Book Review: Wrong by David Freedman

 

I often write about the logical errors in the design of medical studies of personality disorders, psychotherapy outcomes, and labeling behavioral problems as some sort of brain disease because of some average difference on an MRI scan. I discussed how epidemiological studies that try to correlate two things are inherently misleading because of the inability to control for other factors which may effect the outcome.

In the book Wrong: Why Experts Keep Failing Us and How to Know When Not to Trust Them, David H. Freedman does an amazing job of showing how experts in a lot of other fields, especially when they interact with public media, draw conclusions which are completely wrong. It’s not that we have made no progress in such things as medical treatments obviously, but the process of drawing valid conclusions is more problematic than people think. Because of contradictory information about, say coffee being good or bad for certain conditions, this may have led to our current craziness regarding obviously effective treatments like vaccines.

Freedman goes into detail about the mis-informational follies of government officials, industry insiders, financial rating agencies, business gurus, stockbrokers, and real estate agents. Experts often pander to certain segments of the public, and may therefore be biased to gain prestige in professional groups, may also be corrupt, and may even fake data to gain publication in a prestigious journal. Scientists may measure what doesn’t matter or toss out inconvenient data. Positive studies need to be replicated but often aren’t, and if they are and the new study doesn’t do so, the second study is unlikely to be published because journals are prejudiced against negative studies.

Business advice is often based on the latest fad. Because of initial enthusiasm, a new philosophy of management may seem to bring added success, but it often does not seem to last and is then replaced by some new fad.  I’ve noticed something similar with teachers – new fads on techniques for teaching kids how to read will be popular but then eventually be replaced by some other new technique. Fads almost never lead to improved learning over time.

When it comes to separating the wheat from the chafe, so to speak, I think the author is at times more pessimistic than I think he needs to be. After all, despite all this, scientists have made real progress with demonstrable effects. He does offer some strategies in the last chapter: with new info, make sure it doesn’t trip any alarms; appreciate the importance of negative findings; see if it includes sensible qualifying statements; see if it’s candid about refutational evidence; see that it includes candid discussions providing context and perspective.

My own favorite question when it comes to whether I think the conclusions of a study is valid or not is, “If I believed this, what else would I have to believe?" For example, most therapists think that people with borderline traits “split” ( ‘They see people as all good or all bad) and have deficiencies in mentalizing’ (reading other people’s thinking or intensions). Yet they aIso think they are master manipulators. How on earth can those things all be true?

I am automatically suspicious of anything that in an epidemiological study purports to show cause and effect relationships between two things. Which is the cause and which is the effect? And how valid is a connection when results could be due to other variables that are impossible to control?  And how about logical fallacies? We used to think marijuana use was a major risk factor for later heroin abuse because many addicts started with pot. But almost all of them had also used coca-cola (a “post coke ergo propter coke fallacy” :)

Racism and African American Mental Health

I have written a few posts about the effects of prior, earlier American racism on African American psychology and how that interacts currently with White preconceptions resulting in a “game without end,” so that common ground is difficult to establish. I’ve been quite clear in saying that despite much progress, there is still a fair amount of both implicit and explicit racism in society, especially in the criminal justice system. 

The usual criticism I get when I write about racism from certain people is that as a white person I have no business opining about such things because I haven’t had the personal experiences that Black people have. (In some circles people also say all whites are responsible for systemic racism, as if tribalism isn’t a major influence all over the world on everyone, but that’s another story).

Well, while it’s true I haven’t experienced certain things personally, such experiences as personal observations, reading different black writers, seeing black patients in psychotherapy, and gaining knowledge of common psychological processes such as the intergenerational transfer of trauma do not count for nothing. If that were true, therapists would never be able to help anyone who was not a personal clone who had never left their sides and were treated the same way by everyone they came in contact with.

Janee M. Steele, Ph.D a black author, wrote a book called Racism and African American Mental Health: Using Cognitive Behavior Therapy to Empower Healing. She was interviewed by Judith Beck, daughter of CBT founder Aaron Beck, and she said a few things that are highly consistent with my viewpoint.

Steele is s a cognitive behavioral therapist, so I would assume she doesn’t do genograms on her patients to uncover the history of a patient's family's past family trauma. Therefore, she may not know all of the implications of her ideas.

She describes a Black woman patient of hers who had significant performance anxiety at work, especially while being observed by her bosses and fellow (white) workers. She told the author she was concerned about being falsely labeled with racist stereotypes. Ms. Steele picked up on the fact that at least some of her anxiety was that these concerns were being attributed to stereotype threat rather than personal deficits.

Although Ms. Steele didn’t say this specifically, it sounded as if the patient had, as of yet, no actual experience with racist attitudes at the job. Furthermore, she was a good employee. While I agree with Ms. Steele that she should be cognizant of stereotype threats at work, and that a sense of powerlessness and internalized anti-Black attitudes may be a factor, I’m not certain the author knows some important ideas about how that may play out.

I have two questions. Why would her patient  ever consider any racist comments to be a valid description of her abilities? She knows very well what she can do. Second, if she were to have such an experience, why couldn’t she  just say in her mind to the offender (or even out loud if there would probably be no other consequences), “f*** off, you ignorant a-hole,” and then go about her business.

These issues are relatively common in minority communities, but are particularly prevalent among African Americans. It makes sense, however, that being overly anxious about doing this may have come about because of fears of her family for several generations of being “uppity,” which in the not-too-distant past could literally get you killed. Even though lynching is not a big issue any more, children can be confused about how much of their intrinsic abilities it would be wise to exhibit even now. Furthermore, these feeling engender a sense of mistrust of other people that may adversely affect their relationships.

The author goes into detail about internalized racism and resultant self-hatred and the devaluation of other Black people. These “core beliefs” result in feelings of inadequacy, powerlessness, and self-blaming. With the above client, she asks about her opinions about racial stereotypes. How did she learn them? Where did they come from? She blamed them on her treatment during her elementary school experiences and the portrayal of Black people on TV. But why should she start to seem to believe some of the stereotypes when they were not true.

To further add to my point, she apparently never mentioned what she learned about racism from her parents and other family members, and their childhood experiences and feeling ashamed of themselves. (They were often ashamed of their being powerless, not of their inherent capabilities). The CBT approach to her was to change the patient’s opinions about black people without invalidating her experiences. A worthy goal indeed.

In the interview, Steele talks about problems experienced by white therapists working with black people. There can be discomfort due to the white folk’s apathy, guilt, and vulnerability. But couldn’t plain old ignorance also be an issue? The author does mention a fear of inadvertently saying something rude or potentially offensive. And there is no mention of therapists who may have a relative lack of understanding of race issues facing a patient who doesn’t trust them to begin with – leading to the game without end mentioned in a previous post.

The author then goes on to talk about the underutilization of mental health services by Black people. She mentions something one of my own black patients told me: people in that patient’s church discouraging use of therapists and saying these folks just need to pray harder.

As the author correctly points out, there may very well be denial of racism by white people who are covertly promoting anti-Black attitudes and discrimination. But it can also be due to inexperience dealing with a variety of other cultures including Blacks with no ulterior motives at all. Just ignorance. Certain sectors in American society seemingly deny that there has been any racial progress at all, even during and after the civil rights movement.

A patient should try to keep an open mind about a therapist until they actually do or say something overtly racist.

 

 

Factors in the Decline in the Quality of Psychotherapy

Jonathan Shedler

Jonathan Shedler, Ph.D. is a critic of many aspects of today's practices in psychotherapy, and many of his views are similar to my own. He recently listed what in his view are the main factors in the dramatic decline of quality psychotherapy (I thank Dr. Steven Reidbord for calling this to my attention):

Deep intrusion of health insurance agendas into psychotherapy and its training

Dramatic decline in reimbursement. Psychologists in managed care paid 70% less than 1980s. “Best and brightest” now choose other careers

Out-of-control proliferation of for-profit graduate training programs that admit and graduate anyone who can pay

Influx into psychotherapy professions of vast numbers of practitioners who lack adequate training and aptitude

Pharmaceutical marketing/PR campaigns changed public perceptions, normalized meds and seeking MH care from primary care doctors as solution for problems in living

Therapy researchers operate in academic silos with little knowledge of psychotherapy and no contact with real-world psychotherapists. Most “therapy” research irrelevant and useless to clinical practitioners

Conflation of psychological problems with DSM diagnoses (by health insurers and academics researchers both)

Conflation of psychotherapy “outcome” with DSM symptom lists (driven by health insurers and academics researchers both)

Rise of social media therapy influencers and their self-promotion (“the death of expertise”)

Intense politicization of therapy professions; emergence of a training culture that incentivizes “right” politics & ideology over professional competence

Impact of tech companies/private equity. E.g., lowest tier therapists recruited, marketed, paid like Uber drivers. Advertising deliberately erases distinctions between levels of training and experience

Low or no barriers to entry; MH field is low hanging fruit for all manner of self-promoters and opportunists

“Clinical supervision” no longer a clinical training relationship with skilled clinical teacher/mentor, but often reduced to an administrative function by clinics/agencies

Runaway bureaucratization—inordinate time spent on forms/paperwork/documentation/ever-expanding bureaucratic requirements that neither benefit patients nor develop clinical skills in therapists

Extreme gender imbalance in training programs (classes often >90% female) with resulting loss of balance and perspective. Male students routinely report feeling unwelcome/marginalized/silenced

Increased emphasis in training programs on paint-by-numbers “manualized” therapies in place of fundamental psychological principles and core psychotherapy skills

Endless proliferation of “new” therapy brands/models/acronyms instead of emphasis on fundamentals skills. Virtually all are repackaging of well-established principles, endlessly reinvented/rediscovered by people lacking profound knowledge

Rampant denial of the role of unconscious mental life

–and neglect of personality & personality pathology. 

-----------------------------------

To those I would add seeing people's problems as "all in their heads" while ignoring family systems and sociocultural issues.

Book Review: The Origins of You by Vienna Pharaon

 

My “Unified Therapy” psychotherapy model, which I’ve been writing about since the publication of my first book in 1988, is meant to treat people who engage in repetitive self-destructive and self-defeating behavior, particularly in relationship contexts. You know, like people who marry one alcoholic or narcissist after another. While looking at their past is essential – in fact I look back three generations to find out why my patients, and their parents and grandparents, act the way they do – what’s even more important is what goes on in the present.

I found that people were acting out roles in their families to stabilize their parents, not for selfish reasons, and were suppressing who they really would want to be if left to their own devices. We all have a tendency to do this due to the effects of an evolutionary process called kin selection. We can choose to do otherwise, but if we do we become subject to terror when our families invalidate us.

Family roles are something modern day therapists pay almost no attention to, so when a book comes out that addresses dysfunctional behavior that dates back to family processes in childhood, I’m keen to read it. The Origins of You by therapist Vienna Pharaon is such a book. She looks at her clients' repetitive dysfunctional behavior in their relationships  as a way for them to feel safe because of earlier interactions with parents. She looks for ways that people do things like act like doormats in relationships – or go to opposite extremes and constantly try to dominate other people.

She addresses five needs from which these behaviors arise, which she says derive from what she calls “origin wounds.” She notes that her clients who had previous therapists often had not mentioned them. The needs which lead to these origin wounds are:

1.       I want to fell worthy.

2.     I want to belong

3.     I want to be prioritized.

4.     I want to trust

5.     I want to feel safe.

After review their childhood history, she uses a lot of popular techniques which are basically supposed to lead to behavior changes after insight into these wounds is achieved, and then has her clients monitor their behaviors for those which lead to conflicts, communication problems, and lack of boundaries. Then they talk about what changes need to be made.

The author claims a fair amount of success doing this, which I don’t doubt. She talks about emotionally abusive parents and a little about physically abusive ones, and domestic violence in the family. But not very much about severe physical abuse and neglect or child sexual abuse which families have refused to acknowledge. In my experience, clients like those who follow the recommendations here would be subject to massive invalidation by their families, which I found eventually and (almost always) undid any positive changes they had made from the type of therapy described in the book.

To her credit, the author does say that these problematic patterns are learned in the family and passed down to subsequent generations. And that the parents also have their own origin wounds, with which I totally agree.

But there are two issues that I (but almost no other therapists) have with her ideas. First, aren’t these people really aware at some level of what they are doing, even when they won’t admit it - even to themselves? Second, are they really protecting themselves, or are they altruistically sacrificing themselves for their parents?

On the first issue, the author does seem to come closer to my point of view in the text and with a couple of her clients. She mentions that a dysfunctional path “is easily recognizable, but sometimes hides in plain sight.” A client named Amir could clearly describe what he was doing but claimed to have no idea why. A long time ago I came to the conclusion that people are not stupid or blind about this, but acted as it they were. To understand what’s going on in my view, check out these posts on a groupthink process called willful blindness.

On the second issue, it’s hard to believe that clients are acting this way because they are protecting themselves, when the patterns are obviously bring them much pain. (There is one selfish motive mentioned above: the phenomenon of existential groundlessness). But as I have said, they are sacrificing their own needs to help maintain family stability.

Which also means that the process going on with the parents continues well into adulthood. The author seems to know this on some level but does not talk a lot about the response of their parents to new changes in the client’s behavior, so it’s hard to judge if she thinks this happens very often. Near the end of the book she does mention only briefly the risk that her clients maybe be “judged, shamed, rejected, or even disowned.”

In general, the author describes these patterns and how to conceptualize them very well, along with techniques which may lead to significant behavioral changes in some families where massive invalidation is far less likely that in those producing offspring with severe personality disorders. 

How Antidepressants Should be Prescribed

 

As psychiatrists are pressured by various business interests to see more and more patients in less and less time, more and more shortcuts have come into practice. Not a good thing. Especially when it comes to anti-depressant prescribing practices. The drugs have become way over-prescribed, and antipsychotic medications are added to them for "augmentation" far more often than necessary. I’ve spoken about the use of symptom checklists, which are screening tests and not diagnostic tests, being used to make diagnoses.

Another recent development has been companies that offer various “genetic testing” to try to predict which medications might work best in a given patient, or what side effects they are likely to get. For example, GeneSight Psychotropic offers a “pharmacogenomic” test which means that it analyzes how your genes may affect medication outcomes. They say: “The GeneSight test analyzes clinically important genetic variations in your DNA. Results can inform your healthcare provider about how you may break down or respond to certain medications commonly prescribed to treat depression, anxiety, ADHD, and other psychiatric conditions.”  

The problem with these tests is that their predictive validity is actually quite poor – even the company admits that “It is important to note that not all patients who received a GeneSight Psychotropic test experienced improved outcomes.”  According to two docs at the NYU School of Medicine, "The tools were developed using small sample sizes, focusing on specific patient populations...and were not tested in real world settings different from the one in which they were developed."

The tests are IMO a waste of money.

Because people are so complicated biologically, psychologically, and socially, I think a far better way for docs to decide which meds to use is to use pattern recognition: Doing a wide-ranging diagnostic evaluation and looking at what factors suggest certain courses of action.

Let’s start with the diagnosis of major depressive disorder. That diagnosis has to be based on a variety of considerations. Symptoms must be pervasive (almost all day every single day, even if you suddenly win the lottery. I exaggerate, but only slightly) and persistent (at least two straight weeks), and the patient’s functioning and stress responses must be significantly different that their norm. (Antidepressants do not work on chronic unhappiness). All symptoms must take place at the same time – having no appetite on Monday and poor sleep on Thursday does not cut it.

If it’s a patient’s first episode, another big issue is that there is no way for the doc to be absolutely certain that it is not a first episode of bipolar disorder rather than a unipolar depression. This is important because if the doc prescribes an antidepressant to a bipolar patient, it can trigger a manic episode – with disastrous consequences. So what is a doctor to do to make sure that doesn’t happen?

Family history is important, since bipolar disorder usually runs in families. If a patient has a family history, the doctor has to be more careful. The problem is of course that the patient might not know if he or she even has a relative who had a manic episode. So what does a good doctor do? In addition to asking about family history, the doc should carefully review the patient’s history for any symptoms suggestive of the disorder. These symptoms should not have occurred only when the patient was high on cocaine, or during a rage reaction upon having found out that the their spouse and best friend were having an affair!

Next, the doc warns the patient about the bipolar issue, and informs patients that in the event of suddenly feeling revved up, they need to STOP the antidepressant and call the office immediately. This instruction can be given at the same time as the doctor describes all possible major side effects with instructions on what to do should they occur. Then, the doctor needs to have the patient comeback for a scheduled follow up visit, preferably within two weeks.

Now, about picking an antidepressant with which to initiate treatment. As I mention, genetic testing is not particularly valuable. It’s always a bit of a crap shoot because a patient’s presentation may be somewhat atypical, but if the doc takes a complete history, it can suggest which agent to try first. If the patient has some obsessive-compulsive qualities, an SSRI like fluoxetine  or escitalopram is a good first choice. If in addition to that there is a lot of anxiety, the SSRI paroxetine is usually the best choice. If the patient has chronic pain, then duloxetine is usually a good starting point. If sexual side effects are a big concern, buproprion is usually the place to start.

Next, the doctor raises the dose of the medication every three to four weeks until there is a response, or it reaches the maximum dose, or until side effects become too big a problem. At this juncture, the doctor should NOT add another, different class of medicine to “augment” the antidepressant, as is suggested by a lot of Pharma commercials. If there has not been a good response to the first drug, the anti-depressant should be stopped, and a trial of a second antidepressant should come next. And again, if no response, a third one. There are diminishing returns here but eventually most patients will have a decent response. If they do not, then than and only then should an augmentation strategy be instituted. Or the diagnosis may need to be re-evaluated.

Close follow up. Close follow up. Close follow up.

My Blog on Feedspot's Top 100 Psychology Blogs

 

Family Dysfunction and Mental Health Blog has been selected by Feedspot's panelist as one of the Top 100 Psychology Blogs on the web.

https://psychology.feedspot.com/psychology_blogs/

Are Effects on Brain Development Due to Psychological Trauma in Childhood Permanent?

 

Romanian children who had been stuck in orphanages in which they had almost no direct interactions with their caretakers had been studied extensively by a group of researchers, as described in the book Romania’s Abandoned Children: Deprivation, Brain Development, and the Struggle for Recovery  by Charles A. Nelson, Charles H. Zeanah, and Nathan Fox.

Generally, the longer these children were in the orphanages, and the earlier they got there, the more damage to their cognitive abilities, social skills, and stress tolerance there was later in childhood after they were adopted by foster families. Some of them even showed reduced circumferences of their skulls. Hard to imagine that was not permanent damage. Most affected children did seem to show some recovery in their development after adoption, but did not seem to get back completely to normal. 

They were not followed much past adolescence in the original study. However,  according to a follow-up study described by the BBC, many of these young children adopted by UK families in the early 90s are still experiencing mental health problems even in adulthood (https://www.bbc.com/news/health-39055704).

Despite being brought up by caring new families, this newer long-term study of 165 Romanian orphans found emotional and social problems were commonplace. Initially, all 165 had struggled with developmental delays and malnourishment. While many who spent less than six months in an institution showed remarkable signs of recovery by the age of five or six, children who had spent longer periods in orphanages had far higher rates of social, emotional and cognitive problems during their lives. 

Common issues included difficulty engaging with other people, forming relationships, and problems with concentration and attention levels which continued into adulthood. This group was also three to four times more likely to experience emotional problems as adults, with more than 40% having had contact with mental health services. Despite their low IQs returning to normal levels over time, they had higher rates of unemployment than other adopted children from the UK and Romania.

Interestingly, one in five of them seemed to have been unaffected by the neglect they experienced. A small percentage, to be sure, but if the types of experiences these children had cause permanent brain damage, how is this even possible?

In current literature about the effects on the brain of trauma, the common opinion expressed by experts is that they are irreversible. Brain changes that are seen in various neurological evaluative procedures - such as different brain scans - do not seem to go away.

I, on the other hand, have theorized that the effects of trauma on the brain may be reinforced by continued interactions with primary attachment figures, whether they be natural or adoptive parents. If this is going on, the brain changes would not go away. Neural plastic changes leading to this would not happen.

But, people may say, many of these traumatized Romanian orphans were adopted into loving families! If what I believe may be true actually is true, why do scars remain in 80% of these orphans?

Answering this question definitively is extremely difficult to do. Surely, due to variations in the genetics of the orphans, some may have been more vulnerable to permanent brain damage than others. I mean, smaller skulls? But again, on average, and not in all of them. Also, the experiences of the orphans in the orphanage probably varied significantly, with a few of them possibly exposed to more helpful caretakers than the others.

What is rarely discussed is how difficult it is to raise children who have been traumatized in the way the orphans had been. They were difficult children with huge behavior problems, and how to provide proper boundaries in a loving manner is something that many parents of very normal children have difficulty doing. No matter how well intentioned the parents may be. Some of these parents might get help from knowledgeable family therapists, but most do not. So in some ways, the children may be continuously further traumatized by angry and frustrated parents who don’t have a clue as to how to best interact with them.

In the original study, there was some preliminary evidence that interventions by therapists with the adoptive parents were helpful, but such interventions did not usually take place. Even when they did, the quality of therapy the parents receive could vary widely.

So addressing the family dynamics of these adoptive families of adult survivors of the Romanian orphanage, so that these behavioral and cognitive deficits are no longer being triggered and reinforced, might possibly lead in many cases to a reversal of both the psychological deficits as well as the brain changes caused by the original trauma.

I like to think so.