PhD/PsyD RANT: Arguing with therapists with no research background is like screaming at the ocean and begging the waves to subside

[PsychSupreme]

I’m not the one who needs everyone to agree with me. Haha.

And I never said people with PTSD shouldn’t get help. 🙄 Something isn’t a disorder or disease just because people on a committee vote it in as one. That’s not how science works.

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[aim-agm]

Nope. Not it at all. Lol.

Without regards to whether they are in fact correct or not, it would behoove you to reflect on the fact that you are giving multiple psychologists a certain impression.

 

[genop]

Without regards to whether they are in fact correct or not, it would behoove you to reflect on the fact that you are giving multiple psychologists a certain impression.

It’s concerning how many incorrect assumptions and mischaracterizations are made by a few psychologists. Good thing most aren’t like that. It’s like some of you are not even reading what I wrote. Lol. Speaking of caricatures, that’s what some are doing with me. Then I keep trying to clarify and explain only for the trend to continue. That’s what happens when people aren’t interacting in good faith and need to have in group/out group dynamic and gang up on people…making strawman and attacking it. I’ve seen you guys do it to others, too.

Speaking of need for agreement, that’s what you guys are doing, not only in this thread, but in other threads with others. So much projection that it’s actually baffling. Feel free to go read the thread about mid levels getting hate. OP is a psychologist and got attacked left and right for not agreeing with everyone.

 

[aim-agm]

It’s concerning how many incorrect assumptions and mischaracterizations are made by a few psychologists. Good thing most aren’t like that. It’s like some of you are not even reading what I wrote. Lol. Speaking of caricatures, that’s what some are doing with me. Then I keep trying to clarify and explain only for the trend to continue. That’s what happens when people aren’t interacting in good faith and need to have in group/out group dynamic and gang up on people…making strawman and attacking it. I’ve seen you guys do it to others, too.

Speaking of need for agreement, that’s what you guys are doing, not only in this thread, but in other threads with others. So much projection that it’s actually baffling. Feel free to go read the thread about mid levels getting hate. OP is a psychologist and got attacked left and right for not agreeing with everyone.

Note that I was careful to make no statement on whether they are correct, and indeed was quite clear that this was irrelevant. In light of that, it is revealing that you focus on this aspect of your interaction with them. Whether that is based on justified sense of being attacked, defensiveness regarding an emotionally important belief, or another factor is beyond the scope of this interaction. What is important for you is recognizing that something beyond a cerebral/intellectual consideration is influencing your engagement in this academic discussion, so that you better understand the interactions and better pursue your goals. It remains irrelevant who is right in their opinions and assessments to whether this is a useful exercise in this and other situations of conflict.

 

[cara susanna]

I’m not the one who needs everyone to agree with me. Haha.

And I never said people with PTSD shouldn’t get help. 🙄 Something isn’t a disorder or disease just because people on a committee vote it in as one. That’s not how science works.

It's a disorder when it causes distress or impairment. Again, PTSD is not a normal (although I hate that word) response. It is an interruption in the natural (normal) recovery process that happens in humans who experience trauma. PTSD makes it impossible to recover and move on from the trauma, and severely impacts the person's everyday life. It's understandable, yes, but so are a lot of behavioral patterns that are maladaptive.

Also, the DSM isn't perfect, but it actually has a lot of science and research behind it. The PTSD workgroup especially put a lot of thought and effort into it, which is why the DSM diverged so much from the ICD-11 when it came to PTSD this time around.

 

[Dazen]

I’ve stated that these people still need help, and should have access to affordable and effective treatment. If it was just being used for billing and to get people treatment, I wouldn’t have a problem with it. However, as I’m sure you’ve read in that thread, that’s not it. People are acting like these DSM diagnoses are real diseases as if it’s a scientific fact, when it’s not. It’s a checklist of a bunch of symptoms having to do with undesirable feelings, thoughts, and/or behaviors that were voted in by psychiatrists and others, many with ties to the pharmaceutical industry.

My big problem with it is that it can and often does have real negative consequences for the person being diagnosed and given a stigmatizing label, and it very often pathologizes normal human experiences and reactions. I think it’s absolutely ridiculous to diagnose people with something and not even take into consideration the context in which those symptoms appeared. Yet, that’s what typically happens with psychiatric illnesses, according to the DSM.

On the medical side, context and etiology matters a lot in most, if not all, cases. For example, a cough due to asthma or smoke inhalation will be treated very differently than if someone got exposed to Covid and is presenting with cough.

With psych, especially now that they’re doing universal screenings in primary care and other areas, they’re literally clicking through a checklist, and diagnosing people in less than 10 minutes with a stigmatizing mental illness that will never be removed from their record, and is not even a true illness in a lot of cases. Someone may have just been going through a rough time.

They get put on psych medications that have side effects and can be difficult to taper off. People think there’s something wrong with them for reacting a certain way to their circumstances, even though a lot of times, it’s a perfectly normal response. (I’m not talking about the catatonic or psychotic patient, or the extreme cases here.)

What’s worse is that I have personally seen how horribly a lot of these “psych patients” are treated when they come in contact with the healthcare system. The stigma, discrimination, and harm is real. I’ve heard it’s bad in the legal world, and it also affects people’s employment opportunities.

Furthermore, once these patients are labeled with a mental illness, their rights can more easily be taken away, or their credibility can and does come under question. If they dare to disagree with the psychiatrist or doctor about their diagnosis, the doctor can just say they don’t have good insight into their illness, or anything is blamed on their mental illness.

I’ve heard of patients with a history of anxiety coming to the ED with chest pain, and they weren’t worked up right away because it was just assumed that it was due to anxiety or panic attack when they were actually having cardiac issues and ended up coding.

I’ve seen a nurse try to give someone an SSRI, and when the patient asked about the potential side effects, the nurse refused to answer his questions, and, instead, said it’s his anxiety that is making him ask questions about possible side effects. Ugh!!!

Many other times, nurses try to forcefully make a patient do something they don’t want to do, so of course, the patient gets agitated. Then the nurse asks the doctor for an antipsychotic to give the patient, even though the nurse’s actions caused the agitation, and it wasn’t a life-threatening emergency to try to get labs by force. Doctor tried to explain the antipsychotic is not indicated, but nurse insisted, so doctor finally caved.

I’ve heard of many instances of doctors blaming patient’s symptoms on anxiety and depression even though they actually had something physically wrong with them. I have so many more examples that I could give.

I read a story where a woman witnessed a murder by her boyfriend and she was just a witness in the murder trial. The defendant’s lawyers tried to get court order or subpoena for all her mental health records including therapy notes, and tried to say she was not a credible witness because of her mental illness. There were other witnesses who provided the same testimony, and yet, she was the one being harassed and having her privacy invaded. Luckily, the judge didn’t allow the records to be released, but her mental illness still became public and a part of the court record. People have run into the same issue of their private psych notes being released to the courts or other side’s lawyers in divorce and custody battles, even though the child was not in danger. There are endless abuses against people with so-called mental illnesses. They can be hospitalized against their will, even though that’s been shown to be harmful…

I want people to get treatment that they need, but I hope the system changes so that they don’t need a label to get it. It’s not ok that vulnerable people get harmed like this. Diagnosing people with mental illness is not benign. If there was solid scientific evidence and pathophysiology to support most of these diagnoses, I would say we should just work more on protecting them from the stigma and discrimination. As it stands, we don’t use the same scientific rigor with mental illness that we do with physical illness. A lot of it is subjective.

I don’t think psychologists are necessarily the ones handing out diagnoses recklessly or as easily as other healthcare professionals. They’re actually probably the ones doing it more responsibly. However, insurance requires a diagnosis during the first visit in order to pay for treatment. I initially thought universal screenings in primary care and non-psych areas would be a good thing. It’s probably led to so much over- and misdiagnosis, and unnecessary utilization of psychotropic meds.

I didn’t even touch on the abusive employers creating toxic environments and excessive, chronic stress that leads to physical and mental problems, and then telling people to call EAP or work on their resilience and self-care. This one makes me irrationally angry. Lol. As much as I hate the overuse of the word “gaslighting”, it’s gaslighting to act like employees who are stressed and anxious from working short staffed in toxic environments are mentally ill instead of the organization being toxic and exploitative.

I think where the disconnect is coming in for me is that our conversation felt like: DSM diagnosis are unscientific -> agreement on flaws on DSM and discussion of its current value add -> proof of how the DSM is misapplied by medical professionals/people over identifying with a label. How the DSM is used is a different issue than whether or not it is reasonably scientifically supported. I think most of us agree that systemic change is necessary, but that can’t be blamed on the DSM.

I also don’t see a world, at least any time soon, where mental/emotional difficulties can be diagnosed without self-report being a key factor. Psychological disorders are based on inner experience and don’t have the same ability to test and confirm via objective methods as medical doctors. Actually, when something previously considered a mental disorder is found to have a physical cause, it has sometimes been passed from psychology to medicine. Psychology also generally treats syndromes (frequently co-occurring symptoms) rather than disorders (pathology and etiology mostly understood). There are almost definitely better classification systems than what we have now that could address things like high comorbidities and diagnoses where two people may not share a single symptom. But it’ll still likely be based on self-report.

Separately, the first day of my psychopathology class my first semester of grad school was spent discussing issues with the DSM. They’re well-acknowledged in the field.

 

[genop]

It's a disorder when it causes distress or impairment. Again, PTSD is not a normal (although I hate that word) response. It is an interruption in the natural (normal) recovery process that happens in humans who experience trauma. PTSD makes it impossible to recover and move on from the trauma, and severely impacts the person's everyday life. It's understandable, yes, but so are a lot of behavioral patterns that are maladaptive.

Also, the DSM isn't perfect, but it actually has a lot of science and research behind it. The PTSD workgroup especially put a lot of thought and effort into it, which is why the DSM diverged so much from the ICD-11 when it came to PTSD this time around.

I respect your views and expertise on the topic. I agree that it’s distressing and causes impairment. I guess I personally take a trauma-informed approach of “what happened to you?” instead of “what’s wrong with you?” (Not saying my approach is better.) I view trauma as a normal response to abnormal circumstances. I don’t need anyone to agree with me and I won’t attack anyone if their views differ. I do think these people need treatment and help.

I’m sure there are people who find comfort in having a diagnosis of PTSD, finding that it explains their symptoms. There are others in whom it might increase feelings of shame or defectiveness since PTSD is not common and yet they got it instead of post-traumatic growth. Shame and self-blame can be prevalent in patients who have been raped or experienced other types of trauma. I’d hate for a label to contribute to that if that’s not what that particular patient needs to get treatment.

 

[cara susanna]

I respect your views and expertise on the topic. I agree that it’s distressing and causes impairment. I guess I personally take a trauma-informed approach of “what happened to you?” instead of “what’s wrong with you?” (Not saying my approach is better.) I view trauma as a normal response to abnormal circumstances. I don’t need anyone to agree with me and I won’t attack anyone if their views differ. I do think these people need treatment and help.

I’m sure there are people who find comfort in having a diagnosis of PTSD, finding that it explains their symptoms. There are others in whom it might increase feelings of shame or defectiveness since PTSD is not common and yet they got it instead of post-traumatic growth. Shame and self-blame can be prevalent in patients who have been raped or experienced other types of trauma. I’d hate for a label to contribute to that if that’s not what that particular patient needs to get treatment.

The problem is that people with PTSD DO see their behavior as normal in response to an abnormal situation. I mean, it's normal in terms that they are following biological processes and commands, but in this case the biological processes themselves are messed up. The body learned to incorrectly associate the trauma with anxiety, and now they will experience distress when they encounter those things regardless. And the way that they try to deal with this--avoidance--only makes that stronger over time.

It all depends on how you frame it to the patient. If you validate, say that your response is very understandable AND it's resulted in a pattern of behaviors that are ultimately keeping you stuck, it generally goes over well. Plus, it's just a label. Adding it doesn't change the situation. Whether I call it PTSD or something else, the symptoms and the impact it has on them are the same. If anything, I think putting that label to it helps them understand that they aren't "crazy" or doing something wrong. Receiving a diagnosis can and often will be validating, provided that the therapist does so in a warm, empathetic manner that is consistent with the recovery model of mental health.

Shame and guilt are two things that majorly impede trauma recovery and that's what therapy needs to address. The reason we have to treat PTSD is because, after 3-6 months, everyone who has recovered generally already will have done so. The rest of them likely need treatment or someone to tell them to try something different. And PTSD is just the shorthand term we use to convey 1) what the problem is and 2) what the treatment needs to be. I think it's helpful to think of diagnosis as a way of communicating.

 

[msc545]

I’m not the one who needs everyone to agree with me. Haha.

And I never said people with PTSD shouldn’t get help. 🙄 Something isn’t a disorder or disease just because people on a committee vote it in as one. That’s not how science works.

You would need to actually evaluate and treat people with PTSD to understand why it is regarded as a mental disorder based on the problems it causes for people. It is neither a voluntary nor usual response to trauma, and the symptoms are clinically significant and debilitating. Nobody trained in mental health would ever suggest otherwise.

 

[Shiori]

I am more familiar with the history of PTSD compared to some other disorders, but PTSD's inclusion in the DSM was strongly influenced by advocacy groups. It was, in many respects, a social justice movement supported by Vietnam vets, feminists, psychiatrists, and other professionals who were seeing the harmful effects of chronic trauma symptoms. I recommend checking it out. It is really interesting!

 

[psycho1391]

I’m not the one who needs everyone to agree with me. Haha.

And I never said people with PTSD shouldn’t get help. 🙄 Something isn’t a disorder or disease just because people on a committee vote it in as one. That’s not how science works.

"The DSM committees will review the research that has been conducted on each condition, examining the quantity and quality of supporting evidence. If there are gaps in the data available for a proposed disorder, the APA may commission its own field trials. When a new disorder is recommended by the work group, a draft version will be produced, on which the mental-health profession and the general public will be invited to comment, most likely via an APA Web site. The final decision will rest with the DSM-V Task Force, the council that will oversee the revision. Whichever diagnoses make it into the next edition of the manual, APA officials say they will be accompanied by a new feature: a list of the potential conflicts of interest of all DSM contributors."

How Do New Disorders Get Into The DSM


You are being a reductionist. I encourage you to fully investigate the process behind a new disorder getting categorized. As you can see above, the general public can comment. So if you want input, I encourage you to sign up for alerts and comment the next time a DSM workgroup rolls around.

 

[deleted1038433]

I think much of the angst I'm seeing in this thread and some of the others is related to an understandable resistance to enforcing ideological conformity by regulatory bodies. Maybe we could shift the conversation to that big baddie instead 🤔

 

[Sanman]

Something isn’t a disorder or disease just because people on a committee vote it in as one. That’s not how science works.

Sure it is as long as the committee is full of experts. That is exactly what a scientific consensus is. By that logic, global warming is not happening and life cannot exist beyond our solar system. Why is cancer considered a disease rather than a normal variation in cell growth? Some might say small cell lung carcinoma is an understandable reaction to inhaling smoke for years. Why treat it? Just get rid of all smoke so it does not happen very often.

 

[genop]

Sure it is as long as the committee is full of experts. That is exactly what a scientific consensus is. By that logic, global warming is not happening and life cannot exist beyond out solar system. Why is cancer considered a disease rather than a normal variation in cell growth? Some might say small cell lung carcinoma is an understandable reaction to inhaling smoke for years. Why treat it? Just get rid of all smoke so it does not happen very often.

Again, I’m not saying not to treat. We need to do both.

Expert opinion is the lowest level of evidence, and doesn’t count as scientific fact. Scientific consensus is usually achieved after reviewing actual scientific evidence. Scientific experiments need to be reproducible. Attention is paid to bias, conflict of interest, sound methodology in the studies, appropriate statistical analysis, confounding variables, other alternative explanations…

As you mentioned, the grief exclusion was removed in DSM 5 criteria for MDD not due to the scientific method, but due to utility of being able to bill for it and treat people who may want/need assistance with their grief response. (I can’t ignore that this results in more people being put on medications, and so many in the DSM work group had ties to the pharmaceutical industry.)

Most physical illnesses have a distinct pathophysiological explanation and are not just based on a list of symptoms that a group of people agree on. A lot of the mental illness diagnoses are subjective and based on certain value systems and culture. It can be dangerous to label behaviors, feelings, and thoughts, things that make people human, as disorders, especially without considering the context.

I presume you know about homosexuality being considered a mental illness in the past, but it’s not anymore. I’m sure people made the same argument that it’s not “normal”, causes distress…when a lot of the distress was due to society’s view of homosexuality and people needing to hide their true nature or undertake conversion therapy.

People are so quick to attack things like EMDR for being pseudoscience. Yet, many mental health professionals had no problem accepting the chemical imbalance theory of mental illness as fact (which has been debunked), without adequate scientific evidence. So many people were put on SSRIs and other psychotropics as a result to “fix” their imbalance/disorder.

Are we just supposed to believe the theory behind why EMDR’s bilateral stimulation works because some experts say so (Might I add, experts who profit from EMDR)? Why is a different standard of proof being applied to EMDR but not mental illness diagnoses?

Btw, I know you and many others have acknowledged issues with diagnostic criteria and categories, so are we really in that much disagreement? From my perspective, I’ve actually agreed with you on practically every single thing you’ve said in your responses to me.

 

[cara susanna]

Again, I’m not saying not to treat. We need to do both.

Expert opinion is the lowest level of evidence, and doesn’t count as scientific fact. Scientific consensus is usually achieved after reviewing actual scientific evidence. Scientific experiments need to be reproducible. Attention is paid to bias, conflict of interest, sound methodology in the studies, appropriate statistical analysis, confounding variables, other alternative explanations…

As you mentioned, the grief exclusion was removed in DSM 5 criteria for MDD not due to the scientific method, but due to utility of being able to bill for it and treat people who may want/need assistance with their grief response. (I can’t ignore that this results in more people being put on medications, and so many in the DSM work group had ties to the pharmaceutical industry.)

Most physical illnesses have a distinct pathophysiological explanation and are not just based on a list of symptoms that a group of people agree on. A lot of the mental illness diagnoses are subjective and based on certain value systems and culture. It can be dangerous to label behaviors, feelings, and thoughts, things that make people human, as disorders, especially without considering the context.

I presume you know about homosexuality being considered a mental illness in the past, but it’s not anymore. I’m sure people made the same argument that it’s not “normal”, causes distress…when a lot of the distress was due to society’s view of homosexuality and people needing to hide their true nature or undertake conversion therapy.

People are so quick to attack things like EMDR for being pseudoscience. Yet, many mental health professionals had no problem accepting the chemical imbalance theory of mental illness as fact (which has been debunked), without adequate scientific evidence. So many people were put on SSRIs and other psychotropics as a result to “fix” their imbalance/disorder.

Are we just supposed to believe the theory behind why EMDR’s bilateral stimulation works because some experts say so (Might I add, experts who profit from EMDR)? Why is a different standard of proof being applied to EMDR but not mental illness diagnoses?

Btw, I know you and many others have acknowledged issues with diagnostic criteria and categories, so are we really in that much disagreement? From my perspective, I’ve actually agreed with you on practically every single thing you’ve said in your responses to me.

I guess I'm wondering how you reconcile the view that mental illness is normal given societal circumstances with the view that it should still be treated. Isn't that pathologizing regardless of what you call it? If it's normal, why treat it?

 

[genop]

I guess I'm wondering how you reconcile the view that mental illness is normal given societal circumstances with the view that it should still be treated. Isn't that pathologizing regardless of what you call it? If it's normal, why treat it?

In the same way that I don’t view obesity as a disease but I still think it should be treated. Obesity actually has a scientific basis, but it’s still not a disease in my eyes.

Saying something is a normal response to abnormal or unhealthy circumstances doesn’t mean I don’t think that response is distressing or worthy of treatment. It’s more of a validation and understanding that we are biological, social beings, made to adapt and respond to our environment. Of course people’s genetic predisposition and other individual factors can predispose them to certain “mental illnesses.” This isn’t a nature vs nurture dichotomy. Both play a role. I don’t think people should suffer needlessly. I guess I just don’t feel the need to medicalize or overpathologize everything (not saying you do), and I’m concerned about the harm that is done when we do. I can think of people’s distress, suffering, and impairment with compassion, wanting them to receive help or treatment to decrease said suffering, without attaching a stigmatizing label to them. I want to minimize harm.

I think we need to better acknowledge the harm these labels can do, and weigh that against the benefits.

I like that ILoveCBT doesn’t focus on the specific diagnosis, but helps her/his patients anyway. I also like the trauma-informed approach.

 

[smalltownpsych]

Some of this discussion reminds me of a professor in our doctoral program who taught us all of the flaws in the history of psychology. Most were legitimate and accurate critiques, but it was still skewed in on,y one direction and thus not really true. If he had taught us only the positives that would not be accurate either. Our current diagnostic system is flawed but only focusing on those flaws leaves out the benefits and also raises the question of what works better? I agree with almost every critique that genop is making and yet I still find DSM to be a useful tool. Also, it’s not like any of the psychologists I talk to don’t know these critiques. Thats a double negative, but I hope the point comes through. Actually, it is the non-psychologists that I have supervised and worked with that seem less likely to understand the utility and limitations of the DSM and to use diagnostic labels simplistically and more harmfully.

Another point is that in our field a label is what we agree that it is and this is fluid and evolving. The foundation of psychology rests on operational definitions and thus why a scientific practitioner is so essential to our practice. From a gross neurobiological stance, most of our disorders involve functioning brains. The whole field of clinical psychology is based on understanding how a normally functioning brain can still lead to dysfunctional behaviors. We label some of these patterns and we also label certain potentially biological factors or vulnerabilities or tendencies that interact with psychological, environmental and social factors that lead to certain patterns aa disorders too. The DSM is obviously reductionistic and any decent psychologist fully understands that. My point to students is that the diagnosis is just one part of the case conceptualization and the case conceptualization Is what really guides intervention. Autism vs Schizophrenia vs Bipolar vs Borderline PD ( ome of our worst labels in many ways, could be a whole thread on this one) doesn’t really provide me that much information about a patient especially since most of the time the label o get isn’t even accurate based on the DSM criteria. So kind of a double stupid dynamic. A stupid person using a stupid tool. Oh well, it makes me look good and justifies my fees because I’m only half stupid. 😁

 

[genop]

Some of this discussion reminds me of a professor in our doctoral program who taught us all of the flaws in the history of psychology. Most were legitimate and accurate critiques, but it was still skewed in on,y one direction and thus not really true. If he had taught us only the positives that would not be accurate either. Our current diagnostic system is flawed but only focusing on those flaws leaves out the benefits and also raises the question of what works better? I agree with almost every critique that genop is making and yet I still find DSM to be a useful tool. Also, it’s not like any of the psychologists I talk to don’t know these critiques. Thats a double negative, but I hope the point comes through. Actually, it is the non-psychologists that I have supervised and worked with that seem less likely to understand the utility and limitations of the DSM and to use diagnostic labels simplistically and more harmfully.

Another point is that in our field a label is what we agree that it is and this is fluid and evolving. The foundation of psychology rests on operational definitions and thus why a scientific practitioner is so essential to our practice. From a gross neurobiological stance, most of our disorders involve functioning brains. The whole field of clinical psychology is based on understanding how a normally functioning brain can still lead to dysfunctional behaviors. We label some of these patterns and we also label certain potentially biological factors or vulnerabilities or tendencies that interact with psychological, environmental and social factors that lead to certain patterns aa disorders too. The DSM is obviously reductionistic and any decent psychologist fully understands that. My point to students is that the diagnosis is just one part of the case conceptualization and the case conceptualization Is what really guides intervention. Autism vs Schizophrenia vs Bipolar vs Borderline PD ( ome of our worst labels in many ways, could be a whole thread on this one) doesn’t really provide me that much information about a patient especially since most of the time the label o get isn’t even accurate based on the DSM criteria. So kind of a double stupid dynamic. A stupid person using a stupid tool. Oh well, it makes me look good and justifies my fees because I’m only half stupid. 😁

I agree 100%.

Thanks for adding your valuable input to the discussion and not mischaracterizing what I was saying. I felt like it turned into a ridiculous debate with some deliberately making straw man arguments. I wasn’t even trying to debate anybody. Lol. I lost count of how many times I had to rewrite the same thing to try to clarify a misunderstanding, only for some to still choose to misrepresent my position. A position that was not vastly different from their own! That’s the baffling part!!! Lol.

 

[genop]

Actually, it is the non-psychologists that I have supervised and worked with that seem less likely to understand the utility and limitations of the DSM and to use diagnostic labels simplistically and more harmfully.

This is a huge part of my concern. A lot of mental illness is diagnosed in primary care or by non-psychologists, and psychotropics are prescribed as first line when the patient may not even have a mental illness. There aren’t enough psychologists as is, so I know it would be impractical to require the diagnosis to be made by a psychologist. I don’t know what the inter-rater reliability is either.

I also felt like some people were minimizing the harmful effects of these labels while inflating the benefits. That’s what made me focus so much on the flaws.

My understanding is, you don’t always need to do a formal assessment and diagnose the patient in order to be able to provide effective therapy. The maladaptive or distressing symptoms can still be treated. Is that correct? I know you said diagnosis is part of the case conceptualization though.

 

[psycho1391]

Scientific consensus is usually achieved after reviewing actual scientific evidence. Scientific experiments need to be reproducible. Attention is paid to bias, conflict of interest, sound methodology in the studies, appropriate statistical analysis, confounding variables, other alternative explanations…

Which is what the DSM committees do.


Again, the majority of us have spent a significant part of our lives studying and gaining knowledge on psychopathology and psychotherapy. We have read and studied empirical research. Some of us have even authored empirical studies regarding mental illness and treatment. Yet, you come in here, with feelings and anecdotes expecting us to not disagree with your posts.

but it’s still not a disease in my eyes.

Again, most of your postings are of your OPINION. "in my eyes" "I feel". These are not scientific arguments.

 

[psycho1391]

My understanding is, you don’t always need to do a formal assessment and diagnose the patient in order to be able to provide effective therapy. The maladaptive or distressing symptoms can still be treated. Is that correct? I know you said diagnosis is part of the case conceptualization though.

You're right. However, you need a diagnosis to bill insurance . The majority of Americans cannot afford psychotherapy without insurance. The system (not just the DSM) has its flaws.

Until we can advocate for a different system, we have to work with what we have and recognize the limitations of systems.

 

[PsychSupreme]

In the same way that I don’t view obesity as a disease but I still think it should be treated. Obesity actually has a scientific basis, but it’s still not a disease in my eyes.

And yet obesity literally has an ICD code. How is that different from PTSD having one/having a DSM code and "being treated?" These classification systems exist to provide a common language for research/clinical purposes and for billing and keeping consistent medical records. The reason you are getting pushback here is because you came to a sub populated largely by mental healthcare experts to complain about how certain mental health disorders (or whatever term you'd prefer) should not be considered disorders, but seem unaware that much of medicine uses the same exact sort of system for classifying "disorder." We classify obesity in a diagnostic manual because it is definable, has known ill effects on health, and should be seen as worth medically treating. We classify PTSD in a diagnostic manual because it is definable, is definitionally not an adaptive state of mental health, and should be seen as worth treating. Both imply an unhealthy (i.e., not conducive to good overall health) state of being, and both can be well-defined (obesity via some useful but flawed method like BMI, and PTSD via a useful but flawed method of statistically measuring symptom intercorrelations and observing responses to the same treatments). So it just seems a little inconsistent on your part to come here and rage against calling PTSD a disorder when it meets every single quality required to be considered a disorder. You might would add some "well-understood pathophysiology" requirement for "disorder" or "disease," but then you'd also have to axe schizophrenia, MDD, bipolar disorders, and half of the non-psychiatric ICD alongside it.

In other words, it seems like you have a very particular axe to grind when there's a whole shed full of the same type of axe just across the street. Not only that, but you've chosen to focus this discussion on PTSD, which happens to be among the oldest officially recognized and consistently understood conditions in the field--other than mood disorders, anorexia nervosa, and schizophrenia, it is hard to think of a disorder with as concrete of a history as PTSD. Post-war "shell shock" was literally the catalyst for psychologists leaving the bench and becoming treating professionals alongside psychiatrists. We have a very good idea of what PTSD looks like because we have observed it concretely for a very long time. There are still questions to be answered and flaws in the construct, but it’s a solid construct at its core. I don't know, it just seems like a very odd hill to die on when it isn't a particularly unique hill.

So, yes, PTSD is an understandable response to circumstances. However:

1. PTSD is maladaptive and statistically not a normal response.
2. PTSD has negative implications for physical and mental health.
3. PTSD can be defined well enough to allow for a common treatment, research, and billing language.
4. Er go, it seems, PTSD is a health "disorder."

 

[Shiori]

The example of grief is also another tricky area. If someone was grieving AND depressed, it was hard to capture that experience with the previous DSM exception. The "override" still excluded some from a more accurate explanation of their symptoms, so people who needed help got lost in the shuffle. A typical grief trajectory does not look like MDD and someone simply experiencing grief should not receive a MDD diagnosis. If someone is doing otherwise, that is not in the spirit of the exception removal.

 

[AcronymAllergy]

The example of grief is also another tricky area. If someone was grieving AND depressed, it was hard to capture that experience with the previous DSM exception. The "override" still excluded some from a more accurate explanation of their symptoms, so people who needed help got lost in the shuffle. A typical grief trajectory does not look like MDD and someone simply experiencing grief should not receive a MDD diagnosis. If someone is doing otherwise, that is not in the spirit of the exception removal.

Agreed. Per this article (and in line with essentially what DSM-5 says somewhere, IIRC):

The bereavement exclusion was eliminated from the DSM-5 for two main reasons: 1) there have never been any adequately controlled, clinical studies showing that major depressive syndromes following bereavement differ in nature, course, or outcome from depression of equal severity in any other context—or from MDD appearing “out of the blue;”2 and 2) major depression is a potentially lethal disorder, with an overall suicide rate of about four percent.3 Disqualifying a patient from a diagnosis of major depression simply because the clinical picture emerges after the death of a loved one risks closing the door on potentially life-saving interventions.

So essentially, there was no scientific evidence supporting the exclusion, and its presence could prevent people from receiving care.

I don't know any psychologist who would diagnose depression if they thought a person were experiencing normal bereavement. But what if, for example, the individual has a history of depression, placing them at greater risk of future episodes; experiences the death of a loved one; and then experiences a subsequent major depressive episode? We would likely treat it the same way we would recurrent major depression, while understanding that (as with depression), some natural improvement may occur.

 

[Sanman]

Again, I’m not saying not to treat. We need to do both.

Expert opinion is the lowest level of evidence, and doesn’t count as scientific fact. Scientific consensus is usually achieved after reviewing actual scientific evidence. Scientific experiments need to be reproducible. Attention is paid to bias, conflict of interest, sound methodology in the studies, appropriate statistical analysis, confounding variables, other alternative explanations…

As you mentioned, the grief exclusion was removed in DSM 5 criteria for MDD not due to the scientific method, but due to utility of being able to bill for it and treat people who may want/need assistance with their grief response. (I can’t ignore that this results in more people being put on medications, and so many in the DSM work group had ties to the pharmaceutical industry.)

Most physical illnesses have a distinct pathophysiological explanation and are not just based on a list of symptoms that a group of people agree on. A lot of the mental illness diagnoses are subjective and based on certain value systems and culture. It can be dangerous to label behaviors, feelings, and thoughts, things that make people human, as disorders, especially without considering the context.

It can be dangerous to address medical conditions without the context. If you think the MDD issue is bad, I was trained in the pain as the "5th vital sign" era of mandated pain assessments and treatment. Medicine treats symptoms all the time without a deeper dive into the causes. We treat diabetes but not metabolic syndrome even though we know the latter can cause the former. Why? it is because we have no treatment for metabolic syndrome beyond diet and exercise. So, treat a symptom of the problem. Same in mental health. Scientific consensus is required because reproducing PTSD in an experimental condition is an idea that would only fly if Dr. Mengele was your IRB board. Short of that, healthcare goes on the best evidence we have for phenomenon that are not completely understood. Not doing so would also have consequences.

I presume you know about homosexuality being considered a mental illness in the past, but it’s not anymore. I’m sure people made the same argument that it’s not “normal”, causes distress…when a lot of the distress was due to society’s view of homosexuality and people needing to hide their true nature or undertake conversion therapy.

People are so quick to attack things like EMDR for being pseudoscience. Yet, many mental health professionals had no problem accepting the chemical imbalance theory of mental illness as fact (which has been debunked), without adequate scientific evidence. So many people were put on SSRIs and other psychotropics as a result to “fix” their imbalance/disorder.

Are we just supposed to believe the theory behind why EMDR’s bilateral stimulation works because some experts say so (Might I add, experts who profit from EMDR)? Why is a different standard of proof being applied to EMDR but not mental illness diagnoses?

Btw, I know you and many others have acknowledged issues with diagnostic criteria and categories, so are we really in that much disagreement? From my perspective, I’ve actually agreed with you on practically every single thing you’ve said in your responses to me.

The flip side is that ignoring distress also occurs and is not helpful either. Look at the history of fibromyalgia and phantom limb pain. So, not labeling things can also be damaging and hinder the transmission of knowledge.

Though with regard to PTSD, your disagreement seems to be more with the language than the symptoms themselves. I feel like your objections would be removed by simply calling is a post-traumatic stress reaction rather than disorder. Which is fine and people refer to it that way as well.

 

[chicandtoughness]

I also expressed concern with calling things a mental illness when the symptoms are a normal response to extreme/chronic life stressors, trauma, etc. and apparently that was a controversial thing to say as well. I even used PTSD as an example. I think I said I don’t think it’s right to tell someone who has been gang raped and has PTSD as a result that they are mentally ill, diseased, or disordered (or to even think of them that way). That doesn’t mean they don’t need help. Then a psychologist said PTSD IS a mental illness. I’m fully aware it’s considered a mental illness in the DSM, but my whole point was that it’s harmful to conceptualize things this way (and unscientific).

Before anybody says not everyone gets PTSD, when I say something is a normal human response, I’m not saying it’s the only normal response. However, it’s an understandable human response to the trauma.

I think the issue is you're not understanding the difference between trauma (although I hate the term, "little t trauma") and PTSD. Trauma is, yes, an understandable response to a stressor. Everyone can experience trauma - folks who have been through hurricanes, anyone who has fought in a war, folks who have witnessed physical altercations. Heck, we all get retraumatized to some level just watching certain news channels. But PTSD is different; PTSD is literally a disorder which implies there is a level of deficit to functioning. It's not a "normal" process of grief/adjustment at all. The DSM is literally a normed manual, which means the disorders identified are ones that do NOT "normally" occur in the greater population.

Most physical illnesses have a distinct pathophysiological explanation and are not just based on a list of symptoms that a group of people agree on. A lot of the mental illness diagnoses are subjective and based on certain value systems and culture. It can be dangerous to label behaviors, feelings, and thoughts, things that make people human, as disorders, especially without considering the context.

People are so quick to attack things like EMDR for being pseudoscience. Yet, many mental health professionals had no problem accepting the chemical imbalance theory of mental illness as fact (which has been debunked), without adequate scientific evidence. So many people were put on SSRIs and other psychotropics as a result to “fix” their imbalance/disorder.

MANY physical illnesses/diagnoses are actually based on lists of symptoms, and "treatment" is simply managing sxs instead of the underlying causes because many times.... we don't know the underlying causes. Let me give you an example: erythema nodosum. It's a diagnosis. It literally means "there's some red bumps on the shins." In the majority of cases, there is no clear etiology or cause. sometimes they're due to viruses, or fungal infections, or STDs, or sometimes even pregnancy. That diagnosis does not explain anything about the etiology, and yet we have named it so that have a way to refer to that set of symptoms without saying "those red bumps on the shin" every time. Other notable examples have been provided by others in your other thread: fibromyalgia, PCOS, MCAS...

I have not met many folks who accept the chemical imbalance theory itself as fact. But it IS a fact that SSRIs do inhibit serotonin uptake and that DOES lead to less depressed mood. So while chemical imbalance is not the proper etiology of MDD (as an example), "balancing the chemicals" DOES treat a particular sx. And that's how psychopharma should be used: as an adjunct to therapy to treat the underlying disorder.

I can think of people’s distress, suffering, and impairment with compassion, wanting them to receive help or treatment to decrease said suffering, without attaching a stigmatizing label to them. I want to minimize harm.


I think we need to better acknowledge the harm these labels can do, and weigh that against the benefits.

I overall understand and empathize with the point you're trying to make, which I believe is to advocate for not over-pathologizing.
I don't know your specific circumstance, but I am going to play devil's advocate and mention that there is often a lot of relief in getting a diagnosis or having a name for what ails a person. I have worked with countless folks who were struggling for years wondering "wtf is wrong with me, am I just damaged?!" but then feel relief when I can tell them hey, it's just ADHD, or it's just OCD, and now that we've figured out what it is, there is help. I would caution against being a warrior for communities that you may not fully be integrated in (for example: many members of the disabled community actually dislike the "differently abled" verbiage).

Out of curiosity what is your license/background?

 

[genop]

Again, most of your postings are of your OPINION. "in my eyes" "I feel". These are not scientific arguments.

I never said my opinion is a scientific argument, which is why I’m careful to state when something is just my opinion.

A couple of you, on the other hand, keep passing on opinions as representing science, like most of the diagnostic labels. Even psychiatrists know these labels are not scientifically valid. Probably because they had to take an extensive amount of science classes like biology, chemistry, and physics in undergrad just like other doctors. Most of the medical education is based in science, too, with great attention paid to pathophysiology and objective, scientific diagnosis and treatment of diseases. A psychiatrist in this very thread has even said the diagnostic labels are pretty much just useful for billing, and no one jumped down his throat. Smalltownpsych also mentioned that the labels were based on what experts in the field agree on. They get it, and still recognize the utility, but they don’t misrepresent it as scientific fact.

I’m not going to engage anymore with people who don’t understand what science is, or are misrepresenting non-scientific things as science. I’ve wasted enough time responding to certain people that I shouldn’t have engaged with in the first place.

 

[genop]

Until we can advocate for a different system, we have to work with what we have and recognize the limitations of systems.

Understand and agree. I hope we advocate for a better system, and find a way to minimize harm and stigma in the process.

 

[WisNeuro]

I never said my opinion is a scientific argument, which is why I’m careful to state when something is just my opinion.

A couple of you, on the other hand, keep passing on opinions as representing science, like most of the diagnostic labels. Even psychiatrists know these labels are not scientifically valid. Probably because they had to take an extensive amount of science classes like biology, chemistry, and physics in undergrad just like other doctors. Most of the medical education is based in science, too, with great attention paid to pathophysiology and objective, scientific diagnosis and treatment of diseases. A psychiatrist in this very thread has even said the diagnostic labels are pretty much just useful for billing, and no one jumped down his throat. Smalltownpsych also mentioned that the labels were based on what experts in the field agree on. They get it, and still recognize the utility, but they don’t misrepresent it as scientific fact.

I’m not going to engage anymore with people who don’t understand what science is, or are misrepresenting non-scientific things as science. I’ve wasted enough time responding to certain people that I shouldn’t have engaged with in the first place.

See, now here's something that will have near universal agreement

 

[smalltownpsych]

This is a huge part of my concern. A lot of mental illness is diagnosed in primary care or by non-psychologists, and psychotropics are prescribed as first line when the patient may not even have a mental illness. There aren’t enough psychologists as is, so I know it would be impractical to require the diagnosis to be made by a psychologist. I don’t know what the inter-rater reliability is either.

I also felt like some people were minimizing the harmful effects of these labels while inflating the benefits. That’s what made me focus so much on the flaws.

My understanding is, you don’t always need to do a formal assessment and diagnose the patient in order to be able to provide effective therapy. The maladaptive or distressing symptoms can still be treated. Is that correct? I know you said diagnosis is part of the case conceptualization though.

Formal assessment is generally not needed to diagnose or treat DSM disorders except for maybe learning disorders. With kids and autism, probably necessary. As far as diagnosis goes, I find that if the label is useful for the patient then we’ll use it. I also will not necessarily quibble with a patient about whether they have schizoaffective vs schizophrenia for example or if they use labels or terms incorrectly. Lately I have been talking more to patients about trauma and how the DSM makes a distinction and how that helps them contextualize and validate their own experiences.

 

[msc545]

I never said my opinion is a scientific argument, which is why I’m careful to state when something is just my opinion.

A couple of you, on the other hand, keep passing on opinions as representing science, like most of the diagnostic labels. Even psychiatrists know these labels are not scientifically valid. Probably because they had to take an extensive amount of science classes like biology, chemistry, and physics in undergrad just like other doctors. Most of the medical education is based in science, too, with great attention paid to pathophysiology and objective, scientific diagnosis and treatment of diseases. A psychiatrist in this very thread has even said the diagnostic labels are pretty much just useful for billing, and no one jumped down his throat. Smalltownpsych also mentioned that the labels were based on what experts in the field agree on. They get it, and still recognize the utility, but they don’t misrepresent it as scientific fact.

I’m not going to engage anymore with people who don’t understand what science is, or are misrepresenting non-scientific things as science. I’ve wasted enough time responding to certain people that I shouldn’t have engaged with in the first place.

You have missed an important fact (although it is rarely stated so missing it is understandable):

The treatment of mental illness is largely an art and not a science, at least not in the sense that chemistry and physics
are. I realize that Psychiatry would LIKE it to be a science and puts great amounts of effort into that goal, but the results have been less than efficacious and at times very harmful.

So of course you would be disappointed and angry if you were expecting science and instead got opinions, since art cannot be adequately or meaningfully described or discussed using science.

 

[genop]

You have missed an important fact (although it is rarely stated so missing it is understandable):

The treatment of mental illness is largely an art and not a science, at least not in the sense that chemistry and physics
are. I realize that Psychiatry would LIKE it to be a science and puts great amounts of effort into that goal, but the results have been less than efficacious and at times very harmful.

So of course you would be disappointed and angry if you were expecting science and instead got opinions, since art cannot be adequately or meaningfully described or discussed using science.

Thanks for your response. I understand it’s largely an art, and a very important one. I know a lot of you are doing very difficult and noble work. Thank you for what you do for such a vulnerable population.

I was disappointed in the disrespectful way a couple people chose to engage and continually misrepresent my stance.

 

[msc545]

Thanks for your response. I understand it’s largely an art, and a very important one. I know a lot of you are doing very difficult and noble work. Thank you for what you do for such a vulnerable population.

I was disappointed in the disrespectful way a couple people chose to engage and continually misrepresent my stance.

Thank you! We too have our own bad apples. My apologies that you were treated poorly.

 

[cara susanna]

I got a PESI flyer for an IFS training and, while hate reading it, I was shocked to see that Kate Chard offers a seminar on how CPT can be integrated into IFS. Why would she be on board with this? Maybe she figures it's better that people get CPT while doing IFS than just IFS?

 

[deleted1038433]

I got a PESI flyer for an IFS training and, while hate reading it, I was shocked to see that Kate Chard offers a seminar on how CPT can be integrated into IFS. Why would she be on board with this? Maybe she figures it's better that people get CPT while doing IFS than just IFS?

Eh, not terribly surprised. I've heard my share of Kate Chard horror stories from people who have worked with her or trained under her. I don't take much stock in the developers of EBPs. I think we're all doing some version of process-based CBT most of the time, regardless of what therapyspeak we are using. I don't get caught up in the cultishness of the current psychotherapy climate.

 

[Sanman]

I got a PESI flyer for an IFS training and, while hate reading it, I was shocked to see that Kate Chard offers a seminar on how CPT can be integrated into IFS. Why would she be on board with this? Maybe she figures it's better that people get CPT while doing IFS than just IFS?

Turns out she likes money too. That VA salary ain't cutting it. She is just trying to keep up with that Ohio cost of living.

 

[cara susanna]

This thread seems the most appropriate place to ask...

Is the fawn response (you know, as in flight/fight/freeze) really a thing? It seems tied into the C-PTSD world and polyvagal theory, which you know I'm not super impressed by empirically.

 

[msc545]

This thread seems the most appropriate place to ask...

Is the fawn response (you know, as in flight/fight/freeze) really a thing? It seems tied into the C-PTSD world and polyvagal theory, which you know I'm not super impressed by empirically.

Fawn response, "C-PTSD", polyvagal theory, EMDR, Brainspotting, "everything is a spectrum" and the like are all tied into the mid-levels world where apparently anything is possible if they just imagine it.

 

[aim-agm]

This thread seems the most appropriate place to ask...

Is the fawn response (you know, as in flight/fight/freeze) really a thing? It seems tied into the C-PTSD world and polyvagal theory, which you know I'm not super impressed by empirically.

Speaking with no particular expertise, I'd say that a "fawn" response exists but would not group it with "fight/flight/freeze." The latter are more automatic, instinctual and reliably produced by sympathetic stimulation, the former involves higher level functions (e.g. social) and is more specifically applied. To illustrate, you might reasonably expect someone with a bear to "fight/flight/freeze" but not to "fawn."

 

[smalltownpsych]

Do people who have had trauma learn to try and avoid conflict. Does calling it a fawn response make sense, not really. Fawns tend to avoid conflict at all costs by freeze and flight and fight if it is a fairly small predator like one of my cats. Also, some patients who are exposed to trauma will react more aggressively interpersonally and most will have a variety of responses depending on the situation, the trauma, their history, their unique biological tendencies and so on. I find these types of overly broad types of jargon to not be very useful and serve most for patients to pin everything in their lives on their illness. Therapy is the opposite since I am trying to help them build more flexible and adaptive responses to complex social dynamics.

 

[WisNeuro]

Kyle Rittenhouse using 'therapy dog' sparks fury

The 20-year-old brought his dog to a TV interview to promote his new book "Acquitted."

www.newsweek.com

ESAs have officially jumped the shark.

 

[WisNeuro]

My state association is hosting an IFS CE for it's monthly CE/didactic. Definitely still glad I never renewed that membership.

 

[cara susanna]

My state association is hosting an IFS CE for it's monthly CE/didactic. Definitely still glad I never renewed that membership.

I got a PESI ad for IFS and yelled at it the second I saw it.

 

[WisNeuro]

I got a PESI ad for IFS and yelled at it the second I saw it.

I expect it from PESI. A state psych association, however, should have no dealings with such foolishness.

 

[quickpsych]

I expect it from PESI. A state psych association, however, should have no dealings with such foolishness.

I had to look up what PESI was and now understand. First thing on their site is a "free 2 day "conference online" CE event on trauma" with the Body Keeps Score guy with a special guest who bills themselves as a "somatic educator and body worker."

I vaguely remember getting an unsolicited mail order catalog from this PESI thing and it offered "all 30 credits you need for renewal of your license for $39!" I'm sure at least half of them would not be accepted as valid CEs.

 

[Sanman]

I had to look up what PESI was and now understand. First thing on their site is a "free 2 day "conference online" CE event on trauma" with the Body Keeps Score guy with a special guest who bills themselves as a "somatic educator and body worker."

I vaguely remember getting an unsolicited mail order catalog from this PESI thing and it offered "all 30 credits you need for renewal of your license for $39!" I'm sure at least half of them would not be accepted as valid CEs.

Sure they would. Half will have garbage content, but they will still be accepted. There is not exactly a high bar for that in any state I have been licensed.

 

[WisNeuro]

I had to look up what PESI was and now understand. First thing on their site is a "free 2 day "conference online" CE event on trauma" with the Body Keeps Score guy with a special guest who bills themselves as a "somatic educator and body worker."

I vaguely remember getting an unsolicited mail order catalog from this PESI thing and it offered "all 30 credits you need for renewal of your license for $39!" I'm sure at least half of them would not be accepted as valid CEs.

Much like diploma mills, APA will pretty much accredit anything that makes them money in some way.

 

[borne_before]

BTW - I just did a "fun" continuing ed to fulfill my ethics requirement from Zur institute: Therapists in the Movies: Exploring Ethics and Therapeutic Boundaries. Bonus: you can download the audio and go for a bike ride while you listen.

 

[cara susanna]

There's nothing better than this thread on Reddit where someone asked about treatment for OCD and a bunch of people are bashing CBT while recommending ERP and ACT

 

[WisNeuro]

There's nothing better than this thread on Reddit where someone asked about treatment for OCD and a bunch of people are bashing CBT while recommending ERP and ACT

The Therapists sub? That cesspool is why I completely believe patients when they report that they've only had really bad therapy in the past, because there are so many straight up incompetent people who learned about 2% of actual therapy foundations and think they are experts, all while buying into the latest woo therapy that sounds new and innovative, usually due to pseudoneurobabble.