Tuesday, September 25, 2012

Guest Post: Does ADHD Exist?

The following guest post comes courtesy of Dr. Marilyn Wedge, author of Pills Are Not for Preschoolers, A Drug Free Approach for Troubled Kidswhich I recently reviewed here as part of TLC virtual book tours.

Marilyn Wedge, Ph.D.

In July, 2012, I attended a talk by the distinguished Chilean biologist, philosopher, and constructivist thinker, Humberto Maturana, at a conference at which we were both speaking. Maturana is best known for his theory of autopoiesis. Simply put, autopoiesis (which literally means self-creation) is the view that the world we inhabit is a world that we ourselves create.

Humberto Maturana

According to Maturana, all reality, including the reality that scientific theories claim to illuminate, is ultimately self-referential, and must therefore take into account the scientists who are doing the illuminating.  All theoretical constructs implicitly contain a reference to the person who is doing the theorizing. And, according to Maturana, it is more honest to be aware of the self-reflexivity of our theories than not to be. He is, in a sense, a modern incarnation of the ancient sophist Protagoras, who famously said: “man is the measure of all things.”
Of course, many people have accused Maturana of solipsism [a theory holding that the self can know nothing but its own modifications and that the self is the only existent thing], but I think this criticism misses the point. The importance of what Maturana is trying to convey can be best grasped if we understand his philosophy as a countermeasure to dogmatism. Maturana’s view is humbling--just as he himself comes across as more humble than one would expect considering his fame and importance as a biologist and philosopher. His ideas lead us to question pronouncements of reality that do not take into account the agenda or motives of the people who are doing the pronouncing.
As a therapist, I found Maturana’s radical constructivist point of view very much in keeping with the way I view my work. When a child or young person enters my office, often he bears one or more diagnostic labels. A parent will tell me, “My son’s teacher thinks he has ADHD or ODD” or “my daughter’s pediatrician says she has ADHD.” 

When you think about it, ADHD is a human construction—in particular, a construction by a panel of psychiatrists who authored a diagnostic manual called the DSM-IV. And many of these panelists—56% of them to be exact—accepted money from pharmaceutical companies during the time they were creating the diagnoses in the manual. Here’s an important example of how the reflexive nature of theoretical constructions has to be taken into account to fully understand their nature.
So the answer to the question “Does ADHD exist” really depends on the agenda of the observer. Personally, I find it more helpful to uncover the underlying social causes of a child’s fidgetiness or distractedness and make targeted changes in the child’s social environment to remove the stressors. Does the child hear his parents fighting or arguing all the time? Is the child being abused? Does the child have a teacher who is not able to give him the extra attention he needs because she must deal with an overcrowded classroom? 

I don’t need to construct a diagnosis of ADHD to help a child. In fact, constructing a diagnosis of ADHD is not helpful at all, because the only way to treat it is by stimulant medications, which may, in the long term, be harmful to the child’s brain development or predispose him to become a drug addict as a young adult. Furthermore, constructing the diagnosis tends to obscure the underlying cause of the child’s distress. The diagnosis doesn’t help me to figure out what I need to do to get kids over their problems. Constructing a diagnosis is, however, very helpful to pharmaceutical companies who want to see drugs, and also to DSM panelists who depend on drug companies to fund their research and provide them with elaborate vacations.
From this we can see the power of Maturana’s constructivist theory as an antidote to dogmatic pronouncements of reality—in particular, those of the psycho-pharmaceutical complex.  Using Maturana’s constructivist point of view, ADHD does not exist as an objective reality, and it is up to the individual therapist whether she chooses to construct a child’s problem as ADHD or not.

Marilyn Wedge, Ph.D.  9/6/2012

Tuesday, September 18, 2012

Psychotherapy Outcome Research and Treatment for Borderline Personality Disorder, Part I

The purveyors of Cognitive-behavioral psychotherapy (CBT), one of the large number of “schools” of thought in the fields of psychology and psychiatry, like to tout their randomized controlled outcome studies (RCT’s) as proof that theirs is the most “evidenced based” type of psychotherapy. When it comes to the psychotherapy of borderline personality disorder (BPD), which provides a microcosm for almost every type imaginable of behavioral/relationship issues that are confronted by psychotherapists, two of the most studied paradigms are actually related more to what many psychologists consider to be the opposite type of psychotherapy: humanistic/psychodynamic psychotherapy.  Those models are called transference-focused psychotherapy, TFP, and mentalization-based treatment, MBT.  

A third “empirically validated treatment” called schema-focused therapy (SFT), while based initially on some CBT concepts, takes quite a detour from those and employs techniques adapted from a number of alternate psychotherapy schools.

Actually, the one type of RCT-studied therapy for BPD that is most associated with CBT, dialectical behavior therapy (DBT), also borrows considerably from other schools of thought.  Not only that, but it really has been shown to be effective only for a couple of BPD symptoms, most notably self-injurious behavior (SIB) such as self-cutting.

John F. Clarkin is a highly respect psychotherapy researcher who has perhaps the most experience of anyone in the field.  He recently published an article in the Journal of Personality Disorders (Vol, 26 (1), Feb. 2012, pp. 43-62) entitled, “An Integrated Approach to Psychotherapy Techniques for Patients with Personality Disorder.  In it, he makes what I consider several extremely important and crucial points in the debate about the various treatment ideologies.

John Clarkin, Ph.D.

First, he points out, the empirically "validated" models often focus only on symptoms and not on the more important and enduring aspects of personality. In fact, in longitudinal studies of affected individuals, the personality disorder criteria and symptoms change over time, often all by themselves, while their interpersonal dysfunction does not change very much at all.  This implies that that, while symptom reduction is important, it is the interpersonal issues that should be the major long term focus in therapy. The heart of the matter in personality disorders is the patient’s conception of self and others.  The ultimate goal of treatment should be interpersonal functioning that allow for pleasure, interdependence, and intimacy in relationships.

Second, the literature on outcome studies is based on average scores on symptom-based outcome measures. This covers up the obvious fact that in any treatment, some patients change and some do not.  This is further complicated by the issues of “comorbidity.”  Patients with BPD, for instance, often meet criteria for one or more additional personality disorders, not to mention additional psychiatric disorders. And even within the definition of a single personality disorder, many different combinations of traits are possible to arrive at the diagnosis. Much more so than in any other field of medicine, patients with personality disorders are highly unique. Therefore, no one treatment can or will work for everyone.

Third, as Clarkin states, “A close examination of the treatment manuals…suggests that each manual contains some strategies that are unique and essential to the treatment, and some that are common (sometimes with different jargon) with other approaches."

A fourth important point he makes is that all of these therapies consist of multiple interventions, and the studies do not show which ones are important and which ones are not, or even more importantly, which ones may even be counterproductive: “…most probably contain low doses of effective practices, ancillary but important aspects that make delivery of the treatment more palatable, superstitious behaviors (those we think that matter but do not), and factors that impede or fail to optimize therapeutic change.”

A fifth point he makes that I would like to mention is that it is the delivery of the techniques that is often more important than the techniques themselves.  Techniques can be done skillfully, “…or in an abrasive, authoritarian, or uninterested aloof way.  There is plenty of research data that suggests that the skill of the therapist can be, in many instances, far more important to good results that an individual techniques."  Clarkin adds, “The therapist is not a technique-dispensing machine. Many of the techniques are applied common sense, and could be read out of a book."

Last, let us not forget that the receptivity of the patient is another major factor in whether or not therapy is successful.  If patient factors are not taken into account, the effectiveness of any technique “approaches zero.”  Furthermore, despite the rejection of the concept of transference by CBT therapists, “Some patients with severe needs for attachment with no relationships outsider of treatment may become intensely attached to and preoccupied with the therapist in ways that are detrimental to growth.”

In short, it makes a lot more sense to integrate the various techniques across treatment strategies from the treatment manuals in a way that tailors them to the particular patient in front of the therapist.  Throughout treatment, individual decisions must be made, which takes a skillfull therapist indeed. 

Of the four treatment paradigms that have been subjected to RCT’s, in my opinion schema focused therapy does the best job. Of course, the concepts of "mental schemas" and “mentalization” share much in common. (I will not be defining them in this post).  

My own model, unified therapy, has not been subjected to an outcome study. I applied for an “exploratory” grant to get some initial (pilot) data and was of course turned down by the National Institute of Mental Health. That may or may not have something to do with the fact that the only family-systems-oriented reviewer on my NIMH review committee was replaced at the last minute by DBT founder Marsha Linehan. Someone on the panel accused me of not being “mindful” enough.  I wonder who that might have been?
But maybe I’m just being paranoid. As Nassir Ghaemi says, the NIMH's " funding is sparingly distributed: the highly conservative, non-risk-taking nature of NIH peer review is well-known." The study most likely to be accepted by the NIMH is one that has either already been done, or whose outcome is not really in doubt.

To be fair, doing meaningful psychotherapy outcome studies is diabolically difficult. In my book, How Dysfunctional Families Spur Mental Disorders, I went into great detail about a lot of the reasons for this. I’ll summarize what I said in part II of this post.

Tuesday, September 11, 2012

Random Psychiatry Jokes

Today's post comes courtesy of my Facebook Page - some random jokes about psychiatrists, therapists, patients, drug companies, alternative medicine, academics, and parents that I've been collecting and or making up.


If you are a member of the habitually offended community, please do not read this.  I don't want you to have a stroke! 

To paraphrase fellow blogger The Last Psychiatrist, "If you have the urge to e-mail me complaining that my good-natured ribbing of human foibles indicates a total lack of empathy or cruel, unrelenting hostility towards patients and others, please don't, your brain is broken."  

And so it begins:

A recent journal article reviewing drug treatments for symptoms of borderline personality disorder was obviously pushing for the use of antipsychotics and anti-epileptic drugs over antidepressants. It concluded "“Antidepressants failed to show efficacy in treating BPD symptoms dimensions OTHER THAN AFFECTIVE DYSREGULATION.” That's like saying that an antibiotic "failed to show efficacy for pneumonia dimensions other than killing bacteria."

"If homeopathy is real, then dumping Osama bin Laden’s corpse in the ocean has just cured the world of terrorism." ~ Shiloh Madsen, on Google+"...what makes them defense [mechanisms] is not that they protect you from pain-- they don't, clearly. They suck at doing this, look around.

The purpose of defense mechanisms is to stop you from changing." ~ The Last Psychiatrist

"Zoloft and Paxil and Buspar and Xanax...
Depakote, Klonopin, Ambien, Prozac...
Ativan calms me when I see the bills
These are a few of my favorite pills." 
         ~ song from the Broadway musical, Next to Normal

"Become a psychotherapist. That way you get paid to chat with people who are more interesting than you are."  ~ Moviedoc

Jerry Scott and Jim Borgman of "Zits" fame have proposed a new psychiatric disorder of adolescence for the upcoming DSM-5, PDRD: Parental Direction Retention Disorder. That's for teens that can't seem to remember stuff their parents tell them to do.

Then there was the psychiatry resident who was not convinced by the faculty that there is no point in trying to talk a psychotic patient out of a delusion using reason and evidence. So he sees this patient who thinks he's Jesus Christ, and goes up to him.
 "Does Jesus Christ bleed?" he asks the patient.
 "No, of course not," the patient replies.
 "Aha, now I've got him!" the resident thinks. 
He pulls out a pin and pricks the patient on the finger. The patient then looks intently at his hand.
 "Well, I'll be darned," he finally says. "Jesus Christ does bleed."

Behaviorists are psychologists who believe that all human behavior is shaped by environmental rewards and punishments, and that the only valid psychological data comes from observing behavior, and never through introspection or speculation about internal mental processes. So two of these behaviorists just made love. One says to the other: “That was great for you. How was it for me?”

Bill Scheft, a longtime Letterman writer, offers this summary of his mother’s parenting philosophy: “You’ll get unconditional love when you do something to deserve it.”

"What's the point of duration criteria for manic episodes? Nobody takes a history anyway." ~ Moviedoc

I think I'll start a new dating service for people with personality disorders. It will run ads like: "Narcissists! Are you looking for that perfect borderline woman who'll be willing to at first feed your grandiosity but later completely destroy it with her help-rejecting complaining? Well look no further! Take our new, free online SCID-II personality test to help us find your perfect match!"

Overheard from a parent desperate to have an exceptional kid: "All the other kids are making sand pies, but only my kid is eating them!"

"Before you diagnose yourself with depression or low self-esteem, first make sure that you are not, in fact, just surrounded by assholes.” -William Gibson

"I only watch TV News for the commercials to keep up with all the new pharmaceuticals I'll need for all the new diseases." ~ John Fugelsang

If we have "Adult ADHD," I guess we should also have "Adult Oppositional Defiant Disorder." There could be two at least two main subtypes, the "Asshole" subtype and the "Angry Young Man" subtype.

Dennis the Menace diagnosed with bipolar disorder! News at 11.

"[psychiatric] Drugs are all about keeping bratty children in check. Or what we used to call 'parenting.'" ~ Bill Maher

The United States may be the only country in the world where parents obey their children.

 "A new study published in The Journal of Pediatric Medicine found that a shocking 98 percent of all infants suffer from bipolar disorder. "The majority of our subjects, regardless of size, sex, or race, exhibited extreme mood swings, often crying one minute and then giggling playfully the next," the study's author Dr. Steven Gregory told reporters." ~ The Onion

The pharmaceutical companies have come up with a new drug that "biological" psychiatrists will be very excited about. It will no longer matter how screwed up patients' lives are or how dysfunctional their families are. If they take this pill, they just won't care any more. The brand name of the drug is going to be Phuquitol.

Classic answers to questions from doctors taking a psychiatric history:
Therapist: "Are you narcissistic?" Patient: "Heck no, I'm too good for that."
Th:  Are you ambivalent?   Pt: "Well, yes and no."
Th: "Are you sexually active?"  Pt: " Nah, I just lie there."
Th: "Are you homophobic?"  Pt:  "No. Some of my best friends are lesbians, but wouldn't want my sister to marry one."

Carl Rogers, one of the founders of modern psychotherapy, believed that empathy, listening, unconditional acceptance, and minimal intervention would allow clients to become increasingly comfortable with aspects of themselves that may be threatening, shameful, scary, anxiety-causing, etc., which would then facilitate growth and eventual change.  Some people think this can be a bit naïve, as evidenced by the following transcript from a therapy session:
Client:  “I am so depressed, I just don’t feel like is worth living.”
Dr. Rogers: “I hear you saying that you are in pain and that you are not sure how you will ever feel better.”
Client: “I really feel I would be better off dead.”
Dr. Rogers: “You really are at your wits ends about what to do.”
[The client stands and moves to the window of the office and opens it up]
Dr. Rogers: “You are showing me how much pain you are in, how desperate you are.”
[The client then jumps out the window to his death]
Dr. Rogers: “Splat.”

Tuesday, September 4, 2012

Pills Are Not for Pre-Schoolers by Marilyn Wedge: The Crucial Questions That Most of Today’s Child Psychiatrists Never Ask

The theme of this blog, as well as of my last book, How Dysfunctional Families Spur Mental Disorders, is that family systems issues have been disappearing from psychiatry in favor of a disease model for everything by a combination of greedy pharmaceutical and managed care insurance companies, naïve and corrupt experts, twisted science, and desperate parents who want to believe that their children have a brain disease to avoid an overwhelming sense of guilt.

I’ve also written about some of the family systems ideas that are being neglected. But the question many readers may still have is: What do systems-oriented family therapists actually do? In an excellent new book, Pills Are Not for Pre-Schoolers: a Drug Free Approach to Troubled Kids, author and therapist Marilyn Wedge shows, with a series of excellent case examples, what can be done.  She demonstrates brilliantly how kids who might be labeled with serious mental illnesses (that they do not actually have) are, in fact, responding to trouble at home.

Marilyn Wedge

Some of the key points that she illustrates are:
  • If a child acts violently angry, the purpose of this behavior is to deflect the anger that one parent is experiencing against the other. Violence is, therefore, usually a sign of parental discord. 

  • Kids hear and understand much more than we think. 
  • A child will do anything to make his or her parents stop arguing.

  • Kids act out parental feelings that the parent can’t express. 

  • Young adults that refuse to grow up and move out are doing so in order to covertly give their parents who are not getting along a reason to stay together. 

  • A parent’s obsession with a child is often a substitute for intimacy in the parents’ marriage.         

  • The pain of one family member always affects all other family members.  

  • Sibling squabbles can reflect parental discord.

She explains how family and home problems become far less likely to be addressed once a child is called bipolar or ADHD. (Magazines – and some advice columnists - are at present labeling any sharp change in mood as a symptom of bipolar disorder).

Of course, even parents who are very much against the use of psychiatric medications are often very sensitive to the question of whether or not they are somehow to blame for the problems of their child.  So if a mental health professional does not know how to handle this sort of parental guilt, and furthermore does not even know what questions to ask to find out if there is any family discord, they are not going to hear about family problem - as I pointed out in a previous post, Don't Ask, Don't Tell.

Wedge shows clearly how this trap can be avoided.

A lot of child psychiatrists these days are so focused on “symptoms” that they miss the forest for the trees. They do not even try to find out what is going on behind the scenes, and they seem to have lost all understanding of what constitutes normal child reactions to family stress.  A clear case of "Don't Ask, Don't Tell."

Wedge discusses some very simple and very crucial questions mental health professionals need to ask both “problem” children and their parents that can often lead to a torrent of new information.
It is often necessary to interview children without parents in the room and vice versa.  Simple but potentially fruitful questions for children include:

  • Who are you worried about more, your mother or your father? 

  • What makes you scared at night? 

  • What would things be like at home if you did not have this problem?

Questions to ask various family members, alone in combination:

  • What was happening in the life of the family when the symptom began? 

  • What is the SECOND biggest problem in this family? 

  • Where and when does the problem NOT occur?  What is happening when the symptom is NOT?

The author goes on to illustrate several family psychotherapy techniques for inducing behavior change in family behavior, in clear and easily-understood language. Most of  these techniques come from a subschool of family systems therapy called strategic family therapy, whose originators include Jay Haley, his wife Chloe Madanes, and Mara Selvini Palazzoli.

My only quibbles with the book are minor.  She may promise a little bit more than systems therapists can deliver. Like many family systems therapists before her, the family members who populate her case examples all seem to be either highly motivated to follow her instructions, or if not, can easily be handled using with a few well-timed paradoxical therapy interventions.  She says she often cures a problem within seven sessions. While this can be the case, often it is not.  

Old habits are hard to break.  The TV show Supernanny clearly shows how almost all of the family members she sees revert to old behavior once the Supernanny leaves.  She leaves and comes back on purpose to deal with this phenomenon.

While the behavior of the children in her examples may be extreme, most of them come from families that have many strengths. I often see a much more disturbed set of patients: parents (I do not treat children and teens) who have almost no personal or family resources on which they can draw, and/or have significant personality problems themselves. The author also clearly states that none of the children in her case examples were abused or neglected.  I do not know how much experience she has with these other types of populations, but clearly they are far more difficult to treat, and there are a lot of them out there.

All in all, however, I highly recommend this book for those parents who actually want to solve their children’s problems, not just cover them up with drugs.