Tuesday, October 29, 2013

Guest Post: Breaking Free of Being the Perfect Child

Today's guest post is by Paul Taylor. This is the fourth post in which a writer recounts his or her own experience in a family with a problematic history, as well as its aftermath. It illustrates a couple of themes of my blog very well: a family role that must be played by a member – or else - and the existential horror and despondency people feel when they try to break away from it. His criticism of cognitive psychotherapy for this sort of problem is also right on.

It is hard being the perfect child. According to my family, I was born perfect. I was quiet and obedient and always willing to help out. From the time I was very small my family relied on me to be the good, responsible child. Although I was not too much older than my siblings and cousins I was relied on to make sure they were safe, happy, and cooperative too.

As I got older and some of the extended family moved away my responsibilities changed. I was now supposed to go to school and do all my work without complaint or question, answering any inquires about what I was learning with an in depth explanation. Then I was supposed to help my younger brother complete his school work while also teaching him what he missed in class due to his ADD. After that came helping with chores like ironing, laundry, dishes, yard work, vacuuming etc. That I was also supposed to do without complaint for as long as it took. 

Every member of the family had set chores and I was expected to not only do mine, as quickly and quietly as possible, but also “help out” with everyone else’s. That meant doing the dirtiest, hardest or most complex jobs while they watched and shook their heads –feeling helplessly confused all the while.

If I finished everything I was then expected to have “family time” which consisted of sitting around the television, watching something my brother and I were not interested in. I was supposed to keep him quietly entertained so we could “be a family.” If, by chance, there was time left over before bed I snuck in reading a chapter or two of my books, which were my only escape from reality.
When I got into my teen years and nothing changed, I began to become uncomfortable with the arrangement. 

I had not made many friends outside of school before then, of course, due to my packed schedule. When I attempted to make plans with friends and let my family know ahead of time, some emergency inevitably came up: a last minute project, a chore that had to be done RIGHT NOW, or just a guilt trip of “not being with your family.”After a few attempts I decided it was not worth the effort and went back to my routine.

Finally when I reached my twenties I realized that my life style was not normal. I started to try to pull away. I knew that I wanted to become my own person and not just the person they told me I was. I wanted to make choices based on my own needs and desires instead of doing what would make them happy or what would not get me in trouble with my family. It was very hard for me to break out of the thinking patterns that had formed from my many years as the perfect child. 

I constantly had to remind myself that I was not responsible for anyone else’s happiness or emotional welfare. I could not change anyone no matter how much I did for them or how much I loved them. In fact I was only allowing them to continue to suffer because they never had to grow as long as I picked up their slack.

At first I planned to move out. I started to squirrel away money for an apartment and shopped around near my work during lunch to see what I could afford. Then a few weeks before I decided I would make my move, a family member had to have emergency surgery.

Well, of course I couldn’t leave then. There was an actual sick person to take care of; the house had one less person to help with clean up, and the person that did not work and stayed home needed a break in the evenings. It was only reasonable.

Six months went by and I decided that I would take a smaller step towards being independent. I planned on going on a trip by myself for two weeks. I would use the money I had saved to pay for the gas, and I had a tent so I could just go on a road trip and camp along the way. I got permission from my work and was all ready to go. I decided to give my family two weeks’ notice so that they could adjust to the idea.

Bad idea.

As I started to pull away, my family teamed up against me. From telling me I was wrong in my thinking to guilt trips to outright anger and abuse, they piled on the difficulties and tried to make me conform to their way of thinking; the way that was easiest for them. I fought back for a while but eventually got worn out, and found myself being sucked back in.

I postponed my trip indefinitely.

However, this time I was aware of what was going on around me. I felt like I was living in another world. I watched in horror as I went through the same day-to-day routine of being the perfect child and cleaning up the messes they left behind. I felt disconnected from reality and just went through my days with a kind of hopeless, formless, pointless movement. Somehow I thought that as long as my body was moving I was still all right and functioning.

What I did not realize is that I had become seriously depressed. I had been depressed in the past but had repressed the dark times in my life to the point where I did not even remember them happening. I tried to function on auto-pilot without my own conscious approval. However, this time around the auto pilot would not engage. I had become too self-aware to let my brain slip into a waking coma.

It got to the point where I would be driving and would consider just letting go of the wheel and seeing what happened. After all, it did not matter one way or the other. What was the point of living like this?

After having several similar thoughts, I sought professional help. Although it did help to have my irrational thinking pointed out to me, it did not help in the sense of giving me something concrete to do.

“Move out,” they said, “Get away.”

Well, that is all well and good for someone to say, but the practicality of it was beyond me. I had been beaten down by the combined forces of my family. From bills to pay to broken down cars to guilt trips and attacks of hysteria I had so much to deal with that even planning a way out was beyond me.

I checked out. I really did. I went to work every day and somehow managed to crank out my job with no brain power. I got home and took care of the chores and bills and things that needed to be done. I chatted pleasantly about the weather, feigned listening attentively to problems, and worked steadily until it was time to fall into bed and start the whole day over again.

Weekends and weekdays were indistinguishable except for the physical activity required. It was much more restful at work, sitting at a desk, then at home running errands, cleaning up messes, and trying to pretend everything was fine.

Hopeless does not even begin to describe it.

I tried to express to my family why I was so angry, or stressed, or just listless. Their solution:

“Just stop thinking so much. Everything will work out.”

Eventually I got fed up with the whole thing. Working with friends I came up with a way to get out of the house. One day I just moved, taking only a couple of bags of clothes and tossing them in the trunk of my car I left.

After the meltdown, things changed. I was still the ‘perfect child’ in some ways but I learned the benefits of boundaries and getting away from people. The physical distance helped me to create a personal space where I could feel safe and grow. It was still very hard for a long time but it has gradually gotten better. My family still attempts guilt trips and manipulation but now that I have time to see things as they really are I can resist them and deal with them in a healthier way.

Author Bio:

Paul Taylor started which offers an aggregated look at those sites to help families find sitters and to help sitters find families easier than ever. He loves writing, with the help of his wife. He has contributed quality articles for different blogs & websites.

Tuesday, October 22, 2013

Docs and Drug Reps

If you’ve been to a doctor’s office any time recently, you’ve probably seen them.  Nicely dressed in suits or pant suits.  Dragging their little bags that look like the carry-ons with wheels you see at airports.  Mostly nice looking and young, male or female. Patiently waiting for the office staff to call them to come in the back.

You don’t generally see what’s going on in the back with them, but these are the drug reps.  The detailers.  The pharmaceutical company salesmen.  They used to bring assorted gifts to the office like pens and other paraphernalia with drug logos on them, but now they mostly come bearing drug samples and lunch.  Due to a recent change in the law, doctors have to “report” any such favors into a database, but hardly anyone looks at it.

The drug reps are there to tell the docs about their latest products. They have to stick to the information approved by the Federal Drug Administration. The doctors certainly need to hear about the newest medications. So what’s the harm?

Well, potentially, plenty.  Most “new” drugs do pretty much the same thing as old established drugs.  Sometimes they have different side effects, some of which are better for the patient and some of which are in fact worse.  Being under patent, they are of course way more expensive than generic drugs which are often just as good or just as tolerable.

As readers of this blog know, the drug companies have been studying the psychology of doctors for decades, and have developed a lot of tricks and misleading tactics to increase sales of their brand named drugs. These techniques are quite powerful, and many doctors do not understand how they are being manipulated, sometimes to the significant detriment of their patients.

As a critic of these marketing techniques, I belong to a group called “Healthy Skepticism.”  Many members of this group argue that doctors should have NO contact at all with drug companies in any form whatsoever. They point to the fact that most doctors think they are not being unduly influenced, and yet believe that most of their colleagues are! The high sales of brand named drugs when generics are available prove, they go on, that no doctor is immune to pharmaceutical marketing tactics. So therefore drug reps are the enemy.

You think I would agree, but I do not. Just because a lot of doctors think they are not being influenced but actually are does not mean that some doctors believe they are not being unduly influenced, and in fact are not. Not everybody kids themselves. It is true that everyone is influenced by others to some degree. So by that reasoning doctors should avoid talking to members of Healthy Skepticism, because then they will be unfairly influenced against the drug companies.

How are we really going to understand misleading marketing techniques if we never personally witness them? How do we keep our eye on Pharma if we are averting our eyes?

Also, there’s that troublesome little fact that we live in a capitalist country, and if capitalists are properly regulated, that’s a good thing.  While I believe deceptive advertising should of course be stopped far more effectively than it has been, I nonetheless do believe in the company’s right to portray their products to physicians in the best light.

Also, when a new drug first comes out, the drug rep may actually be a good if not the only source of information - provided the doctor listens with a critical  ear.  

As Carolyn Rabinowitz, former president of the American Psychiatric Association, was quoted as saying in the September 20, 2013 issue of Psychiatric News, “Drug Companies perform a useful function, and they must make money or they won’t invest in our field." 

I do not blame the drug companies for misleading doctors as much as I blame the doctors for not knowing when they are being misled.

Adriane Fugh-Berman, M.D.

Sanita Sah and Adriane Fugh-Berman of Georgetown University, the leaders of industry watchdog Pharmed Out, recently pointed out in the same article that if doctors know and understand their marketing techniques, then they are in a fairly good position to see what they are doing and to not be taken in. 

Maybe I’m kidding myself, but I let the reps buy me lunch, and yet I still almost never prescribe brand-named psychiatric drugs unless a patient does not respond to, or is completely unable to tolerate, generic drugs in the same class. And so called “diagnostic inflation,” so that everyone seems to need a drug – well readers of this blog know how I feel about that.

For most of the time that I was the director of a psychiatric residency training program, the drug reps provided lunch for the residents at certain classes and for "journal club." The reps were allowed to give the residents a short sales pitch for one of their new drugs, and then they would leave leave the room. After the reps left, I  would critique what they said and point out any exaggerations or misleading information. That way, hopefully, these future psychiatrists would learn to be wary consumers of this type of information.

Now, the drug reps have been banned from providing lunch for the residents, so the residents no longer get this valuable training. When they graduate, they will be less able to resist a sales pitch, not more able. Bad idea.

The biggest psychological trick that drug reps use is taking advantage of our natural tendency towards reciprocity. You do something for me, and I feel obligated to do something for you. It’s not the pen or the pizza, it’s the relationship with the person who brings you those things.

Drug reps are hired more for their likeability and social skills than anything else. As the article states, “And flattery, whether it’s a pleasant conversation over the archetypal pizza or an invitation to speak at a prestigious meeting, gets them everywhere.”

Doctors need to learn this, but most have not. There oughta be a course in medical school about his. Forewarned is forearmed.

Tuesday, October 15, 2013

Book Review: "The Secrets They Kept." The Power of Family Secrets

In my post of June 18, 2013, The Historical Backdrop of Family Dysfunction, I reviewed Deborah Cohen’s fascinating book, Family Secrets, about the cultural forces and historical events in England that generated secrets within families. 

One of the themes of this blog is that the development of secrets within a family can have devastating effects on family relationships, literally over many generations. An excellent example of this is described in a short but beautifully written book by  Suzanne Handler called The Secrets They Kept: the True Story of a Mercy Killing that Shocked a Town and Shamed a Family.

The secret had a highly negative and significant effect on the relationship between the writer and her mother.  When the author learned of it, suddenly much of her own behavior, as well as that of her mother, made a lot more sense.  I find this happens with my patients in therapy. For generating true and lasting behavior change, it is almost always more important that patients gain insight into their family dynamics than it is for them to gain insight (a la psychoanalysis) into themselves.

In this case, cultural and societal attitudes towards, and the treatment of, the seriously mentally ill was a prime factor in both the formerly secret event as well as its aftermath.

Suzanne Handler

When her own son was graduating from college, the writer was suddenly told about the secret by an aunt through marriage. The aunt had promised the patient’s uncle that she would never tell, but the uncle had died. Learning about the secret shocked Ms. Handler to her core. 

She learned that her maternal grandfather, a man she had always had warm feeling for, had killed one of his own daughters, and then tried unsuccessfully to kill himself.

The date was August 16, 1937.  The place was Cheyenne, Wyoming. The cultural group was an Orthodox Russian Jewish Community.  They had found themselves in this somewhat strange place because their group had been diverted to Wyoming from the usual immigrant placements on the East Coast by a Jewish organization.  The mental illnesss of the then 16 year old sister, Sally, had been called “dementia praecox” by the local doctor – an illness now known as schizophrenia.

The girl was on the verge of being committed to the main state mental hospital after two suicide attempts, one of which involved trying to burn down the family’s home. Both the grandfather and this aunt knew what was in store for her at the state hospital. 1937 was in the days before antipsychotic medication, and a commitment was basically a life sentence. And certainly not something to look forward to.

Although the author, who is a journalist, was unable to find descriptions of the hospital milieu at this particular facility during the relevant time period, in general the treatment of the mentally ill in most state institutions was ghastly. This in spite of the efforts of crusaders like Dorthea Dix and Nellie Bly. In institutions across the United States, inmates were often left filthy and naked, given almost inedible food, frequently beaten by the hospital staff staff, and experimented upon with various “treatments” which could be nothing short of barbaric.

Apparently with no way out, Sally begged her father to kill her. When he initially refused, they decided to arrange a suicide pact.  After shooting the girl, her father shot himself twice and then stabbed himself - but somehow lived.

He never served any jail time, however. The prosecutor took note of the unusual circumstances of the murder and agreed that he was unlikely to harm anyone else ever again. He was given a suspended sentence and probation.

After learning of the family secret, the author set out to find out more about what had happened.  The story had been all over the local newspapers at the time, but little was said there about how the family fared after the trial. There were only two living people who were alive at the time of the incident and who could shed light on that – the patient’s mother and her youngest brother, and they were not talking.

Their responses were telling. Mother at first said, “I never want to read or talk about this again.” (Later she did relent just a little and revealed some minor tidbits over the years).  The patient’s uncle was even more closed off. He, “…turned to me, and in a voice that was ice-cold and laced with anger, he muttered under his breath: “Don’t ask me about Sally again. I will never discuss her. Not now and not ever!” (p. 43).

What could possibly account for this conspiracy of silence, especially since all of the other parties directly involved were deceased?  Certainly the shame the entire family must have felt in their tightly-knit minority community had been staggering. There were a number of reasons for this. First of all, no one at the time understood mental illness, and there were all sorts of very negative cultural myths about it.  

Second, Jewish law and ethics forbid both euthanasia and assisted suicide.

Third, and perhaps most important, because of their history in Russia of being a hated and persecuted minority, this community’s mindset was to keep a low profile whenever possible. Their philosophy was to do nothing to bring on negative criticism or trouble. 

This particular family had already brought shame to themselves in the eyes of their community because shortly before the killing, the mother’s oldest sister had done the unthinkable.  She had married a gentile. In response, the family “sat shiva” for her – a ritual used to mourn the death of a family member.

Soon after the grandfather's sentence was handed down, the whole family pulled up roots and moved to California. The writer’s mother married her high school sweetheart, the writer’s father, only four days after the trial ended and headed for California the very next day - dining on foods prohibited by kosher law all through the trip! They may have had to marry quickly because, according to a widely circulated rumor, the shame on the family was about to lead to the writer’s father being prohibited from marrying Mom by his own family. 

In her entire life, the mother went back to Cheyenne only once.

The writer’s descriptions of her grandmother, Sally’s mother, were also very telling. She lived out her days totally devoid of expression. She often sat staring out her favorite window, never answering a door or making a phone call to the writer’s knowledge, and not keeping house well.  (There was some indication that the community from which she came had thought her odd even before the killing).

The effect of all these events on the relationship between the author as a child and her mother was chilling: She “...did not, could not connect with my mother. When she looked at me, I thought I saw disapproval and disappointment reflected in her eyes. I felt unwelcome, a stranger in my own home.”  

Mother seemed uninterested in her. Moreover, Mom’s days seemed joyless, as if she were prohibited from enjoying herself. This attitude rubbed off on the author.

As anyone faced by inexplicable parental behavior would when there is no obvious explanation for it, the writer “...made all my assumptions [about her mother] based on ignorance.” She naturally felt that her mother did not seem to like or want her.  How could she know that her mother may have felt guilty that she had not been able to protect her younger sister? That had actually been her job when Sally was being teased at school because of her odd behavior and dark complexion. 

It also seems likely that grandma became quite depressed, and she clearly had difficulties relating to her own daughter, the writer's mother.

Because of the stonewalling about the incident by the living, the author’s inquiries into the events often raised more questions than they answered. This was also a bit of a frustration for me as I read it, but I am certain that my frustration was absolutely nothing compared to that of the author’s.  

Truly a spellbinding story.

Friday, October 11, 2013

Part 4 of Dr. Allen's Discussion About Borderline Personality Disorder - The Earth Needs Rebels Show on Orion Talk Radio

Part 4 of my discussion of borderline personality disorder on Free Thinking Voice - The Earth Needs Rebels internet radio show was on live Tuesday, October 15, from 12-2 PM U.S. Central Time, and can now be found on their website.  

On the Orion Talk Radio station, additional feeds like Tunein Radio ( for more information on tunein radio and free software).

Here is the link to the downloaded broadcast:  Click on "down" and not on "listen."  The date and times posted for the broadcast: Tuesday, October 15, at 1:05 and 2:05 PM.

The last part of the series, Part 5, will be on live on Tuesday, November 12, from 12:30-2:00 PM U.S. Central Time.

Tuesday, October 8, 2013

Themes of This Blog Seen In Newspaper Advice Columns – Part I

Carolyn Hax

In this series of posts, I will show how several of the issues I discuss in the blog show up in letters to newspaper advice columnists. These columns have historically been written by women, but some men are entering the fray. The first ones were seen in Britain and the writers were referred to as agony aunts.

Of course, some of the published letters may me fakes, and the prejudices of the columnists determine which letters they publish and which of the many that they receive go unpublished. Nonetheless, as I have mentioned in previous posts, in order to have a wide readership, they must bring us problems that resonate with a fairly wide readership. This provides another source of information about human behavior for any mental health professional aware of the fact that the entire world of their patients does not consist of what they see or hear in their offices.

One other important point: there is always way more to the writers’ story than they possibly could tell in a short letter, even if they wanted to.

 I follow Jeanne Phillips (Dear Abby), Carolyn Hax, Amy Dickinson (Ask Amy), and Marcy Sugar & Kathy Mitchell (Annie’s Mailbox).

I will underscore each theme with a title reflecting the blog subject that seems to be discussed in the letters, which will also be a link to a related post. I’m not putting the columnist’s responses in the posts, as I will either give my own take or list any questions that the letter would raise, and lead me to ask, if I heard the story in a therapy or patient evaluation session – the “holes in the story,” as it were.

Most formerly abused adults have covert protective feelings towards their abuser, no matter how bent on justice or revenge they seem to fancy themselves. This particular letter writer admits to these feelings here anonymously, but not to people who know her in her actual life.

2/21/13.  Dear Carolyn: My father was an awful dad. He was the first person to ever call me a “b----” (I was 9) and was absent when he wasn’t antagonistic. Bad, bad Dad. The thing is, I’ve always toed the party line, always said the very best things about him publicly. I lied with a smile for decades and continue to now that it’s pretty clear his days/hours are numbered. I’ve contacted extended family and old colleagues to let them know this great man is ready for the last bits of adulation they may offer. I represent him within our small community and receive and share the sadness of his demise. He’s still so hurtful to me in every way imaginable and yet here I am, being a sucker until the very end. How do I deal with all of the self-loathing for having essentially been complicit in his bad behavior? I can hear (the imagined?) tsk-tsking from your readers (and from you, Carolyn, because you lost a mom who was clearly amazing and devoted). I’ve decided not to speak about any of this as my last gift to him, but it’s costing me. I’m just so angry at myself. How do I deal with it? I genuinely wish him no ill will; I’m just torn up by the lack of justice here. Not only will he never be held accountable for being so unrelentingly selfish and cruel, but now I’m burdened with these feelings that I fear would only make me sound petulant and somehow ungrateful. Moreover, he honestly wouldn’t know what I’m talking about because he is so utterly convinced of his own blamelessness. Help. - Anonymous

Another aspect of families protecting abusive members (the protection racket) is seen in cases in which an entire family pressures the daughter of an abusive father, say, to let him babysit her kids. In a sense, the family is banding together to deny the earlier abuse ever took place, so they must pretend letting him do this is not dangerous. Therefore, they gang up on the protesting parent (I call ganging up in this manner clustering). 

A certain percentage of people in the situation of trying to keep their kids away from dangerous adults actually give in to the family pressure and expose their kids to the risk. And almost all of them have difficulty dealing with the pressure. Here are three examples:

2/22/13. Dear Carolyn: I grew up with a mother who was profoundly manipulative, volatile and mean-spirited. My siblings and I all have anxiety disorders for which we have sought counseling. I have distanced myself from my mother and have a happy life with my husband and 4-year-old daughter.  I have begun allowing my mother limited contact with my daughter out of my mother’s desire to have a relationship with her. I am comfortable with where the boundaries currently are, but my mother is not. She continually pushes to have my daughter for weekend visits (she lives several hours away). I do not believe she would overtly harm my daughter, but she can fly off the handle when upset and has very different ideas than I do about what is acceptable behavior from a ­4-year-old.  My family seems to think I am being unreasonable to hold my mother at such distance. My sister has no personal relationship with her but does allow her to babysit her children. Am I wrong not to allow weekend visits, or am I being realistic? - Anxious Mother

9/9/13.  DEAR ABBY: My 61-year-old father was arrested recently for 30 counts of possession of child pornography. He has had a rough past -- he cheated on my mother and has had multiple stints in rehab for alcohol abuse. During my teenage years he verbally abused me. My mother is in denial about the entire situation and the fact that he is facing time in prison for his actions.  Nine months ago, my husband and I were blessed with the birth of our beautiful baby girl. I feel I must protect her from my parents and my father in particular. Some of my family agree with my decision, others disagree because I am my parents' only child. Am I wrong for not wanting my father and possibly my mother any longer in my life? -- TOUGH LOVE IN FLORIDA

3/5/13. DEAR ABBY: My father-in-law, "Earl," is an alcoholic and an avid gun enthusiast. He owns many weapons; I don't know the exact number. He has been accumulating ammunition at an accelerated rate because he's afraid that large clips will soon be banned. He drinks to excess and becomes belligerent and angry when drunk. Last summer, during one of his moments of inebriation, he shot a gun into the air as a "surprise" to the eight family members who were sitting within two to 10 feet of him. He takes pride in the fact that his guns are kept loaded, as "what good is an unloaded gun?" On two separate occasions, I know for a fact that a loaded gun was found unsecured in his home. When my husband and I travel with our children, ages 7, 5 and 4, to visit his family, we stay in Earl's home. I feel the combination of alcohol and loaded, unsecured guns is not safe for my children. I have suggested to my husband that we stay in a hotel during our visits from now on. The problem is, my husband is unable to stand up to his father. He told me that when he tried talking to him about his concerns, Earl called him a "wimp." Please tell me how to get through to my husband. I don't want to alienate his family, and I do want my children to have a relationship with their grandfather. -- GUN-SHY IN SOUTH CAROLINA


Annie's Mailbox 

2/27/13. Dear Annie: My daughter is a drug addict who is in and out of jail. Over the past 14 years, we have taken custody of her four children. Two of the kids are great. However, the other two are the problem. The oldest girl just turned 18 and moved out. This kid made our lives miserable. She saw counselors multiple times and began cutting herself, and we finally had to have her committed to a hospital. We did whatever we thought would work, but nothing did. She quit school and now lives with any friend who will take her in. Now, one of the other girls is 13 and doing the same thing. It's as if they lose their minds once they hit middle school. Her grades are down, she is getting into trouble at school, she cuts classes and has briefly run away twice. The other two kids are very involved with school and church and are as good as they can be. But, Annie, we don't want to handle the 13-year-old anymore. All of the counseling, the discipline, the problems, it's too much. My stomach is in knots trying to decide what to do. I am so tired of kids who think they know everything but are dumber than dirt, and all of the drama they command. My friends tell me to turn her over to foster care, but no one else is going to worry enough about her. My husband has had two heart surgeries in the past year, and my blood pressure is way too high, even though I take medication. Should I put her in foster care? — Helpless, Tired Granny

Some "More to the Story" questions: The letter writers say that they “tried everything” to discipline their daughter without success, and they seem to be having similar troubles with two of their grandchildren. What is entailed by their phrase “tried everything” – what specific things are those? Did they give up on a disciplinary strategy and go on to another one way too quickly? Did they try to micromanage everything in their daughter's life in order to save her from herself? Or did they perhaps bounce back and forth between over-involvement and neglect?

The writers’ ambivalence over taking care of children is palpable from the letter alone, which, if an accurate reflection of their feelings, puts them at risk of creating children with borderline personality disorder.  It is interesting that half the grandkids do not create any problems.  How do the writers, as well as the children’s mother, relate differently to each child? (I can almost guarantee that they do).  Does a given child remind them of themselves or another relative they had trouble with?  What do the mother and grandparents say to each other in the presence of the grandchildren?

Tuesday, October 1, 2013

Counting Symptoms that Don’t Count, Part II: Compared to What?

In my blogpost of July 24, 2010, Counting Symptoms That Don’t Count, I wrote.

“So what does a doctor who spends so little time with a patient do to save time? I mean besides completely ignoring the patient's relationships, history of trauma, humanity, etc…Well, one thing they can do is ask only about symptoms, and blindly accept the patient's yes or no answer without even checking to see if the patient understands the difference between a transient mood state and a psychiatric symptom. Better yet, before the doctor even sees the patient, he or she can have the patient fill out a symptom checklist, and base his diagnosis entirely on that. (Of course, his secretary could make a diagnosis doing that, so the patient really wouldn't even have to talk to the doctor at all).”

The inappropriate use of self report tests designed to screen patients as actual diagnostic instruments has become even more of an issue than ever. As you may recall from earlier posts, such instruments are purposely designed to cast a wide net so as not to miss someone in need of treatment, and as such, they snare many patients who do not, in fact, need treatment. 

As managed care is tightening its ever present grip, full psychiatric diagnostic interviews are being marginalized. This is especially true in the so call “collaborative care” models, in which psychiatrists merely advise primary care physicians without necessarily seeing the patient themselves. 

Fellow blogger George Dawson, M.D. beautifully describes the problems with the use of a depression screening instrument in wide use called the PHQ-9:  “…let's talk about what is really happening here.  This is all about a patient coming in and being given a PHQ-9 depression screening inventory…  It generally takes most patients anywhere from 1 - 3 minutes to check off the boxes.  Conceivably that could lead to a diagnosis of depression in a few more minutes in the primary care clinic.  At that point the patient enters the antidepressant algorithm and they are they are officially being treated [they may be given an antidepressant on the basis of the pHQ-9 results alone - DA]. The care manager reports the PHQ-9 scores of those who do not improve to the "supervising" psychiatrist and gets a recommendation to modify treatment."

No determination of whether the symptoms are clinically significant. No determination of whether the symptoms reported are merely relatively normal reactions to adverse environmental events. No nothing.

To appreciate why symptom checklists are so problematic, I need to discuss something called a Likert Scale. A Likert Scale asks the patient to “rate” a symptom by level of severity, frequency, importance, or how strongly the test taker agrees with a statement. There is usually a 4 to 7 point scale with a  number attached.  Examples:

Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day -3
(the PHQ-9 Likert Scale)

Very Frequently = 5
Frequently = 4
Occasionally =3
Rarely = 2
Never  =1

Not difficult at all = 0
Somewhat difficult = 1
Very difficult = 2
Extremely difficult =3

Very Important = 5
Important = 4
Moderately Important =3
Of Little Importance =2
Unimportant =1

Notice that the questions are asking the test taker to make a judgment about a symptom, but do not really define each level. It is therefore up to the test taker to decide whether the symptom occurs “often” or is “difficult” compared to some standard. But compared to what? Most people will use their own experience as reference points, and apply the terms according to this subjective standard.

So how is this a problem? Well, for depression inventories, most people have never seen someone with a severe melancholic depression who is thinking, moving and talking at a snail’s pace and who is totally and constantly overwhelmed with his or her depression all day every day for weeks at a time.  

Having never seen this, the average person does not know how bad depressive symptoms can be – unlike an experienced psychiatrist who has seen the whole gamut of depressed feelings. They therefore will not compare themselves to that, which is actually the relevant comparison!

So each test taker is, in effect, creating his or her own scale. What seems like "often" to them might not seem like very often at all to someone else. This makes the results next to meaningless for making a real diagnosis.

For those interested in statistics, the issue was neatly summed up by John Knight, a commenter on a Psychology Today Blog Post that criticized another post I had written.  He wrote:

“Firstly, there is nothing more subjective than self-reporting. How on earth can we treat what a client reports as objective data? Can any patient really detach themselves and report their... 'status' objectively, and interpret their symptoms and place scores on a Likert-type scale in the same manner as everyone else? What about the issue of the relationship to the practitioner? Can a patient be trusted to report objectively without trying to spare the practitioner's feelings? Or the opposite - what if they are annoyed and want to give negative feedback to someone they don't like?

Secondly, these Likert-type scales are often being processed as interval-level data rather than ordinal data. For the statistically uninitiated, ordinal data generally consists of "an arbitrary numerical scale where the exact numerical quantity of a particular value has no significance beyond its ability to establish a ranking over a set of data points" (thank you Wikipedia), whereas interval data will be something like degrees, metres, kilometres, and so on.

A Likert-type scale is ordinal data, but weak arguments and statistical trickery are being employed to treat it as interval data, which is easier to process and looks more scientifically impressive.

To lay off the accountant language for a moment, many CBT practitioners are treating patient self-reports with the same kind of measurable, real-world objectivity that one would treat degrees celsius, metres, kilometres, and so on. That is quite simply disgusting, and should trouble the conscience of any scientist willing to employ the method.”

Another problem is that instruments like the PHQ-9 ask questions about how many days a week a person experiences a symptom, but do not ask how long the symptoms last on a given day when present, let alone about the circumstances in which a symptom makes an appearance.

Let’s look at the questions, and I’d like the reader to envision two scenarios. The first is the melancholic depressive described above. The other is a man who gets involved and preoccupied with his duties at work and feels fine there, but every night after he gets home he becomes embroiled in a continuing conflict with his wife, who is threatening divorce, and only then starts to become extremely upset. 

I think the reader will see how it is quite possible that both of these very different individuals might answer the PHQ-9 questions in almost the exact same way, and come out with identical scores. The first would benefit from an antidepressant. The other would not, and probably needs marriage counseling instead.

PHQ-9 Patient Depression Questionnaire

Over the last 2 weeks, how often have you been bothered by any of the following problems.

Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day -3

1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself—or that you are a failure or
have let yourself or your family down
7. Trouble concentrating on things, such as reading the
newspaper or watching television
8. Moving or speaking so slowly that other people could
have noticed. Or the opposite - being so figety or
restless that you have been moving around a lot more
than usual
9. Thoughts that you would be better off dead, or of
hurting yourself

add columns

10. If you checked off any problems, how difficult have these problems made it for you to do your work take care of things at home, or get along with other people?

Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult

Copyright © 1999 Pfizer Inc.

Oh gee, look at who came up with this scale. A drug company. How convenient!!