Tuesday, October 28, 2014

Victimhood and Self-Destructive Behavior

"Taking responsibility for something and self-blame are horses of two entirely different colors. The former is empowering; the latter is paralyzing." ~ John Rosemond, Ph.D.

"You cannot see red flags while wearing rose-colored glasses" ~ Jim Woods, M.D.

Whenever I get into discussions online about people whose behavior is self destructive and which therefore exposes them to dangerous situations, the same old argument comes up again and again. It is sort of the inverse of the argument that comes up when I discuss parental misbehavior.  I am accused of “blaming the victim” or “bashing parents” as the case might be. 

Of course, there are an infinite number of situations in which people are victimized or during which other bad things happen to them, and they bear absolutely no responsibility of any sort for what happened to them. That goes without saying, but I guess I have to say it anyway. (Lets see how many readers totally ignore what I said in this paragraph).

But those are not the situations under discussion.

Alternately, I may be accused of “condemning” those whose behavior I am discussing, rather than just describing it and elucidating its consequences and origins.

I guess I am being critical in the sense that I don’t think self-destructive behavior or bad parenting practices are good things. Does anyone?  But even if I am being critical, that’s a long way from “condemnation.” In fact, 
I have a lot of empathy for the reasons why people behave in self-destructive ways. But it is actually very unempathic to pretend that their behavior is not self destructive. That would be a lie known even to them, and lying is not an empathic thing to do.

Part of the reason these sorts of issues come up is quite understandable. In many cases in which people have been victimized even though they have done nothing to put themselves in harms way, victimizers have a long and storied history of accusing their victims of somehow having invited the abuse they received, and blaming them for it. This is easily seen in the history of the legal defenses used by rapists, for example.  “She was wearing provocative clothing.”  “She was just playing hard to get and wanted it.” And way too many sexist juries bought into this bullcrap.

I absolutely agree that these kinds of accusations are heinous, lame excuses, and/or completely bogus. They are usually outright lies.

Again, not the issue that is the subject of this post.

There was the situation in the news not long ago where a high school girl got so drunk at a party that she completely passed out. The party was attended by fellow students from the football team. She was gang raped while she was unconscious.  Somehow, pointing out that perhaps she bore some responsibility for putting herself in harm’s way is suddenly translated into “You are excusing the rapist.”

No I’m not. Those are two completely different issues and they are being conflated. The two issues intersect, but they are two different issues nonetheless. Nobody is saying that the rapists should not go to jail and even burn in hell for eternity. But that hardly negates the fact that the victim’s behavior put her in harm’s way. 

It’s almost ironic that people who get upset about discussing the victim’s role in this situation often seem to think that a large percentage of men are pigs who think rape is OK. If that were indeed true, then passing out at a party would be a particularly dangerous thing to do.

If instead of being raped the girl had when she passed out fallen down and cracked her head open on a concrete floor, would we say that the only one bearing any responsibility for what happened was the floor? Sorry, but the argument that no one can talk about what the girl did because some rapist A-hole might be inspired to defend himself by trying to blame his victim is highly problematic. In fact, it’s stupid. If you want to talk about how to handle people that employ manipulate arguments, that's great, but it's another discussion entirely. 

I’m mincing words here. Someday I’ll tell you what I really think.

It’s also bad policy. If we want to help self-destructive adults take better care of themselves, absolving them of any and all personal responsibility for their fate is counterproductive. The first step in addressing a problem behavior like drinking until you pass out is admitting that it is, in fact, problem behavior.

Another highly important point: Taking responsibility for your own actions and acknowledging it is not the same thing as beating yourself up about it. As Dr. Rosemond points out in the quote at the beginning of the post, self-blame is indeed counterproductive. However, conflating that issue with the issue at hand is another argument based on emotion, and not on reason.

How about the issue of whether the girl might have no control over her drinking? People who think alcoholism is a disease may try to advance that point. Unfortunately, this gives the girl the message that she’s just a helpless, ineffectual human being with no intellect or self control. What a great, empowering message to give to someone. If you are helpless to do anything about this issue, why bother to even try to work on yourself?

A version of this whole argument also comes up regarding domestic abuse. If anyone brings up the issue of why someone (particularly a female, but there are also plenty of men who stay in abusive relationships) did not get out at the first moment an abusive pattern was becoming evident, they immediately get accused of blaming the victim. 

Likewise, when someone attempts to look into the psychology of the abusers and what makes them do such horrible things, they immediately get accused of "making excuses" for the abuser. Bull.

Recently there was an article about women whose boyfriends murdered their children. The murderers of course went to jail, but so did the women. They were charged with endangering their children and not protecting them by having made no effort to get out of an abusive relationship. The author of the article was naturally outraged that the mothers would be so "victimized."

The usual argument in this situation is that the abused spouse is afraid to leave because of threats of more abuse, and they or their family members might even get murdered. This argument of course makes the ridiculous assumption that the abuse is not going to escalate and that there is no risk of being killed if they stay. In the cases described in the article, the women did stay, and their children are now dead!

The women who make no effort to get out of a relationship in which they are continually beaten up are indeed afraid to leave because of something. However, that something is obviously not a fear of more beatings.

Another hidden assumption in public arguments is that the woman is so helpless and stupid that she cannot figure out a way to leave. Again, if that is true, why should she even bother to try to get out? Of course leaving is risky, and there are no guarantees that something really bad might not happen. Again, however, there actually IS a guarantee that bad things will continue to happen if they stay. 

Are these people saying that women are just too weak, helpless, and stupid to figure out a way to get out or to get help, especially now that help is far more readily available than it used to be? (And our past history in that regard is indeed a disgrace, so go ahead and pretend I didn't just say that if you must). Is that supposed to make them feel good about themselves? In fact, those things are just what abusers want their victims to think about themselves, so people who worry too much that women will feel "blamed" if someone points this out are in fact aiding and abetting the abusers!

Many women are quite able to successfully leave a bad relationship - but then they go back. And in therapy we see patients all the time who get out of one relationship with an abusive man, and then get involved with another, leave him, and then get involved with yet another one. What's the common denominator in those cases? Are we "blaming the victim" if we look at the woman's pattern of choosing abusive partners?

One other tantalizing clue. If you ask an abused or formerly abused partner why they stayed (at least those that come in contact with therapists), they are far more likely to answer, "Because I love him!" than "Because he threatened to kill me and my family if I left."

Another issue is that some percentage (of course not all by a long shot - I have to spell that out too, I guess) of abused partners are indeed verbally vicious and provocative with their abusive mates. Now, I can say in no uncertain terms that no one has the right to beat up anyone no matter how provocative they are. Again, no argument there, so bringing up this point is yet another diversionary tactic from addressing this point. (Let's again see how many readers seem to miss this last statement). But to pretend that some people do not compulsively poke a stick into a hornet’s nest is to live in Fantasyland.

In an exchange in the comments section in one of my posts on my Psychology Today blog, I mentioned that psychologically healthy women (and men as well - men abused by their wives and partners are not at all uncommon) get out of a budding relationship at the first sign that they are seeing a controlling and abusive partner. Earlier on, the risk that the person leaving might be stalked and killed, while not zero, is much lower than it becomes as the relationship progresses.

I was then drawn into an argument about whether or not people who do get involved with abusers do not realize that this is what they are dealing with until it’s too late.

I again think it’s extremely naive to think that people can’t see what to many people would be obvious. People who are self destructive are frequently “in denial” and lie to themselves all the time.  The old story of the wife insisting that a husband is not having an affair as she washes another woman’s lipstick off his shirt collars while doing the laundry comes to mind. Therefore, accepting someone’s initial description of how idyllic a relationship that later became abusive was at its beginning is probably not wise.

I discussed a frequent occurrence in the therapy of patients who had previously been in abusive relationships: a lot of time patients in therapy will say at first that there were no early signs that their ex-spouse might become abusive. Before long, however, it turns out there were more red flags right from the very beginning of the relationship than one might find at a rally of Chinese Communists, and the patients sheepishly admit that they chose to ignore them. Consciously.

The response I received: “Could this be because the therapist has browbeat them into admitting something that really isn't true--that they didn't know how to recognize them? They don't give out manuals to teenage girls on how to spot abusive guys before they ever go on their very first date.”

I replied: “I guess you'd have to ask my patients if they think I browbeat them, but unfortunately that's not possible. But I don't. And no interpretation is necessary when it's they themselves who are clearly admitting what they were doing and adding relevant details in a highly coherent fashion right on the spot." And I never even accuse them of contradicting themselves, let alone browbeat them. I use a well known and very gentle, non-confrontational psychotherapy technique that's very effective in getting people to open up. I'll describe it in an upcoming post.

Perhaps the patients were all little Dostoyevskys who are able to spin a complex fictional yarn at a moment’s notice that has no plot holes - just to tell a therapist what they think the therapist wants to hear? Without even knowing what the therapist wants to hear?


But of course, you cannot see red flags if you are wearing rose colored glasses, as Dr. Woods pointed out. The question of why some people are attracted to controlling and abusive partners is not answered by saying they are just too stupid to recognize abusive and controlling people. In fact, since they usually grew up with people like that in their families, they are probably better than the average person at recognizing them.

The answer as to “why” lies in the family dynamics discussed throughout this blog.

It is a very wise rule to not jump to any conclusions at all about the role of a victim or apparent perpetrator in any situation until the whole story comes out. And there is almost always far more to the story than you hear at first. The plot, shall we say, has a marked tendency to thicken.

Tuesday, October 21, 2014

The Woeful State of Our Knowledge of the Brain, and the Director of the National Institute of Mental Health

The major theme of this blog is how family systems issues have been denigrated in psychiatry and even psychology in favor of a disease model for everything.  

For this reason, you might think that I would be highly critical of the National Institute of Mental Health and its director, Dr. Thomas Insel. He has led the agency to focus almost entirely on neuroscience to the exclusion of research into family dynamics and other types of social psychological phenomena. Without an understanding of those latter factors, I believe it is impossible to really understand even the neuroscience, let alone human behavior in general.

Dr. Thomas Insel

Insel has been particularly supportive of President Obama’s BRAIN initiative (Brain Research Through Advancing Innovative Neurotechnologies), with its emphasis on such things as bio materials, engineering and nanoscience. He has been critical of the field’s diagnostic manual, the DSM 5, because it is limited to just observable signs and symptoms rather than the causes (etiology) of the various mental disorders.

While I certainly am critical of his neglect of handing out research dollars for social psychological and other such issues in mental disorders, I certainly have nothing against studying the brain in more detail.

I was pleasantly surprised by a recent article about Insel in Clinical Psychiatric News (August, 2014) that showed that he was at least realistic about both the current state of our knowledge about the brain as well as the prospects for our ever really understanding it.

I was particularly pleased about the following facts he emphasized to the newspaper:

“We can get cells to turn into neurons, but getting cells to turn into circuits is still a challenge. We don’t even know what a neural circuit is. We don’t know where it begins, where it ends; we don’t know how big it has to be; we don’t know exactly what the dynamics are.”

“…it may turn out that our brains simply aren’t smart enough to figure out how they work…It may be just a cosmic joke that we’re evolved enough to ask these questions, but not evolved enough to answer them. We’ll have to see.”

And then there’s his comments about the whole issue of emergent properties that characterize anything as complicated as the human brain. As an analogy, think of a car. Is it just a collection of bolts, screws, gears and metal shafts? Well, yes and no. 

It is definitely comprised of those things, but if you just look at those things alone (reductionism), you’d be hard pressed to understand a vehicle which can transport humans and other cargo over long distances. Other properties of the car emerge from the interactions of the parts.

So for the brain:

“…there is this whole body of work now that says, ‘Don’t worry about those hundred cells, or even those individual cells, and don’t even worry about looking at the circuitry because the key activity in the brain that is associated with attention, and thought, and consciousness is very slow oscillatory activity
…these oscillations that go in and out of the cortex create the dynamic of the cortex – some people call these cortical avalanches – seem to be pretty important for the way the mind works.

It would be like saying we want to know what’s on a television screen, and that you actually do better if you step back and get the whole picture, but don’t worry about any given pixel, because the emergent property of that television show is actually the whole thing together.’”

You can say that again!

Tuesday, October 14, 2014

Book Review: How Not to Be Wrong by Jordan Ellenberg

A while back (11/2/11) I reviewed the book Stats.con by James Penston. That book discussed how the statistics used in randomized clinical trials can be highly deceptive. How Not to be Wrong also covers some aspects of statistical misuse, in more detail, and certainly in a much more entertaining way. Some of his comments are funny as hell. 

Jordan Ellenberg

Consider the widespread use of a statistic call the p value, which estimates the probability that the result of a study could have just been a chance coincidence rather than an actual meaningful finding. A study is generally considered positive if the p value is 5% or less.

5% is of course not 0%. There is a one in twenty probability that the study results that are deemed positive were in fact negative. But what happens if journals only publish the positive studies and not the negative ones, when there might be a large number of negative studies, and when the positive study results are not reproduced (replicated) in a second study? Well, people start believing things that are not true, that's what.

The reason for this is because, as the author points out, improbable things actually happen quite frequently. Especially if you do lots and lots of things – like experiments. 

Another issue he mentions is that, if your sample size is too small, the chances increase dramatically that one of your subjects will be an outlier that dramatically but artificially changes the average for whatever characteristic you are measuring. With a small sample, you are more likely to get a few extra prodigies or slackers in a study of people's ability to perform certain tasks. A famous example: if Bill Gates walks into a bar with a few other people, the average guy in the room is a billionaire.  

Here’s how the author starts out a discussion of the p value problem (pages 145-46) :

"Imagine yourself a haruspex; that is, your profession is to make predictions about future events by sacrificing sheep and then examining the features of their entrails...You do not, of course, consider your predictions to be reliable merely because you follow the practices commanded by the Etruscan deities. That would be ridiculous. You require evidence. And so you and your colleagues submit all your work to the peer-reviewed International Journal of Haruspicy, which demands without exception that all published results clear the bar of statistical significance.    
Haruspicy, especially rigorous evidence-based haruspicy, is not an easy gig. For one thing, you spend a lot of your time spattered with blood and bile. For another, a lot of your experiments don't work. You try to use sheep guts to predict the price of Apple stock, and you fail; you try to model Democratic vote share among Hispanics, and you fail…The gods are very picky and it's not always clear precisely which arrangement of the internal organs and which precise incantations will reliably unlock the future. Sometimes different haruspices run the same experiment and it works for one but not the other — who knows why? It's frustrating…
But it's all worth it for those moments of discovery, where everything works, and you find that the texture and protrusions of the liver really do predict the severity of the following year's flu season, and, with a silent thank-you to the gods, you publish
You might find this happens about one time in twenty.
That's what I'd expect, anyway. Because I, unlike you, don't believe in haruspicy. I think the sheep's guts don't know anything about the flu data, and when they match up it's just luck. In other words, in every matter concerning divination from entrails, I'm a proponent of the null hypothesis [that there is no connection between the sheep entrails and the future]. So in my world, it's pretty unlikely that any given haruspectic experiment will succeed.
How unlikely? The standard threshold for statistical significance, and thus for publication in IJoH, is fixed by convention to be a p-value of .05, or 1 in 20... If the null hypothesis is always true — that is, if haruspicy is undiluted hocus-pocus —then only one in twenty experiments will be publishable.
And yet there are hundreds of haruspices, and thousands of ripped-open sheep, and even one in twenty divinations provides plenty of material to fill each issue of the journal with novel results, demonstrating the efficacy of the methods and the wisdom of the gods. A protocol that worked in one case and gets published usually fails when another harupex tries it, but experiments without statistically significant results do not get published, so no one ever finds out about the failure to replicate. And even if word starts getting around, there are always small differences the experts can point to that explain why the follow-up study didn't succeed."

The book covers many subjects about which the non-mathematically-inclined can learn to think in a mathematical way in order to avoid coming to certain wrong conclusions and to zero in on correct ones. Many of these, however, are irrelevant to this blog – the chapters on lotteries come to mind. I of course found those parts a bit less interesting. But the chapters relevant to medical studies are so right on.

Another important topic the author covers is known mathematically as regression to the mean. This phenomenon can lead, as examples, to overestimates about the genetic component of human traits and explains why fad diets always seem to work at first but then later on everyone seems to forget about them. As mentioned, when you average any measurement applied to human beings, the averages can be deceptive.  

In addition to the sample size considerations described above, you can get into trouble if you start with a sample that contains people who are higher or larger on average on the relevant variable that the average person in the general population.

If two tall people marry, their progeny will usually be, on average, tall compared to others in the general population. However, they are not all that likely to be taller than their parents. As Ellenberg states, “…the children of a great composer, or scientist, or political leader, often excel in the same field, but seldom so much as their illustrious parents” (p. 301). Their heredity mingles with chance environmental considerations, and pushes them back toward the population average. That is the meaning of regression to the mean.

To understand this, think about those who embark on weight loss diets. One needs to consider the fact that most people’s weight tends to fluctuate a few pounds either way depending on a lot of chance factors, such as their happening by an ice cream truck. And when are people most likely to start a diet? When their weight is at the top of their range! So by the law of averages, they are probably in many instances going to lose weight whether they diet or not. But when they do diet, guess what happens? They attribute the loss to the fantastic new diet!

I can not say for certain, but I wonder if studies on borderline personality disorders (BPD) yield misleading results because of regression to the mean. Long term follow-up studies on patients with the disorder seem to indicate that it seems to go away after a few years in a significant percentage of subjects. This finding is misleading, however, when you look closer. 

To make the BPD diagnosis, the subject needs to exhibit 5 of the 9 possible criteria. Many of the "improved" subjects merely went from 5 criteria down to 4 of them, and were therefore not diagnosed with BPD any longer. Actually, they became just what we call "subthreshold" for the disorder. Their problematic relationships, however, were still pretty much the same.

These results could mean that subjects with BPD may naturally vacillate between meeting criteria for the disorder and being subthreshold, or between exhibiting a high number of the criteria and a lower one. Which would mean that if they qualified for the diagnosis at the beginning of the long term follow-up study, a significant proportion of the long-term study subjects were at their worst. If so, the study results may indicate regression to the mean, and therefore say nothing else significant about the long term prognosis for the disorder.

Other important statistical issues the author discusses clearly and brilliantly include assumptions that two variables are related in a linear fashion when the are not (non-linearity - cause and effect relationships that are not based purely on an increase in one variable always leading to either an increase or decrease in another); torturing the data until it confesses (running multiple tests on your study data, controlling for different things, until something significant seems to pop up); and the following problem inherent in studies designed to see if two things like being married and smoking are correlated: 

"Surely the chance is very small that the proportion of married people is exactly the same as the proportion of smokers in the whole population. So, absent a crazy coincidence, marriage and smoking will be correlated, either positively or negatively."

Any one who is serious about critically evaluating the medical literature owes it to themselves to read this book.

Tuesday, October 7, 2014

Electronic Health Records: A Slippery S.(L) O.A.P.

In the last few years, the federal government has been pushing doctors to adopt software for recording medical records electronically on computer, and in response several companies climbed all over one another trying to sell Electronic Health Record (EHR) systems. 

In Medicare, the law authorized a higher fee for service rates to “reward” those doctors who began to use them - which in actuality is a payment penalty for those who did not. The cost of the software programs is, by the way, exorbitant - almost prohibitively so for doctors in individual practices or small practice groups in relatively low-paying specialties like pediatrics and psychiatry.

The EHR’s were supposed to increase efficiency and produce cost savings. Lab results from all of the patient’s doctors would be instantly available so that tests would not be repeated needlessly. Doctors would have instant access to prior records without having to mail away for them, and every current doctor would be able to see what the patient’s other current doctors were doing.

Those are admirable goals. Unfortunately, there are some problems with the currently available software that actually have had the effect of negatively impacting patient care. 

Whether these problems were foreseen or unforeseen is a debatable proposition.  George Dawson in his blog Real Psychiatry certainly makes the case that some of the “changes” we have seen in recent practice patterns that were caused by the use of EHR’s are highly consistent with the goals of the money-grubbing, profiteering-at-the-expense-of-patient-health managed care insurance industry. Or as we like to call it, mangled care.

I complained about some aspects about one EHR system I was using in a previous post. I must admit I had been wondering if I might be unusual in having noticed  that there are significant problems.

Well, the American Medical Association (AMA) has noticed them, and they have had enough! According to the AMA Wire on 9/16/14, the AMA has belatedly pointed out the obvious and has taken some action. Well, sort of. Of course, it will probably go absolutely nowhere.

It’s no secret that many physicians are unhappy with their electronic health record (EHR) systems, thanks in large part to cumbersome processes and limited features that get in the way of patient care. Now a panel of experts has called for EHR overhaul, outlining the eight top challenges and solutions for improving EHR usability for physicians and their patients.

This new framework (log in) for EHR usability—developed by the AMA and an external advisory committee of practicing physicians and health IT experts, researchers and executives—focuses on leveraging the potential of EHRs to enhance patient care, improve productivity and reduce administrative costs. Here are the eight solutions this group identified to address the biggest challenges.

In my previous post on this issue, I discussed the extraneous forms like treatment plans and symptom checklists that waste my time, as well as the difficulty in locating specific information in the overly-long patient record. In this post, rather than list the eight proposed "solutions," I will instead focus on a problem that was near the top of the concerns expressed in the above article:

Poor EHR design gets in the way of face-to-face interaction with patients because physicians are forced to spend more time documenting required information of questionable value. Features such as pop-up reminders, cumbersome menus and poor user interfaces can make EHRs far more time consuming than paper charts.

Although physicians spend significant time navigating their EHR systems, many physicians say that the quality of the clinical narrative in paper charts is more succinct and reflective of the pertinent clinical information. A lack of context and overly structured data capture requirements, meanwhile, can make interpretation difficult.

EHRs need to support medical decision-making with concise, context-sensitive real-time data. To achieve this, IT developers may need to create sophisticated tools for reporting, analyzing data and supporting decisions. These tools should be customized for each practice environment."

Ah yes, the quality and the interpretability of the proverbial doctor’s progress notes has gone down the toilet.

So what makes a good progress note? A good progress note does not just describe what the patient looks like during a visit at that particular time coupled with a plan concerning what the doctor is going to do next. It should also indicate what the doctor is thinking about the patient, the patient's symptoms, and the diagnosis. Specifically, which of the patient’s symptoms have changed, and if so, what is the change due to? The medication prescribed? Side effects? A misdiagnosis? A placebo effect?

Does a change in the patient’s clinical picture suggest an alternate diagnosis? Are there any side effects from the medications that the doctor prescribed? How does the patient's clinical presentation relate to any treatment that has been rendered? Does any observed changes in the patient's condition mean the doctor should change the treatment or continue it as is? If a change in medication is planned, over which symptoms is the doctor trying to get better control? If there has been no response to treatment, to what does the doctor think this lack of improvement should be attributed?

In reading over a medical report, another doctor can fairly easily ascertain the answers to the above question from a relatively brief narrative.  On the other hand, the answers to these questions cannot be ascertained from a simple checklist. No how, no way.

In the old days when I trained, we were instructed to use a so-called “S.O.A.P” note.  The abbreviation stands for the different types of information that should be included in the note:

Subjective: A description of the report from the patient regarding his or her own symptoms and overall improvement or lack thereof, as well as any reports of side effects. In the case of antidepressants, the timing of any changes in symptoms should also be ascertained and described, to help rule out a placebo effect.

Objective: What does the doctor observe when looking at the patient? Are there any changes in the patient's physical examination? What changes in the patient’s outward mental status have transpired since the last visit? What are the results of any lab tests that have been ordered?

Assessment: What does the doctor think these results mean regarding the patient’s diagnosis and treatment?

Plan:  What is the doctor going to do next to handle any problematic side effects of treatment, or to handle any failure of the patient to improve?

In psychiatry, a good progress note should also contain information about any changes in the patient's psychosocial situation - particularly any stressors: job changes, divorce, major family battles, deaths, children getting into trouble and the like. This information is important in determining whether any changes in the patient's clinical picture are due to environmental stressors or psychological reactions, and not due to the medication or its failure.

At the multispecialty clinic where I work part time, the useful S.O.A.P. progress note format is at risk of being abandoned. There are still good notes, but many of the progress notes contain almost no indication of what the doctor was thinking about the effects, let alone the pro’s and con’s, of the patient’s treatment.  

Between scrolling through all of the the checklists and the extraneous notes and next to worthless notes, I find myself  wasting an amazing amount of valuable time that I could be spending actually talking to my patient.

I certainly wish the AMA well in addressing these problems. I’m not holding my breath.