Category: Critique of med model and diagnosis

To create his theory of relativity, Einstein had to see things differently.  He had to view the universe not as an object of mammalian proportions, but from the perspective of a subatomic particle.  Essentially, he used imagination and empathy to come to know a new ‘reality’ of existence.

This essay is the second in a series.  We previously outlined a rationale for a 100% voluntary mental health system (read about it here). Now, we take a deeper look at the nature of human experiences that lead to public concern.  We delve deeply into the perspective of that experience and discover ourselves in a whole new realm.

Three ways of seeing experience

To understand where we are going, let’s first take a look at where we’ve been.  Here are some competing models for approaching socially troubling human experiences.

1. The DSM Model of ‘mental disorders’

The DSM Model is based on the Diagnostic and Statistical Manual of Mental Disorders published by American Psychiatric Association.  In no small part, the DSM has been the product of insider turf wars, political compromise, industry needs and billing concerns.(1) It is said to be atheoretical, but unquestionably the DSM views certain aspects of human experience as abnormal/ disorders.  Possibly, this is just a nod to the practicalities of healthcare reimbursement.  However, the process of distinguishing the truly abnormal (insurance pays) from the common effects of a stressful life (you pay) has left something to be desired.

Rote symptom checklists determine whether your anxiety, mood, grief, trauma, substance use, sexuality is ‘normal’ or ‘disordered.’  At a minimum, this is a lousy way to get to know another human being on the worst day of their life. Painful experiences, like getting fired, ending up homeless or being raped in shelter housing are routinely ignored or overlooked. It’s like the teacher pronouncing you ‘learning disordered’ without asking if you studied.

Reliability and validity have proved problematic as well. Individual diagnoses tend to vary, as do predictions of violence and suicide.  Given that single bad call can change the course of a lifetime, concerns like these led whistleblower Paula Caplan, Ph.D., to report to the Washington Post in 2012: “Psychiatry’s bible, the DSM, is doing more harm than good.”  A year later, the National Institute of Mental Health (think science, research, evidence-based) went on record as looking for a more valid approach (full statement here).

2. The Medical Model of ‘mental illness’

In contrast to the DSM, the Medical Model has a crystal clear vision.  ‘Mental illness’ is a real disease.  It is caused by pre-existing genetic, biochemical or physiologic abnormalities. Those affected are susceptible to disregarding personal welfare or that of others. Aggressive treatment (drugs, CBT) is required to correct or mitigate deficiencies.

For all its theoretical congruence, the medical model hasn’t fared much better than the DSM. Treating ‘mental illness’ takes a whopping 15-25 years (on average!) off of the average life span.  The promised ‘chemical imbalances’ and bio-markers still haven’t materialized in the research.  Disability rates have sky-rocketed. Long-term outcomes and relapse rates have worsened overall. (2)  Many suspect that prescribed drugs increase violence and suicide.

3. The Social Justice Model of fundamental human needs

This model comes in no small part from the learnings of World War II, the Holocaust, Hiroshima, and Nagasaki.  In the aftermath of atrocities, the nations of the world were interested in figuring a few things out.  They needed a way for those on all sides to move forward.  They wanted to set the stage for ‘never again.’  Their solution was the Universal Declaration of Human Rights of 1948 (UDHR).

The UDHR is premised on a simple idea.  For all our differences, human beings have much in common.  We all need certain things to live and be well:

• nutritious food, habitable shelter
• safety of person and property
• dignity, respect and fair treatment
• meaningful participation and voice
• support for families to stay together and make a living
• opportunities to develop ourselves across major life domains
• freedom to make sense of experience in our way

Under the UDHR, advancing human rights is a universal, non-delegable obligation. Everyone everywhere is responsible for doing their part.  The peoples of the world understood that the basic requirements for human dignity must be accessible to all.   Without such access, neither individuals nor the human family as a whole will be well.

The theory of human conflict follows from this.  Under the UDHR, conflict arises when human needs are in competition.  It intensifies with time if only some of us have access to what all of us need.

Preventively locking someone up or drugging them against their will is a considerable human conflict. To meaningfully address such issues, the Social Justice Model counsels us to take a step back.  Those we are fearing (sick, disordered, untrustworthy) may be messengers, not madness.  Instead of privileging our perspective, what if we try to see the world through the other’s eyes:

• Is it possible their experience might not be as senseless it seems?
• Is it possible they may be expressing a history of social harms, rather than arbitrarily bent on inflicting new ones?

Before you immediately brush this off, consider the following:

If the nations of the world could adopt these attitudes in the aftermath of Hilter, concentration camps, kamikaze pilots and detonated atom bombs, then why not for modern public safety concerns?  

Support for the Social Justice Model

Nearly 70 years ago, the United Nations predicted the following (UDHR Preamble):

1. ‘[R]ecognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world.’
2. People everywhere long for a world in which ‘freedom of speech and belief and freedom from fear and want’ are the order of the day.
3. ‘t is essential, if man is not to be compelled to have recourse, as a last resort, to rebellion against tyranny and oppression, that human rights should be protected by the rule of law.’
4. ‘[D]isregard and contempt for human rights’ leads to ‘barbarous acts’ that ‘outrage[] the conscience of mankind.’

Now consider this:

1. Research on public and behavioral health impacts

An estimated ninety (90!) percent of those in the public mental health system are ‘trauma survivors.’  We have grown up without reliable access to same basic needs that the United Nations recognized as essential over six decades ago.

The same applies to the other so-called ‘problem’ groups in our society.  Yep, ninety (90!) percent or more of us in substance use, criminal justice, and homeless settings are ‘trauma survivors’ as well.

This is not just about individual needs, but also family needs and the needs of entire communities. These issues affect all of us across demographics.

Don’t believe it?  Check out the following:

• National Association of State Mental Health Program Directors (NASMHPD), The Damaging Consequences of Violence and Trauma: Facts, Discussion Points, and Recommendations for the Behavioral Health System (2004). Full report here.
• National Council for Behavioral Health (Breaking the Silence: Trauma-informed Behavioral Healthcare (2011). Full publication here.
• Nadine Harris, MD, How Childhood Trauma Affects Health Across a Lifetime (TED Talk here.)
• Substance Abuse and Mental Health Administration, SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach SAMHSA (2014). Full proposal here.
• The School of Life, Sanity of Madness (1/18/2016). Full video here.

Yet, for all the fanfare about the need for more ‘trauma-informed care’, there has been little systemic response directed toward basic human needs.  Equally disturbing, behavioral health system involvement has become an independent, exacerbating source of harm for many.

The results speak for themselves.

2. Tremendous explanatory power

In addition to the public health data, the Social Justice Model has tremendous explanatory power.  It offers a straightforward way to make sense of experience (this essay), as well as principled ways to respond (future essay) that could easily be confirmed – or refuted – by research (future essay).

The basic paradigm is this:

1. Resources are seemingly scarce
2. People have basic needs
3. They see a threat or opportunity
4. This sets off a ‘high-stakes’ (aka ‘survival’) response
5. Predictable physical, mental and social effects occur.

The above theory draws on work that has already been done.  In the trauma field, the human survival response (fight, flight, freeze) and its effects are widely known. See, e.g., ‘The Body Keeps Score‘ by Bessel van der Kolk.  As it turns out, you can tweak the same theory to make sense of a broad variety of human experiences that lead to public concern.

3. The ‘normal’ response when the stakes are high

For our purposes, there are two basic nervous systems:

(1) ‘All-is-well’ (parasympathetic) for everyday routines. This covers stuff like eating, sleeping, relaxing, hanging out, having sex, small talk, hobbies, tinkering around…

and

(2) ‘High-stakes’ (sympathetic/ ‘survival response’/ fight-flight-freeze) for responding when the stakes are high.  This is the ‘get your butt in gear’ reaction that takes over when something feels like a big deal.

High-stakes can get involved in all kinds of stuff.  This includes both threats and opportunities.  The critical factor is that (from the person’s point of view) the stakes are high.  For example, here are some things that can set off the high-stakes response for me:

• Discovering new possibilities, new gossip, twenty dollars or my cat in the road
• Taking tests, exams, the best donut or advantage of someone else
• Scoring a point, contract, bargain, victory or high
• Getting paid, laid, yelled at, ripped off, excluded, assaulted or stopped by police
• Going on first dates, adventures, job interviews or a personal rampage
• Performing on the job, in sports, in college, during public hearings or psychiatric exams
• Resisting temptation, peer pressure, arrest, detention or a doctor’s opinion

Suffice it to say, the definition of ‘high stakes’ is a personal matter.  It depends on what you have lived or come to know.  Thus, one person’s ‘high stakes’ might not even register on another’s radar.

4. Explaining intense or extreme responses

To discover relativity, Einstein had to take the perspective of atoms.  To see the value of high-stakes responses, we have to experience what is happening from the high-stakes viewpoint.

When the stakes seem high, human beings are wired to respond in one of three ways:  fight, flight or freeze.

• ‘Fight’ goes after threats and opportunities.  It takes them on or brings them down.
• ‘Flight’ avoids threats and opportunities.  It gets away (runs, hides) as fast as possible.
• ‘Freeze’ hides in plain sight.  It shows no apparent reaction (de facto disappears), giving others nothing to notice or chase.

Despite their clear-sounding names, fight, flight and freeze are not fixed forms of expression.  They are directional tendencies that can occur across many life dimensions. This allows personal strengths, past experiences and familiar (‘tried and true’) behaviors to be optimized for survival value.  Here are some ways that I have expressed fight-flight-freeze when the stakes felt high to me:

 

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Dimensions of Fight-Flight-Freeze

• Physical
  • fight: striking out, yelling, swearing, telling someone to ‘get out! breaking stuff
  • flight: leaving the room, not showing up, running away, cutting, trying to kill myself
  • freeze: doing nothing, hiding in bed
• Emotional
  • fight: raging, hating, envying, craving
  • flight: avoiding, cowering, dreading, numbing with food, drugs, sex, spending, computer, games
  • freeze: poker face, going numb
• Social
  • fight: verbally attacking, ridiculing, blaming others, complaining, rescuing
  • flight: obeying, begging, flattering, apologizing, backtracking, blaming self, compensatory romantic interest
  • freeze: saying nothing, playing along, going with the flow, withdrawing
• Intellectual
  • fight:  arguing, planning, plotting, obsessing, out-smarting
  • flight: distracting, fantasy
  • freeze: forgetting, going blank
• Spiritual/ existential
  • mostly fight:  praying, seeking visions, looking for signs, exploring energy, becoming a deity
  • mostly flight: bargaining with God, trying to be a good person, wishing I were dead
  • freeze: losing time/ awareness/ consciousness

(Please note: Depending on context and underlying intent, the same response may fit in multiple categories.)

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The wide variability of high stakes responses is a tremendous asset to our species.  It ensures that people will respond in numerous rich and creative ways.  When an entire community is facing a threat, this promotes resilience and survival overall. If we all responded the same way to danger or opportunity, a single threat (predator, disease, disaster) could wipe us out. We need the extremes that people tend to under stress to safeguard group survival.

On the other hand, when the stakes are seemingly individual, the virtue of diversity can get obscured. Since only one person is reacting, this can look rather odd to everyone else. Imagine Beatlemania, but only you can see the Beatles. Visuals here if you need them (with a little help from my friend, JH).

It’s also worth noting that there is a dose-response effect.  In other words, the higher the stakes and the longer I’ve been in that frame of mind,  the more intense or extreme my responses tend to get.  Over time, this has become a good way for me or others to gauge how important the needs involved are to me.  For example, if things seem relatively manageable, then my responses tend to be manageable – both by me and others.  On the other hand, if I can’t imagine living or being happy if the needs aren’t met, my responses tend to flair accordingly.

 

6. ‘Sarah, are you calling inappropriate the new normal?’

If you are nodding along with me at this point, thank you for getting it!  On the other hand, if you are feeling confused or disgusted, you are not alone.  Clearly, my experiences violate conventional norms. They routinely get seen as unacceptable, disordered or ill.

On the other hand, like the vast majority of the world, you may be seeing my life from an ‘all-is-well’ perspective.  And, for ‘all-is-well’ living, my responses sure aren’t the norm.

But that is precisely the point I am trying to make.   In behavioral health populations, all-is-well is not the norm.  The norm in behavioral health populations is violence, deprivation, poverty, injustice, and marginalization. In other words, the stakes are high all the time. Problems build on each other, then compound exponentially.  We rarely, if ever, get a break.  We feel like we constantly have to defend our right to be.  In dose-response terms, the dose is enormous.  So, predict a pretty big response.

From my experience, despite a lifetime of trying to learn how to do it differently, that is what keeps happening.  But don’t just take my word for it.  Here is 18-year-old Sabrina Benaim“Explaining My Depression to My Mother.”

And before you say, stop making excuses for yourself and take a little responsibility, consider the following (apart from the 20 years of therapy, thousands of dollars out of pocket, 20+ drugs tried, studying this stuff at the doctoral level, devoting my life to trying to understand it):

There is a really good reason that high-stakes responses are hard to turn off:  Any conscious, reality-based human being should be bothered by high-stakes conditions.  As a practical matter, the high-stakes response is a message. It is like your hand burning on a hot stove. The intense feeling (pain) tells you to move your hand. This prevents further damage. If you just rationalize or drug that sensation away, there is no telling how bad you’ll end up.  (We have the scars to prove it.)

Equally important, it is not an accident that high-stakes responses come across as ‘inappropriate’ and alarming. This is by nature’s design, and it serves a dual purpose:

1. Predators/ competitors are unable to anticipate or plan for what we’ll do.
2. Well-intended others will know that something is wrong.

Hence, while high-stakes responses no doubt alarm and baffle others, that is why it has actual survival value.

This highlights the futility of trying to classify so-called ‘mental disorders’ in a high-stakes population. The very purpose of our responses is to defy explanation. Outsiders are not supposed to know what is going on.  It’s a plus, not a minus when potential predators can’t agree.

The same survival function also explains why observers find these responses so distressing.  High-stakes responses are supposed to cause alarm. This scares outsiders off and alerts those close to us that all is not okay.  If society worked the way nature intended, the outcome would be great.  Opportunists are deterred.  Allies rush to your aid.  Real friends stick around and try to find a way to help.

That’s also a message for would-be helpers.  The assessment tool is built right into the high-stakes system.  The rules are fairly clear if you know what to look for:

 

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High Stakes Rule #1: When something makes it worse, the stakes go up, and responses get increasingly extreme.

High Stakes Rule #2: When something makes it better, the stakes go down and all-is-well eases in over time.

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In other words, the so-called ‘ravings of lunatics’ are actually  ‘rational’ from a high-stakes perspective. They scare off opportunists, attract available allies and weed out would-be helpers who don’t help. If no help is found, they keep us alive and free to keep looking.

From this vantage point, perhaps now you can appreciate the violence – the actual soul torture – of forcing survivors to present as if ‘all-is-well.’  Not only does that obliterate what we have experienced, it takes away what is often the only means we have to communicate our pain to the culture at large.

Suffice it to say, given the state of the world today, you should find us painful to be around.  You should find it difficult if asked to bear witness. That is what puts your hand on the stove burning with ours. That is what motivates you – everyone – to look for the source of the burning.  That is what makes it possible for human beings, in the spirit of Einstein — to get curious about the little guy, wonder what it is like to feel that small and discover a whole new reality outside of ordinary vision.

With the benefit of hindsight, what do you say we also look for a better energy source to power human relationships?  Instead of splitting dissenters off or leveling resistance, how about this time we stick with imagination and empathy and learn to create a  workable, honest fusion?

References:

(1) Caplan, PJ (1995) They Say You’re Crazy: How The World’s Most Powerful Psychiatrists Decide Who’s Normal  (Perseus Books: www.aw.com/gb).

(2) Whitaker, RH (2010). Anatomy of an Epidemic. New York: Random House.

This blog is a contribution to the Campaign to Support the CRPD Absolute Prohibition of Commitment and Forced Treatment. To see all of the Mad in America blogs for this campaign click here.