Words Do Matter in Psychiatry

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

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

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

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

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

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

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

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

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

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

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

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

Invalidating Therapists Act Like Job's Counselors

Recently I heard a story about a man who made a choice regarding his career that was at odds with family expectations. He was roundly criticized by his father, some of his siblings, as well as an uncle.

Much later, when the man started having financial problems, these relatives told him immediately that this was all his fault. According to them, his financial woes just had to be because of the career decision he had made.

This is an example of what I refer to as clustering - family members ganging up on one of the members for breaking a family rule, and pressuring him or her to tow the party line.

In an analogous fashion, some therapists inadvertently feed into a patient's problems rather than help remedy them, and in the process invalidate their own patients. Before getting to that, however, I wanted to mention that the man in question likened his relatives to "Job's Counselors." I of course had heard the story of Job, but I had never heard about that part.

As most readers will know, the Book of Job in the Bible describes the tale of a pious and righteous man named Job, who had considerable wealth as well as wonderful sons and daughters. In heaven, God asks Satan for his opinion of Job's piety. Satan answers that Job is pious only because God has blessed him; if God were to take away everything that Job had, then he would surely curse God.

God then gives Satan permission to take Job's wealth and kill all of his children and servants. Still, Job continues to praise God. Then, God allows Satan to afflict his body with boils; still he remains pious.

Three of Job's friends became known as "Job's Counselors:"  Eliphaz, Bildad, and Zophar. The friends tell Job that his suffering simply must be a punishment for sin, for God causes no one to suffer innocently. This of course, is the exact opposite of the truth as laid down in the story.

So how does this relate to therapists inadvertently invalidating their patients? Well, many therapists focus on alleged defects in their patients and work on such things as "anger management," "distress tolerance skills," or fixing the patient's defective "mentalization" (the ability to accurately assess the intentions of other people). 

These sorts of interventions presume that if someone is upset, angry, or unhappy with the way the world is treating them, then therefore there must be something wrong with them. Even when they are in fact being abused horribly!

Now, in defense of therapists who received reductionistic training, it is true that patients often act as if there is something wrong with them in these sorts of areas. However, as I have discussed in previous posts, there is a big difference in patients' public performance at a task as opposed to what they are capable of doing.

Often the alleged defects are in reality part of one of the dysfunctional family roles frequently described in this blog. People who are exclusively trained in CBT do not know about —or if they do they do not accept—the concept of a persona or false self. CBT made a name for itself by attacking psychoanalysis, its predecessor as the predominant form of therapy, and rejected all of its concepts regardless of whether they were right or wrong.

Researchers in personality disorders routinely make this same logical error all the time in studies. They look at the subjects' reactions without looking at all at what they are reacting to! It is a bit like watching a movie in which all but one of the characters - both their behavior and their verbalizations - are redacted so that the viewer can only see what one character is doing and saying, apparently in a vacuum. And then asking the viewer to guess why the one remaining character talks and acts the way he does.

An excellent example of precisely this appeared in the February 2016 issue of the Journal of Personality Disorders - a study called "Using Negative Emotions to Trace the Experience of Borderline Personality Pathology" by M. Law and others. Research subjects were asked to record their emotions (especially irritability, anger, shame and guilt) five times a day for two weeks, but not the environmental triggers which seemed to create these feelings. 

The authors came to the shocking conclusion that the subject's BPD symptoms and their negative emotions were intricately related. No sh*t, Sherlock.

Wouldn't it have been just a little more informative to have gotten data that would help us understand what sorts of situations were most likely to trigger both the negative emotions and the symptoms of people with borderline traits? Ya think?

Mindfulness or Mindlessness?

“God grant me the serenity
to accept the things I cannot change;
the courage to change the things I can;
and the wisdom to know the difference” ~ The Serenity Prayer

The latest fad in both psychotherapy and self help is “mindfulness.” Mindfulness, which is derived from Zen Buddhism and first made popular in psychotherapy by Marsha Linehan (founder of Dialectical Behavior Therapy [DBT] for borderline personality disorder [BPD]) and others, is basically a set of skills that one can use to better tolerate and cope with emotional distress.

Fads in psychotherapy are nothing new. For a while there seemed to be a new one every few weeks, from "neurolinguistic programing" to "solution-focused therapy." 

Even therapists who swear by the gods of empirical correctness that the techniques of Cognitive Behavior Therapy (CBT) - of which DBT is a variant - are so much more powerful than any other known therapy interventions are subject to fads just like anyone else. Besides mindfulness, there is  another current one, "Acceptance and Commitment Therapy (ACT)," which seems to all boil down to telling people that they "don't have to believe everything they think" in a variety of different ways. 

If CBT techniques are so darned powerful, why would practitioners need to keep discarding the old ones and coming up with replacements? Very amusing.

Anyways, getting back to mindfulness, Gregory J. Johanson, Ph.D. discusses it thusly: 

“For clinical purposes, mindfulness can be considered a distinct state of consciousness distinguished from the ordinary consciousness of everyday living (Johanson & Kurtz, 1991).  In general, a mindful state of consciousness is characterized by awareness turned inward toward present felt experience.  It is passive, though alert, open, curious, and exploratory.  It seeks to simply be aware of what is, as opposed to attempting to do or confirm anything. 

Thus, it is an expression of non-doing, or non-efforting where one self-consciously suspends agendas, judgments, and normal-common understandings.  In so doing, one can easily lose track of space and time, like a child at play who becomes totally engaged in the activity before her.  In addition to the passive capacity to simply witness experience as it unfolds, a mindful state of consciousness may also manifest essential qualities such as compassion and acceptance, highlighted by Almaas, R. Schwartz and others; qualities that can be positively brought to bear on what comes into awareness.

These characteristics contrast with ordinary consciousness, appropriate for much life in the everyday world, where attention is actively directed outward, in regular space and time, normally in the service of some agenda or task, most often ruled by habitual response patterns, and where one by and large has an investment in one’s theories and actions.

Mindfulness was even featured as a cover story on a recent issue of Time Magazine, pictured above. It often incorporates another concept pioneered by Marsha Linehan, radical acceptance. Radical acceptance means completely and totally accepting the reality of your own life. You stop fighting this reality and learn to tolerate it and go with the flow, so to speak. 

Practicing mindfulness techniques can indeed help you to stay calm when things are going badly without resorting to a tranquilizer or booze, although in a sense it accomplishes much the same thing. So therapists like to teach these skills to get their highly reactive, chronically upset, or emotionally unstable patients to calm down and not resort to acting out, such as cutting oneself or other self-destructive or self-defeating acts.

So, is there anything wrong with that?  Well, no, not intrinsically.  Certainly remaining calm and not going off the deep end in the face of adversity is a very useful skill.  Some people prefer learning skills to accomplish this over taking medication or having a stiff drink, although there’s nothing wrong with temporarily taking medications to keep calm either. 

But I started this post with the serenity prayer for a reason. Mindfulness is relevant to the first part of of the prayer – accepting things that one cannot change. What about changing things that need changing? Where does the wisdom to know which things can be changed and which cannot come from, and how does one go about changing them?

People feel emotional pain for the same reason they feel physical pain – it is a signal to the person that something in the environment is wrong and needs attention.  A metaphor I’ve used before:  What if another person is walking behind you continually stabbing you in the shoulder with a pen knife.  If I am a doctor, I can give you an opiate so you don’t feel the pain, and you can go on with your life.  But would it not be much better to get the guy with the knife to stop stabbing you?

Most of the non-psychotic people in therapy who are highly reactive, upset and emotional, and who are not in the midst of an episode of a major affective disorder, are reacting predominantly to the environment. Specifically, the social environment. Even more specifically, as anyone who reads this blog should know by now, the family social environment. Biological psychiatrists and some cognitive behavioral therapists seem to think that it’s all going on inside a patient’s head and has nothing to do with other people.  Bull.

Marsha Linehan herself acknowledges this.  In her Skills Manual for Treating Borderline Personality Disorder, she lists the following goals of the "skills training" portion of DBT treatment.

Goals of Skills Training: To learn and refine skills in changing behavioral, emotional, and thinking patterns associated with problems in living, that is, those causing misery and distress.

Specific Goals of Skills Training:

Behaviors to decrease:

1.      Interpersonal chaos

2.      Labile emotions, moods

3.      Impulsiveness

4.      Confusion about self, cognitive dysregulation

Behaviors to Increase:

1.      Interpersonal effectiveness skills

2.      Emotion regulation skills

3.      Distress tolerance skills

4.      Core Mindfulness skills

Notice that she talks about becoming more effective in dealing with the interpersonal environment before she even gets to her distress tolerance skills - numbers 2, 3, and 4.

Unfortunately, in practice, dealing with specific dysfunctional family interactions is one of the last things many DBT therapists get to, if they get to them at all. Marsha Linehan believes – with precious little of her beloved “empirical” evidence by the way - that the reactivity of patients with borderline personality disorder is both biologically innate AND caused by an “invalidating environment.”  As I pointed out in an earlier post, the invalidating environment is not described well or very specifically - although it seems to be the patient's family of origin - nor is there anything written about what makes family members act that way.

The Skills Training Manual is 180 pages long, including a section containing handouts that starts on page 105 and goes to the end.  Of the first 104 pages, only 14 are devoted to interpersonal effectiveness skills, and most of that strongly implies that the interpersonal problems experienced by someone with BPD are due to their own skill deficits rather than the fact that they are dealing with people who are difficult (if not nearly impossible) or frankly abusive or distancing.  Blaming the victim.

In the handout section, interpersonal effectiveness skills are only addressed from pages 115-133. The rest is all about emotional regulation. Almost all of the skills described in the interpersonal skills section are basic assertiveness skills or are descriptions of “myths” about interpersonal effectiveness such as “I can’t stand it when someone gets upset with me.”  Is that really the worst thing that can happen in a family?

Listing "myths" in a way that classifies them as some of cognitive therapy's irrational beliefs means that the problem is being thought of as a flaw that exists squarely in the mind of thinker. Paradoxically, telling a person with BPD that their thinking is skewed is incredibly invalidating!

Besides, when the patient with BPD says "The other person would get upset with me," what they REALLY mean most usually is "All hell would break lose!"

In all of the DBT handouts, I find only one mention of the fact that it may be the environment that is the problem, not the person in the environment.  In the Interpersonal Effectiveness Handout #3 on page 117, it concedes that "Characteristics of the environment make it impossible for even a very skilled person to be effective."

So what happens if someone with BPD gets assertive with their families? In order to find out the true answer to this question for patients in therapy, the therapist usually needs to ask a version of the Adlerian Question such as: "What would happen if I could wave a magic wand and you could fearlessly stand up for yourself with your parents, and tell them to quit mistreating or invalidating you?

So what are the answers I get when I ask for details - without letting the patient go off on a tangent - about exactly what would happen next if the parents were "upset" with the patient?

Oh, nothing much, he said sarcastically. Just responses that include such minor inconveniences as violence, suicides, suicide threats, increased interpersonal chaos, increased drinking and drug use, parental infidelity or a break up with the patient being blamed for it, further invalidating the patient, taking anger out on other family members, literally exiling the patient or giving him or her the silent treatment for weeks on end. Just to name a few. Nothing too bad, really.

So back to the serenity prayer. Are these things one can change?  You betcha!!  It’s not easy, or the person could easily figure out how to do it and would have already proceeded. It’s emotionally trying.  It requires patience, persistence in the face of adversity, and ingenuity. It usually requires the services of a therapist who knows a little about the family dynamics of BPD.

So if your therapist is telling you to just tolerate the person stabbing you in shoulder with the pen knife, fire your therapist and find one who can actually help you.