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Paula Joan Caplan's Authors Guild Blog

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 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.


By
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

https://www.madinamerica.com/2020/10/ptsd-labels-harm-exposed

 

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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