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SaraKay Smullens Headshot

A Conflicted, Fractured Mental Health System: What to Do?

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When I was in graduate school, I was taught by professors I deeply respected that the best way to understand psychic pain (and the human condition) was to study literature, the classics, theatre, art. I was also taught that to label people, rather than to understand how they got to be who they are, and why, and recognize the individuality and worth of every person, was disrespectful and hostile.

Yes, of course, when someone was very ill, we used the necessary categories to define psychosis and what used to be called "character disorder." But this was for the very ill or very dangerous.

I clearly remember my mentor, Eli Marcovitz, M.D., lecture that all people had some form of emotional difficulty, and that this was a matter of gradation. Dr Marcovitz quoted Maimoides: "The physician should not treat the disease, but the person who is suffering from it."

I also clearly remember the spellbinding lectures of my professor at the University of Pennsylvania School of Social Work, Richard Lodge, DSW. Dr. Lodge used characters from literature and the arts to help us understand how we are all molded by individual development, family dynamics, and the cultural institutions and the realities and opportunities of our individual places of birth.

In the past decades, however, there has been a growing belief that a strict medical model must replace this encompassing diagnostic approach. Yes, medicine has always and must always play an essential role in diagnosing and treating mental illness, but now there is the insistence that emotional disorders be explained through clearly identifiable biological, genetic, and neurological markers. And this is a rigid and potentially damaging approach... as well as an impossible one.

The American Psychiatric Association's published editions of the "Diagnostic and Statistical Manual of Mental Disorders" (known as the DSMs), a breakdown of symptoms and diagnoses, became a vehicle for this growing narrow perspective, as well as the vehicle for insurance reimbursements. However, as explained by National Institute of Mental Heath Director, Thomas R. Insel, "... unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure." (Philadelphia Inquirer, July 9, 2013, C2).

Therapists who see a patient as a whole person, and not a walking illness, can tell you horror stories caused by this approach. I have seen young people destroyed by parents who overmedicate them, calling them ill when they are understandably troubled because they have parents who cannot imagine life without their dependence on them. I have seen adult "children" convince physicians that their parents are ill and in need of drugs (when they surely are not) for their own financial gain. I have seen partners insist that their wives or husbands take unnecessary meds, and in this way control them, rather than work on their marital problems. And surely, try as they may, researchers will never find a gene for kindness, compassion, sincerity, or character.

Yes, meds are important. For instance, those that change the chemistry of the brain through use of serotonin can help one to feel better. But turning to this drug exclusively without talk therapy does not address what in an individual life may very likely be causing the depression. You have most likely read about vast amounts of money researching drugs to address female disinterest in sex with their partners. But important questions are overlooked by this approach: Did anything happen during formative years to make a woman fear sexual intimacy in a committed relationship? Is anything going on in a present relationship that must be addressed for sexual intimacy to be an ongoing part of life together?

Now the newly published DSM-5 has taken this growing "take a pill and fix it" approach to even more dangerous ends. Normal sadness after the loss of a beloved partner falls under the heading of clinical depression. (Isn't deep, persistent sadness following this kind of trauma a continued love letter to a beloved?) A high sex drive is now a hypersexual disorder. (Who, I would like to know, has the skill to measure how high is too high? Are emotional factors involved in this desire? If so, what are they?) Angry outbursts fall unto the category of an intermittent explosive disorder. (Who, I would also like to know, takes into account that certain ways one may be treated can lead to such explosions? Or in the words of my professor, Dr. Lodge, "Every house has a chimney, and people need them too!) Further, there is a dire lack of research on the impact of drugs readily prescribed for the long term. (Think of what research revealed about long term use of hormone replacement therapy.)

Allen Frances, professor emeritus of psychiatry at Duke University, the chair of the DSM-IV Task Force, takes "partial responsibility for diagnostic inflation" and the "shrinking realm of normal" (New York Times, Sunday, March 24, 2013, SR2). He explains:

(Diagnostic) decisions that seemed to make sense were exploited by drug companies in aggressive and misleading marketing campaigns. They sold the idea that problems of everyday living are really mental disorders, caused by a chemical imbalance and cured with a pill.

The new DSM inflates pathology, but inexplicably does not include Asperger's syndrome as an "autism spectrum disorder." This decision, like all decisions in this manual, will have enormous impact on all of our futures and the futures and well being of our families and loved ones. It will impact health care policy, grants, spending, drug use, research, educational systems, insurance company policies, as well as our court systems. Diagnosis and drug prescriptions will change, as will the understanding and appreciation of our own humanity and the humanity of others.

Dr. Frances urges a congressional investigation which insists "on a conversation about a diagnostic system that is far too loose, a drug industry that is far too unregulated and a mental health system that is badly broken." (New York Times, March 24, SR2) His words and direction are both wise and necessary.

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