Why Are There so Many Different "Schools" of Psychotherapy

 

Head honchos of all the differing schools of thought in psychotherapy met together in 1985.

There are currently hundreds of  different “schools” of psychotherapy, each with their own theories to account for problematic behavioral, relationships, and thought patterns in individuals. Most of them are variations on the six major schools of thought in the field: psychodynamic, cognitive, behavioral, affect-focused, existential, and family systems. Still, they often have completely different ideas about what is important to focus on in psychotherapy, as well as the reasons for their clients' problems.

In 1985, the Milton Erikson Foundation put on the first of several "Evolution of Psychotherapy" Conferences, in which they were somehow able to get all the current head honchos of the various schools (pictured above). I was there and it was impressive to hear them present their ideas and argue with one another. Before I even became an academic and while in private practice, I had done extensive reading and noticed that each of these differing, very complex schools of thought had  valuable things to say about human nature, but that each was riddled with some logical fallacies as well as outright distortions.  I decided to attempt to write a book on what I called a "unified theory," which I somehow managed to get published in 1988.

So why so many schools of thought? In a way, this plethora of theories and methodology is not at all surprising in light of the fact that  psychology is still a relatively young science, and having several theories is typical of new scientific endeavors. In the case of psychology, coming together is particularly difficult because of the sheer number and magnitude of natural processes involved, coupled with the fact that we cannot read minds. When it comes to important phenomena such as domestic violence and child abuse, people lie all the time – not only to others but to themselves as well. They do so out of shame or a desire to protect other family members.

 So-called “empirical” studies in the field are, in a sense, collections of anecdotes: the impression of the researcher coupled with the self report of the individuals being studied. To really know with any certainty what is going on with, say, family interactions , experimenters would have to be able to watch them, over a significant period of time when people were not aware they are being watched. This cannot be done to the extent necessary.

The problems in the field are further made difficult to sort out due to the complex structure of the human brain as well as the sheer number of environmental factors which impinge on it.  The brain has billions of neurons, each with up to about 1000 constantly changing synaptic connections caused by a process called neural plasticity. These connections are further impacted by scores of different genes, which do not determine human behaviors but each making certain behavioral tendencies a little stronger or a little weaker.

Relevant environmental influences probably number in the hundreds and come and go in various and constantly changing combinations and intensities. Then there is the so-called “butterfly effect” in which even small differences in initial conditions lead to major differences later on.

Finally, the complexity of the problems that bring clients to therapy varies widely depending on their specific issues. Some problems are rather straightforward like simple phobias or lack of assertiveness with strangers. Others involved horrendous issues such as a family violence or substance abuse and their ongoing effects. One-size-fits-all interventions such as cataloguing irrational cognitions do not really seem adequate for comprehensive treatment.

Treatment outcome studies have been little help. Generally, all the major treatments come out about the same in terms of efficacy. People in SEPI, a professional group  that looked at these issues, used to jokingly refer to this as the “Dodo Bird” (from Alice in Wonderland) verdict: All have won and all must have prizes. Even then, a significant percentage of subjects do not respond that well, and those that do improve often the improvement does not last for more than a year. When one paradigm is directly compared with another in a study for a given condition, 85% of the time the treatment favored by the person designing the experiment "wins" and outperforms the other treatment. This is most likely to something called the “allegiance effect.” Another issue: sometimes acceptance of an idea in the field is due to the eminence of the experimenter and not due to the actual evidence.

It seems to me that many of these schools of thought assume without real evidence that all the problems of people who are repeatedly self-defeating or self destructive, or who make choices in life that make them unhappy, do so because they are mentally deficient in some way. I have categorized these alleged deficiencies as their being either “mad, bad, or stupid.” That is, insane, evil, or unintelligent.  Non-psychotic clients are usually are none of these things.

Furthermore, as described in a previous post, psychological problems are often seen by practitioners and theoreticians alike as existing only in people’s heads, as if the client’s current social and relationship environment is almost irrelevant.  For example, in studies of the alleged over-reactiveness of people diagnosed with so-called borderline personality disorder, subjects keep diaries of when they have strong emotional reactions – “ecological momentary assessment” – but are not asked to also write down what it is they are reacting to.

In the 1980’s and 1990’s, family systems schools began to address this deficiencies – but then they went to the opposite extreme by viewing clients entirely as pawns of their kin groups with no capacity for critical thinking and independent decision making.

Psychiatry, in the meantime, has swung back and forth between, as L. Eisenberg put it back in 1986, brainlessness (Freudian psychoanalysis, for example) and mindlessness (eugenics in the 1930’s and the over-estimation of biological psychiatry in the present).

There are a few of use who are still trying to put all these various ideas together in some sort of valid and coherent form. Gaining acceptance by the field for these efforts is an uphill battle.

Willpower, Groupthink, and the Disease Model for Everything

Columbine School Shooting, public domain 

When addicts say, "I can quit using any time I want to," people usually laugh at them and accuse them of being "in denial." I, on the other hand, believe they are telling the truth. Since they are admitting they don't want to quit, they aren't denying anything. Of course, the big question is why they don't want to quit. It can't be because the substance is making them feel good. They are generally some of the most miserable and unhappy people around.

So maybe they have some genetic defect that causes a “disease” that impairs their self control? While it is true that genetic tendencies can make someone a bit more or less likely to engage in certain behaviors, the majority of these effects are relatively small. 

If genes were causing the problem, one wonders how 12 Step Programs, which are based on religious conversion techniques that demonize people’s ability to make good choices for themselves and ask people to surrender to group norms and do what they are told, would ever succeed. Last I heard, changing your religion does not lead to major changes in one’s genome. Or its physiological effects.

I suspect the group’s views and where their ideas come from have something to do with the addict’s problems. Before they quit, they are proving the group’s opinions about the evils of willfulness, and after they quit they are proving the group’s belief system once again, but in a different way.

And is it really true that they can’t control their urges? Does an alcoholic actively engaged in drinking and driving usually take a big swig of Jack Daniels just when a cop pulls up in the lane next to them? Well, I suppose some might, but I suspect that such individuals are again going out of their way to prove their group’s idea that their willfulness is creating their problems. But most will keep the bottle hidden. So I guess they can control their urges even while intoxicated with their favorite beverage.

And of course, as I have previously pointed out, animal models of alcoholism are generally poor because scientists can’t seem to find any rats that hide the bottles. And the bottles that people hide are almost always found eventually. Usually  by spouses and family members. Imagine that.

Another point: Non-academic people in the addiction discussion also talk a lot about how co-dependency and enabling spouses and relatives are part of the problem in someone’s addiction (see Al-Anon), but somehow today’s scientists seem to think these other folks have nothing to do with the addict's problems. Really?? In what alternate universe?

I find it impressive how today’s psychology academics seem to go to any extent to avoid looking at dysfunctional family dynamics as a major cause of behavior that is destructive to one’s self or others. For another example, look at speculation about the causes of the recent spike in students committing mass shootings at schools. If the role of the parents is looked at at all, it seems that their only role is giving their kids access to weapons and ignoring danger signs, but not in creating the environment conducive to motivating their children to act that way in the first place.

Now of course having access to assault weapon is a prerequisite for committing these crimes, but what about the literally millions of homes in the United States in which such guns are found? If the presence of guns were the only problem, these shootings would have been going on at the current frequency for the past decades and decades.  For a similar reason, even overt child abuse alone cannot explain the shootings, as the vast majority of abused children do no such things. There has to be other things going on in these families. What, for example, are the parents saying to these kids and to each other, and how are they reacting in general to kids who start to have fantasies of violence? 

One of the Columbine shooters in the above picture literally collected an arsenal of weapons in his house prior to the act. When interviewed by the press, his mother said she didn't know about it. I wonder how the shooter interpreted the fact that his mother apparently pretended to not even notice the obvious.

No one seems to be asking these essential questions. Sad.

Pathological Narcissism and Pathological Altruism: Two Sides of the Same Coin

 

 “A good life balances our own self-interests with other people’s needs…Healthy narcissism is where passion and compassion merge, offering a truly exhilarating life.” ~  Craig Malkin

Balance in life. Lately, that seems like an unknown concept in our black-and-white, all-or-none thinking times. 

In his book, Rethinking Narcissism, Dr. Malkin distinguishes healthy versus unhealthy narcissism, the latter being characterized by the (dictionary) definition of excessive interests in one’s own importance and abilities. (In fact, as a described in a previous post, its base [in Narcissistic Personality Disorder] is often a subconscious sense of inferiority combined with a sense of not being appreciated by others).

On the other hand, caring for others at one’s own expense also has healthy and unhealthy versions. I’ve also written about, using Barbara Oakley’s term, pathological altruism - in which one’s sacrifices not only lead to misery or deprivation for the giver but also backfire and lead to harms for its objects.

Although it’s a bit of an oversimplification, I also illustrated it with something I called the Mother Teresa Paradox: if she’s right and giving to others is life’s greatest reward, then by not allowing others to give anything to her, she is in effect depriving everyone else of what she herself defines as the best life has to offer. 

A common example in our culture is: the whore/Madonna complex, in which even married folks feel they are evil if they enjoy sex too much with one another. Especially women. Men at times and in certain social circles have been allowed to enjoy it with non-spouses, who are nonetheless derided as whores, because of a need by their group for them to have sins to atone for on Sundays.

I believe, and my Unified Therapy psychotherapy paradigm is based on this, is that this sort of craziness is a result of the evolution of individuality out of collectivism over the last three centuries, as described in the marvelous book Escape from Freedom by Eric Fromm. Sometimes it’s best (and was especially in the past) for the survival of our species if under many circumstances we sacrifice ourselves for the tribe. But that has become increasing less necessary and even counterproductive as science and technology have taken center stage. Nonetheless, we are still primed by our genes to do it (due to kin selection), but it is becoming more and more counterproductive. 

Our own family interactions sometimes don’t keep up with changing environmental contingencies, leading to something called cultural lag, which leaves families confused and conflicted over which standards to follow in this regard.

This in turn can lead parents to give destructive mixed messages to their children. We do have the power to use our critical thinking skills to get everything back into a healthy balance, but are often severely invalidated by our own families whenever we try, leading to a horrible sense of not knowing who we are or what we are supposed to do any more (called anomie or groundlessness).

In situations in which a whole family is conflicted over some issue, this is often indicated when people behave compulsively in one extreme way or in the opposite extreme way, or bounce back and forth between the two extremes.

Problems like these have to be discussed if they are to be solved, but people are often too ashamed or defensive to do so. The countermeasure is empathy, which comes from doing research into one’s family background in order to understand why our parents are driving us crazy. How to employ this is described in both my psychotherapy paradigm for self-destructive behavior (which by definition cannot be selfish unless an individual is nearly brainless) and in my self-help book for somewhat more functional families.

It was really impressive when my patients had an “a-ha” moment that led to the reaction of “So THAT’S why they act that way!" It was very liberating for them, although that freedom can still easily be undone by aggressively invalidating family attachment figures. I teach strategies for getting the parents to stop doing that.

If you are in a cycle of self-destructive behavior, such as, say continually going back to an abusive marriage because your parents seem to be blaming you for it (and if you have been going back, it is not “blaming the victim” to say that you bear some responsibility for your own plight), my message to you is to learn about this stuff and how it has affected you personally and your family, and to take charge.

Bad Child Psychology in Schools – How to Make Kids Feel like a Big Burden to Resentful Parents

 

Why aren’t many kids seemingly growing up as maturely as they used to any more? Why are mental health problems and suicidal ideation as well as actually suicides increasing? Why are more and more children losing self confidence and feeling defective? 

In a new book by Abigail Shrier, Bad Therapy: Why the Kids Aren’t Growing up, the author blames the mental health establishment. So does the parenting guru I’ve been reading for years, John Rosemond. And psychologists are indeed a big part of the problem. But both miss an important aspect of the phenomenon.

 

The definition of “traumatized” in children has been expanded beyond all recognition by the profession. In the mental health field, consideration of the effects of adverse childhood experiences have gone back and forth from one extreme to the other: the serious ones at times are almost completely ignored. At other times child abuse was thought to be everywhere. And now trauma is seen as almost any occurrence that makes a kid in the least bit unhappy or stressed. 

I described what has been going on at the college level in my review of the book, The Coddling of the American Mind, with students' reactions to “microaggressions,” and political incorrectnesss being equated with PTSD caused by a terrifying combat experience. 

Nowadays, according to Shrier, kids are seen as being unable to put aside even hurt feelings in order to concentrate on the school work in front of them. Resilience is now seen as “accepting” these “traumas” rather than dealing with them in a potent manner. Personal agency has seemed to have “snuck out the back door.”

 

And 40% of the current, rising generation has received psych treatment versus 26% of gen-X’ers when they were younger. More and more phony psych diagnoses are put on kids, often at the suggestion of teachers. More and more children are afraid to be wrong in school laboratories or to test new ideas for fear of making a mistake. Bullies are being suspended less and less frequently for fear of damaging their self esteem. American children are more likely than others to exaggerate all kinds of risks.

 

For those mental health professionals who do recognize all this as a problem, the usual explanation for why it is happening is that when parents and teachers over-protect and over-pathologize their children, they are preventing them from learning social skills which, it is believed, cannot be “taught” in most cases but must be learned through trial and error. 

If a parent always steps in, or even when parents don’t let their children go out to play or walk to school because they believe that something bad will happen to them, the kids are said to never get the chance to learn those things. As the author also points out, sometimes feeling mildly to moderately anxious or moody can be a good thing since it can motivate kids to evaluate their situation and lead them to take action.

 

Now don’t get me wrong. There is much truth to these assertions. What’s missing, however, is the way this sort of treatment by parents and teachers is interpreted by the children themselves. The children start to see themselves as a big burden to their over-anxious, worrying parents. Not only that, but the parents seem angry about it. I believe that if a child feels like too big a burden to their parents, they may start to think their parents would be better off without them. This could increase their risk of suicide.

 

Why? Because, as I have been arguing for years, children are willing to sacrifice their own best interests in order to stabilize their parents. This is due to the evolutionary force called kin selection. It is not just that kids don’t experiment with new behavior in order to figure out how to, say, respond to a bully. Hell, there are TV shows, YouTube channels, and many other sources for suggestions that they could try out at school. But as long as they feel the need to let their parents take care of them, they are not motivated to become independent. "Enabling" parents lead to co-dependent children.

 

Schrier does allude to this aspect of the process involved here, but it is not clear to me that she truly appreciates the extent of the issue. She does say that kids often feel responsible for their parents, and may feel like a “constant burden to their stricken parents.” She also says that there is nothing scarier to them than parents “overmatched and afraid.” She has also noticed that people who make parenting look exhausting do not seem all that fond of the kids they raised. If an untrained observer like the author can see this, then guess what? So can the children. And they will be induced to make any necessary sacrifice.

Intergenerational Transfer of Trauma: The Unrecognized but Essential Mechanism

In my last post about the internal family systems therapy model, I discussed how some newer models (ones that come close to my own) seem to completely ignore the ongoing nature of repetitive dysfunctional family behavior even after the children grow up. Or as the book It Didn't Start with You by Mark Wolynn sometimes does, what happens with an adult child’s interactions with parents in the present.

I have championed the idea of the intergenerational transfer of dysfunctional family “rules” that are due to a previous group or individual trauma. I am very happy to report that this subject seems to finally be getting the attention it deserves. In my very first book, originally released way back in 1988, I proposed very specific mechanisms through which this occurs. 

While there is a genetic component to this such as changes in the body's stress response reactions (e.g., release of cortisol), why do we think these have to be permanent? If they were, then treatment or therapy would do precious little.

Perhaps the reason they do not change is that they are continually reinforced in the present. Neural plasticity tells us that brain circuits are strengthened or weakened depending on how much stimulation they get, and relevant interactions with parents do not stop at age 18, or even at age 3-5 as  some analysts used to think. Especially since the circuits are created and then reinforced (or not reinforced) by attachment interactions in the first place.

The subtitle of the book under review here is How Inherited Family Trauma Shapes Who We Are and How to End the Cycle. The author mentions that in many many cases traumatized parents and grandparents avoid talking about what happened to them, mostly out of shame. I completely agree. However, that does not mean that there is nothing that can be communicated through a variety of other behaviors in ongoing interactions.

Wolynn gets ever so close to understanding what’s going on, but is IMO missing the continuous drama. When he notices that sometimes parents have not discussed the trauma, he in fact does wonder how then the trauma might be passed down. He over-emphasizes genetics.

It is true that if a mother were traumatized, that can affect how she interacts with a kid, which can itself be traumatizing. This can lead to epigenetic changes (genes being turned off and on) in the child that affects their reactivity and perhaps their proneness to certain medical and psychiatric disorders. But that’s as far as it goes. He mentions that epigenetic changes occur mostly through a chemical process called methylation, but seems to think they are not reversible. If a gene that regulates other genes can be methylated, it can be unmethylated.

He gives an example of a boy named Jessie who at the age of 19 suddenly developed severe insomnia accompanied by freezing, shivering and an inability to keep warm. He had no major problems sleeping before this. He had to drop out of college because of these symptoms. Doctors could find nothing wrong. Jessie later revealed to Schwartz that he had only recently became aware of the fact than an uncle he never knew he had froze to death – at the age of 19. 

So does this mean that this was some sort of genetic effect? Even the author seemed bit skeptical. Let’s face it: genes do not and cannot contain specific memories like dates when traumas occur. Maybe the father, whose brother it was, started acting strangely in some way when his son reached that age.

Wolynn also falls for an aspect of the heritability fraud when he agrees that all children grow up in the same family, so this must be a “shared” environment. But somehow he is also aware of the Murray Bowenesque understanding that parents can relate to each of their children much differently than to the others for a variety of reasons. This is especially common in so-called dysfunctional families.

Not to mention the fact that siblings can all be affected by the family trauma in very different ways despite the specific nature of the mother’s traumas and any resultant internal conflicts. And some of children may not affected much at all. He never addresses the clear contradiction in these ideas. What distinguishes those who do from those who don’t? Are their genomes that different? 

Another thing that Wolynn does not seem to be aware of is similar to the lack of understanding by Richard Schwartz in internal family systems therapy that I described in my last post. He does not quite seem to get that a lot of the people he writes about are not protecting themselves, but are in fact self-destructive. The case of “Elizabeth” on page 205 illustrates this clearly. According to the author, she felt rejected by her mother and so feared that everyone else was going to reject her. She would then feel left out and all alone.

But her response to this? Isolating herself. Left out and all alone. The very thing she claimed to fear! At her job she almost completely separated herself from co-workers and would barely talk to anyone all day.  She was not described as being anywhere near stupid enough to not see the rather obvious results of what she was doing.

In this case as a therapist, I would ask a modified version of the Adlerian question to find out who she was sacrificing herself for: If I had a magic wand and could make you accepted and popular, and prevented you from screwing that up, who might be negatively affected?

 

Internal Family Systems and Marital Therapy

 

As most of my readers know, I believe in a family systems view of the way patients who are repetitively self-destructive or self-sabotaging are acting. I do not think it’s “all in their heads,” but that it serves some sort of purpose for the members of their families as a whole. 

Furthermore, this is ongoing and continues to take place in the present, not only when they may have been initially traumatized as children. The family continues to interact over the trauma, because most people continue to have relationships with their parents. If they don’t seem to, it’s often because they are communicating through third parties. In this and the following post, I’m going to illustrate how the field does not take this into account, even when they look at systems issues.

I have also been writing about how the psychotherapy profession has seemingly given up on family systems theory, except for some masters level family therapists, because of a variety of social factors. Some readers may argue with me about that because of the growing popularity of Richard Schwartz’s Internal Family Systems Therapy. I really had not read much about it because I always wondered why he was dealing with internal models of the family system and not the actual living family members. Sort of like Schema Therapy or working on one’s “inner child.”

I finally got around to reading a book he wrote for lay readers in 2008 called You Are the One You’ve Been Waiting For. Although I think the kind of treatment described therein can indeed be helpful in many situations in which interactions with one’s parents are not too complicated, I do not think it would have helped most of my patients with severe personality disorders.

And even in cases in which it does work, IMO it would be even more effective if it paid attention to some other factors which the author seems completely unaware of, as illustrated by an extensive case example he wrote concerning a narcissistic doctor he names “Kevin” and his wife “Helen,” who was described as a bright woman with a career of her own. I will talk about this case in a moment.

One thing about the IFS model that I’m not enamored with is his descriptions of peoples’ personality “parts” — protectors, controllers, exiles, critics and tor-mentors. I would like to believe he is speaking metaphorically, but he seems to be following along with the tradition (in my opinion inaccurate) of dividing up a personality into little beings running around inside someone’s head with thoughts, desires, and feelings all their own – not unlike the animated characters inside a girl’s head in the Inside Out movies. Just like the psychoanalysts used to refer to id, ego, and superego as if they were parts of the brain. I find the concept of a “false self” to be much more useful.

A bigger problem is that he sees the problematic behavior of people as trying to protect themselves from reliving past hurts. He says they scan the environment looking for threats and run away at the slightest hint of one. 

That wasn’t at all what I saw in my patients. 

People who couple off with people in a dysfunctional relationship were not only not looking for red flags, they were actively ignoring them! If anything, they seem to be attracted to certain dangers, like a woman from an alcoholic family who marries one alcoholic after another.

I see them as protecting their parents and the ongoing systems dynamics, not themselves per se. I fail to see how being self-destructive can be selfish, unless someone is unbelievably unintelligent. I will give a possible explanation of Kevin’s and Helen’s behavior in that case, consistent with this idea, so back to that.

According to the author, for thirty years Helen had put up with Kevin’s “carping about her taste in clothes, her child rearing, her political opinions, her education, her intelligence, and her logic.” He frequently dissed her in public. She also was said to hate his long work hours and felt neglected. And now she suddenly said if he didn’t straighten up and fly right, she was outta there.

Wait…she put up with this behavior for thirty years before the ultimatum? Why so long? And how did Kevin interpret her staying despite the fact that he must have repeatedly heard many of her complaints during that period. The author attributes Helen’s sudden attack of courage to their youngest child graduating high school, but many people with kids still at home get divorced. 

Furthermore, the book does not mention any ongoing interactions during the marriage with parents and in-laws, despite the fact that he attributes Keven’s behavior to his parent’s behavior towards him when he was a kid. Did the parents just evaporate? Did Helen possibly get brave because they - or her own parents -  died? We don’t know.

According to the book, Kevin’s father left his mother when he was seven, after a fight between them in which the dad hit his mom. The Dad remarried and never saw Kevin again. Mom then went on to have a series of problematic relationships. Sometimes, she seemed to not want to have Kevin around. Kevin handled this by throwing himself into academic and professional success and becoming fiercely independent. I believe this was meant to demonstrate to his mother that he did not “need” her or anyone else. 

After some individual and couples counseling with the very empathic Doctor Schwartz, and when he is starting to get in better touch with himself, Kevin remembers blaming his mother for his dad’s leaving and making her cry just after the breakup when he was seven. He says the “little boy” inside him would rather die than upset her again.”  That sounds like, in his mind at least, he is protecting her - not himself - and feels guilty about what he did.

What I would hypothesize is that the mother indeed felt very guilty about the Dad leaving her and how it affected Kevin, and was blaming herself. This is why she became uncomfortable when he was around and seemed to prefer he be gone and be independent of her “bad” (in her view) influence on him. So he tried to make her feel less guilty by being successful without any need of her. And later maybe displaced the anger he felt towards his mother onto Helen (while displacing his anger at his abandoning father onto his co-workers). 

So perhaps Helen’s “job” was to stabilize him by allowing him to do this displacing. Her initial attraction to him was probably due to something similar to this dynamic going on in her own family.

When he got better, he was able to be more empathic with his mother’s behavior because he realized she felt she did not really deserve any love. I agree that understanding a parent’s problematic behavior helps people feel better about themselves – and about the parents. But of course this aspect of her mother’s behavior just kicks the question of the reason for all this back another generation. Why was she like that?

Schwartz comes quite close to understanding of the dialectical way dysfunctional couples interact, with each enabling the false self of the other and punishing any evidence of each's own true self. Each denies that they need this help themselves even as they give it to the other. They have motives for doing so that have to do with stabilizing their parents, but they also hate that they have to be like this. They are ambivalent. So they also complain about it. Mixed messages!

Schwartz gets away from these ideas by instead thinking that "vicious circles" of interactions are present- just as systems therapists also suppose. But then he also calls it a dance. In a dance one member of the couple may be leading, but simultaneously, the other is closely following. If either fails to do their part, there is no dance.

Once a couple gets in touch with these patterns, however they do it, this means that there is another issue (apart from ongoing interactions with living parents) that arises that may further greatly complicate making changes. Even if, say, the wife is ambivalent about her role, she has thought all along that her husband wanted and needed her to perform it. So if he suddenly says he no longer wants this without acknowledging his ambivalence, at first she won’t believe him. 

But if he somehow convinces her he is sincere, the wife is still prone to think to herself, “Hey wait. I have been sacrificing for him for all this time, and only now he tells me that he did not want me to! And he no longer wants to enable me?” She feels betrayed. This of course also comes out as a double message as her true self really wants the change too. Schwartz talks about members of the couple being triggered by the other, but misses this very important reason why.

 

New Podcast: Unmasking Overprotective Parenting

Unmasking Overprotective Parenting

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

Psych Meds: Under-prescribing Benzodiazepines and Over-prescribing Anti-Psychotics

 

Wikimedia Commons: Various Pills, Unknown author, Creative Commons Attribution-Share Alike 3.0

I often write about the misuse of psychiatric drugs (and disease mongering by big Pharma). Recently, two journal articles have been published that are in line with what I’ve been saying. (Caveat: I want to make it clear that I am not against the use of psychiatric drugs, which can be very useful and effective when prescribed properly to the right patients).

One of my pet peeves has been the demonization in the psychiatric literature of a class of drugs called benzodiazepines. Probably because they are cheap as well as effective. This includes drugs like Valium, Librium, clonazepam and Xanax. They are used for sleep and anxiety disorders. Whenever they are referred to in the psychiatric press, references to the names are almost always immediately followed by the phrase, “but of course they are addictive.” 

In contrast, references to other drugs, say anti-psychotic meds, are never accompanied by the words, “but of course they can cause diabetes and chronic movement disorders." Nor is any such statement attached to references to a far more often-abused class of drugs: stimulants like Adderall.

Even more strangely, this statement is also usually NOT applied to the references to the so-called “Z-drugs” like Ambien and Lunesta (which are newer and more lucrative for pharma), even though they work in almost exactly the same way as benzos and are just as addictive.

Benzo’s are highly effective for the treatment of short-term insomnia and anxiety, and particularly for the highly disabling panic disorder when it does not respond to an antidepressant alone. While benzo’s certainly can be abused, most of the time they are not. They are listed by the FDA as Schedule 4, which means low abuse potential. Adderall is Schedule 2, meaning a high potential for abuse.

So is benzo addiction really a big problem, especially now that doctors can see if their patients have been getting them from more than one provider? (With the exception of the most addictive benzo – Xanax - there is also no big street market for them). In general, shorter acting drugs are more addictive than longer acting ones, since withdrawal symptoms come much more quickly. 

A new, huge study in Denmark has been published that is consistent with my experience (Rosenquist, T.W. et. al., “Long-Term Use  of Benzodiazepines and Benzodiazepine-Related Drugs: A Register Based Danish Cohort Study.” American Journal of Psychiatry 181.3, March 2024).  It found that only 15% of users stayed on the drugs for over a year, and only 3% for more than 7 years. The median dose stayed rather stable in this population. Long term use of Z drugs was on average higher than with those on a benzo. Patients escalating their intake to higher than prescribed doses was uncommon and was found mostly in people that abused other drugs.

An accompanying editorial in the American Journal of Psychiatry points out that conditions like dementia, drug abuse, and other chronic illnesses often cause bad outcomes, not the treatment itself. As to overdoses, with benzo's they almost are never fatal unless the drugs are combined with opiates (on which one can overdose all by themselves).

When it comes to the overuse of antipsychotics, adding them to an antidepressant in “treatment resistant depression” is widely discussed in the psychiatric press - no doubt because many mental health consultants work for Pharmaceutical companies. 

Now don’t get me wrong, these medications definitely can work in this capacity – I had luck adding Abilify to an antidepressant. (As soon as that drug went generic, the exact same TV ads for depression using a replacement brand-named drug named Rexulti started. The two drugs are nearly identical [what does that tell you?)]. 

The issues are: 1. Using two drugs when one will suffice, and 2. The potential severe side effects of anti-psychotics (especially diabetes and a chronic movement disorder called tardive dyskinesia). There are safer “augmentation” drugs like lithium to try first.

I’ve discussed in a previous post one big reason why depression is labeled "treatment resistant" when it may not be: the conflation of major depression with chronic unhappiness. The latter almost never responds to an antidepressant (not counting the times when it acts like a sedative and is only effective due to that side effect). 

Also, you can be chronically unhappy before a major depressive episode even starts and that is your baseline. If you end up at your baseline, then the antidepressant did work! In that case, the next step should be psychotherapy, not more meds.

These issues tie in with an idea discussed by H. Paul Putman III M.D. in the April 2024 issues of Psychiatric News. He points out that much of what is labeled “treatment resistance” is actually a treatment impasse, meaning the doctors have not done everything they needed to do with the antidepressant or ruled out other causes for the symptoms. They have perhaps not slowly raised the dose until the maximum, or if this becomes precluded by side effects, then trying the same strategy with a second antidepressant and then a third. 

Medical causes such as endocrine disorders have not been ruled out. Maybe there was a rupture in the alliance between the patient and the doctor. Or the patient has not been taking the prescribed antidepressant at full dose all along - or not taking it at all. Interactions with other medications have not been evaluated. Co-occurring psychiatric disorders that are complicating treatment have not been considered.

Putman says the term “difficult to treat” should be substituted for “treatment resistant.” But then Pharma might not make as much money.

 

Private Equity, Greed, and the Deterioration of Medical Care in the United States

Wikimedia Commons: 16th Annual Global Private Equity Conference

by Empea1077, C. C. Attribution-Share Alike 4.0

                                    Wikimedia Commons: 16th Annual Global Private Equity Conference     

 

This post discusses highly troublesome recent developments in the practice of medicine, including in psychiatry. So-called private equity firms have been buying up businesses, streamlining them by cutting staff and making employees work longer hours, loading them up with debt, and stripping out their assets. And then they sell them off at a big profit. They take the money and run, often leaving a hollowed-out shell of a company behind. At present in the United States, they have been buying up medical practices and hospitals at an alarming rate. Are your doctors spending less and less time with you and discharging you form hospital stays prematurely? This may be the reason.

In one recent example from April, financially-strapped Steward Health Care sold its nationwide physician practice to UnitedHealth Group subsidiary Optum. In the wake of this, a U.S. Senate subcommittee met in Boston to address ongoing concerns that the corporatization of healthcare is putting patients and providers at risk. Private equity companies across the country were said to be quietly making profits while infiltrating everything from fertility care to hospice care.

In the case of Steward, the roots of this date back to 2010, when the private equity firm Cerberus Capital Management agreed to acquire the financially struggling non-profit Caritas Christi health system in Massachusetts for more than $800 million. That company now operates more than 30 hospitals as the country's largest private for-profit hospital chain, but Cerberus has been selling off its stake in Steward, leaving the chain saddled with large financial liabilities that are causing future hospital shutdowns.

While screwing over an already struggling hospital system, executives were reaping profits. According to the Wall Street Journal, as the Steward ship was sinking, the CEO bought a $40M yacht!

Ellana Stinson, an emergency medicine physician at Boston Medical Center and president of the New England Medical Association, testified that, "Practicing medicine in PE [private equity]-led places is no longer about patient safety or quality, but about making medical decisions and judgements due to corporate decision-making with profit motives at the expense of patients." Many buyouts are of hospitals and other facilities that are already struggling and may have higher Medicaid and Medicare populations.

Stinson pointed to the more than 550 emergency residency positions that notably went unfilled  in last year's Match cycle as representative of ongoing concerns about this issue. "A profession once competitive when I first began my medical journey is now one of the least competitive fields to enter as students bear witness to the destruction of the profession," she said.

These firms also like to force doctors to spend inordinate amounts of time filling out useless forms on electronic medical records. In a study conducted by Wakefield Research, “An overwhelming 94% of respondents expressed that the absence of user-friendly insights negatively affects patient care, resulting in several harmful consequences,” including “delayed treatment initiation (53%), prolonged hospital stays (52%), and incorrect treatment plans (47%).”

These trends are clearly having major adverse effects on patients. After private equity acquisition, medical centers have exhibited an increase in hospital-acquired adverse events, despite a shift to a lower-risk case mix, as shown by a study of Medicare data. Admission at a private equity hospital was associated with a 25.4% greater risk of hospital-acquired conditions compared with treatment at a non-private equity hospital. Driving the difference were more falls and central line-associated bloodstream infections along with a doubling in surgical site infections, despite fewer central lines placed and a younger and less dually (Medicare/Medicaid) eligible population compared with the controls.

On the psychiatry side, over-medicating patients and under-training staff, as well as rampant falsification of patient records, plagued a North Carolina psychiatric hospital, according to an ongoing series of reports from North Carolina Health News. More than a dozen former employees of Brynn Marr Hospital in Jacksonville, North Carolina described a chaotic and violent environment dangerous for both patients and staff, according to the reports. Sexual violence and rape was a recurrent issue; police reportedly responded to 129 calls for alleged sexual assault and rape at the hospital from January 2019 to September 2023. Other hospitals owned by the same parent company as Brynn Marr, Universal Health Services, have reported similar issues.

 

Another example: Kohlberg Kravis Roberts is an investment company founded in 1976. Recently, KKR acquired hundreds of facilities for people with disabilities, which, under the new ownership, led to conditions in which residents were “consigned to live in squalor, denied basic medical care, or all but abandoned,” according to reportage from Buzzfeed.

Research also suggests  that PE acquisitions are associated with price increases in 8 of 10 specialties, and that these price increases are particularly high in metropolitan areas in which a single PE firm controls more than 30% of the market.”

 

 

 

Book Review: Breaking Free by Rachel Jeffs

In writing about groupthink, I’ve become aware of how amazingly powerful it is. The best illustration of that is people in cults – they are willing to destroy themselves when the group or its leader demands it. In the worst cults, members separate themselves from all other sources of information like books, media, or the internet that stand any chance of getting them to stop believing whatever their dear leader wants them to believe. Anyone can readily see how insane some of their ideas are, yet they all profess to believe them, well, religiously.

And they'll do almost anything they are told. Would you let a child of yours writhe in pain from a broken bone for a week because your leader didn't want them to be exposed to doctors except as a last resort? In the book reviewed here, that's one of the things that would happen.

In this book, the cult is the Fundamentalist Later Day Saints (FLDS) under Warren Jeffs. It was written by one of Warren Jeff’s older daughters, Rachel, who somehow managed to eventually escape and re-establish some sanity.

FLDS was a polygamous offshoot of the Jehovah’s Witnesses. Jeffs ended up with 78 wives and 53 children. Some of these wives had been previously married to Jeff’s own father before his father's death. Jeff described himself as God’s “prophet” who spoke directly with the supreme being. Despite demanding a puritanical ideology from his followers, he married girls as young as 14 or maybe even younger, and had them commit lesbian sex acts in front of him. He also molested at least two of his own prepubescent daughters, though he managed to get them to keep it a secret. He had six wives at the time.

Many of the rules he insisted his cult members follow were arbitrary, and were all "directed by God," who nonetheless changed His mind from time to time. Jeffs demanded strict obedience and hard work from everyone. Males often did not get paid for their work. And yet everyone almost always followed his instructions to the letter, no matter how crazy they became. Jeff would then offer them “blessings” from the “Heavenly Father.”

Men and women who hardly knew one another were assigned marriages. The “sister wives” — some of whom actually were real sisters and half-sisters — were supposed to get along and not be jealous of one another. But of course they couldn't help themselves.  Again, when it came to actual behavior, they always did what they were told to do. Husbands would often play one of them off against the others by showing favoritism as to which of them he would spend the night with.

Even though Rachel finally managed to escape and start to think for herself, in the book she still seems to indicate that many times she still fears she that is displeasing God.  In the book, this thought  seemed mixed with the horror of never seeing many of her family members ever again, which I think is the real fear. Her five children are never going to be able to see their father, who is still in the cult, ever again.

You can sense that all along she sort of knew her father couldn’t really be talking to God, yet still told herself he was and that therefore her soul was in danger. She knew all too well what happened to members who left or were thrown out of the group, but often thought the source of her conflicted ideas was her own sinfulness. 

It took her father telling others that God had told him that she had engaged in behavior that she knew she had not done. God, after all, wouldn’t lie like that. But as mentioned, at times she felt that a newly-found desire to leave her church was “the most wicked thing possible.” "Flirting with Damnation" is the title of one of the chapters in the book. At times, her real fear of being cut off almost seems to metamorphize into the religious one.

The cult was based primarily in a town called Short Creek, which straddles the border between Utah and Arizona. They had been pursued by the law there in the distant past for their polygamy, but had returned when the heat was off, so to speak. There was also an offshoot of the cult in British Columbia Canada. Young girls were often trafficked from one of these locations to another, often by their own fathers, so the men could marry them.

The cult had been left alone by the government for about 50 years, but in 2003 the state of Utah started to arrest and prosecute cult members for both underage sex and polygamy. Warren Jeffs knew he would be a target, so he started establishing colonies in which to hide in other states. As he moved around, and especially later after he was arrested and given a life sentence, he started to issue more and more strange instructions from God and “corrections” for certain cult members. From jail. More and more normal activities were said to be forbidden – having fun was almost illegal.

Everyone continued to follow him as he issued “corrections” to those who he deemed “unworthy.” They did so after his corrections became more and more heinous. He would send some members, usually males but sometimes females, away. And their children could never see them again. Rachel had been prevented from attending her own mother’s funeral. He moved people from one of his “refuges” to another, and sometimes punished them by putting them with a kind of solitary confinement, with very little food, for a month or two. There were many more horrible pronouncements I won’t describe here.

The level of willful self-destructiveness of people in a cult such as this is almost beyond comprehension. I finished the book wanting to hear more about how she handled the conflicted feelings she surely had after she left and was separated from everything she knew growing up.