Where the Analysts Went Wrong: Introduction

Cognitive Behavioral Therapy (CBT) is currently the predominant psychotherapy treatment paradigm taught to clinicians-in-training in psychology graduate schools. However, when I first received psychotherapy training in the mid 1970’s, by far the predominant school of psychotherapy was psychoanalysis. We did receive a smattering of behavior therapy training, and we were even assigned one book about family systems ideas by Virginia Satir. Our training program was a bit unusual in that regard. 

Just like the CBT industry does now, analysts exaggerated the validity of the scientific evidence for psychoanalytic theory, and made grossly inflated claims about the effectiveness of psychoanalytic treatment. Its theory was applied to everything, even to schizophrenia, although by then it was pretty clear to most of us that they were completely wrong about that condition. I’m surprised analysts did not try to treat ingrown toenails with psychoanalysis.

Just as now, economics played a huge part. (That’s why I just called it the CBT industry).  When I made some rather mild criticisms of one aspect of CBT theory and practice on my Psychology Today blog, a CBT therapist wrote a rebuttal, and several people wrote in to say how unethical I was because I was not practicing a “scientifically validated” form of psychotherapy, and was therefore by implication a snake oil salesman. 

Readers of my book, How Family Dysfunction Spurs Mental Disorders, know that the “evidence base” in all of psychotherapy is actually quite weak, and that CBT controls the funding of research and denies it to practitioners from other schools – although nonetheless there are still many studies from other schools that are every bit as strong (or should I say as weak) as the CBT studies. That includes analytically-oriented therapies, as a meta-analysis by Jonathan Shedler in the February-March 2010 issue of the American Psychologist clearly showed.

Not to mention that most psychotherapy outcome studies rely on so-called treatment manuals that spell out what therapists are supposed to do, so that all the therapists in the study are doing the same thing – regardless of how the patient is reacting to what they are doing.  NO competent practicing clinician does that. 

Psychotherapy involves science of course, but in many ways it is an art form as well. People are complicated, and each patient is unique in many ways, and can always choose to respond positively, negatively, or not at all to any intervention made by a therapist.

Additionally, each treatment manual is comprised of multiple ingredients – some of which may help or be the primary active ingredient, some of which may do nothing, and others of which may actually be counterproductive. And yet many CBT proponents argue as if everything they do has been scientifically proven.

It is clear to me that CBT practitioners say this stuff for the same reason that Big Pharma controls and distorts the practice of doing, and the dissemination of results from, studies of medication effectiveness: They want to “sell” their goods and stamp out the competition. (BTW, that does not mean that therefore a pharma-sponsered study has NO validity - only that bias must be taken into account).

Analysts also protected their turf back in the day, very arrogantly, although ultimately they failed. As a trainee, if you criticized any aspect of analytic theory, you were told in no uncertain terms that you needed to go into psychoanalysis yourself, so you could find out why you were “resistant” to analytic theory. In other words, the only reason you were questioning the theory was because you were neurotic!  

This recommendation involved the use of not one, but three logical fallacies, all wrapped up in a single statement. It was a non sequitur, since someone might be questioning the theory for any number of other reasons besides their own psychological issues. It was an ad hominem attack, since it was going after the questioner and not the question. And of course it was begging the question.  The accusation of being neurotic might be true if analytic theory is true, but that is the very issue in doubt and under debate.

Another trick that different economic interests in mental health use to denigrate the competition also involves the issue that all of the so called schools of therapy do not consist of single ideas, but consist of a large number and a wide variety of different ideas and techniques that are tied together by some common threads. Anyone who bothers to think about it has to know that some of these ideas could be wrong while others could still be right, or that an idea may have validity for some situations and for some phenomena while being inappropriate for explaining or addressing others.

For instance, people in the field may try to argue against all the ideas of a particular school, even though many are obviously quite valid, by throwing up a few incidences of when the school had something clearly wrong. They will of course pick the most egregious examples they can find. To criticize psychoanalysis, they might bring up such discredited - and now fairly much discarded - analytic ideas such as "penis envy," or the wild overemphasis on the Oedipus Complex.

Hyper-biological psychiatrists love to bring up the awful effects of the fallacious psychoanalytic theory of the “schizophrenogenic mother” to argue against all of psychotherapy, not even just psychoanalysis! I tell biological reductionists that if they don’t hold the theory of schizophrenogenic mothers against psychotherapists, then I will not hold the theory of eugenics against them.

I even hear Pharma-sponsored speakers indirectly and implicitly attack therapy by posing really, really stupid questions such as “What is better for depression –medication or psychotherapy?”  Well, first of all, that’s like asking, “What’s better for patients with coronary artery disease, taking nitroglycerin when they feel chest pain, or losing weight?” Those two interventions target two completely different aspects of the problem. 

Second, the question lumps together all types of psychotherapy. What type of therapy are we talking about? Which interventions? It would be like me arguing against the use of medication by pointing out how ineffective penicillin is for treating clinical depression.

Just as with many aspects of CBT (CBT'ers please take note that I am saying that), many aspects of psychoanalytic theory retain much explanatory power. They are so widely accepted that they have even become part of the cultural conventional wisdom in industrialized countries.

Who doesn’t believe that people sometimes take their anger out about something on someone or something else?  Mad at your boss, come home and kick the dog? That’s the defense mechanism of displacement. Yeah, like that never happens.

Intrapsychic conflict creating emotional and interpersonal problems because people want something really bad but feel guilty about it? Check. Conversations have unspoken subtexts?  Check. Acting towards authority figures in a certain way because they remind you of your father? That’s transference. Check. CBT folks may prefer to call the phenomenon schemas instead, but it's still transference. 

People wanting to avoid unpleasant subjects and in response changing the subject or explaining away inconvenient facts? That's resistance. Check.

Forgetting about unpleasant memories? Well, whether that’s unconscious or subconscious may be debatable, but the fact that repression exists? The whole Catholic Church child molestation scandal started with a case of "recovered" memory. Check.

The analysts are even right about personality problems stemming from childhood experiences within the family. The attachment literature is extremely powerful, and we all know that one of the biggest risks for just about every psychiatric condition in the DSM is a history of childhood abuse and/or neglect.

Ah, but there is where the psychoanalysts started to go wrong. They seemed to assume that childhood experiences completely determined what psychological problems a patient has and that subsequent experiences were somehow inconsequential. Orthodox analysts believe that your personality is fixed by the time you are five years old. Some go back even further than that.

Of course, if subsequent experiences could not affect personality, it would do a person no good at all to go into psychoanalysis, because the experience of psychotherapy would have absolutely no effect - according to the orthodox analysts’ own assumptions about personality formation.

The thing is, family experiences that start to create problems for children do not magically disappear when a child reaches a certain age.  In fact, they often go on and on and on in sometimes somewhat different forms until the parents die. And the human brain is structured to be highly responsive to what parents do, even in adults.  That will be the subject of Part II of this post.

Sodas Apparently Turn Parents Into Bad Disciplinarians

Reuters (8/16, Seaman) reports that research published online in the Journal of Pediatrics suggests that soda consumption may be linked to certain behavior problems in children. 

Investigators followed the habits of about 3,000 mother-child pairs. Information on soda consumption was compiled when the children were 5 years old. The mothers were asked to self-report how many servings of soda their child drinks on a typical day, and to answer a series of behavioral questions. The investigators say they found a correlation between 5-year-olds’ soft-drink consumption and aggression, attention problems and withdrawn behavior. Previous research has suggested an association between soft drinks and older children’s aggression, depression and suicidal thoughts.

Probable intervening variable: Mothers who don't limit their children's food choices or amounts thereof are also very likely poor administrators of other necessary forms of discipline, which in turn creates the aggression, attention problems and withdrawn behavior in the kids. 

But you'll rarely see a possibility like that mentioned in a journal article or the news report about it.

Repeat after me: Correlation is not causation. Correlation is not causation.  Correlation is not causation...

Manage Care Insurance Declares War on Psychotherapy

Beware: Managed care can be hazardous to your health

The old joke is that “managed care” insurance should be more accurately termed “mangled care” insurance.

At the annual meeting of the American Psychiatric Association in May in San Franciso, Susan Lazar, M.D, a psychiatrist in private practice, discussed the cost effectiveness of psychotherapy. While new federal laws and the upcoming Affordable Care Act mandate equal treatment of mental and physical health problems, access to psychotherapy in particular is under attack from insurance companies. 

“For the past three years, many insurance companies, including Cigna, UnitedHealthCare, and Kaiser Permanente, began severe restrictions on mental health care, particularly psychotherapy,” Dr. Lazar said. She added that patients most in need of more prolonged and intensive psychotherapy are typically the patients whose treatment and services are threatened.

Long term psychotherapy is often the first line treatment for a number of psychiatric conditions, including personality disorders and chronic severe anxiety mixed with depression.  Medication certainly can augment treatment in cases like those, but it is literally just a band aid. In children and adolescents, family psychotherapy is particularly important, and it is disappearing at an alarming rate as kids are plied with potentially toxic central nervous system depressants and stimulants to shut them up and keep their parents’ anxiety and guilt under control.

Psychotherapy has also been shown to be extremely cost effective according to many studies, yielding savings not only in overall health care costs and utilization, but in disability, destructive or antisocial behavior, and other societal costs. That does not, of course, mean than it is cheap.

Large multi-site and meta-analytic studies have demonstrated that psychotherapy reduces disability, morbidity and mortality; improves work functioning, and decreases psychiatric hospitalizations. Psychotherapy teaches patients life skills that last beyond the course of treatment. The results of psychotherapy tend to last longer than psychopharmacological treatments and rarely produce harmful side effects.

The American Psychological Association tried to send out warnings in a 2010 paper titled, Where Has all the Psychotherapy Gone? According to the author of that paper, 30 percent fewer patients received psychological interventions in 2008 than they did eleven years earlier; since the 1990s, managed care has increasingly limited visits and reimbursements for talk therapy but not for drug treatment; and in 2005 alone, pharmaceutical companies spent $4.2 billion on direct-to-consumer advertising and $7.2 billion on promotion to physicians, nearly twice what they spent on research and development.

While the percentage (3.37) of Americans who received outpatient mental health care in 2007 was very similar to the proportion of those (3.18 percent) receiving such treatment in 1998, the pattern of that care changed. Overall there was a decrease in the use of psychotherapy only, a decrease in the use of psychotherapy in conjunction with medication, and a big increase in the use of medication only.

In 2008, 57.4 percent of patients received medication only, indicating that compared with treatment patterns in 1997, approximately 30 percent fewer patients received psychological interventions. This trend was noted particularly among those with anxiety, depression and childhood-onset disorders – the very conditions that respond best to longer term psychotherapy.

For children being treated, 58.1 percent received medication alone and no other interventions. This despite the lack of research supporting the safety and usefulness of many of these medications.

The burgeoning managed care industry has developed strategies to reduce the costs associated with the mental health and substance abuse benefits portion of both public and private health insurance plans. Over time, management of these benefits has resulted in controlling provider fees, strict limitations on episodes of inpatient care, and a reduction in the average number of outpatient visits per patient treated.

Interestingly, prescription drugs are not typically part of the costs managed by these carve-out plans. By 2006, the costs of psychotropic drugs accounted for 51 percent of mental health care spending. Per capita expenditure for psychotropic medications tripled from 1996 to 2006.

If patients and potential patients do not complain to their employers as well as to their politicians, this situation will only get worse as the insurance companies develop even more ways to get around mental health parity mandates. And even if you don’t need help, do you really want to live in a society in which you might often find yourself surrounded by unstable individuals who can’t get help?

It’s getting dangerous out there.

Dr. Allen Discusses Borderline Personality Disorder - The Earth Needs Rebels Show on Orion Talk Radio

Dr. Allen discussed his ideas about borderline personality disorder in detail (this time it's just him and the host) on The Earth Needs Rebels Show broadcast on Orion Talk Radio http://oriontalkradio.com from Tonawanda, New York, 1650am and global on the internet, with additional feeds like Tunein Radio (http://tunein.com for more information on tunein radio and free software).

Here is the link to the downloaded broadcast: http://oriontalkradio.com/archives.htm.  Click on "down" and not on "listen."  The date and times posted for the broadcast: Tuesday, August 13, at 1:05 and 2:05 PM.

Parts 2 will be on live September 10 from 12-2 PM U.S. Central Time.

Dr. Allen on HuffPost Live Video News Network

Dr. Allen participated in a panel discussing freeloading family members on The Huffington Post's video news network, HuffPost Live (live.huffingtonpost.com). 

Here's the link: http://huff.lv/19eAnD9

Are the National Institute on Drug Abuse and Big Pharma in Bed?

Nora Volkow, M.D.

At the annual meeting of the American Psychiatric Association (APA) in San Francisco in May, Nora Volkow, the director of the National Institute on Drug Abuse (NIDA) was just brimming with a lot 'o news about the square of the hypotenuse. No, I'm sorry, I mean about how much more we know about drug abuse because of brain imagining techniques. This new knowledge she spoke of was summarized in the Psychiatric News, the newspaper of the APA, in the June 21 issue.

The gist of the story was that the drugs themselves impair certain brain circuits, which must then be somehow strengthened through treatment.

One of the points she raised is that drugs like methamphetamine cause dopamine receptor signaling to be decreased in the pre-frontal cortex - the part of the brain known to be crucial in executive control (decision making). Thus, the normal brakes on someone indulging in something are supposedly damaged.

If this be true, one might think that she would be up in arms about the widespread, indiscriminate use of amphethamines like Adderall in children. At the very least, a high percentage of ADHD diagnoses are given to kids suffering from the effects of living in a chaotic environments of one sort or another, and for whom family therapy would be the most important treatment. Perhaps there are some cases of ADHD that are due to neurotoxin exposure or something like that in which the benefits of the use of stimulants outweigh the risks - a questionable assertion itself since the average academic gain for ADHD-diagnosed kids on stimulants is all of about three whole months.

For some reason, however, while she acknowledges in other venues that prescription drug abuse, including that of stimulants, is a major problem, she continues to maintain that stimulants are safe and effective when used for ADHD.

She does admit in one article that ritalin basically works the same way in the brain as cocaine! So is she saying that there is some point at which the alleged adverse affects on executive functioning she was going on and on about at the APA magically become inconsequential?

And yet, she also spends some of her time exaggerating the adverse effects of the devil weed , marijuana, in a campaign to keep it illegal.  It seems there is a double standard she has towards the risks of the drugs sold by Pharma compared to those that are not.

How much worse than the physiological effects of pot, one might ask, are the adverse effects on potheads of jailing them and turning them into felons for the rest of their lives. Or the risks to black kids? They are no more likely than white kids to smoke pot, but are four times more likely to be arrested for it. These are not adverse effects?

"Think about it: Do you want a nation where your young people are stoned?" she was quoted as asking.  I hate to break this to her, but any kid who wants to get marijuana already can. It's like one of the biggest cash crops in several states.

I don't think she has come out in favor of prohibition against alcohol or tobacco, two substances with far more potential adverse physiological effects than pot ever thought about having, so that she might at least be consistent. Does she think that young people aren't already getting "stoned" on booze? As mentioned, she does not seem to be all that concerned about the adverse effects of the stimulants - that she herself describes - when used for legal and "proper" uses. More on that in a sec. Nor does she mention that prescribed stimulants are diverted to "non-medical" uses far more often than even opiates!

It seems almost like she thinks the risks of drugs are entirely dependent on whether or not drug companies make money from them.

I am not surprised by any of this. Many years ago I listened to a talk from someone from NIDA about the horrible effects of dopamine depletion in the brains of regular amphetamine users.  I thought about getting up and asking a question, but someone beat me to it. "Doesn't this happen in kids taking stimulants for ADHD?" the fellow asked. 

The answer? "But the drugs work so well!" As if that were an answer. Now I don't know if NIDA and Big Pharma are in bed together, but that answer sure made me wonder about it.

Another truely breathtakingly bizarre point Volkow made at the APA, as reported in the newspaper (unless the journalist got it wrong):

"Among both lab animals and humans, voluntary initiation of drug use leads to subsequent loss of control and development of addiction among 10% of subjects. The lab rats and mice are uesful for refuting old stereotypes.

Some people still consider addiction moral turpitude, she said. 'But how can you develop the same phenotype in a rat, who have no moral precepts?'"

This argument is a bit of a straw man, since thoughtful mental health professionals these days are not so much concerned with the issue of sin, but more with the question of whether or not drug abuse is due to deliberate and purposeful self-destructiveness. The fact that the 10% figure applies to both rats and people seems to argue for some sort of genetic cause, does it not?

But rats having the same phenotype as human beings? Really?!? I personally have never met any rat that understands the negative effects that a drug might be having on it, or that is able to anticipate the future consequences of continuing to imbibe. People do have these abilities. Furthermore, as I have already pointed out in various venues, scientists still have yet to locate any rats that hide bottles of alcohol.

And now back to that whole executive functioning thing. Methinks she is grossly exaggerating certain of the risks from drugs used entirely to get high. (Anyone remember the scourge of "crack babies?"  Turns out that was all one big - and racist - lie).

Seems to me the supposed "impairments" in executive functioning in addicts that she talks about are awfully specific and limited. In the past, a lot of cocaine addicts, for example, used to burglarize houses and fence the goods to support their habits without even getting caught. It would seem to me that quite a bit of executive functioning is being exhibited in that endeavor. Imagine what master criminals they might be if they had unimpaired executive functioning. It boggles the mind!

And if addicts do have a sort of brain damage, how can some of them suddenly just stop using after attending just one meeting of a 12 step program, and then stay sober by continuing to be in the program? Not as many as we'd like, but still many do. The 12 steps were based originally on techniques used by Protestants to get others to adopt their religious beliefs, not treat brain dysfunction. So how is it that what is essentially a change in cognitive beliefs can fix a brain overnight?

I have argued that many of the brain changes observed in MRI studies are actually conditioned responses due to neural plastic changes in brain structure and function in response to the social environment (No, not all of the observed changes. Some can indeed be due to drug effects, trauma, or disease. Duh). The conditioned changes can indeed happen in relatively short time frames. But literally overnight? Please.

Antidepressant Medication and Bipolar Disorder: The Lies and Confusion Continue

The continuing stoow-ry of psychiatric research that has gone to the dogs

In my last book, How Dysfunctional Families Spur Mental Disorders, I discussed my theory that the drug companies of Big Pharma seem to go out of their way to demonize entire classes of drugs once they are mostly available as generics, so that practitioners will use their new brand named drugs instead - regardless of whether or not they are as effective or more dangerous. This happened with benzodiazepines, which now seem to be referred to absurdly as the most addictive and dangerous substances on the planet and full of "side effects" - which don’t actually occur in the real world in the vast, vast majority of patients who take them.

(BTW. demonizing generics does not just occur in psychiatry. One patient told me that a relative was given an anticoagulant that was more dangerous than generic Coumadin because, according to the doctor, “That’s what the drug companies want us to do”).

I wrote that I suspected that the same strategy is now being applied to antidepressants. Most of them have gone generic. (The ones that haven’t yet are Viibryd, Cymbalta, and Prestique.  Although no more effective that the generics, it amazes me how many doctors seem to use them as first line drugs). All of sudden we are being deluged by both news and journal articles questioning whether the drugs are effective. I have written in previous posts on this blog that placebo response rates for antidepressants have gone up significantly every decade, indicating that the patient population being used in the studies is changing. 

Specifically, so-called contract research organizations are being given financial incentives for finding patients that they can diagnose with major depression, and potential patients are given financial incentives for exaggerating their symptoms so they can get paid for being research subjects. So the studies are using patients that don’t really have the diagnosis they are supposedly being treated for. No wonder they have a high placebo response rate. This higher rate makes the advantage of the drug over placebo in these studies seem highly questionable.

A similar process is happening in doctors’ offices all over the country. Diagnostic interviews are getting sloppier and more slipshod all the time. A new study published by Psychotherapy and Psychosomatics, according to the June 2013 issue of the newspaper Clinical Psychiatric News, seems to be highly consistent with this idea. The authors ascertained whether patients who were identified by their doctors as depressed actually met DSM criteria for major depressive disorder. Results with 5639 participants showed that only 38.4% of these patients actually met the criteria!

This phenomenon has led to a couple of ironic developments. First, the rabidly anti-psychiatry zealots point to the bad studies as “proof” that psychiatric meds are a hoax, while of course completely ignoring all the earlier studies that show that antidepressants are highly effective. The more severe the depression, the more likely a patient is to respond to them.

Second, people both inside and outside of the psychiatric profession unfairly rail against the diagnostic manual, the DSM, for not having valid criteria, when the real problem is in many cases that many doctors are not applying the criteria to the patients in making "diagnoses!"

Then there is the matter of the use of antidepressants in the depressed phase of bipolar disorder.  Of course, as I have said many times, the duration and pervasiveness criteria for bipolar episodes, either manic or depressed, are more and more often ignored, which calls into question whether the diagnoses in studies are even correct.

Anyway, in my book I brought up a study by Sachs and others in the New England Journal of Medicine, the most prestigious journal in all of medicine, that purported to show that antidepressants work worse than placebo in this population. I showed how the authors of the study used a sample of patients that were especially treatment resistant, having already failed a trial of at least one previous antidepressant, but did not acknowledge this fact in the paper at all. I was even able to question the author through a third party, since my e-mails directly to Sachs were ignored, and he steadfastly refused to answer the question, “What percentage of your sample had failed a previous antidepressant?”

Now comes another bogus study that purports to show the same thing as the Sachs study. According to an article in Medscape on May 20, 2013, “Investigators at Brown University in Providence, Rhode Island, found there was no difference in hospital readmission rates among patients who received antidepressants and those who did not." Since the authors are strongly implying that the patients had to be readmitted because their antidepressant was not working, this is taken to mean that antidepressants don’t work in bipolar depression.

That antidepressants do not work in bipolar depression is a flat out lie. Psychiatrists like myself have been using antidepressants successfully in bipolar patients for thirty five years. Of course, true bipolar  patients need to be on a mood-stabilizer first, preferably lithium, so they don't switch from depression into mania.

So what’s wrong with this study? Well, just about everything. First of all, we do not know if these patients were correctly diagnosed for the reasons discussed above. Another huge problem: all over the country, hospitalized patients with borderline personality disorder are being misdiagnosed with bipolar disorder because of the “everything is bipolar" craze, coupled with the fact that insurance companies will often not pay for hospital stays if the patients are given the correct, "lesser" diagnosis! 

The subjects in this survey were undoubtedly a very mixed lot. The study did not address whether the patients even took their medication after they were discharged. Non-compliance rates for all medications are very high according to every available study that has looked at this issue. Also, we do not know what percentage of these patients may have fallen into the “treatment resistant” category described above. Most depressed patients are treated as outpatients, not inpatients, so the ones that are hospitalized have often failed a trial of outpatient medication.

Adding to this is the fact that antidepressants do not work for at least a couple of weeks, while managed care insurance companies will not pay for that length of stay. Therefore, patients on antidepressants are often discharged before the doctor knows whether a particular antidepressant even worked. Often patients do not respond to one antidepressant but do respond to a different one. 

Hence, discharge and re-hospitalization rates tell us pretty much nothing about the effectiveness of antidepressants in the depressed phase of bipolar disorder.

The International Society for Bipolar Disorders (ISBD) Task Force recently released its long-anticipated recommendations on antidepressant use in bipolar disorders. "The take-home message is that antidepressants have a questionable benefit-risk and should only be used in certain cases in bipolar disorder," said Dr. Eduard Vieta, who presented the recommendations on behalf of the ISBD Task Force, in an interview.

Eduard Vieta

"First, they shouldn't be used in mania or in mixed episodes, they should only be used in bipolar depression in patients with a history of a good response in the past to antidepressants and no history of rapid cycling or switches into mania right away," he said.

“Further, antidepressants should not be used in patients with bipolar disease with mixed features during a depressive episode or some manic symptoms during depression.” 

The recommendations said that antidepressants should not be used as monotherapy for bipolar depression, or in rapid cycling. 

I have a few reactions to this.  

1. Duh! We've known about the risks of using antidepressants alone in Bipolar I patients since the sixties. We've also known that they are perfectly safe and highly effective if a bipolar patient in a depressive episode is on an effective mood stabilizer, preferably Lithium.  

The way that the recommendation is made, however, is highly misleading. Antidepressants indeed should not be used as "monotherapy," but not because they are ineffective for depression. It may sound to some doctors that this is what is being said. The real reason is because patients need to be on a second drug to prevent switching into mania.

2. What are they defining as "rapid cycling?" A majority of patients who get this diagnosis nowadays are not bipolar at all, but have anxiety disorders, mixed anxiety and dysthymia, and/or personality disorders - otherwise known as 'crappy childhood syndrome." A lot of drugs can cause these folks more harm than good if improperly used!  Why single out antidepressants?

3.  How are we supposed to know if a patient will respond to an antidepressant in cases of patients who have never taken one, if we are not supposed to use them unless the patient already has a history of responding to them? That would be quite a trick! Additionally, a history of a switch into mania is not a contraindication for antidepressants unless this history took place when the patient had been adequately medicated with a mood stabilizer. If they switched when not taking one, that fact would be completely irrelevant. Even the Sachs study showed patients on a mood stabilizer don’t switch into mania with antidepressants.

4. As for so-called mixed episodes, they are in reality manic episodes, with the difference being that the patient feels really uncomfortable instead of the more typical euphoria. Since they are in a manic state and not a depressed one, of course antidepressants should not be used!

Medical Racism in America: a Giant Mind-Boggling Game Without End

An explosive book that came out last year, Black and Blue:  the Origins and Consequences of Medical Racism, should have reverberated throughout the medical community and caused we physicians to closely examine our own prejudices and how they have affected the behavior of, and our relationships with, our black patients. 

So of course there has hardly been a whimper in the medical community. I did see a rather bland, "balanced" (almost namby-pamby) review by two African-American psychiatrists in the American Journal of Psychiatry, the official journal of the American Psychiatric Association. I don’t think much will come of it.

The author of the book, University of Texas professor John Hoberman, explains many of the reasons why the medical profession does not look at itself much in this regard, most of which I will not discuss in detail here. One of the biggest reasons can be summed up in one phrase: the mutual estrangement of puzzled Whites and resentful Blacks.

John Hoberman

Just to be extremely clear, there is no doubt that the problem of racist beliefs in medicine started with white racists and not their black victims. Many of the ideas about physical and mental differences between Blacks and Whites came from the colonialist opinions of Europians that Africans were more primitive than white people – less further along than Whites on the evolutionarily scale and therefore sub-human. Thus, their bodies and minds were supposedly simpler and therefore less or more prone to certain diseases. 

As seen originally by colonialists,  the black body, being more simple, was hardier than the white one. Black skin, for example, was thought to be tougher. This conveniently provided slaveholders a justification for working their slaves in the cotton fields for long hours in the hot sun. At the same  time, being supposedly simpler mentally, slaves could be thought of as less likely to get depressed, so the myth was born of the happy black slave, grinning from ear to ear with his strong white teeth while eating watermelon, content being taken care of by his benign white masters.

While physicians in general no longer express these ideas, derivatives of them became part of medical folklore and were passed down as an oral tradition from medical student to medical student. For example, observations by white doctors of what a non-naïve individual would see as the understandable reluctance of Blacks to be put under anesthesia (and therefore under the complete control of a potentially racist doctor), was instead put together with the notion of black hardiness, and voila!  Black patients are far less likely even today of being given adequate anesthesia during surgery.

Hoberman describes in detail how racist ideas from the past have morphed into medical folklore about Blacks concerning the treatment of diseases of nearly every organ system.

Disparities in the health care of white and black patients such as the one just mentioned have been endlessly documented, so their existence should not be in the least controversial. White doctors unfamiliar with the racist history of American medicine, however, are likely to misinterpret the mistrust of their black patients as an innate tendency to be non compliant - or just plain lazy - which in turn makes the white doctor reluctant to put a whole lot of energy into convincing black patients to follow their advice.

Black patients have good reasons for their mistrust of the medical profession, including of psychiatrists.  White physicians tend to think that 1962 was a long time ago.  That was the year the American Medical Association stopped deferring to Southern state medical associations (doctors have to join the state and national associations at the same time), and allowed all African American physicians to become members.

Then again, I guess 1972, while more recent, seems like the distant past to such physicians.  That was when the Tuskeegee Syphilis Experiment came to public light -  a clinical study conducted between 1932 and 1972 by the U.S. Public Health Service to study the natural progression of the untreated disease in rural African American men who thought they were receiving free health care from the U.S. government. The men were never told they had syphilis, nor were they ever treated for it.

When I moved to Memphis, I was impressed that seemingly every African American I spoke with was aware of this history – even those who were not particularly educated.  For white doctors, not so much. Unfortunately, human beings have very long memories. The Serbs and Albanians, for example, still have strong feelings about a battle that was fought in the year 1389! 

It doesn’t help when white doctors like conservative commentator Sally Satel blame treatment disparities entirely on the resistant attitudes of black people without any reference to this history.  She also writes that racial profiling is important in medicine and justifies this idea (http://www.nytimes.com/2002/05/05/magazine/i-am-a-racially-profiling-doctor.html?pagewanted=all&src=pm) with the example of the implications for choosing medications based on the real difference in the racial distribution of different versions of enzymes that metabolize certain drugs (different alleles on the genes responsible for producing the metabolizing enzymes). 

In picking on one of the extremely few areas where there actually are racial differences, she ignores the far greater quantity of ideas within medical folklore purporting differences that do not in fact exist.  Like the supposed proneness of the black brain to produce hallucinations in psychiatric disorders, for example (originally attributed by doctors to its “primitive” state).

The mistrust of racism in medicine has unfortunately led a significant proportion of Blacks to believe in some seemingly far-fetched conspiracy theories. Many Blacks believe HIV and birth control programs were invented and designed by the white establishment in order to commit genocide against minority groups. 

These conspiracy theories even reached all the way to Africa, leading to the disasterous AIDS policies of South African president Thabo Mbeki. To most Whites, these theories sound completely irrational and paranoid. Of course, historically, Planned Parenthood was indeed founded by an Anglo-American eugenicist, one of whose goals was to limit the number of children of east European immigrants to the United States, whom she considered genetically inferior beings.

There is also a rather crazymaking problem for Whites who attempt to take an interest in the whole problem of the consequences of racism on black folks. This problem was exemplified by the vicious attacks on Senator Patrick Moynihan for his 1965 report, “The Negro Family: The Case for National Action.” The report discussed the “pathology” that racism had created for many Blacks and their families.

According to the Hoberman’s book, the black intelligentsia protested the report with sentiments something akin to, “How dare some white social scientists tell black people who and what they are?”  They thought that the report pathologized and stigmatized black urban culture, and that it seemed to be an oblique endorsement of old racist biology that regarded black people as inherently diseased and beyond salvation.

This has led to a situation where even today it is considered a breach of academic etiquette for any white social scientist to theorize about Black culture. I personally was crazy enough to do some of that in my first book, since a problem seen frequently in the Black urban poor community provided the clearest example of a point about the development of family system dynamics I was trying to make. Fortunately - I guess - that section of my book was completely ignored by reviewers. Whew!

So one of the reasons that white doctors are reluctant to look at their own attitudes and the history and consequences of medical racism is a fear of open discussions about that very subject. They do not want to be considered racists. So what are they supposed to say?  That racism did not create a host of problems for African Americans, so they do not seem to pathologize them and over-generalize about them? If it did not, then what is the big deal? If they ignore the problems, they could then be accused of covertly wanting racist practices to continue. Damned if you do, damned if you don’t.

Maybe if we just do not bring up the subject, no one will notice. Except maybe for that troublemaker Hoberman.

So here we have the explanation  for the “mutual estrangement of puzzled Whites and resentful Blacks” phenomenon. To oversimplify a bit, Blacks will not tell doctors that they are mistrustful of white doctors (and of Black doctors as well, for reasons discussed in the Hoberman’s book) for fear of being labeled as paranoid, and white doctors are afraid of getting labeled as racist no matter how they discuss the problem!

This is a perfect example of the family system game without end on a larger, societal scale, which makes solving this problem so devilishly difficult. No one trusts anyone else who claims they want things to be different, so anything anyone does or says can be - and invariably is - reframed as just the same old thing – just another manifestation of the Black belief in the incorrigible racism of all Whites, or of the White belief in the presence of innate Black pathology and inferiority. No wonder we get stuck!

This game without end can lead to paradoxical and at times bizarre situations. Hoberman bemoans the fact that black kids are much less likely to get stimulants for “ADHD” than white kids, which he attributes partially to white doctors’ subconscious belief in the stereotype of the “happy Negro” described above. Black mothers, on the other hand, do not want their kids to take these drugs because they believe that the drugs would be used to pacify young black males and rob them of their spontaneity, thereby making social control of Black people easier.

I doubt that the motives of most White doctors are that pernicious, but the mothers are actually right about the effects of the drugs. In this case, the idea that stimulants are being used to control behavior is correct, and the black kids are better off not getting the drugs. The problem is not, as Hoberman implies, that black children are not getting a needed medication, but that too many white kids are getting medication they do not need instead of getting family therapy! Of course, black families are not getting as much of that as white families either.

The author’s solution to the problem of medical racism, although he probably does not know about the concept of the game without end nor necessarily totally appreciate the intricacies of interpersonal miscommunication, is for medical schools to teach the history of medical racism and about the presence of incorrect folkloric beliefs that many physicians still hold. This way, the doctors would hopefully not misinterpret the lack of cooperation they receive from their black patients, and take time to explain more about what they are recommending, and reassure the patients that they understand any reluctance the patient may have to follow their doctorly advice. 

Hoberman admits, however, that there are not very many people available who are qualified to even begin to teach such a course.

As to his book itself, it is sometimes annoyingly repetitive, and at time a little confusing. When he discusses discrepancies in the care of black and white patients, it is sometimes unclear if his examples are due in his opinion to medical mythology, a misunderstanding of actual differences, black mistrust of white doctors, or all of the above. Nonetheless, since there aren’t many books that take this whole subject on, I recommend it.

An Internet Article about Abusiveness

http://saludify.com/why-do-people-abuse-psychology-of-abuser/

Guest Post: The Good Enough Parent: How Children from Abusive Families Sometimes Do Not Seem To See Their Own Abusiveness

Today's guest post is by Sara Dawkins. This is the second post in which a writer recounts his or her own experience in a family with a problematic history. She addresses the confusion a child can feel when parents who have themselves been abused by their own parents do unto others what had been done to them. ~ D.A.

This is a topic that is very close to my heart so it is difficult for me to write about. Let me start with something that is a little easier. First of all, I will talk about my partner. His father, to be precise. My partner’s father was abused as a child. As was his father. I am sure the cycle continued for many generations. However what got me to really recognize this idea in my own life was something my partner said to me the other day:

“My father is proud of the fact that he is a better father than his father was, but that’s not very hard to do.”

Wow. He was so right. Just because the father came from an abusive home, that did not mean that his own abusive behavior was better in some way. As a matter of fact, my partner’s father can’t even see how abusive he is, as a father and as a spouse.

That brought me around to thinking about my own family. Both my mother and grandmother were from abusive homes, as was my father.

My father was practically abandoned for most of his life and when his parents were around they were verbally and physically fighting with one another. Although he was not hurting in material things, he did not get any instruction about how to behave, and was left to his own devices. He turned into a very selfish individual. Instead of trying to avoid repeating his history of abuse with his children he simply gave up. He stayed home for much of my young life, yes, but withdrew to his bedroom as soon as he got home and only left it to go to work. He did not interact much with my brother and I;  when he did it was only the minimum required so that he could feel as if he had “done his duty.” 

Eventually the stress of even that much involvement got to be too much for him and he left. He never did seem to see that he was falling into the same cycle of abuse that he had suffered through. After all, he could tell himself, he didn’t leave… for a while.

Likewise, my grandmother came from a difficult home. Her father was an alcoholic and the family lived in basements and with relatives because he would drink away his paycheck or simply not go to work at all. From this lifestyle my grandmother learned to work hard and try to keep everything as perfect as possible so that she, hopefully, would not have him get angry at him when he got home. 

She later married a man who was much like her father, and as her children grew up under his verbally and physically abusive hand, she cleaned and kept everyone looking good. To this day she defends her father and is in denial about the abuse she lived through. By keeping everything whitewashed in her mind, she was simply repeating the process of enabling abusers and was keeping the process going.

Needless to say my mother grew up feeling abandoned by her mother and abused by her father. Shockingly, she chose to fight the trend. Although she could not fight off the effects completely, she did not give into the same habits that had plagued the generations before her. Don’t get me wrong. She still had many issues. She was prone to rage and verbal abuse. However, she decided that her children were not going to suffer like she had. 

She was determined to break the cycle. I have to admit, she works really hard to do so. She is not perfect by any means, but when she does fall into those bad habits she always makes sure to apologize for them and tell us what she should have done instead. By thusly changing the pattern, she has been successful at breaking most of the bad habits that plagued our family. Although we are not completely unaffected, my brother and I are moderately well adjusted. I believe that the most important thing she taught us is to be mindful of our actions.

Sometimes people that have been abused do not seem to see the abuse that carries on in their lives. They have many of those same habits and ways of thinking. Sometimes they just assume that they are better parents because they do not do exactly the same thing or do not do everything their parents did. Being a ‘better’ parent does not make you a good parent or even a non-abusive one.

It really hurts me to see that my uncles are not as cognizant of this as my mother is. They have many of the same abusive behaviors in their homes and yet they act as if they can’t understand why their children are acting out, being rebellious, running away, or just giving up. They don’t see that they are just continuing a cycle of abuse.

I know how difficult it is to break habits that you have grown up with and I am thankful that my mother was able to give me some understanding and insight into her mind. This has helped me to break the cycle within my own relationships and live a healthier, more balanced life.

Author Bio

Sara is an active nanny as well as an active freelance writer. She is a frequent contributor of http://www.nannypro.com/.  Learn more about her at http://www.nannypro.com/blog/sara-dawkins/.