Increasing Placebo Responses in Psychiatric Drug Studies

In 2013, authors Rutherford and Roose  [American Journal of Psychiatry, 170  (7),  723-733] wrote a paper that discussed the results of a previous study that had found that the placebo (inactive "sugar" pill) response rates in random clinical trials (RCT's) of antidepressant medication had risen at a rate of 7% per decade over the past 30 years. Consequently, the average difference between active medication and placebo observed in published antidepressant trials decreased from an average of 6 points on the Hamilton Rating Scale for Depression (HAM-D) in 1982 to only 3 points in 2008.

Now the lead author of that paper and his colleagues have found something similar going on in RCT's between 1960 and 2013 of anti-psychotic medications for schizophrenia (the findings were published on line in October in JAMA Psychiatry). Most interestingly, in the 1960's, patients who received the placebo in such studies actually got worse on them.  By the 2000's, however, they were getting better on placebo.

Even more striking, the average RCT participant receiving an effective dose of medication in the 1960s improved by 13.8 points on the Brief Psychiatric Rating Scale (BPRS), whereas this difference diminished to 9.7 BPRS points by the 2000's.

What the heck is going on here? Are the medicines somehow becoming less effective than they used to be?

In their article from 2013, Rutherford et. al. try to explain this by looking at such things as expectancy (what do subjects think is going to happen with their symptoms), a statistical phenomenon known as  regression to the mean (see this post for a definition), the amount of contact subjects have with the study doctors, the social desirability of certain responses, and the “Hawthorne Effect” (subjects in an experiment improve or modify the aspect of their behavior under study simply by virtue of knowing that the behavior is being measured).

While the expectations of the average John Q. Citizen that antidepressants will work may have increased somewhat over the decades because of such things as celebrities describing their experiences with depression or commercials for Cymbalta and Abilify, there has also been a lot of negative information on that same score on television shows like Sixty Minutes and from the anti-psychiatry rants of Scientologists and others.

Whether these two influences completely cancel each other out is debatable, but I think it is safe to say that many of these possible reasons for a change in placebo response rate advanced by authors have in fact not changed significantly since the 1960's. In fact, if people in the 60's didn't think antidepressants would work, expectancies would have been lower, not only in the placebo group, but in the active treatment group as well.

If certain factors that affect placebo response rates have not changed a lot, then those factors can not explain the rise in the placebo response rates

The authors also mention a couple of factors that I believe to be more on the mark: first, that assessments of eligibility for a clinical trial may be biased toward inflated symptom reporting at the beginning of the study - when investigators have a financial incentive to recruit patients - and second, that most research participants in the 1960s and 1970s were recruited from inpatient psychiatric units, whereas current participants are symptomatic volunteers responding to advertisements.

The biggest change in research with RCT's over the period in question is that many studies are no longer done in medical schools, but by private entities called Contract Research Organizations (CRO's). The doctors who run the studies are paid for each subject they recruit, and subjects only get paid if they are recruited. This means that there are not just one set of financial incentives for everyone to exaggerate their symptoms at the beginning of a study, but two! This tendency will lead to a higher placebo response rate because after they are recruited, subjects no longer have an incentive to exaggerate their symptoms. So they seem to get better.

It is very easy to bias a research diagnostic interview. I'll get to that in a minute, but first a digression.

I was fortunate to train at a time when patients could be kept in the hospital for several months if necessary, so we got to see the patients in depth over a considerable time period, and could watch medication responses. People who have trained more recently do not see this any more.  Antidepressant responses clearly took a minimum of 2 weeks  - and then only if the patient responded to the very first drug given at the first dose given.

Because most patients do not understand this, the doctor can usually discriminate a placebo response from a true response by observing when the patient starts to get better combined with the rate at which they improve. Since subjects don't know what to expect, being on this timeline could not be due to the expectancy factor, which in turn is necessary for a having a good placebo response.

I can tell you that a severe, properly diagnosed melancholic depression almost never showed a significant placebo response.  The placebo response rate was probably about the same as the placebo response rate to a general anesthetic.

Another thing we observed was that patients with an acute schizophrenic reaction did not seem to get any better at all with such things as additional contact with doctors, which might be expected if a placebo response were taking place. In fact, the more you spoke with them, the more likely it would be that you would hear evidence that patients had a significant thought disorder than if you just had a briefer, casual conversation with them.

A thought disorder is at least as important as delusions and hallucinations in showing that someone is, in fact, someone with schizophrenia. People with a thought disorder see relationships between things that are completely illogical (loose associations). For example, the first patient I ever saw with schizophrenia in medical school believed that everyone who wore oxblood-colored shoes was a descendant of George Washington.  

Huh?

Anyway, back to the question of biasing diagnostic exams. This is particularly easy when diagnosing a clinical depression. It is important to distinguish them from those people who are merely chronically unhappy.  People with a clinical major depression, especially with so-called melancholic features, are a very different breed of cat.  

The  symptoms of both disorders do overlap a bit, so there are some cases in which it is really hard to tell one from the other. However, in the majority of cases it is a fairly easy call. It is, provided you do a complete psychiatric assessment, over several days, to see if a symptom of depression meets the requirement known as the Three P's: 

The symptoms need to be pervasive (they do not go away depending on what the patient is doing at a particular time), persistent (lasting almost all day every day for at least two weeks), and pathological (the patients symptoms and functioning differ to a highly significant degree from the patient's usual state). In addition to the three p's, all of the patient's symptoms have to always occur simultaneously.  

These types of characteristics do not usually show up on the type of symptom checklists used to assess patients in clinical trials, because the checklists are mostly based on a patient's self report.  Unfortunately, the majority of people do not know the difference between a clinically significant symptom and one that is not. The rate of false positive responses on checklists is staggering.

Many studies instead use something that is called a semi-structured diagnostic interview (such as one called a SCID) to make a diagnosis. It is called semi-structured because it tells the examiner to ask certain questions exactly as they are posed verbatim. However, the examiner is then free to ask any follow-up questions needed to clarify the clinical significance of any symptom the patient reports.

If you want to diagnose major depression regardless of whether or not the patient actually has it, all you have to do is accept every "yes" answer a patient gives to a question about a symptom without any follow-up questions to see if the symptom is characterized by the three P's. If the patient answers "No" to a question, however, you keep pumping the patient for additional clarification until you can find something the patient says that will justify changing the "no" answer to a "yes."  Voila.

Book Review: Ghost of My Father by Scott Berkun

Half of all profits from this edition of Mr. Berkun's book, Ghost of Our Fathers (Berkum Media, 2014) will be donated to Big Brother Big Sisters of America

Our parents, or our primary caretakers when we were growing up, have a profound effect on us for our entire lives. They have this effect whether they like or not, and whether we like it or not. Attachment research has shown that their interactions with us help shape our mental models of both the world and how relationships are supposed to operate under various environmental contingencies (schemas).

The part of the brain called the amygdala, central to our fight/flight/freeze reactions to fearful stimuli, has specific cells that respond only to the face our mothers (or primary female attachment figures) - and nothing else. It also contains cells that respond only to our fathers/male attachment figures - and nothing else.

Even those who have managed to become more self-actualized or differentiated from our families of origin - who can follow our own muse and live according to our own independently formed beliefs - still hear or feel those old tapes of our parents' admonitions whenever we do things of which our parents routinely disapproved. I know I do, and my parents have been gone for decades. We can choose to ignore these tapes, but there is often a nagging doubt that arises in our minds whenever we do.

In his new book, Scott Berkum describes a feeling of being haunted by the past as well as by the ongoing behavior of his father, and does so eloquently using the words of a poet. I'll mention some examples of his beautifully-worded descriptions of some of the phenomena discussed previously this blog shortly.

Most of what I have written about dysfunctional family interactions on this blog as well as my blog on the Psychology Today website concerns what happens when parents give us contradictory or mixed messages about what is important to them, as well as what they expect from us. But what happens when they seem to give us almost no signals at all? When the parent is a big cipher? This is what happened to the author in his relationship with his father, and I suspect, though to a much lesser extent, with his mother.

His father was gone much of the time during his childhood, spending most of it working or at the racetrack gambling. He completely abandonned the family and the patient's mother twice in order to have extended affairs - once when the patient was eight years old, and once when the patient was in his forties. And yet when he returned each time, the mother would want him back, take him in, and take care of his needs.

He seemed to have little interest in what was important to the author. Much of the time he seemed to barely acknowledge his son's presence. The only sustained interactions they had seemed to occur at the dinner table, when the author, his siblings, and his father  would debate political and social issues. Father would seem to purposely take up a provocative position on the issue, and then stick with it no matter what arguments the author came up with.  Dad would never concede a point.

The author was plagued thoughout his life with a feeling that he was unworthy of his father's attention, and that nothing he did mattered to his Dad.

The author tried on numerous times to do what I recommend to my patients in therapy: attempt to empathically confront Dad to try to find out what made him tick and what he was really thinking (metacommunication). Unfortunately, each time he tried he ran up against a brick wall that would never come down. His father seemed to be incapable of discussing feelings. If the author pressed forward anyway, the conversation would devolve into a shouting match.

The book does not describe what was said during these explosions. With my patients in therapy, I try to obtain a blow-by-blow description of exactly what was said,  in chronological order, as best the patient can remember. This often gives hidden clues about the emotional processes that are taking place in both participants during the battle, as well as to why they are reacting the way they are.  In turn, this can suggest ways to have conversations that do not go in the usual direction and do not become fighting matches.

Interestingly, Dad did apologize for his behavior on one rare occasion and even expressed his love, but both the apology and the expression seemed to ring hollow with the author, who more or less rejected them.

Of course, when the author rejected them, he may not have realized that this let his father off the hook as far as further elaborating on the problem at hand- which was likely the father's goal all along. Saying what a family member wants to hear in a seemingly insincere way and/or when it is least expected often leads to such a rejection of the expressed sentiment. The person who does this then walks away thinking, "Just as I thought - he didn't really want to hear that, but at least I tried." This is an example of the game without end.

The author does discuss some genogram information, although whatever therapists he saw may not have not called it that nor known exactly how that information might best be used to design more productive family interactions in the present. The information about his father's upbringing was rather telling, and seemed to explain one statement the father made in the middle of one of the author's attempts to metacommunicate: "Your problem is you remember too much."

The author's paternal grandfather was described as "the quietest man I ever met." The author adds that he "...was always watching professional wrestling when we visited. He'd stare into the television as if he and it were the only thing left on the planet. His social skills, even with his own grandchildren, were non existent...I don't remember him ever saying a word to me."

No doubt Dad's father had done to him pretty much what he did to his own son. 

Clearly this was Dad's unfortunate role model for being a father. Clearly there was a family rule against fathers and sons communicating meaningfully. The author also admits that he shared some traits with his father - at times more than he cared to admit even to himself - demonstrating the intergenerational transfer of dysfunctional traits. The father must have tried to handle his own feelings by trying to "forget" what had happened.

A clue as to the origin of the family rules is that the father's paternal great grandfather  fled to the US from Ukraine in 1902 to avoid being drafted into the army, leaving his brothers behind. Undoubtedly there was a lot more to that story, especially since the brothers died in the Holocaust many years later. Was there some resulting hidden guilt and shame that had to be kept out of mind and never discussed?

The book is supposed to be primarily about the author's relationship with his father, so Mr. Berkum gives limited attention to his relationship with his mother. While he described them as close, it sounds as though certain subjects were off limits with her as well - like why she remained involved with such a distant man, and why she would take him back after a second betrayal.

The only person in the family who seemed to be able to express anger was the author's sister Tracy, who of course went overboard in doing so. Interestingly, the parents seem to keep her around almost as a pet - she lived with them or next door to them even after she married and had kids - until she, like the author himself did as a rather young man, finally moved away to escape. 

No doubt the parents needed Tracy's expressiveness to release some of their own pent-up rage.

Some concepts from the blog that the author describes poetically:

Distancing: "He mastered wounding us just enough that we'd leave the conversation as quickly as we could." (p. 11).

Existential groundlessness: "...we forget when we become adults that the armor made to survive our youth no longer serves us...yet removing it is painful...it puts us at odds with our family and friends, as tribes prefer to stay with patterns of the past. Most people convince themselves that removing their armor is something they don't need to do. And their families, complicit in the same denial, reward the defense of the status quo, ensuring the...same armor, and the same ghosts, will be passed on to the next generation..." (p. 17).

The power of family ties:  "It is curious, perhaps even strange, that the choices of my father would impact me so profoundly at forty years old." (p. 22).

"I didn't realize that just because you're done with the past doesn't mean the past is done with you."

Mutual role function support: "Each person needs the other badly, in the way an alcoholic needs another drink. When one takes a drink of the other...it feels good. It covers certain holes, allowing them, in moments, to be forgotten, but does not fill them. My mother and father love each other for that feeling, and hate each other  for the same reason." (p. 114).

On the feeling of not counting for his father, after a brief encounter after he returned late from the racetrack:  "It was the bottom of the barrel of his day..." (p. 150).

I could go on. This book is a brutally honest memoir, well worth reading.

Intrapsychic Conflict and Dysfunctional Family Patterns

There have not been a lot of studies done looking at how personality problems affect individuals over three generations within a family, and how they may be passed down from one generation to the next. Today’s emphasis is studying mostly biogenetic factors.

However, the few studies that have been done generally show the same types of things. Although there is never a one to one correlation (because people’s development is affected by the chaotic interactions of thousands of different variables – genetic, biological, interpersonal, and sociological), certain issues are highly likely to be passed down.

Earlier studies have shown what is known as intergenerational transfer of certain types of dysfunction for, as examples:

• Boundary disturbances such as maternal overprotection and relationships characterized by lack of affection, enmeshment, and/or parent/child role-reversals (Jacobvitz et. al., Development and Psychopathology, 3, 513-527, 1991).
• Emotional dysregulation with poor disciplining skills with children (Kim et. al., Journal of Family Psychology, 23(4), 585-595, 2009).
• Substance abuse with parental substance abuse combined with abuse and/or neglect and low levels of family competence (Sheridan, Child Abuse and Neglect, 19 (5), 519-530, 1995).

In understanding this process, I try to incorporate concepts from different "schools" of psychotherapy. The most important task in integrating different psychotherapy models is to pose the question of how concepts from different therapies might relate to one another, and how slight modifications to specific aspects of these concepts may make relationships between them more clear.

In this post, I will focus on the relationship between several such concepts. We have the concept of intragenerational transfer of dysfunctional behavior from Bowen family systems therapy. Then we have a primary concept from psychodynamic therapy, intrapsychic conflict. People have conflicts between their innate desires and the values they have internalized as they grew up within their family and culture. 

To see how these two concepts can both be valid and also when combined explain certain human behavior, we can take a closer look at the intergenerational transfer question.

The attachment theorist Bowlby first suggested that these transfers occur, not through specific observable behaviors like “abusiveness” or psychiatric diagnoses per se, but through the generation of mental models of interpersonal behavior in the affected children. These working mental models are now called schemas by both psychodynamic and cognitive-behavioral therapists. They are also subsumed under the rubrics theory of mind or mentalization by another set of psychodynamic therapists. We need to look at the subjective experiences of the involved children throughout their development.

Zeanah and Zeanah (Psychiatry, 52, 177-196, 1989) discuss the concept of organizing themes. They mention that studies show that abusing mothers tend to attribute more malevolent motives to their own children compared to other people’s children. More generally, they react with more annoyance and less sympathy to videotapes of crying infants than do non-abusive mothers. To think that these patterns would not be noticed or sensed by children through their daily interactions with their parents, and would not affect the development of their schemas, would be extremely naïve.

In turn, abusive mothers reported more threats of abandonment and role reversals with their own mothers than did control mothers.

These findings are probably the tip of the iceberg in terms of subtle characteristics of repetitive parent-child interactions, and as the Zeanahs say, “Patterns of relating are considered to have more far-reaching consequences than specific traumatic events” (p.182).

When Bowen therapists started doing the genograms of their patients, which describe family interactional patterns over at least three generations, they noticed something that has not really be described much in empirical studies. While some children of dysfunctional parents had problems that were similar to their parents -  such as substance abuse - other children seemed to have developed behavior patterns that were exactly the opposite – they became teetotalers!

I have seen this sort of thing many times in taking genogram-related family histories from my own patients. One son of a workaholic will also be a workaholic, while his brother becomes a complete slacker who can’t seem to hang on to a job, or who does not even bother to look for one and goes on disability of some sort. Or who is enabled by the workaholic father.

In fact, in some families one generation has a lot of alcoholics, the next generation a lot of teetotalers, and the third generation goes back to having a lot of alcoholics. Or impressive successes in one generation are followed by remarkable failures in the next. McGoldrick and Gerson, in their book Genograms in Family Assessment, traced the genograms of some famous people like Eugene O’Neill and Elizabeth Blackwell and readily found such patterns.

If these sorts of issues were entirely genetic, it would be difficult to explain how progeny of the same parents could be so completely opposite from one another, as well as completely opposite from their own parents. So what might be going on psychologically within people that might lead to interpersonal behavior with their own children that generates such bizarre patterns?

This is where intrapsychic conflict may come in. Say a father was a young adult during the Great Depression of the 1930’s. He had grown up feeling that work defined him, and that he was obligated to keep his nose to the grindstone in order to support his family. He was lucky enough to have a job, but his boss made his life miserable. He could not quit because he would not be able to get another job, and therefore he began to subconsciously resent the very values with which he has defined himself.

This could lead him to develop an intrapsychic conflict over hard work which starts to tear him apart. He may relate to each of his sons in a manner that – very subtly - suggests to one son that he too should be just like him, while the other son is subtly rewarded for acting out the father’s hidden resentment towards hard work and self-sacrifice.

Likewise, a patient might come from overly-strict religious parents who had rejected any and all hedonistic pursuits, but who had preached to their child about the evils of alcohol in a highly ambivalent manner. Such ambivalence usually arises in them because of their having received mixed messages from their own parents. Their son may feel pushed to rebel, and therefore lead a licentious, alcohol-drenched lifestyle. Such a person often destroys himself in the process, because if his parents observe him being successful in spite of drinking, this would exacertate the conflict in his parents and destabilize them. This would frighten him. So he becomes a self-destructive alcoholic.

His behavior would be sort of compromise. He would be following the repressed urges of his parents and allowing some expression of them, while at the very same time showing his parents that repressing the urge was indeed the way to go.

In the next generation, his children may “rebel” just like he did, but the only way they can do so is by going to the opposite extreme themselves. They become teetotalers. Their children, in turn, “rebel” by becoming alcoholics.

I’m tremendously over-simplifying this process so the basic outline is clear to the reader, but I see these types of patterns – with many fascinating twists and turns - every day in my practice.

Dumb Hidden Assumptions in Drug Abuse Research

The mental health professions these days seem to want to blame their patients' repetitive problematic or self-destructive behavior on just about anything except what is, in the large majority of cases, the primary causes: family dysfunction and adverse childhood experiences (ACE’s). And I mean, they would rather it be almost anything else.

In my post of February 26, 2011, I discussed how a slight increase in aggressive thoughts following the playing of violent  video games by adolescents was translated by researchers into the games being a major risk factor for the development of youth violence. The fact that most compulsive video game players are inveterate couch potatoes who do not get out much never entered into discussions.

Not surprisingly, a recent longitudinal study (Fergus0n et. al., J. Psychiatr Res 2012; 46: 141-146), showed that, by taking other variables into account such as intra-family violence, the correlation between video games and even short-term aggression could no longer be established.  Another older paper from the same lead author (Ferguson and Rueda,  J Exp Criminol, 2009; 5:121-137) showed that aggressiveness in the laboratory, as expected, did not correlate with violent acts in real life.

Focusing on minor targets like video games risks leading social activists and public policy makers to ignore the far more important causes of youth violence like child abuse.

So of course, now that the tide is turning against the insane drug war against  marijuana, which has turned a significant percentage of the population into criminals (who tend to only be prosecuted if they happen to be African American), the folks who refuse to look at reality are now publishing "studies" that attribute a host of problematic behavior almost entirely to the devil weed – while all the while making the most ridiculous hidden assumptions imaginable. 

People who feel the need to be stoned all the time have enough problems; we do not need to make up a bunch of other ones.

In Carl Hart’s book High Price , he recounts his adventures as a reviewer of potential drug abuse studies for funding from the National Institutes of Health. He mentioned that the research agenda was being controlled by the National Institute on Drug Abuse (NIDA). He makes it clear that they were only interested in studies that showed the dangers of street drugs, not on studies which countered the many myths in the field that he had described in the rest of the book. (NIDA also ignores the dangers of the very same drugs they demonize when Pharma sells them for conditions such as "ADHD").

Now comes a study out of Australia and New Zealand: “Young adult sequelae of adolescent cannabis use: an integrative analysis” by Edmund Silins and others. (Lancet Psychiatry, 2014;

1: 286–93). Here is the abstract:

Methods: We integrated participant-level data from three large, long-running longitudinal studies from Australia and New Zealand: the Australian Temperament Project, the Christchurch Health and Development Study, and the Victorian Adolescent Health Cohort Study. We investigated the association between the maximum frequency of cannabis use before age 17 years (never, less than monthly, monthly or more, weekly or more, or daily) and seven developmental outcomes assessed up to age 30 years (high-school completion, attainment of university degree, cannabis dependence, use of other illicit drugs, suicide attempt, depression, and welfare dependence). The number of participants varied by outcome (N=2537 to N=3765).

Findings: We recorded clear and consistent associations and dose-response relations between the frequency of adolescent cannabis use and all adverse young adult outcomes. After covariate adjustment, compared with individuals who had never used cannabis, those who were daily users before age 17 years had clear reductions in the odds of high school completion (adjusted odds ratio 0·37, 95% CI 0·20–0·66) and degree attainment (0·38, 0·22–0·66), and substantially increased odds of later cannabis dependence (17·95, 9·44–34·12), use of other illicit drugs (7·80, 4·46–13·63), and suicide attempt (6·83, 2·04–22·90).

Interpretation: Adverse sequelae of adolescent cannabis use are wide ranging and extend into young adulthood. Prevention or delay of cannabis use in adolescence is likely to have broad health and social benefi ts. Efforts to reform cannabis legislation should be carefully assessed to ensure they reduce adolescent cannabis use and prevent potentially adverse developmental effects.

Funding: Australian Government National Health

The authors claimed to control for confounding variables, but most of these "controlled" variables were unrelated to ACE’s or ongoing family chaos. They were such things as age, sex, ethnicity, socioeconomic status and mental illness. The authors did control for a few possibly relevant parental variables like alcohol use, tobacco use, divorces, and history of depression. But not for how the parents actually behaved around their children, how they treated their children, child abuse or neglect, how chaotic the home environment was, or how and how consistently the children were or were not disciplined.

What on earth makes people who draw the conclusion that the drug was the primary cause of the lower achievement become so stupid that they don't see that frequent drug use is a sign that the teens already had emotional problems before they even started smoking - and that it was these problems that predate the drug use that were the real cause of both the drug use AND the poor performance?

The authors used exactly one rather vague sentence in their discussion to refer to this possibility, which most readers will miss: “…cannabis use in adolescence could be a marker of developmental trajectories that place young people at increased risk of adverse psychosocial outcomes.” (p. 291). 

Ya think?

More to the Story in Tales of Family Dysfunction: How Therapists Get the Whole Picture

She never mentions the word addiction

In certain company

Yes, she tells you she's an orphan

After you meet her family

~ The Black Crowes

In several recent posts (12/27/13, 5/27/14, 10/28/14) I brought up the idea that a story about someone’s family life that one hears from a patient in therapy, in a news story, in a letter to an advice columnist, or directly from friends and acquaintences, is quite often, shall we say, incomplete. The story is true as far as it goes, but it often leaves out details and information about the context in which it occurs.

In therapy, as the therapist gets to know the patient, listens carefully, and employs certain techniques to help patients get past their shame, guilt, denial, and protection of family members, the whole story gradually emerges. As I mentioned before, the plot thickens. The added information puts everything the patient told the therapist before in a whole new light.

This more complete information allows the therapist to do something called pattern matching. The full story will remind an experienced therapist of common dysfunctional family patterns that may apply to the patient’s situation, and about which the patient would have no way of knowing.

The therapist can then mention that in other similar cases such and such explained similar family behavior that was otherwise inexplicable and confusing to the patient, and inquires if this is what might be going on with the patient and his or her family. This in turn may allow the patient to understand many things in ways they never thought of before.

Before describing a commonly-used psychotherapy technique (which is a version of the facetiously named Columbo style of questioning, named after a famous TV detective, described in the post of 3/13/12), I would like to refer back to a previous post, popular among readers, about parents pretending to be clueless about why their adult children are no longer speaking to them.

In that post, another reader wrote in and mentioned some possibile details that perhaps the aggrieved parent may have conveniently left out.

A more recent letter to advice columnist Amy Dickenson (10/14/14) is a bit more revealing. The cut off parent initially attributes the cut off to what she readily admits was a rather trivial argument. However, as the letter goes along, the parent reveals additional information that shows that she was not so clueless after all, and the advice columnists calls her on it:

Dear Amy: The last time I spoke to my adult daughter was five years ago. I hosted a first birthday party for her son at my home and she severed ties with me after a petty argument. Since then, she has given birth to additional children, and for several years, I sent cards and gifts in the hopes of reconciling. I stopped giving because the only response I received was through secondary sources; she never responded directly to my e-mail or letters. I feel I had every right to be angry that day long ago. Both she and her husband were upset over my choice of party decorations (among other things). Post-fight, it came out that she felt unsupported during my marriage to my abusive ex-husband. And although I divorced him many years ago, it was evidently still acutely painful for her… — Wronged Mother

Dear Mother: You have chosen this space to try to restate your original gripes against your daughter… I can't help but wonder, however, about your daughter's feelings. In the midst of all the detail you supply, you mention your marriage to an abusive ex-husband. Is it possible that this estrangement is based on your daughter's anger over your inability to protect her from an abusive situation?...

Now in this case the mother had moved on from attributing the cut-off to the argument over party decorations and started getting into the important issues involved. But as mentioned, some patients in therapy or who are interviewed in news stories act like their initial explanation is the totality. It’s their story, and they are sticking to it.

So how do therapists help patients give them the relevant details necessary for the therapist to make an educated guess about what is really going on covertly during repetitive dysfunctional family interactions? The technique is a simple one in principle but difficult in practice, because it requires a therapist to remember everything the patient has said since the very beginning of psychotherapy.

My memory is unfortunately not that good, so I take extensive notes after every session. Just prior to the following session, I do a quick overview of all of my previous notes to refresh my memory.

As patients talk about what’s on their mind concerning ongoing issues, they will often mention something in passing which seems to contradict something they told me earlier in therapy. This usually happens while they are discussing seemingly unrelated matters.  (I just happen to be paying closer attention to what they said than most people).

As therapy progresses, they often mention the same or analogous contradictory information again. Some time later, when several examples of such ambiguities have arisen, I politely ask them to clarify for me how seemingly contradictory statements they have made fit together. I do this without accusing them of trying to obfuscate issues or to confuse me. In fact, I ask them to help me understand this from a position of my being confused, and perhaps just too thick to understand it (this was the technique Columbo used to get perpetrators to confess to crimes).

This is when patients start to admit that they had not been completely candid with me at the beginning of therapy. The amount of detail, internal consistency, and new information that starts to come out shows me that they are not making things up to please me. If and when that happens, their story begins to fall apart.

Another technique that helps clear up plot holes involves the responses the patient makes to any observation the therapist may make. This involves not only whether the patients are agreeing or disagreeing with what the therapist has observed, but what then follows.

Back in the day when psychoanalytic therapies were king, we were taught that there were four possible patient responses to any observation or interpretation a therapist makes. First, the patient agrees with the therapist, and then a bunch of brand new information begins to come out. That’s obviously the best outcome.

The second best outcome is that the patient disagrees with the therapist, but a whole bunch of brand new information nevertheless comes out. This usually means one of two things: 1. That the therapist is partially correct, but is missing something important. 2. That the therapist is bringing up something prematurely, before the patient is quite ready to admit to certain things for any of a variety of reasons.

The second to worst outcome is when the patient agrees with the therapist, but then gets quiet, with no additional information coming forth. This usually means that the patient is agreeing with the therapist only for the purpose of telling the therapist what the therapist seems to want to hear.

The worst outcome is when the patient disagrees with the therapist and then gets quiet. That usually means the therapist is way off, and it is time for him or her to ask for the patient's thoughts, and then shut up and just listen.

An Unwarranted Hidden Assumption in Research on Personality Disorders

One of the major reasons I became interested in family systems theory, tribalism, family myths, social psychology, and other manifestations of collectivism was because I noticed a big problem with the major forms of psychotherapy practiced on individuals: psychodynamic and cognitive-behavior therapy, and, though to a lesser extent, humanistic therapies like Gestalt therapy.  

All of these forms of individual therapies pay way too much attention to the way patients are reacting, and not nearly enough attention to what it is they are reacting to.

It’s a bit like looking at someone who is falling apart after recently having personally witnessed their entire family being beheaded by terrorists, and concluding that he or she has “poor distress tolerance coping skills.” Well, maybe not quite that bad, but you get the idea.

Some psychologists talk about something called the fundamental attribution error. According to Richard Nisbett and Lee Ross in their 1980 book, Human Inference: Strategies and Shortcomings of Social Judgment, this is defined as “the assumption that behavior is caused primarily by the enduring and consistent disposition of the actor, as opposed to the particular characteristics of the situation to which the actor responds.”

Richard E. Nisbett, Ph.D.

Of course, internal predispositions, one's past history of learning due to environmental reinforcement, and free will are very important in determining how people are going to respond to a given situation. With people who have personality disorders in particular, however, to say that their living in a family war zone, as frequently described in this blog, is not a huge part of the problem seems to me to be the height of absurdity.

I thought of this issue recently after reading an article entitled “Ecological Momentary Assessment in Borderline Personality Disorder: A Review of Recent Findings and Methodological Challenges” (Santangelo, Bohus, & Ebner-Priemer, Journal of Personality Disorders 28 (4), pp. 555-576). 

Ecological Momentary Assessment (EMA) is a research technique designed to look at behavior and internal processes outside of the confines of what is called retrospective reporting. Retrospective reporting is the subjects' response to questionnaires about the way they normally respond in their daily lives - in hindsight.

People in studies using this technique are given a diary to fill out several times per day at regular, fixed intervals as they live their normal lives. They are instructed to record certain feelings and reactions they are experiencing. In the article’s abstract, it says that EMA is “characterized by a series of repeated assessments of current affective, behavioral, and contextual experiences or physiological  processes while participants engage in normal daily activities.”

As the authors reviewed the results of prior studies using this methodology in subjects with borderline personality disorder (BPD), one of those hidden assumptions I defined in a previous post just jumped out at me. The authors were inherently ignoring issues created by the fundamental attribution error. 

The definition of EMA in the article's abstract mentions “context,” by which I assume they mean the environmental context, but in the studies and in their discussion about them, the issue of environmental context seemed to be missing in action. The subjects were always asked about how they were responding, but almost never asked about what it was that they were responding to!

The authors’ literature review focused on five of the DSM’s (the official diagnostic manual of the American Psychiatric Association) criteria for BPD: 1. Affective instability. 2. Dissociation and transient paranoid ideation. 3. Interpersonal disturbances. 4. Self esteem disturbances. 5. Suicidality.

Now, one legitimate reason for doing these studies is to check on the validity of the diagnostic criteria for BPD, in which case descriptions about how the subjects’ families were behaving would be somewhat irrelevant. Since the diagnostic criteria were used to establish the diagnosis of BPD before the studies were even done, if the studies seemed to indicate that the criteria are turning out to be invalid, that would have to mean one of two things:

1.       Patients with BPD have been invariably lying through their teeth - on an impossibly consistent basis - in giving even superficial descriptions of their personal symptoms and experiences during diagnostic interviews ever since the syndrome was first recognized, or 
2.      The experimenters in the various earlier studies were lousy diagnosticians and were not applying the criteria in a valid manner.

Now, since I would assume that neither of these things was generally true, a finding that the subjects did not experience these symptoms would be most surprising. Of course, generally the subjects did experience the symptoms, although perhaps in some cases not quite in the generally accepted way. This sort of a conclusion is very close to being a tautology – that is, “a rose is a rose.”

But I digress. The authors clearly mention that some of the symptoms they are looking at occur in response to stress, but generally the subjects are not asked to describe the actual stresses to which they are responding. For instance, they say that subjects with BPD were found to be “more prone” to experience stress than controls. 

The problem with this is that it that assumes that the stressors that the controls are responding to are of equal frequency, severity, and nature as the stressors to which the subjects are responding. But no descriptions of those essential factors are presented. Perhaps if the controls were living in a more stressful environment, they would experience the stresses in a fashion more similar to that of the BPD subjects. 

Why are the subjects not also asked in their diaries to describe the stressors to which they are reacting? Is it all in their heads?  (It’s All in Your Head was the original title of my last book. Damn those academic publishers who thought that title was too colloquial). Or is it because therapists, like a lot of people these days, don’t want to look at what is actually going on in families?

Another issue is that, even if the diaries did ask about stressful interactions with intimates, and even if patients described them honestly and included their own behavior in their descriptions, the experimenters would still be in the dark about how severely stressful they were. That is because these interactions have subtexts, as I described in my post The Obvious Secret of Interpersonal Interactions Within Families. 

Words and behaviors during family interactions take on additional shades of meanings within the context of all prior interactions, and these meanings can significantly add to the stress level of the involved parties. In fact, without knowing the entire history of the patient's family interactions, the experimenter's judgments about the severity of the stress would by necessity be extremely flawed. 

As far as I know, there is only one method by which a mental health professional can obtain this data: long term psychotherapy with the involved individual. This should also include occasional conjoint sessions with the patient and family members, to get their sides of the story. The stressors of every single patient have qualities that are unique to them.

Without any descriptions of the nature of the stressors, we can not really come to valid conclusions. Of course, a possible assumption that should be made is this: people who are under severe stress are undoubtedly more likely to respond with more severe reactions than people who are under far less significant stress. 

Duh!