Monday, October 14, 2019

Different Schools of Thought in Psychotherapy

At last count, there were over 200 different "schools" of psychotherapy, each with its own ideas about why people act in self-defeating ways or in ways which bring them emotional or even physical pain, and how to help them to stop. Of course psychotherapy is, despite having been around for a hundred years, a young science, but our field is more difficult to study “empirically” than any other. 

The problems we have are enormous because we cannot read minds, and people can choose to some extent how they react to any therapy intervention. Patients withhold information about their situations from therapists all the time due to protecting their families from negative judgments, guilt, shame, or a concern the therapist might not be interested in it.

In psychotherapy outcome studies, seemingly minor variations in therapist techniques that are in fact vitally important (such as body language and tone of voice) aren’t even measured. There are no good active control treatments, and, when two therapies are compared,  the therapy method favored by the first author of the study comes out ahead 85% of the time due to the authors’ biases (allegiance effects). 

We cannot do double blinding because that would mean the therapists wouldn’t know what they were doing, which would not be a good test of the treatment. And of course once again there can be a major lack of complete candor by subjects. Much of the study results are based on patient self report, a notoriously unreliable method of data collection. And there is no way to distinguish an act patients may be playing for their family of origin (a false self or personafrom their real beliefs and feelings, or performance from ability.

The ecological fallacy – thinking all patients with a particular disorder react exactly like an average patient - is rampant in the literature. If 20 % of clients with a particular problem respond to one intervention and 40% respond to a second one, this does not mean that the second one is better for everyone than the first. The 20% who responded to the first one could actually get worse with the second one.

There is also a huge and highly problematic groupthink problem in the psychotherapy field, with purveyors of various schools claiming a monopoly on truth. Often the need for ideological purity, the admiration for an academic leader within a hierarchy, or the profit motive causes science to take a back seat in favor of a group's other interests. 

Fallacious arguments ensue. One of the most common is that entire complex groups of theoretical constructs that characterize a given school are rejected in total by another school, as if, if one theoretical part of a school is wrong, the whole thing must be wrong. Psychoanalysis may have been wrong about penis envy, for example, but dismissing intrapsychic conflict entirely as a construct because of that is - in a word - stupid.

Another is that a phenomena that two schools are looking at but explain differently are just being called different names and are given different explanations, which are then accepted by a given school as gospel without even a thought to investigating other possible explanations. I recently wrote in a post about how both the cognitive-behaviorists' "irrational thoughts" and the psychoanalyst's "defense mechanisms" probably serve the same purpose, but that neither school explains that purpose with reference to group dynamics - IMO the key factor.

There is still hope. IMO we have to look for recurring patterns in our therapy patients (not in research subjects, because contact is minimal) as well as within their social milieu. At times, we have to meet with clients along with their significant others in order to get a more well-rounded picture. We have to do so in long-term psychotherapy, because it takes quite a while for the whole story to unfold. 

We should do this in order to figure out commonalities and in order to figure out what questions to ask. In particular, we should look for evidence of motivated reasoning in what our clients report – logical fallacies, inconsistencies and contradictions (sometimes voiced months apart – the importance of extensive therapy notes cannot be underestimated), and defensive reactions. If handled well, this will help us unearth what clients may be trying to hide from us. 

Doing so also suggests questions we may have not thought to ask, or pay attention to environmental variables we were not even aware of that turn out to be major contributing factors to psychopathology that demand attention.

Tuesday, September 17, 2019

The Myth of the First Three Years

Obviously, people of any age can learn new information and change their behavioral responses to a wide variety of environmental contingencies. If that were not true, and people could not adapt to changing environments throughout their lives, it is highly unlikely that homo sapiens would have survived as a species. After all, we are relatively small, not particularly swift runners, have no natural armor or large talons with which to defend ourselves, and can die from extreme temperatures at either end of the thermometer. And yet, here we are.

The entire practice of psychotherapy is in reality predicated on the view that change is possible. If people become immutable at a certain age, then how would therapy ever help them change?

Ironically, however, somehow schools within the field of psychology often like to insist that most of our habits are completely fixed during childhood. According to the early psychoanalysts, for example, our personalities are completely developed by the time we are 5 years old. People with borderline personality disorder were thought to have “fixated” at the age of two! This meant that any psychological development after that completely stopped.

Neuroscience data is frequently cited by people who like to think they have neuroscience expertise but really do not – like many of today’s “biological” psychiatrists. In doing so, they often make assertions based on study results that have limited applicability to the psychological phenomena under discussion, or have no basis in findings from studies whatsoever. A book (recommended by parenting columnist John Rosemond) that came out way back in 1999, The Myth of the First Three Years by John T. Bruer, Ph.D, describes a particular heinous example of pseudo neuroscience that took hold with the participation of several politicians and celebrities. The misinformation is thoroughly dissected by Bruer.

The dumb idea goes something like this: the neurons in the brain develop hundreds or even thousands of synaptic connections per second until we reach the maximum number of such connections at age 3. The connections then start to be pruned. This means that the number of synaptic connections decreases over time. Therefore, kids under three need to be properly stimulated. They must be read to, learn their abc’s as early as possible, attend pre-schools, and listen to a lot of classical music. They need to become “scientifically correct.” If not, a window of opportunity will be closed forever.

This idea has led to a lot of parental guilt and anxiety, which my readers will immediately know that I think is far more damaging to kid’s psychological development than missing too much Mozart. Because of kin selection, we are probably more affected by the emotional state of our attachment figures than pretty much anything else that isn’t crazy severe like being under constant physical threat by one’s government. 

Parents who feel they may have damaged their child by, say, putting them in the wrong day care program (or heaven forbid, not putting them in any day care program at all) often become emotional wrecks who then overindulge their children, trying to prevent them from experiencing any or all emotional stress. When they seem to failing at that, as they must, they may then at times react with fury and even strike out physically with a child.

In reality, synaptic pruning probably leads to much higher brain efficiency in reacting to the environment in which the child is raised, but some people got the insane idea that the loss of neural connections after age three means something entirely different. They think that the period between ages 0-3 determines your IQ among other things, and if we want smarter and more resilient kids we must provide the proper stimulating environment or the development of our future abilities will be compromised severely. 

It is true that some aspects of the nonsensical idea may have  limited applicability to some of our psychological abilities - like learning a second language without having an accent. Almost impossible to do after the age of 12-14. But to think that somehow all of our abilities are like that is patent horse crap. Undoubtedly some of the neuroscience described in Bruer's book has become out of date due to increases in our scientific knowledge base in the last decade, but I think his basic premises remain intact.

What may get fixed in the first three years is that children become permanently much more responsive to their attachment figures than to anything else in the environment. The “serve and return” process described in an earlier post is probably related to this. Most neuronal tracks in brain are plastic in that they can form, or become stronger or weaker, over one’s entire lifetime. However, certain nerve tracks in the limbic system that are conditioned by one’s environment to respond with fear are highly resistant to major alterations. Certain faces – faces of kin – may trigger and reinforce a lot of automatic social responses to different people and situations.

The idea that children who are exposed to one environmental event or another develop immutable brain changes - other than those exceptions just listed - has even affected the highly important research in adverse childhood experiences like child abuse. Researchers do brain scans of abuse victims as adults and compare them to control subjects who had more loving childhoods, and differences in the size and activity of certain tracks remain. Hence, these researchers state, these brain changes are now irreversible.

Well they may be, but we still don’t really know. I kind of doubt it. There is some limited evidence that some of the changes can modulate with therapy, as described in a recent review article in the German journal Nervenarzt (November 2018) by  Schmahl, Niedtfeld & Herpertz. Their conclusion:

Although the overall database is still sparse, clinical improvement in psychotherapy appears to be associated with modulation of brain structure and function. Frontolimbic regulation circuits including the amygdala, insula, anterior cingulate cortex (ACC) and other prefrontal areas appear to be involved in these changes. An important finding is the eduction of initially increased amygdala activity after successful Dialectical Behavior Therapy (DBT).

Interestingly the last author, Herpertz, tended in the past to over-emphasize biogenetic factors over interpersonal and other environmental factors when I have spoken with her at meetings.

The folks that do the studies on untreated adults seem to think that, because they are no longer being actually beaten or molested, that the involved brain tracks are no longer being strengthened through environmental reinforcement. That also must mean that continued negative interactions with the attachment figures have come to a complete stop. Nonsense. These children continue to be around them throughout their lives, or in some cases do cut them off, but hear about them through other relatives. The “different” brain structures are thusly maintained. If that reinforcement were to be corrected, maybe those tracks would start to revert back to the size and activity levels seen in the control subjects. 

In order to know, scientists have to take into account whatever happened in childhood plus everything that happened afterwards.

Sunday, August 25, 2019

New Interview on Podcast.

I speak about why so many behavior problems have been redefined as diseases on a new podcast at:

Thursday, August 22, 2019

Irrational Beliefs vs. Defense Mechanisms

The current predominant school of thought in psychotherapy is called cognitive behavioral therapy (CBT), which replaced the previously dominant school of thought, psychoanalysis (PA). There are of course, other psychotherapy schools - over 200 of them as a matter of fact. Why? Well, as I described in a another post, because of three facts: 

1. The brain is so complicated. 
2. We can’t read minds. 
3. People lie not only to others but themselves. 

Psychology is still a very young science. 

It is in a phase of development that the scientific philosopher Thomas Kuhn, in his classic book The Structure ofScientific Revolutions, called the “pre-paradigmatic stage.” This means that in young sciences in which not a lot is known, a lot of theories compete with one another for dominance until the evidence accumulates to the point in which one model starts to predominate. After a while, some problems with that model arise, which then leads to the development of new models. For instance, although Newtonian physics still works for large objects, it falls apart at the subatomic level, where it has been replaced with quantum physics.

Understanding that this is the way science works has not stopped a lot of psychologists and other therapists from loudly claiming that their model is the only correct one. The psychoanalysts used to do it. When anyone dared to question the theory, they were told they needed to get into psychoanalysis to find out why they were resistant to its ideas. Three logical fallacies in a single sentence! (For those readers interested in logic: ad hominem, non-sequitur, and begging the question. If you want more detail, e-mail me back channel).

Now the CBT people are playing this same “We are right and you are wrong; we are superior to everyone else” game. Historically, the game went down this way: Psychoanalysis attributed “neurotic” behavior (showing signs of mental disturbance but is not psychotic) to conflicts in individuals between their biological urges – their id – with their values that were internalized from their upbringing – the superego or conscience. CBT people said this was all a buncy of nonsense, and went on to cherry pick certain parts of PA theory that were obviously incorrect to throw hot water on all of the PA ideas – which is another one of the tricks that indicate “groupthink” is operating instead of “facts and logic.”

Which brings us to what is postulated to be the cause of neurotic behavior which cognitive therapists champion (behaviorism – rewards and punishments - seeming to have almost disappeared from the therapy arsenal of a lot of CBT therapists). Starting with Albert Ellis and latter with Aaron Beck, they attributed it to “irrational thoughts.” Someone thinking, for example, that they simply must be this or that, or torturing themselves by imagining unlikely worst-case scenario outcomes which would then prevent them from even trying something new that they might just excel at.

So who’s right? Well, both of them. But don’t tell that to any of them on either side. I once mentioned what I am about to say to Albert Ellis at a psychotherapy conference, and he practically laughed in my face in front of a whole audience. Anyway, the key is something that authors Jonathan Haidt and Gregg Henriques have discovered: Logic in human beings did not evolve to arrive at truths. It evolved to justify group norms. 

Groups have to stick together to survive; they can’t be constantly arguing about everyone’s individual ideas about what to do when they are, say, attacked by another tribe. So group cohesion has survival value – at least it used to. It still does to a significant extent, but with the advent of technology and other modern developments, not nearly as much as it once did.

Before I understood this, I was bothered by something I called the “problem of stupidity.” Why were people torturing themselves with these thoughts which are obviously and transparently stupid or illogical.  Even seemingly highly intelligent people do this all the time. Are we all really that dull-witted? I didn’t think so, so I asked myself why these people are seemingly acting as if they are that dumb.

See if you can spot the irrational idea in a recent letter (8/14/19) to advice columnist Dear Abby:

8/14/19. DEAR ABBY: I've been with my boyfriend, "Rocko," for two years, but in the late months of last year… He would disappear for days at a time, block my phone number and ignore me. I was sure he was seeing another woman or taking drugs because he is an ex-addict. Two months ago, he was arrested. I was right -- Rocko was on drugs and had been hanging out with another woman… I hate myself, and I can't stop wondering why I wasn't enough.

See it? Her boyfriend is an addict and a cheater, yet this woman wonders why SHE wasn’t enough for him! It wasn’t his glaring and obvious faults and limitations: his problems were all due to her and her being inadequate to meet all of his needs. How nice of her to blame his irresponsible behavior on herself rather than hold him accountable!

If we assume that she is not stupid enough to think this is a logical conclusion, then we have to ask ourselves why on earth she doesn’t just dump the S.O.B. and find someone who will treat her right. I answered this by looking at the end result – what I call the net effect  - of her continuing to think this way. It’s obvious. She ends up staying with a man who cheats and uses drugs. So this would have to be her intent.

(But why on earth should she want to do that? The answer to that question in my opinion lies in her playing some sort of dysfunctional role in her family of origin which requires her to do this in order to stabilize her unstable parents. Explaining that part is beyond the scope of this post, but various roles are discussed in detail in previous ones).

So the irrational belief generates anxiety which then prevents her from acting in her own best interests. This allows her to continue to sacrifice herself for her kin group – a process known in evolutionary biology as kin selection. Guess what? The defense mechanisms of PA accomplish the very same thing. Analysts think that defense mechanisms are meant to control anxiety, but as a fellow blogger known as The Last Psychiatrist once said, if that were true, they sure do a lousy job of doing that. No; in fact, they too are meant to either create anxiety or do other things which lead people to avoid doing something that might conflict with their role in their family.

If for example your role in your family is to be a scapegoat so that your frustrated father can blame you for all of his problems and not have to feel bad about himself, his behavior is bound to make you angry. Your anger makes it hard for you to maintain the scapegoat role. You may eat (or repress) a certain amount of it, but some of it must be discharged somehow. So you come home and kick the dog (the defense mechanism of displacement).

Defense mechanisms or irrational thoughts? You say tow-may-tow, and I say tow-mah-tow. They are the same damn thing!

Tuesday, July 30, 2019

Book Review: Leaving the Witness by Amber Scorah

One of the review quotes on the cover of this amazingly written, disturbing, enthralling, absolutely brilliant work (I could barely put it down) was “part Orwellian groupthink expose.” Although it is also a tragedy and a suspenseful account of preaching in a Communist country that forbid foreigners from doing just that, for purposes of this blog, I will focus on the groupthink part. I am currently in the midst of editing a book on groupthink in science, and clearly my model of self destructive behavior sees it as a sacrifice to one’s kin group rather than as a selfish act (Selfish self-destructiveness? Only if all such people had the IQ of a kumquat).

The book tells the story of growing up in a cult, in which people were strongly discouraged from talking to anyone or looking at any source of information that might call into question its belief system. Going to college was forbidden. People went to meetings several times a week where the idea that Armageddon was about to happen at any minute was constantly presented, along with the idea that only the true believers would be saved. 

People who broke the rules or questioned orthodoxy were “disfellowshipped.” This meant that they were completely shunned by all family and friends, although they were allowed to sit in the back of the meeting halls, unacknowledged, to be further indoctrinated with the propaganda in hope that eventually they would be accepted back into the fold— after a couple of years of this treatment.

Scorah recounts going to China to surreptitiously preach the cult’s gospel. Once there, she found that there were many fewer group members around than she had been used to, and she credits that fact with how she came to be exposed to other ways of understanding the universe. This in turn led her to start questioning the group’s theology and its claim to have a monopoly on the one true religion. She had to have an above-ground job, and took one working on a podcast about China. One listener began writing to her and helped her to see how badly she had been indoctrinated.

As she started to engage in critical thinking, her entire family then acted as if she did not exist (with one major exception — her sister. Might the sister now be serving in the role of switchboard?). There has been no contact with them.

But was this the whole story? I think not. One has to ask the question: why would the author be the one person who was able to start questioning the groupthink—even with the realistic fear of being exiled hanging over her head— when the vast majority of her fellow preachers in China did not fall into this trap? Although it’s impossible to prove on the basis of what is written about a family in a book, the author’s description of her family certainly leads one to suspect the usual culprit in such scenarios: family dynamics and shared intrapsychic conflict with ambivalence.

In fact, her family was not monolithic in its beliefs in the cult, although they professed to be. Neither of her parents went to meetings more than yearly, and would not explain to the maternal grandmother— who was not born into the cult—why that was. Scorah’s father was an alcoholic and her parents eventually divorced, both huge no-no’s in the cult.  The grandmother also seemed to take great joy in providing the “benefits” of the cult to the author when Scorah was growing up. 

Together this all sounds like there was strong ambivalence about the cult’s beliefs within the family, with her parents acting it out. They may have given up their daughter—who received very little attention from them according to her own descriptions—to the grandmother as a gift, in order so that she could make up for grandma's failure to properly indoctrinate the mother.

Furthermore, grandma’s favorite child, the mother’s brother – I repeat, grandma’s favorite child—left the fold and then proved the folly in doing so by getting into drugs. The family predicted that he would eventually end up in jail, and of course this is exactly what came to pass! This sound exactly like the dynamics I write about in describing the role of the black sheep.

So perhaps (and I really think it’s nearly certain) the author had picked up on the family ambivalence over the cult and its rules. This may have been why she had been attracted to preaching in a far away, forbidding place all along, where she would no long be subject to constant drumming in her ear about the group’s orthodoxy.

Another interesting aspect of groupthink that the author writes about - with the most elegant descriptions of it that I’ve ever read -  is existential groundlessness. This is the tremendously aversive feeling one gets when one breaks the rules or questions the mythology of one’s kin group or social group:

“But if I didn’t believe, my life would be over. I was paralyzed, because there was no answer to this problem. The stakes are too high to do anything.” (p. 171).

“This world was the only one I had ever been a part of, and I didn’t know who I was without it.” (p. 200).

“Nothing was as I had thought it was. And there was nowhere to go back to; I couldn’t, because it was a dream, it was all a story, all of my life was made up, and I had awoken to this concrete.”

That last quote illustrates yet something else about groupthink in the modern world: willful blindness. Throughout the book Scorah strongly implies that until her awakening she truly believed, without question or doubt, every nonsensical myth that was taught to her by her cult. But later in the book she implies that this was not really the complete truth. For example, on p. 231, she lets on that a part of her knew the gig: “We policed ourselves to sustain our nirvana. We shared a willful blindness disguised as innocence and purity…but it takes a great deal of mental effort to hide from what one sees, whether that effort is subconscious or purposeful…That once I decided to believe, I believed, no matter what doubts came…I had been in ‘the truth’ because I was afraid of the truth.”

Tuesday, July 9, 2019

NAMI, Big PHarma, and Family Therapy

Back in the beginning of June 2019 I received an e-mail from a manager in marketing and communications in NAMI inviting me to write a blog post for them, as they were planning on featuring articles in August about personality disorders. I replied that I would be happy to do so. However, I wrote, since I discuss the relationship between family dynamics and personality disorders, what I write might be offensive to some of NAMI readers. The manager then suggested to me that I could avoid that and write about what it means to have a personality disorder and how they are diagnosed. 

I agreed to do it, but had a strong suspicion that they would not like what I would write. I believe that personality disorders are different from other diagnoses in the DSM diagnostic manual and that the now-eliminated separate classification (Axis II) should have been retained. A copy of said blog post follows this introduction.

I was right. Soon after I turned in the post, I received an e-mail from higher up on the NAMI food chain, the Director of Marketing Communications.

She wrote: “…it appears there may be a misunderstanding about the agreed upon blog topic about what it means to have a personality disorder and how they are diagnosed. There are elements in your submission that do not align with NAMI’s position and educational materials about personality disorders. We align with the DSM-5 categorization of personality disorders as mental illness.”

I wrote back thanking them for the opportunity, but basically saying that I was not going to write a post as if the definition of "mental illnesses" in the DSM diagnosis list was not broad, and that it obviously covered some behavioral syndromes that are not brain diseases. Furthermore, by design,the DSM says nothing about etiology (causes of the disorders).

So why did I sort of know this would happen?

NAMI started out in life as advocates for the severely and chronically mentally ill – mostly people with schizophrenia. In the past, they had done some great work in this regard. I know that members were rightfully furious with both psychoanalysts and especially family systems therapists for blaming what is essentially a biological brain disease on family dysfunction. Of course, stressful family environments can make the presentation of any psychiatric or physical illness worse, but most readers probably know by now that I do not believe that schizophrenia is caused by family double binds or schizophrenogenic mothers.

Unfortunately, the NAMI membership morphed into those who dislike anyone who would dare suggest that ANY diagnosis in the DSM just might be created by severe family dysfunction. This position was attractive to the guilty parents I mention in the masthead of this blog, who do not want to look at their own family dysfunction, and therefore put a lot of store on phony “biological” psych disorders like pediatric bipolar disorder and adult ADHD. They joined the parents of people with actual brain disorders in the advocacy group.

In the post I submitted, I purposely did not mention adverse childhood experiences or family dysfunction in making the case that personality disorders (not including Cluster A – see the post) were behavioral syndromes and not brain diseases. Still, some members of NAMI might suspect that that was the implication of the piece. Unfortunately, there was also a second thing going on at NAMI that, although I cannot absolutely prove that the two factors led to the rejection of my post. They clearly seem to point in that direction.

This second process happened around the time that there was a major change in how NAMI derived the bulk of its funding. In October of 2009, the New York Times reported that Senator Charles Grassley had been looking into how patient advocacy groups like NAMI were getting a good portion of their funding from big PHarma. He found that drug makers from 2006 to 2008 contributed nearly $23 million to the alliance, about 75% of its donations. NAMI has long been criticized for coordinating some of its lobbying efforts with drug makers and for pushing legislation that also benefits industry.

Although I was unable to find more recent reports, there is little reason to think that this has changed significantly. Of course, if all DSM diagnoses were brain disorders, then they should be treated with pills, not psychotherapy. This increases drug sales. NAMI has clearly fallen under their spell.

Here’s the rejected post:

Is a Personality Disorder a Brain Disease?

Personality disorders (PD’s) are mental disorders defined as problematic, lasting patterns of behavior, thinking, and inner experience, exhibited across many social contexts – but, importantly, not all contexts. This latter point is seldom appreciated. The patterns are in fact often dependant on specific types of interactions and situations with certain other people, and may completely disappear at other times. People who exhibit symptoms of one of the more severe disorders, borderline personality disorder (BPD), are well known for creating arguments between doctors and nurses on hospital wards by acting sweet around one set of them, while acting horribly around the other set (the infamous staff split).

With the exception of the Cluster A disorders, described below, they are likely not brain diseases but problems with functioning, especially in relationships with others, and in my opinion the behavior patterns are learned responses. Because the behavior can be quite extreme, some people and clinicians think they simply must be brain diseases, but the neuroscience does not support that. The fact that the behaviors appear and disappear depending on social context shows this; real brain diseases like Alzheimers are not like that. Furthermore, findings on fMRI studies and heritability studies, often cited to “prove” that PD’s are brain diseases, are misleading or fraudulent. Readers can follow the links here to understand how.

Another odd characteristic of PD’s is that there can be over a hundred different combinations of traits that all lead to the same diagnosis. Some traits may even seem contradictory. Narcissistic personality disorder requires at least 5 of 9 different characteristics— Any 5— or any 6, 7, 8, or all 9. One trait is an excessive need for admiration, but another is “takes advantage of others.” It is hard to think of a worse way to gain people’s admiration that to make them feel used!

A patient can also simultaneously show symptoms of several different PD’s in any possible combination. One study showed that once someone is diagnosed with BPD, they also qualify, on average, for 1.6 other PD’s. Any others.

The traits that make up PD’s are said to be maladaptive. This means they cause problems for the intimates of the involved individuals, but also in the long run are self-destructive or self-defeating for the person with the disorder. Over the short run, these traits may be used to solve certain types of interpersonal problems, but the “solution” does not last and prevents the use of better ways to resolve ongoing problems.

PD’s were at one time thought by psychiatry to be different from all other psychiatric disorders. They were placed on a separate “axis” from other disorders - Axis II. Of course, all human behavior involves the brain, but as I have argued, PD’s are likely “functional” or behavioral disorders. For this reason, I was in favor of keeping Axis II. However, because insurance companies often refused to authorize treatment for them— despite the fact that they can be highly disabling and require extensive therapy—Axis II was eliminated. (Psychiatry does not consider causation in describing its diagnoses, because the true “causes” of almost all of them are not known for certain).

As mentioned, the personality disorders are subdivided into “clusters” that have common themes. The first, Cluster A, consists of disorders that are usually a prelude to more serious brain conditions such as schizophrenia, and probably have little in common with the PD’s in the other two “clusters.” For this reason, I believe that they should not have been classified as personality disorders in the first place, and they will not be discussed further here.

The most serious personality disorders are seen in Cluster B, the “dramatic” disorders. Antisocial p.d., the most difficult to treat, is characterized by disrespect and disregards for the rights of others, often leading to criminal behavior. They rarely come to therapy voluntarily.

BPD is currently the most common. I have noticed a marked increase in its prevalence since I was in training back in the mid 1970’s, which makes me think it is related to ongoing developments and changes in our culture. It is also seen much less commonly in traditional cultures. People with BPD often react with strong anger or panic to seemingly minor slights. This has led some psychiatrists to believe that BPD is a variation of bipolar disorder, but good evidence says otherwise. People with BPD are impulsive, self-destructive, and may cut themselves or engage in other self injurious behaviors. They often worry about being abandoned by loved ones. A history of overt physical or sexual child abuse is a feature in the backgrounds of many of them, although certainly not all of them.

Cluster C personality disorders exhibit highly prevalent anxiety or fearfulness. Those with avoidant PD, for example, are socially inhibited, feel inadequate, and are hypersensitive to negative evaluations by others. They constantly worry about what other people think about them,

Because of their now-you-see-it, now-you don’t nature, a variety of information must be taken into account to make an accurate PD diagnosis. Good clinicians specifically ask about some of the more severe symptoms and behavior in a good psychiatric diagnostic interview, which includes a complete history of the patient’s upbringing and relationships over the course of their lives – things asked about less and less recently. Often it takes more than one session for the clinician to see the patterns. A patient’s behavior with the doctor and with the staff also provides clues. Interviews with the patient’s significant others may reveal important information, although they may at times be just as misleading as patients sometimes are.

Thursday, June 20, 2019

Book Review: Breakdown: A Clinician's Experience in a Broken System of Emergency Psychiatry by Lynn Nanos

This impressive book goes into detail concerning the horrifying deterioration in the psychiatric care of the Severely and Persistently Mentally Ill (SPMI’s - primarily people with schizophrenia) in the United States that I have personally witnessed since I was a resident in psychiatry in the late 1970’s in California.

By the time I had started my residency, the passage in California of the Lanterman Petris Short (LPS) Act in 1972 - followed by the passage of similar laws in many other states - had for the most part cleared up a lot of the abuses in the state hospital system that anti-psychiatry groups still go on and on about as if they were still common. It insured that the cases of patients who had been hospitalized involuntarily would be reviewed by the courts within 17 days or sooner. Psychiatrists in the system could no longer just let patients languish in the hospital forever by merely following what a previous doctor had said without doing their own personal evaluation, or avoid closely following the patients’ condition to see if there were any changes.

No longer would patients linger in hospitals for years because of a misdiagnosis. For example, patients with the very treatable bipolar disorder (in which psychotic episodes are often relatively short-lived) had often been diagnosed with the far less treatable schizophrenia (especially if they were African American) Occasionally someone had been hospitalized for decades because unscrupulous relatives conspired to steal their money by labeling them with a mental illness with the help of a gullible or greedy psychiatrist.

After the laws mandating court review were in place,  people who were hospitalized back then often agreed to stay much longer than 17 days -  because their paranoid delusions and hallucinations had been somewhat controlled with anti-psychotic meds. Up until then they had anosognosia - the lack of awareness that anything might be wrong with them. After they became less delusional, they began to understand that they needed treatment.

Psych meds often take two to three weeks just to kick in, or need to be changed to something else after that period of time because one agent was ineffective while another might not be - which in a sense would restart the whole clock - so often they had to remain hospitalized for several weeks. 

This time frame also allowed psychiatrists in training to see first hand the course of major psychiatric illnesses and monitor longer term responses to it. It also allowed doctors time to make a better determination about whether the patient’s primary issue was drug abuse rather than some other chronic mental illness, and refer drug abusers to appropriate rehab treatment.

Committed psychotic patients at that time could be forced to take anti-psychotic meds even if they refused prior to their court review. That has since changed in most jurisdictions. I cannot for the life of me see the point of committing a patient involuntarily  if the doctors cannot then treat them.

Even though the state hospitals were beginning to discharge their long-term patients under the justification that the meds would allow for effective outpatient treatment, hospital stays were long enough to allow ward social workers to arrange for placement in board and care type living situations, get the patients enrolled in Social Security Disability (SSI) to pay for it, and make follow-up appointments in community mental health centers so that patients could continue to receive their medications. Community mental health centers were also far more numerous and available for this purpose than they are today.

The LPS criteria for hospitalizing someone against their will were very reasonable: mentally ill and a danger to self, a danger to others, or gravely disabled. The latter meant that due to their mental illness they were unable to provide for their own food, clothing, and shelter. A cardboard box on a street did not qualify as the ability to provide for their own shelter as it seems to today. 

A “danger to self” did not just mean suicidal, also as it seems to today; it could refer to dangers to self due to delusions and poor judgment, such as walking naked into someone’s house who might mistake them for a burglar and shoot them. Sometimes doctors considering a “603” 72-hour commitment holds had to pump relatives for information they could use to justify that. I recall one patient’s family finally tell me, after I asked many follow-up questions, that the patient had tried to get out of a moving car.

The author of Breakdown, Lynn Nanos, is a social worker who works for a psychiatric emergency services team, and has seen and documented the monstrous changes in the previously described public mental health treatment of chronically ill SPMI’s. She provides sad, disturbing, and hair-raising case studies of suicides and murders of both family members and strangers due to the premature discharge of dangerous, delusional patients who did not think they were ill and refused treatment.

Due to the mutual biases of the so-called patients’ rights advocates on the left of the political spectrum, and tax-phobic politicians and government agencies on the right of the political spectrum, hospital stays have been whittled down to just a few days, so that anosognostic patients are either not  referred for psychiatric follow-up at all, or do not show up even if they had been. Many are discharged with no prescription medication to take after they leave.

Nanos makes the case that the commonly-heard idea that chronic psychiatric patients are less likely to commit violence than others is highly misleading. It ignores the significant minority of mentally ill folks who do have violent propensities – and who are often more dangerous than others -  when their violent episodes could have been stopped if they had received proper medication. Not to mention that the violence-prone mentally ill are highly unlikely to participate in the epidemiological studies that are the basis of the misleading argument. Dead family members have lost all of their rights. Many suicides of those who are “dying with their rights on” could also likely have been prevented.

Many of these patients now end up in jail. The patients’ “rights” warriors never seem to inquire as to why this might be the case. Could it be that such patients don’t realize they are mentally ill and are responding to command hallucinations to assault others, or are committing nuisance crimes like disturbing the peace or trespassing because they do not know any better? Even when they kill someone, the not-guilty-by-reason-of-insanity defense seldom succeeds (particularly after John Hinckley tried to kill President Reagan, who himself did not appear to think mental illness was real when his administration attempted in the early 1980’s to kick all the chronic schizophrenics off SSI until the courts stepped in), and they of course are sent to jail rather than to a hospital.

According to the author, private hospitals often tend to favor hospitalizing malingerers who fake mental illness in order to have a place to stay and receive food, over the more highly disturbed and potentially violent SPMI’s who really need the beds. This, along with drastic decreases in the number of available beds, has led to a situation in which patients are stuck in hospital emergency rooms  - manned by staff that are ill-equipped to handle them - for days at a time until a bed is finally found or until they are in frustration discharged by the facility to the streets. There are also financial incentives to treat “easier” patients due to the fact that they have shorter hospital stays and hospitals are financially incentivized to keep stays short.

Government agencies often listen to “peer support groups” comprised of individuals who think the signs and symptoms of schizophrenia and other psychoses are just some variant of normal.

Nanos makes a good case for assisted outpatient programs (AOTs), which help patients stay with treatment despite not being forced to take their medication. Mental health professionals attempt to persuade the recipients to adhere to their prescribed medications and attend their clinical outpatient appointments with psychotherapists, psychiatrists, and case managers. All AOT involves intensive case management services and comprehensive supervision.

In court-ordered AOT, judges order seriously mentally ill patients to adhere to their outpatient regimens. AOT’s seem to be even more effective when judges are involved, probably due to what the author refers to as “black robe syndrome.”

Several studies indicate that AOT’s, particular those that last 180 days, significantly reduce violence, readmissions to hospitals, no-shows at outpatient appointments, arrests, jail time, self-harm, suicide attempts and substance abuse, while significantly improving the self care of SPMI patients. Nonetheless, even AOT’s are opposed by various special interests. In Massachusetts, its opponents even include the National Alliance for the Mentally Ill, which is supposed to be advocating for these patients.

Unfortunately, these patients are downright lousy at advocating for themselves, so it’s going to take a lot of other people speaking up before things go back to the far more functional way they were just a few decades ago.

Wednesday, June 5, 2019

Private Insurance Circumvents the Mental Health Parity Treatment Act

The Mental Health Parity and Addiction Equity Act of 2008 is a federal law that generally was supposed to prevent group health plans and health insurance issuers that provide mental health or substance use disorder benefits from imposing less favorable benefit limitations on such treatment than on other medical or surgical treatments. So far, it hasn’t come close to accomplishing its goal, although a recent court decision may possibly change that.

Supposedly, if a group health plan or health insurance coverage includes medical and surgical benefits and mental health benefits, the financial requirements (such as deductibles and co-payments) and treatment limitations (such as number of visits or days of coverage) that apply to the mental health must be no more restrictive than those that apply to the medical/surgical benefits.

However, insurers were easily able to "circumvent" the consumer protections intended in the legislation by imposing maximum numbers of doctor visits and/or caps on the number of days an insurer would cover for inpatient psychiatric hospitalizations. They played with the definition of “medical necessity” in psychiatry.

Insurance companies often make doctors and hospitals jump through hoops to even obtain a decision by the insurance company that their proposed treatment is “medically necessary.” For inpatient treatment, managed care companies adopted what amounts to a  code word: dangerousness. If a patient is not specifically and imminently homicidal or suicidal, the insurance company would mandate that  the patients be thrown out of the hospital and onto the street. Science and the best interest of the patients were really non-factors in this decision, which were basically based solely on greed and profiteering.

Suicide rates for patients soon after discharge from a psychiatric inpatient facility are much higher than suicide rates in the general population. This problem has gone up significantly in recent years due to patients having many fewer days in the hospital than they used to.

Yet another trick was companies deciding which psychiatric conditions were severe enough to warrant hospitalization, and which ones were not, irregardless of the severity of a patient’s symptoms and functional capacity. For example, doctors in a hospital near where I work appeared to have been pressured by the facility to make diagnoses that were more likely to be covered by insurance even if their patients did not meet criteria for those disorders. The result was that the patients were often put on medications that were ineffective, not indicated, and/or potentially toxic.

Within my own patient population of people with borderline personality disorder, “bipolar disorder” was the go-to option.

In the recent court decision mentioned above, on February 28, 2019 the US District Court for the Northern District of California found that United Behavioral Health (UBH), the country’s largest managed behavioral health care organization, illegally denied coverage for mental and substance use disorders based on flawed medical necessity criteria (David Wit, et. al. v. United Behavioral Health).

UBH was noted to have internally developed medical necessity guidelines that comprehensively fell short of accepted standards of care to deny outpatient, intensive outpatient, and residential treatment to UBH beneficiaries. They only paid for the alleviation of a patient’s acute symptoms, but not of any underlying condition – particularly chronic conditions.

The court said that the fact that a lower level of care is less restrictive or intensive does not justify selecting that level if it is also expected to be less effective. Placement in a less restrictive environment is appropriate only if it is likely to be safe and just as effective as treatment at a higher level of care in addressing a patient’s overall condition, including underlying and co-occurring conditions.

Effective treatment of mental disorders includes services needed to maintain functioning or prevent deterioration. Appropriate duration of such treatment should be based on the individual needs of the patient and not on some arbitrary guidelines regarding the duration of treatment for a given disorder.

Even though the plaintiffs in Wit v. UBH were enrolled in plans that are exempt from the federal parity law, the court recognized that mental disorders are chronic illnesses and rejected the insurers’ practice of treating only the acute symptoms. This may establish a precedent for plans covered by the parity law.

Will the recent court decision make any difference? I have my doubts. Insurance companies can be experts in not paying for the adequate care of their subscribers.

In an upcoming post, I will be reviewing a book about the even more disgusting horrors currently being inflicted on the severely and persistently mentally ill by the public mental health system.