Psychiatry's Mirror II - The Myth of the Mental Health System

There are issues with the system worth addressing, both in its structure and execution.

In order for a psychiatrist to do their job properly & effectively, they have to be intelligent. Their entire job is essentially one big guessing game. How accurate that guess is is entirely based on the intelligence of the doctor. Unlike the somatic (more accurate term for physical in this context)^[1] health field where there are numerous physical instruments and pieces of technology used to evaluate patients in relation to symptoms, the mental health field only has subjective analysis. Nobody has ever been objectively diagnosed with a mental health disorder. It is not possible. The way things are structured, the only source of information a psychiatrist has to evaluate a patient is whatever comes out of the patient’s mouth. That’s it. It is then on the psychiatrist to accurately interpret the information, perceive the patient as holistically as possible, and piece it all together to build a profile of the patient and then compare that to the list of diagnosis. This means the quality of healthcare a patient receives is significantly reliant on the doctor’s intelligence, more specifically their ability to accurately perceive, interpret and piece together.

There isn’t anything wrong with this conceptually. The issue is when this concept meets reality, because being a psychiatrist or doctor in general is not an inherent display of intelligence. If something is not inherent, it is not guaranteed. In order for a job position to be an inherent display of intelligence, the greatest inherent risk of losing it has to be the decline or absence of said intelligence. If you’re in a position where you will be discarded without question if your intelligence is lacking, then simply being in that position would be an inherent display of it. I could look at you and confidently know there is no way you would still be here if you didn’t have what it takes.

Engineers are a great example. Knowledge is the necessary baseline but intelligence is what even makes the role of an engineer mean anything. They’re remarkable. Their entire job is to problem solve with the information they have and piece things together accurately and effectively. They have to answer questions that haven’t been already. You may know as much as an engineer, but it means nothing if you can’t think like one. Just as importantly, if an engineer can’t meet the standards of intelligence needed by the people signing their checks, they’ll more than likely be out of a job. All of this together means that if someone is currently an engineer, you’d be right to view it as an inherent display of intelligence. The job is not only intellectually demanding but the person themselves runs a real risk of job loss if they can’t keep up. Both of these elements need to be present for you to be able to look an entire group of people as an inherent display of intelligence.

Obviously a large part of a doctor’s job is problem solving too. That’s the whole reason you go to see one in the first place. However the way these two professions problem solve is quite different. Both doctors and engineers have a baseline of required knowledge in order to do their jobs effectively. They both have to run tests to see what information can be extracted from them. But the final piece of the puzzle is one that an engineer has to come up with on their own. It doesn’t exist yet. The whole point of their job is to create one. This requires intelligence. The final piece to a doctor’s puzzle already exists. Now getting to that piece could still easily be a display of intelligence, like cheese in a maze, but only if the doctor in question no longer has the blueprint on what to do.

Generally speaking when you go to see a doctor for something they primarily run tests, read the data, and navigate based on their education as to where that data should lead them next. If all a particular doctor does is run the tests they were taught to run, read the data they were taught to read, and go in the direction they were taught to go in based on that data, there is no critical thinking involved.

If a doctor is presented with alleged symptoms that don’t align with the data generated, and they just throw their hands up and go “shit I don’t know”—which is very common by the way—there is absolutely zero intelligence being displayed. They were presented with a problem their education and experience did not have a direct answer for and gave up. Do you think an engineer can do the same thing every single time without getting fired?

Now alternatively, if a doctor is in a position where they no longer know what exactly is going on and they are dedicated to solving their patient’s problem, the only option left is to think critically. There is no longer a blueprint, a true or false checklist, to guide them every step of the way. That doctor has to use the information given by the patient, their own history as a physician, their background education, information that can be guessed or inferred despite not being directly given, and their intellect, in order to solve the problem. If at any point a doctor does this successfully, that is a display of intelligence.

If a doctor happens to be intelligent, then this was already true before they ever went to med school. It would still be true even if they weren’t in that job position. Whether or not a doctor is intelligent is defined by the individual themselves, not their profession.

The perception of doctors is similar to the one of teachers, in the sense that on the surface it seems like what you know determines how good of a teacher you are, when it’s actually your ability to communicate new ideas effectively. In this case, yes, the teacher is very educated and informed. This doesn’t change the fact that they can still be bad at their job. Intelligence plays a role in the quality of service they provide since the greatest teachers can adapt their methods of communicating those ideas based on the person they’re teaching it to. Even though you technically could just learn how to do that through education, an ability like that is still heavily reliant on intelligence. Imagine a scenario where a teacher is able to figure out how to pivot aspects of their teaching based on the attributes of the thing that the student isn’t grasping. The teacher would already know what the underlying disconnect likely is between the student and the concept, and is now able to bridge it. That’s a skill no one can really teach you, for you to be able to execute it so effectively.

So even in the most literal version of what we’re talking about, which is someone whose entire job is reliant on them knowing more than you, the quality of service is still largely influenced by that person’s intelligence. The only thing that is inherent to a teacher is what they know, not their ability to teach. It sounds backwards, but that is our reality. Sure, if a teacher is abysmal at their job in which students are seemingly always failing then they might get the boot. But be realistic, a bad teacher usually doesn’t mean grades across the board that are so horrific they see punishment. Nor are grades themselves even an inherent indication of the teacher’s ability to teach or the student’s ability to understand the material. That would only be true with an intelligent teacher and well crafted curriculum.

An argument could be made that it at least required intelligence to graduate med school. There’s a lot that could be said but none of it matters as much as this; it is impossible for any system of schooling to verify the intelligence of the student unless it presents the student with a problem they’ve never been given the answer to. The problem has to be intellectually demanding by nature, with an answer that no amount of mental textbook flipping could provide. The answer has to be something that the student themselves has to create. I highly doubt med school is doing this.

The only thing it truly has to do is verify that you know the information. Cause theoretically if you know the information, you should be more than capable at doing your job effectively. Quite honestly, med school wouldn’t be wrong for that either. It’s not responsible for how you conduct yourself or handle patients. No traditional academic schooling is. Their only job is to educate. They can’t police what you do or how you think. Not to mention, even if you were the most intelligent person on Earth you still wouldn’t be able to do much as a doctor without the necessary knowledge. If I’m wrong about any of this then the physicians that are currently active aren’t doing a great job at setting an example that proves otherwise. Also, if you’re not punished for a lack of intelligence within the job itself, why would you be punished for a lack of intelligence during the process to acquire said job?

Medical school is undoubtedly a lot of work, energy and commitment. For a lot of people it’s also a lot of sacrifice. Intelligence not being a requirement doesn’t take away from any of these things. Why do we have a culture that allows the amount of effort something took to be undermined by the level of intelligence needed to achieve it to begin with?

In order for the mental health system to run the way it should and with any hope at real credibility, it needs a rigorous vetting process to make sure the psychiatrist in question doesn’t just know the information but also actually possesses what it takes to accurately judge a patient and treat them accordingly. There are a near infinite number of ways that a symptom can be expressed as well as a near infinite number of contexts in which that symptom can exist in, which doesn’t even acknowledge the vast range of symptom intensity. It is a vital skill to accurately judge which expressions mean what and where they land on that spectrum. It’s like the grown up version of shape sorting, except the psychiatrist has to figure out which shape it is they’re currently dealing with.

Again, the whole thing is a guessing game, and the thing itself that psychiatrists are tasked with guessing is very abstract. Nobody having ever been objectively diagnosed with a mental health disorder is reflective of the fact that there has never ever been an objective mental health disorder in the first place.

The psyche is the subject of the mental health system. No psyche, no system. The way in which a system builds upon its subject has to align properly with the subject itself, otherwise it will fail. The psyche is abstract, which means anything related to it is also abstract by default. It is not tangible and has never been tangible. You cannot objectively measure anything about it. For a field with the authority to decide globally what objectively is and isn’t wrong about another human being, that is a big fucking deal. If you can’t objectively measure something, you can’t present anything related to those measurements as objective either.

Picture a cop pulling someone over for the suspicion that they’re drunk. They talk to the driver and they even look and sound drunk. There’d be nothing wrong about the cop assuming or believing that this person is most likely drunk. However it would be a problem for that driver to get arrested, charged & convicted with a DUI off that alone. That’s why we have the breathalyzer. It is some form of objective evidence that the driver’s blood alcohol level was above the legal limit. Not to mention, there are people who can either mask their drunkenness well or simply don’t display it as overtly as others. Meaning someone over the legal limit could get away with it if all we had was the cop’s subjective opinion. There are also many things that could mimic drunken behavior that have nothing to do with alcohol, meaning someone could get wrongfully convicted if all we had was the cop’s subjective opinion.

A diagnosis is a “professionally” acknowledged grouping of symptoms that occur simultaneously or sequentially, consistently. A symptom is a “professionally” acknowledged deviation from the baseline of what is “normal” or “healthy”. The baseline itself is inherently a declaration of how a human being is objectively supposed to be. In order for a baseline to be created, there has to be accurate enough measurements to determine it. Measurements are the centerpiece—the foundation to everything diagnostic. In order for there to be measurements, there has to be a measuring process.

The integrity of a diagnosis can only be as strong as the integrity of its symptoms. The integrity of a symptom can only be as strong as the integrity of the baseline that symptom deviates from. The integrity of a baseline can only be as strong as the integrity of the measurements used to determine it. The integrity of the measurements can only be as strong as the integrity of the measuring process itself. Think of this chain like a Matryoshka (or Russian) doll. The largest doll gives life to the next one, and so on. This means if the largest doll has red lipstick, the other dolls will have red lipstick. If the largest doll is smiling, the other dolls will be smiling. If the largest doll is lacking integrity, the other dolls will lack integrity. In this context, the measuring process is the largest doll.

In order for it to reach the level of integrity we should be holding it to, it needs to be objective. Interpretation, opinion, or debate cannot be present at any point during the process. This ensures that the measurements the process generates are not only accurate but also irrefutable. However people decide to interpret this data afterwards is irrelevant. What matters is that the data itself was not created using any human input.

The instruments and technology used during this process also need to be reliable. They need an exceptionally high percentage of accuracy in measuring what they measure, as well as an exceptionally high percentage of reliability that it will produce the same quality of results across subsequent uses. Meaning if you were to run the same tests on the same subject repeatedly, the data generated will more or less be the same.

Lastly, the process itself needs to be doable by practically anybody. Meaning if you used the exact same tools from the original process, you should be able to generate the near exact same measurements. With human input being irrelevant, it doesn’t matter whose generating it. More importantly, if you’re going to dictate what objectively is and isn’t wrong about other human beings, then the data you use to determine this should be reproducible and verifiable by damn near anybody. If something is factual, then everybody should be able to prove it.

In the field of somatic health, you can see the best of these three. Modern instruments & technology allow us to measure various things about the human body with immense accuracy, and these tools are reliable enough at reproducing the same quality of data. At no point during this process is human input present. It only shows up after the data has already been generated, which does not reflect the integrity of the data itself. If you yourself had access to whatever tools were used during that process, you could also verify that it is legitimate, objective and irrefutable. These tools include things like MRIs, CT scans, pulse oximeters, weight scales, X-Rays, electrocardiograms, thermometers, optical coherence tomography, and ultrasound imaging. In the psychiatric field, you see none of this.

Everything in the Diagnostic and Statistical Manual of Mental Disorders (or DSM) is subjective. There are people who have the authority to decide what is too abnormal to go untreated, based on opinion. Homosexuality was a sociopathic personality disturbance in the DSM from 1952 to 1987.^[2] Sensitivity towards the subject aside, there is no explanation for its addition or removal that’s rooted in anything objective. If you tried to make a case, either the addition or removal will make you contradict yourself. If the DSM is strictly what is abnormal thinking or behavior, and nothing else, then there was no valid reason for its removal. If the DSM is strictly thinking and behavior that needs to be treated, then explain what kind of objective process justified its addition in the first place and allowed it to remain for 35 years. And if you think that was a long time ago—it wasn’t.

The way this system determines the validity of an alleged symptom highlights this problem further. It relies on there being a threshold that has to be reached. All healthcare systems do this. It’s very similar to the baseline concept. If a patient’s symptom deviates too far from the baseline, and reaches the established threshold for that symptom, it will now be recognized as such. This can only be done accurately through measurements. If humans are supposed to have 1,000 white blood cells, and the threshold is a deviation of 300 or more, and you have 650, you are now recognized as having a symptom. There is nothing to argue about. There is nothing to interpret. Most importantly, context does not change the validity of a raw symptom. Context can change if a symptom is valid in relation to a specific diagnosis, but context cannot change the validity of a symptom on its own merit. So while context might mean that your white blood cell deficiency is no longer a symptom of Diagnosis 1, it will not change the fact that you are experiencing a white blood cell deficiency. It would still be recognized as a symptom in somatic healthcare.

In psychiatry you don’t have that kind of integrity. At every single layer there is not only subjectivity but a vast range of variables. At layer 1 you have the established threshold itself, which not only was created through subjectivity but is also open for interpretation—which is a highly unpredictable variable. Then at layer 2 you have both the doctor’s interpretation of the threshold and how much they choose to respect it. This is another highly unpredictable variable. Then at layer 3 you have the doctor’s interpretation of what the patient is describing, which will then be evaluated against the threshold that doctor abides by. Bias, ego, respect and intelligence all play major roles in this interpretation, and none of these things are vetted before someone becomes a doctor. All of these are highly unpredictable variables that now all interact with and influence each other which amplifies the issue. This is precisely why a person could see several psychiatrists and receive both a wide range of conclusions and conflicting information. This already tends to be a problem in somatic health; how could it not be exponentially worse in mental health when it has no real guardrails?

Now just because something is abstract doesn’t mean there’s nothing of value than can come from it. In an ideal mental health system, things would still be abstract anyway. You can’t change that. But you have a system that likes to operate under the guise of objectivity which is fully incongruent to the entire thing it revolves around. It postures itself as if it has objective answers. It never has and never will. Even in an ideal system where it’s highly effective at helping patients and adapting to their needs, it still couldn’t advertise itself as having objective treatment. Especially not in the same way the somatic health field can.

The ceiling on psychiatry’s reliability is inherently always going to be lower than that of somatic health, and that’s even in the best case scenario. As it currently exists, there is nowhere near enough integrity and way too many uncontrolled variables for anyone to even suggest that this system is structurally sound. And even if the system was operating in a way and at the level it should be, it still wouldn’t be for everybody. You can’t say the same for the somatic healthcare system. It provides the objective treatment options for whatever health condition you may have. The effectiveness of said treatment could be confidently and objectively measured. This system should’ve only ever been advertised as an option, not the option. This system should’ve never been seen in the same light as our somatic healthcare either, and if that was the case then maybe it would’ve put some effort in actually earning any respect.

It’s terrible that the vast majority of people simply view this system to be the sibling of the one they’re actually familiar with. They don’t judge this one on its own merit. They allow it to piggyback off the perception of something else. Detaching the two systems in your head is important. If the thing each system is completely revolved around—the psyche and the human body—are completely different things in every single aspect, then why would it make sense for one to try and mimic the other?

The mental health system clearly needs an overhaul and my vision for what it should be has a new perspective at the very center of it. The one it currently possesses is flawed. It sees mental illness as simply something you’re born with, but I suspect it’s much more a natural response to the world around us. If you recognize the psyche as a much more individual experience rather than a collective one, with a baseline that is nearly nonexistent, you start to see the picture a bit differently. When you stop believing in our current model for diagnosis and rather prioritize the less abstract—the symptoms—you start to see the picture a bit differently. When you process the fact that a human mind is taking in every last atom of information around it, and processing it in its own unique way, under its own unique circumstances, you start to see the picture a bit differently. When you view the psyche as the brain expressing itself, especially as a means to interact with the world around it, you start to see the picture a bit differently. Then eventually, your perspective has changed.

The way I see it, there are 2 sets of variables. The first set is the brain itself. It’s made up of an unknown number of variables, none of which can be measured. To better understand this, there are 8 billion brains out in the world. That is a massive spectrum. Even if the differences between one brain and the next in line on that spectrum are very minuscule, it doesn’t change that each mind attached to every brain is unique. Like fingerprints. I truly don’t believe there are 2 minds that are exactly the same, even if they effectively are. This means that not everyone is going to have the same response to the world around them and the reality they live in. Some brains are going to be more impacted by certain things than other brains. Some brains are going to experience more friction with certain things than other brains. Some brains are going to be more compatible with the modern world and society we live in than other brains. The combinations and possibilities here are endless, and that is just one of the two sets of variables.

The second set of variables are the circumstances that brain is born into and living under. When I say circumstances, I mean quite literally every single detail about one’s reality. The psyche is vast and everything affects it. Absolutely everything. The human mind takes in every last atom of information around it. As much as it can comprehend. This means that every single detail about your reality will affect your psyche. How much those details affect it will vary. Many, if not most, are minuscule, but no matter what, all those details add up across the span of one’s life. Which is already major, but then those effects interact with each other to amplify existing ones and create new effects that also interact with existing ones. If this sounds so large and intricate that it sounds like a chaotic mess, that’s because it is. Both sets of variables are so large on their own that even if we could measure them we still couldn’t comprehend the scale.

In order for you to understand the second set of variables, you need to truly think about how many variables exist in this context. “Everything” sounds too vague to trigger any real thought, but think about it. Think about as many things as you can possibly think of that the brain can have compatibility with and against, or maybe more simply, how many things the brain can have an opinion on. No matter how mundane or irrelevant they may seem, each and every one of those things is another variable.

Mental illness more than anything sounds like what happens when two sets of variables don’t just have compatibility issues with each other, but are also actively clashing with one another. It’s what happens when a brain leaning more heavily on one side of the spectrum, perhaps the more “vulnerable” side, is forced to live and grow under circumstances it should’ve never been paired with. The fact that it was is comparable to putting two animals in a cage that should’ve never been within 50 miles of each other. Considering the relationship between the brain and the world around it, the brain is basically at the mercy of the world it lives in. Should the dice roll go against the favor of the brain in question, the circumstances it’s forced to live under will cause its vulnerabilities & incompatibility issues to flare up—constantly, consistently, all the time, for years. This is absolutely terrible for that brain’s long term development, as well as its more immediate health.

If you need a visual, there’s something called brownian motion.^[3] When molecules are submerged in liquid at low temperatures, they don’t move much.^[3] At high temperatures, they move at very high speeds, bouncing around and colliding with each other.^[4] The type of liquid also affects how the molecules move.^[5] So imagine that the first set of variables are the molecules, the second set of variables are the liquid those molecules are submerged in, and they are both inside a glass container, which is the psyche. Imagine that every time the molecules hit the glass, they cause damage to it. But of course, the slower they move the less damage they cause. If they move slow enough, nothing will happen on impact. Now imagine that the higher the compatibility between a set of molecules and the liquid they’re in, the less heat their interaction generates. At peak compatibility, the entire bottle may as well be frozen.

With all that laid out, you can visualize both ends of a spectrum. On one end, you have a set of molecules submerged in liquid they have a very high compatibility with. This means almost no heat is being generated, so the molecules move around very slowly, and the glass that contains the both of them never suffers any damage. It’s quite peaceful isn’t it? Not much is going on.

Now visualize the other end of the spectrum, where there is no compatibility. Worse than that, the molecule and liquid type are two things that should never be near each other. This means an extreme amount of heat is being generated, so the molecules bounce around unpredictably and uncontrollably at very high speeds; slamming into both each other and the glass; constantly, consistently, nonstop, until either the liquid is changed or the glass shatters. Now put those two visuals side by side. That is both ends of the spectrum. One where a person is “normal” and the other where a person is severely mentally ill. And don’t forget, that first set of variables (or molecules) are all their own individual thing. Each and every last one of them has their own compatibility with the liquid they’re submerged in, as well as individual compatibility with each other.

When you look at it this way you will start to see the problem with the system’s perspective, the one that alleges you are simply born that way. It only acknowledges one set of variables. If the system was right, that would mean no matter what, two people with very similar brains should exhibit symptoms throughout their life regardless of what happens to them. Sure, the system is aware that circumstances can exacerbate the intensity of symptoms or potentially create new problems, but not only is the acknowledged scope of those circumstances significantly smaller, none of this changes the marketing that if you are mentally ill you will still be showing symptoms one way or another.

However… imagine two people with very similar brains. One of them was born into and raised in ideal circumstances so their vulnerabilities never flared up. Their second set of variables paired very favorably with their first, minimizing friction. Which means to everybody else they are not “mentally ill”. If they went to see a psychiatrist they wouldn’t be deemed as ill either. They wouldn’t reach the threshold. Their brain was favorably paired with circumstances it naturally has a very high compatibility with, and if the psyche is the brain expressing itself, then that person’s psyche is a natural reflection of this relationship.

Now take the other person in this example. Very similar brain, but they weren’t born into or raised in ideal circumstances at all, causing their vulnerabilities to flare up constantly during their development. Their second set of variables paired horribly and aggressively with their first, causing intense amounts of friction between the two. Which means to everybody else they are mentally ill. If they went to see a high quality psychiatrist, they’d be deemed ill as well. They’d have no issue reaching the threshold. The relationship between the two sets of variables is abysmal, with the brain spending the overwhelming majority of its existence being forced to engage with circumstances it has zero compatibility with. Circumstances it is also essentially being attacked by. If the psyche is the brain expressing itself, then that person’s psyche is a natural reflection of this relationship. That is the whole point of this perspective. Someone’s psyche is a natural reflection of the relationship between their brain and the world around it. Instead of removing accountability from those circumstances, they’re fully acknowledged instead.

With the perspective established, the rest of the overhaul can begin. Starting with the system’s attitude. No more labeling people “treatment resistant” because half baked methods didn’t work on them. Instead of having a one shoe fits all, take it or leave it mentality, it would understand that there are too many variables responsible for one’s psyche to operate like that. It would aim to progress patients rather than “treating” them; doing what it can to give patients the guidance and power to change their circumstances as much as possible. It would aim to restore patient trust towards the system. It would aim to make patients feel confident about the help they’re receiving and more confident than ever about their lives & future. It would view the whole point of what it does to be alleviating psychological distress amongst patients. It would view the entire act of service it provides as a collaborative effort between patient and doctor. It would recognize that it’s still in its infancy and will have to continue working with patients intimately to improve the quality of its care. It would strive for as much cohesion as possible. It would also take itself less seriously, or rather, not allow itself to be so rigid. The system has no business being that way. If it acknowledged the nature of what it’s dealing with it would understand that it needs a fluid nature to match it.

The next change is psychiatry. Kill the concept of mental illness altogether. It’s impossible to create one with a lick of objectivity, the perspective needed to even think of creating one is inherently flawed, the current structure is too reductive as is, and it’s also simply just not needed. Symptoms however are much “realer”, as they’re what a patient actually experiences. They much more directly reflect a patient’s psychological distress. Still abstract of course, but at least the root of it is much realer. So instead of an illness, patients would be “diagnosed” with a symptom group based on relevance, such as Mood Symptoms, Thought Processing Symptoms, Social Symptoms, Psychosis Symptoms, and so on.

Each symptom group would also have multiple types, should it be necessary. Subjective measurements as what should be specified as a type would simply be based on patterns of patient expression and behavior. If patients tend to express a certain combination of symptoms in tandem with one another, or it’s very observable that certain behaviors tend to coexist, and that combination of symptoms is treatable as its own group, then that would be a subclass of symptom grouping. So for example, you could be diagnosed with Type A Mood Symptoms, or Type B Psychosis Symptoms. Of course, you could also get diagnosed with multiple types of the same symptom group.

By design this structure is much more fluid and much more in line with the nature of the psyche, as these classifications are supposed to coexist simultaneously (if applicable). Mental health disorders tend to see a lot of overlap anyway, to the point of an accurate diagnosis for many patients being legitimately impossible. This would eliminate that problem almost entirely. Patients would also receive a much more intimate and accurate reflection of their psyche, due to the perfect balance between broadness and specificity. For example, the core of bipolar disorder would be split down into Type B Psychosis Symptoms and Type C Mood Symptoms, and the patient could receive a more specific and accurate conclusion of symptoms relative to who they actually are. Breaking down illnesses into more specific groupings of symptoms also allows a stronger emphasis on the actual treatment, with the mindset that treatment is the end goal and a diagnosis is simply a means of providing it securely to a patient. Most importantly, it should be understood that the one and only reason we even have these symptom groupings is to be able to provide effective treatment. There would be an official acknowledgment that they’re not objective, and simply just names used to help track and treat.

This also means that the DSM is no more. Instead there’d be the Reference Book for Symptoms of Psychological Distress (or RBS). “Reference Book” is more reflective of the emphasis on treatment over diagnosis, compared to “Diagnostic Manual”. “Symptoms” instead of “Mental Disorders” respects the impossibility of an objective disorder in the first place and reflects the better diagnostic system. “Psychological Distress” is quite simply what it is that this entire system deals with. It’s also extremely respectful towards the two sets of variables and their potential to cause issues due to their relationship, and it’s also a term that shows sincerity towards patients due to shifting the implications of what’s going on with them (which is a separate topic entirely). So this all means that the full official title for a “diagnosis” would be, for example, Type A Psychosis Symptoms of Psychological Distress. The much more colloquial term would simply be “Type A Psychosis”.

If this seems complicated in any way, it’s really not. This is more or less just breaking down disorders into more digestible pieces. No matter what we name a grouping of symptoms it doesn’t change the treatment options we have and their effectiveness towards different issues either. If anything it can allow those treatment options to be more effective by having a more specific list of groupings that it’s effective towards.

As for how some current disorders would be effectively treated if they’re being split down, it doesn’t really take much to introduce the concept of symptom pairing. If what’s referred to today as bipolar disorder was broken down into Type B Psychosis & Type C Mood then it can simply be an acknowledged pairing within the system. Theoretically you could still have informal names for pairings anyway, meaning “bipolar” technically doesn’t have to completely die out. It would simply be the “slang” term for when someone has both Type B Psychosis & Type C Mood.

As for how this would affect people currently diagnosed with mental illnesses, it would mostly be positive. Killing the concept of mental illness entirely would push people to naturally view themselves more holistically and not limit themselves to the confines of a single label, especially when the naming convention is as stripped down as possible. They’d understand better that they live with something, not under it. Labels aren’t all bad though, since they do allow people with similar minds and similar experiences to connect with each other, support each other, and understand themselves better. One label can effectively communicate so much between two people that don’t even know each other.

I mentioned broadness before and that’s because in this context, if people were to connect based on symptom grouping, you’d actually see a wider range of people able to contribute. Many members of different disorders tend to have more in common with their experiences than they’d think. By having a less reductive labeling structure you could get a much more potent sense of community. Mania for example, there’s a few conditions that share it like bipolar and schizoaffective.^[6][7] By collapsing them down people would only have one label in which mania is relevant instead of being arbitrarily divided further, which allows for a stronger community. There is nothing to be lost by breaking down those walls.

Having a more blended together spectrum of official mental health labels would also help regarding stigma and how people approach these things. For the “normal” population, these labels would end up having such a wide range that people will naturally have a more open minded approach and perspective of these labels. By how much, who knows. But if there’s a grand merging of groups into one label, the experiences and intensity would become much more visibly varied. And that’s if people could even keep up. The naming convention of these groupings wouldn’t be as easily identifiable for anyone that isn’t involved with the system in some meaningful way. This could effectively make it something that only those with psychological distress would readily understand, while for everyone else it’s too confusing to even know what to stigmatize.

In addition to illness, this overhaul would kill off psychiatry as its own practice too. Psychologists are already a thing. Just grant them the ability to prescribe medication. Considering how many psychiatrists just do whatever they feel like and toss pills in patients’ faces till one “works”, let’s not act like it’s some sort of specialty that requires its own profession entirely.^[8] Even conceptually it doesn’t. Medication should be seen as a treatment option, rather than the only thing that can alleviate symptoms. Especially considering how many people aren’t compatible with the current offerings of medication. Having an entire branch of care dedicated to promoting the opposite and posturing itself as the only acceptable form of it completely disrespects this.

Instead of medication being seen as a primary form of treatment it would be seen as temporary relief, with some exceptions being made when it is seemingly the only form of effective treatment. It would be understood that medication doesn’t actually do anything to address what’s causing the psychological distress, it simply lowers or eliminates the effects of it. Hence why it would be seen as “temporary”. The goal wouldn’t be to keep a patient hooked on meds forever, it’d actually be to progress the patient to a point where medication isn’t even desired anymore for the benefits.

Everyone has a certain about of bandwidth, meaning how much bullshit they can handle simultaneously. I think people would be amazed at how much better they could handle life and their symptoms on their own if they had less things taking up that bandwidth. If many patients are at about 90% or higher of their maximum bandwidth due to circumstance, it would seem impossible to get better without drugs or “professional” assistance in general. If psychology did what it’s supposed to patients could see a meaningful reduction in how much bandwidth is taken up. Meaning the patient has a lot more energy towards managing aspects of their symptoms on their own. Not to mention, the less bandwidth, the less variables to interact with. I think there’s many people on medication who don’t actually need it forever. Or at least not as much.

As for the structure of psychology, it would be much more respectful of the patient’s agency by giving them significantly more power in how they’d like the course of their treatment to go. Brand new patients of a doctor would always be informed at the very beginning about what their options are, the relevance and effectiveness of those options, the power the patient has, and how the course of treatment should make them feel. It would also disclose that the system isn’t for everyone, and that the doctor themselves may not be the perfect match. Patients deserve full disclosure about the service they’re paying for. There’s no good reason not to give it to them.

As for the psychologists themselves they would have an intimate understanding of all the treatment options, and instead of assigning treatment strictly based on symptom group, the psychologist would gain an intimate understanding of the patient and then intelligently decide which treatment options sound like they’d be the most beneficial to them. The psychiatric approach in comparison is heavily centered around diagnosis which is the wrong way to go. This new approach would see diagnosis as nothing more than a means to unlock certain treatment options for a patient. Patients wouldn’t even be formally diagnosed with anything unless they had to be. The psychologist would simply inform the patient that they are seemingly apart of a certain symptom group otherwise. The prioritization of personalized treatment over diagnosis would see significant benefit amongst patients and actually encourage psychologists to gain an intimate understanding of their patients instead of throwing them into a box.

Considering the agency patients would have in how they’d like the service they’re paying for to go, there’d be a pretty nice range in how the course of treatment could play out. If the patient expresses needing help with their distress for specific reasons, the psychologist would try to help the patient in relation to those reasons and adapt their methods.

If the patient expresses that they’d rather give up majority control to the doctor, then the doctor would intelligently create a treatment plan for the patient that they think would be the most effective. They go over it with the patient, the patient addresses any concerns, and if all is good, they go through with it. The patient would let the doctor decide what is and isn’t working based on their judgement, with minimal input from the patient themselves.

If the patient expresses they’d like a more collaborative effort, then the patient would give input on how they’d like to be treated after being informed of the options. Both parties would give input throughout the course of treatment. If the patient expresses that they don’t feel something is working, or they wish something about it was different, the doctor would give their input and try to adjust the treatment plan accordingly. The doctor would of course also inform the patient of their professional opinion, which the patient will also use to decide how they’d like things to change. Across the entire spectrum of approaches, patient concerns are always respected and addressed.

Considering how large the spectrum of issues they’d be dealing with is, there’d likely be different specialty types of psychologist. To be clear, all of them would be able to conduct their job effectively a base level. It’s just that they would have a primary area they’ve dedicated themselves to treating most effectively. Ideally it would be set up in a way where you most likely only need one specialist regardless of how many symptom groups you’ve been diagnosed with. With enough time it’d likely be clear what the priority of specialist should be for a person apart of multiple symptom groups. So for example, if you have Mood Symptoms and Social Symptoms, you could prioritize a Social Specialist Psychologist. The way they help treat your social symptoms could potentially see a subsequent alleviation to a varying extent of your mood symptoms. Or of course you could get an expert opinion from a psychologist as to which specialist type would likely provide the most relief.

This would coincide with a much better cohesion within the system itself. As it currently is, the entire system feels like it doesn’t even communicate with itself. You’ll hear something from one “professional” that isn’t even acknowledged by another, with the consistency in quality being non existent. It’s a terrible feeling. The system by design and by attitude would strive for the highest level of cohesion to make sure that a patient is not only accurately guided throughout the system but that different parts of the system itself are also synergizing like they should to provide the patient the smoothest and most effective experience. This means no more invalidating another doctor’s diagnosis of a patient and demanding a reevaluation in order to take the patient seriously. This means making sure the design of each part of the system is created with the other parts of the system in mind, with constant refinements along the way to make sure that when one part of the system wants to snap in place with another, it’s doable. It should be to a point where it feels like the system is simply a massive spectrum that is lightly divided into separate pieces.

Therapy would provide emotional progression while psychology would provide mental progression. And obviously considering that relief of one thing can provide relief for another, this means that together, with good design, they could naturally sygnerize to progress a patient much better than had that patient gone through either one individually. The severity of one’s symptoms could dramatically reduce with this pairing. There would also be a way of writing patient’s files that easily allows them to be sent to & interpreted by other mental health professionals. This means that progress made in psychology could easily be interpreted by that person’s new therapist, and vise versa. This would also coincide with the less rigid design of the system, which makes it so that professionals across the spectrum are more than familiar with things involving parts of the system they’re not even involved in.

Both psychology and therapy would be giving patients the tools to handle their circumstances better but also giving them the tools to change them. It feels like the system only cares to make the patient change themselves when there is still an entire reality around them that is capable of being changed. It also feels like it tries to force people into the mold of what’s “normal”, rather than giving them the tools to better their life specifically. It would be extremely powerful for a patient to basically modify both sets of variables instead of just one. Significant amounts of growth and progression would be seen. Both fields would work to empower the patient in an authentic way that allows those changes to be possible.

In addition to the static information the system would have regarding the psyche, it would also have a lot of dynamic information regarding much more social and contemporary issues. Things like cultural differences, economic background, religious background, being a first generation American, the current state of the world, the political landscape, etc. These are all real things that greatly affect people.

Our current system, is it equipped to help a young black adult with the unique issues they face growing up in a black community with a black family? Or even just this country? How about a young asian one? A young latino one? Considering how many minorities deal with issues directly related to their cultural & racial background, this is a massive oversight by the system. It should deeply understand how people from different backgrounds normally get treated under common conditions. Is this system even equipped to help patients that come from more impoverished communities and the effects that can come from living there? Is it even aware of those effects?

As society changes, as culture changes, as the world changes, the system should be changing too. It should always have a part of itself that is constantly adapting as a direct response to the world we live in. It should be doing what it can to gain an intimate understanding of those changes. They’re all variables. Variables that need to be accounted for. The system wouldn’t be able to catch every little change but it simply shouldn’t be clueless enough to have nothing to offer about the big ones either.

Considering that adolescent issues would be a different range than adult issues, it seems worth it to create a whole new type of therapist that specializes in dealing with youth, from ages 14-19. They’d also be trained in helping patients smoothly transition to the rest of the system once their relationship with a patient is ready to come to a close. Legally they could not have a patient above age 19. These professionals would simply be called “Adolescent Therapists” (or ATs).

To help protect the teenagers, guidelines will be read out loud to them at the beginning of the first session as to what counts as inappropriate relations and interactions between them and the therapist. They will have to sign a document acknowledging these guidelines were read out loud to them and they understand them fully. This will help to establish boundaries and make sure that the teen is fully aware of what their therapist shouldn’t be doing or saying to them, as well as what the teen themselves shouldn’t be doing or saying. These guidelines have to be reread and resigned once every year starting from the first session date.

As the for the structure of adolescent therapy, it would have 2 main priorities that separate it from regular therapy. The first is that it would have an intimate understanding of contemporary adolescent issues, with the second being that it provides teenagers a sense of genuine safety and agency.

Majority of the time both inside and outside the system, teenagers are dismissed when they try expressing their issues for no other reason than the fact that they’re seen as children, which means their lives are less serious, less meaningful, and less respectable by default. Often times things get strictly reduced to “teen angst”. And then for some reason everyone gets surprised when they end up doing something they weren’t supposed to.

Even in general, adolescents are often stripped of any agency or autonomy no matter what’s going on. That shit is fucking annoying. I don’t think people realize how important it is emotionally to have someone who genuinely respects your voice as a human being at that age. Having the system provide this would do a lot of good for their development, especially in understanding respect better. Respect for themselves and from other people. It would help them know what it looks like when someone is truly listening.

Teenagers would also be able tell their adolescent therapist anything in confidence, without it being reported. In general across the entire system, a patient cannot receive legal or psychiatric punishment for anything said while receiving treatment. The fact that this isn’t true single handedly tanks people’s trust in the system and their willingness to be honest.

Despite the school system not necessarily being apart of the mental health system, the way it responds to mental issues still needs to be addressed. It is absolutely terrible. If your guidance counselor or school in general gets a whiff of you wanting to harm yourself they go ahead and call your parents about it. What kind of dumb shit is that? I understand that in an ideal world you would call that kid’s parents and they would get everything sorted out properly, peacefully and lovingly. The kid would be receiving the help they need once the school reports the incident. But in an ideal world, a kid wouldn’t feel like killing themselves in the first place.

Notifying a kid’s parents is extremely irresponsible. Not only are parents typically one of the biggest reasons a kid would even be in that position, you also have no idea what their home life is like. You are setting kids up. Especially those that are first generation Americans. You think immigrant parents understand any of this shit? You really think their initial reaction to hearing their ungrateful child wants to die is to switch up their behavior and take the kid out for some damn ice cream? Are y’all stupid? And then you have the kid taken out of school to be evaluated which costs money? Out of nowhere this kid now has their entire spot blown and their personal state of mind as the center piece of several people’s attention. Do any of you think about things before you do them?

How about ask the kid if they would rather their parents not be notified. Which is exactly what this overhaul would do. Regardless of their answer, have a paper full of resources you can hand them so they know what their options are. Primarily how to find an adolescent therapist and schedule with them.

As for psych wards in this overhaul there’s not much to say. The concept is fine but the execution is awful. Any needed changes are either ones that have naturally already been resolved by this point in the overhaul or are solely tied to how much staff decide to treat their patients like actual people. The only thing I could really say is patients cannot be involuntarily held for more than a day for suicide attempts. There would not be a soul capable of being held involuntarily past 7 days for any reason.

Aside from making it so that insurance companies can’t exploit patients, I don’t think there’s anything left in this system redesign. When it comes down to it the patient will always be at the mercy of the doctor they end up seeing. I realistically don’t see any way to truly make sure that any doctor that’s out of line gets booted. A change like that is a change that every healthcare system in this country would have to make, as well as one that would require a huge societal shift in attitude towards malpractice.

When taking into account everything this chapter has discussed it can make you wonder what the motives of the system are. It postures itself as caring about the patient and operating from a sincere place, but its structure has never reflected that. Its behavior has never reflected that. And there are people who were once apart of the system that would tell you the same thing, like Daniel Mackler, who was a therapist for 10 years with a wide range of experience; spending six and a half of those years as a private practice.^[9] He loved his job and was passionate about it. Claims he even “gave his heart and soul to it”. And yet he ended up quitting.^[9] In 2018 he explained why, in a video titled “Why I Quit Being a Therapist”.^[9]

He begins by going into how he personally finds the diagnostic system ridiculous, counterproductive, and harmful, overall stating that it isn’t really based on anything scientific.^[9] Then he discusses his feelings on medication. In his own words he says:

“Another thing [that I find ridiculous] is this whole thing about medication, psychiatric drugs. We’re supposed to push people, therapists are supposed to push people into taking psychiatric drugs. If you have this problem you’re supposed to take this drug, this problem you’re supposed to take this drug, oh you have sleep problems! you can take this drug, and, oh you have this kind of mood problem or this kind of mood problem well you’re supposed to take t h i s drug or THIS drug and if you have a side effect of -this- drug you’re supposed to take this drug and it, it becomes really ridiculous. Especially when you consider how unhelpful and downright dangerous so many of these drugs are and how difficult it is to get off these drugs.” ^[9]

– Daniel Mackler, 2018

He explains that as a psychotherapist he was specifically trained to help people to get on these drugs by “up-talking” these medications.^[9] He even compares it to tactics that waiters use to get you to buy alcohol at restaurants.^[9] As a therapist, his education trained him to refer patients to a psychiatrist or medical doctor whenever they were having an issue considered “outside the bounds” of what therapy was able to help said patient with.^[9] This is part of why there are a large number of therapists that will redirect their patients to psychiatrists for basically any problem.^[9] He also mentions that having a patient kill themselves can bring upon the greatest risk of punishment for a therapist, so a therapist is supposed to use force to stop that from happening.^[9] Daniel however never felt like he had to dial 911 or hospitalize anyone in his own career, despite having many intense and suicidal patients.^[9] He was even known as the guy that could deal with the more “fucked up” and complex patients which prompted his colleagues to send him their fucked up patients for him to deal with instead.^[9]

As a man that actually got into the system for the right reasons, Daniel actually listened to his patients and paid attention to how many of them expressed medication wasn’t helping them at all.^[9] Unfortunately, therapists are actually discouraged from getting patients off medication.^[9]

Daniel then goes on to explain a story he had about going back and forth with an insurance company trying to be greedy, which also wouldn’t be the first or only time something like that has happened:

“… someone who had been hospitalized multiple times. I was working with this person 2, I think 3 times a week, and the person had stayed out of the hospital for about 6 months which was the longest in their adult life they’d ever stayed out of a hospital. Well I got a call from their insurance company… ‘You’re not authorized to see this person 2 to 3 times a week, that’s considered completely unacceptable! We’ll only authorize once a week.’ And I was like ‘Yea, but, it’s actually considering how much it costs to go into the hospital for this person.’ It was like $1,000 a night to go into the hospital, and this person was going into the hospital all the time using it basically as a sort of therapeutic help even though it wasn’t helpful.

Now how much was I getting paid? For a 45 minute session I think I was getting paid $37 a session? $38? So basically, one night in the hospital was the equivalent of about… 28 psychotherapy sessions with me? And so I was only seeing the person 2-3 times a week. Now the insurance company didn’t agree with that. They said ‘Wellllll no we can’t pay for that’ and then [finally]—I kept arguing, I said ‘You gotta do it! Come on this is actually helping this person’ and they said ‘Well, what’s your treatment plan?’ Now I know the mental health field LOVES confidentiality except when it comes to insurance companies who don’t want any confidentiality at all. They want to totally intrude into the therapy and they want to know everything that’s going on so for people who already have some sort of fears and paranoia about people knowing what their business is, it’s not very comforting to know that the insurance companies can dig right in and basically legally before they pay get all the information.

So the insurance company asked me ‘Well what’s their treatment plan?’ I said ‘Well their treatment plans’ actually very simple. Keep them out of the hospital’ and they said ‘Well that’s not a sufficient treatment plan!’ I was like ‘Well how about the treatment plan is doing all the things that hospitalization should’ve done but didn’t do because it wasn’t effective?’

Funny thing is the insurance company after about 2 months of arguing (and I think not even paying for some sessions) finally agreed to give 2-3 times a week therapy to help this person stay out of the hospital because they realized, actually, they were saving tens and tens and tens of thousands of dollars just by helping this person come to therapy and actually get better help to stay out of the hospital. Because what did this person really need? The person needed somebody to talk to! It wasn’t like genius. I think actually the irony of so much of psychotherapy is made into this mysterious world of ‘Wow the therapists are- what they do is such brilliant stuff and there’s so much insight involved’ Well actually, I think a lot of people can do exactly what psychotherapists do and do it much much better if they just have a gift for being able to have a comfortable caring respectful conversation with another person. And lots of people can do this.”^[9]

– Daniel Mackler, 2018

Later on in the video he makes a point that those who need help from the system the most are able to afford it the least, and explains how therapists are able to weed out the people that will pay less whether out of pocket or through insurance, and “weed in” those that can pay more.^[9] Daniel felt that by design, he as a therapist was put under immense pressure to make money and to “run his business”.^[9]

He also detailed friction with his own colleagues, stating that he couldn’t even be honest with them about his work because the more honest he was the less supportive they were.^[9] He felt isolated, and when he would express that feeling, his own colleagues would start to treat him the same way they would their patients.^[9] This all leads to him mentioning that people who started out as promising therapists actually become worse therapists after going through the training for it.^[9]

Mackler goes into much more detail about his experience as a therapist specifically during this 30 minute runtime, and I encourage everyone to watch it for themselves. For this chapter, I only went over the relevant portions as they pertain to it. While I haven’t seen any other videos from him, he seems to be doing great work on his channel with content that would likely be of much use to anyone that feels they’d need it.

When you remember that somebody has to pay for everything you see within the system, you remember who, or what, is really responsible for its operation. Would it be in their best interest for my version of the system to exist? It seems pretty convenient to have a system in place that keeps people in line that aren’t doing well because of the environment & quality of life you’re directly responsible for and making them believe they’re the weird ones for having so much friction with it. Does it not? Run things the way you want to for your own benefit and then have an entire system dedicated to promoting the idea that there is only ever something wrong with the people who are most negatively impacted by your way of operation.

There’s a book by French psychoanalyst Pierre-Félix Guattari & French philosopher Gilles Louis René Deleuze titled Anti-Oedipus: Schizophrenia & Capitalism.^[10] Published in 1972, the book explores (as you can imagine) the relationship between schizophrenia & capitalism.^[10] I learned about it from watching Elena’s video titled A rant about being certifiably insane.

Originally I was going to read it and include it at length in this chapter but I don’t care for books so the shit would’ve taken forever. I still think it’s worth mentioning though so you’re all aware of its existence. When I get around to it I’ll share my thoughts on it, but for now I’ll let Elena explain the book herself with both an excerpt she pulled and her own interpretation of the book as a whole:

“‘We’ve seen that the relationship of schizophrenia to capitalism went far beyond problems of modes of living, environment, ideology, etc, and that it should be examined at the deepest level of one and the same economy, one and the same production process. Our society produces schizos the same way it produces Prell shampoo or Ford cars, the only difference is that schizos are not salable. How then does one explain the fact that capitalist production is constantly arresting the schizophrenic process and transforming the subject of the process into a confined clinical entity? Why does it make the schizophrenic into a sick person? Not only nominally but in reality? Why does it (capitalism) confine its mad men & mad women instead of seeing in them its own heroes & heroines? Its own fulfillment? And where it can no longer recognize the figure of a simple illness? Why does it keep its artists and even its scientists under such close surveillance? As though they risk unleashing flows that would be dangerous for capitalist production and charged with a revolutionary potential, so long as those flows are not co-opted or absorbed by the laws of the market? Why does it form, in turn, a gigantic machine for social repression?’”^[10][11]

(speaker) – Elena, 2022
(source) – Anti-Oedipus: Schizophrenia & Capitalism, 1972

And now for her summary:

“Think of the term schizophrenia as a reference to anyone who is mentally ill with symptoms that cannot be hidden or that the experiencer of doesn’t feel the need to hide. Now think about how many artists and scientists exhibit eccentric behavior, thoughts & ideas. Think about how ‘thinking outside of the box’ has been the reason for revolutions for scientific innovation, for some of the greatest artistic expressions known to man; and capitalism takes our art, our ideas, our thoughts and deepest journeys, repackages them, and then sells them to the population. They are co-opted and absorbed by the laws of the market just as they say in that quote. They take that which has soul and make it soulless, then sell it to the masses as something to be gawked at, something quirky, different, weird, something worth observing but not understanding.”^[11]

– Elena, 2022

The next chapter:

Borderline Personality Disorder

Somatic Definition by Cambridge Dictionary
Working with LGBTQ Patients by American Psychiatric Association
Brownian motion by Britannica
Brownian Motion by BYJU’S
International Encyclopedia of Education by Penelope Peterson, Eva Baker and Barry McGaw – 2010
Bipolar Disorder by Mayo Clinic
Schizoaffective Disorder by Mayo Clinic
Psychiatry’s Mirror by Blessings Stranded – December 13, 2024
Why I Quit Being a Therapist — Six Reasons by Daniel Mackler by Daniel Mackler – January 4, 2018
Anti-Oedipus: Capitalism and Schizophrenia by Pierre-Félix Guattari & Gilles Louis René Deleuze – 1972
A rant about being certifiably insane by M Elena – November 13, 2022

The Myth of the Mental Health System

w r I t t e N b Y b L e S s I n g S s t r A N d e d

Psychiatry’s Mirror II

Borderline Personality Disorder