Wednesday, March 21, 2018

The DSM-5: A Flawed Document

For all official purposes--including insurance claims--psychotherapists are required to use the diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, currently in its fifth version (the DSM-5). Unfortunately, the DSM is a limited and even inaccurate text that in some areas reflects social and cultural biases. It has been written and revised by a team of psychiatrists who are mostly male, even though the majority of mental health clinicians are female and aren't psychiatrists. I and many other therapists find it to be of limited usefulness for diagnosis and assessment.

The DSM diagnoses were developed using the "medical model," which means they are symptom-based. The problem with this model is that although it describes what disorders look like, it does not describe their etiology--how they came to be. Although the DSM includes information about prevalence and prognosis, it doesn't describe how and why disorders develop.

The reason the DSM categories and descriptions are symptom-based is because that's what insurance companies and pharmaceutical companies want--they want to know how many symptoms a patient has because this can be fairly easily measured. Non-medical therapists and psychoanalysts are more interested in the underlying psychological structures and dynamics of a patient's illness, because our goal is not just symptom reduction, which can be temporary, but lasting change.

Perhaps the best example of a discrepancy between the DSM and other models are the different conceptions of Borderline Personality Disorder. The DSM description is a grab bag of symptoms that can also be found in people with Post Traumatic Stress Disorder. This can lead to diagnostic confusion. Psychoanalytically-oriented therapists, on the other hand, assess Borderline Personality Disorder based not just on symptoms but on factors such as which psychological defenses the patient uses, what type of interpersonal relationships they have, and how they manage stress. Ultimately this type of assessment allows us to differentiate between BPD and PTSD, to tailor treatment more effectively, and to better predict outcomes (prognosis).

Cultural biases are also found in the DSM. The criteria for Anti-Social Personality Disorder (sociopathy) include law-breaking. Whose laws? Laws vary from country to country and from state to state. Some laws may be unjust. This DSM criterion equates conformity and obedience with mental health. A psychoanalytically-oriented therapist is more interested in other criteria such as the patient's capacity for empathy, presence or lack of deceit, personal responsibility, presence or absence of aggression/sadism, and capacity for trust. The DSM criteria also do not address the fact that certain groups are more likely to come in contact with the police for reasons that have nothing to do with their personalities.

Similarly, the DSM criteria for Histrionic Personality Disorder includes "consistently uses physical appearance to draw attention to self." Women are encouraged to use physical appearance to draw attention to self, in Western cultures. This may have resulted in more women than men being diagnosed with HPD, although there is no evidence that women are more likely to have this disorder.

The influence of pharmaceutical companies is well-known among clinicians. A disorder originally called "Minimal Brain Dysfunction" was re-labeled as "Attention Deficit Hyperactivity Disorder" by the pharmaceutical industry, in order to better market their drugs. Many patients are unaware that "ADD" as many people call it, is a disorder invented by people who weren't acting on behalf of patients. Again, the listed symptoms of ADHD can overlap with other conditions, especially abuse and neglect of children. It's easier for a doctor to write a prescription than to call child welfare or to recommend parenting classes. It's the parents who are paying the doctor's bills, in most cases.

It's been said that "the winners write history." They also write the laws, the rules, and the diagnostic criteria.

Sunday, March 4, 2018

Are Movies Bad for your Daughter?

Perhaps the first answer I would give to this question would be "Not as bad as video games are for your son." At least most movies have story lines and characters that can be compared and discussed in relation to real life situations, rather than depicting enemies as mere targets. But the movies you and your children watch are filled with sexists messages that can have effects on young girls. 

With all the attention given to film content because of the "#Metoo" and "TimesUp" movements, I've been pondering what I was exposed to as a child. The sad conclusion I came to was that although what I was exposed to, in the 1970s, was bad, today's films aren't much better and possibly are worse.

I wasn't bothered by the "Bond girls," back when I was 12,  because they were mostly heroines and even action heroines in some circumstances: Think of "Pussy Galore," an air commander with a fleet of all-female pilots--almost a radical feminist statement! (if they hadn't been mostly 22- year old blondes). Or Tully Masterson, who tried to avenge her sister's death with a sniper rifle. Most of the sex was depicted by suggestion and innuendo. Today's action movies are either cartoon/comic adaptations that have no relationship to real life, or, they are live action movies with male heroes (Liam Neeson, Vin Diesel, Tom Cruise, Daniel Craig) in which the female roles aren't memorable. The last Bond movie I saw, "Skyfall," was execrable and featured females as failures and quick victims, but was dressed up with Judi Dench in the minor role of "M." And because Daniel Craig was tied up filming that movie and the next Bond film (which needless to say I did not see), the sequels to "Girl with a Dragon Tattoo"--an immensely popular story with an unusual heroine and a feminist message--did not get made. 

An insidious message that has persisted and perhaps even gotten worse is the message that women can't be friends with each other. I've noticed this even in recent,  so-called feminist films: Whereas in the "Hunger Games" books Katniss Everdeen had a female friend, this small role was excised from the films. The cinematic Katniss has no female friends. In "Maleficent," purportedly a feminist twist on the "Sleeping Beauty" fairy tale, Aurora plays with seemingly male forest creatures, Maleficent's companion is a male crow, and the three fairies who raise Aurora are depicted not as friends but as a group of catty, quarreling women who insult each other. As in the Hunger Games movies, the positive female relationships are family relationships--mother/daughter, stepmother/daughter, sister/sister. The message is that outside of the family, other women can't be trusted.

Parents might want to think about another message besides misogyny that their daughters might grasp from misogynistic films: The message that adults aren't role models. I'll never forget my response to the movie "M*A*S*H" when I was around 11 or 12: When the "heroes" humiliate the "Hot Lips" Houlihan character by ripping her shower curtain off and exposing her to a crowd, I realized this action was supposed to be cheered by the audience. Since I knew what they were doing was wrong, the message I received was that adults didn't care about the difference between right and wrong and were a bunch of hypocrites. These type of movies, which are still extremely common, should not be viewed by children under 15. In fact, they should not be viewed at all. 

What children need is to see are depictions of other children with whom they can identify, who have friends (including same-sex friends) and who solve problems,  and depictions of adults who are icons or role models. Today's movies and TV don't cut it. You can solve this problem by encouraging your children to read books. 

Tuesday, February 27, 2018

It Gets Better--Sort Of

A couple of years ago I heard something about a public service campaign aimed at gay teens, called "It Gets Better." I think the notion was to tell teens that they wouldn't get bullied after they left high school. I don't recall seeing any of the actual PSAs, and frankly I questioned the campaign, because bullying doesn't go away when you leave high school. What does change is that the older you get, often, the more resilient you are.

Studies over the years have found that mental health improves with age. This runs counter to the popular culture presentation of aging, which is mostly one of increasing decrepitude. But can anyone really be surprised? The older you are, the more struggles you have faced and overcome. In most cases, you can look back at a life of achievements and feel pride. The perspective of time helps one to weather disappointments with the view "This too shall pass." 

The distorted messages about aging given by popular culture are destructive. If young people believe that old age--typically defined by movies and tv as being over 55 or so--is a time of decline and ugliness, they won't look forward to it. They will be more likely to smoke cigarettes, do drugs, not save money, and generally behave recklessly, under the assumption that living past 55 is unimportant and perhaps something to be avoided.  And yet a study recently quoted by AARP found that 80-year-olds are more content with their lives than 20-year-olds are.

Aging, especially for women, is portrayed as something hideous by the media. Unfortunately, many women believe this propaganda and go to great lengths to forestall the signs of aging. The advantages of looking older aren't mentioned--the big advantage being a steep drop in sexual harassment.

It is true that growing older means physical decline--often more decline than what many young people realize. But physical decline isn't what it used to be. Most jobs no longer require physical fitness, and modern conveniences help the partially disabled compensate. Mental health is more important for happiness than physical health--a lot more important. 

One of the many misconceptions about older people among the young is about fun. To illustrate: Some months ago I was at a bar with a friend around the same age as me, and the bartender, a 20-something male, asked us if we were going somewhere from there. When we told him we were going to a concert movie for a hard rock/heavy metal band, he thought we were playing a joke on him. "But why would we be joking?" my friend replied, mystified. She's a few years younger than me, and perhaps was just learning that 50-year-old women are seen by some 25-year-old males as hags whose hobbies are restricted to card games, restaurants and an occasional Broadway show. Where do they get these ideas? Movies and television. In fact, most middle-aged people and even older people, up to an extent, engage in the same hobbies all their lives. Eventually, injuries and arthritis mean the end of extreme sports and contact sports, but tastes in music and the arts don't go away--they are more likely to expand than to contract (and who did the young bartender think invented rock and metal music--it was my generation!). I was able to laugh at the ageism (and sexism??) because as you get older, you develop a thicker skin. The older you get, the more you know, and knowing more makes you smug.

Lifespans are getting longer, and many do not anticipate this. I have an 85-year-old colleague with whom I do consulting work. On a recent vacation in California, I met a 96-year-old Park Ranger at a national park. She'd gotten bored in her 80s and decided to get a job. Her job was to speak with tourists about the history of the shipbuilding industry in Richmond, California, and her time working there as a black woman in a pre-integration era. She spoke for a half hour without notes. Who needs to read history when you can hear it directly from the source? And yet, I read in respectable newspapers and magazines that we need increased immigration to make up for a lack of younger workers in the US. If people work to their 80s and 90s, how much younger do younger workers need to be? Besides jobs involving physical labor--which are increasingly being done by machines--which jobs need to be done by youth?

The strange dichotomy between the real world and the world depicted by the media intrigues me. My best advice to the young is look with your own eyes and speak to older people to find out what growing older is really like.

Wednesday, February 21, 2018

Historical and Psychological Explanations for Gun Culture

The debate about gun control again rages, in the wake of a shocking mass killing. Proponents of gun control argue that European and other countries have stricter gun laws and far fewer shootings. But no one seems to be asking the question: Why do those other countries have stricter gun laws? Why do we have lax gun laws and enforcement and a strong gun culture? The answers can be found in our history and in psychology.

The basic motivator for most behaviors is fear.  The first white settlers to the US were mostly fleeing religious persecution. Many Americans don't think about how and why we have the freedom of religion that's enshrined in our First Amendment and doesn't exist in most other countries. How bad was the governmental persecution that prompted people to get in a boat and travel thousands of miles to a wilderness? No one takes such a step unless they are motivated by fear for their lives and for their basic rights.

Later, Britain took control over the US settlements as a colony, with all the exploitation and oppression that that involves. Today, when most people think of "colonialism," they think of white people oppressing brown and black people, not white people oppressing other white people--even though a colonial conflict persists in Northern Ireland. This confusion, especially in the minds of young people, is because of a type of political correctness that has infected education in the US. The early American colonists lived in fear and hatred of the British overlords. European countries have long histories of warfare and conflict, but those conflicts were between established states or tribal or feudal groups that were loyal to their leaders. People felt oppressed by foreign invaders or would-be invaders, not by a foreign occupying power. There is a deep psychological difference. To be ruled over by a foreign, oppressive force in your own country leaves a psychological impact that warfare alone does not. One could compare it to the difference between stranger rape on the street and growing up being sexually abused by one's stepfather.

To make matters worse, the settlers settled in an already occupied country, and were engaged in frequent conflict with the Native Americans. This history has little parallel with anything that happened in Europe--at least not since Europe in prehistoric times.  And, the Americas were wild. Wolves and bears went extinct in England before the contemporary era, but even today humans in the US are still occasionally attacked by bears and mountain lions. The American West was sparsely populated, and law enforcement was often in the hands of civilians.

The cultural memory of being surrounded by threats and ruled by an oppressive foreign government is fairly fresh.  When people talk about the Second Amendment, they aren't talking about shooting guns as a pastime. They are talking about a cultural fear that is deeply embedded in our country, a fear that our government may exploit or oppress us and use their monopoly on arms to do so, and a fear that our neighbors also may be a threat and there will be no one who will come to our aid.  The more culturally homogenous and older nations of Europe don't have these deep-seated cultural fears.

There are more recent historical and sociological phenomena that have led to mass shootings both in the US and in Europe. The status of white men is in decline. Most of the shooters have been white males. There is a widespread erroneous belief that poverty leads to both interpersonal violence and to rebellions. In fact, history's revolutions have typically occurred when a middle class has felt exploited or treated unfairly. When the middle class believes they aren't getting something that's due to them, they will rebel--the French Revolution is a good example. Today's white males are given messages from popular culture--such as from pornography, advertising, and films--that they are entitled to women's bodies, to consumer products and to status--yet in reality they are living in a society in which they have less privilege than their fathers did. This sets up a belief among young white men that they are getting shafted--that they aren't getting what's due to them.

A culture steeped in fear of government oppression and fear of a dangerous environment creates a gun culture. Who would give up their guns if they thought they might be needed to overthrow a tyranny or protect against civil strife? Meanwhile, recent historical and cultural changes have created a demographic of entitled yet resentful young males. Mix in disorders that I've previously identified in this blog as being implicated in mass violence--sociopathy, narcissistic personality disorder and delusional disorder--and the only surprise should be that there aren't more mass shootings.

Thursday, January 25, 2018

Crimes in Plain Sight

There's a common thread in two front-page news stories. In California, parents hid their severely abused children in plain sight. In Michigan and elsewhere, a doctor sexually abused teenage girls right in front of witnesses. No one did anything.

Why don't people notice what is right in front of them? Here is a list of answers:

1. A lingering belief, left over from agrarian patriarchy, that children are the possessions of their parents, rather than individuals with human rights.

2. A belief in "maternal instinct," which is translated to mean all mothers love their children and know what's best for them.

3. A mistaken faith in designated authorities and a corresponding lack of confidence in one's own judgment.

4. A mobile and transient society that is overpopulated and overworked and encouraged to spend leisure time with electronic gadgets rather than with other people.

5. The American tradition of individualism, which in contemporary society has been termed the "right to privacy"-- although no such right actually exists in the Constitution.

6. A tolerance of "difference" that has gone well beyond notions of equal rights to mean tolerance of pathological behaviors.

All of the above reasons relate to the horror in California. One neighbor thought that the children's bizarre nighttime activity must be some sort of therapy for special needs children. The neighbor believed the children must have a disorder that he, as a layperson, couldn't possibly understand, and he ignored the most obvious possible cause of the children's malfunction--abuse. Why would we be surprised--we live in a society that has given dozens of different names to children's disorders that obfuscate the fact these disorders are caused by abuse or neglect. Examples include "Fetal Alcohol Syndrome," which is caused by maternal alcoholism, and "Oppositional Defiant Disorder," a fancy term for bad behavior in children that is caused by poor parenting or in some cases neglect or abuse.

Churchgoers, fellow students, college professors and neighbors didn't question why the family wasn't social, because we live in a society in which "entertainment" comes from glowing screens rather than human interaction.  More puzzlingly, some ignored the extreme thinness of the children and in one instance, the fact one child wolfed down food when it was available. But in a society in which we are encouraged to celebrate different "body types" (note the "Fat Acceptance" movement) and any and every kind of diet, no matter how unnatural, the witnesses probably felt uncomfortable asking questions. (How far are we from an Anorexia Acceptance movement? Not far). Even failure to obtain basic medical care for one's children, such as vaccines against fatal communicable diseases, is considered acceptable in many circles. Increasingly, we live in a society in which questioning another's behaviors or way of life is considered "intolerant," "judgmental" or even bigoted.

No one reported Dr. Nassar because he was a highly respected and credentialed doctor (Reason #3). But credentials and peer recognition do not guarantee good ethics. No one believed the children because many do not believe that children, including their own children, possess judgment (Reason #1). Despite the fact that many parents cater to their children's whims and treat them inappropriately as friends, a condescension toward children persists in our society. There used to be an old saying, "out of the mouths of babes" comes wisdom, but like so many old aphorisms that represented the distillation of thousands of years of knowledge, it has fallen by the wayside in favor of credentialism. More incredibly, no one questioned why a male doctor would choose to specialize in treating adolescent girls. Perhaps many were uncomfortable asking this question, believing it would imply some sort of "misandry" (a word with which I recently became acquainted, via the internet). The fear of being called a bigot has become paralyzing (#6).

I honestly don't believe it was lack of compassion nor laziness that kept people from noticing and reporting what was right under their noses. It was the messages of our society that teach people that  credentials trump common sense, that they shouldn't judge others' behavior, that parents know best and that no one actually doesn't love their children. None of these messages are true.

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.