Tuesday, July 19, 2016

Ambiguous Language and Recognizing Emotional Conflicts in Others - Part II

The literary critic William Empson took Freud's idea of intrapsychic conflict as a springboard for appreciating the art of the poet, which in turn is a way of understanding the poet. Empson conceptualized intrapsychic conflict along psychoanalytic lines, but his ideas can just as well be relevant to a conflict between the individual's self and the family system to which that self belongs. In the book, Seven Types of Ambiguity, he listed different types of literary ambiguities which indicate increasing levels of confusion in the minds of the reader, the characters, and perhaps the author.

One of the reasons that literature excites us is because we identify with or contrast our feelings with the feelings of the characters as they encounter various predicaments. Those feelings are frequently not fixed, but mixed. Both we and they are plagued with doubts and contradictions. In much the same way, we can enter the internal world of others within our social system. In both cases, we are confronted with various degrees of ambivalence and confusion.

Empson's seven ways in which levels of "two-mindedness" are manifested in language are the subject of this post. Their presence can be used to alert a listener to the possibility that a motivational conflict is present in the speaker. Being able to spot this is key to understanding and then constructively discussing (metacommuncating about) repetitive dysfunctional family interactions. In general, the degree or level of the speaker's awareness of his or her ambivalence increases as we proceed down the list.

1. A statement's makes possible comparisons to several points of likeness or difference. This type of ambiguity turns on the fact that any idea or emotion causes a multitude of associations within the mind of the listener, and also because different people have different associations. A choir, for instance, can lead one person to recall positive images such as grand churches and angelic singing, while for another it summons negative images such as overbearing nuns in Catholic school or guilt-inducing sermons. This is precisely why people use metaphors and why metaphors make language so rich; a single word can stand for so much. A statement is ambiguous when the listener finds himself or herself wondering which of these many potential references and feeling states is in the mind of the author or speaker.

2. Two or more alternate meanings are fully resolved into one because to what a metaphor is really referring seems fairly clear. This device may or may not be ambiguous, depending on whether or not a question exists as to the actual meaning of the author.

 3. Two apparently unconnected ideas are suddenly connected. A good example of this type of ambiguity is the pun. An ambiguity arises whenever a question exists as to whether or not to connect the meanings, or about how to connect them. I remember an instance in high school in which I made a remark to a friend about another fellow student whom I disliked - which that guy overheard - about how he belonged to an anti-nuclear weapons organization. I mentioned that the fellow "was in SANE."
4. The speaker indirectly expresses mixed feelings or ambivalence without admitting to them, through the use of exaggeration. Confusion can be communicated, for instance, by provoking in the listener a sense of "methinks he doth protest too much." In other words, when individuals overstate their feelings, a listener may get the idea that they are covering up opposite feelings. The process involved can also be understood as a manifestation of a the defense mechanism known as reaction formation. Individuals may defend against an unacceptable idea by becoming obsessed with the opposite idea, or defend against an unacceptable impulse by compulsively acting in ways contrary to the impulse. A good example was the scandal that surrounded the television evangelist, Jimmy Swaggert. He had vociferously condemned from the pulpit all those who gave in to the "sins of the flesh." As it turned out, and as many of his critics had suspected all along, he had been giving in to the same temptations himself.

5. An individual communicates two ideas which may contradict one another in passing from one of them to the other, but does not address the question of their apparent inconsistency. The speaker either does not seem to be holding both ideas in mind simultaneously or never juxtaposes them, so that the issue of their possible mutual exclusiveness can arise for discussion and clarification. For example, a man may expound on his belief that the only road to satisfaction is hard work, and then go on to complain about how bummed out he feels at his own job. As a therapist, I often notice such possibly contradictory statements made literally weeks or even months apart. A therapist really has to pay attention and write good notes about sessions to pick up on this.

 6. The speaker says something in a way that actively signals to the listener that there should be some doubt as to what has been said. The speaker appears to have avoided making a commitment to an idea or expressing his or her true feelings. In this situation the speaker cannot be held accountable for holding any particular opinion. Damning with faint praise would be one example. When a basketball coach describes a player as "tenacious on defense, and always gives one hundred and ten percent," he is generally not describing one of his starters. A second example is the use of words like "strictly," "exactly," or "totally," as in, "she was not, strictly speaking, very intelligent!” A third way is through the use of nonverbal communication. A grin or a raised eyebrow will often negate the content of what is being said at the lexical level. In all of these cases, the listener is forced to guess what the speaker really means.

7. The last type of ambiguity is a full contradiction, in which the author or speaker obviously seeks to "have it both ways." In type seven, speakers make statements which indicate neuroticism or indecisiveness. They may go on and on ad nauseam describing the pros and cons of particular viewpoint or course of action without ever making a decision. They may obsessively waver back and forth on an issue. They may without warning plunge from the heights of ecstasy to the depths of despair, or from the idealization to the denigration of a person, thing, or concept.

Tuesday, July 5, 2016

Ambiguous Language and Recognizing Emotional Conflicts in Others - Part I

In my post of 12/2/14, intrapsychic conflict and dysfunctional family patternsI discussed what I believe to be the most important way to integrate three of the major schools of psychotherapy: psychodynamic, cognitive-behavioral, and family systems. To boil it down, conflicts that people experience over what to think and how to behave (intrapsychic conflicts) are triggered and reinforced, on a variable intermittent reinforcement schedule, by family members who are stuck with rules of behavior that are no longer adaptive because of changes in the ambient culture. In a sense, the whole family shares the intrapsychic conflict.
The family members in this situation give one another mixed or contradictory double messages about what behavior they expect from one another.
If you are stuck in this situation and are motivated to recognize the double messages and to try to discuss the conflicts in a meaningful way (metacommunication), how might you recognize when other family members are thusly conflicted? This post and the next will discuss how to do that. Specifically, I will show the intrinsic ambiguity that is a feature of all language is used by those conflicted to accomplish two goals:
1. Keeping their conflicted feelings, beliefs and motivations unclear to other people.

2. Keeping those things unclear to even themselves to avoid anxiety.

Linguists tell us that any sentence in any language can be interpreted at two different levels - which may then conflict. One level is the purely lexical or object level, that is, what the specific words actually mean. The other level is the meta level. This level concerns the relationship of the two conversants in which any statement is made. The context provided by the entire history of the relationship between the two conversants alters the meanings of the sentences.

If I say to a friend "I love ice cream" as we pass an ice cream parlor, I may not merely be conveying a message about my preferences in dairy products. I might also be suggesting, for example, that we stop and have an ice cream. The indirect nature of the request may, for example, indicate that I lack the power in the relationship to just demand that my friend go into the parlor with me. The power differential is part and parcel of the nature of the relationship between the two people.

 Whenever two people who have formed a relationship have a conversation, any statement made may refer to either the object or the meta level. The two levels may seem to be in harmony or they may contradict each other. Another way of looking at this phenomenon is that all statements may refer either to the feelings, thoughts, and intentions of the individual apart from the relationship context, or to the feelings, thoughts, and intentions within the relationship context.

When the listener does not know which of these descriptions best applies to a given statement, an ambiguity is created about the motives of the person making the statement. The statement, "I love ice cream," is an example of a statement in which the object and meta levels would not be contradictory in most social situations. It is totally consistent for me to both like ice cream no matter who I am with or even if I am alone and for me to want my friend to accompany me to an ice cream parlor right now. If, on the other hand, I make this statement as we pass an ice cream parlor while implying that I would rather be somewhere else, then the motivation behind my statement becomes ambiguous. And confusing.

Individuals will invariably react to such ambiguity, but they do not tend to think of the communication as ambiguous. For instance, if a widowed mother says to her son, "You don't care about me; you never want to come when I desperately need you," it is natural for him to assume that his mother wants him to change his behavior. He believes that she wants him to gladly come over whenever he is needed. 

It seems that he will continue to believe this, even if the requests for help are made with impossible frequency at times clearly inconvenient for him and without a shred of gratitude on his mother's part when he complies. He may continue to believe this, in fact, even if criticized every time he complies with his mother's request.
The son in this situation is in a rather strange bind. He is being criticized by his mother for attempting to please her. To add insult to injury, her requests are almost impossible to follow without a complete disregard for his own needs. Interestingly, most people in such a predicament do not come to the conclusion that the mother may not, in fact, really want the help she asks for, or, alternately, that she does not even know whether she wants it or not. The idea of an intrapsychic conflict being the cause of such behavior is not generally considered, even though it is the most common cause. 

The idea that the mother is knowingly pushing the helper away for some ulterior motive is one that just does not appear to most people to make any sense. However, this is precisely what is happening. This is the "net effect" for which the behavior was designed.

The ambiguity is Mom's motivation in this case suggests the possibility that his mother has a conflict within herself over her dependency needs. Perhaps she is not happy being looked after by her son, but might believe, for example, that being independent is not proper for a woman. No matter how the son behaves in regard to the issue, she becomes displeased. because his actions interfere with either her true desires for independence or the rules required by her gender role. He is in a "no-win" situation. However, her displeasure does not result directly from the son's behavior, but from her own internal conflicts.
With this in mind, let us look at the ambiguity of the "you don't care about me" part of her statement. It may refer not to the son's lack of concern for his mother per se, but to the motives behind his helping behavior. It could mean that she believes that the son's behavior is based on his own selfish wish to look after and dominate her, rather than on her desire to be looked after by him. He could be helping her because he likes being a kingpin, for instance - not because he cares about her.

Within the context of dysfunctional family relationships, it is often true that consideration of the seemingly less likely interpretation of a statement reveals the truth as to what is really going on!

In the next post, we will look in more detail about the semantics of intrapsychic conflict. 

Tuesday, June 21, 2016

For Big Pharma, Charity Begins at Home - and at Taxpayer Expense

Martin Shkreli

According to an article in the British Medical Journal, from 2011 to 2014 drug companies have increased the prices of four of the top 10 drugs sold in the United States by more than 100%, and the prices of the remaining six by more than 50%. 

Most people are familiar with the story of Martin Shkreli, former chief executive of Turing Pharmaceuticals. In August 2015, he purchased a generic drug called Daraprim that treats toxoplasmosis—a life-threatening parasitic infection that many AIDS patients contract—and immediately raised its price by more than 5,000 percent. He has not been alone. The price of many generic as well as brand-named drugs has skyrocketed. In psychiatry, an old antidepressant named Parnate, available since the early 1960's, can cost over $250 per month. It probably ought to be one of those five dollar generics.

What a lot of people may not know is that these price increases are part of what seems to be a scam to bleed tax dollars from Medicare. According to a recent article in Bloomberg News, within days of increasing the cost of Darapin, Turing contacted Patient Services Inc., or PSI - a charity that helps people pay for the insurance copayments on costly drugs. Turing wanted PSI to create a fund for patients who had the AIDS complication that could be treated with Daraprim.

PSI, as it turns out, is one of seven patient-assistance charitable organizations commonly known as a copay charities. There are also many smaller ones. They offer assistance to some of the 40 million Americans covered through the government-funded Medicare Part D drug program.

Having just made Daraprim much more costly, Turing was now seemingly offering to make it more affordable. But that is hardly the whole story. It is also a story about how U.S. taxpayers support a billion-dollar system in which charitable giving is, in effect, a very profitable form of investment for drug companies—one that may also be tax-deductible!

Drug companies know that, all other things being equal, the more expensive they make a drug, the fewer people will purchase it. However, if insurance pays for the drug, then this is is no longer much of an issue. The kicker is that when the Part D Medicare drug law was passed, it included a provision that Medicare, with its leverage on negotiating drug prices created by the size of its insured population, cannot bargain with drug companies for lower prices. If the insurance company uses a "charity" which covers patient co-pays and the so-called donut hole, patients will fill their prescriptions and taxpayers end up paying the huge price increases.

As the Bloomberg article points out, "A million-dollar contribution from a pharmaceutical company to a copay charity can keep hundreds of patients from abandoning a newly pricey drug, enabling the donor to collect many millions from Medicare. The contributions also provide public-relations cover for drug companies when they face criticism for price hikes."

The article added, "Fueled almost entirely by drugmakers’ contributions, the seven biggest copay charities, which cover scores of diseases, had combined contributions of $1.1 billion in 2014. That is more than twice the figure in 2010, mirroring the surge in drug prices. For that $1 billion in aid, drug companies get many billions back.

According to a recent article in USA Today, charity-run funds are now facing new scrutiny by prosecutors in two states and by The Department of Health and Human Services' office of the inspector general. But the focus is only on whether or not co-pay charities favor donor companies' drugs over those sold by other companies. No one is challenging the whole scheme.

Those who are concerned that the government spends too much money and that the national debt is too large should ask themselves why politicians prohibited Medicare from negotiating volume discounts with Pharma companies, thusly creating these lucrative opportunities for them at taxpayer expense.

Tuesday, June 7, 2016

Marketing Methamphetamine Clones for Fun and Profit

From 2010 (when I first started this blog) until 2013, I published several posts about the United States Department of Justice assessing huge fines against several large pharmaceutical company for off-label marketing and false advertising about several different psychiatric drugs. Somehow in September of 2014, I missed  a big one. 

That time, a large fine was assessed against my least favorite of all the drug companies, Shire Pharmaceuticals - the maker of the methamphetamine clones Adderall and Vyvanse. They also make a version of Ritalin called Daytrana.

As far as I'm concerned, this company is nothing but a dope dealer that cares only for profits and not a whit for their victims - er, I mean consumers. The company does its best to convince doctors to dope up kids who have various behavior problems - which in reality are mostly due to problematic parenting and/or chaotic home environments - with highly abuseable and dangerous stimulants. 

I have written several posts on the huge increase in prescriptions for these medications in children over the last twenty years or so. Now, we are seeing a huge increase in prescriptions of these drugs to adults for the adult version of "ADHD." While there may be both adults and children with minimal brain dysfunction who have a real disorder that requires this medication, most people who are given this diagnosis present with symptoms which are caused by other factors. The biggest ones: the effects of bad environments mentioned above which create anxiety and low moods, and amphetamine abuse. The later patients lie to their physicians in order to get the drugs. 

The drugs not only get people high, but are also used as performance-enhancing drugs for mental activities—much like steroids are used to enhance performance for physical activities.

Currently, medications to treat ADHD are one of the most lucrative sectors of the US drug market, totaling more than $10 billion in sales - 83 million prescriptions in 2014, according to data from IMS Health, ”with adults using more of these medications..." The “2013 edition of the Diagnostic and Statistical Manual of Mental Disorders... relaxed the definition for” ADHD in adults."

ADHD symptoms are easily faked. A 2010 study found that 22% of adults tested for ADHD exaggerated their symptoms. And that was probably only those subjects who would admit to it! Such exaggeration has been made much easier by the wide availability of online symptom checklists. 

Getting back to the matter at hand, Shire Pharmaceuticals LLC  paid a $56.5 million fine to resolve civil allegations that it violated the False Claims Act as a result of its marketing and promotion of these drugs. As one can easily see from the above figures, that's actually a very small cost of doing business. Among other things, they marketed Adderall XR based on unsupported claims that Adderall XR would prevent poor academic performance, loss of employment, criminal behavior, traffic accidents and sexually transmitted diseases. 

Shire medical science liaison allegedly told a state formulary board that Vyvanse “provides less abuse liability” than “every other long-acting release mechanism” on the market.  However, the government contended that no study Shire conducted had concluded that Vyvanse was not abuseable, and, as an amphetamine product, the Vyvanse label included an FDA-mandated black box warning for its potential for misuse and abuse. Shire also made allegedly unsupported claims that treatment with Vyvanse would prevent car accidents, divorce, arrests and unemployment. 

Interestingly, the Justice Department was alerted to these marketing practicing by whistleblowers. The allegations arose from a lawsuit filed by Dr. Gerardo Torres, a former Shire executive, and a separate lawsuit filed by Anita Hsieh, Kara Harris and Ian Clark, former Shire sales representatives. The lawsuits were filed under the False Claims Act’s whistleblower provisions, which permit private parties to sue for false claims on behalf of the government and to share in any recovery. 

The marketing of stimulants for "adult ADHD" is as heinous as the marketing to children and teens. According to an article published by Medscape, "... the prevalence of [supposed] ADHD in adults these days is about half that in children. For years, the legitimacy of the adult ADHD was based on the belief that it was a condition that started in childhood and, for some, persisted into adulthood. 

But last year that hypothesis was shaken by the publication of a provocative, long-term study that followed more than 1,000 New Zealand children until age 38. In that study Terrie Moffitt, PhD, a psychologist at Duke University, and her colleagues found that in childhood, 6% of those in the study had ADHD. At age 38, that number had dropped to 3%.

And the biggest surprise was the lack of evidence of significant overlap between the two groups. Only 5% of those with ADHD in childhood still met the criteria at age 38. And only 10% of those who met the definition at age 38 were among those with the supposed condition in childhood.
The Medscape news article concluded from this data that "Studies suggest people diagnosed with ADHD as adults may have a condition that differs from ADHD seen in children." Wow. I would come to a different conclusion. Namely, that most of these patients did not have "ADHD" at all, but something else entirely.
And in yet more marketing-of-dope-to-children news (without a peep out of the pesky National Institute for Drug Abuse or the FDA), there’s a new, candy-flavored amphetamine on the market. Adzenys is chewable and fruity! Dr. Alexander Papp, affiliated with University of California, San Diego, asked, “What’s next? Gummy bears?”

Tuesday, May 24, 2016

Invalidating Therapists Act Like Job's Counselors

Recently I heard a story about a man who made a choice regarding his career that was at odds with family expectations. He was roundly criticized by his father, some of his siblings, as well as an uncle.

Much later, when the man started having financial problems, these relatives told him immediately that this was all his fault. According to them, his financial woes just had to be because of the career decision he had made.

This is an example of what I refer to as clustering - family members ganging up on one of the members for breaking a family rule, and pressuring him or her to tow the party line.

In an analogous fashion, some therapists inadvertently feed into a patient's problems rather than help remedy them, and in the process invalidate their own patients. Before getting to that, however, I wanted to mention that the man in question likened his relatives to "Job's Counselors." I of course had heard the story of Job, but I had never heard about that part.

As most readers will know, the Book of Job in the Bible describes the tale of a pious and righteous man named Job, who had considerable wealth as well as wonderful sons and daughters. In heaven, God asks Satan for his opinion of Job's piety. Satan answers that Job is pious only because God has blessed him; if God were to take away everything that Job had, then he would surely curse God.

God then gives Satan permission to take Job's wealth and kill all of his children and servants. Still, Job continues to praise God. Then, God allows Satan to afflict his body with boils; still he remains pious.

Three of Job's friends became known as "Job's Counselors:"  Eliphaz, Bildad, and Zophar. The friends tell Job that his suffering simply must be a punishment for sin, for God causes no one to suffer innocently. This of course, is the exact opposite of the truth as laid down in the story.

So how does this relate to therapists inadvertently invalidating their patients? Well, many therapists focus on alleged defects in their patients and work on such things as "anger management," "distress tolerance skills," or fixing the patient's defective "mentalization" (the ability to accurately assess the intentions of other people). 

These sorts of interventions presume that if someone is upset, angry, or unhappy with the way the world is treating them, then therefore there must be something wrong with them. Even when they are in fact being abused horribly!

Now, in defense of therapists who received reductionistic training, it is true that patients often act as if there is something wrong with them in these sorts of areas. However, as I have discussed in previous posts, there is a big difference in patients' public performance at a task as opposed to what they are capable of doing.

Often the alleged defects are in reality part of one of the dysfunctional family roles frequently described in this blog. People who are exclusively trained in CBT do not know about —or if they do they do not accept—the concept of a persona or false self. CBT made a name for itself by attacking psychoanalysis, its predecessor as the predominant form of therapy, and rejected all of its concepts regardless of whether they were right or wrong.

Researchers in personality disorders routinely make this same logical error all the time in studies. They look at the subjects' reactions without looking at all at what they are reacting to! It is a bit like watching a movie in which all but one of the characters - both their behavior and their verbalizations - are redacted so that the viewer can only see what one character is doing and saying, apparently in a vacuum. And then asking the viewer to guess why the one remaining character talks and acts the way he does.

An excellent example of precisely this appeared in the February 2016 issue of the Journal of Personality Disorders - a study called "Using Negative Emotions to Trace the Experience of Borderline Personality Pathology" by M. Law and others. Research subjects were asked to record their emotions (especially irritability, anger, shame and guilt) five times a day for two weeks, but not the environmental triggers which seemed to create these feelings. 

The authors came to the shocking conclusion that the subject's BPD symptoms and their negative emotions were intricately related. No sh*t, Sherlock.

Wouldn't it have been just a little more informative to have gotten data that would help us understand what sorts of situations were most likely to trigger both the negative emotions and the symptoms of people with borderline traits? Ya think?

Tuesday, May 10, 2016

Book Review: Prescriptions Without Pills by Susan Heitler

When I first started to develop my integrative psychotherapy paradigm, unified therapy, a central problem I focused on was how patients could fruitfully discuss sensitive family dynamics with their parents without the conversation turning into just another variation on the same exact dysfunctional theme. How could someone confront highly invalidating and/or abusive parents about their interactions, with a goal to stopping them, without the conversation devolving into mutual rage, defensiveness, attacks, and/or emotional cutoffs?

I was amazed at how family members could be such experts at re-framing something meant to be constructive back into something highly destructive. Readers of the comments to my blog posts on Psychology Today know that even today many people think I am the insane one for even thinking it is possible to interrupt this admittedly highly malignant process.

After I first developed and wrote about some good strategies for keeping things constructive, I came across a helpful book by Susan Heitler, Ph.D., called From Conflict to Resolution (W.W. Norton, 1990), which described several strategies for detoxifying toxic interchanges between intimates as well as between patients and therapists. The book helped me to refine and expand upon my repertoire of strategies. Since every family and family member responds differently, the more strategies I have in my bag of tricks, the more different patients I can help.

I later briefly met Dr. Heitler at a meeting of the Society for the Exploration of Psychotherapy Integration, an organization to which we both belong. Its purpose is to look into ways to integrate various ideas from the different "schools" in psychotherapy— primarily the psychoanalytic/psychodynamic therapies and cognitive behavior schools.

(As an aside, I have since become less involved with the organization for two reasons. First, the leaders of the group were afraid that if they succeeded in devising an overarching theory, then they would just become yet another therapy school. I, on the other hand, was tired of exploring and was interested in actually doing. Second, family systems and social psychology were woefully underrepresented in the group. Since humans are among the most social of organisms, that just seemed crazy).

Dr. Heitler has now written a self-help book for lay readers which goes over a lot of the same territory as the Conflict book, Prescriptions Without Pills: For Relief of depression, anger, anxiety and more. The title stems from an opinion we both share: today there has been an explosion of excessive prescribing of anti-depressant and anti-anxiety medication to clients who just have problems in living. While she is not against the use of medication, it is often just plain ineffective for many problems with which people come to mental health professionals. Antidepressants for example, as I have written about many times, are completely useless for chronic unhappiness as opposed to Major Depressive Disorder.

The book is chock filled with very useful suggestions for people who are locked into what were once termed neurotic styles. (See the book of the same title by David Shapiro from way back in 1965). The term neurosis has unfortunately now been practically banned from psychological discourse and psychiatric diagnosis because its role as a "cause" for any psychological problem has not been "proven." 

It refers to problems created for people because of internal conflicts between what they would like to do based on their own preferences and what they think they are supposed to do based on the "rules" they have learned from their ethnic group, religion, and most importantly their families of origin. "Style" refers to such things as ways of thinking and perceiving, modes of subjectively experiencing other people, and repetitive, unthinking types of stereotypical behavioral transactions in various circumstances within one's interpersonal relationships.

People who will benefit most from this book are those who learned these styles growing up and who have gotten into some bad habits which create sadness (the author uses the word depression but seems, at least in this book, to have conflated major depression and dysthymia, the differences between which are elucidated in this post), anxiety, anger, and/or addictive behavior—but who are generally functioning fairly well in some areas of their lives, have minimally cordial relationships with their parents and siblings, and are highly motivated to change. They will find the suggestions in the book quite helpful in getting problematic behaviors and feelings under control. This in turn will help them with their love life and their work life as they interact with others.

I do not believe that people with more severe personality pathology and highly dysfunctional families will be able to successfully avail themselves of these strategies for reasons I will also mention in a bit. So this book will not be as helpful for folks like that.

Dr. Heitler describes the typical habitual ways neurotic people respond to problems, particularly interpersonal ones. The one healthy one is to define and boldly face the problems and to work on solutions to them. The unhealthy ones include folding (leading to discouragement and low moods; fighting (leading to anger and aggression); freezing (leading to chronic anxiety); and fleeing (obsessively burying oneself in a substance or behavior and becoming addicted to it).

A big part of the techniques for changing the bad behavior when it starts to occur is stopping and thinking about what the real nature of the problem is, as well as the reasons behind one's own seemingly overly-strong, over-the-top emotional reactions. The reasons for those are often past experiences with important attachment figures (emphasis on the word past. If those experiences are ongoing, that's a 'hole 'nother level) which bring up strong feelings.

For instance, if when you were growing up your divorced father frequently did not show up for his visitation days when he was supposed to, and in response you started to think that you are basically unlovable, then any time another person disappoints you, you might over-react even if the other person had a very valid reason for not doing what you had expected. 

This is actually a way of conceptualizing what the psychoanalysts call transference. Many cognitive behaviorists claim they don't believe in it, even though they actually do but just call it by another name: mental schemas.

Dr. Heitler recommends visualization techniques one can use to let one's mind recall the important precipitating events from one's past. The techniques can be thought of as another way of employing what the analysts call free association.

She also suggests many useful questions to ask oneself and ways of thinking that one can use to explore one's own psyche, to change perceptions about what other people might really be doing and thinking, and clarifying dilemmas in life. She describes how one can use their own strong feelings as a vehicle for constructive engagement with other people in order to solve mutual problems.

When discussing mutual problems that occur in intimate relationships, certain words and phrases often lead to more conflict than light. The author provides a useful list of words to use and words to avoid in what she calls the Word Patrol.

The reasons these otherwise wise and productive suggestions are likely to fail in people from more disturbed families with ongoing repetitive dysfunction relationship patterns is because they are quickly and easily overcome by powerful family reactions to the patient's new behavior. If your new behavior causes your mother to suddenly stick her head in an oven, metaphorically or literally speaking, or if everybody you know and care about comes down on you like a pack of hungry wolves with the strong message, "You're wrong, change back," most people will wilt and go back to the way they were. This process is particularly vicious in families that produce people with borderline personality disorders, as described in this post.

Instead of responding with less defensiveness and anger, dysfunctional family members can twist around what anyone says no matter what words are used or avoided. They can employ ambiguity and double messages to such a degree that the person who is trying to engage them in problem solving does not know what was actually meant or whether or not any issue was really resolved.

This does not mean that family members in families like these cannot be reached. They most definitely can be. But the process is way more difficult and intricate than the solutions described in this book might seem to imply.

Tuesday, April 26, 2016

Successfully Confronting One's Family of Origin Members: What Comes Next?

A commenter on one of my blogposts posed what I thought were some very good questions. The post itself was about how some other therapists think I'm a horrible therapist because I send my patients who come from highly dysfunctional or abusive families back into the hornet's nest to confront and hopefully change ongoing repetitive dysfunctional interactions with family of origin members.

The anonymous commenter asked: Even if a patient is able to confront or dialogue with their parent to stem the abusive behavior, wouldn't that be just the beginning of the work of patient? Just because Mom and Dad have stopped being the insufferable fools that they are, a) they don't necessarily understand the family dynamics at work and b) their corrected behavior is not going to help the patient with his habitual emotional responses that have hampered his life. Once Mom and Dad have been more or less straightened out, what is the patient's next move?

I realized that, although I covered this in detail in my books for therapists, I had not really addressed the answers to these questions here in the blog. So here goes:

First of all, the dialog with the parents usually does include an empathic discussion of the family dynamics and the reasons for the parents' problematic behavior (metacommunication). The goal is to do this without condoning any of their past or current damaging behavior. That problematic behavior is the most powerful trigger and reinforcer of the patient's dysfunctional role within the family. (Many of these roles have been described in detail in previous posts, and are models for the various personality disorders).

How individuals play the dysfunctional roles in everyday life is based on a model in their heads of how to respond to various social situations with significant others. These models are called role relationship schemas. These schemas and the resultant behavior are performed automatically and subconsciously in response to various pre-determined social cues, and are therefore performed thoughtlessly in most situations.

When the parents stop feeding into and/or triggering someone's schemas, this seems to start to free the person up to experiment with alternate ways of relating to others. While going through this process, however, the individual may often also experience something called post-individuation depression or groundlessness in which they come to the realization do not seem know who they are any more. They have yet to become acquainted with the true self that they had been, before this, invariably suppressing throughout much of their lives. Paradoxically, their role behavior or false self feels real, while their true self feels false!

As a therapist, I explain this feeling to them and reassure them this horrible feeling will soon pass.

Many patients will then spontaneously start to experiment with new ways of relating to others. If not, typical cognitive-behavioral psychotherapy interventions from the therapist - which would have before this point been quickly overpowered by the reactions of family members - suddenly become very effective in moving patients forward.

Finally, the patient is instructed on how to handle the issue of family relapses. It is almost inevitable that they and the parents will at some future point fall back into their old dysfunctional habits. As we all know, long-time habits are indeed quite hard to break. However, once the earlier metacommunication had taken place, it is fairly straightforward to bring the relapse up with the parents and refer back to what had been discussed and decided upon earlier. The patient is instructed to wait until everyone cools down before attempting this maneuver.

Before I terminate therapy with a patient, I praise the patient for taking what we had discussed in therapy and employing that which we had decided to do so effectively. I believe it is important that patients take a realistic view about giving credit where credit is due, so they can have confidence that it was they who had actually accomplished the goals of therapy. This reassures them that they can therefore carry on without the therapist's help - and without the therapist having to pretend that the therapist had nothing to do with it at all, as some family systems therapists recommend.

Tuesday, April 12, 2016

Direct to Consumer Drug Advertising: There's a Sucker Born Every Minute

Have you seen them? TV and print ads advocating the use of a new drug called Rexulti as something that can be used to augment an antidepressant when the antidepressant alone does not completely relieve all of your symptoms. These ads are only slightly different than ads you may have seen in the past for Abilify, which was also touted for the exact same indication.

As it turns out, both of these drugs are manufactured and distributed by the same companies: Otsuka Pharmacuetical Company and its marketing partner Bristol-Myers Squibb. And guess what? Abilify recently went generic (which means its original manufacturer has lost its patent protection and therefore its monopoly on the drug) under its chemical name, aripiprazole. 

Rexulti's chemical name seems oddly similar: brexpiprazole. Coincidence?

Well here are pictures of the chemical structures of the two compounds.

Remarkably similar, no? In fact, these drugs have effects on people that are nearly identical, have only slightly different side effects, and they both have the exact same indications. And of course they are not antidepressants at all as many of you have probably been led to believe, but antipsychotics: meant to treat delusions and hallucinations in schizophrenia, bipolar disorder (the real kind), and major depression with psychotic features.

(BTW, we've always known that any antipsychotic medication can augment an antidepressant in some patients. However, they have potentially very toxic side effects, and there are other, safer drugs which can also augment an antidepressant, such as lithium and a thyroid hormone named T3. I think benzodiazepine drugs such as clonazepam do as well, but drug companies are not about to do studies confirming that, because benzo's are so cheap and free of side effects).

There is one very big difference between Rexulti and Aripriprazole: the price. Generic Aripiprazole will be much, much cheaper. Why on earth would anyone ask for an expensive drug when a cheaper, nearly identical drug with the same effectiveness and nearly the same side effects is available?

Well of course they would not. Which is where the direct to consumer ads come in. The company wants to keep up its profits, so it pushes their new drug without any reference to their old one. And people are suckered into demanding it from their doctors. As someone once said, no one ever went broke underestimating the intelligence of the American people.

Now I can't prove that the company developed Rexulti in anticipation of losing its patient protection on Abilify, but the timing is a bit suspicious, wouldn't you say?

Drug companies have lots of tricks to extend their patent protections aside from just coming up with new conditions for which a drug is indicated, coming up with an extended release version of the same drug, or newly combining the drug with a second drug. 

Some drugs are converted to other drugs in the body which are in fact the compounds that have the desired effects (active metabolites). So after the parent drug goes off patent, they release the active metabolite as a "new" drug. Think Effexor vs. Prestique.

Some drug compounds come in two different versions which have the same chemical formula but different geometry - the two molecules (enantiomers) are mirror images of one another. One of the two versions may be effective for a given symptom while the other may have little effect. So drug companies first issue a mix of both versions (racemic mixtures), and when that drug goes off patent, they release a drug which is  the pure, active enantomier. Voila, new more expensive drug, new patent, and the clock keeping track of how long the company retains exclusive ownership of the drug starts to tick anew. Think: Celexa vs. Lexapro, and Prilosec vs. Nexium.

So if you pay attention to those ads, you will be being taken as sucker.