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Maui 2008 178

One of the sticking points with some folks in AA is the step that says you will surrender to a power greater than yourself. Surrender is not the American way, or maybe more accurately, not the Protestant work ethic way. You must give 110% even though that is not really possible. For example in running, you bonk before your glycogen levels fully deplete. Your brain takes care of you by telling you to take it easy. Think of what happens to the motherboard on your computer when you overclock the processor to increase power. You overheat and fry it. And yet, if we don’t succeed we are encouraged to keep trying to the point of attempting to get out of a hole by continuing to dig. I think of it as a Vietnam syndrome – just keep sending troops and keep bombing and victory will inevitably come. Somehow we didn’t learn much from that experience.

In Chinese philosophy there is the concept of wu wei or nonaction, trying not to try, or effortless effort. A similar state in western psychology is the flow state described by Mihály Csíkszentmihályi. It is when you are in the zone. You cannot force yourself into flow or wu wei, you have to let go – surrender – and just be with it. When you become aware you are in that state, you are out of the moment and you lose it.

We have known for a long time that outcomes for people diagnosed as mentally ill have better outcomes in third world countries than in the west. People are treated differently in the “less advanced” cultures. In the west, we also put labels on people and then try to force them to behave in what we consider socially appropriate ways. For over 50 years the work of Brown, Birley, Vaughan, Leff, Wing and others found that the expressed emotion in families was a primary causative factor in rehospitalization in psychiatric facilities. Behaviors that got on family members’ nerves were more likely to cause trouble than the psychiatric symptoms. I came across their research in the late 1970s while working on a rehospitalization factors study at a state hospital. Expressed emotion was not touted as a factor in causing mental illness – no schizophrenogenic mother theory. It was just that when someone is criticized in certain ways, even when caring and concern are at the heart – sometimes feeling judged and pushed does not lead to the outcomes that are desired by the one expressing concern. And that is true regardless of whether one is ill or not.

In the recovery movement, the shift is to treat people with dignity and respect. Ezra E. H. Griffith has edited a comprehensive book that covers issues like involuntary commitment. It is called Ethics Challenges in Forensic Psychiatry and Psychology Practice. It is an excellent read addressing all the variables we face in social control when we treat people with psychological problems differently than those with physical problems, for example, diabetes.

It also got me to wondering about how wu wei might come into being when treating those considered chronically and seriously mentally ill. The July 1, 2016 Invisibilia episode has an intriguing take. You can listen to it here. It is called The Problem With the Solution. It starts with an American dream kind of product invention, and then looks at solutions in mental illness. It reminded me of Scott Miller saying that once something is defined as a problem, it gets worse. Could a reframing, a surrender into acceptance, be one solution? The podcast looks at the story of Ellen Baxter and her search for understanding with her family. That search took her to college and to Geel, Belgium, where people diagnosed with mental illness live with foster families who accept them for who they are and have no idea of the person’s diagnosis. Does Geel, Belgium have a humane, kind and respectful solution? Baxter began a project in New York called the Broadway Housing Project. It is not only humane, it is also cost effective. Also mentioned is Jackie Goldstein and Voices of Hope. You can read more about Jackie Goldstein and Voices of Hope here. Be sure to listen to the bonus story of William Kitt at Invisibilia. Information about the Broadway Housing Project and Ellen Baxter is at http://www.broadwayhousing.org/. There is also this 1993 New York Times article – https://www.nytimes.com/1993/12/19/magazine/ellen-baxter.html.

The title is the second line of the Tao Te Ching.  To make sense of the world, we attach names to everything, and sometimes think the name and the thing are the same thing. But a word is just a sound we agree on as a representation of something, and no two of us experience that something exactly the same way. My notion of the color blue or experience of an apple is different than yours.

In behavioral health, diagnosis is a driving force. Some folks find putting a name to a behavior helps very much. For others, it does not help and may even hinder change, particularly when that name says that one is diseased and will never get better.  At times, the person becomes the name. The medical model in the past has functioned that way, and in an ironic way has actually increased stigma while seeking to lessen it. (see Models of Madness, edited by Read, Mosher, and Bentall)

In about ten days, the DSM 5 will be released.  NIMH has decided not to use it. There has been ongoing controversy about how it was put together.  Salon has a pretty good article about this at http://www.salon.com/2013/05/05/the_book_of_woe_psychiatrys_last_stand/.

When it comes to diagnosis in behavioral health, the United States goes its own way, just as it has done with measurements.  The rest of the world is metric, while we stick to the old standard system.  The rest of the world uses the ICD 10, while we are using the DSM IV TR for now. The US is scheduled to change over to the ICD 10 in a couple of years. Unless of course it is postponed again. We will see. After all, we were supposed to convert to the metric system decades ago.  For a short time, even highway signs displayed both miles and kilometers. No more.

This afternoon I got to participate in my first field trial for the World Health Organization in its beta work on the ICD 11.  I was given a list of diagnoses with the diagnostic criteria for each one – diagnoses covering areas such as PTSD, grief, stress reactions – and then given two case studies to diagnosis. I was then asked about my diagnosis and the criteria I used, severity of symptoms, and how confident I was of the diagnosis.  I found the criteria to be more descriptive and straight forward than the DSM. I have been using the DSM since the original version III and have never particularly been comfortable with it in terms of its practical use, other than you have to diagnosis in order to bill. And you need to be extremely careful of what diagnostic label you give to someone because it will most likely follow them for the rest of their lives with various consequences along the way. I wish that were emphasized in graduate schools and treatment programs more. Give the least pathological diagnosis possible.

The feel I got from the initial study was that the at least in what I read, there is less of a pathology orientation and more of a descriptive approach. I hope that stays the case. I am looking forward to the next trial.

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