Existentialism and the DSM-5: Humanizing Mental Health
What is the link between existentialism and a manual that gives most people on the planet their mental health diagnoses? From Major Depressive Disorder, to ADHD, to Asperger’s Syndrome, the Diagnostic and Statistical Manual of Mental Disorders is the book in which psychiatrists, psychologists, and other mental health professionals find the codes needed that allow insurance companies to cover the treatments provided. Sad to say, these labels often become the identity by which many people come to see themselves for the rest of their lives.
Humanizing mental health treatment has been a long time in coming. In other words, it’s high time that focus be turned to more humane approaches to healthcare treatment, in mental health fields, and beyond. The field of psychotherapy, which helps those who: (1) suffer from emotional pain; (2) find challenges to daily living in work, love or play; or (3) are experiencing blocks to self-actualizing, has a jaded history in its attempt to stay true to its most important edict to “do no harm.” Our field could really use a wake-up call: from the early botched lobotomies, to opening-and-then-closing of thousands of mental hospitals leaving countless troubled souls to live on the streets, to modern-day psychiatric excesses of over diagnosis and over-reliance on pharmacological approaches to solving what are often existential problems, and reducing human feelings to biological etiologies. In these less than humanistically-based approaches, mental health treatment loses sight of the person-centered aspects of the problem, in which (wouldn’t you know it) the true healing lies.
With global and economic upheaval pushing people (and institutions) to the edge, perhaps the time is ripe for a new era of humanistic psychology to infuse every field that’s interested with awareness of existential humanistic values of self-responsibility, unconditional regard, and empathic engagement, woven, with intentionality, into internal institutional templates and approaches to corporate culture. It could make a world of difference in work-life meaning, contributing to workplace happiness and productiveness.
So many people the world over are suffering from a form of existential whiplash from the economic tumult and personal loss of an identifiable being-in-the-world that makes ego syntonic sense to them. Lost jobs, economic hardship, familial collapse, loss of home, hearth and hope—such existential crises cannot be fixed by pills alone. The current controversy over proposed new diagnoses in the upcoming DSM-5 has psychologists and mental health professionals deeply concerned, as they see so many of these struggling people identified as mentally ill, given a diagnostic number, and treated with a cocktail of prescribed medicines that don’t come close to addressing what is really wrong. Speaking out against what they see as the dehumanizing of psychological care through over medicalization and over diagnosis of vulnerable populations of children and the elderly in particular (but touching the lives of the general public, as well), through revolt against the proposed DSM-5, the mental health community is shouting a resounding, “No!” Last fall, within months, more than 10,000 mental health professionals, organizations, international psychological groups, and others, had signed an online Open Letter petition asking the DSM-5 Task Force and the American Psychiatric Association to show greater transparency in their process of vetting some of the more controversial new diagnostic criteria (http://www.ipetitions.com/petition/dsm5/). News media outlets and bloggers were quick to tell this David and Goliath story of the foot soldiers who see the impact of mis-diagnosis and the harm of over medication, and are standing up to the giant psychiatric publishing monolith as it moves the DSM-5 each day closer to press (it is due to close its review process in February 2012, and be published in May 2013).
In order to ensure safe and sound mental health diagnosis of the American public and increasingly those in other cultures around the world, the DSM-5 must be bound and published only after its contents have been conceived and executed in a scientifically-based and transparent way. In the name of the professional psychological community, The Division 32 Open Letter Committee wrote a follow-up letter to the DSM-5 Task Force on January 9, asking for their pleas for transparency to be addressed. (http://dsm5-reform.com/the-open-letter-committee-calls-for-independent-review-of-dsm-5/)
Some worrisome new diagnoses include: Attenuated Psychosis Syndrome where, by trying to identify psychotic tendencies early and preventatively, a diagnostic net is cast so wide that quirky or eccentric teenagers, in so-defined outlying stages through which many adolescents pass, will be mislabeled with APS. Another new mental disorder of concern is Disruptive Mood Disregulation Disorder for children and adolescents, allowing for kids who are acting out to end up with long-lasting diagnostic labels. Similarly, Major Depressive Disorder, which in the DSM-IV used a bereavement exclusion to acknowledge the normal and natural grief process after the loss of a loved one lasting up to one month before MDD could be diagnosed, is shockingly, in the new DSM-5, shortened to a mere two weeks. Proper medication can still be prescribed without the need for a life-long diagnosis of MDD, a mental illness, hanging like an insurance albatross around the unsuspecting person’s neck. The proposed diagnosis of Mild Neurocognitive Disorder for elderly patients could easily lead to over-medication of this already over-sedated population, especially those who live in nursing homes. And, reportedly Asperger’s Syndrome, describing those with a high-functioning intellectual level of Autism, who often have an intense, keen, special interest in which many could be considered “gifted,” is disappearing, and simply becoming part of the autistic spectrum, along with other changes to diagnostic criteria garnering attention from national media outlets like The New York Times, Time Magazine, Bloomberg, and NBC Nightly News.
The over-drugging of nursing home residents, as well as foster children (who are prescribed mind-altering antipsychotic drugs at a rate 5 times that of non-foster children), have been hot topics in the news lately, including testimony on Capitol Hill by a 12-year old foster child on his life altering experience on psychotropic medication. Meanwhile, the unprecedented increase in the diagnosis of ADHD has led to a widespread shortage in attention-hyperactivity medicine for those who actually need it. It is these vulnerable populations whose existential realities are most at risk. Who speaks for these people? Who makes sure there is no harm done? In the name of humanity, and an inter-subjective revelry that makes clear that if I-am-not-for-you and you-are-not-for-me, there is no real hope, who is in charge of watching the henhouse and speaking up for the voiceless? We would be well served to see the truth of our interdependence, and figure out how to achieve the healing we are after from that place.
Social media’s town square, Twitter, speaks to the over diagnosis/over medication issue from many corners of the globe. One tweet, from @metroidbaby, ironically states: “Oh boy the new DSM-5 is gonna have all sorts of exciting new disorders for me to get diagnosed with!” (January 12, 2012 9:29 PM)
Recent scientific studies also highlight the problematic nature of over diagnosis and over prescription of antipsychotic medication:
· Antipsychotics and Mortality in Dementia (Corbett & Ballard, 2012) looks into the use of powerful antipsychotic drugs in the elderly population, in which the authors report that “a series of lawsuits and settlements … suggests that many pharmaceutical companies have improperly promoted these drugs to doctors and nursing homes for many years.”
- APA Responds to Reports on Antipsychotic Prescribing (Wolfe, 2012) in which “[n]ew research on alleged overuse of psychotropic medications in both nursing-home and foster-care settings signals a need for better training of nonpsychiatric physicians and increased funding to bolster the mental health workforce, according to American Psychiatric Association in recently submitted congressional testimony.”
- Senator’s Proposal on Antipsychotics Generates AMA Opposition (Moran, 2011) in which the “[American Medical Association] opposes a proposal requiring physicians who use atypical antipsychotics and other medications with black-box warnings for off-label purposes to certify in writing that the use meets certain government requirements."
- And, most recently, after being taken to court by the state of Texas, the drug maker, Johnson & Johnson, agreed to a payout of $158 million in a case involving the improper marketing of the antipsychotic drug Risperdal to children, and others in the state’s Medicaid program, after FDA warnings against doing so.
Through first-hand accounts from the trenches, the alarm bells are sounding throughout the psychological and mental health communities, warning of the harm done by psychiatric false-positives and psycho-pharmacological overkill, as well as pointing to recent scientific research findings that stress the real-world experiences of over medicated patients, among them children and the elderly. This may well be the existential issue of our time: how to foster a willingness to presence humanistic engagement with one’s own personal phenomenology.
Visiting with a girlfriend recently over Sunday brunch in Old Town Alexandria, Virginia, down the road from the DSM-5 Task Force offices, she told me the story of her daughter, a 21-year-old college student who was nervous about exams. With her family of origin comprising an older sister heading to medical school, and two accomplished lawyer parents, the girl sought out a therapist off campus. Calling home after the session, she reported to her mother that after she told the therapist her story, the first suggestion was that she get a prescription for Wellbutrin, the anti-depressant medication. As it turned out, my friend’s daughter never filled the prescription; she said just talking about it made her feel better.
If we invite our clients to run to the medicine cabinet every time they feel psychic or emotional pain, we are taking the short cut: but to where? We end up doing a disservice to the people we are chartered to serve. If the key factor in successful psychotherapy is the alliance between the patient and the therapist (Wampold, 2001), it is our job, through the relationship, to help clients face the existential stuff of their lives directly, and discern ways to re-enter the path to personal growth and development. Therapists act as guides in the therapeutic encounter, becoming, as it is, the relational metaphor for our clients’ waltz with life itself. It is not Pollyanna to talk about therapy in this way; it is existential truth.
As gatekeepers to a field vulnerable to decisions based on pharmaceutical industry influence, it is up to all mental health professionals to stand for the public trust and ensure the proper, uncorrupted distribution of mental health services, and consideration therein of the personhood of each and every consumer of the product we market—which is a personal reorientation to one’s self-actualizing tendency, humanistic connection as therapeutic change agent, and an honoring of the individual nature of each person’s being-in-the-world. We need to be careful not to unintentionally lobotomize the human race through the over prescription of unneeded and downright dangerous medications, through financially driven trends in diagnosing and prescribing. Only through a person-centered, humanistic approach can the being-based or ontological realities of the person-in-therapy, as well as the therapist, enter the room as valuable stepping-stones to well-being.
-- Dr. Donna Rockwell is a member of the Division 32 Open Letter Committee, http://dsm5-reform.com/
Corbett, A. & Ballard, C. (2012). Antipsychotics and mortality in dementia. American Journal of Psychiatry (169)1, 7-9.
Moran, M. (December 16, 2011). Senator’s proposal on antipsychotics generates AMA opposition. Psychiatric News (46)24, 1b-28, American Psychiatric Association.
Wampold, B. (2001). The Great Psychotherapy Debate: Models, methods, and findings. Mahwah, NJ: Routledge.
Wolfe, J. (January 6, 2012). APA cites a need to use practice guidelines when prescribing antipsychotics in nursing homes and foster-care facilities. Psychiatric News (47)1, 7-7, American Psychiatric Association.