Fevers of Unknown Origin

The ideas and viewpoints expressed in the posts on the Ideas and Creations blog are solely the view of the author(s). Luther College's mission statement calls us to "embrace diversity and challenge one another to learn in community," and to be "enlivened and transformed by encounters with one another, by the exchange of ideas, and by the life of faith and learning." Alumni, faculty, staff, students and friends of the college are encouraged to express their views, model "good disagreement" and engage in respectful dialogue.

It is always valuable to have your profession viewed from an outside perspective. What follows is a view from within the profession of how I would hope to respond and think if a student asked me for an extension on a paper, informing me that his or her anxiety and depression had been acting up and making it difficult to concentrate on his or her work:

I'm really sorry to hear that. I'm glad you feel comfortable sharing that with me. I want to respect your privacy, so you certainly don't need to share any personal details, but may I ask how you are doing? Please know that I will keep this between us unless there is some kind of emergency.

Are you finding the support that you need from your friends and family? What can Luther, and more specifically, what can I do to help as your professor? I can't be your therapist, but I want to do anything I can to support that process.

Are you working with a professional that you feel understands your experiences and is helping you to live a valued life? If not, can I help you with a referral?

Anxiety and depression are becoming more common on college campuses. We have solid science to back this up, including annual surveys conducted by counseling centers across the country. In fact, Luther participates in such research.

I want to make sure you have a good counselor. An accurate diagnosis is a major component in designing an effective treatment plan. I have conducted more than 1,000 psychological evaluations and hundreds of hours of individual therapy. I have been through five revisions of the DSM, the so-called "bible" of my profession. It is far from perfect, but I want to make sure that you have a counselor that takes into consideration the various reliabilities and validities of the diagnostic categories and the quality of the science behind associated treatments versus Dr. Phil, drug commercials, historical anecdotes, etc. No classification system is probably perfect. Medicine has its FUOs (Fevers of Unknown Origins) and ornithology has its LBBs (Little Brown Birds). I imagine that in all fields, there will always be a struggle between nefarious forces like commercialization and politicization versus the advancement of a compassionate science, but your counselor should be able to sort through these competing influences and bypass any agendas, personal or professional. It is my job to realize that what cured my fever may not work for you and that I need to own the origins of my fevers. My guess is that even the "real" Bible has its inconsistencies and prejudices and that some people try to manipulate the wisdom in that book. Honestly, I can't say that with authority, because that's not my area of scholarly teaching, practice and research. So, I'm going to leave fevers, birds and gods to those experts. All I know is what I know and I try really hard not to be certain of that.

I guess what I'm trying to say is that life can certainly seem confusing at times with misinformation, counterintuitive principles, unintended consequences, and the like. Anxiety and depression can take so many forms and while there is clearly value in learning from painful experiences, there is no wisdom in suffering needlessly. I've had patients with significant depression not engage in basic hygiene for weeks and I've had patients with significant depression present with a smiley face and meticulous grooming. All were hurting underneath and it was affecting their lives. I have seen patients wanting a diagnosis when one wasn't warranted and I have had patients discount diagnosable suffering for decades. In all cases, regardless of whether a diagnosis is warranted or not, it is our responsibility to promote their autonomy working from their perceptions of their conditions, regardless of how ultimately valid that might be. We meet them where they are. While it is easy to cherry pick the semantics of specific criteria to build a case or a generalization one way or another in some feverish manner, the most important criterion for any diagnosis is if the symptoms, however they are presented, even if they wax and wane at times, are interfering with you having a successful life. I'm pretty sure we could find unethical scientists and practitioners in any field, but that's not a valid indictment of a profession and discounts extensive positive contributions that likely far outweigh the proverbial bad apples. I would never encourage you to stop voting just because our political system has some corrupt elements. Let me help you participate in life. A helping professional never risks stigmatizing human suffering in any way.

And, probably just like in class, your old professor is rambling a bit, but I want you to know that a successful life is what I want for you and that I and many other people on this campus take your pain seriously and want to help. My office door is always open.

Unless it's closed, I guess, but then email me. Do you mind if I email you in a week or so to see how you're doing?

Thank you for stopping by and sharing.

Take good care of yourself.

Joe Breitenstein

Joe Breitenstein

Joseph Breitenstein, Luther associate professor of psychology, aims to teach his students to appreciate psychology as a practical science that promotes self-awareness and good citizenship by aiding the disadvantaged. He is also a licensed clinical psychologist who conducts assessments, often in forensic settings. When not spending time with his three daughters, he usually engages in silent sports like hiking, snowshoeing, cycling, canoeing and swimming. He particularly enjoys exploring natural areas in his home state of Wisconsin, preferably in his vintage wood and canvas canoe.

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  • May 23 2018 at 2:44 pm
    Robert Shedinger

    Thanks, Joe, for your interesting and creative response to my blog post. I certainly endorse your compassionate and understanding approach to hurting students and believe I have responded in a similar way to those students who have chosen to confide in me. As you say, we must meet people where they are. I fully agree. And psychological counseling is your area of professional expertise, not mine.

    I am, however, raising the larger academic and interdisciplinary question of the influence of cultural (political, economic, and social) forces on our construction of mental illness/mental health and the deeper question of what it means to be human. This bigger question is not the bailiwick of any one academic discipline, but invites insights from psychiatry and psychology as well as from religious studies, philosophy, sociology, literary studies, biology and neuroscience, and undoubtedly others. It is this larger interdisciplinary discussion that I believe we need to have but that we often try to avoid.

    I know it may look like I am overstepping the bounds of my expertise, but my ideas on this larger question have been formulated in conversation with those who do have that expertise. My criticisms of the modern mental health industry is informed by the work of psychiatrists like Elio Frattaroli, Joanna Moncrieff, Allen Francis, Irving Kirsch, David Healy, and Erick Turner, among others. I have also been influenced by the work of psychologists like Gary Greenberg and Lisa Cosgrove, the latter who is a fellow at the Edmund J. Safra Center for Ethics at Harvard University and co-authored "Psychiatry under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform." All of these experts and more like them would probably say that the problems with the modern mental health industry go far beyond a few unethical scientists or practitioners, but are systemic to the way mental illness has been constructed over the last thirty years since the publication of DSM-III in 1980.  These kinds of big, uncomfortable questions are exactly the questions that should be animating our work in an academic institution.

    Anyway, thanks for a stimulating read. It looks like we will have an opportunity to continue this conversation next fall with the Farwell lecture of Jonathan Haidt. I am not familiar with his work, but his new book, "The Coddling of the American Mind: How Good Intentions and Bad Ideas are Setting Up a Generation for Failure," certainly sounds provocative and timely.






  • May 23 2018 at 6:31 pm
    Joseph Breitenstein


    Thank you for taking the time to read and respond to my perspective.  My students will be the first to tell you that I share many of your concerns about the DSM and the mental health care delivery system in general.  It is a system, like health care in general, that is deeply flawed and adversely affects many fundamental human rights.  Obviously, there are many professionals that share these opinions.  My hope is that between constructive criticisms and the nature of science being a self-correcting enterprise, many of these flaws will eventually be eliminated. 

    But the system, as broken as it is, successfully treats thousands of people every day and dozens and dozens of peer-reviewed studies are published every year that validate treatments.   My concern is that focusing almost solely upon the criticisms potentially weakens your arguments and may inadvertently stigmatize mental illness.   It appeared as if some readers were offended and no student should ever have been "outed."  I feel like a better approach would have been to recognize successes in the field and the need for improvement along with potential implications for society, while encouraging people to get quality help within that broken system if needed.  Perhaps the stronger the argument, the more gentle and balanced our approach needs to be.  (Ironically, this is often true in treating patients.) 

    Practicing professionals live with broken systems every working day.  We see the DSM for what it is and connect with our patients with an evidence-based, compassionate science that often transcends diagnosis.  Blanket criticisms of the DSM may neglect these important characteristics of therapy.  In addition to scholarly readings and conversations, I would strongly encourage anyone with interest in the field to directly follow the day-to-day implementation of psychotherapy over a long period with an experienced therapist to perhaps best illuminate successes, failures and complexities.  I would welcome the opportunity to collaborate in that or any related regard.




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