Thursday, October 14, 2021

PS - Examples of Cultural and Socioeconomic Bias Still Existing in the Mental Health Community

As mentioned below, though I've mentioned many times that I think there are great therapists, out there (I have one), I also think the our mental health community overall still somewhat semi-consciously enables some of the worst aspects of our culture and our broken economic system.

In fact, you would be amazed at the number of wealthy people given more mild, socially acceptable, temporary, and/or victim diagnoses versus poor people, and how many men are diagnosed with more mild, socially acceptable, temporary, and/or victim diagnoses versus women.

How do I know?

I first noticed this during my initial education in clinical social work,  after reading the few studies that exist on it and we discussed it in class - and since then, I previously typed notes for inpatient hospital admissions for 25 years as a medical transcriptionist - including psychiatric admissions. 

(For the past two years, however, I'm a pharmaceutical transcriptionist for an independent marketing firm, transcribing interviews between pharma and payers or clinicians.)

I could give numerous examples, but one example in particular stood out as the most glaring example, when I typed two notes on the exact same day, one after the other, for a behavioral health center in the Midwest, which perhaps best illustrates the socioeconomic and gender bias - and it was just about 4 years ago (but was memorable as the most obvious and best example I have ever typed).

But before I re-transcribe these two consecutive reports from memory for you, there's a few things you need to know first.

First, you need to know the diagnoses field in psychiatric inpatient reports goes like this:


AXIS I - Clinical biological/neurological/chemical conditions or disorders.

AXIS II - Personality disorder and/or mental or emotional retardation.

AXIS III -  General medical conditions.

AXIS IV - Psychosocial and emotional stressors.

AXIS V - Global Assessment of Function (a scale that assesses the patient's currently ability to function). 

Secondly, you need to know that the gender of the clinician didn't make a difference - male and female clinicians equally seemed prone to this bias - women were just as "guilty" of this as men.

Most importantly, you need to know that these are not exact copies of the original reports - these were retyped based on memory (they were that memorable).

HISTORY OF PRESENT ILLNESS:  This 15-year-old white female was admitted after telling her mother of passive suicidal ideation without a plan, as well as thoughts of self-harm in the form of cutting.  
She states that she had these feelings for a long time, but initially didn't tell her mother for fear of burdening her, going through a divorce and financial struggle. 
She attempted to talk to a guidance counselor at school, but abruptly ended her appointment, stating she felt like she was whining, after the counselor seemed dismissive and didn't take her seriously.  
She said she finally told her mother because the thoughts were starting to scare her, and she didn't know "the right way to tell people how bad she felt inside" or what to do about it, and expressed perhaps she was "just lazy, stupid, and crazy."  
She states that she has always struggled with self-esteem, chronic emptiness, and a sense of abandonment, especially when her parents separated, and that she can't remember the last time she felt happy, but only just recently was having suicidal thoughts and thoughts of self-harm.    
She has been sleeping 16 hours a day, not showering, and overeating.  She struggles with shame from overeating and her appearance.  


SOCIAL HISTORY:   She was an average student previously, but her grades have dropped to failing, mostly due to not attending school.  She formed childhood friendships, but claims to have lost all of her friends after isolating herself, and "not being normal" like they are.  Her mother appears supportive and concerned, but admits she has to work much, and the father is uninvolved due to a new relationship. 


PHYSICAL EXAMINATION:   Patient is alert and oriented x3, disheveled in appearance, morbidly obese.  Pupils were equal, round, and reactive to light and accommodation.  Cranial nerves II through XII are intact.  Mood is sullen and withdrawn, and she gives rare and brief eye contact.  When encouraged by her mother to speak and express herself, she speaks, but becomes tearful, emotional, and increasingly agitated and  animated; however, this examiner was able to redirect her, assure her of treatment, and calm her down.  By the end of the evaluation, her mood had improved and she appeared to brighten.  Judgment and insight are poor, thoughts were  tangential and somewhat disorganized.  
She appears to show no remorse for the suicidal gestures with her guidance counselor and mother, and openly admits she still has suicidal ideation, but no plan.


AXIS I:      Rule out bipolar depression. 
AXIS II:     Rule out borderline personality disorder.

AXIS III:    None.

AXIS IV:    Recent divorce of parents, family financial issues, weight gain.

AXIS V:     GAF score not assessed.  





HISTORY OF PRESENT ILLNESS:   This 16-year-old white male was admitted after his teacher noted that he had carved the words "I WANT TO DIE" on his arms.    
He also expressed aloud to his class that he had a gun and was either going to kill them or himself.  
He admitted to this examiner that he had no gun, he didn't mean it, and admitted he did it to "get attention" and "get more help."  


SOCIAL HISTORY:  His parents, who were both present during the examination, were supportive and attentive, and stated that there had been no recent changes to the family environment.  They stated he often does and says things like this at home, but this was the first time he'd done so at school.  
The parents stated that there were no known triggers, other than they'd noticed it was at its worst when he felt they were giving more attention to his brother than him, and when he was "bored."  
The patient corroborated his parents' perception, stating that though he likes his brother, he can't stand when he gets more attention than he does from his parents, and they "have a very competitive family." 
When asked if the patient ever became aggressive or violent, his parents stated that his only aggression was directed towards his brother, in the form of sudden outbursts, and that he had engaged in kicking, punching, and hitting him, which the patient corroborated, stating he doesn't hate his brother, he just hates the attention he gets.  
He added that he has trouble concentrating for too long, and often does these things out of boredom.  
The patient and his parents stated that he was previously a straight-A student and on the honor roll at his private school, but recently states he has been bored in class and not provided with enough intellectual stimulation.    
He denies trouble with sleeping too much or too little or changes in appetite.


PHYSICAL EXAMINATION:   Patient is alert and oriented x3, well-groomed in appearance.  Pupils are equal, round, and reactive to light and accommodation.  He gives good eye contact with the examiner throughout the examination.  He is wearing a short-sleeve shirt, and his arms are covered with cuts, including the words "I WANT TO KILL MYSELF,"  which prompted this visit.  His wounds were treated by the medical staff.  Mood was stable, but  he appeared anxious and fidgety.   Judgement and insight are intact, thoughts were linear and goal directed.  He stated that now that he was receiving attention, he felt better. 


AXIS I:      ADHD, rule out ASD (autism spectrum disorder). 
AXIS II:     None. 
AXIS III:    None. 
AXIS IV:    None.  
AXIS V:     GAF not assessed.

Now, I realize I wasn't there to witness either patient in person, and that there may have been things they didn't mention, because they have to be careful as these are legal documents, so I'm only basing this on what was dictated.

But does anyone else but me see what's wrong with this picture?

So let me get this straight ...

The 16-year-old private-school rich boy literally carved "I WANT TO DIE" on his arm, then wore a short-sleeved shirt in the winter so everyone could see it, and announced loudly to his class that had a gun (but didn't) -  gets nothing but ADHD and possible autism?

But the girl that told two people privately she was having suicidal thoughts that scared her is being ruled out for a personality disorder?

I literally was scared for both of them, after typing these, for different reasons - afraid the girl was going to suicide, one day, being dismissed, and the boy was going to hurt someone else one day -  particularly his brother!?!

And what are they going to say, when these things happen - "Oh, the poor thing had ADHD and autism" - despite the fact that people with those diagnoses don't usually hurt other people (or at least mean to) - and "Oh, well, she was a borderline and beyond help anyway. She threatened and then finally did it, big surprise, who cares."

No - neither of those responses is okay - and proof of enabling a sick, biased culture.

Okay, in case you're still clueless as to what's wrong with this picture after pointing out the most glaring aspect first, here are more problems with how this was handled, despite known protocols to prevent these biases that were not used:

First of all, no one should be diagnosing anyone with a personality disorder - male OR female -  before at least the age of 18, perhaps even 21 (or even 26, considering we know now the human brain isn't fully developed until then) unless they've actually committed a victim crime like murder or rape.

Because diagnosing a teenager with a personality disorder is like pronouncing a lifelong sentence or branding them with a scarlet letter,  male OR female.  It's like sending a teenager to adult prison for life, over an impulsive teenage mistake, that he or she may actually feel remorse or even shame for later, as an adult. 

(In fact, this is the reason why our criminal justice system sends teenagers to a juvenile detention center, rather than adult prison, and why juvenile records are sealed.)

Clinicians know better, they've been educated and trained against doing so (or at least I was), and yet they continue to do it - often because of pressure by the parents - or the teachers - to diagnose them with something and want them medicated.

Because we know that teenage hormones are crazy, they're just learning how to cope with the world, how to regulate emotions, and how to express them more appropriately than as a child, and the consequences of not doing so, as well as we can never underestimate children modeling the behavior or adults in their immediate environment, but learning other ways of coping from others, over time.

In fact, there's some movement in the psychiatric community to wait until 21, or even age 26, considering what we know now about the human brain not fully developing until age 26 via CAT scans and SPECT scans.

Secondly, why is she under suspicion for bipolar disorder, when apparently at some point, she clearly stated "she can't remember the last time she felt happy," indicating she did not experience any manic episodes?

And her motivation for suicidality isn't rejection or abandonment, which is a prerequisite of borderline personality disorder - it's feeling trapped in her current weight and life?

Thirdly, why is he suspected for an autism spectrum disorder when he gave eye contact the whole time (and she didn't), when inability to sustain eye contact is a known feature of autism (as well as depression and anxiety)?

So, here's some background.

It is well known that almost all patients diagnosed with borderline personality disorder are women, and that almost all patients diagnosed with narcissistic personality disorder are men.

This, of course, is gender biased, unfair, and untrue - I can guarantee you I've met men who are suspect for being borderlines and women suspect for being narcissists, and I'm sure whomever is reading has, too.

But let's presume that's true - that more women are borderlines and more men are narcissists.

Why would that be?

Gee, it wouldn't be because our culture favors assertive men with the outward appearance of strong self-esteem, and vilifies assertive women with strong self-esteem, creating personality problems, would it?

Nah, of course not ;)

Also, until the DSM-V was published in 2013, the criteria list for borderline personality disorder was 14 items long (the longest of any personality disorder) and included things like "promiscuity," when no such feature existed on any personality disorder for men.

This aspect of the disorder in particular was a subject of debate in the mental health community for years (I remember a heated class debate about it an abnormal psychology class in college, with many young women objecting to this item, and the male professor agreeing it was sexist, but that was the criterion by the DSM-III, at that time).

Also, before the DSM-V, it became a well-known problem in the mental health community that when a female patient expresses suicidality or engages in self-harm, regardless of age - or when they don't feel like the patient is progressing (which could be due to their own incompetence) - or even when they simply don't know what to diagnose a patient with, but have to put something on their insurance claims to continue to pay for therapy - clinicians would previously throw them in the grab-bag diagnosis of borderline personality disorder.

Now, that is not to say that there aren't real bunny-boiling, fatal attraction borderlines, out there, that hit the full criterion, there certainly are - but the psychiatric community finally realized this was being overly diagnosed - much like bipolar disorder was being overly diagnosed in the 2000s, and autism-spectrum disorders are being over-diagnosed today.

They also finally officially recognized the gender bias that existed in that diagnosis, and after further trauma studies, that suicidality among women was not always in response to rejection or abandonment, and did not automatically mean a personality disorder. especially in teenage females.

Also, they felt the criteria for the disorder was too long, and in fact, noted that most American women hit at least 4 of the 14 points - i.e. chronically low self-esteem, feeling of emptiness, self-sabotage with success, feeling "invisible" to others, and postulated this may be a cultural problem that needed further study (and boy, are they getting those studies now, after Trump lol).

Thus, to their credit, in 2013 with the DSM-V, they shortened the list - and either took certain points out completely (like inability to take responsibility for behavior, because that's become a common American problem for both men and women), or revised them.

For instance, the "promiscuity"  language was changed to "excessive sexual behavior," and is now listed under the umbrella of "impulsive behavior," rather than being off as its own criterion by itself.

The "suicidality" and "self-harm" aspects were clarified in that they must be in response to perceived rejection or abandonment. 

This is because we learned more about suicidality in women and trauma (more about that below), as well as clinicians saw that self-harm skyrocketed in teenage girls and gay boys in the late 90s and 2000s, which disappeared by adulthood.  They also discovered self-harm occurs in both male and females, often as a secret behavior rather than a manipulation, and for those engaging in it past their teenage years, it's found even in actually in high-functioning people as a way to deal with stress or shame after trauma with burdening others. 

(For example, workaholic Lady Gaga has admitted to self-harm, which began after her rape 15 years ago.)

These changes have occurred because we have studied more about trauma, especially after the Iraq/Afghanistan war. 

As a result, we've learned the most common motivation for suicidality in most women (and gay men) is NOT rejection or abandonment, actually, nor always a manipulation -  the motivation is often the same as heterosexual men - trauma reaction and/or he or she either feels either "permanently damaged" or trapped in a situation from which they see no way out.

The only gender difference appears to be that women are statistically more likely to seek medical care in general versus men. 

And yet, we, as a culture, still cling to these antiquated ideas about men and women, nonetheless, even in clinicians who supposedly now know better, as you can see above.

Now - why does this happen?

Well, IMO, as I said, the psychiatric/psychological community is still semi-consciously enabling our broken socioeconomic culture which assumes that wealthy people - especially white males - are sane and stable, and thus receive temporary or mild, less stigmatized diagnoses - even PTSD is considered by our society as more justified in male soldiers versus women who have been raped or abused, and is empathized with more.

The other problem is, as you can see in AXIS V, the psychiatric/psychological community focuses their definitions of mental illness solely around a patient's ability to function in daily activities and in society, as well as their grooming and their mood during the actual session (as you can see in the PHYSICAL EXAMINATION).

(Mind you, judgment, insight, and thought processes are not assessed by any sort of objective testing tools, they're a subjective assessment by the clinician.)

So essentially, if a person either has great-paying commercial insurance or pays out of pocket for the full fee (to avoid a psychiatric claim on their insurance), never misses work or school, appears well groomed, and never cries or seems angry during a session (even though that's the goal of therapy, to uncover those raw emotions), then they're perceived as "stable" in mood and function, and thus less likely to receive a diagnosis.

Never mind they could be terrorizing everybody else in their home, class, or office so badly that they end up seeking therapy - according to mental health definitions, they're stable, simply because they can function - which essentially only means they eat normally, sleep normally, shower, and go to school or work everyday.

So guess who gets diagnosed with something chronic then?

Their victims :)

However, I can report that I know a few therapists who started to wake up to these issues in the psychiatric/psychological community, after Trump - realizing how many people assumed wealthy people, especially white men, were sane, despite obviously unhealthy behavior - and are beginning to reassess whether "global assessment of functioning" may not be the best indicator of mental illness, after all, because they may be treating the the victims of the sickest power abusers in society.

Clinicians have already known for years that the sickest power abusers in our society never see the inside of a therapist's office, or at least don't stay in therapy, because they think it's everyone else with the problem, and others' reactions to their behavior are "oversensitivity," "weakness," or "they're crazy, not me."

If the wealthy do enter therapy, many expect to be coddled, waited on, and patted on the back, as if therapists are their servants, because they're paying them - and many therapists comply, do nothing but tell them they have every right to everything they do, rather than confront them on their behavior, out of both assumption of stability and fear of loss of a big paycheck.

For the record, I wouldn't trust any therapist that never confronts me, because they're not being honest, we all can be shitty sometimes.

Plus being confronted is the only way you'll see change, which is what therapy is for - to change your behavior, since you can't always change your environment.

Even if truly a victim of something, a good therapist will confront you on overly avoiding things or handling things in unhealthy ways, and new coping skills to handle these feelings.

Regardless, I think we can all agree that our society is sicker than ever - and IMO, we're not going to see any marked improvement in the antiquated cultural ideas until the mental health community itself recognizes its own socioeconomic bias - and if you've got a good therapist, they'll admit this exists to you.

I think a good indication that there may be change on the way, however, is how many therapists openly expressed in articles their shock of how much sicker society as a whole was than they realized, after Trump.

Because remember, they're only seeing those that seek help, and the sickest people out there never will ;)

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