Tuesday, December 20, 2016

Yet Another Drug Company Fined for Off-Label Marketing of Psych Medication

Since I started this blog way back in March of 2010, I have posted several times about big Pharma companies being fined for the off-label marketing of various psychiatric medications. Well, the hits just keep on coming.

The Consumerist was one of several news sources to recently report that: 

"New York Attorney General Eric Schneiderman announced the settlement Thursday resolving allegations that Bristol-Myers Squibb improperly marketed and promoted the drug Abilify.
Abilify — the brand name for the prescription drug aripiprazole – is a second-generation antipsychotic prescription drug, commonly, commonly referred to as “atypical antipsychotics,” that were originally used to treat schizophrenia.
According to the states’ complaint, which was also filed today, BMS engaged in off-label marketing, which is the promotion of drugs for uses that are not FDA-approved.
For example, the complaint claims that BMS improperly promoted Ability for pediatric use and for use in elderly patients with symptoms consistent with dementia and Alzheimer’s disease.
This, despite the fact that in 2006, Abilify received a “black box” warning stating that elderly patients with dementia-related psychosis who are treated with antipsychotic drugs have an increased risk of death.
Additionally, the complaint alleges that BMS violated state consumer protection laws by misrepresenting and minimizing the risks of the drug including metabolic and weight gain side effects and by misrepresenting the findings of scientific studies.
Under the proposed agreement, BMS is prohibited from promoting Ability from off-label uses; making false or misleading claims about the drug; compensating health care providers for attended promotional activities; using grant funds to promote Ability; and providing samples of the medication to health care providers who do not intend to use it for labeled purposes."
Bristol-Myers Squibb settled the claims with 43 states for a total of 19.5 million dollars. That sounds like a lot of money, but for big drug companies, it is actually a paltry sum. Fines like that are considered a cost of doing business

As readers know, I am rabidly against the use of antipsychotic medications in non-psychotic children, which is unfortunately becoming more and more common. However, I must admit I have negative feelings about that black box warning regarding the use of any (not just Abilify) antipsychotic medication in patients in nursing homes with advanced dementia due to Alzheimer's disease or other severe brain conditions. 

Things have gotten to the point where docs are afraid to prescribe these medications even in such patients who are actively psychotic with hallucinations and/or paranoid delusions, for which there are no other effective treatments.
Even in non-psychotic demented patients, antipsychotic meds are often the best agents for controlling assaultive behavior in this population. Unlike other sedatives, they do so while only minimally exacerbating memory and cognitive deficits in these people. Our society seems to want to pay nursing assistants only the minimum wage to take care of our impaired family members as they age. Long-term facilities are very expensive as it is. Not only that, but we under-staff them as well. While there may be psychosocial interventions which would reduce assaultive patients with dementia, we do not want to pay people to provide them.

Given those conditions, what is left? Medications, that's what. Do we really want to expose underpaid and overworked caretakers to dangerous aggressive behavior from patients who basically have no life anyway - just to prevent a tiny percentage of them from dying a little sooner due to the medications' cardiovascular side effects? Time to either pay up or shut up.

Tuesday, December 6, 2016

Parents and Adult Children React to My Descriptions of Borderline Family Dynamics

Parents and Adult Children React to My Descriptions of Borderline Family Dynamics

In my post about the family dynamics of Borderline Personality Disorder (BPD), I describe the role of the spoiler. A child or adult child of a family that exhibits the family patterns described in my posts on this subject begins to behave in ways which turns things around. The child invalidates the parents' efforts to "help" or "take care of them" in nasty ways. He or she essentially responds to invalidation by making comments that invalidate the parent right back. 
The reason the children do this is because they believe the parents need a child to be a target for their anger, and volunteer for the gig. They give the parents just cause by behaving in unreasonable and infuriating ways.
When it comes to the people who make comments on my posts on this and similar subjects, it always fascinates me how parents usually think I am putting all the blame on them for the family problems, while the adult children with the disorder react to the exact same post by thinking I am putting all the blame on them! 
Family systems therapists used the term punctuation to describe these types of reactions. People take something that is an ongoing problem created by continual reactions to feedback from two people with each other, and look at just one isolated segment of it - thereby breaking up a process artificially into misleading cause and effect relationships. They then react accordingly.
Of course, there are readers who do see the whole of the patterns in their lives but still do not know how to put a stop to them. In many cases the problems continue in spite of honest declarations of personal responsibility and even apologies -because there continue to be underlying issues that remain unaddressed.
I have reproduced two comments and my replies which illustrate these phenomena quite well. The first comment doubles as a description of spoiling behavior which illustrates it far better than I ever have.

The Blame Game
Submitted by A Mother of a Possibly BPD Child on November 6, 2016 - 11:39am
Regarding blaming the parents for "invalidating" feelings: I think it's a dangerous idea that all feelings are valid. Does anyone truly believe this?
When you are dealing with someone whose thinking is so distorted that they misperceive all your motives and react to your natural withdrawal as abandonment after they have been screaming abuse at you for an hour, you will just distort your own thoughts if you try to get into their head. If I say to my daughter "When you told me X it hurt my feelings," she often perceives that as an attack and starts to mock me: "Oh did that hurt your feelings? POOR YOU!" This can often escalate, and soon she is telling me what a horrible parent I am. That she is in so much pain that she'd lash out at me like this (again) does *not* mean I was abusive to her. She did not learn how to talk that way from us. We would never say something like that, even though she tells other people that's how we talk to her, and she probably believes we do. We did not cause that pain. Her mind did.
And this is the crux of the matter: just because someone perceives something as hurtful does not necessarily mean it's time to blame someone for hurting them. If someone trips and falls on you, and you scream, and they get mad at you for hurting their ears and making them feel ashamed with your tears of pain, should you feel sorry for them, since they honestly feel hurt by what you did? Should you feel mortified at yourself for inflicting such a nasty guilt trip on them with your tears? Some feelings *are* invalid! We invalidate our own feelings all the time. We *have to* if we don't want to be complete narcissists. A non-BPD person might feel a flash of anger at the ear-pain, but they would quell it, and then feel sorry they fell on you, sorry they hurt you accidentally. And if the screamer is non-BPD, they will probably be furious for a second at being fallen on, but then accept the apology and understand that it was an accident, perhaps even apologize for the loud sound they made - and everything will be fine afterward.
But if it isn't like this, the non-BPD screamer might reflect that they shouldn't have screamed and they certainly shouldn't have cried, since that just escalated things with the BPD person. But they were just behaving the way they would to anyone who fell on them. The reason they might think they shouldn't have screamed though, was because it made things into a conflict they didn't want, and they knew they could have avoided it.
And here's something else that's important: if (in the scenario with the falling person being BPD) the screamer pretends nothing bad happened afterward and tries to be loving again as if the falling person had been apologetic and understanding, are they *enabling* this bad behavior? Spoiling a tantrum-thrower? And if the falling person is the screamer's child, is the screamer not providing a terrible role model for the child? Should the *child* learn to tolerate this kind of behavior in other people? Should they not stand up for themselves and have high standards for their own behavior and that of other people?
Parents want to teach natural consequences, encourage empathy, and model the way one should behave in certain situations. BPD totally warps this. You start to think it's impossible to teach anything useful. You start to think that *ANY* response you have is doing irreparable harm to the BPD person. Walking on eggs to reduce conflict, or refusing to tolerate bad behavior - it's all bad. So what would be *good* for a BPD person? How would we recognize it?
As parents, we are not mind-readers. However we respond to behavior, it should teach something (how to respond, how not to respond, natural consequences, etc.) If the behavior is terrible and entirely lacking in empathy and remorse (just self-loathing, which doesn't do a darned thing to enact change), and if normal parenting only makes it worse, that cannot be - and is not - our fault for not knowing what would set the kid off this time. Of course we guess, of course we suspect - but we don't *know*. If we knew, we would necessarily be mentally ill too!
If we as parents caused this escalation by "invalidating" some feelings that originated in a distorted version of reality, or if we offended the child by refusing to be her punching-bag, that means LIFE itself would have provoked the same outburst. We just happen to be here trying to get her to have some self-knowledge and resilience. We are trying to help her learn how to deal with the real world. The real world will never be as careful as we are trying to be. The real world will never ask itself "Should I try not to take this personally, since she's clearly in so much pain she doesn't know what she's saying, or should I just react the way I normally react, since those are the natural consequences??"
The real world will react to BEHAVIOR. Often wrongly, often nonsensically, often (sad to say) maliciously. We are supposed to prepare kids for this! And as parents, we are supposed to train our kids to control their behavior and take responsibility for their actions. But what if, despite our best efforts, they don't learn this?
Many of the families that seem to shun someone who stops behaving so abusively were probably put through hell and just can't take any more. It's like they were holding up the car out of sheer adrenaline, and now the car is gone, they are burned out and need a break. Castigating them for shunning the person is asking way too much of them. Those were the natural consequences. Natural consequences usually teach non-BPD people how to control themselves and take responsibility for their actions. But what works with BPD people?
Parents of BPD kids need support and skills, not blame. They need tools to cope with a situation that is literally crazy - and quite possibly crazy-making.
blame game - my response

Submitted by David M. Allen M.D. on November 6, 2016 - 4:21pm
Hi A Mother of a Possibly BPD Child,
"Blaming" and finger pointing are counterproductive, but all adults - both parents and adult children alike - have to take responsibility for their part in the family dynamics if these dysfunctional patterns are ever going to stop.
What you have written is a beautiful description of spoiling behavior by a child (or an adult child) with borderline personality disorder. It is designed on purpose to invalidate YOU. The child thinks for various reasons that you need them to do that, believe it or not.
For an explanation of how this seemingly crazy situation may arise in families even if there is no obvious abuse, see the posts

Communication to Estranged Children
Submitted by Ria on November 12, 2016 - 2:10pm

I am so grateful for the comments of adult children on this page. It gave me insight in the feelings and minds of adult children who cut off parents. My daughter has cut me off a year ago - it happened a few times before she had children, I always reached out and tried to mend the relationship, but now the grandchildren are used as pawns. Although I am broken with the loss of my daughter as well as grand children, I have decided it is final this time. I was not the perfect mother, not even a good one. At 64, after many years of therapy, after two marriages, I understand that. 

I know my daughter is angry and anxious and use this cut-off defense after irrational anger outbursts - this time in front of the kids, which was the final straw for me. But you cannot cut off love and wipe out precious memories. I wonder all the time if she is happier without me in her life. Perhaps she has a better chance of growth, sorting out her own anger and pain without me. I want her to be happy and content within herself. It saddens me even more when I read of the bitterness and pain adult children express here and I cannot help to think: is there anything more I can do for her? Can I help her? Or is letting go the better option? I know no one can really answer, but let's talk about this. I know there are really evil people, but many parents were simply damaged as children. When they have children, usually when they are very young, they have no skills or boundaries or knowledge of parenting to care emotionally for their young, especially 38 years ago when information and education was not a given. The result is emotional abuse, neglect, and / or physical abuse. The horrible old cycle - how do we break it?

Communication my response

Submitted by David M. Allen M.D. on November 12, 2016 - 2:42pm

Hi Ria,
Of course I can't say anything about your situation in particular, but in general, of course it is best for parents to acknowledge their problematic behavior in the past, explain what they had experienced with their own parents, and apologize.
However, if the parent then goes on to continue to feel too guilty and beat themselves up for their past flaws, that may backfire. The adult child may then start to think that the parent is better off without them - just as you say you wonder about your kids being better off without you - because the child sees that his or her presence makes the parent feel really bad. In response, they may continue to avoid the parent so as not to add to the parent's burden. 
Additional point not in my original reply: Alternatively, they may act nasty to feed the parent's guilt because they think the parent wants to be punished for various sins - or they may go back and forth between the two depending on whether the parent seems to need to be punished or then starts to feel too guilty.

Tuesday, November 22, 2016

Unintended Consequences of Behavior: The Importance of Systems Thinking

Having been introduced to psychotherapy by psychoanalysts and, to a lesser extent, behaviorists (cognitive therapy had not yet caught on), I was very impressed when a friend of mine first introduced me to family systems theory. It taught me about the importance of feedback in interpersonal interactions. The actions of person A in a relationship do not "cause" the actions of Person B in response. Both A and B are continually affecting each other's behavior simultaneously, as each person assesses the motives and intentions of the other. A relationship evolves over the the entire time the relationship between two people exists.

People are not rats; they do not just respond to what the other persons just did, but to what they just did in relationship to everything else they have done during the history of the relationship. Additionally, we are not robotic automatons, even though most of what we do most of the time is just responding to the usual environmental cues. It is estimated by neuroscientists that about 80% of what we do during our day involves no conscious deliberation whatsoever. However, if something unexpected happens as we do that, we will then think about it.

Systems thinking is one of the main themes of Peter M. Senge's best-selling book, The Fifth Discipline, first published in 1990. The book discusses common errors business people make because of a lack of appreciation of feedback effects that take a certain amount of time before those effects become apparent. The most common examples are described using something that he calls Systems Archetypes. Understanding them is not just important in business but in all human interactions, including within family systems.

He lists ten of them. In this post, I would like to summarize just three that I think are the most relevant to the subject matter covered in this blog.

Perhaps the most famous of the archetypes is one Senge calls Shifting the Burden to the Intervener. It is the one described by the common proverb about teaching people to fish rather than giving them a fish. When a person or a group of persons is having some sort of problem that they cannot solve, they often call upon a consultant who does not tell them about general aspects of how to solve certain types of problems, but actually steps in and solves the problem. 

The next time a problem arises, the consultant is brought back to solve it. The long-term result is that the original group never learns to, or is not motivated to, solve similar problem themselves. This is the nasty side effect created by so-called helicopter parenting.

Another systems archetype is far less widely known. Senge calls it Success to the Successful. I mentioned a good example of it in my last post. It is seen in students who do poorly in school who then get diagnosed with some psychiatric disorder. 

The basic pattern is that kids in a classroom are somewhat in competition for the teacher's attention and praise. The kids who start out as attentive and well-behaved gain praise and positive attention from the teacher, while the ones who do not start out that way are seen as undeserving of praise. The teacher's negative attitude toward the latter children is observed by these students, who then start to see themselves in a negative light. 

Due to their loss of self confidence, they start to put even less effort into their schoolwork, which then feeds back into the teacher's negative view of them, which leads them to become even more discouraged, and so on. This archetype is the basis of many a case of what is commonly referred to a "self-fulfilling prophecy."

The third archetype I will mention is called Balancing Process with Delay. This occurs when a group or individual overcompensates for something in one way or another because there is a significant delay between what they have started to do and its effects. An illustrative example many of us are familiar with is a shower in which the temperature of the water responds sluggishly to changes in faucet position. 

Because the water seems to stay cold, a poor guy in the shower turns up the temperature, but nothing much seems to happen. The delay is due to the distance of the faucet from the hot water heater. So he turns it up again. If he keeps doing that, he suddenly finds himself getting burned due to a large, sudden and unexpected rise in the water temperature.

Because of delays in business, shortages of something can suddenly turn into a glut of that product, which then leads to another shortage as producers react too quickly to market conditions. In families, this may be seen in parents who had been abused as children. They try to be unlike their own parents by going to the opposite extreme and letting their child get away with murder. In response, the child starts to feel like the parent does not really care about them, because the parent seems to ignore it if they do something self-destructive like coming home intoxicated or failing in school.

When that child grows up and has a child, he or she may overcompensate back in the other direction, and become too harsh! In looking at genograms, we sometimes see entire generations going back and forth between two extremes. A generation of alcoholics begets a generation of teetotalers who beget a generation of alcoholics; a generation of workaholics begets a generation of slackers who beget a generation of workaholics, and the like.

Tuesday, November 8, 2016

Psychological Problems in Kids and Teens: New Study Looks at Parental Discord as a Major Cause

One of the recurring themes of this blog is the tendency of mental health researchers and practitioners to look at patients' symptoms without any investigation into the home environment, and decide that they, or their brains, are the entire problem.

Psychological problems in kids are roughly divided into externalizing behaviors and internalizing behavior. The former is basically acting out: doing poorly in school, being hyperactive, being oppositional, getting  into fights, throwing tantrums and the like. 

The latter refers to things like anxiety and depression. Either way, today kids who have any of these problems are in danger of being labeled with mental disorders such as ADHD, bipolar disorder, and even "oppositional defiant disorder," which I refer to as "spoiled brat disorder." And of course there is "conduct disorder," which I refer to as "juvenile delinquency."

These know-nothing researchers act as if living in a tense or chaotic home environment is good for children's emotional life and that they do not become distractible or agitated under these circumstances.

As I have often joked, when it comes to looking at the home environment, most mental health professions will - if they say anything at all - label it as "within normal limits (WNL)." What WNL usually really means is "We never looked." If they do "look," they may ask the parents one or two questions about discipline, and take their answers at face value as well as valid or complete.

Or if they really want to pretend they have obtained the whole picture, they can ask the child's teacher what the kid's behavior is like at school. Of course, teachers are likely to have less patience with kids who are distractible, and then have lower expectations of them. The kids will pick up on this, and the teacher's attitude causes these kids to become even more distressed, which makes the teacher have even less patience and lower expectations of them, and so on in a vicious circle. (This long-term process was described by Peter M. Senge in his amazing book, The Fifth Discipline).

Researchers in psychiatry, as I described in a post about borderline personality disorder researchers, are even worse than practitioners at ruling out environmental causes as the explanation for symptomatic children. They never even read summaries of the literature produced by developmental psychologists.

One developmental psychologist, E. Mark Cummings, summed up quite nicely the type of results that this literature routinely shows . He was quoted in a recent article in the Atlantic ( that described a recent study ("The Multiple Faces of Interparental Conflict: Implications for Cascades of Children's Insecurity and Externalizing Problems,"  P.T. Davies, R.F. Hentges, J.L. Coe; E.M. Cummings, Journal of Abnormal Psychology [in press]):

“Children are like emotional geiger counters,” said E. Mark Cummings, a professor of psychology at the University of Notre Dame who has conducted extensive studies on the effects of marital discord on kids for more than 20 years. Children, he explained, are incredibly attuned to parents’ emotional communication with each other; they’re keenly aware that, for their parents, nonverbal expression is key to communicating feelings.

For many couples, holding onto a grudge—smoldering but not letting a disagreement erupt into a fighting match—may seem like the best way to deal with a conflict. But research shows this kind of discord can significantly interfere with a child’s behavior and sense of emotional security. When exposed to prolonged unresolved conflict, kids are more likely to get into fights with their peers at school and show signs of distress, anger, and hostility. They may also have trouble sleeping at night, which can undermine their academic performance. In fact, according to various studies that measured children’s emotional responses to interparental hostility, disengagement and uncooperative discord between couples has shown to increase a child’s risk of psychological problems, including depression, anxiety, social withdrawal, and aggression."

Here is the abstract of the study. Notice how the study was longitudinal - meaning it looked at parental behavior and children's reactions to it over an extended period of time - and used multiple measures and multiple observers. Researchers also actually observed the family members interacting with one another while engaged in various conflict resolution tasks. That's what a researcher has to do to in order vastly improve his or her chances to see what is really going on at home and to see what the most important causal factors are for psychological distress in young people.

This multistudy article examined the relative strength of mediational pathways involving hostile, disengaged, and uncooperative forms of interparental conflict, children's emotional insecurity, and their externalizing problems across 2 longitudinal studies. Participants in Study 1 consisted of 243 preschool children (M age = 4.60 years) and their parents, whereas Study 2 consisted of 263 adolescents (M age = 12.62 years) and their parents. Both studies utilized multimethod, multi-informant assessment batteries within a longitudinal design with 3 measurement occasions. Across both studies, lagged, autoregressive tests of the mediational paths revealed that interparental hostility was a significantly stronger predictor of the prospective cascade of children's insecurity and externalizing problems than interparental disengagement and low levels of interparental cooperation. Findings further indicated that interparental disengagement was a stronger predictor of the insecurity pathway than was low interparental cooperation for the sample of adolescents in Study 2. Results are discussed in relation to how they inform and advance developmental models of family risk.

Tuesday, October 25, 2016

Discussing Dysfunctional Family Patterns with the Family: More Tricks of the Trade

Offering Theories Better than Asking Questions

As I have discussed in many previous posts, when adult children try to figure out the reasons behind their parents' confusing behavior, they usually conclude that the parents are either mad, bad, blind, or stupid. I mean, how else can you explain the following bizarre parental behavior: denying the obvious, giving double messages that put their child in a damned-if -you-do/don't situation, seeming to want their children around (often in a caretaker role of some sort) while simultaneously seeming to hate their guts, putting up with abusive spouses while making excuses for them, being completely preoccupied with one sibling while acting like another child barely exists—and a host of other unfortunately fairly common dysfunctional behaviors.

I believe, as readers of my blogs know by now, that most parents who act like this are neither mad, bad, blind nor stupid. They are instead acting out roles with their children - in a highly ambivalent fashion - that they themselves had learned in their own families of origin. These roles stabilized the grandparents, who were themselves highly conflicted about certain family and cultural norms and rules of behavior.

Mothers who have gender role conflicts are a really good example of what I am talking about. They often give out mixed messages to their daughters about both having careers and having children. Their daughters are somehow also expected to get some man to take care of them while simultaneously being independent.

Just asking the parents why they are doing what they are doing usually leads to more obfuscation, non-sequiturs, denial, and various other ways of invalidating the person who poses the question and/or disqualifying their own true beliefs. Or even worse, questions sometimes even lead to violence, suicide attempts, and other forms of acting out. 

"Why" questions are also particularly likely to lead to either aggressive or defensive remarks because they can sound accusatory—sorta like asking a child, "Why is your hand in the cookie jar?"

Asking "yes or no" questions is equally problematic. It also often leads to responses that are less than edifying about what the parents are trying to accomplish with their bizarre behavior. The parents can just answer "yes" or "no" with no additional explanation.

One trick in metacommunication is based on the idea that in human interactions, certain verbalizations seem to require certain responses, making it more likely that when they are used, the other person will feel obligated to respond in certain ways. They may say things that are more enlightening or clear. Of course the strategy I am about to describe is not foolproof, but it does increase the odds that a useful exchange may take place.

The trick is for the person to empathically offer some speculation about family interpersonal processes that may be triggering problematic feelings or behavior in the parent. There is something about tentatively offering someone someone a hypothesis that makes it much more difficult for them to merely agree or disagree. Hypotheses seem to demand more than questions; they increase the likelihood that the parent will feel it necessary to explain what is wrong or right with the hypothesis, rather than just giving out an unexplained acceptance or rejection of it.

This is especially true if the adult child overtly labels the intervention as a guess, thereby giving the parents an "out" that allows them to reject the guess if they are just feeling too threatened to respond with more information. This technique makes it difficult for the parent to provoke a power struggle with the adult child over the accuracy of the hypothesis.

The potential metacommunicator can base speculations or hypotheses on any information concerning his or her family that is already available, or on typical patterns that they have seen or read about in my blogs or elsewhere. Having done one's family's genogram often provides a good source of such guesses. Such hypotheses should always be offered in a tentative and non-threatening manner.

Continuing with the gender role conflict situation mentioned above, for example, the adult child might say something to her mother like, "I don't know if this applies to you or not, but in other families where a woman's career choice is an issue, mothers often feel bad because their daughters get to do things the mother always wanted to do but was not free to do. I wonder if this might apply to our situation?

Tuesday, October 11, 2016

Stupid Researcher Tricks

When David Letterman was a late night TV talk show host, he had a recurring segment called "stupid pet tricks." In this vein, this post is titled "stupid researcher tricks." The authors of certain studies in psychiatry employ logical fallacies - either knowingly or in some cases unknowingly - in their discussions of their results. This often results in their drawing totally misleading conclusions from their data.

I will discuss two telling examples of such fallacies. The first involves employing a hidden assumption that is not true. I discussed the general issue of hidden assumptions in a previous post. The particular example in this post can actually be thought of as Part II of my post on the heritability fraud. The second example involves a subtle logical fallacy known as the ecological fallacy: making inferences about individuals based on data obtained that characterizes an entire group, using averages on various measures, to which that individual belongs.

In the previous "heritablility" post I wrote about how that term is falsely used as a synonym with "genetic" in studies that purport to sort out genetic versus environmental factors leading to the development of personality traits or behavioral disorders. The statistic is developed from twin studies: identical versus fraternal twins, and/or those identical twins raised together and those raised apart. 

As previously described, these studies - despite frequent claims to the contrary - do almost nothing to sort out genetic versus environmental influences. The reason is because the statistic is based on phenotype (the final interactional product of genes + environment) and not genotype. As such, it includes a mix of purely genetic factors and factors that result from gene-environmental interactions, and there is no way to know how much of each is contained therein.

Another aspect of these studies I mentioned in the previous post: they also divide environmental influences into "shared" (family and home) and "unshared" (peers, media, teachers, and other outside factors). I mentioned that a determination of which parts of an environment are shared by siblings and which are unshared has a lot in common with finding water with a divining rod, because parents do not treat all of their children alike. Nor does each twin have exactly the same interactions with each and every other family member from the moment they are born to the moment they die.

Interestingly, the "shared" environments in these studies usually come out as less important in leading to behavioral issues than the "unshared!" This would mean that family and parental behavior is less of a factor in personality development than outside influences - something that runs counter to logic for a variety of reasons (for example: which peer group someone chooses to hang out with - when there are several different ones to choose from -  is not an accident).  

The researchers almost have to find that family is less important that peers and media because they just ASSUME that each twin is subject to identical influences inside the home. If you make this assumption, and then if the twins turn out differently on some characteristic, of course the home will appear to have no influence!

Maybe these ignoramuses should read the family systems literature on how siblings are treated differently. The more dysfunctional the family, the bigger the differences! 

Example number two, studies that employs the ecological fallacy, involves those that compare two different psychotherapy treatments for the same disorder. These studies are relatively uncommon, as most psychotherapy outcome studies compare a treatment with a "control" condition like a wait list or "treatment as usual" rather than with a second type of treatment. (Those control groups are also invalid, but that is a matter not relevant to this discussion).

In the few studies that compare one school of therapy with another, an interesting statistic is that 85% of the time, the treatment favored by the person designing the experiment "wins" and outperforms the other treatment [Luborsky, L., Diguer, L., Seligman, D. A., et. al. 1999.  "The Researcher’s Own Therapy Allegiances:  A “Wild card” in Comparisons of Treatment Efficacy." Clinical Psychology: Science and Practice, 6, 95-106]. This is due to something called the allegiance effect - the more enthusiastic a therapist in a study is about their own school, the better the patient tends to do.

But even ignoring this clear-cut sign that research conclusions in comparative outcome studies are inherently misleading, let us suppose that with one therapy treatment in the study, 45% of the patients improve significantly, while in the other, only 30% do. The conclusion of the researchers: the first treatment is superior.


This conclusion presupposes that all patients react to treatments somewhat identically, despite the fact that the majority (or at least a significant percentage) of patients in both arms of the study did not improve. It is quite likely that some patients are more comfortable and do much better with one of the therapy treatments than with the other. Of course there is no way to know for certain, but it is quite possible that the 45 percent of people who respond to the allegedly superior treatment are very different in many respects than are the 30% who respond to the allegedly inferior therapy.

A well-designed study, on the other hand, would have to recognize these differences and would look at the characteristics of the four different groups that comprised the study: those who got better with treatment A, those who got better with treatment B, those who responded poorly to treatment A, and those who responded poorly to treatment B. The researchers could then match the patient with the type of therapy they seemed to do best with, and then and only then compare outcomes.

In other words, as I have pointed out elsewhere, no matter what therapy intervention you use, some people will improve with it, while others either will not improve or may even get worse! Different strokes for different folks, people.

Tuesday, September 27, 2016

Confronting Problematic Parents: Getting Siblings and Other Interfering Relatives to Butt Out

In this blog, I have written many posts about the different strategies for metacommunicating or openly discussing any ongoing repetitive dysfunctional interactions between parents and adult children. The goal is to put a stop to them to everyone's satisfaction. Whenever people attempt to initiate this process, somehow word seems to get out to the rest of the family that something is afoot, and everyone gets scared. 

I'm not always sure how this even happens; my patients may swear up and down that they have not said anything yet to anyone. But sometimes even relatives that did not seem to be involved at all seem to just come out of the woodwork and get involved.

Even so, it is usually predictable which family members are going to try to interfere and abort the whole process. Doing this, in the family systems literature, is called triangulating oneself into two other people's relationship. Despite appearances to the contrary, it is not done out of spite but out of fear— often the very same fears that the person who plans to metacommunicate has about the whole process. Most often the triangulator is a sibling, but sometimes it's an aunt or an uncle.

If it's a grandparent, that complicates matters quite a bit, so I will not be discussing that here. Sometimes one's own spouse may get in the way - that is a indicative of a very important marital issue - and again will not be addressed in this post.

Before getting started with the metacommunication process with a primary attachment figure like a parent, it is usually first necessary to try to prevent these other relatives from interfering. In this section I will discuss strategies for accomplishing this. Another caveat: the larger the family, the more potential triangulators there are. If multiple people are likely to get involved, this can make things more complex by orders of magnitude - so if you have a small family and want to do this, be thankful.

As with all metacommunication, detriangulation strategies need to be developed and tailored to the individual family member who is being targeted. I will just be presenting a prototypical, basic strategy here.  

The most typical detriangulation strategy consists of four tasks:

1. First, metacommunicators inform the potential triangulator about their plans to talk to the parental figures, and explain the justification for doing so. They explain what they may have discovered about the family dynamics, and also explain in some detail the approach with the parent they plan to take. The planned approach is something that should have already been worked out by the person, with or without the help of a therapist trained in effective techniques and strategies.

2. The metacommunicators then ask the triangulator what concerns he or she may have about the consequences of the aforementioned plan. As I mentioned, these concerns often turn out to be nearly identical to the reservations that the metacommunicators had when they first considered embarking on the process. 

For siblings and other relatives, the concerns usually center around a fear that the primary target will not be able to handle the confrontation, and may decompensate in some way, or that the confrontation may create tensions in other important dyadic relationships within the family (for example, between the parents). Sometimes, a sibling may fear having to step into a family role previously played by the metacommunicator.

3. Third, the metacommunicators attempt to reassure the triangulator about his or her concerns. The metacommunicators describe how they plan to prevent the negative reactions in the parents that the potential triangulator is concerned about.

They also admit to the triangulator that they themselves have had similar concerns. Even though they may have felt the same exact way in the past, however, metacommunicators often become extremely annoyed with the relative for having any negative attitude towards the plan. As difficult as it may be to muster, an empathic response based on identifying the triangulator's feelings in oneself is far more effective in getting the triangular to keep out of it.

If a metacommunicators can remain empathic during this discussion, the potential triangulator may even make helpful suggestions about how the patient can refine the strategy!

4. Last, and very importantly, the metacommunicators make the following type of statement to the potential triangulator: "I really think it would be best if I handled this myself, so I would appreciate if you did not talk to Mom about this before I have had a chance to do it. However, if you feel that you must warn her or discuss with her the issues as they apply to you, then go ahead and do so." 

The last sentence is designed to reduce the likelihood that the potential triangulator will go ahead and interfere! Family systems folk call this a paradoxical request. The statement appeals to the triangulator for cooperation while indicating that the patient will not be drawn into a power struggle about it.

Many times, a sibling, for example, is already aware that the family behavior patterns are problematic in the way the patient describes, and becomes only too happy to let the metacommunicators try to take care of it. Furthermore, if the triangulator were to broach the taboo subject with the target, the initial negative reactions might fall on him or her. Better someone else than them!

If the triangulator does go ahead and spill the beans, so to speak, the metacommunicators will be in a better position to ask the target about what the triangulator had said. Knowing this will help them better understand any negative reactions from the target that were set up by the triangulator’s interference. 

Tuesday, September 13, 2016

More Studies Reveal Widely Known Facts to be Actually True

As I did on my posts of November 30, 2011,  October 2, 2012,September 17, 2013June 3, 2014, February 24, 2015, and December 15, 2015, it’s time once again to look over the highlights of the latest issue of one of my two favorite psychiatry journals, Duh! and No Sh*t, Sherlock. We'll take a look at the unsurprising findings published in the latest issue of the latter. My comments are in bronze.

As I pointed out in those earlier posts, research dollars are very limited and therefore precious. Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already known to be true but have yet to be "proven"? Such an approach increases the success rate of studies almost astronomically. And studies with positive results are far more likely to be published than those that come up negative.

This last few months has been such a treasure trove of studies of the obvious, my descriptions of the individual studies listed will be a little briefer than usual.

At the end of today's issue of No Sh*t Sherlock is a special section on some new shocking and counterintuitive findings about things we used to think were good for your mental health and well-being - but turned out not to be.

12/15/15. Adolescents Who Abuse Prescription Pain Medicines May Be More Likely To Have Sex, Participate In Risky Sexual Behaviors

HealthDay (12/15, Haelle) reports that adolescents who abuse prescription pain medications may be “more likely to have sex or to participate in risky sexual behaviors,” a study published online Dec. 14 in Pediatrics suggests
Impulsive, self destructive people were, I guess, previously thought to be highly selective in which impulses to indulge.

12/15/15. Study Shows Reduced Patient Satisfaction When Computers Are Used Excessively In Exam Rooms

On the front of its Personal Journal section, the Wall Street Journal (12/15, D1, Reddy, Subscription Publication) reports on a study published the previous month in JAMA Internal Medicine, which found that patients whose doctors spent a lot of time looking at a computer screen during examinations rated their care lower. 
And here we thought that patients just hate doctors who pay close attention and listen to them carefully.

12/23/15. College Students Who Smoke Marijuana Appear More Likely Than Their Peers To Skip Classes

HealthDay (12/23, Norton) reports, “College students who smoke marijuana appear more likely than their peers to skip classes – which eventually leads to poorer grades and later graduation,” a study published in the September issue of the journal Psychology of Addictive Behaviors suggests. 
This finding is just so difficult to explain.

1/6/16. Many Single Mothers with Minor Children are Sleep-deprived, CDC finds

The Los Angeles Times (1/6, Kaplan) reports in Science Now that a data brief from the Centers for Disease Control and Prevention’s National Center for Health Statistics reveals that “44% of single moms living with children under the age of 18 fall short of recommendations to get at least seven hours of shut-eye each night.” Thirty-eight percent of single fathers who live with their children “sleep less than seven hours per night,” the report found. 
I just don't understand why these parents can't make their days last more than the usual 24 hours.

1/22/16. Prevention Programs for Youth Most Effective When At-Risk Families Are Clinically Stable

Programs that teach stress management and cognitive-restructuring skills may help to prevent the onset of depression in teens at high risk for depression, but how effective they are appears to depend largely on the mental health of youth and their parents when the intervention begins, according to a study published online this week in the Journal of the American Academy of Child and Adolescent Psychiatry
At last the long-sought proof that the more severe a disorder, the worse the prognosis tends to be.

3/2/16. Study Suggests Factors Predictive of Violent Behavior in People With Mental Illness

Results from a meta-analysis in Psychiatric Services in Advance shows that three factors may be associated with an increased risk for adults with mental illnesses to commit community violence in the near future. They are alcohol use, exhibiting violent behaviors, and being a victim of violence within the past six months. 
Booze fuels violence? Past behavior a predictor of future behavior? Who'd'a thunk??

3/16/16. Disruptive Patients may Get Worse Care from Physicians

HealthDay (3/15, Dotinga) reports, “‘Disruptive’ patients may get worse care from physicians,” studies suggest. 
Can't be. Doctors have been trained to be completely unaffected by annoying people. (Well, psychoanalysts anyway).

4/21/16. Eating Disorders May Be More Prevalent At Schools With A Greater Proportion Of Female Students

HealthDay (4/20, Preidt) reports, “Eating disorders may be more prevalent at schools where a greater portion of the student body is female,” research suggests. 
I just never noticed the higher prevalence of women among patients with anorexia and bulemia.

5/25/16. Severely Obese Children Picked On, Bullied More Than Normal-Weight Kids

HealthDay (5/25, Reinberg) reports, “As early as first grade, severely obese children are getting teased, picked on and bullied more than normal-weight kids,” research published online May 25 in Child Development indicates. Researchers arrived at this conclusion after gathering “data on nearly 1,200 first graders from 29 rural schools in Oklahoma.”  
Did these researchers ever go to grade school?

5/27/16. Depressed Patients Who Attempt Suicide Four Or More Times May Have Higher Risk Of Eventually Dying By Suicide, Research Suggests

Medscape (5/26, Brooks) reports, “Depressed patients who attempt suicide four or more times have a higher risk of eventually dying by suicide compared with their depressed peers who have never attempted suicide or who have done so fewer times,” research suggests. 
The fifth time is the charm.

6/2/16. Higher Out-of-pocket Costs Lead to Reduced Adherence

A literature review of 160 articles and abstracts identified a clear relationship between cost sharing, adherence, and outcomes. Of the articles that evaluated the relationship between changes in out-of-pocket costs and adherence, 85% showed that increasing patient out-of-pocket medication costs leads to reduced adherence. 
Did these researcher ever hear of the law of supply and demand? Guess not.

6/16/16. Hospital Deaths more Costly and Involve More Tests and Procedures than Deaths at Home

On its website, NPR (6/15, Kodjak) reports people who die in hospitals “undergo more intense tests and procedures than those who die anywhere else” and that more is spent on people dying in hospitals compared to people who die at home, according to an analysis by Arcadia Healthcare Solutions. 
I was wondering about that (not!)

7/1/16. Problem Of Missed Medication May Increase With Age, Failing Memory

HealthDay (6/30, Preidt) reports that a study published in the Journal of the American Geriatrics Society “suggests that the problem of missed” medication “rises with age and failing memory, especially for men.” The investigators found that other factors linked to “medication lapses” were “memory deficits” and having “trouble with the tasks of everyday living.” 
Gee, people with memory problems forget things.

And now for the special section that details how we have recently discovered that many things in the environment that were once thought to be sources of tremendous joy and uplift turn out to actually be downers that create various negative feeling states and are risk factors for depression and anxiety.

These include childhood abuse and neglect, poverty, post-partum depression, traumatic experiences, cancer, kids having parents with chronic severe migraine headaches, having your livelihood threatened by a disciplinary action from a licensing board, diabetic retinopathy, having a premature infant, and combat experiences.

I bet you think I'm making this up. Sorry, but you just can't make this stuff up.

3/1/16. Study finds children who face adversity before age 5 struggle in school

Kaiser Health News (2/29, Gillespie) reports a study published in the journal Pediatrics found that “adverse childhood experiences [ACEs] before age 5,” including “neglect, abuse and dysfunctional home lives,” were associated “with poor academic and behavioral performance in kindergarten.” 
These researchers just don't understand that these kids just have ADHD.

3/17/16.  Low-Income People Exposed To Rats In Urban Environment May Be More Likely To Have Depressive Symptoms

According to the NBC News (3/16, Fox) website, a study conducted by the Johns Hopkins Bloomberg School of Public Health and published online Feb. 10 in the Journal of Community Psychology reveals that “people living in Baltimore’s low-income neighborhoods who see rats as a big problem are significantly more likely to have depressive symptoms such as sadness and anxiety.” 

3/21/16. Women Who Have Had Postpartum Depression May Not Have More than Two Children, Study Indicates

HealthDay (3/18, Preidt) reported, “Women who’ve had postpartum depression may not have more than two children,” the findings of a study published in the January issue of Evolution, Medicine and Public Health suggest. 
Depression was previously thought to be so much fun that everyone wanted to go through it as many times as possible.

4/25/16.  Exposure To Traumatic Events May Be Associated With A Host Of Potential Negative Behavioral And Physical Effects

Medscape (4/25, Melville) reports, “Exposure to one or more potentially traumatic events in a lifetime is associated with a host of potential negative behavioral and physical effects, ranging from mental illness and depression to substance abuse, asthma, and” hypertension, the findings of a new report from the Substance Abuse and Mental Health Services Administration’s Center for Behavioral Health Statistics and Quality indicate. 

4/28/16. Cancer Diagnosis may be Associated with Increased Risk for Anxiety, depression

HealthDay (4/28, Preidt) reports that research published in JAMA Oncology “details the psychological damage” a cancer diagnosis “often leaves in its wake for patients.” Investigators “found much higher rates of anxiety, depression and even drug and alcohol abuse for those who’ve been told ‘you have cancer,’ compared to healthier people.”  Healio (4/28) reports that the study indicated “the risk for mental disorders appeared stronger among patients whose cancers had poorer prognoses.” 
5/31/15. Childhood Trauma May Increase Risk of Adolescent Drug Use, Study Shows

Children who experience traumatic events prior to the age of 11 may be more likely to use marijuana, cocaine, nonmedical prescription drugs, or other drugs as teens, according to a report online in the Journal of the American Academy of Child and Adolescent Psychiatry

6/27/16. For Teens, Living With Parents Who Have Chronic Migraine May Negatively Affect Activities Of Daily Life, School Performance.

Medscape (6/24, Davenport) reported, “For adolescents, living with parents who have chronic migraine has a negative effect on activities of daily life and on school performance and is associated with increased rates of anxiety,” research suggests. 
Parental misery and pain were previously thought to have no effect on their children whatsoever.

7/15/16. Patient Complaints Against Physicians and the Ensuing Complaint Review Process Seriously Affect Physicians' Long-term Psychological Well-being 

and can lead to their practicing defensive medicine, results of a large qualitative survey show. Led by Tom Bourne, MD, PhD, from the Department of Surgery and Cancer, Imperial College London, United Kingdom, the study is an analysis of responses to qualitative questions as part of a larger anonymous survey completed by almost 8000 physicians. 
7/8/16.  Severe Diabetic Retinopathy May Be Associated With Depression, Study Suggests

MedPage Today (7/7, Minerd) reports, “Severe diabetic retinopathy...was linked to depression, and its presence should prompt clinicians to inquire about a patient’s mental health,” research suggested. The findings of the 519-patient study were published online July 7 in JAMA Ophthalmology.  

7/21/16Parents Of Extremely Premature Infants May Be More Likely To Become Depressed Than Parents Of Full-Term, Healthy Infants

Reuters (7/20, Rapaport) reports, “When babies are extremely premature, parents are about 10 times more likely to become depressed than mothers and fathers of full-term, healthy infants,” research suggests. Included in the study were “113 mothers and 101 fathers of preemies, as well as 117 mothers and 151 fathers of healthy, full-term infants.” The findings were published online July 18 in JAMA Pediatrics.

8/12/16Female Service Members who Experience Combat may have Much Higher Risk of PTSD than Those Who do Not

Reuters (8/10, Rapaport) reports, “Women in the military who experience combat have a much greater risk than those who don’t of developing post-traumatic stress disorder (PTSD) and other mental health issues,” researchers found after examining “data from post-deployment mental health screenings for more than 42,000 women enlisted in the US Army and deployed in Iraq and Afghanistan from 2008 to 2011.” The findings were published online Aug. 1 in the Journal of Traumatic Stress. 

I wonder how many other things that were once thought to joyful actually are not.