Jung At Heart

I have written here many times about what I see as the shortcomings of the diagnostic system we use in mental health.

It would be nice to imagine that there were some scientific way to determine diagnosis, but there is none. Absent biological or chemical tests to establish diagnoses, we fall back on consensus reality and struggle with the unevenness of such a standard. What we have in the DSM IV is an attempt to develop, by consensus, descriptions of all disorders thought to be reflective of mental illness of one kind or another. Categories have been expanded and elaborated in the years since the first edition was published; yet, all but the rarest of categories still depends on the subjective judgment of the examiner. Local custom, training of the examiner, examiner biases, insurance coverage, perceived stigma carried by various diagnoses, and funding sources can all influence the diagnosis made as much as the behavior and history of the patient.

That such factors as funding sources and examiner bias influence diagnosis goes against the image of the medical model as scientific. However, subjective and external factors often matter more than the symptoms displayed. In private practice, the fact that medical and insurance records cannot be guaranteed to be private, the tendency is to choose the least stigmatizing diagnosis possible. Occasionally a professional might apply a more serious diagnosis to someone they find irritating, in an unconscious attempt at retaliation. Or a facility has beds for patients with one kind of diagnosis but not another, so the effort is made to fit the patient where the space is. Or health insurance severely limits coverage for treatment for minor disorders but is more generous for ones that are more serious, resulting in the push to gain coverage, not strive for accuracy in diagnosis. All of these disturbances, in what we might like to believe are an orderly and scientifically based process, reflect variations in the consensus reality and its deviance from the ideal.

You really should read this post on CP&P and be sure to read the comments also as the guest poster, Tim Desmond gets at the issues really well.

I'm with Jung on this :

It is generally assumed in medical circles that the examination of a patient should lead to the diagnosis of his illness, so far as this is possible at all, and that with the establishment of the diagnosis an important decision has been arrived at as regards prognosis and therapy. Psychotherapy forms a startling exception to this rule: the diagnosis is a highly irrelevant affair since, apart from affixing a more or less lucky label to a neurotic condition, nothing is gained by it, least of all as regards prognosis and therapy. (Jung, CW 16, p.86)

There has been considerable talk lately of the potential for violence arising from inflammatory rhetoric and advertising in the current presidential campaign. Efforts to associate Obama with terrorists and terrorism, violence against ACORN, and race-baiting have all been in the news in the last few days. And yet it is difficult to look at and consider these problems because we are in a political campaign. The shape of this kind of battle makes considered reflection difficult. 

There are huge forces at work in our country today and they bring with them an increased need to pay attention. As Jung said:

The change of character brought about by the uprush of collective forces is amazing. A gentle and reasonable being can be transformed into a maniac or a savage beast. One is always inclined to lay the blame on external circumstances, but nothing could explode in us if it had not been there. As a matter of fact, we are constantly living on the edge of a volcano, and there is, so far as we know, no way of protecting ourselves from a possible outburst that will destroy everybody within reach. It is certainly a good thing to preach reason and common sense, but what if you have a lunatic asylum for an audience or a crowd in a collective frenzy? There is not much difference between them because the madman and the mob are both moved by impersonal, overwhelming forces. *

* "Psychology and Religion" (1938). In CW 11: Psychology and Religion: West and East. para.25

I have been watching, and sometimes writing about it here, the cascade of revelations about unreported money, withheld research, and other disturbing issues within psychiatry. The disclosure last week that Charles Nemeroff, one of the major figures in psychiatry today, had lied about how much money he received from drug companies -- a whole lot -- seemed to be a tipping point of some kind. Because since then there have been articles and editorials questioning ethics and the place of greed in this whole mess. Judith Warner of the NY Times wrote about greed. Friday, the Times weighed in with an editorial. Critical bloggers likewise -- Furious Seasons, CP&P, Carlat -- have written about this issue and eloquently. If you haven't already, I urge you to read them.

The Times editorial concludes:

"The tactics included delaying publication of studies that found no evidence that the drug worked for some disorders, spinning negative data to make it look more positive and bundling negative data with positive findings to neutralize the results. Pfizer denies any such manipulation. It will be up to the courts to pass final judgment on what looks like tawdry behavior."

This is far more than tawdry behavior. That there has been manipulation of data and results on research conducted by investigators who cannot be unbiased seems to me to cast in doubt a great deal of what has been touted as truth in the field over the last several years. 

Americans seem especially fond of research evidence to support behavior. We like it when there are studies to cite to explain what we choose to do. So we have the vast number of people who talk about their "chemical imbalance" to explain why they take SSRI's and many of them compare their treatment to the insulin required by diabetics. Because it all sounds scientific, it must be real and true, right?

But what now? How are we to understand the field now when so much of the research is tainted? And so many have a vested interest in the protocols which have emerged from it? Greed on the part of those who receive payments from drug companies for hawking certain drugs or for their research is one thing, but greed plays a deeper and more pernicious role in this enterprise as well.

Many therapists that I know would prefer to practice outside of the current third party payment system. They chafe at the paperwork, at the intrusion into the treatment, at the fact that they cannot set fees or frequency according to the needs of the patient but rather according to the insurance paying for the treatment. But they stay in the system because of greed, their own and their patients'. When patients must pay out of pocket for treatment, it is a lot harder to collect $100/hr or more for therapy. But when insurance picks up the tab for some or most of it, higher fees are possible. Patients are happy because they pay less per visit; therapists are happy because they receive more income. I am not saying that there is something evil or sleazy about this -- it is not in the same league as accepting hundreds of thousands of dollars for biased work -- but it is about greed.

In fact, the entire system is built on greed. Maximizing income while minimizing payment has been driving the system for around 20 years at least. Insurance companies want to pay out the least amount possible that they might be profitable and please their shareholders. Pharmaceutical companies want their drugs prescribed as frequently as possible in order to maximize profit and please their shareholders. Psychiatrists want to earn at the levels many of their physician colleagues in other specialities earn so they do what yields the most income  and they withdraw from providing psychotherapy and turn increasingly to medication practices. Psychologists and social workers want to earn more so they accept the intrusions of insurance companies in order to charge higher fees. Patients want to pay as little as they can so they choose therapists who will accept their insurance which will pay for the sessions even if treatment gets interrupted before it is completed. 

At the level of the practitioner and patient, greed is almost certainly not a conscious motive but it is a driving factor nonetheless.  That hardly anyone is trained in any method other than CBT these days is not because it is the most effective approach -- we have research emerging pretty regularly now that other approaches work as well or better. It is because it is most easily regulated and controlled by the insurance companies who pay the bills that allow the therapists to earn a healthy income and patients to pay out very little. Greed.