Paula Joan Caplan (July 7, 1947 - July 21, 2021)

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)?
 

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.

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?

Initially published on December 30, 2019, at https://www.madinamerica.com/2019/12/invisible-children-foster-care/

For people who have recently lost a loved one, holidays that others seem to be happily celebrating are hard. For the uncountable thousands of children of refugees whom the United States government has taken from their parents and put in cages, isolation from their families must be excruciating. But what about the nearly half a million foster children in this country, who are even less visible than refugee children, rarely the subjects of media reports except in the case of a death or a lawsuit? How are the holidays for current and former foster children? To be sure, some foster parents are loving and supportive, but far too often, being a foster child means something terrifyingly different.

I learned this 40 years ago when I was working as a psychologist at the Toronto Family Court Clinic in Canada. Some of the people we were asked to evaluate were children or youth deemed neglected or abused by Children's Aid Society (CAS) workers. Each time one of us clinicians was asked to recommend whether to leave the person in their home or send them to foster care, it pained us to know that there might be pros and cons for each option. We couldn't be sure whether or not a child who was living in a home where there were difficulties had a strong love or need for their parent(s), and we knew that, while some foster parents were wonderful, others were cruel (and some that had seemed wonderful turned out to be terrible). In still other cases, the foster parents were just a bad match for a particular child.

We also knew that in order to acquire greater certainty, we would have had to do far more observation and information-gathering than we had time for, and that in some cases, only the passage of time would reveal what mattered most, but that might be too late for the child. When what is at stake is nothing less than the security and happiness of a human being, these uncertainties and practical barriers often leave the frontline workers and clinicians feeling all at sea, helpless to find the truth but given the task of making crucial recommendations.

Forty years ago, both the children and teenagers who were in the system and their birth or adoptive parents were likely to be labeled as incorrigible, resistant, unworkable, and "mentally ill" and to be much less able to resist the system's dictates if they were poor and/or belonged to racialized groups than if they were white and wealthier. Times have changed far too little. Two major changes in recent decades have been the explosions in the use of psychiatric labels and prescription of psychiatric drugs for children — not just by psychiatrists but also by other clinicians and frontline workers (many of whom are quick to recommend the drugs even if they themselves cannot prescribe them).

Being a Foster Child
Please join me in imagining trying to live through just one of the following kinds of trauma, keeping in mind that many foster children experience more than one and often all of them:

--Being moved often — dozens of times not being rare; never knowing when one will be moved yet again; being shifted from one school — and thus one teacher and set of classmates — to another
--Never feeling loved and secure
--Being abused by foster parents or siblings
--Being diagnosed as "mentally ill" even though one is feeling utterly understandable grief, terror, and/or rage at being separated from one's original family or at never having felt secure and loved even in that original family
--Feeling overwhelmed, bewildered, unseen, and unheard as the system moves one around, often with little or no attention to what is helpful
--Having little chance to learn social and other skills for coping with everyday problems, never mind those that plague foster children
--Being put on psychiatric drugs that are more likely to harm one's body and brain than to help in any way (see Robert Whitaker's Anatomy of an Epidemic)
--Turning to illegal drugs to dull the grief, abandonment, helplessness, and/or despair
--Sliding into the juvenile justice system and later the adult prison complex because of how one expresses painful feelings or because, once turning 18, one has no way to support oneself and begins stealing food or dealing drugs just to get by
--Imagine homelessness, literal homelessness after long years of emotional rootlessness.

Jana Kaplan, a former foster child now in her sixties, summed it up well when she told me that foster children are "bromeliads, sometimes called 'air plants.' We grow without roots, without soil."

What the Numbers Show
All of this is documented in a welcome (and unusual) six-part investigative series published this month in the Kansas City Star, to which Kaplan drew my attention recently. Based on a year's worth of research by reporters Laura Bauer, Judy L. Thomas, and Eric Adler, the series, titled "Throwaway Kids," shines a spotlight on the vulnerability of foster children and on a Senate initiative to address their needs and growing numbers. The series is one every American should read and never forget.

The reporting team found that 23,000 children go into foster care each year, and in 2017, 443,000 children in the United States were in such care, an increase of 12 percent from five years earlier. They then recount the kinds of problems that send children into foster homes, including poverty and the kinds of neglect that are fairly easy and inexpensive to fix.

Part Two of the Star series includes this stunning news: Despite U.S. Congressional action in 1980 that set family preservation as a higher priority than removing children from their families, only a small fraction of all monies spent in the child welfare system is used for that purpose: "Collectively, in child welfare budgets across America, more money is spent on investigating families than on trying to keep them together — 17 percent for child protective services versus 15 percent for in-home preventive services."

As a result, "Kids who could have stayed in their homes take up beds in good foster homes that are needed for severely abused and neglected children whose safety is in jeopardy. Because of that, kids from Oregon to Florida and states in between are forced to sleep in child welfare offices or homeless shelters."

According to the Star, the National Council for Adoption estimates that the yearly foster care cost per child is about $25,000, whereas the cost of preserving a family average only $5,000-10,000 per child. But even if the cost of family supports were higher, is it fair to compare the immeasurable value of keeping children where they may be otherwise secure and loved to the monetary cost of helping their parents stay or get out of poverty? These efforts could include providing comprehensive, low-cost or no-cost health insurance, so that a family member's illness doesn't send the household spiraling into poverty, or providing practical, community-based help and moral support to a parent who is ill or coping with someone else's illness to prevent their being deemed negligent of their child, who is placed into foster care as a result. A woman who stays with an abusive partner because of a realistic fear of not being able to feed her children without the abuser's financial support would also benefit from financial help, and one who stays because she fears the abuser will implement threats of more physical violence if she leaves could certainly benefit from both moral and practical supports to help her do so rather than having her children taken away.

While politicians and other talking heads in the media describe the economy as thriving, they ignore those at the low end of the income scale, and clearly, child welfare matters more than money. Sadly, though, as a nation, the U.S. generally harshly judges rather than genuinely helps poor people. Years ago, Barbara Ehrenreich commented on this judgmental attitude's creation of a barrier to change, making the tongue-in-cheek suggestion that the government give the poor enough money to live on decently… but subject them to public shaming on a regular basis.

Possible Solutions… and Barriers to Implementing Them
To be sure, some families are dangerously neglectful or abusive. For those parents whose drug or alcohol abuse leads them to mistreat their children, stricter government oversight of doctors who hand out drug prescriptions like candy and states paying for and directing parents into proven substance-abuse programs would be far better than removing their children from an otherwise loving home. The alternative is sending them into the black hole of foster care, playing Russian roulette with the children's need to feel cherished and secure.

Regardless of the justifications offered for taking children into foster care, classism and racism plague the system today, just as they did four decades ago. "Black children enter foster care at a significantly higher rate than white children," according to the Star, and poor families and families from racialized groups are more likely than wealthier and/or white families to be punished in this way for being "dysfunctional" or having a physically messy or dirty home. Too often, child welfare workers — whether because they are overworked or for other reasons — don't see, or consider, the love between parent and child in such situations.

Furthermore, once the child welfare system connects with a family, those who are poor or from racialized groups tend to lack "the money or power to push back against government intervention," according to attorney Ira Lustbader, an attorney who represents children in class action lawsuits.

Where is the legal system in all this? In the past 40 years, nearly three dozen states have faced lawsuits citing foster care abuses, a remarkable figure in light of the powerlessness of foster children. But even in Illinois, a state that had improved its foster care system, a recent lawsuit was necessary to get it to stop transporting foster children in handcuffs and leg shackles. Alarmingly, the Star's review revealed that some states are currently being sued "for the same issues that plagued other systems 15 to 20 years ago," and a recent Rhode Island lawsuit alleged that "children in Rhode Island are more likely to suffer abuse or neglect if they are in foster care than if they are not."

Outcomes
What happens to children who go through the foster system and then age out of it at just 18 years old? More than 4,000 of them become homeless each year, thus making them subject to sex and/or drug trafficking. Former foster children are about half as likely to graduate from high school as are their peers, the Star found.

The reporters also surveyed prison inmates and found that one in four had been in foster care, some of whom reported moving more times than they had birthdays. Compare that to the mere 3 percent who graduate from college. The journalists also quoted Gerald Marshall, a 37-year-old Texas death row inmate, who observed, "The state that neglected me as a kid and allowed me to age out of its support is the same state that wants to kill me."

And consider those foster kids who, even if they have not ended up in the prison system, have been slapped with psychiatric labels and put on psychiatric drugs. These young people can suffer for the rest of their lives from the woefully mistaken belief that, because they were so labeled, they are "mentally ill," defective, or twisted. As documented in Robert Whitaker's book Anatomy of an Epidemic and countless Mad in America articles and webinars, the negative consequences of taking these drugs even briefly, and the effects of withdrawing from them, can last for many years.

Uncounted millions of former foster children remain invisible — at holiday times and throughout the year — in the loneliness and rootlessness that they feel. This is true even for many of those who have stayed out of the prison system, graduated from college, raised children, and contributed in many ways to the good of society. They deserve our attention and our care.

What's to Be Done?

What can parents do when they see that the authorities plan to take their children from them? I would say they can hire a lawyer, but that means either having enough money to do that or finding attorneys or other entities that provide legal help pro bono. And it's not as though family courts are devoid of racism and classism, as well as rampant mother-blame, so even if parents get their day in court, there's no guarantee that even deserving ones will be able to keep their children. Such parents can also assert their rights under the Adoption Assistance and Child Welfare Act, the 1980 legislation mentioned above, which mandates a focus on keeping children in their original home and trying to help and preserve the family, by contacting local and state officials. But do I have faith that that will change the system? Not much.

One useful step that any of us can take is to contact the bipartisan Senate Caucus on Foster Youth, co-founded by Republican Sen. Charles Grassley and Democratic Sen. Mary Landrieu, now chaired by Sen. Grassley and Sen. Debbie Stabenow. Their goal, they say, is to break the silence about current and former foster children and they have listened to them, leading to the passing in 2018 of the Family First Prevention Services Act, aimed at keeping as many children as possible at home… and safe. We can express appreciation for the Caucus's work and ask how we can help.

We can also urge our legislators to support the Fostering Stable Housing Opportunities Act, now making its way through the 116th Congress, which would give foster youth access to affordable housing when they reach 18.

And no matter where we live, we can contact our representatives in the U.S. Congress and our state legislatures and governors to ask them to increase expenditures to help struggling families. And we can demand they ride herd on the vast array of abuses that plague the foster care system, crushing the souls of children who deserve so much better.

Initially published June 18, 2019 at https://www.madinamerica.com/2019/06/critique-diagnostic-terminology/ Please note that this was written about the publication MadInAmerica (MIA) and its policy about naming psychiatric diagnosis. Robert (Bob) Whitaker is the founder of the publication and the author of the extremely important book, Anatomy of an Epidemic, a scrupulously researched book about the truth about psychiatric drugs.

By Paula J. Caplan, PhD
June 18, 2019

I appreciate Bob Whitaker's encouraging me to write this essay after I had written to him several times over the years to express concern about how Mad In America deals with psychiatric diagnoses. Below, I will report his responses to my concerns and my replies to those.

I need to begin with some history, so that readers will understand why I feel so passionately about an MIA practice that might seem to some to be relatively trivial.

In 1985, I had been teaching the Diagnostic and Statistical Manual of Mental Disorders as an advocate, believing the advertising produced by its publisher, the American Psychiatric Association, and by its Task Force leader Robert Spitzer, to the effect that it was a scientifically-grounded document. Then, through a series of events described in They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal, in 1988 I accepted the invitation of DSM-IV Task Force head Allen Frances to serve on two DSM-IV committees. In that capacity, over two years I received internal communications, mostly but not solely with regard to the two DSM labels "Self-defeating Personality Disorder" and "Premenstrual Dysphoric Disorder," and through these I was shocked to learn that the ways that "abnormality" and its varieties were chosen and described within the manual were extremely far from scientific (this troubled me all the more because I am an author of a textbook about research methods) and that those heading the Task Force minimized and even denied harm that getting any of their labels could cause. When I utterly failed to persuade them to come clean with the public about the unscientific nature of the labels and their criteria and to warn of the harm they could cause, I felt I had no choice but to resign on moral, ethical, and professional grounds.

Since then, the more I have spoken and written publicly about these matters, the more I have learned two kinds of things. One is that there is a vast array of approaches to reducing human suffering that do not involve calling sufferers 'mentally ill' and that are proven to be effective. The other is that I have received letters, email messages, and in-person reports from thousands of people whose lives were variously harmed or ruined and from loved ones of labeled people whose lives were ended due to sequences of events that began with a psychiatric label.

I have called psychiatric diagnosis "the first cause of everything bad in the mental health system." https://www.youtube.com/watch?v=-qIQqRl94_Y&t=22s     If they don't diagnose you, they cannot "treat" you, whatever that means in various contexts. But once they give you even what sounds like the most innocuous label (often Adjustment Disorder is named as the least dangerous), there is almost no limit to what they can do to you in the name of "treatment"… and too often, they escape all accountability because the diagnosing and the kinds of treatment that tend to follow are considered "standard of care."

Since few laypeople (and even surprisingly few professionals) have any idea about these facts concerning psychiatric diagnosis, when they are suffering and seek help in the mental health system, they rarely even know to ask the therapist such questions as, "Do you have to give me a diagnosis? If so, which one will you be giving me? What steps are you taking to protect me from the many kinds of harm that can result from getting a psychiatric label? If you are going to recommend ways for me to feel or function better, how are you going to decide what to recommend, given that treatments based on assumptions about unscientific categories might help me but might be harmful and might not work?"

Furthermore, the mental health establishment that uses these labels and falsely claims that they are "scrupulously scientific" (in the words of DSM-IV head Allen Frances describing his edition), helpful, and not harmful has vast wealth and media access. Mad in America has reached huge audiences and successfully educated untold numbers of people about the truth, but even MIA and other publications that challenge traditional practices still have a long way to go to reach and persuade as many people as does the establishment.

As a result, when anyone in the few challenging publications uses any psychiatric diagnosis without signaling that they are constructs and unscientific, I feel alarmed for those who will be strengthened in their mistaken beliefs about the labels. An example would be an article about a researcher's study of "children who have ADHD." Some people have learned to challenge what the DSM and APA brass claim, but for those who trust that what they read on MIA is far more likely to be well thought out and true and thus not misleading, I am especially concerned about their vulnerability to the reification of the categories by MIA specifically.

There are simple ways to signal that these diagnoses are constructs and unscientific, and over the years, I have repeatedly expressed my concerns to MIA when they publish pieces in which psychiatric diagnostic terms are used without a single mention of the fact that they are NOT scientific, that it is NOT helpful to use these terms when trying to alleviate suffering or help people change their behavior IF THEY WANT TO, and that getting ANY psych label exposes one to a vast array of kinds of harm, and that there are MANY other approaches that do NOT involve pathologizing or drugging and that have few or no risks and are shown to be effective. I have begged MIA to stop this practice and instead, for instance, simply to put all such labels in quotation marks or to include a simple sentence such as, "This is a review of a research report about children who have been given the ADHD label, which is not a scientifically supported entity" or "Our study was of people who had been given the Bipolar Disorder label, so since it is known that this label does not represent a scientifically supported entity, we ensured that our participants all reported struggling with changes in mood they felt they could not control."

In the June 9, 2019 MIA weekly newsletter, an article is described as showing "how genetic models of 'schizophrenia' explain very little." This is a perfect and very simple and unobtrusive way to solve the problem. And in articles, the first time a psychiatric label is used, it can be put in quotation marks followed by a note that it is in quotation marks this first time it appears in the article because it has not been shown to be a scientifically valid category, but that the reader is urged to think of quotation marks going around the label each time it appears in the piece.

MIA reader and longtime advocate Amy Smith suggests a couple of other approaches: One is to run a succinct header or footer on every page of articles that include mention of psychiatric diagnoses, making MIA's positioning clear, and, in her words, "proudly wearing their ideology on their sleeve," since it is clear from most of the content of the publication's articles that they aim to publish the truth. Her other suggestion is that for specific articles that are glaring in their use of unscientific constructs, MIA could insert a "Note from the editor" in between the title of the article and the body of the text to make this kind of point as it relates to that article.

Bob Whitaker, who knows I have tremendous respect for his own many scrupulous pieces of research and writing, has replied to these suggestions by stating that he sets the editorial rules for MIA and does not plan to change in response to my concerns. He replied further that MIA has "many blogs published deconstructing [psychiatric diagnoses], and published reviews of articles published in journals with that theme." Given the overpowering and pervasive extent to which "psychiatric diagnosis as truth" has permeated Western culture and is fast spreading to other parts of the globe, and given that not every reader reads everything published on MIA, I don't think this is sufficient justification for failing sometimes or at all to implement the kinds of solutions suggested above.

Bob also wrote to me that MIA is using psychiatric diagnostic terms because they signal "societal speaking about this diagnosis that exists in our society, and not because we are saying it is valid." I find this frankly alarming. There are many terms that, for instance, are sexist, racist, ageist, etc., that either now or previously have been widely used, and the harm that goes with their use is perpetuated and can rub off on readers. In addition, how in the world is a reader supposed to know that in a particular MIA piece, a diagnostic term is not supposed to be thought to be valid if there is no disclaimer to make that clear?

Finally, Bob wrote that "To put quotes around [psychiatric labels] every time just becomes superfluous, and in reviews of science articles reporting on that diagnosis, would just put us in the position of wearing an ideology on our sleeves that would discredit our reviews." I have two responses to this:

(1) As a longtime editor myself, I am aware that one of the solutions suggested above allows for more editorial elegance than do the others. Fine. I don't care which solution is implemented when. Just please consistently convey the truth rather than helping perpetuate harmful untruths.

(2) I would think a greater concern about ensuring that MIA publishes credible assessments of scientific research would be not avoiding "wearing ideology on its sleeve" but rather omitting the extremely important information that the studies under review were based on the use of psychiatric categories that have been shown to be unscientific, unhelpful, and often harmful. Doing the latter means that such reviews would include the whole truth, not omitting the parts that someone is scared will make them look biased.

I hope that Bob will reconsider the MIA policy about this matter.