Wyatt Ehrenfels Weighs in on Role of Mental Health Commission
wyatteh...@yahoo.com
Psychologists, Mandatory Mental Health Screening for Children
New Development Actualizes Fireflies in the Shadow of the Sun's
Fictional Sub-Plot
source: http://www.fireflysun.com/book/New_Freedom_Commission.php
(See source for embedded links and graphics)
A Presidential Commission on Mental Health has the support and funding
from Congress to subject your child, without your consent, to mandatory
mental health screening in the public schools. There. I buried the
lead. But lest you think that I spoiled a suspenseful build-up to this
sensational headline, let me assure you that it gets worse. Much worse.
The unfortunately-named "New Freedom Commission" will also expand the
role of mental health professionals in the schools and grant them
authority to require your child to take psychotropic drugs like
Ritalin. Yes, I know the claim sounds a bit kooky, but the truth is
sometimes outrageous. And the problem may be worse yet. If the
Commission models its treatment programs after the Medication Algorithm
Project (TMAP) implemented by the Texas Department of Mental Health
Services in 1996, mental health professionals will be required to
adhere to a recipe-style set of guidelines that match specific
pharmacologic agents to broad classes of disorders coded in the
Diagnostic & Statistical Manual of Mental Disorders.
President George W. Bush established the New Freedom Commission on
Mental Health (NFC) on April 29, 2002, ostensibly to eliminate
inequality for Americans with disabilities. The Commission's members
met monthly to analyze the public and private mental health systems,
visit innovative model programs across the country and hear testimony
from the systems' many stakeholders, including dozens of consumers of
mental health care, families, advocates, public and private providers
and administrators and mental health researchers. July 22, 2003, the
Mental Health Commission produced its final report. October 2, 2003,
Representative Grace F. Napolitano (D-California) submitted to the
first session of the 108th Congress Resolution 292 (HCON 292 IH)
"expressing that Congress should adopt and implement the goals and
recommendations provided by the President's New Freedom Commission on
Mental Health through legislation or other appropriate action to help
ensure affordable, accessible, and high quality mental health care for
all Americans." A three-term Congresswoman who won re-election to the
38th District with 71% of the vote, Napolitano seemed like the safest
choice to submit the incendiary bill. A champion of mental health
needs, Napolitano was named "Legislator of the Year" by the National
Mental Health Association for fouding the Congressional Mental Health
Caucus and securing $500,000 for a school-based mental health program
to curb suicides in Hispanic females (Latina Adolescent Mental Health
Program). On October 6, Resolution 292 was referred to the Health
Subcommittee of the Committee on Energy and Commerce chaired by
Representative Michael Bilirakis (Florida) and Charlie Norwood
(Georgia). An attempt by Rep. Ron Paul to add language to the omnibus
spending bill (Labor, HHS, and Education Appropriations Act for FY
2005) to require parental consent for any mental-health screening of
children with federal money failed to garner more than 95 votes. With
the defeat of the parental consent provision, federal bureaucrats move
one step closer to an authority to order an inestimable number of the
nation's youth to take psychotropic drugs.
What You Can Do
But there is still time to put an end to this.
You can express your displeasure directly to the committee
electronically http://energycommerce.house.gov/107/feedback.htm or by
phone.
Phone calls are a quick and effective way to voice your opinion. The
phone will be answered by a member of the Representative's staff. Say
that you would like to give your views on Resolution 292 that the
Health Subcommittee will soon be considering.
You may also e-mail members of the subcommittee individually, or at
least those for whom e-mail addresses are available. If an e-mail
address is unavailable, and if you wish to contact the representative
electronically rather than by phone or letter, go to
http://www.house.gov/writerep/. Select a State from the drop-down menu
and type in a zip code for the Representative (I will provide the state
and zip code information for some representatives below).
Contact Information for Members of Health Subcommittee
Rep. Michael Bilirakis, Florida [zip: 33618-4404] (Chair) (by D.C.
office phone 202.225.5755 or home district phone 813.960.8173)
Rep. Charlie Norwood, Georgia [zip: 30907] (Vice-Chair) (by phone at
D.C. office 202.225.4101 or home district phone at 706.733.7066)
Rep. Ralph M. Hall, Texas rmh...@mail.house.gov (by phone at D.C.
office at 202.225.6673 or by home district phone at 972.771.9118,
903.892.1112, or 903.597.3729)
Rep. Fred Upton, Michigan [zip: 49007] http://www.house.gov/writerep/
(by D.C. office phone 202.225.3761 or fax 202.225.4986)
Rep. James C. Greenwood, Pennsylvania [zip: 18901]
http://www.house.gov/greenwood/contact.shtml
(or by D.C. phone at 202.225.4276 or home district phone at
215.348.7511)
Rep. Nathan Deal, Georgia [zip: 30721]
http://www.house.gov/deal/contact/default.shtml
(or by phone at D.C. office 202.225.5211 or home district 706.226.5320)
Rep. Richard Burr, North Carolina richard....@mail.house.gov (or
by phone at D.C. office 202.225.2071 or at home district 336.631.5125)
Rep. Ed Whitfield, Kentucky ed.whi...@mail.house.gov (or by phone at
D.C. office 202.225.3115 or at home district 270.885.8079,
270.487.9509, or 270.826.4180)
Rep. Barbara Cubin, Wyoming Barbar...@mail.house.gov (or by phone
at D.C. office 202.225.2311)
Rep. John Shimkus, Illinois [zip: 62704]
http://www.house.gov/shimkus/emailme.htm
(or by phone at D.C. office 202.225.5271 or home district 217.492.5090)
Rep. Heather Wilson, New Mexico ask.h...@mail.house.gov (or by phone
at D.C. office 202.225.6316 or home district office at 505.346.6781)
Rep. John B. Shadegg, Arizona j.sh...@mail.house.gov (or by phone at
D.C. office 202.225.3361 or home district office at 602.263.5300)
Rep. Charles "Chip" Pickering, Mississippi [zip: 39301] (or by phone at
D.C. office 202.225.5031 or home district 601.693.6681)
Rep. Steve Buyer, Indiana [zip: 47960] (or by phone at D.C. office
202.225.5037 or home district office 574.583.9819)
Rep. Joseph R. Pitts, Pennsylvania pitts...@mail.house.gov (or by
phone at D.C. office 202.225.2411 or home district office at
610.444.4581, 610.374.3637, or 717.393.0667)
Rep. Mike Ferguson, New Jersey [zip: 07059]
http://www.house.gov/ferguson/get_address2.shtml
(or by phone at D.C. office 202.225.5361 or home district office
908.757.7835)
Rep. Mike Rogers, Michigan [zip: 48912]
http://www.house.gov/mike-rogers/contact/ (or by phone at D.C. office
202.225.4872 or home district office 517.702.8000)
Rep. Sherrod Brown, Ohio she...@mail.house.gov (or by phone at D.C.
office 202.225.3401 or home district office at 440.245.5350,
330.865.8450, or 440.365.5877)
Rep. Henry A. Waxman, California [zip: 90048]
http://www.house.gov/waxman/contact.htm
(or by phone at D.C. office 202.225.3976 or home district office at
323.651.1040, 818. 878.7400, or 310.652.3095)
Rep. Edolphus Towns, New York [zip: 11207] (or by phone at D.C. office
202.225.5936 or at home district office at 718.272.1175)
Rep. Frank Pallone Jr., New Jersey frank....@mail.house.gov (or by
phone at D.C. office 202.225.4671 or at home district office at
732.249.8892, 732.571.1140, or 732.264.9104)
Rep. Bart Gordon, Tennessee bart....@mail.house.gov (or by phone at
D.C. office 202.225.4231 or at home district office at 615.896.1986,
931.528.5907, or 615.382.9712)
Rep. Anna G. Eshoo, California anna...@mail.house.gov (or by phone at
D.C. office 202.225.8104 or at home district office at 650.323.2984,
408.245.2339, or 831.335.2020)
Rep. Bart Stupak, Michigan stu...@mail.house.gov (or by phone at D.C.
office 202.225.4735 or at home district office at 989.356.0690,
906.875.3751, or 906.786.4504)
Rep. Eliot L. Engel, New York [zip: 10463] (by phone at D.C. office
202.225.2464 or home district office at 718.796.9700, 845.735.1000, or
914.699.4100)
Rep. Ron Paul ( http://www.house.gov/paul/mail/welcome.htm) may also
want to hear from you if he is compiling letters or a list of
opponents.
You may also express your displeasure with one or more of the bill's
other 33 co-sponsors (e-mail addresses forthcoming):
Rep. Patrick Kennedy (D-RI)
Rep. Edolphus Towns (D-NY)
Rep. Lloyd Doggett (D-TX)
Rep. Fortney Stark (D-CA)
Rep. Carolyn Kilpatrick (D-MI)
Rep. Anna Eshoo (D-CA)
Rep. Jose Serrano (D-NY)
Rep. Dennis Cardoza (D-CA)
Rep. Timothy Murphy (R-PA)
Rep. Michael McNulty (D-NY)
Rep. Maurice Hinchey (D-NY)
Rep. Martin Frost (D-TX)
Rep. Chris Bell (D-TX)
Rep. Howard Berman (D-CA)
Rep. Louise McIntosh Slaughter (D-NY)
Rep. Brian Baird (D-WA)
Rep. Ron Kind (D-WI)
Rep. Henry Waxman (D-CA)
Rep. Lucille Roybal-Allard (D-CA)
Rep. Juanita Millender-McDonald (D-CA)
Rep. Carolyn McCarthy (D-NY)
Rep. Dale Kildee (D-MI)
Rep. Gary Ackerman (D-NY)
Rep. Raul Grijalva (D-AZ)
Rep. George Miller (D-CA)
Rep. Danny Davis (D-IL)
Rep. Julia Carson (D-IN)
Rep. Elijah Cummings (D-MD)
Rep. Jim McDermott (D-WA)
Rep. Chris Van Hollen (D-MD)
Rep. Barbara Lee (D-CA)
Rep. Marcy Kaptur (D-OH)
Rep. Anibal Acevedo-Vila (D-PR)
By using public schools as children's mental health centers, parents
may find themselves not only unable to stop the screening, but also at
a disadvantage as far as monitoring the process. As a parent, I would
have never thought to accompany my child to school the day of the
routine check for head lice, but just how involved will I be allowed to
be when the school determines my child needs to be referred out for
therapy? The legislation has not been processed in committee. Many of
the details in this paint-by-numbers approach to mental disorder
screening still need to be filled in. Other guidelines may be watered
down. But a cautiously alarmist position is required to address a
series of unspecified guidelines as they gestate in committee and
before the public recovers the eventualities like a descending capsule
on NASA radar after the black out. A computer test like that developed
by Orwellian-named model program "TeenScreen" composed of only 15 items
and yielding no DSM diagnosis may seem no more invasive than having
your finger pricked or turning your head to cough while someone other
than you or your spouse pinches your testicle. However, there is a lot
to consider because, in actuality, even this E-Z take and E-Z score
exam is potentially more comparable to a public proctology exam than a
pin-prick, setting in motion a comitragic sequence of events that may
bare false witness about your true condition and may require that you
submit to remedies more damaging than the disease.
Children are not the only population targeted for this invasive
screening. Imagine a world where you're forced to get a mental health
evaluation whenever you need medical help of any kind. You can be
required to submit to a psychological evaluation administered by
hospital staff while your waiting for back surgery. Moreover, you are
not exempt from the mandatory screening if you do not have a history of
mental illness. You are not exempt from the mandatory screening if you
do not exhibit clear signs of mental illness. The language of the bill
gives the Commission authority to impose its subjective vision of
mental hygiene on anyone and everyone. In the words of the Commission's
Final Report:
The Commission supports implementing systematic screening procedures to
identify mental health and substance use problems and treatment needs
in all settings in which children, youth, adults, or older adults are
at high risk for mental illnesses or in settings in which a high
occurrence of co-occurring mental and substance use disorders exists.
In addition to specialty mental health and substance abuse treatment
settings, screening for co-occurring disorders should be implemented
when an individual enters the juvenile or criminal justice systems,
child welfare system, homeless shelters, hospitals, senior housing,
long-term care facilities, nursing homes, and other settings where
populations are at high risk. Screening should also occur periodically
after an individual enters any of these facilities...When mental health
problems are identified, children, youth, adults, and older adults
should be linked with appropriate services, supports, or diversion
programs. Additionally, given the high incidence of substance use
disorders among parents of children in the child welfare system, where
indicated, these parents should be screened for co-occurring disorders
and linked with appropriate treatment and supports.
Earlier this week the issue was brought to the attention of Wyatt
Ehrenfels, and Ehrenfels was asked to address the daunting prospect of
giving mental health care providers control over our lives. "To a
certain extent I sympathize with the rather fierce and hysterical
professionalism legislators like Napolitano have thrown at the issue of
teen suicide and discrimination against the mentally disabled. But as I
will make clear in my report, there are less invasive ways to ensure
support and services for persons with mental illness. And in the report
that follows, you will also understand the consequences of implementing
the Commission's recommendations.
The meddling officiousness and general invasiveness of the Commission
went largely unexplored until Jeanne Lenzer of conservative e-zine
WorldNetDaily issued her report (06.21.04) alleging plans by the
President "to screen the whole U.S. population for mental illness" as
part of a "sweeping initiative to link diagnoses to treatment with
specific drugs." Dave Eberhart of NewsMax.com (11.11.04) writes that
"under new law being considered, the federal government would require
that every child in America undergo psychological screening and receive
recommended treatment, including drug therapies." Even Association of
American Physicians & Surgeons (AAPS) officials, led by surgeon and
Representative Ron Paul, M.D. (R-Texas) denounced what they described
as "a dangerous scheme that will heap even more coercive pressure on
parents to medicate children with potentially dangerous side effects."
The idea is particularly ghoulish to anyone familiar with Psychology's
model of training and professional development, like author and social
psychologist Wyatt Ehrenfels, who has spent the better part of the last
three years raising questions about the health of Psychology's academic
and professional communities. "[Psychologists] were ineffective but
largely benign when their policies and procedures subverted scientific
requirements for institutional aims and when their personal prejudices
targeted the careers of individuals whose personalities did not present
the academic community as a group with the perfect fit and paragon of
mental hygiene. But all this talk in the Commission report about
bridging a soon-to-be-expanded workforce of mental health professionals
to public communities like schools is all shades of ominous." Largely
an exposé, Ehrenfels's 800-page Fireflies in the Shadow of the Sun
incorporated a couple of fictitious subplots to symbolize the broader
implications of Psychology's policies, procedures, and prejudices, but
Ehrenfels admits to being spooked by the spate of recent events in
which these hypothetical events are playing out in reality, including a
comprehensive White House initiative to give psychologists more control
over our lives. Having been completed in late 2000 (published 2004),
the book identifies a Democratic White House as the source of the
malfeasance. "I always thought it would be the other party, with its
appetite for regulation and its emphasis on political correctness and
sensitivity training, that would foster a culture of officious meddle,"
commented Ehrenfels, adding that "the effort to combat the
stigmatization of mental illness will likely backfire by producing a
culture of mental illness comparable to the race consciousness
buttressed by their high-octane, steroid-enhanced brand of diversity
and multiculturalism."
The incendiary language is contained in Chapter 4 of the Commission's
final report, titled Early Mental Health Screening, Assessment, and
Referral to Services Are Common Practice. In the section Early
Assessment and Treatment Are Critical Across the Life Span, the
Commission writes:
"Quality screening and early intervention should occur in readily
accessible, low-stigma settings, such as primary health care facilities
and schools...The extent, severity, and far-reaching consequences make
it imperative that our Nation adopt a comprehensive, systemic approach
to improving the mental health status of children...For consumers of
all ages, early detection, assessment, and linkage with treatment and
supports can prevent mental health problems from compounding and poor
life outcomes from accumulating. Early intervention can have a
significant impact on the lives of children and adults who experience
mental health problems. Emerging research indicates that intervening
early can interrupt the negative course of some mental illnesses and
may, in some cases, lessen long-term disability. New understanding of
the brain indicates that early identification and intervention can
sharply improve outcomes and that longer periods of abnormal thoughts
and behavior have cumulative effects and can limit capacity for
recovery.
Clearly, school mental health programs must provide any screening or
treatment services with full attention to the confidentiality and
privacy of children and families...The Commission recommends that
Federal, State, and local child-serving agencies fully recognize and
address the mental health needs of youth in the education system. They
can work collaboratively with families to develop, evaluate, and
disseminate effective approaches for providing mental health services
and supports to youth in schools along a critical continuum of care.
This continuum includes education and training, prevention, early
identification, early intervention, and treatment...The Columbia
University TeenScreen® program provides a model for early
intervention.
Treatment Algorithms Triggered by DSM Diagnoses: DSM Diagnostic
Categories Inherent Subjective
Arbitrary. Treatment algorithms are triggered by diagnoses. The
diagnostic categories are provided by The Diagnostic and Statistical
Manual of Mental Disorders (DSM) published by the American Psychiatric
Association. The DSM disorders are inherently subjective
classifications created arbitrarily in social committes as a
professional convenience, namely to give a community of 400+ schools of
psychotherapy a common language with which to address one another and
sources of third party reimbursement (i.e. insurance companies).
Unreliable. Evidence suggests that trained professionals do not
reliably draw the same conclusions regarding classification of
individuals using the DSM, and not all clinical psychologists are
trained to make differential diagnoses, those tough calls between
related but distinguishable disorders or disorders with similar
presentations at different stages.
Calcified. The DSM is arguably responsible for retarding scientific
progress in clinical psychology. Ever since faculty search committees
began using their fetish for external funding sources to thin their
stack of applications, psychological researchers started pursuing
grants like the Grail. And since funding agencies tend to award grants
for proposals clad in DSM diagnostic nomenclature, the DSM became
Biblical, which is to say, Da Vinci code for a map of the psychological
landscape. The DSM has become the universal language of clinical
researchers, driving psychological inquiry into a Holland tunnel
between a Gotham Psychology and... well... Jersey. The institution-wide
epidemic of selection attention that ignores normal psychopathology and
fractures the human condition into pieces beyond the skills of All the
Kings Horses and All the Kings Men is such that bold new ways of
thinking about psychopathology become systemically impossible. Any
progress in mental health research is measured in units of miniscule
deviation from a disorder as presented in the DSM.
Homogenizing. If we are going to customize treatment, which is to say
develop individual treatment plans as called for by the Commission, it
will require substantial case conceptualization skills on the part of
the psychologist to offset the DSMs dehumanizing and deindividuating
classification scheme. Having trained with psychologists and
understanding the effects of the training model from both a behaviorist
and evolutionary perspective, I have no confidence in the case
conceptualization skills of the all-too-common psychologist. And let's
face it -- when the Commission speaks of "individual" treatment plans,
it really means finding the right DSM category for the individual. That
is a far cry from true customization.
Materialistic/Medical Model Means Medication Is Never Far Away. The DSM
carves in stone sets of symptoms as they typically cluster across a
population and thus likely reflect an organic contribution. And this
should come as no surprise to anyone who knows the manual is published
by the American Psychiatric Association. The DSM is based on an
implicit medical model of psychopathology, meaning that for many mental
health professionals, the thought of a psychpharmacologic agent is
reflexively triggered by the thought of a DSM disorder. Once you or
your son or daughter is diagnosed with a DSM disorder (Generalized
Anxiety Disorder), or even an associated feature (Anxiety), the
diagnosing mental health professional or any other mental health
professional examining the file down the road, will consider
medication.
Most Psychotropic Medications Not FDA Approved for Use in Children.
Since the vast majority of drugs are not tested on children (who would
volunteer their child for such an experiment?), the effects of various
drugs on children is unknown except for the anecdotal evidence amassed
for drugs that become necessary to treat some medical
(non-psychological) condition. Recently, preliminary research suggested
that Prozac, the only antidepressant certified as safe for children,
may make kids more suicidal. (other major antidepressants prescribed
for kids already have been found to raise the risk of suicidal
behavior). In March, 2004 the FDA requested drug companies relabel ten
antidepressants to warn parents that young patients should be watched
for worsening depression and anxiety. Dozens of parents had testified
at a hearing that antidepressants caused their children to kill
themselves. An FDA advisory panel chairman opened many eyes to the
problem of individual differences when he stated that antidepressants
seem to generate more suicidal behavior in some, but prevent suicide in
others. While child or teen depression can pose critical risks to life
and health, wouldn't you want to exhaust your treatment options before
resorting to medication, rather than taking the advice of a mental
health professional recommending medication as an adjutant treatment?
Wouldn't you want to know whether you're dealing with a mental health
professor who knows the difference between a psycho- or exogenic
depression and a biological one? Because not all depressions are equal.
I was depressed for weeks after learning someone had broken my high
school record in the 600 meter track event. I was also depressed to
learn that one of my very pretty 21-year-old high school teachers, for
whom I had a bit of a thing, announced her engagement to some gomer
(well, okay, she didn't actually call him a "gomer" and I didn't know
him, but didn't I owe it to myswelf in that condition to assume he's a
gomer?). I was down and -- who knows? -- maybe an antidepressant would
have picked me up. But maybe other things would have picked me up.
Maybe allowing myself to feel depressed and then psychologically
resolving the depression helped me to grow -- to mature -- to channel
my mood in artistic creations and athletic achievements -- and to learn
to fall for women within one standard deviation of my age. Maybe an
antidepressant would have killed me. One thing I know for sure is that
psychologists themselves, by 'medicating their therapeutic model'
(co-opting the DSM from psychiatrists and lobbying for prescriptive
authority for them or their ilk), have denied themselves an opportunity
to grow and mature as therapists. Psychologists have adopted a
materialistic bias that has caused them to foreclose on many issues and
phenomena as brain-based and, by waiting for colleagues to solve the
riddles of the world in a test tube called the cranium, have
relinquished their responsibility to actually use their own brains in
favor of templated treatment protocols and prescription pads. When my
PC kept freezing up on me and my monitor displayed my icons in a funky
color, I correctly diagnosed the problem as a hardware problem and
opened my tower case to a replace an aging video card, but not
everything I see on my screen can be fully explained by what's inside
the tower case and monitor. While these are clearly invaluable in
running the PC, I wouldn't be able to perform the vast majority of my
tasks without software. Think about that before you dismiss the mind as
a linquistic proxy for what is not yet known about the brain or as a
pork byproduct of so many firing neurons. You would not be at all
satisfied if I tried to use the Big Bang Theory to explain the
recession of 2000. Well, generic brain-based explanations have that
same homogenizing effect on people. At least in the medical field, the
roles of doctor and scientist can be bridged by medical tests that
afford the physician a fairly accurate picture of exactly what is
happening inside a person at a given moment. A battery of artfully
designed psychometric and projective tests (I see some used in clinical
assessment, though seldom in clinical research), can do the same for a
psychological profile of an individual, but I don't hear the Commission
recommending we use MMPIs, MMCIs, and Rorschachs as screening devices.
The tests are just too long and expensive (the MMPI is about 550
questions) and psychologists want to limit exposure to these tests to
those who really need them when they really need them. They can be
effective, especially when combined with other tests in a
hypothesis-driven battery. How probing do you think the 15-item
TeenScreen device will be? I haven't seen the test, but if this is an
omnibus test assessing for multiple disorders, I would expect a list of
such state-of-the-art items as "1. I feel depressed...2. I am giving
serious thought to ending my life. 3. I feel anxious...4. I am seeing
things that are not really there", but if this a test of a single
disorder (e.g. depression) and if I know my Tests & Measurements, I
would have to say that the test author opened his Thesaurus and found
fourteen different ways to re-word the first question, "1. I feel
depressed?" to get the minimum required coefficient of internal
consistency (e.g. Cronbach's alpha). In either case, all the screening
may amount to is a paper-and-pencil subsitute for asking the child
whether he or she does not feel right. And if the child uses his or her
pencil or keyboard to say 'no' (and according to TeenScreen, its tests
have a 30-35% positive rate), you have automatic referrals for therapy
for 400-420 students in the 1,200-strong high school mandated for
further clinical evaluation. I am beginning to understand why I have
not seen mental health professionals asking tough questions of the
Commission plan. So far, all this may be benign enough, but what is the
obligation of parent and child after the initial consultation or
intake? And where is this sequalae of events recorded? Hopefully not in
the school's file system. And more to the point, what happens next?
Medical Treatment in Non-Medical Science. Unlike an abnormally high
level of creatine in a CBC report, the level of anxiety or depression
in the 'mental bloodstream' is fraught with interpretation problems.
Our science has not developed to the point where we can say anything
meaningful about an individual's occupational functioning and quality
of life based on a score of x on this or that paper-and-pencil
questionnaire. The methods used to establish the psychometric
properties of a questionnaire -- what we know about a questionnaire's
reliability and validity -- is based on aggregate data. Seldom if ever
do psychological researchers treat individuals as a series of n = 1
experiments, following a series of individuals over an extensive period
and examining each of them indepth. We never really look at variance
within individuals, preserving that person's integrity and
individuality and drawing conclusions within the person before
extracting commonalities across persons. No. What we do is the
statistical equivalent of grinding individuals through an industrial
sausage press, generating rules for which the vast majority of
individuals are, to one degree or another, exceptions. So even if a
reliable instrument is used to diagnose an individual as having this or
that disorder, know that this does not mean we can be reasonably
certain the individual has that disorder. There will be false
positives, and this is not acceptable where we are forcing individuals
without cause and with no known history of psychopathology to submit to
these questionnaires. There will be cases where the burden will fall on
individuals testing positive on such and such a questionnaire to prove
in a follow-up intake with a mental health professional that they are
not certifiably anxious or depressed. And since the DSM is an
implicitly medical classification scheme, psychotropic medications will
always be regarded as a prospective treatment for the individual,
depending on the algorithm or the subjective preference and philosophy
of the professional.
A Diagnostic Culture: Sensitive Diagnosticians, Stubborn Labels. There
will be cases where mental health professionals assign trait-like
status to what are actually normal states. By this I mean that
individuals, especially children, are given to 'just passing through'
this or that psychological condition developmentally or situationally.
Unfortunately, the culture of assessment and diagnosis is prone to
viewing varying weather patterns as climatology. I all-too-often
witnessed this firsthand during my graduate training. Psychology
professors loved to diagnose their graduate students, if not with a DSM
disorder, then with some character flaw. They were always telescoping
classroom attitudes and behaviors, drawing characterological inferences
from them and then broadcasting these impressions to the rest of the
truth-squading faculty during an end-of-academic-term witch hunt
masquerading as an academic performance and progress evaluation
meeting. Once the student was saddled with this slanderous
characterological designation, he was listed as a subject for intense
and enduring scrutiny and effectively case managed for the remainder of
his or her career as a graduate student. Expectations were
recalibrated, and a case was built against the student's
"professionalism" and "fit." Everything "went in the file." In most
cases, the professors ended up seeing things they never would have seen
if they did not have their radar on, and despite the fact the
professors as individuals did not have a problem with the student, they
all labored under this free-floating idea that the student, having been
indicted by the faculty as a whole, is a problem and that, as a
professor, there was still due process yet to be meted out. The
professor felt responsible to rule one way or another on the student's
behavior in his or her classroom or in capacity as his or her
teaching/research assistant and, to appear useful and credible, no
report on the student was ever completely clean. There would always be
at least traces of the character diagnosed/indicted by the faculty, and
even if the reporting professor did not think the reported traces would
make trouble for the student, at least one other faculty member would
perceive the traces as evidence of an unwillingness or inability to
adjust on the part of the student.
The Assessment Tools: Just How Will the Individual Child or Adult Be
Diagnosed
Just how will the individual child or adult be diagnosed? The
Commission tauts the not-for-profit foundation-funded Columbia
University TeenScreen® Program as a model youth screening program, the
goal of which is "to ensure that all youth are offered a mental health
check-up before graduating from high school. TeenScreen® currently
identifies and refers for treatment those who are at risk for suicide
or suffer from an untreated mental illness in 69 middle/high schools
across 27 states. However, the one feature of the TeenScreen® Program
the Commission seeks not to emulate is its parental consent provision.
In the TeenScreen® Program, "all youngsters in a school, with parental
consent [emphasis added], are given a computer-based questionnaire that
screens them for mental illnesses and suicide risk. At no charge, the
Columbia University TeenScreen® Program provides consultation,
screening materials, software, training, and technical assistance to
qualifying schools and communities. In return, TeenScreen® partners
are expected to screen at least 200 youth per year and ensure that a
licensed mental health professional is on-site to give immediate
counseling and referral services for youth at greatest risk...When the
program identifies youth needing treatment, their care is paid for
depending on the family's health coverage." In light of the fact many
of the students identified as at-risk by the program did not seek
mental health services, the Commission reported that its biggest
challenge is to "bridge the gap between schools and local providers of
mental health services and, in times of fiscal austerity, to ensure
that schools devote a health professional to screening and referral."
The Columbia University TeenScreen® Program is pilot-testing a shorter
questionnaire that is less costly and time-consuming for the school to
administer and it also trying to adapt the program to primary care
settings. Since the TeenScreen® does not offer a diagnosis (indicating
only the likelihood of a mental health problem), TeenScreen®
recommends (and Commission legislation may require) that all screening
tools be followed up by a clinical interview with a trained mental
health professional to determine if further evaluation is needed.
Follow-Up with Whom?Mental health professionals come in many shapes and
sizes. There are school psychologists, clinical social workers (M.S.W),
clinical Psy.D. psychologists with a potentially solid background in
assessment and treatment modalities, clinical Ph.D. psychologists whose
graduate training may have emphasized research skills, and M.D.
psychiatrists. Will the student be referred to the inhouse school
psychologist? With all the talk in the report of bridging gaps between
schools and local providers of mental health services, the legislation
may fund the hiring of part-time contractual mental health
professionals, or may send the student out into the community. But I'd
be interested to note whether the legislation places any requirements
on the class of mental health professional. Clinical social workers
come cheap. With only master's level degrees and no greater than a year
of practical clinical experience, inexpensive social workers tend to be
the choice of cash-strapped clinics or hospitals to staff mental health
service positions. Only psychologists are sufficiently trained to
administer, interpret, and report most questionnaires, but a computer
questionnaire developed by the likes of TeenScreen (especially a short
15-item version) may not require much expertise and may breed a new
class of specialist familiar with this one test, or may require the
inhouse school psychologist (or for that matter, all mental health
professionals) to be familiar with the test. If treatment algorithms
like those used in Texas are adopted nationally, could a TeenScreen
test outcome indicating psychotic or suicidal features require a direct
referral to a psychiatrist?
Treatment Algorithms. A Texas-Size Boondoggle?. Critics of the plan
suggest that the random testing of millions of people makes little
sense to anyone but the drug companies that will stand to profit from
the potential customers. The New Freedom Commission's proposed
treatment programs are based on the Texas Medication Algorithm Project
(TMAP). TMAP, started in 1996, is designed to develop, implement and
evaluate not just a set of medication algorithms, but an
algorithm-driven treatment philosophy for major adult psychiatric
disorders treated in the Texas public mental health sector. The
ultimate goal of TMAP is to improve the quality of care and achieve the
best possible patient outcomes for each dollar of resource expended.
TMAP is a treatment philosophy for the medication management portion of
care. According to TMAP's web site, the phased development and
evaluation of the treatment guidelines begins with the creation of
algorithms, specific stepwise graphical sequences, through what is
called "consensus conferences" (i.e. scientific evidence and expert
clinical consensus). In layman's terms, the committee agrees
(remarkably without a sole voice of dissent) to a set of best practices
concerning the use of specific psychotropic drugs for each of a number
of mental disorders. Knowing that the science is not that advanced (and
is also conflictual), Wyatt Ehrenfels smiles mockingly at the unctuous
discussion of consensus, no doubt proferred to pre-emptively slam the
door on dissent by attempting to overwhelm the inevitable critic with
the sheer brute force of a socially engineered "unanimity of experts."
The figure below illustrates a TMAP algorithm developed for
non-psychotic depression:
In an exclusive interview with NewsMax, Representative Paul likened the
program to a "therapeutic nanny state," adding "it's not hard to
imagine a time 20 or 30 years from now when government psychiatrists
stigmatize children whose religious, social, or political values do not
comport with those of the politically correct, secular state."
Wyatt Ehrenfels presented an array of concerns over the false positive
rate associated with paper-and-pencil questionnaires in the TeenScreen
program (Columbia Health Screen; Columbia Depression Scale; Diagnostic
Predictive Scales; Columbia Health Screen). "I am concerned primarily
about precedent. Right now, it would appear from the examples that are
being pushed to the front of this slideshow that the schools will
screen for debilitating forms of likely biologically-based disorders of
mood and anxiety. If this is the case, then it would support the fears
of parents and professionals like Dr. Paul that mental health
professionals would require the administration of psychotropic
medication to our children and administer these drugs by way of the
TMAP algorithms. The fears grow exponentially when we consider any
NFC-empowering legislation in light of an independent movement to vest
non-medically-trained clinical psychologists with prescriptive
authority. The American Psychological Association, which threw its
weight behind the prescriptive authority movement, recently went on the
record to applaud the Final Report of the President's New Freedom
Commission on Mental Health. For details, I would have referred you to
any one of a number of links on the American Psychological Association
web site to APA press releases about the legislation (e.g. "APA
Applauds Final Report of President's New Freedom Commission on Mental
Health"), but the links are uncharacteristically and unanimously
broken, including a report boasting the President's selection of an APA
member for the Commission. For any of you who doubt the political clout
and determination of the American Psychological Association, I remind
you that this political engine managed to persuade New Mexico
legislators to grant psychologists with no medical training the
authority to prescribe medication over the objections of the
bewilderdingly outmaneuvered and outsmarted American Medical
Association and American Psychiatric Association. In addition to the
APA Public Policy Office, the administratively and politically
hyperactive-but-inattentive APA includes a Public Education Campaign, a
psychology-in-the-media listserv, a Practice Directorate with "Lobbying
Facts Sheets" and "Advocacy Alerts", an Office of Policy and Advocacy
in the Schools (the APA is currently trying to standardize content for
high school psychology curricula), and a Science Student Council
(APASSC).
Just imagine what a Brave New World could be created when
psychiatrists, pharmaceutical companies, and a critical number of
psychologists, backed by the American Psychological Association, join
forces to implement a vision of community mental hygiene.
The Potential for Abuse
But I am also thinking ahead. Whatever 'algorithms,' for lack of an
honest word, are adopted to treat these compelling mood and anxiety
disorders, I suspect it would not be long before some psychologist or
federal bureaucrat seeks to make his or her mark on the world by
expanding algorithms beyond the non-psychotic depression to
non-clinical forms of normal psychopathology, and even personality,
seeking to brand every child who does not play well with others.
Psychology's academic communities tend toward this state of affairs, as
witnessed by the CV of the APA's administrative savant that boasts a
sole responsibility for changing the way we indent paragraphs...and by
the incorrigible propensity of trigger-happy diagnosticians within
graduate faculties to assassinate student personalities in
end-of-academic-term evaluation meetings under the guise of evaluating
academic performance and classroom attitudes. In the NFC, we find
recommendations to feed a common urgeb to paternalism among
psychologists and politicians.
Practically speaking, I am also concerned by the absence of
reassurances the diagnostic information about the child will not be
made available to a teacher for use as a tool in the personality
conflict with a student. There will be teachers who will give in to the
urge to use the diagnoses to skew their perception of the student or to
defend the assignment of grades and tasks that make the previously
unlabeled condition part of the student's day-to-day legacy. As a
student who knows what it's like to have been embattled in graduate
school, I distinctly remember the rather odd behavior from faculty at
during the stretch they confined their perceptions of me to meetings
behind closed doors. Not until that end-of-academic term faculty
meeting did the better part of a semester's behavior toward me make any
sense. My career was nearly posthumous by the time they came forward
with their concerns about me, and they did not seem interested in
offering me much of an opportunity to address them. Even though DSM
diagnostic constructs were not involved in the sustained indictment of
my professionalism and fit, this is where the psych profs demonstrated
a creativity with which they mobilized scientific gravitas around
otherwise informal, unsubstantiated, and recklessly arbitrary buzzwords
like 'professionalism,' 'arrogance,' 'collegiality,' and 'willingness
to adjust.' There would be nothing more abhorrent than to see the DSM
used as a defamation delivery device within middle schools.
Allocating government resources to ideologies organized around visions
like that of "a healthier Nation" has occassionally proven fatal in the
history of our civilization, especially when the vision requires so
many different and remote agencies to plug into one another. If the
number of instances in which the word 'integration' and 'consensus' are
used in connection with the NFC is any indication, we can be in for the
kind of cataclysm, conjuring images of George Orwell and Aldous Huxley,
that usually involves mass hysteria, post-traumatic stress, or
acopalyptic vision. The NFC envisions the aid of Everything from the
National Institutes of Health to the media to middle schools, and even
cites the usual marketing unmentionables-if-not-imponderables as
dialogue meetings, consumer-to-target audience, interpersonal contact
methods, and speaker's bureaus. The language even includes
"collaboration between the public and private sectors and close
coordination with consumers and other stakeholders is encouraged to
reduce the possibility of sending mixed messages or duplicated messages
to the public." Just what does this statement mean, anyway? It's
statements like these that prompt such questions as 'okay, I want a
complete list of everyone within the purview of the defined stakeholder
and 'what does it mean to mean to duplicate a message to the public?'
Often the cures bring about the very ills they were designed to prevent
and may be construed as a symptom of a latent disease in the
practitioner himself. And the name for the remedy typically includes
valuative terminology ("New Freedom") that will make the paradoxical
outcome even more painfully obvious.
Successfully transforming the mental health system, hinges, in part, on
better balancing fiscal resources to support using proven,
evidence-based practices. The Commission encourages public- and
private-sector payers to reframe their reimbursement policies to better
support and widely implement EBPs...The Commission urges the Centers
for Medicare and Medicaid Services (CMS) to provide technical
assistance to States on how to effectively finance EBPs.
"Okay. Being as youthful and neurotic as some of the children in the
targeted population, the science of Psychology has simply not
progressed to the point of proven, evidence-based practices. In many
cases, we have research pointing us in the direction of practices that
may work, even if we don't know or care why they work. Legislation like
this will no doubt stunt genuine scientific progress by making it
prematurely accountable to social goals and scrutiny, and by making
people's careers in science contingent on using or finding the next
proven thing. Once we introduced grants and other forms of funding into
the padding of CVs and the search for new tenure-track faculty, we
marginalized and corrupted phenomena that is not competitively suited
to this kind of incentive system. Do you think I can get very far
professionally staking my career on the study of dreams? The further
the phenomenon from the social and material context of the science, and
the further the theory or the methodology from unspoken aspects of the
'consensus,' the less likely it is to survive in a department of
Psychology, which is why we know so little about dreams and why,
metaphorically speaking, our science does not balance its technical
missions to Mars with its reconnaissance missions to relatively
chimerical Saturn. Once we cut the ribbons on some of these screening
and treatment algorithms, we will find them as difficult to change as
the Diagnostic and Statistical Manual of Mental Disorders on which they
are based. And if you think the DSM tunnels our vision of phenomenology
now, just wait until we add yet another layer of social legitimacy and
tie it into an even larger economic pie.
No Jacket Required
The Commission could achieve its goals of providing mental health
services to those who need it without having to enact such recklessly
compulsory and comprehensive legislation. One compromise would be a
selective referral system whereby better-trained primary health
providers, primary caregivers, and school officials could be trained to
identify problems in at risk children. But to pass every child and
adult through the gates of psychologically unsophisticated
psychologists and psychiatrists is not the answer. Integration within
the psychological community itself, through the dissemination of
arbirary and superfluous standards for research, teaching, and
professional training, has created a like-minded and brow-beaten
community of mindless drones, standard bearers, and administrative
savants. The stronger the network of shared expectations connecting
individual professionals, the greater the deterioration in the quality
of each professional's wits. Considered collectively, the screening
devices (assessment), the DSM (diagnosis), and the algorithms
(treatment), even where sprinkled with the subjective judgment of
dubiously trained mental health professionals, will combine to create
an historic defamation and stigmatization delivery device.
A Broad Chracterization of Psychology's Academic Communities
The psychological community is likely to support the Bill because the
Bill vows to expand the mental health professional workforce. The Bill
is also written by fellow mental health professionals, with a fiercely
professional rhetoric that appeals to the culture of standard bearers
and administrative savants that currently govern Psychology. Applying
everything I've learned about social and personality psychology to this
community, turning our lenses inward so to speak, I can trace much of
'who we are' and 'what we do' to dysfunctional social processes and
socially facilitated knowledge out of tune with reality. The best
treatment practices desired by the Commission cannot possibly be
derived from the practices that currently promote research and training
that itself suffers from ADHD. I am reminded of this long term facility
for the care of the elderly in my home town. The floral gardens around
the facility were always so vital and manicured, and the Chem Lawn
truck could often be seen parked outside. No one had any idea at the
time that residents inside the facility were being scalded by hot
shower water or starved to death by desultory staff who forgot to feed
them. Based on a superficial glance at its scientific and professional
persona, Psychology would come off as looking fairly diligently
organized and attentive. But this is only because it is trying to come
to grips with substantial internal disarray, and the methods and
products erected to conceal and compensate for the disorder achieves
little more than that.
Many of the standard operating policies and procedures that govern
everything in departments of Psychology, including knowledge
production, faculty selection, and professional training, fosters a
regulatory culture inconsistent with real academic freedom and
intellectual diversity. Ranking and aspiring members of the
psychological community alike are behaviorally reinforced and generally
socialized by an idea professional development that puts us at odds
with requirements for maturation, individuation, and genuine scientific
progress.
The structure of career inducements and incentives, the sheer
competition, a ubiquitously saturated labor market, and the zero sum
nature of employment in Psychology encourages an excessively,
gratuitously, and prematurely fierce professionalism -- a world of
arbitrary and superfluous 'standards' -- that have less standing in
science than in service to personal and institutional aims. To the
extent that an individual member reaches career milestones by
identifying with (or internalizing) these standards, in effect by
embodying the bloated epistemology of this field, the person's own
capacity for formulate independent judgments is compromised and,
consequently, the person is forced to rely on the external standards
(and the consensus of others it represents) to function as a mental
health professional. This is a vicious cycle of escalating
co-dependence and devotion.
Psychologists and psychology professors can present themselves as quite
altruistic. As you might imagine, they know how to make a good
impression and manage public perception. But if you look more closely,
you will see that the public relations persona conceals and compensates
for prejudices. For example, behind a fetishistic rhapsodizing about
multiculturalism/diversity -- behind a paternalistic regard for the
welfare of their students and the public -- is a hatred for a diversity
of ideas/interests -- a professorial campaign against individual talent
and freedom. There is a form of black-and-white thinking among
psychology professors, limiting the depth of their diversity so that it
is only skin-deep. In fact, graduate faculty despise products of
individual thought because it does not conform to established ways of
thinking codified in research and teaching policy governing everything
from the use of textbooks to the design of research. Most of the
psychologists I know hate people and want their clients to succumb to
their vision of adjustment to an external world. In other words, most
psychologists want to preside over the world's mental hygiene as police
officers and policy analysts. Nowhere is the disparagement of the
personal more evident than in our current view of professionalism.
Maturity, humanity, and individuation have come into conflict with this
regulatory mentality, a mentality that locates a person's most
significant activity outside the self. The self-indulgent ruminations
and readings of the classic scholar and the exploratory research of the
detective are treated as a lamentable dalliance and a shunning of
obligations that are considered socially productive. In departments of
Psychology, you are nothing if you are not a grant recipient, media
maven, program developer, or policy analyst. Whenever economic exigency
prompts a politician to consider cutting public funding for something
associated with mental health (e.g. sex research), the APAs policy
action committee mobilizes its 60,000+ strong membership, and e-tools
like listserv-disseminated public policy action alerts send
psychologists swarming like locusts over Capitol Hill (see APA Click
Away from Capitol Hill. Is it any wonder a university mantra like "the
pursuit of truth" could be abandoned in favor of "commitment to
excellence," measured -- how else? -- but in degrees of compliance with
policies and procedures?
Cynics might argue that the concept of 'development' currently deployed
by administrative savants is geared primarily to mass produce
serviceable standard-bearers for their academic and professional
communities. I am one of these cynics. And as a cynic, I intend to
advance my argument that broad acceptance for the deindividuating and
dehumanizing conception of professional development (as a schedule of
resume-ready achievements that meet requirements for the preservation
and advancement of a career) is antagonistic to our view of adult
maturation.