Friday, March 2, 2012
Society for Humanistic Psychology holds national conference at Point Park University March 29-April 1
Point Park University will host the Society for Humanistic Psychology’s fifth annual conference in Pittsburgh March 29–April 1, 2012. “Person, Consciousness and Community” will bring together members of the Society, a division of the American Psychological Association, to discuss theoretical and practical applications of considering the person in the context of community. The public is invited to select panel discussions and events.
Early career psychologists and young faculty members and scholars are expected in record numbers, as the Society for Humanistic Psychology continues to see increasing interest from professionals early in their professions.
“Young practitioners are starting with a humanistic understanding of the person,” says Brent Dean Robbins, Ph.D., coordinator of Point Park University’s psychology program, and co-chair of the conference with Robert McInerney, Ph.D.
“There’s a ‘renaissance’ in humanistic and existential psychology going on, and the annual conference reflects this. There will be much youthful energy and new voices being heard as young professionals come and present their work.”
The conference’s keynote speakers will be:
Isaac Prilleltensky, Ph.D.
Constance Fischer, Ph.D.
Robert Stolorow, Ph.D.
A number of the symposiums and panel discussions will be open to the public, including these being held in the GRW Theatre on Point Park’s downtown Pittsburgh campus:
Drugging our Children: How Profiteers are Pushing Antipsychotics on our Youngest, and What We Can Do to Stop It (Thurs., March 29, 4 p.m.)
How and Why to Treat Patients Without Psychiatric Drugs (Fri., March 30, 10 a.m.)
The Legacy of R.D. Laing (Fri., March 30, 1 p.m.)
A Most Dangerous Manual: Division 32 Presidential Symposium (Fri., March 30, 5 p.m.)
Celebrating the Women of Humanistic Psychology (Sat., March 31, 9 a.m.)
Martin Luther King's Vision of the Beloved Community and Humanistic Psychology: Common Ground (Sat., March 31)
All sessions emphasize the theme of community and the importance of healing relationships in the lives of individuals and in therapeutic environments.
“The emphasis on community is a natural extension of humanistic psychology because of its strength-based, prevention-focused emphasis on the well-being and thriving of persons,” says Robbins.
The Point Park psychology professor co-authored the Society for Humanistic Psychology’s open letter about proposed revisions to the “bible” of American psychiatry, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. The letter and online petition outlines concerns that the revisions could result in an increasing number of individuals being labeled as having mental health disorders, and given powerful psychiatric drugs, for behaviors that are within normal ranges. The proposed revisions are the subject of A Most Dangerous Manual: Division http://www.blogger.com/img/blank.gif32 Presidential Symposium during the conference.
A select number of students in Point Park University’s psychology program and Confluence Psychology Alliance will present posters at the conference.
The complete schedule for “Person, Consciousness and Community” is available on the conference website. For more information, email Brent Dean Robbins or Robert McInerney.
Saturday, February 18, 2012
Allen J. Frances, M.D. at Psychology Today reports:
The storm of opposition to DSM 5 is now focused on its silly and unnecessary proposal to medicalize grief. DSM 5 would encourage the diagnosis of 'Major Depressive Disorder' almost immediately after the loss of a loved one- having just 2 weeks of sadness and loss of interest along with reduced appetite, sleep, and energy would earn the MDD label (and all too often an unnecessary and potentially harmful pill treatment). This makes no sense. To paraphrase Voltaire, normal grief is not 'Major', is not 'Depressive,' and is not 'Disorder.' Grief is the normal and necessary human reaction to love and loss, not some phony disease.
All this seems perfectly clear to just about everyone in the world except the small group of people working on DSM 5. The press is now filled with scores of shocked articles stimulated by two damning editorial pieces in the Lancet and a recent prominent article in the New York Times.
The role of public defender of DSM 5 has fallen on John Oldham MD, president of the American Psychiatric Association, and a good friend of mine for 45 years. John is a smart and good person placed by the unkind fates in the unenviable position of having to defend untenable DSM 5 decisions. He makes a soldierly attempt- but his arguments ring hollow and are tone deaf to the dangers of the DSM 5 proposal and all the obvious reasons it has met such universal scorn. I wish it were someone else on the other side of this question, but there is no alternative but to show the four ways in which Dr Oldham's arguments badly miss the point.
Dr. Oldham defense can be accessed at: (http://www.medscape.com/viewarticle/758788)
1)"When we say that we are recommending removing this exclusion of grief from the diagnosis of depression, people have misinterpreted this to mean that therefore everyone who is grieving after the loss of a spouse will be diagnosed as depressed. That is not at all the case. Even if you meet the criteria for depression, it doesn't mean that you're going to have treatment slapped on you. It just means that maybe you'd have a conversation about it with your doctor and perhaps agree to a watchful waiting period and be alert to how things go and maybe check in a little more frequently. Nothing is automatic; there are lots of options."
Annotation: Nothing could betray more clearly the ivory tower world view that consistently leads DSM 5 astray. In the real world, most diagnosis of mental disorder and most prescription of medicine is done by primary care doctors- who have little training in psychiatric diagnosis, spend fewer than 10 minutes with each patient, and are often influenced by drug company marketing. There is no way that even the most skilled psychiatrist can distinguish normal grieving from mild depression- we must not expect primary care doctors to do it. Watchful waiting is wonderful- but all too rare. Drug companies will jump greedily into this vast new market. This is not at all APA's intent, but it is a dreadful unintended consequence that must be (but hasn't been) factored into a complete risk/benefit analysis.
2) Dr Oldham notes that the DSM IV bereavement exclusion is "very limited; it only applies to a death of a spouse or a loved one. Why is that different from a very strong reaction after you have had your entire home and possessions wiped out by a tsunami, or earthquake, or tornado; or what if you are in financial trouble, or laid off from work out of the blue? In any of these situations, the exclusion doesn't apply. What we know is that any major stress can activate significant depression in people who are at risk for it. It doesn't make sense to differentiate the loss of a loved one as understandable grief from equally severe stress and sadness after other kinds of loss."
Annotation: Yes indeed. 'Major Depressive Disorder' is currently applied carelessly and inappropriately to the expectable reactions people also have to others of life's severe stresses- divorce, loss of job, financial difficulties, etc. This is precisely why studies so often show no advantage for medication over placebo in the treatment of depression- many of the people studied aren't really depressed. There is an obvious opposite solution that would correct this and also achieve the consistency Dr Oldham seeks. DSM 5 shouldn't broaden MDD to include grief- rather it should narrow MDD to cover only real depressions. Consistency and more accurate diagnosis can be achieved by raising the severity and duration requirements for 'Major Depressive Disorder' whenever symptoms occur in the context of a powerful stressor.
3)"We want people to get treatment who need it."
Annotation: They already do. DSM IV is completely explicit that the MDD diagnosis should be made whenever grief has clearly turned into depression- ie when the bereaved becomes suicidal, or psychotic, or has severely impairing symptoms, or has had similar depressive episodes before. DSM IV aint broke on this, making the DSM 5 fix even more nonsensical.
4) Dr Oldham says this was not a snap decision. "There was a lot of very thoughtful discussion about it. Nobody saw it as just clear as it could be. It was not an immediately agreed upon consensus. This is something that is sensitive and needs to be thought about carefully, and we recognize that"
Annotation: The DSM 5 decision making process is puzzling and opaque in the extreme. A small group of otherwise very smart people make a decision that solves no outstanding problem, is based on no credible scientific literature, arouses remarkably strong opposition among mental health and medical professionals, creates a frenzy of press scorn, and seems crazy and insulting to the community of grievers. The consensus that needed achieving was not within the narrow confines of a few die hard DSM 5 enthusiasts. DSM 5 is a document with wide public health and public policy implications. It must represent a consensus of the literature and of the field. Instead, it is now DSM 5 against the world. This is no way to develop the consensus needed in an official diagnostic system.
The interesting but very sad thing is that Dr Oldham leaves absolutely no running room for DSM 5. He could have said something like: "This change is still being studied. It is still just a draft proposal and we are very grateful for all the input which will certainly go into the final decision." Instead, he paints himself into a tiny corner, stalwartly defending the indefensible.
This is clear writing on the wall that the DSM 5 decisions on many other equally reckless proposals are also written in stone. If DSM 5 won't back down in the face of this extraordinary pressure on grief, it is probably dug in on many of its other controversial and harmful proposals. My previous lingering hope that external opposition might lead to useful compromises was naively predicated on the overly optimistic assumption that the American Psychiatric Association would follow the rational path, cut its losses, and reject the worst DSM 5 suggestions. Instead, it is APA to the barricades.
So where do we stand? Most likely scenario: The press will increasingly pick DSM 5 apart and expose all of its considerable risks. APA will keep missing the point, continue to provide lame defenses, and follow its blind momentum forward to a premature publication date. A lamentably poor quality and terribly risky DSM 5 will be published. DSM 5 will be roundly rejected outside the United States and will have greatly diminished sales (and hopefully influence) within. But the drug companies will aggressively promote its suggestions to swell further the already swollen sales of antipsychotic, stimulant, antidepressant, and anti-anxiety drugs. The epidemic of childhood obesity will get worse; the illegal market in stimulants will flourish; polypharmacy will increase; and the severely ill will continue to get short shrift- and all sorts of other harmful unintended consequences will also flourish.
Up until this point, I had hoped DSM 5 could save itself if only enough pressure were applied to make it see the light. This no longer seems likely and government intervention is probably the last (and possibly the only) resort.
Friday, January 27, 2012
Allen Frances at Psychology Today reports:
A front page story by Ben Carey in January 24th's New York Times carries the poetic title: 'When does a broken heart become a diagnosis?' It describes a puzzling proposal by D.S.M. 5 to transform what is now considered normal grief into Major Depressive Disorder.
D.S.M. IV already recognizes that some people respond to loss with severe problems that warrant immediate attention. It therefore encourages the diagnosis of major depression whenever bereavement is persistent or is associated with severe, impairing, delusional, or suicidal symptoms. D.S.M. IV thus makes a crucial distinction between the transient pain of expectable grief and the severe and/or persistent symptoms of major depression. D.S.M. 5 proposes to eliminate this distinction. It would allow the diagnosis of major depressive disorder after only two weeks of fairly mild symptoms.
The point of departure of the Times article is a landmark review co-authored by Jerome Wakefield and just published in World Psychiatry, the official journal of the World Psychiatric Association. An accompanying editorial written by Professor Mario Maj (president of the Association) also strongly opposes the D.S.M. 5 proposal.
I asked Dr. Wakefield to summarize the findings of his review. His reply:
1)There is no scientific evidence to support diagnosing as major depression two weeks of grief-related depressive feelings of the kind currently excluded from diagnosis. The D.S.M. 5 literature reviews cite dozens of studies, but NOT ONE has samples of people who would get the diagnosis under the new D.S.M. 5 rules.
2) The two most rigorous studies both show that people experiencing short periods of mild grief (of the kind excluded by D.S.M. IV from the diagnosis of major depression) are no more likely to go on to further diagnosable depression than are people in the general population -- whereas real depression has a high rate of recurrence. This directly contradicts the D.S.M.-5 assertion that there is 'no difference... between grief-related depression and any other depression.'
3)There is no evidence that normal grief-related depressive feelings (of the kind now excluded from diagnosis) are associated with a greater risk for suicide.
4) Contrary to D.S.M.-5 claims that potential treatment benefits justify its proposed change, there are no controlled studies demonstrating any drug benefit for expectable grief symptoms of the kind now excluded. The D.S.M. 5 proposal could result in the over-medication of millions of the bereaved -- even though antidepressants are already under challenge as no more effective than placebo for milder depressions.
Dr. Wakefield goes on to point out that:
An estimated 8 to 10 million people lose a loved one every year, and something like a third to a half of them suffer depressive symptoms for up to month afterward. The proposed change would pathologize them for behavior previously thought to be normal. Until now, bereavement is one area that has been immune to the excessive encroachment of psychiatric diagnosis. This is because studies show that many depressive symptoms are common during normal grief, and it is obvious from common experience that grief after loss of a loved one can be very intense and involve depressive symptoms even when it is entirely normal.
I also asked Russell Friedman, Executive Director of the Grief Recovery Institute, to put a human face on the issue: "Imagine that your spouse of 52 years has just died. In the weeks that follow, you experience some or all of the typical reactions to this overwhelming loss. You are sad and lose interest in things. You find it hard to focus or concentrate. Your sleeping patterns are off. Your eating habits are out of whack. If you do manage to sleep, you wake up exhausted, not rested at all, and lacking energy. Your well-meaning daughter brings you to the doctor. You tell him what's going on and he quickly slaps on a diagnoses of Major Depression and prescribes pills. Drug companies will have a feeding frenzy exploiting this huge new market. They will spend hundreds of millions of dollars 'educating' doctors and the public on the D.S.M. 5 revelation that grief is a psychiatric illness. This is madness."
This is a classic case of 'if it aint broke, don't fix it' -- especially if the fix will cause many new problems. D.S.M. IV usefully distinguishes the mild, transient, and self-correcting symptoms of normal grief in contrast to the severe and persistent symptoms of clinical depression. Grief is the normal and absolutely unavoidable price we must pay for having the capacity to love -- it is most certainly not a disease. There is no reason and much risk in turning expectable grief into diagnosable mental disorder. D.S.M. 5 would cheapen the dignity of grief; substitute an impersonal medical procedure for traditional, deeply embedded cultural rituals; and result in much careless and unnecessary use of medication.
The D.S.M. 5 proposal to medicalize grief has always seemed strangely incongruous just on the face of it. Most people not hermetically sealed within the D.S.M. 5 inner sanctum immediately recognize how ridiculous it is to apply the label 'major depression' to someone after just two weeks of perfectly normal symptoms of bereavement. Hopefully, Dr. Wakefield's careful review bringing data and common sense to the issue will penetrate the D.S.M. 5 denial of the obvious. We must preserve the dignity of bereavement and protect it from the inappropriate encroachment of D.S.M. 5 diagnostic ambitions.
Tuesday, January 24, 2012
Allen Frances at Psychology Today reports:
Elizabeth Lopatto has written an excellent piece in today's Bloomberg News summarizing concerns that DSM 5 will expand the boundaries of psychiatry, increase the already existing diagnostic inflation, and promote the excessive use of medications to treat life problems that don't really require them.
The Vice Chair of the DSM 5 Task Force tries to defend DSM 5 but with statements that have a strange Alice-in-Wonderland out-of-touch-with-reality quality.
Quote 1: "The idea of medicalising normality comes from a perspective
that there are no psychiatric disorders, and you need to avoid
stigmatizing people by giving them one."
Response 1: Wow. This argument implies that all of the criticism that has been specifically directed at DSM 5 must be really be based on a more general bias against psychiatry and against diagnosis. Where does this straw man come from and how can it possibly apply to me- a very concerned critic of DSM 5, but a determined defender of psychiatry when it is done well and with respect for the appropriate uses of psychiatric diagnosis and treatment. The DSM 5 proposals are criticized (by me and many others) because they are poorly conceived, poorly written, unsupported by convincing evidence, and likely to have dangerous unintended consequences. The point is that DSM 5 would expand psychiatry beyond its competence (treating clearcut, more severe psychiatric disorders) by focusing attention instead on milder conditions for which diagnosis and treatment will often do more harm than good- and waste much needed mental health resources.
Quote 2: “Our intent is not to increase or decrease prevalence, but to make
something that is more accurate and scientifically based.”
Response 2: This is a strange claim. The petition to reform DSM 5 (endorsed by 45 mental health organizations) was made necessary precisely because the science supporting the DSM 5 proposals is so very weak and incomplete. The future users of DSM 5 have made the completely reasonable request that there now be a more rigorous scientific review of its proposals, done independently from APA, and using the widely accepted methods of evidence based medicine. Moreover, it was a serious error of the DSM 5 field trials not even to attempt to measure the impact of its proposals on prevalence rates, when this will have such a dramatic effect on individual and public health (see my immediately preceding blogs).
Quote 3: "The revision should be 'a living document'... That’s so we can convene expert panels more frequently in the future.”
Response 3: A previous quote along the same lines was even more alarming- that DSM 5 is a admittedly a set of insufficiently tested hypothesis, but can always be teshttp://www.blogger.com/img/blank.gifted later after DSM 5 is published. No. No. No. DSM 5 is an official nomenclature that will affect people's lives now- not a document to set an agenda for future research. DSM 5 should be a public trust, not a public health experiment. Everything in it must be safe and scientifically sound. And given this experience, having APa convene expert panels doesn't seem like such a great idea.
Bottom line- DSM 5 needs to drop its controversial proposals or have them subjected to a thorough and independent review; it needs to be much more carefully written; and it must be field tested again to determine if it can achieve adequate reliability and what will be its impact on prevalence.
Anything less will lead to a careless and potentially quite harmful DSM 5.
FULL ARTICLE HERE.
Monday, January 23, 2012
Allen Frances at Psychology Today reports:
My biggest concern regarding DSM 5 is that it will dramatically increase the rates of mental disorder and cheapen the currency of psychiatric diagnosis. The DSM 5 proposals do this two ways: 1) by reducing thresholds for existing disorders; and, 2) by introducing new high prevalence disorders at the boundary with normality. Unless corrected, DSM 5 may create millions of newly mislabeled 'patients,' with resulting unnecessary and potentially harmful treatment, stigma, and wasteful misallocation of scarce resources.
In a recent commentary in the American Journal of Psychiatry, the DSM 5 leadership defend their opposite position. They admit that they are indifferent to the manual's impact on rates and justify this on the grounds that no one knows for sure what the true or optimal rates should be. In an earlier blog, I chided the Task Force fohttp://www.blogger.com/img/blank.gifr ignoring the real world harmful unintended consequences that will follow the dramatic increase in prevalence rates caused by their untested and risky proposals.
The Task Force has come back with the following Q and A which popped up at the APA website, apparently in response to my warnings about diagnostic inflation. You can find it at:
"Q: Was prevalence estimated in the DSM-5 Field Trials?
A: The prevalence of every target diagnosis evaluated in the field trial was estimated.
Q: Will the prevalence of DSM-5 disorders be very much higher than the
prevalence of DSM-IV disorders?
A: In general, the prevalence rates of the diagnoses evaluated in the Field
Trials are slightly lower than DSM-IV prevalence rates."
The wording is remarkably misleading. Note that the DSM IV rates in the field trial were "estimated" by chart review, but that the DSM 5 rates were ""evaluated" by systematic interview. This results in a totally meaningless comparison of apples and oranges. The DSM IV and DSM 5 rates should have been systematically compared (as is customary) using common data gathered in the field trial diagnostic interviews. This is absolutely standard research operating procedure- always compare apples to apples, don't switch assessment methods. It is beyond understanding why this simple step was omitted in the DSM 5 field trials and why chart diagnosis is offered now as a lame substitute.
The Q/A prediction that DSM 5 prevalence rates will be lower than DSM IV is wrong, impossible, even laughable. It is obvious that most changes suggested for DSM 5 will increase prevalence rates above those in DSM IV, often quite dramatically. And most clearly, this is the case for the new diagnoses whose high rates could not possibly be estimated given the limitations of the field trials. The DSM 5 team should most certainly know better than to claim that DSM 5 won't raise prevalences. I am not sure which of the two possible interpretations is worse- that they are being deliberately misleading or that they are terminally self deluded. Either way, the failure to measure prevalences in the field trial is an unaccountable error and the failure to reckon the risky consequences of DSM 5 proposals is just plain reckless.
As I first pointed out before the DSM 5 field trials began, the proper design should have included:
1) For existing disorders- Ratings of DSM IV, ICD 10, and DSM 5 criteria items to allow comparison of rates across the three systems.
2) For new disorders- sampling their likely rates in general psychiatric settings, in primary care, and (by telephone) in the general population.
The academic centers that were selected for DSM 5 field testing are ivory towers that don't generalize well to the real world. Indeed, most psychiatric diagnosihttp://www.blogger.com/img/blank.gifs and medication treatment is now done by primary care doctors and the impact of DSM 5 must be tested where it will most be used.
The whole purpose of field testing is to identify and correct problems in preliminary DSM suggestions before they are set in stone as official guides to diagnostic practice. The design of DSM 5 field trial unaccountably left out the most important question (its impact in rates) and the most important settings (routine clinical practice). The DSM 5 leadership now provides a fudged, incorrect, and belated reply to the risks of diagnostic inflation- don't worry, trust us, it won't happen. This is nonsense- diagnostic inflation will most certainly happen unless DSM 5 is corrected before publication. Such willful blindness is a sure prescription for bad surprises and serious unintended consequences.