Words That Work in Deceptive Drug Company Advertising to Physicians

"It depends upon what the meaning of the word 'is' is." ~ Bill Clinton

I recently came across a rather humorous document from a legal action that was taken way back in 2008 against the drug company giant AstraZenica (AZ) in litigation over marketing issues with its antipsychotic drug, Seroquel (Quetiapine). I thought it would be fun to share with my readers.

It came from the United States District Court, Middle District of Florida, Orlando division in the matter of Seroquel products liability litigation, Case # 6:06-md-01769-ACC-DAB, on April 24, 2008.

It was a Q&A between a lawyer and the AZ executive who was involved in organizing the slides used in promotional talks given to physicians. It concerned the use of the term "unsurpassed" in slides used to market the drug.

Seroquel was one of the newer "atypical" antipsychotic medications. They were called that to distinguish them from the old, "typical" antipsychotics like Haldol. The old drugs were notorious for causing acute neurological side effects such as a Parkinson's disease-like tremors and muscle spasms (which can be easily countered with another class of drugs), as well as a long term one called tardive dyskinesia (TD) that could become permanent. 

To see what TD looks like, watch the Batman Movie The Dark Knight with Heath Ledger playing the Joker, who I guess was supposed to have been an ex mental patient, and was portrayed as having the mouth movements typical of TD.

The new '"atypical" drugs are much less likely to cause these neurological problems, but instead are far more likely to cause metabolic syndrome - weight gain, increased cholesterol, and even diabetes. (Recently released ones in the last few years are better on this score as well, but Seroquel is one of the worst offenders in this regard). Pick your poison. Atypicals have never been shown to be more effective than the typicals for the hallucinations and delusions characteristic of psychotic disorders.

In fact, AZ's own documents showed that the company analyzed 10 studies, and found that none of them showed that Seroquel was superior to any other antipsychotic drug.

So how did AZ spin this in its sales presentation to doctors? Their slides said the drug was "unsurpassed" in efficacy the treatment of schizophrenia. They found that this word was one that worked.

This is funny because there are two different definitions of "unsurpassed." The definition most people think of is "superior in achievement or excellence to any other." In other words, most people would think that the slide indicated that Seroquel was the most effective antipsychotic drug available.

The more literal definition, however, is "as good as or better than any other." This means that other drugs can be equally as good. Obviously, that wasn't the message that the slides were meant to convey to the doctors, but because the lesser known definition exists, this gave the company plausible deniability against the charge that it was making claims unsubstantiated by any research - even though that was the take home message most people would take home. Pretty sneaky!

The company man responded to questions about this with mental sommersaults, some of which - as my friend Peter Parry points out - are cringe-worthy. So here it is (minus some objections by the involved lawyers):

Q. Let me just read the conclusion to the jury and then ask you a question about it. "Conclusions. The intended claim of 'superiority versus Haloperidol' is highly unlikely using these data, however 'a claim of equivalence is not ruled out.' Did I read that correctly?

A. Yes, you did.

Q. Were you ever informed of that Technical Document No. 5 or its conclusions?

A. I have told you twice already no.

Q. Okay. Do you think you maybe should have been informed of this information before you Went around making claims of unsurpassed efficacy?

A. No, because I took my guidance from the head of clinical, the disclosure committee, and the SERM group. By the way, how is

equivalence different from unsurpassed?

Q. Do you really think you get to ask me questions? Is that what you think this process involves, that you get to ask me questions and I give you answers?

A: I'm trying to answer your question.

Q. Well, let me ask, since you asked me a question, let me ask you a

question: "Unsurpassed," "unsurpassed,"- what does that mean?

A. It means --

Q. Nobody is better; right?

A. It means equivalent.

Q. So if I really -- I'm trying to think of something. If I tell

somebody that I went to a track meet and I saw an athlete that has been

unsurpassed, I mean he was -- her, let's say her. Her ability to do the broad jump and the high jump and the relays were unsurpassed, and I was just so impressed and I go and tell you it was unsurpassed, you believe that means I'm saying she was equivalent to everybody else at the meet?

A. Possibly, yes. That's the correct grammar. Possibly, yes. She

was possibly better; she was possibly equivalent.

Q. And if I come home and --your child, you said, is 5 years old?

A. I have got two.

Q. How old are they? Mine are 22, 20, and 17. How old are yours?

A. 3 and 5.

Q. When your child comes home from school let's say from first grade

and says, "Daddy, I" -- well, I don't think first grade. And your child may be smart because you are smart. So let's just go to fifth grade. Go to

fifth grade. "Daddy, my grade in my English class was unsurpassed." What

are you going to say, "Congratulations.You made the same grade as everybody else"? Is that what you are telling this jury, is "unsurpassed" means the same?

A. Yes, it does, it means the same as or better. That's exactly what it means.

Q. So -- that's exactly what it means. So when AstraZeneca -- I'm glad to know this. This is interesting and I'm glad we're getting this out here. So when AstraZeneca made the claims of unsurpassed efficacy in regard to Seroquel, what they were meaning to say was, "We are just the same as everybody else"; is that right?

A. No, but I think we were incredibly careful with the use of grammar to depict what the clinical studies showed and concluded.

Q. You were trying to be tricky?

A. No. We were being incredibly precise and using the correct language. Of course, the language varied from country to country and label to label. The global impression from the safety and efficacy review group was our efficacy was unsurpassed.

Q. And you said in order to use that language, using your words, you were being incredibly careful; is that right?

A. No, I didn't. I said "incredibly precise."

Q. "Incredibly precise"; is that right?

A. Yes.

Q. All right. So if somebody understood the term "unsurpassed efficacy" to mean that you were better than others, they were just being incredibly what, dumb?

A. No. We would never make a claim without showing supporting documentation. So, for example, in the U.S., the doctor could read the label,he could read the FDA approval, and he could see the total span of facts.

Q. I'm not asking about the label and I'm not talking about the FDA

approval. I'm talking about what you've called at various points during this deposition a slogan or a phrase used in regard to Seroquel, and that was unsurpassed efficacy. Are you telling this jury honestly under oath that you were being so incredibly precise in the marketing of Seroquel that "unsurpassed efficacy" really meant that "We were the

same as everybody else"? Is that what you're telling this jury?

A. No. I'm saying that we chose that word to explain the fact that in the studies that we had done, our efficacy was unsurpassed when used in the right patients in the right dose in the right population. You can read a document like this without the context and it would be easy to be misunderstood about the total conclusion for what we say about Seroquel. 

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Dr Allens Book for Therapists about Treatment of Borderline Personality Disorder Now Available in Paperback

Now available in paperback at http://www.amazon.com/Psychotherapy-Borderline-Patients-Integrated-Approach/dp/1138012750/ref=mt_paperback?_encoding=UTF8&me=

Adventures in the Veterans Hospital Mental Health Clinic Part I

Kafkaesque: of, relating to, or suggestive of Franz Kafka or his writings; especially:  having a nightmarishly complex, bizarre, or illogical quality.

Rube Goldberg machine: a contraption, invention, device or apparatus that is deliberately over-engineered or overdone to perform a very simple task in a very complicated fashion, usually including a chain reaction. The expression is named after American cartoonistand inventor Rube Goldberg (1883–1970). Over the years, the expression has expanded to mean any confusing or complicated system.

Much to my own relief, I retired recently from my part-time job at the Veteran's Affairs (VA) hospital seeing patients in the mental health outpatient clinic. While I found the patients interesting and challenging, the VA bureaucracy was at times as infuriating as one might guess. 

The Kafkaesque nature of the system in which I worked can best be illustrated by an experience I had with my picture ID card. The VA does extensive background checks on employees - as well they should - and requires fingerprinting when their identification cards get renewed every few years. 

The card contains a computer chip which allows the bearer access to the VA computer system, most notably patient electronic medical records. A few months ago, the computer chip in my ID card malfunctioned - way before its renewal date. I thought it should be no big deal to get it replaced. Yeah right. 

Not only did I have to get fingerprinted again and wait several days for them to be processed, making it extremely difficult to actually treat patients in the interim, but they also required me to produce two forms of picture identification.

The VA did not accept its own picture identification card for this purpose, which had not expired, as one of the two!

Before I go further with more bizarre stories about the place, let me make a couple of things clear. The fact that the VA is a governmentbureaucracy does not mean that private companies cannot be just as nuts - or even crazier. They can certainly be far more hostile. I used to work for one. As a friend of mine who worked for both of my former employers said, at least the VA bureaucracy was predictable in its crazy decision making, while the private firm we worked for was crazy but whimsical. Sort of like the Dilbert comic strip.

Let us turn to the issue that made the news: problems with scheduling patient appontments in a timely fashion. Much of the coverage in the news simply ignored the fact that an influx of new patients who are veterans of the wars in Iraq and Afghanistan has overwhelmed the VA healthcare system. There are just way more people reliant on VA than ever before. This happened without a commensurate increase in funding or staff until just recently, and there is still a lot of catching up to do.

In 2003, The VA expected to see 4.7 million veterans in its hospitals and clinics, up more than 54 percent just from 1996. The influx of newly-injured and/or mentally traumatized vets has continued every year since then as the wars dragged on, and funding of the system for the treatment of these wounded warriors did not keep up. Not even close. Frankly, the politicians who yell "support our troops" the loudest do NOT believe in supporting our troops after they leave the service.

In mental health in particular, visits to mental health clinics have skyrocketed as the military has attempted to change the "macho" culture that discouraged such visits in the past.

So what to make of the bureaucrats who kept phony schedules to hide the fact that veterans often had inordinate waits before they received an appointment? Well, when you give employees a mandate to do something as a condition of continued employment, and you don't give them the tools and resources needed to accomplish the mandate, they will naturally become passive-aggressive and do crap like that. They have no choice. 

And we know how bureaucracies treat whistleblowers, so everybody shuts up and goes about their business doing their best to get around the double bind they are all in.

To get patients seen in a timely fashion, you would think that the place would, at the very least, be very quick about putting in the appointment system the times when various doctors are available in their clinics to see and treat patients. Again you would be wrong. Whole clinic days of mine would disappear from my upcoming January schedule in the computer for an upcoming new year, and it would take two or three months of me complaining about it for the clinic times to reappear. I could not schedule anyone! 

I finally found out why it took so long. At least this is what I was told: There was just one person doing this job. Not one person for a few clinics. One person for the whole humongous medical center! 539 provider schedules, give or take.

Still, in the defense of the VA, at least part of the fault for patients not getting seen in time by a doctor may have in some cases lied with the patients. I can not speak for VA facilities in Phoenix or the rest of the country, but here is a photograph of an actual sign displayed prominently at the entrance to the VA hospital in Memphis:

In addition, at least in the mental health clinic I worked in, one of the doctors was always available to see every walk-in patient who came in without an appointment - even if they hadn't stopped near that sign to get checked in.

Furthermore, the hospital had what they called a "patient advocate's" office, where vets could complain about problems they were having getting seen. The patient advocate was usually very effective at getting them in.

If the patients described in the news media who died before they got in for an appointment were that sick, maybe they should have not just followed the instructions of the schedulers about how soon to come it. "I vas only following orderz" is not a good excuse.

Still, it is clear that the VA does tend to be a lot more concerned with looking good rather than actually doing good. For an illustrative example, a mandate came out that veterans who were diagnosed with mental trauma and post traumatic stress, either from war or military sexual assault, had to receive a certain number of psychotherapy sessions within a prescribed period of time after their initial evalutation.

The hospital administrators recently bragged in an e-mail to the department that they had met the target. 

What they actually did was to put all of these patients into group therapy, which in my experience was, in a lot of cases, next to worthless - instead of giving them the much more effective individual treatments. The VA where I worked does not have nearly enough psychologists on staff to provide individual treatment to everyone who needs it, and the ones they do have are mostly busy doing other things because they are maldistributed as well. 

For post traumatic stress disorder uncomplicated by major personality disorders, in my estimation the most effective psychotherapy treatment is something called prolonged exposure (PE), a type of desensitization treatment. Another treatment that is "empirically validated" - by which some people mean that there are some studies, no matter how pathetic, showing that it is minimally effective - is called cognitive reprocessing therapy (CPT). That in my experience is less effective for a lot of patients than PE.

Commensurate with my experience at the VA in Memphis, an article in the journal Psychiatric Services by Watts and others published in May of 2014 found out that, nationwide, the percentage of veterans who received any sessions of either PE or CPT was six percent. Six percent! But our VA bragged about fulfilling the mandate because the veterans were seen by a mental health professional the correct number of times. Well sort of seen, anyway.

More on looking good rather than doing good in upcoming posts in this series, coming soon to a blog near you.

An education in medication WMHD15

Today is my 75^th day on antidepressants. Sertraline, to be exact. I’d never heard of it until the day I had a breakdown in my doctors’ surgery’s reception, and at first I treated it like a child hating its new baby sibling. This tiny, tiny white pill was apparently going to help things, but I had no idea how and resented it for being so smug in its ability where I lacked it.

But now we are best friends. The kind of friendship where you walk into the friend's kitchen and help yourself to food, know how to work the oven, and make yourself at home taking control of the TV remote. We’re comfortable, we’re tight, and if it ever moved away, I would cling on to its ankles wailing that Skype calls would never be enough.

Today is also World Mental Health Day. So, to mark it, I've written down the things I have learnt since starting medication, in the hope that it might help others who are battling between unwelcome sibling and clingy friend.

- You will not feel better straight away. At first, you might even feel worse. Side effects can come in all shapes in sizes. They may be worse than period pains, and they might not appear at all. I always felt sick in the mornings, felt high as a kite at 2pm, and had restless legs at night. I also couldn't orgasm for a month, but the less said about that the better. Too soon, man, too soon. Regardless, antidepressants need a good few weeks, maybe even months, to survey your mind and settle in well. Sometimes they’ll fit in quickly, and sometimes they won’t at all. For the latter, you should go back to your doctor to try something else, and that is okay. There are a bunch of different antidepressants which work well for different people. But give it time.

-  Medication does not replace your own strength. As well as expecting it to work faster than it did, I couldn’t understand why I didn’t feel... Brilliant. Fine. Happy. Excited. I got frustrated that I’d finally accepted medication but it wasn’t fixing anything. Medication isn’t a fixer. Medication gives you the time and space to breathe, and it gives you a kick up the arse. It quietens down the terrible monsters in your mind and turns up the volume of your own confidence, self-worth, and motivation. Now, I wake up and I actually get out of bed. I go out for a run because I don’t clock any voices telling me not to bother and I cheer myself on the whole way instead of listening to the dark laughter about how stupid I am for even attempting to get fit. The voices are trapped in a binbag in the corner of my mind. And if I do happen to hear them, in any context, I stop. I wait. I breathe. I re-evaluate what has just happened. I think. I carry on.

-  Telling people you’re on medication gets easier. I was incredibly reluctant to tell people I was on antidepressants. Not because I felt like a failure for having to take them, but because I was terrified that they wouldn’t understand. I quickly realised that that’s not my problem. I am looking after myself and that’s all that matters. I didn’t tell a lot of best friends for weeks, and some only found out when I wrote my initial blog post about it. Thankfully, everyone was lovely. Some didn’t quite understand and some admitted they didn’t know what to say, but no one judged me. Now it’s easier to tell people, if I feel the need to. I’m taking medication to fix something broken in me, like any other illness.

-  You might have to set rules and do some taming. What has been harder than telling people I’m on antidepressants, is telling people I can’t really drink. Telling me, specifically. I like a drink. I like my 2 for 1 cocktails and cold glasses of wine. So telling people that I can no longer indulge is worse than killing a kitten. My doctor said that alcohol can have different effects on different people so to just be careful with it. At first, I was fine. I was careful with wine but carried on merrily with spirits and cocktails. Now, I’m off everything. For now. I started to feel incredibly tetchy, anxious and emotionally exhausted, and days after a night out were a write off. I felt groggy, down, and hated myself. So sometimes, although medication is awfully clever, it can run riot and you have to hold back on some things, much like stopping a toddler having too much sugar.  

-  How you know your mental health ‘dips’ to be may change. This is something that only hit me the other day. Now that I’m generally better at looking after myself and stopping any flickers of bad mental periods before they develop, anything I cannot control can have a bigger effect on me, because the change in my mood is more drastic. As an example, last weekend, my boyfriend and I had a slight ‘miscommunication mishap’, let’s say, and he snapped at me. I was feeling totally fine and happy in that moment, so his snap took me by surprise and I felt all the blood rush to my feet. I got a lump in my throat, the monsters in the binbags tore their way out when my medication's back was turned, and I immediately started to panic and had a desperate need to burst into tears. It was tough, and totally unavoidable. This wasn’t a thought to calm, or a social situation to deal with, it was an instant trigger for me, and I wasn’t prepared for it because I was feeling happy. Pre-meds, it wouldn’t have triggered anything. I would have been so ‘flatline’ in my mind anyway that I would have blamed myself and thought it was standard for him to be mad at me, and would have just been quiet and depressed for the rest of the day. This time, him snapping totally caught me off guard and I couldn't understand, so the effect was a lot more physical. It was panic rather than depression and something I wasn’t used to. Now I’m aware that my body and mind may react differently to before, and I’m prepared for it.

-  You will have bad days. You just will. Medication does not fix everything, and sometimes your antidepressants will take the day off. But the bad days won’t last (if they do, go back to your doctor - you may just need your dosage upped or medication changed) and you just have to ride it out. Don’t get angry at yourself, it’s not your fault and you haven’t done anything wrong. Sometimes you might just be a bit exhausted. Take some time to look after yourself. Don’t beat yourself up if you can’t get out of bed or can’t be bothered to shower. Do some things you enjoy; watch some trash telly (I recommend Catfish), eat a whole tube of Pringles, and hound your friends on WhatsApp to get them to send you links of cat videos on YouTube. You will be okay.

-  This is not a concrete situation. I say this for two reasons. Firstly, I’m struggling with getting hooked on the idea that antidepressants are beautiful and will solve my problems for the rest of my life. In an ideal situation, you will be on medication for six months to a year (this is what my doctor is aiming for with me), because in that time you will hopefully have worked on some coping strategies to look after your mental health without medication. Antidepressants can be addictive, and not relying on them is definitely something I know I’ll have to keep working on. At the moment, I’m terrified of the thought of ever coming off them. But I know that one day I should try. (However, it’s very much worth noting that if you cannot deal with coming off them, that is okay and nothing to be ashamed of. It just goes without saying that if you can try and work through any mental health blips without them, go for it. But of course each situation and each person is different.) Secondly, if you are struggling with the idea that you are on medication in the first place – always remember that does not have to be forever. Nothing is concrete. You are constantly a work-in-progress. We all are.

- You are the bravest person in the world. Battling with your own mental health is tough, especially in a society where stigma is still rife. Taking the steps to control your own body and mind, get better, and look after yourself when it’s the last thing your little monsters are telling you to do, is incredibly brave. You should be proud of yourself.

Now go and grab some Pringles. The next episode of Catfish starts soon.

For more information on antidepressants, see Mind's information and support page: http://www.mind.org.uk/information-support/drugs-and-treatments/antidepressants/#.VhUE1iDBzGc

For more information on World Mental Health Day 2015, search the hashtags #WorldMentalHealthDay and #WMHD on Twitter, and see: http://www.mentalhealth.org.uk/our-work/world-mental-health-day/world-mental-health-day-2015/

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Dumb Hidden Assumptions in Drug Abuse Research

The mental health professions these days seem to want to blame their patients' repetitive problematic or self-destructive behavior on just about anything except what is, in the large majority of cases, the primary causes: family dysfunction and adverse childhood experiences (ACE’s). And I mean, they would rather it be almost anything else.

In my post of February 26, 2011, I discussed how a slight increase in aggressive thoughts following the playing of violent  video games by adolescents was translated by researchers into the games being a major risk factor for the development of youth violence. The fact that most compulsive video game players are inveterate couch potatoes who do not get out much never entered into discussions.

Not surprisingly, a recent longitudinal study (Fergus0n et. al., J. Psychiatr Res 2012; 46: 141-146), showed that, by taking other variables into account such as intra-family violence, the correlation between video games and even short-term aggression could no longer be established.  Another older paper from the same lead author (Ferguson and Rueda,  J Exp Criminol, 2009; 5:121-137) showed that aggressiveness in the laboratory, as expected, did not correlate with violent acts in real life.

Focusing on minor targets like video games risks leading social activists and public policy makers to ignore the far more important causes of youth violence like child abuse.

So of course, now that the tide is turning against the insane drug war against  marijuana, which has turned a significant percentage of the population into criminals (who tend to only be prosecuted if they happen to be African American), the folks who refuse to look at reality are now publishing "studies" that attribute a host of problematic behavior almost entirely to the devil weed – while all the while making the most ridiculous hidden assumptions imaginable. 

People who feel the need to be stoned all the time have enough problems; we do not need to make up a bunch of other ones.

In Carl Hart’s book High Price , he recounts his adventures as a reviewer of potential drug abuse studies for funding from the National Institutes of Health. He mentioned that the research agenda was being controlled by the National Institute on Drug Abuse (NIDA). He makes it clear that they were only interested in studies that showed the dangers of street drugs, not on studies which countered the many myths in the field that he had described in the rest of the book. (NIDA also ignores the dangers of the very same drugs they demonize when Pharma sells them for conditions such as "ADHD").

Now comes a study out of Australia and New Zealand: “Young adult sequelae of adolescent cannabis use: an integrative analysis” by Edmund Silins and others. (Lancet Psychiatry, 2014;

1: 286–93). Here is the abstract:

Methods: We integrated participant-level data from three large, long-running longitudinal studies from Australia and New Zealand: the Australian Temperament Project, the Christchurch Health and Development Study, and the Victorian Adolescent Health Cohort Study. We investigated the association between the maximum frequency of cannabis use before age 17 years (never, less than monthly, monthly or more, weekly or more, or daily) and seven developmental outcomes assessed up to age 30 years (high-school completion, attainment of university degree, cannabis dependence, use of other illicit drugs, suicide attempt, depression, and welfare dependence). The number of participants varied by outcome (N=2537 to N=3765).

Findings: We recorded clear and consistent associations and dose-response relations between the frequency of adolescent cannabis use and all adverse young adult outcomes. After covariate adjustment, compared with individuals who had never used cannabis, those who were daily users before age 17 years had clear reductions in the odds of high school completion (adjusted odds ratio 0·37, 95% CI 0·20–0·66) and degree attainment (0·38, 0·22–0·66), and substantially increased odds of later cannabis dependence (17·95, 9·44–34·12), use of other illicit drugs (7·80, 4·46–13·63), and suicide attempt (6·83, 2·04–22·90).

Interpretation: Adverse sequelae of adolescent cannabis use are wide ranging and extend into young adulthood. Prevention or delay of cannabis use in adolescence is likely to have broad health and social benefi ts. Efforts to reform cannabis legislation should be carefully assessed to ensure they reduce adolescent cannabis use and prevent potentially adverse developmental effects.

Funding: Australian Government National Health

The authors claimed to control for confounding variables, but most of these "controlled" variables were unrelated to ACE’s or ongoing family chaos. They were such things as age, sex, ethnicity, socioeconomic status and mental illness. The authors did control for a few possibly relevant parental variables like alcohol use, tobacco use, divorces, and history of depression. But not for how the parents actually behaved around their children, how they treated their children, child abuse or neglect, how chaotic the home environment was, or how and how consistently the children were or were not disciplined.

What on earth makes people who draw the conclusion that the drug was the primary cause of the lower achievement become so stupid that they don't see that frequent drug use is a sign that the teens already had emotional problems before they even started smoking - and that it was these problems that predate the drug use that were the real cause of both the drug use AND the poor performance?

The authors used exactly one rather vague sentence in their discussion to refer to this possibility, which most readers will miss: “…cannabis use in adolescence could be a marker of developmental trajectories that place young people at increased risk of adverse psychosocial outcomes.” (p. 291). 

Ya think?

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Conquering Writers Block III When life gets in the way

My previous posts on writer's block, wherein I introduce the model and then discuss the various "flavors" (based on a completely unscientific poll) are here and here, respectively.

If you read Monday's post, you'll recall that I said I was going to discuss the first two flavors today, but then I realized there was just too much to tell you, so I'm going to do a post on the second flavor (brain clog) on Friday, and I'll focus on only the first (broader life/mental health issues) today.

Now, it would be kind of flip of me to say to you: "If it's broader life/mental health issues, just go deal with those and come back when you're done. Then your writer's block will be gone!"

I would suck if I said that. It doesn't work like that. Sure, there are transient life situations, like moving apartments, or starting college or a new job, or having any kind of illness that is treatable and goes away. Sometimes you can just wait things out. But if there's something chronic, if you are a typical adolescent or grown-up who is juggling multiple roles ... telling you to go "deal with that" so you can get back to writing is pretty laughable. It's far more complex than that. You do have to deal with it, though. Every day. But it's probably more of a management process than a "clear the decks so everything else is perfect" thing.

Now, if you think you might have a clinical issue, like depression or anxiety, that is affecting your ability to write, it's worth taking a look at. I won't go into too much depth here, but I would say that it would be worth it to consult with a competent professional to see if you can get treatment to improve your ability to manage those symptoms across settings and situations.

But as for the other "chronic life stuff" issues ... you'll get back on track quicker if you take the time to figure it out and sort it out. On Monday I responded to a comment by Lydia Sharp, soon-to-be-published author and blogger extraordinaire. She basically asked what to do when there are multiple life-and-other-stuff causes for writer's block. It reminded me that ... this is usually the case, actually. I responded to that comment with a (kinda long) comment of my own, which I present again today. Only with pictures. And no spelling errors.

[By the way? This? This is how I work with clients. No magic--just systematic approaches to complex problems...]

If you were to come to me and say, "Help! I haven't written a page in over a month!" ...

I'd sit down with you and map out the problem. We'd put the writer's block in the middle (like in the diagram I presented on Monday), but I'd make it specific to YOU. Like, whatever you as a writer are having trouble doing (e.g., getting a certain amount done, failing to make time in the busy schedule for writing, or whatever it is--and if there's more than one thing, we'd do this for each one).

Then we'd build a model of what's causing the block, just like in that diagram. But again, for an individual person, it would be more specific. We'd think of as many causes, no matter how big or small, and write them around the problem.

Here's what one of those diagrams might look like:

After we make our map (it might be more complex than this one), we know the things that *could* be targeted to get you writing again. We could target some of the different thoughts, or the structure of the schedule, or the supportiveness of the partner and other natural supports, etc. But there's no way we can tackle all of them at once! We have to prioritize.  So we would consider a few questions:

1. Which one do YOU think would make the most difference, and which one(s) are you willing to work on?

2. Which one(s) would give us the biggest bang for our buck? Like, are there any that could have a big, quick impact or affect several writing problems (or problems in other areas of your life)?

3. Are there any practical, quick and easy fixes? We can tackle those--as long as we're also tackling more fundamental ones as well. These would be things like finding a way to get the computer fixed or finding a way around that.

4. Are there any that have to be addressed before we can get to some of the other ones?

5. Are there any that have been proven to affect writer's block? (like, research shows that thinking you're a failure can really decrease mood and productivity)

6. Are there any causes that are tightly connected to the problem and happen right before the problem crops up? (again, often the thoughts)

7. Which one(s) are happening right now, as opposed to being historical causes (things that might have happened a long time ago--usually those historical events/causes give rise to the things in #6, so that's how those are addressed)?

The causes we choose to tackle wouldn't have ALL those characteristics, only one or two of them, but based on your priorities, we'd pick one or two, and then we'd develop a specific intervention to address them. What would YOU choose? Should we design an intervention to address some of those negative thoughts? Should we discuss how to restructure your schedule? Should we talk about how you can ask your partner for some mutual support?

We'd reassess frequently to see if the intervention is working, and if it's not, we'd analyze why (using the same process as above!)

And ... that's it. It's not a perfect, simple process, but it organizes something that can often feel unmanageable and therefore undoable. I promise you--mapping it out instead of letting it stay big and hairy and overwhelming ... it will help you feel better and more in control. And that is an excellent first step.

I'll be back on Friday to talk about BRAIN CLOG.