Wednesday, September 28, 2011

Antipsychotics Are For Psychosis, Not Insomnia Redux

In my post of February 16 of this year, Antipsychotics Are For Psychosis, Not Insomnia, I reported on the increasing off-label (non FDA-approved) prescription of so-called atypical antipsychotic medication for insomnia and anxiety, despite the risk these drugs pose of causing metabolic syndrome (diabetes, obesity, and increased blood cholesterol and triglycerides [blood fats]) as well as an irreversible neurological problem called tardive dyskinesia. 

Somehow doctors - mostly primary practitioners but many psychiatrists as well - have been brainwashed into thinking that this risk is somehow much less than the risks posed by addiction from sedatives and hypnotics  - the old fashioned tranquilizers and sleeping pills. (Tranquilizers and sleeping pills are actually one and the same thing, by the way.  What's the difference?  Marketing.  Some of these drugs are marketed for sleep and some for anxiety, but they all do both of these things).

Anyway, a class of drugs called benzodiazepines are the most commonly used drugs indicated for insomnia and anxiety.  These include drugs like Valium, Librium, Ativan, Klonopin, Dalmane, Restoril, and Xanax.  They replaced the far more addictive and dangerous barbiturates several decades ago.

A newer (and of course much more expensive) group of drugs (Ambien, Lunesta and Sonata) were marketed as being "different" from the other benzodiazepines, so many doctors are much less afraid of prescribing them than the old drugs. 

In truth, these drugs work almost exactly the same way as the older benzo's.  They also cause sleepwalking. And they are every bit as addictive.  In fact, according to my prime source for all things concerning drug abuse, Rolling Stone magazine, the latest fad in D.C. is staying awake while on Ambien. Apparently, you can get really high if you do that. (Now that you know, please don't go out and do it!)

Of course, mild and moderate anxiety and insomnia can often be treated without any medication at all, but don't even get me started on that.

Actually, benzo's (with the possible exception of Xanax, which is very short acting), are not abused by themselves very much at all by addicts.  When was the last time you read a horror story in the news about valium addiction? It is also almost impossible to die from a benzo overdose if no other drugs are taken with them.

The drugs can create trouble, however, when they are combined with opiates - in which case one can overdose on the combination and die.  Unfortunately, this has been happening with increasing frequency lately.  But I digress.

Not only are benzo's by themselves pretty safe, but they have almost no side effects at all except in the elderly.  Compare their risks with the risks of atypical antipsychotics, and it is absolutely no contest at all.  Personally, if I had to choose, I would much prefer to be addicted to a benzo than be addicted to insulin shots!

Despite this obvious discrepancy in the risks, the problem of the misuse of prescriptions for antipsychotics by physicians to treat insomnia and anxiety continues to worsen.  In the September 2, 2011 issue of Psychiatric News, an American Psychiatric Association newspaper, there were two headlines side by side:  "Antipsychotics Increasingly Prescribed for Anxiety" and "Concern Raised Over Antipsychotic Use for Sleep Problems."

Even well known drug company apologist Charles Nemeroff was quoted as bemoaning the use of antipsychotics for anxiety disorders like panic disorder.

For insomnia, the biggest seller is the drug Seroquel (Quetiapine), which is second only to Zyprexa (Olanzepine) in causing metabolic syndrome.  Indeed, Seroquel is probably the most sedating atypical.  The article in the paper pointed out that a lot of physicians who prescribe this medication do not even bother to monitor the patient for increases in weight, blood sugar, and serum fats. 

The article about insomnia was prompted a large increase in prescriptions for this drug for insomnia in military personel.  According to the Department of Defense, in 2001 20-30 soldiers per ten thousand were treated for insomnia.  By 2009, the figure had soared to 226 per ten thousand. 57% of all prescriptions of Seroquel were for insomnia! 

Soldiers reported gaining an average of 6.3 pounds each on the drug.  Only 61% had a check of their blood sugar within six months of starting the medication.  Fortunately, no actual cases of diabetes were found.  The author of the study that generated these statistics agreed with my theory that these drugs were being used by physicians instead of benzo's because of fear of addiction.

That reasoning is a bit like the reasoning of people who will not fly in a commercial airplane for fear of a crash, but refuse to use seatbelts when they ride in a car.  These doctors apparently are completely clueless when it comes to evaluating relative risks.

Wednesday, September 21, 2011

Borderline Personality Family Dynamics: The Parents, Part I

In my post of 2/6/11, Dysfunctional Family Roles, Part I: The Spoiler, I opined that the basic problem in the "borderline" family (one that produces offspring with borderline personality disorder [BPD]) is that the parents in such families see the role of being parents as the end all and be all of human existence, but all the while, deep down, they either frequently hate being a parent or see their parent role as being an impediment to their personal fulfillment.

I also explained how the person with BPD develops the Spoiler role in response to the double messages that this emotional conflict leads such parents to give off to their children.

It's all well and good to try to understand the behavior of the individual with BPD in terms of a response to parental problems, but that just kicks the question of an explanation for the disorder back a generation. In order to fully understand BPD, we have to ask, "What on earth makes these parents so damn neurotic that they compulsively have children and then covertly resent them?" 

If the parents are not patients themselves, the only way for a therapist to get to the bottom of this is by helping the patient with BPD to construct a special type of family genogram.  A genogram is sort of an emotional family tree, and is a mainstay of the type of family systems therapy designed by family therapy pioneer Murray Bowen.

Murray Bowen
Using historical figures and geneology records as illustrations, the book Genograms: Assessment and Intervention by Monica McGoldrick and Randy Gerson describes how genograms can be constructed .

Monica McGoldrick

The genograms described by Bowen therapists are, in my mind, incomplete.  They concentrate on which relatives were overinvolved or underinvolved with which other relatives, and whether these relationships were hostile or friendly.  IMO, this leave out an awful lot of important information.  Two individuals may easily have a hostile and enmeshed relationships with each other over one area of functioning, say work or love, and yet still be very distant, friendly and uninvolved with each other over a different area of functioning. 

In other words, these genograms omit the content of the family squabbles.  When the content is added to the genogram, one can then look for the historical experiences of the family that may have created the picture that is taking place in the present.

While I have indeed seen the parents of adult children who exhibit BPD in therapy and traced their genograms, I have also coached patients with the disorder themselves to construct their family's genogram.  We try to go back as far as we can to figure out what family experiences led to the parents' conflicts.  Sometimes the story goes back more than three generations and we may lose the historical scent, so to speak, in that no one alive knows what happened way back whenever.  Usually, however, certain patterns come to the fore.

In Part I of this post, I will describe the one most common major issue, and the resultant behavior patterns, that I have discovered leads individuals within a family to develop a severe conflict over the parenting role.  In Part II, I will describe some other ones.

All of these issues may seem very common everywhere, and indeed they are.  Most families that face them do not produce emotional conflicts significant enough to create BPD pathology.  Rather, the issues in families that do have been magnified signficantly by an interacting tableau of historical events impacting the family and the individual proclivities of each and every family member and descendent. 

I will not describe the details of the magnification process here, but a full explanation can be found in my book, A Family Systems Approach to Individual Psychotherapy.

The most common cause of conflicts over the parenting role stems from cultural rules regarding gender role functioning.  Over the last century the opportunities open to women to explore their interests and ambitions have gradually expanded, and having a lot of children certainly put a damper on their ability to do this.  If a woman came from a family where the women were very bright and had a natural proclivity for being ambitious career-wise, this would often create difficulties for them since they lived in a male-dominated culture that was at best unfriendly to female career ambitions. 

To demonstrate how this might play out in a hypothetical family, I often discuss the evolving role of women in the United States since World War II. During the war, when all the men went off to fight, women in the United States entered the workforce in large numbers for the first time - in order to build the airplanes and tanks.  This phenomenon was known as "Rosie the Riveter." 

Some women found the experience of a career exhilerating, but when the war ended, they had to go back to just being wives and mothers once again.  The US govenment even made propaganda films thanking the women for their important work, but then encouraging them to go home and get barefoot and pregnant once again.  I have seen some of them; by today's standards they are positively jaw dropping. But effective. The Rosies did what they were told, and that is why we had the baby boom.

Rosie the Riveter
The daughters of this generation came of age in the sixties, when the women's liberation had started in earnest.  Women were more and more torn between the earlier gender role requirements and the new cultural opportunities expectations, and some women (as well as some men) did not make the transition very smoothly at all - for a variety of reasons.  One common reason: the Rosie the Riveters, having had a taste of the career world, would vicarioulsy live through the career aspirations of their daughters, but at the same time be extremely frightened by them.

Having children could easily bring the whole craziness to a head for some families.  Even today, parents feel very guilty about not spending as much time with their children as they would like, and they are often criticized at every turn by their own parents as well as the Phyllis Schlafly's of the world.  (Phyllis Schlafly was a career woman who made a career out of bashing career women).

Phyllis Sclafly
In doing genograms, one can often see just how far a family's operating rules lag behind the current cultural norms .  In anthropology, this problem is called cultural lag.  The cultural progression in Western nations, which is mimicked within certain families, was thus:  First, women really could not have careers at all.  Then, they could have careers, but only when they were single.  Then - and here is where many families with BPD members are stuck - they could only have careers when they had not yet had children.  Then, they could have careers even if married with children, but they had to give priority to the husband's career.  Last, both men and women were entitled to the same freedom.

Gender role confusion and conflict can, given the right combination of ingredients, create a nasty intrapsychic conflict over the very act of procreating. 

In Part II of this post, I will look at the rest of the historical factors and patterns that can create such a conflict: Deaths and illnesses, financial reverses, religious demands, parent-child role reversals, being the eldest child in a traditional family, and having children to "save the marriage."

Wednesday, September 14, 2011

Why Do Some Siblings From Troubled Families Turn Out Fine, While Others Flounder?

Tag - You're It!

One nice thing about Google Blogs is that Google provides blog authors like myself with the search terms used in search engines that have led potential readers to find our blogs. 

One recent search term leading a reader to one of my posts struck me.  It was "Five children.  One BPD [borderline personality disorder].  Why?" 

What an excellent question!

Unbelievably, I still occasionally hear the argument that this or that behavioral disorder could not possibly be shaped primarily by dysfunctional relationships with parents, because other children of the offending parents turned out quite different.  That fact proves the disorder is biogenetic?  Of course, in addition to growing up in the same household, siblings also happen to share many of the same genes - but that point is seldom brought up by people who make such claims. 

Anyway, neuroscientists already know for certain that complex behaviors in human beings are not determined by single genes or even by groups of genes.
That siblings turn out different is quite true.  In fact, they can and often do turn out to be polar opposites!  In some families, for example, one son may become a workaholic and the other a lazy freeloader who refuses to keep a job.  I have difficulty imagining a genetic mechanism that would lead to an outcome like that, but it can be easily explained by looking at family dynamics and psychology.
The ridiculous assumption implicit in the sibling argument is that parents treat all of their children the same. 

Do you have siblings?  Do you have more than one child?  Tell me if the siblings are all treated exactly the same by your parents or in your family.  Come on, be honest.

The Smothers Brothers comedy duo in the sixties and seventies made an entire career out of feigned sibling rivalry summed up by Tommy Smother’s catch phrase, “Ma always liked you best.”  Clearly this theme resonated with a lot of people.  Does anybody really treat all of their children in a nearly identical manner?  How could they?  Children are born with major differences from one another that force parents to react differently even if they try not to. 
"Ma always liked you best."

Even more important, anyone who thinks that some parents do not pick out some of their children to treat like Cinderellas and others to treat like princesses has his or her head in the sand. 
In some ethnic groups, contrasting and seemingly unfair treatment of siblings because of their birth order is actually mandated by the culture.  For example, in some Chinese families the oldest son is groomed to inherit the family business, while his younger brother inherits much less if anything.  In many Mexican American families, the oldest daughter has the duty to look after her younger siblings.  She may have to forego her own high school social life in order to do so, while her younger sister has far fewer family obligations and gets to party on. 

Of course, parental behavior is hardly the only influence on how children turn out after they grow up, but it remains one of the most important and potent ones.
Indirect evidence that children are responding to environmental contingincies in the family and not to genetics is also provided by a phenomenon I have occasionally seen that I call sibling substitution. 
I derived this term from a similar term, symptom substitution, which is a subject that was a bone of contention between psychoanalytic therapists - who thought psychological symptoms were caused by an individual’s internal emotional conflicts - and behavior therapists - who thought that symptoms were caused by environmental rewards and punishments impacting certain behaviors. 

The behaviorists claimed that if they just taught patients new and better habits and reinforced them, then they would be completely cured. The analysts said that would not work because the patient’s underlying conflict would still be present, so the patient would therefore develop a new and different symptom.  The behaviorists claimed to have proof that their side won the argument, but that might be because they cured things like phobias that were not caused by internal conflicts in the first place.  Neither side had any evidence for their argument when it came to dysfunctional personality traits.
What I noticed was that if I somehow successfully helped patients to significantly change a dysfunctional role that they were playing within a family of origin, they often did not develop any new dysfunctional behavior, just as the behaviorists would have predicted.  Unfortunately, a previously unaffected brother or sister would suddenly step into the role they vacated!  Hence, no symptom substitution.  Sibling substitution.  While as a patient's therapist I did not owe anything to his or her sibling, I still found this result less than satisfying.  I helped a patient, but in the process I helped screw over his brother!  What good is that?
To illustrate, say that one sibling is the “Chosen One” who has agreed to fulfill a dysfunctional role: He's the one who never gets married so that he remains free to never leave home - in order to keep an eye on an ailing mother after a father runs off.  Let us further suppose that the Chosen One suddenly says to Mom, “I can’t do this any more.  I’m moving out so I can have a life of my own.  You need to find someone your own age to take care of you!” and actually moves out (Mind you, this is something most people playing such a role are highly unlikely to ever do). 

If he follows through, he will usually first suffer universal condemnation from every relative he has.  If that powerful family maneuver does not get him to change his mind, as it usually will, a brother may then move in with Mom and take his place.  The brother may even develop marital problems that lead to a divorce so that he can free himself up to do so.
As an aside, this sequence of events might seem to indicate that all the siblings in such a family had, until this point, been perfectly willing to let one of their number stay in the unhappy position of Chosen One so they could selfishly go off and lead their own lives.  However, selfishness may not be the complete reason they had stayed out of Mom's problems. 

They may pressure the Chosen One to stay in the role, not just to let themselves off the hook, but because they think their mother actually prefers the Chosen One in the role, and wants no one else to play it.  The Chosen One was, in a sense, picked out by Mom specifically to play the role. The Chosen One is treated by the siblings in the way they do for Mom's benefit, not just their own!
So how does it happen that only one sibling among many is chosen to be and volunteers to be (almost always both)  the Chosen One in a situation where a role is not determined culturally by sibling position or gender?  For simplicity’s sake, lets call that person “It,” like in the game of tag. Before I give my opinion on that question, I want to describe a recent journal article that attempted to look at why siblings turn out so different from one another when they allegedly grew up in the same environment.
In an article in the Journal of Personality Disorders entitled, “Psychopathology, Childhood Trauma, and Personality Traits in Patients with Borderline Personality Disorder and Their Sisters,” Lise Laporte, Joel Paris and others studied the sisters of female patients with BPD.  They state in the abstract: "Most sisters showed little evidence of psychopathology [mental problems]. Both groups reported dysfunctional parent-child relationships and a high prevalence of childhood trauma.
Dr. Joel Paris, my colleague in the Association for Research in Personality Disorders

They concluded that the psychological traits of “affective instability” [high reactivity and emotionality] and impulsiveness predicted the degree of borderline pathology over and above the effects of childhood trauma or adversity.  They do not claim that these traits are genetic or inborn exactly, but that seems to be the implication.  Of course, inborn traits do affect the likelihood of the development of borderline personality disorder, but perhaps not in the way that the authors of this study imply.  More on that shortly.
On closer look at the actual numbers, however, a somewhat different picture emerges.  True, only three of 56 sisters in the sample had the disorder themselves, and parental neglect was equally prevalent among the patients and their sisters. However, 76.8% of patients with BPD reported emotional abuse, while only 53.4% of sisters did.  The severity of this type of abuse was also higher for the patients.  Differences in sexual abuse were even more pronounced, with 26.8% of patients and only 8.9% of sisters reporting such abuse.  In this case, however, the severity of the abuse suffered was similar.
As the authors point out, we know that childhood trauma alone does not lead predictably to any specific psychological disorder, but seems to be a risk factor for almost all of them. 
So is resilience in the face of severe family dysfunction primarily genetic?  The short answer is that we do not have the foggiest notion.   In order to really find out, we would have to genotype babies and then do prospective studies lasting all the way through childhood in which the family was filmed twenty-four hours a day – an impossible task.  Maybe the focus of maladaptive parenting was greater on one child than another, and the difference in focus is what leads to the affective instability and impulsivity in the affected sibling – although genes clearly might make one sibling somewhat more prone to these traits than another. 

The authors discount the idea that the dysfunctional parenting was differentially applied  to the sisters in their study, despite the significant differences in some of the numbers.  The sisters, they wrote, reported “equally impaired” relationship with the parents.
But this conclusion may be due to the fact that the important differences in parenting between siblings are far more subtle than studies of this type can possibly measure.  The number of beatings by the father, for example, may be the same for the two girls, but what about everything else that takes place in the father's separate relationships with the two daughters?  Was the father nicer to one than the other at those times when he was not being abusive?  What was said to each girl during the beatings?  I find that details such as these are of crucial importance in understanding patients with BPD.
As I said in my blogpost of Sept 15, Childhood Sexual Abuse Taken Out of Context: “Studies that examine psychological and social variables in child sexual abuse (CSA) tend to focus on factors such as who the perpetrator was, what type of abuse was suffered (penetration vs. fondling, for example), the severity and frequency of the abuse, and whether the social welfare or criminal justice system became involved. Rarely, the response of non-abusive relatives to CSA victims, usually the mother, is examined. ..

Clearly, most of the victim’s interactions with perpetrators and bystanders alike occur at times when abuse is not occurring, and these other parts of such relationships may also have profound effects on the victim’s later relationships and self image. Again, due to their staggering complexity and intermittent nature, they are difficult to study using statistical techniques.

Contextual factors include the entire history of the relationship between the victim and the perpetrator: what is said during, before, and after the abuse; what the relationship between victim and perpetrators is like when the abuse is not taking place; what other people in the family are doing at the time of the abuse and at other times; how each family member relates to the victim; who if anybody knows what is going on and whether or not they intervene; and a whole host of other characteristics of the interpersonal environment of the victim.
Even during abuse, a victim’s interactions with a perpetrator is not limited to the sex act alone. Words may be spoken; other activities may occur right before, right after, and even simultaneously.”  
These considerations are, while of vital importance, are almost impossible to quantify.

“So get to the question of why one child is singled out already,” I hear you complaining.  “Why would parents focus their conflictual behavior on one or perhaps two of their children, leaving the others relatively unscathed?"  OK, OK, I'll tell you why I think that happens. 
In families with several children, which child or children become the primary focus of the parents’ conflicts and problems depends on a variety of factors.  Certainly a child’s innate temperament plays a role, so we cannot leave genetics completely out of the equation.  A parent who really does not fully want to be a parent but who feels guilty about this impulse (something commonly seen in families that produce a child with BPD), will react more problematically to an innately difficult child than to an easy child.  The latter simply requires a lot less attention, while the former requires much more time. 
Additionally, the problems exhibited by a difficult child may feed into a parent’s guilt over wishes to be free of family burdens.  The parents may become concerned that perhaps their unacknowledged dislike for taking care of children is the cause of the child’s problems.  Hence, parents who are already feeling overburdened yet guilty will often feel guiltier with difficult children.  In response, they often try to overcompensate by getting more involved with those children, which may then further increase their resentment over the parenting role.  The difficult temperament of the child and the internal conflict of the parents feed off of one another, leading to more family conflict and chaos, and so forth.

I will describe how the parents may develop such an internal conflict in my next post. 
Another major factor which determines which child or children become “It” has to do with the natural similarities between particular children and the parents themselves, or between the children and other family members with whom the parents may have had a conflictual or problematic relationship.  Parents are well known to both identify and counter-identify with their own children. 
Say, for example, the mother is the oldest sister in a traditional Chicano family and had been required to give up her social life or college as a young woman in order to take care of her younger siblings.  She then grows up and has children of her own, thrusting her back into the exact same, conflictual position. Because of identification, she might feel sorry for her oldest daughter and envious of her youngest daughter.  Conversely, depending on the extent and severity of her resentment and her conflict over it, she might be harshest on the eldest daughter, who reminds her most of herself.
Either way, the manner in which she interacts with each daughter will be completely different. 
In a similar fashion, light skinned vs. dark skinned children in black families may be the seed of subconscious differential treatment by parents.
Yet another major factor in one child becoming “It” is that parents may often subconsciously displace conflicted feelings about their own parents or other family members on to children who have a physical resemblance or a similar innate personality to the problem parent. That child may then become the focus of the parent’s anger, guilt, or a variety of other problematic feelings, thereby creating a special bond (be it positive or negative) with that particular child and not with any of the others.
Because of the multiplicity of factors involved, determining the exact reasons why one child is the primary focus in any particular family is a speculative and difficult endeavor.  Luckily, in psychotherapy an absolutely accurate and precise identification of these factors is not necessary for planning strategies for altering dysfunctional interactions.  An educated guess will usually suffice.

Thursday, September 8, 2011

The Increase in Psychiatric Disability in the USA

As an academic psychiatrist, I supervise residents in an outpatient psychiatric clinic whose patients are predominantly on Medicaid (called Tenncare in Tennessee).  Many of these patients were able to qualify for Tenncare because they are on Social Security disability (SSI), and the majority of these had been placed on disability for psychiatric reasons based on the recommendations of previous psychiatrists.
In this clinic we see patient after patient with obvious personality problems who seems to be able to take care of almost any task that "normal" people can all do except hold a job. They have been labeled by psychiatrists with phony or inappropriate misdiagnoses such as bipolar II, adult ADHD, and even Asperger's syndrome. They had been put on disability with their psychiatrist's blessing.
Their families gladly go along with the psychiatrist's assessment because they do not want to take responsibility for having helped to create the patient's psychological problems in the first place.
My sources tell me that the same thing is happening all over the country.
Patients who really do have bipolar disorder should almost never be on disability anyway because, in the vast majority of cases, it is a highly treatable illness, and people are completely normal if they take their medications, are not in a manic or depressive episode, and do not have any co-occuring psychological issues.
ABC News recently reported that applications for SSI have gone up considerably since the start of the recession.  The obvious implication is that people who are just plain unemployed are attempting to support themselves by claiming to be disabled.
Then there is the outright disability fraud known in some circles as crazy checks, as I described in my post of October 10, 2010, in which parents coach their kids to act out of control for a psychiatric disability evaluation.  As I have said, apparently fooling psychiatrists into making serious diagnoses on kids who are acting out – or just plain acting – is as easy as pie.
The states have gone along with this charade because it transfers a lot of their welfare costs to the Feds. What a difference this is from the 1980's, when the Reagan administration was kicking people off of the disability roles who really were disabled (e.g., patients with chronic schizophrenia). The courts finally had to step in to stop this. I used to do SSI evaluations in California back then and saw this first hand. My evaluations were often completely ignored.
We've gone from one extreme to the other.
I do not bring up this issue merely to infuriate taxpayers.  The whole disability process has another, far more destructive and insidious effect.  It can be extremely damaging to the mental health of the involved individuals.
Consider this: if your entire family, along with professionals who are supposed to be experts, believe that you are impaired, who are you to argue? People in this situation are not only being paid to think of themselves of disabled, but really do start to believe that they are damaged goods. 
Their self-esteem, already in trouble because of their having been scapegoated by their families, goes down the toilet.  They truly and deeply believe that they are both brain damaged and big losers to boot.  They are validated in this belief by the most powerful people in their environment.

Read this description of a patient from a fellow psychiatric blogger (Thought Broadcast): 

"When I first saw her, she appeared overweight but otherwise in no distress.  An interview revealed no obvious thought disorder, no evidence of hallucinations or delusions, nor did she complain of significant mood symptoms.  During the interview, she told me, 'I just got my SSDI so I’m retired now.'  I asked her to elaborate.  'I’m retired now,' she said.  'I get my check every month, I just have to keep seeing a doctor.'

When I asked why she’s on disability, she replied, 'I don’t know, whatever they wrote, bipolar, mood swings, panic attacks, stuff like that.'  She had been off medications for over two months (with no apparent symptoms); she said she really 'didn’t notice' any effect of the drugs, except the Valium 20 mg per day, which 'helped me settle down and relax.'

Keisha is a generally healthy 27 year-old.  She graduated high school (something rare in this community, actually) and took some nursing-assistant classes at a local vocational school.  She dropped out, however, because 'I got stressed out.'” 


Getting someone like this off of disability is nearly impossible. Even if they start to believe in themselves and begin to succeed, they would then lose their Medicaid and would not be able to pay for the treatment that might help them to maintain their employment and make further gains. They are literally trapped by the disability system into feeling themselves to be nothings and nobodies.
And a lot of psychiatrists are doing this to their patients. 
Please keep in mind, however, that there also are a plenty of psychiatrists who are as appalled by this trend as I am.  
R. Scott Benson, M.D., the speaker-elect of the General Assembly of the American Psychiatric Association (APA), confirmed in yet another way this whole picture in a personal communication with me.  He said, “The APA has a Business collaborative. There are articles by HR [Human Resources] managers lamenting the fact that psychiatrists in general do not seem to believe that people should work.
I have been doing reviews for Disability Insurance companies and people with what appear to be mild symptoms are kept off work with no change in their treatment plan. Then they are depressed that they do not have money, lose their house and car, etc. Yes the SSI disability racket is a strange beast. The money never seems to be spent on any kind of treatment."
MentalHealthWorks, an APA publication, actually had to spell out the following recommendations to psychiatrists concerning disability:
Principle #1. Inability to work is a psychiatric crisis.

Principle #2. Return to work is a fundamental goal of treatment.

Principle #3. Occupational disability is a complex biopsychosocial phenomenon. 

Principle #4. Symptoms are not impairments; impairments are not disability. A decline in function is often temporary and does not need to meet the threshold of total incapacity. Disability often includes interpersonal issues at work, physical complaints, other medical conditions, and psychological issues.
Like, Duh! You mean these things are not obvious to someone smart enough to get into and get through medical school? Really?!?

And check out this personal communication from Randy Bock, a family practitioner who specializes in addiction treatment:
“I had a woman today who wants to go on naltrexone [a treatment for opioid addiction]. She had been doing heroin and just finished a detox.

Recently she was at [a halfway house].  They 'made' her apply for Social Security/disability (‘which they do for everyone’); so as to get their own bills paid regularly … including multiple drug tests/week. Additionally once she got her 'disability check' they were taking 'half her income' - some $400…
The halfway house sent her to a psychiatrist who diagnosed her promptly with 'PTSD, bipolar, anxiety, depression,' and gave her a disability finding.

She says they wanted her to ‘leave her past’ (which in this case meant also her job) and ‘only look forward’, and that involved her not working (at all) for the subsequent 14 months in the halfway house.”
Author Robert Whitaker (Anatomy of an Epidemic) has made a lot of noise about the large increase in psychiatric disability recently, but completely misidentifies the cause.  His thesis is that the appropriate use of psychiatric medication has been making people worse, and he seems to think that if a patient gets worse, it must be due to the medications.  This is circular reasoning.
A psychiatrist who does a complete evaluation of ALL possible biological, psychological, and social factors affecting a given patient is in a much better position to make the call as to exactly which factors have led to a patient’s deterioration (and yes, Alto, not infrequently it is from debilitating side effects from medication that are ignored by the doctor).
Then again, as another fellow blogger Moviedoc cracked, that is a moot point because problem psychiatrists are not taking much of a history nowadays anyway.