Sunday, July 10, 2016

Truth v. Fads Part 3--"Choice" isn't always Empowerment

There is a trend in our society promoting the idea that every choice someone makes about him/herself is a form of empowerment. This idea is demonstrably false. For example, people choose to shoot heroin, smoke crack cocaine, to commit suicide and to starve themselves to the point of death or near death. These are not acts of empowerment (an exception might be those who commit suicide who are terminally ill and in  intolerable pain).

Some would counter by saying the examples I have given are examples not of choices but of illnesses. Yes and no. For example, anyone who has been an addictions counselor, or who has spent time in a 12-step group, knows that although people don't choose to have the disease of addiction, they do choose to use drugs and alcohol. Acceptance of "powerlessness" doesn't mean denial of personal responsibility.; in other words, addicts may be persons who are vulnerable to the effects of substances, but they still choose to use them. The notion of "powerlessness" in the 12-step program  refers to the acknowledgement of one's need for help, the inability of the person to manage by themselves. Acceptance of "powerlessness" is the first step in reaching out for help. Continuing to make bad decisions often involves rejection of help. If one looks at the entire 12-steps, it becomes obvious that much of the program is about the acceptance of responsibility.

Likewise, many treatment programs for persons with conditions such as Borderline Personality Disorder--which is correlated with suicide--emphasize healthy choice-making. 

There are many types of choices that do not represent empowerment, and the list is too long to discuss here. Perhaps instead we should take a look at the basic concept of "choice" and the concept of "empowerment."

Many so-called choices are not only unhealthy, but are not free choices at all. The extent to which people are affected by social pressures and psychological manipulation is generally underestimated. . The average person does not want to believe he or she purchased a particular model of car or a type of beer or breakfast cereal because of advertising, but the reason corporations spend millions of dollars on advertising is because it works. Throughout history people have conformed with what their families and communities expected even when it was oppressive. In some cases this has been due to conscious fear and awareness of the consequences of defying the norm. However, often such behavior is rooted in a common psychological defense known as "identification with the aggressor," in which persons, especially children but also adults, merge their identity with that of a more powerful entity as a defense against fear. Identification with the aggressor is unconscious, as all psychological defense mechanisms are. In the age of modern media, influential pundits and their legions of followers may be viewed in a similar way to how parental figures and community leaders were viewed in earlier societies. I believe this may extend to a broader use of "identification with the aggressor."

Facilitating the effects of the dysfunctional messages that people read and hear  is a confusion in the popular vocabulary between "normal" and "healthy." Something can be the "norm" (what most people do) yet be  pathological. For example, it's the norm in parts of East Africa for parents to hire someone to remove the clitorises of their daughters. This is a mutilation that results in total loss of sexual pleasure for most women, as well as disability in areas including urination and childbirth, and even death in some cases.  It is part of "culture" but a pathological aspect of culture. The fact that it is the "norm" or that it is "cultural" doesn't make it healthy. A current catchphrase asks us to "respect cultural differences" or even to "respect other people's cultures." This phrase should be reworded as "respect the power of culture to shape people's behavior."

Walking the streets of New York City anyone can see milder versions of female mutilation that have been "normalized": A percentage of younger women wear shoes with heels that are 3, 4, or even 5 inches high. It's not totally clear to me how people walk in these shoes (someone recently told me they receive fat injections in the balls of their feet) but what I am sure of is that this behavior ultimately leads to deformation of the feet and injuries that are not only painful, but  that over time could instigate chronic conditions such as arthritis. Yet we accept this behavior because it has been normalized, and also, because we view it as the person's "choice."Is it really the person's choice, or a conformism to ideas of what it means to be "feminine"? based on fear of stigmatization and identification with the aggressor(s)?

Recently I've been reading some stories in the media in which people defend their own, or others' decisions to have cosmetic surgery, or even to bleach darker skin, as being "personal choice."  In the logical moments of these debates, people acknowledge that these decisions are made due to social pressures and they do not represent "free choice" nor "empowerment." Almost as often, however, I read statements to the effect that if someone chooses to alter their appearance, we should not ponder why or question this behavior, but accept it simply because it is the person's "choice." These simplistic and naive assessments may serve to encourage pathological behaviors and may also distract the public from serious questions about social pressures, discrimination, and in some cases, issues of mental illness.

Thursday, June 30, 2016

Truth v. Fads Part II: Online Reviews and Psychiatry

In previous generations, when a young person wanted advice on life's questions, she or he often consulted with an elder or with an expert.  Today, people are more likely or just as likely to look for answers on the internet. Let's look at the differences:

Elders relied on their own experience and also "folk wisdom," the accumulated knowledge of hundreds or thousands of years, typically distilled into proverbs and aphorisms (more about folk wisdom in a future blog post). Experts, such as professionals, rely on professional training, advanced education and professional experience. The internet is a catch-all of information, some of which comes from reliable sources but much of which does not. Recent studies have found that people put a lot of credence into online reviews of products and services, but the findings of these online reviews did not accord with the assessments of highly regarded consumer organizations such as Consumer Reports. The New York Times cited this study:
“Navigating by the Stars” was published in April in The Journal of Consumer Research. After analyzing 344,157 Amazon ratings of 1,272 products in 120 product categories, the researchers found “a substantial disconnect” between the objective quality information that online reviews actually convey and the extent to which consumers trust them...Nearly half the time, Amazon reviewers and the Consumer Reports experts disagreed about which item in a random pair was better. Moreover, average user ratings [on Amazon] did not predict resale value in the used-product marketplace, another traditional indicator of quality."

The Atlantic magazine cited some other studies:
"in Nielsen’s 2015 “Global Trust In Advertising” report, for instance, around two-thirds of respondents indicated that they trust consumer opinions posted online... As for young people, a 2014 poll found that Millennials consider online peer reviews to be slightly more trustworthy and memorable than professional ones.This shift in attitude has taken place despite frequent discoveries of fraud in crowdsourced reviews. In 2013, for example, after concluding a year-long investigation called “Operation Clean Turf,” the New York Attorney General’s office ordered 19 companies to pay more than $350,000 in fines for flooding various review sites with phony endorsements. Last October, Amazon sued more than 1,100 people for offering to create fake product reviews for $5 apiece."

 It's scary to think that many people are basing decisions on the statements of random anonymous persons on the internet, who have no consequences for their actions stopping short of outright libel.  I have seen this behavior in my practice:

 Several times over the past several years, I have given a patient the name of a prescriber to contact for a medication evaluation, but the patient came back to me the following week and reported that she or he never contacted the prescriber because they looked him/her up on the internet and found negative reviews (mostly on Yelp).  I wanted to say, and perhaps should have said, "You trust the opinion of a random anonymous person on the internet over the recommendation of your therapist?"  So far I haven't said this, perhaps afraid to make it seem like I was personalizing. However, therapy doesn't work if the patient doesn't put any credence into what the therapist says, so perhaps I should discuss these incidents.

 The opinion by a professional of another professional is more reliable than the opinion of a random anonymous person  who has no accountability, perhaps an unseen agenda and may even be a paid shill for someone else (negative review) or for the reviewee (positive review). Reviews of psychiatrists especially should be looked at askance, for reasons that may be obvious.

Why would I refer someone to a bad prescriber if I am going to continue working with the patient, as the wrong medication would make my job harder and increase liability risk?

I did  point out to one such patient that the prescriber in question may have gotten negative reviews due to refusal to prescribe addictive medications that many drug addicts seek. The patient's response was "I hadn't thought of that." But it's one of the first things that would occur to a mental health professional, especially one with a background in addictions counseling,  because we are aware that such behavior is common.

50 years ago people sought the opinions of experts and of elders when making important decisions. Today people are seeking the opinions of unseen random strangers. Which is more reliable? 

Sunday, June 26, 2016

Truth v. Fads Part One: Dating Advice for Heterosexual Women

Recently I suggested to one of my patients who's having some dating issues that she read the 1990s bestseller "The Rules." I noted that although the book contains some advice that might seem superficial about makeup and other trivialities,  the basic theme is about setting boundaries and limits with people--something that many people, especially women, often have difficulty doing.  She read the book and found it useful, but told me that when she told her friends she was reading "The Rules," they were shocked because, they claim, the book is anti-feminist.

I'm a feminist. The definition of feminist in the popular imagination seems to have changed in the past 20 years, but I don't think the actual definition of feminism has changed. A feminist from 20 years ago (or 40 years ago) and a feminist today presumably agree that feminism is about equal rights under the law and a belief that men and women are intrinsically equal, that men are not superior to women.

There were arguments starting in the 1970s in favor of the interpretation that feminism implied that men didn't have to pay for women on dates and that women should feel free to ask men out on dates. However, until fairly recently I had been under the impression that those arguments never really caught on and the they were finally tossed out after "The Rules" explained how these social gestures had nothing to do with feminism. Apparently I was wrong. From what I've heard from several patients in their 20s and early 30s as well as what I've been reading in the popular media, there remains an interpretation of feminism that has less to do with equal rights and more to do with a promotion of the idea that women should adopt  male behaviors in dating, such as asking men on dates and even proposing marriage. Copying other people's behavior doesn't have much to do with equal rights. If women and men are equal, then why should women be told to act more like men? Telling women to act like men carries an implication that women are doing something wrong. This fits in with a tendency women have to blame themselves, a probable factor in the higher rates of depression among women compared to men. Many feminist philosophers have argued that society overvalues male behavior and undervalues female behavior.

Anyone who has studied biology or even just watched nature programs and documentaries from time to time is aware that most animals engage in elaborate courtship and mating rituals. In many species of birds, males must court females through helping them build nests or by putting on elaborate displays. Male deer fight each other to prove who is the dominant male who should mate. Males have been proving themselves for the right to mate for tens if not hundreds of millions of years--how could humans think that  popular fads can overrule Nature's rules? They don't. Evolution has decided that females should select males based on the male's efforts at winning over females, because this ensures survival of the fittest. Nature doesn't think that males are superior to females. Nature has simply developed a set of rules--Rules--to ensure survival of the fittest. Expecting a man to pay on the first date doesn't mean you're not a feminist woman--it means you are following a rule that has been tested and proven by Nature for a hundred million years.

Some in the popular media seem to argue that biological mating isn't relevant to contemporary dating because contemporary dating is about having fun and lots of casual sex. In reality, most women want to find a mate. The notion that what women seek is lots of casual sex with various friends, acquaintances and strangers is something that has been promoted by self-styled opinionators, many of whom are not women. These individuals may have agendas that have nothing to do with promoting health and happiness for women.

Making a man prove himself means not asking men out on romantic dates, not asking a man to marry you, and expecting that on a first date that the man will pay for all or most of the expenses. Because if a man can't take the initiative and responsibility to pursue the woman he wants, he isn't worth your time, and, as another book said, he might "just not be that into you." Men have a tendency to know what they want and to pursue what they want in romantic and sexual relationships. If they don't pursue, it can mean they don't want the other person that much but are just going with the flow because why not? It's not uncommon for a man to allow a sexual relationship to go on even if he doesn't want to marry, doesn't respect and/or doesn't even like the other person. Trust me--I've had a lot of male patients and I've been able to directly hear statements to this effect.

 Men and women aren't the same. There are biochemical/genetic/psychological differences between the genders that do not imply a difference in equality but do mean difference. Equal doesn't mean identical. Women are genetically engineered to become more emotionally invested in relationships over time (although men may develop dependency for different reasons).  Women are also more likely to be infected with STDs by their partners and are the only gender that can get pregnant. These are some of  the reasons why women should be cautious about romantic and sexual relationships and should set high standards for mates.

If you want to find the truth about any subject, don't look to what some columnist on a trendy website says. Try looking at the evidence that has been proven over time, and the more time, the better. I plan to write more following this theme.

Sunday, June 19, 2016

Psychopaths Among Us

As the number of mass shootings seems to be on the increase, many have wondered what types of people commit these acts. As I noted in my June 20, 2015 post,  some of those who are racially motivated may have Delusional Disorder. I noted in my May 31, 2014 post, some may have Narcissistic Personality Disorder and/or Bipolar Disorder perhaps exacerbated by the wrong type of medication. But the diagnosis most often correlated with violent behavior is Antisocial Personality Disorder, which is better known by its earlier terms, sociopathy and psychopathy. All three terms refer to the same condition.

It used to be believed that psychopathy (I'll use that term for this blog post) was a rare condition. It isn't a rare condition. Studies referenced in the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-V) indicate the rate of Antisocial Personality Disorder, or psychopathy, is somewhere between .2 and 3.3 percent of the population.

It is commonly and inaccurately believed--including by some members of my profession--that psychopaths are found mostly in the criminal justice population. I used to work with people paroled from state prison, in the 1990s, and I have seen a rate of psychopathy in my private practice that is about the same as what I saw in my job with the parolees. Most of the parolees were persons who were arrested for selling drugs or committing burglaries or robberies in order to support heroin addiction or addiction to crack cocaine, not because they were seeking psychopathic thrills. Psychopaths have come to my private practice for a variety of reasons including having been arrested, having committed a serious crime that did not result in arrest but resulted in interpersonal problems, and because of job problems, educational problems, addiction, and depression.

It is also commonly believed that psychopathy is untreatable or barely treatable. Some therapists like to say that "the only reason psychopaths come to therapy is to learn how to be better psychopaths." Is this true?  The psychopathic persons who came to see me who were struggling with depression or early recovery from addiction very definitely wanted help for those problems. I do believe that I helped them, but the underlying personality disorder remained more or less intact. The persons who came to treatment due to outside pressure were less treatable but I do believe we were able to work on some issues when the patient was being honest with me. I only recall one psychopathic patient who I became convinced was simply making up stories, perhaps in order to get a thrill out of manipulating someone.

Psychopathy, or Anti-Social Personality Disorder, is usually characterized by difficulty following rules and social norms, deceitfulness, lack of empathy, impulsivity and aggression. It is thought to be more common among men, but I question that statistic, because half the psychopaths who have come to my private practice have been women. But perhaps female psychopaths are more likely to seek treatment.

The best treatment, as it is in many disorders, is prevention. The DSM-V notes "Adoption studies indicate that both genetic and environmental factors contribute to the risk of developing antisocial personality disorder." Past studies have correlated psychopathic behavior with childhood abuse and neglect and with inconsistent parenting (parents who disagree over rules or a parent whose discipline seems arbitrary). Ideologies that provide a rationale for violence help psychopaths commit violent acts. Societal alienation may exacerbate the characterological lack of empathy. Anyone who sees him or herself as having little to lose is more likely to commit a violent act that ends in his or her own death or arrest. This last factor indicates that depression may exacerbate psychopathic behavior, although I am unaware of any scientific research on this subject. The DSM specifies that for antisocial personality disorder to be diagnosed, the person must have had some symptoms starting before age 15. Perhaps if we did better screening, referral and treatment of children and teens exhibiting psychopathic behaviors, we would not see so many acts of mass violence. Treatment should include treatment for parents or other significant family members as well as parent training to teach appropriate discipline. In some cases, removal of the child from the home may be necessary, but because such removals are usually done long after the damage is done, and because foster and adoptive homes are also often not optimal, this may not result in prevention of violent acts.

Many factors contribute to psychopathic behavior. To prevent acts of mass violence, reasonable gun control laws should be combined with early intervention for children exhibiting serious conduct problems and lack of empathy for others.

Sunday, June 5, 2016

Obesity and Depression

Are there links between obesity and depression?

People used to think that the link between obesity and depression was that fat people were depressed because they didn't like how they looked.  Later it was theorized that some people overeat because they're depressed--although depression often makes people lose their appetite.  I believe there may be a biological link between obesity and depression: Depression has been linked to inflammation (see my June 29, 2013 post on Vitamin D and mood) and obesity can increase inflammation. Therefore, it is possible that obesity can biologically contribute to depression by increasing inflammation.

There are other negative psychological effects from obesity. It can make people give up (or never try) activities that might make them feel better, such as exercise. It can make people self-conscious, which can lead to social withdrawal. 

I read a news article recently that implied losing weight is next to impossible. It was based on the experiences of contestants in "The Biggest Loser" who gained most or all of their weight back. The reason was that their metabolism slowed to a crawl after they lost weight. I don't think "The Biggest Loser" is a model for weight loss, because the weight loss program it advocates, extreme exercise, probably isn't feasible for many people and may not even be healthy. The show also uses public humiliation as a tool, and that doesn't help people.

It is possible to lose weight and keep it off.  I've worked with several persons who lost large amounts of weight that they managed to keep off--and none went to a weight loss camp. The most important elements in weight loss may be motivation and the taking of personal responsibility (which could be undermined by reliance on a trainer). 

Several persons who came to see me had already begun or completed their weight loss program before coming to therapy--perhaps change in one area motivates change in another. Here are some of the various methods with which they lost weight:

1. Weight Watchers--50 lb weight loss (I also knew someone in school who lost 100 lbs through Weight Watchers). Weight Watchers teaches portion control and healthy eating while providing social support.

2. Nutritional Counseling--60 lb weight loss. The nutritionist provided education as well as support.

3. Daily gym workouts (no trainer involved!) combined with eating only a Greek salad for dinner--100 lb weight loss. Exercise not only burns calories but also relieves stress. Exercising while listening to music may be especially effective and may provide a "safe space" where one escapes the stresses of daily life.(The person's main exercise was the elliptical machine, which avoids excess stress on the feet)

Therapy can help. I helped someone lose weight  by having her write in a journal everything she ate, along with when she ate it and other relevant information. We would discuss what she wrote, in our sessions. This method allows for the analysis of emotions and thought patterns that trigger overeating. Hypnotherapy may also be helpful for some people. 

I believe overeating is an addictive behavior no different in its psychological basis than addiction to alcohol or cocaine. Obese persons who aren't interested in losing weight can be observed to use the same sorts of denial and minimizing statements that one hears from active alcoholics and drug addicts. Behaviors such as secret use/bingeing, arranging social activities around the substance  and avoidance of others or activities that interfere with use, can be seen in both chronic drug users/alcoholics and the obese. Both drug addicts and morbidly obese persons have higher than average rates of childhood trauma according to some studies and many grew up in households in which addictive behaviors were common. After giving up drugs or alcohol, some people turn to food, and there's been some evidence that people who have had weight loss surgery are at increased risk for  problem drinking.

Given the similarities between overeating and alcohol/drug addiction, can a 12-step group help? I've heard mixed reports of Overeaters Anonymous, the 12-step program for food addicts. The 12-step  model was originally based on abstinence, and abstinence from food isn't possible. However, some may benefit from the support in OA.

Obesity isn't a problem because of how it makes you look. It is a serious health condition that not only raises one's risk for fatal conditions including diabetes, heart attack and stroke, but also can increase depression through increasing inflammation and reducing recreational and social activities.

Tuesday, May 17, 2016

Preventing Suicide

In the past year or so, the news media have reported on a couple of disturbing research studies that showed rising suicide rates. The latest study reported that suicide has been increasing in every age group except the elderly. What is prompting this increase and what can be done about it?

Many have speculated that economic hard times are behind increasing suicides. This could certainly be a possibility for the increasing rates of suicide in middle-aged people, many of whom lost retirement savings and jobs, or lost homes, during and after the crash of 2008.

Increased suicides among girls age 10-14 is more of a puzzle. One theory is that increased social media bullying is the cause. If this is true, an easy way to decrease these suicides is to not give your daughter a smartphone until she is old enough to tolerate or stand up against bullying. That kind of personal strength is unusual in people under age 15. Facebook supposedly doesn't allow accounts for people under age 13, but I don't know if this is enforced at all. It's really up to parents to protect their children. Likewise, it's important to ask your child about bullying and take steps to address it if it occurs, including speaking with the school principal, switching schools and/or taking legal action. Harassment and stalking are against the law regardless if the perpetrator is a teen, and Title IX of the Civil Rights Act forbids sex discrimination in education, which could make sexually-related bullying a federal violation if it is tolerated by the school.

Teen girls are now subjected to more degradation than ever before. Besides social media harassment, they also now have male peers who view internet pornography, and who may as a result view girls and women as subservient or degraded sex objects. Some girls may be pressured into sex acts as a result, and viewing of some types of pornography is a trauma for a young person. Pop music stars such as Beyonce and Miley Cyrus perform burlesque acts that may confuse 11 and 12 year old girls, who are told that these sexually objectifying performances are acts of empowerment, while at the same time they are derided as "sluts" if they dress the wrong way or date boys. Overweight girls are teased, but thin girls are also derided in popular culture--take a look at Meaghan Trainor's hit video "All About That Bass," a profane, vicious, bullying rant that is promoted as "happy" music on Amazon. Trainor's songs are marketed to young teen girls.

The more I think about it, are we really surprised that suicide is on the rise? Perhaps the reason the suicide rate of the elderly is not rising (despite the fact it historically has been higher than for other age groups) is because elderly people are more likely to have assets that weren't as affected by the 2008 crash, Social Security incomes, and a lack of involvement in degrading aspects of popular culture.

In terms of specific risk factors and prevention, something that we know about suicide is that it is often an impulsive act and often based on cognitive distortions. Even when times are bad, most people are able to recognize that things can get better. People commit suicide because they don't see a way out. They develop a narrow way of thinking that blocks out options. They also often don't believe that others can or will help them. They don't "reach out" for help. These thought patterns and behaviors are referred to as "hopelessness and helplessness," and mental health professions screen for suicide risk not just through asking patients how depressed they feel and whether they have had thoughts about suicide, but also by assessing whether the patient has any plans for the future and whether the patient has a social support network. People can be very depressed and feel like they don't want to live, but if they feel connected to others they are less likely to commit suicide. Someone who does not have anyone in whom to confide is far more likely to commit suicide than a depressed person who reaches out for help. This brings up another possible reason why suicide is on the increase--some studies have found that more people are reporting few or no close friends, in comparison to previous decades.

If we want to live in a society with a low rate of suicide, we need to have a stable economy that provides some security for everyone, we need to encourage friendship and mutual trusting  relationships,  and we need to protect vulnerable persons such as young girls from degradation via the internet. 

Thursday, April 28, 2016

Why I Left the Aetna Panel

In February, I made a decision to terminate my relationship with Aetna, the health insurance company, and also decided to terminate my relationship with the 1199 National Benefit Fund. Some patients have asked me why I did this. The truth is that I'd come to the realization that I was in abusive relationships with these entities, and the only way to deal with being in an abusive relationship is to leave that relationship.

Aetna does pay providers a bit more than some other insurers, but in every other way they demonstrate contempt for the providers who actually do the work for which Aetna takes the profit. Aetna messed up my credentialing twice, first when I initially applied in 2008, then again in 2014 when I changed my tax ID number. These screw-ups meant I wasn't paid for months and that I wasted hours of my time on the phone and writing emails as well as resubmitting claims, in order to resolve the problems. Aetna also denied claims for bogus reasons, such as in one memorable case when they told me my patient's auto insurance might have already paid the claim. The patient didn't own a car. I eventually spoke to someone at Aetna who was as puzzled as I was by this bizarre statement. She resolved the issue, but only after both I and the patient wasted time trying to resolve the unpaid claim.

The last straw for me with Aetna was in early February, when I received a phone call from a third party, "ArroHealth," saying that I needed to turn over case records on four patients. I inquired as to the reason and was told "it's the annual risk assessment," which I knew to be a lie.  I'd been credentialed with Aetna for almost 8 years and had never heard of an annual risk assessment. Moreover, all of the cases were closed, so a risk assessment was beside the point. I don't turn over confidential health records without a good reason. I informed "ArroHealth" that the cases were closed, I was no longer in touch with the patients, and their confidentiality waivers for Aetna were now out-of-date. Of course, what many people don't know is that when you sign up for health insurance you sign a statement allowing the insurance company to look at all your health records. Regardless, this is never something I would do without consulting with the patient. I found out later some of my colleagues dealt with this by asking patients to write letters to Aetna or to ArroHealth saying they were refusing the release of their records. But I didn't want to involve former patients at all. Moreover, because of the consulting work I do as an auditor, I know that payors are capable of finding bogus reasons to take back money from providers. I am not giving back one cent of any money paid for work that I have done. I told ArroHealth that I wasn't going to release the records. Within one week I had decided that if I maintained my relationship with Aetna, I would be subject to more of the same, so I faxed them a termination letter.

As for the 1199 National Benefit Fund, which ironically is a plan for health and hospital workers in New York, they processed by tax ID change application by immediately eliminating my old tax ID number, but waiting six weeks to instate my new tax ID number. This meant that I was listed as an "out of network" provider for six weeks. I don't know if this was extreme incompetence or done deliberately, but the end result is that they owe me hundreds of dollars for a patient's incorrectly processed claim. Although I filed an appeal, I have not been paid.

I counsel my patients not to tolerate abuse and disrespect and I would be a poor role model if I allowed myself to continue to be mistreated by these organizations.