Sakyong Mipham Rinpoche on Becoming a Buddhist
Many people these days are reading books about Buddhism, practicing Buddhist meditation, and applying Buddhist principles in their work and personal lives.
If you are one of those who is interested in the dharma, you may come to a point where you want to decide whether you really are a Buddhist or whether you are not.
The formal decision to become a Buddhist is marked by the refuge ceremony, in which you take refuge in what are known as the three jewels: the Buddha, the dharma, and the sangha (the community of Buddhist practitioners). Some people who take the refuge vow wonder afterwards if they made the right choice, so it’s important to consider seriously whether becoming a Buddhist is what you want to do with your life. Taking refuge is not a temporary situation. Once you take the refuge vow, it’s supposed to last forever.
Taking refuge is about how we are going to lead our lives. We take refuge because we have looked everywhere for a place we could be content, where we could reduce our anxiety. But when we looked at our world, we realized that there is no place for us to find harmony, or to understand the nature of things.
We take refuge in the Buddha because we are taking the same journey as he did. The Buddha lived in a palace and had good food and drink. If there had been movies then, he would have watched them all. He did everything there was to do, yet he realized that something was still not quite right. So like the Buddha, we ask, “Where is our life taking us?” and, like the Buddha, we look inside to understand the mind.
When we take refuge in the Buddha, we take the Buddha as an example. The Buddha is not a god—this is not a theistic situation where Buddha is better and we are worse, or he is the boss and we are the servants. In fact, Buddha is us. We are Buddha, but we have not yet realized our full buddhahood.
The Buddha realized that there is really no self. When he looked at the self, that self we hang on to so tightly, he realized that it does not really exist. From a greater point of view, he not only saw beyond personal ego, he also overcame the notion of external phenomena altogether. The Buddha realized the egolessness of both self and other. He actually overcame the whole world of duality—samsara and nirvana, existence and non-existence, eternalism and nihilism.
So we look at the Buddha with respect and appreciation for showing us how to live our life. When we take refuge in the Buddha, we take shelter from confusion, chaos and suffering. We are overcoming our discursiveness and our conflicting emotions. It is very personal. Nobody else can identify that thought for you; nobody else can deal with that emotion for you. You have to work it out for yourself.
When we talk about taking refuge in the Buddha, we mean the qualities of the Buddha that are inherent within us. The Buddha possesses wisdom, compassion and power: wisdom so we know what we are doing, compassion so we have a soft heart and care about others, and power so we can continue the journey. We call that buddhanature. We are taking refuge in our intrinsic enlightenment.
This leads us to the dharma, which is the second aspect of taking refuge. What’s important is not so much who the Buddha was but what he expressed—the truth, the dharma. The Buddha’s message that there is no self was “a fearless proclamation of the truth.”
When we begin to meditate, we discover that we’re always thinking about things such as who we know, where we’ve come from, what we’re going to do. We realize that our idea of who we are is all in relationship to other. We have created this individual identity in relationship to other.
So at a certain point, when our mind begins to relax and our thoughts begin to disappear, we may become a bit frightened. Our sense of boundary begins to dissolve. There is no one to talk to. There is no one there. We realize we’re just holding on to an idea of who we are; we are holding on to a conceptualization. In fact, everything we engage in is conceptualization. The process of meditation helps us realize the truth of the dharma. So can we be that fearless? Can we look at what is there—or what is not there?
When we take refuge in the dharma, we are not following some prescribed path. We really have to look inside our own mind, and the dharma helps us to do that. Truth is constant, so the dharma provides some stability in our life. The dharma acts as our protection; it protects our mind and it protects our heart.
Finally, we take refuge in the sangha, the people who are on the path with us. Those who are in the sangha are warriors, because they are trying to overcome samsara. Members of the sangha support one another and care for one another. They are not perfect, but they inspire us because they are people who want to deepen their practice of mindfulness, awareness and compassion. The sangha is also a container. When we practice together, the sangha helps our discipline. We realize that there are other people around who are going through the same thing. That gives us a feeling of encouragement.
We are talking about taking a special path. But this path has been traveled by great practitioners before us, and it is now up to us to travel it. We must understand this is completely possible; there is no reason at all that we cannot travel this path. Yes, we all have our own individual situations or karma—some of us tend to be a little bit more lazy, some of us tend to be more uptight. We all have various tendencies. But the truth remains the same. It is unchanging within us.
That is the beauty of the dharma: it is completely available. We don’t need any particular credentials in order to understand it. On the other hand, we do need to hear, meditate and contemplate. We do need to understand what we are doing. We do need to correct our misunderstandings.
Taking refuge does not mean that we take Buddha’s words as the unquestioned truth. We must question the words of the Buddha. We need to ask, “Is this real? Does this actually work? Does it make sense?” The Buddha didn’t say, “I am going to save you.” He said, “You have the ability to make your situation better. You have all the capabilities. It is up to you.” Ultimately, that is the truth in which we are taking refuge.
Sakyong Mipham Rinpoche is holder of the Buddhist and Shambhala lineages of his father, the late Chögyam Trungpa Rinpoche. In 1995 he was recognized as the incarnation of the great nineteenth-century Buddhist teacher Mipham Rinpoche.
You’ll find Sakyong Mipham’s “The Myth of Permanence” in our new November ‘09 issue.
Saturday, September 26, 2009
Shambhala Sun - Sakyong Mipham Rinpoche on Becoming a Buddhist
Dharma Quote of the Week - Gratitude
HEALING WITH FORM,
ENERGY AND LIGHT:
The Five Elements in Tibetan
Shamanism, Tantra and Dzogchen
by Tenzin Wangyal Rinpoche
edited by Mark Dahlby
more...Dharma Quote of the Week
As practitioners, we are taught to think about the gift of the precious human body. We have been born in places where the dharma is taught, at a time when teachers are accessible and where transmission is obtainable. We live where there is the political freedom to follow our spiritual paths. Our living conditions are good and we have the leisure to practice.
What we often lack is the recognition of the gifts we have already received. Sometimes we remember how good our lives are when we are brushed by tragedy, but then, caught up again in our normal lives, we forget. We are driven away from gratitude and appreciation by dark and negative forces, by habitual dissatisfaction and constant stimulation. When others have more than us, we feel envy, but in a world where so many people have less than us, we often don't recognize how fortunate we are.
The teachings often focus on view, meditation, and behavior. What this means is that the way we see determines how we feel and think. And how we feel and think determines how we act. When we look from a dualistic viewpoint, we see an imperfect world and we live as troubled, imperfect beings in that imperfect world. When we see the world in its perfection, just as it is, we are buddhas, living in a pure land, surrounded by other buddhas.
Until we have pure vision and realize the perfection of the world and the beings in it, it is helpful if we can accept the imperfections of the world as a natural part of life, as the material with which we can work. When we turn away from any aspect of the world, we turn away from parts of ourselves. By opening to the world and accepting it as it is, we open to deeper dimensions of our own being. Complete acceptance is the end of hope and fear, the end of fantasies of the past and future. It is living entirely in the present, in what actually is.
--from Healing with Form, Energy and Light: The Five Elements in Tibetan Shamanism, Tantra and Dzogchen by Tenzin Wangyal Rinpoche, edited by Mark Dahlby, published by Snow Lion Publications
Eight Laws of Social Change – Stephan A. Schwartz Ph.D.
Maybe if our politicians could apply these laws? Check out the podcast link, it's a nice discussion.Eight Laws of Social Change – Stephan A. Schwartz Ph.D.
Social Change requires wisdom, character, patience, and the willingness to forego any personal credit.
- Law – Individuals (individually) and the group (collectively) share a common intention.
- Law – Individuals and the group may have goals and cherish the potential outcomes.
- Law – Individuals in the group authentically accept that their goal may not be reached in their lifetimes.
- Law – Individuals in the group authentically accept that they may not get either credit or acknowledgment for what they have done.
- Law – Each person in the group regardless of gender, religion, race, or culture enjoys fundamental equality while the various roles in the hierarchy of the effort are respected.
- Law – Individuals in the group forswear violence in word, act or thought.
- Law – Individuals in the group make their personal lives consistent with their public postures.
- Law – Individuals (individually) and the group (collectively) always act from the beingness of integrity.
Source:
* Stephan A. Schwartz Ph.D., futurologist, THE POWER – The Eight Laws of Social Change, Powerpoint presentation
* Audio interview with Stephan A. Schwartz Ph.D., The Eight Laws of Social Change, presented by Blogtalkradio Paranormal Perceptions, host Dee Disparti, aired 17. January 2008Important social changes in USA were abolition, public education, penal reform, women’s suffrage, civil rights, nuclear freeze, environmental protection.
Friday, September 25, 2009
A Call for Workshops, Papers, and Posters for The Second Biennial Integral Theory Conference
C'mon, you know you want to share your wisdom with us.
A Call for Workshops, Papers, and Posters forIn late July 2010, John F. Kennedy University and Integral Institute will host the second biennial Integral Theory Conference, the world’s largest academic conference devoted to the field of integral theory and practice. The conference will take place at the JFK campus and Hilton Concord and provide a forum where scholars and practitioners in this burgeoning movement can gather for intellectual exchange, community building, and networking. We expect this year’s event to sell out again with over 500 people in attendance.
The Second Biennial Integral Theory Conference
The theme of this year’s conference is Enacting an Integral Future. Enaction refers to the individual and social practices we take up to interact with reality and which in fact bring reality into being through a participatory process of observer, mode of observation, and observed. The principle of enactment is foundational to the post-metaphysical commitments of integral theory. The theme will inform the opening night presentation as well as the keynote presentation by Dr. Robert Kegan – Harvard’s renowned developmental psychologist.
Although the theme of enaction need not be used as the theme for any workshop, individual, or poster presentation, we will be asking all accepted presenters to briefly address the modes through which they are “enacting” their work—that is, discussing what perspectives are the primary foundation for their presentation (for example, 1st-, 2nd -, or 3rd-person perspectives, or some combination of these). The intention will be to support the goal of knowledge integration and to help attendees contextualize what they hear. This need not be done in the language of the AQAL model, but in the way of each presenter’s choosing. More details will be given upon acceptance.
Information will be provided below detailing:
• Call for Pre-conference Workshops
• Call for Papers and Presentations
• Call for Poster Presentations
Please note: All accepted presenters—whether doing workshop, paper/presentation, or poster—will receive a discount on their registration fee. Details are given in the sections below.Call for WorkshopsWe are pleased to announce that the 2010 conference will include half-day and full-day pre-conference workshops on Thursday, July 29th. Participants will be required to signup and pay in advance. The submission deadline for workshop proposals is November 15th, 2009. Notification of acceptance or rejection will occur on January 15th, 2009. We anticipate having up to two full-day and four half-day workshops, depending on the number and quality of proposals.
Workshops may be academic, applied/practical, or experiential in focus. In general, any topic that is acceptable for papers and presentations (see below) is acceptable for workshops.
Please note: Individuals accepted for workshop presentations will have their entire tuition fee for the conference waived. They will also receive a complete set of the 2010 Conference recording (MP3s), a copy of the book Integral Theory in Action: Applied, Theoretical, and Critical Perspectives on the AQAL Model (SUNY, 2010) edited by Sean Esbjorn-Hargens, as well as an official conference t-shirt.
Workshop Proposal Submission Guidelines:
Please note: Because of the highly competitive nature of the process, we need some uniform way of comparing presentations. Submissions that do not conform to the following guidelines will be returned.
Proposals should be single spaced in Times font 12 and include:
• A 250-400 word abstract of your proposed workshop along with a title, institutional affiliation of the presenters (if any), and contact information. Include a brief justification for the workshop, including anticipated benefits to the Integral academic community.
• A two-page outline which details the organization of your workshop. Include the specific topics and subtopics you plan to cover as well as any experiential exercises and multimedia elements you plan to include.
• Please include up-to-date CVs for each member of the presentation team. If accepted, we will later ask for a biography (150 words) to place in the conference materials.
• Suggest a target audience and the maximum and minimum number of participants for the workshop.
Workshop proposals will be subject to a refereed review process. The deadline for workshop proposals will be November 15th, 2009. Please send to: Mark Forman, Ph.D. at mforman@jfku.edu. Please contact Dr. Forman if you have any questions.Call for Papers and Presentations
At this time, the conference will begin accepting presentation proposals. The submission deadline for proposals is November 15th, 2009. Notification of acceptance or rejection will occur on January 15th, 2009. We anticipate having 80 spaces for presentations, but well over that number of submissions; it will be a competitive process. Note last year we accepted 100 submissions but have decided to reduce the number in order to allow for more 90 minute presentations this year. Those presenters and presentation teams that are accepted will be required to submit 15-20 page doublespaced scholarly paper detailing their work by May 15th, 2010.
The length of the presentations at the conference will be either 60 minutes or 90 minutes. 60 minute presentations should include at least 15 minutes for questions and discussion, while 90 minute presentations should include at least 30 minutes for this purpose. The length of presentation offered will be given upon notification of acceptance. We expect presenters to strike a creative balance between 3rd-person didactical, 2nd-person dialogical, and 1st-person experiential components.
While it is expected that many presentations will reference the AQAL (“all-quadrant, all-level”) model associated with Ken Wilber, presentations which feature alternative perspectives and critiques of the AQAL model are strongly encouraged.
As with the first conference, John F. Kennedy University and Integral Institute are proud to co-sponsor eight $500 awards for Best Papers at the Integral Theory Conference.
• Four awards will be given for the best presentations and papers from each of the quadrant perspectives associated with integral theory.
• One award will be given for best overall theoretical contribution.
• One award will be given for best overall empirical or research contribution.
• One award will be given for best constructive criticism of integral theory.
• One award will be given for best alternative to integral theory.
Please note: All individuals who are accepted for papers/presentations will receive a $100 reduction on their tuition fee for the conference.
These Best Papers along with some other outstanding papers from the conference will be published in the Journal of Integral Theory and Practice and might appear in an anthology as part of the SUNY series in Integral Theory.
A list of the 2008 winners can be found on the conference website. These papers are being published in Integral Theory in Action (SUNY 2010) and will be available at the conference.
The presentations may address original work in the following areas:
Theory and Research Presentations
Theory and research presentations may either include discussions of specific research results, assessment tools, and areas of theoretical interest or more broadly address issues of methodological pluralism, or theoretical comparisons (e.g., Wilber as compared to Bhaskar). These presentations should use concrete examples of application when possible to illustrate their theoretical points.
Presentations on theory and research may focus on any of the following areas.
• Integral Research (e.g., study results, the development of specific measures, Integral Methodological Pluralism, mixed method designs, and validity).
• Alternative and Complementary Approaches to Integral Theory (e.g., Gebser, Aurobindo, and various recent voices such as Almaas, Bhaskar, Ritzer)
• Critical Views of Integral Theory (e.g., limits of current interpretations, missing components, and textual analysis of Wilber’s writings)
• Improvements to Integral Theory (e.g., further differentiations, clarifications, expanded analysis, recommendations, and new interpretations of AQAL)
Applied Presentations
Presentations that focus on specific applications of Integral Theory will receive greater consideration than broad overviews. For example, rather than presenting how quadrants, levels, lines, states, and types apply in general to sustainability, presentations that go into detail concerning the use of one or two aspects of Integral Theory and present case study material will be prioritized. Also, we value applications that highlight what did not work or illuminated areas of concern regarding a given integral approach.
Presentations on application may address any number of areas including the following areas:
• Individual Transformation (e.g., psychotherapy, coaching, Integral Life Practice)
• Community Wellbeing (e.g., medicine, healthcare, nursing, social work)
• Institutional Development (e.g., business, leadership, organizations, education)
• Global Dynamics (e.g., ecology, sustainability, politics, international development)
• Spirituality (e.g., pastoral care, consciousness, integral buddhism, spiritual direction)
• Aesthetic Expressions (e.g., art, creative writing, film analysis, movement)
• Gender Explorations (e.g., sexuality, embodiment, feminism)Presentation/Paper Submission GuidelinesPlease note: Because of the highly competitive nature of the process, we need some uniform way of comparing presentations. Submissions that do not conform to the following guidelines will be returned.
Proposals should be single spaced in Times font 12 and include:
• A 250-300 word abstract of your proposed presentation along with a title, institutional affiliation of the presenters (if any), and contact information.
• A two-page outline which details the organization of your presentation. Include the specific topics and subtopics you plan to cover as well as any experiential exercises and multimedia elements you plan to include.
• Please include a 150 word biography of each of the presenters. If accepted, we will later ask for a truncated biography (60-75 words) to place in the conference materials.
• A 15-20 page, double-spaced original (i.e., unpublished) scholarly paper to be submitted by May 15th, 2009. Please note: In rare cases we may accept a paper that has been accepted for publication or has recently been published. Failing to produce a paper will result in your presentation spot being given to a presenter on the waitlist with a scholarly paper.
Proposals will be subject to a refereed review process. The deadline for proposals will be November 15th, 2009. Please send proposals to: Mark Forman, Ph.D. at mforman@jfku.edu. Please contact Dr. Forman if you have any questions.Call for Posters
At this time, the conference will begin accepting proposals for poster presentations. We especially encourage current undergraduate and graduate students to consider submitting proposals for posters. The submission deadline for poster presentations is December 15th, 2009. Notification of acceptance or rejection will occur on February 15th, 2009. Please note: The deadline is later than the presentation deadline so as to give those who were not able to get a presentation slot a chance to submit a poster presentation.
Poster presentations involve creating a visual representation of your work on posterboard, usually involving some combination of an abstract, graphs, tables, figures/images, and schematics. Conference attendees will circulate through the space during the times you will be presenting, viewing the posters and collecting written information During the specified periods it would be good to have a 3 to 5 minute verbal presentation prepared to help introduce your ideas and topic to attendees. Presenters can also provide attendees copies of your paper or handouts that summarize your key points.
The conference is going to make a significant effort this year to highlight poster presentations, including setting them up in the lobby area of the Hilton Concord before and after the major gatherings on Friday and Saturday evening.
John F. Kennedy University and Integral Institute are also proud to co-sponsor two $250 awards for the best poster presentations at the Integral Theory Conference. As with the papers, while it is expected that many presentations will reference the AQAL (“all-quadrant, all-level”) model associated with Ken Wilber, posters which feature alternative perspectives and critiques of the AQAL model are strongly encouraged.
Please note: All individuals who are accepted for poster presentations will receive a $50 reduction on their tuition fee for the conference.
Poster Presentation Submission Guidelines
Please note: Because of the highly competitive nature of the process, we need some uniform way of comparing presentations. Submissions that do not conform to the following guidelines will be returned.
Proposals should be single spaced in Times font 12 and include:
• A 250-300 word abstract of your poster topic along with a title, institutional affiliation of the presenters (if any), and contact information.
• A one-page outline which details the organization of your presentation. Include the specific topics and subtopics you plan to cover as well as any multimedia elements you plan to include (i.e., such as a video run on VCR or laptop).
• Please include a 100 word biography of each of the presenters. If accepted, we will later ask for a truncated biography (60-75 words) to place in the conference materials.
Proposals will be subject to a refereed review process. The deadline for proposals will be December 15th, 2009. Please send proposals to: Mark Forman, Ph.D. at mforman@jfku.edu. Please contact Dr. Forman if you have any questions.
2010 Integral Theory Conference
Welcome to the 2010 Integral Theory Conference blog!
Posted: August 15th, 2009
We left the last conference feeling extremely positive about the state of the Integral academic community and the value
this type of gathering has for the emerging field of Integral Studies. We are extremely excited to be in active planning for the next event. Among the best of the early news for the 2010 conference is that Robert Kegan has agreed to keynote! We are truly looking forward to his participation.ofWe received a tremendous amount of positive feedback as well as constructive criticism from last year’s attendees. In our off year, we have compiled the feedback we received and have been thinking hard about how to improve the structure and experience for both participants and presenters. Some changes we are doing for this year include: preconference workshops, extending the length of many presentations so as to allow for more dialogue and interaction, and more “down time” in the schedule for social and community engagement. We are also planning to have a larger presence on the web and a fuller integration and use of technology--using this blog as well as twitter to keep you up-to-date with the workings of the conference. The next 11 months will be a time of intense planning and anticipation and we welcome your ideas and visions for the event.
Yours,
Sean Esbjörn-Hargens Ph.D. & Mark D. Forman Ph.D.
Conference Founders and Organizers
Mike LaTorra - Cyborg Buddha: Science and Spirit
Cyborg Buddha: Science and Spirit
Brain science reveals how meditative states of bliss and personal transformation can be achieved without religious baggage.Science and spirituality in Western civilization began to go their separate ways centuries ago, when astronomy, biology and other observational and experimental disciplines showed in no uncertain terms that the religious world-view inherited from the Bronze Age religions of the Middle East did not correspond to the world that could be measured. The Earth most definitely revolves around the Sun, and not the other way round.
Prayer, meditation, chanting, fasting, contemplation of sacred images and the ingestion of mind-altering substances have been prescribed for spiritual aspirants for millennia. What’s new is our present capacity to scientifically examine the physiological and neurological correlates of spiritual experiences. Until scientific studies had been conducted, spiritual states were often dismissed by much of the scientific community as being unhelpful to leading the good life as reason understood it. At best, prayer and meditation might have been allowable as some sort of coping mechanism for dealing with stress, fear and depression. So these practices were deemed to be something akin to autohypnosis or merely comforting self-delusion. They certainly could not produce physical changes or long-lasting psychological improvement. Or could they?
Today there is a growing volume of hard scientific evidence that contemplative practices produce measurable, benign changes in the brain as well as in subjectively reported moods and observed behaviors of practitioners. Meditation has been shown to lower blood pressure, increase the ability to focus attention, and make people feel happier. All this can be achieved with or without any supporting framework of justifying religious beliefs. Atheistic philosophers and scientists such as Sam Harris and Patricia Churchland practice meditation regularly.
Machines to measure brain activity as well as other physiological processes were crucial to proving the case that meditation has real value. The next step is to develop technology that can facilitate or even induce the states that meditation produces, but without the need for years of patient practice.
Can a machine deliver bliss? Can technology induce Enlightenment? And can a man-machine hybrid, a cyborg, become Buddha?
My answers are: Yes. Maybe. And... of course!
The blissful states exist in a range. Everyone has experienced at least the lower levels of this range, whether by accident or design. The higher levels are not so easy to reach, although instructions for doing so have been available for millennia. Pharmacological substances grant temporary access to some bliss states, but with significant cost to the body in the form of side effects and aftereffects (not to mention certain legal issues). Learning to meditate your way to bliss takes longer but is more controllable, yet it also takes a toll on one’s brain chemistry with consequent after-effects. In any case, easy access to the bliss states via machines projecting targeted electromagnetic fields will soon be widely available. However, even there, side effects and after-effects still warrant caution.
Enlightenment (which should actually be called Awakening) also comes in a range of levels. Essentially, it is like a fourth state of consciousness beyond normal waking, dreaming and deep sleep. Enlightenment/Awakening is a special type of understanding, analogous to what occurs when you understand anything: a puzzle, a theorem, etc. Except in the case of Awakening, one understands the nature of all possible experience and the hollowness of the egoself idea.
The gradual enhancement of the human body through mergers with machines will yield a hybrid: the cyborg. Any sufficiently complex system (like a human or an advanced AI computer) that exhibits awareness can realize Enlightenment. So I believe. This claim must still be tested for AIs. Cyborgs, however, can certainly attain anything accessible to humans and even more.
Working toward understanding how these developments may be brought about, and what impacts they may have, are goals of the Cyborg Buddha Project of the Institute for Ethics and Emerging Technologies. Our project aims to promote discussion of the impact that neuroscience and emerging neurotechnologies will have on happiness, spirituality, cognitive liberty, moral behavior and the exploration of meditational and ecstatic states of mind. All are welcome to participate in this great adventure.
IEET Board member Michael LaTorra [mlatorra@gmail.com] is an Assistant Professor of English at New Mexico State University, a Zen priest a the Zen Center of Las Cruces, and author of A Warrior Blends with Life: A Modern Tao. He runs the Trans-Spirit list promoting discussion of neurotheology, neuroethics, techno-spirituality and altered states of consciousness.
Seed - Rethinking Addiction
Rethinking Addiction
Research Blogging / by / September 23, 2009
What makes someone an addict? The clinical definition of drug “dependence” is flexible, but may still mislabel individual choices as disorders.
A member of my family died as a result of her alcohol abuse in her early 20s, leaving two children to be raised by their father. Clearly her addiction was horrible, and if it could have been prevented, many people would have been spared a lot of anguish.
But consider the case of an independently wealthy man, living alone, with no dependents. He sits around his mansion all day, playing video games and freely sampling from his vast storehouse of illicit drugs. He’s just enjoying himself and he’s not directly hurting anyone. Is he a society-menacing addict?
That’s the scenario presented by “DrugMonkey,” an NIH-funded biomedical research scientist who blogs anonymously at ScienceBlogs so that he can candidly assess the research of his peers. Two weeks ago he discussed an August study published in the journal Addiction that attempts to define clinical dependence on the rave-fave drug “Ecstasy,” or MDMA. We often think of true addicts as street junkies who prostitute themselves or steal from others to support their habits, but in reality there’s a wide variety of behaviors associated with abusing mind-altering substances. They can range from the casual drinker who sometimes has a few too many martinis, to the pothead who still lives in his mother’s basement, to a talk-show host zoned out on antidepressants.
The American Psychiatric Association’s DSM-IV-TR is the reference most doctors use to diagnose mental disorders, and it offers two definitions of problems relating to recreational drug use. The first, “substance abuse,” simply suggests that abuse is any use of a substance that leads to physical, mental, social, or legal harm to oneself or to others. The second, “substance dependence,” is what we more commonly think of as addiction and includes a list of seven criteria, only three of which are needed to qualify.
Technically, our wealthy drug user could be classified as an addict: He has developed a tolerance for the drugs, he feels withdrawal symptoms if he stops using them, and he often uses more than he planned. Are most MDMA users more like this benign hobbyist or more like street junkies who have clearly measurable detriments to society? DrugMonkey tells us about a study of 593 individuals who had used MDMA at least five times. The researchers, led by Linda B. Cottler, found that about three-quarters of these individuals showed the symptoms of abuse or addiction.
That sounds pretty bad, but DrugMonkey notes that only 17 percent of users report a “persistent desire/unsuccessful effort to cut down or control use.” Among this group, the median number of pills consumed during their lifetime was just 50, which, again, hardly seems like a persistent problem. On the other hand, 68 percent of users reported “withdrawal” symptoms and 87 percent said they continued to use the drug despite physical or psychological problems.
So while many MDMA users can be clinically classified as abusers or addicts, it’s unclear that MDMA use is a problem on the order of heroin or crystal meth. Heroin, reports the UK’s Transform Drug Policy Foundation, has cost thousands of lives and caused huge crime problems in Britain alone. The issue is so bad that the Foundation and others are now recommending providing heroin itself as a “treatment” for the worst abusers. Better they get quality- and quantity-controlled, government-provided drugs than live a life of crime to buy illicit, possibly poisonous drugs from dangerous gangsters.
DrugMonkey makes the argument that a drug problem is actually different from clinical drug dependence. A single mom working a job with a no-tolerance policy for absenteeism could have a much bigger problem on her hands after one bout with MDMA than our hypothetical wealthy carefree addict.
Indeed, partially because APA’s definition of drug dependence is so flexible, researchers have begun to apply similar reasoning to other “addictive” behaviors. I reported earlier this year on a study in Psychological Science claiming that 7.9 percent of US kids are “addicted” to video games. Dutch psychiatrist Walter van den Broek uncovered a similar study purporting to show that 4 percent of Australian undergraduates were “dependent” on the internet. Van den Broek isn’t buying it: He doesn’t agree that the scale the researchers used adequately defines dependence.
Perhaps the real problem is attempting to lump all these behavioral problems into the basket of clinical dependence. No one denies that some children play too many video games or that MDMA abuse is a serious problem for some individuals. But does it make sense to classify a college kid spending too much time on Facebook in the same category as a woman who lives on the street and sells her body to support a heroin habit? Can our definitions of addiction and our social deterrents against it actually cause more harm than they prevent? Researchers, students, and advocates continue to debate this issue on their blogs. There’s more discussion about addiction on ResearchBlogging.org.
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Bookforum - Who is afraid of the reaper?
Who is afraid of the reaper?
What happens when you turn forty-five: You realize you will only ever read so many books, there are only so many movies, so many trips, so many new friends — it has always been this way, but at forty-five you realize it. From FT, who is afraid of the reaper? A review of Annihilation: The Sense and Significance of Death by Christopher Belshaw (and more and more); The Philosophy of Death by Steven Luper; Our Stories: Essays on Life, Death and Free Will by John Martin Fischer; and Death by Todd May. A review of Staring at the Sun Overcoming the Terror of Death by Irvin D. Yalom. Facing the End: Mark S. Schantz on death and dying in American culture. A review of Choosing to Die: Elective Death and Multiculturalism by C. G. Prado. Live free, die free: The Final Exit Network, a right-to-die organization, battles government euthanasia accusations. A review of The Future of Assisted Suicide and Euthanasia by Neil M. Gorsuch. An article on the case for killing Granny: Rethinking end-of-life care. Ross Douthat on a more perfect death. The great unknown demands faith in something, be it biology or the Bible. A review of Death Becomes Them: Unearthing the Suicides of the Brilliant, the Famous, and the Notorious by Alix Strauss. The Death Guy: Gary Laderman has mixed feelings about becoming the "go to" professor when someone famous dies. An interview with Colin Dickey, author of Cranioklepty: Grave Robbing and the Search for Genius. Far too often, obituaries are drab and sanitised affairs, so Matthew Reisz asks scholars how they might word their own death notices.
Thursday, September 24, 2009
Break Up Insurance Monopolies
SUBJECT: Break Up Insurance Monopolies
America's health insurance companies have had a pretty sweet deal for decades.
They can pick and choose their customers and deny coverage to anyone with any sort of pre-existing condition -- even acne. They can get away with dropping your coverage when you get sick.
And since 1945 they have been exempt from the antitrust regulations that apply to nearly every other industry, rules that protect consumers from anti-competitive business practices like price-fixing.
That's why I just sent a letter to Congress, supporting the Health Insurance Industry Antitrust Enforcement Act, which will eliminate the outdated insurance industry antitrust exemption, and force health insurance companies to compete fairly -- like virtually every other business in America.
Please join me by sending a letter to your members of Congress as well:
http://ga3.org/campaign/hcr_antitrust
Upaya Dharma Podcasts - Dogen’s Circle of the Way parts 3/4 of 4
Dogen’s Circle of the Way part 3 of 4
Speakers: Sensei Kaz Tanahashi & Irene Kyojo Bakker
Language is like the finger pointing to the moon, begins Kaz Sensei. The Dharma goes beyond the sutras, yet they remain important to the path. Buddhism is not outside or inside the scriptures; the experience of full enlightenment is to swallow and spit out the moon. Irene Kyojo reminds us that the Circle of the Way is literally beneath our feet in Dokanji, Upaya’s zendo. Our practice is something we do by learning, and we learn by doing. She offers us ways to look at the practice wholeheartedly through Dogen Zenji’s teachings.
[Play] Dogen's Circle of the Way part 3 of 4 [54:22m]: Hide Player | Play in Popup | Download [Play]
* * *Dogen’s Circle of the Way part 4 of 4
Speakers: Sensei Kaz Tanahashi & Roshi Joan Halifax
Kaz Sensei playfully looks at elements of the English language to illustrate how much we rely on language to understand reality. Roshi Joan tells the history behind Upaya’s Dokanji (Circle of the Way) zendo and the story of the Hundred Year Flood with lessons about practice: taking care of each other, living through catastrophes despite our precautions, taking responsibility for what matters. Every moment counts and we must not become complacent in our daily comforts. “Do not squander your life” is the final cry we hear at the end of the day in sesshin. Can we truly live this way every day?
Vanity Fair - The Sick Business of Health-Care Profiteering
These are the key points:
It should come as no surprise, then, that we spend 17 percent of our G.D.P. and more than $7,500 per American per year on health care. That’s 50% more than any other industrialized nation. Meanwhile, the quality of care we get in return has fallen to embarrassing new lows. According to the World Health Organization, our health-care system ranks 37th in overall quality and fairness, placing us between Costa Rica and Slovenia. We rank 41st in infant-mortality rates, alongside Slovakia and Serbia, and dead last among 19 leading industrialized countries in preventable deaths. Nearly two-thirds of personal bankruptcies in the U.S. are caused by illness, yet more than three-quarters of those people actually had health insurance when they fell ill. In other words, we’re all getting ripped off.Here is the whole article - this is must reading for anyone who thinks the status quo is just fine.
The Sick Business of Health-Care Profiteering
Think Wall Street’s titans are the highest paid C.E.O.’s in the land? Think again. With median annual compensation of more than $12 million, medical moguls take the pay prize, even as the quality of care we receive falls to embarrassing new lows. As the debate over health-care reform intensifies, the author catalogues the industry’s unbridled profiteering.
WEB EXCLUSIVE September 24, 2009
It’s become a national pastime to bash Wall Street’s lavish pay packages, but as we enter the vortex of another health-care showdown, consider these overlooked facts: With median annual compensation of more than $12.4 million, C.E.O.’s at the big health-care companies make two-thirds more than their counterparts in finance and are the highest paid of any industry. The health-care industry’s total annual profit has grown to an estimated $200 billion, and it doled out nearly $170 million in campaign contributions in 2007 and 2008. It now spends more than any other industry lobbying the federal government—$3.5 billion over the past decade and a record $263 million in the first six months of this year. That’s six lobbyists and nearly half a million dollars for each member of Congress. It’s been a good year on K Street, too.
It should come as no surprise, then, that we spend 17 percent of our G.D.P. and more than $7,500 per American per year on health care. That’s 50% more than any other industrialized nation. Meanwhile, the quality of care we get in return has fallen to embarrassing new lows. According to the World Health Organization, our health-care system ranks 37th in overall quality and fairness, placing us between Costa Rica and Slovenia. We rank 41st in infant-mortality rates, alongside Slovakia and Serbia, and dead last among 19 leading industrialized countries in preventable deaths. Nearly two-thirds of personal bankruptcies in the U.S. are caused by illness, yet more than three-quarters of those people actually had health insurance when they fell ill. In other words, we’re all getting ripped off.
Health-Insurance Companies
Gambling investors’ money on exotic securities in pursuit of outsize returns may be a dubious profit model, but what could be worse than the health-insurance industry’s core model: screwing sick people to boost margins. President Obama has taken aim at big health-insurance companies and their “record profits.” While it’s true they’ve managed to more than triple their profits over the last eight years, they’ve still only lifted their average margin to 3.4 percent, enough to place 87th out of 215 industries. But they shouldn’t be complaining about lackluster profits when they’re paying their C.E.O.’s and executives as extravagantly as they are. Dishing out this much scratch, it’s a wonder they’re making any profits at all: Aetna C.E.O. Ronald Williams has helped purge millions of members from the company’s rolls; his total annual compensation in 2008 was $24,300,112. Angela Braly, who has promised that WellPoint “will not sacrifice profitability,” also saw a raise, to $9,844,212. Cigna’s Edward Hanway saw his pay cut in half and still hauled in $12,236,740, but he was forced to manage a major P.R. crisis after the company initially refused to approve a liver transplant for a 17-year-old girl, which it said was “outside the scope of the plan’s coverage.” She died just hours after Cigna changed its mind and decided it would pay for a new liver after all. Despite a 75 percent pay drop in 2008, cutting him down to a humiliating $3,241,042, UnitedHealth Group’s Stephen Hemsley put on a brave face for Congress, assuring legislators: “Our mission at UnitedHealth Group is to help people live healthier lives.” UnitedHealth has been fined tens of millions of dollars for claims-processing violations (i.e., stiffing patients and doctors). Hemsley’s predecessor, William McGuire, resigned amid a stock-options backdating scandal in 2006. He still walked away with nearly half a billion dollars in stock options. Hemsley surrendered $190 million in options himself, but with $744,232,068 left over, he should be fine.
Even C.E.O.’s at “not-for-profit” insurance companies (like most state Blue Cross and Blue Shields) collect multi-million-dollar compensation packages, even as their companies pay little in the way of taxes. Blue Cross of Massachusetts’s C.E.O., Cleve Killingsworth, got a 26 percent raise in 2008, to $3.5 million, and Blue Cross of North Carolina’s C.E.O., Bob Greczyn, pulled down nearly $4 million after a 19 percent raise. Gail Boudreaux left Blue Cross of Illinois in March with $15.3 million. The not-for-profits can be just as freewheeling with expense accounts. In early September, a state audit found that Blue Cross of North Dakota used premiums to pay for a $238,000 sales managers’ retreat in the Cayman Islands and a $34,814 retirement party for an executive.
The bottom line for health-insurance companies is that things like new livers really eat into profits. But it’s not just the expensive life-and-death stuff they’re rejecting. While health-insurance premiums have more than doubled in the past decade, a recent study by the California Nurses Association found that the six biggest insurers in California denied an average of 21 percent of all claims in the first half of 2009, with PacifiCare denying an astonishing 39.6%. The nurses were able to conduct their study, the first of its kind, only because California requires insurance companies to provide detailed records of claims denials. (It’s the only state with such a mandate.)
On August 17, Representative Henry Waxman sent out a letter to 52 health-insurance companies asking for revenue and profit figures over the past five years, a list of employees making more than $500,000 a year, and an itemization of expenses for “all conferences, retreats, or other events held outside company facilities” since 2007. The deadline for responses was September 14. When the details are released, we can expect a collective gasp.
Hospital Operators
The companies that manage hospitals post annual average profit margins of 5 percent, slightly better than the insurers. Hospital Corporation of America, founded by former senator Bill Frist’s father and brother, saw revenues climb 23 percent, to $28 billion, in 2008 with a tidy (if comparatively tiny) profit of $673 million. The Nashville-based company is doing better in 2009, doubling second-quarter revenue over last year. Back in 2002, H.C.A. paid $1.7 billion in fines to settle charges of Medicare and Medicaid fraud, the biggest settlement for an individual corporation in U.S. history at the time. And now H.C.A., whose outgoing chairman, Jack Bovender, made $6.87 million in 2007 and reportedly rides around Nashville in a cherry-red Ferrari, is fighting a class-action lawsuit alleging that “systematic understaffing” at H.C.A. facilities endangered patients.
Tenet Healthcare’s rap sheet is equally impressive. In 1994 the company settled with the government for $362 million after allegedly holding patients at psychiatric hospitals against their will and paying bribes and kickbacks for patient referrals. In 2006 it agreed to pay the government $900 million to settle charges it had bilked a billion dollars from a special Medicare fund by marking up its prices 477 percent over actual costs. While it’s been a turbulent ride for Tenet’s shareholders lately, C.E.O. Trevor Fetter is still allowed 75 hours’ worth of personal use of the company jet each year and pulled down a cool $9.7 million in 2008.
HealthSouth’s Richard Scrushy used to throw garish fêtes on his 92-foot yacht, the Chez Soiree, and was worth an estimated $300 million at the peak of the party. He’s now serving an 82-month sentence for bribery, conspiracy, and mail fraud; in June, he was ordered to pay $2.87 billion in damages to shareholders. “I have no interest in having money,” Scrushy told the judge when pleading for leniency at his sentencing. “I’m just a pastor.” HealthSouth lawyers are still trying to seize the Chez Soiree, now dry-docked in Florida.
Laboratory Testing Companies
The $50 billion medical-lab-testing sector’s average profit margin is a healthy 8.2 percent, putting it just above restaurants and below oil and gas equipment and services. The mother of all lab-test companies, Quest Diagnostics, earned a 9.1 percent margin during the last year, just a hair behind Exxon Mobil. In April, Quest settled with the Justice Department for $302 million for misbranding one of its tests, the Nichols Advantage Chemiluminescence Intact Parathyroid Hormone Immunoassay. (With names like these, they could just as well charge you for their afternoon coffee and call it Post Meridien Genera Coffea Robusta on your bill.) Despite the fine, Quest’s revenues were up 3.5 percent in the second quarter of 2009, to $1.9 billion, and its C.E.O., Surya Mohapatra, pulled down $11,964,632 in compensation last year.
In March, California attorney general Jerry Brown announced a civil lawsuit against seven medical labs, including Quest and LabCorp, for allegedly overcharging the state’s Medi-Cal program by up to 600 percent for routine tests. “In the face of declining state revenues,” he said at a press conference, “these medical laboratories have been ripping off our medical program for our most vulnerable people.” The suit claims that Quest was charging Medi-Cal $8.59 for simple blood-count tests while billing other clients $1.43 for the same test, and that LabCorp was charging Medi-Cal five times what it was charging others for hepatitis C antibody screenings. A little more than a decade ago, LabCorp paid $173 million to settle fraud allegations arising from the Justice Department’s Operation labscam crackdown on fraudulent lab-company billing. LabCorp C.E.O. David King’s pay was $8.2 million in 2008. The company posted a $514 million profit, with a margin of 11.4 percent, tying it with the Burlington Northern Santa Fe railroad corporation.
Giant settlements for lab-billing scams have been commonplace since the 1980s, but Congress has failed to implement any real anti-fraud protections for Medicare: a paltry $756 million is currently devoted to fraud prevention, less than one-fifth of one percent of Medicare’s annual budget. Given the unbridled pillaging going on, it’s little wonder Medicare is projected to become insolvent by 2017. The Government Accountability Office has estimated that 10 cents of every dollar spent on Medicare is lost to fraud, which means that $42 billion is expected to vanish this year. That’s $280 picked from the pocket of every wage-earning American.
Health-Care Real-Estate Investment Trusts
Where the health-care industry really stretches out the profit margins is in Real Estate Investment Trusts (reits). Essentially hospital and health-care-facility landlords, the folks with money in health-care reits are used to seeing double-digit returns. Last year they ranked second, behind only the beverage business, with a 24.6 percent average profit margin. Despite the real-estate doldrums, the bluntly branded Health Care reit, Inc., has recently been called a “hot stock” for basking in net margins of nearly 40 percent. So although C.E.O. George Chapman’s compensation was a meager $5.2 million in 2008, he’s bound to do better in 2009.
The biggest of the health-care reits, Health Care Property Investors, Inc., paid its C.E.O., James Flaherty, $6.54 million last year. The company points out on its Web site that “The healthcare industry is growing and is expected to represent 17.7% of U.S. Gross Domestic Product in 2010,” as if this is good news for everyone, and illustrates in a graph that this percentage is expected to top 20 percent by 2018. Trivia: At this pace, by the year 2300, 100% of our GDP will go to health care. The future indeed looks rosy for reits: aging baby-boomers will drive the growth of long-term-care facilities for years to come.
Big Pharma
With more than $300 billion in annual revenue and nearly $50 billion in profits, Big Pharma is the 800-pound gorilla in the room. The pharmaceutical industry’s share of G.D.P. has more than tripled since 1980, and its average profit margins are now better than 15 percent. The checks forked over to the men at the top of the big drug companies take the cake. Forest Labs’ C.E.O., Howard Solomon, has made an average of $33 million a year over the last six years. (He is 81 years old, so you can adjust for seniority.) Abbot Labs’ C.E.O., Miles White, reeled in $25.3 million last year, with profits up 35 percent, to $4.88 billion. Merck’s Richard Clark and Bristol-Myers Squibb’s James Cornelius each pulled down $17.2 million. Pfizer C.E.O. Jeff Kindler’s pay package was $13.1 million, and Wyeth’s C.E.O., Bernard Poussot, saw a 69 percent raise, to $21.3 million. The two companies merged and purged 19,500 workers (a marriage made possible by tarp money, to make matters worse), which landed Poussot a “change of control” bonus of $24 million. Unlike Tenet’s C.E.O., whose personal aircraft use is capped, Poussot is actually required by the board of directors “when feasible” to use Wyeth’s toys for personal travel, “for security and other reasons.” Somehow this is all news to New York City’s well-heeled mayor, Mike Bloomberg, who said on his radio show last month, “You know, last time I checked, pharmaceutical companies don’t make a lot of money, their executives don’t make a lot of money.”
Given the fact that pharmaceutical-industry innovations have increased the expectancy and quality of life for countless people, most Americans tend to give the drug companies wide moral latitude. And the drug companies have done everything they can to exploit the free pass in pursuit of profit, which occasionally lands them in hot water. In January, Eli Lilly was ordered to pay more than $1.4 billion as part of a civil settlement and plea agreement for their “off-label promotion” of the anti-psychotic drug Zyprexa. In early September, Pfizer paid a record settlement—$2.3 billion—for the unlawful marketing of the painkiller Bextra.
In stark contrast to all this greed, general physicians make about $148,000 on average a year, with heart and nuero surgeons topping the scale at around $550,000. (Who wouldn’t want his heart surgeon to be making good money?) But even your heart surgeon is making less than 5 percent of what the average health-care C.E.O. earns. No wonder doctors are cranky these days. Their salaries are flat, and they’ve been forced into indentured servitude by the insurance companies, whose reams of unnecessary paperwork clog their offices and cut into their time with patients. After years of double-digit increases, malpractice-insurance premiums have stabilized in many states in the last 12 months or so, but family physicians still pay an average of $12,500 annually. Premiums for specialists like neurosurgeons can run well over $100,000 a year in some states. Patients are cranky, too, having seen their premiums more than double in the last decade.
So why have the Democrats pushing health-care reform been reluctant to draw attention to the profound profiteering going on in the health-care biz? Why won’t they just spit it out: as long as our health-care system is a casino-haven for ambitious M.B.A.’s, Wall Street brokerages, middlemen, and bottom-feeders looking for easy money, it will remain broken for the rest of us. Pointing out how deeply we’re getting our pockets picked, and by whom, would surely rouse umbrage in the insured and uninsured alike.
Politicians deny that the money they get from health-care interests has in any way swayed their opinions on reform, but it sure seems to have flagged their resolve. In the first six months of this year, Senator Blanche Lincoln brought in $325,350 from health-care-industry interests. She recently came out against the public option, the biggest menace to insurance companies because, in theory, it could lure away potential costumers. Senate majority leader Harry Reid, who supports a public option but thinks it ought to be privately run, collected $382,400. Senator Max Baucus, chair of the bipartisan “Gang of Six” health-care-reform committee, has brought in $1.5 million since he began holding hearings in 2007. In May, Baucus had 13 doctors and nurses arrested who showed up at Senate hearings to demand that single-payer advocates be heard. Earlier this summer, the senator charged $2,500 a head to lobbyists and execs wanting his ear during the 10th annual Baucus golf and fly-fishing retreat in Big Sky, Montana, his home state. If your congressman isn’t busy cashing checks, or taking appointments with lobbyists, he’s probably busy getting shouted down at a town hall somewhere.
With the Democrats message dead on arrival, once again the reform-minded are proving to be no match for the cyclopean assault unleashed by the biggest industry in America. Health-care companies have mobilized at least 50,000 of their employees to write letters and attend town-hall meetings, on the premise that their industry faces a grave existential threat. The insurers’ leading lobby, America’s Health Insurance Plans (A.H.I.P.), prepared a “Town Hall Tips” memo, urging them to remain calm and not shout at members of Congress. A.H.I.P.’s president, Karen Ignagni, told The Wall Street Journal that town-hall meetings are an opportunity for industry employees “to strongly push back against charges that we have very high profits.” I wonder how many of them are on the lists of $500,000-a-year-plus employees due on Rep. Henry Waxman’s desk last week.
In his speech to Congress last week, President Obama sowed the seeds of compromise, delivering a watered-down, three-point plan for health-care reform: 1) compel insurance companies to treat their customers more fairly; 2) create an insurance “exchange” of affordable health plans for individuals and small businesses; and 3) require everyone to carry basic health insurance in the same way car insurance is mandatory.
By making health insurance compulsory for 46 million Americans, Obama’s plan could be a boon to hospitals and hospital-equipment-makers. “The expected spending could positively affect the top-line growth of many healthcare providers” was rating agency Moody’s assessment. Insurance companies also stand to do very well, particularly if a public option doesn’t come to pass. Even if it does, the president reassured the industry that in any event the Congressional Budget Office has estimated that fewer than 5 percent of Americans would sign up for it. The flood of government-compelled premiums could generate $1 trillion in revenue for health insurers over the next decade. Health-insurance stocks spiked the day after Obama’s speech, signaling approval of the direction the White House is steering the conversation. Over the past three months, Humana shares have gone up 26 percent, Aetna’s stock is up 21 percent, and UnitedHealth has gained 7 percent.
The administration’s plan could also mean a windfall for medical-supply companies, testing labs, and drugmakers. In July, the perennial Harry and Louise returned to the airwaves, but this time they’re bankrolled by Big Pharma and are advocating for reform. Why? Because “drug and insurance companies stand to benefit when tens of millions more Americans have coverage,” as President Obama said in June. The drug companies put a dollar figure on the potential benefit, offering to invest $80 billion in the president’s plan, in the form of Medicare discounts and other concessions over the next decade. Republican senator Olympia Snowe, a member of the Gang of Six and a key figure in the debate, thinks it’s a wise investment. “The savings offered here appear to be more than offset by new drug sales,” she told the Associated Press. In early August, as a worrisome proposal that would allow the government to negotiate drug prices was making the rounds in the House, Big Pharma flexed its muscles, demanding the White House explicitly acknowledge that drug companies wouldn’t be on the hook for anything beyond the agreed-upon $80 billion. The White House obeyed.
Despite the boorish antics of Joe Wilsons everywhere, the American people’s support for fundamental health-care reform remains steadfast. Depending on who’s doing the polling, between two-thirds and three-quarters of Americans support a public option and up to 75% want to see more regulation of insurance companies. With this kind of mandate, the fight is the Democrats’ to lose.
Matt Kapp is a Vanity Fair reporter-researcher
Psychotherapy Brown Bag - A dimensional model of mood and anxiety disorders: Moving towards DSM-V
The first article, which I am posting here in full, looks at mood disorders (Axis I), the second one, which I am only linking, looks at personality disorders (Axis II).
Now, go read A dimensional model of personality disorders: Moving towards DSM-V, the more interesting of the two articles for me.A dimensional model of mood and anxiety disorders: Moving towards DSM-V
by Michael D. Anestis, M.S.
In May 2012, the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is due for publication. As has been the case each time the DSM - our guideline for mental health diagnostic decisions - has approached revision, substantial controversy exists regarding the changes that should be made. In the first two versions of the DSM, mental illnesses were described in vague paragraphs that made assumptions regarding causes (e.g., unconscious conflicts from childhood) often based upon the scientifically weak theories of psychoanalysts. Beginning with DSM-III in 1980, a greater emphasis was placed upon reliability, with specific symptoms based in large part upon observable behaviors taking precedent in an atheoretical system. The system was further refined in subsequent years, leading to our current version, the DSM-IV-TR. Despite substantial improvements in the validity and reliability of diagnoses, the DSM still has many problems and, as a result, researchers and clinicians have been campaigning for various shifts, some more radical than others, in our approach to conceptualizing mental illnesses.
This article will by no means touch upon all of the controversies surrounding the creation of the DSM, nor will it effectively summarize all of the strengths and weaknesses of our current system. Instead, the goal is to provide a description of an article recently published in Psychological Assessment by the eminent scholars Timothy Brown and David Barlow (2009) of Boston University that details their proposal for a new diagnostic system for anxiety and mood disorders.
The Problem - Weaknesses in the Current Diagnostic System
Brown and Barlow (2009) opened their article by explaining the various weaknesses of the DSM-IV-TR, with the aim being to emphasize the areas in which DSM-V needs to provide tangible improvements. Along these lines, the authors noted that, while the reliability of the current DSM is a marked improvement over earlier versions, there are still several sources of problems in this area. They cited a study by Brown, DiNardo, and colleagues (2001) in which participants were administered structured clinical interviews by two different clinicians in order to determine the degree to which the clinicians would agree on diagnoses. The goal, of course, was to determine how reliable the DSM diagnoses actually were. Although the results were fairly strong, they noted six distinct sources of error:
- Clients often reported different information to the different clinicians. This reduces reliability because the clinicians are not left with the same information from which to work.
- Clients reported identical information to each clinician, but the clinicians disagreed on whether or not the symptoms caused sufficient distress and/or impairment to justify a diagnosis
- The clients' symptom levels actually changed between interviews, thereby leading to legitimate disagreements
- The clinician improperly applied the DSM diagnostic rules and thereby arrived at improper diagnostic decisions
- The clinicians disagreed on whether symptoms of one disorder were better accounted for by another diagnosis
- The DSM itself was unclear in its description of symptoms, thereby hindering differential diagnoses
In addition to reliability problems, Brown and Barlow (2009) noted that the current DSM exhibits problems with comorbidity. When an individual has comorbid diagnoses, this means that they meet criteria for more than one diagnosis at the same time. As it turns out, comorbidity is the rule, not the exception. In other words, clients meet criteria for multiple diagnoses more often than they meet criteria for only one. At first glance, this might not seem like much of a problem. After all, this might simply reflect the fact that different disorders often cluster together. A closer examination of the phenomenon, however, reveals several problems that emerge from this situation. For instance, Brown and Barlow (2009) noted that the comorbidity of social anxiety disorder (SAD) and depression is, in large part, accounted for by the fact that both disorders are characterized by low trait levels of positive affect. In other words, it might not be that these two distinct phenomena co-occur but rather that both the symptoms of depression and SAD are, in large part, accounted for by the general tendency to experience chronically low levels of positive emotions and that making the distinction between the two different disorders is less important than emphasizing the shared characteristic.
Brown and Barlow (2009) also noted that the high levels of comorbidity in the current DSM might actually cause clinicians to understate the presence of certain symptoms. For instance, Brown, Campbell, and colleagues (2001) found that the presence of panic disorder was predictive of decreased risk for SAD and specific phobias. Given that all three disorders share several important characteristics, including avoiding feared situations, this was surprising. The explanation, however, is quite simple, The DSM diagnostic rules often lead clinicians to assume that symptoms of diagnoses such as SAD and specific phobias are better accounted for by other diagnoses such as panic disorder and, as a result, the client's list of diagnoses does not make any mention of clinically impairing symptoms that are associated with the other disorders.
Brown and Barlow (2009) saved their strongest criticism of the current DSM for last. As it currently stands, the DSM calls for categorical diagnoses. In other words, you either have a diagnosis or you do not. With the exception of depression, which allows for specifiers such "severe" or "mild," there is no description of severity in any DSM diagnoses. Importantly, the decision to use a categorical system and the number of symptoms required to meet the cut point for each diagnosis are not based on empirical research. In other words, an arbitrary line was drawn by a committee to determine whether or not an individual meets criteria for a mental illness. Now, to be fair, the DSM also includes "not otherwise specified" diagnoses, which allow clinicians to still provide a recognized diagnosis to an individual who is obviously distressed or impaired but who does not meet criteria for a mental illness, but the arbitrary nature of the cut points is an obvious issue nonetheless.
The Proposed Solution - Brown and Barlow's (2009) Idea for a New Approach
Having established that the current version of the DSM is imperfect, Brown and Barlow were left to offer up something better. After all, it is easy to be a critic, but the real value rests in the ability to provide incrementally valuable alternatives capable of improving the situation. Simply tearing apart imperfections does little to help anyone and, remember, this entire field exists to provide effective care to individuals suffering from very real problems. Fortunately, neither Brown nor Barlow were interested in being mere critics and, while we can certainly debate the value of their proposed system, it is worth taking a look at what they propose in order to figure out where the field might be heading and what the best possible solution might be.
Quite frankly, the system proposed by Brown and Barlow (2009) is complex and the article in which they described the system was fairly dense, so my efforts to explain their thoughts here come with the disclaimer that, in order to fully understand the concepts, your best bet is to read the actual article. That being said, their system essentially boils down to ditching our current system of diagnostic categories for mood and anxiety and instead measuring the degree to which individuals exhibit elevations on particular variables known to relate to mood and anxiety disorders. Specifically, they propose considering:
- Anxiety/neuroticism/behavioral inhibition (A/N). In other words, the degree to which the individual experiences chronically elevated levels of negative emotions and demonstrates a tendency to inhibit prepotent responses.
- Behavioral activation/positive affectivity (BA/P). In other words, the degree to which an individual tends to engage in approach behavior and to experience chronically elevated levels of positive emotions.
Research has shown that individuals experiencing anxiety disorders as well as depression tend to exhibit highly elevated levels of A/N. Additionally, depression and SAD tend to involve low levels of BA/P and mania involves high levels of BA/P. In other words, all of these disorders are related to particular combinations of these variables and, as such, developing a profile of the degree to which an individual exhibits high or low A/N and BA/P could provide a more comprehensive picture of what is going on with a client than we can get from a simple yes/no decision regarding whether or not the client meets criteria for one or more diagnoses.
Simply looking at these two variables, however, does not give us enough information. After all, if SAD and depression are characterized by similar patterns of A/N and BA/P but are also characterized by different symptoms and outcomes (e.g., suicide risk profile), then we need to know more about what is going on with the client. Brown and Barlow (2009) thus propose that we further assess the presence, severity, and frequency of avoidance behaviors and examine the functional relationships of A/N with the characteristics traditionally associated with particular diagnoses.
So, Brown and Barlow (2009) see mood and anxiety disorders unfolding as follows: an individual has genetically predetermined levels of A/N and BA/P. In the presence of life stress, specific features of classic diagnoses are triggered and become evident, resulting in clinical distress and impairment. Importantly, although specific factors (e.g., intrusive thoughts) are often associated with one particular diagnosis (e.g., OCD), they often appear in other disorders as well, so assessing for their presence instead of just assessing for diagnoses would allow clinicians to better understand everything going on with each client. Brown and Barlow (2009) listed the following as specific features that should be assessed:
- Fight or flight response: when triggered inappropriately, this results in panic attacks. Panic attacks themselves often become the central focus of A/N.
- Somatic symptoms: the degree to which the individual is focused on unexplained physical symptoms and/or sensations of unreality associated with dissociation.
- Ego-dystonic intrusive thoughts: the degree to which an individual experiences unwanted and aversive thoughts (e.g., thoughts of harming one's own children).
- Social evaluation: the degree to which an individual exhibits a fear of being negatively evaluated by others
- Past trauma: the degree to which an individual focuses on or responds strongly to (e.g., flashbacks) cues of a past traumatic event
Pulling it All Together
Brown and Barlow (2009) thus propose that, when a client presents at a clinic, he or she should be assessed for levels of A/N and BA/P. This will provide a basic profile of their vulnerability to traditional mood and anxiety disorders. Furthermore, the clinician should assess the presence, severity, and frequency of avoidance behavior and the degree to which the client is exhibiting the specific features listed above. So, in the end, the client does not receive a diagnosis, but rather a description of the degree to which he or she maintains particular levels of negative and positive emotions as well as the specific manner(s) in which his or her emotions manifest in response to stress.
What is the Purpose of All This?
The idea here is to ensure that our assessment provides us with the optimal amount of information about the client and his or her struggles rather than focusing too narrowly on arbitrarily designed categorical diagnoses that might leave out important information relevant to treatment approaches. This system would remove the need to make differential diagnoses that cause one diagnosis to be subsumed within another and would no longer overlook the clinical implications of subthreshold symptoms.
Are there potential pitfalls to this system?
Here is where my article diverges a bit with the Brown and Barlow (2009) one. The authors noted that clinicians might be hesitant to utilize this system because it is relatively complex and unfamiliar. They also noted that, as of now, there is no single empirically tested assessment measure capable of performing the tasks they recommend and, as such, we have no research upon which to base the cut points that would be needed in order to inform insurance companies regarding the need for services. I agree with all of these critiques.
What they did not spend much time discussing - and to be fair, they could not discuss everything in depth in a single article - was the impact this would have on empirically supported treatments (ESTs). ESTs have been developed for several disorders. Although various forms of cognitive behavioral therapy (CBT) work for essentially all of the disorders involved in this new system, other forms of therapy such as interpersonal psychotherapy (IPT) have not been validated on all of the diagnoses. As such, it becomes unclear when each treatment would be most useful. The authors proposed that we develop transdiagnostic treatments and noted that they had developed one based upon CBT, but in doing so, we will be left without the mountains of prior work implicating particular treatments for specific diagnoses. We would have to essentially start over, which can take a very long time. The end result might be better, but we would be assuming substantial risk and would be left with a transition period certain to cause a significant amount of confusion and unrest both within and without the professional community.
So is this the answer?
Well, Timothy Brown and David Barlow are both substantially more informed on these matters than I am, but I find myself undecided on the best course. Data indicate that many disorders are dimensional in nature, so I am very much in favor of a system that measures severity of illness and assesses all symptoms. At the same time, I am a huge proponent of ESTs and am skeptical of any approach that would leave us without the benefit of all the work that has led us to this moment. Additionally, I am not convinced that a dimensional system will result in cut points that are any more valid that those that have currently been established and I can not help but fear that insurance companies would utilize their own cut points that minimize the likelihood of clients receiving effective mental health care.
The bottom line is, there will be no perfect answer. The question is how to best ensure incremental improvements in DSM-V that allow for more valid and reliable diagnoses and an easier path toward empirically supported care.
Your thoughts?
Where do you see the DSM-V going? Do you like Brown and Barlow's model? What do you think are its pros and cons? Even if you think it is the best system, do you think it could be effectively implemented in every day practice?
If you would like to learn more about the DSM and current conceptualizations of mental health and psychotherapy, we recommend the following resources, all of which are available through our online store:
- Clinical Handbook of Psychological Disorders, Fourth Edition: A Step-by-Step Treatment Manual
by David Barlow
- A Guide to Treatments that Work
by Peter Nathan and Jack Gorman
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
