Monday, May 30, 2011

The Limits of Cognitive Psychotherapy

The purveyors of the type of psychotherapy known as cognitive-behavior therapy (CBT), which is currently the predominant psychotherapy paradigm being taught in psychology graduate degree programs, like to claim that their type of therapy is the most "evidenced based" of all psychotherapies and is therefore vastly superior to the more humanistic and relationship-oriented types of psychotherapy. 

It is true that they have more studies than anyone else, but that is because they have very limited treatment goals which are very easy to measure, and they do not study complex people who have a lot of different (comorbid) psychological problems.  Even so, their claims of the superiority of their evidence base are highly inflated.  I go into exactly how in detail in How Dysfunctional Behavior Spurs Mental Disorders. 

It is also true that they control the funding for psychotherapy outcome research and deny the followers of other schools a chance to prove their mettle in randomized clinical trials.  Psychotherapy researchers refer to the "cognitive behavioral mafia" at the National Institute of Mental Health.

One of the major components of CBT is cognitive therapy, first pioneered by psychologist Albert Ellis and then refined by psychiatrist Aaron Beck.  Cognitive therapy is based on the idea that human beings are fundamentally irrational creatures in that they make a lot of logical errors whenever they assess the risks and benefits of various situations and courses of behavior.  These irrational ideas then lead to out of control emotions like unreasonable anger and depression.

Albert Ellis
 Ellis speaks of people "depressing themselves" with worst case scenarios (catastrophizing), or by drawing broad conclusions from single examples (e.g., "Since I failed this test, I'll fail all the ones in the future" - overgeneralizing), or by setting up absurdly high standards for themselves with a lot of musts and shoulds.  He liked to call this last one "shoulding all over yourself."

Aaron Beck
Cognitive therapy is designed to employ something called collaborative empiricism.  The patient and therapist get together to discuss the logical fallacies in some of the patient's thinking and to objectively examine the "evidence" for his or her beliefs.  If the individual can become more of an objective, empirical, scientific type, he or she will not experience chronically negative emotional states - or so the reasoning goes.

A current and popular version of cognitive therapy is called Acceptance and Commitment Therapy (ACT).  At slight risk of oversimplifying this therapy, it consists almost entirely of trying to teach people that they do not have to believe everything that they think.

It's interesting that when CBT therapists start to deal with more significant self-destructive behavior, such as that seen in personality disorders, then what they do starts to look a lot more like what humanistic or relationship-oriented psychotherapists do.  IMO, one big reason for this is the existence of certain types of beliefs that human beings tend to hang on to as if their lives depended on it, notwithstanding even the most obvious evidence to the contrary. 

This type of belief was first identified by psychoanalytic pioneer Karen Horney.  She referred to them as positive value blockages, for reasons I will describe shortly.  They are held by individuals.  Later on, family systems therapists noted a similar phenomenon at the level of the kin or family group.  They called these collectively held notions family myths.  Of course, dogmatic myths are also seen at the level of the subculture, where one might refer to them as theology.

Karen Horney

Try to challenge these beliefs, and in response you get a version of," My mind is made up; don't confuse me with the facts." Trying to challenge the rationality of positive value blocks or family myths using cognitive therapy is like trying to convince a Birther that President Obama was born in Hawaii.

Horney's idea of positive value blocks, which she conceptualized as defense mechanisms, is tied to the idea of a false self, which also called a persona.  Children growing up in dysfunctional families who are subjected to rejection, brutality, withering criticism, ridicule, and/or hostile control will feel safer when they act in certain ways which are rewarded by the family environment, but which may run counter to the way they really feel deep down inside of them.  The different sorts of behavior that fill this bill leads them to develop certain character types. 

According to Horney, when such children - and later when they become adults - act in these ways, they often pretend to be proud of their behavior, but deep down they feel alienated from themselves and full of self-hatred.  This neurotic or conflictual pride is a glorification of a phony self.  This false pride is usually supported with a number of ideas which justify the character type.  These ideas often take the form of proverbs or slogans such as, "Nice guys finish last."  Such ideas act as blocks to the expression of a person's true self (which might wish to be nice), and this is what is meant by the term positive value blockages.

An individual's family often not only shares these beliefs, but lives by them.  Some beliefs can be specific to certain individuals within the family (for example, what one family member is "really" like and who within the family he or she is closest to), while others apply to everyone.  The ideas in this context are what is referred to as family myths.  They justify and support a set of rules which dictate how each family member should behave, and what family roles each must fully and compulsively play, in order for the family to function in a predictable way (family homeostasis). 

The myths function as a belief system which the family uses, often defensively, to explain its experience to itself.  They are sometimes not verbalized explicitly so as to avoid any challenges to them. They can be taught implicitly through various forms of acting out and family rituals.  However, they may also take the form of oft-verbalized adages just like positive value blockages do in individuals. 

I had one patient who justified never trying to change a bad situation with three different proverbs:  "the grass is always greener on the other side," "the devil you know is better than the devil you don't know," and "you've made your bed so now you have to lie in it."  All three slogans had been repeated to her ad nauseam by her parents when she was growing up.

Therapists, challenge these ideas without understanding how central they are to a person's psychology at your own risk.  Your patient will fight you tooth and nail, and you will get absolutely nowhere. Cognitive therapists, put that in your pipe and smoke it.  Or is that just another family myth?

Wednesday, May 25, 2011

Pro-Death Florida Legislators Run Amok

A physician determines that a patient, while not an imminent suicide risk, is a longer-term risk.  The patient has a history of impulsiveness, and under an acute stress might make a sudden and thoughtless decision to take his life.  The doctor inquires if the patient owns a firearm, and the patient answers in the affirmative.  The doctor advises the patient to get rid of the guns in the house so as to prevent any quick, irreversible decisions that might be made by the patient in an agitated state.

Someone in law enforcement finds about this and reports the doctor.  The physician is then arrested and convicted of violating Florida Bill 432.  He is then sentenced to five years in prison, and fined five million dollars.

I bet you think I am making this up, but believe it or not, this bill was actually proposed by members of the Florida state legislator, and similar proposals are planned by the NRA in several other states:

The bill would make it a felony for a physician or any medical worker to ask a patient or the patient's family whether they own a gun.  This might include prohibiting pediatricians from advising parents on gun safety issues when there are children in the house.

After a large protest from physicians, the bill was finally amended to offer an exception to the legislation that would shield doctors from prosecution in cases that involve mental health issues, such as the patient who is suicidal.  It then passed both Florida houses and is expected to be signed by the governor.

Now contrary to what you might think, I tend to be rather right wing on the subject of guns and gun control.  I want firearms to remain legal and available.  I worry far more about collective violence than random crime, since many more people have been killed by groups and by governments over the years than by criminals. 

The governments of Syria and Iran would have a lot more trouble convincing their troops to mow down political demonstrators if their troops were afraid that they might be fired upon by snipers on rooftops all over the city.  Think something like that could not happen here?  Probably not, but then again, there was this little incident at Kent State in the sixties that came pretty close.  And then there were all those lynchings in the South.

On the matter of doctors advising patients, however, I think the proposed legislation is completely insane.  Besides being a gross violation of free speech, accepted community standards of practice, and professional ethics, it has absolutely nothing to do with the Second Amendment. 

A therapist cannot force a patient to get rid of their guns, although I personally would refuse to treat any potentially suicidal patient who did not agree to do this. 

Even if patients agree, they could lie to the doctor, or go out some time later and purchase another gun.  One patient I know who killed herself checked "yes" on the application to purchase a handgun on the question that asked if she suffered from a mental illness.  They sold her the gun anyway.

Well, you might protest, you do not need a gun to kill yourself.  You could go to a bridge and jump off, or obtain some pills and overdose, or hang yourself in the closet.  What is so important about getting rid of guns?

The answer is that using a gun is quicker and easier than any other method, and usually more deadly.  Other methods take some minimal advance planning, so are unlikely to be employed impulsively.

I'll bet these legislators call themselves pro-life, too.

Friday, May 20, 2011

The False Theory That Refuses to Die

"The great tragedy of Science — the slaying of a beautiful hypothesis by an ugly fact."  ~ Thomas Huxley

The presence in the brain of a "chemical imbalance" is one theory about the cause of certain mental illnesses. Specifically, the basic concept is that neurotransmitters -  the different chemicals that are released from the ends of brain cells into the space between two neurons (synapses) and are the means by which two neurons communicate - are out of balance within the brains of patients suffering with clinical depression or schizophrenia. Therefore, medication which helps these conditions must surely correct these "imbalances."

In the case of clinical depression, two neurotransmitters are thought to be the primary culprits. Because antidepressants increase the amount of serotonin and norepinephrine in synapses, these monoamines or catecholamines - different name for the class of chemicals in which they are classified - this was presumed to be the mechanism of action through which the drugs helped depressive symptoms.

Zoloft Ad

Research into other mental illnesses such as schizophrenia also found that too much activity of certain neurotransmitters such as dopamine was correlated with these disorders.  The basic problem with this theory is that it is wrong. There is no evidence that a "chemical imbalance" is behind serious clinical depression. 

A few problems with this idea: 

First, the effect of antidepressants on serotonin and norepinephrine in the brain is immediate, but the therapeutic effects do not begin to appear until after about a week and a half pass by, and the full effect takes 3-6 weeks.

Second, all of the drugs affect the monoamine neurotransmitters, but some people respond to one but not another, while others do not respond to the first but do to the second.

For a third point, I quote neuroscientist John J. Medina, author of the wonderful Molecules of the Mind column in the Psychiatric Times.   From his April column: 

"When we consider the molecular mechanisms of SSRI interactions, it is easy to resort to commonly taught ideas about interactions that involve a single synapse.  Nothing could be further from the truth. 

The most comprehensive neurological view of SSRI actions must take into account the participation of thousands of individual neurons strung together in coordinated, complex neural networks.

And not just serotonergic neurons.  The cells are in contact with many other central nervous denizens, from adjacent glial cells to the extracelular matarix into which the cells are embedded."

And yet, the monoamine theory refuses to die!  "Biological" psychiatrists have become obsessed with monoamine neurotranmitters and the parts of the neurons which snap them up and react to them - the neurotransmitter receptors. I think that horse has been beaten to death.  Studying receptor physiology will, I predict, not lead to any new drugs with a different mechanism of action from the ones we have now.

The propaganda coming from Big Pharma continues to push the importance of the neurotransmitters and their receptors, even when the significance of many findings of receptor differences is completely unknown.  A recent ad that does this is discussed in Dan Carlat's blog.

For one thing, these monoamines make up only about 5% of all neurotransmitters in the brain.  For another, all the other ones, most notably glutamate and GABA, all regulate each other in a cascade of two-directional influences among thousands or even millions of cells. Last, all neurotransmitters are widespread throughout the entire brain.

Now do not get me wrong.  Just because one theory about how antidepressants work is wrong, this does not mean that the drugs do not work.  Clinically, in properly diagnosed patients, they work fabulously.  I have personally witnessed their dramatic positive effects in literally thousands of patients.

There are other reasons why recent studies seem to show that antidepressants do not work in moderate to mild depression (NO honest study says they do not work in severe depression). Not the least of these reasons is that the drugs have mostly gone generic and Big PhARMA has a vested interest in seeing other, less effective drugs being used.  See my 8/31/10 post, SSRI TalesThe drug company marketing departments are so sophisticated that they use the anti-psychiatry zealots to help them sell more (and more dangerous) brand named drugs!

To those that think antidepressants never work, I have one word for you:  Bullsh*t!

For ages, we did not know how aspirin works.  I am not sure that we really do now.  But it relieves an awful lot of headaches for sure.

Sunday, May 15, 2011

Ve Have Vays of Making You Talk, Part II: Nitpicking and Accusations of Overgeneralizing

In Part I of this post, I discussed why family members hate to discuss their chronic repetitive ongoing interpersonal difficulties with each other (metacommunication), and what usually happens when they try.

I discussed the most common avoidance strategy - merely changing the subject (#1) - as well as suggested effective countermoves to keep a constructive conversation on track.

The goal of metacommunication is effective and empathic problem solving. In this post, I will discuss two other avoidance strategies, nit-picking examples of problematic interactions, and it's opposite, accusations that the person initiating metacommunication is over-generalizing about how pervasive the problematic reaction really is.

I will also discuss counterstrategies that are often effective in getting past these avoidance maneuvers. As with all counter-strategies, maintaining empathy for the Other and persistence are key.

Strategy #2: Nitpicking

In attempting to metacommunicate about behavior patterns within the family system, family members will at some point be forced to discuss particular examples of the behavior pattern that they have in mind in order to make their point. A problem with the use of any example is that, no matter how clear-cut it may appear to be, there will always be aspects of it that are open to nuances of interpretation.

The targeted family member can often sidetrack an attempt at metacommunicating by quibbling with some minor aspect of the metacommunicator's example. Metacommunicators need to be alert to this so that they can refuse to become embroiled in nitpicking discussions about trivial issues. For example, in order for an adult daughter to discuss the effects on her of her mother's unreasonable requests for immediate assistance at all hours of the day and night, she would undoubtedly have to bring up an example of such a request.

The mother could easily sidetrack the issue by quibbling over the reasonableness of any instance that the daughter might bring up. The urgency of a need for assistance is always open to question. The daughter's talk with her mother might turn from an attempt at metacommunication into an argument over how badly the mother needed help three months ago. The issue of the effect of the mother's behavior on the daughter would be entirely lost.

To counter nitpicking, I recommend making statements such as, "Perhaps that wasn't a perfect example, but there are many instances where this sort of thing seems to happen. I think you know what I'm talking about."

A metacommunicator can often bring up a series of sequential interactions that, while all different to some degree, seem to follow a similar overall pattern. The metacommunicator can then talk about the overall pattern while refusing to argue about whether any specific example is truly representative.

Strategy #3: Accusations of Overgeneralizing

Instead of nitpicking, the target may attempt to quibble with the patient's examples of family behavior by accusing the metacommunicator of over-generalizing. No matter how often individuals behave in a similar fashion, there are always times when they do the opposite. A hateful person is at times loving, an incompetent one competent, and so on.

The other person can attempt to contradict a family member’s assertions about anyone by bringing up a counterexample. Just as with someone designing a true-false test, one should be careful to avoid the use of words such as always and never in discussing the behavior of any family member.

If they are caught over-generalizing, metacommunicators can agree that the other person’s counterexample is valid but maintain that most of the time, the person being discussed behaves as they have described. Additionally, metacommunicators can often use the counterexample in the service of strengthening the point that they are trying to make. The counterexample might indicate the presence of a hidden conflict in the person being discussed or might be evidence of some hidden quality that he or she possesses.

An example is a patient who was in the process of metacommunicating with her mother about the family attitude toward men. Although the females in the family seemed to be overly dependent on men, their verbal behavior indicated a marked disdain for them. The patient's mother had, in fact, cleaned up after her fair share of alcoholics. So had the patient.

The mother constantly spoke of how irresponsible the male of the species was and about all the sacrifices a woman must make for her husbands and lovers. These kinds of statements, made in front of both her daughters and sons, had striking effects on the family. The patient and her sisters felt obliged to go along with their mother's opinion; they instinctively rejected any potential suitor who might exhibit strength. Her brothers and nephews, on the other hand, acted as if they were non compos mentis, as if to live up to the mother's expectations.

In the course of the discussion of the family problem, the mother protested that the patient was over-generalizing. While the mother had had several irresponsible partners, her current lover was very dependable. She knew that there were men on whom a woman could count. The patient quickly admitted that her mother's current relationship did seem to be an exception – and a significant improvement.

She added that she realized that her mother wasn't always critical of men. "Nonetheless, in light of your horrible experiences with your own father and your husbands, I can see why you might be concerned about the inadequacies of men. I know your statements are just meant to warn me, but they are still very disheartening."

This example also illustrates a very important principle of effective metacommunication: always give the other person the benefit of the doubt regarding his or her motives, and even praise these motives whenever possible, before describing the negative effects of the other’s behavior on you and asking them to be aware of it. This principle is basically the same one described in my post of April 9, Putting an End to the Game Without End.

Tuesday, May 10, 2011

Let Go and Let God

Al-Anon is a well known 12-Step program that branched off from Alcoholics Anonymous.  It, along with Alateen for adolescents, is a self-help group for the relatives and spouses of alcoholics.  It considers the people who often live with Alcoholics and who either try to "fix" them or cover for and protect them to be "enablers" or "codependents."

Wikipedia defines co-dependency thusly: "It is a tendency to behave in overly passive or excessively caretaking ways that negatively impact one's relationships and quality of life. It also often involves putting one's needs at a lower priority than others while being excessively preoccupied with the needs of others."  In a sense, the co-dependent is addicted to dealing with relatives and romantic partners who are themselves addicted to alcohol.

The alcoholic hides the bottle; the co-dependent finds it and tries to hide it somewhere else.  In almost all cases, the bottle is somehow found anyway.  (This is one of the limitations to studies that try to employ animal models of alcohol addiction.  No one has ever been able to find rats who hide bottles).

Alanon's basic message can be summed up in one phrase, "Let go and let God."  What this is supposed to mean is that co-dependents, like their alcoholics, are too willful.  They wrongfully think that they should, and are powerful enough to, take  responsibilty for the problem drinker.  Hence, they need to "let go" of this need to be powerful, and surrender their will to a higher power.  They need to "let go" and leave their alcoholic's problems for God to take care of, one way or another.

This is actually helpful advice, but not for the reasons advanced by 12 step programs.  12 step programs are based on Protestant techniques that are used to convert others to that religion.  While there is psychology involved, it is a phenomenon that would be most appropriately studied by social psychologists, and sociologists, since it involves group dynamics.

On the surface, "Let go and let God" seems to be advice to not do anything about the alcoholic's self destructive behavior, but to leave it in other hands.  The paradox, however, is that by not enabling, they are in fact doing something - something, in fact, that is completely different.  As I described in my post, The Mother Teresa Paradox, if you constantly try to protect people from themselves, you interfere with their motivation for taking responsibility for themselves.

But it goes deeper than that.  If you compulsively rescue alcoholics, then they and everyone around you will start to think that rescuing them is something you need to do.  Why, if you did not have an alcoholic around, they tend to think, you would not know what to do with yourself.  The alcoholic will not deprive you of this role, so he or she will continue to drink - just so you can keep performing it!

So, if you buy into the Alanon philosophy, and you quit trying to rescue the alcoholic, you take away his or her motivation to keep you "satisfied" in this peculiar way.  Now of course this does not guarantee that the affected alcoholics will for sure stop drinking.  They may decide to leave the relationship and find another enabler, or start destroying themselves without any help at all.

However, by changing their approach in this manner, the "co-dependent" is increasing the odds that his or her drinker will change for the better.  By not doing something, they are doing something: employing one of the most effective interpersonal strategies that exist. 

Thursday, May 5, 2011

Keeping the Customer Satisfied

Recently, a Dr. S. Brown wrote in Medscape:

"A while ago, a patient called me to say he couldn't believe I charged him $50 to tell him he didn’t need a chest X-ray. He was a was a 30-something male patient who had had a cough for a few weeks. He had a short visit, wherein I took a brief history of his illness, did his vital signs, listened to his lungs and told him he probably had a viral bronchitis but didn’t need antibiotics or a chest X-ray; his condition would improve with time. He felt he had been overcharged.

I find it increasingly frustrating to do the right things for patients who feel they are being shortchanged if they don’t leave with either a prescription or a requisition. I attempted to explain to him that I make my living mainly by giving professional advice, not by pushing drugs or ordering tests "

The fact that patients seem to demand a prescription when they go to the doctor has led to such things as the overuse of antibiotics. Viruses, which cause a significant percentage of infections, do not respond to them; only bacteria do. Doctors want to keep patients happy, so often will prescribe them even when they know the patient has a viral infection which will clear up all by itself.  The over-prescription of antibiotics, in turn, has led to the emergence of highly antibiotic-resistant bacteria.

Psychiatrists have taken a lot of heat in some quarters for being overly quick with a prescription pad.  If you go to a psychiatrist, you are in fact very likely to leave with a prescription whether you need one or not.  However, some of this situation is accounted for by patients who demand a medication to solve every problem.  It is not due just to psychiatrists being overly enthusiastic about the wonders of modern medicine.

Not that wilting in the face of a patients' demandingness is a legitimate excuse for the doctor to prescribe drugs for everyday problems in living.  Doctors should be prepared to give patients their honest opinion, whether the patient likes it or not.  If the patient gets upset because the doctor says they need individual or family therapy - or perhaps even no treatment at all - then so be it.  If the patients go away angry and see someone else to get a different opinion, that is their perogative.  There is enough legitimate business to keep psychiatrists busy.

Nontheless, what happens if such a patient goes on some website and gives the doctor a bad review, or creates some other kind of negative publicity?  The government has even discussed the use of patient satisfaction surveys for evaluating a physician's "performance."

What if an insurance company demands a diagnosis or refuses to pay for the doctor's negative evaluation?  I do not know for sure if any managed care company has tried to pull that trick, but I have heard tell about it. 

If that happened to me, I would call the insurance company and demand payment, and immediately resign from that insurance company's provider panel if turned down, because I have to spend time doing an evaluation to find out whether or not a patient needs treatment.  I deserve to be paid for my time.

I can nonetheless appreciate how some doctors can succumb to the temptation to take the easy way out and give patients and insurance companies what they seem to want.  Medicine is a business, and alienating potential "customers" can be a poor way to stay in business.

The medicalization of behavior problems has may causes, and the demands of patients for quick and easy solutions to every problem has to be counted among them.