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Comment by DoreenMichele | Hacker News Reader

The root issue here is finding some path forward for helping people. Psychiatry, psychology etc aren't doing a great job with that.

He tries to determine what has happened historically but not why.

Why was this guy using drugs starting at age ten? What led up to that? Shouldn't it be classified as a parenting failure, not a "disorder" on his part?

What was the history with the father? Perhaps assaulting his father wasn't simply due to insanity. Some parents are really awful to their kids and it's a huge problem for the kid. That doesn't necessarily stop being true just because the kid became a legal adult.

Labels determine what mental models we use when trying to intercede in a problem. Different labels get very different reactions and treatment modes.

We need to up our game in myriad ways, but labels are a critical tool for this problem space. I hate labels, but they are a useful communication tool.

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>He tries to determine what has happened historically but not why.

The biggest advance in the history of psychotherapy was to stop asking why and start asking what and how.

The psychoanalysts broadly believed that mental disorders could be treated by revealing and resolving unconscious conflicts and forgotten childhood memories. That's a very slow process, and eventually randomised controlled trials would demonstrate that it wasn't particularly effective.

Rational emotive and cognitive behavioural therapists essentially argued I don't care why you're nuts, I just want to teach you how to be less nuts. If you have habitually fearful or negative thoughts, you can learn to disregard those thoughts as unhelpful and consciously replace them with more useful thoughts. Knowing who to blame for your cognitive bugs doesn't really help you fix them. Aaron T. Beck had the good sense to subject his psychotherapeutic approach to randomised controlled trials, demonstrating that a relatively short course of cognitive behavioural therapy was at least as effective as several years of psychoanalysis.

Psychiatry, clinical psychology and psychotherapy undoubtedly has a lot of shortcomings and there are a lot of patients we don't yet know how to treat effectively. A far bigger problem however is lack of access - the vast majority of people who could benefit from psychiatric medicine simply don't get treated. In the developed world, it's usually fairly easy to get prescribed medication, but there are often long waits or financial barriers to access psychotherapy. In the developing world, most people can't even access SSRIs despite the cost being around $1 a month. Stigma and a lack of awareness are still a substantial barrier to accessing care.

We need better treatments, but the priority right now must be simply to get more people to try the treatments we do have. Trying a treatment with a 40% success rate is obviously better than doing nothing, but nothing is still the default and it's causing immense amounts of needless suffering.

> The biggest advance in the history of psychotherapy was to stop asking why and start asking what and how.

> Rational emotive and cognitive behavioural therapists essentially argued I don't care why you're nuts, I just want to teach you how to be less nuts.

This is part of why schema therapy is getting so much attention right now: it takes CBT but combines why, what and how into a cohesive whole. The success rates seems to be even better than CBT, a lot better in some cases.

[0] https://en.wikipedia.org/wiki/Schema_therapy

It's interesting that a lot of the 'hot new thing' therapies are around Personality Disorders or PTSD. I'm curious what the theory is to apply this to depression or anxiety. And what about dissociastive disorders, or oppositional defiant disorder, or autism?

> oppositional defiant disorder

Tangent: I have a lot of skepticism about that one being a proper disorder on its own, in the same sense that I wouldn't consider "fever" an illness in and of its own, but a symptom of other illnesses.

I agree, but even then, should the symptom be treated with the same treatment designed for personality disorders? What is the evidence of it? etc. I genuinely don't know these things.

From a Nursing perspective, which is a meld of sociology-psychology-medicine, it helps to ask the why to build compassion toward the individual in direct care situations. The overlap between mental health and what makes someone act like a jerk or insecure is almost 1:1 and hard to discern from the outset, but contextualization separates the two.

Psychiatry, psychology etc aren't doing a great job with that.

I'm not sure that's a fair criticism. They're certainly not doing a perfect job but the number of people who have a higher quality of life than a century ago is a real success.

There are people who are living fulfilling lives who would have been housed in mental institutions or who would have long since killed themselves, given the state of mental health care 50 or 60 years ago.

I believe its a perfectly fair criticism because honestly what has western psychiatry accomplished on a broad scale over the last two decades? Self-reported mental illess which correlates with poor health outcomes overall has shot up. Suicide rate is up. Resources dedicated to mental health and the mentally ill can't be dedicated elsewhere. There has been a pretty substantial stalling when it comes to developing truly innovative new drugs and therapies. Most of what's being developed are new takes on ssris, cbt, talk therapy etc. Most of the existing therapies are getting less effective over time which I would guess is due to saturation/diminishing returns.

The Mental Health field collectively doesn't know what the fuck it's doing. More time and money is spent on mental health every year and things are actually getting worse. People are not as skeptical of the mental health field as they should be. Either our current efforts are counterproductive or they're failing to address a bigger picture concern which outweighs any positives of increased mental health treatment.

I hail from the hard sciences and used give a all the psy* disciplines a considerable amount of flack. But then, what do you know, I found myself in need of their help, and now I live a much happier life thanks to a doctor who knew their way around the application of CBT. And I'll never talk sh*t again :)

>Labels determine what mental models we use when trying to intercede in a problem. Different labels get very different reactions and treatment modes.

I think he ever-so-briefly touched on a different angle of that problem: "The psychoanalysts don’t like it because it ignores the “unique milieu of individuality.” The more biologically-oriented clinicians don’t like it because it ignores biology. The DSM lacks “validity,” they say. A diagnosis based on a combination of symptoms is, they might argue, like a constellation of stars — sure, you could reliably identify the Big Dipper, but no one would argue that the Big Dipper is a valid interstellar system. It’s just a name."

The problem is that the label matches no defined model; which is why I think that everyone dislikes it.

>I hate labels, but they are a useful communication tool.

Agreed but without the matching underlying models, they're just added toil; especially, if they're only "valid" in niche use-cases (such as clinical settings).

For example, we have a general idea of what Schizophrenia is but when it comes to the classification, diagnosis, and/or treatment, that's when we lose context. Schizophrenia isn't - implicitly - the same classification, diagnosis, and treatments across the board for every patient. So, effectively, you're coupling a large group of individuals under a very generic label, which has no effective model applied to it.

I understand that cancer may have similar characteristics. All cancers are similar in that they are uncontrolled cell division, but the causes, symptoms, treatments, and characteristics of every cancer can be very different.

Exactly. It's often useful to have a label to describe a set of symptoms that you see occurring together over and over again, even if they don't always have the same root cause. The problem is when doctors mistake the existence of a label for understanding.

But we don't have that level of knowledge yet when it comes to schizophrenia. The closest I can get to such an absolute is "all schizophrenia cases are similar in that they manifest as sensory inputs uncorrelated to the outside world", but that isn't really a useful classification -- that description is based on symptoms, not on causes.

I think we only have a partial understanding of cancer as well. Uncontrolled cell division is something in between a symptom and a cause.

I was a homeschooling parent and had a role in a TAG/parenting/education organization to support that role. My feedback on very difficult kids, some of whom had been failed by multiple experts, was pretty popular, enough so that I de facto got "referrals," though I had no real formal credentials and charged no money. Parents would just talk to friends and say "Go talk to her" basically.

In many cases, these were Twice Exceptional kids who had started doing really strange things around the time they were toddlers or preschoolers. The strong negative reactions of adults around them then compounded the problem and made it an intractable issue.

I was often able to help parents back off from this dynamic so the family and child could get unstuck. I wrote an anecdote about that sort of process in January. It can be read here: https://raisingfutureadults.blogspot.com/2019/01/the-hand-li...

I'm a former military wife and homeschooling parent. People are quick to be dismissive and tell me I don't know anything about x, y or z, etc.

But my experiences suggest to me that a lot of mental health issues are rooted in relatively prosaic cases of "kids do weird and stupid things because they are kids, some kids do very weird and stupid things for various reasons, and parents often don't have effective tools for handling the situation, thereby compounding the problem." My experiences also suggest that a lot of this is fixable, without drugs or therapy, if you can help the family disengage from long-standing patterns of interaction and help the child in question understand where their dysfunctional behaviors came from in a non-blaming manner and give them some better answers and/or just breathing room to change on their own without interference.

I spent about two weeks writing the above piece and it's based on many years of education and experience. It got more than 60k page views and people are republishing it, some with my permission and giving me credit.

I would like to do more of that kind of writing, but it made me zero money. I am routinely told my writing has zero value and I should go get a real job. I'm not good at the self promotion thing etc.

I think I know some useful things that could help parents avoid becoming mired in the kinds of problems this man in the article has. But I have no audience and people who know what I used to do mostly are in my past or simply unwilling to vouch for me, including some prominent people on HN who knew of my work in that area at the time, to some degree or another.

I've largely made my peace with the fact that I can't afford to write for free and lots of people on the internet expect excellent content for free. They don't want ads and they don't want to pay anything for it either. No, they don't want to be a Patreon supporter.

So I content myself as best I can with leaving comments on the internet and generally being percieved as a blowhard and arm chair politician type who has an opinion on everything and zero credibility.

Que sera, sera.

> My experiences also suggest that a lot of this is fixable, without drugs or therapy, if you can help the family disengage from long-standing patterns of interaction and help the child in question understand where their dysfunctional behaviors came from in a non-blaming manner and give them some better answers and/or just breathing room to change on their own without interference.

Helping the family change how they interact with their children is therapy!

But it was often accomplished in one or a few emails, not months or years of intensive effort.

Someone would join the list and complain about the intractable, crazy making behavior of their impossible child. I would write a reply and say something like "That's a common issue with gifted kids. It's due to boredom and is easily solved by keeping them adequately occupied." They would go "Oh. My. God. That makes so much sense! Just before the last incident, he did actually say out loud 'I'm bored.'" and a long-standing, intractable pattern of problem behavior that had stubbornly resisted all prior intervention would largely disappear overnight once the parent made sure to keep their kid adequately occupied.

Or a parent of a particularly hard case would exchange a few emails with me for a week or two and then report back to me months later that all these terrible, intractable issues had magically changed and it had involved almost zero effort on the part of the parent who had spent years sinking enormous time, money and effort into resolving these problems, all to no avail until they spent a little time talking to me.

If it was therapy, it was like an *easy button" version of it, very unlike the roughly 3.5 years of intensive therapy I pursued in my youth to get my personal issues to simmer down to a dull roar before really resolving things around the age of forty when I got divorced and yadda.

> Why was this guy using drugs starting at age ten? What led up to that? Shouldn't it be classified as a parenting failure, not a "disorder" on his part?

"So you say your father broke your arm.... This isn't a bone fracture! It's bad parenting, now go home, no medical attention for you".

You are looking to see if some mental/physiological process is in disorder, so it's not about whether you caused it or your father caused it. The question to ask is does the patient fit in box X, because we have scientific studies saying that a large number of patients in box X when given treatment Y move to box Z, which is classified as being better than X.

You're missing his point. A doctor can treat you every time your father breaks your arm but the problem you have doesn't lie with your body or your brain. Yet the first line approach to mental health is treating the patients as the problem, assuming their brains are malufunctioning, and giving them behavioral therapy and drugs. If your depressed because your father keeps breaking your arm no amount of ssris and therapy will fix that...

I'm not saying the mental health field doesn't take into account external factors. It does especially psychology. I still think psychology overestimates how sick people are and underestimates how sick society is.

"So you say your father broke your arm.... This isn't a bone fracture! It's bad parenting, now go home, no medical attention for you"

So your father broke your arm at age ten. And broke your arm annually every year thereafter because he's an abusive asshat. And doctors decided to label you with some bizarre form of osteoporosis that must be the underlying cause of your frequent and mysterious fractures. And when you finally smack dad in the head with a hammer as an adult in self defense, it goes in your file that you are not only crazy but also dangerous and violent, even though you've never been violent with anyone else ever.

Better solution: You need a restraining order on your father who should not see you without court supervision while he finishes up his jail sentence for assault and battery and child abuse. He goes to therapy. You get put in a safe environment with adults who don't break your arm annually while claiming it's you that's defective.

Definitions are much too narrow, there is so much overlap, ultimately though therapeutic methods don't differ quite so wildly. The handful of conditions he was displaying are common differential diagnoses with very similar treatments.

However, there are stigmas attached to certain diagnoses and not their differentials so some people prefer less negative labels.

In my experience with world class psychiatrists your views are a little outdated, generally the more academic practitioners are much more like Dr Barron.

This is different situation here. He is not doing therapy nor treatment for this guy just evaluating for the study.

I realize that. I don't think it's pertinent to my point.

It matters very, very much whether we label someone as "a victim of a crime suffering PTSD" or "crazy" by some fancier term for crazy. If the diagnostic tools he is using make no effort to make such distinctions, they won't make that distinction for purposes of clinical treatment either.

Don't you think it's pretty damning for psychiatry if this guy is the first one who figured out he's actually ill from taking drugs, after decades when he was treated as mentally ill?

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