Tuesday, May 26, 2015

Guest Post: The Challenge of Prosperity

Today's guest post concerns the work of Dr. Cheryl Rampage, Senior Vice President for Programs and Academic Affairs at The Family Institute at Northwestern University. She has shown how a family's being financially well off can at times actually increase the risk of anxiety, depression, and substance abuse in their children.

Cheryl Rampage, Ph.D

When we think of wealth, we often think of all the opportunities and perks that come with it. However, the common misconception that wealth is the solution to all of our problems is negated by recent research that shows while money can give children a head start in life, it can actually impede on their personal and emotional growth as they get older. 

In fact, adolescents who come from a wealthy household are 20 to 30 percent more likely to suffer from depression or anxiety than other teens. But there are ways to combat it. 

Cheryl Rampage's Counseling@Northwestern’s paper, “The Challenge of Prosperity: Affluence and Psychological Distress Among Adolescents,” sheds light on this issue—and ways to address it. Interested readers can click on the title of the article to read the whole paper.

While her research shows that prosperity can impose psychological distress on youth, parents and guardians can step in by following best practices. According to Dr. Rampage, parents can mitigate the risks of wealth by providing structure at home, unconditional love and consistent communication with their adolescents. The infographic below illustrates the ways in which affluence affects children’s mental health in early childhood and adolescence and what parents can do to positively contribute to children’s overall development.

Learn more about the challenges of wealth and prosperity from an infographic. It is shown below and available in a larger image at

Brought to you by Counseling@Northwestern’s Online Masters in Counseling

Tuesday, May 19, 2015

Whatever Happened to Assertiveness Training?

My fellow blogger over at BehaveNet had an interesting entry on 4/23 that described an experience with a consultant who came to talk to a psychiatric hospital staff on the topic of "physician burnout." The consultant suggested that the psychiatric staff consider using mindfulness techniques to basically chill out about all the stresses under which they have been working.

In the mindfulness post that I wrote, which is linked above, I opined that so-called mindfulness techniques can be quite helpful under certain types of circumstances. Most important, they can help one stay relaxed and clear-headed when being subjected to environmental stressors that fall mainly into two categories: 1. Common, everyday types of stresses due to the vicissitudes of life that change from day to day and that almost all of us experience, or, 2. Those stressful environmental contingencies over which one has zero hope of changing or correcting. (Mindfulness techniques can also help one stay more relaxed when tackling situations that need to be changed or corrected).

The stresses that lead to physician burnout may not fall into one of these two categories. In fact, one of the most common causes is managed care insurance companies and business types with no medical or psychiatric expertise who are constantly telling doctors what they can or cannot do, and making their professional lives miserable. 

What this consultant seemed to be recommending was using mindfulness techniques as a means of employing something that is definitely not called for in this type of situation: passivity

Insurance companies and business people need us doctors more than we need them. We should be doing whatever we can to get them out of the way of effective patient treatment as well as to stop them from preventing us from having a normal and balanced work/life schedule.

The BehaveNet blogger hit the nail on the head: "Dr. Meredith's prescription of mindfulness to address the problem suggests to me a strategy to get physicians to devote adequate time to contemplation of our navels so we will learn to tolerate even more abuse and exploitation with a smile and a "Yessuh, Massah." The blogger suggests that instead doctors push back, refuse, resign, set limits, make demands, and maybe even disrupt things.

This recommendation should also be applied to what psychotherapists do with their patients.

There is unfortunately a current psychotherapy craze of teaching mindfulness techniques to help patients with major family issues to learn to tolerate their stressful family and relationship lives with more equanimity. This is crazy. Not to mention invalidating to patients, as it seems to imply that the problem resides entirely with them. Instead, therapists should be inspiring them, and teaching them how, to fix the situations that are creating their stress in the first place.

I am not saying that the patients' own behavior does not contribute to the dysfunctional family patterns of which they are a part. Clearly it does. But that just means they have to change their own behavior in reaction to the abuse, distancing, and double messages which they receive on a daily basis from their family system members. Doing so is in fact a good strategy for stopping these patterns, not merely tolerating them better.

Cognitive behavior (CBT) therapists have become the biggest champions of using mindfulness techniques for patients with these personality/family problems. This is ironic because back in the 1970's those very same CBT therapists were the very ones who labeled being passive a form of psychopathology! As also mentioned in the BehaveNet blog post, they used to advocate something called assertiveness training.

Basically, in response to mistreatment, assertiveness training theory described one helpful general pattern of responding and three dysfunctional ones. The dysfunctional ones were labeled passive (just sit there, take it, and do nothing about it), aggressive (attack the other person verbally or even physically to impose your will on them), and passive-aggressive (mad at your husband? Burn his toast).

The healthy response was called assertiveness - that meant speaking up for yourself and demanding respect without trying to bring the other person down, disrespecting their needs and viewpoints, casting aspersions on them, or in any way attacking them.

After a period of teaching assertiveness skills to their patients, CBT therapists began to back down from it little by little. They were later forced to admit that the "healthy" responses they taught might get someone beat up or killed in some situations, so it might be best to let some things go.  If you speak up when someone butts in front of you in line these days, the other person may go ballistic and hit you or even pull out a gun. Thankfully this does not happen very often if one is not aggressive, but it is a risk.

Additionally and gradually, the CBT therapists began to fall into the trap of thinking that everyone's problems are all just in their heads. Just like the psychoanalysts they replaced. Last, when it came to intractable family dysfunction, assertiveness skills just did not seem to work all that well anyway.

I have found that with ongoing repetitive family problems, the sort of generic assertiveness skills taught by CBT therapists in fact do not work. That is because family members have developed a whole repertoire of counter-moves that scream to the member attempting to be assertive, "You are wrong, change back." Some of these counter-moves are quite frightening - I described many in a previous post. All involve the person who is trying to be assertive being invalidated in some way and made to feel small for daring to speak up.

This hardly means, however, that the proper strategy for handling these problems is passivity. What I discovered is that the assertiveness training techniques that used to be taught had to be modified to fit the sensitivities and histories of each of the other family members being addressed. These modifications were different for every family, and they had to be tailored specifically to each one. No "one size fits all" here. 

Furthermore, there is no way to know in advance which strategy might work best in a given context, but there was almost always one that could be devised that could help diffuse the family drama significantly for any patient.

I discussed many different strategies in my series of posts in this blog on How to Disarm a Borderline and in another series entitled Ve have Vays of Making You Talk.

So, the CBT therapists had the right idea about assertiveness training before they kinda gave up on it and resorted to the "distress tolerance skills" that are actually part and parcel of what they used to label dysfunctional passivity. They instead should have listened to some of the ideas from family systems therapists in order to improve their therapeutic techniques. 

Mindful passivity? Plenty of time for that at a certain point in the future. As the lyrics from an old song by "Weird Al" Yankovic that used to be played by satirical disc jockey Dr. Demento proclaimed, "I'll be mellow when I'm dead."

Tuesday, May 12, 2015

Adventures in the Veterans' Hospital Mental Health Clinic - Last Part

This post continues on from my post of 4/28/15 about the practice of psychiatry in the outpatient mental health clinic at the Veterans' Affairs Hospital in Memphis, from which I retired a few months ago. In the last post, I discussed the first of two reasons for my quitting my position about a year earlier than I had planned.

The issue of being short staffed relates to the second issue that caused me to abruptly curtail my expected period of employment with the VA. That will be the subject of this post.

In line with recent trends everywhere in psychiatry, the MD's on staff at the VA were basically not expected to do regular psychotherapy but were there only to write prescriptions for psychoactive medication. This policy was of course never clearly spelled out, but everyone knew it. As mentioned before, however, there were nowhere near enough Ph.D. psychologists to provide psychotherapy to all who needed it.

Furthermore, there were no psychologists on staff who specialized in what I specialize in, the individual psychotherapy of borderline personality disorder (BPD). Such patients are not at all uncommon in the VA population. The clinic did provide some of the "skills-training" therapy groups that are but one of three parts of a treatment known as dialectical behavior therapy (DBT), but even the DBT purveyors' own studies show that the groups without the individual psychotherapy component of DBT are not very effective.

I was able to provide regular psychotherapy for two of these patients anyway, but only because one of the doctors on the inpatient psychiatry unit was having a lot of trouble with these particular ones. Their behavior was creating significant problems on the ward, and additionally they were using up a lot of resources. 

The inpatient doc literally begged my supervisor to accommodate my schedule in order to allow me to see them regularly, and she reluctantly agreed. Of course, if I had been the one to ask for psychotherapy time for a patient I was seeing, it was highly unlikely that such accommodations to my schedule would have been forthcoming.

Then one day there appears a note in the electronic medical record for one of my medication-management-only patients with BPD, alerting me to the fact that she was making vague suicide threats. Luckily, I knew the patient fairly well, and surmised that she was probably just reacting to her frustrations at the limitations on her own treatment at the VA, and was probably not an imminent suicide risk.

But then I thought: What if she had been? In such a case, there would have been a note in the chart advising me of a potentially life-threatening problem for which I was technically responsible, but which I was not being allowed to actually treat. And there would be no one else to send her to so she could get adequate treatment. 

Inpatient treatment could buy time if the suicide risk were very high, but it usually causes patients with BPD to get worse in the long run, and is therefore best avoided except in extreme circumstances. And one still needs to refer the patient for continuing psychotherapy after discharge. That was the very problem the inpatient doctor had with my two therapy patients!

In response to the warning about the patient I had received, I documented my dilemma in the patient's electronic medical record - consequences be damned. I then finally admitted to myself that I had to get out of the VA very soon.

Tuesday, May 5, 2015

Words That Work in Deceptive Drug Company Advertising to Physicians

"It depends upon what the meaning of the word 'is' is." ~ Bill Clinton

I recently came across a rather humorous document from a legal action that was taken way back in 2008 against the drug company giant AstraZenica (AZ) in litigation over marketing issues with its antipsychotic drug, Seroquel (Quetiapine). I thought it would be fun to share with my readers.

It came from the United States District Court, Middle District of Florida, Orlando division in the matter of Seroquel products liability litigation, Case # 6:06-md-01769-ACC-DAB, on April 24, 2008.

It was a Q&A between a lawyer and the AZ executive who was involved in organizing the slides used in promotional talks given to physicians. It concerned the use of the term "unsurpassed" in slides used to market the drug.

Seroquel was one of the newer "atypical" antipsychotic medications. They were called that to distinguish them from the old, "typical" antipsychotics like Haldol. The old drugs were notorious for causing acute neurological side effects such as a Parkinson's disease-like tremors and muscle spasms (which can be easily countered with another class of drugs), as well as a long term one called tardive dyskinesia (TD) that could become permanent. 

To see what TD looks like, watch the Batman Movie The Dark Knight with Heath Ledger playing the Joker, who I guess was supposed to have been an ex mental patient, and was portrayed as having the mouth movements typical of TD.

The new '"atypical" drugs are much less likely to cause these neurological problems, but instead are far more likely to cause metabolic syndrome - weight gain, increased cholesterol, and even diabetes. (Recently released ones in the last few years are better on this score as well, but Seroquel is one of the worst offenders in this regard). Pick your poison. Atypicals have never been shown to be more effective than the typicals for the hallucinations and delusions characteristic of psychotic disorders.

In fact, AZ's own documents showed that the company analyzed 10 studies, and found that none of them showed that Seroquel was superior to any other antipsychotic drug.

So how did AZ spin this in its sales presentation to doctors? Their slides said the drug was "unsurpassed" in efficacy the treatment of schizophrenia. They found that this word was one that worked.

This is funny because there are two different definitions of "unsurpassed." The definition most people think of is "superior in achievement or excellence to any other." In other words, most people would think that the slide indicated that Seroquel was the most effective antipsychotic drug available.

The more literal definition, however, is "as good as or better than any other." This means that other drugs can be equally as good. Obviously, that wasn't the message that the slides were meant to convey to the doctors, but because the lesser known definition exists, this gave the company plausible deniability against the charge that it was making claims unsubstantiated by any research - even though that was the take home message most people would take home. Pretty sneaky!

The company man responded to questions about this with mental sommersaults, some of which - as my friend Peter Parry points out - are cringe-worthy. So here it is (minus some objections by the involved lawyers):

Q. Let me just read the conclusion to the jury and then ask you a question about it. "Conclusions. The intended claim of 'superiority versus Haloperidol' is highly unlikely using these data, however 'a claim of equivalence is not ruled out.' Did I read that correctly?
A. Yes, you did.
Q. Were you ever informed of that Technical Document No. 5 or its conclusions?
A. I have told you twice already no.
Q. Okay. Do you think you maybe should have been informed of this information before you Went around making claims of unsurpassed efficacy?
A. No, because I took my guidance from the head of clinical, the disclosure committee, and the SERM group. By the way, how is
equivalence different from unsurpassed?
Q. Do you really think you get to ask me questions? Is that what you think this process involves, that you get to ask me questions and I give you answers?
A: I'm trying to answer your question.
Q. Well, let me ask, since you asked me a question, let me ask you a
question: "Unsurpassed," "unsurpassed,"- what does that mean?
A. It means --
Q. Nobody is better; right?
A. It means equivalent.
Q. So if I really -- I'm trying to think of something. If I tell
somebody that I went to a track meet and I saw an athlete that has been
unsurpassed, I mean he was -- her, let's say her. Her ability to do the broad jump and the high jump and the relays were unsurpassed, and I was just so impressed and I go and tell you it was unsurpassed, you believe that means I'm saying she was equivalent to everybody else at the meet?
A. Possibly, yes. That's the correct grammar. Possibly, yes. She
was possibly better; she was possibly equivalent.
Q. And if I come home and --your child, you said, is 5 years old?
A. I have got two.
Q. How old are they? Mine are 22, 20, and 17. How old are yours?
A. 3 and 5.
Q. When your child comes home from school let's say from first grade
and says, "Daddy, I" -- well, I don't think first grade. And your child may be smart because you are smart. So let's just go to fifth grade. Go to
fifth grade. "Daddy, my grade in my English class was unsurpassed." What
are you going to say, "Congratulations.You made the same grade as everybody else"? Is that what you are telling this jury, is "unsurpassed" means the same?
A. Yes, it does, it means the same as or better. That's exactly what it means.
Q. So -- that's exactly what it means. So when AstraZeneca -- I'm glad to know this. This is interesting and I'm glad we're getting this out here. So when AstraZeneca made the claims of unsurpassed efficacy in regard to Seroquel, what they were meaning to say was, "We are just the same as everybody else"; is that right?
A. No, but I think we were incredibly careful with the use of grammar to depict what the clinical studies showed and concluded.
Q. You were trying to be tricky?
A. No. We were being incredibly precise and using the correct language. Of course, the language varied from country to country and label to label. The global impression from the safety and efficacy review group was our efficacy was unsurpassed.
Q. And you said in order to use that language, using your words, you were being incredibly careful; is that right?
A. No, I didn't. I said "incredibly precise."
Q. "Incredibly precise"; is that right?
A. Yes.
Q. All right. So if somebody understood the term "unsurpassed efficacy" to mean that you were better than others, they were just being incredibly what, dumb?
A. No. We would never make a claim without showing supporting documentation. So, for example, in the U.S., the doctor could read the label,he could read the FDA approval, and he could see the total span of facts.
Q. I'm not asking about the label and I'm not talking about the FDA
approval. I'm talking about what you've called at various points during this deposition a slogan or a phrase used in regard to Seroquel, and that was unsurpassed efficacy. Are you telling this jury honestly under oath that you were being so incredibly precise in the marketing of Seroquel that "unsurpassed efficacy" really meant that "We were the
same as everybody else"? Is that what you're telling this jury?

A. No. I'm saying that we chose that word to explain the fact that in the studies that we had done, our efficacy was unsurpassed when used in the right patients in the right dose in the right population. You can read a document like this without the context and it would be easy to be misunderstood about the total conclusion for what we say about Seroquel.