Pornography Addiction

Is pornography addiction a real condition? In the book I co-edited, Groupthink in Science, we have a chapter by Nicole Prause, a neuroscientist who has been very active in this debate (and is mentioned prominently in the book I’ll be talking abut). She makes what I consider an extremely good case that this “addiction” model is nonsensical. I agree.

In her book, The Pornography Wars, academic sociologist Dr. Kelsey Burke examines in fine detail both sides of this ongoing debate without clearly taking a position either way. She talks with a variety of academics and members of interest and church groups and gets them to open up considerably about their opinions. Clearly, a lot of the debate is based more on ideology than on science. On both sides! As we all know, sex is a subject that has created a huge disturbance in human culture, what with religion, gender issues, Victorian culture, and the like.

My own view is that sex negativity is still rampant in the United States, despite the fact that most people these days engage in relations prior to marriage. They often feel somewhat guilty about it afterwards. Interestingly, this has put radical feminists and religious fundamentalists on the same side of the pornography debate. What strange bedfellows indeed.

Now, to be extra clear, sex trafficking and being forced to participate in a porn film are issues that are completely legitimate. No one should be forced to do anything like this against their will. But in my mind, those issues are very different than the question of whether pornography per se is bad for anyone, and if so, who and in what way? Or the question of whether watching it compulsively in maladaptive ways is a “disease.”

I believe questions about addictions as true mental diseases should be limited to those substances, such as alcohol and opiates when used to excess, lead to tolerance and serious withdrawal symptoms. Just about anything can be used to excess and create negative consequences for the users and their associates. To me, most so-called “addictions” are nothing more than self-destructive behavior designed to have certain affects on family relationships and romantic partners.

I’d now like to list a few examples of the evidence for what I am saying here from the book in question. Research in this field, the author points out, depends on self-reports by subjects - which is not objective data, and which are highly dependent on the types of questions researchers ask and how they are phrased. There is, for example, a phenomenon called acquiescence, in which subjects’ responses are likely to go along with the values implied in the question - for example asking only about negative consequences but avoiding questions about positive benefits.

Lying about issues with moral implications is widely prevalent. Does anybody really believe that a female brought up in an evangelical religion will admit to secretly enjoying watching porn and having experienced no actual negative consequences from doing so outside of maybe feeling guilty? Additionally, it is obvious that people’s beliefs about porn influence the consequences they experience during and after watching it.

Another issue is correlation versus causation. Is watching porn bad for marriage, or does a bad marriage lead to more porn viewing? An interesting finding: Protestant men are more likely than any other, group, including atheists, to consider themselves addicted to porn. Yet they report watching less porn than the other groups. Several studies show that religious commitment is a better predictor of people believing  they are addicted than actual porn usage.

As I have discussed in several other posts, the fact that the brain’s connections are plastic and change all the time when exposed to environmental influences makes claims that neuroscience has “proved” that a porn “addicted” person has an organic disease incorrect. As Dr. Burke points out, nature and nurture and their interactions are what lead to most brains study results. And the boundaries between these things are “far from tidy.”

Another point: just because someone has a higher libido than someone else does not mean that they are sex addicts - they just want sex more often. Also, home porn may often be a cue for some other reward like masturbation. In a laboratory setting, contingencies like these aren’t in the cards.

Then there is a prominent Protestant theological teaching.  A quote from one of Billy Graham's recently posthumously-published newspaper columns sums it up concisely. He writes, “All people are sinners in need of a Savior.” What this means is clear from his sermons: prohibited but universal individualistic desires such as lust are evidence that we are all evil in the eyes of God and need to renounce our biological nature and follow what God – really the church – tells us to do. Or else. In the words of a woman at a church group’s conference on the harms created by porn addiction, "...after the Garden of Eden we’ve been running from God ever since.”

This also has led to perceptions about men versus women’s sexuality. Religion teaches us that sin was created by a woman’s curiosity when Eve bit into the apple. In the middle ages, women were actually considered the lustier of the two sexes due to the impurity associated with Eve’s curiosity. In the 1800’s during the industrial revolution and mass migration from family farms into cities, this changed into its opposite: women changed from Eve to Mary. Women were thought to want sex, not for itself, but only in order to insure the commitment of marriage. “Why buy the cow if you can get the milk for free?” was a question asked by confirmed virgins. Although men were thought to want sex way more than women, they were also perceived as being less in control of their behavior. Masculinity was defined as being in control, so if they “conquered” the natural sinfulness of a porn addiction, this was thought of as an accomplishment.

In my opinion, the function that all this mythology serves is to show the negative effect of allowing yourself to express lust, so the people who are doing without get to feel more justified in giving freer sex up. Said one Christian who had “overcome” a porn “addiction,” quoted in the book, he was “…tired of not being the person that God made me to be.”

Well, what about those radical feminists? They are certainly not primarily evangelical Christians. Nonetheless, they have without realizing it accepted the Christian dogma while trying to frame it as something else. Both Evangelicals and radical feminists believe that men feel entitled to sex and women are both objectified and victimized. The radical feminists seem to implicitly accept the idea that women cannot want and enjoy sex as much as men, despite the fact that they can have multiple orgasms and men cannot.  The general sex negativity towards women's lust prevalent in both sexes  in our “patriarchal” society  was summed up nicely by Elise Loehnen: "Good women want to be seen as sensual, warm and inviting of sex, but not overtly interested."

Because of the prevalence of these gender attitudes and in order to sell more, porn does in fact  frequently show women being objectified by men. The feminists  use this to “prove” their point, ignoring that this occurs because of the cultural groupthink expectations of the audience. And there are plenty of women who somehow enjoy watching porn as much as men do even under these circumstances.

Racism in Medicine

Opening of anatomical theater at medical faculty at Bogomolets National Medical University circa 1853

                                               Unknown author.  Creative Commons Attribution-Share Alike 4.0

 

When I read the program for any medical meeting, such as the annual American Psychiatric Convention, there has for years been a plethora of talks and  forums about racism in medicine, equity and diversity, and the like. Perhaps medical offices really are rife with bigotry and a lack of concern for minorities – particularly black people.

Now don’t get me wrong. I’m sure there is still some racism in medical practice perpetrated by today’s doctors, just as in the rest of society. But people seem to lose sight of the fact that there has been tremendous progress in decreasing it in most of U.S. society. As author Steven Pinker writes in his book Enlightenment Now: "But it's in the nature of progress that it erases its tracks, and its champions fixate on the remaining injustices and forget how far we have come." (p. 215).

I once got into an argument with a young African American woman about this. She said there hadn’t been any progress here, even after the civil rights movement!  The odd thing was that at the time we were enjoying a meal at a restaurant here in Memphis. I reminded her that when I was a kid, we wouldn’t have been allowed to eat together like that. In fact, she probably would not have been allowed in the restaurant at all. Her answer? Something to the effect of “Well, they still don’t like us here. It was probably better when it was out in the open.”  Really? 

The problem with poor outcomes in medical treatment for Black patients has several different causes besides racism, such as poverty, the crazy medical insurance situation in the U.S., and what I'm about to talk about. To hasten further progress, ALL of the various causes should be addressed. And before accusing me of "blaming the victim" in what I'm about to discuss, please keep two things in mind. 1. Just because behavior can be easily understood and justified does not automatically mean that it can't also be counterproductive. 2. When it comes to the results of repetitive human interactions in current U.S. society, "It's all my fault" and "I had nothing to do with it" are almost always false positions to take.

I’ve written before about the “game without end” aspect of relationships between Blacks and Whites (7/23/13, 1/17/13, 4/3/12). The basic point is that a lot of difficulties in the current relationships between Blacks and Whites stems from past racism, not current racism.

In a study presented at the 2023 American Association for the Advancement of Science annual meeting, Somnath Saha reported that he had came across a cluster of studies showing that black people with cardiovascular disease were treated less aggressively compared to White people. This professor of medicine at Johns Hopkins University began poring through medical records. He found that doctors are more likely to use negative language when describing a Black patient than they are with a White patient. He found them described as “really difficult,” “non-compliant,” and “uninterested in their health.”  He attributed this to implicit bias by physicians— unconscious judgments that can affect behavior.

Now, again, implicit bias is a real thing. We ALL profile other people, because we can't read minds. But is that the whole picture? Two studies bring up an important point. In an article talking about Saha’s study, Antoinette M. Schoenthaler (a professor of population health and medicine at New York University's Grossman School of Medicine), said that disparities in pain management are pervasive and widespread across the medical profession. But she also mentions a reason for it that is seldom brought up: "Patients of color go into an appointment with feelings of heightened anxiety because they're expecting mistreatment.;  we've seen minoritized patients have higher blood pressure in the context of a clinical visit because of these expectations of anxiety and fear, and disappointment."

Medical mistrust leads to greater health disparities in minority communities, according to a poster presentation at DNPs of Color annual meeting held in Washington, DC, October, 2023. It is not a phenomenon but a “true medical issue,” said Clydie Coward-Murrell, MSN-Ed, BSN, RN, an African-American. “This clinical issue is not as prevalent in other minority communities simply because of the atrocities in health care that African Americans had to suffer for hundreds of years.

Can anyone blame black patients for being suspicious of white doctors? They seem to all know about the Tuskeegee syphillus experiment in which severe damage was done to black patients. They may even know that black surgery patients were in the past given less anesthesia than whites because doctors thought they had a higher pain tolerance – a myth left over from slavery times invented by slaveowners so they would not feel so bad about whipping them. They'd literally have to be crazy to completely trust doctors.

So maybe that’s part of why they seem to be angry and non-compliant with medical treatments? And if that’s true, then couldn’t that be a significant factor in explaining why other studies show that black patients seem to have worse outcomes than white patients with similar conditions? Because they don’t follow doctors’ orders as blindly? In that vein, let me tell you what one of my black psychotherapy patients told me: She had to hide the fact that she was seeing a therapist because her fellow church members would give her an extremely nasty round of criticism if they knew. Accusing her of just not praying hard enough.

In my own experience as a medical student, resident, and psychiatrist, I have not personally witnessed a whole lot of obvious racism in my instructors and colleagues. Of course I am not black so I might not have seen racism that was present since it would not be directed at me. But I was a residency training director at a Southern medical school for 16 years. I had a lot of black psychiatry residents, and none of them complained about this. 

We were told by the dean in charge of residency programs that, although our school did not have affirmative action, if there was a black applicant and a white one of roughly equal qualifications, to take the black one.

The only time I ever personally witnessed really nasty racism (and simultaneous sexism) among doctors was way back in the early 70’s when I was a medical student in San Francisco. Clearly, my school was ahead of its time so I had a biased sample – my class was 20% female at a time when there were a lot fewer elsewhere (there are now more female medical students than male ones). A Black female classmate wanted to become an orthopedic surgeon. Surgeons were by far the biggest Neanderthals for these issues back then. Boy, did they ever give her a raft you know what when she applied.

So all this talk among doctors about how racist they all are is not something that only they hear. Black people hear it too. So what they are hearing is that they are right to be suspicious of white doctors. While racism in medicine must still be addressed, talking about it way too much has the potential to backfire and make the problem worse rather than better.

I am Interviewed on Two New Podcasts

 I'm interviewed on two new podcasts. 

The first describes my background and how I got interested in the family dynamics of self-destructive behavior (particularly borderline personality disorder) and its psychotherapy:

https://www.youtube.com/watch?v=XPQdl664QgM

In the second one, I talk about my self-help book, Coping with Critical, Demanding, and Dysfunctional Parents: Powerful Strategies to Help Adult Children Maintain Boundaries and Stay Sane:

https://www.youtube.com/watch?v=MLM6tvLe_Oo&list=PLOSSy_bIynJqUnE3ilzI9UR7J92aYeCI2&index=42

Genes vs Environment: Neuroscience Nonsense

 

Functional magnetic resonance imaging by Washington Irving, public domain

In an article in the Washington Post on 8/2/23, cultural critic Kristen Martin wrote an essay about how some best-selling books express great confidence in theories of the brain that are in reality still in their infancy - and unproven. She mentions a book I reviewed, The Body Keeps the Score by Bessel van der Kolk, a well as The Grieving Brain by Mary-Francis O’Connor.

The author believes that “neuroscientific wisdom is now recirculating into new mediums, calcifying into consensus that we can’t stop parroting.”

In reality, our understanding of the human brain, while increasing rapidly, is still in its infancy. Scientists have to contend with about a trillion connections between billions of brain cells that constantly change in response to the input of literally thousands of environmental and interpersonal influences (neural plasticity). I have written several times about how this problem manifests itself in studies using a type of brain scan called an fMRI, which basically measures blood flow in parts of the brain as the brain’s owner is engaged in a variety of mental tasks.

Another doctor likened trying to make any generalizations about repetitive behavior from observable differences in brain scans to trying to know how the stock market is doing by measuring electricity usage at the stock exchanges.

I write about how results that differ between groups are labeled as “abnormalities” when in fact they might indicate normal differences in the performance of the task in people who have had differing prior experiences and have learned to approach the task in different ways. They may be accomplishing differing goals - and without having to engage in conscious deliberations.

Martin also says that people consult neuroscience to validate what they want to believe or what they already know. “Tracing all of our messy emotions, reactions and habits to the workings of electrical currents and neurochemicals lets us off the hook.”

She references some work with brain scans that adds even more fuel to our opinions on the matter. In 2009, a neuroscientist put a dead salmon through an fMRI and detected activity in its dead brain. It is easy to produce a false positive finding just from statistical noise in the scans.

She adds, “A scan can correctly identify the areas of a person’s brain that are receiving blood flow at a particular moment, but we can’t definitively say that activation of a brain region equals a particular emotional or cognitive state.” A part of the brain called the amygdala produces negative emotions like fear, but also positive ones, like happiness.

Even more striking was a review from 2020 by Duke University professor Ahmad Hariri. It reanalyzed 56 published academic studies based on fMRI analyses, and found that the results usually do not come out the same on a second scan.

As I have also written about extensively, misleading fMRI study results are routinely injected into the still highly prevalent nature-nurture debates in psychology and psychiatry. Genetic influences on behavior are routinely exaggerated by the field in conclusions that are based on brain scan research. 

Book Review: Educated: A Memoir by Tara Westover

In 2019, I wrote a review of a book by Amber Scorah titled Leaving the Witness about a woman growing up as a member of a cult-like religion. People in that group were taught to avoid talking to anyone or looking at any source of information that might call into question its belief system. As with most cults, people who broke the rules or questioned orthodoxy were completely shunned by family and friends.

My interest was how people routinely convince themselves of the most outrageous beliefs - ones that could easily be seen as preposterous even if thought about briefly - and hang on to them for dear life in order to avoid an almost unbearable feeling of groundlessness (also called existential groundlessness or anomie). The roots of this are from the biological effects of an evolutionary process called kin selection. In my review I said I thought the author had written the most elegant descriptions of that experience I’d ever read.

Well, Ms. Scorah has met her match in Tara Westover. Furthermore, Westover’s book talks about what happens in a case in which the “cult” consists ONLY of the members of someone’s family of origin. They were ostensibly Mormons, but the vast majority of practitioners of that religion did not subscribe to many of the clearly bizarre ideas of this particular family, especially those of the author’s father.

Westover writes that he may have had bipolar disorder. Of course I have no way of knowing for sure, but the consistency of her descriptions of him argues against this. In true bipolar, the person thinks normally when not in a manic or depressed state, which is usually most of the time. Some of the father’s strange ideas did not seem to be delusions per se but were based on conspiracy theories that are now widely believed. Included were dramatic ideas about the “Illuminati” and an anti-Semitic tirade called the Protocols of the Elders of Zion.

Other of his beliefs were even more far out: the public schools were all agents of Satin, so none of the seven children in the family attended public schools. All doctors were all part of this conspiracy, so no one was taken to a hospital. 

Mother always went along with whatever ideas were expressed by the Father, but when alone with the author, she would sometimes seem to indicate that indeed she knew better.

One of the biggest issues for the author was her relationship with her older brother Shawn, who was sometimes hyper-involved with her but at other times physically abusive to her. If she mentioned this to her parents, they did not seem to believe her, so she quickly learned to keep it to herself –sometimes even by telling herself that maybe she had dreamed it or that she was crazy so what had clearly happened was a figment of her imagination.

Strangely, Westover was able to get into BYU despite a paucity of education by studying for the college entrance exams, through books and other recommended sources from people she knew at her church. Most of this reading presumably would have been highly disapproved of by her father. It took her two tries at the test to get the requisite score, but she somehow kept at it. Her father has always said he thought that women should just get married and run a household, but as I will mention later, some of his behavior was inconsistent with that idea.

Once she got to BYU, a Mormon school, almost none of the students had the same belief system she did. They could hardly believe she had never even been to high school. She did not share anything about her unique family experiences. She frequently told herself she was not qualified to be there. Nonetheless, she was able to persist with the encouragement of some of her advisors who saw how bright she was. And she was bright enough to eventually get into highly competitive and prestigious graduate programs at Cambridge University in England, and at Harvard!

She frequently returned home and usually fell back into old family patterns, but something pushed her leave again and again to continue with her “satanic” education.

At school, the feelings and thoughts produced by her sense of groundlessness almost tore her apart, despite her ongoing successes. The way she experienced groundlessness was brilliantly described in a variety of amazing (and rather horrifying) ways throughout the book. Examples: she writes, “It was not that I had done something wrong, but I existed in the wrong way. There was something impure in the fact of my being.” 

When she started to experience her clique at Cambridge as a sort of family, she felt damned by those feelings: “No natural sister prefers a stranger to a brother…and what sort of daughter prefers a stranger to her own father? That feeling became a physical part of me.” Later she had the thought, “It seemed like I made a thousand mistakes, driven a thousand knives into the heart of my own family.”

The blow that stopped her from making frequent return home visits was after, in private e-mails, her mother admitted she should have protected her daughter from Shawn. And then her older sister admitted to her that she had been through many of the same things with Shawn that the author had. Even Shawn’s ex-girlfriend confirmed how he was. Surely now her Dad would believe her. Except in his presence, her mother and her sister started lying again, denying that they had said anything of the sort!

So how was the author able to break through the powerful effects of family dynamics and achieve her educational accomplishments? Again, I have no way of knowing for sure, so I'll speculate based on the available descriptions as well as my psychotherapy experience with other families. I could of course be completely wrong..

I suspect that her parents, despite any insistence otherwise, were both secretly highly conflicted about education, family roles, and religion, so she was getting a mixed message. The author does not tell us anything about her grandparents that might clue us in to where this confusion came from originally, but some of the parents' behavior seemed to scream it out. 

Some examples: as mentioned, father preached about traditional gender roles, and his only other daughter followed them. But somehow, when he had been injured and couldn’t run his business as before, he allowed his wife to develop her own business selling alternative medicines that brought in more money than he’d ever made, and he was supportive of her doing this. Also, when Tara started singing in local shows as a teen, he would always come to hear her sing, and appeared to be as proud as punch.

Mother, while not overtly telling the author to get educated, would often subtly push her into getting on with it – as long as Dad was not around. 

But the mind-blowing fact that seems most in line with my speculation is this: of seven siblings in the author’s family, three kids left the “homestead” and four stayed. The three who left got Ph.D.’s, while the four who stayed didn’t even have high school diplomas! The possible acting out of the ambivalence of this family thusly described in one sentence.

The Foster Care to Homelessness Pipeline

 

In a previous post, I discussed one big reason for the increase in tent cities for the homeless: the defunding of critical parts of the mental health safety net. In this post, I’m going to talk about another one: unplaceable foster children who age out of the system.

I was first made aware of this problem by a counselor in Texas. Then I noticed a headline that said much the same thing she described was going on in California. According to the counselor, some residential treatment facilities have recently been closed by the governor of Texas. The ostensible reason was that there were accusations made against people there of abusing children, but instead of fixing that problem, they closed them down.

Unplaced foster children there may now live in unregulated rentals, on the floors of churches, in some donated spaces or in hotel rooms. At one place, girls aged 12-20 don’t go to school, don’t have rules or clean up. The place itself is usually filthy. The girls are also allowed internet access so they often “run away” to meet various men, and most aren’t on birth control.  

Meanwhile, in California, things are just as bad. According to reporting by the Investigative Reporting Program at UC Berkeley, hundreds of Los Angeles’s county’s abused children ended up in hotels like the Biltmore Hotel downtown. In December 2021, the then-director of the city’s child welfare agency quietly struck a deal with the hotel’s operators to house foster youths and their social workers at the cost of $89 a night.

The children placed in the hotels are usually among those with some of the most significant untreated trauma and the gravest histories of violence. Though group homes frequently have security and teams of staff members, children in the hotels have often been supervised by a single social worker, sometimes with scant knowledge of their backgrounds, little training to de-escalate potential violence and no on-site colleagues when things go wrong, according to DCFS policy documents. Assaults on staff members are not unusual.

In two cases, in particular, the kids ran away from an unregulated placement and ultimately died in shootings.

Many children are put into the foster system after being removed from an unsafe home. This can mean that children all over the country are entering the foster care system who may have had parents who were drug addicts, abusers, or criminals and are prone to acting out and violence, which makes them nearly impossible to place in foster homes. When they turn 18, they are no longer wards of the state and many are then out on the street.

According to the National Foster Care Institute, after aging out of foster care, approximately 20% of former foster youth will experience homelessness.

I inadvertently put the wrong YouTube address for my video about family issues that feed into guilt in women trying to balance career and family

 

https://www.youtube.com/channel/UCPjK28Du95eX2ZdWTT5_6TQ

I also corrected the web address on the original blog post.

Homelessness, Prisons, and Mental Illness

 

The problem of homelessness in the United States has finally been getting more attention lately. A big part of this population has a chronic severe and persistent mental illness like chronic schizophrenia. Not only that, but a lot of these mentally ill folks are now in jail instead of mental hospitals. As I have previously mentioned, the largest mental hospital in the country is LA County Jail. They have usually been arrested for petty nuisance “crimes.” Private for-profit prisons are only happy to have these folks to increase their inmate population and their profits.

Digging a little deeper, as did author Lynn Nanos in her book Breakdown, the problem of what to do with these people seems almost impossible to solve. There is a shortage of hospital beds, and therefore patients pile up in emergency rooms with no place to go. Many people who have schizophrenia have no insight and don’t think they are mentally ill, and refuse treatment. 

Hospitalizing patients involuntarily has become highly controversial, with so-called “patients’ rights” advocates, some of whom don’t believe schizophrenia is a real mental illness, helping to change the criteria for involuntary treatment so that many who used to be hospitalized no longer meet the criteria.

Even if patients agree to treatment and a hospital bed can be found, there is no place to send them after discharge, and many return to the streets. There are very few places in which they can receive outpatient treatment, so they often go off medications and end up just where they had started.

On the street, homeless mentally ill persons who create a disturbance are evaluated by policemen who don’t know how to evaluate them properly but arrest them instead. They usually have no money and cannot bail themselves out.

The idea that this problem is insolvable is ironic because, when I started my psychiatric residency in Los Angeles in 1974 and throughout the following decade or two, the problem was solved! Let me tell you how. The Lanterman-Petris-Short Act of 1967 in California helped stop the many patient abuses that occurred in previous years in mental hospitals, such as families putting away relatives for endless hospitalization for various motives, some of which were nefarious. 

With the act, you could no longer hospitalize patients involuntarly endlessly. The longest you could hold them against their will was 17 days (28 if they were actively suicidal), with patients having the right to judicial review within 72 hours. Many of the details in the bill were then adopted in states across the country,

Back then, an individual could be hospitalized involuntarily if they met the following conditions: they obviously had to have a diagnosable mental illness. Then they had to be a danger to themselves, a danger to others, or gravely disabled. This last term meant that they could not provide for their own food, clothing and shelter. And this included patients who were living in cardboard boxes on the street, which at the time the bill was passed were relatively rare for reasons I’m about to describe. Now, because of patients’ rights idiots, that no longer is the case - it seems like someone practically has to be starving to death because of their illness in order to qualify.

Policemen back then seemed to know enough about mental illness to triage people they took into custody to psychiatric emergency rooms, which have now themselves become rather rare. We had a great one when I first moved to Memphis in 1992, but it was eventually destroyed by the business types who, as is now more common than ever, wanted to transfer the funding to their own pockets. 

Memphis also had a training program in mental illness for police, who formed what was called a Crisis Intervention Team or CIT. They were trained by psychiatrists and psychologists including me. The CIT model was later adopted by police forces across the country. It still exists here in Memphis. The problem is there are very few psychiatric emergency rooms to bring them to, and the medical emergency rooms not only can’t handle them but have no hospital beds to which they can send people.

Since psychotic people, unlike in the past, became treatable with medication so they could be released, state hospitals began to downsize. But they still had beds available. In LA, Camarillo and Metropolitan State hospitals were still in business. Patients in ER’s could be sent there, or to a county psychiatric hospital, or to some private hospitals that still had psych wards and contracted with the county. I worked at a private hospital that did this after my residency. This all began to change in the Reagan administration when states began to close the hospitals.

After discharge, programs were in existence to greatly reduce the odds of re-hospitalization. Patients who were unable to work because of their illness could be put on social security disability (SSI). This would then pay for housing for them in numerous “board and care” homes -  which seem to be disappearing for the most part. According to the Los Angeles Times, an estimated 142 facilities in California closed in the first quarter of this year alone with a loss of 3057 beds. 

Reagan tried to kick people with schizophrenia off the SSI roles because he didn’t believe in mental illness (Karma: he later developed one himself, Alzheimer’s disease). The courts eventually stepped in to stop him.

And the biggest difference from now is that there were a whole lot of community mental health centers we could refer them to for treatment after they were discharged. These now seem to be disappearing at a frightening pace. 

Politicians used “tax cutting” ideology to basically defund them, although the tax money often went to one of the politician’s own pet projects. We used to have several community mental health centers here in Memphis when I first moved here, which no longer exist.

Amazing how we had next to no homeless mentally ill patients in Los Angeles and Memphis back them. Problem (was) solved.

The Slow Evolution of Gender Roles

I write frequently about a phenomenon called cultural lag that I stole from sociology  and modified a little. What is it? Cultural lag, as originally defined, is when there are differences in the rate of change between different groups within a society. For example, if one group adopts a new technology more quickly than another group, this can lead to a gap in knowledge and understanding between the two groups. This gives the first group an advantage in the job market. In my Unified Therapy model, it happens specifically when the culture evolves to, and begins to demand, a more individualistic way of being and relating to others. This process was well described in historical terms by Erich Fromm in his classic book, Escape from Freedom.

 

Previously present cultural mandates about such things as gender roles, having children, and independence from family have been internalized by families, who follow a series of rules about these areas. In turn, if everyone follows the rules, the family functions smoothly – called family homeostasis. This is highly adaptive - when the rules within a culture are fairly clear. When these rules evolve, many families literally can’t keep up with the changes, and their family rules and the resultant behavior becomes maladaptive in the larger society. Cultural changes are now starting to come more quickly, leaving more and more families in the dust.

 

Nowhere is this more apparent that in the area of gender roles. In the not too distant past, women were not allowed to vote, or own a credit card. (The way the Taliban treat women in Afghanistan is almost like a frightening parody of what this used to look like). Within my lifetime, women started to join the workforce in large numbers, often times in jobs women in the past ever thought about performing. The feminist movement has led to a more egalitarian society. But the old ways still gnaw at many people. 

 

One extremely common pattern is that, with household chores, much of the division of labor between wives and husbands remain stuck in old patterns. People may read about how easy it is to “have it all,” when in fact in today’s culture this is often next to impossible for middle and working class women. We also have feminists on one side denigrating stay-at-home mothers, while on the other are preachers telling women that they are screwing up their children by not being home with them. At the same time, many employers are asking for more and more time from employees and don’t give a damn about their child care responsibilities. I posted a video describing one aspect of this in detail.

 

These issues have led to a lot of guilty parents, most frequently the mothers, because even now they are on average more responsible for children than male parents. While some of the oft-described differences in income between men and women doing the same jobs is indeed due to sexism, some of it is due to the fact that many women have to take care of the kids so they don’t work as many hours.

 

My understanding of this issue was recently supported by a study that showed that  more wives are now primary earners, but still spend less time performing most household chores, let alone child care. As described in USA today on 4/15/23 by Jessica Guynn:

 

“This research shows that wives earn as much as their husbands in more marriages today than ever before. So why do men still spend more time at work, relaxing and socializing and less time mopping floors, cooking dinner and picking up kids from school than their spouses? Most of the time when we talk about gender equality, we focus on the workplace where women are sharply underrepresented at the top, face discrimination in hiring and promotions and are paid less for the same work. But gender disparities don’t just happen from 9 to 5.”

 

“The gender gap in unpaid work has been narrowing, but the reality remains that married mothers do more unpaid work than single mothers,” said Aliya Hamid Rao, an assistant professor in the department of methodology at the London School of Economics. Men are still the main breadwinners in more than half of opposite-sex marriages, but the share of women who earn as much or more than their husbands has tripled over the past 50 years, according to a new study from the Pew Research Center. In about a third of marriages – 29% – husbands and wives earn roughly the same. In 16% of marriages, wives are the breadwinners. But housework and caregiving responsibilities are still widely considered women’s work.

The Conflation of Chronic Sadness With Major Depression

When I bring up with many other professionals the idea that major depression is now over-diagnosed by relabeling what used to be called dysthymia as "mild' major depression, a lot of them seem to disagree. Or they just tune out. “That’s just your opinion,” I might hear. Well, luckily the DSM-V now provides evidence that I am on the right track. In the DSM-V, the term “dysthymia” has been replaced! It is now called Persistent Depressive Disorder. 

As I have discussed in many previous posts, my opinion about major depressive disorder is that it is more of a brain disorder than mere unhappiness. The word depression itself is a symptom, not a disorder. It is in the interest of drug companies to conflate chronic psychological unhappiness with major depression so they can sell more antidepressant drugs to people who will not actually benefit from them.  Now,  it is also possible to have both, which is called double depression.

While many of the criteria are the same for the new diagnosis as the previous criteria for dysthymia, there are subtle differences that obscure the difference between that disorder and major depressive disorder. In a percentage of people with the latter disorder, it may become chronic. This is seen in the new definition of the disorder, which reads “This disorder represents a consolidation of DSM-IV-defined chronic major depressive disorder and dysthymic disorder. These disorders should not be consolidated.

There is one additional change which is telling. The only specific criteria for the disorder that has been changed has gone from “The disturbance is not better accounted for by MDD or MDD in partial remission” to “Criteria for Major Depressive Disorder (MDD) may be continuously present for 2 years, in which case patients should be given comorbid diagnoses of persistent depressive disorder and MDD."  Double depression has nothing to do with the length of the major depressive episode.

Drug companies have enlisted academic psychiatrists to become “key opinion leaders” in order to push this idea, and have even advocated the use self report surveys designed to screen for major depression (therefore having a lot of people test positive who don’t really have the disorder  – false positives) as diagnostic instruments.

This has led to a host of articles in the popular press that seem to indicate that antidepressants are nothing more than placebos. Nothing could be further from the truth, but a lot of psychiatry critics like Robert Whitaker have seized on “research” articles (which do a crappy job of making the correct diagnosis) that seem to show this to be the case.  After all, since most anti-depressants are generic,  it's better for drug companies' bottom line if instead of those drugs, expensive new anti-psychotic drugs can be recommended instead.

The critics also use the fact that we don’t know exactly what causes major depression to dismiss the whole diagnosis. The incorrect hypothesis that the condition is due to a “chemical imbalance,” which is sometimes advanced by clinicians, must mean that it is not a real disease. Dumb. Clinicians have often used this oversimplified idea to convince resistant patients to take the medications. Researchers rarely if ever actually said that a chemical imbalance was the cause of the disorder.

Of course, it’s not always easy for clinicians to tell the difference between dysthymia and major depression in a given patient, but in most cases it’s fairly straightforward.  There is nothing that stops anyone from being chronically unhappy when they are not having an episode(the euthymic state) of major depression. And major depression is episodic with normal-for-them baseline mood periods in between episodes.

A good clinician will define a response to antidepressants as good if the patient returns to their baseline. They don’t have to be in a good mood to have had a good response, but may just need psychotherapy like any other dysthymic patient. Nonetheless, many of these patients who have double depression are mislabeled in the literature as “treatment resistant,” which means that docs are encouraged to add still more drugs to antidepressants to “augment” them. There are of course patients who actually are treatment resistant and need this augmentation, but in my 45 years of practice this was a relatively small contingent.

Briefly and in an oversimplified manner, distinguishing the two disorders has to do with the “three P’s” – persistence, pervasiveness, and pathological. (You can tell if a study employs the correct definitions by seeing how the diagnosis was made with their subjects. The P’s are emphasized in an excellent diagnostic interview called the SCID). Persistent: this is the duration criteria. An episode has to last at least two weeks. Admittedly, the two-week criteria is arbitrary, but is put in so clinicians don’t make the diagnosis after too short a period.  The “everything is bipolar” crowd routinely poo poo's the duration criteria.

Pervasive: the symptoms have to be present nearly all day every day no matter what goes on in a patient’s life. This means that if a patient were to win the lottery, it wouldn’t cheer him up all that much.  Pathological: this means that the ways that the patient reacts to any stress is different from the way they might react if they were not in an episode. See the lottery statement. Also, if a lover were to, say, break their heart, this would not always make a whole lot of difference in how bad they feel.

These issues are not seen with good doctors, who not only know how to take a complete bio-psycho-social history but actually still do them.

Medicating Normal - an Interview

I was interviewed today on the Facebook page for a movie called "Medicating Normal" about the current problematic state of psychiatry - such things as malignant polypharmacy, the over-diagnosis of bipolar disorder and other b.s. diagnoses, doctors spending too little time with patients for a good evaluation, and such.

It can be seen at:

https://www.facebook.com/watch/live/?ref=watch_permalink&v=1479833659217305

ACE’s, Brain Changes, and Likelihood of Diseases

As mentioned in my post of January 31, there are many studies showing a correlation between Adverse Childhood Experiences (ACE's) and a wide variety of psychiatric and physical conditions. This is probably also true of the effects on offspring of certain parental behavior problems.

Correlation does not mean causation. Answering the question of whether two characteristics that correlate are also involved in a causative relationship depends on a number of factors. How strong is the correlation? A weak correlation can be a statistical fluke, If there is a lot of natural variation in the characteristics being discussed, the found relationship may just be a coincidence. 

Are there other variables that are not controlled for that create the correlation?  In order to verify any relationship seemingly uncovered in any given study, repeated experiments that lead to the same result become necessary. And even if causation is involved, we may not know which variable was the causative factor and which the result.

The metrics I tend to use also include my answers to the following questions: If A and B are indeed causally related, what else would I have to believe? Can I think of a third, uncontrolled-for variable that could account for both A and B? Can I come up with any logical and known facts or data that might be the explanation for an apparent causative relationship, or does it seem inexplicable or even off the wall?

Last, is this result consistent with what I have seen clinically in my 40 plus years as a psychiatrist, or does it fly in the face of it? Now here it is possible that I might be looking at only confirmatory evidence of my opinions and discounting disconfirming evidence (confirmation bias), although I like to think I have at least a modicum of objectivity. 

So I also ask other psychiatrists and therapists if they’ve seen the same things I have in their clinical experience. When I do that, I have to take into account that I asked my patients a lot of questions that most therapists never even think about asking – for example, “What does your mother-in-law think about this problem your daughter is having?” So they might or might not be able to give me any relevant information.

Many studies showing the same thing makes for a stronger case for causation. When it comes to ACE’s and later illnesses, both psychological and physical, they usually pass most if not all of the tests above with flying colors. And they keep on coming in. Here’s some recent additions:

 

1.    Childhood Adversity Tied to Race-Related Differences in Brain Development

In this study, exposure to trauma was linked to lower gray matter volume in key brain regions in black kids. Among children ages 9 to 10 years, white kids showed greater gray matter volumes compared with black kids in the amygdala, hippocampus, frontal pole, superior frontal gyrus, rostral anterior cingulate, pars opercularis, pars orbitalis, lateral orbitofrontal cortex, caudal middle frontal gyrus, and caudal anterior cingulate (all p<0.001).

Compared with white children, black children had experienced more traumatic events, material hardship, and family conflict and lived in more disadvantaged neighborhoods, while their parents/caregivers had lower income and educational attainment and were more likely to be unemployed.

This analysis provides evidence that contradicts claims about inherent race-related differences found in the brain.

Dumornay N.M., et. al., "Racial disparities in adversity during childhood and the false appearance of race-related differences in brain structure." Am J Psychiatry 2023

 

2.    Childhood Adversity Tied to CVD in Early Adulthood

Children who experience adversity ― including serious family illness or death, poverty, neglect, or dysfunctional and stressful family relationships ― are at increased risk of developing cardiovascular disease (CVD) in early adulthood, a large Danish study of patients aged 16 – 38 has found. Compared to young adults who experienced little adversity in childhood, peers who experienced high levels of childhood adversity had about a 60% higher risk of developing CVD, the researchers found.

 

Bengtsson J. et al. “Childhood adversity and cardiovascular disease in early adulthood: a Danish cohort study.” Eur Heart J. 2023 Feb 14;44(7).

 

3.    Adolescents’ positive perceptions of their relationships with both their parents are associated with a wide range of favorable outcomes in young adulthood.

In this study of more than 15,000 adolescents, higher levels of adolescent-reported parental warmth, parent-adolescent communication, time together, academic expectations, relationship and communication satisfaction, and maternal inductive discipline were all associated with favorable outcomes in young adulthood.

Participants rated their depression, stress, optimism, nicotine dependence, substance abuse symptoms (alcohol, cannabis, or other drugs), unintended pregnancy, romantic relationship quality, physical violence, and alcohol-related injury.  

This was done while controlling for age, biological sex, race and ethnicity, parental educational level, family structure, and child maltreatment experiences.

Ford, et. al. “Associations Between Mother-Adolescent and Father-Adolescent Relationships and Young Adult Health.” JAMA Netw Open. 2023;6(3)