Tuesday, January 27, 2015

If All the Docs are Doing it, is it not Malpractice?

Part of the legal definition of malpractice includes the idea that the treatment provided falls below the accepted standard of practice in the medical community.  In other words, it must be shown that the practitioner was acting in a manner which was contrary to the generally accepted standard operating procedures that are currently being widely used by other physicians in the city in which the doctor practices.

For a malpractice case to be successfully pursued in court, the treatment must also be shown to be negligent and of course result in some quantifiable harm to the patient. But what happens if certain harmful procedures were being widely performed by almost all of the other doctors in the community? Even if the harms are predictable and significant, is a doctor protected from liability just because "everybody's doing it?"

Many mothers back in my day used to answer their kids' protestations that "other kids get to do it!" with, "If everyone jumped off a bridge, would you do it too?" I can't speak for others, but mindlessly following the herd was not something that was encouraged in my family system.

I do not know off hand what the answer is to the question above. Perhaps some malpractice attorney who happens to read this might write in with the answer. The reason I thought of this question was something I recently read in the psychopharmacology (psych drug) newsletter Biological Therapies in Psychiatry (July 2014) about how often kids are monitored for side effects when they are prescribed psychiatric medications.

Regular readers of this blog know that I think that the diagnosis of pediatric bipolar disorder is in the vast majority of cases a scam, and that prescribing antipsychotic drugs to children to control their behavior is a reprehensible activity. Kids should not be sedated into being less affected by family dysfunction.   

That would be bad enough, but what is worse is that antipsychotic drugs have potentially dangerous side effects. Particularly with the newer, "atypical" antipsychotics, there is a significant risk of causing weight gain, type II diabetes, and high cholesterol. These risks may be higher in children and adolescents than they are in adults.

If a patient is psychotic, the benefits of these medications generally outweigh the risks, especially if the patient is monitored for the emergence of these side effects. And there are few other options. (Sometimes one drug in a class will do it in a given patient, but not another drug in the same class). If patients are not psychotic, and very few kids are, the benefits decidedly do not outweigh the risks.

At the very least, the doctor should take blood tests periodically to see if these side effects are developing. You would think that doing that would be the standard community practice.

Well, if you thought that you would be wrong. 

In a retrospective study by Delate and others (JAMA Pediatrics, 2014 May 5) of pediatric patients started on an atypical antipsychotic within the Kaiser Permanente system HMO in Colorado, the authors found that only 1 patient out of 1023 received the full recommended panel of baseline and follow-up blood monitoring!

That's right; you read correctly. 1 out of over 1000, or one tenth of one percent. Of course we don't know if kids in other health plans are being treated this negligently, but I would not be surprised.

So if almost all of the doctors in a community are making little kids jump off bridges, does this mean that they are not going to be held liable if they are sued for malpractice?

Tuesday, January 20, 2015

Family Communication: Countering Relatives Who Go Off on Tangents

In my blogposts about family metacommunication, one issue I discussed is the tendency of people to change the subject when discussing anything touchy. When a person is afraid to or does not want to go into depth in discussing a particular repetitive interactional pattern with a family member, for whatever reason, a subtle switch from the issue under discussion to some other matter is often a successful strategy for avoiding further dialogue about it.

This is particularly easy to do if there are a whole bunch of similar issues that are all inter-related and intertwined with one another. As I wrote in the previous post: 

Another related misdirection strategy is to mix several separate but highly interconnected issues so that none of them is ever completely discussed. For example, one woman was in a complex family system in which her husband would find ways to distract her from her anger at her parents and vice versa. Whenever she expressed anger at one of her parents, the husband would do annoying things to draw away her anger from her parents towards him Similarly, when she was ready for war with hubby, one of her parents would act out and draw her wrath towards them.

The woman's genogram revealed that the problems in this system were related to gender issues (whether men should take care of women or women should pursue independence), concerns regarding the adequacy of males in the family to take care of their women (her husband felt that he was supposed to protect his wife but felt inadequate to do so and angry about "having" to shoulder the responsibility) and even class (how much money was being brought in).

The discussion would change from one of these aspects of the problem to another at the drop of a hat. Because the aspects were all so interconnected it was indeed difficult to talk about any one of them without talking about the others. For example, when the issue of the husband's adequacy came up, the issue of why he was like that would also arise. Because the subject of any conversation jumped around, however, any conversations about the issue would end up going in circles with nothing being resolved.

In this post, I want to discuss another useful strategy under these circumstances for keeping family metacommunication on track in order to get to the bottom of a single issue. Another way to look at the problem of subject changes is that the mix-up of issues allows people to go off on a tangent that is related to - yet different from - the main theme the metacommunicator is trying to clarify.

The trick here is to remember the definition of a tangent from your old geometry class in high school. Tangents are related to circles, and look like this:

If you go to the tangent line and trace it backwards, it always goes right back to the circle. Analogously in metacommunication, the "circle" is the main theme that ties all the different tangents together.

Any tangent someone goes off on can be thought of as just another example of the main theme - the circle in the diagram.

As an example, let us take a hypothetical situation in which there is a highly conflicted relationship between a mother and a daughter who come from a typical highly dysfunctional family - one characterized by many examples of major gender issues common to many members: the females getting involved with men who are drunk, abusive, and/or cheating; whether or not they should leave relationships with such men; expressing anger at such men; mothers who do not protect their children from abusive men or from witnessing domestic violence; conflicts over being tied down by children leading to neglect and invalidation of them; enabling children who don't take care of themselves; depending financially on either unreliable men or good providers who mistreat women, and so on and so forth.

There are indeed families characterized by all of the above conflicts- over several generations. If there are several sisters, aunts, great aunts and female cousins acting out several of these themes, one can see how easy it would be to subtly avoid focusing in depth on any one theme, or for that matter, on any one relationship.

So what might tie all of these gender-related themes together as they play out in metacommunication about problematic behavior patterns between a mother and her adult daughter who has children of her own?

Here we can make use of the concept described in a previous post: intrapsychic conflict leading to ambivalence leading to mixed and/or contradictory messages. Anything the mother says to her daughter regarding any of the above behaviors can be translated into a message to the daughter to either "act (or relate to the issues) like me" or "do not act (or relate to the issues) like me." Usually both within the very same conversation!

In this case, a good strategy might be for the daughter to express confusion about what the mother is trying to tell her in terms of following or not following mom's example no matter which aspect of the gender dysfunction is brought up. She might say something like, "Gee Mom, sometimes it sounds like you are criticizing me for doing the same things you do, while at other times it sounds like you are criticizing me for not doing them. I'm confused about what you think is the right strategy when, for example, my ex-husband keeps calling me on the phone several times a day."

A typical dysfunctional conversation might go something like this:

Mother: "I told you to block his phone number and stop talking to him."

Daughter: "But you let Dad keep bugging you all the time."

Mom: "Well, I do that for your sake 'cause I know you still care a lot about him, so it's better if we are civil to each other."

Daughter: "But wouldn't that also apply to my sons from my ex?"

Mother: "Well you don't seem to want to be bothered with your kids' feelings half the time anyway."

In this example, the mother has subtly changed the subject from how to handle an ex-husband to the daughter's parenting practices. If the daughter were to engage the mother on that issue, the mother might then talk about how the daughter is still financially dependent on her ex and needs to support herself better so she can get rid of him. Nothing would ever be resolved.

The counter-strategy is to take each tangent the mother goes off on and reconnect it to the circle or main theme. Any criticism the mother makes of the daughter on any of these inter-related subjects can be used as yet another example of how the mothers statements confuse the daughter in regards to whether or not she should follow her mother's example.

If the daughter starts with the statement above describing her confusion about whether or not mother thinks the daughter should emulate her, and the issue of the stalking ex comes up, the daughter would not say, "But you let Dad keep bugging you all the time." She would instead say, "I'm confused when you say that, cause that sounds like you are saying I shouldn't let my ex keep bugging me like you put up with Dad."

If mother then brings up her having put up with Dad for the patient's sake, that of course contradicts mom's initial advise for the daughter to cut off her ex when there's a child involved there. The daughter might then bring up that seemingly contradictory advice as a way to get back to the circle once again. 

The daughter would be ill-advised to come right out and accuse her mother of being hypocritical, as that would usually lead to the mother becoming defensive. Instead, she could blame her own confusion about what the mother is trying to say:

"Well I'm again kinda confused now. Are you saying I should handle it like you did for the sake of my sons, or that I should do the opposite of what you did and cut off my ex?"

Of course, this strategy could have good results, but it could also backfire.

The mother might at that point be struck by how she is giving the daughter double messages, which might then allow her to take pause and start to discuss why she herself might be confused on these issues - a good result. On the other hand, the strategy might also make her feel guilty and want to change the subject yet again. 

Mom might try the strategy of saying that her situation with the daughter's father is somehow different than the daughter's situation with her ex. Naturally, in some ways every situation is somewhat different, but in doing this she would be ignoring all the ways in which their situations are similar.

Figuring out the next move on the daughter's part would probably require the services and advice of a knowledgeable therapist. A therapist can tailor a counter-move for the daughter, using his or her knowledge of several different things: 

Knowledge of the mother and daughter's prior interactions; the therapist's own experience successfully countering the daughter's having done the very same thing to the therapist as her mother does to her within the context of psychotherapy; and information from the genogram about the source of the mother's ambivalence that can be use to empathically advance their conversations toward problem resolution.

Tuesday, January 13, 2015

What Happens if Adults with Borderline Behavior Start to Act Better?

People who have dealt with those who have been diagnosed with borderline personality disorder (BPD) often wonder why those folks persist in their often infuriating as well as self-destructive behavior when it seems so obvious that they are making themselves as well as everyone who cares about them completely miserable. 

When I first started to treat them, I know I did. These patients were not psychotic, nor were they stupid, so why did they persist in dysfunctional behaviors in the face of overwhelming evidence of their consequences. So I started asking the magic, Adlerian question: What would happen if you got better and stayed better?

As I described in that previous post, patients would often answer with the non-answers, "I'd just find some other way to screw things up" or "I cannot even imagine what that would be like." I would not accept those "answers" and pressed on.

When the answers finally started to emerge, I was totally amazed. One thing that might happen was described in my very last post. If a patient with BPD got better, their families would run for the hills. Exile them. Shun them. Abandon them. Anyone wonder why those with BPD have "abandonment issues?" Wonder no more.

But abandonment was far from the worst or the most likely outcome when patients acted beter.

I found that something family therapy pioneer Murray Bowen described was quite real - only that it was the just the first thing that would begin to happen before things got far far worse.

I found that the power of family members to invalidate anything a therapist tries to teach a patient should not be underestimated. As first pointed out by Dr. Bowen, they will literally gang up on a patient with messages that scream, roughly translated, "You're wrong! Change back!"  Previously uninvolved family members may come out of the woodwork, and previously sympathetic family members may suddenly turn on the patient and scream things like, "HOW CAN YOU TREAT YOUR MOTHER LIKE THAT!?!" 

I dubbed this phenomenon "clustering." Try to imagine what it would be like if everyone you know and loved started to come after you like that. If you don't think you would wilt, you are kidding yourself. And that would be true even if you came from a family that was relatively functional to begin with. Imagine having been invalidated like that for your whole life.

As I said earlier, however, that would only be the first thing that would happen if someone with BPD started to act better. The next thing that happens is that the parents start to act out in alarming and frightening ways. I'm talking about things like parents making suicide threats or actual attempts, increasing drug or alcohol abuse to alarming levels, worsening domestic violence, family members getting thrown out on the streets penniless, or any children left in the home starting to be abused, neglected or molested. You know, minor, inconsequential stuff.

Furthermore, as first pointed out by Lorna Smith Benjamin, in "borderline families" all these problems would be blamed on the patient, who would be subtly expected to somehow exert control over them.

Think you'd be able to turn your back on your family if all this happened to you? Very few can. Even if you could, it would only be because your family would, through their own behavior, engineer your dismissive attitude - so that you would continue to not only be their scapegoat, but so they could also label you as an uncaring son of a bitch as well. 

Americans like to think that they don't care what their families think of them. Horse manure!

In response to all of this, individuals with BPD usually start to actively undermine ("spoil") any efforts anyone might make to encourage them to continue with their "good" behavior - without telling anyone (including a therapist if they have one) about any of their family's behavior - and revert right back to the way they had always been. 

Sunday, January 4, 2015

Addict Cleans Up, THEN is Shunned by Family

An interesting letter appeared in the advice column Dear Abby on 11/30/14:

DEAR ABBY: I am a former drama queen and addict now enjoying long-term sobriety, or trying to. What's missing in my life is my family. Since returning from rehab, I have been "going it alone" -- and I'm not sure why. My kids are the only grandchildren in the family. I work and go to school. I am pleasant. There have been some rough spots I have had to deal with, and when I have needed to, I have called my mom or sister, but they don't call me or visit. They have expressed no love for me through all of this. When I call, I feel like I'm intruding. Aren't I entitled to their love and caring? I feel abandoned. It's hard doing things on my own. My family lives close by, so distance isn't the issue. What am I missing? I want my kids and me to have a family, but when I try to reach out, I end up hurt by their lack of interest. Should I just get on with my life? I have been going through this for years. -- MOVING ON IN FLORIDA

DEAR MOVING ON: It's possible that the "drama" and turmoil you put your family through while in the throes of your addiction is the reason your mother and sister avoid you. They may be reluctant to take a chance again. Because they have made it plain that they aren't interested in a closer relationship with you and your children, you should absolutely get on with your life.

Abby's response was predictable. There were also several comments on the website from the public about the letter, and the commenters were more or less unanimous: the letter writer had probably "burned her bridges," the family probably got sick of giving her one chance after another and were burned out, etc. etc. 

After all, as another commenter opined, "
Addicts hurt a lot of people and cause a lot of problems." The family's response is due to their need for "self preservation." The writer probably used to call them "only when she needed something."

These responses were in fact so predictable that the letter writer herself undoubtedly knew what she was going to get. She was setting herself up, and making herself look bad while all the while criticizing her poor family. The criticisms of the family did not go over well at all with Abby's readers. With her criticism the writer was in fact garnering sympathy for her family, rather than making them look bad. She had to know that would happen.

The burning bridges thing probably contains an element of truth. But more likely a half truth.

How did this former drama queen/addict turn out the way she did in the first place? Wasn't she in fact raised by the very family that is now shunning her? How many chances did they give her before giving up on her? When she was actively using did they get involved with her over and over again?  Enable her? Try to "rescue" her?

Notice that she identifies herself as a former drama queen. Where did that label come from? Is that what everyone in her family would call her over and over again until it became a role she would play in order to confirm their opinion of her? 

Was she in fact the only one in the family who had been expressing feelings that everyone else was stuffing? Was she the identified patient, as  family systems therapists call such folks, who gets all the blame for a problem shared by the entire family?

And most importantly, did they abandon her only after she cleaned up?

Inquiring minds want to know the answers to these questions before passing judgment.

This is a counter intuitive way to look at this. I understand that. But when the whole story comes out from patients in therapy, the answers to my questions are often yeses. Respected interpersonal theorist Lorna Smith Benjamin describes an analogous dynamic in which she lists two of the four characteristics she has observed in families that produce offspring with borderline personality disorder (BPD) - who often share many characteristics with both drama queens and addicts:

1. Parental love and concern is elicited only by misery, sickness and debilitation

2. Family chaos - The borderline individual is subtly blamed for problems or expected to exert control over them.

(The other two characteristics:  3. Episodes of traumatic abandonment are interspersed with periods of traumatic over-involvement, and 4. Efforts by the person with borderline disorder to establish autonomy are interpreted by the family as indicated disloyalty).

What may be happening in the case of the letter writer is that her family needs a black sheep, and she was elected to play the part. Because she finally stopped playing the part, they then shun her. In this situation, they would be in effect be punishing her for not being who they need her to be. However, they would also be helping her out in a strange way - by protecting her from their own pernicious presence. As Dr. Benjamin has also said, pathological behavior can be a gift of love.

This could be the real answer to the letter writer's question.