Thursday, August 22, 2019

Irrational Beliefs vs. Defense Mechanisms

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

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

Psychology is still a very young science. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tuesday, July 30, 2019

Book Review: Leaving the Witness by Amber Scorah

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tuesday, July 9, 2019

NAMI, Big PHarma, and Family Therapy

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

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

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

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

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

So why did I sort of know this would happen?

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

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

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

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

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

Here’s the rejected post:

Is a Personality Disorder a Brain Disease?

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

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

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

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

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

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

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

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

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

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

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

Thursday, June 20, 2019

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Wednesday, June 5, 2019

Private Insurance Circumvents the Mental Health Parity Treatment Act

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tuesday, May 7, 2019

Personality Disorders: Researchers Continue to Make Misleading Assumptions

In this blog I have discussed several instances of researchers making unwarranted assumptions about both their study populations and in interpreting their results in a variety of ways. In this post, I’d like to focus on three recent articles about personality disorder research. The first is a possible refutation of a common presumption, while the second two assume facts not in evidence.

The difference between “cannot” and “do not:” Confusion based on lack of attention to subject motivation, and ignorance of the concept of “false self.”

Shane MS; Groat LL. “Capacity for upregulation of emotional processing in psychopathy: all you have to do is ask.” Social Cognitive & Affective Neuroscience. 13(11):1163-1176, 2018 11 08.

Could it be that a psychopath’s apparent lack of ability to be empathic stem from differences in motivation rather than ability? This article is certainly possible evidence that this is the case. Perhaps people who routinely engage in anti-social acts suppress empathic responses because that is their role in their family. That what has been observed results from subjects’ false selves

This study of course does not address that latter issue, but thinking about it certainly suggests something which could explain the results. (Of course, it would help in that endeavor if we could read minds, because the thing about a false self is that it is based on someone lying to themselves in order to fulfill a social function, so they are highly unlikely to tell experimenters the truth during a short interview).

In any event, in this study, high-psychopathy participants showed typical, significantly reduced neural responses in the brain on an fMRI to negatively-toned pictures under passive viewing conditions. However, this effect seemed to disappear when the subjects were instructed to try to maximize their naturally occurring emotional reactions to these same pictures!

The locations of these increased neural responses included several brain regions involved in the generation of basic emotional responses and which have often been shown to be reduced in psychopathic populations. Thus, despite baseline differences from non-psychopaths,  high-psychopathy participants appeared capable of deliberately manifesting emotional responses to the negatively toned pictures within several brain regions believed to underlie emotional processing. 

Of note was that the magnitude of these deliberately evoked emotional responses was comparable to levels exhibited by low-psychopathy participants’ during passive processing.

A high index of suspicion versus an “inability” to correctly read the mental states of others

Quek et. al., “Mentalization in Adolescents with Borderline Personality Disorder.: a Comparison with Health Controls.” Journal of Personality Disorders, 33 (2):145-165, April 2018.

Mentalization refers to an individual’s capacity to understand and interpret the meaning of one’s own and others’ behavior by considering underlying thoughts, feelings, intentions, and desire. As in other studies, this was “measured” in adolescent subjects with borderline personality disorder (BPD) and normal controls while interpreting the mental states of others shown in pictures, videos, and narrative vignettes of people in various social situations.

The authors of this paper mention almost in passing that the ability to mentalize  is thought to develop within the context of, and is dependent on, the quality of infant- parent interactions. In the experiment, the differences between the performance of the BPD subjects compared to the control group on the various tests became much greater when the material they interpreted suggested attachment-related stress or arousal. 

Additionally, the major differences between BPD subjects and controls seemed to primarily involve what the authors describe as hypermentalization (that is, making much more complex inferences than expected about social cues, signs, and mental states) by the BPD subjects, rather than through a loss of detail.

Despite all this, the authors don’t seem to consider the obvious possibility that attachment figures’ influence on their children’s ideas about the social behaviors of others continues unabated long after they are no longer infants.

So let’s do a mental experiment. How might you evaluate the motives of other people if you were to grow up in an family environment characterized by your being constantly invalidated and given highly confusing double messages about how you are supposed to think and behave, and even being verbally abused— if not physically or sexually abused—if you seem to have guessed wrong about that? Do you think you might have a higher index of suspicion about other people’s intentions than someone who did not grow up in that environment? Do you think you might have more difficulty making sense of other people's behavior? Ya think??

So, do kids with BPD grow up in that environment? Well, in addition to Linehan’s theory of an invalidating environment being part of the etiology of BPD, and my own paper from 2005 (Comprehensive Psychiatry, 46[5] pp. 340-352) which showed that adults with BPD reported about three times the number of double messages from their parents than non-BPD controls, consider the following paper.

Changing parent’s behavior towards BPD children can make those with BPD better—but their behavior apparently had nothing to do with their kids having developed the disorder in the first place

Grenyer et. al., “A Randomized Controlled Trial of Group Psychoeducation for Carers of Persons with Borderline Personality Disorder.” Journal of Personality Disorders 33 (2):214-228, April 2018.

As mentioned in a post on my blog on Psychology Today, researchers into BPD have of late developed an interest in the “burdens” on parents and other caretakers (almost always other relatives) of having a child or adult child with the disorder. Such “carers” are the subject of this particular study, and were recruited through flyers distributed to mental health services, local media, patient advocacy groups, and patient family and support networks. The recruits were put into groups and given a lot of “psychoeducation” about their charges.

The first thing that jumped out at me in this paper was the fact that, even though the carers were evaluated for being critical and over-involved with their BPD children, there was nothing mentioned about seeing if the parents had been guilty of physically or sexually abusing their charges when the fledgling BPD patients were children. This, despite the fact that every empirical study done on this subject in BPD patients finds a high level of significant abuse history. Of course, parents who respond to flyers and volunteer to be research subjects in this sort of study are highly unlikely to have been seriously abusive. So right away, the experiments are selecting for a somewhat atypical sample of parents of children with BPD.

The second thing that jumped out at me was that the psychoeducation provided for the subjects was supposedly based on Bowen family therapy theory, when the researchers mentioned and seem to know absolutely nothing about one of the major tenets of that theory. You know, those that involve intergenerational transfer of dysfunctional family patterns. The researchers mention nothing about the parents being somewhat responsible for the development of the disorder in their kids in the first place!

That they seem to make this assumption is even more awe-inspiring when you look at what was being taught to the parents and which apparently led to improvement in the BPD child’s behavior as well as in the parent-child relationship. They were taught to:

1.      Be non-judgmental, validating, attentive and appropriate.
2.      Reduce their reactivity and try to remain calm and “mindful.”
3.      Attend to their own needs through staying connected with friends and family, attending to their own physical and mental health, and taking breaks.
4.      Model appropriate assertiveness and setting appropriate boundaries and ground rules for the relationship.
5.      Get outside help when crises arise and having a crisis plan.

So, if they had to be taught these things, and if doing those things leads to improvements in their children, maybe the fact that they were doing the opposite of those things all the time previous to the experiment was what was creating their child’s problems in the first place. Exactly what you would expect considering the family dynamics of BPD.