Latest / Radically Genuine / 123. Clashing Perspectives: Personality Disorders and the DSM w/ Dr. Daniel J. Fox
Transcript
- Welcome to the Radically Genuine Podcast. I am Dr. Roger McFillin. The Diagnostic Statistical Manual 5, otherwise known for the general public, the DSM has ballooned over 300 psychiatric diagnoses. In a new study, researchers found that about 60% of the authors working on the latest edition, which was the DSM-5-TR, has financial ties to the pharmaceutical industry. In total, more than 14.2 million dollars of pharma money went to the DSM-5 TR task force and review group members. But DSM-5 is also an enormously profitable commercial venture. DSM is a perpetual bestseller, netting the American Psychiatric Association millions in yearly profits. On social media, psychiatric lingo is thrown around to describe complex... complex aspects of living and personality, we have an entire generation self-identifying with psychiatric disorders. Personality disorders are liberally thrown around and even used as weapons to discredit others. It's not that out of the ordinary to hear scorned exes throw out the terms narcissist, sociopath or borderline. They're even used in divorce court to justify custody arrangements. How are we gonna make sense of all of this? What actually is a personality disorder? Can a personality actually be disordered? With over 300 psychiatric conditions, can we even reliably trust these diagnoses even have any validity? It's not uncommon for people diagnosed with borderline personality disorder under one professional go to somebody else, they're diagnosed with bipolar disorder. and then a range of other conditions based on who you're actually talking to. So we sought out an expert to try to make sense of all of this. We've brought on Dr. Daniel Fox. He is a licensed psychologist in Texas, international speaker, and a multi award-winning author. He's been specializing in the treatment and assessments of individuals with personality disorders for over 20 years, both in the state and federal. Sean (02:26.16) prison system, universities, and in private practice. His specialty areas also include ethics, burnout prevention, emotional intelligence, amongst other things. He is the author of the borderline personality disorder card deck, just 50 ways to balance emotions and live well with borderline personality disorder. Complex borderline personality disorder, how coexisting conditions affect your. BPD and how you can gain emotional balance. Antisocial, narcissistic, and borderline personality disorders, a new conceptualization of development, reinforcement, expression, and treatment. He's also the author of the Borderline Personality Disorder Workbook, an integrative program to understand and manage your BPD. He's also the author of Antisocial, Borderline, Narcissistic, and Histrionic Workbook, Treatment Strategies for Cluster B Personality Disorders. And finally, Narcissistic Personality Disorder Toolbox, 55 practical treatment techniques for clients, their parents, and their children. So you see he has a wealth of knowledge and experience in this area. Looking forward to picking his brain. Dr. Fox, welcome to the Radically Genuine Podcast. Dan Fox (03:41.965) Thank you. Thank you Roger. I appreciate it. Thank you for having me. This is a great opportunity. Thanks Sean (03:48.74) So doc, let's just start with trying to define what actually is a personality disorder and how do psychologists who specialize in this area generally conceptualize personality pathology. Dan Fox (04:06.197) The way that I like to describe a person and to just sort of simplify it outside of the DSM, it's essentially the inability to adjust your behavior based upon the environment that you're in. What happens is that you have, and all of us do, we have particular patterns, beliefs, behaviors, and patterns of response based upon different interactions, different environments that we're in, so on and so forth. So what a personality disorder does is that it prevents the individual from adjusting to that situation. So if you're in a restaurant, you would behave the same way towards your kids and your spouse that you would if you're at home. Most individuals, depending on of course, the severity of the disorder, so on and so forth, most individuals can adjust, right? A lot of times you're having an argument, you might lower your voice a little bit, so on and so forth. However, those with personality disorders don't. And it's not that they don't want to, depending on the personality store, but it's a lack of insight. They don't really take in the environment, what's going on. So they stay wedded to these maladaptive beliefs, behaviors, and patterns, regardless of the situation they're in and their inability to adjust to those various situations. Sean (05:22.576) All right, so let me ask a question here. So human beings, generally speaking, don't do things that don't work out for them, right? Like we're very adaptive, we're very flexible. When things aren't working out for us, we change, right? So are you saying that someone who has a personality disorder continues to do the same things over and over again, kind of expecting different results, but yet continues to stay in these same patterns and... They don't work for them and they are not becoming flexible and adaptive and shifting in order to kind of grow from that experience. Dan Fox (06:02.45) That's great. And the reason why I really like how you framed it, because the component that we have to consider is insight. Insight is critical. And that is one of the universal components across all personality disorders, is impaired insight. So in order for us to adapt to various situations, we have to have the insight, not only into our own behavior, but to what's going on in the environment. and who else is in that environment with us for us to adapt efficiently. So insight becomes imperative, an imperative aspect. Sean (06:39.472) Okay, so can you define for our audience what actually insight means? Dan Fox (06:45.121) Insight is the ability to recognize not only what's going on inside of you and in the environment, but also how the environment is impacting the other individual and how you can manage that because just like you said, it's adaptive. So for us to adapt to that situation, but personality just sort of throws all that out the window. But insight again, it's a dimensional construct too. So we can't just say insight is insight or insight is not insight. How's that? Sean (07:20.272) Okay, so if there's a lack of insight then, what would bring somebody into treatment to be evaluated and to enter into therapy if they don't have an acknowledgement or awareness that they're struggling? Dan Fox (07:34.121) So typically what happens is, so individuals, right, that they develop these patterns of response, these beliefs, behaviors, and patterns over time for them to get through life, whatever obstacles, abuses, neglects, whatever those issues may be, whether they're internalized, externalized, whatever they may be. So the individual lacks this degree of insight and their adaptability. We see that impairmen, it... it broadens out over time so they can continue to function. It's very much, it's not based on choice, and that's a huge misunderstanding of personality disorder. People think, well, just snap out of it. But it becomes adaptive over time. So because it's adaptive, doesn't mean it's healthy. It's that they are using these strategies in order for them to exist over time. So perhaps adaptive isn't the best word, but it's more. internalize for them to exist and function. Because if they didn't, they probably wouldn't survive that environment or past experience. Sean (08:41.388) Okay, so if we're talking about these enduring patterns, right, and maybe we'll speak to them as being maladaptive, there has to be some environments in which they are adaptive, or it probably wouldn't continue to endure, right? Is my kind of understanding of this. So let's just use narcissism for an example. That is really thrown out quite liberally on. social media, like these kids are being exposed to these TikTok reels now where like everyone is a narcissist. And obviously, you know, human beings have this tendency to act in their own best self interests. So it can lend itself to overgeneralization. And this is the problem, I think, with American culture is you take something that is meant to be identified with a small percentage of the population, and it, you know, causes this functional impairment. And then we start overgeneralizing it to large portions of the population because they do represent some aspect of humanity. So how do we actually define what narcissism is as a clinical condition and how would someone like this behave in a way that it does cause enduring impairment? Dan Fox (09:58.933) So I think that what I hear you asking, so the heart of that is the colloquial usage and then the clinical usage. And like with my doctoral students, I'm always trying to explain to them that once you kind of are our field, right, that, you know, Roger, when you and I, right, we get into our field, we get licensed, we start seeing clients, so on and so forth, when we use particular terms, particularly clinical terms. It has greater weight. I don't care if you're with your best friends or your family or you're with strangers and you're doing a lecture. So for you and I to say, well, you know, this person, it could be some political figure, whoever it is, and say, you know, this person's a narcissist. That has greater weight than let's say, Bob or Barbara who are not professionals in the mental health field. And what happens is that you have all of these TikToks, you have all of these Instagrams and things like that and YouTubes and things like that. And everybody's throwing around this word and it becomes this really heated term and descriptor. Typically for people that they find to be egregious, people that perhaps are malicious, have a malicious intent, so on and so forth. So if we talk about the clinical term, specifically the clinical term, right? That very small... percentage of the actual population who would qualify for narcissistic personality disorder. These individuals have beliefs, behaviors, and patterns that are maladaptive. Now, how are they maladaptive? Why are they maladaptive? All of us build an interpersonal system and circle that reinforces our belief of self and the world. And people with personality disorders, narcissists, antisocials, individuals, borderline individuals, we all build this interpersonal circle. And what happens is for narcissistic individuals specifically, they use a strategy called enlistment. And enlistment is very fascinating because you see this, particularly for genuine narcissists. And when I say genuine narcissists, these are people that would qualify according to the DSM various criteria for narcissistic personality disorder. Dan Fox (12:21.297) And they use enlistment. And I like to use an example of going to a bar, right? Let's say that I'm a narcissist, right? I go into a bar and I'm gonna pick up these three women. It really starts like the start of a joke, right? This psychologist goes into a bar, right? So I go into this bar, right? And there's three women there. Go up to the first woman. And we're talking, chatting a little bit, right? And she has some earrings on. I see those earrings. And I say, oh, those earrings are really nice. Now I'm the narcissist in this point, right? Not really, but in this case, yeah. So I go up to the first woman, and I say, oh, you know, those earrings are really nice, but they do kind of make your earlobes hang down. And she's like, what? Beat it, right? So she tells me to get out of there, right? So I get out of there. Then I go up to the other one, right? Go up to the second woman, and we're chit chatting for a little bit, stuff like that. She has this necklace on. Sean (12:56.933) Yeah. Dan Fox (13:17.005) And I say, oh, that's a really nice necklace. I mean, it makes your neck look fat, but you know, it's a nice necklace. She says, what? Beat it. So then I beat it. Go up to the third person, right? Go up to the third woman. Right, we're chit chatting for a little bit, so on and so forth, right? She has a new sweater, she has a sweater on. And I said, oh, that's a nice sweater. It kind of makes your shoulders look droopy. And then she says, oh, I know. Can you believe it? I wasn't gonna wear the sweater today and now I'm... Really all the, now we're having a conversation about what's wrong with you. And we see that narcissists do this, and this is called enlistment. And we see this time and time again. And it's not a conscious effort. It's not that third woman in the example is like, oh, I really like people who make me feel small and broken and so on and so forth. That isn't it. It's that they're open to the idea of, and it's usually, it's not as direct obviously as my example, but. They're open to the idea or they're willing to accept adverse feedback about how they present, who they are and how they function. And these individuals, narcissistic personality disorder individuals, utilize that and they enlist these people so they fill their social circle that reinforces their maladaptive beliefs, behaviors and patterns. So no one challenges them. Sean (14:38.296) Well, have you ever read the book The Game? I was just thinking about that. Neil Strauss? Yeah. Remember that? Uh huh. So this is a great book. I read this and it's called The Game. It's really about pickup artists. Yeah. It's like peacocking. I think that's what the term was. Well, they define the term, no, they define the term negging. Don't you remember negging? Uh huh. That negging was an effective pickup strategy where you find some flaw within the woman. Dan Fox (14:53.726) Peek-a-boo! Sean (15:06.092) It's a male pickup artists. They found that you find some flaw within the in the woman. And the woman in attempts to try to almost become accepted is more likely than to try to earn that pickup artist attention and they use this as a strategy. So I mean, I'm gonna challenge you I don't know if all those things necessarily represent narcissism in itself. I want to have a question about it. How do you factor in a cultural relevance? Because the scenario you were just describing it like you could be at the Jersey Shore and like, that's what a bunch of guys would do at a bar. But then you go down to the south. And that's a totally unacceptable behavior. And that person will be perceived much differently. It's almost like the my cousin Vinny situation, you know, you, he goes down to the south and they looked at him as this person that was completely like a fish out of water and Who's to determine how do you in your assessment process? How do you factor in cultural relevance? Yeah, hold on and then there's also like Developmental period so like talk about a bunch of frat boys. Okay Yeah in the manner in which they're you know, they're behaving and they're acting between the ages of like 18 and 22 And does that just reflect a general? Narcissism for that period that developmental period in your life and the culture in which you culture in which you reside in, right? So all these seem to be factors. Dan Fox (16:37.065) Yep. So, and I think, so, are we talking about narcissistic personality disorder, the full disorder, which is the combination of symptom and traits, or are we then stepping outside of the actual clinical definition, going back to more of a cloak wheel, somewhat description, but you're talking about the singular trait of narcissism, not narcissistic personality disorder. So I think we definitely have to be clear on what we're talking about there, but. What I would say is whether you're in Jersey or you're in London or you're in Alabama, the individual, right, the narcissist, continues to seek out the individual who is willing to accept that sort of deriding. They enlist these individuals, regardless of where they are in the world, because what happens, and I will say, it's not just in identifying partners. We see it in children. We see it in families, absolutely, because you see that you become part of that interpersonal circle. So I understand the difference in culture, absolutely. And in that specific example, we see it, because I've worked with people from all over the world, even in like Saudi Arabia, even in certainly London, in Australia, things like that. We see these same patterns of behaviors. They may not be as... descriptive or specific as a bar or something like that. But perfect example, you mentioned about the frat boys and things like that. That's enlistment amplified, absolutely, because it then becomes a gaggle of these frat boys that enlist these particular behaviors that are then deemed to be appropriate. So they engage in these behaviors and then they're, to use the term you said is negging, right, that's what we're saying? So then... Sean (18:30.104) Yeah, not my term. Not my term. That's Neil Strauss' book, which is about 10 years old now. Oh, I think it's older than that. Nope, 2015. Just saw it. Dan Fox (18:32.369) What's that? Right. Dan Fox (18:42.761) But it's interesting, right? Because we would gravitate towards that. Like if, I can tell you that, so the people, and perfect example is, so my friends, right? The people that I'm closest to. So I'm originally from New York, and I'm closest to people that tend to share that kind of similar cut, sarcastic, straightforward kind of way of being, so to speak. But I'm not that type of person. So let's say if I was single, I went into a bar, I approached somebody. and wanted to engage in a conversation. And I started to do those things, my friends would be like, what are you doing? And that, because that type of behavior just isn't tolerated within my social circle. So then the social circle starts to correct it. But if I was a narcissist, what I would do is I wouldn't be friends with somebody like that because that person would know, you don't wanna challenge me because that's gonna be a nightmare for you. And I'm just not gonna hang out with you. So I'm gonna hang out with people who accept that negging, not your term, but still, negging, negging type behavior. Sean (19:47.576) Yeah. So to me, I want to differentiate between a behavior and action versus this idea of like a personality construct or trait. So when you think about DSM diagnoses, like when you're trying to meet this clinical criteria for narcissistic personality disorder, the first one is that grandiose sense of self-importance. might exaggerate achievements and talents expected to be recognized as superior without even the achievements that are existed. And there's this general fantasy of unlimited success and power, brilliance, beauty, ideal love, the belief that they are special and require excessive admiration. And when we talk about enduring patterns, that doesn't necessarily adapt. Right? That's not flexible and adaptive based on the environment. And like Dr. Fox mentioned, I'm sure they would seek out environments in which they can receive that type of admiration. So these are kind of like these enduring patterns that are not susceptible to treatment. Would you agree? Dan Fox (21:02.569) So I would say yes and no. So I think what happens is that if we talk about the fantasy state of the developing narcissist, so a lot of times what happens is that you see individuals and narcissists don't really achieve much. It's such a small component of individuals who actually qualify for narcissistic personality disorder who actually. Sean (21:25.04) Wait a second, hold on, I'm gonna challenge you there. Did you just say narcissists don't achieve much? Oh, I would completely disagree and say there's an entire subset of society that allows these people to achieve at a higher level than the average person. So this goes back to like culture. Let's see, so how does the narcissistic, then the narcissist comes across as highly confident, right? Dan Fox (21:31.781) Right. Dan Fox (21:35.303) Okay. Dan Fox (21:43.605) Okay. Uh-huh. Look, exam. Sean (21:54.668) So add somebody who has this high degree of confidence of self-importance, but yet is also smart and talented. Doesn't that give them a unique? Dan Fox (22:04.605) Well, you're making an assumption there too, but go ahead. Sean (22:07.596) Yeah, saying there are, I mean, there's intelligent people across the spectrum. So you'd have intelligent narcissist too, right? And unintelligent narcissist. Right. So unintelligent narcissist, like you don't have a shot, but someone who's really intelligent and a narcissist, don't you think that they're more prone to go into like politics, for example? Dan Fox (22:26.033) Okay, so if we talk about like politics or we talk about your CEOs and you're talking about your influential so on and so forth narcissists. So first, now we're broadening it out. So are we talking about pathological, healthy, or are we talking about again, enlistment is a huge part particularly for politics, right? Politics, politicians that classify. as narcissistic personality disorder, and not every politician, right? We could use presidents of the United States. Not every president of the United States is going to qualify for narcissistic personality disorder. Some absolutely will. Now, from our standpoint, because we don't know them, we can only look at their particular persona. But those individuals is a smaller subset of narcissists. When we broaden out to the... full picture of those individuals who qualify for narcissistic personality disorder. Most of them engage or believe in success more from a fantasy level. Let me give you an example. I had a client about 15 years ago, right? And he came in and he said, I'm a great guitarist, Doc. I'm a great guitarist, right? And I said, oh yeah. I said, oh, that's really great. Do you play in a band? Do you do whatever? He goes, Doc, I don't have to play. I know. I know I'm the best. What? Right? It's that kind of fantasy, right? And certainly if I were to pick up a guitar, because I play a little myself, right? If I were to pick up and say, well, let's kind of play together. This would be a good, you know, therapeutic activity, whatnot. The odds of that narcissist picking up that guitar is so small. And again, we're talking about the smaller subset of the larger group. Most of these individuals are not willing to risk, right? You and I, we went to school and we took a risk on ourselves, whether it's loans, Dan Fox (24:23.986) time, 70% of all individuals in graduate school end up divorced or out of the initial relationship in which they were in when they started graduate school. So we took that relational risk. So when we look at all of these factors, we have a smaller subset, particularly for politics. Now 21 years in the federal prison, I can just tell you, in working with high society, Dan Fox (24:51.561) the genuine narcissistic personality disorder spectrum, that narcissism is intact. Those people around them, they're yes men and women and things like that, absolutely were enlisted, or they wouldn't have them in there. So, absolutely. I mean, but again, if we look at the entire spectrum, we talk about intelligence. Intelligence is a factor, but we know that it's not actually connected to psychopathology. So we have to consider those factors. Sean (25:22.796) Well, I'm gonna, I would say that 95% of people who actually would meet criteria for narcissistic personality disorder never end up in front of you and I. Why would they? Dan Fox (25:35.681) I'm so glad you said that. So I think that a lot of that has started to change. And I would say probably about maybe seven or eight years ago, if we had this conversation, I would say, I think you are absolutely right. Narcissists do not participate in treatment. They are not interested in treatment. They are treatment rejecting. And 95%, that's huge. That means you have just the 5%. But here's what's happened. And I think is that... We have a generation that's coming up and I think that they define themselves by the negative. They're trying to identify who they are, trying to discover who they are, and they're doing that by the negative. This is largely driven by TikTok, it's driven by all this social media stuff, it's also driven by other factors as well. But, so you have these individuals with a very tenuous sense of self. And narcissism, you can try to expand that as much as you want and say, oh, I'm great, I'm the best, things like that. It's hard to get noticed on TikTok. It's hard to get noticed on Instagram and YouTube and stuff like that. So the way to do that is to be more extreme, more extreme. But how many videos, we only know about the videos that we actually notice. So anyway, when we go to narcissistic wounds, when we talk about individuals who come into treatment with us, We're talking about in the long-to-narcissistic spectrum, these individual has incurred a narcissistic wound. The more fragile the central core self, the higher the likelihood of incurring that narcissistic wound. Now the narcissistic wound, it depends, because are we talking about a grandiose type of narcissism or are we talking about a vulnerable type of narcissism? So when we look all the way back to 1999, Wink's initial... definition and conceptualization of your vulnerable narcissist and your grandiose narcissist. Your vulnerable narcissist is likely to come into treatment and we as therapists align with them because we don't think they're narcissists. Not initially, because we used to think that they were separate, that they were mutually exclusive and in different individuals. You've got Bob is a vulnerable narcissist and you've got Barbara who is a grandiose narcissist. That's not what... Dan Fox (27:56.261) research has found in the last five, eight years, we find it's two sides of the same coin. So what we have to recognize when we talk about coming into treatment, vulnerable presentation is what we're likely to see. They're gonna come in and they're gonna say something like, I'm really suffering. I don't know what to do. I feel lost. Everything is against me. Doc, this pain is so great. I don't even think you can understand it. It's so hurtful. It's so broken. I'm just burning inside. There's no way that you're gonna initially say, wow, those are narcissistic statements. But they are. They're vulnerable narcissistic statements because they're saying, my pain is so great that you or no one else can understand it. And we as therapists, We fall for it until we start to repair their sense of self, and then that grandiose side starts to come out. And then we're like, what the heck? I don't know if we can say the other one. What the heck is going on? Who is this guy? Girl, whoever. So we are seeing more come into treatment because we're having an increase in narcissistic wound, poor ability to cope, and more tenuous core structure inside many of these individuals. Sean (29:02.255) Hmm. Dan Fox (29:21.225) down to like where BPD is, like probably, you know, treatment rejecting BPD is exceptionally rare, probably maybe 15%, 20%, when we talk about your narcissist, is it that low? Absolutely not. I would say maybe 80%, but I'll tell you, in the last like seven years or so, I have people calling me, and these are, and I'm not trying to be misogynistic, but I'm putting it out there, but these are men. Because men, if we just look at it from a gender standpoint, are more resistant to going to treatment, typically anyway. So I have men calling me saying, duh, I think I'm a narcissist. What am I gonna do? I'm gonna ruin my family, I'm ruining my family. You know, dah, dah. I have not seen this before. Now, when we get into treatment, typically we go down that same very... typical trajectory of identification, treatment, resistance. And then I think completion rate is exceptionally low. But yeah, I think more. Sean (30:33.236) I'm trying to put myself in the shoes of our audience here who is skeptical of the mental health system to begin with for good reasons. And that's kind of part of our podcast is trying to help educate people on how the DSM in itself can be a dangerous diagnostic statistical manual because it assigns these labels to people sometimes without strong validity. It can be used against them to take away rights, and it has throughout our history. And so you're describing this narcissist in a way that it can be widely applied to lots of different people under different conditions. So we've talked about here about the fragile nature of Generation Z, for example, who they're growing up with their face and phones and they're exposed to social media. where your value is based on the number of likes that you receive. They're entering into a culture that in a lot of ways does not necessarily teach resilience. We see inflated grades, helicopter parents, a number of other cultural variables that have intersected with itself that allows somebody to present as much more, have a fragile ego for the lack of a better term. And then they come across failure or struggle. It's... very difficult for them to kind of accept that it's such a hit to their ego. It's harder for them to recover than maybe previous generations who were raised differently. And so that's the challenge in trying to throw these categorical diagnoses at someone. Because when I think of a narcissist, I don't think about just different personality traits that can express itself in an individual therapy setting. I think about What also includes that lack of empathy, that grandiose sense of self, the belief that really there's not much wrong with them, regardless of what the evidence suggests in front of them. And it'd be very rare for them to seek out the mental health system. And I think we have somewhat evidence to say that when someone meets that strong criteria, Sean (32:45.568) If anyone has a certain level of self-awareness and intelligence, they're learning how to read the room around them to be able to get their needs met. And that's where we get into certain professions like politics. Like when you're in politics, you are in some ways an actor. You really do thrive off the attention that you get from others. And when we look at the American political system, We can say that politicians in a lot of ways are the actor, not necessarily the one who's always driving policy. There's often larger entities behind them that are driving policy, the ones that are funding their campaigns for the most part. But when you think about somebody who really desires that attention to such an extent and has this enormous ego and profound sense of self, they might have many different sexual partners, they might cheat on their wives. Dan Fox (33:31.143) Oh. Sean (33:42.304) when they do get into a relationship, maybe that relationship is only there to serve their political ambitions or other ambitions that they may have. They might seek out another partner who is very similar to them. I have a hard time conceptualizing those people struggling in interpersonal emotionally in a way that drives them into therapy. For one, it would probably be viewed as a weakness in their own minds. But I know what you're saying, because especially in kind of psychoanalytic, writings and so forth, you use these words, you know, quite frequently to be able to apply to different aspects of the self and the personality and how it presents itself. But I find that somewhat dangerous. I think that contributes to the wide expression of labels to diverse groups of people along a spectrum and then pathologizes them. And I don't see how we're benefiting from those type of conceptualizations. Dan Fox (34:42.173) And I would agree. I mean, in that, in your question or your statement, I mean, I agree with a lot of that, but I think that a lot of it falls on parents, right? Is it, you know, are we raising kids with boundaries? Are we raising kids with, you know, understanding their sense of self? Are we willing to challenge them in their development instead of giving them, you know, to learn from a phone or giving them a materialistic reward, or how often do parents sit down with kids and help them early on to construct their personality and their sense of self? And when they experience barriers and blockades, how do you learn from that? So you're narcissists a lot of times during their early developmental period because their parents, if they're narcissists, and they're not always, but... If they're narcissists, what they do is their child becomes an extension of them. Right. So when they experience any type of stress, the failures on the child. So then the child then internalizes that failure. Oh, so I'm not great because I'm broken. But when that same child has a sense of success, then the parent is quick to say, see, look how I helped Billy. I helped Billy. The reason why Billy is a success is because of me. So failures are on the kids. So what happens is you internalize that and then broaden that out to a current generation of parents who may not be paying that much attention. And I'm in no way saying that parents or individuals that have kids, children, whatever, with mental health concerns, that they're not parenting and doing their job. That would be a massive misinterpretation of what I'm saying. What we're talking about is that typical development of the narcissistic individual or having a narcissistic parent. But I think that we have to build senses of self in kids and in others. And part of that is letting our kids experience stress, failure, and anxiety, but doing it in a secure environment. And without that, that opens the door to more pathology. And it becomes you have an entire generation that defines themselves by the negative. Dan Fox (37:08.101) And if you define yourself by the negative, you embrace the negative. So before we were meeting, I was just meeting with someone else and we were talking about what are the purpose of YouTube videos, right? What is the purpose of putting this information out there? And there's so much out there. How much is based on research? How much is based on genuine clinical experience from someone like myself as opposed to others who say, that they are such and such and don't work with clients or haven't in 15, 20 years, whatever it is. And I said, well, I think that we have to be able to apply something that individuals can use and utilize that they can build those strategies. Interestingly, when I look at my analytics, I see that a lot of people are interested in identification of the problem. And in a lot of my videos, I always at the end, always mentioned some strategies, things that they can do. how to reach out, find a therapist, so on and so forth. And if you look at the analytics, when do people drop off? A lot of them drop off as soon as I start talking about strategy. Sean (38:11.916) Mm. Sean (38:16.393) Yeah, I want to go back to something that Sean mentioned earlier about culture and context. I am really interested in just evolutionary biology because I think it's important for us to understand that evolutionarily we've had to adapt over time in order to survive and procreate. When you think about the range of diversity of personality behavior, at some point, it had to have been adaptive, or it would have probably not continued to thrive, right? So let's think about, you know, for example, you know, those who are aggressive and violent. So aggressiveness and violence are still maintained in our society and culture. If there was no benefit for being aggressive or violent, it wouldn't continue to present itself in our culture. Same thing with, if you would think, narcissism. It has to, in some way, be reinforced. It has to be adaptive in some context. Or, from an evolutionary perspective, it would not have survived. So is there a better way, maybe, to consider the range of diversity that exists other than disordered. So this is the problem I have with my field is that everything's compared to the average. What what the norm is considered normal. Yeah. And anything that deviates on the spectrum away from the norm then becomes disordered. But, you know, let's just see Donald Trump, for example, you know, a lot of people during the election and when he was president wanted to diagnose him from afar. A psychologist, psychiatrist would say that he is a narcissist. He is the textbook definition of what is a narcissist. Yet, he is a multimillionaire, billionaire, multi, you know, a lot, owns many companies, rose to the highest executive position in our political system. Is that disorder? Yes, it deviates from the norm. But who gets to identify that as disordered and why? Dan Fox (40:36.977) I think that, so if we want to go down the political realm, particularly, how individuals with narcissistic traits can rise to particular levels, I mean, we're going to end up right back in enlistment and so on and so forth. But also, I think that there is, and particularly with politics, you end up with such a distorted view of one individual. And when you talk about... people that have millions or billions of dollars and so on and so forth, when you start to unpack that and you start to look at the reality behind that, you see that they don't, that it is an affectation that they put forward and say, oh, I have all of this and I have all of that. Well, you don't. And that is a component of narcissists. It's peacocking, right? To go back to, I believe that Shawna yourself mentioned, yeah, earlier. And it is, it's strutting and saying, because I'm strutting and because I'm a pretty peacock, everybody should treat me beautifully. Yeah, well the world doesn't work that way and when we talk about evolution when we talk about you know particular parts of the world maybe that Where survival is critical you find a lot less narcissism? Now when we talk about more lack of a better word developed You know society so on and so forth where there are laws there's protections right that there are particular factors in place that allow for variations of function and self, you're going to see more narcissism. Greater access to affectations, you're going to see more narcissism. Now, does that equal a greater percentage of narcissistic personality disorder? The research doesn't really support that. It just shows an increase in narcissism. But I think, to go back to what I interpret as your main point of your statement, is that the harmful effect of the DSM and that system, and sort of, you know, any deviation from the norm is considered aberrant. Again, we've got to go back to that dimensional model. And it becomes that, can the individual thrive and function? Typically, narcissists implode or explode over time. And I think that, you know, you can have someone make it to their seventies, but you're not seeing a whole bunch. There's always going to be those outliers. Dan Fox (42:58.609) There's always going to be those individuals that are able to make it that far. In coming up for me, the DSM, well, there was no internet. Whoa, I just dated myself, so hold on. There was no internet. I am dumbfounded on a regular basis that anyone can look up the DSM. I remember I was watching The Sopranos. I don't know if you guys saw that. But there's one part, yeah, it's a great show. And I think it's the first season and Dr. Melfi, right? She leans over and she grabs the DSM-4, not even the TR, it's the four. And she starts flipping through it, right, with Tony and stuff. And I'll never forget thinking, man, that is so inappropriate because you're not supposed to do that. I mean, it's a system, right, for identification of pathology based on those who understand it. But. Sean (43:27.864) Yeah, great. Dan Fox (43:55.533) should you and I and the three of us and everyone else, should we be able to go into a 7-Eleven and get an X-ray and then say, yeah, you know what? That does look like a fracture. No, no, we shouldn't. So I think that part of the problem is, is that there's been this massive release of information that is being misused and misunderstood. Most people look only at criteria A, drives me bananas. I tell my students this all the time, there's more to it than just criteria A. There's B, C, D, E. There's other factors. People don't pay attention to that because they don't know how to use it. And that becomes the problem. Sean (44:35.568) But I think the problem is that it's a categorical identification of something as complex as personality, emotions, and behavior. So it lends itself to those problems already, because if you're going to talk about things on a dimensional scale, it's always to what degree, to what form of impairment. So I guess if you look at like a Donald Trump, maybe he exhibits some of the symptoms and some of those quote unquote symptoms have allowed him to have certain degrees of success in the circles in which he lives. But does that necessarily mean that it is functional impairment? Does that create impairment for the individual? And the answer may or may not be true, but it depends on really knowing the person. Like if he thinks divorce in itself, because it's struggled to be able to maintain a relationship is painful, well, then you could maybe identify that as functional impairment. If you are being sued. and experienced distress over that, then yes, I guess you could identify that as functional impairment. But what if you don't? Right? What if you do not experience the level of distress for getting sued, or for divorce or relationship problems, then where's the functional impairment? Right? So it becomes some, it becomes relatively subjective and arbitrary in how we designate it, because we're all human beings. And then we think about things through our own lens. Well, it would be upsetting for me. It doesn't seem to fit into these norms. Therefore, I'm going to disorder it. And I think that's the challenge with the DSM, with diagnoses and our profession generally. And I think you're gonna run into those same problems with your students. I remember being in my doctoral program and learning this and people say, well, that's me or that's me or I'm like this, I'm like that. And of course, like to a degree, we can all experience this on some form of a spectrum. There's times we can be really self- focused. And that can be very necessary and valuable for our development. There might be some other times you're desiring attention to some extent to some degree. But it always comes down to this causing functional impairment. And that is where it is challenging for many people to be able to understand how so yeah, you're responding to the disordered part of it as it is an impairment, but isn't it if it is a Sean (46:59.684) They're exhibiting strengths in other areas that fall outside the norm. So I want to throw something to you, uh, Dr. Fox. Um, I listened to an interview, uh, with Michael Lewis and he was talking about Sam Bankman Frieden. I saw you did a YouTube video on his book. So this was right around the time that his book was coming out. As I listened to that interview, I, I was kind of, I was listening to the relationship between his parents. His father was a psychiatrist. And the way that Sam Beckman Fried had grown up and ultimately what led him down, you know, this whole crypto path of he calculated everything. So in my mind was when I was listening to the conversation with Michael Lewis, I was thinking, Oh, I think this guy's probably was, or is a sociopath. The father recognized it early on and wanted to not consider him disordered, but push him in a direction where possibly he could create more. greater good for society. You read the book and I'm not asking you to diagnose him, but what was your takeaway in terms of Sam Bankman Fried's personality and is it disordered? Thoughts. Dan Fox (48:10.965) Okay. So, the same Bank Ben Fried, so from the book, the way it was portrayed, you know, through Michael Lewis's lens, I think that, you know, you see an individual who is struggling to understand the function of the world, right? How it functions. And I think that when you have people that function as he did through the lens of the book, right, everything I'm going to say is obviously through the lens of the book, because I don't know the guy, you know, so on and so forth. And the media, you know, will... put that aside. So with this one book. But I think that you have somebody who's very exceptionally bright, was for a very long time, has poor interpersonal skills, but then they realize that you can use a cost benefit analysis in order to determine interaction patterns. And those interaction patterns, then you can use them in order to reach a particular level, lack of a better word, success, acceptance, whatever it may be. But this guy doesn't want acceptance. What he wants is... that he wants a level of benefit with low cost, which everybody else does too. And I'm not normalizing his behavior or anything like that and the money and so on and so forth. But I believe that he got caught up in those relationships and people aren't nice and linear. I mean, we know that. We know that. Because then I want to circle back to what... And is it okay that I call you Roger? Cause you can call me Dan, you gotta call me Dan. But I think that this individual that you see, like I initially when I was reading it, I said, oh, maybe he's on the autistic spectrum that we're seeing some traits there. But he's not, I don't believe he is based upon again through the lens of the book. I think that you have somebody who is exceptionally high functioning, who's trying to understand the interpersonal world that doesn't really. Sean (49:41.936) Of course, yes. Dan Fox (50:06.965) operate on a nice cost and benefit analysis. And then you realize this new burgeoning area of cryptocurrency, and it's so ill-defined that you can then try to add this framework of cost benefit to get a greater understanding. And I think that he was able to do that to a very small degree. He did lose a sense of control and insight. I don't, having worked with sociopaths, for over two decades. He doesn't come across as a sociopath to me. What he did, that behavior may hit as sociopathic behavior, whereas he had Elmira research and he used that in order to funnel money, because if we start saying that funneling money is, that's probably more of anti-social behavior than it is sociopath. Sean (51:02.232) Yeah, I'm trying to think back to Roger's comment about, you know, why the adaptive personalities, you would think those would be forced out of, um, out of a society if they didn't benefit you with like, why do they still exist? I see people like maybe Elon Musk or Sam Bankman Fried trying to push certain areas to progress what their idea of a better society would be, um, by often doing things that are outside the norm that many people would feel uncomfortable doing. for a greater good. Is that why they would still exist in society? Or, you know, the human behavior would still allow it to happen? Because it is rewarded, and you can have great success and meet the criteria for a quote unquote personality disorder. Which goes back to probably one of my earlier statements. In fact, there are papers written out there that it provides a evolutionary advantage in a capitalistic society. So think about where we are in the United States currently. What about the top 1% just keep getting richer and richer and richer? They own the politicians. They're able to influence policy. The banking industry has become absolutely criminal. And if one of the core traits of somebody who kind of works on this triad of antisocial personality disorder, narcissism and maybe, you know, histrionic or maybe some other condition is kind of a lack of empathy, but desire for attention, power and control. You can see that, that they can work on the fringes of what society deems morally acceptable because they don't adhere to those rules. And so I think they are actually in positions of power and influence because they don't follow the conventional rules. Because they're rule breakers. They are rule breakers. We'll sit here, you know, the three of us and, you know, I'd have a hard time laying anybody off. You know, I'd be, I'd think about their families and their kids and a number of those things. That doesn't necessarily make you a really good business person in capitalistic society. I'll say you're a horrible business person. Yeah. Sean (53:20.44) Because you have to almost think how does it benefit me or how does it benefit the shareholder or how does it benefit the company? And that's where I would argue with Dr. Fox. I said that a subset of those people, if they have the intelligence, if they have the skill set, that lack of empathy and that desire for power and control provides them an advantage in culture. Dan Fox (53:43.537) Mm-hmm. And I think, but now we've kind of swung a little bit from narcissism more to the antisocial spectrum, right? And... Sean (53:51.288) But let's face it, it's not so clear, right? It's not like you're either one or the other. And that's the problem with our field, the DSM. And everyone says, I am everything. I have this, I have that. When they blend together in a way that serves someone's life in their lifestyle. Dan Fox (54:11.429) Yeah, but also, so just to sort of encapsulate a lot of what we're just talking about, first of all, I think we absolutely touched on using the DSM appropriately and understanding it. So you talk about, earlier you mentioned about dysfunction, that divorce and then subsequent depression, and that is, does that qualify as a disorder? But the universal criteria across all. all disorders in the DSM is socioeconomic dysfunction. Now, the problem is most people who read the DSM focus on A. That's not in A. That's always in the last little paragraph. Sometimes it's D, E, whatever it is, F in some cases. You have to hit socioeconomic dysfunction to qualify. If you don't, that's why you have the unspecified if you have to qualify. The DSM-5, I think is making an effort, and I can't even believe that you have me supporting the DSM here. I can't, I don't know how you did it. You guys are doing a hell of a thing, but right, that, because, but, and then I'll say this and then completely just be hypocritical in a second. So, but the point of the DSM-5 is for us as a field to recognize the dimensionality of all of these traits and all of these symptoms. Sean (55:15.804) Hehehe Dan Fox (55:36.113) and we have to look at the individual and not keep stamping everybody, oh, you know what? Like bipolar disorder, for example, massively misdiagnosed. We have two years of typical, and this is research supported, average amount of time is two years misdiagnosis period. Then they finally say, oh wow, you really meet criteria for bipolar disorder. Who knows what the heck they were diagnosed with before that. Because again, you have a misapplication, a misunderstanding of the system in which it works. Also, is it a perfect system? God no. And is it, are components of it broken? Yeah. Sean (56:10.832) It's a horrible system. The whole thing should be thrown out, Doc. Dan Fox (56:16.009) But if we did that, how would we identify behaviors that are self-destructive? How would we identify patterns that are destructive to themselves? Sean (56:29.52) How do we identify them? You speak to them, you describe them, you articulate them, you conceptualize them, and you apply it to the individual under that context. The problem with trying to use a DSM is we throw out these terms as if they're widely applied to people in the same way. I have a clinic here that specializes in the treatment of BPD. We have full model comprehensive dialectical behavior therapy, well-trained. uh, psychologists, board certified. We do it very, very well. I've been working with that diagnosis of BPD for quite some time. I've never met the same person twice. In fact, a lot of times there are just such extreme similar, uh, dissimilarities between people based on their own life experience. But we use the same diagnosis because of the pervasive patterns and interpersonal struggles, uh, fears of abandonment. identity development concerns, and emotion dysregulation, those core deficits in those areas. So we label it. But at the same time, if you look at all the other diagnoses, a lot of the other mood disorders that exist, they can meet comorbid diagnoses at the same time, because they all overlap. And that's the problem. They overlap and they don't define the person. I think they've created harm. So I do believe we should throw it out. work on a more dimensional system, use more science, especially in terms of like evolutionary biology and talk about things in terms of on a spectrum. Like Harvey Weinstein is a great example of this, right? Before the Me Too movement, you can sit down with Harvey Weinstein, right? You can do a full psychiatric evaluation on him and you could probably come to some conclusion around narcissism or antisocial personality disorder. But where are you going to find the impairment? Like where are you gonna find the functional impairment until he gets arrested, right? So we're talking about before he gets arrested, he's got power, he's a multi-billionaire, he's running, you know, he's running Hollywood for the most part. You sit down and how do you diagnose somebody like that? Dan Fox (58:43.241) So I think first of all, and. I think that you just basically, you just supported everything I just said, so I appreciate that. So in that being that, I think that you have to have someone qualified to do that assessment. Let's go back 15 years before Harvey Weinstein, right? You pulled back the curtain, you saw that. These aren't new behaviors for that individual. But I can tell you that if you had a qualified individual actually doing the assessment, using the measures appropriately. identifying particular personality aspects, various traits, and functional patterns, you would absolutely be able to not conclusively, right? Because what in our world is conclusive? I mean, where you say A always equals B, hmm? Sean (59:28.624) A broken tibia, cancer, a broken tibia, cancer. That's conclusive. Dan Fox (59:33.881) No, you're going to say that cancer is always conclusive. So what's the conclusion? Is that if you have cancer, there's so many variations of cancer. By the way, if we throw out the DSM, better throw out the PDR and all that other stuff too. So then cancer doesn't exist. So now we have to talk about, well, just, and you did a great example because you talked about and you used BPD because you shouldn't, if you don't believe in the DSM, you shouldn't use that term. So then that means you'd have to say, well, we have a variety of clients that have patterns that are pretty similar to one another. However, they are different because we do have underlying patterns of abandonment, some emptiness, some rejection sensitivity, and we see propensities toward these issues. However, and that means that you are then describing each individual in such a broad, broad way that you and I and other professionals that are in the field trying to use lenses so we understand what's going on. The DSM is not for identification, it is for treatment. And we've gotten away from that. It is not meant for self-definition. And like with my clients, when I start with them, they say, well, I'm BPD. Whoa, no, you're not. You may have BPD, but you are not BPD. Cancer, great example. There's so many variations of cancer. Cancer doesn't equal death. So we can't say that it's always conclusive. Sean (01:00:50.808) Yeah, well, let me... Well, I mean, you can identify a tumor. You can identify a broken tibia. Dan Fox (01:00:58.633) Tumors are always cancer. Sean (01:01:01.676) Well, you can get it tested and you can determine if it's malignant or benign. Ben or benign. So I'm just saying there's objective testing that exists. Dan Fox (01:01:10.185) But you have to classify that tumor, right? What would you use if you didn't have systems like this in place? The imperfect. Sean (01:01:14.072) But that actually does drive treatment, Doc. So like if, when my kid tears his ACL and has a broken tibia and he has to go see an orthopedic, that does drive the treatment. There's gonna be a surgery, there's gonna be an intervention. But in our field. Dan Fox (01:01:27.805) Well, wait, we're not gonna have specialists anymore. We don't have specialists anymore because there's no DSM, there's no PDR, there's no system, you don't have a specialist, that's gone. Why would we have a specialist? You don't have any system in which to put them in. Sean (01:01:41.536) Well, I think we're making two separate arguments. I'm trying to say that when you go see an orthopedic surgeon, for example, that we can clearly identify a condition, and that drives treatment. But if you go see a psychiatrist or a psychologist, that's not so clear. And the use of a DSM, which is crude, limited constructs that were originally brought into the system for classification to be part of the system. So actually, psychiatrists and psychologists could bill. under the burgeoning healthcare system that uses insurance and to be part of the system, just like the ICD-10 which existed. Is it also kind of guardrails for treatment modalities? Well, it's attempted to do that through an entire movement of identifying empirically supported or empirically validated treatments, but they're based on invalid constructs. So I think what Dr. Fox is trying to argue is that there's clinical value to identifying these disorders because it guides the treatment. And I'm going to say, I'm going to disagree with him. I'm going to say individual conceptualization of a patient's history and problems can guide an intervention, but a diagnosis doesn't drive an intervention because it's categorical, it's invalid. It doesn't... take into account all the individual patient variables that exist. I think it's a problem. I think it has harmed us, not helped us. So that's my argument. Dan Fox (01:03:17.929) Yeah, no, and I respect it and I absolutely hear it. However, the point of the DSM-5 is to step away from the categorization, right? Because it oversimplifies the condition. When used appropriately, how we're supposed to use it, which many people don't, but we're supposed to see it as categorical. We'll notice in the DSM-5, can't believe it got me to... with in the DSM-5, right? That you have mild, moderate, severe, in some cases extreme. If we're gonna talk about personality disorders, you have the alternative model of personality disorder, which is much more functional. It's much more complicated, but it talks about core content and surface content. It talks about those driving internal factors of then what drives individuals, right? To behave in a particular way that is destructive, that creates socioeconomic dysfunction, that then impacts not only how they live their life, but also relationships. But we don't have that because people complain. So that's why it's still in section two. We have the 10 that were there from 1980. If we go all the way back to the DSM-1 in 1952, then we see that they were so confused about what was going on. You had all these conditions. And when you talk about the development of the initial DSM 1952, you're talking about Physicians, right, because there were psychologists at times, so you have psychiatrists and physicians that were treating mental health concerns, and they're like, I don't know what the hell you're talking about. What are you talking about? Just Steve, whoever Steve is. And then they're like, well, wait, we need a system in which we can communicate. Has that become convoluted and adulterated and all of that over time? Absolutely. Do I think that it serves a purpose when people understand what it is and use it correctly? I do. I think that it helps us to communicate as professionals to one another. Is it perfect? God no. Is it misused? God yes. And we're going to see more and more of it. The more people are able to Google it and say, oh, criteria A, oh, wait, I have periods of time where I have high energy. I'm not sleeping a lot. I'm restless. I feel like, oh man, you know, I'm bipolar. Or, you know, I come in and I get agitated. Oh, I'm bipolar. Wrong, impulse control disorder. Dan Fox (01:05:40.869) So I think that it is absolutely misused, millions of times a day, but I think that the underlying purpose and what it can provide is helpful. Is it perfect? God. Sean (01:05:54.584) Yeah, I think it can be I can I think it can be really harmful. Let's imagine let's imagine a situation where and it's hard for us in the United States actually manages but let's just look, you know, globally, let's say you lived in Ireland in the like, the Northern Ireland, okay, in like the 19s. Let's go back to the 1930s 1920s. And you resisted the occupation of the the British Crown, the British government in your territory, right? You thought yourself of an independent state and 80% of the population would just adhere to the, the Crown's rules, curfew at 10 o'clock, pay your taxes, and so forth. Okay? But there was a percentage of Northern Ireland that would resist it and they gathered together with a with an army that would fight against the occupation of the British army. Some people believe that they were meant to be free and they will never be controlled by anyone and your rules do not apply to me. Couldn't they be provided a quote unquote personality diagnosis or designation by those in positions of power, of authority to support the state, for example? Dan Fox (01:07:21.27) I don't want to be flipping, but back in that time, they didn't have that and they would have probably shot them in the street. Sean (01:07:26.412) Yeah, but I'm just saying you can easily then just say that could happen in this culture, this context. Things we do see is the person with the more powerful attorney in a situation can hire a psychiatrist or psychologist to do in a full evaluation and then be able to identify the person that they're suing with a personality disorder or a mental illness diagnosis. You see this in marriages too, where one partner... Dan Fox (01:07:27.997) Yeah, yeah, yeah. Sean (01:07:54.228) identifies as the other to have these personality constructs and diagnosis. And you can always pay for that diagnosis and bring it into court, because an expert will come and they will get on the stand and they will use their pseudoscientific concepts around the DSM and maybe a personality measure that they administer. And then Cherry picks some evidence to fit it, go on a stand and say, this person meets DSM criteria for borderline personality disorder, narcissistic personality disorder, and boom, now we're making it something that it was never intended to do. So like, so Dan, I mean, you're describing it in these terms where we can generally speak to it with the right person who's using it responsibly to help conceptualize a person in a collaborative relationship, to drive some intervention. Maybe we can then also use it to build their insurance. And it just kind of misses the greater context of the problems with psychiatry diagnosis and psychology is because people believe that they're really definitive, they're really enduring and they're objective and we can use these measures. And once an expert uses the diagnosis as if that has no negative consequences. Dan Fox (01:09:15.433) So, in many ways, I think what you're tapping into is professional ethics, right? Is using diagnostics appropriate? You can put it on the medical field as well, right? You can put it on certainly the psychiatry, psychology, mental health field as well. I think absolutely. I think that that's why you have people who do a good job, whether they're putting the tires on your car. They're fixing your car or they're helping you develop adaptive strategies so that you're not cutting yourself. Right. So that when you encounter something that ignites a core content of rejection sensitivity and you get a feeling of intense despair and you don't have adaptive coping strategies instead. So then you decide to cut yourself that that's then you go to someone who can help you manage and learn those things. I think that you have professional ethics. You have people who know how to use it. Is that gonna be adulterated and has it been used inappropriately across time? We could go before the 1920s. And absolutely, without a doubt, human beings are driven to find the angle. They always are. And the cool thing about it is we got these neat little boxes, right, that we're all addicted to. We have all of this great luxury. I don't have to be in the room with you guys, as much as you guys look like you got a nice room going, so it'd be nice to be there, but I don't have to. Do you think we'd have all this access and it was a horrible thing, but with a pandemic? Absolutely not. So I think we're talking about professional ethics. And trust me, I've given testimony, I've been in court, I've worked with people that have done things we won't even talk about on here. And- that they have found mental health providers who have said, they're, nah, they're fine, they're fine. They're fine. So, but again, I think you're talking about skill level, you're talking about ethics, you're talking, there's so many components. And I don't think to say that the DSM is the center. Sean (01:11:32.964) Doc, let's face it, you can talk to five different people who can give five different diagnosis. So any system that lacks that inter-rater reliability is not a valid system. And I think we have to move beyond acting like it does. I know we're trained that way. I know we go in, I know you benefit from it. You're a psychologist who writes books on the disorder and teaches in the school, so you benefit from it. But any system that allows for that Dan Fox (01:11:33.001) devil of it all, not the ring religion! Sean (01:12:02.648) degree of inter- or, ir- reliability is a, is problematic. And that's once, once you integrate it into society and act as if they're real, discrete clinical conditions, as if there's real strong evidence to support it, well, that's when we run into the problem that currently exists. And then yes, okay, then there's certainly unethical professionals, but there's also a spectrum of professionals. You know, there's really strong doctors and there's really poor doctors, but they're all doctors. and they all have a license and they all can be identified as an expert. But when the system itself is misused, when the diagnoses are identified as disorders, as if they are any other medical condition with objective reliability, and we communicate it that way, that's why you have a society saying, I have borderline personality disorder. I have bipolar disorder. I am this. This is what has been brought into our culture. Dan Fox (01:13:00.209) Not to cut you off, but they say I am. They use it as a description of self. Sean (01:13:03.48) They say I am and they say I have, right? They say I have and I am, right? I have this or I am this. Like you go out into the grocery store, you don't wear your mask during the pandemic, you get COVID, you say I have COVID, right? But does someone actually have ADHD? Do they have borderline personality disorder? Or is just this a way we as a society have communicated symptomatology? Dan Fox (01:13:05.969) Yeah, I would either prefer to say I have. Sean (01:13:31.736) You know, something, if somebody is struggling with focus and attention, regardless of the cause, because it has no explanatory value, then I can add on the diagnosis. If somebody without having any explanatory value meets this criteria for borderline personality disorder, regardless of the person's history, context, you say, I have this, right? But it doesn't really give us any information on how to intervene. Dan Fox (01:14:00.061) Okay, so first and foremost, I think that if we take the initial part of your argument, that means we're also throwing out medicine too. But it's nice that we're able to use it. Yeah, it is. Well, because you can go to one doctor who can say it's COVID, another, even if you have a test, because tests aren't 100%. So I can take a COVID test at this point. Nothing is 100%. You're using a lens against... Sean (01:14:09.861) No, it's not throwing out medicine, doc. Don't say that. No, it is not, doc. You can have objective testing. Dan Fox (01:14:27.401) the DSM saying because it's not perfect and because it can be misused, it has no value. Sean (01:14:34.037) Doc, are you actually comparing making a psychiatric diagnosis to making the diagnosis of strep throat, for example? Dan Fox (01:14:48.286) Because I'm thinking. That's why it's quiet. Thinking. Sean (01:14:51.216) You're gonna have to think long hard on that one because you don't want to go down that road. You don't want to compare narcissistic personality disorder to the diagnosis of strep throat. Dan Fox (01:15:01.053) Well, that does bring up the issue of what do we talk about the neurological correlates that we can identify that show... You know what? Let's play a little. I mean, you know, this, I really, I'm kind of enjoying this really. I mean, this is really great because I think these are discussions that need to happen, like I'm not a delicate flower. I'm not a wallflower. Sean (01:15:09.916) You sure you want to go down this road with me? I'm warning you ahead of time. Okay, let's do it. Gloves are on. Sean (01:15:29.472) Agree. Yeah, I agree. Dan Fox (01:15:30.901) And I'm not arrogant enough to believe that if you don't believe what I believe, then you have no value. That's ridiculous. But I think that ultimately that we're seeing, for example, neurological correlates. I'm going for it, Roger. I'm going for it. But what we find is that narcissists, individuals with classified narcissistic personality disorder have a greater proponents of gray matter than those that don't. I know. Sean (01:15:56.736) Oh God, such, oh my God, doc, doc. Dan Fox (01:16:00.737) I mean, I wish I said it. This is great. Sean (01:16:03.78) Doc, that is such pseudoscientific nonsense. You're trying to, so if you talk to any leading neuroscientist and you ask them, on a scale of one to 10, how much do we really know about the human brain, the inner workings of the human mind? They're gonna say, maybe a three at best, right? And if you're gonna try to take like, Dan Fox (01:16:08.962) Oh my god. Sean (01:16:31.924) imaging studies to try to identify the presence of a psychiatric disorder. No legitimate scientist is going to say we know much about that. Because of such the rate, hold on, I said legitimate scientist, not a scientist, a legitimate scientist, because this goes back to ethics, right? And I made this point on a previous podcast, you take somebody who's depressed, for example, right? They're in a depressive episode. Let's say it's legitimate. Let's say they Dan Fox (01:16:41.473) Oh, hold on, well, now that... Sean (01:16:59.716) They lost their job and their girlfriend left them and their dog died, okay? Dan Fox (01:17:03.433) But you don't like the DSM, so you can't use depression. So go, something else. Sean (01:17:06.24) No, I don't use major depressive disorder. I can say depression because that's a word that we use to describe something that is very typical and normal to the human experience. I can use extreme sadness, I can use other words. Depression exists as a condition. There's nothing called major depressive disorder. That's made up. That meets these criteria for two weeks and you would have like five out of nine symptoms. That's completely different, Dr. Fox. But let's say that somebody does You know their dog dies there, they lose their job and their girlfriend leaves them, right? And then like three weeks later, okay, you get them under an FMRI and you're measuring different aspects of the brain that are activated, right? Obviously there's gonna be like a depressed brain, potentially, right? Because in the crude limited matter that we measure a depressed brain, okay? Does that mean there's something wrong with his brain? Let me just answer that question. Does that mean there's something wrong with his brain? Dan Fox (01:18:07.733) I think that what you're doing is I think that you're extrapolating from that one particular instance. We have individuals that... I know. Oh, I believe me. I see it. Sean (01:18:12.492) No, I'm going to walk you down a path here. I just need you to answer the questions first. I've been down this path. Dr. Fox, good luck. But because, wait, because how you answer, how you answer the question determines like where we're going to go in this discussion. Would you say that there's something wrong with his brain? Dan Fox (01:18:19.889) Yeah, John, I think it's coming. I'm feeling it, but I'm liking it. Dan Fox (01:18:33.253) In three weeks, that brain is not going to look the same as an individual that has experienced depression, as you're saying, for ongoing three years. You're going to say that those two brains will look the same because our system is so just all over the place. And by the way, it's our medical system because fMRI, right, that is just a whole horrible, horrible system. So we're going to say... that years an individual who is depressed for years, right? We don't wanna go down any diagnostic roads, right? They're depressed for years. That brain is gonna look the same as someone for three weeks? Sean (01:19:13.56) I don't know if someone's brain is, I think the brain of an engineer is gonna look different from the brain of a teacher. I think the brain of an artist is going to look different, an artist who's 27 is gonna look different from an artist who's 56. And I think my brain will look different in the morning than what it does at night. I think you're Sean's brain, this is my brother across me. I think if we analyzed our brains and at different times of the day, what I'm telling you is we can't extrapolate conclusions from such crude and limited technology. Dan Fox (01:19:26.453) Your fMRIs are youthless. Sean (01:19:41.1) And it doesn't mean that there's something wrong with somebody's brain. The brain is still a complex mystery as is the human experience. So it depends, why is someone depressed? Why is somebody depressed after three years? Are they metabolically ill? Are they overweight? Have they been on these psychiatric drugs for three years? Yes, there's gonna be a diversity of different brain imaging and the way the brain works. Dan Fox (01:19:49.557) Thank God we have those strep swabs. Sean (01:20:05.944) But that doesn't create a, there's no conclusion that says that meets this criteria for a diagnosis and we can do a brain imaging study and diagnose somebody from that. We've never gotten to that point with our technology. And so when I say that a legitimate scientist is going to acknowledge those limitations and not communicate these things as if they're hard science. And that's the problem. I don't think psychiatry and psychology are hard science where if I can put someone through an X-ray and see a broken tibia, we can identify that along with other things, right? There's pain, the inability to walk. So we're trying to meld those two systems which became a problem in American society. And the moment we started melding those two systems is when we started to create this idea that the emotional experience and human behavior can be limited to some biological correlate, some identification genetically, or even going as far as brain chemical imbalances. which has led to the mass manipulation of these complex concepts to the entire Western world, basically to medicalize it and to sell drugs. And we have to be, psychologists to be ethical, we have to be aware of the limitations of our field and how we diagnose. And that's for we cannot compare strep throat to histrionic personality disorder as if like, they're both can be easily and objectively identified in the same way. Do you get my point, Dr. Fox? Dan Fox (01:21:38.097) I do get your point, just to say with the strep throat, I think there's more than one type of strep throat. And I think that we have to look at those variations. But also, I think that we also have to recognize that a five-year-old doesn't know as much and can't run as fast as perhaps a 25-year-old, right? And what we're doing is, is we're looking at psychology, Sean (01:21:42.86) Hehehehe Dan Fox (01:22:07.353) which is a pretty young science, and we're comparing it to medicine, which has been around a lot, lot longer. Now, we can kick the hell out of psychology all day and all of that, and we can say that the DSM is imperfect and all this other stuff, and I get it. But the reality is, and boots on the ground and front-line psychologists and mental health who are up against, you know, what am I working with? What am I doing? Who is this person? They need a system, right? They need some way to understand who they're working with so that when they say that, you know, your example of the person who has experienced a degree of loss for three weeks, that's not the same type of depression and issues and factors as somebody who has experienced depression for two years. I just think it's different. I think that I... Sean (01:23:05.708) Yeah, but doc that person who experienced depression for three weeks can turn into that person depressed for two years based on how they cope, based on how they live, based on how they respond. And I wouldn't say that's anything that's related to their brain that you could then predict ahead for three years, which is my point. When you because you started this conversation with like neurological correlates, right? That was your point. Dan Fox (01:23:13.329) Yes, absolutely. Dan Fox (01:23:29.334) So now... Dan Fox (01:23:36.989) Yeah, but now if we're going to talk about predictability, so do you believe that the DSM should have a higher predictability factor? Because I don't think medicine has a great predictability factor either. Sean (01:23:50.024) I would burn that fucking book and throw it out. And if you know how I feel about that. So no, I don't think it's reliable. I don't think it's not research-based. It has poor iterative reliability. It tries to take the complexity of the human experience and put it into a categorical diagnosis to medicalize it and fit it into a system and that in itself does harm. So no, I think it has no value. Dan Fox (01:23:57.834) I do know, I'm getting a sense of how you feel. Sean (01:24:18.472) zero value. The only value it has in a system is at this point is to bill insurance, which then has problems after that. So now I don't see any value. And I think everyone who I'm starting to interact with in my field actually acts as if these diagnoses are real. And they struggle to conceptualize, understand people. including all the context variables that exist over the course of a lifetime. I think it's made poor clinicians, dumber clinicians, limiting therapists to try to fit into that box than understanding people. I think it does harm. Dan Fox (01:25:02.025) So you mentioned a clinic that you work in, or you have a clinic. Sean (01:25:07.836) I run a practice, yes. Dan Fox (01:25:10.089) So in that practice, how do you talk about conditions and treatment you don't use the DSM? So I'm assuming it's all private pay. I'm all private pay. I'm just trying to get a sense of. Sean (01:25:20.32) No, we have to work. No, doc, listen to me, listen. We do have to use the diagnosis because I work in a system, I have no power there. So the people who come here use their insurance, they use their health insurance. And that was a decision for us to make because hardworking people who have health insurance want to be able to utilize that for mental health services. So I have to work in the system. That doesn't stop me from talking about its problems and trying to make change. But now this is... Dan Fox (01:25:47.753) But in the 1920s, you're going back to the 80% then. So you're one of the 80% that's like, yeah, you know what, all right, England, yeah, it's cool. Let's all be quiet. Because the 20% are getting shot in the face. So which is it? I mean, I guess. Sean (01:26:00.941) I would say Roger's getting shot in the face. Dan Fox (01:26:04.486) And it's a nice face, that beard, I'm looking at it, and that's a sharp looking beard. I could never pull that off. Sean (01:26:07.756) The truth of the matter is, Sean and I aren't here if we didn't have a great grandfather who left Ireland to come to the United States. But no, that's not my point. The point is, this is psychologist to psychologist here. And you want to know how do we talk about cases without using DSM diagnoses? That's your question, right? All right. So, I mean, but yeah, so let's try. Dan Fox (01:26:30.185) Yeah, yeah, I mean, you can, I get it. Sean (01:26:36.068) give me a DSM diagnosis and I would talk about it without, you know, calling it using the word or using the language. Dan Fox (01:26:44.269) Let's try something else. Let's try, okay, give me a minute. Okay, so 34 year old, right, white female, experienced extensive abuse, engages in private self-harm behavior, often will rub her neck as though it looks like that she is, has hung herself, does this about three or four times a month. Only when her children are coming over, not when the abusive partner is present, also has an extensive history of opioid dependence, alcohol, has overcome a cocaine addiction, but that one's kind of suspect. I don't know whether or not we're going to believe that. And says, I'm going to leave him tomorrow. Sean (01:27:42.892) Okay, so let me give you two different ways to describe a case. You tell me which one is more clear or more effective. This person has borderline personality disorder and histrionic personality traits. All right, put that to the side. That's A. That's A. Now let's talk about B. Dan Fox (01:27:58.586) Yeah, yeah, that, oh, that wouldn't be right, but okay. All right. Okay. Yeah. Sean (01:28:01.94) Well, I mean, how would we know? I mean, that's the problem. That's my point, right? Right. I think that's the value here is you have two psychologists that are debating over how to apply a label to somebody. And if anything, the value that anybody's getting from this listening right now, if you're someone who's in the mental health system, it's like, it's arbitrary. But that's why I mean, your doc, you're kind of proving my point for me, right? I want to know what the hold on. So doc says, well, that's not right. Dan Fox (01:28:08.776) Yeah. Dan Fox (01:28:13.41) I did it! Dan Fox (01:28:22.718) Well. Sean (01:28:25.816) Well, what the fuck? What is right? You give me limited data in like a one minute time frame and then you have to apply a diagnosis to it. That's why it's I'm talking here. This is why this is why it's invalid in itself. So what's the most effective way I would describe the person doc in a manner in which you did, but I'd be much more understanding contextual variables. I want to know when that person's more likely to use cocaine. When is that person more likely to fake a suicide attempt? potentially and how is that informed by what that person has learned, their experience in their life? Obviously, there's clear problems with self-regulation, the ability to regulate intense negative emotions. I have no idea how the environment responds in such a situation, so there's consequences to that. But we would be pushing ourselves to understand who this person is, how did they live, what did they learn, what happened to them, how does this serve them in these contexts but doesn't serve them in other ones? What would we have to target in a therapy, in a treatment? Is it around emotion regulation and distress tolerance skills? How do we best create a therapeutic treatment plan to help target areas which lead them to self-injure or turn to substance uses, which we would definitely think as multiple presenting problems to try to regulate intense negative emotions. But again, without knowing how the environment responds, we don't know how maladaptive it is. under what conditions. We don't know the partner that person has, the nature of their kids. How do people respond when she's suffering and struggling? And so that's my point is when you have a diagnostic label, it provides no explanatory value. It's just a label that two intelligent, well-meaning people can even disagree in, but you can't disagree about facts. The person has a trauma history, the person abuses this, the person cuts this. Dan Fox (01:29:58.525) Right? Yep. Absolutely. Dan Fox (01:30:11.454) Right. Sean (01:30:21.592) this amount of times in a week, that you can't debate because they're objective. You get my point? Dan Fox (01:30:26.697) Right. Mm-hmm. Yep. And the point that I initially was trying to make is, okay, so within your clinic, to talk about all of that, so what happens is, is that if you disagree so vehemently with the DSM, but you're okay using it in order to get reimbursement. So you use it, so I think you should be private paid. I really think you should. Sean (01:30:46.028) I'm not okay using it. Don't- I'm not okay using it. But my- Sean (01:30:55.036) But then most of the people can't afford to come see me. That's it. It's a difference. It's a difference between paying $15 and $185. And so that's an ethical decision because the system exists whether I'm involved in it or not, but I'm involved in it to help people. What I do outside helping people, getting on this microphone, getting on other podcasts, writing, doing the things I'm doing, that's to change the system. Having these conversations are to change the system. Dan Fox (01:30:58.513) Well, then I think them. Sean (01:31:24.12) But yet, unfortunately, it exists. And I am a psychologist under licensure laws. There's certain things I have to do, whether I agree with them or not, going back to personality disorders, right? I have to be able to adapt and be flexible because what I really wanna do is serve my clients. But we do have to make changes. Ethically, we have to do make changes about how we categorize this and how we give people effective care. I do think, I don't have to agree with it to participate in it. Dan Fox (01:31:52.789) But well, but I think that the problem is, I think that in order to change it, then you have to resist it. I think that you can't in one hand say, yeah, you know, I'll accept the money, that's great. But on the other hand to say, oh, it's horrible and it's not fair and it's unfair, it's terrible. Sean (01:32:05.292) I accept less money, Doc. Doc, I accept, Doc, come on, don't, let's be clear here. I accept less money by being part of the system. I'll ask you a question, how much does it cost for somebody to see you for an hour for therapy? Dan Fox (01:32:22.357) 250. Sean (01:32:23.468) Yeah, for us, we accept what the insurance pays, which is like 150. You make a hundred dollars more an hour than me. OK, so I don't benefit. Dan Fox (01:32:32.605) Yep, yep, yep. Are you sure you wanna go down this road, Ryder, because it's not gonna be good for you. Sean (01:32:38.352) I, Doc, I don't benefit. I actually can do much better financially by, by leaving the system. Dan Fox (01:32:48.949) So you asked how much I charge for someone to see me. So then I'm assuming you're making the assumption that it's 250 an hour. I see people along and I know you're gonna run with this one, right? So I work with people with personality disorders, right? I do not take insurance because insurance typically is gonna make me do this stuff, that stuff, and then they're gonna tell me down the road, well, too bad, I'm not working with them anymore, right? I don't charge them for emergency phone calls. I don't charge, right? Sean (01:32:53.518) Yeah. Dan Fox (01:33:16.333) I see my client way, way three times a week. I only charge them once. Sean (01:33:18.648) Doc, I'm not putting you on a defensive. I don't think you're doing the wrong thing, Doc. You don't have to defend that to me. I was just repeating back to you why I don't benefit from being in the system. I don't in any way criticize you for what you're doing. I think what you're doing, I'm sure you're doing great work. I think you care about people. And you deserve to get paid. You deserve to get paid for what you do. I don't want to go down that road at all. I don't think what you're doing is wrong. I'm just letting you know the decision that I made is I want to serve people who otherwise wouldn't be able to afford it. And, in order to do that, you have to submit a CPT code which uses the diagnosis. Yeah, I choose to be in that system for just to be able to help a lot of people I could never otherwise have helped. So I don't want to get down that road. Dan Fox (01:34:09.289) And I understand that. I understand that. And I think that the problem with sometimes, I think the problem that we encounter with these arguments, and you and I are saying a lot of the same things in that, you know, is the DSM a perfect model? Absolutely not, right? I think that it has a degree of utility. Is it the end all be all? Do we have? Would I say that it is the mental health Bible? I mean, my eyes are closed to say that because it pains me to say that, right? Because it's not just a simple tool or item. It's not the central item. Just as, right, whether it's a medical test or whatnot, is that there are additional components that people have to take into account, right? And the woman that I'm... I described, right, that is someone who, you know, yeah, she met a whole host of disorders. And the reality is, and since you said fuck, I'm going to say shit. So I'm going to say, but I don't give a shit about all that stuff because my approach is it can be conceptualized using the DSM because if I'm going to teach other mental health providers, I need to have a descriptive common ground. But do I use any approach? because I talk about core content and surface content. You don't see that written anywhere because we're talking about complex issues related to particular individuals that have unique suffering that other mental health providers will not touch. Insurance companies will not reimburse them, right? Have I worked with people for exceptionally low rate, including zero? Yeah. Did I love working in the federal prison system? Why? because the federal government paid me for 21 years to work with these people that were underserved and unrecognized. And I'll tell you, boy, I could tell you some amazing, amazing stories. And I could tell you some gross ass stuff too, but I won't. But I get it, I really think we're saying the same thing. I'm your brother, man. I just don't have that nice beard. Sean (01:36:22.833) Yeah, the value is the debate in the discussion. Like, yes, you guys are coming at this from two different ways, but you both are you know, working within the system that exists. Roger, I'm gonna say has like that oppositional defiance where he wants to rebel against everything that's so broken in an order to try and fix it. Or maybe Dr. Fox, I might be applying this incorrectly. You're you're working with the system as it exists for the ultimate goal of just trying to help people. You're both trying to help people. It's just a matter of how you're going about doing it. I mean, there's, I think there's clear disagreements here that presented itself over the course of the of the course of the podcast. He believes there's value in the categorical diagnoses using a DSM. He thinks there's value as a descriptor and being able to communicate between professionals. And he believes he believes in the value of psychological evaluation making a diagnosis and using it in the system I mean that's there's differences that exist I on the other hand would say that its existence is harmful That you're limiting the complexity of the human condition to put these labels and disorders and now it's five six seven because it's Dan Fox (01:37:12.991) That's true. Sean (01:37:36.284) unreliable. Once the label is assigned, people see themselves or apply things that aren't even about them. Not only them, but the system. I mean, you can get denied health insurance based on that disorder. You can lose your kids based on that disorder. You can lose your wealth based on those labels when they are unreliable and invalid. And one of the things that happens is to try to create validity around it. You have an entire subset of the medical profession, psychiatry, trying to legitimize themselves and trying to create them as legit, discrete medical disorders. And so what gets communicated to the general public does not meet scientific validity and legitimacy. And it takes people like myself to speak out against that, to inform people that because Sean (01:38:33.632) or neurological underpinnings that we've been able to identify. The drug that's using to treat this is much less effective than what you've been told and then the side effect profile and the problems associated with it are quite problematic and the long-term use is unstudied. All these things are grounded facts. So we speak out against them. And that's what I believe you have, we have an ethical right to do it. Now to work in a system to be Dr. Fox and say, all right, I'm going to specialize in this area as identified by the DSM. He has knowledge around that. You want to bring someone on to talk about DSM diagnoses around personality disorders. He's dedicated his life to using the measures, to communicate, communicating them in terms of ways that their clients can understand. And he sees value in it. Well, that's where I would, I would disagree. And I don't think our science is. quite strong at all. In fact, I find it extremely misleading to general public. But I know how we're taught. I mean, he's Dr. Fox is teaching so you have to teach to APA accreditation, you have to teach to the books that are out there. The DSM is the late is the diagnostic manual that's being utilized. So you have to teach psychologists therapists to be able to categorize what they see in front of them. My point is I just think that is harmful. Dan Fox (01:40:06.861) And I certainly see, I see your point. I think that it is a bit of a broadening of the argument within a system in which we operate and function. And I do believe that we provide a needed service, but I would say as far as the misuse of the DSM, I think that you can absolutely see that. So the criteria, the way it was originally constructed categorically was in 1980, right? So they put out these criteria, so on and so forth. And then, so let's say we just go from, all right, so people have had access or professionals had access, 1980 and 1990. We didn't see this manifestation of self, of defining self by the negative, by what's wrong, right? By these diagnostic labels, right? So I think the point of your argument, I think that if we look at the last 15 years, social media, right, access, access to information, the simplistic misuse of mental illness, of mental health to justify behaviors, to justify a poor definition of self, I think that we see those things. That I think is not the DSM's fault. I think that... that is in part the misuse of information that can be used appropriately to communicate issues and concerns between two professionals. Okay, go. Go! Sean (01:41:43.088) Doc, in 1980, how many diagnoses existed in that DSM? I think that was DSM 3 in 1980, right? Dan Fox (01:41:50.797) That was, it was DSM3. Well, you know what? So that's an interesting point, right? When you go from one to two, two was just a mess. So two was out. Sean (01:41:59.92) I'm gonna say it was like 250. No, it wasn't, Sean. Don't jump in there when things you don't know what you're talking about. We looked at, I'll pull it up. I'll pull it up. Uh-oh. Dan Fox (01:42:05.501) Yeah. So it did grow exponentially. And to be honest, I don't know the number. I know that it grew exponentially. Yeah. But I'm very curious to hear. Sean (01:42:20.948) Oh, Sean's right. Thank you. DSM DS DSM three was the big jump. So you go and so you go from I don't whatever was in DSM one and two and then you jump to 265 disorders and DSM three and then you continue to exponentially jump up right at one point homosexuality was Dan Fox (01:42:23.214) Oh, Sean! Sean, huh? You and I! Dan Fox (01:42:29.649) That's right. Dan Fox (01:42:44.107) Yeah. So how many are in five though? How many are in five? Sean (01:42:48.421) I know there's over 350, but they speak to close to 500. It's just a strange. Sean (01:42:58.828) It's just a strange way to try to identify and communicate the complexity of conditions. You're trying to turn it into the ICD. You're trying to turn it into something that medical professionals have used to classify conditions. And it was just a wrong decision. It was the wrong way to go. So, your argument is that, it had value at a certain time in a certain culture. And the reason that it's misused right now isn't necessarily because of the DSM itself. I'm saying the existence of the DSM allows it to be misused because it is so limited, because it is so simplified. The I have this can be, as soon as the general population has access to this information, they can start then identifying with them. But doc, it's just not the practitioner, it's not just the patients. It's not just the general population, it's the doctors too. How do you go to over 20% of the population at certain times on an antidepressant, right? So like, how can you go from something. Dan Fox (01:44:09.109) Well, okay, wait, are we talking about DSM or now we're talking about that in the United States, the United States consumes 75% of the world's medication, right? And it is massively overprescribed. I mean, now we're going to get into a whole other discussion. So if we're going to talk about the DSM, that's cool. And I'm right there with you, right? That it is a... I... Sean (01:44:30.372) But you can't separate the two. You can't separate the existence of major depressive disorder in its arbitrary limitations of two weeks of feeling bad and then the mass prescriptions of antidepressant drugs that were developed to treat this disorder we made up. You can't separate the two. Dan Fox (01:44:56.925) I don't believe that they are always intertwined. I don't believe that. I don't think everybody with major depressive disorder is the same. I believe that people exhibit major depressive disorder in different ways. And I think you would agree with me in that. Otherwise... Sean (01:45:15.084) I would say there's no such thing as major depressive disorder, so of course they're going to exhibit in different ways. Dan Fox (01:45:20.745) Okay. So that's a yes that you agree with. Okay. So if we look at that, but even those with major depressive disorder, we have mild, moderate, severe, and extreme, right? And not everyone with major depressive disorder takes medication. So one A doesn't always equal B because you have individuals, right? And we talk about treatment and we talk about engagement. And when you learn coping strategies and management strategies and so on and so forth. Sean (01:45:25.184) Yes, absolutely. Sean (01:45:48.408) You know what diagnostic expansion is, diagnostic inflation? When you put something in such a limited category and you say it's a medical condition, and then you create symptoms that can be widely applied to the human population at a given time in their lives, you increase the use of the diagnosis. The only value to increase the units of the diagnosis and to call it major depressive disorder is to sell drugs for it. And let's not act like the designation of mild, moderate, severe is not subjective either. We're using self-report measures. To me, what would be diagnosed as severe would be really difficult, very severe impairment in functioning, like people unable to get out of bed, it should be a certain amount of time, it should have a degree of chronicity to it. Like there's a lot of factors to it, but people are assigned the label of severe major depressive disorder all the time because if you spoke about in terms of mild or moderate, then people would see that as potentially invalidating and make the case for why it's severe. And then you add another words, well, I'm masking, right? So I am really severely depressed. I'm just good at masking it. All these things become part of the cultural lexicon. And the core problem is how we diagnose. The core problem is the diagnostic system in itself. It allows for where we are today. The reasons we have problems is because of how we talk about it, how we identify it, how we teach medical professionals, how we teach psychologists, how we teach therapists. That is why we have diagnostic inflation. Dan Fox (01:47:36.325) And I don't disagree with all that. I guess where we'll differ is to say that the removal of one component changes all. It doesn't. I mean, if you burn the DSM and somehow everybody gets amnesia and forgets about the DSM and things like that, it doesn't fix the problem. I think that... Sean (01:48:00.94) I'm not so sure about that. So let's use depression as an example, ask you a question. What if we communicated depression as transformative and necessary? As a culture, we said that in all likelihood, you are going to go through a tough time in your life that would meet the old criteria for DSM-5, but instead of viewing it as an illness, Dan Fox (01:48:03.729) Well, I mean... Sean (01:48:30.092) instead of viewing it as a disorder, we spoke about it as transformative. It is your body, your mind, your spirit, sending you really important messages to pay attention to. There's something that exists in your life that you need to change. And that can incorporate even biological aspects about this because obviously we work, we live in a sick society right now. So, you know, people with metabolic illness and thyroid conditions and sleep disruption. then develop symptoms that meet that major depressive disorder diagnosis, low mood, being lethargic, fatigue, all these things that can affect your thought processes. But if we just communicated it different, instead of disorder and a medical condition, something that deserving of assistance and help, of course, but it was transformative. It's here to serve you. That's cultural. And so anything that can be shifted. by how a culture views it is not very objective, is it? Dan Fox (01:49:35.481) No, and I would agree with everything you just said. I would agree with that. I think that just washing away the DSM, it doesn't achieve your goal. I think that it's not the devil. If you get rid of the devil, you don't have only heaven, not to get biblical. I mean, you know, I'm not a big old guy. But you don't. I mean, the world doesn't work the way, just as you mentioned. We are more complex beings. Are we more complex than a book with over 300 disorders in it? Yeah. I mean, yeah. Which is why, and it goes back to, I believe that we need to be knowledgeable of the various conditions that we encounter. I think we have to be knowledgeable about different treatment modalities and working with individuals to help them overcome the barriers that they encounter. Do I think that the DSM is the end all be all to that? God, no. But I think that. Training getting training right us learning what we're looking at how to treat it how to work with it How to help people identify and not identify you as the person By this, you know, oh, I'm depressed. I'm major depression disorder. I'm BPD. I'm NPD People are more than that and it has to become a separation But we don't and the more the reality is the more that we've got all this social media and all this other stuff and people want to simplify it to do a definition of self because they're not doing, and this includes professionals too, they're not doing what, and here come the air quote, what perhaps they should be doing, which is that you have to learn about it, you've got to deal with those barriers, and you've got to learn to overcome it. I don't think that the DSM cures it all. I just don't. Sean (01:51:22.736) Well, I'll just simplify to this and we'll work towards conclusion. The existence of a DSM does identify them as medical conditions and as categorical diagnoses. So it is used to fit in a medical system and medical systems use categorical diagnosis for the diagnosis of disease. So it is the communication to the general public as a disease state, as a disorder, and certainly with biomedical origins. So that in itself is misleading. Dan Fox (01:51:29.973) You can go all day. Sean (01:51:53.732) at best and completely fraudulent at worst. So once you eliminate that conceptualization, you are shifting how the American people, how Western cultures actually view their lives and the emotional experiences of those lives. And so I think that's a necessary step in the right direction when some of these systems have to be rebuilt. And I do think psychiatry and psychology are going to need to be rebuilt. We had a psychiatrist on here once who said, Really, if it's just about communication, we can put it under like five categories, right? We can talk about mood, we can talk about anxiety, we can talk about kind of like obsessions and compulsive behaviors that exist, and you can talk about like psychosis and delusions. And that's enough to be able to like communicate symptomatology if you wanna categorize it. You can just put it under that, a general mood. Is that Dr. Brett Deakin? No, he's a psychiatrist. from, um, uh, Dr. From Colorado, who, uh, Heacock, Dr. Heacock. Yeah. And he's a psychiatrist who said, yeah, I mean, if it was just about communication, uh, which in some way you're advocating for, let's keep it simple for what it act, you don't need to have like 30 different diagnoses under anxiety, right? Let's just call it the general, it's the experience of fear and the, and the human fear response. And that could manifest itself in worry. It can manifest itself post-trauma. You know, there's ways that you can communicate and articulate these conditions without using that book, which its own existence right now, as I mentioned when I started was. financial for the most part. You're talking about something that's totally corrupt. $14.2 million in pharma money goes to the DSM-5TR task force and review group members, and then in itself, for everyone having to buy it with each revision, that's millions of yearly revenue. It's corrupt. And I do think this podcast has to be able to... Sean (01:54:01.944) you know, identify the corruption where it exists, the pseudoscience where it exists, but talk about alternatives. You know, so when I say we can end the DSM, I really mean it. And that's not just to blow up a system that has some form of value. No, I think it's harm, but we can grow in the way we talk about the human condition. And unfortunately, psychology, clinical psychology, has not advanced itself by integrating into the system. We've had to become a part of it to survive. And I think that's an unfortunate consequence of melding with the medical model and the medical system. And yes, unfortunately, I have to be a part of it with the diagnoses, because there's no other way for me to provide my services, even if I didn't accept insurance. By my licensure law, I still have to provide a diagnoses. And that's the problem. You know, it's so intertwined to be a licensed, I'd have to say I'm not gonna be a licensed clinical psychologist. And then obviously then someone just says, I'm not practicing within my scope of expertise, which wouldn't be true. To become a licensed psychologist, I just have to follow your rules. I have to pass your test, your exams, I have to jump your hoops, and then I have to live by your rules. So in order for me to actually be critical of the system in which I work in, I have to do other things. I have to do consulting, I have to do speaking, I have to do a podcast. And that's the direction which I've chosen. And Dr. Fox, I do really appreciate you coming on here and talking about your perspective, right? And sharing your viewpoints on this. And you work within these diagnoses, you've created interventions, you've created workbooks, you've written extensively on it. How can people... find you to learn more about who you are and your work outside of today's debate that it turned into. Dan Fox (01:56:02.033) Yeah. So, I mean, I have a website. I do sell copies of the DSM-5. No, I'm just kidding. But I'm just kidding. I'm messing with you. No, I have a website and you can find me, you know, it's drdfox.com. Also, I have a YouTube channel as well. If you just Google Dr. Daniel Fox, I'll come up. Sean (01:56:13.939) laughter Dan Fox (01:56:29.961) But ultimately though, what I think is important is that I think that these kinds of conversations have to happen. It's okay for Sean, Roger and myself, for us to not sit around and say, oh, I totally agree with you, I totally agree with you. We can't, we're losing the joy and the benefit of debate. And I think... because people are sensitive and overly sensitive. And I dare to add the over, but, you know, I think that we have to be able to hear, you know, I mean, and I respect your viewpoint. I don't agree with all of it, but I agree with a lot of it. And, you know, Sean obviously wholeheartedly agrees with me, which is correct. And I'm not just kidding, but. Sean (01:57:24.632) You just discredited your position for your entire podcast. Dan Fox (01:57:27.789) Oh, man. Oh, no. But I do. I think that we need to have these discussions, and I think we're having fewer and fewer of them. And we need to be professional, mature, and be able to go at each other respectfully. And that's how we grow. And I think that we're losing that because people are becoming, to go back to... Um, you know, and, and I, and I know we need to end, but just to, just briefly to say that, um, I think, you know, we. We interpret everything and we quickly internalize it and make it about me. You know, I, I'm comfortable with who I am and, you know, and all that other stuff. You don't have to agree with me. And I respect your, your viewpoint. And you're going to help the field go forward. I'm going to help the field go forward in, in various ways. And I think it's, it's okay to do that. And I respect you guys for having the podcast and, you know, and recognizing we don't have to agree. But. Let's hash it out, man. Let's tear it up. Not the book, the conversation. Sean (01:58:28.964) That I agree with. Yeah. That I agree with. It was a radically genuine conversation. It totally was. Yeah. I'm happy that we, that we were able to kind of transition into that and, and have some back and forth. And I hope the listeners themselves saw that as, as valuable. Dr. Fox, I want to thank you for a radically genuine conversation. Dan Fox (01:58:53.989) Yes, well you're very welcome. Thank you guys. Thanks for inviting me on, I appreciate it.