Thursday, January 18, 2018

Is the Mainstream Media a Good Source of Information on Mental Health?

It's all relative, I suppose, but my answer to the question above would be "no."

Over the past 10 years, maybe longer, I've read numerous erroneous articles in mainstream media  sources on health and mental health. One of the reasons I started this blog was to offer a professional's viewpoint on complex issues relating to mental health. With a professional degree and license, and experience in the field for what is now more than 26 years, I am an expert. Why don't mainstream media sources hire experts to report on health issues? Occasionally they do--for example, CNN  employed Sanjay Gupta, a surgeon, to do health-related reporting for a number of years. However, even a doctor isn't necessarily qualified to discuss every specialized area of healthcare.

Good reporters diligently seek out experts for commentary and quotes. However, without professional training, even an intelligent lay reporter, and the reporter's editors, may not be able to understand or evaluate sources of complex information. This is a problem many media outlets don't want to address, probably because paying staff who also have professional degrees might require a larger budget.

Here are some examples of inaccurate or incomplete mental health reporting in the mainstream media:

A couple of days ago, The New York Times published a news feature about disparities in opioid addiction treatment that appear to fall along racial and income lines. The reporter found that lower income and black and Hispanic patients tended to go to methadone programs, while higher income, white patients were more likely to see private doctors and receive suboxone treatment. The implication was that rich white people receive better treatment. However, a  careful reading of the entire article revealed that some patients preferred methadone and that methadone programs offer social services that private doctors prescribing suboxone usually don't. The main drawback of methadone programs, revealed by a close reading of the article, is that they often require daily or twice weekly visits, which is time-consuming. But the fact that a treatment is time-consuming does not mean that it is worse or less effective. It may mean the opposite. I wonder how many readers took the time to ponder this, and how many persons glanced at the headline and felt rage at what they assumed was racial injustice? This type of journalism fans the flames of division in our society.

Moreover, in my experience as an addictions counselor, the 12-step program--an abstinence-based program that is free and has no side effects--has helped tens of thousands or maybe millions of people worldwide recover from addiction. The Times's article didn't mention these programs, and I wondered if the reporter thought that 12-step programs are only for alcoholics. The reporter interviewed MDs, but didn't appear to have interviewed non-medical addiction counselors. Did he even understand that such persons exist? Or perhaps he thought their opinions wouldn't be as credible as those of MDs?  I even wondered if the reporter was given a task by an editor to write about discrimination in treatment, and found the facts to fit the prescribed story.

Sometimes The New York Times has printed essays by a writer named Daphne Merkin. In one very long negative essay on psychotherapy, "My Life in Therapy,"  she revealed that she has been a patient in psychotherapy for decades. Ms. Merkin is not a mental health professional. She complained about the lack of efficacy of her treatment but also revealed that she had been confused about how to participate in treatment. If someone has been a patient for decades, this would indicate a chronic condition, and all mental health problems to some degree involve distorted perceptions. In addition, the fact that someone would have an important question about treatment but be unable or unwilling to voice and discuss it with their therapist might raise the possibility that there is something wrong with this person, and then there's the question of why someone would continue in treatment that is not helping her.  Why publish such an article, a lengthy first person diatribe from someone who has no expertise in the subject but some sort of personal grudge?  Curiously, the Times recently gave Ms. Merkin a platform to critique the "#MeToo"  movement, an assignment that should have been given to an established, credible feminist author. Apparently, as long as someone is a "writer" they are allowed to expound on any subject, regardless of whether the person has expertise, scholarship or judgment.

But the most most ridiculous example I can think of from The New York Times was an article  a few years ago about the lack of male psychotherapists. This is a serious issue, as some patients might do better with male therapists. But the writer Benedict Carey commented that one problem for a female therapist might be not understanding that her male patient's participation in a bar fight was just part of a fun night out. I've had many male patients, and one was stabbed in a bar fight. He almost died, and it wasn't a fun night out. Does anyone really enjoy being beaten up or stabbed? Surely, glee in violence cannot be the reason we need male psychotherapists.

I started this blog post with the intention of using examples from across the media, but the post has gotten long using just examples from The New York Times. Maybe the problem is even worse than I thought.

Thursday, January 4, 2018

Some Important Tips About Being in Psychotherapy

Over the past 30 years, the general public's understanding of psychotherapy has declined. This is because of the growing influence of health insurance companies and pharmaceutical companies, which prefer that people take psychiatric medications rather than going to psychotherapy. It's not uncommon for me to hear patients use the verbiage of pharmaceutical companies without realizing they are doing so. This societal change has caused problems for me and other therapists.

Here is a brief summary of some aspects of being in psychotherapy and how therapy works, that used to be common knowledge but are now mostly unknown among persons under 45:

1. You do not have to use normal social rituals with your therapist. You do not have to shake your therapist's hand, ask them "how are you?" or inquire whether they had a good time on their vacation. It's the one type of  relationship that's about you and not the other person, and this is part of why and how psychotherapy cures.

2 Your therapist wants to hear everything. I discussed this in a previous post. Your history of sexual abuse, your porn habit, your poor money management and bad credit--people go to therapy to talk about the things they can't talk about elsewhere--that's one of the reasons why therapists exist. If you tell lies to your therapist or avoid mentioning important information, your therapy will not be effective.

3. If your therapist confronts you on something you did or are doing in therapy, such as repeatedly showing up late, or behavior in the session, such as sexual provocativeness, the purpose is for the both of you to explore what the behavior means. You do not have to say "I'm sorry." Instead, you should ponder the meaning of your behavior and work with the therapist to understand it. Things that other people say that are meant as criticisms are meant by your therapist to prompt self-exploration. (On the other hand, if the dysfunctional behavior continues, the therapist has a right to stop working with you).

4. The reason for #3 above is that an important part of what's called "insight-oriented therapy" (also known as psychodynamic therapy or psychoanalytically-oriented therapy) is a discussion of the dynamic between the therapist and the patient. In longer-term therapy, particularly therapy that lasts more than two years, patients often undergo a regression and start re-enacting childhood behaviors with the therapist. This is a phenomenon known as "transference." In some cases it is very important for the therapist and patient to discuss the interaction between them and what it means, as behavior in the session may reflect long-standing behavioral patterns or relationships in early childhood.

Psychotherapy is about more than learning "coping strategies." A patient could research coping strategies on the internet. Ultimately psychotherapy is about personal growth through a specific type of dyadic relationship. Psychotherapy harnesses the human tendency to grow and develop through interaction with another person. When psychotherapy is effective it is a permanent cure--perhaps not a 100 percent cure, but a cure that does not go away when the therapy ends--unlike medication.

Your Privacy

This morning I read this story in The New York Times. Not to worry--because I'm old-fashioned (as well as verging on old) I don't keep patient records in a "cloud" or even on my computer. My records are written in pen-and-ink and are stored in a locked file cabinet in my apartment in a doorman building.

Wednesday, November 15, 2017

Some Thoughts on Our Addiction Epidemics

Newspapers are full of stories about the U.S.'s opioid epidemic. It's only one of several addiction epidemics that are ravaging the country, although it's the one that is getting the most attention from politicians and the media. The root cause of all these epidemics is profits.

Approximately 10 percent of the population is thought to be predisposed to addiction, from a combination of genetic and early environmental factors. Such persons can become addicted to anything--drugs, food, sex, shopping. Persons without this predisposition can abuse substances, and will develop a physical dependence to a substance with certain chemical properties if they use it regularly enough--but it's a matter of opinion whether these persons can truly be called "addicts." But even if only 10 percent of the population are truly addictive personalities, that's enough, more than enough, to create an epidemic. Since that percentage doesn't change, why do addiction epidemics appear and disappear in societies?

When evaluating any phenomenon, it's important to ask the question "Who benefits?" The current  identified culprit for the opioid epidemic is the pharmaceutical industry. Some states are suing pharmaceutical companies for engaging in allegedly deceptive marketing practices. This may be a valid allegation, and it makes for good politics, but the main culprit is doctors. Medical training includes extensive study of anatomy and physiology. There is no way a licensed M.D. doesn't know that an opioid is addictive. I don't believe for one second that any M.D. was bamboozled by a pharmaceutical company into believing that a new opioid wasn't addictive. Doctors prescribed these pills because they wanted happy consumers.

There are many ways to manage or cure pain--physical therapy, surgery, acupuncture, massage therapy, ergonomics, nutritional counseling to lose weight and yes, psychotherapy (because mental pain increases physical pain). But there's an old saying, "If your only tool is a hammer, every problem looks like a nail." Only M.D.s and a couple of other professions are licensed to prescribe pills, so that is what they do. They don't do physical therapy or acupuncture, and even among psychiatrists, few do psychotherapy anymore--they leave that job to non-medical therapists, because prescribing pills is more profitable. Primary care physicians and psychiatrists increasingly use only one tool--pills.

A good primary care physician refers patients to necessary adjunctive treatments, but many do not do these referrals, partly because insurance often doesn't pay for them, but also because many doctors want to believe that what they do is the "real" treatment. It's also what is profitable for them.

Opioids aren't the only substance causing an addiction epidemic. There has been a worldwide plague of addiction to benzodiazepines that has flown under the radar because it seemingly has not caused an epidemic of overdoses or crimes. But that's probably because there's no illegal alternative to "benzos." People don't overuse benzos and turn to an injectable street drug because such a drug doesn't exist. They also don't necessarily think of themselves as "high" on benzos. Although a  drug is classifiable as "addictive" based on whether it is likely to cause tolerance and dependence, the general public and perhaps some doctors identify addictive substances by whether they cause a "high." But life experiences can cause "highs." In the field of prescribing, the issue of concern should be whether the substance causes physical tolerance and dependence. What pills am I talking about? Benzodiazepines include Xanax, Klonopin and other commonly prescribed anti-anxiety medications. Other sedating drugs that aren't benzos, such as Ambien, may also induce tolerance and dependence.

A few years back I saw a new patient who appeared "strung out." She denied illegal drug use. I took a look at her list of prescribed medications, and saw that it included daily Xanax. I suggested she talk to her doctor about discontinuing this medication, and she told me that she had done so but that her doctor had advised against it, because, he told her, it would take her a year to taper off the medication. I've learned that this is indeed true, it takes patients months or years to detox/taper off such medications (detox from heroin takes about 8 days in an inpatient facility). Is such use of these medications, originally developed to treat severe anxiety, justified? I do not believe so. Panic disorder is often well-controlled with SSRI anti-depressants or a combination of SSRIs and psychotherapy. SSRIs may become less effective over a very long period of use, but do not create the kind of tolerance and dependence created by controlled substances.

But the worst epidemic of our time is the obesity epidemic. The culprit is the food and beverage industry, and few politicians have the courage to attack this industry. Junk food is more popular than opioids. The media directly benefits from advertising by the food and beverage industry, not from advertising for controlled substances (it may be illegal; I'm not sure). Yet the obesity epidemic kills millions more people than the opioid epidemic.

Other addiction epidemics of our time include video game addiction and online pornography addiction (a subset of sex addiction). The Wall Street Journal and other publications recently reported  about a study that found that a main reason for declining participation in the workforce by young males was video game addiction. Other studies have found evidence for sexual dysfunction caused by online pornography, and there's no question in my mind that online porn has contributed to a general cultural misogyny, stories of which I hear in my practice. I don't see any political crusades against video games or online porn. So far the general public seems to believe that these are harmless activities, and the companies that produce these products--some of which are multinational, powerful corporations--don't appear to answer to anyone.

Tuesday, October 31, 2017


Over the past year I had been experiencing the pervasive sense that large numbers of people in the US were going crazy. From neighbors, colleagues, patients and random persons on the internet I heard statements that sounded extreme in their despair, fear and rage. At times the statements entered the realm of clinical paranoia. I was told by left-of-center persons that America was full of Nazis, and by persons to the right that the "Left" was engaged in a purposeful campaign to destroy the Constitution and install a totalitarian regime. I blamed the media and our two main political parties for the incessant drumbeat of hysterical "news" stories, inflammatory language and demonization of others that fed this mass hysteria. But it turns out that the real story is even weirder: It was the Russians.

Why do people succumb to propaganda and why can't they see that they are being manipulated? There are many factors:

Conformism: Humans are social animals and want to "belong." If a group of people with whom someone wants to associate insists on a shared belief system, many people will adopt the beliefs even though those beliefs have no basis in fact. The strong need to "belong" will override logical thought processes.

Displacement: Persons with histories of abuse or neglect in childhood deal with anxiety, anger and even outrage, but may be unable to connect those emotions with their childhood experiences due to wanting to protect the images of their family members. Instead, they direct their fear and outrage toward public figures or groups or imagined groups. It is emotionally convenient to fear and hate those you don't personally know.

Self-esteem: Many people revel in a belief in their own moral superiority. By aligning themselves with what they see as a virtuous or righteous position and condemning others who disagree, they feel better about themselves.

What can counter these dangerous tendencies? Here are some tips:

1. Learn history. The better educated and older people I know demonstrated less susceptibility to the propaganda, and not just because they don't use Twitter. It's that they (we) have seen it all before, and what we haven't seen personally we have read about. Propaganda and popular hysteria are nothing new. There have been waves of mass hysteria throughout history, often with atrocious, catastrophic or genocidal results.

2. Use logical analysis to assess claims made by groups, including established groups. It doesn't matter who made the argument or published the news story if it doesn't make sense.

3. Listen to your gut instincts. If something seems fishy, it probably is. If you can't put the pieces together, maybe it's because they don't fit. Ask yourself: Is something missing from the story? Does the story seem too bad or too good to be real?

4. Live a healthier lifestyle: Acknowledge your childhood traumas, build your self-esteem in healthy ways and seek friends who don't demand that you agree with their political beliefs. Talk to different types of people and listen to them.

Tuesday, October 24, 2017

Harvey Weinstein Heads to Rehab

Yesterday I read that Harvey Weinstein is checking into a facility for treatment of "sex addiction." Is repetitive sexual harassment or sexual assault a form of sex addiction? 

Sex addiction, like any addiction, is a repetitive, compulsive behavior. The hallmark of any addictive behavior is that it is experienced as being outside of the person's control. A common self-test for addiction is to try to stop the behavior for a period of time. If you find that you are engaging in the behavior after you told yourself you wouldn't, this could be a sign of an addictive disorder. Simply making something a habit is not itself  a sign of addiction. If the behavior is under the person's control, an addiction has not been established regardless of how dysfunctional the behavior is.

Sex addicts typically either frequent prostitutes, pick up random strangers for sex on a regular basis, or spend hours masturbating to online pornography. Some also compulsively attend peep shows and strip clubs. Eventually they start to realize that they are spending enormous amounts of time or money (or both) on their sexual activities, and perhaps endangering their health or even their lives. At this point an addiction has been established, and sometimes, people seek help.

Based on the publicly reported evidence, Weinstein appears to have exercised great control and planning in his harassment activities. Subterfuge and the assistance of allies appear to have been involved in the various scenarios that have been reported. The cost of hiding the behavior appears to have been calculated. This type of planning and execution is rare in addictive behaviors, because, as I said, the hallmark of addiction is that the behavior has spun out of control. In addition, on a deeper psychological level, addiction is about a regression in which the person unconsciously grants power to a substance or behavior, enacting a dominance/submission dynamic in which the addict is the submissive. In Weinstein's case, it's obvious that the dynamic went the other way in his encounters with young actresses and models.

If it's not an addictive disorder, is it possible that Weinstein has a different clinical disorder? It's possible and perhaps likely, but it may be one that it is extremely difficult to treat. Pleasure in exercising control and dominance over others is sadism, a psychological phenomenon that is rarely treated because sadists don't seek help. I'm not aware of any standard treatment protocols for sadism except perhaps psychoanalytic therapy to resolve early childhood traumas and conflicts, but, as sadists are rarely interested in such treatment, there isn't a lot of evidence regarding outcomes. Sadism is often a component of antisocial personality disorder (also called sociopathy or psychopathy) and this disorder is notoriously difficult to treat. Confrontation and limit-setting may be the only ways to address sociopathic behavior. People, like other animals, respond to negative consequences for behavior.

Tuesday, October 17, 2017

Normalization of Pathological Behavior, Part One: Psychological Defense Mechanisms

Since the Harvey Weinstein revelations, I've been thinking about the normalization of pathological behavior. This is a common phenomenon in our society and in most societies.

This article in The New York Times summarizes the reasons why women often don't report sexual harassment--mainly, that they fear retaliation. There are other factors, however, that make people in general turn a blind eye to harmful and pathological behaviors. These include psychological defense mechanisms such as denial, rationalization and dissociation, effects of mass culture, and deliberate propaganda by vested interests that uses rhetorical tricks to minimize atrocities. I'll address psychological defense mechanisms today.

Psychological defense mechanisms serve to ward off anxiety by distorting reality. In rationalization, the mind invents "reasons" why something happens that aren't really logical, but serve to distract from an unpleasant or frightening reality. In dissociation, consciousness is altered so that an experience isn't perceived at all in daily consciousness, but may be acted out unconsciously, or remembered while in an altered state (such as hypnosis). Denial is a phenomenon in which "the existence of unpleasant realities is disavowed; [it] refers to keeping out of conscious awareness any aspects of external reality that, if acknowledged, would produce anxiety" (Kaplan and Sadock, "Synopsis of Psychiatry," 2007 edition). Denial and dissociation are closely related.

The mind resorts to defensive maneuvers in order to preserve physical health. Overwhelming stress can cause great damage to the body--altering hormones, damaging the immune system, interfering with sleep and worse. The survival instinct will undermine the mind's ability to accurately perceive reality in order to avoid the physically damaging effects of overwhelming fear.

People who have been victims of rape or other traumas not infrequently experience dissociation. Aspects of the trauma may be blocked from conscious awareness.

Sometimes trauma survivors invent "reasons" why the incident occurred (rationalization). As the general population is made aware of behavior such as Weinstein's, others may also engage in denial or rationalization. People don't want to believe that another human could be that horrible, and perhaps especially, when that human is the same gender as they are. It's too frightening.

The way to overcome denial, dissociation and rationalization is to speak about the crimes and traumas. Overwhelming evidence eventually destroys the use of distorting defense mechanisms, in all but the psychotic.