Edited Dec 28
This post is a rewritten comment on Dr Alex Langford's argument in favour of the diagnosis of mental illnesses.
I thank dr Langford for stating his views on "mental illness" so explicitly and unequivocally. Because ...
When opinions are stated explicitly, it is possible to think about them explicitly, and to respond explicitly.
If dr Langford had been an unknown psychiatrist, I would not have bothered to respond. But he seems to be a respected defender of the diagnosis of mental illness, and he contributes to THE MENTAL ELF, a website dedicated to "Reliable mental health research, policy and guidance".
I don't know enough about the technicalities of research to evaluate it, but I can think critically about policy and guidance. And while I do not doubt the good intentions of dr Langford and The Mental Elf, I am concerned about their seeming inability to realize that mental help can be discussed from many different frames of knowledge.
Frames of depression
In FRAMES AND NETWORKS OF UNDERSTANDING PSYCHOSIS I quoted from a suggestion by Sam Thompson, @uilleannair:
In clinical practice, try as far as possible, to let the service users themselves identify the conceptual frame (ie, biological, psychological, social, or any combination thereof) within which their difficulties are understood.
If I ever need this kind of help again, I hope to meet helpers who know that different conceptual frames exist.
In dr Langford's conceptual frame, this is depression:
Depression feels like someone has reached inside your chest and torn out your soul with a rusty spoon. And is laughing at you about it.
There are no souls in my conceptual frame, and there have never been rusty spoons in my depressions. But I do recognize the dead fish of Allie Brosh, who has written (and drawn) the best description of depression that I have seen so far:
In part 2, Allie Brosh writes:
It would be like having a bunch of dead fish, but no one around you will acknowledge that the fish are dead. Instead, they offer to help you look for the fish or try to help you figure out why they disappeared.
The problem might not even have a solution. But you aren't necessarily looking for solutions. You're maybe just looking for someone to say "sorry about how dead your fish are" or "wow, those are super dead. I still like you, though."
In this comment section dr Langford has another description of depression:
I've been depressed, and I never thought I had a brain disease, but it helped to know that others had felt the same kind of awful, and because we’d be lumped into a group called “depression”, people had found out what helped. Forgetting that diagnosis doesn't mean “brain disease” can lead to a whole lot of harm.
I accept and respect what dr Langford wrote as his personal and subjective experience with depression.
And it does not fit my personal and subjective experience with depression. I have always known that others “had felt the same kind of awful”, so I did not need to hear that from anyone.
Being lumped into a group called “depression” has helped Langford know that others had felt the same, and that people had found out what helped.
When opinions are stated explicitly, it is possible to think about them explicitly, and to respond explicitly.
If dr Langford had been an unknown psychiatrist, I would not have bothered to respond. But he seems to be a respected defender of the diagnosis of mental illness, and he contributes to THE MENTAL ELF, a website dedicated to "Reliable mental health research, policy and guidance".
If dr Langford had been an unknown psychiatrist, I would not have bothered to respond. But he seems to be a respected defender of the diagnosis of mental illness, and he contributes to THE MENTAL ELF, a website dedicated to "Reliable mental health research, policy and guidance".
Frames of depression
In FRAMES AND NETWORKS OF UNDERSTANDING PSYCHOSIS I quoted from a suggestion by Sam Thompson, @uilleannair:
In clinical practice, try as far as possible, to let the service users themselves identify the conceptual frame (ie, biological, psychological, social, or any combination thereof) within which their difficulties are understood.If I ever need this kind of help again, I hope to meet helpers who know that different conceptual frames exist.
In dr Langford's conceptual frame, this is depression:
Depression feels like someone has reached inside your chest and torn out your soul with a rusty spoon. And is laughing at you about it.
In part 2, Allie Brosh writes:
It would be like having a bunch of dead fish, but no one around you will acknowledge that the fish are dead. Instead, they offer to help you look for the fish or try to help you figure out why they disappeared.
The problem might not even have a solution. But you aren't necessarily looking for solutions. You're maybe just looking for someone to say "sorry about how dead your fish are" or "wow, those are super dead. I still like you, though."
In this comment section dr Langford has another description of depression:
I've been depressed, and I never thought I had a brain disease, but it helped to know that others had felt the same kind of awful, and because we’d be lumped into a group called “depression”, people had found out what helped. Forgetting that diagnosis doesn't mean “brain disease” can lead to a whole lot of harm.
And it does not fit my personal and subjective experience with depression. I have always known that others “had felt the same kind of awful”, so I did not need to hear that from anyone.
Being lumped into a group called “depression” has helped Langford know that others had felt the same, and that people had found out what helped.
OK. I accept and respect that.
But does dr Langford insist that lumping people into diagnostic groups of mental illness is the only helpful form of mental help that exists?
If so, I cannot respect that.
In my frame, depression is not a group one can lump people into, and being lumped requires uncritical compliance, which is not mentally healthy for me. I need to take responsibility.
My post on "Evaluating authority" ends like this:
If I had chosen instead to be compliant? A "good patient"?
I think I would have been long dead.
And this, to me, is a misery wrapped in an enema: "Live free or die" in a context of mental help.
Mental health authorities seem to require unquestioning compliance.
And ...
Can unquestioning compliance ever be mentally healthy?
But does dr Langford insist that lumping people into diagnostic groups of mental illness is the only helpful form of mental help that exists?
If so, I cannot respect that.
In my frame, depression is not a group one can lump people into, and being lumped requires uncritical compliance, which is not mentally healthy for me. I need to take responsibility.
My post on "Evaluating authority" ends like this:
Is psychiatry scientific?
These brain scans look very scientific, and Langford showed them in his argument for the diagnosis of mental illnesses, after writing “Mental illnesses are simply illnesses which involve the brain, but show themselves in a form we think of as 'the mind'”.
Illnesses that involve the brain, but show themselves in the mind? Is that a scientific definition? Is it falsifiable? Could someone please explain what it means?
The image might give the impression that psychiatrists can diagnose depression simply and scientifically by looking at a brain scan, but near the end of his argument, Alex Langford wrote:
“Some say, well, you've had years to find a simple cause or test for these disorders, things like depression, and you haven’t done it. So depression can’t be a real illness!»
So … blue in brain scans isn't a simple and scientific indicator of depression after all?
What is treatment-resistant depression?
How do experts on "mental illness" know that it is the depression that is treatment-resistant, and not the treatment that does not work?
I ask because I had debilitating seasonal depressions for the first 16 years of my adult life. They disappeared when I began to liberate my personal story from the collective stories of my surroundings.
That worked for me, and I am not speaking for anyone else, but there might have been a lot of blue if my brain had been scanned when I was “dying in depression” every winter.
And since I got rid of my symptoms of depression without drugs or other therapeutic interventions … would they have been treatment-resistant in the mental help services?
Opinions and anosognosia
From where I stand, Alex Langford's descriptions and conclusions are based on opinions, not on "science".
I agree with this:
And psychiatry is the only branch of medicine that has the power to override personal choice with subjective and unfalsifiable concepts like "treatment resistance" and "lack of insight".
In "On insight and what not to do to people in pain" I wrote:
When experts on the diagnosis of mental illness define disagreement and non-compliance as "lack of insight", anosognosia, I look for insight. I look for their insight into the lives of the people they find lacking in insight; I look for their insight into their own lives, emotions and reactions, I look for their insight into the importance of critical thinking, integrity, responsibility and autonomy, into the difference between truth and opinion, into knowledge about frames and networks.
I look very hard for awareness that even if their frame fits them and others, it does not fit everyone.
I cannot sit in Alex Langford's frame. Maybe this is because our minds work differently?
In my frame the difference has to do with an ability to fit into collective stories. It seems to be "normal" to fit into religious, political, psychotherapeutic or societal stories. And I admit that I am a bit jealous of this ability, as it might have made my life a lot easier.
I recognize the mindset that Martha Crawford LCSW describes in Skin Deep:
Everything enacted in the room and yet unacknowledged seeps inside me. At any given community meeting, class parent gathering, cocktail party all the unnamed, unspoken affect rings louder in my ears than any verbalized dialogue, as I take in a mouthful of toxicity that I would be too impolite, off-putting or downright bizarre to spit out:
“Excuse me, but isn’t it interesting that you chose to cut Harriet off here, just as she was elaborating on her point? Did the two of you quarrel earlier in the evening? I’ve noticed that even though you are smiling, that something about your tone makes me uncomfortable, or even feel scolded… Is there something I have done previously that offended you? Perhaps we were discussing something that was unsettling or threatening to you? I can’t tell what the subtle tension in the conversation is about, but it felt hostile somehow, and I’d feel much more comfortable if you could talk about what may be angering you directly. Oh! and could you please pass that red-pepper hummus? So yummy!”
I get mental rash and blisters from collective stories and information "enacted in the room and yet unacknowledged". And repressing those reactions was a major cause of my depressions.
"Depression" is a name for a lot of different symptoms. Sometimes the symptoms might have physical causes, more often they are natural reactions to things that have happened or are happening in individual lives. And I have no idea if this is true, it's just an explanation that works for me. An opinion.
Can people who know that depression is a mental illness accept and respect it as my opinion?
In my frame, depressions are different, individuals are different, minds are unique and unknowable, so what helps will also be different, and a mentalising approach might be the most efficient way of looking for the best individual solutions to the problems of an individual's depression:
Different approaches to understanding patients in general practice in Denmark: a qualitative study
Mentalisation involves being aware of and absorbing and understanding mental conditions in oneself and others. Many mental processes are involved – not only thoughts and emotions, but also needs, wishes and fantasies. In all social interactions, for example in the relation between patient and doctor, the ability to perceive and interpret the intentions, impressions and emotions of oneself and others is central.
This definition is by Bengt Mattsson, professor emeritus at the unit for general medicine, University of Gothenburg, from his article “Om läkares olika fallenhet att relatera till patienter”. The title can be roughly translated as “On doctors’ different ways of relating to patients”.
The study he describes found four different ways of relating to patients, many of whom had mental problems:
Mentalising: Emotionally engaged, welcoming attitude, accepting of differences, curious and intent on understanding thoughts, emotions and impressions. Often able to connect with the patients’ situation from a broad overview.
Limited mentalisation ability: Interested in the problem but could not always see a connection with other life situations. Limited interest and curiosity, uneven seriousness and respect for the patient.
Rejecting: Limited patience, could dismiss the patient’s perspective, did not reflect much over their own role in the interaction. Might scoff at patients with mental problems.
Biomedical: Focus on categorization, diagnostics, rating scales and medical treatment. The doctors were neutral and did not wish to be involved in psychological circumstances. The narratives of patients were considered information to be fitted into a biomedical frame.
Which approach would you prefer if you were depressed?
RELATED LINKS:
A paper "Real evidence-based medicine":
According to Altmetrics, our paper on #RealEBM was 2014's most tweeted-about paper in @bmj_latest. http://t.co/ckOMxppZVT
— Trisha Greenhalgh (@trishgreenhalgh) December 26, 2014
Bruce E. Levine: "Would We Have Drugged Up Einstein? How Anti-Authoritarianism Is Deemed a Mental Health Problem"
Electroconvulsive Therapy: Whose decision is it? by @steweatherhead & @THEAGENTAPSLEY
Dr Langford linked to the following five articles in Antidepressants are not ‘happy pills’ :
Is psychiatry scientific?
These brain scans look very scientific, and Langford showed them in his argument for the diagnosis of mental illnesses, after writing “Mental illnesses are simply illnesses which involve the brain, but show themselves in a form we think of as 'the mind'”.
Illnesses that involve the brain, but show themselves in the mind? Is that a scientific definition? Is it falsifiable? Could someone please explain what it means?
The image might give the impression that psychiatrists can diagnose depression simply and scientifically by looking at a brain scan, but near the end of his argument, Alex Langford wrote:
“Some say, well, you've had years to find a simple cause or test for these disorders, things like depression, and you haven’t done it. So depression can’t be a real illness!»
What is treatment-resistant depression?
How do experts on "mental illness" know that it is the depression that is treatment-resistant, and not the treatment that does not work? Opinions and anosognosia
I agree with this:
And psychiatry is the only branch of medicine that has the power to override personal choice with subjective and unfalsifiable concepts like "treatment resistance" and "lack of insight".
In "On insight and what not to do to people in pain" I wrote:
When experts on the diagnosis of mental illness define disagreement and non-compliance as "lack of insight", anosognosia, I look for insight. I look for their insight into the lives of the people they find lacking in insight; I look for their insight into their own lives, emotions and reactions, I look for their insight into the importance of critical thinking, integrity, responsibility and autonomy, into the difference between truth and opinion, into knowledge about frames and networks.
I look very hard for awareness that even if their frame fits them and others, it does not fit everyone.
I recognize the mindset that Martha Crawford LCSW describes in Skin Deep:
Everything enacted in the room and yet unacknowledged seeps inside me. At any given community meeting, class parent gathering, cocktail party all the unnamed, unspoken affect rings louder in my ears than any verbalized dialogue, as I take in a mouthful of toxicity that I would be too impolite, off-putting or downright bizarre to spit out:
“Excuse me, but isn’t it interesting that you chose to cut Harriet off here, just as she was elaborating on her point? Did the two of you quarrel earlier in the evening? I’ve noticed that even though you are smiling, that something about your tone makes me uncomfortable, or even feel scolded… Is there something I have done previously that offended you? Perhaps we were discussing something that was unsettling or threatening to you? I can’t tell what the subtle tension in the conversation is about, but it felt hostile somehow, and I’d feel much more comfortable if you could talk about what may be angering you directly. Oh! and could you please pass that red-pepper hummus? So yummy!”
Can people who know that depression is a mental illness accept and respect it as my opinion?
In my frame, depressions are different, individuals are different, minds are unique and unknowable, so what helps will also be different, and a mentalising approach might be the most efficient way of looking for the best individual solutions to the problems of an individual's depression:
Different approaches to understanding patients in general practice in Denmark: a qualitative study
Mentalisation involves being aware of and absorbing and understanding mental conditions in oneself and others. Many mental processes are involved – not only thoughts and emotions, but also needs, wishes and fantasies. In all social interactions, for example in the relation between patient and doctor, the ability to perceive and interpret the intentions, impressions and emotions of oneself and others is central.
This definition is by Bengt Mattsson, professor emeritus at the unit for general medicine, University of Gothenburg, from his article “Om läkares olika fallenhet att relatera till patienter”. The title can be roughly translated as “On doctors’ different ways of relating to patients”.
The study he describes found four different ways of relating to patients, many of whom had mental problems:
Mentalising: Emotionally engaged, welcoming attitude, accepting of differences, curious and intent on understanding thoughts, emotions and impressions. Often able to connect with the patients’ situation from a broad overview.
Limited mentalisation ability: Interested in the problem but could not always see a connection with other life situations. Limited interest and curiosity, uneven seriousness and respect for the patient.
Rejecting: Limited patience, could dismiss the patient’s perspective, did not reflect much over their own role in the interaction. Might scoff at patients with mental problems.
Biomedical: Focus on categorization, diagnostics, rating scales and medical treatment. The doctors were neutral and did not wish to be involved in psychological circumstances. The narratives of patients were considered information to be fitted into a biomedical frame.
Which approach would you prefer if you were depressed?
RELATED LINKS:
A paper "Real evidence-based medicine":
— Trisha Greenhalgh (@trishgreenhalgh) December 26, 2014
Is Britain hooked on happy pills? Is Britain depressed or just medicalising a normal range of emotions, asks psychiatrist Dr Joanna Moncrieff
Why ARE so many people being labelled bipolar? More and more celebrities say they have it, but here a top psychiatrist warns the disorder is far too readily diagnosed, leaving many trapped on 'zombie' pills
- What it means to be bipolar has undergone a transformation
- Once seen as rare and disabling, it now vaguely refers to 'mood swings'
- The drugs used to treat the condition are powerful, harmful - and profitable
Record numbers on 'happy pills' Psychiatrists warning over soaring use of pills in 'depressed Britain' By Laura Donnelly, Health Editor
By Will Self: Psychiatrists: the drug pushers Is the current epidemic of depression and hyperactivity the result of disease-mongering by the psychiatric profession and big pharma? Does psychiatry have any credibility left at all?
By Giles Fraser: Taking pills for unhappiness reinforces the idea that being sad is not human If you have a terrible job or home life, being unhappy is hardly inappropriate. Pathologising it can only make everything worse
The description of the party - the half-felt, vaguely detectable feelings that people are pretending, but not doing it very well - are painfully accurate !
ReplyDeleteRealizing that I noticed things others did not, was one of the factors that disappeared my depressions and anxiety attacks. I call it "having canary senses" ... as in "miners' canary". I've written about it in Norwegian, but not translated.
DeleteDealing with it, in a combination of respecting what my canary senses tell me and thinking critically about them by comparing with other information, has been an important factor in my liberation process.
And canary senses are a real handicap in much of standard mental help.
Thinking back at what I knew of my mother, who often lost touch with reality, I think she had very strong canary senses that she was never able to use.