Here's the back story: a famous, well-respected psychologist writes a hugely complex journal article and then gives an interview to TIME Healthland online. The interview is as confusing as the journal article, and great controversy ensues in the profession.
Are people being mislead and confused? Are they being harmed? Does he have a valid point?
9/19/2011
6/24/2011
When Leadership Fails: What seems to be the problem at Sacramento State?
In the past few years, Sac State has spent and wasted well over one million dollars on lawsuits that could easily have been avoided. These are text book examples of what it costs when management ignores workplace harassment. It’s a text book example of what happens when leadership fails.
The most recent case to hit the news (see story) has actually been going on since 2005. After spending money on four investigations and who knows how much in attorney fees, the campus ended up paying $900,000 to three female professors. And it’s not over yet.
It’s an issue that could have been put to rest five years ago at hardly any cost at all. You have to wonder if It was anything other than administrative incompetence that has kept it going.
What happened is that three female professors reported that students had come to them with complaints about Professor Wilfrido Corral. He was sexually harassing students. The three professors reported the complaints, as required, and four students came forward. An investigation found their complaints to be valid, and one student got a $15,000 settlement from the University. But things got ugly after the the three professors complained. As described by campus attorney Dawn Theodora: "Corral basically went on a vendetta against them … they were just doing their jobs.”
So first we have harassment, and then we have retaliation.
And what did the campus Human Resource managers do about Professor Will Corral? Well, basically nothing. They put a letter of reprimand in his personnel file (a letter that would later “disappear”) and they made him take the sexual harassment training that all staff are required to take anyway.
Before any of the other faculty knew about the investigation or the findings, Corral was elected to be the new Department Chair. Corral took the reins early and started retaliating against the whistle blowers. And then in August, he was seated as Chair.
The women didn’t seem to understand why someone who preys on students and retaliates against whistle blowers would be seated as a Department Chair. Why would the campus allow someone like that to maintain a position of power? They complained even more when he took control.
Porter woud later tell an investigator that they spoke to the woman who complained the loudest. They were: “trying to explain … that human resources had taken the appropriate action against Corral.” He thought the woman was just “not letting it go.”
Dave Wagner told the investigator that maybe she didn’t know about the letter of reprimand, and so she “probably felt that nothing was done.” Wagner said that “she views everything as black and white” and “probably believes that Corral should have been fired.”
Obviously, he should have been fired, perhaps maybe just to protect students. And if for some reason he wasn’t to be fired, why would they grant him a perch from which to prey?
Peter Lau, the campus Affirmative Action Officer met with Wagner and Porter about this. Lau told the investigator that there was “no policy in place that would allow them to remove him or otherwise prevent him from taking the Chair position.” So it was like they didn’t know what to do.
Porter was in the meeting when the decision was made, but in discussing it later, he “could not recall who was responsible for making the decision to allow Corral to assume the Chair.”
Obviously, the decision was the responsibility of Dave Wagner, the Vice President for Human Resources, He was in the meeting as the high man on the organizational chart. Referring to the fact that Carrol had sexually harassed students, Wagner later recalled that “it was difficult to determine if the conduct by Corral was unwelcomed.”
Maybe it’s true that the two students who accepted Corral’s dinner invitation welcomed the invitation. But it is hard to imagine that they wanted him to hit on them, or talk about being a “sex addict” or to “talk about doing it doggy style.” It is certain that they did not welcome that as dinner talk. The complaints from the students were well founded.
Years went on and it wasn’t resolved and just got worse. Corral would retaliate and the women would complain and there would be investigations and nothing would change. There was mediation and there were meetings with the Provost, Joe Sheley (the other No. 2 man on campus). Eventually, two of the professors who complained retired early, totally stressed out.
The generous interpretation is that despite their positions, Sheley, Wagner and Porter just didn’t get it. They didn’t get that there was anything wrong or that these things just fester and don’t go away. Sheley later told the investigator that he “does not believe anyone at the University overlooked the issues or concerns with respect to Corral.” Perhaps not, but they didn't seem to understand what it was that they were looking at.
Wagner and Porter described the situation as an “intradepartmental policy dispute,” a “personal dispute,” and an “interpersonal issue.”
It had apparently become that. It became personal. The women were angry that their complaints had been ignored. They were in pain, it wouldn’t stop and there was some sporadic use of abusive language.
But that wasn’t the problem. The problem was that there had been no remedy for the retaliation. It was no longer about the original complaint regarding the harassment of students, now it was about the fact that Corral had gone on the attack against the women “who were just doing their jobs.”
Retaliation is illegal, and juries treat retaliation more seriously than even harassment and discrimination claims.
Jurors tend to have a hard time when someone says that they were mistreated because of their status or who they are. The jurors think: “they treated everybody badly, it wasn’t because she was a woman.” On the other hand, in retaliation cases, jurors naturally understand when someone says they were mistreated because they complained. Most people are cautious about complaining, they know what can happen. And juries know that it’s not right and that people shouldn’t be bullied.
The problem at Sac State is that the campus treated the problem like it was “failure to communicate.” They treated it like the women were the problem and that their complaints were about nothing more than the ordinary tribulations and minor annoyances that often take place at work and that all employees experience.
There is no general civility code for the American workplace. Skilled leadership and good judgment are required to to know when complaints are serious and how they should properly be handled. Sac State just didn’t get it, and the problem only got worse.
Eventually, the women sued, at a cost to the campus of at least a million dollars. The women got $900,000. The campus has defended that payment as having been made in good faith. The campus had to admit that the women deserved the money.
As for Corral, he’s what’s keeping it going now.
Eventually, after years trying to avoid the problem, the campus had to actually fire him. So now he’s suing the campus. You can just wait to hear his attorney say: “in all these years, the campus never did anything … they didn’t think he did anything wrong.”
Campus attorney Christine D. Lovely said in a hearing that he was fired for “immoral and unprofessional conduct,” which is exactly what the women complained about in 2005.
The problem at Sac State is that this is not an anomalous case. It’s not something out of the ordinary. There is a case to be made that at Sac State, complaints about abuse are routinely ignored and that the behavior is tolerated or effectively condoned. That is what seems to have happened in the case above and the generous interpretation is that it was the result of mismanagement and bad leadership.
In the past few years, the campus has had to settle other lawsuits that are eerily similar to this. They’ve settled with people who had the resources and the stamina to take the matter to Court. That’s public information. What is not public is how many people with valid complaints gave up. We also don’t know how many didn’t even bother to complain, knowing that nothing good would come of it?
There is a pattern here, or perhaps a few. If you read the cases, you can see in each one that with just a bit of good judgment and a bit of leadership courage, these matters could have been handled effectively at little or no cost. People wouldn’t have been troubled and the campus wouldn’t have done damage to itself.
What seems to be the problem?
Update: this case settled later in 2011. Corral dropped his complaint and retired, or something.
See: "When Leadership Fails" for an account of another, similar case at Sac State.
The most recent case to hit the news (see story) has actually been going on since 2005. After spending money on four investigations and who knows how much in attorney fees, the campus ended up paying $900,000 to three female professors. And it’s not over yet.
It’s an issue that could have been put to rest five years ago at hardly any cost at all. You have to wonder if It was anything other than administrative incompetence that has kept it going.
What happened is that three female professors reported that students had come to them with complaints about Professor Wilfrido Corral. He was sexually harassing students. The three professors reported the complaints, as required, and four students came forward. An investigation found their complaints to be valid, and one student got a $15,000 settlement from the University. But things got ugly after the the three professors complained. As described by campus attorney Dawn Theodora: "Corral basically went on a vendetta against them … they were just doing their jobs.”
So first we have harassment, and then we have retaliation.
And what did the campus Human Resource managers do about Professor Will Corral? Well, basically nothing. They put a letter of reprimand in his personnel file (a letter that would later “disappear”) and they made him take the sexual harassment training that all staff are required to take anyway.
The legal documents suggest that a turning point came in August of 2006.
Before any of the other faculty knew about the investigation or the findings, Corral was elected to be the new Department Chair. Corral took the reins early and started retaliating against the whistle blowers. And then in August, he was seated as Chair.
The women didn’t seem to understand why someone who preys on students and retaliates against whistle blowers would be seated as a Department Chair. Why would the campus allow someone like that to maintain a position of power? They complained even more when he took control.
Handling what had now become an ugly affair were Human Resources Vice President David Wagner and Associate Vice President Kent Porter. On the organizational chart, they sit right below President Alex Gonzales.
Porter woud later tell an investigator that they spoke to the woman who complained the loudest. They were: “trying to explain … that human resources had taken the appropriate action against Corral.” He thought the woman was just “not letting it go.”
Dave Wagner told the investigator that maybe she didn’t know about the letter of reprimand, and so she “probably felt that nothing was done.” Wagner said that “she views everything as black and white” and “probably believes that Corral should have been fired.”
Obviously, he should have been fired, perhaps maybe just to protect students. And if for some reason he wasn’t to be fired, why would they grant him a perch from which to prey?
Peter Lau, the campus Affirmative Action Officer met with Wagner and Porter about this. Lau told the investigator that there was “no policy in place that would allow them to remove him or otherwise prevent him from taking the Chair position.” So it was like they didn’t know what to do.
Porter was in the meeting when the decision was made, but in discussing it later, he “could not recall who was responsible for making the decision to allow Corral to assume the Chair.”
Obviously, the decision was the responsibility of Dave Wagner, the Vice President for Human Resources, He was in the meeting as the high man on the organizational chart. Referring to the fact that Carrol had sexually harassed students, Wagner later recalled that “it was difficult to determine if the conduct by Corral was unwelcomed.”
Maybe it’s true that the two students who accepted Corral’s dinner invitation welcomed the invitation. But it is hard to imagine that they wanted him to hit on them, or talk about being a “sex addict” or to “talk about doing it doggy style.” It is certain that they did not welcome that as dinner talk. The complaints from the students were well founded.
Years went on and it wasn’t resolved and just got worse. Corral would retaliate and the women would complain and there would be investigations and nothing would change. There was mediation and there were meetings with the Provost, Joe Sheley (the other No. 2 man on campus). Eventually, two of the professors who complained retired early, totally stressed out.
Why is this case still unsettled, even now in the Summer of 2011? It continues because of administrative incompetence.
The generous interpretation is that despite their positions, Sheley, Wagner and Porter just didn’t get it. They didn’t get that there was anything wrong or that these things just fester and don’t go away. Sheley later told the investigator that he “does not believe anyone at the University overlooked the issues or concerns with respect to Corral.” Perhaps not, but they didn't seem to understand what it was that they were looking at.
Wagner and Porter described the situation as an “intradepartmental policy dispute,” a “personal dispute,” and an “interpersonal issue.”
It had apparently become that. It became personal. The women were angry that their complaints had been ignored. They were in pain, it wouldn’t stop and there was some sporadic use of abusive language.
But that wasn’t the problem. The problem was that there had been no remedy for the retaliation. It was no longer about the original complaint regarding the harassment of students, now it was about the fact that Corral had gone on the attack against the women “who were just doing their jobs.”
Retaliation is illegal, and juries treat retaliation more seriously than even harassment and discrimination claims.
Jurors tend to have a hard time when someone says that they were mistreated because of their status or who they are. The jurors think: “they treated everybody badly, it wasn’t because she was a woman.” On the other hand, in retaliation cases, jurors naturally understand when someone says they were mistreated because they complained. Most people are cautious about complaining, they know what can happen. And juries know that it’s not right and that people shouldn’t be bullied.
The problem at Sac State is that the campus treated the problem like it was “failure to communicate.” They treated it like the women were the problem and that their complaints were about nothing more than the ordinary tribulations and minor annoyances that often take place at work and that all employees experience.
There is no general civility code for the American workplace. Skilled leadership and good judgment are required to to know when complaints are serious and how they should properly be handled. Sac State just didn’t get it, and the problem only got worse.
Eventually, the women sued, at a cost to the campus of at least a million dollars. The women got $900,000. The campus has defended that payment as having been made in good faith. The campus had to admit that the women deserved the money.
As for Corral, he’s what’s keeping it going now.
Eventually, after years trying to avoid the problem, the campus had to actually fire him. So now he’s suing the campus. You can just wait to hear his attorney say: “in all these years, the campus never did anything … they didn’t think he did anything wrong.”
Campus attorney Christine D. Lovely said in a hearing that he was fired for “immoral and unprofessional conduct,” which is exactly what the women complained about in 2005.
The problem at Sac State is that this is not an anomalous case. It’s not something out of the ordinary. There is a case to be made that at Sac State, complaints about abuse are routinely ignored and that the behavior is tolerated or effectively condoned. That is what seems to have happened in the case above and the generous interpretation is that it was the result of mismanagement and bad leadership.
In the past few years, the campus has had to settle other lawsuits that are eerily similar to this. They’ve settled with people who had the resources and the stamina to take the matter to Court. That’s public information. What is not public is how many people with valid complaints gave up. We also don’t know how many didn’t even bother to complain, knowing that nothing good would come of it?
There is a pattern here, or perhaps a few. If you read the cases, you can see in each one that with just a bit of good judgment and a bit of leadership courage, these matters could have been handled effectively at little or no cost. People wouldn’t have been troubled and the campus wouldn’t have done damage to itself.
What seems to be the problem?
Update: this case settled later in 2011. Corral dropped his complaint and retired, or something.
See: "When Leadership Fails" for an account of another, similar case at Sac State.
6/22/2011
When it comes to psychological health, management just doesn't get it.
When it comes to the psychological and mental health of workers, managers tend to think they are doing everything right. Employees would typically beg to differ.
That is the implication of a new study released by the Canadian Conference Board and reported in the Canadian press (see source note caveat below). The report title was: Building Mentally Healthy Workplaces.
I haven't read the full report,* but the data look good. They surveyed over a thousand people and did a fair number of in-depth interviews. They surveyed almost 500 executive managers and slightly more workers.
Here is the big finding: while 82% of managers said that their company "promotes" a psychologically healthy workplace, 70% of workers said they didn't.
It's a huge disconnect in perceptions, and it makes you wonder if management ever really "gets it."
Workers know when they are suffering from psychological health issues and they know what their organization did or did not do to help. Their perceptions can be trusted.
I have written before about studies showing that managers typically do not pay enough attention to the people they supervise. They are usually too busy paying attention to the people above them, those who can affect their careers. This study is consistent with that observation, and in addition, it says that the managers aren't even aware of the problem. They apparently think everything is OK and that things are being well-handled.
Karla Thorpe, the lead author on the project told the press that "managers are actually very confident in their skills and abilities to help employees ... they say they're very comfortable having conversations with their staff" about personal concerns and difficulties. Most of the employees interviewed thought the opposite. Most of them said that their supervisors don't know much about mental health issues or psychological difficulties. They don't talk to the workers and the workers are not comfortable talking to them.
For this study, "mental health issues" were broadly defined and included "ordinary" depression, stress and anxiety disorders. Some people surveyed had experienced significant mental illness. Whatever the case, it is certain that many of them were troubled because of workplace stress and that it was a productivity problem for most of them. When people are not healthy, they don't perform as well, even though it costs the same to employ them.
This is a fundamental issue with respect to organizational competence.
Organizations invest in human talent and can't afford to waste it. Ignoring the health of the worker goes right to the bottom line. In the workplace, psychological health is the big cost factor when it comes to safety and productivity. That is where the big money is lost or saved.
In Canada, just like in the U.S., the majority of those who can't work and have to take time off because of health concerns are taking time off on disability because of psychological problems. There are huge numbers of people who suffer work related psychological troubles in any given year.
Most managers believe that they are competently managing the well-being of their workers. Only 26% of workers would say that their supervisor "effectively manages mental health issues."
The importance and the cost to every organization is such that for a manager, this should be a fundamental competency, tending effectively to the human talent.
For the study's authors, the take away message is that an organization cannot afford to waste talent and that there are steps to be taken. There are various ways organizations should be proactive in reducing the stigma, preventing hostility and retaliation, and providing support.
The prescription is all good and sensible, but it doesn't go far enough.
Yes, people should be cared for effectively. Whether it is because of organizational values or just the bottom line concerns, companies have to assume some responsibility to help their workers.
It is not enough, however, to help them when they are troubled. You need to help them when they are well and to keep them psychologically healthy. At least half of the time, when a worker is becoming emotionally disabled it's about something that's going on at work. It could also be something that is happening at home because of something gone bad at work.
It's not about too much work or too many deadlines. It's about the things in the workplace that demoralize people and drain the satisfaction from work.
People suffer from work when they have complaints that no one will listen to or problems that no one will solve. It's when they say to themselves, "why won't someone take care of this?!" that they start to go mad. People lose faith in the organization when management doesn't solve things or take care of stuff. People start to wonder if things will change and why they are working there.
People cannot deal with stress when it doesn't seem worth it, and that's when it costs the organization.
The Canadian study supports the idea that a psychologically healthy workplace is good for business. This is well known. What they have identified, however, is something more. It's a fundamental flaw in the business or organizational model. What they have shown is that management does not understand the problem, and even worse, they don't know that they don't understand it. They don't know that they don't know what to do.
The report argues that organizations should do more to support workers who are hurt or harmed psychologically. I would argue that organizations should do more to keep them from harm.
*There is a hefty fee to read the 74 page report. This article is based on the press released summary from the Canadian business think tank.
That is the implication of a new study released by the Canadian Conference Board and reported in the Canadian press (see source note caveat below). The report title was: Building Mentally Healthy Workplaces.
I haven't read the full report,* but the data look good. They surveyed over a thousand people and did a fair number of in-depth interviews. They surveyed almost 500 executive managers and slightly more workers.
Here is the big finding: while 82% of managers said that their company "promotes" a psychologically healthy workplace, 70% of workers said they didn't.
It's a huge disconnect in perceptions, and it makes you wonder if management ever really "gets it."
Workers know when they are suffering from psychological health issues and they know what their organization did or did not do to help. Their perceptions can be trusted.
I have written before about studies showing that managers typically do not pay enough attention to the people they supervise. They are usually too busy paying attention to the people above them, those who can affect their careers. This study is consistent with that observation, and in addition, it says that the managers aren't even aware of the problem. They apparently think everything is OK and that things are being well-handled.
Karla Thorpe, the lead author on the project told the press that "managers are actually very confident in their skills and abilities to help employees ... they say they're very comfortable having conversations with their staff" about personal concerns and difficulties. Most of the employees interviewed thought the opposite. Most of them said that their supervisors don't know much about mental health issues or psychological difficulties. They don't talk to the workers and the workers are not comfortable talking to them.
For this study, "mental health issues" were broadly defined and included "ordinary" depression, stress and anxiety disorders. Some people surveyed had experienced significant mental illness. Whatever the case, it is certain that many of them were troubled because of workplace stress and that it was a productivity problem for most of them. When people are not healthy, they don't perform as well, even though it costs the same to employ them.
This is a fundamental issue with respect to organizational competence.
Organizations invest in human talent and can't afford to waste it. Ignoring the health of the worker goes right to the bottom line. In the workplace, psychological health is the big cost factor when it comes to safety and productivity. That is where the big money is lost or saved.
In Canada, just like in the U.S., the majority of those who can't work and have to take time off because of health concerns are taking time off on disability because of psychological problems. There are huge numbers of people who suffer work related psychological troubles in any given year.
Most managers believe that they are competently managing the well-being of their workers. Only 26% of workers would say that their supervisor "effectively manages mental health issues."
The importance and the cost to every organization is such that for a manager, this should be a fundamental competency, tending effectively to the human talent.
For the study's authors, the take away message is that an organization cannot afford to waste talent and that there are steps to be taken. There are various ways organizations should be proactive in reducing the stigma, preventing hostility and retaliation, and providing support.
The prescription is all good and sensible, but it doesn't go far enough.
Yes, people should be cared for effectively. Whether it is because of organizational values or just the bottom line concerns, companies have to assume some responsibility to help their workers.
It is not enough, however, to help them when they are troubled. You need to help them when they are well and to keep them psychologically healthy. At least half of the time, when a worker is becoming emotionally disabled it's about something that's going on at work. It could also be something that is happening at home because of something gone bad at work.
The critical action step to be taken by an effective manager in a competent organization is to make certain that workplace stress factors are properly managed and resolved.
It's not about too much work or too many deadlines. It's about the things in the workplace that demoralize people and drain the satisfaction from work.
People suffer from work when they have complaints that no one will listen to or problems that no one will solve. It's when they say to themselves, "why won't someone take care of this?!" that they start to go mad. People lose faith in the organization when management doesn't solve things or take care of stuff. People start to wonder if things will change and why they are working there.
People cannot deal with stress when it doesn't seem worth it, and that's when it costs the organization.
The Canadian study supports the idea that a psychologically healthy workplace is good for business. This is well known. What they have identified, however, is something more. It's a fundamental flaw in the business or organizational model. What they have shown is that management does not understand the problem, and even worse, they don't know that they don't understand it. They don't know that they don't know what to do.
The report argues that organizations should do more to support workers who are hurt or harmed psychologically. I would argue that organizations should do more to keep them from harm.
*There is a hefty fee to read the 74 page report. This article is based on the press released summary from the Canadian business think tank.
6/20/2011
The DSM: more like the Boy Scout Handbook than the Bible
The Diagnostic and Statistical Manual is being revised. Often described as the psychiatric bible, there are plans for the DSM to be released in a 5th Edition. It is a work in progress.
Naturally, people ask: "if it's like a bible, why would it need to be revised?" And then they wonder: "Am I suddenly going to be cured or suddenly declared mentally ill?"
Years ago, psychiatry declared that no one was neurotic anymore. For the DSM-5, they are planning to eliminate any reference to hysteria, which means they will finally get Freud completely out of the consulting room.
Do you tend to get angry and upset, more so than most people? Then you might soon be suffering from "temper dysregulation disorder." If your kid is troubled or disturbed, there will be a new label for that, something other than the catch-all phrase, "bipolar." If you lose interest in sex and can't get started, there is a diagnosis for that too.
People in the professions argue about whether and how the DSM should be revised.
There is a concern that if any changes are made, it will suggest that they didn't get the science correct the last time around. That uncertainty could cast doubt on the entire psychiatric enterprise. Psychiatry has gotten it wrong before, most famously when it classified homosexuality as a mental illness just waiting for a cure. This adding and deleting of disorders will be the part of the argument that will get the most attention in the press.
For psychiatry, there is no end of critics. For the field in general, there is no end to the "alternative theories." The alternative "paths" to health and understanding range from the plausible to the fantastic. The fear is that change could sow doubt and confusion.
There is also a concern about the fact that the DSM is meant to represent consensus judgment. In other words, it is being done "by committee." That would perhaps be OK if everyone agreed, like in the way that everyone agrees about the symptoms of a cold or a heart attack.
In the case of the DSM-5, there is deep disagreement at a number of levels, including at the level of basic measurement. Part of the argument has to do with whether or not we are looking at categories of disturbance (like pigeonholes) or dimensions of pathology, with each person's troubles being made up of different, individual elements.
The stakes in this process are high.
The last time the DSM was revised, the committee said that kids could catch bipolar too, just like adults. In response, there are now many more "bipolar" kids taking medications. All drugs that alter mood or mind have risks, and those risks can be hard to judge in the case of a growing brain and a developing mind.
Yes, some kids need medications. But medications have become too handy as the cure for everything. That is a risk factor in itself, especially when it results in a failure to also seek psychotherapy. No child on meds should be without a therapist, period.
Lurking in the background of the DSM revision process is the pharmaceutical industry. Markets may open or close for them. Messages may need to be changed. They do sell drugs, don't they? Suspicions about profit motives have already infected the debate about how we diagnose.
To those in the intellectual leadership of psychiatry, a branch of medicine, the stakes have to do with the very definition of mental life.
NIMH (the National Institute of Mental Health) is intent on defining everything mental, emotional, and behavioral as "clinical neuroscience," like a collection of circuits and chips in our brains. From the definition of human psychology, the goal is to remove thoughts and ideas, attitudes and perceptions, and learning and development. Actually, the goal is to explain the psychological in terms of the biological hardware.
This movement began in earnest in the 1990's, a period that was officially dubbed the "Decade of the Brain." Many believed that the focus on the brain was leading to a mindless psychiatry. That is perhaps the key problem presented for psychiatry in formulating a new diagnostic manual. There is absolutely no way to get the science of mental life correct if the first step is to eliminate reference to the mental. It's not just neuroscience. It's also psychology.
In considering the controversy surrounding the diagnostic changes, we really have to ask: what is the purpose of the manual?
There is in fact a need for complex, rigorous, narrow and detailed criteria for research purposes. But in clinical work, the goal of understanding and describing the individual is often better accomplished by broader categories, unique qualifiers and unique symptom descriptions. In clinical work, the ultimate objective is to arrive at a diagnostic formulation that fits the individual patient and that provides a way to plan for treatment. You want to understand and describe the person, not the pigeonhole.
In the end, I expect that the DSM-5 will be a useful guide. I think it will be like the Boy Scout Handbook.
It will not be written in stone and it will not tell you what do in every unique and specific situation. It will guide us through many diagnostic dilemmas and it will provide fundamental data about how those people have come to be troubled and how they are having difficulties in life.
One of the things I remember best from my Boy Scout Handbook was how to treat a snake bite. They wanted you to sterilize a knife, apply a tourniquet, cut open the victim and use the snake bite suction cup from your snake bite first aid kit to suck out the poisonous venom.
That advice has long since changed, and for good reason. It was like field surgery.
There is no reason that the DSM should not change as well.
Naturally, people ask: "if it's like a bible, why would it need to be revised?" And then they wonder: "Am I suddenly going to be cured or suddenly declared mentally ill?"
Years ago, psychiatry declared that no one was neurotic anymore. For the DSM-5, they are planning to eliminate any reference to hysteria, which means they will finally get Freud completely out of the consulting room.
Do you tend to get angry and upset, more so than most people? Then you might soon be suffering from "temper dysregulation disorder." If your kid is troubled or disturbed, there will be a new label for that, something other than the catch-all phrase, "bipolar." If you lose interest in sex and can't get started, there is a diagnosis for that too.
People in the professions argue about whether and how the DSM should be revised.
There is a concern that if any changes are made, it will suggest that they didn't get the science correct the last time around. That uncertainty could cast doubt on the entire psychiatric enterprise. Psychiatry has gotten it wrong before, most famously when it classified homosexuality as a mental illness just waiting for a cure. This adding and deleting of disorders will be the part of the argument that will get the most attention in the press.
For psychiatry, there is no end of critics. For the field in general, there is no end to the "alternative theories." The alternative "paths" to health and understanding range from the plausible to the fantastic. The fear is that change could sow doubt and confusion.
There is also a concern about the fact that the DSM is meant to represent consensus judgment. In other words, it is being done "by committee." That would perhaps be OK if everyone agreed, like in the way that everyone agrees about the symptoms of a cold or a heart attack.
In the case of the DSM-5, there is deep disagreement at a number of levels, including at the level of basic measurement. Part of the argument has to do with whether or not we are looking at categories of disturbance (like pigeonholes) or dimensions of pathology, with each person's troubles being made up of different, individual elements.
The stakes in this process are high.
The last time the DSM was revised, the committee said that kids could catch bipolar too, just like adults. In response, there are now many more "bipolar" kids taking medications. All drugs that alter mood or mind have risks, and those risks can be hard to judge in the case of a growing brain and a developing mind.
Yes, some kids need medications. But medications have become too handy as the cure for everything. That is a risk factor in itself, especially when it results in a failure to also seek psychotherapy. No child on meds should be without a therapist, period.
Lurking in the background of the DSM revision process is the pharmaceutical industry. Markets may open or close for them. Messages may need to be changed. They do sell drugs, don't they? Suspicions about profit motives have already infected the debate about how we diagnose.
To those in the intellectual leadership of psychiatry, a branch of medicine, the stakes have to do with the very definition of mental life.
NIMH (the National Institute of Mental Health) is intent on defining everything mental, emotional, and behavioral as "clinical neuroscience," like a collection of circuits and chips in our brains. From the definition of human psychology, the goal is to remove thoughts and ideas, attitudes and perceptions, and learning and development. Actually, the goal is to explain the psychological in terms of the biological hardware.
This movement began in earnest in the 1990's, a period that was officially dubbed the "Decade of the Brain." Many believed that the focus on the brain was leading to a mindless psychiatry. That is perhaps the key problem presented for psychiatry in formulating a new diagnostic manual. There is absolutely no way to get the science of mental life correct if the first step is to eliminate reference to the mental. It's not just neuroscience. It's also psychology.
In considering the controversy surrounding the diagnostic changes, we really have to ask: what is the purpose of the manual?
There is in fact a need for complex, rigorous, narrow and detailed criteria for research purposes. But in clinical work, the goal of understanding and describing the individual is often better accomplished by broader categories, unique qualifiers and unique symptom descriptions. In clinical work, the ultimate objective is to arrive at a diagnostic formulation that fits the individual patient and that provides a way to plan for treatment. You want to understand and describe the person, not the pigeonhole.
In the end, I expect that the DSM-5 will be a useful guide. I think it will be like the Boy Scout Handbook.
It will not be written in stone and it will not tell you what do in every unique and specific situation. It will guide us through many diagnostic dilemmas and it will provide fundamental data about how those people have come to be troubled and how they are having difficulties in life.
One of the things I remember best from my Boy Scout Handbook was how to treat a snake bite. They wanted you to sterilize a knife, apply a tourniquet, cut open the victim and use the snake bite suction cup from your snake bite first aid kit to suck out the poisonous venom.
That advice has long since changed, and for good reason. It was like field surgery.
There is no reason that the DSM should not change as well.
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