Where the Analysts Went Wrong: Introduction

Cognitive Behavioral Therapy (CBT) is currently the predominant psychotherapy treatment paradigm taught to clinicians-in-training in psychology graduate schools. However, when I first received psychotherapy training in the mid 1970’s, by far the predominant school of psychotherapy was psychoanalysis. We did receive a smattering of behavior therapy training, and we were even assigned one book about family systems ideas by Virginia Satir. Our training program was a bit unusual in that regard. 

Just like the CBT industry does now, analysts exaggerated the validity of the scientific evidence for psychoanalytic theory, and made grossly inflated claims about the effectiveness of psychoanalytic treatment. Its theory was applied to everything, even to schizophrenia, although by then it was pretty clear to most of us that they were completely wrong about that condition. I’m surprised analysts did not try to treat ingrown toenails with psychoanalysis.

Just as now, economics played a huge part. (That’s why I just called it the CBT industry).  When I made some rather mild criticisms of one aspect of CBT theory and practice on my Psychology Today blog, a CBT therapist wrote a rebuttal, and several people wrote in to say how unethical I was because I was not practicing a “scientifically validated” form of psychotherapy, and was therefore by implication a snake oil salesman. 

Readers of my book, How Family Dysfunction Spurs Mental Disorders, know that the “evidence base” in all of psychotherapy is actually quite weak, and that CBT controls the funding of research and denies it to practitioners from other schools – although nonetheless there are still many studies from other schools that are every bit as strong (or should I say as weak) as the CBT studies. That includes analytically-oriented therapies, as a meta-analysis by Jonathan Shedler in the February-March 2010 issue of the American Psychologist clearly showed.

Not to mention that most psychotherapy outcome studies rely on so-called treatment manuals that spell out what therapists are supposed to do, so that all the therapists in the study are doing the same thing – regardless of how the patient is reacting to what they are doing.  NO competent practicing clinician does that. 

Psychotherapy involves science of course, but in many ways it is an art form as well. People are complicated, and each patient is unique in many ways, and can always choose to respond positively, negatively, or not at all to any intervention made by a therapist.

Additionally, each treatment manual is comprised of multiple ingredients – some of which may help or be the primary active ingredient, some of which may do nothing, and others of which may actually be counterproductive. And yet many CBT proponents argue as if everything they do has been scientifically proven.

It is clear to me that CBT practitioners say this stuff for the same reason that Big Pharma controls and distorts the practice of doing, and the dissemination of results from, studies of medication effectiveness: They want to “sell” their goods and stamp out the competition. (BTW, that does not mean that therefore a pharma-sponsered study has NO validity - only that bias must be taken into account).

Analysts also protected their turf back in the day, very arrogantly, although ultimately they failed. As a trainee, if you criticized any aspect of analytic theory, you were told in no uncertain terms that you needed to go into psychoanalysis yourself, so you could find out why you were “resistant” to analytic theory. In other words, the only reason you were questioning the theory was because you were neurotic!  

This recommendation involved the use of not one, but three logical fallacies, all wrapped up in a single statement. It was a non sequitur, since someone might be questioning the theory for any number of other reasons besides their own psychological issues. It was an ad hominem attack, since it was going after the questioner and not the question. And of course it was begging the question.  The accusation of being neurotic might be true if analytic theory is true, but that is the very issue in doubt and under debate.

Another trick that different economic interests in mental health use to denigrate the competition also involves the issue that all of the so called schools of therapy do not consist of single ideas, but consist of a large number and a wide variety of different ideas and techniques that are tied together by some common threads. Anyone who bothers to think about it has to know that some of these ideas could be wrong while others could still be right, or that an idea may have validity for some situations and for some phenomena while being inappropriate for explaining or addressing others.

For instance, people in the field may try to argue against all the ideas of a particular school, even though many are obviously quite valid, by throwing up a few incidences of when the school had something clearly wrong. They will of course pick the most egregious examples they can find. To criticize psychoanalysis, they might bring up such discredited - and now fairly much discarded - analytic ideas such as "penis envy," or the wild overemphasis on the Oedipus Complex.

Hyper-biological psychiatrists love to bring up the awful effects of the fallacious psychoanalytic theory of the “schizophrenogenic mother” to argue against all of psychotherapy, not even just psychoanalysis! I tell biological reductionists that if they don’t hold the theory of schizophrenogenic mothers against psychotherapists, then I will not hold the theory of eugenics against them.

I even hear Pharma-sponsored speakers indirectly and implicitly attack therapy by posing really, really stupid questions such as “What is better for depression –medication or psychotherapy?”  Well, first of all, that’s like asking, “What’s better for patients with coronary artery disease, taking nitroglycerin when they feel chest pain, or losing weight?” Those two interventions target two completely different aspects of the problem. 

Second, the question lumps together all types of psychotherapy. What type of therapy are we talking about? Which interventions? It would be like me arguing against the use of medication by pointing out how ineffective penicillin is for treating clinical depression.

Just as with many aspects of CBT (CBT'ers please take note that I am saying that), many aspects of psychoanalytic theory retain much explanatory power. They are so widely accepted that they have even become part of the cultural conventional wisdom in industrialized countries.

Who doesn’t believe that people sometimes take their anger out about something on someone or something else?  Mad at your boss, come home and kick the dog? That’s the defense mechanism of displacement. Yeah, like that never happens.

Intrapsychic conflict creating emotional and interpersonal problems because people want something really bad but feel guilty about it? Check. Conversations have unspoken subtexts?  Check. Acting towards authority figures in a certain way because they remind you of your father? That’s transference. Check. CBT folks may prefer to call the phenomenon schemas instead, but it's still transference. 

People wanting to avoid unpleasant subjects and in response changing the subject or explaining away inconvenient facts? That's resistance. Check.

Forgetting about unpleasant memories? Well, whether that’s unconscious or subconscious may be debatable, but the fact that repression exists? The whole Catholic Church child molestation scandal started with a case of "recovered" memory. Check.

The analysts are even right about personality problems stemming from childhood experiences within the family. The attachment literature is extremely powerful, and we all know that one of the biggest risks for just about every psychiatric condition in the DSM is a history of childhood abuse and/or neglect.

Ah, but there is where the psychoanalysts started to go wrong. They seemed to assume that childhood experiences completely determined what psychological problems a patient has and that subsequent experiences were somehow inconsequential. Orthodox analysts believe that your personality is fixed by the time you are five years old. Some go back even further than that.

Of course, if subsequent experiences could not affect personality, it would do a person no good at all to go into psychoanalysis, because the experience of psychotherapy would have absolutely no effect - according to the orthodox analysts’ own assumptions about personality formation.

The thing is, family experiences that start to create problems for children do not magically disappear when a child reaches a certain age.  In fact, they often go on and on and on in sometimes somewhat different forms until the parents die. And the human brain is structured to be highly responsive to what parents do, even in adults.  That will be the subject of Part II of this post.

Sodas Apparently Turn Parents Into Bad Disciplinarians

Reuters (8/16, Seaman) reports that research published online in the Journal of Pediatrics suggests that soda consumption may be linked to certain behavior problems in children. 

Investigators followed the habits of about 3,000 mother-child pairs. Information on soda consumption was compiled when the children were 5 years old. The mothers were asked to self-report how many servings of soda their child drinks on a typical day, and to answer a series of behavioral questions. The investigators say they found a correlation between 5-year-olds’ soft-drink consumption and aggression, attention problems and withdrawn behavior. Previous research has suggested an association between soft drinks and older children’s aggression, depression and suicidal thoughts.

Probable intervening variable: Mothers who don't limit their children's food choices or amounts thereof are also very likely poor administrators of other necessary forms of discipline, which in turn creates the aggression, attention problems and withdrawn behavior in the kids. 

But you'll rarely see a possibility like that mentioned in a journal article or the news report about it.

Repeat after me: Correlation is not causation. Correlation is not causation.  Correlation is not causation...

Manage Care Insurance Declares War on Psychotherapy

Beware: Managed care can be hazardous to your health

The old joke is that “managed care” insurance should be more accurately termed “mangled care” insurance.

At the annual meeting of the American Psychiatric Association in May in San Franciso, Susan Lazar, M.D, a psychiatrist in private practice, discussed the cost effectiveness of psychotherapy. While new federal laws and the upcoming Affordable Care Act mandate equal treatment of mental and physical health problems, access to psychotherapy in particular is under attack from insurance companies. 

“For the past three years, many insurance companies, including Cigna, UnitedHealthCare, and Kaiser Permanente, began severe restrictions on mental health care, particularly psychotherapy,” Dr. Lazar said. She added that patients most in need of more prolonged and intensive psychotherapy are typically the patients whose treatment and services are threatened.

Long term psychotherapy is often the first line treatment for a number of psychiatric conditions, including personality disorders and chronic severe anxiety mixed with depression.  Medication certainly can augment treatment in cases like those, but it is literally just a band aid. In children and adolescents, family psychotherapy is particularly important, and it is disappearing at an alarming rate as kids are plied with potentially toxic central nervous system depressants and stimulants to shut them up and keep their parents’ anxiety and guilt under control.

Psychotherapy has also been shown to be extremely cost effective according to many studies, yielding savings not only in overall health care costs and utilization, but in disability, destructive or antisocial behavior, and other societal costs. That does not, of course, mean than it is cheap.

Large multi-site and meta-analytic studies have demonstrated that psychotherapy reduces disability, morbidity and mortality; improves work functioning, and decreases psychiatric hospitalizations. Psychotherapy teaches patients life skills that last beyond the course of treatment. The results of psychotherapy tend to last longer than psychopharmacological treatments and rarely produce harmful side effects.

The American Psychological Association tried to send out warnings in a 2010 paper titled, Where Has all the Psychotherapy Gone? According to the author of that paper, 30 percent fewer patients received psychological interventions in 2008 than they did eleven years earlier; since the 1990s, managed care has increasingly limited visits and reimbursements for talk therapy but not for drug treatment; and in 2005 alone, pharmaceutical companies spent $4.2 billion on direct-to-consumer advertising and $7.2 billion on promotion to physicians, nearly twice what they spent on research and development.

While the percentage (3.37) of Americans who received outpatient mental health care in 2007 was very similar to the proportion of those (3.18 percent) receiving such treatment in 1998, the pattern of that care changed. Overall there was a decrease in the use of psychotherapy only, a decrease in the use of psychotherapy in conjunction with medication, and a big increase in the use of medication only.

In 2008, 57.4 percent of patients received medication only, indicating that compared with treatment patterns in 1997, approximately 30 percent fewer patients received psychological interventions. This trend was noted particularly among those with anxiety, depression and childhood-onset disorders – the very conditions that respond best to longer term psychotherapy.

For children being treated, 58.1 percent received medication alone and no other interventions. This despite the lack of research supporting the safety and usefulness of many of these medications.

The burgeoning managed care industry has developed strategies to reduce the costs associated with the mental health and substance abuse benefits portion of both public and private health insurance plans. Over time, management of these benefits has resulted in controlling provider fees, strict limitations on episodes of inpatient care, and a reduction in the average number of outpatient visits per patient treated.

Interestingly, prescription drugs are not typically part of the costs managed by these carve-out plans. By 2006, the costs of psychotropic drugs accounted for 51 percent of mental health care spending. Per capita expenditure for psychotropic medications tripled from 1996 to 2006.

If patients and potential patients do not complain to their employers as well as to their politicians, this situation will only get worse as the insurance companies develop even more ways to get around mental health parity mandates. And even if you don’t need help, do you really want to live in a society in which you might often find yourself surrounded by unstable individuals who can’t get help?

It’s getting dangerous out there.

Dr. Allen Discusses Borderline Personality Disorder - The Earth Needs Rebels Show on Orion Talk Radio

Dr. Allen discussed his ideas about borderline personality disorder in detail (this time it's just him and the host) on The Earth Needs Rebels Show broadcast on Orion Talk Radio http://oriontalkradio.com from Tonawanda, New York, 1650am and global on the internet, with additional feeds like Tunein Radio (http://tunein.com for more information on tunein radio and free software).

Here is the link to the downloaded broadcast: http://oriontalkradio.com/archives.htm.  Click on "down" and not on "listen."  The date and times posted for the broadcast: Tuesday, August 13, at 1:05 and 2:05 PM.

Parts 2 will be on live September 10 from 12-2 PM U.S. Central Time.

Dr. Allen on HuffPost Live Video News Network

Dr. Allen participated in a panel discussing freeloading family members on The Huffington Post's video news network, HuffPost Live (live.huffingtonpost.com). 

Here's the link: http://huff.lv/19eAnD9

Are the National Institute on Drug Abuse and Big Pharma in Bed?

Nora Volkow, M.D.

At the annual meeting of the American Psychiatric Association (APA) in San Francisco in May, Nora Volkow, the director of the National Institute on Drug Abuse (NIDA) was just brimming with a lot 'o news about the square of the hypotenuse. No, I'm sorry, I mean about how much more we know about drug abuse because of brain imagining techniques. This new knowledge she spoke of was summarized in the Psychiatric News, the newspaper of the APA, in the June 21 issue.

The gist of the story was that the drugs themselves impair certain brain circuits, which must then be somehow strengthened through treatment.

One of the points she raised is that drugs like methamphetamine cause dopamine receptor signaling to be decreased in the pre-frontal cortex - the part of the brain known to be crucial in executive control (decision making). Thus, the normal brakes on someone indulging in something are supposedly damaged.

If this be true, one might think that she would be up in arms about the widespread, indiscriminate use of amphethamines like Adderall in children. At the very least, a high percentage of ADHD diagnoses are given to kids suffering from the effects of living in a chaotic environments of one sort or another, and for whom family therapy would be the most important treatment. Perhaps there are some cases of ADHD that are due to neurotoxin exposure or something like that in which the benefits of the use of stimulants outweigh the risks - a questionable assertion itself since the average academic gain for ADHD-diagnosed kids on stimulants is all of about three whole months.

For some reason, however, while she acknowledges in other venues that prescription drug abuse, including that of stimulants, is a major problem, she continues to maintain that stimulants are safe and effective when used for ADHD.

She does admit in one article that ritalin basically works the same way in the brain as cocaine! So is she saying that there is some point at which the alleged adverse affects on executive functioning she was going on and on about at the APA magically become inconsequential?

And yet, she also spends some of her time exaggerating the adverse effects of the devil weed , marijuana, in a campaign to keep it illegal.  It seems there is a double standard she has towards the risks of the drugs sold by Pharma compared to those that are not.

How much worse than the physiological effects of pot, one might ask, are the adverse effects on potheads of jailing them and turning them into felons for the rest of their lives. Or the risks to black kids? They are no more likely than white kids to smoke pot, but are four times more likely to be arrested for it. These are not adverse effects?

"Think about it: Do you want a nation where your young people are stoned?" she was quoted as asking.  I hate to break this to her, but any kid who wants to get marijuana already can. It's like one of the biggest cash crops in several states.

I don't think she has come out in favor of prohibition against alcohol or tobacco, two substances with far more potential adverse physiological effects than pot ever thought about having, so that she might at least be consistent. Does she think that young people aren't already getting "stoned" on booze? As mentioned, she does not seem to be all that concerned about the adverse effects of the stimulants - that she herself describes - when used for legal and "proper" uses. More on that in a sec. Nor does she mention that prescribed stimulants are diverted to "non-medical" uses far more often than even opiates!

It seems almost like she thinks the risks of drugs are entirely dependent on whether or not drug companies make money from them.

I am not surprised by any of this. Many years ago I listened to a talk from someone from NIDA about the horrible effects of dopamine depletion in the brains of regular amphetamine users.  I thought about getting up and asking a question, but someone beat me to it. "Doesn't this happen in kids taking stimulants for ADHD?" the fellow asked. 

The answer? "But the drugs work so well!" As if that were an answer. Now I don't know if NIDA and Big Pharma are in bed together, but that answer sure made me wonder about it.

Another truely breathtakingly bizarre point Volkow made at the APA, as reported in the newspaper (unless the journalist got it wrong):

"Among both lab animals and humans, voluntary initiation of drug use leads to subsequent loss of control and development of addiction among 10% of subjects. The lab rats and mice are uesful for refuting old stereotypes.

Some people still consider addiction moral turpitude, she said. 'But how can you develop the same phenotype in a rat, who have no moral precepts?'"

This argument is a bit of a straw man, since thoughtful mental health professionals these days are not so much concerned with the issue of sin, but more with the question of whether or not drug abuse is due to deliberate and purposeful self-destructiveness. The fact that the 10% figure applies to both rats and people seems to argue for some sort of genetic cause, does it not?

But rats having the same phenotype as human beings? Really?!? I personally have never met any rat that understands the negative effects that a drug might be having on it, or that is able to anticipate the future consequences of continuing to imbibe. People do have these abilities. Furthermore, as I have already pointed out in various venues, scientists still have yet to locate any rats that hide bottles of alcohol.

And now back to that whole executive functioning thing. Methinks she is grossly exaggerating certain of the risks from drugs used entirely to get high. (Anyone remember the scourge of "crack babies?"  Turns out that was all one big - and racist - lie).

Seems to me the supposed "impairments" in executive functioning in addicts that she talks about are awfully specific and limited. In the past, a lot of cocaine addicts, for example, used to burglarize houses and fence the goods to support their habits without even getting caught. It would seem to me that quite a bit of executive functioning is being exhibited in that endeavor. Imagine what master criminals they might be if they had unimpaired executive functioning. It boggles the mind!

And if addicts do have a sort of brain damage, how can some of them suddenly just stop using after attending just one meeting of a 12 step program, and then stay sober by continuing to be in the program? Not as many as we'd like, but still many do. The 12 steps were based originally on techniques used by Protestants to get others to adopt their religious beliefs, not treat brain dysfunction. So how is it that what is essentially a change in cognitive beliefs can fix a brain overnight?

I have argued that many of the brain changes observed in MRI studies are actually conditioned responses due to neural plastic changes in brain structure and function in response to the social environment (No, not all of the observed changes. Some can indeed be due to drug effects, trauma, or disease. Duh). The conditioned changes can indeed happen in relatively short time frames. But literally overnight? Please.