The Taproot Podcast - The Death of the DSM: Why The Book For Sanity is Making us Crazy

Episode Date: January 10, 2026

Is the DSM Dead? The "Bible" of Psychiatry, The Thud Experiment, and The Crisis of Diagnosis Episode Description: It dictates every diagnosis you receive, every medication you’re prescribed, and every insurance dollar spent on your mental health. But what if the "Bible of Psychiatry" isn’t actually scientific? Pull back the curtain on the Diagnostic and Statistical Manual of Mental Disorders (DSM) to reveal a document in crisis. From the secret backroom deals that voted diagnoses into existence to the "checklist revolution" that stripped therapy of its meaning, we investigate how American mental healthcare became a system of billing codes rather than healing. We explore the infamous Rosenhan "Thud" Experiment that humiliated the psychiatric establishment, the accidental creation of "false epidemics" like ADHD and Bipolar II, and why the National Institute of Mental Health (NIMH) effectively abandoned the DSM years ago. Most importantly, we ask the hard question: Why does the system demand you be "broken" to get help, yet deny you care if you are "functioning" enough to work? If you have ever felt misunderstood by a diagnosis, frustrated by the medical system, or wondered why your "high-functioning" suffering doesn't seem to count, this episode is the validation you’ve been waiting for. In This Episode, We Cover: The "Thud" Experiment: How 8 sane people got committed to asylums and proved psychiatry couldn't tell the difference between madness and sanity. Reliability vs. Validity: Why the DSM prioritized "agreeing on a label" over "finding the cure." The Productivity Trap: How the "Clinical Significance Criterion" denies care to people who are suffering but still employed. The "False Epidemics": A look at how diagnostic inflation created the modern ADHD and Autism boom. The Divorce of Psychiatry & Therapy: Why your psychiatrist doesn’t do therapy anymore (and why that matters). The Future: Moving beyond the checklist toward a model of narrative, systems, and human connection. Quote from the Episode: "The DSM is not a description of nature. It is a description of what American healthcare requires nature to be." Resources Mentioned: The Myth of Mental Illness by Thomas Szasz The Book of Woe by Gary Greenberg The STAR*D Study’s true remission rates (2.7%) Hierarchical Taxonomy of Psychopathology (HiTOP) Connect & Listen: Subscribe to hear more critical investigations into the mental health system. If this episode resonated with you, please leave a review and share it with a friend who needs to hear that they are more than a billing code. Keywords for SEO: Mental Health, DSM-5, Psychiatry, Psychology, Trauma, ADHD, Neurodivergence, Joel Blackstock, Taproot Therapy, Clinical Depression, Bipolar Disorder, Big Pharma, Medical History, Rosenhan Experiment.

Hey guys, it's Joel. Welcome to the Taproot Therapy Collective podcast. And this is going to be a little bit deeper of a dive. I've got a couple questions after the last essays that we did. Some of this will be a little bit of a retread because some of the questions, you know, said, hey, what's the real deal here? Is it more comprehensive than that? And so I'm going to be more comprehensive, which means I've got to go over some of the same stuff again. But this is a history of the DSM.

And I think that it's one of the bigger questions that, I don't hear talked about much in psychotherapy. If something's coming up in therapy a lot or coming up with colleagues a lot, but I don't see people writing about it and talking about it, especially when therapists all agree on something and they're not talking about it. Those are the articles that I try and write. And in that vein, this is what this article is. So, you know, love it or hate it, there's this thing called the Diagnostic and Statistical

Manual of Mental Disorders. And it's published by the APA. And it functions as this definitive classification system for the mental health conditions in the United States. So every diagnosis that we give, every insurance claim we file, every treatment plan that we have to justify with a soap note, and then you have to have a treatment plan to write, it all flows through this DSM categorical architecture. And that's part of the system. It's not something that you can really opt out of. So, you know, it is for all practical purposes, this Bible of American psychiatry.

And yet the fact that we have to diagnose under its criteria is one of the most controversial issues that I've encountered in the field, which is weird because, you know, everybody has. has to do it. Yet a lot of people off the record will tell you that they don't really like it or don't really care, which itself, you know, should indicate a problem when the clinical rules are different than the clinical judgment on a level like that. And I'm not picking a huge side. I'm not saying that we should throw out all diagnostic criteria or that, you know, if you diagnose anybody, you're pathologizing them or some of the arguments that people think that I should make. Not that they're right or wrong. I'm just, I'm undecided and I'm always trying to acquire new perspectives and new information.

But, you know, to understand, I definitely have critiques of the DSM. And one of those is that it doesn't really have any sort of unifying singular vision, which means that it becomes a very hard lens to use because it doesn't know how it wants to conceptualize anything. And that happens for a lot of different reasons. So one of the things that, you know, I want to make an argument about is like, I'm not, I want to refute is I'm not arguing against science. I'm not arguing against evidence-based practice.

I'm pointing out places where the science that we assume is scientific might not be very scientific, which is not an argument for pseudoscience. It's an argument for introspection and reflection. And we should do that, you know. We should have those conversations. So the DSM-1, you know, it starts with this kind of dynamic paradigm where, you know, Everybody's talking in the post-World War II era on the basically the language of like, you know, Freud and Jung still. There's neuroses and there's reactions and there's these dynamic processes that we don't necessarily use to conceptualize things with diagnosis anymore.

But it's trying to describe those in a statistical manual. And so it's talking about sort of balancing forces, you know, the language of psychoanalysis, more or less. And so that nomenclature explicitly used the term reaction for many conditions, like a schizophrenic reaction. So it was more in communication with the environment to doing something to a person than a person just kind of doing something in a vacuum, which is one of my criticisms of what the DSM looks like now. You know, a depressive reaction. They're assuming that this is reacting to something either internal or external. So it's a part of a system, which is, you know, probably a better way to do it. And so it reflected this belief that the symptoms were manifestations of this patient's struggle to adapt.

Again, that's a conceptualization that I like. That's why I'm not saying that we should do psychoanalysis again or classical union analysis. That's something that I write about because I use elements of it, but it's not something that I do. So, you know, that's not what I'm making a case for it. I'm saying that there are useful things of that model that we have lost. Like a neurosis was not the separate, you know, species of existence, but it was an exaggeration of a normal defense mechanism. And so that's why some of that language is now inevitably coming back as trauma becomes this focus.

You know, if you look at the history of mental health initially kind of like in the 60s, all of this focus was on schizophrenia. Like that was the most interesting thing ever and it sucked up all the money. And then autism became incredibly trendy. I guess ADHD in the 90s. And then all of a sudden, you know, in the 2000s it was autism and that sucked up. up, you know, all the money. And then the next big thing was trauma. Now, you know, trauma and PTSD and what those are and how we should think about them is the huge conversation.

And, you know, that diagnostic criteria in the DSM 1 and 2, they weren't lists of symptoms, but they were narrative paragraphs. They were short descriptions of a prototype that the clinician was expected to match against a patient's presentation in the room. So the psychiatrist's judgment was what made it. You know, do you feel like these fours, forces are present. And this relied on interpretive skill and theoretical orientation. No one's going to ever be 100% competent. But most people who have gone through this process probably understand how to talk to somebody and figure out what is going on. That's another thing that modern DSM doesn't really like. It doesn't want you to use that subjective judgment. And my point,

a lot of my point with this piece and a lot of other pieces is that subjective judgment is completely inevitable. And because of it is completely inevitable, when you say, oh, here's a purely objective or logical system, what you've done is hidden the subjectivity from yourself, and then you don't know what it is. And that's a problem, because it was somewhere. And I think that's what's happened now in the DSM-5. So like Freudian psychoanalysis, it might interpret like a patient's silence as resistance, rooted in an anal retentive personality structure. Or while a psychiatrist with a more biological or social orientation who's medicating now they may just see that differently with good reason

I mean not all silence is resistance you know there's a lot of things that could cause that and now that the field has matured scientifically in the technique I think that the underlying conceptualization of the manual is not helping us use those techniques as well so while this approach offered this rich, you know, humanistic and individualized view of suffering, it also failed this fundamental test of science, which is reliability. And that refers to just consistency of measurement. You know, if two patients see the same psychiatrist, I mean, if two psychiatrists see the same patient, they should have the same diagnosis. But a lot of people were just wrong. And, you know, doctors are kind of loathe to criticize each other publicly. A lot of

that's for liability. And a lot of it's for, you know, being at the top level of hierarchy. They don't want to be seen, you know, fighting too loudly. And so they don't like to disagree. And because they don't like to disagree, um, they didn't like to say, well, you're the wrong one and you're the incompetent one or, you know, whatever. And so this, the most famous of this was this US, UK diagnostic project. And it compared these diagnostic practices in New York and London. And they found that American psychiatrists diagnosed schizophrenia of much more than the British ones. And they were, they were likely, the British psychiatrists were likely to diagnose manic depressive illness, uh, bipolar, is bipolar disorder now for the same clinical presentation. You know, if the symptoms and the case

study look relatively the same, they would have a different diagnosis. So it demonstrated that schizophrenia in the DSM2, it wasn't like a stable biological entity, but it was sort of culturally and theoretically dependent. And I would argue that that is because psychosis is a whole lot about culture and technology and the metaphors we draw from those. I've argued that. And if you look up the ritual and animism piece, that's a deeper dive on that. There's a podcast and there's a blog. on it, looking at how psychosis changes based on culture and it changes over time because you're dealing with deep metaphors of the brain, which a lot of times are mystical and religious and highly symbolic and symbols are not universal and symbols are not completely biological.

So of course psychosis is going to change. So this collapse of reliability was not just this academic embarrassment. It was an existential threat to psychiatry. So without reliable diagnostic systems, epistemology, epidemiology of just studying the, and that's the reason the DSM exists is they want to study diseases, but mental health is messy. It's not cancer or the flu. It's, I don't know, some anxiety, some depressions. How do you group these things together? Big problem. I'm not saying that I have a perfect answer here. I'm just sort of critiquing and offering my perspective,

but the researchers couldn't count how many people had a disorder if they couldn't agree on what the disorder was. So there's already sort of this feud there where people always feel like somebody else is doing it wrong. So inner R.D. Leng, who's a Scottish psychiatrist, really interesting guy, very understudied. I've never heard another colleague talk about him, and I think he's a fascinating person. But he, um, not just in the things I mentioned here, he should look up some of his schizophrenia stuff, but, you know, he writes the divided self and he argues that what looks like

madness was often a sane, intelligible strategy, um, for surviving unlivable situations in the past that's still happening. So he had a more trauma informed. A lot of these guys did, pretty early in the 60s. They had a more modern trauma-informed thing where it wasn't a moral deficiency or a lot of the things that people posited or bad genes. You know, they weren't eugenicists. And so Lange posited that the schizophrenic person was not a broken machine, but they were an existential voyager and they were entering the deep mind. And he suggested that bizarre speech and behavior of the psychotic patient were coded mechanisms about double binds that were put on society or put on the individual.

And there is some truth to that because when a person is given a false choice as a child, you know, it's called a double bind or by a society where it's like, you know, work hard and be successful. But if you're not successful, you're not working hard enough because the system's never wrong and I can never get ahead. I'm kind of being gaslit to a point where I feel like the problem when I'm really not. Same thing with a parent that's like, you know, always speak your mind and I want to know who you are and why you're being silent. And then you tell them and they're like, well, I don't like that's the wrong thing. That's not who you are.

you know you get all of these things emerging in psychoanalysis where they say okay there's a a dream of an object in a patient's mouth and i'm doing the dream analysis and they say the object is glass and if they but they're choking they can't breathe but if they swallow it then they swallow this glass bottle and they're keeping it inside it's too much and if they get it out of their mouth they have to break it and then they get it wounds them you know and this is really about the double bind that they were placed on in childhood because if they were said who they were their real self if it came out then they were wounded like the glasses wounding them but if they swallowed it and kept it inside then it was too much and they weren't living authentically and

because their parents and mommy put them in this position that's why now they have schizophrenia but this trauma led to this split well now we know that schizophrenia is pretty genetically determined trauma can set it off it certainly doesn't help so can certain drugs we think maybe they just raise the age of onset or lower the age of onset too earlier, but you would have gotten schizophrenia anyway, maybe a little bit of both. These early guys didn't think of schizophrenia that way. They thought it was completely determined by the environment. Now we act like it's completely determined by the genes. We need to meet in the middle here. You know, there's a part of my critique of my profession is that it's always overreactions to a problem that go too far in the

wrong direction every time. And they kind of zigzag everywhere if you look at the history of psychotherapy. So, you know, that perspective was terrifying to mainstream psychiatry at the time, which was, you know, largely pretty like racist and eugenicist and, um, and, uh, obsessed with morality. So your genes had failed or your, you know, fortitude. You were, you know, not as strong as somebody else. They saw it as this, the patient's fault somehow. The patient was wrong. Um, and so the, the patient's delusions, you know, are actually a poetic truth. You know, that's kind of the Jungian take. And psychiatry is a attempt to cure them with drugs or shock. therapy, it was not medical benevolence. It was this political violence where you're trying to repress

somebody. And then Thomas Zazz, you know, in 1960, Zaz says, you know, Ling is kind of coming from the left. He's a socialist and into existentialism and, you know, Lecon and Frankfurt School stuff, probably, based on his writing. I don't know that he's ever said that. I don't think he cites Lecon anywhere that I've read. I haven't read all of Ling, though, so I don't know. Anyway, so, you know, Zaz is more right-wing. He's like a libertarian, like get off my lawn. I want to grow marijuana and have a bunch of guns and I can do whatever I want on my land. That's kind of, you know, his orientation. So it's more of a right-wing argument saying the same thing.

And he says, you know, illness is a structural, functional deviation of the body. And the mind is not a physical organ. It's just a concept. So it can't have a pathology. You know, there can be no illness of the mind. There's only problems in how you live. And if you change how you live, you can do better. You maybe need to take medication.

you maybe need to think differently. You may, you know, that it's always about something that you should be able to gain control over, which is, you know, kind of a bootstraps right-wing thing, but it's also sort of making the same argument as a lefty like Leng. Zaz's contending that psychiatry was the pseudoscience, and it was used by the state to police social deviants. He, you know, is sort of, you know, maybe looking at, the persecution against outgroups, which is not typically associated with the bright wing, at

least now, but, you know, labeling behaviors such as illnesses or society that is, you know, avoiding these difficult ethical work of dealing with conflict, that they're just sort of taking people away so they don't have to actually figure out how to integrate them into society and do something with them and make room for like the real diversity of humanity. And so this mental illness label allowed the state to just incarcerate innocent people. And so Zaz is a right-wing guy. He's more about, you're taking away, you know, my freedom of autonomy. He's not as much into it for the collectivism and relational energy of Leng.

But they mostly make the same argument. So Rosenhan, he provides this empirical conviction. And I looked up more information about Rosenhan since the last one because you all asked. But in the 73 study, You know, he publishes in science under the name on being sane in insane places. And, or the title, not the name. Yeah, he didn't, it wasn't pseudo eponymous or however you say that. So anyway, it was this sort of sociological experiment.

One that you probably could never do today. So he says he's getting eight pseudo-patients, just people to pretend to be patients. And they're sane because they're students. And they have no history of mental illness at all. And it includes a psychology graduate student, a pediatrician, a psychiatrist, and a psychiatrist, a painter, a housewife, and their instructions are super precise. You know, we want you to present to the psychiatric hospital admissions office and complain

of hearing voices. And the voices are unfamiliar. You know, it's not something you know. They're of the same gender as you. And they only say three words, empty, hollow, and thud. That's all you say. They say. And beyond that single fabrication, that's just one lie.

They're able to be completely truthful about everything else. Are you hearing the voices now? What do? there's no other impairment. They just say, you know, one time I heard empty hollow thud. And this was calculated, you know, because he's knowing that the psychiatrist don't really listen or don't really follow a lot of the things that it says that they're supposed to be investigating, which still happens.

You know, they kind of slap a diagnosis on you. And he's kind of, what he's trying to do is make the medical system more thorough and say, okay, well, shoot, you know, we're just kind of slapping people around and discharging them, and slapping them in and slapping them out. but we need to actually sit with people and treat them. And the current sort of profit-driven system, the way it's evolving, is not working. So we need to spend more time. Like he's trying to get it to do something good.

But when you make somebody who has a problem insecure, a lot of times they don't do something good. They just do something to deflect, which is what happens. And so 12 students are selected, 12 students of psychology, and they go in and all 12 are admitted when they say this. And they're honest about everything else. The only lie is I heard hollow doll thought, be sad by a voice.

And there was this sort of stickiness to the label. Once they were flagged as insane or having schizophrenia, I'm not calling people schizophrenia as insane. It was, you know, his language and his document, is that, like, once these pseudo-patients are admitted, they cease having any symptoms. And they spoke normally, they behaved cooperately, they told the staff they felt fine.

Yet the whole staff, blinded by this label, reinterpreted their normal behavior as pathological, which was the point, is that he was trying to say that when you make this subjective and people have biases, then they just go ahead and use those biases subjectively, which the role of science is supposed to remove bias from procedure in psychology. So when pseudopacients took notes on their experiences, nurses recorded this in the chart. The patient engages in this writing behavior. And they interpreted it like it was this compulsive symptom of psychosis, but it was really just a dude who was bored. And so, he's writing down in his journal because he's going to be in a mental institution for the next week. And then, you know, boredom induced walking because they're bored, was seen as a nervous agitation that they were neurotic. And the average daily contact with the doctor was about six to eight minutes. You know, the point is for them to get their medical records when they get out so that they can see what everyone was saying about them that, you know, would probably be colored by just these kind of whims that psychiatry was using at the time.

And keep in mind, this is a hospital. There was probably pretty good psychology happening in clinics, but he was trying to say that hospitals should act more like a therapy clinic or an individual therapist's office, which, of course, a hospital is not going to do, even when you prove something like this. So, because it would be expensive. So, you know, these patients were not ever declared sane or misdiagnosed. The hospital admitted nothing after they could get no more symptoms of schizophrenia,

which if you have a psychotic break, even if you're in the pro-dromal period, you're going to see behavior over the amount of time that these people were admitted, and you were from 19 to 52 days. So they were providing evidence that they did not have schizophrenia to anybody who was using even the pretty loose, you know, non-checkless-based system at the time. There was just, there's no way for somebody who has mental illness like that to go in for 52 days and not have another single symptom without any medication. So the label didn't work.

But they were, they never said, oh, oops, we made a mistake. They just said, oh, it's in remission now. Well, how did it get there? You know, that doesn't make sense even what they knew, what they knew about the diagnosis of the time. So, Rojanthand's conclusion was pretty bleak. He said, you know, these salient characteristics that lead to diagnosis reside in the patient's environments and not in the patients themselves. He had proven this, you know, when he brought the clinical gaze of the intuitive, you know, expert into the hospital where the sickest people were being treated, that all the patient illness was like largely this myth. If they had done something different, they probably could have treated these people better.

They didn't have to be there. They didn't. Not all of them needed the treatment they were kidding. So these forces are all sort of converging on psychiatry at this time. There are civil rights activists who say involuntary commitment is a violation of liberty. And a lot of times, especially in the South it was. Black people were just sort of targeted. Or Hispanic people at that time, you know, there weren't as many Hispanic people in the South that there were African Americans.

But, you know, gay rights activists say, you know, you said that homosexuality is a mental disorder, you know, and it's not hurting any to consenting adults. The public starts seeing things like one flu over the cuckoo's nest and things that are, you know, sort of based on what's happening. And they just start seeing mental institutions as these are authoritarian drug pushers and enforcers like Nurse Ratchet. And then you have, you know, scientific researchers. Studies start showing that inter-rater reliability is terrible. It's not working. insurance companies are not wanting to pay for vague reactions or the person who wants to sit in psychotherapy for 30 years just to have a friend.

And pharmaceutical industry needed this humongous, this homogeneous, not humongous, sorry, they needed like a consistent group of patient populations for randomized controlled trials, because if you gave a schizophrenia drug to everybody who kind of said, like, well, I got so manic or depressed that I had like a little bit of a schizophrenia-like symptom and then they didn't get better, then that doesn't really mean that your drug doesn't work because you gave it to somebody who doesn't have schizophrenia, but we can't define or triage schizophrenia at all clearly. So like what even is it? And how do we know how to study if we don't have a population to give drugs to?

Which is a good problem. I mean, that's one of the reasons you need diagnostic criteria. They're not wrong. You know, I'll say something nice about the pharmaceutical industry. You do need a group of people that you're studying in order to do a study. So the profession is viewed a soft, subjective, and politically compromised. And the stage is sort of set for this revolution. So when the DSM3 task force is assembled, Robert Spitzer is put in charge.

And this is in 1980. It's sort of during a conservative push for saying conservative doesn't really mean a ton because our political parties change so much in this country, but relatively quickly, not just recently. I mean, it's definitely speeding up because of the Internet and stuff. But conservatism during this time was saying we want accountability. We don't just want money given away. we wanted to know that it works.

You know, the bootstraps ideology, but it was about like you have to, bureaucracy should come in here and it should prove that you're actually the best worker and we want a meritocracy and we don't want to give money to all the schools. We want to see which schools is doing it right and give them the money

and then the other schools will get it together, which again is not a bad thing. It's just that when you start to add bureaucracy to test for things that are not necessarily testable, you can't find it because it's not testable. You know, I remember like during the Bush administration, they needed to prove that after this like restructuring of the new Laurel in school systems the test scores gotten better but the test scores hadn't gotten

better when you privatized everything and fired all of the career teachers and brought on all these teach for America grads and privatized all of it and so they just gave a different test and they were like well the score on this test is higher than the other one but that's not scientific because it's two different tests and it was designed to get the result they wanted um you know um what's another example of that there's um I had it, and I'm blanking on it. This is the kind of thing that I probably should cut if I had more time in an editor. But, yeah, so you have that sort of conservative energy happening.

Oh, I know what it is. Adam Curtis, you know, in one of his movies, he's talking about when Thatcher and Reagan come in, and Thatcher's like hospitals that aren't seeing a bunch of people that aren't being successful, that are just letting these people malinger in wine and drink water on the government dime, We want you to prove you're not doing that. So we're going to judge you based on the number of beds. So another thing that happens is they just change the assessment metric. So a lot of these hospitals that needed funding and didn't want to be scrutinized and didn't have time to, you know, make an argument that you're doing a good job or you can just do a good job.

Like if you go to most workplaces and you listen to the person who's always by the water cooler talking about how great they are and what of a great job they do, usually the person that's advertising that all the time isn't working and they're one of the worst people there. Same thing with these systems. Like if somebody's doing a good job and you ask them to like track everything and do heuristics and get data and then really prove it, they can either do what they're hired to do or they can try and be defensive and babysit themselves with numbers. And so what happened in Britain is that they just reclassified like chairs in the hospital to beds and then said, yeah, everybody had a bed. This is how many patients we saw. You know, real thing. Lots of things like that when you try and introduce accountability into these systems. So Robert Spitzer, he's this, you know, the main guy for the DSM3.

He's a Columbia professor and he's described usually as like a brilliant guy, but kind of different, you know. And he had undergone like psychoanalytic training, but he never really fit the mold of this like empathetic interpretive analyst. Spitzer was more uncomfortable with ambiguity. He never really liked the kind of subjectivity of therapy. And so in the 1970s, he was obsessed with categorization and data and had been sort of put into administrative roles because he wasn't really very good in therapy. He wasn't like warm or relational. And so he, that rejection maybe made him or inability to do therapy made him want to make it, you know, a different thing. If you want to psychoanalysis, there's probably a little bit of that there.

But he, he's very bright if you ever. anything that he writes, he's smart, but that, you know, again, that doesn't always help you do something good. So the problem in the field was that it was very fractured. Psychoanalysts believed depression was condolous by anger turned inward. You know, biological psychiatrists believed it was a chemical imbalance. Behaviorist wanted it to be learned helplessness that, you know, treat everybody like a lab rat. Behaviorism is growing, exploding in the late 70, you know, in 1975 through 1985, that's where American behaviorism people see it as this thing of like, you don't have to deal with cognition or emotion at all.

You can just train people because we're, we just sort of input machines. And so Spitzer's reaction is propose a manual that, you know, ignored the cause entirely. Similar to Beck with CBT, like quit talking about how this stuff got here, talk about what to do because they were angry that psychoanalysts were navel gazing and wasting time, which, you know, valid. So it would solely focus on description.

It wouldn't matter why the patient was depressed. It only mattered that they had depressed mood, insomnia, weight loss, and fatigue for two weeks. You look at symptoms. And this was this diplomatic, you know, master stroke because it allowed Freudians and biological psychiatrists to use the same codes. But it was also this philosophical retreat from ever trying to figure out, like, what these things were or how we thought the mind worked. We just didn't have to know.

We'd have put symptoms together and drew lines around symptoms and called that a diagnosis. But it was just sort of a thing we were making up. So we abandoned the why. there's no reaction to something anymore. Reaction to what and when was the reaction? There's no dynamic force. It's just check these boxes. If these three things, then you have that,

which paves the way for Psychoform when Prozac comes out as this sort of, you know, mainstream third-gen thing to sweep the world. And so the innovation of the DSM three is checklists. And it was, you know, supposed to be this diagnostic criteria where all the psychiatrists will, agree now because if the patient checks this box for one doctor, they'll check that box for the other

doctor, they'll have the same diagnosis. Now we're speaking the same language, right? And again, like, when I look at people like Beck or Spitzer, who I think did a bad thing to the profession, or at least took it in too far of, you know, the other direction, I don't really have any problem with them personally because the problems they're addressing were real. And I also think that those people are kind of this inevitability. It's kind of like Columbus gets all this credit for discovering North America. But like, if you let Columbus like ships sink there's enough ships bumping around in the Caribbean there's so much exploration and interest in that region but it would have been discovered you know the next year like it he just happened to be in the right place at the right time somebody was going to do this stuff it happens to be spitzer and back um that do you know a kind of objectification and surface level let's get the practical let's get to the practicality by scraping the depths out of the thing somebody was going to do that It happens to be them, but, you know, like I don't really have an axe to ground against them because I just think that that they would have been replaced by the next guy. They would have done that.

But Rosenhan, his experiment destroys psychiatry's reliability, and the checklist fixes that. And so this shift to this bureaucratic methodology now feels more scientific, which when I see people who think that they're purely logical, what I see is a fear of interior space and an insecurity, but maybe that's just me. maybe you don't. And so it's just taking responsibility away from the clinician. You know, I did not, I know, I knew that she the manual did. This is just what you have. So it's objective. And now you have this disorder.

I don't just think that. You don't have to fight with me about it or explain yourself. Just the objective things about you give you the objective thing here. And it doesn't really matter why you did it. If this is going on, you've got it. And so the checklist system is popular. And it sees this like reification of psychiatric. disorders where a diagnosis of like major depression becomes treated as a thing that the person has

instead of a description of what the person is experiencing or a description of a process within the person. So now the diagnoses get tacked onto you. It's not just a way of thinking about how you think, which is that's the change that's important here. We're not thinking about thinking anymore. We're putting people into boxes that they don't always fit into. And so, So this bureaucratic, like, I have people some of the time that are just like, I have to have a diagnosis, I have to know. And I'm like, look, you got a little bit of this. You got a little bit of that. But I got to either check three boxes for this one or five boxes for that one. And you don't meet criteria for any of them. But this is why I think it got there. This is what I think that you're

doing. This is what I think you're compensating for. This is how I would treat that. And you came here to get better, right? So this is how you could be treated. But you're landing in this vague or more general diagnosis just because you kind of have elements of these this dopamine disorder or asd or ADHD but you don't totally meet criteria if you want a diagnosis based on the book if you want to all refer you to psych testing and i've had two or three that go and they pay a lot of money and they do these all-day psychiatric tests and i flip to the end of those reports when i get them and they say this person doesn't meet criteria for any of these things but they show um you know they show um symptoms of these but just not enough to meet diagnosis and it's like okay

Yep. That was an expensive way to get back there. If you want to just wait two or three more years, the diagnosis will be different anyway. And then when it's different, you can just go ahead and get the newest one. So there's this feeling that happens at this point, which we still have, that if we have this scientific answer that explains why we are the way we are, all of a sudden we won't feel the way we feel. And I think that's a problem, too, because that isn't true. You know, the diagnosis doesn't help you.

It guides the treatment that helps you. And a lot of people view diagnosis as treatment. Like a lot of people will go get diagnosed with autism now and then be like, oh, this explains so much I have autism and then leave and never pursue treatment or changing anything. It's like, well, why did you need this got random guy to tell you that you had this thing that they made up, basically? You know, like we could make up lots of different ways to do this. This is the one we have right now. and I'm not saying that they shouldn't do that.

I'm just saying that that's something that a lot of people do. And it seems strange to me because the whole point of diagnosis is to guide treatment to change the way you feel. And if you're just getting the diagnosis to sort of justify the way you feel, why do we need psychology at all at that point? You know, it's just like a card catalog or something in a library. It's a Dewey Decimal system for people. It's not like a tool to affect the way that we live and feel. feel and relate, which is what I think it is, but some patients don't because they want a diagnosis and then they want it in one session and then they want to leave.

So Spitzer even says later the pharmaceutical companies were too delighted with the DSM3 and the checklist created this perfect target for drug development. He regrets that. And then he sort of sees, you know, things like the panic disorder and things he sort of thought should be treated, just drugged. And then the hospital leaves the walls of the hospital. have the DSM-3 because you don't have to go to the hospital anymore. You know, all of a sudden the hospital can come to you.

And, you know, one of the issues that I have and a lot of people have with people that are over-medicated is that you're taking a behavior that you really could change if you wanted to, and then you're adding in a drug that takes a chunk of your personality and these other things so that you don't have to change it. And I think you should treat trauma and get to, you know, as high of a functional state as you can and then medicate the things that are sort of endogenous the way rain works and are not going to go away and that you should definitely weigh the pros and cons of medication. That is a little bit more measured of an approach than we've had for the last 20 years.

But, you know, I'm not the king of the world. So who cares what I think? But that implicit in that DSM3 is this revolution where we don't define the phenotype, the symptom, reliably, then the genotype, the gene, and the biological mechanism, it would never be found. So it's seen as like if we put all these symptoms and categories, then we'll find the cause, and it won't be what the psychoanalyst think. It'll be some brilliant new science thing. So this is just this pragmatic placeholder that we're doing until neuroscience can explain to me why everybody's depressed. And this assumption was never fully articulated, but there's this

pervading idea that psychiatry would assume have its own germ theory. of the specific cause of the thing. Just as medicine discovered pathogens or specific diseases, psychiatry would discover specific brain lesions or neurotransmitter imbalances or genetic markers or something that they can point to that it's explaining behavior that makes it a little bit more biological than just symptoms together. But that never happened, you know? And they were expecting it to happen.

Like in the DSM-4, I think a lot of people who were initially conceiving of it, why it didn't change anything people thought would change and it didn't go in a direction people liked was that when they announced publication the initial idea was like we're going to put we're going to like the human genome project by that point will be really far along so we'll have all that data and that'll probably give us some information but then it about like the difference the connection between biological biology and psychology but then it didn't like the human genome project wasn't super useful for understanding these things. And so then they had to publish something,

and the APA certainly makes a lot of money publishing the DSM. So they also have other incentives to do that. And so you get, you know, this, like Alan Francis, has this kind of reaction to the DSM3. And he says that it's diagnostic inflation, that the checklists are so easy to use and they're so divorced from any context that the boundaries of mental illness are expanding too rapidly in normal human suffering,

you know, grief or shyness or boisterousness, or the individual psychology of the person, that somebody who is a hypochondriac or that somebody who views themselves as a victim who needs help and they can't learn to feel better on their own. They need to figure out what's wrong with them through some external source. They're going to be more likely to collect all these diagnosis, which still is true. You know, Francis is right. And so he says the DSM-4 is this conservative, reaction and his goal was to like hold the line against this proliferation of new disorders and say we don't need you know all of this new stuff that's just going to every time anyone feels bad now they have a diagnosis

which is an argument you know people still make and so when you move to the DSM 5 there's this new idea of like spectrums like people have been talking about autism spectrum and they wanted to have this paradigm shift but the problem is like like the committees that make these things are enormous and their subcommittees. I mean, it's like a Congress within a Congress and a Senate, and there's psychiatrists and clinical psychologists and social workers. And the social workers get up and the social workers say, like, well, this is the person in the environment theory and you're being too pathologizing. And of course, nobody listens to them. Well, I mean, one of the DSM-5 people, the lady who did the grief,

the new grief diagnosis, she was a PhD social work teacher who found all this sort of cultural and sociological information and then turned it into a diagnosis that they did accept. So I'm not trying to downplay the role of social workers. I just mean that if the biomedical model has to choose between the lived experience of a social worker and the profit motive in health care, who do you think they're going to pick? And like the, so the people, short version of that is that not everybody on these things agrees. So a lot of times there's like the main people, the chair and the board, like have this sort of

grand vision for what it's going to be, just like they did with, I mean, the DSM3 may be. the only one that, like, from beginning to end was telling the same story or it finished the story that it set out to tell. The four and the five didn't do that, which is a lot of my issue with them. They started to get all these spectrum diagnosis and things into committee. And then, and we don't know a ton about exactly. I mean, people talk. There's some people that said some stuff.

But, like, there's NDAs that stop anybody from doing whatever because you don't want there to be this political backlash where somebody comes out and they're like, so and so don't want trans people to have bobby blah or so-and-so doesn't want whatever and then and then all of a sudden you're involving the public with external pressure on this thing that's supposed to be whatever so I don't think the NDAs are terribly nefarious in their intention they may be terrible they may be a little bit nefarious in their effect but a lot of these things we don't know like if somebody's saying something outside of the room and then they're on the committee then they probably said the same thing in the committee so you can kind of know what people say but this is not a public

process. Very little of it is public. And even to the people in it, I mean, there's these sub-hearings that review evidence and then the bigger board listens to everybody and then they make a decision. And then ultimately, it's up to this kind of small group in the chair to sort it through the entire process and publish another book. So this isn't just like one guy sitting down and all of psychiatry votes for it. You know, Spitzers, the chair. Like these are huge processes. And by the time we got at the DSM-5, it was ginormous, like one of the most complicated, you know, projects. And I wonder if does people get paid email me if you know that like if i want to be like a dsm 6 writer which i don't but like if i flew up there and sat there for like four months do you make a lot of money doing that how

much do they pay these guys or are they just doing it for like the street cred i would like to know that and i don't um anyway so the these aspirations was that you put everything on a spectrum so you're not going all the way back to processes but you are saying like hey it's not just a checklist it's kind of like this is whatever and the critics hate that and they're like autism spectrum disorder what is this? Like you're putting a spectrum between a person who can't talk or function at all, all the way down to somebody who had like a shut in mail with an overprotective mom. And you're saying like, that's the same thing. You know, they're like, they don't like that. Because that's, I mean, it is a huge range. But if you're going to move to a spectrum thing,

which is probably a better way to do it, probably not a perfect way, but a better way than what we were doing in the fore. Then you need to kind of commit to that and do it. But when they get into committee, they fight. And the vision is not ever really fleshed out or finished. And so you get all this stuff crammed into the end of the book, basically. Like those treatment revisions used to be tiny, like in the early ones where they were like, or not treatment revisions. Those are the individual. Those are the treatment revisions are like where they're like, this is Microsoft Windows 3,

but it's not Microsoft Windows 95 yet. This is Microsoft, you know, NT. It's we're working on XP, but we're not. done with it it's the 4.5 or the you know 5.2 it's like the in-between version that's not what I mean what I'm trying to talk about is appendixists the appendixists used to be tiny they were like here's some useful information like differential diagnostic trees and then hey here's some stuff we talked about that seems important but we haven't quite this is proposed for future consideration so you know if you want to research it or if you want to think about it and may publish something like

way in on that for the next version they used to be teeny tiny and now that they can't agree on like how to write the book and there's these giant you know paint by committee things then the appendixes have just ballooned and what they do is they take the whole spectrum thing and they say like hey we think this is right but we're not going to make it real yet um so we're just going to stick all of that in the end so it's not part of the book but it's still saying like hey we think this is real but the spectrum stuff is completely at odds with the diagnostic checklist which is still how the book functions so like what are you doing you know that's that's another thing that's interesting is like I think you could have every psychiatrist in the world sit down and try and make a DSM that they like.

That's their favorite version. And you would never end up with anything like this. Because, you know, science is done through debate, but not all debate is science. And you look at these books and it's like the core unit of, you know, is a reaction and a process in the DSM-5. But the categorical checklist is this discrete disorder category. And then the nominal spectrum that you can kind of pay attention at the end. end is this huge umbrella category. But then also, yeah, just think about all those things all the time that sort of contradict

and are based on like three different eras and four or five different conceptualizations dagwood sandwich together that don't really make any sense. So it's like, what am I supposed to do, man? Like you would never, ever get this book out of one mind. And it basically is like a study in why conflict resolution. It's like a document of conflict resolution instead of a deal. of a diagnostic and statistical manual. It doesn't make a ton of sense if you read it cover to cover and try and do what it says

because it's not really telling you how to think about this stuff or how, and the whole point of these are to say this is how the APA thinks and conceives of it. Maybe here's some options and ideas, but like this is our idea and we don't have one anymore and we're just publishing that. Weird. So the scientific rationale for that conclusion is pretty robust. There's these logitudinal and cluster analysis. the data that they look at and it suggests that there's this distinction you know between uh for autism

especially because asperger's was always problematic to them there's this distinction between autism and asperger's but it's kind of artificial because where do you draw the line you could draw it anywhere so let's just make it a spectrum where it just the diagnosis is the line and so clinicians really feel like that's going to happen and at different sites they were applying those labels and consistently anywhere if you make it a line it's a lot easier to put people on it and not exclude anybody who needs it and not at anybody who doesn't, which is the whole point of a diagnosis is to keep the ones that don't have something, but you can't agree on what it is or where it comes from out and then keep the people that all do have it, keep them in it.

So how that operationalism of the ASD spectrum, it raises all these concerns when they're saying, like, but how do we operate based on that assumption? Like these people say, this is how the neurodevelopmental brain works, we think, and this is how conscious and cognition works based on the science. And then the people who are saying, we have to do something with that information. How do we operate based on that assumption? Get mad.

And they say, you know, research indicates the specificity of this criteria is better. But the sensitivity, you know, how well it is to pick it up and find it is less. And this means that there's a significant, you know, subset of individuals, particularly those with higher cognitive functioning or those that were previously diagnosed, you know, with other things, they're going to lose access to services under this spectrum role because the spectrum is making more people included, but it's also making people that are not similar to that line that you're drawing

be kicked out. So like if you have a diagnosis, it's just a checklist. You either fit the criteria you don't. If you have a line, you have to have a whole lot of symptoms that you like, that you have to have a whole lot of symptoms, that you are similar to. But if you had some of those symptoms than a diagnosis that aren't really on that line or the

diagnosis goes away, then you have people who have something that isn't diagnosed now that no longer can receive medical care. And that happens with a bunch of these. And I'm not going to go through every change. I mean, you can look that up. That's not the point. You know, the schizophrenia categories, which never really made a ton of sense to me. I mean, I don't think there's been a catatonic schizophrenia patient.

in America for, you know, 100 years. Those diagnoses, like, go away and they become more just psychosis disorders. And, you know, and Alan Francis says that by turning schizophrenia into attenuated psychosis, in a lot of instances, this would lead to this massive medicalization of weird or eccentric people who there's nothing wrong with. They have the right to do that. and the false positive rate for predicting conversion to full psychosis. Like this person has schizophrenia, you want to know that that person's going to get,

basically what you want to do with schizophrenia because it's a long age of onset. There's a progenital period. And the progenital period is where like you're doing stuff that's like kind of odd, but you're still connected to reality. So like you wander around and all of a sudden you have this delusion and you're like, hey, that's kind of weird. I don't know why I think that, but I know it's true. But you're relatively well functioning.

You have a little bit more of those than you lose total. with reality, have a psychotic split. You know, if it's not treated, do you have maybe the possibility of brain damage or doing behaviorally a thing that messes you up? So the whole point of the disorder is like, how do we catch these people who are in the prodromal phase who believe some odd stuff or having strange, aberrant beliefs pop up that weren't there before? How do we catch that to predict the onset of psychosis?

Like, that's what you want in a schizophrenia diagnosis that works. But they can't do that because if you say, hey, everybody who's acting like they have the prodromal phase of schizophrenia and believe some weird eccentric stuff, go ahead and flag them with a psychosis disorder. Now you're picking up people who may never have a full psychotic split. And so there's kind of this fight. I would say my answer to that if you care is that like psychosis is something that you can be more at risk for, kind of like cancer. Like you can have the genes for cancer or you can smoke with cigarettes to get cancer or you can have the diet that does or doesn't give you cancer.

But like all of those risk factors add up to the thing being more likely. And so there's some people, a lot of people, that are going to get schizophrenia anyway. It doesn't matter what they do. It's just, you know, as far back as we can go, grandma did something weird. Dad had bipolar disorder. This person had dopamine disorder. Dopamine disorders run in families a lot. I've got so much of the genes for the thing that when I hit 18, I'm going to have this thing happen in college.

Other people maybe have it where they're going to have a sort of psychotic break, but they take LSD and they do marijuana, and that makes the outcome way worse. The break is worse than it would have been. Other people may never have gotten it except the inviote. environment doesn't protect them. They have a little bit of the genes and those things compound. But the DSM was not, it wasn't, you know, doing it in a probability or a cumulative way. It was trying to move to a spectrum. And what I'm describing makes sense, but that isn't a spectrum, right? I like the spectrum more than the checklist, but the spectrum still can't do this thing that I'm describing, which is, you know, how do you catch people and add up basically

likelihoods and risk factors and then say all of these things contributed to this happening as a causative thing. They're like, well, that's too much information. We may not have all of it. You know, we don't know how many drugs they use or will use. And we don't know their genetic history. And, you know, how do you screen for that? And I don't really know other than sit with a patient for a couple hours and talk to them

and get all that information, which is what I do. And then say, okay, you know, this is kind of what I think. This is what I think the trauma is, which can be treated. And this is what the dopamine disorder is, which, you know, treating the trauma is going to bring down the symptoms of that some. but I think you're always probably going to need medication for OCD or schizophrenia because you may be on less than if you didn't treat the trauma. I can have that conversation with a patient, whereas a book like this fundamentally can't tell people how to have that conversation with a spectrum conceptualization. I hope that that makes sense.

So the DSM 4 was this model of personality disorders, which is like 10 distinct categories like narcissistic borderline avoidant. And that is kind of recognized by the time the fives being written is like scientifically bankrupt because there's like all this comorbidity where you're like, well, the borderline is acting histrionic right now. So I'm going to give her that one or I'm going to give him that one. And but then there's all this overlap. So the same thing that the DSM3 was supposed to get rid of, you know, you're disagreeing on diagnoses again. So there's this overhaul for personality disorders.

There's a bunch of stuff in it where they say basically Criterion A, which is like, what's the level of personality functioning on a zero to four rating of impairment? You know, if it's not causing a problem, we're not going to pathologize it. And then Criterion B is like pathological personality disorder traits. Do you have any of these traits? And let's put them in five domains of like different types of different types of personality traits we're looking for negative effectivity, detachment, antagonism, disinhibition, psychoticism. I don't know that that's a better way to do it. It may just be a more complicated one. I think you're probably going to end up with the same comorbidity things.

I mean, one of the other things is like testing and implementation fatigue. Like you can make these systems incredibly complicated. But the reality is that the more complicated you make them, the less people will do it right. Because an ER doctor is overworked and a therapist is just trying to get to the thing that they want to do. When you tell them that they have to do like reams and reams of other stuff for hours, just less people do it. and then the diagnosis don't mean anything anyway. So there's another, you know, problem with this system. So the big thing that happens is, you know, the NIMH, the federal governments,

the National Institute of Mental Health, with Thomas Insull as director, but it probably would have happened anyway is like, I'm not going to use the DSM anymore because the DSM has never really been reliable or valid. And we can't succeed if we're using this to study things because the symptoms that we're clustering together aren't really going to make research any better.

It's not going to figure out if drugs work. It's not going to figure out if this type of therapy treats this type of thing because you're just calling it PTSD, but really PTSD is like four things. So which one of the four was it? Just looking at PTSD diagnosis doesn't mean anything. And I agree with that critique. I don't really agree with the NIMH

on a ton of stuff, but I don't think that's wrong because, I mean, he may be right. for the wrong reasons there, but like PTSD where? Like is it somatic re-experiencing? Is it a mood dysregulation? Is it, um, is it a relational, um, you know, projection and attack like type of type of antagonism there that's not quite a personality disorder? Because if somebody has an unfair expectation about relationships from trauma, um, and

they're, you know, like trying to control other people with whatever because they don't feel like safe if whatever and that comes from a trauma, not like an early attachment thing. it's not a personality disorder. It is PTSD. You're going to treat that type of PTSD completely different from flashback re-experiencing. And you're going to treat both of those types differently than somebody who has, you know, somatic overwhelm and like mood dysregulation and panic type trauma.

Like that's going to be a different kind of therapy. Maybe they have all three, maybe they have two of them. But haven't done this for a long time. Those are different types of memory. The type of your brain that thinks of yourself as the story is a different memory process than the one that like, you know, hears voices indrospectively and like,

remembers these relational things than the type that is like relational memory. And that's different from the like deep implicit embodied emotions of how your body remembers to feel emotion. There's a lot of neurology that backs up my point, but I'm not going to go on like a defense of that. But like you see those things different clinically. Neuroscience also indicates that those memory systems are kind of different. So like my ax to grind is like,

why are we just calling all of that PTSD? What type of memory is the trauma end? How did it get there? And what symptoms is like? causing even the new PTSD diagnosis just don't do that well um so uh look you know we talked in that other episode that I did um about like borderline personality disorder is it's strange because it's this like weird um fossil of these older systems that they're trying to fit into the new one because it's very useful for certain types of clinicians to conceive of that um but then it doesn't

really fit with any of the new assumptions that we're making. So how do we say, like, the old assumptions were wrong, except they sort of got this one right? How do you do that? You can't? Because borderline originally comes about when they're saying, hey, there's psychotics who are totally not in reality. And then there's neurotics who are in reality, but they're suffering and have these, you know, emotional distresses. And then there's borderlines that are in the middle, the border, that's where the term comes from, the border between neurosis and psychosis, where they're in on planet Earth most of the time. But then all of a sudden, reality becomes plastic when they feel one emotion and then they they're not lying they really

believe it um so we can't say that they're lying but also the things that they believe you know there's six people there we all see it it didn't happen that way they felt attacked but nobody really attacked them actually they were the problem and then they deflected and confabulated a new version later that matched their self-image so what do we do with these people because we can't call them psychotic because they don't have schizophrenia and we can't call them neurotic because this is more than an anxiety disorder but then you change to a checklist system and then you still keep it and then you go back to spectrum and it's trying to be conceived of in all these ways you know what is the border on a spectrum right um so you have all of those things happening and there's a ton of secrecy

again with the dsm five um you know the dsm five was like the most secretive uh enclosed of all the processes which again i don't think they did for nefarious reasons um i think they did it to keep the public as not a and in the news too largely because with the DOS and four one of the things that happened is they had these committee meetings about how they were going to get rid of Asperger's and it like leaked to the news or it wasn't a secret so it was available for the news and then everybody freaked out and started like writing all these articles and being like all these people aren't going to have care and like I can't work because my son gets these federal benefits of psychiatrists delete them then I won't get money they wanted to avoid that for the five so that they didn't have to be in

conversation with the public and the public's didn't have the ability to influence the process by like heckling or interacting with the people or writing about what they're talking about as they're talking about it. And a lot of the things that they added in the four and five for children, I think are entirely made up ways for parents to diagnose something is wrong with this child instead of like, how does the environment support the child? I don't really like any of the child think, but I'm not a child psychologist, so I'm not an expert in that also. Who cares what I think? But when you go through, you know, at the end of this, one of the reasons why I want to cover the history of how it got here is like I've seen a ton of hostility to the DSM, but no one's allowed to talk about it because we all have to like largely build insurance and be professional. And so again, I'm not saying this is my opinion.

I'm just kind of giving you a lay of the land and how it gets here. But you see hostility to the DSM in my experience and like about half of clinicians hate it or don't care. about it. But it's the thing that we're all supposed to be using and do use to some extent. And like when I was in training, I was like shocked because I went to somebody I won't name, but they were the person that was in charge of me when I got out of school. Or they were in a supervisory capacity. And like multiple people were like, yeah, I don't care about the diagnoses because I have this one ax to grind against the DSM. It doesn't make sense anyway. So just put something you can build and then move on. I'm doing this on the behalf of

an institution. I'm not talking about Tapread or any individual practice I've ever been on. This was at the instruction of psychiatrists and stuff. So it's not like, it wasn't my decision. That's what I was told to do. But I was like, what? We were taught it was the gold standard of evidence and all this stuff. And then you enter the workforce and really high up people are saying like, I don't care about it. So like one of the things that the diagnosis, one of the points I want to make is the DSM has created this paradox where there's diagnosis as treated as both this identity defining thing.

But it's also utterly meaningless at the same time. And a lot of people treat diagnosis like it's a horoscope or worse, this excuse to behave however they want. Oh, I have to do that. I have autism. I have to do that in Portland. It's like, no, man, like, if you can give me like a 30 minute explanation of all the things that I need to do to enable you as a stranger in a store, then like maybe you're not neurodivergent

enough to like warrant my participant. Like, I'm respectful to everybody. I'm a trauma-informed therapist. I'm talking about where people use basically. diagnoses that they have is when people weaponize the language of psychotherapy because of the internet or these Facebook support groups or whatever to get other people to do what they want when they could do for themselves and I'm not like a you know bootstraps cut Medicaid person like hopefully you know that if you're watching the show I'm talking about abuse when somebody is disguising themselves as the victim

with the language of psychology and because a lot of people do that it makes diagnosis like look worse. And so, you know, some people cling to it, the diagnosis. They define themselves by it. Like I said, you know, some people want a diagnosis, but no treatment, which again doesn't make sense to me. And then the other, and they orient their whole self concept around a diagnosis, which is never what it was supposed to be or is, but the public perceives it that way. And then other therapists and patients have been diagnosed with so many things. They've been to the ER 20 times in three states and they've gotten 20 diagnoses in the last 15 years and they're just like it's all BS. It doesn't matter because nobody even knows what it is.

They tell me to have a different thing every time I switch psychiatrists, which is true. Like if you want to make an argument that this thing is scientific at all, everything they did to three was to make it more valid and psychiatrists still don't agree on any of this stuff. So if they don't agree and everyone's getting different diagnosis from different psychiatrists, then you either have to say one of two things is true. one, the book doesn't really work, or two, American medicine is in comp, the book does work, and American medicine is incompetent at applying it. So the system doesn't work.

But you can't continue to pretend that these things work, because how can that be true, that this thing is completely valid and reliable and consistent? And then half of my patients that have switched psychiatrists a couple times and been to the R a couple times have nine different diagnoses with no overlap that are wildly different. Like, I'm not talking about like bipolar versus schizophrenia or schizoaffective versus bipolar. I'm talking about way all over the book. How does that happen? Right. But if you know the answer to that question, email me. But like, there also seems to be this pervasive belief among patients that a diagnosis is this permanent thing that all clinicians have access to because

we've made it so important and that if you get it, it'll follow you for your whole life. I've had so many people that are like, I don't want to go to therapy because I don't want you to diagnose me with this because if you get diagnosed with borderline or if you get diagnosed with this, you. And that's, you get diagnosed with then you'll have it for the rest of your life. And I'm like, no, if you have schizophrenia, you'll have it for the rest of your life. If I diagnose you with schizophrenia and you don't have it, you're not going to get it.

But other doctors will think that, not unless you tell them or you give me a release of information to send your records to that guy. There's not like one club we all hang out at. There's not like one giant medical record that we all log into and look at. Like, it's your medical record. Unless a court tells me that I gives me a HIPAA waiver

and says that I have to give it to a judge or you sign an ROI. It's not going anywhere. But again, there's this perception that it's the most important thing because the profit motive is treating it that way. So patients assign this mysticism to it. That it must be important when I think it's probably one of the least important things. You know, if we didn't have a DSM, I still think I could get where I was going with patients. I wouldn't be sitting there being like, well, I don't know what they have.

So how could I possibly treat them? The only scientific way to deal with anxiety is not to tell somebody to relax or relate to them or see where it comes from or how often it happens or like, you know, what part of their body does it live in? Or what does it do to their posture if I tell them to experience it in the room and then share my observation? I don't want to do any of that. If I don't have a diagnosis of the type of anxiety they have and then I can't go be told based on that diagnosis, what's evidence based? How could I ever treat anxiety? I mean, nothing can be self-evident. I think it's the least important part because if you burned the book, I could still probably do psychotherapy on you. And not because the book,

ever existed, you know, like, I use the DSM, but I'm just saying I don't think that that is the most important part of your treatment with me. So to combat this inflation of diagnosis that the checklist cause, Alan Francis and the DSM-4 task force, they introduced this clinical significance criteria. So they say to receive a diagnosis, the symptoms will must cause clinically significant distress or impairment and social, occupational, or other important areas of functioning. and their intent was to create this gatekeeping mechanism where it's like look don't read about this thing on webmd or facebook or hear that your friend got diagnosed and then decide like oh my gosh i once was nervous i'm a neurotic and then go to try and get a diagnosis um like during coven like one of the things

that would come up in the consultation groups like nationally if i asked people it was like all these people were like basically getting depressed and anxious sometimes because they were you know shut in during COVID. Some people like that. But I think sometimes because they had to spend time with their family all day. And because of the anxiety, they decided they had ADHD and they all got on like Rital while they were like at home. And that like happened nationally during COVID. Like a lot of therapists talked about it with me.

And it's like, I don't know. So I'm sorry. I'm losing my train of thought. But so Alan Francis with the DSM, you know, four when he's saying, that the gatekeeping mechanism is trying to stop people from doing that. Like, don't just be in a situation that makes you nervous and then decide, do you have an anxiety disorder?

But the problem with it is when you tie suffering to behavior, when people are higher functioning or they're more resilient, or they're a little bit brighter or a little bit more emotionally intelligent, and they're coping better, you exclude people who are suffering, but they're not acting on it because they're mature or they're, you know, more capable, from treatment. I mean, some of the sickest people that I've ever seen, like with a dissociative

disorder or something, it was so compartmentalized where they were so afraid of being the abuser, they made sure that that suffering never hurt anybody. They never turned it outward. They never abused anybody. They took care of everybody. But then they went in private and they hurt themselves with alcohol or with dissociation with panic attacks and they built routines so that this didn't interfere with their functioning. But they were still, you know, emotionally in hell. So I think that the point of psychology is to treat suffering, not to say, go behave badly and then we'll fix your behavior so you can go back to work. I have a big issue with that conceptualization of like, you know, you are a cog in the grease and capitalist steam engine. And your only job is to, you know, make that thing work.

We don't really care how you feel. That seems like a scary direction for psychology to go. So, you know, who benefits from a diagnostic system that only represents. recognizes suffering when it impairs productivity. Insurance companies benefit because if you're, you know, working, then basically there's a lot of reasons why they don't have to pay for your treatment. Employers benefit because they don't have to accommodate workers that have something that's not affecting their output and the economy benefits because you have a lot of people who don't

take time off work to do things. But I don't know that that's true because I don't think in the long run the economy benefits from people suffering some of the time. but you know who doesn't benefit the person who's coming in to receive care the patient if a human being is suffering and they're told that suffering doesn't count because they can still work you're gaslighting people who may be some of the most sick people except they're more compassionate because they don't want to hurt other people or affect other people who depend on them and so they're internalizing a lot of suffering but it's still real just because you can't see

it doesn't mean it's not real just because you can't count it doesn't make it's not real and you have some clinicians who are like well if it doesn't show up on the scale, how do you see it? And it's like, just because you can't see it doesn't mean it's not real. And there's some people who came in for a session and they're telling me how great they are. And I'm like, man, are you okay? You know, and then they just start crying because they're not. They're coming in to tell me about how great they're doing and how in control they are. But it's not true. And it's the clinician's job to see that it's not true and give them the chance to be honest about it. So what would like a more humane criterion work? Do I have anything

to say other than whining about the history and weighing in on like what I think of all the participants in the process of history. I mean, I think a truly patient-centered diagnostic system would not ask, can you work? It would ask, are you suffering? The sud, the subjective unit of distress, is a lot more important than we've made it. And if the answer is yes, then that should be enough, suffering's indication for treatment. I think one of the biggest failures is that we know the brain is like mesh networks and how it works. And because we know it's networked, it's like affecting these kind of

regions. And a lot of the problem with the brain, the DSM5 was that the QEG research and the MRI research where they thought that they would have ways to like map these symptoms onto biomarkers or these diagnoses on the biomarkers. When they really got it in, the other people who like don't like that form of empiricism because it's a little bit subjective, like tore it to shreds, we think. And then they weren't able to use all this data and research that they said that they were going to use when they did it. So if they didn't use it, somebody didn't like And if you look at those lists of people, you can probably tell what the sides of these arguments are. But one of the things that I don't understand is that I read a lot of neuroscience and cognitive science because I think it's interesting and they're doing a lot of the work that psychology used to do, academic psychology used to do, is like they make theories about processes in the brain because based on results that they get in subjective intuitions.

But there's not a way to measure a lot of these things. Like QEG has a lot of limitations. Like, fMRI has like wonderful structural resolution, but it takes forever to get. So you're missing this data with QEG. You can see within the fraction of a millisecond, but you have these 13 electrodes. They're on the top of the brain. And a lot of people, and we're basing this on an assumption that I think is true, that you can make determinations because the brain is networked based on what's happening

on the top level of the neurons. You can make determinations about what's happening. excuse me at deeper levels inside of the brain. Like one of the, and that when you could, and we know that that is happening because when we stimulate the outside of the brain, the deep brain changes, you know, like on scans.

So we know that that's true, but there's this like, oh, we can't see it yet, so we can't believe it's real. Well, you're just not ever really going to be able to see everything in psychology. Like you can't.

You have to kind of feel how things work. And, you know, I've said before, like even in quantum physics, that's kind of how a lot of people are discovering things is intuitively, even though ultimately they got to justify. it with math, the discovery happens there. And a lot of these discoveries aren't allowed in this process anymore because of the bureaucratic nature of how they're fused together on these committees.

So why can't psychotherapy, you know, have this same conceptual flexibility as the harder sciences that are studying the same organ? Like, why? And I think a lot of times the answer is academic insecurity. Like I was told I can't talk about anything other than my specialization and my specialization, you know, bumps up against another one. So I have to retreat back into mine instead of fusing them together. And another one is this insecurity of like, well, I can't be taken seriously unless I'm acting on completely empirical information. Well, guess what? Your need to do that is a subjective bias that most of the time is wrong. So your need to be this logical being is being fueled by an emotional energy. So like we are always running on emotion, man. Like you can't take the

subjectivity out of science, not this type of science. And, you know, at this point, you can look like in a computer of any major medical system, and you can see the frequent flyer with hundreds of diagnosis. So you just have to make the case that the checklist doesn't work. That isn't, that drawing lines around clusters of symptoms isn't really going to get you anywhere scientific. It's not going to get you where any scientific, it's not going to get you anywhere scientific when you're trying to find out the back end, the why, these things are there.

And it's not going to get you anywhere scientific when you're trying to figure out the how-to of treating them, you know, clinically, because as we do this, the outcomes get weirder and worse. But then also, like, it doesn't tell you how to get to, like, a better understanding of what the disorder is because you decide, you're the one that created it. You drew the box around the symptoms. And then you expect this other information to materialize. Well, it's been a long time since 1980. And it hasn't done that yet. So let's rethink the system. And then the document itself has these contradicting assumptions, like I was saying. It tries to pivot in one direction, but then those pivots get held up by committee that can't agree,

so they end up with an incomplete vision, but then this other part is assuming a different thing. Or, I mean, the end of the book, like a lot of that spectrum disorder is basically telling you to ignore the stuff that is canon, the stuff that's in the appendix of like, yeah, consider this. But what you're telling me to consider is contradicting the thing that you're saying is real in the actual book. And again, you know, this is a diagnostic. manual. So it's not like you have to read between the lines in order to see these things. Like they're not going to tell them themselves and say like do two different things that are opposite. But a lot of ways that ESM5 is telling you to do that. It's a Dagwood sandwich of a bunch

of theories that don't really go together. And you know, there's also one of the reasons why this is that they won't look at is they want to have psychiatrists on these panels, but they also want to have clinical psychologists. But obviously the psychiatrists have more power. And they also want to have social workers, but obviously the clinical psychologists are taken more seriously and have a little bit more power than the social workers, the LPCs. I mean, hell, the LPs is probably treated more seriously than the social workers. But, you know, when you read like Yolam, or somebody who's like the gateway drug that brought a ton of people into this profession, Yolam was the gateway drug for a lot of people in my generation, like he was doing therapy for an hour before we ever adjusted medication.

And he was doing therapy weekly. Psychiatrists don't do that anymore. So maybe one of the things that we should just, I don't think that's a good system. But like, if we're going to do that as an, because of our economic engine, if we're going to do that because of the structural hierarchies of the hospital, the psychiatrist probably has never been in therapy. They probably have never done therapy. And if they have, it's going to be like CBT or DBT at a student counseling center or something, you know, and I'm talking about the vast majority. I'm not saying that there's no psychiatrist out that that does this. I'm saying all of the incentive structure of our world made sure that this stuff changed drastically from how it, used to work, and the incentive

structure will control most of what happens. If you're going to do that, then maybe you need a different manual for conceptualizing medication and therapy. Because there's not that much overlap anymore. So if there is, they're two different jobs. I don't think they should

be, but if you're going to make them two different jobs, maybe you need two different job manuals. So if you meet a psychiatrist that's doing therapy today, you're likely to find that they're like 80 or something, because nobody can afford, I mean, hospitals don't want to have psychiatry at all. They have to, but what they want to do, like if you see a billboard where hospitals advertising, it's going to be for delivering

babies or not curing, but treating cancer, because that's where they make money. That's what they can charge all this money for. You know, psychiatry, they would get rid of if they could, but they got to have it. But nobody really wants to do it. I mean, there's people that feel called to do it, go into it but it's not like one of the high earning things because we moved to this service-based system and they're looking at psychiatry and they're like where's the service it's all just like talk even psychopharm it's just like you asking them these questions so like where's the service um so you know there's the that whole system is i guess the detail that i lost left out of the last episode. You know, I talked about the Starrgy study. I talked about a lot of the things that are

indications that the system doesn't quite work. But this is the history. This is how it ended up in the place that it ended up. So, I mean, what do you do? I mean, I think you can re-legitimize subjectivity as just a valid way to discover and organize things. You know, a lot of people feel like there must be sort of some common variable that maybe is indirect pathway regulation. That's a pretty good theory where the sensory gating is bad. And so, you know, information that should be filtered out is not. And so you get this powerful intuition. And that indirect pathway, it's kind of in people that are more mystical and eccentric, you know, maybe more likely to be on the autism spectrum, but also to have a dopamine disorder that these sort of should go fit together. I mean, that'd be one way

to do it is to kind of get clinicians to feel this stuff out and see what are you treating this stuff with and if you're treating a lot of things the same way, maybe they're related. You could discover things in subjective ways. But then you also need to replace quantitative dominance with qualitative study. I think the numbers in the meta-analysis is what's leading a lot of these processes into the words, because if they can't find it into the numbers, if they can't find it in those numbers, then they just don't think it's real. And there's just a lot of things that you're never going to see on a meta-analysis that you

will see in therapy if you do it for three years. years. You will see patterns that you will never see on a spreadsheet. I'm sorry, but you will. And currently, the wisdom of the field is locked behind these profit paywalls, these private notes and isolated therapists. And we need a Wikipedia of clinical practice. Like, we need an open source, high quality access that isn't super expensive because people that make what I make are just not going to be able to pay $8,900 a month to subscribe to these giant libraries, yet we're supposed to follow it in space practice. So I'm like borrowing my friend's login and trying to figure out how to, you know, do a library, you know, records request for these papers that I want

to read. And there should be a way to share kind of qualitative data easily that's open source that doesn't give total ownership of it to a company to just profit off of your work where you could retain ownership, but also share it, retain a patent. opportunity without, you know, things like that would benefit the communication in the field in a way that we just, we don't seem to have anymore. And then fourth, I think that we should teach philosophy and narrative and neuroscience in graduate schools. I think that therapists need more neuroscience than they get because they're talking about

polyvagal theory in these neurological concepts, but a lot of times they're using them wrong. You know, I went out and learned this stuff and took classes on it and got downloaded lectures and everything, and I'm not an expert, but I know enough because I need to know it for my job, but we don't get it in school. And it was just sort of, it's never like they were like, you have to learn philosophy because you're going to be a therapist in like 1940 or something. But they just sort of assume that people of that station would have absorbed these things

that were what we call the liberal arts, the humanities, and the philosophy and some anthropology and sociology. They just assumed that you would like be versed in the liberal arts if you were going to be in a human field. That's not true anymore. So we need to build that into the curriculum because you do need it to do this work. And then fifth, you know, and most importantly probably we had to replace that functional criterion with a suffering criterion. Psychology should exist to reduce human suffering, not to optimize human productivity. And so I think that path forward is about choosing between science and narrative. And it's about realizing that science is a narrative. And it's the greatest, most

complex and most rigorous study that we've ever tried to tell and I don't want to attack science here I want to tell its story better I want it to be more scientific we often treat mathematics as if it were this bedrock of reality itself but the numbers are not what's real so you know like this is a time where we're going into this unhealthy place where there's all this pseudoscience that is replacing medicine basically because medicine in general is alienating so many people. Either they don't have the money to afford it, the insurance to pay for it,

or they don't have access to it, or they can't navigate the field because they have bad experiences with it. But lots of reasons we're alienating people who I would like to bring towards science. But what's happening is they're running into pseudoscience because they're getting alienated. And so a lot of people are like, I don't want to critique this because maybe there's some problems with it,

but don't throw the baby out with the bathwater. you're going to drive people towards pseudoscience if you tell them there's problems in health care. That's like the missionary argument to me. I mean, some of the more horrific sexual abuse places that you see are these sort of like places that are driven to do like missionary work because they're in this place and they're like,

well, we can't admit that there's a problem because we're the city on the hill here and we came to minister to people and set a good example. And so we got to cover it up and pray it away and find some way to minimize it and repress it because we can't admit there's a problem because we're here to represent the good, whatever. And when you're saying I can't criticize my profession, because if I criticize it, I'm discrediting it, you're discrediting it when you don't criticize it and everyone knows you're lying.

Or everyone thinks that you're dishonest or that you're blind or that you're naive or whatever. You alienate people when you can't have these conversations. And you don't have to pick between the DSM and Crystal Healing on TikTok. You can point out problems with both of those things. And like before the people who write me, write me and say they work so hard at their PhD, they care so much, they help so many people. Remember that cult leaders think that too. Okay. Like people put enormous work into these belief structures that are not tied to science.

So can you. So can I. And it's our job as humans to interrogate that impulse not to pretend that it isn't there because we're good people who work hard and believe serious things. Everybody thinks that, dude. Everybody thinks that about themselves. You know, people believe things because they believe them for a long time. And they defend them because they're traditional and they're old and they have a history. Well, I just told you this history.

What do you think about it? And half the time I make an argument like this, people start telling me how this system works, how the committees work, what they look at. I know the process. I know the history. That's why I think that there's a problem with it. Don't explain to me how it works. Like that makes me go, oh, okay. Well, if they have a committee, fine.

No. Like academia is not an exception. to these things any more than a TikTok influencer. And if you don't believe that, go Google like what are the biggest scandals in academia 10 years before now? Because you'll find out what everyone did wrong when they no longer are stakeholders in the thing. Right. They're not going to sell on themselves right now.

But there's huge problems with academic research in every error. And there are now too. We are not an exception to history. And so like the DSM5, you know, look at high top, look at the hierarchical. taxonomy of psychopathology. I mean, that's a better system with it as P factors. And they are a general factor of psychopathology. And they represent this overall susceptibility.

And like I was talking about with schizophrenia or what became the psychotic disorder. And they also look at spectra. So these broad dimensions, the intersection of these things, like where these symptoms come together around certain nodes, but not even putting them on a line like a spectrum and not putting them on a checklist. That's probably a more useful way to study. That's probably a more neuroscientifically and cognitive science evidence-based psychology. I think we need to bring more neuroscience. We need to bring more cognitive science into psychotherapy in a way that that specialization of academia resists. And those are my conclusions. I think, you know, that if we're

we don't offer a therapy that is narrative and deeply relational, will continue to lose patience to those who do, even if that person is a pseudoscience influencer that's offering them a lie, because they're still telling them a story. And I'm telling you, I'm reading this book. I don't know what the story is. I don't know what the assumptions are. I don't know what they want me to do with the information. I think they published it because they got a huge committee together and they had a fight and then they published a book. And that's not a very good story. Thank you.