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Thursday, October 11, 2018

Another Pharma Trick for Overstating the Effectiveness of their Drugs: The Will Rogers Phenomenon



Will Rogers

Big Pharma has a number of ways, many of which have been described in this blog, of making their drugs look a lot better than they actually are. And some psychotherapy researchers use the techniques to push their favored school of thought. I recently came across another one of which I wasn’t aware. 

It is easiest to see with drugs used for cancer chemotherapy, but can be applied in other cases.

It is called the Will Rogers phenomenon (and is also called Stage Migration). It is an apparent epidemiological paradox. The Rogers reference comes from a remark made by the famed humorist Will Rogers about migration during the American economic depression of the 1930's: "When the Okies left Oklahoma and moved to California, they raised the average intelligence level in both states."

With cancer drugs, it comes from changes over time in the way the severity of the disease is assigned to patients - how the various stages of a disease are determined in each case. (Stage I is when the cancer is smallest, has not spread, and is usually the most easily treated. Stage IV is the most advanced with metastases). The issue comes about because the technology for staging a cancer in a given patient has improved significantly. This can produce spurious improvements in stage-specific prognosis, even though the outcome of individual patients has not changed.

New imaging tools have allowed detection of cancer metastases before they became evident clinically. As a result, more patients are classified into the more severe metastatic disease stage from the less severe single tumor stage. Such a 'stage migration' resulted in an improved survival of patients in both the less and the more severe disease stages. (Multiple sclerosis is another disease where this sort of thing has taken place).

Some studies compare a new treatment to the treatment of so-called historical controls who had received other treatments. This is usually done because carrying out placebo-controlled studies in potentially dying patients is unethical. The Will Rogers phenomenon is recognized as one of the most important biases limiting the use of historical controls groups in experimental treatment trials. 

Essentially, the use of different diagnostic criteria may generate spurious improvements in the medium-term prognosis which then may be wrongly interpreted as treatment effects.

In psychiatry and psychology, placebo controlled studies can be done ethically, but a variation of the Will Rogers phenomenon can still take place because of how rigorously DSM diagnostic processes are applied to patients. When I first started training, the criteria for major depression and mania were rigorously applied in treatment studies; now they are often applied sloppily – on purpose. 

Chronic unhappiness, which may respond very well to cognitive behavioral psychotherapy, is often now misdiagnosed as the more serious major depressive disorder. If you have a bunch of those folks in your psychotherapy outcome study, CBT can be “shown” to be effective in major depression by including people in your study who really don’t have major depression.

The more serious depressions respond better to antidepressant medications. Since most antidepressants are now generic, drug companies who want doctors to use other, more profitable drugs like Latuda can do the same thing to “show” that antidepressants are actually less effective than they actually are. Placebo response rates in antidepressant studies have gone up about 10% every decade, and this is what I believe to be the reason.

Friday, September 28, 2018

Differences in the Size and Activity levels of Brain Parts: Long-Term Potentiation




One of the ongoing themes of this blog is the nonsensical practice of some researchers in psychiatry of routinely labeling differences in size and activity levels of parts of the brain, as seen on brain scans such as fMRI scans, between various diagnostic groups and control subjects as abnormalities (See the posts http://davidmallenmd.blogspot.com/2010/03/neural-plasticity.html and http://davidmallenmd.blogspot.com/2013/02/neural-plasticity-and-error-management.html).



These researchers seem oblivious to a now well-established process within neurons called long term potentiation (LTP). Briefly, if a synapse – the point between two nerve cells at which a nervous electrical impulse passes from one neuron to the other – is stimulated by individuals’ interactions with the environment that leads to learning, this produces a long-lasting increase in signal transmission between the synapses of those two cells. In other words, the power of the connection starts to increase. Conversely, if such a connection is hardly ever stimulated, its power decreases. This is probably the way memory works. Hearing a fact once in a lecture may not lead to its being remembered for long, whereas if someone keeps studying the fact, the memory of it becomes stronger.


It is important to mention that structural changes in the size and shape of the pre- and post-synapse parts of neurons may mediate permanent or near-permanent changes in synaptic efficacy. Growth may allow for an increase in the size or number of active zones on both sides of the synapse. The “spines” of the cell can increase in volume after LTP induction. While the degree to which structural re-organization of synapses occurs in adult animals is not yet clear, the process seems to involve a neurotransmitter (a chemical substance that is released at the end of a neuron cell by the arrival of a nerve impulse and, by diffusing across the junction, causes the transfer of the impulse to another neuron) called brain-derived neurotrophic factor (BDNF).

If a particular synapse is almost never stimulated, it can disappear altogether. Conversely, LTP is associated with an enhanced recycling of a part of the structure of the synapse, and this process could eventually result in the formation of a new, immature spine.

In other words, the more a part of the brain used for a particular purpose is used, the more likely it is to increase in size due to this process. When many synapses are involved in an individual's interactions with the environment, size differences in those parts of the brain can therefore easily be conditioned responses rather than abnormalities.

Saturday, September 1, 2018

Book Review: Judas by Astrid Holleeder




Imagine what it might be like to grow up in a home in which unpredictable periods of sheer terror and physical abuse were the norm. In this book, the sister of one of the Netherland’s most notorious criminal and crime boss—Willem Holleeder—describes the consequences. In brilliant detail, she sheds light on the bizarre interrelationships between her, her infamous brother, and her sister Sonja, all of whom grew up in such a home.

“My father treated his children the same way he treated his wife. He beat us, no matter how small and defenseless we were. As with my mother, he didn’t need a reason—he made one up on the spot. That was how he justified his actions. It was always “our own fault”—we made him do it” …Our behavior at home was exemplary…We were all compliant good kids who never broke any rules…filled with the smell of booze and my father’s unpredictability, those days seemed endless. Only one thing was certain: there would be shouting and hitting.”

Yet when these children became adults, breaking rules became almost a daily occurrence.

Their father’s attitude toward women was that he was the “boss.” Every day he’d scream “Who’s the boss?” and his wife would answer, “You are the boss.” He believed that “…women were inferior beings, their husband’s property, and whores by nature.” His wife was not allowed to leave the house for fear she might encounter other men, and if he came home and she happened to be home, there was hell to pay afterwards.

Yet Astrid became a lawyer.

Willem started early in criminal activities , and the family was often intimately involved. He first became widely know when he and Sonja’s Husband Cor, along with some others, kidnapped Freddy Heineken—the heir to the Heineken Brewery fortune. Of note was that their father had worked for the brewery for most of his adult life.

The Heineken family ended up paying the ransom; Freddy was released for 35 million Dutch guilders. Most of it was eventually recovered by the authorities, but not all. Questions about what happened to the rest eventually led to a falling out between Willem and Cor. After two previous attempts, Willem eventually had Cor murdered. During the first one, Cor’s car was shot up – with Sonja and their son in it.

Astrid had been more or less pressured by Willem to serve him as a sort of consigliere. She would give him legal advice and helped him keep the rest of the family in line, while he kept her in line with various threats. As far as the attempts on the life of the brother- in-law, he at first acted all innocent and “helpful” to the family. He was an expert at manipulating family members and strangers alike by either turning on the charm or by scaring the hell out of them. 

Gradually Astrid and Sonja figured out that it was Willem who had put the contract out on Cor, and because Willem seemed willing to kill even family members, they eventually turned on him.

Although highly mistrustful of the authorities for a variety of valid reasons (assuming Astrid’s reasons were honestly described) and constantly fearful for their own lives, they began working with the Dutch Justice Department. They eventually testified against their brother and helped put him in prison. He remains there, but the trials of several charges against him drag on. Both Astrid and Sonja are at present in hiding.

The author knew that Willem has put a contract out on her and her sister and that their days are probably numbered. She never forgave him for Cor’s murder. She knows he has put out hits on a significant number of murder victims, many of whom having been his former partners in crime.

Nonetheless, she still felt guilty about putting her own brother away. Such is the power of family-of-origin bonds. The last two sentences of the book say it all:

“The only reason you’re still alive is that you want to take our lives. But despite that certainty, Wim, I still love you.”

Monday, July 30, 2018

The Relationship between Marital Problems and Family of Origin Dysfunction






The essay In Consultation: Becoming a Therapist for Each Other: How to Deepen Couples Therapy by Ellen Wachtel Ph.D. in the Psychotherapy Networker from July/August 2018 answers a therapist’s question about a difficulty the therapist consistently ran into in his work with married couples. The question involved how to deal with the emotional difficulties of one of the members of the couple without derailing the work on the couples’ relationship issues.

Since in my experience both members of couples who seek marital therapy usually come to the relationship with pre-existing emotional issues – which I believe to be highly relevant if not crucial to their marital problem – that problem would come up no matter which member of the couple the therapist focuses on. Dr. Wachtel seems to understand this when she correctly points out that, “It’s common for one person in a couple to believe that the lion’s share of the problems in the relationship arises from the other’s emotional difficulties. As a firm believer that ‘it takes two to tango,’ I try to resist joining with that point of view.”

Unfortunately, she also adds, “But sometimes it’s just too big a stretch to see both partners’ contributions as anywhere near equal.” Nonetheless, she goes on to point out that, no matter how clear that seems to be,  the person “chosen” for individual work invariably reacts with, “’Why me? Shouldn’t she (or he) get therapy too?’ Or ‘I react the way I do because he’s so provocative.’”

I must say I agree with the member of the couple who says that. While one member’s dysfunctional behavior may be far more dramatic or dysfunctional than that of the other, in my opinion both members of the couple have a stake in their relationship continuing in its current dysfunctional form. The way this goes down and the reasons it happens were discussed in my previous posts “I’ll enable you if you enable me” and The Obvious Secret of Interpersonal Influence in Families.”

Briefly, each member of the couple is enabling the other member to maintain a role function that each believes necessary to stabilize their own parents, who are unstable due to an intrapsychic conflict that is shared by the entire family. I call this mutual role function support. Each member of the couple thinks the other member of the couple needs them to play this role because both of them compulsively act out their roles in the face of repeated and obvious drawbacks and negative consequences. Each person would deny this if asked for various reasons, so the other person has to guess why that person continues in their self-defeating or self-destructive habits, and they usually make the guess based on watching their partner interact with the partner’s parents (cross motive reading).

Wachtel comes very close to this formulation by recommending approaching the couple issues by saying, “We’re all stuck with some emotional issues from our childhoods, and even if we work on them in individual therapy, they’re still likely to have a hold on us. In our work together, we’ll try to find ways to keep these issues from affecting the relationship as much as they are now.” She also helps each member of couple construct their genogram to “get a window” into the source of problematic patterns. 

I would add that the emotional issues are not just from childhood but are in fact family emotional issues that are continuous and ongoing.

I have a lot of respect for Dr. Wachtel. She, along with her husband Paul, wrote a book called Family Dynamics in Individual Psychotherapy: A Guide to Clinical Strategies, the first edition of which came out in 1986.  This was one of the first books that attempted to integrate family systems ideas into individual psychotherapy.  (I must also admit I was a little annoyed when it came out because I was still trying to find a publisher for my first book, which attempted to do the same thing, and they beat me to it!)

Unfortunately, in this piece for the magazine, she falls into the exact same trap that Murray Bowen—the family systems therapy theorist who first started tracing dysfunctional relationship patterns through genogram construction—fell into. With his patients, as pointed out by Daniel Wile in his book on couples therapy, Bowen used education, logic, and collaboration to help educate his patients on the reasons for their self-destructive behavior. 

When he sent them back to their families of origin, however, he taught them to use the paradoxical interventions, therapeutic double binds, and strategic maneuvers that are part and parcel of Jay Haley’s alternative type of family systems therapy. In a way, he coaches patients to use this type of therapy on their family members instead of employing Bowen therapy. Wile asked why Bowen did not coach his patients on how to use Bowen therapy on their parents.

Wachtel starts to go down this route. She recommends to each member of this couple to offer support for, rather than merely challenge, the other member’s need to persist in each one's seemingly unproductive habits. In strategic family therapy, this is a paradoxical technique which often seems to have the opposite effect from what it seems to be intended to have: the partner might, in response to being given a green light, start to “be more able to hear his own internal voice that questioned the need to do the task.”

While this might help in couples that come from only mildly dysfunctional families, in my experience with more highly dysfunctional families, any good that comes from a paradoxical prescription will in fairly short order be undone due to the continued  and more powerful influence of the families of origin of each member of the couple. The parents and other family  member, as I often say, will invalidate the efforts of their adult child to step out of their dysfunctional family role with devastating effectiveness.

I find that members of a couple, with the right coaching, can move from the mutual role function support that attracted them to one another in the first place to becoming allies in the efforts of each to deal with his or her primary attachment figures. After constructing the two genograms, the therapist can help devise strategies for each member of the couple to stop dysfunctional interactions with each’s own parents. This can be done with the full understanding of the spouse so the spouse knows why their mate is suddenly trying to change things and understands how the devised strategies might actually work.

In fact, they can practice the strategies with each other. The spouse role plays the role of the other spouse’s targeted parent – and the spouse is usually well acquainted with that in-law and can do so very accurately – while the spouse practices the moves and countermoves planned with the therapist. This practice allows each one to stick with the script more effectively in the face of problematic responses from the parents.

I go into more detail about this process in my upcoming self-help book, due out November 1.

Tuesday, July 10, 2018

The Amazing Complexity of Environmental Research in Psychiatry





In my Psychology Today post of 12/24/12, Why Psychotherapy Outcome Studies are Nearly Impossible, I discussed the large number of variables that are not taken into consideration in those studies which bring any conclusions drawn from them into question. These include variations in therapist techniques that aren’t measured, sampling problems with people that can have wide variations in their proclivities and sensitivities, problems with finding an active control treatment, the lack of double blinding, and lack of complete candor by subjects.

The same types of issues apply to epidemiological research into environmental risk factors for various psychiatric disorders. Most studies try to measure the effect of a single environmental exposure on a single outcome—something that rarely exists in the real world.

In a “viewpoint” article from JAMA Psychiatry published online on June 6, 2018, by Guloksuz, van Os, and Rutten ("The Exposome Paradigm and the Complexities of Environmental Research in Psychiatry"),the authors discuss characteristics of the environment as they do function in the real world. They speak of multiple “networks of many interacting elements…”

Individuals are exposed to these elements as they accumulate over time, so that one single exposure usually means very little. Exposure also is “dynamic, interactive, and intertwined" with various other domains including those internal to individuals, what individuals do within various contexts, and the external environment itself—which is constantly changing. Last but not least, each individual attributes a different, and sometimes changing, psychological meaning to everything that happens to them. This meaning attribution can alter the effect of each environmental exposure dramatically.

Each environmental factor confers risk for a "diverse set of mental disorders." These factors are far from universal so that some people remain completely unexposed to them. They interact with each other so they are not independent. They are time sensitive. They are dose dependent even within similar environments, meaning individuals are not exposed to them at the same level. They can be subject to being confounded by each individual’s differing genetic propensities.

With all that to consider, drawing final conclusions from a few studies just does not cut it as real science. But the field tends to believe in those conclusions as if they were gospel.

Wednesday, June 27, 2018

Words Do Matter in Psychiatry





I was pleased to see that in the June 2018 issue of one of the newspapers for psychiatrists, Clinical Psychiatry News, a psychiatrist by the name of Carl T. Bell wrote about something I have been harping about in this blog and elsewhere for years: the sloppy use of psychiatric terminology by both the public and by many psychiatrists themselves.

Glad to know I’m not the only one who has noticed this.

He brings up three examples: the use of the words (two of which also have a common meaning separate from the corresponding terms in psychiatry): traumatized, depressed, and bipolar.

Colleagues of his had used the word traumatized as something that happened to a person who was the subject of a statement by another person that has come to be known as a “microaggression.” A microaggression is defined as “a statement, action, or incident regarded as an instance of indirect, subtle, or unintentional discrimination against members of a marginalized group such as a racial or ethnic minority.” 

Worrying about that sort of thing has become endemic on college campuses recently. Especially if it unintentional, the result of the big ado is a communication to individuals that they are so fragile and vulnerable that they can’t handle anything. It also has led to a suppression of free speech.



As far as I know, there has never been an example of a microaggression, or even a direct verbal insult, in and by itself leading anyone to develop post traumatic stress disorder (PTSD). According to Dr. Bell, being stressed by something like that, or by your boss chewing you out, is a far cry from being traumatized. Being distressed by something like the death of a parent is a little worse. It can come up from time to time, like on the anniversary of the death. However, in both of these cases, unlike in PTSD, “the mind is able to make peace with the reality…and life goes on.

“Traumatic stress, on the other hand,” he adds, “is an event so painful and disruptive that it runs the risk of breaking the mind’s ability to make peace with the event…[and it] disrupts or destroys normal psychic life.”

I would add that if everyone around you treats you like you are so fragile that the slightest stress will do that, you start to believe it even though you probably aren’t that fragile at all. And if you feel like that, you are probably not going to take measures to actively oppose and undermine things like racism, sexism, and homophobia. If enough people think like that, it is paradoxically a great boon to racists, sexists, and homophobes everywhere.

I’ve already covered the misuse of the term depression in my post of November 24, 2015, Depression is a Symptom, not a Psychiatric Disorder. Major depression is a clinical condition has many physical symptoms and is something that can be quite disabling, while being unhappy, sad, grieving or even demoralized is not the same thing at all. The latter conditions do not respond to antidepressants in the least, but researchers doing current studies on antidepressant efficacy have become very sloppy and often do not exclude the latter people as they should.

Bell then addresses how the term “bipolar” is creeping into common usage to cover things such as being moody and having difficulty regulating one's moods and having a bad temper (especially in kids, I might add). For maybe thirty minutes or an hour. And many psychiatrists just take patients at their word when they misuse the term, and prescribe unnecessary and ineffective mood stabilizers.

In that vein, another article in the April issue of the same newspaper quoting a Gabrielle Carson M.S. talks about the issue of tantrums in children. It advocates investigating the child’s symptomatology to rule out bipolar and other mental disorders, as well as clearly behavioral problems like so-called disruptive mood dysregulation disorder, ADHD, and oppositional defiant disorder. 

The only mention of environmental factors that might lead to the tantrums is a quick and superficial reference to child abuse and school bullying. But the article says absolutely nothing about the far most common cause of frequent tantrums by children (as discussed by child psychologist and columnist John Rosemond as well as other people who actually look at what goes on in the child’s home): problematic parenting practices such as acting like a friend to your kids instead an authority figure, letting them make decisions that should be made by the adults, compulsive yelling or lecturing, and inconsistency in administering discipline.

Saturday, June 23, 2018

A new interview of Dr. Allen by life coach Delaney Kay




A new interview of Dr. Allen by life coach Delaney Kay:

https://www.youtube.com/watch?v=ncknmZnesnI

Tuesday, May 15, 2018

60 Minutes on Grandparents Raising Grandchildren: Reading Between the Lines





On Sunday, 5/13/18, the news magazine show Sixty Minutes aired a new story about grandparents raising grandchildren which focused entirely on the epidemic of opioid addiction as the primary cause of the middle generation taking such poor care of their kids that the grandparents had to “take over.” 

The show reported that there are now over one million grandparents raising grandchildren because of their own kids’ failings

This hearkens back to my very first post on my Psychology Today blog, back on June 22, 2011, in which I discussed the already skyrocketing incidence of grandparents raising their grandchildren because of their dysfunctional children’s abdication of the parental role (rather than in those cases of temporary needs like a military deployment). Note that this post was written well before the current brouhaha about the opioid epidemic.

I discussed the idea that the children were, in a sense, being “gifted” to the grandparents, who seemed to the children to have a pathological need to raise children despite continually complaining about it.

I wrote that the major apparent (pardon the pun) reasons were because the children:

1. Carry the psychiatric diagnosis of borderline personality disorder (BPD) and neglect, abuse or otherwise endanger their children. 


2. Have antisocial traits and end up in jail (antisocial personality disorder is also a Cluster B personality disorder just like BPD). 

3. Are addicts or alcoholics. Many of those folks may also exhibit significant Cluster B personality traits at one time or another, although in addicts the traits may disappear if and when the addict cleans up.


As most of my readers will know, I believe that the parents’ intrapsychic conflicts over the role of raising children is by far the most important cause of cluster B symptoms and acting out by their children and adult children. 

Furthermore, the grandchildren in these cases are also being subjected to its manifestations and might later develop the same disorders themselves.

In a previous newsmagazine show from around the time of the earlier post, grandparents raising their grand kids were heard to say how much they loved taking care of the grand kids, but how chasing after them made them soooooo tired! And clearly if we heard that, so did the grand kids. So the grandparents end up doing to the grandchildren the same problematic things that they did to their own children.

Some of these grandparents were interviewed on the Sixty Minutes segment, and the reporter discussed how they were plowing through their retirement savings, having to downsize and not go on previously planned vacation trips, arguing more between themselves, and even worrying about how they would find the money to treat their own illnesses like, in one case, cancer.  Again, if we heard this, so do the grand kids. In fact, one child was asked what the grandparents were giving up in order to take care of them, and replied, “Grandma had to give up dating. She says it all the time.”

Two grandparents protested, “We can’t not do it [take care of the grand kids]; they’re our family!”

When it described what went on before the grand kids were “rescued” by their grandparents, the story did a good job of describing how older siblings would have to become so-called “parentified children” for their younger siblings, and how they felt they had to grow up too fast. I described what can happen in that situation in a previous post.

So was there any evidence that these grandparents may have engaged in problematic relationships with the absent parents that affected the middle generation’s irresponsible behavior with their own kids? Well, no direct evidence, but a couple of things were mentioned in passing that might suggest that this was the case.

In two of the described cases, the grandparents spoke of keeping track of what was going on with their kids and grand kids as the parents became homeless and crashed at various shady dives and crack houses along with their children. Rather than simply calling protective services to investigate, one set of parents bought their child a van and put a tracking device on it, while another set said they camped out across the street from one of said crash pads to make sure that their grandchildren were not being abused. Apparently all night long!

We don’t know for certain how long this sort of “tracking” was going on, but my guess is: a long, long time. As readers recall from my previous posts, the parents’ conflicts over their parental role in many (but not all) of these cases leads them to vacillate between severe over-involvement and severe under-involvement with their kids. One of these two poles often predominates much (but not all) of the time. This creates the double message to the children, “I need you-I hate you.” Constant tracking is one manifestation of the over-involved polarity.

So am I dismissing all of the so-called evidence that opioid addiction is a biogenetic disease over which these parents have no control, and that it has nothing at all to do with family dynamics? Well, yes. If you believe these people have absolutely no control over their drug use, you would also have to believe that:

1.     12 Step Programs like AA and NA could never work. Especially when the addict has "hit bottom" (that is, when the addiction is at its worst).   

2.  The way the drugs makes them feel is so all-encompassing that they lose all ability to reason and the ability to appreciate the harm they are doing to themselves and their own children, or lose the ability to care about that at all.     

3.  If you pointed a gun at them and told them that if they picked up the drug or drink in front of them you would shoot them the moment they did, assuming they believed you and were not overtly suicidal at the time, then they would have to go ahead and let themselves die.



Do you really believe those things?

Monday, April 16, 2018

11 Laws of Systems Thinking





Systems thinking is one of the main themes of Peter M. Senge's best-selling book, The Fifth Discipline, which I reviewed back on November 22, 2016. Family systems therapy - which is at the heart of my form of psychotherapy for personality disorders - is based on systems thinking, and looks at the role of the interactions of all family members over at least three generations in the genesis, triggering, and reinforcement of self-destructive behavior in individual members. 

Senge's book discusses eleven “laws” that apply to the behavior of individuals within groups who are engaged in trying to solve a variety of difficulties that affect the achievments of the group’s goals. The laws look at how a wide variety of different variables interact over the long term, and discuss the folly of efforts to try to reduce problems down to just simple relationships between only two or three variables over the short term.

In this post, I list the eleven laws from the book, with a few minor changes or additions I made to make them more relevant to problem solving specifically in dysfunctional families—as opposed to just any organization.

11 Laws of Systems Thinking.

#1: Today's problems come from yesterday's "solutions." In our desire to avoid conflict, we solve problems by avoiding them. Inevitably, the problem comes right back more intensely and in an even more frightening aspect. Solution: Learning to negotiate and solve problems cooperatively in a win/win manner.

#2. The law of reversed effort: the harder you push, the harder the system pushes back. Attacking the people in the system creates resistance. For example, the more you lecture children about something, the more likely they will be to keep doing whatever you are complaining about.

#3. Dysfunctional family and other problematic interpersonal group behavior gets better before it grows worse, and conversely, it grows worse before it gets better.

When we sacrifice our own needs in order to give the family or group what it seems to need, this stabilizes it over the short run, but since structural problems and ongoing shared intrapsychic conflicts are never dealt with or even addressed, this soon starts causing more problems over and over again.

Conversely, when problems are finally addressed, people often escalate their previous dysfunctional behavior in order to test whether everyone else really wants change - but if everyone sticks to their guns, the problematic behavior eventually subsides and then starts to go away altogether (except for occasional relapses which must then also be openly addressed).

#4. The easy way out usually leads back in. Quick and easy solutions often lead to weak and poorly thought out approaches that backfire. Solutions that come from a desire to avoid conflict or difficulty overlook the deep listening required to reveal the emotional core of family issues.

#5. The cure can be worse than the disease. Without thinking about ALL of the interacting variables, we often fix the wrong problem or approach the right problem inappropriately. Reactions and counter-reactions often leave us in a worse place than we where we started.

#6. Go slow to go fast. Rushing to completion leads to a lack of thoughtfulness and reversals of direction to go back and pick up missing pieces.

#7. Cause and effect are not necessarily closely related in time and space. We often assume the solution to be close to the problem, but most often, today's problems were caused by decisions made long ago but forgotten.

#8. Small changes can produce big results -- but the areas of highest leverage are often the least obvious. Taking the widest possible systemic view allows us to see the small changes that will have long term and beneficial outcomes.

#9. You can have your cake and eat it too -- but not at the same time. Patience is its own reward. Rushing produces compromise such as "I'll cut off my leg if you cut off yours." Taking the long view allows you to accomplish more and reap the benefits of the work.

#10. Dividing an elephant in half does not produce two small elephants. One must look at groups as a whole. Simply dividing people in a family or organization into separate, smaller groups will not produce the same dynamics, nor double the value. The right hand has to know what the left hand is doing.

#11. There is no blame. Perhaps the most critical of the laws of systems thinking, stopping blame eliminates the fear that turns employees or family members against you. Don't try to change people, change systems. Discover the systems problems and you can change the entire direction of a work group or family.



Thursday, March 29, 2018

Drug Abuse and Drug Companies





As most readers will know, opiate abuse and overdoses have increased dramatically in recent years, and it’s all over the news. Some of the public may even be aware of the role of drug companies and drug distributors in the process – the latter being recently profiled on an episode of Sixty Minutes. Let’s look at the role of the drug companies.

A Pharma executive, a billionaire, was arrested in October on charges of bribing doctors to prescribe opioid painkillers. (http://fortune.com/2017/10/26/john-kapoor-insys-therapeutics-arrested-net-worth/). The Department of Justice arrested Insys Therapeutics founder John Kapoor, 74, in Phoenix. Kapoor was charged with using bribes and fraud to prop up sales of a pain medication called Subsys, a fentanyl spray typically used to treat cancer patients suffering excruciating pain. Fentanyl is 50 to 100 stronger than morphine, and contributed to the overdose deaths of pop stars Prince and Tom Petty.

When it comes to drugs of abuse, the lunatics seem to have taken over the asylum in medicine these days. In their push towards huge profits, dangerous drugs are being hawked when cheaper, less toxic, and less addictive alternatives are available for treating some conditions. And as discussed in this blog, whole diseases such as “adult adhd” have been invented out of whole cloth.

For those readers who may not know, potentially addictive drugs are referred to by the Drug Enforcement Agency (DEA)  as “scheduled” drugs. Schedule I drugs are the illegal ones. Schedule II drugs are those with the highest abuse potential: narcotics and stimulants. Schedule  IV drugs are those considered to be of low potential for abuse. If you didn’t know how the drugs were scheduled, you certainly would never know it from listening to presentations by doctors working with Pharma.

Pharma hires doctors to do research on as well as give talks to other doctors about their products, totally with the goal of increasing sales – if patients do happen to benefit in some way, all the better – but that is hardly a requirement. The slides that are presented during the talks are furnished entirely by the drug company after being approved internally; the doctors giving the talks are not allowed in most instances to use their own slides.

Pharma is particularly known for employing what they call “Key Opinion Leaders” (KOLs) to give promotional talks to doctors around the country. The more academic credibility they seem to have the better – that is one source of determining who might be a KOL. But it is not the only one.

Pharma can actually get any given doctor’s prescribing records from the pharmacy industry (unless the doctor “opts out” of allowing his or her data to be mined in this way. Most docs are not even aware of this option—and having the information publically available is the default position). Pharma then uses this data to see if prescriptions for their products increase after one of their KOLs makes a presentation. 

Those doctors that make the best salesmen are hired again and again, while those who do not measure up are dropped.

A colleague of mine has taken a course required in Tennessee for licensure that discusses the “proper way” to  prescribe drugs of abuse. The course was sponsored by our malpractice carrier. According to him, one year the leader of the course scolded the doctors present for not prescribing enough opiates to people with chronic pain. 

The doctors were told how much suffering they were causing these patients by withholding these medications. Just one year later, after the “opioid crisis” hit the news, the same course was given. Only this time, the doctors were scolded because they were prescribing these “suddenly” dangerous and highly addictive substances to their patients with chronic pain!
I have discussed in previous posts how the risks of that class of medication (Schedule IV) have been wildly overblown in the medical literature and in public news stories. As well as being classified as “low abuse potential” by the DEA, they do not cause intoxication, and have next to no side effects compared to just about any other class of meds in most patients. I am not saying they are never abused, but usually only by people that mix them with opiates and alcohol. 
And of course any individual can have a bad reaction to any drug. It seems benzo’s are never discussed without the admonition that the “are addictive,” or have a few side effects in (some) patients – while drugs like amphetamines (Schedule II) that are abused far more often, and have more potential adverse or toxic side effects, are enthusiastically pushed.
And I do mean pushed, as in supplied by pushers masquerading as drug companies. I recall a “grand rounds” (a major lecture at an academic department in a medical school) from maybe 18-20 years ago in which the KOL was saying that about 18% of all adults should be on high doses of speed, that the reason that many of the parents of kids diagnosed with ADHD were substance abusers was because, "If you had a kid with ADHD, you'd drink too," and that kids who had ADHD could concentrate intensely on video games in an arcade despite multiple and pervasive loud distractions all about because that is "not concentrating." (I always wondered what the heck it supposedly was). I kid you not.
As another amazing example of drug pushing, one news service for psychiatry called MDLinx devotes a whole e-mail newsletter to articles extolling the use and virtues of drugs like Adderall and Concerta. Some recent examples:
MDLinx Psychiatry 3/13/18 - Ranked, sorted, and summarized by MDLinx editors from the latest literature.
IN THE NEWS
SHP465 mixed amphetamine salts effective, safe for ADHD in adults
Liz Meszaros, MDLinx, 03/08/2018

Researchers investigate the link between ADHD and risk of self-harm
Paul Basilio, MDLinx, 02/23/2018


Study of 23,000 people links ADHD with genetic signature for delay discounting. Paul Basilio, MDLinx, 12/11/2017
They also have a section of their more general psychiatric newsletters also devoted to this goal that is called the ADHD Resource Center: A collection of articles and features related to ADHD with articles like:


            National Conference & Exhib Conference

Of course, none of these Pharma sales mechanisms would matter that much if there were not already a ready market for abusable medications. That market is growing, and adverse childhood experiences and family dysfunction are a huge part of that problem.

Still, as Steppenwolf used to sing, “G-d damn the pusher man.”