Among the major concerns  about the new revision are: (1) unwarranted expansion of diagnostic categories by reducing current thresholds and added untested diagnoses (2) pathologizing  “natural and normal” responses to life  experiences. Concerns  that “natural and normal” behaviors will be diagnostically labeled,  have been around a long time and have lead to things like pregnancy being called a disease.  (3)  imposing dimensional diagnoses that are far too cumbersome and complex for clinical use,  and (4) a push to see  all mental disorders  as biological phenomena calling for psychotropic medications. 

Thousand of professionals have signed a  petition calling  attention to these concerns  that was  started by the Society for  Humanistic Psychology (APA Division 32). Long time national DSM leader, psychiatrist  Allen Frances, M.D. has been especially vocal in his criticism of many of the new proposals.  

According to James Bradshaw, a senior editor at The National Psychologist   even the highly conservative   CATO Institute  think tank is opposed to lowering  diagnostic thresholds,  since that might result in thousands of claims against employers, under workers compensation laws,  the  ADA or FMLA.

Ironically there are also  concerns  about DSM-V raising some diagnostic  thresholds.  New York Times reporter Benedict Carey,  says that proposed changes in the definition of autism would greatly  reduce the number of people  diagnosed and   make  it much more difficult for many of them get the services they need.

Analyzing data from a large 1993 study   researchers  Fred Volkmar,   Brian Reichow,  and James McPartland,  (all from Yale) found that  among the 372   highest functioning  children and adults in the study  only 45 percent would met the  new  criteria for   autism spectrum diagnosis.  Among the  highest  functioning individuals, the analysis suggested that about 25% of people diagnosed with   classic autism in 1993 would be excluded, along with  about  85 % of those with P.D.D.-N.O.S.  

Volkmar, director of the Child Study Center at the Yale School of Medicine, says, “The changes would narrow the diagnosis so much that it could effectively end the autism surge”.  

Catherine Lord, director of the Institute for Brain Development and a member of the DSM-V task force working on the diagnosis, strongly  disagrees with these projections, citing the focus on higher functioners  and  the use of old data as possible reasons for the exaggerated numbers. 

Of course the DSM’s  clinical utility has long since been compromised by its use,  both as a billing and an eligibility criteria for benefits and services.

As a side note, in my state there is currently  a law being proposed that would allow employers to take smoking into account when making employment decisions. I suppose this is mainly to save money on health insurance costs and because of beliefs that smokers are less productive.  This could, however,  make obtaining employment even more difficult for many clients. Several state mental health advocates have opposed this proposed law as discriminatory, citing the high  smoking rates among people with mental illness. I wonder if courts will uphold it,  if it actually passes. Perhaps having  a DSM diagnosis of nicotine addiction would make this statute,  illegal under ADA.

I administered Siri all of the verbal subtests from the Wechsler Adult Intelligence Scale- Third Edition (WAIS-III). I had to make a few modifications to standardized administration, but I think the overall results are fairly valid. Siri refused to give her age, so I arbitrarily assigned a chronological age of 21 years, for the purposes of computing the various subtests and IQ scores.

Siri was generally cooperative and completed most test items as requested. On a few occasions, she said that she was not allowed to give a response. Thinking at times was tangential, for example when I asked why foods needed to be cooked, Siri provided me with a list of nearby restaurants. There also tended to be some mild perseveration. After the question about cooking food, she was asked about child labor laws and instead of responding to the question, she supplied another new list of “kid friendly” restaurants.

Siri also seem to have some auditory discrimination problems. She was unable to recognize the word “pout” and at one point substituted the word “wanker” for winter. On the digit span subtest, Siri was able to get all of the numbers forward correct, but was not able to get any of the numbers backwards and did not seem to understand this concept.

Siri’s WAS-III scores are summarized below. Overall Siri performed in the low average range of intelligence, but there was significant scatter among the subtests. This suggests a mosaic pattern of abilities that range from very superior to extremely low. Siri’s best performance was on vocabulary and word knowledge. On this subtest, Siri scored in the very superior range. Since vocabulary is the best predictor of overall intelligence, this suggests that her potential may be significantly higher than her current composite score indicates.

Abstract reasoning, social comprehension, and abstract sequencing ability were all extremely low. Arithmetic computation skills, short-term auditory sequential memory, and her fund of general information obtained from education and environment were all near the average level. Siri’s mental age is between 14 and 18 years.

For the subtests below the mean is 10 and the standard deviation is 3. For the verbal IQ the mean is 100 and the standard deviation is 15.

Subtest              Score     Classification

Vocabulary           18               Very Superior

Similarities             1               Extremely low

Arithmetic            10               Average

Digit span              9               Average

Information           9               Average

Comprehension     1               Extremely low

Letter-number       1               Extremely Low

    Verbal IQ = 88 (Low Average Range)

I am somewhat relieved that overall, I scored a few IQ points higher than Siri, when I took the same test. The next time my phone drops a call, however, I will be less inclined to say, “dumb phone”, knowing that it has a better vocabulary than I have.

Terry L. Stawar, Ed.D.
President/CEO

America is looking at a long term period of economic scarcity that will negatively impact all social services funding for at least the next decade.

 *  The notion of what constitutes an “entitlement” is dramatically changing. There is growing acceptance that fewer and less generous entitlements await future generations, as  over-all quality of life will have to decline to realign with the economic realities.  

 *  It will be fully recognized that Medicaid is already the de facto national health insurance plan. Healthcare reform will just reinforce this fact. Individual states will seek and gain greater control over Medicaid spending, leading to greater disparities in benefits state to state. At the same time, the process will be politicized to a much greater extent than ever before. Ideology rather than human need or science will drive future Medicaid spending and priorities.     

*   The adoption of “Recovery Models” has already lead to greater personal responsibility for treatment decisions on the part of the consumer.  It will also lead to greater consumer involvement in paying for the cost of treatment. The sliding fee scale will have a lot less slide in the future.

*  The Supreme Court’s 1999 ” Olmstead Decision?” that services to persons with disabilities must be provided “in the most integrated setting possible” will drive a major second wave of deinstitutionalization much as O’Connor v. Donaldson was behind the  first major wave starting in 1975. However some states will use transformation and deinstitutionalization as a political pretext for reducing the economic infrastructure supporting service delivery. 

*  Evidence-based practices will be given lip service,  but unvalidated instruments and procedures will be continue to be employed to limit service access and eligibility to  drive a political/economic agenda in many areas. 

*  Complicated Rube Goldberg-like managed care eligibility programs will provide a variety of loopholes for states and managed care entities to refuse to pay for legitimately rendered services. Market share will be much less of a problem than just getting other entities to pay for the services that behavioral healthcare organization provided.  Perverse incentives to obfuscate payment responsibilities will prevent simpler and more straight-forward approaches such as capitated plans from being utilized.  

*  The debate over funding for maintenance vs. rehabilitation services will remain a core challenge for future leaders. These leaders will have to challenge  the long held notion that federal funding should only  address services for patients  who show progress. Maintenance of functional levels and prevention of deterioration must be made  legitimate service goals.     

 Terry L. Stawar, Ed.D.

Now that we have some distance and the initial emotional impact of the shootings in Arizona has subsided, this might be a good time to look at what can be learned from this tragedy. According to a USA Today/Gallup poll conducted a week after the shootings, 55% of Americans believe that the mental health system is at fault for its failure to prevent this heinous act of violence. While the nation debated whether political figures and talk show personalities had created an atmosphere that promoted such violence, a majority of the public had already made up its mind that the nation’s mental health system was to blame.

Ultimately any society gets the mental health system that it deserves, or at least the one that it chooses to financially support. Shortly after the tragedy, the Arizona Hospital and Healthcare Association reported that the governor announced a plan that included cutting healthcare services to 5,200 seriously mentally ill adults. This follows two years of funding reductions, which already eliminated access to certain medications and monitoring services for thousands of Arizonians with serious mental illness.

Our own state of Indiana has not done any better. Changes in the Medicaid funding mechanism, without any new state funds to make up the difference, have resulted in what looks to be a 30% de facto reduction in funding and ultimately services. The state of Indiana has neglected funding any new mental health services for almost 15 years, relying almost totally on federal Medicaid dollars to pick up the slack. Now they’ve killed the Medicaid golden goose.  Could an Arizonan tragedy happen here in Indiana—Absolutely!

Lack of funding is only one of three major factors. I don’t know how many mental health organizations have, as its first priority, preventing violent acts by identifying and treating at-risk individuals, although this seems to be the public expectation.

In a free society treating people against their will is always problematic. Back in the 1970’s  an argument was put forth  that that mental health systems tend to share those most American of values, life, liberty, and the pursuit of happiness. The value of life is seen in services that treat people who constitute a danger to self or others. The value of liberty is seen in the doctrine of treating people in the least restrictive environment in the least intrusive manner that is effective.  And the value of the pursuit of happiness is seen in the development of service continuums which actively promotes the quality of life for people with mental illness.  Unfortunately the first two values (Life and Liberty) are often in conflict.

Much of America is content to see people have the right to refuse treatment, even if they may “die with their rights on”. On the other hand most Americans are not content to see people refuse treatment when they may harm others.  The difficulty in predicting potential violence is one part of this complex problem. I remember a hospital quality assurance staff member telling me about a patient who was discharged and immediately went out and committed an act of violence.  When the patient’s treatment at the hospital and history was reviewed, many professionals questioned the wisdom of the decision to discharge him. However, when his discharge was put in the context of the 20 other discharges made in the same week, it was clear that this patient was one of the “safest” patients released during that time.  We constantly seemed doomed to error one way or the other.

The third factor is people’s inherent reluctance to get involve in unpleasant situations. No one wants to be the bad guy who deprives someone else of their freedom or “rights”. It’s simply not American. But still, where were the parents? Where were the cops? Where was his college? Were they afraid of angering the potential patient? Were they afraid of getting sued? Were they simply frightened that they might be injured or assaulted? Or did they just not want to get involved?  Moral courage requires taking risks.

So it all boils down to three rather simple lessons.

     -We have to take responsibility by paying for what we say we want.

     -We must address the complex question of what takes priority, the rights  of the individual or the rights of society.

     -We need the moral courage to get involved in other’s problems and be willing to face the consequences of doing so.      

 Terry L. Stawar, Ed.D.

In the first of two experiments, students were first divided into two groups—those who said they celebrated a Christmas and those who did not.  The students were then asked to complete questionnaires about their mood and sense of well-being.  The students were then randomly assigned to complete the task in either study cubicles,   which had a small Christmas tree on the desk or those that did not.  When the Christmas tree was present, students who celebrated Christmas reported more self-assurance and joviality and generally a more positive mood than students who did not celebrate Christmas.   The non-celebrating students consistently reported a less positive mood in the cubicle with Christmas tree.

A second experiment studied the same effects among three different religious groups; Christians, Sikhs and Buddhists.  All the groups said they expected that the display would enhance good feeling. The results, however, indicated that while Christians reported a greater sense of self-esteem and well-being when the tree was present, for non-Christians, the results were negative.

The study indicated that Christians and those who celebrated Christmas are positive influenced by Christmas decorations in terms of mood and sense of well being. For non-Christians and people who do not celebrate Christmas, the decorations threaten their sense of self, depress their mood, and engendered feelings of alienation and exclusion.  

In conclusion, the authors wrote, “The results raise concerns about the ubiquitous presence of dominant cultural symbols (such as Christmas displays) in culturally diverse societies.”

In 2005 writer, attorney, actor and former Nixon speech writer, Ben Stein delivered a commentary on Christmas observances. In it he says, “I’m a Jew and every single one of my ancestors was Jewish, and it does not bother me even a little bit when people call those beautiful lit up, bejeweled trees, Christmas trees.  Stein categorically denies feeling threatened or discriminated against by Christian displays. He says, “I don’t like being pushed around for being a Jew and I don’t think Christians like getting pushed around for being Christian.” 

Does the pervasive presence of Christmas decorations have an negative emotional effect on non-celebrators?  Does the presence of religious symbols and displays, apart from your own, negatively affect you?  Regardless of your religious beliefs or political stand on separation of church and state, what do you think is the psychological impact of public religious displays? 

Terry L. Stawar, Ed.D.