The apex and decline of evidence-based psychotherapy and psychiatry

By Brent Potter, PhD

I am grateful to be alive during to see the apex and decline of evidence-based psychotherapy and psychiatry. Honestly, I didn’t think that I’d see anything like it in my lifetime. It was looking pretty daunting for a while, but we’re not only making substantial progress, but winning.

Please don’t mistake me—we have plenty more to do. We’re not in the clear yet, but we’re light years ahead of where we were roughly 20 years ago. Last week, I had breakfast with a physician who was interested in meeting with me. He has some ideas about how to bring focused psychoeducational courses to children and teens in public schools. A friend suggested we meet and all he knew about me was that I had some experience with these sorts of programs. In any event, during the course of the conversation he asked, “How do you feel about psychiatric medications?” I told him. Perhaps it was the coffee, but I was feeling especially open and even expressed that I didn’t think psychotherapy was always the best or highest intervention. After offering my critiques of medications and psychotherapy, he sat silent for a minute, apparently thinking. He finally smiled, looked up, and responded, “I agree with 95% of what you’re saying.” The conversation continued along very productive, positive lines.

This event doesn’t prove anything, of course. I offer it as one example of the kind of interaction that is far more common these days. Those of you who have been a part of the recovery / critical psychiatry / anti-psychiatry (whatever title you prefer) movement will recall that, in the past, any critique of the psychiatry-psychotherapy juggernaut was heresy. I thought it may be helpful and/or useful to offer a few reflections here on what’s going on. The recovery perspective, psychology and history remain passions of mine. Some of what follows is from my newest book, Elements of Reparation: Truth, Faith, and Transformation in the Works of Heidegger, Bion, and Beyond (Karnac, 2015).

STEM is an acronym that stands for Science, Technology, Engineering and Mathematics. STEM represents, of course, the fields outlined by the acronym but the word is used descriptively as a kind of standard of validity of what a given field (e.g. psychology) should be. STEM can be used synonymously with the phrase ‘natural science’. STEM psychology today focuses on research and what is deemed as natural scientific clinical tools of assessment, diagnosis and treatment. This includes so-called evidence-based approaches, such as cognitive behavioral therapy (CBT) and similar manualized approaches, such as dialectical behavioral therapy (DBT). As with psychiatry and the DSM, STEM approaches have been the object of grave criticism. Jonathan Shedler’s (2010) seminal research clearly demonstrates that psychodynamic therapy is more effective than cognitive-behavioral therapy (CBT) / manualized approaches to mental health treatment as well as these modalities utilized in combination with medication management.

As if this were not enough, Shedler (2013a) writes, “One piece of news is that NIHM just dissed the newly-released DSM-5, and dissed it in a big way. Insel’s [NIMH director] post basically says that DSM is useless for understanding mental health problems and that its fundamental premise—that mental health conditions can be classified meaningfully on the basis of overt symptoms—is flat out wrong. NIMH will no longer fund research based on DSM diagnosis.” And Shedler is correct, the federal funding source of the DSM, NIHM, has pulled its funding. Insel (2013) is taking a hard right STEM turn, seeking a “new nosology” based on the following:

  • A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,
  • Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,
  • Each level of analysis needs to be understood across a dimension of function,
  • Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.

It may strike some that those adhering to non-STEM disciplines and approaches applaud NIHM’s maneuver. In fact, many, if not most, non-STEM professionals do applaud it, as it represents an awareness that the DSM is highly flawed in a variety of different ways and since they do not believe that NIHM, nor anyone else, is going to find the biomarkers they are seeking. Decades of dedicated research, countless dollars and cutting-edge technology have thus wielded nothing, probably because varieties of human distress are not solely reducible to biological causal agents. To date, there is no blood test, mouth swab, spinal tap, organ biopsy, hair sample, nor any other medical means of assessing a supposed psychiatric disease. In fact, as I will show, there is a mounting body of epigenetic research clearly demonstrating where distress, chemical abuse / dependency and a host of physical ailments come from.

Concerning so-called evidence-based therapies, Shedler (2013b) reviews the literature and finds that academic researchers have “usurped and appropriated the terms ‘evidence based’ to refer to a group of therapies conducted according to step-by-step instruction manuals…The other things these therapies have in common are that they are typically brief, highly scripted, and almost exclusively identified with CBT.” He goes on, “The term ‘evidence-based therapy’ is also de facto, a code word for ‘not psychodynamic’.” Basically, it is not the case that CBT and similar approaches are more effective, they were simply studied more in research settings. By way of absurd example, this is tantamount to me developing a ‘Brent’ therapy, only conducting research on the ‘Brent’ approach to therapy, praising the outcomes of the research only investigating the ‘Brent’ approach, branding it as evidence-based and prescribing it as the best modality of treatment. As Shedler also points out, devotees of evidence-based approaches go so far as to admonish other approaches (e.g. psychodynamic) as being unethical for not practicing CBT or something similar. Shedler (2013c) concludes:

Claims that “evidence-based” therapy is more effective than real-world therapy lack scientific basis. Academic researchers have been selling a myth—one that enhances the careers and reputations of academic researchers, but not necessarily the well-being of patients.

It is not just my conclusion that the therapies promoted and marketed as “evidence based” confer no special benefits. It is the official scientific conclusion of the American Psychological Association, based on a comprehensive review of psychotherapy research by a blue-ribbon expert panel.

All of the aforementioned issues are addressed succulently and cleverly by my friend, Loren Mosher in his resignation letter to the American Psychiatric Association. Briefly, Mosher, who passed away in 2004, was a psychiatrist, clinical professor of psychiatry and chief of the Center for Studies of Schizophrenia at NIHM from 1968-1980. Following the ideas of Laing, he Mosher was made famous for his establishment of therapeutic households for persons suffering from emotional distress. From 1970-1992, Mosher was research director of the Soteria Project. Soteria, by the way, was the Greek goddess of protection and deliverance. The Soteria Project sought to provide progressive, non-drug, non-hospital, residential facility support for people going through their own metanoia. One can think of the Soteria House and other associated residential sanctuaries as the American equivalent, in many ways, to the residences of the Philadelphia Association that Laing helped establish in 1965. The history of Soteria, including many remarkable successes, is outlined in Mosher and Hendrix (2004), Soteria: Through Madness to Deliverance. Mosher is considered something of a hero in the recovery community. In a letter he penned on December, 4, 1998 to then then-president of the American Psychiatric Association, he wrote:

Dear Rod,

After nearly three decades as a member it is with a mixture of pleasure and disappointment that I submit this letter of resignation from the American Psychiatric Association. The major reason for the action is my belief that I am actually resigning from the American psychopharmacological Association. Luckily, the organization’s true identity requires no change in the acronym.

Unfortunately, APA reflects, and reinforces, in word and deed, out drug dependent society. Yet it helps wage war on “drugs”. “Dual diagnosis” clients are a major problem for the field but not because of the “good” drugs we prescribe. “Bad” ones are those that are obtained mostly without a prescription. A Marxist would observe that being a good capitalist organization, APA likes only those drugs from which it can derive a profit – directly or indirectly. This is not a group for me. At this point in history, in my view, psychiatry has been almost completely bought out by the drug companies. The APA could not continue without the pharmaceutical company support of meetings, symposia, workshops, journal advertising, grand rounds, luncheons, unrestricted education grants, etc. etc. Psychiatrists have become the minions of drug company promotions. APA, of course, maintains that its independence and autonomy are not compromised in this enmeshed situation. Anyone with the least bit of common sense attending the annual meeting would observe how the drug company exhibits and “industry sponsored symposia” draw crowds with their carious enticements, while the serious scientific sessions are barely attended. Psychiatric training reflects their influence as well: the most important part of a resident’s curriculum is the art and quasi-science of dealing drugs, i.e., prescription writing.

These psychopharmacological limitations on our abilities to be complete physicians also limit our intellectual horizons. No longer do we seek to understand whole persons in their social contexts – rather we are there to realign our patient’s neurotransmitters. The problem is that it is very difficult to have a relationship with a neurotransmitter – whatever its configuration. So, our guild organization provides a rationale, by its neurobiological tunnel vision, for keeping our distance from the molecule conglomerates we have come to define as patients. We condone and promote the widespread use of misuse of toxic chemicals that we know have serious long term effects – tardive dyskinesia, tardive dementia and serious withdrawal syndromes. So, do I want to be a drug company patsy who treats molecules with their formulary? No, thank you very much. It saddens me that after 35 years as a psychiatrist I look forward to being dissociated from such an organization. In no way does it represent my interests. It is not within my capacities to buy into the current biomedical-reductionistic model heralded by the psychiatric leadership as once again marrying us to somatic medicine. This is a matter of fashion, politics and, like the pharmaceutical house connection, money.

In addition, APA has entered into an unholy alliance with NAMI (I don’t remember the members being asked if they supported such an association) such that the two organizations have adopted similar public belief systems about the nature of madness. While professing itself the “champion of their clients” the APA is supporting non-clients, the parents, in their wishes to be in control, via legally enforced dependency, of their mad/bad offspring: NAMI with tacit APA approval, has set out a pro-neuroleptic drug and easy commitment-institutionalization agenda that violates the civil rights of their offspring. For the most part we stand by and allow this fascistic agenda to move forward. Their psychiatric god, Dr. E. Fuller Torrey, is allowed to diagnose and recommend treatment to those in the NAMI organization with whom he disagrees. Clearly, a violation of medical ethics. Does APA protest? Of course not, because he is speaking what APA agrees with, but can’t explicitly espouse. He is allowed to be a foil; after all – he is no longer a member of APA. (Slick work APA!) The shortsightedness of this marriage of convenience between APA NAMI, and the drug companies (who gleefully support both groups because of their shared pro-drug stance) is an abomination. I want no part of a psychiatry of oppression and social control.

“Biologically based brain diseases” are certainly convenient for families and practitioners alike. It is no-fault insurance against personal responsibility. We are all just helplessly caught up in a swirl of brain pathology for which no one, except DNA, is responsible. Now, to begin with, anything that has an anatomically defined specific brain pathology becomes the province of neurology (syphilis is an excellent example). So, to be consistent with this “brain disease” view, all the major psychiatric disorders would become the territory of our neurologic colleagues. Without having surveyed them I believe they would eschew responsibility for these problematic individuals. However, consistency would demand our giving over “biologic brain diseases” to them. The fact that there is no evidence confirming the brain disease attribution is, at this point, irrelevant. What we are dealing with here is fashion, politics and money. This level of intellectual /scientific dishonesty is just too egregious for me to continue to support by my membership.

I view with no surprise that psychiatric training is being systematically disavowed by American medical school graduates. This must give us cause for concern about the state of today’s psychiatry. It must mean – at least in part that they view psychiatry as being very limited and unchallenging. To me it seems clear that we are headed toward a situation in which, except for academics, most psychiatric practitioners will have no real, relationships – so vital to the healing process – with the disturbed and disturbing persons they treat. Their sole role will be that of prescription writers – ciphers in the guise of being “helpers”.

Finally, why must the APA pretend to know more than it does? DSM IV is the fabrication upon which psychiatry seeks acceptance by medicine in general. Insiders know it is more a political than scientific document. To its credit it says so – although its brief apologia is rarely noted. DSM IV has become a bible and a money-making best seller – its major failings notwithstanding. It confines and defines practice, some take it seriously, others more realistically. It is the way to get paid. Diagnostic reliability is easy to attain for research projects. The issue is what do the categories tell us? Do they in fact accurately represent the person with a problem? They don’t, and can’t, because there are no external validating criteria for psychiatric diagnoses. There is neither a blood test nor specific anatomic lesions for any major psychiatric disorder. So, where are we? APA as an organization has implicitly (sometimes explicitly as well) bought into a theoretical hoax. Is psychiatry a hoax – as practiced today? Unfortunate, the answer is yes.

What do I recommend to the organization upon leaving after experiencing three decades of its history?

  1. To begin with, let us be ourselves. Stop taking on unholy alliances without the members’ permission.
  2. Get real about science, politics and money. Label each for what it is – that is, be honest.
  3. Get out of bed with NAMI and the drug companies. APA should align itself, if one believes its rhetoric, with the true consumer groups, i.e., the ex-patients, psychiatric survivors etc.
  4. Talk to the membership – I can’t be alone in my views.

We seem to have forgotten a basic principle – the need to be patient/client/consumer satisfaction oriented. I always remember Manfred Bleuler’s wisdom: “Loren, you must never forget that you are your patient’s employee.” In the end they will determine whether or not psychiatry survives in the service marketplace.

While all of the aforementioned items are indeed true, it is also true that I do not deny that people suffer, sometimes terribly, from emotional and psychological states of mind. I also acknowledge that these forms of distress tend to fall along typical, archetypal lines. There is no doubt that people report feeling depressed, anxious, experiencing unusual states of consciousness, etc. Mercifully, today we know the causes of these forms of distress which also contribute to a host of physical ailments. As promised earlier, I will address this topic.

We don’t need a stitch more research…This stuff is painful and therefore we dare not look at it in ourselves and therefore we don’t open to its existence in others and then we have to look for all kinds of other reasons. If you deny pain, going to early experience and early loss and early trauma, then the world becomes very complicated and justifies all kind of complicated explanations. Yet if we see that a child has certain needs and, if you meet those needs, that child will be just fine and, if you don’t, he’ll have to adapt somehow and those adaptations are the basis of dysfunction late on. That’s really simple. They call it simplistic. It’s not simplistic, it’s simple. The world is really very simple. We make it complicated because of our denial…

We have the evidence. It’s just that the evidence is not incorporated. So when they talk about evidence-based practice, they are looking at a very specific kind of a very narrowly defined sense of evidence. If you actually look at the science–it’s not that the science doesn’t exist—we know how the children’s brains develop, we know how the chemistry of the brain develops, we know how behaviors occur as a response to either nurturing or emotionally impoverished environments. We don’t need more research. (Mate, 2012)

The question naturally arises as to where distress arises from, if they are not brain diseases. The answer, as succinctly put by Mate, is clear: developmental stress and trauma. The word ‘trauma’ comes from the ancient Greek τραῦμα (wound, damage), which is akin to θραύω (to break, break in pieces, shatter, smite through). As previously mentioned, trauma is inherent in life. It and its outcomes vary in degree, but not kind, from those labelled as insane and everyone else. Epstein (2013) in his The Trauma of Everyday Life, aptly points out that it is impossible to avoid trauma. No matter how well-intentioned, well-resourced, educated or any other positive attribute one may have, he or she will invariably experience stress, loss, grief, sickness or hardship of one kind or another. No one is spared from trauma, to a greater or lesser degree. Imagine, if you will, one such event in your life. Now imagine if the felt sense of that event were multiplied exponentially or if there were a series of such events. It is not at all difficult to imagine the some of the impacts this would have. For some, stress and trauma are normative. When this happens, especially during formative developmental years, the result is often something that will likely be labeled as mental illness and/or substance abuse or dependence in adulthood.

The recovery movement is a ‘sibling’ of contemporary existential-humanistic and contemporary psychoanalytic schools of thought that are emerging as psychiatry and STEM psychology fade. In mental health recovery, often referred to as wellness programs, individuals who have successfully recovered aid those who are early in recovery. These people, often professionals are often referred to as peer bridgers or simply peer support specialists. Both groups tend to see human distress as a normal part of life, rather than as a disease or something to be moralized or pathologies in any way. Forms of distress are simply seen as an organic part of living. The goal of recovery support, is to partner with the client and develop an individualized recovery plan. Nothing is forced upon an individual or even suggested. The idea is to join with the client in his or her process and to utilize his or her strengths to aid in the process of recovery. Often, if the client desires it, family and other community supports are utilized. There is no cookie-cutter process in recovery; from their perspective, each recovery is unique and intensely personal to the individual and his or her life context.

Recovery, seen as an organic process, experienced some setbacks during the 1940s and 1950s in the US, as the predominant way of contending with psychological distress was institutionalization. Even during the deinstitutionalization, beginning in the 1970s, it was assumed that recovery was not possible from so-called psychiatric diseases. We still see some of this today, unfortunately. Nonetheless, the recovery movement persevered, refusing to adopt the limiting and errant beliefs of the psychiatric establishment. Laing and his colleagues made substantial headway in establishing therapeutic household that still remain today, such as the Philadelphia Association in the UK. Following Laing, Mosher, as already mentioned, was successful in his work at Soteria House. To this day, Soteria houses still exist in various locations. In a similar vein, the consumer and psychiatric survivor movements began taking hold in the 1980s and 1990s and are still quite active to this day. By 2002, the President’s New Freedom Commission on Mental Health solidified a way for a system wide paradigm shift.

Of note, in the recovery movement, is the well-resourced and expanding organization, Recovery Innovations. The organization constellated around the notion of recovery, from its entry level employees to its administration. Their international expansion is testimony to the efficacy of its educational, clinical and peer support programs. With this organization, having a recovery story, of some kind, is considered a strength, not a detriment. Their states mission: “To create opportunities and environments that empower people to recovery, to succeed in accomplishing their goals, and to reconnect to themselves, others, and to meaning and purpose in life.” Their service values are hope, empowerment, wellness, personal responsibility, community focus and connectedness. Their organizational values include quality, creativity, friendliness, quality team, cultural competence and financial stability. Impressively, their entire international business operates on a non-hierarchical fashion. They go so far as to have what they call “wellness cities” where all supports are offered in a single setting. The services offered include, but are not limited to, peer support, education, medical services, mental health services, employment and crisis services. The vision of the business “was a transformation in the service delivery system grounded in the belief that people with mental health and substance abuse challenges do recover and move on with their life.” The domains deemed critical to recovery are represented in the services provided: “The principle ingredients of this transformation include hope, education, employment, peer support and self-help” (Recovery Innovations, 2008). I present Recovery Innovations, since it is remarkably effective in regards to supporting people through recovery and also being fiscally sound. There are other organizations such as MindFreedom International, The Icarus Project and PsychRights that also participate in and support the recovery movement.

BrentPotterPicDr. Brent Potter is a psychotherapist and wellness specialist with 20 years of direct clinical service. He is the Director for the Society for Laingian Studies. Brent is the author of numerous articles whose topics include: innovative and effective mental healthcare models, analytical psychology, humanistic psychology, existential-phenomenology, psychoanalysis, the psychotic register of the mind, character and personality disorders, chemical dependency and child / adolescent mental health concerns.

More by Brent Potter on Beyond Meds:

Books by Dr Brent Potter:

References:

Epstein, M. (2013). The Trauma of Everyday Life. New York: The Penguin Press.

Insel, T. (2013). Director’s blog: Transforming diagnosis. National Institute of Mental Health. [On-line] Available: http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml

Irvine, C. (2009). Men Lie Twice as Much as Women. The Telegraph [On-line.] Available:  http://www.telegraph.co.uk/news/uknews/6186358/Men-lie-twice-as-much-as-women.html

Mate, G. (2012). Gabor Mate, M.D.: Attachment = wholeness and health or disease,

ADD, addiction, violence. Retrieved 2/28/14 from http://vimeo.com/5541641

Mosher, L. (1998). Letter of Resignation from the American Psychiatric Association. {On-line] Available: http://www.moshersoteria.com/articles/resignation-from-apa/

Mosher, L. & Hendrix, V. (2004). Soteria: Through Madness to Deliverance. Bloomington, IN: Xlibris LLC.

Potter, B. (2015). Elements of Reparation: Truth, Faith, and Transformation in the Works of Heidegger, Bion, and Beyond.

Recovery Innovations. (2008). History. [On-line] Available: http://recoveryinnovations.org/history.html

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, (65)2, pp. 98-109.

Shedler, J. (2013a). Is NIHM brilliant, stupid, or both? Psychology Today, Oct. 13, 2013. [On-line] Available: http://www.psychologytoday.com/blog/psychologically-minded/201310/is-nimh-brilliant-stupid-or-both

Shedler, J. (2013b). Where is the evidence for evidence-based therapies? Psychology Today, Oct. 02, 2013.  [On-line] Available: http://www.psychologytoday.com/blog/psychologically-minded/201310/bamboozled-bad-science

Shedler, J. (2013c) Bamboozled by bad science. Psychology Today, Oct. 31, 2013. [On-line] Available: http://www.psychologytoday.com/blog/psychologically-minded/201310

‘Borderline Personality Disorder’, the Failure of Psychiatry and Emergence

By Jacqueline Gunn, PsyD and Brent Potter, PhD

Authors, Borderline Personality Disorder: New Perspectives on a Stigmatizing and Overused Diagnosis (Praeger, November 2014)

 

When you are reading our book, be prepared to challenge your view of what is called “borderline personality disorder” and even the way you see all so-called psychiatric ‘disorders’.

This is what we have done as co-authors.  We sound a little strong at times, but we really believe in what we are presenting.

We take you through exactly why we take this approach, give you historical context and also explain some experiences with real people who are suffering.  To this end, client’s stories at the end along with a few narratives written by clients themselves along the way. We stick faithfully to the experiences themselves rather than upon theoretical constructs and other abstracted materials. Our approach is not experience-near, but experientialist; we don’t hypothesize, abstract, nor construct theories from human experience.

Here’s the overview of the journey that’s in store in our book. The fields of psychiatry and so-called scientific, evidence-based psychology are as aware of their historical-environmental context as a fish is to its being wet—they are oblivious; the most obvious and necessary context eludes them. You’ll notice in every book you pick up on ‘borderline personality disorder’, that the authors assume that it is a psychiatric syndrome / disease as outlined in the clinical literature. None of them even look at the basic assumptions or historical, cultural and environmental contexts wherein the supposed syndrome or disease was invented. You read this correctly: All of the mental illnesses outlined in the diagnostic guide for psychiatrists and other mental health professionals, the Diagnostic and Statistical Manual of Mental Disorders (DSM), are inventions. Said differently, there is no biological evidence for any one of the disorders outlined in the DSM. There is no blood test, mouth swab, hair sample, biopsy, spinal tap, x-ray, brain-imaging, nor any other sort of “We’ll have to send this off to the lab,” way to diagnose or confirm psychiatric diseases. Zero. The contents of the DSM are constructed by committees of professionals, most with financial ties to the psychopharmaceutical industry, and then voted upon.

That the diagnoses are diseases and/or syndromes reflecting a chemically imbalanced or otherwise defective brain organ is a ‘given’. Yet the fields of psychiatry and natural science psychology proceed as if their hypotheses, perspectives and diagnoses are facts, like wind or gravity. And like wind or gravity, diseases just happen. If brain diseases are like other medical diseases, they happen independent of other factors. They simply are due to this or that neurochemical mishap and there is no need for any further investigation or thinking outside the realm of biology. When varieties of human distress are understood as diseases, critical thinking is off the hook. The phenomena are decontextualized, stripped of context and any meaning outside of biological hypotheses.

It makes sense that clinicians, for the most part, accept this ‘given’. Psychology students today learn that psychology is the study of human behavior which, in turn, is the exclusive product of the brain organ. Brain organ events produce human behavior. The DSM categorizes anything that is considered defective or maladaptive in such happenings. These are so ‘given’ in the education and training of mental health professionals that the presuppositions and contexts are entirely ignored. These diagnoses are accepted as facts. Every clinician, for example, knows that it is commonplace for clinicians to simply refer to a client by his or her diagnosis; “the schizophrenic,” “the one with major depression,” “the borderline” or, sometimes, “the borderliner.” While it is impossible to stand outside our cultural-historical context, it is possible to examine some of the history, context and philosophical assumptions inherent in our worldview.

This is one of the major challenges and accomplishments of this book: sticking descriptively with the phenomenon itself without lapsing into established opinions, ideas and long-held understandings. We also do not deny that various, typically expressed, forms of distress exist. People do become distressed, sometimes in long-standing ways. What is often labelled as mental illness varies in degree, but not kind, from what everyone experiences.

This work stands out as distinct from all other books written on ‘borderline personality disorder’ and other so-called psychiatric diseases. We do not assume that BPD is what is outlined in the DSM and the literature on psychopathology. At no time do we refer to it as a diagnosis or psychiatric disease. This is why you will repeatedly see ‘borderline personality disorder’ in single quotation marks. It isn’t a thing, like a disorder residing solely in the brain organ of an individual. An individual only takes up possibilities disclosed to him or her by the cultural-historical environment. To say otherwise would be to say that the individual creates them out of nothing which, of course, would be absurd. Since distressing states of mind are variations of common human experience, they are expressed in typical ways. For these reasons, we do not consider ‘borderline personality disorder’ in a decontextualized fashion.

The causes and conditions of what is often labelled as ‘mental illness’ are known. There is no further need to research its origins. Though the literature is unambiguous on this score, it is not popular; that is, it doesn’t further the financial interests of the psychiatric establishment. It is nonetheless true.

It is the aforementioned failures of psychiatry and psychology that demand this book be written. The context provided herein is the story of how the very fields charged with the care of distressed persons came to treat them in such stigmatizing and reprehensible ways. Concurrently, it presents the meaning and experience of people contending with developmental stress and trauma which is often labelled as ‘borderline’.

The fact that this work is heralded as controversial bespeaks the tsunami of energy invested in maintaining and promoting the hegemony of understanding ‘borderline personality disorder’ as is—without context, history, compassion, truth.

The diagnosis Borderline Personality Disorder (BPD) strikes fear and loathing in the hearts of most mental health providers. It is unquestionably one of the most stigmatizing and overused diagnoses in existence. Often diagnosing someone with this label is a clinical punch in the gut to the client and also a means of communicating warning to other clinicians. It is the 21st century version of the scarlet letter or, more aptly, the scarlet label.

‘Borderline’ is to psychiatry as psychiatry is to medicine. Psychiatry’s multiple functional failures—scientistic, misogynistic, literalistic, moralistic, personalistic, pathologizing, Eurocentric, etc.—have sparked interest in what actually works. Most people, these days, have had or know someone who has had a horrible, if not outrightly dehumanizing, experience with the mental health system. Upon this ground of failures, new approaches are emerging, such as the recovery movement.

Recovery, seen as an organic process, experienced some setbacks during the 1940s and 1950s in the US, as the predominant way of contending with psychological distress was institutionalization. Even during the deinstitutionalization, beginning in the 1970s, it was assumed that recovery was not possible from so-called psychiatric diseases. We still see some of this today, unfortunately. Nonetheless, the recovery movement persevered, refusing to adopt the limiting and errant beliefs of the psychiatric establishment. R.D. Laing and his colleagues made substantial headway in establishing therapeutic household that still remain today, such as the Philadelphia Association in the UK. Following R.D. Laing, Loren Mosher was successful in his work at Soteria House. To this day, Soteria houses still exist in various locations. In a similar vein, the consumer and psychiatric survivor movements began taking hold in the 1980s and 1990s and are still quite active to this day. By 2002, the President’s New Freedom Commission on Mental Health solidified a way for a system wide paradigm shift.

Of note in the recovery movement, is the well-resourced and expanding business, Recovery Innovations. The organization constellated around the notion of recovery, from its entry-level employees to its administration. Their international expansion is testimony to the efficacy of its educational, clinical and peer support programs. With this organization, having a recovery story, of some kind, is considered a strength, not a detriment. Their states mission: “To create opportunities and environments that empower people to recovery, to succeed in accomplishing their goals, and to reconnect to themselves, others, and to meaning and purpose in life.” Their service values are hope, empowerment, wellness, personal responsibility, community focus and connectedness. Their organizational values include quality, creativity, friendliness, quality team, cultural competence and financial stability. Impressively, their entire international business operates on a non-hierarchical fashion. They go so far as to have what they call “wellness cities” where all supports are offered in a single setting. The services offered include, but are not limited to, peer support, education, medical services, mental health services, employment and crisis services. The vision of the business “was a transformation in the service delivery system grounded in the belief that people with mental health and substance abuse challenges do recover and move on with their life.” The domains deemed critical to recovery are represented in the services provided: “The principle ingredients of this transformation include hope, education, employment, peer support and self-help.” I present Recovery Innovations, since it is remarkably effective in regards to supporting people through recovery and also being fiscally sound. There are other organizations such as MindFreedom International, The Icarus Project and PsychRights that, in their own ways, participate in and support the recovery movement. And the recovery movement itself a symptom of the surge of interest presently growing out of the failed assumptions of medical model interventions to psychological distress. There are others and it will be fascinating to see what other successful endeavors will arise to replace the fallen juggernaut. This is a great time to be in the field!

See also: The Scarlet Label (Borderline Personality Disorder)

jacJacqueline Simon Gunn, Psy.D. is a Clinical Psychologist in private practice in Manhattan, a freelance writer and author. She is the former Psychology Internship Training Director and Clinical Supervisor of The Karen Horney Clinic. Gunn is bold and irreverent in her storytelling – she likes to ‘tell it like it is.’ Using wit and guts in straight-forward narrative style, Gunn’s writing shows her readers that fact-is-stranger-than-fiction. And she hopes by baring truths her readers may find some inspiration along the way.

BrentPotterPicDr. Brent Potter is a psychotherapist and wellness specialist with 20 years of direct clinical service. He is the Director for the Society for Laingian Studies. Brent is the author of numerous articles whose topics include: innovative and effective mental healthcare models, analytical psychology, humanistic psychology, existential-phenomenology, psychoanalysis, the psychotic register of the mind, character and personality disorders, chemical dependency and child / adolescent mental health concerns.His first book, ‘Elements of Self-Destruction‘ is out via Karnac Books and he has three forthcoming books. ‘Borderline Personality Disorder: New Perspectives on a Stigmatizing and Overused Diagnosis’ (co-authored with Jacqueline Gunn, Praeger, 2014), ‘Elements of Reparation: Truth, Faith, and Transformation in the Works of Heidegger, Bion, and Beyond (Karnac Books, 2014) as well as ‘Prometheus Rising: Stealing the Fires of Cultural Collapse’ (co-edited with Michael Mantas, Fire Theft Publications, 2015).

**purchase here: Borderline Personality Disorder: New Perspectives on a Stigmatizing and Overused Diagnosis

The Scarlet Label (Borderline Personality Disorder)

By Brent Potter PhD

The diagnosis Borderline Personality Disorder (BPD) strikes fear and loathing in the hearts of most mental health providers. It is unquestionably one of the most stigmatizing and overused diagnoses in existence. Often diagnosing someone with this label is a clinical punch in the gut to the client and also a means of communicating warning to other clinicians. It is the 21st century version of the scarlet letter.

In Borderline Personality Disorder: New Perspectives on a Stigmatizing and Overused Diagnosis, Jacqueline Simon Gunn and I outline the history of attitudes about the (perceived) feminine gone awry. We show that current diagnostic conceptions do not bespeak a psychiatric disease of chemically imbalanced brain organs, but are the logical outcome of long-standing attitudes about women through history. We do not deny that there are patterns of experience typical of emotional chaos and we demonstrate that men too suffer from distress presently labeled as ‘borderline’. In order to stick with the experience itself, contemporary humanistic and psychodynamic views are presented as ways of re-visioning BPD. We also present clinical material to reflect lived experience of working with people struggling with some of the issues outlined. These clinical narratives are presented also to provide the clinician, both new and experienced, with concrete ways of taking up and relating to the experiences of those distressed. It is our hope that someone suffering from intense emotional states will find, without stigma, his or her experience reflected accurately in the book’s pages. If what is outlined in these pages seems to resonate with behavior of a friend or family member, we hope this provides insight, a more open path to compassion.

I am proud to say that we worked with a number of non-psychiatric resources and received permission to compile and put into print a directory, Wellness and Recovery Resources. The reason for doing so is based upon Jacquie’s and my belief that there is no cookie-cutter solution for folks interested in recovery and wellness. As Jung said, “A shoe that fits one person pinches another; there is no recipe for living that suits all cases.” Unlike many of our colleagues, neither Jacquie nor I believe that psychotherapy is the answer for everyone. Don’t get me wrong, it proves to have amazing and often life-saving benefits for some people. So too does 12-step programs but, again, it’s not for everyone. More often than not, the path of recovery / wellness – I prefer to simply call it ‘life’ – involves a number of activities that are tailored to the individual. Sometimes it’s nutrition, exercise, group or community involvement, education, employment / different employment, etc. etc. It usually takes some trial and error to find the combination that best suits one.

In any event, it’s time to return to the individual in cultural context without engaging in the binary thinking that presently plagues our times. The form of distress often labeled as ‘borderline’ is neither a disease nor a choice. This holds true for every form of distress, not just BPD. Varieties of psychological distress are almost always the result of protracted developmental stress and/or trauma. The individual always is living in historical-cultural context. It is necessary to understand both unto themselves and in terms of how they interact. If done successfully, we see so-called ‘borderline’ people contextualized—extremely hurt, traumatized people set up against 4,000+ years of a derogatory cultural narrative of feminine madness. Again, staying away from simplistic binary thinking, it is important to note too that this kind of distress does, more often than not, cause much suffering in the lives of those in the person’s life. A good analogy may be someone in active drug or alcohol addiction. This person too has suffered a lot during his or her childhood and suffers too the same burden of essentially being kicked out of culture, dehumanized. It is also true that the addict’s behavior negatively impacts the lives of many others. Such things are difficult, complicated, painful. And yet, we must avoid the temptation to run to moralistic, literalistic, scientistic, binary thinking. To do so circumvents true understanding and the opportunity to work towards wholeness.

Clearly, a volume of books could be written on any number of these and related topics. Our hope is that this book provides some more context and contact with the human person behind the label. Unlike most insurance companies and practitioners we believe that there is hope, always, both for suffering individuals and also the culture wherein such damage is incurred.

I want to thank Beyond Meds for the invite to write this brief piece. Beyond Meds continues to be my favorite blog and has been so for quite a while. I also welcome correspondence via email (brentpotterma@yahoo.com) and on Facebook.

jacJacqueline Simon Gunn, Psy.D. is a Clinical Psychologist in private practice in Manhattan, a freelance writer and author. She is the former Psychology Internship Training Director and Clinical Supervisor of The Karen Horney Clinic. Gunn is bold and irreverent in her storytelling – she likes to ‘tell it like it is.’ Using wit and guts in straight-forward narrative style, Gunn’s writing shows her readers that fact-is-stranger-than-fiction. And she hopes by baring truths her readers may find some inspiration along the way.

BrentPotterPicDr. Brent Potter is a psychotherapist and wellness specialist with 20 years of direct clinical service. He is the Director for the Society for Laingian Studies. Brent is the author of numerous articles whose topics include: innovative and effective mental healthcare models, analytical psychology, humanistic psychology, existential-phenomenology, psychoanalysis, the psychotic register of the mind, character and personality disorders, chemical dependency and child / adolescent mental health concerns.His first book, ‘Elements of Self-Destruction‘ is out via Karnac Books and he has three forthcoming books.

The book is schedule to be out in November of this year and is available for preorder: Borderline Personality Disorder: New Perspectives on a Stigmatizing and Overused Diagnosis

Elements of Self-Destruction

Introducing a new book by Dr. Brent Potter.

By Brent Potter PhD — Director of the R.D. Laing Institute

Elements of Self-Destruction

click to view book

click to view book

“You have to diagnose her now,” my colleague said. “What? I just met with her for an hour-and-a-half. Plus, I’m off the clock in ten minutes.” The response: “It is procedure here that the assessment, diagnosis, and paperwork be completed and turned in directly after the intake session.” It was my first assessment at my first job as a clinician. I felt no sense of reassurance as I, the dutiful new employee, plopped myself down and thumbed through the DSM, the so-called diagnostic ‘Bible’ of mental health. I had 10 minutes left and, mercifully, the DSM provided highly simplistic ways to diagnose. For those without time to read—apparently I was not the only one—it had convenient little boxes with bullet points. I just had to match ‘x’ number out of ‘y’ amount of symptoms and poof, there was a person’s diagnosis. While I was doing my job as instructed and following DSM protocol I wondered, was diagnosis supposed to be this quick and easy? I remember thinking that I had spent more time deciding whether to order ‘pickles’ or ‘no pickles’ on my dollar burger for lunch. Maybe it was the burger, but I felt nauseous. Now, almost 20 years later, the feeling hasn’t left. Shouldn’t diagnosis take a little more time? Shouldn’t I meet with someone two or three times to get a better sense of things? Does an hour-and-a-half constitute a thorough assessment?

I guess I shouldn’t have been surprised when I learned that ‘therapy’ was often constructed of 15 minute check-ins with the client, primarily to document whether or not he or she was medically compliant, suicidal, homicidal, or relatively ok, so the therapist could move on to the next person on the 80-100 client caseload. The local newspaper listed us as the eighth largest employer in the county with an employee annual turnover of 50%. That’s a lot of therapists coming and going. I found that those working for the organization were not evil people; they tended to be well-meaning newbies, like me, caught between a burgeoning bureaucracy and chronically disturbed, traumatized populations. Of the few clinicians who could not or would not leave, most of them became bitter, emotionally calloused, fried. I saw myself as standing between a sick system limping from crisis to crisis, under ever decreasing funding, and clients who were chronically disturbed and barely getting the help they required. It did not take a deep or lengthy philosophical analysis to see that the overall picture was one of plain insanity. I found these factors to be true not only at this clinic, but at most of the other settings where I worked over the two decades that followed. While working at these places, I established a private practice and continued working with the child and teen sufferers of abuse and neglect, so-called chronically mentally ill and chemically dependent populations. As I suspected, these people suffered for reasons that made perfect sense relative to the contexts of their histories. These were not psychiatrically diseased cases, they were human individuals doing the best they could to survive often impossible circumstances.

This is my first book. Perhaps it represents my own attempt to make sense of the destructive elements of the psyche as they manifest in the individual as well as in broader socio-economic contexts.  I hope to point out the ways in which we are all ‘in the soup’, as it were. We all suffer the madness of our times. Who is deemed ‘mentally ill’ and who is ‘normal’ is really a matter of who is making the decision and within what context. Our level of neurosis, or sociosis, as J.H. van den Berg aptly called it, is really just a matter of degree, but not kind.  In providing clarity of contexts to the elements of destructiveness, I present some ways out of our private and shared madness.

Beyond Meds has been (and continues to be) my favorite blog site. I am grateful for the opportunity to write this blurb. I hope you enjoy my book and I welcome all correspondence. I can be reached on my Facebook page, email, brentpotterma@yahoo.com, or by phone (818.337.9701). Thank you, Brent

BrentPotterPicBrent Potter, Ph.D., LMHC, CMHS, MMHS

Dr. Brent Potter is a psychotherapist with 20 years of direct clinical service. He is the Director for the Society for Laingian Studies and the R.D. Laing Institute. He teaches doctoral level courses at the Pacifica Graduate Institute. Brent is the author of numerous articles whose topics include: innovative and effective mental healthcare models, analytical psychology, humanistic psychology, existential-phenomenology, psychoanalysis, the psychotic register of the mind, character and personality disorders, chemical dependency and child / adolescent mental health concerns. His first book, ‘Elements of Self-Destruction’ is due out via Karnac Books in February, 2013