Feb 22, 2012
DSM-5: Allen Frances vs the American Psychiatric Association 3/3
Both contain the same introduction that provide some background to dr. Frances and my own ideas, that I will not reproduce again, since I have provided links.
The above two parts are from eleven days ago, and since then I wrote also some more on the subject of DSM-5:
In this Nederlog I will quote and discuss another article by dr. Frances in the Huffington Post, dated yesterday, but I will first say a few things about what I will call psychotherapy, for lack of a better term.
1. About the practice of psychotherapy
If you have read some of what I wrote about the DSM 5, e.g. what is linked above, you might have come to believe I am an opponent of psychotherapy.
Actually, I am not, though I am rather sceptical about much of what is on offer in that field, and I am myself not a consumer of the enormous supply of psychotherapies, and never was. (*)
Let's first define terms, using the first three paragraphs in the Wikipedia article "psychotherapy":
The main reasons I am not against psychotherapy are that there is an obvious demand for it, and that there are rather a lot of human problems that are not obviously medical or somatic, and that are, in a not very precise or clear sense, psychological, for which one can get help of some kind, by people who do have some training and education, and who may have some expertise, for giving that sort of help.
It may or may not help; I may or may not myself believe that a psychotherapy or psychotherapist that's on offer on the health market makes sense or will be effective; the therapy or the therapist may or may not be honest and reliable; the therapy may or may not have some foundation in science - but in general terms it is a fact that there is a large market for psychotherapy in some form or shape, and there are quite a few people who are willing to pay considerable amounts of money to get some form of psychotherapeutic help, and indeed there also are quite a few people who believe they were helped by one or several of the many forms of psychotherapy (and besides there also are quite a few who believe they weren't helped by any of it, indeed).
So... as long as what is on offer is not obviously false, fraudulent, dishonest, plain nonsense, or harmful, and if also it is true that those who offer it have some more or less decent qualifications, such as a degree in psychology or medicine, I am not in strong principle against it, though I may not believe in it, and may myself tend to believe, as in fact I do of many psychotherapies I have read about, that it is scarcely credible they are of much help to anyone other than the therapist who offers it for money.
Even so, some may feel benefited by it, and may be willing to pay, and if the product they pay for is not provably dangerous or harmful, all I can say is that I hope the clients do find some relief from what ails them, and in general terms they are and should be free to spend their money as they please, and caveat emptor.
My main problem is with claims about psychotherapies that are false, such as that they are based on science if they are not, or that they will cure something if there is no strong and independent proof that they do, or when they are exceedingly expensive while having little to offer but promises without real factual support.
Here it is clear to me that many psychotherapies promise more and cost more than I think is fair and decent for what is offered, but then I think so about many other products people may spend money on, and there are legal defenses against swindle that do apply to psychotherapies on sale as they do apply to other things that are sold.
Hence, while I do not believe that many psychotherapies on offer are really helpful, and while I also do not really believe most psychotherapists have the sort of insight in others, or in others' problems, that they pretend, or maybe really believe, they have, that is not a sufficient basis to be against psychotherapy in general, nor is it a sufficient basis to insist that few or hardly anyone has been helped by any of it. (**)
The reason I am against the DSM-5 is not that it is part of the sort of psychotherapies that psychiatrists offer:
The reasons that I am against the DSM-5 are (1) that it seems thoroughly unscientific to me, while it is claimed to be - "evidence based", "medical" - science by the APA, which in my trained eyes is just immoral bullshit; and (2) that the quite unscientific DSM-5 is presented by the APA as a way to diagnose people's problems in rational and empirical and scientific terms, while being no such thing at all, since it is neither rational nor scientific, and for the most part not even empirical; and (3) that the DSM-5 promises to give far more power and influence to psychiatrists than they have now, while falsely diagnosing most human beings as being in need of psychotherapy, namely for being abnormal or deviant or being ill of a somatic disease; and (4) that the DSM-5 seems to me to be an utterly dishonest, unscientific, and thoroughly irrational document that is calculated and designed to serve the interests of psychiatrists, of drug companies and of state bureaucracies, without having any real moral or scientific basis, and at the cost of the rights, the interests and the payments of patients.
I am neither against psychotherapy nor against psychiatry: I am against pseudoscience, false promises, the abuse of patients, and against a psychiatry that seems to be calculated and designed to serve the interests of psychiatrists and state bureaucracies, while deceiving its patients about its scientific foundations or its real possibilities, that are generally far less than psychiatrists say they are, even if it is also true that there are honest psychiatrists who really do or did help their patients - but then indeed, to my way of thinking, most often because they were kind, commonsensical, and indeed meant to help someone in distress, rather than because they had deep theoretical veridical knowledge of what makes a human being human. (***)
I have arrived at the latest article of dr. Frances, published in the Huffington Post, dated February 21, 2012, that starts thus:
Personally, I am not amazed. This seems to be the way of doctors Kupfer and Regier: While pretending in public that they are producing an open public document, in fact the document they are producing is being produced in secret, by small committees sworn to secrecy, and without anyone not in these committees having any good idea about what's going on there, nor having any say about it, nor having any real possibility of publicly discussing such proposals as the committees have arrived at.
To me it seems also quite intentional: This is the way that doctors Kupfer and Regier want it to happen, for they know probably at least as well as I do that in a really free open discussion about the merits of the DSM-5, where not only the editors who make it up have a voice about its contents, but also qualified others, that it would be made mince meat of.
So it is clear why doctors Kupfer and Regier publicly pretend to want and to do precisely the opposite of what they in fact do and want, which is to pilot the DSM-5 to its being published without anybody qualified to criticize it rationally - outside the staff of the DSM-5 - having had much of a chance to do so, and without the editors of the DSM-5 having to reply rationally to public criticism, or not until after it is far too late to have any practical effect, and the DSM-5 has been published.
Dr Frances continues with an explanation why these - dishonest, irrational, immoral - tactics of doctors Kupfer and Regier are so frightening:
Quite so - and if you do want to impose a new set of standards by which all manner of persons may be sectioned, convicted to legal punishment, judged to be (un)fit to work, and judged to be insane, and if you want to do this without anybody qualified (who is not a psychiatrist of a DSM-5 comittee) having any or much access to your new set of standards before they are made official and will be used by courts and by bureaucracies and by doctors as if these new standards are based on rational science and decent morality, then you follow the tactics of doctors Kupfer and Regier, or so it seems to me, and you consistently say "the thing that is not", and pretend to discuss in public while you're making such discussions mostly impossible or quite useless, and you continuously and falsely insist that what you propose is "evidence-based science" while what I really can see is mostly a set of manipulative criterions without any good evidence of any kind, that is designed, so far as I can see, to manage, manipulate and mislead the public rather than to help them, and that is also falsely pretended by its makers to have rational and empirical scientific foundations, while it also is falsely pretended by its makers to have been publicly discussed and to have been open to rational criticism by qualified others, in an open and fair discussion.
More dr. Frances:
As I indicated, I mostly agree, except that I do not understand "Under normal circumstances": It seems to me that dr. Frances seems here to be thinking in terms of what he regarded as "normal" while compiling the DSM-IV, of which he was the chief editor. I am quite willing to believe him but clearly his successors with the DSM-5 have quite different ideas about what is and should be "normal" and about how criticism should be faced and dealt with.
My own answer to the question asked is: No, there will not be a last-minute save or indeed much improvement or much of a public discussion of any kind, and I believe that is on purpose: Doctors Kupfer and Regier want the DSM-5 to be published without their giving a real chance to professionals from other professions than psychiatry, or indeed to professionals from psychiatry who do not wholeheartedly agree with them, to discuss the DSM-5 publicly with its makers.
The following is Ms Chapman's prose:
Quite so, and for my money Dr Kupfer does it deliberately, for the reasons I stated in my previous paragraph: He simply wants to prevent public discussion as much as he can, while pretending he likes to see it. Hence all that unclarity.
More by Ms Chapman:
Quite so, and my own inference is that "the public" - including many psychologists, many psychiatrists, many counsellors, and many lawyers, all of whom wanted to comment on the DSM-5 and discuss its proposals with its editors, precisely because the DSM-5 is effectively a new foundation for psychiatry dreamt up by the committees that wrote the DSM-5, mostly in secret, mostly without any outside consultation or criticism from outsiders - have been effectively and skilfully sidelined and outmanoeuvred, while doctors Kupfer and Regier keep lying to that public that they do want the very public discussion they so effectively have made impossible.
More prose by Ms Chapman:
Yes, indeed - and it also seems to me that what Dr Regier pretends are "scientific hypotheses" are no such thing at all, and that what he is offering are in fact incompletely tested or totally untested recommendations for making medical diagnoses, on the pretext that these diagnoses may be tested after having been accepted. To me this sounds like quite clever and quite dishonest lying and sounds as - conscious, deliberate, planned - medical malfeasance.
It sounds like medical malfeasance, precisely because the recommendations do not concern the speculative risks in a portfolio of shares, but concern the direct interests and rights of patients - who will be diagnosed, and indeed will be misdiagnosed, with untested diagnoses, and who have the right to be protected from being used as guinea pigs for finding out whether Dr Regier's untested recommendations will be harmful: Untested recommendations for the making of medical diagnoses are harmful and are malfeasance.
Here is Ms Chapman's final paragraph:
I quite agree, except that I may be considerably more cynical than Ms Chapman may be - but then I am a psychologist and philosopher: I think that what Dr Regier and Dr Kupfer want to foist on the public is a DSM 5 that they know very well to be not scientifically sound, that they know very well to have not been properly tested as to its safety, nor did it have any fair and repeated round of attempted verifications and scientific public discussions, as a diagnostic manual should have, all of which is not fit for the purpose it is advertised to be fit for: The rational scientific diagnosis of mental illness.
Back to dr. Frances:
Actually, from my own point of view, that tends to be quite impatient of nonsense or lies presented as if it were sense or truth, and also because of the awful prose style, Ms Jones, Ms Chapman, and indeed dr. Frances should be much admired for being some "of the most knowledgeable people on earth about DSM 5": One becomes so only if one genuinely cares for patients, and has considerable will-power and, at the very least, a good intellect.
Also, dr. Frances is right that dr. Jones is somebody who has a definite right to speak on the matter of the DSM-5 and its contents, and to engage in public discussions about its merits: She and other counsellors must have much experience of how a diagnostic manual like the DSM works in practice, and must have useful knowledge about its dangers.
What follows is Ms Jones' text:
Ms Jones is bound to know all these things much better than I do, but the conclusions that follow are (or ought to be) quite unsettling to the DSM-5's pretenses: It is for the most part not empirically tested, and therefore cannot possibly be empirical science. Therefore, as far as I can see: Legally, medically, morally and scientifically, a Diagnostic Manual that is not even based on proper empirical tests that its diagnoses work, must be quite intentional medical malfeasance.
More text by dr. Jones:
I agree with dr. Jones that it may have been "a catastrophic decision", but what worries me more is that it is both an immoral and a dishonest decision, and again must be medical malfeasance - which is actionable, doctors Regier and Kupfer! - for one just has no right to seriously propose and publish a diagnostic manual whose diagnostic criterions have not properly been tested.
More text by dr. Jones:
I quite agree - and I'd say myself that counsellors will "find themselves unable in good conscience to use DSM 5", if indeed, like dr. Jones, they want to treat people honourably, honestly, morally and on the basis of real, tested and verified scientific knowledge, rather than on the fictions produced by committees composed of persons who have strong interests (or whose colleagues, at least, have strong interests) that these fictions be publicly and legally accepted as valid and applicable and seen as if they were fact. Again, in what is claimed to be medical scientists, this is medical malfeasance.
The last paragraph by dr. Jones:
As it happens - see DSM-5: Some sensible ideas about the DSM-5 - P.S. - dr. Jones may well have been too optimistic and may be mistaken: The colleagues of dr. Regier, dr. Kupfer and dr. Creed have manipulated themselves also into the remaking of the ICD. Then again, dr. Jones may well be right in suggesting that it is morally correct and intellectually and legally feasible - and financially a lot cheaper! - to abstain from using so flawed, so dishonest, so unscientific and so immoral a text as the DSM-5 promises to be, and to use instead the DSM-IV, if only on the ground that it has the merit of being properly field-tested.
Back to dr. Frances:
Here is dr. Rockwell:
The interested reader who is not a psychologist, psychiatrist or medical doctor should realize this is a quite strong and rather amazing result, for psychologists, psychiatrists and medical doctors, nor their professional organizations, are prone to protesting much, especially not if what they protest against are what - nominally - count as their colleagues.
More text by dr. Rockwell:
Speaking for myself, having read rather a lot of psychiatry, I must assume John Oldham, MD, gets a kick out of this: Snubbing many thousands of what should count as his colleagues, and snubbing over forty of their professional organizations as well, and telling them in effect that he, John Oldham MD, knows the lot of them are just ignoramuses, who don't know what they are talking about. For Mr Oldham MD is the sort of medic who presumes to know that only his very own kind can judge the expertise of his very own kind - as if that is plausible, rational, fair or honest, or indeed tenable in a court. ("Your honor, upon my oath: Anybody who is not a member of my association - and that includes you, Mr Justice - is not competent to judge what the members of my association believe, desire, say or do.")
That is effectively what Oldham MD is telling the world, and if I would not have read rather a lot APA and DSM-5 prose lately, I would have little hesitation in pronouncing him to be either mad or drunk.
But now I must admit I think he isn't: He seems to be simply implementing the plan of the APA that seems to come to this: Snub all critics of the DSM-5, publish as little as possible about it; do not reply to any criticism, no matter who makes it; blacken all critics, whoever they are; and avoid all honest discussion and all real testing - simply print and publish the DSM-5, and from the money that generates start a publicity campaign that tries to convince the public that "A New Dawn" has appeared (as Tony Blair, in many way a shrink-like politician, did say, as soon as he acquired power) in psychiatry, and then proceed to blacken all opponents as being incompetent or disturbed (and don't forgot that by then the APA will have far more powers to lock people up, and far moral formal criterions to paint them as "disordered", "maladjusted", or what not).
Here is dr. Rockwell's reply to Oldham MD:
Quite so - but if doctors Oldham, Regier, Kupfer, Creed etc. get their way, the DSM-5 will be foisted upon the public and upon the judiciary without any rational discussion, without any good empirical testing, without any independent authority, without check and without balance, all on the basis of the fallacy of authority that a fallacious authority like Oldham MD gets his kicks from: That anybody who is not a Catholic priest is unfit and incompetent to judge the pretensions or theology of the Catholic Church or the failings of Catholic priests - except that Oldham MD formulates this impertinent lie for psychiatrists and the DSM-5 rather than for Catholic priests and the theology of St. Thomas.
Back to dr. Frances, who returns to a theme and an institution I commented on before:
If dr. Rockwell is unaware of its existence, as I also was, until a few days ago, when I learned about it through dr. Frances, it can't be "universally respected". I certainly don't respect it, nor do I disrespect it: I lack the relevant knowledge to judge it.
Perhaps dr. Frances is right that involving the Cochrane Group may be a good idea, but I don't think he is right in his claim that there is "no other way to guarantee a scientifically sound and credible DSM 5".
I can think of three other ways at least, that do at least go a good way in the right direction:
The first is to simply insist that a DSM-5 that has been produced in the way it has been, simply is not real science, nor is it morally acceptable, because it is medical malfeasance to foist an untested diagnostic manual upon the public, included the judiciary;
the second is to insist that the DSM-IV is a far better diagnostic instrument - even while it has known flaws, meanwhile - that has been field-tested, so psychiatrists, psychologists, lawyers, counsellors, medical doctors and others who want to do their work in a morally correct way should avoid the DSM-5 for making psychiatric diagnoses, simply because of their professional ethics, that does not allow them to impose untested diagnoses upon the public; and
the third way is for psychiatrists who agree with dr. Frances, to band together with the psychologists, counsellors, lawyers and medical doctors who also agree with him, of which there are, in view of the more than 11,000 signatures mentioned above, and the more than 40 professional organizations, far more than the merely 36,000 members of the APA, and collectively design a much better diagnostic manual than a committee of secretively operating mere shrinks can do, and make it into a public tool and form like Wikipedia or the Stanford Encyclopaedia of Philosophy.
At least the third way would offer what dr. Frances desires: "a scientifically sound and credible DSM", though indeed it would not be owned by the APA, nor would it be designed by only psychiatrists.
Here is more by dr. Frances:
I agree, but it seems to me very probable that this will not happen - which is why I formulated my three alternatives above.
Here is dr. Frances's last but one paragraph:
Again I agree mostly, and the list of things that dr. Frances lists as the APA's "public purpose" shows how important a diagnostic manual like the DSM is, and namely for those who do not make money with its help, but who are either subject to its diagnoses, or who rely on its accuracy and truth to help them judge others:
The conclusion to be drawn is again that the DSM-5 cannot be relied upon for its diagnoses, for these have been mostly made up by secret committees that were not controlled, nor open to public inspection or discussion, nor subject to control by other professionals in health-care, nor can the DSM-5 be used by the state or by judges as a scientific empirically tested framework to judge people by, since it is neither properly scientific, nor really empirically tested.
Dr Frances last paragraph is simply this:
I fear that what happens if psychologists, medical doctors, lawyers and counsellors do not band together to oppose the DSM-5 and to produce a better diagnostic manual of mental health, is that the public will be much abused; many legal judgements will be rationally baseless; and very many patients will be misdiagnosed, forced to use improper medication, and mistreated and libelled in the name of psychiatric "evidence-based medicine" - that to me, at least in the shape of the DSM-5, looks like intentional fraudulence and medical malfeasance.
In my opinion, the DSM-5 should not be used by honest and competent medical and psychological people who mean to do well to their patients in an honest way, and the DSM-5 should either be terminated or disregarded, while much good might be done, both for patients and for health-care and legal professionals, if a much larger group than a secret committee of psychiatrists start cooperating on a new and better diagnostic manual for judging mental health than the APA is capable of offering.
As to ME/CFS (that I prefer to call ME):
Short descriptions of the above:
1. Ten reasons why ME/CFS is a real disease by a professor of medicine of Harvard.
2. Long essay by a professor emeritus of medical chemistry about maltreatment of ME.
3. Explanation of what's happening around ME by an investigative journalist.
4. Report to Canadian Government on ME, by many medical experts.
5. Advice to psychiatrist by a psychiatrist who understa, but nds ME is an organic disease
6. English mathematical genius on one's responsibilities in the matter of one's beliefs:
7. A space-
and computer-scientist takes a look at psychology.
See also: ME -Documentation and ME - Resources
The last has many files, all on my site to keep them accessible.
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