The Suicidal Thoughts Workbook is Now Available!

**You can listen to an audio version of this post here.**

I’m excited to share that my book, The Suicidal Thoughts Workbook: Cognitive-Behavioral Therapy Skills to Reduce Emotional Pain, Increase Hope, and Prevent Suicide, was officially published on July 1, 2021! I’m honored that my former graduate school mentor, Dr. Thomas Joiner, wrote the foreword.

One of my driving passions is sharing science-guided, helpful mental health information directly with the people who most need it. I took what I learned from years of research, therapy, and other life experiences and channeled all of that into the creation of The Suicidal Thoughts Workbook. My deepest hope is that readers will feel supported and empowered with strategies for coping with suicidal thoughts. I also hope that the workbook will help people to better understand how to support loved ones who struggle with suicidal thoughts. For therapists and crisis workers, I hope that the workbook will strengthen your confidence and expand your tools for helping people with suicidal thoughts. The book chapters were structured around a leading theory of suicide that was developed by Dr. David Klonsky (the Three-Step Theory). To give you an idea about the scope of the book, here is the table of contents:

I was also thrilled to collaborate with a brilliant artist, Alyse Ruriani, MAATC, to create two illustrations for the book (stickers and other items with these illustrations are available here).

I’m grateful for the positive reviews from people who read advanced copies:

“Kathryn Gordon’s workbook helped me self-reflect when I didn’t feel like I could handle my thoughts. When all feels lost, resources like this are exactly what we need: hopeful, analytical, educational, and practical. I will absolutely be recommending the book to others who might be feeling the same pain of suicidal ideation or hopelessness as well as those who are looking to better understand and help their loved ones.” 
—Marie Shanley aka Mxiety, mental health advocate and live talk show host, author of Well That Explains It

“Kathryn Gordon has translated our best theoretical and scientific understandings about why people are suicidal into an elegant, accessible, and easy-to-use workbook. Short chapters are full of practical and reproducible worksheets that walk the reader through hope and healing. She pairs her deep knowledge of the suicidal person with her expertise in cognitive behavioral therapy to create an invaluable resource for clients, their family and friends, and mental health professionals.”
—Jonathan B. Singer, PhD, LCSW, president of The American Association of Suicidology, and coauthor of Suicide in Schools

“Immediately helpful, this outstanding workbook offers wisdom and big-impact strategies to give you hope—that you can cope with setbacks, work through painful thoughts and feelings, find greater meaning in life, address obstacles to success, and live with purpose. Written with a supportive, encouraging tone, Kathryn Gordon guides you through the challenge of addressing suicidal thoughts, feelings, and behaviors with insight, self-compassion, and action. For anyone overwhelmed by pain and hopelessness, this essential resource will help you take the necessary steps to get your life back.”
—Joel Minden, PhD, licensed clinical psychologist and author of Show Your Anxiety Who’s Boss

The Suicidal Thoughts Workbook has my highest recommendation. The content is informed by Kathryn Gordon’s extensive clinical expertise and deep knowledge of the research literature. The writing is beautiful, clear, and accessible. Gordon has a gift for communicating with her readers and making suicide risk understandable and surmountable.”
—E. David Klonsky, PhD, professor of psychology at the University of British Columbia, developer of the Three-Step Theory of Suicide

“For anyone who’s ever struggled with thoughts of suicide or who has a loved one who does, this workbook is a must-have. Kathryn Gordon is kind and practical in her approaches to managing suicidal thoughts, and in helping us find what we might have lost during the many years of struggle – hope.”
—Janina Scarlet, PhD, award-winning author of Superhero Therapy

“This book is outstanding—compassionate, packed with practical exercises, and based on research, theory, and clinical practice. It can help readers to suffer less, to stay safe, and to want to live. The Suicidal Thoughts Workbook stands alone just fine as a self-help book, and it also will be a good complement to psychotherapy.”
—Stacey Freedenthal, PhD, LCSW, psychotherapist, University of Denver associate professor of social work, and author of Helping the Suicidal Person: Tips and Techniques for Professionals

“I am tremendously grateful for the opportunity to endorse this helpful tool. Having survived suicide attempts, I can honestly say that I wish I had something like this that could have helped me better understand everything that I was dealing with on the inside. Kathryn Gordon, thank you for thinking about those of us who struggle everyday with this invisible illness—we are forever grateful.”
—Kevin Berthia
, Suicide survivor/advocate/speaker, founder of The Kevin Berthia Foundation 

“Suicidal thoughts and feelings can sometimes end in death. And even if people don’t act on them, suicidal thoughts are incredibly painful in the moment. The good news is that for many people, using the skills in this book can help a person cope with suicidal thoughts and intensely painful emotions. Studies show that most people who use skills like the ones in this book can significantly reduce their suffering and help them build a life worth living. It is possible to recover, and this book is a good place to start.”
—April C. Foreman, PhDL.P., executive board member of the American Association of Suicidology 

The Suicidal Thoughts Workbook is a true gem in a world where suicide vulnerability exists in the shadows of shame and fear. Kathryn Gordon brilliantly weaves her professional expertise as a therapist and researcher to deliver a comprehensive workbook that breaks down each layer of suicide complexity, from why suicidal thoughts occur to specific strategies for developing personalized solutions. Most impressively, the workbook is genuinely empowering, offering hope to those who might otherwise feel hopeless.”

—Rheeda Walker, PhD, University of Houston professor of psychology and author of The Unapologetic Guide to Black Mental Health

You can order The Suicidal Thoughts Workbook wherever books are sold (e.g., Amazon, BookShop, and Book Depository for free international shipping), and the first chapter is previewed on Amazon. If you’re thinking about ordering my book or already have, thank you so much for the support! If you find my book useful, please consider leaving a review on Amazon or Goodreads and telling your friends about it. For books like this, word-of-mouth recommendations and social media posts about the book make a big impact!

With gratitude and wishes for good mental health,

Katie

Clinician Resources for Working with Suicidal Clients

Last week, USA Today published an article with this quote:

Suicide is the nation’s 10th leading cause of death, yet experts say training for                  mental health practitioners who treat suicidal patients — psychologists, social                      workers, marriage and family therapists, among others — is dangerously                                inadequate.

That article prompted this post. If you’re a therapist interested in learning more about working with clients who experience suicidal thoughts and behaviors, I hope that you’ll find this useful.

Books

Articles

Websites

forest-396025_960_720

We Must Treat Suicide Like a Public Health Crisis

Suicide is a major public health problem in the United States. In 2018, we lost nearly 50,000 people to suicide. That means that 1 person, in a deeply pained state, ended their life every 11 minutes. Left behind are heartbroken family members, friends, and communities who desperately wish they could have helped. Suicide rates are the highest they have been in 50 years, which stands in stark contrast to the declining rates of other types of death (e.g., stroke, heart disease).

Popular press articles have speculated about explanations for climbing rates, including smartphone use, scarce research funding, a weakened social safety net, and income inequality. Many suicidologists agree that we do not yet really know why this is happening. One public response has been to launch campaigns against stigma that encourage help-seeking. These efforts involve people, including celebrities like Lady Gaga, Logic, and Demi Lovato, openly sharing their struggles with suicidality. Another response has been to increase research devoted to understanding suicidal behavior and its prevention. Despite significant funding constraints, the past several years have resulted in a greater scientific understanding of suicidal behavior, how to treat it in a therapeutic context, and how to reduce risk in moments of crisis. If stigma has decreased and scientific knowledge has increased, why are suicide prevention efforts not stopping more deaths?

Many current initiatives advocate for intervening after a person has become suicidal, including improving access to quality mental health care and suicide hotlines. These downstream components are absolutely necessary, but insufficient on their own, for reversing current trends. Suicide prevention must include directing additional, comprehensive resources toward the root causes that put people on a trajectory toward suicide in the first place. As Archbishop Desmond Tutu said, “There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they’re falling in.”

A society that is serious about stopping suicide must expand beyond a model where an individual is identified as mentally ill and then referred for services that they may or may not be able to access. Even if all financial-, stigma-, and discrimination-related obstacles were removed to accessing quality mental health care (as they should be), and all existing therapists conducted scientifically-guided practice (as they should do), the field could not adequately meet all of the mental health needs. There simply are not enough therapists, hospital beds, and crisis line staff in many pockets of the country to provide services to all who suffer at the time they need it. And with suicide prevention, time is of the essence.

A public health approach means acknowledging that personal and population health are inextricably linked and that individual-level suicidality occurs within the context of societal structures. It means pushing for health equity, maximizing population-level well-being, and preventing many more people from reaching the point where suicide is viewed as the only escape from their pain. To illustrate the importance of this approach, consider the lead poisoning crisis in Flint, Michigan. Childhood lead exposure is linked to several adverse adulthood outcomes, including worsened mental health. It is absolutely necessary that Flint residents receive safe drinking water immediately, along with services to help with the damage that’s been done. However, effective prevention initiatives must also identify what allowed the lead poisoning to occur and continue in the first place (e.g., racism, irresponsible politicians) and create safeguards (e.g., policy, structural changes) to stop them from happening again.

What do these types of suicide prevention initiatives look like? They would financially empower communities to nourish mental health from the beginning stages of life (e.g., paid parental leave, affordable housing, quality education and health care, fostering community connections). These policies would also allocate resources to people and organizations with the multidisciplinary expertise and experience needed to design, implement, and evaluate community-level policy changes that directly target factors that contribute to suicidality: isolation, illness, unemployment, incarceration, adverse childhood events, and homelessness.

With Flint, the need for a holistic, preventative approach is obvious. A system that stops lead from getting into water is the most powerful way to reduce a repeat of human suffering – more so than providing services after the damage has been done (though this is completely necessary as well). The same holistic approach must be applied to suicide prevention: help those currently struggling and devote resources to upstream prevention. If we want to reverse the trend of increasing rates, save lives, and mitigate suffering, we must treat suicide like a public health crisis.

Water, Waterfall, Landscape, Travel, Outdoors, Iceland

Acknowledgment

Many, many thanks to my sister, Linda Gordon, for sharing her expertise in public health and anthropology with me. Our discussions about these topics inspired this post.

Suicide Prevention Information & Resources

More Information about a Public Health Approach to Suicide Prevention

Can Offensive Political Speech on Campus Cause Trauma?

strongertogether-1-e1552360966863.jpg

I went on Half Hour of Heterodoxy to talk about student reactions to political extremists giving speeches on college campuses. I was grateful for Chris Martin‘s interesting questions and wanted to expand on a few of the discussion points.

What’s the definition of trauma?

The DSM-5 defines trauma as exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: 1) directly experiencing the traumatic event(s), 2) witnessing, in person, the event(s) or the event(s) as it occurred to others, 3) learning that the traumatic event(s) occurred to a close family member or close friend, 4) work-related repeated or extreme exposure to aversive details of traumatic event(s).

Do political extremists cause trauma when they speak on campus?

DSM-defined trauma is unlikely to occur at these events unless there’s actual or threatened violence involved (e.g., 1, 2, 3, 4). It’s important to avoid watering down the term trauma through misuse in situations where it doesn’t apply. However, I don’t think fear of acute trauma typically drives the opposition to political extremists on campus. I think the fear is more commonly about political extremists using campus appearances to spread discriminatory beliefs that perpetuate social inequities. The sense of threat comes from historical knowledge about the uses of propaganda, and it’s amplified when violent acts are carried out that reference this propaganda (e.g., 1, 2, 3, 4). Some political extremists explicitly state that they’re trying to recruit college students to their causes (1, 2) and have developed strategies for persuading people through coded language (e.g., 1, 2, 3). Despite trauma being an unlikely consequence of these speeches, there is a robust literature showing that experiences of discrimination are related to worse mental and physical health (e.g., 1, 2, 3)* and that people can have physiological stress responses when exposed to discrimination and racism.** For example, it’s been proposed that these types of stress responses contribute to birth outcome disparities between Black and White women in the United States (e.g., 1, 2). 

What should universities do?

1) Actions should be individually-tailored for the particular university and involve discussion with students and faculty, instead of something pushed top-down from administrators. Include mental health experts in these conversations.

2) Express support for faculty and students. Even if you disagree with their viewpoints, don’t ridicule students or erroneously reduce all of their concerns to an inability to handle differences of opinion. Students are exposed to politically extreme views in spaces outside of campus speeches, and that exposure often shapes their beliefs about the particular speaker and the potential for harmful societal consequences. It’s not helpful to deride students who respond by using their time and resources to organize nonviolent protests to combat social inequality.

3) Don’t equate mental health issues with weakness or confuse therapy with avoidance. Normalize discussions about mental health on campus. University-wide e-mails are sent around about flu shots and other medical issues – it can be helpful to do the same with mental health information and resources. When people seek counseling, the first step involves determining whether the person has a mental health problem. If a student refers to something as trauma when it’s not, therapists provide them with that valuable corrective feedback. There’s also a misconception that therapy is about unconditional reassurance or hand-holding, but it’s actually all about empowering people to face their problems skillfully.

4) Be precise in stating your rationale for hosting speakers on campus. I doubt that many university administrators think there is educational value in speeches by people like Richard Spencer. Usually, they’re motivated by the importance of upholding free speech principles and are legally obliged to host speakers in public spaces. I’ve heard some arguments that there are educational and mental health benefits to having political extremists on campus (e.g., via exposure to “new and challenging” ideas). The free speech argument is compelling, but the educational and psychological growth arguments are not. I’m not aware of any evidence that exposure to inaccurate, dehumanizing ideas about groups of people confers psychological benefits (if you are aware of such research, please share it with me). For example, some students have opposed Ben Shapiro speaking on their campuses. As I have written about, he spreads false information about suicide and trans people (also watch Natalie Wynn refute Shapiro’s claims). It’s hard to comprehend how learning inaccurate ideas, which are used to restrict rights (e.g., 1, 2), add value to students’ lives. When someone argues that accuracy and education don’t matter when it comes to protecting free speech, I find that much more convincing and honest.

A recent video by Natalie Wynn included a nuanced description of her response to Ricky Gervais telling transphobic jokes in his comedy specials. She made it clear that the thing that bothered her wasn’t that he’s allowed to tell those jokes (she’s a huge proponent of free speech) or even that the jokes are unoriginal, unfunny, or offensive. Rather, she’s afraid that he’s spreading untruthful ideas that make the world a harder place for people like her (she’s a trans woman). Her descriptions reflect the kind of complexity and clarity needed for productive conversations about the psychological effects of these types of speech.

*This paper describes the complexities of measuring discrimination in research.

**Individual differences between people and situations determine the extent to which any particular person will be affected by an event.

Information & Resources

Accurate information about trauma and posttraumatic stress disorder is available here.

For student organizer perspectives, listen to Hoai An Pham here (episode 10) and read Maximillian Alvarez’s article here.

Chris Martin‘s Half Hour of Heterodoxy podcast has featured guests with a variety of opinions on free speech and other campus-related issues.

Two particularly thoughtful academics who write about campus free speech issues are Aaron Hanlon and Jeffrey Sachs.

I’ve learned a lot about First Amendment litigation from reading work by Ken White and FIRE.

I co-wrote a blog post on college mental health that you can access here.

Acknowledgments

In preparation for the podcast, I reached out to three people with relevant expertise and experience: Dr. Yessenia Castro, Linda Gordon, and Carly Marten. They generously shared research, articles, resources, and their thoughts with me. I’m thankful for how much they deepen my understanding of these issues and for all that they do to make the world a better place.

A Short Guide to Everything You Need to Know About Eating Disorders

nedawareness_week_2019-shareables1

In honor of National Eating Disorders Awareness Week, I will attempt to create a post that links to everything you need to know about eating disorders.*, **

*Or at least gets you within a couple of clicks of a lot of things that are good to know.

**Scientists and clinicians don’t actually know everything we need to know about eating disorders yet, but I’ll share what we do.

Definitions

The Diagnostic and Statistical Manual of Mental Disorders includes formal definitions of eating disorders, such as anorexia nervosa, bulimia nervosa, binge eating disorder, and others. Even if someone does not meet full diagnostic criteria for an eating disorder, they may still struggle with eating disorder symptoms such as body dissatisfaction, loss-of-control overeating or undereating, preoccupation with food, weight, or shape, or unhealthy weight loss behaviors (e.g., abusing laxatives, self-induced vomiting, compulsive exercise). If you’re curious about your own eating behavior, you can take an online screening here.

Causes

There are a variety of different factors that increase the risk for eating disorder symptoms. You can read about them here or see the biopsychosocial model below for some of the main factors associated with eating disorders.

eatingbiopsychosoc.png

Treatments

Current research-supported eating disorder treatments include: family-based or Maudsley treatment, cognitive-behavioral therapy, integrative cognitive-affective therapy, and interpersonal psychotherapy.

There are also some scientifically-informed self-help books available:

Help Your Teenager Beat an Eating Disorder

Overcoming Binge Eating

The Body Image Workbook

Additional Eating Disorder-Related Topics

Activism

Emotion Regulation

How to Help A Loved One

The Marginalized Voices Project

Statistics

Suicide

Warning Signs

Weight Stigma

More Eating Disorder Resources

Association for Behavioral and Cognitive Therapies

Academy for Eating Disorders

Find Treatment

Helpline

Maudsley Parents

Mirror-Mirror

National Eating Disorders Association

Podcast Episodes on Eating Disorders (1, 2, 3)

How Psychologists Capture the Complexities of Mental Illness

When it comes to understanding and treating mental illness, clinical psychologists must strike a balance between grouping people with shared characteristics together and recognizing people’s individual paths, circumstances, and needs. Below I’ve described some of the models that clinical psychologists use to reflect these complexities.

1) Biopsychosocial Model

Most modern psychologists understand that mental illness is the result of both nature and nurture. Accordingly, biopsychosocial models map out biological, psychological, and social risk factors for mental health outcomes and highlight potential intervention points. This model is so prominent that clinical psychology graduate programs require education in human development, individual differences, and biological, cognitive, affective, and social aspects of behavior, and you can’t become a licensed psychologist without passing a formal test on these topics. The idea is that mental health outcomes result from the interplay of biological, psychological, and sociocultural factors and that different people arrive at outcomes through different combinations of factors. Here’s a sample I constructed from some suicide risk factors:

biopsychosoc

2) Diathesis-Stress Model

People with identical genetics (i.e., monozygotic twins) and people with shared stressful events (e.g., witnessing the same violent act) can have different mental health outcomes. For example, many people with family histories of eating disorders will not develop eating disorders. Likewise, many people who have been bullied about their weight will not develop eating disorders. A diathesis-stress model of eating disorders explains this by saying that a person must have both a vulnerability (e.g., a genetic predisposition) and a significant stressor (e.g., weight-related bullying) to develop an eating disorder.

DSM

3) Multifinality and Equifinality

People who experience a similar event (e.g., trauma) can have disparate outcomes that depend on other factors (e.g., financial resources, societal views of survivors). This is called multifinality. Meanwhile, people with similar outcomes (e.g., posttraumatic stress disorder) can arrive there via distinct pathways (e.g., surviving sexual assault, a car accident, being the victim of gun violence). This is captured with the term equifinality.

EM

4) Distal vs. Proximal Factors

Most research on mental illness focuses on a few risk factors per study. Organizing findings across studies can feel like fitting puzzle pieces together to create a holistic picture. One way to do this is by grouping risk factors in terms of how far in time (distal) and how close in time (proximal) they are to the onset of mental illness. For example, strategies for reducing distal risk factors for adult depression may include public policy efforts to prevent childhood maltreatmentincrease access to quality health care, and decrease discrimination. Meanwhile, therapy for individuals with depression may focus on more proximal factors (e.g., enhancing coping skills, increasing social support, behavioral activation).

distal proximal

5) Nomothetic vs. Idiographic

I highly recommend this article by Beltz, Wright, Sprague, and Molenaar (2016) for detailed definitions of these terms:nom idioFor example, imagine that a client gets diagnosed with obsessive-compulsive disorder (OCD). In order to figure out the best way to help, a therapist begins with nomothetic information (e.g., the diagnosis) to select a treatment. A randomized clinical trial suggests that a type of cognitive-behavioral therapy called exposure and response prevention (EX/RP) leads to significant improvement among 80% of people with OCD after 17 sessions. Based on available information, EX/RP is a good place to start. However, it’s possible that the client will be among the 20% of people who don’t respond to EX/RP. Therefore, therapists must also pay attention to idiographic information after initiating treatment (e.g., by regularly assessing the client’s OCD symptoms over time). If the client’s not responding to therapy, the idiographic data signal that the therapist must figure out why and make appropriate changes.

ni

For more information on nomothetic and idiographic approaches, check out:

Clinical Practice as Natural Laboratory for Psychotherapy Research: A Guide to Case-Based Time-Series Analysis

Clinical Versus Actuarial Judgment

Single-Case Experimental Designs for the Evaluation of Treatments for Self-Injurious and Suicidal Behaviors

What Can the Clinician Do Well?

I’ve described frameworks that clinical psychologists use to understand people’s mental health needs at multiple levels while respecting their individuality. The dedicated people working hard to alleviate suffering in the face of these challenges give me hope for the future of the field.

img_0818-e1549833493956.jpg

In Defense of Diagnosis

In “Why I Do Not Attend Case Conferences,” Paul Meehl (1973) described reasoning errors that emerge during case conceptualization conversations among mental health professionals. One of the issues Meehl discussed at length (pp. 272-281) was an antinosological bias, defined as “an animus against diagnosis.” Here’s his response to a common objection to diagnostic labels:

passage

Meehl described his style there as “highly critical and aggressively polemic,” which he justified by saying, “If you want to shake people up, you have to raise a little hell.” The second section has a much more constructive tone. Both sections are valuable, and I agree with his overall thesis that compassionate, effective mental health care requires clearheaded case conceptualization. Meehl is also correct that 1) meaningful diagnostic systems are crucial for advancing the field and 2) some critiques of the Diagnostic and Statistical Manual of Mental Disorders (DSM) reflect misunderstandings of the diagnostic process. I’ll discuss some of the major criticisms and benefits below.

Criticisms

1. The DSM pathologizes nonpathological behavior.

Barbara_Gittings,_Frank_Kameny,_and_John_Fryer_in_disguise_as__Dr._H._Anonymous_

Barbara Gittings, Frank Kameny, & Dr. H. Anonymous, gay rights activists at a 1972 APA convention

This is true in specific cases. One of the most well-known examples is homosexuality being labeled as a mental disorder in older versions of the DSM. As a result of persistent, organized activism bolstered by research, homosexuality was removed from the DSM. You can learn more about it in excellent podcast episodes by This American Life and Radiolab. Currently, the DSM developers attribute elevated mental health problems among lesbian, gay, and bisexual people to discrimination, actively oppose conversion therapy, and push for policies and law that reduce disparities. In order to prevent future harm, this history must be considered in diagnostic decisions. As Martin Luther King, Jr. said, psychology shouldn’t label people as maladjusted for not adjusting to bigotry.

However, we should also consider that appropriate diagnoses have helped people access beneficial services (e.g., children with intellectual disabilities or autism receiving accommodations in school and other public places). Additionally, the DSM specifically instructs clinicians to only assign diagnoses when a cluster of multiple symptoms: 1) causes clinically significant distress and/or impairment, 2) is persistent and severe for a length of time, 3) deviates significantly from developmental expectations, and 4) cannot be attributed to other factors (e.g., medical, cultural). These types of safeguards reduce the likelihood of pathologizing nonpathological behavior.

2. People are over/misdiagnosed.

Misdiagnosis occurs for many reasons ranging from improper assessment procedures, failure to consider pertinent contextual factors, and biases. For example, attention-deficit/hyperactivity disorder is a meaningful diagnostic category with real-world implications. Nonetheless, there’s evidence that it may be overdiagnosed, which can lead to inappropriate treatment plans.

Issues that exacerbate the problem include 1) lack of funds/insurance coverage for comprehensive assessment procedures and 2) diagnosers who rely too much on their intuition instead of established diagnostic tools. The Ethical Principles of Psychologists and Code of Conduct lays out stringent rules for assessment. A system that ensures adherence to these rules would reduce misdiagnosis while permitting proper diagnosis for people who need treatment and/or services.

use of assessments

3. Classification decisions are made by people with conflicts of interest.

There have been some egregious examples of psychiatry researchers receiving large sums of money from pharmaceutical companies and not properly disclosing them. One instance is covered in a PBS Documentary and in this New York Times article:

grassley

In an effort to address this problem, DSM-5 panel members were required to disclose conflicts of interests. Cosgrove and Krimsky (2012) made a compelling case that further action was needed:

COI

To be clear, psychiatric medications have helped numerous people and are warranted in particular circumstances. However, steps must be taken to reduce potential biases driven by the pharmaceutical industry.

4. Labeling someone with a mental disorder is stigmatizing.

Despite signs of improvement, prejudice and stigma continue, especially for certain mental health conditions. The solution is to eradicate the stigma rather than the nosology (but it’s worth listening to Szasz’s arguments opposing that idea). When properly applied and understood, diagnoses can alleviate suffering by pointing to effective treatments, connecting people with support and advocacy groups, and evoking compassion. This was nicely demonstrated in Crazy Ex-Girlfriend:

I’m aware mental illness is stigmatized/But the stigma is worth it if I’ve realized/Who I’m meant to be/Armed with my diagnosis

5. Diagnostic categories do not accurately reflect nature.

There are different versions of this, but I’ll focus on the most common: 1) most mental health problems are dimensional (occurring on a continuum) rather than categorical (e.g., there are gophers and chipmunks, but no “gophmunks“), 2) there’s too much variability within diagnostic categories for them to be meaningful, and 3) DSM symptoms are not necessarily the core symptoms of disorders (e.g., for depression).

In response, 1) people have proposed replacing the categorical model with empirically-informed dimensional models (e.g., even if psychopathy occurs on a continuum, it’s quite meaningful to diagnose those in the highest range), 2) diagnostic presentation variability depends on the diagnosis (e.g., people with bulimia nervosa have more in common, on average, than people with borderline personality disorder) and fewer diagnoses with more specifiers could help (e.g., see Pincus, 2011), 3) network analyses are useful for identifying the central symptoms of mental disorders. A concern about major DSM changes is that they will disrupt the work of clinicians and researchers (see Pilkonis et al., 2012). Despite these issues, we need to create a DSM that’s better at carving nature at its joints rather than resisting change or giving up the enterprise altogether.

Benefits

1. Agreed upon definitions facilitate clinically-relevant research.

I agree with McFall’s Manifesto (1991), which states that “the future of clinical psychology hinges on our ability to integrate science and practice” (to hear this debated, check out this Talk of the Nation episode). For example, treatment research for bipolar disorder has more generalizability to real-world clinical settings when therapists and scientists use the same operational definition of bipolar disorder. Moreover, consistent mental disorder definitions across studies makes cumulative knowledge possible. Classification systems enhance communication and research, which contribute to the big picture goal: alleviating suffering.

2. Diagnoses convey useful information when derived from appropriate assessment procedures.

Accurate diagnoses point to literature on the causes, correlates, and effective treatments for specific mental health problems. If an adolescent girl is accurately diagnosed with anorexia nervosa, we learn that she has an increased risk for bone fractures, arrythmias, depression, and suicide and should be monitored for each of these dangers. Importantly, we also know that family-based treatment is likely to be a good treatment option for her and that her parents can connect with parents experiencing similar struggles. To learn more about the process for evaluating levels of empirical support for therapies, look here for youth treatments and here for adult treatments.

3. Diagnostic feedback (when done well) can lead to positive effects.

People tend to experience positive feelings (e.g., optimism, relief) after receiving diagnostic information derived from appropriate assessment procedures and delivered in a collaborative, constructive manner. Similarly, there’s evidence that taking personality inventories and being told about the results from a therapist leads to increased self-esteem, more perceived self-competence, and lowered distress. Why would people feel better after learning about their mental health problems and potentially maladaptive personality characteristics? My guess is that people already know that they’re experiencing certain kinds of issues. When a therapist demonstrates an understanding of the problems by placing them in a meaningful context, they feel validated and hopeful that they can be helped.

4. Diagnostic labels enhance communication between treatment team members and aid continuity in care.

Diagnostic labels ease the transition for clients from one therapist to another (e.g., by saving them from having to repeat assessment procedures) and by communicating efficiently to other members of their treatment team (e.g., social workers, psychiatrists, physicians, clergy).

5. The DSM-5 has improved since the original version and has built-in mechanisms for change.

Despite the hindrances mentioned above, the DSM has formal, built-in processes for evolving with new scientific discovery. New versions are created with the explicit goal of making the classification system better reflect nature. Hyman (2010) argued that we should not reify existing diagnostic constructs. Instead, we must remember that diagnoses are constructed for clinical and scientific purposes. Therefore, improving the DSM requires openness to change and flexibility.

reify.png

In conclusion, despite the concerns highlighted above, I agree with Meehl that antinosological biases impede progress and that mental health classification systems should be improved rather than abandoned altogether. I’m grateful for the dedicated clinicians and scientists working to deepen our understanding of mental health and feel encouraged by efforts to use that information to improve people’s lives.

thank-you-for-reading-81.png

—————————————————————————————————————————————–

In an effort to keep this post relatively brief, I highlighted some main points and examples. Some of the more technical, in-depth things I’ve co-written about classification are linked below:

The Classification of Eating Disorders – The Oxford Handbook of Eating Disorders

Empirical Approaches to the Classification of Eating Disorders – Developing an Evidence-Based Classification of Eating Disorders

Nonsuicidal Self-Injury Disorder: A Preliminary Study – Personality Disorders: Theory, Research, and Treatment

Patients’ Affective Reactions to Receiving Diagnostic Feedback – Journal of Social & Clinical Psychology

Suicidal Behavior on Axis VI – Crisis

Taxometric Analysis: Introduction and Overview – International Journal of Eating Disorders

The Validity and Clinical Utility of Binge Eating Disorder – International Journal of Eating Disorders

—————————————————————————————————————————————–

A major inspiration for creating the Jedi Counsel blog and podcast was to demystify issues surrounding diagnosis through analyses of fictional characters.

3000x3000_JediCounsel

10 Hamilton Quotes for Therapists

Hamilton

Like many people, I am enamored with the music from Hamilton. There are so many things to like – all the hip-hop (e.g., Cabinet Battle #1!), the psychologically complex and nuanced development of the characters, the diversity of the creators, cast, and crew, and the powerful storytelling of US history. Because I like to explore mental health in fictional characters, I was tempted to with Hamilton as well (i.e., why did Burr and Hamilton end up on such different trajectories?). However, they are based on real people and real lives, so I don’t want to speculate about them (at least not in a blog post). So, similar to what I did with Star Wars, I decided to make a list of 10 quotes from Hamilton, that in my opinion, may be useful for therapists working with Hamilton fans (who are numerous these days).

1)  On mindfulness and gratitude:

Look around, look around at how/Lucky we are to be alive right now!

2) On taking healthy risks and decreasing unhealthy avoidance:

Rise up! Time to take a shot!

3) On acceptance, patience, resilience, and meaning-making:

Love doesn’t discriminate
Between the sinners
And the saints
It takes and it takes and it takes
And we keep loving anyway
We laugh and we cry
And we break
And we make our mistakes

Death doesn’t discriminate
Between the sinners
And the saints
It takes and it takes and it takes
And we keep living anyway
We rise and we fall
And we break
And we make our mistakes
And if there’s a reason I’m still alive
When everyone who loves me has died
I’m willing to wait for it
I’m willing to wait for it

4) On self-empowerment/accepting that one cannot change other peoples’ behavior:

I am the one thing in life I can control

5-6) On understanding historical context for clients who may belong to marginalized groups:

You want a revolution? I want a revelation
So listen to my declaration:

“We hold these truths to be self-evident
That all men are created equal”

And when I meet Thomas Jefferson

I’m ‘a compel him to include women in the sequel!

A civics lesson from a slaver. Hey neighbor
Your debts are paid cuz you don’t pay for labor

7) On not equating self-worth with work achievements

I don’t pretend to know
The challenges you’re facing
The worlds you keep erasing and creating in your mind

So long as you come home at the end of the day
That would be enough

We don’t need a legacy

8) On self-compassion:

Look at where you are
Look at where you started
The fact that you’re alive is a miracle

9) On not letting perfectionism interfere with productivity:

Burr (on the U.S. Constitution): And if it fails?
Hamilton: Burr, that’s why we need it
Burr: The constitution’s a mess
Hamilton: So it needs amendments
Burr: It’s full of contradictions
Hamilton: So is independence
/We have to start somewhere

10)  On prioritizing health and balance:

Take a break