Peter Breggin Goes Off the Deep End

Peter Breggin

Peter Breggan is a psychiatrist who is often highly critical of the use of any and all psychiatric medication, which makes him the favorite psychiatrist of the rabid anti-psychiatry movement along with Tom Ssazz. 

For some of these zealots, it is very understandable why they hate psychiatrists so much.  As anyone who reads my blog knows, incompetent psychiatrists or those docs who have been brainwashed by big Pharma often do a lot of damage to patients through misdiagnosing them, using inappropriate medications, and/or not monitoring their patients for side effects.

I cannot blame such victims for having a highly emotionally charged negative attitude towards my entire profession. 

Still, that does not make everything they think correct.  In fact, it often kind of impairs their ability to be objective about psychoactive substances.

Personally, I always felt that Breggin has used half truths to justify some of his opinions.  But now I think he has gone completely off the deep end. 

After reading what follows, I have this to say to anyone who still thinks he has a shred of credibility: You should look into joining the Flat Earth Society. You’d fit right in.

A news article by Phil Willon of the Los Angeles Times appeared on June 12, 2012, with a follow up story the very next day and again on June 21.  I quote parts of the three stories:

“A San Bernardino County prosecutor Tuesday urged a jury not to be swayed by testimony that the antidepressant Zoloft put a former Westminster police detective in a fog that made him not responsible for kidnapping and raping a waitress in 2010. Deputy Dist. Atty. Debbie Ploghaus called the so-called Zoloft defense, backed by a psychiatrist's testimony, "a bunch of baloney" and a desperate attempt by Anthony Nicholas Orban to sidestep overwhelming evidence against him.

Orban was identified by the victim, was implicated by his best friend, was captured on security video footage at the scene of the attack and left his police service weapon, with his name on it, in the victim's car. Ploghaus told the jury that while bar-hopping in Ontario before the kidnapping, Orban groped a woman's chest, grabbed a man's crotch and repeatedly texted a former girlfriend hoping for an afternoon tryst. "He was a highly trained officer who wanted to have sex. He had sex on the mind. Don't forget that," Ploghaus told jurors in her closing argument.

The Westminster detective is accused of abducting the waitress, then 25, as she walked to her car after a Saturday shift at the Ontario Mills mall. His police service weapon drawn, Orban forced the victim to drive to a self-storage lot in Fontana, according to authorities. The victim told the jury that Orban sexually brutalized her in the parked car, hidden behind tinted windows, as people walked a few feet away.

At one point, Orban snapped pictures with his cellphone, telling her to "smile for the camera." He chambered a round in his semiautomatic pistol, shoving the barrel deep into her mouth as tears rolled down her cheeks, she said. "He said if I cried, he would kill me," the victim told jurors. "Then he pulled the gun out and said, 'I think we'll continue this in the desert.'"

Orban had shared eight margaritas and two pitchers of beer with a friend, and was seeking sexual encounters before he kidnapped the victim at gunpoint and made her drive to a Fontana storage facility, where he raped her, Ploghaus told jurors.

Orban's attorney, James Blatt of Los Angeles, said the assault ran counter to a life spent protecting community and country as a police detective and a Marine veteran of the Iraq war. The only plausible explanation for the defendant's behavior, Blatt argued, was the potent effects of Zoloft, which sent Orban spiraling into an "unconscious" delirium.

"At the time he was not aware, not aware of the torturous things he had done,'' Blatt told the jury…The victim sat in the front row of the Rancho Cucamonga courtroom, clutching a friend's hand, as the prosecutor recounted her testimony that Orban rubbed his weapon against her face during the attack.

Now here’s the relevant part:

The defense relied on Dr. Peter Breggin, a New York psychiatrist and critic of psychotropic drugs who has testified in other cases across North America. Breggin said he believed Orban suffered a psychotic break from reality shortly before the kidnapping and was in an unconscious state of delirium, void of control or memory, during the attack. "I don't even think he knows he's tormenting her," Breggin testified. "He would not under any circumstances behave like this if he was not driven over the edge by the drugs." Orban had temporarily quit taking Zoloft, prescribed by his psychiatrist, then resumed it at full dosage five days before the attack, which Breggin said sent him into a state of manic psychosis.

Breggin testified that Orban had stopped taking the prescribed antidepressant, then resumed it at full dose, provoking a psychotic break during which he was "delirious" and not fully aware of his actions.

The prosecutor criticized Breggin as "intentionally misleading" and told jurors that the scientific community rejects his medical theories. Ploghaus' medical expert, Dr. Douglas Jacobs, an associate clinical professor at Harvard, testified that Zoloft has been prescribed to millions of people and proved to be safe. There has been no evidence that Zoloft causes delirium or unconsciousness, he said.

While antidepressants can definitely cause someone who actually has bipolar disorder to become manic (more on that near the end of the post), and even though Breggin used the word "manic" in his testimony, symptoms of mania were not what Breggin and the defendant testified to.  


They said he was in an unconscious state of delirium.  That is not and has never been alleged to be a symptom of mania at all.  And the degree of the planning and execution of the series of events involved in the rapes is entirely inconsistent with delirium, which is defined as a disturbance of consciousness - reduced clarity of awareness of the environment with reduced ability to focus, sustain or shift attention - and is usually caused by metabolic abnormalities due to a medical condition or to an overdose of certain drugs, Zoloft not being one of those drugs.  


The actions of the defendant seemed  pretty focused to me! In fact, it sounded as if he were mentally quite sharp even though he had mixed the Zoloft with a lot of alcohol. (Being drunk is not at all the same as being delirious).


And then there was this from the defendant:

Within days, he said, he was overwhelmed, hearing voices at night, contemplating suicide and fantasizing about killing his wife and dog.

Sounds more like depression to me, not mania.  Perhaps a “mixed state,” but those are fairly rare.

And the kicker: the prosecutor questioned the defendant about parallels between his testimony and similar accounts in a magazine and book by a well-known critic of psychotropic drugs.  Orban acknowledged reading both works, but denied they had influenced his testimony.  Oh, and the critic who authored the book?  Breggin!


And now to the issue of antidepressant-induced mania. Apparently no one else testified that the detective had any history of having the disorder.  If he were bipolar and Zoloft was going to make him switch into mania, it would have most likely already happened when he was first taking the drug – not when he resumed it after a short break.  Resuming a “full dose” may lead to other side effects, but not that one.  As far as I know, the ability of antidepressants to kick someone into a manic state is not dose-related.

Besides, very few patients in a manic state become violent rapists. 

And patients in a manic state still can still tell right from wrong unless they are out-of-their-mind psychotic.  There was apparently no evidence he was delusional.  (If there is, then I might have to take back some of what I am saying about this case, and, if it turns out that the detective had a grandiose delusion that raping the woman would somehow save the world from an alien invasion, owe Dr. Breggin an apology).


As to the rape being "counter to a life spent protecting community and country?"  As we all know, soldiers in Iraq and police are never guilty of violent behavior.  Before he died, you could have asked Rodney King.  And I suppose we know for a fact that this was not just the first time he got caught.

What this is, barring further revelations about the defendant’s history of mental illness, is a variation of “The devil made me do it.”  Or perhaps a version of assassin Dan White’s defense in the case of his murder of two San Francisco politicians, “He did it because he was depressed, as evidenced by the fact that he was pigging out on a lot of Twinkies.”

Dan White assassinated  San Francisco Mayor George Moscone and  Supervisor (and gay hero) Harvey Milk on November 27, 1978, and was sentenced to only seven years

Apparently, the jurors also thought it was a stupid defense:

A jury of eight women and four men deliberated less than a day before dismissing that defense and finding Orban guilty of kidnapping, two counts of rape, two counts of forced oral copulation, two counts of sexual penetration with a foreign object and one count of making a criminal threat.

Orban is now facing a sanity hearing to determine whether he knew the difference between right and wrong at the time of the attack. He almost certainly faces a life prison sentence if the jury determines he was sane. If declared insane, he would be sent to a state mental institution for treatment, and later could be released. The same jurors have been impaneled for the sanity proceeding.

"What it comes down to is whether, at the time of this incident, he understood the difference between right and wrong," Orban's attorney, James Blatt of Los Angeles, said outside the courtroom. "I believe [the jury] will keep an open mind in reference to the sanity phase."


Addendum (6/27/12): The jury rejected the insanity defense, although some prosecutors apparently did blame the alcohol (rather than the Zolfot) for his "mental fog."  That's nonsense, too, considering the intricacies of his actions during the attack.  Looks like he had a lot of tolerance to the booze.

Disease Mongering in a Respected Journal and Plausible Deniability

In my post of August 31, 2011, Plausible Deniability, I illustrated how doctors under the sway of pharmaceutical companies widely distribute a completely invalid “take home message” to readers of journal articles and those who listen to academic-sounding presentations, while simultaneously providing themselves with an “out” so that they can deny doing just that.  Some of these strategies have been created from information gathered from the drug company marketing departments' intensive research into physicians and the way they think (see post: Physicians As Unwitting Research Subjects, 1/3/12). 

Apparently, these strategies are widely disseminated to physicians and researchers working with Pharma.  They are just too common.  A great example occurred in a rebuttal to a letter to the editor that I and several of my partners in crime (Peter I. Parry, Robert Purssey, Glen I. Spielmans, Jon Jureidini, Nicholas Z. Rosenlicht, David Healy, and Irwin Feinberg) managed to get published in the June 2012 issue of the Archives of General Psychiatry.  The Archives is considered one of the two top journals in psychiatry.

The letter was highly critical of a study that was published in a previous issue.  The article was one I blogged about in a previous post (More Disease Mongering in a Respected Journal, 8/13/11).  The gist of our published letter was described in that post, and I will not repeat it here.

However, let me use the rebuttal to our letter, printed in the same issue of the Archives, to illustrate how the authors avoid actually addressing the criticisms in the letter and deny that they meant to conclude from their "study" that which was highly implied by their journal article.  The latter issue is what I previously referred to as plausible deniability. 

Please keep in mind that when journals publish letters to the editor that are critical of one of their published studies, they allow the authors of the original study to respond to the criticisms, but that is where it ends.  They do not give letter writers the chance to respond in the journal to the rebuttal.  (It is a situation similar to that of reporters at a presidential press conference who are not allowed to ask follow-up questions).  So I’m doing it here.  Next to what they wrote in said rebuttal, I will provide my own commentary.

We are pleased to respond to the points raised by Allen et al, some of which take material out of context and quote news media articles beyond our control. For example, the letter states that “The message is that almost half the patients with a major depressive episode have undiagnosed bipolar disorder and are ‘not receiving necessary mood stabilizer treatment.’” The authors are well aware of exactly how the news media were going to interpret their study.  Ditto doctors who read the article.  The drug companies have apparently taught these authors that readers will routinely ignore the disclaimers that they list next in their rebuttal – a case of plausible deniability.  The article is designed to give a very specific “take home message.”  The success of this strategy is illustrated by those very news stories over which they are now saying they have no control.  Of course they don’t need to have direct control to achieve this goal.

Our actual statements are: "Based on these studies and the major differences in treatment guidelines for MDD [major depressive disorder] and bipolar disorder, we recommend that, among patients with MDEs [major depressive episodes], the presence of bipolar features, including all those with significant predictive value reported in this study, should be investigated carefully before a decision is made to prescribe antidepressants. If patients exhibit bipolar symptoms that impair everyday functioning, treatment with a mood stabilizer or an atypical antipsychotic may be useful." The take home message from what they “actually said:” exactly what we said it was.  This paragraph subtly equates "bipolar features" with agitation seen in major depressive disorder - a fact nowhere in evidence.  


This conflation is even more pronounced in the abstract of the article (the short summary at the beginning of the article which is usually the only thing that most busy physicians actually read). The introduction states "Many patients with major depressive episodes who have an underlying but unrecognized bipolar disorder receive pharmacologic treatment with ineffective regimens that do not include mood stabilizers."  This sounds like the article is going to demonstrate unrecognized signs of bipolar disorder and will "orient" anyone who reads the whole thing to think along those lines.

They assert that “The study’s findings are based on a ‘bipolar specifier’ requiring ‘no minimum duration of symptoms’ and ‘no exclusion criteria,’ ” and that “Any subject who came to psychiatric attention with an angry, agitated, or elated response to environmental triggers or psychoactive substances might have met criteria for ‘bipolarity.’ ”  

The criteria, stated in the “Methods” section of our article,1(p793) were (1) an episode of elevated mood, an episode of irritable mood, or an episode of increased activity with (2) at least 3 of the symptoms listed under Criterion B of the DSM-IV-TR …The minimum duration of symptoms required for a hypomanic episode was 1 day. Here the authors are flat out contradicting themselves! I quote from the original article itself: “No minimum duration of symptoms was required and no exclusion criteria were applied.” (page 793).  And exclusion criteria in the article do not exclude active drug abusers, which we brought up and the authors just ignore in their rebuttal.

 We assessed the duration reported for hypomanic episodes in 5 groups. Among subjects with major depressive episode with hypomanic episodes, 7.8% reported episodes of 1 day’s duration; 2 to 3 days’ duration was more frequent than 4 to 6 days.  Even if they did have a minimum duration criteria, the DSM criteria for even a hypomanic episode is four days.  Really, one day? In patients who met criteria for major depressive disorder?  Riiiight.

…associated with (3) at least 1 of the 3 following consequences: unequivocal and observable change in functioning uncharacteristic of the person’s usual behavior, marked impairment in social or occupational functioning observable by others, or requiring hospitalization or outpatient treatment.  Neither the article nor the rebuttal tells us how the study doctors made the determination that there was an unequivocal  “change in functioning uncharacteristic of the person’s usual behavior. “  Especially since under their rules you only have to agitated for a day, and if you took cocaine or had a big fight with your mother, you might have an unequivocal change in your “usual” functioning. What the phrase is supposed to mean is that the patient’s functioning has unequivocally changed under any and all environmental contingencies.  They would have to be more reactive than they usually are to all unpleasant situations to a similar degree. 

So how do would the study doctors know this?  Did they take the patient’s or a family member’s word for it?  I can tell you beyond a shadow of a doubt that patients rarely really understand what psychiatrists mean by this phrase.  The only way a doctor can know this is the case is to observe the patients several times over several weeks, both during and outside of the specified time period.  


Even a close approximation would require taking an extensive psychosocial history including evaluating current environmental stresses as well as an exploration of the nature, past history of, and current status of the subjects relationships with spouses, lovers, parents, and children.  Maybe they did that, but I doubt it, because doctors like these tend to denigrate the importance of such factors in favor of “disease” explanations.  And it would take a LOT of time.

No exclusion criteria for manic/hypomanic episodes associated with antidepressant or other drug use were applied. So people who got agitated from a side effect of an antidepressants were not excluded by their own admission.  Someone gets a side effect from a drug, and that proves they are manic? 

Importantly, the initial eligibility criterion was that patients have presented to clinical settings for evaluation and treatment of a major depressive episode per DSM-IV-TR criteria. These sequential criteria, applied by senior psychiatrists in each country, are entirely inconsistent with the assertion that the psychiatrists conducting the assessments enrolled “any subject who came to psychiatric attention with an angry, agitated, or elated response to environmental triggers.” 


The statement that 23.2% of subjects experienced elevated or irritable mood triggered by antidepressants did not “define the subjects as having ‘bipolar disorder.’” Rather,it addresses the DSM A criteria, which are essential, but not sufficient, for diagnosis of bipolar disorder. As Figure 1 in our article shows, mood lability while taking antidepressants occurred in 55.8% of bipolar specifier–positive vs 23.0% of bipolar specifier–negative subjects (odds ratio, 1.7;95% CI, 1.4-2.0) and mania/hypomania while taking antidepressants occurred in 37.2% of bipolar specifier–positive vs 3.4% of bipolar specifier–negative subjects (odds ratio, 5.7; 95% CI, 4.4-7.5).  Sorry, but with this paragraph the authors are still implying that their subjects MAY be bipolar, and assumes precisely what the article is supposed to show – that a patient who is agitated when depressed could have a manic symptom.  So if patients with an agitated depression are more likely to become more agitated on an antidepressant than depressed patients without agitation, that is supposed to show that they might be bipolar?  Only by circular reasoning.

Allen et al view their position as part of a “debate” about the “ever-widening bipolar spectrum.” We consider data, not debates, as central to the progress in the scientific understanding of mood disorders.  Ha!  This is a brazenly outrageous statement. The “debate” is specifically ABOUT "data" like theirs – both its validity and what it means.

They make several references to borderline personality disorder. The BRIDGE study assessed for comorbid diagnoses in all subjects. Five hundred thirty-two patients (9.3%)met DSM-IV-TR criteria for borderline personality disorder. This large sample provides an opportunity to analyze patients who met borderline criteria vs those who did not. We are completing a manuscript that will provide useful evidence on this subject. Maybe they should have said this in the original article.  But we know from the work of Zimmerman and others (My Psychology Today blogpost 12/11/11) that many patients who have borderline personality disorder are misdiagnosed.

Allen et al cast unseemly aspersions that the BRIDGE study was a vehicle to promote sales of an antipsychotic drug sold by sanofi-aventis. sanofi-aventis has no antipsychotic with an indication for bipolar disorder.  Here the study authors are being complete weasels.  The misleading point is contained in the phrase “with an indication for bipolar disorder.”  What they say is literally true - in the United States. Unfortunately, Sanofi does have an antipsychotic drug called amisulpiride (brand name, Solian). In fact, in the United States, it is not FDA-approved for any indication, let alone for bipolar disorder.   


However, Solian is approved and widely marketed in Europe and Australia, and at least according to Wikipedia, used for bipolar disorder.  (This may be why the study was conducted overseas). In addition, Sanofi also sells a preparation of depakote, which while an anticonvulsant and not an antipsychotic, is widely used in both actual and misdiagnosed bipolar disorder. 

Besides, as I described in my post of 6/12/12, marketing for off-label uses of drugs for bipolar disorder is unequivocally rampant.  Maybe the authors didn’t know this?  NOT.

We know of no evidence that this was the case at any stage of development and execution of the BRIDGE study. Sanofiaventis ceased financial support for analyses of the study in 2010. All work subsequently conducted has been achieved by our local funds. The drug company got out of the game just in time for the authors to claim they were not biased due to the funding source. Actually, the original article says “The sponsor of this study (sanofi aventis) was involved in the study design, conduct, monitoring, data analysis, and preparation of the report.” 


In addition, all of the clinicians recruited for the study received fees, on a per patient basis, from Sanofi-Aventis in recognition of their participation in the study. The key lead authors, all with significant Pharma connections, did not disclose their other pharmaceutical company ties.  These authors: Allan H. Young, MD, Jules Angst, MD, Jean-Michel Azorin, MD, Eduard Vieta, MD, Guilio Perugi, MD, Alex Gamma, PhD, Charles L. Bowden, MD.  


They should be ashamed of themselves.

Epidemic of Mania, Pharmaceutical Company Type Claims Yet Another Victim

It seems like just when I get finish with a post about yet another drug company getting in trouble for off-labeling marketing of a drug that is used in bipolar disorder, another company adds itself to the list.  This time, it is Abbott Laboratories, maker of the second-line drug for mania prophylaxis, Depakote.  Depakote is effective for mania prophylaxis, although probably not as effective as lithium.  Still, drug companies just refuse to satisfy themselves with honest marketing of an effective drug.

ABC World News (5/7) reported, "Tonight one of the largest drug companies, Abbott Laboratories has agreed to a staggering settlement" with the US Justice Department. "Today $1.6 billion in criminal and civil fines for improperly marketing the anti-seizure drug Depakote in nursing homes. The company convinced the nursing homes to use the drug to treat aggression in dementia patients, despite the lack of credible evidence that the drug was effective for that use." 

This fine included $700 million in criminal penalties.   

The AP (5/8) reported, "At a news conference at the Justice Department, US Attorney Timothy Heaphy said that the top levels of Abbott carried out a strategy of systematically marketing the drug for purposes other than what federal regulators had allowed. The illegal conduct was not the product of 'some rogue sales representatives,' said Heaphy, the US attorney for the western district of Virginia. He said the company engaged in the strategy from 1998 to at least 2006." 

Other off label (non FDA-approved) indications for which the drug was marketed included schizophrenia and autism.  


For a while, it seemed to me that every time I saw a hospital report about a patient diagnosed with schizophrenia, they had been treated with Depakote along with the usual anti-psychotic medication.  As far as I could tell, it added nothing to the treatment of delusions and hallucinations other than some extra sedation.  I never understood the rationale for this practice. Now it's clear.

Abbott's off-label marketing efforts were directed at nursing-home directors, geriatric doctors, and other long-term care providers in addition to psychiatrists.  The company also gave doctors illegal kickbacks to talk up off-label uses so that sales of depakote would increase.

GUEST POST: When Conflict Brings You Together… And Then Drives You Apart

You initially bonded over a drink as you both shared similar tales about upbringings that could have mirrored one another’s. The abusive relationship with alcohol and drugs, the physical bruises that left far deeper emotional ones, the lack of communication within the family… these were things you both experienced and they bonded you together. You became inseparable because no one else could possibly understand what you had gone through. Until one day it all fell apart. The very glue that held you two together in the first place became a repellant, something you want nothing more than to leave behind forever, but their presence is a constant reminder…

This situation happens more often than you probably realize. Two people with common conflicts in their backgrounds meet and fall madly in love with one another, bonded by their mutual past troubles. This was true for one of my acquaintance and his wife. They both shared rough upbringings and came from broken families, and this shared past made them inseparable… for a while. 

This scenario is all too common for people coming from broken pasts. The troubles they face bind them in a way that true love, shared passions, and positive upbringings binds others, until one day the past troubles become a rock in your shoe. It’s annoying, but not entirely detrimental.

However that rock slowly morphs into a wedge that creates more conflict, and before you know it a full-blown wall between you and your professed lover. Such was true for my acquaintance. He and his wife followed a tumultuous course; one that almost exceeded his own troubled past, until they finally couldn’t stand to be around each other anymore. But why does this happen? How does something so binding become something so revolting?

One reason is that the constant reminder becomes unbearable. While you were initially able to share and empathize with one another over similar circumstances, when that becomes the defining point in your relationship the reminder of your past can become the only thing you’re able to see when you look at your partner. And that constant reminder can become unbearable to the point that it ruins the relationship. For my acquaintance, this meant turning to alcohol and drugs in an effort to blur reality and forget. It meant turning into himself and all the dark demons that had been following him.

Then there’s the point of needing to actually deal with the source of the problems. Being able to talk about something and share experiences with one another is not synonymous with actually confronting demons in your past and dealing with them. Sure you can talk through some of the basics of problems that are rooted in your past with someone who has been through a similar upbringing; however the basics are just that – they’re a superficial way of “dealing” with all of the negative emotions. 

What you really need is to talk to someone who is trained in helping individuals move past life events that have had a negative impact. At that point one or both of you should consider seeking professional help.

When you’re commiserating with someone over conflicted experiences you likely are only able to add your own two cents about a similar event. This rallying of negative emotions only adds fuel to the fire, and instead of diminishing the negativity it helps it flourish. For my acquaintance this meant that they went through harsh benders on drugs and alcohol together, pooling their shared miseries and fighting as they regained soberness. It was a never-ending cycle of bad happening upon worse, until they finally came up for air and found the strength to separate from one another. 

Neither is perfect now, but both are at least pursuing a future that doesn’t include rebounding negativity off of one another.

Dating someone who has a similar conflicted upbringing as you can be a breath of fresh air at first. However if left untreated, it can become stale, or worse, drive the two of you farther into a pit of despair, leaving your relationship stagnant instead of thriving.

Elizabeth’s Bio:

Liz just a simple lady tries to convey some of what it is like to date online through dating websites. For any further information on online dating you can email her at: liznelson17 “@ “gmail.com.

The Terrible Twos... And Threes...In Perpetuity

But if you try some time, you just might find, you get what you need

John Rosemond, the least favorite parenting authority of the ADHD/Pediatric Bipolar apologist crowd, wrote a wickedly excellent newspaper column that appeared in my local paper on May 3 of this year.  I hope he does not mind if I quote from it liberally.

Somebody wrote to him inquiring about a four year old who continued to throw temper tantrums when he could not have or do something he wanted.  The writer thought that four years old seemed a bit old for this type of behavior, which is referred to in the vernacular as the “terrible two’s.”  As in: two years olds.

John Rosemond

Dr. Rosemond noted that until recently, such temper tantrums were rare after a toddler’s third birthday.  Only during the last two generations has that changed.  He defines the “terrible two’s syndrome” quite clearly and concisely: tantrums, belligerent defiance, persistent impulsivity, and separation anxiety.

Sounds a lot like the new bulls**t diagnosis for children that was proposed for the upcoming edition of the psychiatric profession’s diagnostic manual, the DSM-5, called temper dysregulation disorder.  (I think the proposal has been dropped, but it may have just been renamed.  We’ll see).

Rosemond blames the recent prolongation of toddlerhood on parents who keep their kids at the center of their attention “in perpetuity,” and on the parents' enabling behavior.  He defines the latter as “doing for children what they are capable of doing for themselves, however imperfectly.” As a further result of these changes in parenting philosophy, American society is now saddled with “large numbers of perpetually dependent children” who “don’t cope well with the realities of life."

Central to these realities is neglect of what Dr. Rosemond cleverly refers to as the “Mick Jagger Principle:” You can’t always get what you want.

Another very important point that he makes in his column is that the enabling parents are actually victims themselves.  He states that there is tremendous peer pressure on parents to “enter into co-dependent relationships with their kids, and be constantly stressed, anxious, and guilt-ridden as a consequence.” I wrote extensively about the explosion of parental guilt and the peer pressure that reinforces it in my book, How Dysfunctional Families Spur Mental Disorder. But I have also experienced the peer pressure first hand.

When one of my children was in college, she decided to take advantage of a “study abroad” program offered by the college, and spent a semester in Australia. In those days, internet connections were not up to what they are now, and overseas telephone calls were still relatively expensive.  


There was something around called a “phone card.”  This pre-paid card allowed the person who bought it a certain limited number of minutes to spend talking on the phone.  We gave our daughter one card for each month she was to be in Australia.

Of course, she used up the first card in less than two weeks, and was then upset that she could not call us.  She was, no surprise, experiencing a bit of loneliness. 

Well, when we mentioned this turn of events to a couple of our friends, they pounced on us with surprising ferocity.  What was the matter with us?  Why did we not just give her another card?  We could afford it.  Our daughter was lonely, and how could we just let her suffer like that.  We were just terrible!  Neglecting our parental duties! 


Listening to them, you would have thought we had just hired Ivan the Terrible to travel to Australia and impale her.

Gee, loneliness.  How awful!  How unendurable!  A bit shell shocked, we nonetheless stood our ground.  The ability to delay gratification is a very useful skill to develop, and we wanted our daughter to be able to learn to do just that.

I remember when I first went off to college.  There were some days when I was very lonely – even somewhat depressed.

I was barely 17, away from my family for the first time, and 400 miles away from my high school sweetheart as well.  I was also in a very strange and unsettling (but fascinating) new world:  Berkeley, 1966-1967, at the height of the Haight-Ashbury hippie days, before the hippies had been discovered by the media.  


Furthermore, almost all of the college girls I had contact with were older than me. (In those days, not only were cougars unheard of, but most girls would not date a guy so much as one day younger than them.) And girls were outnumbered almost two to one by the boys.  

And in those days, we didn’t call home at all, because long distance calls were expensive.  We actually wrote letters.  Snail mail.  Getting replies took days or longer.

Well, I somehow survived.  And I wouldn’t trade that year for anything.  Watching the Grateful Dead for free in Golden Gate Park before they had recorded their first record.  Watching Jim Morrison invent diving into the crowd from the stage at a Doors concert.  Dancing to the Jefferson Airplane, live, at the Fillmore Auditorium.  And we had to hitchhike across the Bay Bridge to get there because none of us had a car.  My parents would never have let me do that back at home.  Priceless.

Important Conference

Where Does Psychotherapy Go from Here?

This post was written, with my input, by Gregg Henriques, Ph.D., one of my partners in the Unified Psychotherapy Project.

A little while ago a NY Times article wondered where the field of psychotherapy was headed. After profiling some of the field’s most prominent thinkers in cognitive behavioral, psychodynamic, and humanistic approaches, the author sensed that the field was on the cusp of, well, something. But it was not at all clear what that ‘something’ would be. He wrote, “As psychotherapy struggles to define itself for an age of podcasts and terror alerts, it will need ideas, thinkers, leaders. Yet the luminaries here, many of whom rose to prominence three decades ago, were making their way off the stage. And it was not clear who, or what, would take their place.”

So what will be psychotherapy’s next great thing? Will there be a so-called fifth wave? Individual psychotherapy (i.e., not counting systems views, which operate at another level of analysis) has seen four great waves. First, there was psychoanalysis, with its emphasis on the unconscious conflicts, early experience and transference. Then came behavior modification, stemming from learning theories organized into procedures for desensitization and changing contingences. Humanistic/experiential psychotherapy, which rejected the mechanistic determinism of both psychoanalysis and behaviorism and instead emphasized emotions, conscious motives, and human potential can be considered the third great wave. Finally, cognitive psychotherapy, with its emphasis on thoughts and interpretations, can be considered the fourth great wave.

So, will there be another great wave in psychotherapy? Perhaps forms of Zen-based mindfulness? Brainwise therapies? Maybe something connected to the technological explosion? While these are exciting developments, we believe the next wave will be a different kind of wave; one that will bring consolidation and clarification to the field. Instead of yet another movement defined against those that have come before, what is desperately needed now is a systematic approach that provides a common language and conceptual framework that allows practitioners to see how the key insights from the major perspectives can go together to form a coherent whole. 


Moreover, such an approach will more directly connect psychotherapy to the science of psychology. Philosophers of science talk about fields moving from a pre-paradigmatic state where competing schools advocate fundamentally different visions of reality to a paradigmatic state where a shared frame emerges that aligns the key insights into a coherent whole. We believe psychotherapy is on the cusp of such a transition, and the next several decades will bring a much more unified vision of the field.

Knowledgeable practitioners of the specific schools of thought will probably balk at the suggestion of conceptual unification. They will rightfully point out that the different perspectives are deeply anchored into fundamentally different visions of what it means to be human. To eclectically put them all together, they argue, yields a form of mush, something far less—not more—than the sum of its parts. The unsystematic blending of ideas is a weak intellectual solution. 


This is why the eclecticism of the 1980s gave rise to psychotherapy integration movement (also find a summary of Dr. Allen's contribution here) of the 1990s. Integrationists realized that a taking a bit from this perspective and a bit of that technique quickly leads to chaos, and over the past several decades integrationists have tried to carve out pathways to pull together different strands of thought with integrity. Yet the integration movement itself may be stalling, perhaps as a function of its own success. For as the integration movement has gained traction, various pathways and forms of integration have proliferated (e.g., common factors [what the therapy models all share], technical eclecticism [borrowing techniques but not theory from other schools], assimilative integration [borrowing some ideas from another school], and theoretical integration and so forth). There is so much variety and so little form that it is becoming increasingly meaningless to identify as a psychotherapy integrationist.

As co-chairs of the Unified PsychotherapyProject, we are part of a small but growing group of academics and practitioners who argue that the conceptual unification of psychotherapy is possible (for a book outlining how, see here). If this is so, the field of psychotherapy will shift from being pre-paradigmatic to fully paradigmatic. The Project’s founder, Jeffrey Magnavita, put the issue this way…

"[P]sychotherapists behave like members of competing tribes, with different esoteric languages and rituals. Unification assumes that we all work in the same realm with the same processes regardless of the subsystem or specific domain we emphasize and specialize in. A unified model encourages us all to be aware of the larger picture and even if domain-specific treatment is undertaken, an understanding of the system and interconnections of domains and processes keep us alert to other possibilities for further developments."

The point of this rather lengthy post is to share an outline of a unified model of personality and psychotherapy that is gaining traction and is providing practitioners a convenient way to think about individuals in a manner that is consistent with the major perspectives and modern personality theory. A more detailed articulation of the model was just published  in a new journal, The Journal of Unified Psychotherapy and Clinical Science. (It is important to reiterate that what we are sharing here is a model of the individual, and thus it exists at a different level of analysis the family, group, or societal level).

Let’s start with mapping the larger picture that Magnavita referred to. Here is a map that identifies the key variables that a professional psychologist would need to consider.

The three circles in the middle identify the intersection of the three domains of knowledge most immediately relevant for a psychotherapist, namely personality theory (i.e., how are people built and what makes them unique), psychopathology (i.e., what are the kinds and causes of suffering and psychological dysfunction), and psychotherapy (i.e., what are the kinds of interventions and therapeutic processes associated improving psychological functioning and well-being). These three domains are imbedded three broad contexts. The red circle represents the Neuro-Biological context, with refers to a) the broad evolutionary history of our species; b) the unique genetic makeup of the individual; and c) the individual’s current neuro-physiological constitution. 


The green arrow represents the life history and developmental context, namely the distal and proximal variables that played a key causal role in the current situation. Finally, the blue circle represents the relational and sociocultural contexts in which the person (and therapist and therapy!) is embedded (think here of Bronfrenbrenner’s ecological systems model).

Although in Freud’s psychoanalysis the trifocal points of psychopathology, personality and treatment were all closely connected, with the emergence of behavioral and cognitive therapies and the Diagnostic and Statistical Manual the field of psychotherapy has largely drifted away from personality theory and instead focused primarily on psychopathology. Current academic research generally matches specific interventions to psychopathology categorized by the DSM, with virtually no systematic attention paid to the individual’s personality make up. We believe that interventions should be guided by holistic conceptualizations, not just lists of symptom presentations. That means we need to systematically consider personality dynamics, as well as the biological, developmental, and social contexts. In this blog we share the outline of a view of personality can align us directly with interventions and conceptualizations that cut across the major domains of individual psychotherapy.

A conference presentation at the 2010 meeting of the Society for the Exploration of Psychotherapy Integration  in Florence, Italy vividly affirmed the need for a more unified approach toward conceptualizing people in psychotherapy. The presentation consisted of Drs. Leslie Greenberg and Paul Wachtel  analyzing a videotape series of cognitive behavioral therapy for perfectionism conducted by Dr.Martin Antony . The patient was a motivated, attractive young woman completing a graduate degree in psychology who strove for perfection in many areas of her life. She was extremely focused on organizing, planning, and succeeding at everything she did. She also had occasional panic attacks and issues concerning her body image.

What was striking about the presentation was how Dr. Antony focused almost exclusively on daily activities, habits and actions, and the thoughts associated with them. In contrast, her emotions, relational processes and internal working models, and the way she defended against uncomfortable images, feelings, or impulses were essentially ignored. For example, at one point in the first session, Dr. Antony inquired about the woman’s eating patterns and, with tears welling up in her eyes, she hesitantly reported that she purged about once a day. Dr. Antony made little acknowledgement of her feelings or of her pained experience sharing this information. 


Not surprisingly, Drs. Wachtel and Greenberg criticized the way these elements were glossed over. Indeed, at one point, Dr. Greenberg commented that he did not believe that cognitive behavioral therapies treated the whole person. It is likely, however, that a cognitive behavioral therapist might retort that Greenberg’s EmotionFocused Therapy  similarly does not focus on the whole person but only the emotional part. Or perhaps the individual would question the assertion by arguing that no system focused on the whole person in the manner that Greenberg implied.

We believe there are holistic maps of individuals that can guide practitioners and connect psychotherapy to both modern personality theory and psychopathology, and we share the outline of our approach here. This post, which originally appeared on Dr. Henriques's Psychology Today blog, complements a prior recent post, AnotherBig Five for Personality,  which articulated that one of the major distinctions in personality theory has been between temperament and character. Temperament (i.e., traits) refers to the broad and general dispositions of an individual; in contrast character refers much more to one’s unique identity and what is learned in particular situations. 


Personality research and theory has varied in terms of its focus. Although Freud’s theories and other early formulations were initially concerned with character, in the 1950s research on traits exploded, and the ‘Big Five’ (i.e., traits of extraversion, neuroticism [emotional reactivity], agreeableness, conscientiousness, and openness) probably represent the most prominent work in personality over the past several decades.

Although traits are crucial to consider for a good conceptualization (see, e.g., Singer’s excellent book Personality and Psychotherapy), it nevertheless is the case that traits are broad, general dispositions that are quite stable in adulthood and unlikely to be largely modified. Thus, they are not really the central focus of psychotherapy interventions. Thankfully, personality researchers have begun to recently turn their attention back to character. Dan McAdams’ has, for example, argued that character can be further divided into characteristic adaptations (the ways an individual specifically learns to adapt to specific situations) and identity (one’s self-concept, self-esteem, philosophy of life), and he argues for a tri-level view of personality (traits, characteristic adaptations, and identity). McAdams has focused much of his attention on identity, and noted that there is “no general Big Five theory of characteristic adaptations”.

What is remarkable is that work on a unified approach to conceptualizing individuals in psychotherapy has been developed that delineates precisely what McAdams said was missing—it offered a ‘Big Five’ map of the systems of characteristic adaptation! Delineated in the prior Big Five blog, the five systems are, in order of development: 1) the Habit System; 2) the Experiential-Affective System; 3) the Relationship System; 4) the Defensive System; and 5) the Justification System. Here is the map (for a more detailed discussion, see here).

On the left side, the three broad contextual domains (biological, developmental and sociocultural) are represented. The circle in the middle represents the personality of the individual, specifically the systems of adaptation that are often the focus of interventions. These systems are described in a previous blog. From the vantage point of developing a conceptualization useful for psychotherapists, here is a brief description of each domain of adaptation, with questions about each that might be asked.

A. Habits and Daily Activities. This domain refers to the daily activities and patterns of behavior that the individual engages in. Common domains to assess include

1. Patterns of sleep and wakefulness (# hours sleep per night, naps, ease falling or staying asleep, nightmares)
2. Eating (regularity of meals, restrictive or overeating, unusual or unhealthy diet)
3. Substance use (frequency, intensity and duration of nicotine, alcohol, and illicit/prescription substance use)
4. Exercise (frequency of exercise, degree of physical fitness)
5. Regularity of routine
6. Daily stressors (e.g., noise, traffic, heat)
7. Hobbies, interests, leisure time

B. The Experiential System. This domain refers to the embodied phenomenological state (i.e., the felt experience of being). It is organized by affect, although includes perceptions, drives, and images. Common domains to assess include:

1. Are there dominant emotional states that are chronically active/accessible, emotions that are expansive or under regulated? What about emotions that are over controlled?
2. Does the individual know how he feels? Can he “get in touch” with his feelings? Is there harmony or alienation between the explicit justification system and the experiential system?
3. What is the general degree of emotionality? Levels of trait extraversion? What about levels of trait neuroticism?
4. Is the individual able to stay centered and mindful of what is happening at the experiential level?
5. Can the individual express his feelings effectively? Does the individual have trouble with experiencing all or some emotions? Are there secondary emotions that are covering up primary emotions?
6. Has there been a trauma that overloaded the experiential system? Does the individual experience strong images or flashbacks?
7. Does the individual have gut feelings or a sense of things being either good or off? Is there a lot of fantasy or day-dreaming?
8. Are there any unusual/bizarre sensations or experiences (i.e., hallucinations)?

C. The Relational System. This domain refers to the internal working models or self-other schema the individual has developed to navigate the social environment. Common domains to assess include:

1. What is the person’s sense of relational value…to what extent do they feel generally respected, admired, loved and appreciated as opposed to neglected, rejected and criticized? Has that changed recently?
2. Does the individual generally feel secure in her relationships? Do they have issues with trusting others and do they ever get paranoid? Do they have intimate connections with others? Have they had a lot of relationship failures?
3. What was the attachment history? What were their early relationships (parents, siblings, early friends) like?
4. Have they experienced a traumatic loss or betrayal from another?
5. Is the individual more agentic (self-focused, concerned with power and autonomy) or more communal (other focused, concerned with affiliation and connection)?
6. Is the person more or less agreeable? How does the individual handle conflict? Are they aggressive, assertive or submissive? Do they adopt a fairly agreeable or hostile stance in relationship to others?
7. Are they particularly sensitive to criticism or rejection? Do they fear abandonment? Do they have trouble being alone?
8. Do they experience conflict between relationship motives of power and love or autonomy and dependency? When down, do they experience splits between feeling shameful (feel they are to blame) or hostility (feel others are to blame)?

D. The Defensive System. This refers to the general harmony between the systems, the filtering between self-conscious and subconscious processes, and processes like cognitive dissonance and psychodynamic defense mechanisms. Signal anxiety activates the defensive system. Common domains to consider include:

1. Does the individual seem guarded, hesitant to disclose, resistant to elaborating on all or certain elements of their story?
2. Do they get words or body language in response to certain questions?
3. How do they cope when they feel stressed?
4. Do they engage in rationalizations or suppression/repression or other similar processes?
5. What do they try to avoid feeling or experiencing? Do they have any affect phobias? Core fears?
6. Do they demonstrate good insight and are they able to reflect on what drives them? Can they laugh at their foibles or defense? Or does such conscious self-reflection activate anxiety and a closed off response?
7. When does their attention shift? Do they systematically shift away from certain topics? When do they seem less clear, less focused? Are there times in which it is hard to follow their logic?

E. The Justification System. This refers to the self-conscious, language-based belief-value networks that individual uses to make meaning out of his world, and to consciously understand himself and others. In regards to assessing the justifying self, cognitive and narrative/existential therapies allow a lens to view aspects of this portion of the psyche. Thus, thinking about the individual’s justification narrative (the story they have about themselves in relationship to the world) and automatic thoughts/inferences/core beliefs are useful concepts to bring to bear in understanding this domain. More specific elements include:

1. What is the general functioning of their verbal system (i.e., their verbal IQ)? Vocabulary usage, complexity of sentences, etc.
2. To what extent is their identity coherent and complex? It is rigid, certain, simplistic, hard and foreclosed? Or is it multifaceted, open to criticism, textured? What is the level of ego development? Do they reflect on who they are and why? Are they able to give complex, textured answers to reflective questions or are they brief and underdeveloped?
3. What is their driving purpose in life? Do they connect to a higher power or follow particular religious teachings? Do they care about politics or have active views/philosophies regarding how the world works? Are they concerned with their own local reality or do they reflect on where values come from, where the country (or world) should be headed?
4. What is the degree of self-regulation and self-control? What is their level of conscientiousness? What about their need for control? Do they exhibit a lot of self-discipline or are there problems with impulsivity?
5. What is their self-esteem? Do they engage in a lot of self-criticism and negative self-talk? Is there an internalized parental voice constantly judging them? Do they have core beliefs about self that are negative? Or do they see themselves as a positive protagonist in the story of their lives?
6. What is their general level of self-efficacy? Do they perceive themselves as resilient and capable of handling things or weak, an emotional wreck? Do they have high levels of agency? Adaptive levels of an internal locus of control?
7. Are they known to others or do they frequently filter their private thoughts from their public thoughts?
8. What is the individual’s overall evaluation of their life? Their reflective degree of life satisfaction?

Now where did this map come from? It came from applying the lens of a unified model of psychology to the key insights of the major perspectives in psychotherapy! And that is the point we want to make here. The major perspectives align with each of the domains of characteristic adaptation! Here is the alignment.

When approached from this angle, modern personality theory meshes well with the various approaches to psychotherapy. And it is clear that the various approaches in psychotherapy have emphasized different domains of character adaptation.

Our perspective is that the time has passed for the single schools with their specific interventions targeting only a part of the system. Instead, what will be revolutionary about the fifth wave is that it will lay out a truly comprehensive vision of psychotherapy that connects to the science of human psychology in a manner that allows us to appreciate our humanity grounded in the knowledge of science.