Pages

Thursday, April 29, 2021

Book Review: The Quick Fix by Jesse Singal



 

As someone who has been a critic of many of the excesses and science fiction currently present in clinical psychology, psychiatry, and psychotherapy, I have often been frustrated by how little attention has been paid in these professions to the problems that I bring up. Yeah, I know, awwww, poor me, people won’t listen to me. But aside from my narcissistic injury, a lot of patients are receiving substandard care due to the alignment of the forces described in the masthead of my blog.

This excellent and entertaining book by Singal tackles similar issues that have recently been plaguing experimental and social psychology. For those who don’t know, the field of academic psychology is actually two separate fields: clinical psychology, which deals with psychotherapy and other treatments for people with psychological problems, and experiment psychology, which studies both normal and abnormal psychology from an academic perspective. Interestingly, these two branches of the academic discipline are often very critical of each other, and members often refuse to communicate with one another.

Singal’s focus is on what he clearly shows is an explosion of overly-simplified ideas about how to change widespread social behavior, which have been widely taken up by politicians, corporations and the media and praised in TED talks, but which are often backed by very weak and inconsistent evidence that was obtained by highly suspect means and invalid experimental designs. 

Unfortunately, quick fixes have a strong appeal to human beings who are often averse to complicated formulations that look at the wide variety of different influences on human beings that results in their overall behavioral tendencies.

He tackles such widely-believed ideas as the importance of self esteem, fear of so-called “super-predators,” and the belief that societal forces like sexism and racism can be defeated by victims who act as if they were powerful, have grit, or think positively. He looks at notions of “implicit bias” that corporations have been using to train their employees to make themselves feel better about decreasing racism and sexism in their midst—without actually doing anything about the explicit biases which are really at the heart of the problem. Let’s focus on repairing individuals without any reference to the collective forces with which they are faced! Gee, sounds a lot like my criticism of the current treatment of patients with personality disorders.

He brings up, often in very humorous ways,  frequently ignored issues that are widespread in psychological research such as self-report bias, third variables that aren’t even considered, the fundamental attribution error (familiar to my readers), the file drawer effect (studies which come out negative are not reported so that the number of positive studies is misleading), the questionable use of p values, overgeneralizing by ignoring the context in which a research project was done, range restriction in statistics, the “jangle” fallacy (calling the same phenomenon by different names),  social desirability considerations in subject self-report, hypothesizing after results are known to explain away seemingly contradictory results (“HARKing”), the lack of replication in findings, and “bullet point” bias (oversimplification of complex situations).

Wow! Highly recommended.

Friday, April 9, 2021

Creativity and Self-Actualization




One of the themes of this blog concerns the forces that interfere with the ability of people to self-actualize, or express themselves and their opinions, and act on their own personal desires, even when their kin or social group may not always be supportive. Self-actualized people do not always follow in groupthink patterns during which they will go along to get along, agreeing with the family or ethnic groups ideas and philosophies while remaining willfully blind to any information that contradicts the group mythology.

 

Although she did not put it in those terms exactly, the question of whether the ability to do this is an important contribution to creativity in the arts and sciences was addressed by Nancy C. Andreasen, a well known psychiatry professor at the University of Iowa College of Medicine and the former editor in chief of The American Journal of Psychiatry, in an article entitled Secrets of the Creative Brain in the July/August 2014 issue of the Atlantic magazine. 

 

She describes a study she has been doing with a lot of creative people, many of whom are celebrities. In the article, she first discusses the often purported relationship between genius and madness, and found that there is indeed some truth to the idea that there is some. The incidence of mental illnesses in her subjects and their family members is indeed higher than expected. Although some of it may involve heredity, as evidenced by the incidence of schizophrenia, most of the psychiatric disorders found in her sample were those that primarily involve interpersonal dysfunction: certain mood and anxiety disorders and alcoholism.

 

Why might that be? Her answer speaks to my speculation about the role of self-actualization in creative people:  

 

“One possible contributory factor is a personality style shared by many of my creative subjects. These subjects are adventuresome and exploratory. They take risks. Particularly in science, the best work tends to occur in new frontiers. (As a popular saying among scientists goes: “When you work at the cutting edge, you are likely to bleed.”) They have to confront doubt and rejection. And yet they have to persist in spite of that, because they believe strongly in the value of what they do. This can lead to psychic pain, which may manifest itself as depression or anxiety, or lead people to attempt to reduce their discomfort by turning to pain relievers such as alcohol.”



To be innovative in one’s field involves the ability to persist in letting one’s mind work in the face of scorn and rejection from one’s peers. Even though it does hurt, innovators didn’t let rejection of publications or grant application stop them from continuing. They also had the wherewithal to be proven wrong at times and yet not be discouraged from continuing to search widely for better answers to technical questions.

 

Creative genius also involved the willingness to teach oneself about a wide variety of subjects rather than be spoon fed by teachers only in one’s chosen field of endeavor. Andreasen noted that many of her subjects were what she referred to as autodidacts – basically self-taught. Many had gotten in trouble with their school teachers for pointing out times when the teacher said something that was not true. She also found that many of her subjects were “polymaths” – people who read widely not only in their chosen area of expertise but in many subjects, both in the sciences and the humanities.


This sounds like self-actualization to me.


 


Tuesday, March 16, 2021

Loose Associations Between Various Clinical Attributes of Patients Sharing a Diagnosis




Doctors are being pressured more and more to make quicker and quicker clinical decisions using information from studies that show correlations between certain symptoms and certain genes and other patient attributes, both psychological and physical. They are at risk of becoming sucked into a Lake Wobegon effect - the fictional town where it was said everyone’s intelligence is above average. Clinicians should still  assess each individual separately in order to avoid conclusions based on the ecological fallacy (thinking all patients with a particular disorder react exactly the same as the average patient with the disorder). In fact, most people with a certain characteristic fall outside of the average value when looking at another characteristic that seems to correlate with it.

Some people object to personality disorder diagnosis for a similar reason: each person with these disorders presents somewhat differently than the “average” person with the disorder.

However, this whole problem does not mean that we should completely avoid making diagnoses or looking for other correlating characteristics which are likely to be found in the average person in a group. This information can provide a clinician with clues as to where to start an investigation. The diagnosis of borderline personality disorder, for instance, correlates strongly with the spoiler role developed in families in which the parents have conflicts over the role of being a parent. This knowledge is useful in telling a physician or therapist what questions to ask the patient when exploration of the relevant factors begins. 

It does not, however, mean that an initial inquiry is guaranteed to be fruitful, only that in many cases it will be, so starting there may save the clinician a lot of time looking at things that will turn out to be irrelevant. For it to be useful, however, the doctor must treat an initial idea as an hypothesis, and be completely open to the possibility that the hypothesis may turn out to be wrong.

Obviously, the strength of any discovered correlation affects how soon one should start looking for it. Much of the personality disorder literature these days is clinically useless because the correlations “discovered” are either too small, too obvious, or too unimportant to mean much of anything in helping the clinician develop some sort of psychotherapeutic strategy. A study by Wildey et. al. in the  August 2020 issue of the Journal of Personality Disorders found correlations between so-called externalizing disorders like antisocial personality disorder or substance abuse and the negative quality of a person’s relationships using multiple assessment methods. Ya think?

Some studies even look for associations between qualities that are actually intrinsic to the definition of a personality disorder and the disorders themselves. A rose is a rose last time I looked. Like people with BPD being very reactive. I kid you not.

Even dumber is looking at so-called “mediating” variables. For example, one study in the Journal of Personality Disorders by Sato et. al, in the April 2020 issue found that “rejection sensitivity” was mediated by attachment anxiety, the need to belong, and self-criticism. You mean if you think negatively about yourself but still want to fit in, that might lead to anxiety? I know academics face the need to publish or perish, but as I am fond of saying, “No Sh*t, Sherlock.”

Tuesday, February 23, 2021

Book Review: The Shattered Oak by Sherry Genga

 


This involving book, based on a true story but with some facts altered, is written as a first person account (although it is not the author's story) from a woman involved in a severely physically and emotionally abusive marriage. The author takes the reader on a fascinating tour inside her mind and thought processes.

The book strongly implies that she made no effort to leave for many years, and says that her parents refused to help her do so, under the rationalization that they were too afraid of her husband. She finally does leave and files for divorce. The narrative does not discuss the husband’s behavior during the divorce, but it appears that it went fairly uneventfully and without any stalking by her ex. She received the house and custody of their three daughters in the settlement, and her ex seems to have made alimony payments regularly.

Three years later she has a “nervous breakdown,” and describes in vivid terms her overwhelming sense of doom due to her depression. She makes three serious suicide attempts, and describes her ambivalence over abandoning her children and leaving her eldest daughter to take care of the other two, while all the while also feeling tremendous guilt over her daughter having had to take care of her in a parent-child role reversal.

She finally gets committed to a horrible mental hospital and given ECT against her will. Although she does not say she was diagnosed with major depressive disorder, her disturbing descriptions of her thoughts and feelings while in the depressed state are impressive, and give the reader a sense of what it might be like to have been in her shoes. It later turns out that she did not have a typical major depressive disorder, but one caused by a medical disorder, Cushing’s disease, which leads to very high level of the stress hormone cortisol, a steroid. A major depressive syndrome is seen in 50%–70% of the cases of Cushing’s syndrome. 

She opines that the high levels of cortisol may have come from high levels of stress, which, she implies, seems to have increased rather than decreased after she got out of the marriage. As it turns out, however, that was not the case at all. Her disorder was caused by a tumor of the pituitary gland.

It does not mean that anyone is “blaming” her for the severe abuse she suffered, but it is extremely important in the mental health field's attempts to prevent others from following in her footsteps, to pose the question of why she stayed with her husband for so long, and why she felt more stressed out after the divorce than during the time she was with her husband. There is no way we can know the answers to this question for certain just from the descriptions in this book, but there are several tantalizing clues.

The usual excuses offered up to justify the behavior of women who repeatedly return to an abusive relationship often do not hold water, but especially so in this case. As per her own description, she was in far more danger of being killed by him over the long run if she stayed than if she left. While they were together, he constantly threatened to kill her and even fired gunshots at her, narrowly missing her head on purpose. There were literally bullet holes in the walls.

She also knew very well that he was violent before they were married, because there were episodes of it back then.

And why would she be more stressed out after she left if, as it seems, her ex was not stalking her? The narrator admits that she still loves her husband even after the divorce despite all the pain he put her through. She offers a very interesting hypothesis about why he abused her: he came from a highly abusive family himself, and was taking his anger out at them on her. The question she keeps asking herself is how she could have helped this man to become less bitter. Presumably, how else. What she had been doing clearly did not work. Her question is consistent with my hypothesis about  this case

Readers of this blog can probably guess what that hypothesis is: the odds are pretty good that she was sacrificing herself so that her husband, whom she loved, could continue to channel his destabilizing anger away from his own parents, and that her doing something like this might have also been her role in her own family of origin. You know, the family that refused to help her leave her husband. At the end of the book we find reasons that this hypothesis would certainly necessitate further exploration. 

She was treated like a servant by her own parents growing up, especially compared to her two siblings, who could seem to do no wrong in her parents' eyes. Her older brother finally tells her that she was the result of an affair that her mother had had with a neighbor, and she was not her father’s biological daughter. Might the father have taken his anger at her mother out on her, with her mother going along with the program in order to keep the family together? You be the judge.

I wonder what her parents' upbringing might have been like.




Tuesday, February 2, 2021

The “Logic” of Researchers in ADHD

 



About 15-20 years ago or so, when I was still Director of Psychiatric Residency Training at the University of Tennessee Medical School, I went to a grand rounds (a teaching conference involving the whole department) to hear a talk by a doctor about adult ADHD. It turned out to be more of a drug commercial for some or other stimulant the sponsor of the talk was selling.

The guy basically said that this pseudo-diagnosis was in fact incredibly common – up to 14% of the adult population – and all of them should be taking significant doses of one of the most dangerous and addictive class of drugs that are available by prescription – classified by the FDA in the same category of abuse potential as opiates like morphine. Wow.

During the Q&A at the end of the talk, the subject of ADHD in children came up. Someone asked him why so many kids diagnosed with the disorder could go to a video game arcade (which had at the time only recently gone the way of the dinosaurs) and concentrate with tremendous focus on the game they were playing despite all sorts of buzzers and bells going off, flashing lights everywhere, and scores of people milling all around talking to each other. The speaker opined that this was “not concentration.” I’ve heard that sentiment many times before and since from Pharma shills. Well if it isn't concentration, I wondered, then WFT is it?

Another skeptic in the audience from child psychiatry asked him about the high incidence of alcoholism in the parents of ADHD patients. His response: “If you had a kid like that, you’d probably drink too!” Oh, I see. Alcoholism is caused by having rambunctious children.

I should have gotten up and cussed the dude out for saying heinous stuff like this, but my boss in the department might have frowned on it.

All this reminds me of another talk I once heard from someone from the National Institute for Drug Abuse during an outside medical meeting. He was going on and on about how cocaine, another stimulant BTW, depletes a chemical in the brain called Dopamine, which makes it nearly impossible for abusers to enjoy anything but the drug. Someone (again, not me) got up and asked, “But aren’t we doing that when we prescribe stimulants to our kids?” The speaker’s answer, “But the drugs work so well.”

So I’m guessing that the answer to the question that was actually asked, which the speaker completely avoided, was, “Yes.”


Friday, January 8, 2021

The Decline of Academic Medicine in the US




In an article called “The precipitous decline of academic medicine in the United States" from the American Academy of Clinical Psychiatrists by Richard Balon, MD and Mary K. Morreale, MD, the authors describe how the profiteering currently infecting medical treatment in this country is also in the process of destroying medical education.

Some of what they wrote:

“Structural problems in academic medicine exist within all parts of its tripartite mission: education, clinical care, and research. With clinical care, there are tedious requirements for documentation in difficult-to-navigate electronic medical record systems, demands on productivity in the form of ever-increasing [office visits], and senseless demands from managed-care organizations. All of these clinical demands reduce the time for teaching, which, ironically, university deans expect us instructors to increase. Similarly, education has been increasingly regulated by what has been referred to as the ‘medical-education industrial complex.’ Regulatory agencies have introduced changes with possibly negative consequences and no evident benefit.

 

“Academic research—at least in psychiatry—has been experiencing an ‘intellectual crisis,’ leading to the conclusion that ‘evidence-based medicine does not appear to provide an adequate scientific background for challenges of clinical practice in psychiatry and needs to be integrated with clinical judgment.’ And despite the glow that research funding brings to investigators and administrators, the sad fact is that, for the institution, research is a money loser.

 

“Due to the pandemic, in anticipation of a loss of $350 million, Johns Hopkins ‘imposed a hiring freeze, canceled all raises, and warned about impending furloughs and layoffs….’…[despite] Johns Hopkins had $10 billion in assets and a $6 billion endowment …Leadership compensation at Johns Hopkins is similar to the business world, with the university’s president earning $1.6 million in salary and an additional $1.1 million in deferred and other types of compensation.

 

“In Michigan... the CEO of the William Beaumont Health system affiliated with Oakland University had a total compensation of $5.9 million in 2018, with a base salary of $1.85 million, a bonus of $1.6 million, deferred compensation of $1.66 million, and $810,000 in other compensation.”

 

And here I thought that this had only happened at the medical school I worked at, the University of Tennessee in Memphis. When I first started there as psychiatry residency training director in 1992, the faculty practice group called UTMG was a delight to work with. The administrators worked for the doctors. We were told that we had to bring in 160% of the UTMG portion of our annual salary in patient care activities. The department was flush with cash, with a million dollar reserve for research and other academic activities. Faculty could earn extra money by seeing extra patients, keeping a percentage of every additional dollar they brought in.

 

The psychiatric emergency room at the public hospital, run by our department, was a model. We also trained police to deal with mental illness through the formation of what was called a Crisis Intervention Team, which was copied by several police departments throughout the rest of the country. Police became experts at de-escalating conflicts and apprehending the seriously mentally ill safely, transporting them to the Psych ER for evaluation. (Does this sound like something that might help the police regain public trust in today’s atmosphere? I think so).

 

Meanwhile pressure was building to install managed care models, especially after Medicaid in Tennessee was changed into Tenncare, which called for the formation of several HMO’s to provide treatment. UTMG decided that they wanted to form one, which they called TLC. Having experienced managed care in California, I warned everybody what might happen, but no one would listen. One child psychiatrist thought managed care was a good idea and advocated for it.

 

Before long, the doctors were working for the administrators instead of the other way around. Top administrators were paid over a million dollars apiece. The department’s reserves suddenly disappeared. UTMG drained the Psych ER of funds until it had to close. The child psychiatrist who advocated for managed care had his own pet project, a day care center for teens, destroyed. Faculty members were told they had to keep working any extra hours that they had been working – but without any of the extra pay they had been getting! Faculty members were also suddenly told they were “losing money” for the organization, even though they were bringing in the same amounts they had been, and even though the state - not UTMG - was paying for the faculty’s office rent and the cost of their phone system!


Saturday, January 2, 2021

New Podcast about Borderline Personality Disorder



 https://podcasts.apple.com/us/podcast/3-borderline-personality-disorder-with-david-allen-m-d/id1546807211?i=1000503914329&fbclid=IwAR3DJ5gJiYv0i--LphqaTZk67gkctxgJhjjNNisSc7AFeFjlMDLarV4A9_I


Tuesday, December 15, 2020

Borderline Hyper-reactivity: Compared to What?




One of my complaints about the research literature on the so called “hyper-reactivity” of patients with borderline personality disorder (BPD) is that the authors of such studies almost always look at the quality and frequency of their subjects’ responses without ever looking at what they are responding to.  Since mood instability is the most central part of the definition of the disorder, of course they will have more reactions. By definition, they’ve been selected for it!

 

Two recent studies show that patients with BPD really don’t seem as different from others as one might expect. They both provide strong evidence for my point of view. One showed that the specific reactions to interpersonally threatening stimuli of patients with BPD  is not all that different from those of anybody else.  It looked at skin conductance responses (SCR, a measure of stress) in patients and healthy controls.  The second investigated whether or not patients with other psychiatric disorders responded differently. They found that they all sort of responded the same, in spite of the fact that - once again  - the source and severity of the environmental events which triggered the patients was ignored.

Here’s some descriptions from the study abstracts.

1.   Hillmann K; Mancke F; Herpertz SC; Jungkunz M; Olsson A; Haaker J; Bertsch   K. Psychopathology. 53(2):84-94, 2020. Intact Classical Fear Conditioning to Interpersonally Threatening Stimuli in Borderline Personality Disorder.

 

Threat hypersensitivity is regarded as a central mechanism of deficient emotion regulation, a core feature of patients with borderline personality disorder (BPD). In this study, patients with BPD showed larger conditioned prolonged conditioned skin conductance responses (SCR) (a measure of stress) and subjective stress and expectancy ratings  to interpersonally non-threatening and neutral than interpersonally threatening stimuli, while interpersonally threatening stimuli elicited higher SCR compared to non-threatening or neutral stimuli in healthy controls. 


While the overall the results suggest no alterations in fear conditioning to generally aversive stimuli in BPD, it’s quite interesting than when someone in the environment is non threatening, patients with BPD react with MORE stress. One possible explanation: the people around them most of the time are more likely to attack them when most  other people would have let their guard down.

2.  Kockler TD; Santangelo PS; Limberger MF; Bohus M; Ebner-Priemer UW, Specific or transdiagnostic? The occurrence of emotions and their association with distress in the daily life of patients with borderline personality disorder compared to clinical and healthy controls.
Psychiatry Research 284, 11262, 2020).

 The authors wanted to see if hyper-reactivity to stress was specific to BPD or was seen as much in other disorders. Using e-diaries, they compared patients with BPD, normal controls, patients with bulimia, and those with PTSD. The majority of the comparisons (anxiety, sadness, shame, disgust, jealousy, guilt, interest) revealed transdiagnostic patterns, which means that the same reactivity was seen in the other disorders. The only major exception was that patients with BPD exhibited anger more frequently than any of the clinical groups or in healthy control. 


As mentioned, nothing was looked at concerning what the anger was about. So maybe anyone would be angry if exposed to whatever it was the patients with BPD had been exposed to. 

Friday, November 20, 2020

Treatment of Bipolar Disorder Goes Psychotic

 



Ever since I did my psychiatric residency training way back in 1974-1977, bipolar disorder (then called manic-depressive illness) was the easiest of the major psychiatric disorders to treat medically. There was (and is) absolutely no evidence the craziness of the patient during a manic episode or a bipolar depressive episode is amenable to any psychotherapy technique, although therapy might be important when the patient is euthymic (that is, not in a manic or depressive episode – which is most of the time) to deal with the aftermath of their having been psychotic or for other co-morbid psychological problems. Euthymic bipolar patients can have co-occurring personality disorders and anxiety disorders and anything else just like anyone. Since, when euthymic, they are in fact just like everyone else.


If you want to see what a manic patient looks like, look at this video of Charlie Sheen (https://www.youtube.com/watch?v=pipTwjwrQYQ). He actually took a show on the road but had no act. Now, cocaine can mimic mania, but he’d taken cocaine before and he never acted like this. See videos of him when he was back to his usual self to see the difference. Sheen denies he was manic, but I’m not sure I believe that.


Anyway, about 80% of these patients could tolerate and were responsive to lithium for prevention of manic episodes. The longer they took it, the more likely it would be to also prevent depressive episodes as well. If the patient got depressed while taking lithium, antidepressants worked just great. Journal articles saying they do not were full of crap – the most important of these is discussed in this post.  Most of my patients on lithium were basically symptom free for decades, no matter if I saw them in a public clinic, an academic clinic, or a private practice environment.

 

When patients first got manic, we used antipsychotic medications to bring them down, usually in inpatient settings, because lithium takes a couple of weeks to kick in. Once lithium was on board, we discontinued the antipsychotic medication because they didn’t need it any more. The only other time we used antipsychotic medication in bipolar patients was during depressive episodes in which the patient also had delusions and hallucinations (psychotic depression). Again, the antipsychotic meds could often be discontinued after the episode was over.

 

When a patient couldn’t tolerate or was not responsive to lithium, we would then use antipsychotic medications as the only alternative back then, but always had to worry about them causing a neurological disorder (tardive dyskinesia [TD]). Until it was found that the anticonvulsants Tegretol and Depakote were good for mood stabilization – so then they became the second line drugs.

 

When the new, “second generation” antipsychotics came out, which can cause huge weight gain and diabetes in addition to TD, the drug companies started to push them. The use of lithium started to plummet. After it was found that some of them had some antidepressant effects – although usually only to augment an antidepressant – Pharma started to push them even more. Despite the major risks, use of them increased from 12% of cases to 53% of cases between 1997 and 2008.

 

Not only that, but the number of patients diagnosed with bipolar disorder inflated by more than double since 2000. Everybody and their brother who had any mood symptoms at all were misdiagnosed with it, most due to the insane idea known as “bipolar spectrum,” or as I call it, B.S. Another study in the Journal of Clinical Psychiatry that I wrote about previously  showed that 40% of patients in their sample who met clear DSM criteria for borderline personality and not for bipolar had been misdiagnosed as bipolar by a prior mental health professional, as well as 10% of all of the other patients.


Caveat emptor, which in this case means, let the patient beware!


Tuesday, October 27, 2020

Debate over “No Suicide Contracts” presumes Patients are All Alike





An article entitled No Suicide Contracts: Can They Work by Caroline Roberts M.D. came out in the August 2020 issue of Clinical Psychiatric News. No suicide contracts (NSC’s) had been given for years by therapists and psychiatrists to potentially suicidal patients. The contract essentially gets the patient to sign off on a statement that they will not kill themselves. Alternatively, the patient commits to calling someone if they think they might make an attempt. Some NSC’s ask them to call a suicide hot line, while others say to call the therapist.

 

For quite some time now, however, use of NSC’s has been discouraged in the literature because they may give therapists a false sense of security. There is no clear-cut evidence that they are “effective.” In some populations, such as borderline personality disorder (BPD) where the patient may want to invalidate the therapist, they might even backfire. Or patients may not keep their word because they know the therapist might commit them to a mental hospital. They might not want to go there.

 

Dr. Roberts (“She helps you to understand and does everything she can” ~ say the Beatles) makes the obvious point in her article that the answer to the question of whether NSC’s can work “is conditional on the unique combination of patient, clinician, and therapeutic relationship.” And, I might add, the unique family dynamics and history of prior treatment that each patient brings to therapy. How could anyone think that the question of whether any intervention either will or will not work does not depend on everything that has happened before, during, and after the signing of the contract – both in the patients’ lives and in their relationship with the therapist?

 

This is yet another example of the ecological fallacy, in which an entire group of people is characterized just by its average member. It’s like the old joke about a drowning victim who couldn’t possibly have died in a certain lake because its average depth is only three feet!

 

Of course, no intervention is going to be effective 100% of the time in anyone. For one thing, new things can happen to a patient in between therapy sessions. Family fights can break out or people can be dumped by lovers. A loved one might even pass away.

 

Telling a patient to call a hot line will generally be less effective than if the patient can talk to the therapist personally. The patient may think (and I agree) that therapists should care enough to be available during emergencies, and to have someone who can substitute for them if they are not available. Therapists should also know how to empathically get patients off the phone in non-emergency situations.


With patients with BPD, therapists will most likely have better results with an NSC if they have validated their patients without having fed into their false selves.


The therapist can ask patients if they are afraid they might be committed, and let them know that commitment will only be used as a last resort to save the patient’s life, and that the therapist realizes that patients can feel even worse when thrown into a mental hospital.

 

Simple answers to complex questions are usually simple minded, as they are here, and are only employed by simpletons.