![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 10 to 34 of 35. Go back in thread:
Posted by alexandra_k on September 13, 2006, at 8:44:21
In reply to Re: internet and the manufacture of madness... » alexandra_k, posted by Dinah on September 13, 2006, at 6:31:39
> Wow. I'm wondering if that could be rewritten in more neutral terms. If I saw that on my receipt, I would never be able to drag myself back to that clinician and show my face.
Thats nothing, you should see some of their other ones!
;-)
> I think it might make me withdraw from people altogether, feel stigmatized by my illness, and feel dysphoric.
Its OTHER dx's that are supposed to make you do that... But wait... Maybe that particular dx confirms itself ;-)
> They're blaming the internet for that?
No. Sorry... I should have made that clearer. The first guys were saying they found 'good evidence' for a new kind of disorder. One that is (to be fair) induced by the taking away of dx label. The stress and identity confusion that people go through when they get a dx of a severe disorder taken away. So clinicians pronounce you cured (or alternatively dx'd i guess) and because your dx had become part of your identity (because of persistent posting to a site in support of people with that dx, lets say) you... increase problematic behaviours (as one example) in order to get the dx back again... That was their thought.
I just found this in hunting through the ICD. Thought it was interesting. Kinda semi sorta related, but not what they were talking about at all. This one seems to have more to do with the stigma around getting a dx in the first place.
> I wonder how much of it is iatrogenic.
You mean therapist / clinician / diagnostician induced? Well... They were the ones who handed out the dx so in a sense they are the proximal cause...
> I guess that's one of the secondary diagnoses they don't put on your receipt for insurance purposes. And I suppose my reaction would be why...Is it ICD code or DSM code that goes down for insurance purposes? I could be wrong... But I thought that DSM code was used in the US. That that was... A huge motivation for the DSM. The ICD provides general medical codes (it is used primarily to figure prevalence rates for diseases and such especially that figure on discharge forms and death certificates - i think).
But I guess it is kinda semi sorta related to fictitious disorder (which is a DSM disorder)... And of course there is always the good old NOS. Don't know how much medication / therapy / social intervention your average health insurance policy gives you for the treatment of that one anyways ;-)
Posted by Dinah on September 13, 2006, at 9:44:00
In reply to Re: internet and the manufacture of madness..., posted by alexandra_k on September 13, 2006, at 8:44:21
My pdocs put down both codes. My therapist puts down none at all.
I was going to say that this must be the only subspecialty where such judgemental terms are used in descriptions.
But then it occurred to me that that might not be true.
It would seem that there could be judgement neutral revisions.
Posted by Jost on September 13, 2006, at 22:00:07
In reply to Re: internet and the manufacture of madness..., posted by Estella on September 11, 2006, at 2:55:39
Did you mean Szasz?
as in Dr. Thomas Szasz?
also-- did you read the comments?
Is the original article there?
I read the first comment-- wow that guy needs an editor-- real bad.
He makes the original article sound pretty awful-- although I don't see how the internet plays into what he talked about.
I'll have to read more later-- but sounds fairly pernicious to me, at first glance. Not the internet part, but the part about there being "facts" about autonomy that are similar to facts about doing a high jump-- if you think the facts are calculable concrete details like "strength of one's legs" and "height of the jump"--
and also their analogy between the kind of automony that they're talking about and some type of moral or philsophical concept of autonomy. Iie according to the comment)
But I'll have to see if I have time to look at it.
Jost
Posted by alexandra_k on September 13, 2006, at 23:21:48
In reply to Re: internet and the manufacture of madness... » Estella, posted by Jost on September 13, 2006, at 22:00:07
> Did you mean Szasz?
> as in Dr. Thomas Szasz?yes indeedie do. he has been given an unnecessarily hard time imho. if you can access the above articles (which i guess you can) then i'll hunt down an article by Szasz which is fairly short so you can see what i'm saying if you like. i mean i disagree with some of his assumptions, but he isn't a raving loonie. he makes some very good points.
> also-- did you read the comments?yes i did.
> Is the original article there?first link is the original article.
second link takes you to the table of contents for that edition of the journal.
there are three responses / commentaries. well... two responses and one response to the response.> I read the first comment-- wow that guy needs an editor-- real bad.
lol. yeah i agree. thats why i said 'where do they find these people'? generally it is quite a good journal (imo) so that article surprised me greatly.
> He makes the original article sound pretty awful-- although I don't see how the internet plays into what he talked about.
yeah. though... i think in many respects the original article was pretty awful...
> I'll have to read more later-- but sounds fairly pernicious to me, at first glance. Not the internet part, but the part about there being "facts" about autonomy that are similar to facts about doing a high jump-- if you think the facts are calculable concrete details like "strength of one's legs" and "height of the jump"--i guess i'll have to read it again... i don't remember that part. i was browsing looking for something else but hit upon that. i'm more interested in the taxonomy debate and whether the notion of dysfunction / disability / illness is objective or essentially involves a value judgement.
> and also their analogy between the kind of automony that they're talking about and some type of moral or philsophical concept of autonomy. Iie according to the comment)i don't remember that either...
did sound a little like they thought that patient autonomy was a bad thing, however. see what happens? the loonies get ahold of the internet and congregate making themselves worse...
Posted by alexandra_k on September 13, 2006, at 23:27:18
In reply to Re: internet and the manufacture of madness... » Estella, posted by Jost on September 13, 2006, at 22:00:07
> I read the first comment-- wow that guy needs an editor-- real bad.
That would be this guy:
Harold Merskey, MA, DM, FRCP, FRCP(C), FRCPsych is Professor Emeritus of Psychiatry at the University of Western Ontario. He is widely published on neuropsychiatry, hysteria, pain, psychopharmacology, medical classification, and occasionally on psychiatric history and bioethics. Recent articles include "Pain Disorder, Hysteria or Somatization?" which was published in Pain Research & Management (2004) "The Persistence of Folly. A Critical Examination of Multiple Personality Disorder. Part I. The Excesses of an Improbable Concept. Part II. The Defence and Decline of Multiple Personality Disorder (by August Piper & Harold Merskey)," in the Canadian Journal of Psychiatry (2004). He can be contacted at 71 Logan Avenue, London, Ontario, Canada N5Y 2P9, or via e-mail at: harold.merskey@sympatico.ca.
:-)
Posted by alexandra_k on September 14, 2006, at 9:19:37
In reply to Re: internet and the manufacture of madness... » alexandra_k, posted by Dinah on September 13, 2006, at 6:31:39
> Wow. I'm wondering if that could be rewritten in more neutral terms.
what do you find to be not neutral about it?
(i'm serious. there is dispute about whether illnesses are objective or essentially value laden / judgemental so i'd be interested to know what you find value laden / judgemental about it)
Posted by Dinah on September 14, 2006, at 9:52:10
In reply to Re: internet and the manufacture of madness... » Dinah, posted by alexandra_k on September 14, 2006, at 9:19:37
I suppose this would be the sentence
"an excessive dependence on and a demanding attitude towards others"
It seems that there could be a more neutral way to put that. I had one yesterday, but I can't bring it to mind right now.
I think that the issue about rather pscyh diagnoses are value laden is a most important one. Clearly the mental health community itself has decided they *can* be, since they have removed various "illnesses" from the DSM. But I also get the feeling that the Axis II disorders especially are culturally based, and do have a values judgement built into them. An ideal of "healthy" that is tied into what the community values. Isn't it generally agreed that some disorders listed in the DSM (esp. Axis II) would not be considered disorders in some parts of the world? And that in other parts of the world, there might be diagnoses of people who weren't sufficiently affiliative? Clearly if someone could go to a different society with the same set of "symptoms" and be judged fine there, and ill here, then the judgement of illness is based on a lack of adherence to customary cultural norms rather than a true illness?
Posted by Phillipa on September 14, 2006, at 17:54:53
In reply to Re: internet and the manufacture of madness... » alexandra_k, posted by Dinah on September 14, 2006, at 9:52:10
Very true. The only example I have is not a country one but a region one. Up North if you walked around with a Bible in your hands in a psych hospital they would deem that you were religiously preoccupied. Which could lead to many AXIS ll dx. Now here in the South it's so common most patients carry them around read from them all the time. Love Phillipa
Posted by Jost on September 14, 2006, at 19:59:42
In reply to Re: internet and the manufacture of madness... » Jost, posted by alexandra_k on September 13, 2006, at 23:21:48
From the comment (which might not be about everything in the initial article), the article discussed severe neurological disabilities, and their relevance to patient autonomy. Not mental illness type disabilities--although perhaps they draw conclusions about that, too-- but it seemed more concrete types of neurological deficits.
He gave the case of John-- I wasn't sure what neurological deficits John had, but they were described as severe. More importantly, it seemed, John not only lacked the ability to recognize through his self- observation that he had a deficit, but also the ability to integrate information from others to that effect.
The authors seemed to use this to draw a conlcusion that a person with neurological deficits needed to be able either to observe the deficit and/or to take in information from others about the deficit to be able to have autonomy. Or that inability to do these things would impair or exclude autonomy.
Since I found myself disagreeing, on a basic level, with this premise--although it might have some truth too-- I didn't read that carefully. The commenter's view is probably closer to mine--
even more so, if the ideas that I mentioned before (about the high jump, eg) were applied to socalled "mental illness."
I'll look at the initial article, though--
Jost
Posted by Jost on September 14, 2006, at 20:04:02
In reply to internet and the manufacture of madness..., posted by Estella on September 11, 2006, at 1:06:07
yeah, the comment I read was:
Agich, George J., 1947- Seeking the Everyday Meaning of Autonomy in Neurologic Disorders
It was about a paper by Anderson, Joel, and Lux, Warren: "Knowing Your Own Strength: Accurate Self-Assessment as a Requirement for Personal Autonomy"
The article you cited did talk about the internet, so I'll read that.
I guess there were several articles and comments on them.
Jost
Posted by alexandra_k on September 14, 2006, at 20:30:00
In reply to Re: internet and the manufacture of madness..., posted by Jost on September 14, 2006, at 20:04:02
Ahhhhhhhhhhh.
I haven't read that article :-)
The first link I provided gave you a link to the article about the internet (I posted the abstract in my post).
The second link I provided gave you a link to the table of contents for the whole journal. The first article in the journal was indeed about patient autonomy. It is an interdisciplinary journal between philosophy, psychology, and psychiatry and sometimes the philosophers and psychologists worry about neurological conditions rather than more paradigmatic examples of mental illness, yeah. Some people think that neurological disorders should count as mental illnesses (being disorders of the mind after all).
If you scroll down through the table of contents...
You should find the article about the internet (the one I posted the abstract for). Just below that article there are two responses (sounds like you read the first of those) then the authors of the main article respond to the two respondants.
I did think I'd missed something...
:-)
Posted by alexandra_k on September 14, 2006, at 21:25:41
In reply to Re: internet and the manufacture of madness... » alexandra_k, posted by Dinah on September 14, 2006, at 9:52:10
> "an excessive dependence on and a demanding attitude towards others"
Okay :-)> I think that the issue about rather pscyh diagnoses are value laden is a most important one.
Yeah, there is a lot of debate...
> Clearly the mental health community itself has decided they *can* be, since they have removed various "illnesses" from the DSM.
Yeah, that is true. I guess the debate is fairly much around the issue of whether mental illnesses are *essentially* value laden or whether psychiatric classification can approximate the objectivity of... classification of clades in biology (for example).
According to the folk theory of biology whales are fish. Then the biologists come along and tell us that whales aren't fish they are mammals. According to folk theory of biology trees are a natural kind. Then the biologists come along and tell us that trees aren't a natural kind. There aren't any interesting generalisations that you can make about trees in general and whether something is a tree or a shrub can depend on climate and other environmental conditions.
The DSM has been critiqued for being something like a systematisation of folk theory of mental illness. A lot of the categories in the DSM haven't been validated and it is very unclear that you can make interesting generalisations on the basis of the current dx categories. Psychiatry isn't as well developed as a science as biology is. One of the hopes is that pscyhiatric nosology should improve so that it captures real kinds of mental illness.
There would be a problem with this approach if psychiatry was essentially value laden in a way that biology (as an example) is not.
Wakefield has been influential for his 'harmful dysfunction' analysis of mental disorder. He thinks that there are two components to mental disorder.
1) An (objective) dysfunction / disorder / disease within the individual.
2) A value judgement that that dysfunction / disorder / disease is bad.
He thinks that both conditions are necessary and that they are together jointly sufficient for mental illness.He has been critiqued on a number of grounds. With respect to his first condition, some have argued that the notion of disorder / dysfunction / disease is essentially value laden and hence the notion is not objective.
Medicine and some aspects of biology also make use of the notion of disorder / dysfunction / disease, however. If those notions are essentially value laden then psychiatry, medicine, and those aspects of biology would be in trouble with respect to being a proper (objective) science. Perhaps...
> An ideal of "healthy" that is tied into what the community values.
Perhaps... Though... If I break my leg then there wouldn't seem to be any problem in saying that my leg is objectively malfunctioning, disordered, or diseased. How I feel about my leg being broken, whether I think it is a 'good' or a 'bad' thing, however, would seem to be a seperate matter.
> Clearly if someone could go to a different society with the same set of "symptoms" and be judged fine there, and ill here, then the judgement of illness is based on a lack of adherence to customary cultural norms rather than a true illness?
The judgement is. But is there a fact of the matter about whether the person is ill or not? If you think dysfunction / disorder / disease is objective then it follows that people can be wrong with their judgements.
If mental illness is a neurological dysfunction / disorder in the sense that there are neural mechanisms that are malfunctioning then psychiatry (once we have hit upon the true natural kinds of nature) would seem to be similarly objective.
Some people argue that psychiatry, medicine, and biology more generally requires value judgement because you can't cash out function / malfunction (dysfunction or disorder) in a way that doesn't require value.
Ruth Millikan has done a lot of work (in philosophy) on how function / dysfunction can be cashed out in a way that doesn't require values (it is determined by physical facts and a historical notion of 'proper function').
e.g., the proper function of the heart is to pump blood. the heart does a lot of things besides pumping blood, however, it makes thumpity thump noises, for example. If the heart made thumpity thump noises rather than pumping blood then the organism would die, however. If the heart pumped blood but didn't make thumpity thump noises then the organism could be just as well off as a heart that pumped blood and did make thumpity thump noises. The heart was selected (by natural selection) in virtue of its pumping blood. Hence, the proper function of the heart is to pump blood.
You could say that treating survival as the organisms 'good' is to introduce values. But... seems to be a pan-cultural 'good' so thats okay. Maybe psychiatry can similarly cash out the notion of disorder, dysfunction or whatever in a naturalistic way that isn't interestingly value laden... Or maybe not. Even the biology case is controversial. Still, if psychiatry only requires values in the way that biology requires values then that isn't terribly interesting... Most people agree that biology is a proper objective science so there isn't such a problem.
Just some ravings (sorry I didn't have time to edit...)
I'm not sure what I think...
Whether it is possible for psychiatric taxonomy to be objective (similarly to biological classification of clades) or whether that will never work because classification essentially requires value judgements where the value judgements that are required vary across cultures...
I'm not sure what I think...
Is the term 'excessive' something that can be cashed out objectively or is it essentially value laden? (going back to the terminology you thought required value judgement). Is the term 'demanding attitude' something that can be objectively assessed or is that essentially a value judgement too? Hard to say... I agree such language should be curbed / eliminated if possible.
Posted by alexandra_k on September 14, 2006, at 21:26:43
In reply to Re: internet and the manufacture of madness... » Dinah, posted by Phillipa on September 14, 2006, at 17:54:53
> Very true. The only example I have is not a country one but a region one. Up North if you walked around with a Bible in your hands in a psych hospital they would deem that you were religiously preoccupied. Which could lead to many AXIS ll dx. Now here in the South it's so common most patients carry them around read from them all the time. Love Phillipa
Yes, that is an interesting example.
That just... Don't seem scientific...
Posted by Phillipa on September 14, 2006, at 21:51:41
In reply to Re: internet and the manufacture of madness... » Phillipa, posted by alexandra_k on September 14, 2006, at 21:26:43
Why does it have to be scientific as docs diagnose by the behaviors they see and they can't be measured. No blood tests, no Ct Scans. Just objective and subjective observations of patienst.s love Phillipa ps or what the patient tells the doc for instance hallucinations, delusions, suicidality
Posted by Jost on September 14, 2006, at 22:17:27
In reply to Re: internet and the manufacture of madness..., posted by alexandra_k on September 12, 2006, at 22:59:19
The article actually is about how the internet is a medium for patients to self- (or group-) reinforce an identity that takes as its basis an illness that doesn't "exist." He's concerned about ethic dilemmas and also the harm that may be done to patients who have come to identify themselves as a person with that disorder, and to feel that without the disorder, they have no self.
Such people (according to the article) insist on using the label or resist removal of the label even when psychiatrists come to believe (scientifically so to speak) that the syndrome doesn't exist. Presumably, however, they don't have the particular problem that they believe, and therefore various harms may result, when that disorder's non-existence is denied by/in the internet chat groups.
The person(s) in question may be suffering from some psychiatric condition, but not the one that they believe they are.
The example the writer is about to use is multiple personality disorder. He suggests that in the future, borderline personality disorder may also come to be discredited, and that this might have a similar identity-creating value for certain people. His concern is with groups on the internet, which are elusive to professionals, either because they don't last long, or are scattered around (many small groups exist, and they form and reform elsewhere unpredictably).
The groups are started, maintained and led by "consumers" as opposed to professionals. Presumably his further concern is that the consumers (or potential or ex-patients) whose identities are dependent on recognition of the disorder could make it harder for others in the group to disidentify, or will pressure newcomers to adopt the group identity-lablel. [That last sentence, I admit, is conjecture about what he's about to say-- but if I'm wrong, I'll note it later, but I don't think I am --seems pretty inherent in what he says so far.]
So you can pretty easily see where he's going with that. He does mention "factitious: illnesses, which apparently are a new category in DSM-- and sees some possible connection with that. Ugh. Anyway, I do wish articles could be short--
I'll have to check Mersky-- but I can't believe his writing is as bad as Aitch's (or whatever the guy's name was).
Jost
Posted by Phillipa on September 14, 2006, at 22:47:03
In reply to Re: internet and the manufacture of madness... » alexandra_k, posted by Phillipa on September 14, 2006, at 21:51:41
Jost I really understood that amazing. Love Phillipa
Posted by alexandra_k on September 15, 2006, at 0:03:25
In reply to Re: internet and the manufacture of madness... » alexandra_k, posted by Phillipa on September 14, 2006, at 21:51:41
> Why does it have to be scientific
because we don't want people to be detained in psychiatric institutions against their will and be forced to take psychiatric medications against their will solely on the basis of a psychiatrists subjective judgement. that would be a form of... social control.
> docs diagnose by the behaviors they see
yes including verbal behaviour. behaviours (including verbal behaviour) can indeed be measured. there is fairly good inter-rater reliability for dxing certain symptoms. that doesn't show that it is completely objective (as by their own admission clinicians are supposed to exhibit 'clinical judgement' and the DSM can't be applied by people who haven't been trained / indoctrinated in diagnosis). self report is important too. the dysfunction notion is supposed to differentiate between mental illness (dysfunction within the individual) and 'problems in living' (no dysfunction within the individual but subjective distress), however.
Posted by alexandra_k on September 15, 2006, at 0:13:36
In reply to Re: internet and the manufacture of madness... » alexandra_k, posted by Jost on September 14, 2006, at 22:17:27
> The article actually is about how the internet is a medium for patients to self- (or group-) reinforce an identity that takes as its basis an illness that doesn't "exist."
Yeah I think that is part of it. He also talks about anorexia, however, and I don't think that he is saying (or trying to say) that anorexia is an ilness that doesn't exist. He thinks that the internet can be a medium for those patients to self (or group) reinforce an identity (and behaviours) consistent with the dx of anorexia where those patients may have been improving but for their unwillingness to lose the identity online that they have in virtue of their dx.
(sorry that sounds so garbled)
> He's concerned about ethic dilemmas
yeah. mostly about researchers accessing internet websites where people are displaying photos of their self harm and stuff like that. he said that some of those sites are actually illegal and hence researchers are in an ethical dilemma if they want to study the impact of those kinds of sites on the people who post to the sites when they are risking their internet access through their institution in order to access the sites to study them...
(I wonder if this issue comes up for researchers who want to study such topics as child pornography on the internet?) If you wanted to study chat sites where people are talking about terrorist activities then you might similarly be in an ethics predicament if you felt you needed to access those (illegal) cites in order to conduct your research.)
> and also the harm that may be done to patients who have come to identify themselves as a person with that disorder, and to feel that without the disorder, they have no self.
yeah. if a lot of their identity hangs on their identity as a person with dx x then you can understand that they would be reluctant to give up the dx. that may lead to... an increase in behaviours that lead to... dx x. hence... people get worse.
i wonder if the role he gives to the internet might be a concern with consumer run meetings of people for one kind of dx too? the internet might have a larger version of the problem because you can meet many many more people with dx's that aren't that prevalent.
e.g., the people who wanted to amputate body parts (when there is nothing dysfunctional with that body part).
Posted by Jost on September 15, 2006, at 8:08:22
In reply to Re: internet and the manufacture of madness... » Jost, posted by alexandra_k on September 15, 2006, at 0:13:36
Alex_k,
Thanks for linking to the article. I enjoyed reading it and found it interesting, although maybe not totally news. It did sum up and integrate a certain point of view. I'm not up on the literature at all, but at least it uses a more contemporary approach to analysis of social interactions, such as internet support groups and chat rooms.
Below are the main points. He seems to have a fairly nuanced view of psychiatric disorders as having a value judgment of some kind-- at least potentially-- including a positive value to those who adopt them as a form of identity-- he addresses the instablity of the disease entities themselves, as categories--although not deeply. Summarizes some implications of the change in categories for patients. Not sure how much you'd get out of it for your work, but is easy reading.
Main points: (and I quote a few parts here)."..As a result [of finding groups of people who identify themselves as having an illness that someone themself has, esp. on the internet], people probably become more attached to their diagnosis and iatrogenic identity. In effect, their identity becomes increasingly defined by, and inextricably intertwined with, their diagnosis. Philosopher Ian Hacking calls this process the "looping effect of kinds".
The looping effect of kinds occurs when "people classified in a certain way tend to conform to or grow into the ways they are described" (Hacking 1995, 21; see also Elliott 2003, 227–234). Classification of this sort is an interactive phenomenon. ..
...This is because the classifications that do the classifying "interact with the people classified by them" (Hacking 1999, 123). ...In this spiraling dialectical process, each element—the classification and the classified—mutually reinforce and sustain each other as they evolve jointly. There is considerable evidence that the Hacking looping effect is a genuine sociological phenomenon. In his work on psychiatric labeling, Thomas Scheff refers to [End Page 341] something very similar, which he calls "feedback in deviance amplifying systems" (1966, 97–101). Edwin Lemert describes a related phenomenon called "secondary deviance" (1972, 63). In all of these cases, the focus is on how labels become integral organizing factors in the lives of the individuals who are labeled, as they search for validation and acceptance by bonding with others of their own kind....
...Elliott and Hacking fail to mention one central aspect of the manufacture of iatrogenic identity, namely the role of autonomy...
.....Patient autonomy now includes the ability of patients to contest and defy the nosological edicts of medical authority.....[discusses Multiple Personality Disorder in a la Hacking, and the deep epistemic divide between that and what replaced it, Dissociative Identity Disorder... although internet groups resisted change, and even when accepted it, often simply used the new name as if its meaning were identical to the old one].
...Another more speculative but timely example is Borderline Personality Disorder. In this case, there are good grounds to believe that label change may happen. This could cause serious harm to patients currently diagnosed with that disorder who have finally found an identity—an iatrogenic identity—through their disorder. Again, these are patients who already have problems with identity. This compounds the possible harms of label removal....
[Discusses dimensional vs categorial model in DSM--ie currently DSM uses a categorical model-- ie a group of symptoms from various sources, often anecdotal, is put together, and given a name, suggesting that the cluster of symptoms is a "disease" demarcated from normal behavior. The dimensional model suggests that these "symptoms" occur within all individuals, and are perhaps more prominent in some troubled people, but that they are by no means radically different from characteristic spresent in everyone.]
...The adoption of a dimensional model would represent a drastic change, a significant paradigm shift (Kuhn 1962). It is not clear whether or how much of the original classifications and their labels would be retained. In some dimensional proposals, probably most current terms for these disorders would be abandoned. What if this happened?...
...The search for identity can also take a dark turn in the unregulated virtual communities of the Internet. Some identity seekers attempt to reinforce their sense of iatrogenic identity by indulging in their disease. This is a telling illustration of Lemert's "self-defeating deviance" (Lemert 1972, 85). Certainly, these individuals would surely resist label removal of the official sort. But they even appear to resist label removal of a therapeutic kind. They do no want to get well and instead indulge in how to be sick—more effectively. In this third example, the search for identity has degenerated into a full-fledged madness for identity....
...Consider the fact that there are "pro-anorexia," "pro-bulimia," and even "pro-cutting" sites and chat rooms on the Internet....
...The examples we have examined show that where there exists sufficient consumer interest and solidarity, psychiatric labels and their virtual communities can be kept alive online through the technologies of the Internet. These both validate and reinforce psychiatric diagnoses that may no longer be considered scientifically valid. Thus psychiatric labels may survive among consumers although they have been abolished by professionals....
...First, because persons often identify with their label, to remove a label is to threaten a person's identity. Saying the label is no longer legitimate, or was a mistake in the first place, can therefore cause serious harm, particularly to persons already suffering from disorders that implicate identity. Second, the retention of psychiatric labels by consumer forces that operate independently of the psychiatric establishment can possibly cause further harm to patients if the labels are truly empirically invalid. New, more scientifically appropriate labels may not be adopted and more effective treatments may not be sought....
...web sites that offer consumer label survival after official label death may prevent sufferers from getting better help and treatment. There is also the worrisome possibility that sufferers in search of solidarity and a validated identity may be lured by "pro" disease sites quite contrary to the ideals of health and recovery. In both cases, the potential harms are considerable..."
Louis C. Charland, Ph.D. (Philosophy, University of Western Ontario, 1989) is currently Associate Professor in the Departments of Philosophy and Psychiatry at the University of Western Ontario, where he also holds a joint appointment with the Faculty of Health Sciences. He worked as a program consultant and research analyst in the area of health for several successive branches of the provincial government of Ontario, Canada. Following this, he held several bioethics-related positions at McGill University in Montreal and the University of Toronto. Charland has published widely in the philosophy of psychiatry and the philosophy of emotion. In 2003 he was awarded a Visiting Member Fellowship at the Institute for Advanced Study in Princeton, New Jersey. He can be contacted at the Department of Philosophy and Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada N6A 3K7, or via e-mail at: charland@ uwo.ca. His web site can be found at: http://publish.uwo.ca/~charland.
~~~
My comment:
His concerns are first, that professionals do not sufficiently recognize the role of the internet, esp. support groups and chat rooms, where people with various shared characteristics, Including a psychiatric diagnosis, meet to support one another . This is a powerful tool for establishing and reinforcing identity, esp. for those whose identities are unstable, or unrealized. Professionals also have not taken care to think through the effects of de-labeling these disorders, on individuals previously labeled with them-- ie whose identity is iatrogenic (ie caused by the medical profession).
He regrets the power of these groups to resist reconceptualizations of mental diseases, which may provide better treatment to those who suffer them.
At the same time, there are ethical problems in taking away the identity that supports individuals' coping and ability to connect to others ( ie the disease they've identified with).
Plus he is further concerned about the effect of consumer "choice" of disease, or recruitment of individuals to their "illness"-- for example, the pro-anorexia sites, or pro-amputee sites. In his view, these sites are so strongly committed to the value of the originally-problematic disorder, that they may pressure those with uncertain identities or with great needs for social approval into adoption of harmful or at best mistaken definitions of their identity.
Yet (again, in his view) it may be ethically dubious, as well, as technically difficult, to locate these individuals and to try to deprive them of their present identities, under the guise of educating them about the current state of psychiatric knowledge or belief.
Jost
Posted by alexandra_k on September 15, 2006, at 11:25:24
In reply to Re: internet, manu. of madness- anorexia {trigger} » alexandra_k, posted by Jost on September 15, 2006, at 8:08:22
Hey. I'm glad you enjoyed it. I'll admit that I was searching for another topic altogether, but that I read through that article interested in the internet stuff.
I'm not up to date on the literature either. Not with respect to that issue anyway. I guess I read the odd thing in virtue of my interest in babble, but it isn't really a professional interest.
> He seems to have a fairly nuanced view of psychiatric disorders as having a value judgment of some kind-- at least potentially-- including a positive value to those who adopt them as a form of identity--
Yeah, I guess that is so. I never thought of that...
> he addresses the instablity of the disease entities themselves, as categories--although not deeply.
Yeah. I guess he is more focused on Hacking's notion of a 'looping kind' rather than natural kinds.
> ."..As a result [of finding groups of people who identify themselves as having an illness that someone themself has, esp. on the internet], people probably become more attached to their diagnosis and iatrogenic identity. In effect, their identity becomes increasingly defined by, and inextricably intertwined with, their diagnosis. Philosopher Ian Hacking calls this process the "looping effect of kinds".
Yes indeedie do. Hacking is an interesting read, actually. I've read "multiple personality and the sciences of memory" and I've got "the social construction of what?" though I don't think I'll read the latter properly because I think that the ideas I'm interested in are fairly much captured in the former...
> The looping effect of kinds occurs when "people classified in a certain way tend to conform to or grow into the ways they are described" (Hacking 1995, 21; see also Elliott 2003, 227–234). Classification of this sort is an interactive phenomenon. ..Yeah. That is kinda cool...
Hysteria
Hysterical Paralysis
Multiple Personality Disorder
Dissociative Identity Disorder
Dissociative Fuge
Are typically thought to be paradigmatic examples of these looping kinds. In fact... The 'progression' from hysteria to hysterical paralysis to hysterical personality / hysteriod personality / borderline personality / post traumatic stress / multiple personality / dissociative identity disorder... Is supposed to be a case of looping kinds too...
> ...This is because the classifications that do the classifying "interact with the people classified by them" (Hacking 1999, 123). ...In this spiraling dialectical process, each element—the classification and the classified—mutually reinforce and sustain each other as they evolve jointly.Yeah.
There is considerable evidence that the Hacking looping effect is a genuine sociological phenomenon.
Yes indeed. When you study people... People change in virtue of being studied. So you report them the way they appear to be when you study them. Then you report your findings. Then your findings influence the concept which affects peoples behaviour which affects what you will find when you study people... And so on and so forth.
So dx can indeed be a matter of 'hitting a moving target'. At times anyway...
> .....Patient autonomy now includes the ability of patients to contest and defy the nosological edicts of medical authority.....[discusses Multiple Personality Disorder in a la Hacking, and the deep epistemic divide between that and what replaced it, Dissociative Identity Disorder...
Though he doesn't say so explicitly I'm thinking that he is gesturing towards the "right to remain multiple" movement (which - in some instances - seems to be based on an erroneous conception of what is going on...)
> although internet groups resisted change, and even when accepted it, often simply used the new name as if its meaning were identical to the old one].
That has indeed happened I can vouch for that. Most people who are sympathetic to the DID dx undervalue the distinction between MPD and DID considerably. Some therapists even. In order to... Reassure patients. I'm not sure what good it does them... But it surely does happen...
> ...Another more speculative but timely example is Borderline Personality Disorder. In this case, there are good grounds to believe that label change may happen.Given that there are... 256 ways in which to meet dx criteria (according to my memory of what fineline bob computed at any rate) I'm not surprised...
> This could cause serious harm to patients currently diagnosed with that disorder who have finally found an identity—an iatrogenic identity—through their disorder. Again, these are patients who already have problems with identity. This compounds the possible harms of label removal....
Yeah. Though... If they have problems with identity confusion already...
> ...The adoption of a dimensional model would represent a drastic change, a significant paradigm shift (Kuhn 1962).I disagree. Firstly, I think that is a misuse of Kuhn's notion of a paradigm shift. Secondly, I'm not sure how much the dimensional model is a 'drastic change'. The dimensional model can be interpreted into the current categorical approach (via the notion of a threshold). There are problems that arise at the symptom level the way there are problems that arise at the dx level at present...
> In some dimensional proposals, probably most current terms for these disorders would be abandoned.
I don't think that follows. Or if it does... It would be because we would have found better categories of mental illness to 'believe in'.
> Some identity seekers attempt to reinforce their sense of iatrogenic identity by indulging in their disease. This is a telling illustration of Lemert's "self-defeating deviance" (Lemert 1972, 85).
so they have 'self defeating deviance'?
surely... the function of the behaviour sould be... assessed rather than assumed...> they even appear to resist label removal of a therapeutic kind.
maybe because the label removal... isn't theraputic for the individual.
> They do no want to get well
now that is a judgement if ever i saw one...
> and instead indulge in how to be sick—more effectively.
and there is another one too...
> In this third example, the search for identity has degenerated into a full-fledged madness for identity....
hence the authors have a radically new kind of disorder that they wish to take credit for discovering...
> ...The examples we have examined show that where there exists sufficient consumer interest and solidarity, psychiatric labels and their virtual communities can be kept alive online through the technologies of the Internet.
can they be kept alive without the technologies of the internet (ie in in person meetings between like minded individuals?)
> These both validate and reinforce psychiatric diagnoses that may no longer be considered scientifically valid.
i don't have much faith in scientific validity. diagnosticians might say (in hindsight) 'you can't have BPD because people with BPD dont get better until their 40's BY DEFINITION'. they can retain their belief by saing 'you have been misdiagnosed'... or... i can maintain... no dammit i was borderline. i AM borderline... but you know what? i'm 28 and i'm doing one f*ck of a lot better than i was before. why would i retain my identiy as a borderline individual in the face of 'scientists' pleading misdiagnosis? BECAUSE IT GIVES OTHER PEOPLE WITH A DX OF BORDERLINE PERSONALITY HOPE OF IMPROVING BEFORE THEY ARE FOURTY. and given what we know about the effects of looping kinds... that might be what is required in order to MAKE people with BPD improve before they hit their 40's. and if enough people F*CKING INSIST ON IT then it will carry through to the 'scientists' observations of how 'gee people with BPD can improve in their late 20's' WHICH GIVES PEOPLE HOPE.
How can they not see / acknowledge this?
> Thus psychiatric labels may survive among consumers although they have been abolished by professionals....
No sh*t. I wonder why...
> Professionals also have not taken care to think through the effects of de-labeling these disorders, on individuals previously labeled with them-- ie whose identity is iatrogenic (ie caused by the medical profession).
Indeed.
> He regrets the power of these groups to resist reconceptualizations of mental diseases, which may provide better treatment to those who suffer them.And he doesn't see the good in the consumer movement...
> At the same time, there are ethical problems in taking away the identity that supports individuals' coping and ability to connect to others ( ie the disease they've identified with).Indeed.
> Plus he is further concerned about the effect of consumer "choice" of disease, or recruitment of individuals to their "illness"-- for example, the pro-anorexia sites, or pro-amputee sites. In his view, these sites are so strongly committed to the value of the originally-problematic disorder, that they may pressure those with uncertain identities or with great needs for social approval into adoption of harmful or at best mistaken definitions of their identity.Yeah. In my experience the most significant form of pressure is COVERT pressure. In teh form of 'you have finally stopped denying what has been apparant to us all along'. There is covert pressure in the form of INCREASED ACCEPTANCE.
> Yet (again, in his view) it may be ethically dubious, as well, as technically difficult, to locate these individuals and to try to deprive them of their present identities, under the guise of educating them about the current state of psychiatric knowledge or belief.
Locating individuals... I didn't get that at all. That is an interesting point. I thougth he was bemoaning how he couldn't frequent some of those sites in order to study the posters because the sites were illegal. But yeah... Locating individuals and...
Pushing the current medical model on them?
Didn't the last model harm them enough?
I"m not sure tha tthey consider that...
Posted by Jost on September 15, 2006, at 17:55:42
In reply to Re: internet, manu. of madness- anorexia {trigger} » Jost, posted by alexandra_k on September 15, 2006, at 11:25:24
> >they even appear to resist label removal of a therapeutic kind.
?maybe because the label removal... isn't theraputic for the individual.
~~ He does recognize that-- that if you have identity issues, and get your identity from a label, that you'll resist giving it up-- and acknowledges that that's reasonable, and understandable. It's that he's concerned about people in that category who may be losing out.
> >They do no want to get well
>now that is a judgement if ever i saw one...
I think, though, that he was only referring to some people not all-- he distinguished two groups: first, people who resist removal of the label because it constituted their source of identity, but who might otherwise want appropriate treatment, even if it involved a temporary loss of secure identity, esp. if their concerns about identity were addressed.
But second, a group who more actively resist any attempt to help them "recover" (if that's the right word really) from their disorder. ie, the pro-anorexia sites, or pro-amputee sites.
My problem with his analysis is that he never makes an argument from groups like that, which are extreme and even inflammatory examples, to people who have more "ordinary" diagnoses. Extreme disorders seem to me to offer an identity as special that may be very hard to give up, because one doesn't go to that extreme to be special, unless there's some great disruption in the ability to feel okay, much less special.
So I'm not sure you can simply reason from extremists to people who are depressed, or anxious, where one's identity might be centered around being a depressed person, which could involve an idea of being specially sensitive. That type of identity, being relatively more moderate, and culturally dispersed, doesn't involve extreme constructions of self as to be different,even outrageously and disruptively so-- And it seems that they might be easier to replace with other, more constructive forms of specialness, or effectiveness, or satisfaction in life.--since the identity they confer doesn't involve claims of such great uniqueness, or unconventionality, or violation of norms.
Plus, it isn't necessarily bad to make judgments. Sometimes we're so afraid of seeming unfair to outsider groups or individuals, they we fail to make appropriate distinctions. I'm not sure if that's the case with his judgments. He doens't make blanket judgments of people who resist giving up labels-- although he overrates the science of any psychological categories at the moment.
I certainly agree with you on that.
Jost
Posted by alexandra_k on September 16, 2006, at 3:37:05
In reply to Re: internet, manu. of madness- anorexia {trigger}, posted by Jost on September 15, 2006, at 17:55:42
hey :-)
i wonder if the identity confusion preceeds the initial dx or whether the dx results in identity confusion. (that could be about the harms of dx). then people manage to find some peace with their dx (by meeting people they get along with online) then... their dx is taken away and they have identity confusion once more. maybe identity confusion can be something of a looping kind.
> My problem with his analysis is that he never makes an argument from groups like that, which are extreme and even inflammatory examples, to people who have more "ordinary" diagnoses.
one of them talked about schizophrenia. Janet Frame was the example. How she felt when they told her that she had never been schizophrenic.
> Plus, it isn't necessarily bad to make judgments.
Sure. Categorisation isn't inherently bad. What I'm trying to capture with the notion of 'judgement' is the notion of a value judgement or a normative judgement.
I was thinking about that more with respect to the ICD criteria I posted.
Posted by alexandra_k on September 16, 2006, at 8:32:06
In reply to Re: internet, manu. of madness- anorexia {trigger}, posted by Jost on September 15, 2006, at 17:55:42
Thanks for the discussion :-)
I found it really interesting. I hadn't thought of some of those points.I have wondered about how much posting to Babble keeps me thinking of myself (my identity or identities) as mentally ill. In some sense... I identify quite strongly. I mean... I don't tell (very many) people IRL. But I tell a couple. Not my precise history... But I've met a couple people who have experience of depression and I've said I understood and we kind of... Look out for each other a little, I guess. Kind of know to take special care. Have a sort of shared sense of identity, perhaps.
I wonder how much posting here... Really thinking of myself as mentally ill... Keeps me back from moving beyond. Usually the feeling doesn't last long though and I realise that I DO have a bit of a hard time IRL sometimes. And I think mostly... Posting here helps.
Some boards I've posted at... There are a number of people with a certain theoretic orientation... Or with trauma or abuse issues... I can find that hard sometimes. I mean... Sometimes it helps me to talk about that kind of stuff. But if trauma / abuse survivor becomes part of your identity... Dammit that can be a hard one. Thinking of yourself in that way... I'm fairly sure that in my experience (I wouldn't talk for anyone else) but in my experience overly focusing on it makes the ruminations memories etc that much worse.
I don't know.
Most things are a mixed blessing, I guess.
I guess they are focused on the sites where people actively encourage each other along...
But you know... I'm sure that if we went back in time when homosexuality was considered a mental disorder... Gay support groups probably had the same rap. I don't know... Hard to say...
Posted by alexandra_k on September 16, 2006, at 8:48:02
In reply to Re: internet, manu. of madness- anorexia {trigger} » Jost, posted by alexandra_k on September 16, 2006, at 8:32:06
I had my suspicions... And I had my suspicions recently confirmed.
BIOLOGICAL REDUCTIONISM
In philosophy biological reductionism is the view that mental properties can be reduced to biological properties.
(Okay so there is controversy over whether you are dealing with facts, objects, properties, or kinds, but so as not to complicate things too much...)
DUALISM
In philosophy dualism is the view that mental properties (facts, objects, properties, or kinds) cannot be reduced to biological properties.
Hence... One can't be a biological reductionist and a dualist at the same time on pain of contradiction...
Wakefield criticises the medical model of mental illness for:
1) Being biologically reductionist
AND
2) Being dualist
Hence... WHAT THE HELL IS HE TALKING ABOUT???Turns out that the lay of the land seems to be...
BIOLOGICAL REDUCTIONISM
Is a methodology. As a methodology one studies the biological facts. (e.g., genes, neuro-science, pharmachology)
Hence it makes sense to talk of
PSYCHOLOGICAL REDUCTIONISM
Is a methodology. As a methodology one studies the psychological facts. (e.g., cognitive-behaviour theory or whatever and therapy)
(In philosophy psychological reductionism would probably be... Berkeley's idealism which is fairly unfashionable since Locke...)
DUALISM
Is... Get this... The view that one methodology is unrelated to the other. Hence you don't need to worry about those people over there. So both the biological and psychological reductionists (so to speak) were considered dualists (so to speak).
Dammit.
Why can't there be a consensus on terminology?
There needs to be a terminology police.
PBC
(Please be comprehensible)
;-)
Posted by gardenergirl on September 19, 2006, at 0:07:31
In reply to different terminology and talking past..., posted by alexandra_k on September 16, 2006, at 8:48:02
>
> PBC
>
> (Please be comprehensible)
>
> ;-)LOL
gg
>
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