Leave Me Alone, I'm Lonely



When I discussed the concept of distancing in my July 6 post, Distancing: Early Warning, I described parents who distance their adult children thusly:  The parents act in an obnoxious manner that makes their adult children wish to avoid them. However, the fact that the parents are indeed pushing their children away is often somewhat obscurred by the fact that the parents keep demanding contact with their progeny.  The kicker in all this is that the  parents even do that in such a way that it has the opposite effect.  Still, the adult children frequently come back over and over again for more abuse.

I also pointed out that in these situations the parents may secretly believe that their children are better off without them. Hence, they engage in distancing to protect the children from themselves.

I would like to provide readers with some real examples.   

However, if I used examples from my practice, other therapists who do not like my family systems conceptualization (and there are many who do not) might accuse me of inducing my patients to make up this stuff just to please me.  These therapists do not believe this sort of odd behavior ever really happens.  So instead, I will use examples that I have been collecting from several different newspaper advice columns.  The columns are written by Jeanne Phillips (Dear Abby), Carolyn Hax, Amy Dickenson (Ask Amy), Harriette Cole, and the team of Marcy Sugar & Kathy Mitchell (Annie's Mailbox). 

Dear Abby

         

Amy Dickenson

Harriette Cole



Now of course the writers of advice to the lovelorn columns are not trained therapists, and their suggestions to the readers who send in problems vary widely from the very psychologically sophisticated (Carolyn Hax) to the often naive, all too obvious, and glib (Annie's Mailbox).  

Nonetheless, in order to be successful at writing such a column, all of them have to be adept at writing about issues that resonate widely with readers.  They have to pick out a few letters that pique their readers' interest from the hundreds that they typically receive every day.  And it is not just females who read the advice columns, as was the case back when they first started.  (In England, advice columnists were once called "agony aunts" because they dealt with female letter writers who were always agonizing about something). 

Academic psychiatrists and psychologists tend to look down their noses at the popular press, and are often dismissive of advice columnists as well as op-ed writers who author columns on psychological issues -  as if non-professionals cannot make valid observations or have informed opinions.  That just shows how short-sighted the academics can be.  What they see in their offices and read in journals is frankly a highly skewed view of human nature.  They ignore the popular press at their peril.  And they need to get out more.

The problem of what I call distancing parents comes up quite frequently in the letters advice columnists choose to publish; what follows are a whole bunch of examples culled from recent columns.  (Of course, there are also a whole litter of letters by parents denouncing the dastardly dreadful dirty deeds of their ungrateful a-dult offspring, which not only allows me to alliterate but gives me material for another post later on.  Distancing is often a two way street).

According to one writer, her parents insisted on monopolizing most of her and her husband's social time.  When the couple moved out of state, hoping to solve this problem, her parents literally bought a house a couple of blocks away from theirs in the new state, and  moved into it.

A father, after divorcing the writer's mother when the writer was small, would rarely show up to spend time with his children when he had promised to.  These no-shows had always been a crushing disappointment for the kids.   Nonetheless, after the kids grew up, he constantly complained about how they refused to visit him.

The mother of one letter writer always cried to her about how awful she, the mother, was being mistreated by the writer's husband. From the writer's perspective, however, it was actually the mother who was consistently verbally abusive to the husband.

Whenever another letter writer disagreed with her father, he would reply, "Maybe I'll just kill myself."

When a writer's father became chronically ill, her mother constantly asked her to come over and help take care of him.  If she could not make it for whatever reason, the mother would launch into a long teary rant about how she, the mother, never got to go anywhere.  No matter how much the writer helped, Mom would constantly describe her as the "unhelpful sibling" when discussing the situation with the writer's sister.

Another writer had been physically and sexually abused by her father when she was a child.  After he died when the writer was an adult, her mother would go on and on endlessly about what a saint he had been.

A mother constantly blamed her daughter for the mother's divorce from the writer's father, although the mother would gush to complete strangers about what a wonderful daughter she had.

One mother was a real Cassandra; everything she talked about was gloom and doom about the future.  However, if her adult daughter was not all sunshiny about everything, the mother would berate her.

Another writer's parents always gave expensive gifts and money to the writer's older siblings, but never gave her anything.

When a writer and her husband generously took in her elderly and apparently agorophobic mother-in-law, Mom expected them to stay in the house with her 24/7 and would never want to go out herself. She also made huge messes in the house and constantly henpecked the writer's husband about what he was and was not doing.

One writer's mother repeatedly lied and gossiped to the other siblings about each of her adult childen behind their backs.

A writer complained that her mother had always treated her like crap, but doted on the writer's daughter.

A mother who was overprotective of her children when they were kids still expected a writer to check in with her every single night.

Another parent constantly embarassed her daughter in front of the daughter's friends; if the daughter did not do everything the mother told her to do, the mother would curse at her and call her names.

The parents of another writer consistently favored one of the writer's daughters over the other grandchild in a highly ostentatious way.

Finally, when one writer was literally dying of cancer, her mother made plans with a single friend to find a way for the friend to marry the writer's husband after she died.

That last one may seem over the top, but believe me, I've heard far more bizarre examples from my patients.   The parents described in these posts were pikers in comparison. It never ceases to amaze me how creative people can become in devising ways to annoy other family members.  Every time I think I have heard it all, boy am I ever in for a surprise.

Epidemic of Mania, Pharmaceutical Company Type (Bipolar Disorder P.C.) Claims Seventh Victim

Just as I thought I had heard the last about drug company mania mania, yet another example pops up.  Posts on this subject are starting to become a regular feature on this blog.  For the seventh time, the Justice Department has fined a pharmaceutical company for off-labeling marketing one of their drugs for a psychiatric indication for which there is no data, and once again the psychiatric indication is mania.  I hope these posts have not become monotonous.

This time the company is Elan pharmaceuticals and the drug - seemingly always an anticonvulsant or atypical antipsychotic - is the anti-seizure medication Zonegran.

According to the justice department press release at http://www.justice.gov/opa/pr/2010/December/10-civ-1444.html,  "Elan promoted the sale of Zonegran for a wide variety of improper off-label uses including mood stabilization for mania and bipolar disorder, migraine headaches, chronic daily headaches, eating disorders, obesity/weight loss and seizures in children under the age of 16.

Elan’s off-label marketing efforts targeted non-epilepsy prescribers and the company paid illegal kickbacks to physicians in an effort to persuade them to prescribe Zonegran for these off-label uses. Under the terms of the plea agreement, Elan has agreed to pay a criminal fine of $97,050,266 and plead to a misdemeanor violation of the Food Drug and Cosmetic Act. EPI will also forfeit $3.6 million in assets.

In addition, Elan has agreed to pay $102,890,517 to resolve civil allegations under the False Claims Act and related state statutes that the company illegally promoted Zonegran and caused false claims to be submitted to government health care programs for a variety of uses that were not medically accepted indications and therefore not covered by those programs."



The company was not accused of trying to expand their market by expanding the definition of bipolar disorder the way Eli Lilly did with their marketing for Zyprexa (see my March 22 post, The Zyprexa Documents).   However, would anyone be surprised if they had done this as well?  Any moody patient becomes fair game for a bipolar diagnosis.

Typically, the company "targeted non-epilepsy prescribers."  Translation: primary care doctors and perhaps psychiatrists. Apparently they are fairly easy targets to manipulate.

Child Abuse Politics

The United States Government's Department of Health and Human Services just issued a report stating that 1740 children in the US died at the hands of their primary caretakers in 2008 due to abuse or neglect  (http://www.commercialappeal.com/news/2010/dec/14/tennessee-ranked-fourth-child-abuse-deaths/). 

Elizabeth Loftus and the False Memory Syndrome Foundation promptly issued a joint press release stating that the childrens' memories of having been murdered had been falsely implanted by unscrupulous therapists.



Meanwhile, wildly indignant child abuse advocates accused the government of a serious undercount, and pegged the actual number of cases at closer to 300,000,000.

Tangled Emotions

In a very funny sequence in the delightful new Disney animated fairy tale, Tangled, Rapunzel steps down from the tower that the woman whom she thinks is her mother has insisted she stay cooped up in all her life. She goes outside and touches the ground for the very first time - without that woman's knowledge.

She immediately experiences severe mood swings as she goes back and forth from the heights of ecstasy to the depths of despair over and over again in a very short time. One minute she is marveling at the feel of grass as she runs through. The next minute she is crying and wailing, "Oh, I'm a terrible daughter!" Soon thereafter she beams as she thrills in splashing through her first pool of water. Shortly after that she anxiously frets that she is hurting the woman who raised her and whom she loves.

The Harvard Guru of Drugging Children, Joseph Biederman, would probably diagnose her as bipolar.  The male character who entices Rapunzel to come down out of the tower, however, is a much better diagnostician.  He observes that she seems to be at war with herself.

Ah yes, neurosis.  That old Freudian psychoanalytic term that signifies a conflict going on within a person (intrapsychic conflict) that allegedly creates the severe anxiety and self-defeating behavior seen in patients who come for psychotherapy .  Different psychoanalytic, existential, and humanistic psychotherapy theoreticians (that is, those from certain schools of thought within the field) disagree over precisely what it is that "neurotic" people are most often conflicted, but they all stand by the concept.  

Freud thought the conflict was between our internalized values and our biological urges - most frequently aggression and libido (psychic and emotional energy associated with drives). 

Psychoanalyst Heinz Kohut thought it was over our needs to be validated, depend on others, and have a place to fit in within a family that may provide us with none of those things. 

Experiential therapists such as Carl Rogers and Fritz Perls thought it was over what our social system wants us to do and our need to self-actualize (achieve one's full potential through creativity, independence, spontaneity, and a grasp of the real world). 

Erik Erikson saw it as a struggle to negotiate different developmental stages over our lifetime, such as the struggle between the forces of identity and role confusion during adolescence or the struggle between the forces of integrity and despair in the elderly. 

Existential therapists think it concerns our need to find meaning and connection in an absurd universe in which our own death looms. 

Family Systems pioneer Murray Bowen thought it was between the forces of togetherness and the forces of individuality.

Almost all of the above concerns, one might note, center around a battle between doing what others expect of us and our own internal needs and desires.  Social conformity versus going our own way.  Such conflicts are hardly a novel or esoteric concept, and certainly they are well known to all of us.  Yet the term neurosis has almost disappeared from the psychiatric lexicon.  A huge mistake, in my opinion.

The term neurosis was all over the place in the first two editions of the diagnostic bible of the American Psychiatric Association (APA), the DSM, until the DSM III came out in 1980.  Then it was unceremoniously dropped.  To be sure, it had been invoked as a causative factor in disorders and behaviors which we now know it had no business being associated with, such as severe obsessive-compulsive disorder and homosexuality.

Just because it was not one of the major causative factors for some psychiatric or behavioral conditions does not mean, of course, that it is not a major causative factor in any of them.  Surely all of us think twice about doing what we want to do when we might be disowned by our parents or thrown in jail if we indulged ourselves.  Yet we still have our own powerful personal needs and desires.  That such conflict creates anxiety in us which can lead us to some strange compromises is almost indisputable.

But starting with the DSM-III, the powers that be wanted the list of psychiatric disorders to be merely descriptive and not get into the highly controversial area of what actually causes them (etiology).  Saying intrapsychic conflict is a major cause of a disorder is just psychoanalytic theory, so the reasoning goes.  And analysts have without a doubt been wrong about a great many things.

So psychiatrists are now stuck with the only official list of diagnoses in medicine that avoids the whole question of the causation of disorders.  It's like a compendium of the symptoms of infectious diseases that never mentions viruses, bacteria, or parasites!

A Great Post About Affect Regulation in Children from Dr. Claudia Gold

http://claudiamgoldmd.blogspot.com/2010/12/how-parents-and-children-regulateand.html

How to Disarm a Borderline: Part IV: The Kernel of Truth

Before reading this post, particularly if you are going to try this at home with a real adult family member with borderline personality disorder (BPD) (which is not recommended without the help of a therapist), please read my previous posts Part I (October 6), Part II (October 29) and Part III (November 24).  In this post, I will begin to run down specific countermeasures to the usual strategies in the BPD bag of tricks used to distance and/or invalidate you, as well as to make you feel anxiously helpless, anxiously guilty, or hostile.

When people with BPD try to distance you (again refer to my Distancing: Early Warning post of July 6), you can use the momentum generated by their attempt to push you away to actually move closer to them in the emotional sense. The idea is a bit like the philosophy of Judo, in which the momentum of an attack on you is converted into something used against the other person - with one exciting exception (apologies to C&R Clothiers for my boomer fans in LA) . In dealing with BPD, the goal is for both sides to win.

Tone of voice is crucial.  You can use the same, and exactly the right, words and sound as if you are indeed feeling helpless, guilty or hostile, or you can sound like you are at peace with yourself and with your own limitations.  Since this post is not an mp3 you can listen to, I will do my best to describe how you should sound. 

You should make any of the counter-statements described below sound completely matter-of-fact.  You should sound warm but not condescending, and like you are taking the opinion of the person with BPD seriously even if you do not agree with it. 

#1:  Wild accusations and exaggerated overgenereralizations.  When those with BPD make overly dramatic, hyperbolic statements or accuses you of having ulterior motives for what you are doing or saying, they are literally inviting you to invalidate them (See my post Validating Invalidation from September 23). 

What is going on here is that, since people with BPD have usually been invalidated on a recurring basis by their family of origin, they respond by making it easy for those people to continue to invalidate them.  And they will often practice this skill on lovers and mental health professionals, or even on innocent bystanders when those bystanders try to be helpful. 

I know it is hard to believe that they have an altruistic motive for behaving the way they do.  They will not usually admit to it, and if they do it will be in a disguised and very subtle manner so you will likely misunderstand what they are saying.  I explain the biological reasons why we are all willing to sacrifice ourselves to our kin group in my books, How Dysfunctional Families Spur Mental Disorders, written for the lay public, and A Family Systems Approach to Individual Psychotherapy, written for therapists.  Most people in the mental health field do not agree with this idea.

In countering this ploy, the idea is to resist the invitation to invalidate them without agreeing to all the exaggerated histrionics or without agreeing that you are some kind of schmuck.  Remember, disagreement and invalidation are not the same thing.  The key:  no matter how awful or crazy-sounding what they say is, there is always a kernel of truth in it.  Always, no matter how small.

The countermeasure, taught to me by the best professor in my residency program, Rodney Burgoyne, is therefore to validate the kernel of truth in the statement and simply ignore all the exaggeration and the negative implications.

Let's start with hyperbole or exaggeration.  My favorite statement of this sort of all time is "Life is a sh*t sandwich, and you have to either eat it or die!"

Eeewwww!  The temptation here to reassure the person who says this that things can not possibly be that bad.  Wrong move.  The counterstatement should be something like, "It sure sounds like you've been having a pretty bad time of it."  Trust me, anyone with BPD is frequently quite miserable for very valid reasons.

Or how about, "Why bother going to a therapist?  They're only in it for the money!"  I used to hear that as an accusation as in, "You don't care about me, you're only in it for the money!"  I could get all defensive sounding and say, "Well you know this is how I make my living!" or I can say very matter-of-factly, "Well, after all this is how I make my living." 

I always thought it was better for the patient to have a highly paid professional therapist rather than an amateur.  The amateur would be too busy out making a living to have much time to devote to the patient's therapy and learning how to be a good therapist.  You get the idea, though.  If you want the patient to get help, you say much the same thing in the third person.

"You don't really care about me" is a favorite accusation of people with BPD that is very hard to validate.  After all, how can you really prove that you care about someone?  You could argue til the cows come home and you still could not prove it.  In truth, there is literally no way to prove it. 

So why bother? Besides, at those times during which they are giving you a really hard time, in actuality you don't care, or wish you did not.   I usually reply, "I wish there was something I could say that would convince you that I do care."

Another type of accusation is more indirect and has trap within it.  Someone in LA, for example, might say, "Anyone who is willing to put up with this horrible smog and traffic is a moron."  Assuming that you happen to live there, this statement in effect classifies you as a moron.  If you agree with it, you are saying that you are one.  Of course, if the person with BPD also lives in LA, he or she is also admitting to being an idiot, so if you agree, you are insulting him or her as well.  So what's the kernel of truth? 

Are smog and traffic bad things?  If you answer no to this question, I would have to question either your sanity or your sincerity.  The counterstatement: "Yeah, aren't those things a bitch!"

Coming up in the next post in this series: #2, countering escalating demands on you to do more and more.

Excerpts From My Book Online

There is still no "Look Inside" feature on Amazon.com about my book, How Dysfunctional Families Spur Mental Disorders: A Balanced Approach to Resolve Problems and Reconcile Relationships (I am still bugging the publisher), but if you want to take a peak, you can at Google books at http://books.google.com/books?id=NRFfrE9WlQ4C&printsec=frontcover&dq=How+dysfunctional+families+spur+mental+disorders&hl=en&ei=O6_5TODcDoeglAfZpKzhBw&sa=X&oi=book_result&ct=result&resnum=1&ved=0CDIQ6AEwAA#v=onepage&q&f=false

My Name is Sue! How Do You Do?!!



In my post of June 17 about the movie Thirteen, I wrote about how screenwriters for motion pictures occasionally nail a psychological phenomenon.  Many of them are way off base, but on these rare occasions one seems to be more knowing than many psychotherapists.

Today I would like to highlight some song lyrics that are similarly knowing, and concern a phenomenon that very few therapists even think about - hidden altruism in what seems to be, for all intents and purposes, a very cruel act by a family member.  The song also illustrates how learning more about what makes other family members do what they do can change your entire perspective on your own life.

The song in question is "A Boy Named Sue," which was sung by Johnny Cash and written by the multi-talented Shel Silverstein.  The song was meant to be just a humerous story, and what happens in the story itself is probably unlikely to ever take place, but the general idea is a wonderful illustration of the phenomenon I am highlighting.

The song was originally released in a live version in front of inmates at the infamous San Quentin prison in California.  You can hear from the audience reaction to the lyrics that some of prisoners were quite possibly identifying with them.

The song tells a story about a man whose father abandoned the family when the man was three years old.  Just before leaving, the father named his son "Sue."  Of course, from then on he is relentlessly teased and ridiculed for having a girl's name, and is constantly getting into fights because of it:

         Some gal would giggle and I'd get red
         And some guy'd laugh and I'd bust his head,
         I tell ya, life ain't easy for a boy named "Sue."

The protagonist's anger that his life has been so difficult leads him to resolve to track down and kill his father for doing this to him.  He finally finds his Dad at a bar in Gatlinburg, Tennessee and announces his presence:
       
        And I said: "My name is 'Sue!' How do you do! 
        Now you're gonna die!!"

What follows is a graphic descripiton of the fight they get into "kicking and a' gouging in the mud and the blood and the beer."  Finally, the protagonist gets the upper hand and pulls a gun on his father.  He is about to kill him when the father explains that, although he understands his son's anger and would not blame him for shooting, he had give the son the name because he knew he wasn't going to be around to protect the boy and that the name would force the son to "get tough or die:"

       But ya ought to thank me, before I die,
       For the gravel in ya guts and the spit in ya eye
       Cause I'm the son-of-a-bitch that named you "Sue."

Of course, the protagonist then gets all choked up and they reconcile near the end of the song.  The last line is "And if I ever have a son, I think I'm gonna name him  -----   Bill or George! Anything but Sue!"

The father's explanation puts the Dad's behavior in a completely different light that helps the son "come away with a different point of view" about his own experiences.  Of course, it still doesn't excuse the father from abandoning the family in the first place, but maybe there's some sort of understandable explanation - not an excuse - for that as well.

The phenomenon of distancing described in my post Distancing: Early Warning of July 6 often stems from a parent's feeling that his or her children are much better off if they are not in the parent's presence.  In other words, the parents' guilt and low self esteem dictate that they are doing their children a favor by driving them off.  They see themselves as toxic.  If they had been abusive, they know that they have been the cause of a lot of grief for their kids, they may therefore be somewhat more comfortable if their children hate them. 

It is similar in some ways to the famous old Groucho Marx line, “I wouldn’t join any club that would have me as a member.”

If they really want to be helpful to their kids, however, they need to bite the bullet and 'fess up to what happened, apologize as best they can, and try to understand the family dynamics that led to the awful situation in the first place.   I'll provide some guidance in how to go about that in future posts.

Antidepressants and Suicide Redux

On my post of July 19, Do Antidepressants Cause Suicide, I listed several reasons why antidepressants might increase suicidal ideation in some adult patients.  (I was not talking about children or adolescents since clinical trials in those populations have taken place only rarely). 

Now comes a huge study of adults and antidepressants out of Germany (Stubner, S et. al, "Suicidality as Rare Adverse Event of Antidepressant Medication," Journal of Clinical Psychiatry 71:10, p.1293).  The dataset from the European drug surveillance program was reviewed for patients on inpatient psychiatric units.  142,090 of these patients had taken antidpressants.

Of this ginormous sample, only 33 incidents of suicidality were documented.  12 of these consisted of suicidal ideas only, 18 were actual suicide attempts, and 3 people successfully completed the act.  14 of the 33 cases seemed to be probably, and 19 definitely, related to the medication.  Consistent with my earlier blog post, fully 23 of these 33 of these cases were associated with restlessness.  This is most probably a side effect of antidepressants, and it is one which is completely and very easily treatable.

The authors concluded that antidepressants rarely trigger suicidality, although even this conclusion is hard to be sure of since the attempters were not assessesed at all for psychological, social, or environmental events which might have contributed to their suidality.

Even assuming that a drug was the only cause of the suicide attempts, just 10 patients in this large sample made attempts that were seemingly unrelated to a common and treatable side effect.  10 out of 142,090.  This was in hospitalized patients, who in general tend to be have more serious symptoms and have far more suicidal ideation than comparable outpatients.

The risk therefore is .007 percent in this population.  And that's a maybe.  That is roughly one third of the minimum estimate of the risk of death from having liposuction for cosmetic surgery.

How to Disarm a Borderline, Part III: Overall Philosophy

Before reading this post, particularly if you are going to try this at home with a real adult family member with borderline personality disorder (BPD) (which is not recommended without the help of a therapist), please read my previous posts Part I (October 6) and Part II (October 29).

In this post I will discuss the general philosophy about approaching anyone who is trying to distance you (also see my post, Distancing: Early Warning [apologies to the rock group Rush] , from July 6), particularly if that person is very good at it like an individual with BPD is. In future posts, I will begin to run down specific countermeasures to the usual strategies in the BPD bag of tricks used to distance and/or invalidate you.

An observation held in common by many psychotherapy treatment paradigms for BPD is that respectful treatment of the patient by therapists in the face of the patient’s chaotic behavior patterns often seems to induce the patient to behave less chaotically with the therapist, although not with anyone else. It is particularly important for a therapist to respects differing values while not changing his or her own.

To disarm someone with BPD, you should look to find something that is wise, correct, or of value in the emotions, thinking, and behavior of the BPD person. You should never assume that the BPD’s problems stem primarily from crazy thinking, faulty interpretations, distortions of reality, or maladaptive assumptions. You should assume that individuals with BPD have unhappy lives and therefore, despite all evidence and appearances to the contrary, they really want down deep to act better.

Persons with BPD often have a high level of interpersonal skills, as evidenced by their ability to manipulate others. You should try to keep their considerable strengths in mind as you interact with them.

You should aim to validate the BPD’s reality and try to make sense of their behavior within their current interpersonal environment. See my post Validating Invalidation from Sept. 23 to get a better idea of the importance of being willing to validate someone when that someone is practically inviting you to invalidate him or her.

The troublesome behaviors of the BPD must be looked at not as a problem with the BPD but as imminently reasonable and understandable responses that derive from a problem for the BPD. You should not view the BPD as psychotic, malevolent, immature, or unintelligent but as someone who is struggling with a highly dysfunctional social network.

Remember, you yourself are very likely to be an important part of that dysfunctional social network, so please do not act like you think that you are superior to the BPD in any way. If you do, you are inviting the BPD to knock you off of the pedestal that you put yourself on, and you will not know what hit you.

Never treat the BPD as if he or she is fragile or incapable of being reasonable, particularly when tension occurs in your relationship. Ultimately, no subject should be thought of as too sensitive to discuss. While you should be sensitive to such issues such as incest or family violence, you should try to talk about them when they arise calmly and reasonably even in the face of the BPD’s anxiety or acting out (This ain’t easy, and it is where a therapist for you would be useful if not indispensable).

If you do not agree with what a BPD says, calmly say you disagree without making an issue of who is right and who is wrong. If you feel that something you have said or done is being misinterpreted or being taken out of context, kindly explain what you had meant to say or do without trying to convince the BPD that they got you wrong the first time. Therapist par excellence Lorna Smith Benjamin employs what she calls the Caribbean Solution, named for the behavior of a hotel clerk confronted by an irate guest. You remain calm and friendly but continually reiterate your own opinion about a disputed interaction.

Lorna Smith Benjamin

Be scrupulously honest. If you actually have done something wrong, do not deny or minimize it, but do not go into a big mea culpa either. (The best way to come clean if you were physically or sexually abusive to the BPD when he or she was a child is another matter and will be discussed in a future post). On the other hand, I have seen individuals admit to things they had not done in order to pacify someone with BPD. Not a smart move.

You will have to be comfortable with your own limitations concerning what you can or cannot do for the BPD. Be respectful of your own needs. Never rush in to “take care” of the BPD in an infantilizing manner even when the need to do so seems to hit you across the face.

You cannot be afraid of the BPD’s anger, neediness, or anxiety; and you must be completely unwilling to attack him or her in the face of provocation. Once again, this is where a therapist for you might be necessary.

In summary, be relentlessly respectful of BPD’s suffering, abilities, and values. Be humble without disrespecting yourself or your own well being. Be honest. Communicate an expectation that the BPD will be able to behave in a reasonable and cooperative manner, and play to the BPD’s strengths. And keep it up, or ye olde variable intermittent reinforcement schedule will rear its ugly head.

Diagnonsense: an editorial

I published an op-ed piece in the Memphis newspaper, the Commercial Appeal, on Sunday, November 21, 2010.  It was also picked up by the Associated Press newswire.  You can read it at:

http://m.commercialappeal.com/news/2010/nov/21/my-thoughts-its-never-too-late-to-tackle-issues/

or at:

http://m.apnews.com/ap/db_15980/contentdetail.htm?contentguid=cPLIA3og

Changing the Rules of A Game That Will Not End

You can check out any time you like

But you can never leave

    -----The Eagles

Why is it so damn difficult for family members to stop engaging in repetitive behavior that is clearly driving them all nuts?  Back in baby boom lore, we used to refer to a big question like that as the $64,000 question, in reference to a TV quiz show.  But hey, there's been inflation, so now if we want to refer to a TV game show question, we have to call it the million dollar question.

One reason it is so hard to change was described way back in 1967 by Watzlawick, Beavin, and Jackson in a book called Pragmatics of Human Communication. It was the first book to look at the linguistics of family dysfunction.  That subject later became the main theme of a book that I wrote called Deciphering Motivation in Psychotherapy.  One of the most interesting and curious concepts introduced in the Watzlawick book was called the game without end.  The book describes what happens when someone in a family steps out of a role that they had, up to that point, always been playing in their family system, and tries to get everyone else to change the rules by which the whole family operates. 

What often happens is that no one else in the family is certain that said individual really wants the change he or she is requesting, because he or she had compulsively played the role all the time up to that point.  Leopards do not change their spots, after all.  They all suspect that the request is, in reality, just another maneuver in the same old game that had been going on up to that point. Therefore, no one else takes the request seriously.  This happens even when everyone else covertly would actually be happy with the changes.

The example Watzlawick et. al. used to illustrate what they were talking about was cute, but I did not quite understand exactly what it would mean for a real family.  They imagined a family where the rule was that everything anyone said really meant the exact opposite of what it seemed to mean.  How would anyone in this family go about trying to change this rule? 

If someone said, "Let's change the rule," this would naturally be taken by everyone else to mean its opposite, "Let's not change the rule." Therefore, the rule would stay the same.

Aha, you say.  Why couldn't the person requesting the rule change just say, "Let's not change that rule."  By the original rules of the game, this statement should be interpreted as a request to change the rule.  Not so fast! Remember, everything said under the old rules is supposed to mean the opposite of what it seems to mean.  The request not to change the rule would in fact seem to be a request to change it.  Therefore, under the old rule, it would be interpreted to mean the opposite of that, namely, "Let's not change the rule."

No matter what anyone said about the rules, it could therefore be interpreted to mean a request to go on playing the game with the original rules.  Every move to change the rules of the game could be interpreted as a strategic move to make them continue.

Clever, but what family would ever operate by such a bizarre rule?  It took me a while to truly understand the game without end, but let me see if I can explain it to readers. To understand it, let me describe some actual rules under which real families do operate, and how they can be devilishly difficult to change.  

I will start with a very typical example that you might just recognize.  Let's say a middle aged couple had always operated under traditional gender rules and roles, so that the man had always been the breadwinner and the woman had always taken care of the house and the kids.  After the kids leave, one of them, say the wife, decides that she is really bored being just a housewife and decides to get a job.  Her husband is actually really happy that he no longer has to be the only one responsible for making money, since that had been a real burden for him, even though he had guarded the breadwinner role rather jealously.

The wife tells the husband that, since they are now both working, she wants him to start to help with the laundry, the dishes, and maybe the housework.  He says he agrees, since it's only fair.

We know what typically happens next.  He never starts doing the housework that he promised to do unless she specifically asks him to each and every time.  Never shows any initiative.  She finally gets frustrated having to constantly nag him about the housework, gives up, and angrilly starts to again do the housework all by herself.   The husband is a typical male chauvinist pig, right?

Wrong.  What happened when he first started doing, say,  the dishes?  What happened was that she kept telling him he was not doing it right!  He was putting them in the wrong cupboard, he was missing a spot or two, he was using the wrong detergent, whatever.  The husband starts to think that maybe she really wants to continue to be in charge of the kitchen, like she always has been, and does not really want him there in spite of her request.

He will not tell her of this belief, because he knows she will get angry with him and deny it.  Unbeknownst to him, she is secretly feeling vaguely guilty about making him do the housework, because she was raised in her own family of origin to believe that doing so was the woman's job, and she is guilty of derilection of duty.  She will not admit this to her husband, because she really does want him to help with the housework, despite her overall ambivalence about it.

From her perspective, he keeps doing a poor job in order to get her to take over the tasks again because of his own selfish wish to avoid housework, not because he might think she really wants to keep doing it herself.  After all, she thinks, he actually does know what soap to use, where they keep the dishes, and that he is doing a poor job.  He just acts like he does not.  In actual fact he does indeed act that way - but only because he thinks she's just looking for an excuse to nitpick so she can take over.  When she does nitpick, that convinces him even more that the real reason she nitpicks is because she wants to remain in charge of the house.  Still with me?

This situation is all the more complicated because all these events, mixed signals, thinking about the motives of the other person in the relationship, etc. go on simultaneously.  They do not follow sequentially one after the other.  Understanding this aspect of human interaction was one of the most difficult problems I faced when I created my treatment paradigm, which I call Unified Therapy.  We are all used to thinking sequentially rather than seeing everything as simultaneous.  Systems theorists call this linear thinking.  A leads to B which leads to C, etc.

Systems theorists, on the other hand, see what's going on as a feedback loop - like a vicious circle - but that is not accurate either. The events in the feedback loop are thought of by systems people as sequential even as each even feeds back to the next.  A leads to B which leads to A1 which leads to B1, etc. The mutual (two-way) and simultaneous nature of human interactions is better accounted for by something called dialectical thinking, which I will not go into here.

But why do the people in this situation follow the "new" rules in such a half-assed, irritating manner, when they know doing so will almost certainly elicit criticism by the partner?  They do so because they already think they know what the other person really wants, so they are just providing him or her with an excuse to do what he or she seems to want to do anyway.  They allow the other person to blame them for what is actually a shared problem.  So very thoughtful.

Here are some more examples of the game without end from Deciphering:

1. A wife had been encouraging her husband to be more honest about his true feelings. Consequently, he began to express himself, but in a loud, abrasive, and embarrassing fashion - and in front of her boss.   (Not in the book: he's thinking about the girls he knew in high school.  Which type of guy got to go out with the most popular girls - the sensitive, touchy-feely guys or the macho football players?  Does she really want him to act like the former?)

2. A mother finally got her twenty-five-year-old son to get out of the house and find a job; he opted for a low-paying job at a fast food
when he had been offered a high-paying apprenticeship.

3. The same mother got the boy to fill out his own tax return; he then claimed himself as a dependent so she could not claim him, even though she was still supporting him.

4. A husband had been encouraging his wife to pursue her long-repressed desire to have a career. When she finally got a job, she chose one in which she had to work a different shift than he did. As a result, the couple never had any time to spend together. When he complained, she told him that he never really did want her to be more than a housewife.

5. A young couple encouraged the wife's mother to learn to drive after the death of the wife's father so mom could be more independent.  The mother indeed learned to drive.  However, she would never drive to visit the couple because, she said, they lived too far away. However, the mother would regularly drive a similar distance in another direction.  (She secretly believed that the only reason the couple wanted her to drive was so they could use her as a baby sitter).

There is relatively simple way for game players to end the game without end, but I will save that for a later post.

None Dare Call it Acting Out

Recent headline (November 11, 2010) in the Memphis Commercial Appeal newpaper:  "Survey: 1 in 10 U.S. children has ADHD."  One in ten.  Imagine that!  "Biological" psychiatrists believe that ADHD is a genetic and/or neurodevelopmental disorder.  I can't think of any other such disorder that effects 10% of the entire population.

The survey was performed by the U.S. Goverment.  According to the newspaper article, this represents a "sizable increase from a few years earlier that might be explained by growing awareness and better screening."  Specifically, the number represents an increase of 22% from 2003 to 2007.  The actual numbers of affected kids would be 5.4 million children - an increase of about one million in that period of time. Two thirds of the children were on medication.

Of course, the study seemed to just assume that the diagnoses were all valid.  Surely there are more parents aware of ADHD than ever before, so the "increased awareness" part of the story is undoubtedly true. 

The statistics for the "incidence" of childhood bipolar disorder (also called pediatric bipolar) are even more striking.  Prescriptions for powerful psychiatric drugs to young children for this disorder quintupled in less than four years.  The graph below shows the amazing increase in private office visits for bipolar disorder in children under twenty. 

Source: Pharmed Out

Of course, real bipolar disorder often first manifests in sufferer's late teens, and rarely occurs in children - as reflected in the number of office visits shown in '94-95, before pediatric bipolar diagnosis became a fad.  For decades, the incidence of bipolar disorder was pegged at about 1%, but now suddenly it is almost 5%.  This figure includes many who are diagnosed as "bipolar II" or "bipolar NOS" (see my post of July 24, 2010, Counting Symptoms that Don't Count for a discussion of how the designation NOS has been misused in defining bipolar disorder).

The dramatic increase in diagnosis of both ADHD and pediatric bipolar (without any change in the gene pool) is more strong evidence for the main thesis of my book, How Dysfunctional Families Spur Mental Disorders.  An upspoken and unholy alliance between pharmaceutical companies, biological psychiatrists, and overwhelmed and guilty parents has led to the disappearance in many mental health circles of the use of the term acting out in children in favor of a brain disease model for out-of-control children. 

As defined by Psychcentral.com, acting out is performing an extreme behavior in order to express thoughts or feelings the person feels incapable of otherwise expressing. Instead of saying, “I’m angry with you,” a person who acts out may instead throw a book at the person, or punch a hole through a wall. When a person acts out, it can act as a pressure release, and often helps the individual feel calmer and peaceful once again. For instance, a child’s temper tantrum is a form of acting out when he or she doesn’t get his or her way with a parent. Self-injury may also be a form of acting-out, expressing in physical pain what one cannot stand to feel emotionally.

Heaven forbid we should look at the problematic parenting trends described in detail by parenting columnist John Rosemond or the staggering incidence of child abuse and neglect in creating acting out.  How much more comforting for parents to think they bear no responsibility for how their children turn out.

Nothing Other than Stupid (NOS): Is Being a Rapist a Mental Disorder?

This post relates to two seemingly unrelated topics that were subjects of previous posts.  First, in my post of July 24, 2010, Counting Symptoms that Don't Count, I mentioned the improper use of the "NOS" category of psychiatric disorders in the DSM, psychiatry's diagnostic manual.  NOS stand for not otherwise specified.   This designation is used for patients who just barely miss DSM criteria for a particular disorder, like someone having manic symptoms for six rather than the required seven days, but who are suffering distress and/or dysfunction from their symptoms similar to that from the real thing.  It is not supposed to be used for people who just sorta kinda somewhat resemble people with the disorder on some dimension or other.

Second, in my post of November 3, 2010, Psychiatry Bashing, I kvetched about how pressure from the public is one of the major factors that has led to the misuse of psychiatric drugs and diagnoses by psychiatrists.

Now, one of the things the public is often somewhat hysterical about, and justifiably so, is the release of violent sexual offenders such as serial rapists after they have served their prison sentences.  However, as pointed out by Allen Frances in an article in the September 2010 issue of Psychiatric Times, the length of prison sentences for these felons is partially a product of the public's own misguided pressure on politicians. 

In their zeal to deal with judges who were perceived as "soft on crime," large segments of the public demanded fixed sentences for various crimes, rather than allowing the judge any discretion in the matter.  This actually led in some cases to sentences for those who were termed Sexually Violent Predators (SVPs) that were much shorter than they would have been had judges been allowed to use discretionary sentencing. (This problem has lately been correcting itself, but those sentenced under the old guidelines still have to be released).

What to do?  Well, according to Dr. Frances, twenty states and the federal government have passed laws allowing continued incarceration of SVP's, often for life, in psychiatric settings.  This is, in effect, preventive detention, which is generally considered a violation of due process and unconstitutional in legal circles.  Nonetheless, the Supreme Court has ruled that SVP statutes are constitutional on three different occasions.  In order for SVP's to be subject to preventive detention, however, the court ruled that their dangerousness must be the result of a "mental disorder."  Trouble is, they refused to exactly define what qualifies as a "mental disorder."

This has led to extreme pressure on forensic psychiatrists to invent specious diagnoses in order to protect the public from serial rapists and other SVP's.  One way to do that is through the use of the "NOS" category.  The DSM lists several sexual perversions (paraphilias), such as exhibitionism or fetishism, as mental disorders.  The  definition of a paraphila is recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving nonhuman objects, the suffering or humiliation of oneself or one's partner, or  children or other nonconsenting persons.

By the general definition of a paraphilia, it would seem that a serial rapist would qualify, since rape involves non-consenting persons as well as the suffering and humiliation of the victim.  However, rape is not listed in the DSM as a mental disorder.  Most people correctly think of it merely as a crime.  So under pressure forensic psychiatrists came up with paraphilia NOS, nonconsent. This seems to me to be just a made up diagnosis used to deny criminals due process.  It sure is not in the DSM.  (Then again, why is having a foot fetish a mental disorder?  That is in there).

Psychiatry bashers would undoubtedly have the opinion that forensic psychiatrists are, once again, acting like Nazis.  This opinion does not take into account at least two essential considerations: forensic psychiatrists are under tremendous pressure from all sides to protect the public from SVP's (and who would want to be responsible for unleashing one?), and for a variety of reasons the public is loathe to make rape (or even pedophilia, for that matter), a crime punishable by life imprisonment.

If you were forced into a choice between setting a SVP loose on women everywhere, or making up a diagnosis, what would you do?  Readers?

50 Excellent Therapists Who Blog

Here's a website with an excellent list of blogs by psychotherapists:

http://www.nursingschools.net/blog/2010/11/50-excellent-therapists-who-blog/

I'd like to thank Nursingschools.net for including mine.

Psychiatry Bashing

Anyone who follows this blog or who has read my new book is well aware that I am highly critical of many of my colleagues in the mental health professions. Drugs are prescribed inappropriately and dangerously, diagnoses are made cavalierly and without considering all the evidence, relationship problems and family dysfunction are ignored, and some therapists think that an unresoved Oedipus Complex is the final common pathway for all mental and behavioral problems, or that food pellets and electric shocks are more important than relationships in shaping human behavior.

Furthermore, I have written about how many so-called psychiatric "experts" are in bed with the pharmaceutical companies and how managed care insurance has done its best to devalue all psychiatric treatments.

My own brother-in-law stated, after he read my book, that on the basis of what I had written he would be reluctant to consult any mental health provider.

Nonetheless, I know that there are a lot of ethical and competent psychopharmacologists and psychotherapists doing fine work out there.  They have just become a bit harder to find.  In my book I tell the reader what to look for when they first visit a new clinician.

Folks, there is more than enough blame to go around for the current troublesome trends in the mental health field.  Another party also worthy of blame is the American public.  In fact, none of the horrible practices in mental health could have taken root without the American public's enthusiastic support and participation.

Consider the following: a lot of people these days seem to be looking for a quick cure for everything. For all the anti-drug hysteria in this country, people want to be medicated for everything. Do the hard work of therapy on your relationships? It's too much work!

Distracted at home or at work?  Taken an Adderal.  Doctors will hand them out like water.

As one psychiatry blogger, FunPsych, pointed out, "...many Americans, if given a choice between exercising for an hour a week versus taking a weight-loss pill, would choose the pill...Furthermore, Americans are already overworked and feel pressured to work even more. At least half the patients that I've seen that I want to do therapy with just don't have time for it."  Or so they say. 

Kids out of control? Do most parents want to look at their own parenting practices to see if they are contributing to their children's behavior problems? Some may write to get free advice from the Supernanny and get on TV, but I've already placed several posts about the answer to this question.  Rampant child abuse and neglect?  Nothing but implanted memories and false accusations, according to many.

A psychiatrist who wants to do the right thing can go bankrupt.  If a resident fresh out of training is looking for a job, he or she will find this situation as described by another psychiatry blogger, Pacificpsych: 

"Show me one [psychiatry] job in the entire US ... that entails psychiatrists doing therapy. The entire system consists of psychiatrists being forced to medicate, as well as them being controlled by insurance, UR people, nurse admin, non nurse admin...Show me the clinics or hospitals where you can get a job doing anything else but medicating patients." 

Rehabilitation for schizophrenic patients instead of just meds?  The public will not pay for it, and therefore it has become nearly non-existant in the public sector, and almost as rare privately.

Mental health is the first thing that is cut when state finances get tight?   Why?  I'll tell you why.  Because the mentally ill do not vote, and most of the public does not give a sh*t.  Because many politicians seem to think the mentally ill are all slackers, agreeing with the rabid antipsychiatry zealots (more on them shortly) that all mental illness is a myth. (How ironic that Ronald Reagan suffered from a mental illness - Alzheimer's disease - for the last part of his life).

And then we have the antipsychiatry lot who seem to be incapable of making any distinctions at all. All psychiatric drugs damage people and do nothing else, according to these people.

Apparently they believe there is some vast worldwide conspiracy to ignore the supposed horrific dangers of, say, antidepressants (which have been in use since the 1950's), and that the FDA as well as legitimate FDA watchdog groups like Public Citizen (not to be confused with Scientology's Citizens Commission on Human Rights) have somehow completely missed the millions and millions of patients around the world who have been destroyed by these widely-used and popular drugs.

But we know the FDA is completely in the hip pocket of the pharmaceutical companies.  (Of course, the FDA put a "black box" label on antidepressants on the basis of rather minimal evidence warning of potential suicidal ideation caused in teens and children.  How did that ever happen?)

I received a few comments on one of my blog posts by one reader that I decided not to post. I'd like to share some of them here: 

"Psychiatry is an evil profession, and you know it...Psychiatry has changed very little since 1938, when it was the training ground for the SS - exterminating up to 100,000 German citizens who were deemed "mentally ill" with 'special treatment'...Is psychiatry an evil profession? Absolutely...

I looked [at your blog]. What I found was the writing of a guy who wants to be different from his peers, but isn't. You have very little respect for people who suffer. One minute, describing how their condition is related to past trauma, the next minute ridiculing their behavior. You wrote the book on personality disorders, it appears. Yet your own personality is about as twisted as any person I've ever read...You seem to be a very miserable person, an abusive person...Your arrogance leaves me nauseated...You are an abuser, and YOU KNOW IT !!!!!!!!!!!!!!!!!!!!!!!!!!!!!"

Let's see. If I use a little snarky humor or exaggeration in a blog in order to make a point and to entertain readers (guilty as charged!), then of course I surely must consistently and abusively ridicule my own patients. I suppose I should never see any black humor in my patients' horrible predicaments; if I had any empathy at all I would be depressed along with them. (That's what patients really need: a doctor who is as depressed as they are).

This guy says I am a knowing participant in an evil profession. Psychiatrists like me who have committed people who are a danger to themselves or others are no better than the Nazi psychiatrists who helped exterminate the mentally ill during WWII.  Yes, I know all about Ernst Rudin and the eugenics movement - you will find an interesting discussion of it in Chapter One of my new book.   I guess that makes me a Nazi. There will undoubtedly be a picture of me with a Hitler mustache on some placard someday.

He accuses me of all these horrible things and yet he tells me I am abusive? That's rich! Pot, meet kettle.

Are patients who are terrified by persecutory delusions and hallucinations and who are found running nude on the freeway by the police better off in jail, where many of them in fact are now, or on Skid Row, than in a hospital? 

Pacificpsych also said, "...even psychiatrists who are completely opposed to the current system have no power to change it. They are trapped, unless they are in private practice and doing well there. YOU, yes YOU need to help us. Go to the administrator of the clinic, call the health insurance/medicare/medicaid administrator, call your senator and congressman. Demand that you get proper treatment. That means spending as much time with your psychiatrist as you and your psychiatrist feel is necessary..."

How to Disarm a Borderline, Part II

In my Part I post of October 6, I described how a lot of the difficult behavior of patients with borderline personality disorder (BPD) in their intimate relationships is designed to elicit in the observer one of three reactions: anxious helplessness, anxious guilt, and overt hostility.  Furthermore I expressed the view that, even though they will make herculean efforts to induce these reactions, and are very good and finding other folk's vulnerabilities in order to do so, they secretly hope they will fail in their efforts. 

Every time they succeed, they will do more of whatever it was that worked; every time they fail, they will do less of whatever did not work.  They will not give up easily, and if they've known you for a while, if one trick does not work, they will have a whole repertoire of other behaviors from which to choose. They will know how to push all of  your buttons in the most effective way possible.

Last, because of the variable intermittent reinforcent schedule, if you only occasionally react in the "wrong" way to them, that is worse than reacting badly to them all the time, because they will try that much harder and longer to elicit the "desired" response.  I said that in my next post I would start by saying what not to do. 

Here it is.  It's fairly simple, so this will be a relatively short post.  In future posts I will suggest counterstrategies for the most typical BPD strategies for eliciting the three responses, and then finally advise readers about what to do in the inevitable event that they slip up - so that the variable intermittent reinforcement schedule does not kick in.

IMPORTANT CAUTIONS:  Please be advised that sticking to this program is extremely difficult, so the services of a therapist who knows about these patterns are usually necessary.  Also, this section is designed for adults dealing with BPD adults - over 23 years old, actually.  This is not necessarily what you should do if you happen to be raising a teenager with BPD traits.

Without further ado, what not to do:

A. Try to please the unpleasable.  If they put you in a damned if you do, damned if you don't position (a double bind), try to do something to please them anyway.  If they "yes-but" all of your suggestions for solving any problem they present to you (that is, if they reject any and all offered solutions with a sentence that has the structure, "Yes, I could do that, but...), keep offering more solutions.  If they ask you to do something that is clearly impossible, try your best to do it anyway.

They never forget you have a choice

B. Make sacrifices for them.  Stay up all night talking with them and trying to reassure them about their latest emotional debacle when you have to go to work the next day.  Give them thousands of dollars to help get them out of a financial bind that they had put themselves in with profligate spending and irresponsible behavior.  Drop everything you are doing and rearrange your schedule for the entire day so you can do something for them like right now, even though the chances are 50/50 they will not even be there when you get to their abode - and be sure to cancel any planned activity that you've been looking forward to forever.  Drive a hundred miles out of your way to take them somewhere.

C. Get defensive.  Say, in frustrated tones, "You know, I'm only trying to help you" or "Don't you understand that I have other things to do?"

D. Act hostile.

E. Act guilty.  Because you know down deep you should be able to solve impossible dilemmas, and that their behavior is probably all your fault anyway.

F.  Stand there and take it like a (foolish) man.  Are they slapping you around?  Verbally abusing you will a barage of invective?  Impugning everything you stand for?  Screaming at you?  Just stand there and let them.  Maybe they'll stop.
 
G. Return in kind.  I knew a psychiatrist who got so upset with the verbal nastiness of his patient that he told her she was a dog and that she should have consulted a veterinarian.   See if you can stop the BPD person's pain-seeking behavior by inflicting more pain.

H. Lecture them.  Tell them all about how cocaine is harmful, that they should leave an abusive relationship, or that they should not ride their bicycles at midnight through crime-ridden parts of town in a bikini with hundred dollar bills hanging out their bras.  After all, they are just too stupid to figure these things out for themselves.  They'll tell you they think cocaine is good for them.  Argue the point.

I. Try to rescue the help-rejecting complainer.  Go to their house to try to take them away from an abusive romantic partner.  Let them move in with you rent free.  Loan them money that they will never pay back.  Try to mediate their disputes with others (trying to physically get in between two fighting adults is particularly important - maybe they'll both start in on you).  Cuss out the people who they claim have mistreated them.  Go ahead, I dare you.

APA vs. APA

MANAGED CARE SHOCKER!   Imagine my surprise when I opened my mail and found a letter to me from AmeriChoice by UnitedHealthcare managed care insurance company telling me that psychiatrists were not referring enough of their depressed patients for psychotherapy (presumably to psychologists and social workers.  Nothing was said about psychiatrists doing the therapy themselves).

The letter went on to say that "evidenced-based medicine" has shown that the combination of antidepressants and psychotherapy is more effective than either alone.  This letter was almost as bizarre as another letter I had received not long ago from another managed care company telling me that Abilify or any other atypical antipsychotic medication is not the first choice in augmentation medicine for patients with major depression who do not respond to an antidepressant alone.  No sh*t, Sherlock!

The letter about psychotherapy, as well as the one about about misuse of certain brand-named drugs, is a sick joke coming from managed care, which joined forces with the pharmaceutical companies in the late nineties to try to destroy psychotherapy as we know it.  As I describe in my new book, managed care companies routinely paid psychiatrists a lot more for doing med checks than for doing psychotherapy. In response, psychiatrists stopped doing therapy for the most part, and they began to see medication as a cure all for everything and appropriate for everybody.

Then, mangled care companies started lying to their subscribers about how much psychotherapy was covered under their insurance plan.  In their reading materials, the companies might say that 20 sessions per year were covered, but then they would only certify 4 or 5 sessions as "medically necessary" and refuse to cover any more.  Therapists would then have to spend hours on the phone arguing with clerks about what treatments were medically necessary.  The clerks would try to intimidate the therapists.  Why, the therapist must not be very competent if he or she could not cure the patient in four or five sessions!

For the record, 20 sessions in most mainstream psychotherapy models is itself considered brief therapy, which is most appropriate for patients who are relatively high functioning, have at least some good relationships, and have a single, very well-circumscribed conflict to manage. Diagnositically, they would have only one disorder (no co-morbidity).  This type of case is today rather unusual because patients with anxiety or depression generally have behavioral and relationship issues as well.

In other words, brief psychotherapy works best for the so-called "YAVIS."  YAVIS means young, attractive, verbal, intelligent, and successful.  One might ask why such an individual would even need therapy in the first place.  And, of course, they tend to get better no matter what the therapist does.  For patients who are the most in need of psychotherapy - such as those with serious personality disorders, alcohol and drug abuse, and/or long term repetitive self destructive behavior - brief therapy accomplishes very litle.

After a while, mangled care insurance companies found out that it was not cost effective to hire clerks to argue with therapists, and they were also getting a bad name with employers who are the primary ones purchasing insurance.  I recall a managed care group losing a contract with Matel Toymakers in Southern California because they did not certify as medically necessary psychotherapy for patients who were referred for treatment by the company's own Employee Assistance Program (EAP)! 

So insurance companies quit that strategy and merely racheted down fees for ALL psychotherapists. 

This practice, they found, had a side effect that was just perfect for their ultimate bottom line. Suddenly, psychologists who never before had the slightest interest in prescribing psychiatric medication wanted prescribing privileges.  It was all an issue of money, and little else really. 

(The problem with psychologist prescribers, from this psychiatrist's point of view, is that psychiatric medications not only affect the brain, but may interact with all other organ systems, diseases, and non-psychiatric medications.  If you want to do it, IMO you should go to medical school.  Of four psychologists first trained in psychopharm by the Armed Services, two of them decided to do just that).

Instead of banding together to fight for their patients' needed access to psychotherapy, as well as for their own need to all get paid at rates comparable to other highly trained professionals, the American Psychiatric Association and the American Psychiatric Association got into a turf war over prescribing privileges.  I have come to believe that mangled care has devised a strategy to divide and conquer.  If they did, they were successful beyond their wildest dreams. 
                                                                                                                        

And now they have the audacity to complain about psychiatrists and psychologists not working together, because it would actually save them money? This may seem self-serving coming from a physician, but it is true: Your friendly neighborhood health insurance carrier does not give a good God damn about their patients' mental health.