Pharma Weapons of Mass Seduction Part II

In my post of August 31, Plausible Deniability, I illustrated how Pharma-tainted psychiatrists are able to subtly make marketing points about various drugs while denying that they are doing anything of the sort.  I commented on some of the tricks that were being used.

This post will be the second in an occasional series that discuss the more subtle and insidious devises used by Pharma-connected "experts" to mislead - or should I say con - practitioners.  These "experts" are called opinion leaders by Pharma and are a major part of their psyche ops.  Their marketing departments have been scrupulously studying physician behavior - especially physician weaknesses - for decades.  I will also discuss in future posts some of the ways they have done and are doing that. 

An excellent discussion of the more obvious and better-known pharma marketing techniques can be found at http://www.abc.net.au/rn/backgroundbriefing/stories/2011/3337618.htm.  This program is from the Australian media, but the situation is much the same in the US.  I will not be focusing on those techniques much in these posts.

Pharma marketing targets all physicians, not just psychiatrists, although psychiatrists have been a leading target.  Of course, I am more familiar with the marketing of psychiatric drugs, so my main focus will be those.

Of course, it is ultimately the fault of the practitioner for not taking the time to challenge misleading ideas and to check them out with unbiased and readily available sources of scientific information such as the Medical Letter.  But that is, in a way, the point.  Pharma knows quite well that many practitioners will not have either the time or inclination to do this.  The average physician works about 60 hours per week. 

Not only that, but many are also suckers who can be easily deceived. 



BTW, did you know that 80% of antidepressant medications are prescribed by non-psychiatrists?

In this post I will discuss how Pharma-inspired or paid-off writers in psychiatric newspapers, throw-away journals, and journal supplements denigrate highly-effective drugs (antidepressants and benzodiazepines) that just happen to have gone generic, in hopes that doctors will prescribe more expensive, potentially more toxic, and less effective brand-named drugs (particularly atypical antipsychotics). 

(And yes, antidepressants and benzo's do not work for everyone, can cause severe side effects in some people, can be habit forming, may cause unpleasant withdrawal reactions, blah blah blah.  [All of these problems can be dealt with by a competent physician who follows his or her patients closely].  And a majority of patients need psychotherapy instead of or in addition to medications. No sh*t! So please don't keep writing to me to point out the obvious).

I am going to use as illustrations two articles that appeared in a newspaper called the Psychiatric Times.  I do this because two very recent articles that clearly illustrate my points appeared there, not because I want to pick on that particular publication.  In fact, Psychiatric Times tends to be rather fair in general and is one of the most pharma-critical of the publications I am talking about.

By way of definition:  Throw-away journals are official-looking medical "journals" that are mailed free of charge to all doctors who might prescribe certain drugs pushed by big Pharma.  Psychiatric Annals (Anals?) and Current Psychiatry are two examples from psychiatry. 

They are heavy on full-page and sometimes multi-page Pharma advertisements, and Pharma probably pays to produce and mail them.  The articles they contain are not peer reviewed (sent out to about three independent experts for review of the adequacy of their science prior to a decision by the journal editors about whether or not they should be published).

Journal Supplements are mini-journals mailed along with more legitimate, peer-reviewed journals (and usually having the same cover design) that consist of multiple articles which claim to review a particular topic in the field.  Most doctors are unaware that the articles in a journal supplement are not peer reviewed like the articles in their accompanying primary journal, and that the supplements are usually sponsored by one pharmaceutical company.

First, an article about anti-depressants.  I submit as evidence for my contention in the Plausible Deniability post (that the article by Sachs and others claiming that antidepressants are ineffective in bipolar depression is being used in the field to push other medications) the CME article "Understanding and Treating Bipolar Depression" by Caleb Adler, M.D. It appeared in the July, 2011 issue of Psychiatric Times. As mentioned, there are a lot more articles like this one in various publications.

I pointed out in the previous post that drug companies did not need the folks who authored the Sachs article to recommend anti-psychotics for bipolar depression. They have a lot of other people to do that particular job for them. ("Opinion leaders" is the term Pharma uses for such people), like the authors of articles like these.

The Times article lists a variety of treatment options for bipolar depression including various atypicals and mood stabilizers, and even mentions neurontin and lamictal - both of which have both been shown to be particularly ineffective - before mentioning, at the very last, standard antidepressants.

After focusing on the red herring of antidepressants causing switching into mania - which even the author grudgingly admits can be easily prevented with drugs like lithium that true bipolar patients should be taking anyway - it speaks of the use of antidepressants as "fairly controversial," even though they have been used successfully for over fifty years.

Then the reference to the Sachs et. al. article come in: "Nonetheless, the large STEP-BD analysis did not observe improvement in patients receiving standard antidepressants. Other meta-analyses that have purported to observe an effect may be methodologically flawed."

I do not see any mention that this part of the STEP-BD study was a study ONLY of treatment-resistant subjects, or that it used only two antidepressants for that matter.

And what is the unspoken implication of that last statement about the meta-analyses, even though it may be literally true for any given study? (The reference cited for this statement, by the way, was just another article in Psychiatric Times!) It is this: that any study which purports to show that antidepressants work is probably methodologically flawed, that's what.  There are no similar caveats attached to any of the other drugs mentioned in the review.

A lot of plausible deniability built into the wording though. Brilliant marketing.

The second article concerns benzodiazepines and is titled, "Anxiety Disorders: the Anxious Bipolar Patient" by MD's Khavital Lohano and Rif S. El-Mallakh in the September 2011 issue of Psychiatric Times.  The article correctly points out that many bipolar patients also have severe co-morbid anxiety disorders like panic disorder, which often require additional meds (an instance in which polypharmacy may sometimes be legitimate and necessary). 

In one study, 21% of bipolar patients had panic disorder - a 26 fold higher incidence than in the general population. 

Interestingly, the panic attacks in manic-depressive patients do not occur when a patient is in the manic state.  They occur when the patient is in the normal (euthymic) mood state or, more frequently, in the depressed phase of the illness.

Certain benzodiazepines are, in my experience, far and away the most effective medications for panic disorder, whether it is comorbid with something else or not.  The second most effective drugs are antidepressants. 

Of course, just as with the last article, in discussing treatment options this one goes out of its way to stress that antidepressants can induce mania, without mentioning that anti-manic drugs prevent this from ever happening.

At least antidepressants were the first class of drugs mentioned.  The second?  Antipsychotics, of course.  They are actually stated to be the second line drugs for this indication!  Without FDA approval, I might add.  And the FDA happens to be absolutely right in not approving them for this indication.

Listed third was anticonvulsants like depakote.  Interestingly, the article admits, "There are no randomized controlled trials that examine the use of anticonvulsants for the anxiety component in bipolar patients."  But, naturally, it goes on to state, "However, anticonvulsants appear to have a small effect in reducing anxiety."  Side effects were not even mentioned about either antipsychotics or anticonvulsants anywhere in this article.

Next, under "alternative agents," the article discusses the anticonvulsant gabapentin, which in my experience has very mild tranquilizer-like properties but is not FDA-approved for anxiety. 

LAST, the article finally and very briefly mentions benzodiazepines.  Get this: and I quote:  "Benzodiazepines are clearly effective in many types of anxiety disorders.  However, their use is problematic, and these agents must be prescribed cautiously."  

So what, the fact that antipsychotics can cause diabetes is not problematic and did not need to be mentioned in the article like the problems with benzo's were? Or the fact that depakote can cause polycystic ovaries in females?  No caution needed in prescribing those agents, I guess.

Even in mainstream publications and in the APA Treatment Guidelines, whenever benzodiazepines are mentioned, one almost always also sees a phrase added that is something similar to, "But of course they can be addictive."  On the other hand, when antipsychotics are mentioned, one almost never sees a phrase like, "But of course they can cause diabetes, massive weight gain, higher cholesterol, and an irreversible neurological disorder called tardive dyskinesia."

Prescription Drug Abuse part 2

Top 10 Facts About Prescription Drug Abuse

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.

Anecdotal Evidence and Inductive Conclusions in Psychiatry Part I

“Can a valid diagnosis be arrived at if laboratory tests are not available? Of course it can. Total reliance on on lab tests to the exclusion of other factors when seeking validity is not science but scientism” ~ Hannah Decker, Ph.D

In my post of April 1, 2010, Is “Data” the Plural of “Anecdote?” I pointed out that in most hard sciences, stories about a scientist or practitioner’s personal experience can be contrasted with “empirical” data from studies, and that the latter usually has more validity that the former.  

As I also pointed out, however, “…many of the randomized, placebo-controlled, double-blind drug studies can be every bit as biased as the worst anecdotal evidence. We are now living in an age of 'marketing-based medicine,' as opposed to evidence–based medicine" (randomized = the use of chance alone to assign the participants in an experiment or trial to different groups; placebo = inert sugar pill; double-blind = neither the person evaluating the research subject nor the subject knows during the experiment if the subject received the placebo or the active medication).

In psychiatry, the situation is even more complex, since there are almost no objective lab tests and we can't read minds, so we must rely on the experimenter's personal observations, or answers by subjects to psychological tests in which we do not know how honest subjects are being or even if they really understand the questions, or patient self reports. All of these sources of data, while important, are highly subjective and can hardly be considered "empirical" in the same sense as, say, a chemical reaction.

Another big point about anecdotes is that they are not worthless in science. Some of the most important discoveries in all of medicine were based initially on anecdotal evidence. In Part II of this post, I will describe how to determine the validity and generalizability of conclusions generated from a group of “anecdotal” clinical observations. That is, how can we tell if the anecdotes are the typical situation seen with a particular combination of clinical variables and which therefore can lead to a conclusion that will probably apply to most patients with a given disorder? Are the conclusions probably true, or probably false? 

In this post, however, I want to contrast conclusions based on a “clinical anecdote” with inductive reasoning. Remember, the first step in the scientific method is observation.

According to Wikipedia, inductive reasoning (as opposed to deductive reasoning) is reasoning in which the premises seek to supply strong evidence for, but not absolute proof of, the truth of the conclusion. It is usually based on seeing the same phenomena over and over again without any exceptions.

The truth of an inductive argument is supposed to be probable, based upon the evidence given. The same phenomena involving two variables are observed repeatedly, and other variables which correlate with the phenomena are shown to be not necessarily connected it, and a tentative conclusion or assumption is drawn regarding the relationship between the two variables.

Deductive reasoning, whose conclusions are more certain, is the process of reasoning from one or more general statements (premises) to reach a logically certain conclusion. Deductive reasoning links premises with conclusions. If all premises are true, if the terms are clear, and if the rules of deductive logic are followed, then the conclusion reached is necessarily true.

To anyone familiar with formal logic, deductive reasoning takes the form of a syllogism:

All men are mortal

Socrates is a man

Therefore, Socrates in mortal

If the first two statements are true, then the third statement must be true. Deductive reasoning is considered the entire basis of science by some scientifically illiterate individuals. 

The problem is that both premises in the above examples are inductive conclusions! Just because all observed men have turned out to be mortal does not in any way prove that the next man you come across cannot be immortal!

The first thing you should have learned from your Geometry 1 class in high school is that there is absolutely no way to prove that the shortest distance between two points on a flat two-dimensional surface is a straight line. It is just that every time you measure it, it is. You just have to assume it.

I have a pen in my hand which I am holding about three feet off the ground. Every time I have dropped it under controlled conditions, it fell to the ground. I can never prove that the next time I let it go, it will fall. So let’s see. Well, I’ll be darned. It did it again!

In other words, ALL scientific deductions are based on premises which are unprovable inductive conclusions. Therefore, presto change-o, if no inductive conclusions are scientific, then no deductive conclusions are either. Or in other words, science would not really exist.

Syllogistically:

              All scientific conclusions are based on inductive reasoning

              Inductive reasoning never proves anything

      Therefore, no scientific conclusions are proven.

Bullcrap.

Traumatizing Your Characters Part 2 Types of Trauma

Now that we've established that most people will experience some sort of traumatic event(s) in their lives, and that a huge number of novels focus on trauma and its aftermath, let's discuss different types of trauma!

Trauma isn't ONE THING. It's sometimes hard to define, but here's SAMHSA's definition (lots of resources on that website, by the way--if you're going to traumatize a character, do your research!):

Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual's functioning and physical, social, emotional, or spiritual well-being.

 You see here that you need an event that a person experiences in a certain way, but that also has lasting effects. That's the core of it, but this can take so many different shapes!

Single event:

• car accident
• physical injury or accident
• natural disaster
• terrorism
• physical or sexual assault

We'll talk about treatment in a later post, but professionals agree that single event trauma is often "simpler" to treat than other kinds of trauma, because the individual can focus on grieving and integrating one event. That doesn't mean this type of trauma is no big deal--it can be crippling. But man, are there some extremely effective treatments that work particularly well for individuals who've experienced it.

Books that deal with single incident trauma include Hate List by Jennifer Brown, Speak by Laurie Halse Anderson, and Willow by Julia Hoban. I would say that the majority of YA books dealing with trauma that I've read involve single event trauma.

Episodic:

• domestic violence
• physical and sexual abuse
• combat

With this type of trauma, there are periods of respite in between, and sometimes the surrounding environment isn't utterly toxic, but when things explode, they have a "snowball" or cumulative effect. The traumatic events aren't isolated--they wear a person down.

Books that deal with episodic trauma include The Things a Brother Knows by Dana Reinhardt and The Hunger Games series by Suzanne Collins (Catching Fire is where the author really begins to show the aftereffects of trauma, but she also deepens the trauma with additional traumatic events). Lela, the main character in Sanctum, has also experienced episodic trauma, though it could be argued that her background involves significant developmental trauma as well (see below).


Chronic:

• refugee/forced displacement/warzone
• child neglect and deprivation

Chronic trauma, and particularly early and ongoing child neglect and deprivation, is much more complicated to treat because of the frequency of negative events and the pervasive badness of the environment. Developmental trauma, sometimes referred to as "complex trauma," is also harder to diagnose, because sometimes there is no single event that could be identified as traumatic. Rather, sometimes the entire environment is the issue! This type of trauma gets a post all to itself. As a child psychologist, I think about, talk about, and deal with this type of trauma (in varying degrees of severity) A LOT.

Books that deal with chronic trauma include Living Dead Girl by Elizabeth Scott and Nobody But Us by Kristin Halbrook.

If you're writing about trauma, feel free to share the type of trauma your character has experienced, and how you're thinking about his/her reaction to it. Also, please feel to recommend excellent books that deal with different types of trauma in an authentic manner!

On Monday, we'll move on to a discussion of factors that make traumatic events more likely to cause PTSD symptoms in those who experience them.

Ve Have Vays of Making You Talk Part VI Post Hoc Reasoning

Reproduced from http://xkcd.com/552/

In Part I of this post, I discussed why family members hate to discuss their chronic repetitive ongoing interpersonal difficulties with each other (metacommunication), and the problems that usually ensue whenever they try. 

I discussed the most common avoidance strategy - merely changing the subject (#1) - and suggested effective countermoves to keep a constructive conversation on track. In Part II, I discussed strategies #2 and #3, nitpicking and accusations of overgeneralizing respectively. In Part III, I discussed strategy #4, blame shifting. In Part IV, strategy #5, fatalism.

This post is the second in a series about strategy #6, the use of irrational arguments.  Descriptions of this strategy have been subdivided into several posts because, in order to counter irrational arguments, one first has to recognize them.  I will hold off describing strategies to counter the irrational arguments until after I have describe some of the most common types.

Irrational arguments are used in metacommunication to throw other people. The other individuals either becomes confused about, or unsure of the validity of, any point they are trying to make or question they are trying to ask.  Fallacious arguments are also frequently used to avoid divulging an individual's real motives for taking or having taken certain actions. 

The fallacy I would like to discuss in this post is post hoc ergo propter hoc, which literally translated means "after this, therefore because of this." Under this fallacy, two events that occur in sequence are merely assumed to be causally related. That is, if event B follows event A, then an assumption is made that A caused B, even though many other environmental events were also going on during the time between A and B that could have caused B, either individually or in some combination.

This sort of fallacy can be funny when it is obvious but difficult to detect when subtle. No one would believe a doctor who claims that headaches are caused by a deficiency in the body of aspirin, but the debate rages on over whether the effects on assailants of por­nographic movies caused them to become rapists.

I frequently see this fallacy used in arguments made by the anti-psychiatry crowd.  If some psychiatric symptom developed by a patient occurred after he or she either started or discontinued a drug, they argue that it simply must have been caused by the medication.  Well, sometimes it is, but often it is not.  The further removed in time from when the medication was started or discontinued, the less likely it becomes that the drug had anything to do with the symptom. 

There are a very limited number of drug-induced symptoms that, once started, never go away, and those usually involve a situation in which a drug actually grossly damaged an organ.  Some dyes used in X-ray procedures, for example, may physically damage the kidneys. Tardive dyskinesia, a long-term neurological problem in the central nervous system caused by antipsychotic medication, is one obvious exception.

Withdrawal symptoms from addictive drugs almost always go away after a relatively short period of time.

With patients in psychotherapy, the post hoc fallacy is most frequently seen with during conjoint marital or family sessions. When spotted, such a fallacy may reveal the presence of a family myth.  A family myth is a false belief that assists family members in suppressing those thoughts, feelings, preferences, or behavior deemed to be unacceptable and in allowing one or more family members to continue playing a spe­cific role. The myth may be believed by an individual, a sub­system of the family, or the entire family.

Family myths may take the form of a causal explanation of a family member's be­havior that is not the true explanation. In order to be believ­able, the myth often makes use of the post hoc ergo propter hoc fallacy. In such a myth, the belief in a causal connection is based solely on a sequence of events that takes place in a certain period of of time. If the behavior to be explained begins after a certain event, the behavior is blamed on the event. As with other mechanisms used by people who are attempting to hide their true feelings and beliefs, the proposed cause often re­veals clues to the real cause, even though the proposed cause is meant to be a smokescreen.

One example occurred in a family being seen under duress from a probation officer. A young teenager was caught shoplifting. He lived with his father and his siblings. The mother ­had not only divorced the father but abandoned the family, entirely abdicating any family responsibility in order to pursue a career. The father could rarely spend time with the boy because the firm that he worked for was demanding more and more overtime. The father ­routinely worked fourteen-hour days; he expressed disappointment· that the boy could not take better care of himself without supervision.

The post hoc fallacy was expressed in the session following an incident in which the son picked a fight with another boy who was twice his size. The father theorized that the son had engaged in this rather dangerous activity because he had not had a good night's sleep the night before the inci­dent - and was therefore overly irritable.

This seemed to me a rather odd explanation. When provoked, overly irritable people will sometimes unthinkingly do or say things that they other­wise might keep to themselves, but they seldom go out looking for trouble.

The father appeared to be attempting to veer away from any explanation of the boy's odd behavior that might involve family dynamics, but he unwittingly revealed something about himself. It was he, the father, not the son, who was irritable from lack of sleep.

I later guessed that the boy's acting-out behavior was a feeble attempt to force the father, who was utterly ex­hausted from working so much, to work less. The probation officer had in fact required the father to be at home more in order to supervise the misbehav­ing youngster. The boy was also bidding for more attention, as many therapists would theorize, but I believed that he was genuinely concerned about his father’s mental health.

When I suggested to the father that the boy was, at great per­sonal sacrifice, attempting to indirectly demonstrate his concern by forcing the father to insist on more time off, the father never really bought it. However, soon Dad was spending more time home, and the patient stopped acting out. No causal connection between my intervention and the boy’s subsequent im­provement was ever established. 

Where the Analysts Went Wrong Part II

In the introduction to this post, I mentioned that a major problem with psychoanalytic formulations concerning the origins of personality dysfunction is that they presume that problematic interactions with parents and other family-of-origin members are only powerful in shaping personality functioning with young children.

When I first started getting interested in family systems ideas and started asking my adult patients about their current interactions with their parents and other members of their families of origin, it soon became clear that some of the interactions followed certain patterns than recurred again and again, and that these patterns served as triggers and reinforcers, as a behaviorist therapist might say, for the very feelings and behaviors that the patients were coming to therapy to try to change. 

Until I started asking about these interactions, as I described in my post Don’t Ask Don’t Tell, the patients had not described them in much detail. When they broke out in tears while telling me about them, however, it became hard for them to deny that the interactions were at least part of what was making them feel bad.

These were patients in individual psychotherapy, so I was not a first hand witness to these interactions, although later I found ways to see them in person. And my psychoanalytic and behaviorist psychotherapy supervisors had not discussed what to do about them.

It seemed to me that if my patients were just more assertive with their families, they might be able to change these problematic family interactions. The behaviorists had taught me about something called assertiveness training, so I tried that. The first time I tried it, I tried to teach a Chicana woman to stand up to her father. She wanted none of that. Wouldn’t even really discuss it. So, I thought, maybe it’s some sort of cultural force that I was up against in this particular case.

So how about with a patient from a somewhat more egalitarian culture? I taught an Anglo woman with traits of borderline personality disorder (BPD) to be assertive with her family. Her parents seemed to be subtly sabotaging her efforts to establish independence from them. When she was doing well, they ignored her. Or more like gave her the silent treatment and a cold shoulder. When she was in financial trouble, however, they were always right there to help out -although strangely they gave money to her teenage son rather than to her!

Every week in therapy she would dutifully practice assertiveness techniques, and would leave the session confident that she could address the issues with her family. The very next week, however, she would come back with her tail between her legs.  Her best efforts seemed to have been totally defeated, and she became even more unhappy than she had been, and even less self-confident.

I discovered that as a therapist I was absolutely no match for this woman’s parents in affecting her behavior, either for good or for ill. And it was not just her. I found out – again and again - that parents were way more potent influences on the patient than I as a therapist could ever be.

Behavior therapists do not seem to have figured out that the interactions of a patient and his or her family of origin are important triggers to many of the complaints that patients come to therapy with. Nonetheless, their behavioral interventions do often change certain aspects of a patient’s behavior, and therefore they feel that their patients are responding to treatment. In fact, if a patient’s family of origin is not too dysfunctional, they are correct. The patients change their behavior and the family basically accepts the change, so everything is cool.

But in significantly dysfunctional families? Not so much. The family therapists were right. The entire family will confront the patient in a variety of ways that all boil down to the message, “You are wrong, change back.” Many times I have even seen relatives such as aunts and uncles who previously had had little involvement with the patient come out of the woodwork screaming, “How can you do this to your mother?!?”  

Sometimes the situation would escalate to incredible extremes, with parents figuratively sticking their heads in the oven threatening suicide in response to the patient’s meager attempt at self actualization, or doing what they want and not what the parents seem to want. 

The psychoanalyst Karen Horneyonce opined that “basic anxiety” requires a sense of isolation from others, helplessness, and of being surrounded by hostility. Such perceptions and cognitions are closely related to attachment to others in one’s family system. The human brain encodes social events from the family exceptionally well, and is exquisitely sensitive to them.

“But,” I hear you protest, “a lot of patients with personality disorders are highly oppositional to their parents, seemingly doing the exact opposite of what the parents say that they want. So that theory can not be right!"

My answer to that: these people are oppositional to their parents because that’s what they think the parents need from them. The parents seem to need them to be black sheep. For a further discussion of this point, I refer you to my post about the role of the spoiler.

New developments in neuroscience are consistent with the proposition that parents can have strong effects on their children even as adults, even if they do not want to. Studies have shown that the perception of faces activates specific cells in the amygdala, which is the part of the brain responsible for fear reactions. Different cells there respond to different facial features, and certain cells respond only to one parent or the other. 

The amygdala is also strategically located for generating a rapid and specific autonomic nervous system and endocrine pattern in response to complex social signals. Lesions of amygdala in primates cause an inability to appraise social signals from other members of same species. An afflicted individual cannot distinguish whether another member of their species is coming towards them to fight with them or to mate with them. And again this is in adults, not juveniles.

In general, the attachment system seems to be one of the most important regulators of overall arousal. The amygdala is the first responder within fractions of a second; one’s initial fear orientation is not affected by conscious cognition. However, the signals then go to the other areas of the brain for further evaluation. Information regarding social context directly affects this appraisal process.

Attachment research indicates that the brain regions that compose the limbic system use input from the emotional states of attachment figures to regulate both internal and external responses. Individuals exhibiting so-called disorganized attachment have been found to have parents who display both frightened and frightening responses. 

In a sense, rage and panic are both communicated to and conditioned within the offspring of such parents. According to attachment researcher Mary Main, if parenting generates multiple, contradictory models of attachment, this creates a sense of insecurity in the offspring.

Complex limbic system reactions to the social environment have been found to be specific to important individuals within the family. Problematic reactions such as rage attacks can be seen to occur with one parent but not the other! If interactions with primary attachment figures are highly stressful over prolonged periods, this can have a profound effect on the development of a child’s brain that last a long, long time.

Early learning may be particularly difficult to inhibit. In general, it is much harder to unlearn fear than to learn it in the first place – a fact highly consistent with the experience of psychotherapists trying to extinguish chronic anxiety, particularly chronic interpersonal anxiety. 

Extinction of fear responses has also been found to be context specific. If a fear response is extinguished in one context, it may come right back if an animal is moved to a somewhat different environment. If the new environment is similar to another one such as the early family environment, fearful patterns of behavior learned early in life but inappropriate for the new environment may therefore be seen.

So, early influences are very powerful, but that does not mean that later experiences are inconsequential. When individuals grow up, their parents usually continue to act in ways that recapitulate social interactional sequences from the patient's early life experience. This parental behavior automatically both cues and reinforces old but engrained role relationship schemata (mental models of how to respond to different social cues).  

In turn, these reinforced schemata become more likely to be activated in the patient's current social interactions. This leads to reenactment and recapitulation of these patterns in other relationships. This is the basis of what Freud referred to as the repetition compulsion.

As I have described, parental behavior seems to be an extremely potent environmental trigger for previously learned social behavior. This most likely stems from the survival value of coherent group structure in evolution. As psychoanalysts have hypothesized, children internalize the values and role behaviors of their social system, and conformity to the group has in the past continued to have survival value throughout the life cycle.  

Parental behavior has such a powerful effect in triggering old schemata that it does not have to occur with any great degree of frequency in order for its effects to continue. In adults, the reinforcement of schemata occurs in a manner analogous to the learning theory paradigm of a variable intermittent reinforcement schedule. That is, the powerful parental behavior may be witnessed infrequently but unpredictably, leading the patient to continue to react rigidly in ways consistent with old role-relationship expectations.  

Really Unfortunate Logo Choices for Your New Restaurant Part 1

Adventures in the Veterans Hospital Mental Health Clinic Part II

Continuing on from my post of 3/17/15 on the Kafkaesque nature of the VA bureaucracy, their motto seemed to be, "If we find a problem in the system, we'll come up with a ridiculous solution that may make the problem even worse. Or at the very least, create a whole new set of problems."

For example, not too long ago there were a couple of serious foul-ups at the VA Memphis hospital that were caused by patients being mis-identified by staff and given the wrong treatment. This sort of thing can have disastrous consequences, of course, and it happens from time to time in almost all hospitals. It is quite a serious issue. Of course, in these cases dire consequences are most likely to result  with surgery or in a busy emergency room; such events are fairly rare in outpatient clinics.

The VA solution: Every doctor was instructed to verify every patient's full social security number and full name immediately at the beginning of every single appointment. We were told to do this, not just for patients we did not recognize, but even for our regular patients who we have been seeing for years! And we were told that we had to document that we had done this - again every single time - in the patient's electronic medical record (EMR). No one anywhere else does this.

That may seem like a small although illogical request that wouldn't take much time. The trouble was, we were asked to document a whole bunch of other things almost every visit. Most of these things were completely irrelevant to the visit at hand. For instance, there are so-called "clinical reminders" to ask about certain information at most visits whether it concerned the reason for the patient's visit or not (example shortly). 

With limited time to see each patient and to document the relevant information in the EMR, this added a significant amount of time to a visit that would then not be available to actually evaluate the patient's progress for the problem that was being actively treated.

Most of the clinical reminders were checklists, about which I have complained many times on this blog. One particularly ridiculous clinical reminder was a requirement to perform a depression screening checklist, the PHQ-9. This is just what it says it is - a screening test to see who should be evaluated further for depression. 

It is meant to be used by primary care docs and other non-psychiatric physicians to determine who should be referred to a psychiatrist for these further evaluation, and who does not need one. It is meant to cast a wide net, meaning a positive test does not mean that you have a clinical depression - only that you might and should therefore be screened further.

The VA wanted the psychiatrists to ask their patients to fill one out! If a patient is already being evaluated by a psychiatrist, the purpose of PHQ-9 is no longer operant, so filling one out is completely pointless and an utter waste of time. Unless, of course, someone is such a bad psychiatrist that they think a psychiatric evaluation does not include an evaluation for depression.

I refused to do the PHQ-9's, because I perform a complete bio-psycho-social psychiatric evaluation when I first see a new patient, and I was not going to short change my patients by further shortening our already limited time together by asking questions I already knew the answer to, or was about to go into far more detail about than is possible with a PHQ-9.

Actually, there was at least one psychiatrist on staff who did not do a complete evaluation of every patient. Because this psychiatrist did not make waves, that clinician was allowed to practice what I consider to be piss poor psychiatry for years. Then the doc left. I will discuss what happened in that situation in Part III of this post.