in Toronto showed decades ago. Once girls and women come to understand that they have been acting out impossibly strict societal standards with regard to eating and that their often distorted images of how they look have resulted from those standards, it is easier for them to begin to challenge them, keeping them in acutely conscious view, and to find other ways to feel good about themselves.


Indeed, why is it that so many people, even some astute critics of the traditional mental health system who are happy to challenge the pathologizing of emotional distress generally, cling uncritically to the term and concept of "eating disorders"? We come across it all the time and are genuinely confused and frustrated.


A Critical Omission
Those who challenge psychiatric diagnoses overall usually do so because on the whole they lack scientific foundation and certainly lack scientific validity, and are in fact constructs invented by committees of people with vested interests!  Unlike physical illnesses such as diabetes and cancer, there are not, never have been, and are never likely to be objective tests for the so-called psychiatric illnesses. Critics of psychiatric diagnoses generally readily acknowledge that, for instance, "Borderline Personality Disorder," "Schizophrenia," and "Attention Deficit Hyperactivity Disorder" are constructs without biological basis and have been invented and promoted by a collective of powerful people with questionable objectives that are mainly concerned with increasing their profits, power, and territory.


It is alarming that too often, "eating disorders" diagnoses have been left out of the critical dialogue, leading to a bizarre situation in which almost every class of psychiatric "disorder" is challenged except this one. Why is it alarming? Why indeed would the pathologizing of emotional distress that involves food, eating, and body image be any more acceptable than the pathologizing of emotional distress that gives rise to obsessive thinking, dissociative experiences, or suicidal thoughts and actions? The concept of "eating disorders" is just as dubious as all of the other so-called "disorders."  It is just as much a construct, and it is no more justified to call it "pathological" than, for instance, good old "PTSD."


Traditional mental health professionals have capitalized in many ways on pathologizing socially created problems, and the "eating disorders" concept does this especially blatantly, given the well-documented ways that patriarchal society puts intolerable pressure on girls and women to believe they can never be too thin, persuading them that if they weigh "too much," they will be unattractive to and devalued by men specifically and by society generally. In the process, it has become unusual for girls and women to be comfortable with their bodies, even when they become dangerously thin.

So why do some people who otherwise challenge "mental disorders" claim that the label "eating disorders" is legitimate and must be retained? One argument is that "It's a biological problem, fundamentally physiological!" But the fact that depriving oneself of or bingeing on food has physical consequences no more justifies calling such behavior psychiatrically disordered than it would justify creating the concept "sprained ankle disorder."

Like most people who take comfort in being psychiatrically labeled, some women and men may suppose that the therapist gave them a label because he or she believes they are suffering. But that validation could be achieved by the statement, "I believe you are suffering," which would not add to their burden by conveying the notion that they are also "sick."

Besides masking the powerful social factors causing eating problems, to diagnose someone with an eating "disorder" is to make it extremely likely that they will be told something is wrong with their brain and that they need psychiatric drugs. Also, because severe restriction of food can have, at worst, fatal effects, caring family members may understandably agree to have the diagnosed person hospitalized, and sometimes even ask for this. But once hospitalized, in far too many cases, the person is increasingly medicated and stripped of their sense of agency.


Case Study
Consider the not unusual case of a teenage girl who had starved herself in reaction to her parents' ignoring her pleas that they get a divorce because she could not bear their constant fighting and her father's demeaning of her mother. Her parents resisted, though both of them longed to be out of the marriage, instead of staying together "for the daughter's sake." Talk about turning her reality upside down! When she was hospitalized in a psychiatric ward, her therapist advised her parents to forbid her to participate in the extracurricular activities she adored, where her immersion in the arts and her warm friendships were important in giving her strength to endure her difficult home life.


Allowing her to go home on a brief visit, the therapist also told the parents, "If you put 15 grapes on her plate, you have to make her eat all 15 grapes." Thus, she was deprived of her sources of emotional sanctuary and infantilized, just as her parents' and the doctor's pathologizing of her as the source of the problem involved a stunning lack of respect and regard for the suffering caused by her home situation. And all the while, no one addressed the forces that led to her using starvation as a coping mechanism: her father's demeaning views of real women and society's message that the route to happiness and regard is through weight loss. Many unhappy women go on strict diets when they feel that important parts of their lives are beyond their control, but dieting is something they can control.


What would likely have helped that young woman would have been if first her parents and therapists had really listened to the pain that her parents' awful relationship and her father's demeaning view of women were causing her, and then had worked with her to find ways to reduce that pain. Both parents could have considered her needs rather than the abstract principle that even a terrible marriage should continue because it is better for the child than a divorce. The psychiatrist could also have helped the daughter to spend more time and energy in rewarding activities like her choir practice rather than forbidding them unless she ate what the therapist considered to be "enough." He could also have helped her find ways to gain a sense of agency, given how helpless she was feeling, living with parents who were miserable and a father who demeaned women. And he could have helped her find ways to earn friendship, love, and respect other than by trying to become impossibly thin.


A New Perspective
The Power Threat Meaning Framework for considering emotional suffering could offer an infinitely more hopeful and respectful way of responding to eating distress than the traditional illness narrative imposed by psychiatry.  Lucy Johnstone, lead author of the article "The Power Threat Meaning Framework: An Alternative Nondiagnostic Conceptual System" published in the Journal of Humanistic Psychology, includes this advice:

"The Power Threat Meaning Framework can be used as a way of helping people to create more hopeful narratives or stories about their lives and the difficulties they have faced or are still facing, instead of seeing themselves as blameworthy, weak, deficient or 'mentally ill'."

This framework is a way to understand that "what may be called psychiatric symptoms are understandable responses to often very adverse environments and that these responses, both evolved and socially influenced, serve protective functions and demonstrate the human capacity for meaning-making and agency." The adverse environments of the woman and the girl described above were clear and starving themselves was in both cases a way to try to take some control over how people evaluated and treated them. So helping them to understand that the adverse factors in their environment were unreasonable, inhumane, and harmful; to consider other ways to think about themselves; and to find different, life-enhancing, life-enriching, self-respecting, safe ways to feel a sense of belonging, being loved, and caring for themselves would have been natural outgrowths of a Power Threat Meaning approach to so-called eating disorders.


The Power Threat Meaning Framework would suggest that eating problems should be understood not as a symptom of an illness but as a reaction to difficult experiences, as a threat response, a way of surviving the intolerable, that will on every level make sense. The Framework is ultimately about the process of that sense being made, and surely few would disagree that there are always reasons, always stories behind every type of eating problem.


We both remember too many reasons and stories, just as we remember too many women who we've come across over the years who had internalized the belief that they had/have an "eating disorder."  Just like any other psychiatric diagnosis, it has all too often robbed them of their power, taken away their agency, stolen their hope. The diagnosis of "eating disorder" in all its forms is as much a curse of psychiatry as any of its numerous others. Isn't it time we called it that?


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