Tag Archives: diagnosis

Innocent Dangers: Simply Asking the Questions

This blog was originally posted on August 29, 2013 on the New Existentialist Blog. It was reposted here after the New Existentialist Blog was dicontinued.

“Has your child been evaluated for ADHD?”

Many variations of this seemingly innocent question often serve as the beginning of a dangerous progression. Quite often, teachers, childcare workers, and even physicians untrained in understanding and diagnosing Attention Deficit Hyperactivity Disorder (ADHD) ask this question to parents. However, frequently this question serves as more than medium to obtain information from parents, even if that is the intent of the question.

As a clinical psychologist, I have worked with children in group home settings, hospital settings, and private practice. Many children and young adults I worked with said they had been diagnosed with ADHD and placed on medication for it. Early in my career, I generally assumed that they had been evaluated by a mental health professional if they said that they had a disorder and were placed on medication. As I listened to more and more treatment histories of these individuals, I began to realize this frequently was not the case. I learned the importance of asking very specific questions about their histories:

  • “Who first diagnosed you or suggested the diagnosis?”
  • “Was the diagnosis made by a mental health professional? (If yes) What were the person’s credentials?”
  • “Who prescribed the medications? Was it a psychiatrist or a general practitioner?”
  • “Have you ever had a second opinion about the diagnosis?

Frequently, the journey to being prescribed medication for ADHD began with a teacher or another individual with no training or qualifications to make a diagnosis of ADHD. Furthermore, it was quite common that the path from the original suggestion for an evaluation to the end result of medication never included a visit to a mental health professional. While the teacher or childcare worker may not have technically made the diagnosis, their impact on the process— even if unintentional—essentially served the role of causing the diagnosis.

Photo by Louis Hoffman, PhD

The Innocence

While it would be easily to vilify this process, I do not want to do that. Rather, I would like to highlight the many systemic problems that make it easy for people with good intentions to contribute to a cycle of overdiagnosing and overmedicating our children.

For teachers and childcare workers, they often are working with a large number of children with fewer and fewer resources. They are under pressure from the school to meet certain standards. Parents are often rather intolerant of their children’s peers when they cause disruptions and respond by placing more pressure on teachers to keep things under control. To complicate matters, teachers remain poorly paid and under resourced while given increasing roles, responsibilities, and expectations. It is not easy to be a teacher.

The educational and mental health systems are failing teachers and children as well. Teachers are not being provided with adequate resources and training to address the issues children and teenagers are facing. Many factors such as poor diet (often resulting from poverty), overuse of technology and television, and family problems can contribute to behaviors that give the appearance of ADHD symptoms. Furthermore, these difficulties, even when assembled in a manner that fits the criteria of ADHD according to the DSM5, are often treatable by approaches other than medication.

Yet, teachers and childcare workers are not provided with the more balanced perspective regarding ADHD. In the meantime, they are flooded with materials steeped in the bias of the medical model and advocating for medication as one of the first options for working with attention or behavior problems in children.

Let me conclude this section by returning to the “innocent” aspect of the question. I believe most teachers and childcare workers who ask, “Has your child ever been evaluated for ADHD?” are asking this question with good intentions. They want to maintain a classroom where they are able to focus on their primary responsibility: teaching children. Furthermore, they are not necessarily suggesting that the child be placed on medication. Yet, too often, parents will interpret the suggestion of an evaluation as a suggestion that their child has ADHD. Too often, teachers may not recognize the power or implications of a seemingly innocent question.

There are teachers and childcare workers who do make the suggestions of a diagnosis or encourage parents to consider medication. When this occurs, it is not so innocent, but rather acting in an unprofessional manner by making recommendations outside of one’s expertise. This requires a stronger response. However, I believe this is more the exception than the norm.

DSM5 and the Perfect Storm

The overuse of medication in the treatment of childhood difficulties has already risen to a level that is terrifying and likely to have a significant long-term impact upon our country. Despite an increasing amount of concern being voiced about the overdiagnosis of ADHD and overmedication of children, the pattern continues.

The DSM5 has now lowered the diagnostic threshold for diagnosing children with ADHD. The stated reason for this is that it will increase access to treatment. While this may be true in a few cases, it is much more likely to more dramatically increase the number of children taking medication when this is not the best option.

Many parents are not given and have trouble accessing and understanding resources to help them become responsible, informed consumers of mental health services and products. These resources need to be readily available, balanced, and written in an accessible language. Furthermore, the teachers and childcare workers who are viewed by many parents as important sources of information about their children’s well-being are not adequately trained and prepared relevant to these issues. Individuals who work with children and parents, and who provide advice to parents, need to be trained regarding the limits of their competency, the potential impact and implications of their seemingly innocent questions or comments, and how to respond to parents in a way that encourages them to seek out balanced, accessible information about their child’s behavior, health, and mental health.

Conclusion

Children are entering into a complex, quickly changing world that is hard for children and their parents to comprehend. In this complex cultural system, many terrifying trends are emerging. Many in existential and humanistic psychology are providing strong leadership in promoting greater awareness about these complex issues. It is important that we do not create unnecessary divide in our response. While certainly there are many who are acting in an irresponsible, and at times, reprehensible manner, there are many who are contributing to the problem without an awareness of the issues or any bad intentions. Providing resources and education to these individuals, especially when they are in roles that influence people making decisions about the lives of children, is an essential component of how we need to be responding to these issues.

~ Louis Hoffman

Reflections from the Protest at the American Psychiatric Association Convention: Existential Psychology in Action

This blog was originally posted on June 7, 2013 on the New Existentialist Blog. It was reposted here after the New Existentialist Blog was discontinued.

A few Sundays ago, I attended a protest at the American Psychiatric Association Convention in San Francisco with my Saybrook colleagues, Kirk Schneider, Kristopher Lichtanski, and Shawn Rubin. We attended because of our concerns about Diagnostic and Statistical Manual of Mental
Disorders (DSM5) due to be published next month. Despite numerous strong critiques of this new manual that have been coming from mental health professionals, this book has already been on bestseller lists based on preorders. Saybrook University and the Society for Humanistic Psychology have been among the leaders in voicing critiques of this manual. However, the critiques are quite widespread.

An Honorable Process

I have been proud of humanistic and existential psychology’s leadership in responding to the DSM5. Often, humanistic and existential psychology are seen as a movement of rebels, and occasionally, we get portrayed as radicals. While there is some truth to this (I think it is more accurate to say we tend to be a passionate group as opposed to extremist), it is hardly an accurate portrayal of the broader fields of humanistic and existential psychology. In regard to the DSM5, humanistic psychology has brought forth a balanced critique rooted in scholarship, philosophy, research, and ethical sensitivity. In the initial thrust of voicing our concern, we focused on developing strong critiques while asking for dialogue and an external review.

It would have been easy to take a more radical approach, and other groups have done this. However, our willingness to take a balanced approach has brought about credibility. Recently, I had two interviews about the DSM5 and the concerns about this manual. In one, it seemed evident that the reporter was frustrated that I would not provide anything “juicier.” While sensationalism may draw more attention, it does not bring with it credibility.

Personally, I am glad that other groups are also drawing attention to the DSM5, and I hope that this leads to a much larger conversation about these concerns. As this occurs, I hope humanistic and existential psychology can remain a balanced, credible voice rooted in good scholarship and clinical wisdom.

The Heart of the Concern

There are many places where readers can find a more in depth discussion of the concerns about
the DSM5, so I will not review all of them in this article. Instead, I would direct readers to the
following resources:

  • The Global Summit on Diagnostic Alternatives: An Online Platform for Rethinking Mental Health (http://dxsummit.org)
  • The Coalition for DSM5 Reform (http://dsm5reform.com)

However, let me briefly highlight some major concerns:

Science: Many of the new diagnostic categories have been criticized for being based upon questionable reliability by the DSM’s own standards. Thus, even from within its own epistemological framework, the DSM5 has significant weaknesses.

Peer Review: While the DSM5, during in its development, proposed that it was an open process and receptive to feedback, the evidence does not support this. The Society for Humanistic Psychology’s open letterturnedpetition gained nearly 15,000 signatures and was endorsed by many major mental health organizations around the world. In this letter, there was a call for dialogue and an external review. This was denied. The American Psychiatric Association demonstrated that it was not open to conversation or alternative perspectives even when there was a strong voice of concerns by many mental health colleagues and leaders in the field. The DSM5’s alleged attempts to be open failed as they went around a more thorough and objective peer review process.

Ethical: The DSM5 is lowering many diagnostic thresholds, which will drastically increase the number of people with a diagnosis. As medication continues to be advertised and purported as the first line of treatment, this means many more people will be stigmatized and then placed on medications that have sometimes serious and unknown long-term side effects (they are not old enough to really know the long-term effects) despite safer alternatives.

Economic: There are at least two serious economic concerns with strong implications. First, there exists a serious conflict of interest in that well over half of individuals serving on the DSM committees were also on the payrolls of pharmaceutical companies. Second, while it is touted that the lowered diagnostic thresholds will help with access to mental health, I am not convinced. The insurance companies are well aware that the APA is, in essence, changing what is considered a mental illness to get more money out of them. It is likely that the insurance companies will respond in a way to protect themselves and, in ways, they need to. This may dramatically increase the costs of health care, particularly if it contributes to placing a large number of individuals experiencing temporary life distress onto medications for a long-term period. This impacts everyone. Additionally, it is likely that insurance companies may respond by demanding more evidence to justify treatment, which could mean that many people who really do need treatment will be put through greater scrutiny and possibly have difficulty getting access to treatment. Therapists may see an increase in documentation required to support the need for treatment, particularly when longer-term treatment of more serious issues is warranted. There are better ways to work to assure that people who need treatment have access to it.

Sociopolitical: Already, individuals representing various forms of diversity, including cultural diversity, are more likely to be diagnosed at higher rates than the dominant culture. This labeling can be used in ways to exert power over these groups through stigmatization and furthering group stereotypes. It is likely that the lower thresholds will disproportionately stigmatize these individuals. Additionally, vulnerable populations, including the elderly and children, are already seeing the largest increases in prescriptions of medications. This will likely get worse.

Conclusion

As we stood on the sidewalks outside the Moscone Center in San Francisco, we knew many people who walked by would discard us as extremists. However, if one were to step back to take a more objective look, it quickly becomes evident that the extremists in this case is the perspective of the American Psychiatric Association as evidenced in the new DSM5 manual. It is clear that this manual in many ways meets the criteria of a polarized position, as it represents a “fixation on one point of view to the utter exclusion of competing points of view” (Schneider, 2013, p. v). The American Psychiatric Association demonstrated polarization in rejecting the widespread call for an external review by qualified experts.

Yet, even if we are considered the extremists, rebels, or radicals, there is often a place for this. As Rollo May (1975) stated, “Recall how often in human history the saint and the rebel have been the same person” (p. 35). While none of us protesting the DSM5 would claim to be saints, I am confident that in this situation we are on the same side as the saints.

References

May, R. (1975). The courage to create. New York, NY: Norton & Company.

Schneider, K. J. (2013). The polarized mind: Why it’s killing us and what we can do about it. Colorado Springs, CO: University Professors Press.

~ Louis Hoffman

Note: Although this site is owned by Louis Hoffman, it supports the Rocky Mountain Humanistic Counseling and Psychological Association (RMHCPA), which is a 501(c)3 nonprofit organization. As an Amazon Associate, RMHCPA earns from qualifying purchases made through the links on this page.

Polarization and the DSM5: Conversations About the Politics of Diagnosis and Medication in Mental Health

This blog was originally published on the New Existentialist Blog on September 10, 2013. It was republished here after the New Existentialist Blog was discontinued.

[Editor’s Note: Listen to Louis Hoffman speak about the DSM5 controversy on City Visions radio on KALW.]

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is receiving a dramatic increase of attention since the new version (i.e., the DSM5) became available. This discussion is important given the DSM5 is not just another book; it is a book that impacts daily the lives of millions of people who are struggling with emotional difficulties. Yet, these conversations are not easy and it is important for us to explore why this is.

The Politics of Diagnosis

Lisa Cosgrove has been a leading voice in bringing to light concerns about the DSM-IV, DSMIV TR, and DSM-5. In a 2010 article, Cosgrove, drawing upon previous research, demonstrates how the DSM has displayed a growing conflict of interest. For instance, she documents a dramatic increase in the number of individuals on DSM panels with direct financial ties to the pharmaceutical industry from the DSM-III to the DSM5.

These concerns have led to increasing criticism from individuals within the mental health professions. The Society for Humanistic Psychology (SHP) has been very influential in building a coalition of professionals and professional organizations voicing concerns about the DSM5. In
particular, Sarah Kamens was the primary author of an important open letter to the DSM5
Task Force raising concerns about proposed changes. Under the leadership of Dave Elkins, Brent Robbins, Donna Rockwell, and others, the letter was converted into a petition that has now received more than 15,000 signatures and has been endorsed by many mental health groups and associations around the world, including the British Psychological Society, 15 divisions of the American Psychological Association, and the Association of Black Psychologists, among others. Despite the strong support for the open letter, the American Psychiatric Association moved forward undeterred.

I am very impressed with the leadership of the Society of Humanistic Psychology and proud to have been a board member during the time this occurred. In particular, the leadership of Sarah Kamens, Brent Robbins, Jonathan Raskin, Frank Farley, Donna Rockwell, and others is a beautiful model of advocacy. By avoiding the extremes and remaining open to dialogue, SHP has been able to build a coalition of very diverse mental health groups united in a strong voice.

Polarization

Kirk Schneider (2013) has defined polarization as, “the elevation of one point of view to the utter exclusion of competing points of view” (p. 1). Although similar to extremism, Schneider clarifies that it is distinct in that polarization is not just an extreme view, but one that discounts other perspectives and takes on a more oppositional nature. Extremism, while often dangerous, can represent a healthy position at times. The nature of polarization is more destructive as it represents an extremism that is devoid of critical thought and considerations of different points of view.

Although it seems that some would like to characterize the opposition to the DSM5, particularly the coalition that SHP has spearheaded, as an extremist, radical group, it is evident that this in not the case. This is demonstrated through the ability of SHP to bring together such diverse groups united in a single concern. It seems clear that the motivations to present the SHP coalition as extremists are political and not based in reality.

Instead, it is the position of the American Psychiatric Association that really represents a polarized viewpoint. The American Psychiatric Association, after being heavily criticized for the dual relationships and conflict of interest on the panels of the DSM-IV moved to a more extreme position of a higher percentage of panel members representing dual relationships and conflicts of interest.

Similarly, the SHP coalition advocated for an outside independent review of the DSM5 before
publication. In the American Psychiatric Association’s response, John Oldham, the president of the American Psychiatric Association states, “There is in fact no outside organization that has the capacity to replicate the range of expertise that the DSM-5 has assembled over the past decade to review diagnostic criteria for mental disorders.” This is an extremely bold and narcissistic statement. It is hard to imagine a clearer example of polarization than represented in this statement. If the American Psychiatric Association were truly open to dialogue and confident in the work represented in the DSM5, they ought to have no hesitation in subjecting their work to outside, independent review. They would be confident that any outside panel would confirm that, while the DSM-5 may not be perfect, it was based solidly upon the best science and scholarship available. This was not the case.

Of course, to subject the DSM-5 to such scrutiny, even if it was eventually supported, would be detrimental to the American Psychiatric Association in many ways. This would cost money and delay the significant income anticipated from DSM-5 sales. Furthermore, the American Psychiatric Association had already invested a substantial amount of money in the development of the DSM5.

If it was determined that even a small number of categories needed to be reconsidered, this would be a sizeable expense. Subjecting the DSM-5 to an outside review is a considerable risk and expense, and would likely negatively impact the American Psychiatric Association. Yet, the alternative is to publish a book that significantly influences the lives of millions of vulnerable people with important flaws that could have been prevented. The right choice seems obvious.

Conclusion

Based on the information, judge for yourself. Which perspective is reflective of polarization? Of course, it can easily be stated that the position articulated in this article is biased. This would be correct. I have been involved with the critiques of the DSM-5 and part of the coalition for change. Yet, I am confident that if one were to subject this matter to outside, independent review, it would withstand the test and demonstrate that the SHP coalition has maintained a strong, but balanced critique of the DSM-5
and sought out open dialogue and external review while the American Psychiatric Association has remained insular, polarized, and opposed to what would represent a true open and collaborative process.

References

Cosgrove, L. (2010). Diagnosing conflict of interest disorder: Big pharma works in subtle but powerful ways inside the pages of the Diagnostic and Statistical Manual of Mental Disorders. Academe, 96(6). Retrieved from https://www.aaup.org/article/diagnosing-conflict-interest-disorder#.Ui6pK2RAROe

Schneider, K. J. (2013). The polarized mind: Why it’s killing us and what we can do about it. University Professors Press.

~ Louis Hoffman, PhD