Tuesday, December 20, 2011

Ultra Rapid Cycling Bipolar Disorder

OMG! Watch out for flying pigs!  DUCK!

Pigs in Spaaace

Something I have been harping about for years was finally correctly set straight in - of all places - a throwaway, drug-company supported, pharmaceutical-advertisement infested psychiatry journal - Current Psychiatry. Frozen hell!

In an article by Joseph F. Goldberg M.D., a clinical associate professor of psychiatry at the Mount Sinai School of Medicine in New York, the following summary was highlighted as a "bottom line: "Ultra rapid cycling [bipolar disorder] has not been validated as a distinct clinical entitiy, and frequent mood swings should not be used as a criterion for diagnosing bipolar disorder."

In the diagnostic Bible, the DSM, a rapid cycling bipolar disorder is defined as an individual who has four episodes of depression or mania per year, not per hour.  Yet the "bipolar disorder is everywhere" crowd has insisted for decades that there was such a beast as an "ultra-rapid cycler."  Thus anyone who was moody, had a sudden mood change no matter how brief, or had  the unstable emotions characteristic of individuals with borderline personality disorder, was suddenly "bipolar" and in need of medication for his "bipolar spectrum disorder." 

"Psychotherapy? What's that?" they seem to say.

The supposed existence of rapid cycling was advanced as an argument against using anti-depressant medication in bipolar patients having a depressive episode, because the drugs allegedly induced it.  This argument was even picked up by Robert Whitaker, author of Anatomy of an Epidemic, as a possible reason to be cautious about using antidepressants in general.  An argument based on a phenomenon invented by some psychiatrists that does not even exist!

Funny how after having practiced for 35 years in two states, with a wide variety of clinical populations, and specializing in the treatment of borderline personality disorder, I have never seen rapid cycling, with the possible exception of one case in which sudden episodes of psychosis (not mood changes) would come and go without warning.  Maybe I've just been lucky.  Or rapid cycling could be so rare as to be nearly non-existant.

When I first saw the cover of Current Psychiatry under discussion, I must admit was prepared for the worst.  "Oh no, not again,"  I thought. At least, I figured, I would have more material for a new post with another scathing attack on the whole bipolar spectrum craze.

Then I read the article.  What a pleasant surprise.

Meanwhile, in other myths-about-bipolar-disorder news, a new small study seems to contradict a bit of current conventional wisdom about the disorder: A study published in the January issue of the Journal of Affective Disorders (Baldessarini et. al.,136, 2012 pp. 149–154reported: "Patients with bipolar I disorder show disease progression that is random or even 'chaotic.'"

After following 128 patients with bipolar I disorder for about six years to assess "inter-episode intervals (cycle length)," researchers found that "most current bipolar I disorder patients are unlikely to show progressive shortening of recurrence cycles."

In the past, the impression that bipolar patients had episodes more frequently as they got older, the authors believed, was a statistical artifact caused by a minority of patients with frequent recurrences!

As most of these subjects were being treated with medications, and were probably going on and off of them every so often as patients are wont to do, this is evidence that the treatments do not make bipolar disorder worse over time.

Friday, December 16, 2011

An Update of Some Earlier Blog Posts

There have been some new developments recently concerning some of the issues and stories I have discussed previously on this blog, so I thought I would write a new post that updates some of my previous ones.

First, apropos my post of May 25, Pro-death Florida Legislators Run Amok, about a recently-enacted Florida law prohibiting health care practitioners from even discussing health care concerns about gun ownership with their patents: it was temporarily blocked by Federal U.S. District Court Judge Marcia Cooke. The state plans to appeal the injunction blocking enforcement of the law.

Second, concerning the debate about SSRI antidepressants and whether they are better than placebos:  A Commentary in the December 2011 edition of the American Journal of Psychiatry pointed out that placebo response rates to antidepressants in studies have increased as much as 7% per decade since 1980. 

Not coincidentally, this bizarre inflation of placebo response rates correlates very well with the timing of the rise of the so-called contract research organization, or CRO (  These organizations are usually doctors in private practice who are hired by drug companies to do their randomized controlled studies of medications.  These doctors get paid - quite handsomely - for each subject that they successfully recruit for the study. 

The subjects are, in turn, recruited through offers to pay them for their participation. ABC News recently did a story about stay-at-home moms who turn themselves into guinea pigs to earn extra cash. The use of paid subjects has led to the phenomenon of the "professional research subject" who participates in multiple drug trials.

Under these circumstances, both the doctors and the patients are being given cash incentives for exaggerating their symptoms in the initial evaluation so they can qualify for the study!  Once they are picked, no one then has a financial incentive to exaggerate symptoms on follow-up exams.

No wonder placebo response rates have skyrocketed.

CRO Newspaper ad clues in potential research subjects who wish to get paid as to what symptoms to complain about

Last, there are two developments concerning schizophrenia and its treatment with antipsychotic drugs. 

First, as the states have been cutting back on funding for community mental health centers due to the economic downturn, we are seeing a lot of what is described in the following news article:

After closing psychiatric hospitals, Michigan incarcerates mentally ill

"Wayne County Sheriff Benny Napoleon spoke for most sheriffs when he said, during a community meeting earlier this year, that his jail had become his county's largest mental health care institution.
Over the last two decades, changes in state policy and big cuts in funding for community mental health care have pushed hundreds of thousands of mentally ill people into county jails and state prisons...

"'We closed too many (hospitals), too quickly,' Mark Reinstein, president of the Mental Health Association in Michigan, told me this month. "It wasn't done in a planned, rational way."
Community mental health agencies -- which were supposed to take up the slack but never received the resources to do so -- face continuing budget cuts. The state has resumed warehousing its mentally ill -- this time behind bars...

 "In 1999, a Department of Community Health study -- conducted by Wayne State University -- of jails in Wayne, Kent and Clinton Counties found that more than half their populations were mentally ill and one-third were seriously afflicted, suffering from schizophrenia, bipolar and other psychotic disorders... Since 2008, the state has slashed $50 million from community mental health agencies, with Wayne County absorbing more than half of the cuts.

"Treating one client in a community program costs about $10,000 a year, compared with $35,000 a year to house one prisoner.  Statewide, more than 200,000 people a year use community mental health services, but experts say at least twice that many need them."

To really understand what happens when funding to community mental health centers is cut significantly, one has to realize that fewer patients with schizophrenia will get treated with anti-psychotic medication. Such medication is all the treatment that community mental health centers are providing nowadays.  In addition, those patient with schizophrenia who are seen will be seen much less frequently.  We know from multiple sources that lack of close follow-up highly exacerbates the issue of people not taking prescribed medications (non-compliance).

Off their meds, psychotic patients still end up being incarcerated, but as this story indicates, in jail, not in a hospital. Paradoxically, psychotic inmates are usually then prescribed anti-psychotic medications in prison - at a much higher cost.

One wonders how author Robert Whitaker (Anatomy of an Epidemic), who believes that antipsychotic medications make psychotic people worse, explains away how people with schizophrenia somehow become far more likely to end up in jail when they do not take antipsychotic medication.  Or perhaps he thinks that this development is the result of a malicious government plot .

The question of whether schizophrenia is in fact a real brain disease, and why it has been so hard to pin down the actual pathology, was recently addressed in a newspaper column by neuroscientist  par excellence John J. Medina. 

John J. Medina
An excerpt:

"... a biological explanation for the disease seems heartbreakingly just out of reach. Schizophrenia has a powerful genetic component (heritability percentage is in the low 80s), something I’ve known for years, something that could make it low-hanging research fruit. There is also a large clinical base on which to do studies: schizophrenia afflicts millions of people (the estimated prevalence rate is about 1% of the global population). Despite these seeming advantages, a molecular mechanism capable of describing all aspects of schizophrenia has almost completely eluded researchers.
"There’s a simple reason for this. A deep understanding of schizophrenia at such an intimate level has been hampered by a single technical bottleneck: the lack of a robust in vitro [in the lab as opposed to in the body] disease model.

"That may all be about to change. The results from a study that used cells derived from a deceased patient’s skin tissue has recently been published. Findings from the study may provide just such a model. It is not yet full-fledged schizophrenia-in-a-dish, but the findings portend a powerful future for the field."

Medina then goes on to explain a new technology - a way to produce something called Pluripotent stem cells (iPSC's) which I will not go into here.  Basically, they are re-programmed stem cells.  He then goes on to say:

"With these technologies in mind, I now have the tools needed to understand how to create a dish-bound model of schizophrenia. It involves answering some simple questions: What if you took the skin cells from patients who had schizophrenia and turned them into neurons? Would they exhibit behaviors of typical, healthy cells? Or would they exhibit behaviors reminiscent of previously determined properties of neurons in patients with schizophrenia? If the latter were observed, would you have a robust cellular model of schizophrenia, the missing link in this line of work? A consortium of researchers decided to to find out."

Skin cells from diseased patients made iPSCs that were similar to cells that were obtained from unaffected people.

"The most interesting result came from what happened next. Even though the reprogrammed cells were clearly neural tissue, they did not behave like typically functioning neurons. Several observed differences were eerily similar to previous findings other researchers had seen in tissue samples from patients with schizophrenia."

Despite what you may hear from mental illness deniers, neurons (brain cells) derived from patients with previously diagnosed schizophrenia "exhibit specific, aberrant properties."  I do not wish to get into highly technical neuroscience on this blog, but anyone interested might want to look up definitions for the following terms, and learn about how brain cells from people with schizophrenia differ from those who do not show symptoms of the disorder:

Dendritic arborization,  neuregulin expression, and Global gene expression changes.

After pointing out that this technology does have some problematic aspects to be resolved, Medina concludes: "Having a dish filled with cells that carry many characteristics of a human disease is a lot like having a flashlight in a dark cave. The greatest utility is in the ability to illuminate molecular mechanisms that might go undetected without such a model. It can go a long way toward relieving the frustration often associated with this line of work. Give it enough time and it might even—someday—illuminate a cure."

Undoubtedly, mental illness deniers will find something wrong with any evidence that schizophrenia is a brain disease.  It's in their nature.

Thursday, December 8, 2011

The Cognitive Behavioral Mafia

I recently posted on my Psychology Today blog what I had written in a previous post from this blog, The Limits of Cognitive Therapy.  In it, I had the audacity to criticize one very prominent technique used in Cognitive Behavioral Psychotherapy (CBT), and discussed how it neglects a type of cognition that is central in personality pathology (the family myth). I also complained that CBT therapists grossly exaggerate the strength of their evidence base from randomized controlled psychotherapy outcome studies while simultaneously blocking funding research into other forms of treatment.
Researchers who look at other psychotherapy techniques and are members of the Society for Psychotherapy Research (a group I used to hang with for several years), refer to the "cognitive behavioral mafia" at the NIMH, which systematically blocks grants for research into other therapy schools.  Leading trauma researcher Bessel van der Kolk couldn't get a psychotherapy research grant at one point because of it!
They also blocked me from getting a small grant to study my therapy paradigm, unified therapy.  The grant I had applied for was supposed to be for researchers to get preliminary data – called pilot data – for new ideas.  Although the rejection I got did point out some very valid things I needed to change with the proposed study design (and would have been readily agreeable to doing so and then resubmitting the grant proposal), their biggest criticism of my proposal was that I did not have any pilot data! 

Writing two books on psychotherapy and having 20 years of clinical experience (at that time) did not count at all.  I did not get a low score, I got no score. Roughly translated: faggetaboutit.
In response to my Psychology Today post, not surprisingly The CBT folks went on the attack.  In fact, another blogger on Psychology Today named Robert L. Leahy posted a rebuttal on his blog. I was accused of being a – horror of horrors – psychoanalytic psychotherapist, which I of course am not in the least.
While I can see how many people might have mistaken my post, because of my broad style, for an attack against the entire CBT treatment model - which if you read the post carefully it decidedly is not - I was accused of mischaracterizing the entire field because I was talking about one specific although very central intervention they use.

Cognitive therapy pioneer Albert Ellis called it active disputation and the other cognitive therapy pioneer Aaron Beck called it collaborative empiricism. Interestingly, some other commenters implied that the technique I focused on  is no longer being used at all by the other main innovator of CBT, Aaron Beck.   This is patently untrue.  He just changed the name to cognitive restructuring  or guided discovery.
In the post, I had given an example of a family myth in action in a psychotherapy case.  In the early 1980’s, I was trying out a technique from paradoxical psychotherapy called reframing, in which a family member labels something as bad and the therapist changes the valence to good.  For instance, an acting out child is described as the savior of the parents marriage because he or she is distracting them from their arguments.  (Technique used best by family systems therapy pioneer Salvador Minuchin). 

I was accused by the critics of “arguing with my patient” and that I was both doing and oversimplifying the cognitive therapy technique. Some of them also seemed to dismiss Albert Ellis in favor of Beck, as Ellis definitely did argue with patients until he died, although in a very empathic way. 
Salvador Minuchin

This contention might be true if one’s definition of argument is limited to the type of argument seen in Monty Python’s argument clinic:
 “Yes it is.”
“No it isn’t!” 
“Yes it is!”
 “No it isn’t!” 
What Beck does instead is examine the “empirical evidence” for the patient’s “irrational” thoughts to see if it is consistent with the facts.  That, my friends, is a form of argument (as is reframing –also not merely contradicting the patient).
From a discussion of cognitive therapy on Psych Central: “Cognitive-behavioral therapy, in a nutshell, seeks to change a person's irrational or faulty thinking and behaviors by educating the person…”  They won’t get an argument from me.
Another thing I was accused of was that I did not acknowledge that CBT has changed from the early days and has become a much more complete treatment, even though my original post clearly stated:
It is interesting that when CBT therapists start to deal with more significant self-destructive behavior, such as that seen in severe personality disorders, then what they do starts to look a lot more like what humanistic or relationship-oriented psychotherapists do.  
This criticism was actually one I considered to be fair, and I quickly acknowledged that CBT has evolved considerable from its early days.  However, I pointed out that the evolution mostly consisted of stealing, slightly reinterpreting, and renaming concepts and techniques from other psychotherapy schools.  Even the central psychoanalytic concept of transference, vehemently denied by both behavior therapy and cognitive therapy since their inception, is merely redesignated as “the client's underlying schema about themselves and others.”
Speaking of schemas, the critics particularly complained that I wasn’t acknowledging them because I said that both Beck and Ellis (not CBT in general) have both said repeatedly that they believe that human beings are fundamentally irrational.  The concept of schemas, or mental models of how relationships and other things in the world are supposed to work, did not originate completely within CBT circles. 

Mardi Horowitz was one of the first widely read psychotherapists to talk about it - and he was psychoanalytically-oriented.  The concept of life scripts, which are basically several schemas linked together to form a plan for one’s life, was originated by another therapy school called transactional analysis.
I also happen to know Jeff Young, who is the main champion of using cognitive schemas in therapy.  He had in fact been a protégé of Aaron Beck, and was one of the cognitive therapists in the big NIMH collaborative study on depression in the 80’s (which incidentally also found interpersonal therapy equally effective to CBT in "depression"). Jeff personally told me that many of his former colleagues in cognitive therapy circles turned on him when he started to talk more about issues such as the effects of child abuse.
It is also true that Jeff Young had to go to Holland to get funding for a psychotherapy outcome study of schema therapy.

Another person commenting accused me of "whining" about the CBT mafia because I mentioned that I was blocked by them from getting research funding.
Still another thing that I was accused of doing was denigrating psychotherapy research in general, which is also something I did not do.  I had merely opined that the CBT people were over-selling the strength of their research results. 

Critics immediately jumped into my favorite form of sophistry: circular reasoning.  They basically made the point that because cognitive therapy was scientifically proven (not!), money should not be wasted on studying other paradigms!  In other words, why do we need more studies when we're already convinced.
Many of the critics also seemed to be saying that CBT was some sort of monolithic entity and did not acknowledge that there are several sub-schools of CBT which all approach patients differently  and which argue among themselves about who is right.  There is ACT, REBT, DBT, and schema therapy, to name but a few.  Schema therapy in particular is quite unlike the original form of cognitive therapy, as it not only looks at the developmental origins of so-called irrational ideas but sees the origins as central to the actual therapy. 
At least one critic went on to accuse me of being unscientific because I was not using CBT therapy exclusively with my patients, as well as being possibly unethical because I used "unscientific" treatments:  “It is also clear you practice a therapy with no established evidence base. An eclectic mix that where you've picked and chosen what you like from different schools without the package being subject to evaluation. Overall this sounds like deeply unethical (and potentially dangerous) clinical practice.”
Oh, like that isn't what all therapists do - including CBT therapists who pick and choose from a multitude of CBT interventions based on their experience and preferences and the patient in front of them without having their "whole package" subject to evaluation. Of course, by the critic's reasoning, the originators of all the CBT techniques were all unethical because they undoubtedly tried them out on patients before packaging them for outcome studies.

This critic illustrates another point of confusion: a basic misunderstanding of psychotherapy research. As I said, CBT therapists in treatment studies pick and choose from a multitude of CBT interventions based on their experience and preferences and the patient in front of them and then subjecting the "whole package" subject to evaluation. Since every therapist in the study is doing something somewhat different with each patient, a truly scientific evaluation of “the “package” would be quite a feat!

In fact, outcome research does not focus on specific techniques but on some overall strategies. Finding out which techniques were valuable and which superfluous on their menu of interventions would require something called dismantling studies, which are few and far between. Psychotherapy process research, on the other hand (of which there is a huge literature that dwarfs the outcome research) does focus on specific techniques, and often shows that techniques used by more humanistic and relational therapies are highly effective for certain therapeutic goals.

Adherence to the therapy model by the different therapists participating in an outcome study is another big issue. If it is measured at all, it almost always shows wide variation. There is usually no "red line" by which, if a therapist's adherence to the model goes below a certain point, his or results are not included in the study! So what really worked?  We don't know. 

The critics on both Psychology Today blogs seem to be proving my point that CBT grossly exaggerates its science base. When I and another commenter pointed out specific and highly significant weaknesses in their literature, the silence was deafening.

Also noteworthy that not a single critic had anything to say about the issue that was the main point of my blogpost – the existence and importance of family myths. I asked them for references where this issue or where any social psychological concept that was similar had been discussed by CBT therapists. Not a word.

To my knowledge, cognitive therapists have never written about how many allegedly irrational ideas are held collectively by kin groups.  Ignoring collective phenomena is actually a problem with almost all forms of individual psychotherapy, because therapists are entirely wrapped up only with what goes on inside people's heads.

The sole complaint of the only critic that even mentioned family myths was that I had not brought it up until the tenth paragraph of my original post. (That was because I had to explain some concepts from cognitive therapy before my criticism would make sense). So sue me.

I was too lazy to quote a bunch of studies to demonstrate the weaknesses in their science, and I figured they would merely cherry pick some counter-examples and then summarily declare victory.  However, another reader came to my rescue.
****Submitted by Philip on November 26, 2011 - 6:34am.
I have been reading a number of outcome studies recently because I am seriously worried by claims that 6 to 20 sessions of cognitive behavioural therapy are sufficient to cure such disorders as major depression and anorexia nervosa.
Allow me to summarize, briefly, the findings of a meta-analysis of CBT for bulimia nervosa. The rate of recovery for patients who completed treatment was found to be around 45%. This is quite substantial - a substantial minority of patients recover after and average of 12 sessions of CBT or behaviour therapy (they are equivalent in effect). It should be noted that there is very little follow-up data by which to judge whether or not these patients remained well.
However, consider the following:
20% of patients dropped out of treatment. 40% of patients who were initially considered for inclusion in the studies were excluded from treatment. This is because, as Dr Allen correctly noted, such studies exclude co-morbid patients (those with multiple diagnoses). Thus, the treatment samples are composed of less complex cases.
As an aside, most outcome studies of CBT for depression exclude around 60-70% of patients - again, because these cases are considered too complex to treat with CBT.
Back to bulimia. On average, after completing treatment, patients continued to binge/purge twice per week. So, although the treatment resulted in a statistically significant reduction in symptoms, many - perhaps most - patients remained symptomatic.
Thus, 45% of a restricted sample (which excluded severely disturbed patients bulimia, patients with bulimia and drug or alcohol addictions, suicidal patients with bulimia and patients with 'borderline personality' disorder and bulimia) reportedly recovered (with little follow up data to support this conjecture).
One of the authors of a study reporting these results concluded that CBT is the "treatment of choice" for Bulimia Nervosa. It is the only treatment that has been adequately studied. This is what Dr. Allen is referring to when he notes that the credentials of CBT are exagerated.
If we actually think about Bulimia in the real world - where most patients have severe co-morbid disorders, and 50% also have a borderline pattern of symptomalogy - these studies tell us little about the efficicy of CBT. In the lingo of researchers, outcome studies have little 'external validity'.
Why is it that researchers are unwilling to apply CBT to complex or co-morbid cases? They claim it is because they want to exercise experimental control - they want their studies to have internal validity. That is, they want to know which treatment works for which disorder.
It is also very likely that, were researchers to attempt to treat severely disturbed patients with CBT, they would fail to obtain results which reflect well on CBT. They also would have a hard time getting their work published, for journals do not like to publish null [negative]-findings.
If one is willing to read the research carefully, and has a basic education in statistics and research methods, the evidence supporting the effectiveness of CBT is very modest. Indeed, CBT contains a smaller and less diverse 'evidence base' than does cotemporary psychoanalytic psychotherapy.
What CBT has more of than other psychotherapies is outcome research. However essential outcome studies are, they "prove" nothing about the validity CBT. For all they show, the patient might be cured because of a placebo effect or because of cognitive restructuring. Same same but different.
This is called, by the way, the dodo bird effect: the finding that all treatments are equivalent (whether they be behavioural therapy, CBT, 'psychodynamic' therapy, interpersonal therapy and so on). That's what outcome studies tell us. And we don't know why. It seems that the debate is only just starting, and some have already declared CBT the winner.
Thanks, Philip.
When it comes to getting people to change their behavior, thoughts and feelings, there is always a multitude of ways to skin the proverbial cat.  And every patient responds to interventions differently. This is where social sciences differ from hard sciences like physics.

"CBT therapists are superior to therapists from all other schools of thought, so come see us." This exaggeration of the research results by CBT folks looks a lot like the same phenomenon seen in drug studies these days: it isn’t so much science as marketing.

Friday, December 2, 2011

Mainstream Media Finally Covers a Scandal

Kudos to ABC news for finally reporting on the scandal in which disturbed children in foster care are being drugged to shut them up - rather than being treated for the trauma of coming from abusive or neglectful homes and then being passed around from foster family to foster family. 

Bizarre and pharmacologically absurd cocktails of powerful central nervous system drugs are prescribed after five minute visits with doctors.  Foster parents are often pressured to go along with the practice.

You can find the story at

The government report that ABC describes is the only thing that's "new" about this story.  I have seen  this discussed for several years in the professional media.

Only problem is, while foster kids get treated like this more often than other children, they are hardly the only ones getting this sort of "treatment."

Wednesday, November 30, 2011

Were They Awarded Tenure for These Studies?

It’s once again time to discuss some brand new psychiatric studies that would be just perfect for my two favorite journals, “Duh!” and “No Sh*t, Sherlock.”
As we all know, our collective experiences are nothing more than anecdotal evidence for anything, and what appears obvious to almost everyone cannot be considered true unless subjected to a randomized controlled or epidemiological study. 
Research dollars are very limited and therefore precious.  Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already thought to be true but have yet to be "proven"?  Such an approach increases the success rate of studies almost astronomically.
And studies with positive results are always far more likely to get published than negative ones, so why should an academic take that risk?
Here are some of my favorite recent headlines reported by psychiatric news gathering organizations:
“Body dissatisfaction appears to be the major factor propelling young people on the road to eating disorders.”  Really? I though most people do not complain about being too fat or too thin.  I mean, especially women.
“Sleep disorders are prevalent with mental illnesses.”  And here I was under the impression that depressed, anxious, and paranoid patients slept more soundly than anyone.
“Youngsters with depressed fathers are more likely than other kids to have emotional and behavioral problems, according to a new study of more than 20,000 U.S. families.”  This is so good to know.  I had no idea that having unhappy, miserable adult family members might affect a child’s mood.
"A new analysis released by the Kaiser Family Foundation shows that tough economic times have led to a downturn in doctor visits."  That can’t be true in the United States, where as we all know, everyone gets free healthcare.
"Receiving a diagnosis of dementia increases a person's risk for suicide, particularly if symptoms of depression and anxiety are present," according to a studyresearch published in the November issue of the journal Alzheimer's & Dementia.”  Now come on!  The prospect of becoming senile and a financial and emotional burden on one’s family might cause an already depressed or anxious person to despair?  No way!

“Long-Term US Unemployment Taking Psychological Toll." Now this is really surprising, since we all know money cannot buy happiness.  I was just positive that not having enough food to eat and a roof over your head would hardly matter.

“A history of maltreatment during childhood increases the risk for depression in adulthood and poor treatment outcomes, new research suggests.” Another amazing discovery.  This had never been noticed by either psychiatrists or psychotherapists before now.

And finally, "Violence against women is significantly associated with mood, anxiety, and substance use disorders throughout the victim's lifetime."  Since we already know these psychiatric disorders all have purely genetic causes, we now know that these very same genes also cause women to get beaten up.

Wednesday, November 23, 2011

Ve Have Vays of Making You Talk, Part V: Non Sequiturs

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

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

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

To review once again, the goal of metacommunication is effective and empathic problem solving. In this post, I will discuss an avoidance strategy called fatalism, and describe appropriate counter-strategies to get past it.

As with all counter-strategies, maintaining empathy for the Other and persistence are key.

Irrational arguments are used in metacommunication to confuse other people so that they either become confused about, or unsure of the validity of, any point they are trying to make.  They are also frequently used to avoid divulging an individual's real motives for taking or haven taken certain actions. 

In my first book, A Family Systems Approach to Individual Psychotherapy, I attempted to educate therapists about how their patients will use irrational arguments to confuse them.  I referred to irrational arguments as mental gymnastics. They are particularly effective in emotionally-charged exchanges. 

One can learn to recognize irrational arguments meant to throw someone off the track by learning about the logical fallacies that are taught in debate clubs and philosophy classes.  Today's subject: the non sequitur.  This is a Latin phrase meaning "it does not follow."

A non sequitur occurs when a conclusion is drawn deduc­tively that does not follow logically from the preceding proposi­tions. Someone will take a fact or make a generalization or a categorization, assert than some other fact or generalization is an example of this, and then draw a conclusion.   This process is called deductive reasoning.  

Correct deductive reasoning can best be demonstrated using syllogisms. Let us look at perhaps the most famous of all syllogisms:

                        All men are mortal.
                        Socrates is a man.
                        Therefore, Socrates is mortal.
The first thing one should understand, if one is to correctly evaluate deductive reasoning, is that this is a valid deduction whether or not the initial statements "All men are mortal" and "Socrates is a man" are correct. A deduction - the last statement in the syllogism - can be judged to be valid if the structure of the syllogism is correct. This means that a conclusion can be com­pletely wrong but the deduction can still be valid logically if the conclusion follows correctly from the initial propositions.
The truth of a proposition, as opposed to its logical validity, de­pends upon the truth of the information from which the propo­sition is deduced. In a valid syllogism, if the first two statements are true, the conclusion must be true. The presence in the syllogism of the word all is extremely important. If some men are mor­tal and some are not, Socrates might fall outside the set of "things that are mortal," and the syllogism would become invalid. This is precisely why the equally famous fallacious syllogism

                        The Virgin Mary was a virgin.
                        My name is Mary.
                        Therefore, I am a virgin.

is invalid. The set of "people named Mary" falls both inside and outside of the set of "virgins." Therefore, Marys may or may not be virgins, and the conclusion is thus invalid. In this case it is not true that if the first two statements are true, the conclusion must be true, as would be the case with a valid syllogism.

A word here regarding inductive reasoning is in order. Inductive, as opposed to deductive, reasoning attempts to go in the reverse order. One attempts to make a generalization by examining several phenomena that seem to have something in common. One then makes the leap of faith that because all observed instances of the phenomena have this characteristic in common, therefore all instances of the phenomena, now or in the future, observed and not observed, share the characteristic.

For example, every ­time an object of whatever size or shape is dropped on earth, it falls down. The inductive conclusion is that the set of "things that fall down" entirely subsumes the set of "things that can he dropped" and that anything droppable will fall down if dropped.. One makes the prediction that any new object that can be dropped will head earthward if one picks it up and lets it go.

Now the deduction "since all observed instances of a cer­tain phenomenon behave a certain way or have certain things in common, therefore all future instances of the same phenomenon will continue to behave in the same way and have the same things in common" is in all instances a non sequitur. One might come upon an exception to the rule at any time. In other words, all inductive conclusions are invalid!

Nonetheless, induc­tive conclusions are not necessarily unreasonable and are fre­quently correct. I have in my hand a pencil, which I plan to hold up and then let go. Will it fall? I predict, on the basis of induc­tive reasoning, that it will. Let’s see. Well, I'll be. It did it again!

The reasonableness of an inductive conclusion is evalu­ated not by logic but by whether enough instances of the phe­nomenon have been observed to make a generalization possible and by whether there are any instances that contradict the gen­eralization. Deductive reasoning, or reasoning based on proof, would not be possible without inductive reasoning. It would be impossible to conclude that Socrates was mortal if one could not make the generalization "All men are mortal."

The deter­mination of how many instances are required to decide whether an inductive conclusion is reasonable is a very subjective matter, because no matter how many instances there are, the next one could always be the exception. For this reason, anyone look­ing for mental gymnastics when someone else makes an inductive conclusion best asks the questions: Are there significant excep­tions to the generalization that the first person is is making? If so, are they obvious, if only the person would look for them?

I will now describe a case in which a patient presented a therapist with a goodly number of non sequiturs. She was a single woman who came in complaining about being subjected to severely and significant repetitive sexual harassment by a co-worker.  The question the therapist posed was why she had made an appointment to see a psychiatrist in the first place, since she did not seem to have any evident psychiatric problem.  

As it later turned out, she did not really want to give the real answer because she was  protecting her mother, from both the judgment of the therapist and from her own rage.  So she gave spurious and very sublty non-rational reasons in order to throw the therapist off the track.

Her chief complaint was that she was upset - but only because someone was doing something to her about which almost anyone would be upset. People usually see a therapist because they believe there is something wrong with them or with their reactions to things.  That did not seem to be the case with this woman. Why wasn’t she talking to her boss or a lawyer, the therapist wondered?  Actually, she was in the process of doing both! 

The therapist could not seem to get a satisfying answer from her to the central question, and knew for certain that something else was going on with her when the non sequiturs began.

She first stated that she must have done something to make the co-worker behave in this extreme fashion, because people do not hate you unless you've done something bad to them. This was a non sequitur because she had no proof that her tormenter’s behavior was based on hatred of her, and even if it were, she was quite aware that the causes of hate in the world include a great many other things. Hate can be based on prejudice, jealousy, a chip on the shoulder, or any number of things other than what someone has done to the per­son who hates.

The next bit of curious logic occurred when the patient told the therapist that she just could not seem to make him understand that his gossip was disturbing her. How she could possibly have thought that he was not aware of that was simply beyond comprehension. The therapist told her he thought it kind of her to wish to give him the benefit of the doubt after all he had done to her, but it seemed that she had too much evidence to the contrary to support this thesis.

The first clue about the real reason she thought she needed a psychiatrist came when the patient is­sued yet another non sequitur. She began to get upset with herself for being disturbed by some of the slurs verbalized by her nemesis. She stated that he was just calling her names, after all. Why should just names bother her? Sticks and stones, and all that. She should be able to ignore it, like water off a duck's back. The therapist told her she would be quite an unusual person if she had not found the barrage of insults disturbing.

When faced with a recommendation that we explore why she was so upset that the whole situation bothered her, she balked. She said that if she were to get to the reasons be­hind this seemingly self-defeating behavior, she might find something terrible. Well, she might, but how terrible could it be? How did she know that she would not discover something wonderful? The odds were, of course, that she might find something uncomfortable, but as Albert Ellis (the founder of cognitive psychotherapy) says, feeling that one would not be able to tolerate the discomfort is irrational, espe­cially when the level of discomfort is already so high, and when bearing some additional discomfort could reduce it over the long run.

She correctly guessed that certain information she had re­lated to the therapist might incline him to think that her parents' divorce when she was a pre-teen had something to do with her current reactions. She then added a non sequitur that later turned out to be the essential clue to what was really going on. She said that she was puzzled by why everyone seemed to think that a parental divorce had so traumatized her and added that she had taken the divorce in stride. It was done, and there was no reason to get upset about it. The event just did not bother her.

When she made this statement, she was trying to take what may sound like a rational position. After all, the belief that one cannot stand an unpleasant occurrence makes one suffer more than necessary. The patient was saying more than this, however. She was saying that one should not be un­happy about a traumatic experience. No disappointment. No regret. No anything. Ellis states that regret and disappointment are emotional re­sponses that make sense. She was stating that she was unaffected entirely. Furthermore, the available evidence strongly suggested that she was more than just disappointed about what happened. She could hard­ly discuss the matter without breaking into tears.

Much later, the therapist discovered that what the non sequitur really alluded to was the patient's very rational concern about seeming to be bothered about anything. As it turned out, the patient's mother had been subjecting her for years to frequent guilt-ridden harangues about how bad the mother felt about the divorce. The mother would literally badger her with questions about whether she had been upset and traumatized by it. If the patient appeared distressed about anything, her mother would begin drinking herself into a stupor.

No wonder the patient tried to project an image of not being bothered by things! If she were to admit to being the least bit upset, the mother would feel even guiltier. The mother was already self-destruc­tive; perhaps she would become actively suicidal.

Now that seemed like a valid deduction.

Wednesday, November 16, 2011

The Last Time Biological Psychiatry Over-Reached

There once was another time in recent history when purely genetic explanations for complex human behavior were in vogue just as they are today. You’ve no doubt heard about how two identical twins raised apart were both alcoholics, preferred the color red, and were married to women named Flo.

In reality, most human behavior is learned. For God’s sake, we don’t even instinctually know how to have sex - unless someone tells us or we figure it out by trial and error. (Just the urge is instinctual). Luckily, most of us eventually figure it out.

The following is an excerpt from a chapter called The Brainlessness-Mindlessness Pedulum from my book, How Dysfunctional Families Spur Mental Disorders:


The biological underpinnings of many mental phenomena clearly have their origin in genetics.  Although they are hardly the only determinants of brain functioning, our genes set the parameters by which the structure and abilities of the human brain develop and change over the lifespan.  The subtleties of how the brain functions and what behavioral attributes have genetic components are only now beginning to become clear, but despite the lack of knowledge in earlier times, an interest in the inheritance of mental characteristics was certainly understandable.  

In the 1880’s, a cousin of Charles Darwin named Francis Galton began to think about the relationship between Mendelian genetics and the theory of natural selection in evolution.  The idea that the forces of nature seem to favor the strongest and most adaptive creatures led him to formulate a social philosophy that he called eugenics.  He believed that the human race could be improved through the selection by society of which individuals would be allowed or not be allowed to have children, based on what he believed to be their biologically inherited characteristics. 

The list of presumed inherited characteristics was, even by the loose standards of some of today’s “biological” psychiatrists, absurdly broad. Characteristics thought by many of the followers of eugenics to be genetically transmitted included such traits as sexual promiscuity and even poverty.

Eugenics quickly found many prominent believers, particularly in Germany and in the United States.  Among them were Luther Burbank, Alexander Graham Bell, feminist icon Margaret Sanger, the Carnegie Institute, and the Ford and Rockefeller Foundations.  The philosophy gradually expanded from an emphasis on selective breeding or positive eugenics to the idea that “inferior” members of our species should be forcibly sterilized so that they would never be able to pass down their supposedly bad characteristics.  This was termed negative eugenics.  Some people who believed in the idea that forced sterilization was a moral endeavor eventually jumped to the idea that inferior peoples should be exterminated.

In the United States, the influx of large numbers of European immigrants led to fears that such people might be of inferior stock, and might therefore “pollute” or “contaminate” the gene pool.  Eugenics gave voice and legitimacy to these fears, so it was appealing to a large segment of the American population. In 1910, a man named Harry H. Laughlin established an organization called the Eugenics Record Office (ERO), through which he lobbied politicians to help protect the purity of the human race through restrictions on immigration of peoples from Southern and Eastern Europe.  The peoples from these regions were thought to have “excessive insanity.”   The efforts of the organization led to the passage of the 1924 Johnson-Reed immigration bill which successfully limited the immigration of people from these areas, and completely excluded Asians from entering the States.

Harry Laughlin

The ERO also advocated forced sterilizations of certain segments of society.  It was supported financially by the Carnegie Institute, among others. The idea of forced sterilization of the mentally retarded had already gained acceptance by the time of the founding of the ERO, with the first state law requiring it having been passed in Indiana in 1907.   Eventually, thirty states passed similar laws, resulting in the forced sterilization of over 60,000 Americans.  The practice did not completely stop until approximately 1963.

Laughton was unhappy with the earliest versions of state laws mandating this practice and with their lax enforcement.  He also felt that forced sterilizations should be expanded from just for the “feebleminded” to include the insane, criminals, epileptics, alcoholics, and even the deaf and blind.  He apparently believed all of these characteristics were inherited through genetic mechanisms and that any chance of their being passed on to children had to be eliminated.  He drafted a model law in 1922 that became a template for some later state laws.

He was also influential in a case that came to the United States Supreme Court in which the constitutionality of the forced sterilization of the mentally retarded was upheld: the case of Buck versus Buck in 1927.  Carrie Buck was a woman who was branded as being mentally retarded after she became pregnant following a rape by the nephew of her foster parents.  She was very likely of normal intelligence, as was her daughter Vivian.  Nonetheless, no less a figure than Justice Oliver Wendell Holmes led the way in ruling in favor of the State of Virginia in the case, writing, “Three generations of imbeciles are enough.”

Carrie and Emma Buck
Adolph Hitler and his henchman found this ruling by an American court inspiring.  They loosely used Laughlin’s model law in drafting Germany’s own “Law for the Prevention of Genetically Diseased Offspring,” which went into effect in 1934.  In 1936, Laughlin was granted an honorary degree from the University of Heidelberg in Germany for his work on behalf of “racial cleansing.” 

In a sublime irony, Laughlin himself developed epilepsy in his later years.  Sufferers of this disorder were one of the groups of people he thought should be eliminated from the planet.

The mentally retarded, followed in quick succession by the mentally ill, were among the first victims of the Nazi death machine.  Forced sterilizations began in 1935, followed by the T-4 program for “euthanasia” of the mentally ill in 1939.  One of the architects of this death program was a psychiatrist, Ernst Rudin, as were several of the doctors directly involved in it.  The methods he helped devise for killing individuals with mental problems were later adapted for use in the large scale attempted extermination of those ethnic groups that the Nazis considered genetically inferior, such as the Jews and the Gypsies, as well as of certain individuals within their own ethnic group such as homosexuals.

Ernst Rudin
In the early days of the T-4 program, even small children were not spared.  At one point some families of children with mental problems, who were being told that their offspring had died peacefully of natural causes, became suspicious because they learned that so many of their children seemed to have all died on the same days.  In order to keep the program secret, the Nazis stopped killing the children directly in favor of just letting them starve to death so they would all die on different days.

Meanwhile, back in the United States, support for eugenics waned by the end of the 1930’s because of its association with the Nazis and also because the so-called science behind it was proving to be quite poor.  The Carnegie Institute withdrew its funding of the ERO in 1935 and it soon folded.  Some psychiatrists in the United States, however, apparently did not get the message. 

A psychiatrist named Foster Kennedy gave an address to the American Psychiatric Association’s annual meeting in 1941.  In it, he strongly advocated not only for the forcible sterilization of the mentally retarded, but for killing them, especially if they fell below a certain functional level.  Because he assumed that such individuals were in constant suffering and would be better off dead, he referred to this killing as euthanasia or mercy killing.  His address was published in the Journal of the American Psychiatric Association in July of 1942.  In the same issue an opposing viewpoint by another psychiatrist, Leo Kanner, was also published, along with an editorial.

Leo Kanner
While Kanner had no objection to sterilization, he did object to euthanasia.  He also questioned the validity of assuming that people of low IQ would necessarily beget children who were also mentally deficient, but did not spend any time exploring the ramifications that would ensue for his philosophy if this were indeed the case.  He believed that sterilization should be reserved only for those who could not perform useful work.  He feared that stopping more functional people of low intelligence from reproducing might lead to a labor shortage in unskilled occupations which would adversely affect the functioning of society. 

Of note is the fact that by July of 1942, psychiatrists were already aware of what was going on in Germany.  Kanner noted, “If [journalist and historian] William Shirer’s report is true – and there are reasons to believe that it is true – in Nazi Germany the Gestapo is now systematically bumping off the mentally deficient people of the Reich…” (p.21).