On the Question of Psychiatric Diagnosis

It is a label used by society to determine eligibility for service recipient and service provider, and responsibility for reimbursement of service exchange that takes place within the broad framework of health industry. The criteria for a diagnosis is not static, but a fluid process, based on advancement of knowledge and science, and a common understanding of a social framework to address  behavioral anomalies in the context reducing or eliminating personal and associated social distress.

While the” illness model” (somebody has an anomaly that needs to be fixed by outside intervention) using a biological determinism and interventions involving biological and supportive psycho-social interventions, is palatable and acceptable to all and to many, but “mental illness” as many of us understand with psychogenic origin and or major involvement  of psycho-social factors, is often viewed  as of an “personal existential crisis,” with associated personal and social distress (associated with at risk behaviors” or potential for such behaviors), and this view  may rightfully cause dilemmas and concerns to many.

This “illness” model of” treatment” may violate a sense of personal freedom, ownership for one’s thinking and behavior, originating from within one’s self system, and may work counter to a sense of “personal independence,” personal unique ways of adapting to one’s existential reality, which is also valued as important component to one’s wellbeing and sense of autonomy.

Many believe that social experiences and conditions promote people to develop what one considers “mental illness,” as such the focus should be fixing the “social community and environment,” rather stigmatizing people with a mental illness criterion. Compounding the issue, many people diagnosed to have “long-term mental illnesses” do not have the social support and therapeutic milieu so to speak that many without a dx of mental illness have (e.g., family, work, social group, religious or community affiliation, etc.,), which do provide support as well monitoring of one’ behaviors for any personal and or social distress that may be associated with “at risk behavior tendencies.”

In an ideal society, if a “therapeutic milieu” is structured for all, and people can access participation in various supportive group activities, and where “at risk status” can be monitored within the context specialized support and milieu along with social rule of law for managing any “at risk deviation,” then there will be no need for any “destigmatizing illness label. Persons may choose to enter or exit based on perceived ‘benefits,” and responsibility and onus on providing such satisfaction in entirely on the providers, just like in any consumer oriented buying and selling “exchange of goods and services.”

Additional issue is that “destigmatization” for a specific “mental illness,” such as “schizophrenia” is more of a perception of meaningful lack of progress with the “existing treatment modalities,” for most who are diagnosed with this “malady,” as the so-called “symptoms” continue to persist with “impaired level of functioning” for many in spite of years of involvement in “treatment.” In order to have this egalitarian ideal into practice, societies must be able to routinely build in provisions for all such “entitlements.”  In some ways, Pope Francis’ sermons highlight this view in some way.

But this may again violate many people’s political and social values that one hold, giving too much power to “society” over individual freedom and choice, and valuation of personal freedom and free market thinking.



Facts and Opinions

“Heated Critique” or debates on controversial issues often get mixed up with facts, opinions, and personal faith based beliefs, associated with heightened emotions that are often difficult to sort for rational discourse, as people tend gravitate from one dimension to another.


As I have posted here many times, brain and behavior are two sides of the same coin, different discipline training require emphasis of different perspective, not necessarily negating one over the other. Based on individual needs, we need both perspective involvements based on individual circumstances and needs. It is when over use of one over the other, in the context of promoting one, without objective outcome assessment becomes problematical, and that goes, I believe, for both medication and or psycho-social interventions.


As a psychologist, I have collaborated with psychiatrists in clinical practice and have been in many collaborative research work or publications. In spite of my psychology background and preference for psychotherapy over medication intervention, when my own cousin got severely depressed with psychosis following a successful professional career after retirement, and did not respond to standard psychiatric treatment on outpatient and inpatient basis, and he was functioning at a very  “disabled,” level,  and in spite of my knowledge of his complicated life history, I did not suggest him and the family to pursue psychotherapy in conjunction with all the medication treatment he was receiving.  instead I advocated strongly to him and to his family for a trial of ECT, which he and the family followed through. Eventually, not only he recovered completely, he decided to go off all medications and maintenance ECT against medical advice, and is now maintaining the highest level of functioning possible for his age (e.g., playing tennis, starting his own consultation service, etc.) without any medication, ECT, or counseling services for almost 5 years. I arranged to have him present his case to NE ISPS meeting, and subsequently in collaboration with several ISPS members, we published a case report to highlight the importance for consideration for maintenance of recovery with natural support following successful outcome with “treatment.”

Again, this is a case by case issue, and must be considered in the context of each individual unique personality and present life circumstances, and what has worked and not worked.



The point I am making is that there are different avenues to recovery and management process, where a combination of biological and psychosocial interventions to a varying degree may be needed. Over dependence or over-reliance on one or both beyond ones’ needs may impact recovery and self-autonomy, both of which are interconnected, and reliance of any modality may have iatrogenic or unwanted consequences.

In a field, such as mental health, we often pretend or claim to know a lot, but in actuality may not know a lot, and that goes both for biological interventionist and psychosocial interventionists. It is better to have an open mind and evaluate outcome effects objectively, in the context of our present knowledge, which continues to be a dynamic and fluid. That’s why an open dialogue airing different perspectives is so helpful.


Comment on Spirituality


The Reality of Existential Uncertainty (independent of one’s belief in some form of religious faith or science based knowledge of natural phenomena), and Existential Mystery confront all of us as human beings. None of us know what the next moment of our existence will be with any degree of certainty. Astronomy tells us that Sun is revolving around the galactic center at the speed of approximately 100 + miles per second to take 240 million years to go around, so no human beings have experienced what the next second of Sun’s journey will be.  And from a religious perspective, millions believe that only God knows the future to deal with this Reality of Uncertainty, notwithstanding many people believe in particular faith based practice with symbolic and or concrete representations of the Future.  Science tells us that only 5% of the Universe consists of ordinary (baryonic) matter that we see or visible, 95% is Dark Matter and Dark Energy that we don’t see and are Unknown and Unknowable.  (I have a feeling that much of our knowledge of human behavior and mind may follow this ratio!) Very little is known and knowable, and much may be Unknown and Unknowable. This awareness of Unknown and Unknowable, in a way, like the inevitability of death, is a great unifier whether one is an Einstein or an illiterate person or has a developmental disability or a psychiatric condition, or whether one is rich or poor.

In some ways psychosis and schizophrenia can be viewed as unique adaptation to one’s perceived “existential crisis.” We may all experience such crises in our personal lives, but for many, many people do not get stuck with it, for whatever myriad reasons, and cope with their existential crises with some form of spiritual faiths and beliefs (with a combination of uniquely personal and shared belief systems), and are able to carry on their everyday lives with their own “adaptive mechanisms.”   The importance of focusing on the present momentary existence, freeing oneself from being a prisoner of the past, and incorporating some level of a spiritual perspective, becomes important in any therapeutic perspective as it is with all of us as conscious human living beings passing through out times on this Earth.

And independent of any understanding or insight one may have or may develop, social therapeutic milieu to prompt us and help us to stay connected to others and to the Universe at large is essential to promote positive feelings and to reduce a sense of personal distress and or social distress that are often associated with “mental illness,’ or with “behavioral anomaly of concern.”

I feel this is an area, that is  “social network supportive therapy” if one must say, where much more  attention needs to be paid for “successful recovery” including incorporation of spiritual dimension in the therapy process, reflecting the “normative” social culture and structure in which we all function in some ways, above and beyond therapeutic strategies to impact individual “brain-behavior” functioning.


Commentary on the Dopamine Hypothesis for Schizophrenia


The primary problem with dopamine hypothesis is similar to other medication intervention involving lack of targeted specific effects on a particular brain region and the side effect issue due to brain interconnectivity and feedback loop systems. As I understand, while the beneficial effects of dopamine reduction in the mesolimbic area of functioning is desirable, (reducing “the positive symptoms” of schizophrenia and psychosis), but it is countered by reduction in the frontal lobe and substantia nigra (lower brain) areas causing undesirable side effects, due to reduction of dopamine in these systems, where a higher level of dopamine functioning is desirable. From the brain-behavior relationship perspective, one can potentially develop therapeutic psycho-social interventions demonstrating modification of chemical neurotransmitters, including dopamine, in the brain systems, if more research and funding are directed towards it. This is a desirable advocacy perspective, I believe, which many ISPS members may hold. Any psycho-social intervention will also have to deal with balancing social control and individual choice and sense of freedom. In any event, research in both biological and psycho-social intervention demonstrating targeted beneficial effects with minimum side effects profiles needs to be pursed, as interventions targeted in reducing human distress will have multi-discipline involvements.  Each discipline needs to focus on its own case of advocacy of effectiveness to the mental health consumers and public at large.

Comment on : “The brain’s miracle superpowers of self-improvement”


The brain’s miracle superpowers of self-improvement

The article has implication for a positive psychology movement in terms of stimulating mind-body-behavior from different perspectives to help clients develop new positive self and social identify, superimposing on their long-standing identification with  “illness persona,”  or abandoning effort by therapists  of “repairing the “disturbed model” of self, and helping the client to focus on adapting strategies to deal with the present moments of Existential Reality and help them move onwards to the future for some of their clients.

Believing that “brain-mind-movement” has infinite possibilities of making connections to Reality, exploration and stimulation away from the so-called “disordered” areas of functioning may yield more positive results, specifically for people with a history of persistent psychological problems, who have not responded to the traditional model of “bleeding the wound” approach to generate insight and understanding. Moreover, the evidence for translation of “insight given in therapy sessions” that can be successfully generalized to life outside the therapy sessions or effect changes of one’s behaviors or emotions outside therapy sessions without meaningful therapeutic support in one’s milieu is not that great.

Hopefully, ideas like this may stimulate research and practice explorations with positive results by some ISPS members.

Comment on Recovery and Role of Positive Mental Health

I have taken a position in my individual and collaborative writings the need to highlight and focus on innate resiliency and capacity for adaptation to different life circumstances that we all face. It is a part of our biological and psycho-social-spiritual evolutionary process to make the best of our present reality of our existence, whatever they may be. Circumstances, situations, individual, and collective approaches may vary and social change and culture and our evolving knowledge base that is available. Adverse life experiences or “Dukha,” as Budha would say, is part of our human, or organism’s life experiences, and reflected in our knowledge of nature along with intense awareness of Uncertainty that confront our conscious living existence. No matter how “disabled” a person may present, he or she has the innate capacity for optimal adaptation that is present, and individual and social therapeutic approaches may need to focus how to promote that capacity, with compensatory support services, which may involve a variety of interventions involving biological, psychological, and social approaches of different degree based on client’s own and significant other people’s (involved with client) perceived needs of benefits. No one formula will fit all and needs to be individualized, that is where the challenge for a clinical service provider in engaging in mutually agreed upon strategy with the consumer-client.

Iatragenic effects or negative side effect issue are not only associated with a given intervention, biological or psychological, there is also potential for counter-recovery by fostering identification with the “illness dependent persona” that any ongoing “treatment process” entails, as it may take away client’s inner search for his or her best adaptation and sense of “wellbeing.” Too much focus on “what is wrong,” or “what negative experiences that may or may not have happened in one’s past history, may outlast the benefit beyond a point of, promoting one’s perpetual “obsession” with the past neglecting the use of positive redirection and capacity to make the best of one’s present life circumstances.  After all, from a Reality Perspective, the present moment or reality of living experience that we all face, where past is gone, and future is partially can be predicted, but mostly Unknown. I do acknowledge the importance of advocacy for social policy change with emerging new knowledge base for mental health or for any other social situation, as well as need to address personal grievances for what has been done “wrong,” and ensure societal responsibility to protect future “wrong doings,” but it may be important for a practicing clinician to compartmentalize these processes, and focus on what one can do best to promote recovery within one’s discipline identified professional role, whatever they may be. How to promote capacity and engagement in various “positive redirection” activities, some of which are referred by Brian, and build in “compensatory support” (including therapeutic prompt) in the individual’s personal and social life and the “milieu environment” and collaboration with significant others in client’s life will no doubt involve thoughtful reflection and challenge to service clinicians. Approaching one’s role in some defined ways in terms of what is “possible” and what is not, given one’s unique roles and functions, may help to navigate the process to a mutual understanding and satisfaction for client and client service providers. Peer support roles for both clients and clinicians are important component to this process.

To balance the perspective, it would be helpful to cite any studies that may also show positive changes in genetic expressions and epigenetic effects across generations demonstrating “positive” effects of psycho-social and environmental factors, so research can identify what positive psycho-social factors that one should value and foster.

The other issue would be demonstration of reversibility of negative effects through psycho-social interventions, as that is also an important focus of interest to many members of ISPS types of organization, who engage in using and advocating for the psycho-social perspective, while “reversibility” research on biological and genetic interventions will be most appealing to people who have identifications with that discipline perspective.

My sense is that biological and genetic research in some ways mirror physics and astronomy, where knowledge will always be expanding, but will always be limited by the fact that much will remain Unknown and Unknowable, a simile to the assumption that approximately only 4% of known matter in the Universe is knowable, 96% of all in the Universe consists of Dark Matter and Dark Energy and remain invisible to the human mind, and possibly knowable to some extent by limited indirect evidence.

Nevertheless, it is exciting for the human mind to continuously explore and expand our knowledge base, and our associated conscious ever expanding experience in the process of discovering new intricacies of interrelated connections among physical, biological, psycho-social, and existential-spiritual Realities.


On Multifaceted Reality-: Need to acknowledge subjectivity in experiencing Reality

The Reality is that anything we do or undertake a study has multidimensional reality components, whereby, an event or a behavior can be viewed or studied from various perspectives involving biological, psychological, psycho-social, environmental, spiritual, or any other infinite dimensional factors that one can think of, at both micro or macro levels. (From an existential-spiritual and astronomy perspective, we are all manifestations of One Whole.)  As such, schizophrenia or any other mental illness or “normal or abnormal behavior” have many dimensional perspectives, and use of a given perspective is a function of evolving and changing social and cultural perspectives, often influenced by changing “knowledge base” and public perception of what works and benefits a given person (from both person’s perspective as well as from the care giver or professional helpers’ perspectives). One pursuing psycho-social dimension, as ISPS is dedicated to promote, does not necessarily involve negating other perspectives, or promoting or substituting one “authoritarian-reductionist” model for another.  What is important if one wants to pursue a particular model perspective, is to demonstrate to consumers and public at large, how the specific intervention is helpful, while mindful of potential for any adverse effects or consideration that new information or research may negate any positive effect of an intervention or that a better intervention strategy may evolve to replace or modify the one in existence. Knowledge is multidimensional and fluid, as such, no one discipline or perspective has the monopoly of the “truth.” In spite of all the outward differences, we are all trying to promote what makes the best sense in terms of a clinical intervention, and in this case, as in others, the jury will always be out there to judge the efficacy of an intervention, the perspective of which will also be subject to change with time.

Advocacy for social policy change and clinical intervention and practice research may operate in parallel processes to provide clarity to one’s current functions and roles in a specific situation, as well as any discussion as to what are considered facts and what are considered opinions. Keeping these perspectives separate, and more importantly acknowledging and respecting differences expressed are important.

Conflicting views on various perspectives from disciplines or advocacies for social change in mental health service

I will make a series of brief statements to highlight my perspectives:

1.As living beings, we are always influenced by biological, psycho-social and environmental factors, although they may be considered as separate entities in the context of discussion and in highlighting specific influences, but discussing or advocating for one, does not imply negation of existence the value of the others. 

  1. Service exchange (providing goods and services, including health care) is a part of human society, whereby people do make “living” that includes “profits” that contributes to one’s living existence.  All of us are actual potential customers to each other’s as long as we live, even when we die (e.g., burial service).
  2. In the context of marketing and profit making, services may be provided that may or may not be beneficial, and that goes for all service providers, medical or psycho-social included. Marketing is universal to the process, but it can be “abused.” Research and advocacy are important to counter balance the process.
  3. In the context of professional discipline identification of various services, each discipline knowledge based interventions is going through evolutionary process of change with increased knowledge of the efficacy of specific interventions that are also consistent with evolving cultural and social values and expectations.
  4. “Idealized perfect societies” do not exist, where all levels of “disabilities” are fully compensated through idealized social structure and bio-medical and environmental interventions, and where we all have the capacity to experience “happy-spiritual bliss” as living human beings (although many believe in such a reality after death).  We all live with “imperfections” and that goes with our current status of “mental health treatment and recovery,” which does not mean we need to be satisfied with it, but work to improve in our individual capacities, while doing what our given roles as service providers are. (And that goes with any vocation that people purse in different fields in life.)  In this context neither medical or psycho-social interventions are all “good ” or “bad,” their efficacy and value are determined by individual choices and socio-cultural perspectives based on existing knowledge but subject to evolving change process.
  5. Advocacy of a given perspective is a legitimate pursuit -to make a case on behalf of a given perspective, but when it takes a dogmatic authoritarian stance, it may convince some, but may not have a larger acceptance of audience, and may vitiate its own cause or may promote other “negative effects.”
  6. All kinds of research studies on efficacy, cost-benefit analysis, negative effects of a given intervention are important in our continued enhancement of knowledge and improving our quality of life, and improving particular discipline service provisions. (All the links provided in this Forum is useful to many of us, depending our own interest.)
  7. To advocate and promote a particular discipline perspective, biological or psycho-social perspectives in mental health, one does not need to build its case of efficacy by investing time and effort to tear down and point out deficiencies in other discipline perspectives that are involved in providing services.
  8. Granted the dynamics of evolving knowledge base of any discipline or any human service exchange of information or service goods, we all in our own ways review what we know best, what skills we can use to provide services to others to make a living, and what we do not know, which probably is the larger domain for any discipline or service provider knowledge domain. Yes, our knowledge base and practice of skills will need always in a dynamic mode of change with the emergence of “new information.”
  9. We are all in some ways involved in exchange of services, either as providers or receivers, or both,  and our practice of what we are doing reflects whatever roles we are assuming at a given time.  Often advocacy role for change for one’s discipline service or change in  social perspective or larger social -cultural environment- all  are relevant pursuits, but  need to be dealt separately, and apart from one’s service provider role. Mixing the two will be problematic in the actual context of clinical or service provider roles that one may be employed in.