Treatment vs Accccomodation: Diagnosing the DSM

Teaser from my latest CFN column...

 

“Is there a lot of controversy around diagnosis? Absolutely. Should there be? Absolutely. That is its greatest virtue. It provides opportunity for input from lay people, social workers, and brings us all to the table. We’re dealing with conditions where there is a profound degree of complexity and a profound degree of uncertainty.”

There's an old joke about a patient who goes to see his doctor about a physical complaint. The injury itself doesn't matter - let's say it's typing too much on a blackberry, just for fun.

Patient: "Hey doctor, it hurts when I do this."

Doctor: "So, don't do that."

Buh-doom boom.

Of course, that's not the way it tends to work out in real life, is it? An actual conversation with one's doctor might go like this.

Patient: "Hey doctor, my thumbs are killing me, it hurts to type. You gotta do something."

Doctor: "Have you tried typing less?"

Patient: "Drop the lip, doc - I pay you to fix my problems, so fix this. I've got a report that's due next week and the pain is getting in the way.  Can't you give me some Oxycodone or something to help me get back to work?"

Ouch. No rim shot for that one.

Our healthcare delivery model has changed course over the last century or so into one that’s  consumer-based – health is a service provided, not a lifestyle.  Work, not health, is the focus; instead of trying to improve and sustain health, our medical professionals are being seen more like pit crews. How quickly can you patch up the patient and get them back into the rat race?

Our social/economic model of society is very much a race - competition grows ever steeper and people need to invest more and more of themselves, their time, even their well-being into keeping from falling behind. If you don't have access to the best parts and pit crew, the odds are really stacked against you ever winning. The success of the system comes first - individual benefit is supposed to be an organic byproduct of the free market. 

So, what does this have to do with the Diagnostic and Statistical Manual of Mental Disorders (DSM)?

The DSM is, clearly, a diagnostic tool that is designed to help health practitioners, including those of the mental health variety, identify what's wrong with a person. What's wrong seems to be defined as "that which keeps them from functioning properly within an existing social context."  The goal is to get people back on the line and contributing, after all.  So, the aggressive employer that micromanages staff and stifles productivity is sick. The underachieving welfare recipient is sick. The kid acting up in class - sick. 

This should all sound familiar, because it's the exact same phenomenon we've seen throughout history.  We have a habit of stigmatizing and labeling anyone who is different than what the prevalent voices in society want them to be.  It’s like those differences are a social illness we’re trying to correct.

First Nations people and their insistence on group think and non-Western social customs? That's a problem that needs to be fixed.  Lefties who can't seem to get things done with the tools they're provided? They need to operate from the right if they want to belong.  Women who disrupt the work cycle to have babies and such? Not a good investment in the first place.

See the pattern?

We might like to tell ourselves we're inclusive and really open to supporting people's differences, but when we rest on that opinion, we're deluding ourselves. More often than we realize, we're not accommodating the specific challenges of a person - we're trying to get them to conform.  Even Free Market purists trying to save welfare-state believers from themselves are trying to fix people they see as misguided.

About two years ago I had a chat with a former boss, Leslie Noble (a senior Conservative advisor and Government Relations expert) about top-down management. She was frustrated on behalf of a friend who was Executive Director of a mental health institution. Thanks to a standardized government mandate, the friend was being expected to dedicate allocated funds to solving one problem, when it was a different structural issue that was really threatening her operations. This, Leslie explained to me, was why she is so dead-set against a top-down standardized approach to fund allocation; it stifles people from doing what they need to succeed.

That's at the organization level, but it applies to individuals, too.  Trying to standardize everything is like viewing every problem as a nail – which is what you tend to do, if the only tool in your box is a hammer.  Despite what political hawks try to tell us, you can’t hit your way out of everything.  Of course, the reverse is true, too.  It’s naïve to think you can pass around right-handed scissors and expect everyone to have an equal chance of making the cut, but we do that all the time.  It takes an out-of-the-box thinker to consider the possibility of left-handed scissors, creating not only an innovation that helps lefties succeed on their own terms, but creates an economic opportunity as well.

Not that long ago, I had a great chat with former Attorney General (and genius) Michael Bryant and Sylvia Kim, a wickedly smart social entrepreneur about mental health and social functioning. Michael raised an excellent point - there are probably thousands of "gifted undiagnosed" Einsteins out there who, because they were never exposed to people who knew how to recognize or harvest those gifts and weren't born with an aggressive level of self-confidence and marketing ability, are slowly going mad working in a mail room when they could be curing cancer or solving gridlock.

I bring up madness intentionally, because there's a strong correlation between manic genius and diagnoses of “crazy” - look at this list of famous people with mental illness for just a few examples. Do you know any geniuses yourself? Do you find them a bit high-functioning, maybe have or had substance abuse issues or personal relationship challenges? It's surprising just how much staff of high-performers serve a bit like counselors and support workers, helping to keep the genius focused and keep the individual from going off the rails. If you've ever worked in politics, you'll have seen this, a lot.

Now, consider:

Phiona Mutesi is taking the world by storm as a 17 year-old chess genius. Born in an Ugandan slum, not even really certain of when, it was really nothing more than a stroke of luck that she was able to connect with the supports that helped harness her talents and explore her maximum potential. A slight change of circumstance and the world would be missing something.

On the other end of the spectrum, we have people like Greta Hoaken, a 17 year-old dynamo who started her first business at 13 and is destined to do great things. Sorry, not destined – that implies inevitability.  We like to think good things happen to good people, but there’s zero empirical evidence to say that’s a standard.  Greta had the right supports from her family and community as well as the natural drive to succeed; that’s why we’ll remember her name.

We shouldn’t begrudge Mutesi her luck any more than we should envy Greta her fortuitous background. But we all too often do, don’t we?

It’s a race to the top, after all, and their fortune comes at the expense of our ability to get ahead.  The success of someone else is seen as a negative to us, pure and simple - and we get bitter about that. If we can’t afford the better pit crew, we might just decide throwing a wrench in the wheels of an opponent will help us get to the finish line first.

It’s the same rationale behind Ontario PC Leader Tim Hudak’s attack on foreign workers and foreign students – why should we pay to give outsiders an edge over our people? It’s not fair in a strictly free-market sense, nor does it fit with the goal of creating standardized communities.

In free market theory, money is often described as the life-blood of society and the economy, the heart that pumps it. As we’ve already got a health-related theme going, let’s run with that – if society were a body, would you want to dedicate all your resources to cardio-pulmonary health alone? What about the factors that impact heart health - things like exercise, sleep, stress, diet?

People aren’t machines on the line that unfortunately need quick tune-ups to keep working; they’re complex creatures that are part of an even more complex system – society.  Society is more like an organism than a machine – you don’t get to trade in rusted or malfunctioning parts for new ones.  When you neglect one aspect of society (like the poor) the whole system ends up suffering (crime, illness, economic atrophy). 

Oh, and those foreign bodies joining our economy aren’t a virus to be locked up or run out of town – immigration is more like adding diversity to the social gene pool.  After all, that which doesn’t kill you makes you stronger, right? 

If you want an effective model for understanding individual and social health, you should go back to those troublesome First Nations and take a look at the concept of the Medicine Wheel. A holistic view of individual and social health might not be standard; hopefully we can agree that the standard model has room for improvement.

Which brings us back to the DSM.  By defining a median standard for normal cognitive and social behaviour, we’re stigmatizing those who don’t fit in that box as abnormal.  There will be those who consistently and markedly deviate from the standard; these lateral-thinking folk will be seen as disruptive to the economic race and be more likely to spend time in the pit or get removed from the track entirely. 

Do we really want to normalize or sideline future Isaac Newtons, Abraham Lincolns or Ernest Hemmingways because they don’t fit the standard?  What would we lose if we did?

Society keeps benefiting from the outliers (nutty geniuses like Steve Jobs or captivating artists like Catherine Zeta-Jones) but we make it really, really hard for them to reach and contribute their full potential.  You can chalk that up to the nature of competition, but as with Mutesi and Greta, we see a lot of cases where it’s luck of the draw, not competitive advantage, that helps some get ahead.  At the same time, everyone else is suffering from the stigma of the standardized social race, too – rushing madly just to stay in the same place.  It helps explain why we have an unheralded business crisis here in Canada.

Einstein defined insanity as “doing the same thing over and over again and expecting different results.”  Instead of continuing to add more diagnoses to the DSM, perhaps we should step back and consider if we’ve diagnosed the wrong problem.