Personal diagnostics in a new MHS

Beyond the DSM-5!

original title
Persoonlijk diagnostiek in een nieuwe GGZ
De DSM-5 voorbij!

Jim van Os

book review by
Mira de Vries

Jim van Os considers himself and is considered by others in the Netherlands to be a critical psychiatrist. Just what is his criticism? This review is translated and adapted from the Dutch-language review posted earlier on the MeTZelf blog.

Some books have a subtitle. This one has a super-title. Original!

In the first section of three Van Os sketches what is wrong with the DSM. Criticism of the DSM has been amply published in the English language since the eighties when that book adopted the authoritative form that it still has. You can find many reviews of books that criticize the DSM on this site. Van Os’s criticism is not original, which is evidenced among other ways by his not penning two consecutive sentences without snobby English terms. He doesn’t bother to provide a list of definitions for the Dutch language reader.

In the second section Van Os groans about the bureaucracy to which his profession is subjected. There's hardly any snobby English in this part. He claims “Working in the MHS has practically become a form of voluntary slavery,” and  “Autonomy and own responsibility have to be sacrificed because the government and health care insurers prefer to work with a quantitative system based on coercion.” Poppycock. Nobody is forcing Van Os to work as a psychiatrist in the MHS. If he doesn’t fancy the requirements of his profession, he can do something else.

In the third and last section Van Os sketches what he thinks psychiatry should look like. Among other things he proposes shuffling the diagnostic categories and criteria. It remains unclear how his system would overcome his own objection to the current order  -- “We don’t well know where psychiatric complaints come from nor how we should influence them.” His proposals are no more legitimate than the way it is now. For example, he often mentions psychoses without any explanation what they are or how they can be objectively identified, let alone ruled out. Similarly, he differentiates between light and serious psychoses but nowhere does he clarify how these can be distinguished from each other.

He also wants multiple institutions to be involved in care instead of all services having to be taken from one institution. He doesn’t seem aware that clients are already ping-ponged around among different care providers, diffusing the care providers' responsibility. Nowhere does he discuss keeping costs down. He reviles “market forces” as though there really were a free MHS market. Apparently he expects the taxpayer to give him a blank check.

Van Os’s biggest blunder, however, is not mentioning the foundation on which psychiatry stands: deprivation of liberty. It doesn’t matter one iota that the DSM categories aren’t legitimate because such a sham diagnosis is only necessary to circumvent human rights when detaining people who are considered troublesome by somebody.

In psychiatry, acknowledging deprivation of liberty is taboo. Van Os dutifully keeps to this. Even though he casts doubt on whether the diagnoses in the DSM are real diseases, he writes about “patients” and “people in psychic distress” as though people only submit themselves to psychiatry of their own accord. Yet he betrays himself by occasionally referring to solitary confinement cells (which are standard in Dutch psychiatry) and (involuntary) medication. He objects to neither. He only posits that (involuntary) medication should be discontinued after a while, as though that were possible. Successfully stopping psychiatric drugs is about as common as successfully sewing back a wrongly amputated organ.

How many people in the Netherlands are involuntarily committed is unknown. Nobody is counting, or if somebody is, the number is being kept secret. Statistics wouldn’t show a reliable picture anyway. People often remain in psychiatry their entire lives “voluntarily” after an involuntary commitment that deprived them of their home, job, family life, management of their own finances, social networks, physical health, and mental clarity. That’s like breaking the wings and legs of a bird, opening the cage door, and concluding that the animal is remaining in the cage of its own free choice.

In addition, psychiatry is inflicted on all sorts of people who are incapable of resisting, from preschoolers through disabled people to the elderly. It is also made a condition for accessing services such as assisted living.

It is true that the MHS offers a limited amount of  “psychotherapy” but that only pulls the wool over people’s eyes. Without a sham diagnosis there can be no psychotherapy – MHS workers are not volunteers and have to be able to bill the system for their services. Once such a sham diagnosis is registered in the medical file any opposition can be stifled by threatening involuntary commitment. Van Os doesn’t mention any of this.

Towards the end of the book, Van Os comments that “...many patients, previously seriously disabled, tell you that they recovered on the basis of for instance a diet, vitamins, a guru’s lifestyle insights, breathing exercises, a commune based on eastern philosophy ... it is possible that people experienced important improvement [thanks to quackery] ... because there they found a style of bedside manner and encouragement for self-management that is missing in the mainstream MHS.” His intended criticism of the way people in the MHS are treated lacks logic. The people to whom he refers cannot have been “seriously disabled” or they would not have been capable of locating an alternative healer. Whatever their real or perceived ailment was, the success of the quacks, as Voltaire is purported to have said, is “the art of keeping the patient amused while nature heals his illness.” Quacks achieve that without deprivation of liberty or dangerous drugs because they lack the legal power to so afflict their clients. Nowhere in the book does Van Os suggest removing his own and his colleagues' legal powers of detention and prescription.

Obviously Voltaire's proposed entertainment will not do for everybody. People with real disabilities need practical support. The most expensive, least effective, and most dehumanizing way to offer it is through the MHS.

Instead of falsely portraying himself as a victim and the MHS as a “free market” Van Os could better have pointed out that without psychiatric coercion, pharmaceutical backing, and a socialist payment system (also in the US) the DSM would have remained a thin, obscure booklet.

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