Tuesday, December 8, 2015

Holiday Cheer?

It's the time of year when many employers hold holiday parties for their employees. Some of these parties will be held in venues that serve alcohol, despite the fact that approximately 10 percent of people are alcoholics or have the disposition to become alcoholic.

I've had at least one patient who was fired from a job due to alcohol-related behavior at an office party. Why would employers create situations that facilitate problematic behavior and raise liability risk for the company? Because often managers are people without common sense.

Even without alcohol, office parties may be problematic, because co-workers aren't necessarily friends. People choose their friends, but they rarely choose their co-workers.

The office party may be an attempt by the management to create an image of bonhomie among workers, an image that may  not correspond to reality.

If employers choose to hold holiday parties, they should be optional events and in no circumstance should alcohol be served.

 Increased diversity in the workplace in recent decades has not always meant increased harmony in the workplace. Many male or white employees have not made the mental transition to a diverse workplace.

Free-form banter among persons who have nothing in common except their place of employment is likely to lead to disharmony. In what may go down in history as the worst possible outcome of this type of disharmony, the recent San Bernardino shooter may have been involved in a heated  conversation with co-workers prior to the attack. (Although the couple was planning a terrorist attack for some time, it's not clear that the office party was the original intended target). One newspaper report I read indicated the conversation may have been about "Israel." Why on earth would someone initiate or continue a conversation about a controversial foreign policy subject with a co-worker he or she isn't friends with and especially, if it's likely the co-worker will disagree? In fact it looks like a deliberate attempt at provocation. I've observed, over the course of my life, that many people enjoy provoking others with whom they disagree. This isn't smart behavior, but many people do not use good judgment in social situations.

Having lived and traveled around the world, I've observed that many issues that are life-or-death to persons in foreign countries are viewed as abstractions and appropriate topics for social conversations among Americans. There used to be a commonly-repeated dictum in American social etiquette,  "don't discuss religion or politics," but this dictum has fallen by the wayside.

If you don't know your co-workers well, it's best to avoid any controversial topics of conversation.

Friday, December 4, 2015

What Questions Should You Ask A Prospective Therapist?

The most common question people ask when they contact me is "Are you taking new patients?" In most cases, the person is seeking to make an appointment, so it  would save time if the person just said 'I'd like to make an appointment."  This would result in my saying "do you need an evening slot or can you come during the day?" or "I have a time available at 6 p.m. Monday" or "I'm not taking new patients right now." All of those responses answer the question of whether I am taking new patients or not, as I would never enter a conversation about scheduling unless I was taking new patients. If I am taking new patients, we can get right down to the details of scheduling.

What type of questions should people ask when they contact a therapist? First of all, people should ask whether I take their insurance or what type of fees I charge. I am often surprised how many people ask for an appointment without asking first for this information. When I tell some people that I don't take their insurance, they are surprised. I'm often not sure where the misinformation has come from. I am on some HMO panels and not on others. Many times people have found me through their insurance directory, but sometimes people find me through the internet or personal referrals.

 A few people pay cash for their sessions. I have a sliding scale fee based on income/net worth. On a few (thankfully rare) occasions, a patient who reports a high income has tried to "negotiate" a lower fee. I offer lower fees for people with low incomes, not for people with high incomes.

I sometimes I get a question along the lines of: "What is your orientation?" People aren't asking about my sexual orientation. They're asking about my theoretical orientation. I'm never sure how to answer this question. If I gave a complete answer, it would sound like gibberish to most people. It would sound something like this: "I believe Object Relations Theory, Self Psychology and Ego Psychology are all important. I sometimes use DBT techniques for anxiety disorders and borderline personality disorder. I've been trained in Family Systems Therapy, but when I do couples counseling I mostly just take a problem-solving approach." (that isn't even a totally complete answer).  If you understood all of that, you are probably a therapist yourself.

What I usually say instead is "I'm mostly an insight-oriented therapist, but I sometimes use DBT and other techniques as appropriate." But I don't think most people understand that either. 

There are some questions on subjects other than payment and scheduling that someone might want to ask a prospective therapist:

1. Do you have experience treating (name of problem)?
2. What are the typical types of patients you work with?
3. Are there any types of patients you don't work with? 
4. How many years have you been practicing psychotherapy?

 The answers to these questions are more important than the theoretical orientation to which a therapist subscribes. 

 Newspapers, TV and the internet are full of articles about new types of therapy, often accompanied by claims that the new treatment works miracles. Never forget that today's miracle cure is tomorrow's debunked failure. Almost all of these articles are written by people who aren't mental health professionals. Some of these articles may give a false impression that one can understand different types of therapy by reading articles in the media.

 All types of psychotherapy adhere to some basic principles and most therapists today use a variety of techniques. In fact, if you come across a therapist who is wedded to a particular theory or technique,  you should be suspicious. That type of specialization only works if the therapist is willing to refer out all patients who need a different type of therapy, and in today's economy, most therapists need more patients, not fewer patients. I do refer out people who need a type of therapy I don't do. But mostly I have a general practice that allows me to see a wide variety of patients. Most of them get better.

Sunday, November 1, 2015

Narcissistic Personality Disorder--Diagnosis and Treatment

NOTE: This post has been edited since originally published. I've noticed that Narcissistic Personality Disorder is increasingly being used as an epithet in the media and by the general public. It is actually a serious disorder with a lack of effective treatment protocols, and it is on the increase.

The Diagnostic and Statistical Manual of Mental Disorders' checklist of NPD symptoms for diagnosis is the following. Only five symptoms need be present to diagnose the disorder:

1. Has a grandiose sense of self-importance.
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love.
3. Believes that he or she is "special" and unique and can only understood by or should associate with, other special or high-status people or institutions.
4. Requires excessive admiration.
5. Has a sense of entitlement.
6. Is interpersonally exploitative.
7. Lacks empathy, is unwilling to recognize or identify with the needs of others.
8. If often envious of others or believes that others are envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.

Many people with NPD do not have the stereotypical presentation of being overtly arrogant or haughty.  I believe the DSM model has been based on treatment experiences with white American males. I work with a diverse population and I've noticed that some people, especially women from cultures in which deference and politeness are valued, can have NPD that is only revealed through an examination of their mental content, not their social behavior.

No one has ever come to my practice for treatment of their Narcissistic Personality Disorder. As I mentioned in my previous post, personality disorders are created by the use of pathological ego defenses that are unconscious. People with NPD are unaware that they have the disorder. Most people with NPD whom I've seen have come to therapy because of dissatisfaction with careers, depression, addictions, or problems managing anger. I will confess that I do not believe I have ever cured anyone's NPD, nor am I aware of any therapist who has done so. Most clinicians and theorists believe that NPD is barely treatable and probably not cureable. However, people with NPD can be helped to develop insight and better judgment, and their symptoms of depression and anxiety generally improve with therapy.

Psychoanalytic theorists became very interested in NPD between the 1970s and the 1990s, but the disorder has received little attention in recent years, in terms of treatment protocols. Yet some research has shown that NPD is on the increase, and it can be a dangerous disorder when it involves lack of empathy. It cannot be resolved with medication, and I believe there's a possibility anti-depressants may make it worse, because they increase self-esteem without increasing insight,  which could result in a spike in feelings of grandiosity. Perhaps research will eventually suggest mood stabilizers should be used to treat NPD, but these would not cure the underlying disorder.

Two main theorists have written about NPD: Otto Kernberg, who I mentioned in my previous post, and Heinz Kohut, another psychoanalyst. Kernberg describes a developmental process in which unempathic caregivers give a child the message he or she cannot emotionally depend on anyone. The child may be used for the parent(s)' own purposes, for example, as someone to show off.  This interferes with the normal development of the superego. In normal development, the superego includes a component called the ego ideal, which one might describe as the "carrot" whereas the punitive aspects of the superego are the "stick." In normal development, the ego ideal is a psychic structure based on internalizations of persons, systems or values that are admired and desired to be emulated. Without a healthy ego ideal, the child  develops "pathological grandiosity" in which he or she become his or her own ego ideal, in a sense worshiping him/herself. This self-worship in lieu of healthy internalizations often leads to a feeling of being hollow, because humans are social animals who depend not only on others in the external world, but also on our internalized representations of others.  Kohut developed a slightly different theory that holds that although the ego ideal is necessary for ambition, people with NPD are likely to suffer from a disordered sense of self that is due to a lack of "mirroring" in childhood. His branch of psychoanalytic theory is known as "Self Psychology" and clinicians who follow Kohut's theories tend to believe that therapy that validates a patient's accomplishments as well as emotions,  and tolerates a natural idealization of the therapist,  is curative.

I've worked with many patients with narcissistic traits, but probably only a few who have had full-blown NPD. What I have experienced in my treatment of persons with NPD and of people with the traits, is that they often improve a lot in the first six months of therapy. Their depression decreases, and  if they have had problems managing anger, that usually gets better. They often enjoy therapy. But I've also noticed that after a certain point, the therapy stalls. This can be from a number of reasons, including the difficulty in giving up grandiosity and sometimes, the patient's envy of the therapist, which leads him or her to subtly sabotage the therapy. Here are some examples of how therapy can be only partially effective for people with narcissistic problems:

1. A woman came to see me due to problems with depression and some other issues. She started feeling better and resolved some issues after about six months. But, she continued to complain of some symptoms including a feeling of being "hollow." She continued in therapy and I began to notice what seemed like a change: She came to her sessions directly from work, and I saw that sometimes she wore sexually provocative clothing that seemed inappropriate for the workplace. She began to describe herself and her friends using superlatives that most people do not use in ordinary descriptions. She began dating someone who was sociopathic and although she realized there might be something wrong with him, was adamantly convinced that they had a "special" relationship. She was chronically dissatisfied in her career and frequently changed jobs. I eventually realized, as did she, that therapy was beginning to stall. I had begun to feel that it didn't matter what I said and although the patient was continuing to attend therapy, it seemed we were no longer making progress. Eventually we mutually agreed to terminate her therapy. We had resolved her depression, but not her narcissistic traits. (Note: Although the patient had some symptoms that might suggest mania/bipolar disorder, she lacked the classic symptoms of high energy with little sleep, impulsive behavior that is out of character, and pressured speech. Some symptoms of NPD and bipolar disorder overlap).

2. A woman came to see me for career dissatisfaction among other concerns. Although some of her problems cleared up after awhile in therapy, she did not resolve her career dissatisfaction. We discussed various possibilities for modifying her career, but I began to notice that if I suggested an avenue to explore, she gave me a reason why she couldn't do it or wasn't interested in it. No type of work or activity really appeals to people with NPD unless it involves attention from others, or what could be called fame or glory. The normal reasons why people value their work, such as pride in achieving certain skills or helping others, are meaningless to the NPD. Sadly, many jobs and activities don't result in praise and attention, and the NPD is therefore chronically dissatisfied. This chronic dissatisfaction is why NPD is so often implicated in substance abuse and in chronic depression.

3. A man  came to see me because of career dissatisfaction and some interpersonal events. He had had a traumatic break-up and I hoped that he could find a happy relationship that would help him get over the traumatic break-up. But as he described his dating activities, it became quite evident that he had no empathy for the people he dated and was sometimes quite critical of how a person looked, (even though he was willing to have sex with them regardless of whether he found them attractive). It turned out he'd pursued his career because he thought it would give him a sense of importance, but the reality is that few jobs change the world or make one famous, just as few romantic partners are beautiful or dramatically exciting. I couldn't think of any realistic career path that would give this man what he craved, and he seemed to come to the realization eventually that he wasn't  interested in a committed romantic partner--at which point he left therapy.

There may be a treatment program that is effective for NPD, even though it wasn't, at least not overtly, designed to treat NPD at all. The 12-step program was designed to treat addictions, but as I have studied it over the years, it has struck me how much of it might actually be targeted toward the symptoms of NPD:  The 12-step program insists that its members "deal with life on life's terms," and "turn it over" to a "higher power." It has occurred to me that the "higher power," when internalized, could create a healthy ego ideal. The group norms of the 12-step program, such an anonymity, help to stifle grandiosity and instead provide emotional nurturance through group support. Slogans such as "Easy Does It" and "Live and Let Live" may help temper the rage, envy and other problems that plague people with NPD.  Although the 12-step program may not totally "cure" NPD it may control and ameliorate it.

The therapeutic dyad sometimes sets up a power struggle for the person with NPD by making him/her feel vulnerable. Kohut's idea that the therapist can be idealized and that this is curative I find to be somewhat ridiculous--adults don't idealize people the way children do, or if they do, they set themselves up for a quick disappointment. It's well known that people with NPD often idealize, then devalue others.  Only abstractions--such as a "Higher Power"--can be truly idealized and internalized in adulthood. 

Wednesday, October 14, 2015

Diagnosing and Treating Borderline and Narcissistic Personality Disorders, Part One: Borderline Personality Disorder

Over the past 10 or 20 years there have been increased mentions of Borderline Personality Disorder and Narcissistic Personality Disorder in the media, including newspapers, self-help books and even feature films. These disorders are complex and manifest differently in different individuals. Many times clinicians can't diagnose, or won't diagnose, these disorders in the first session or the first several sessions, especially if the person is initially depressed.

How to diagnose personality disorders remains controversial in the mental health field. The Diagnostic and Statistical Manual of Mental Disorders, the main reference book for diagnosis, uses checklists of symptoms. Is a checklist of symptoms really the most accurate way to diagnose a disorder? A checklist does not describe causes or underlying psychological processes.
The current checklist for Borderline Personality Disorder in the DSM-V, is the following ( only 5 of these symptoms need be present to make the diagnosis). One can see that there might be significant overlap with other diagnoses, such as depression and PTSD:

1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating extremes of idealization and devaluation.
3. Identity disturbance: markely and persistenly unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentialy self-damaging.
5. Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior.
6. Affective (emotional) instability.
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger.
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Starting in the 1970s, a psychoanalyst and researcher named Otto Kernberg began studying borderline personality disorder, a condition that had begun to be identified after the time of Sigmund Freud. Prior to the development of the term "borderline personality disorder," clinicians sometimes came across patients with what they called "ambulatory schizophrenia" or the "As If" personality. What they were trying to describe was a syndrome in which the person functioned mostly normally, and had no obvious evidence of psychosis, but under psychoanalysis or even just persistent questioning, revealed themselves to have highly distorted thought processes. Kernberg came up with a type of initial evaluation to diagnose this condition. He also developed a theory that remains controversial today. He believes that all personality disorders are subsets of borderline personality disorder, because the disorder isn't really a syndrome at all but a type of personality organization--"Borderline" refers to the border between neurosis and psychosis. "Normal" people have a neurotic level of organization (no one is completely mentally healthy), psychotic people have lost the ability to distinguish reality from fantasy, and borderlines, in the middle, remain in touch with physical reality but distort perceptions based on pathological psychological defenses. These distorted perceptions can lead to problems in interpersonal relationships and other issues. Other personality disorders, such as narcissistic personality disorder, function on the same level, but simply manifest differently due to slightly different personality development.

The subject of psychological defense mechanisms is complex. However, this explanation, taken from Wikipedia, is generally correct:

A defence mechanism...reduces anxiety arising from unacceptable or potentially harmful impulses. Defence mechanisms are unconscious and are not to be confused with conscious coping strategies "
... In psychoanalytic theory, defence mechanisms...are psychological strategies brought into play by the unconscious mind to manipulate, deny, or distort reality in order to defend against feelings of anxiety and unacceptable impulses
....Healthy persons normally use different defences throughout life. An ego defence mechanism becomes pathological only when its persistent use leads to maladaptive behaviour such that the physical or mental health of the individual is adversely affected.

Kernberg and others have found that people with borderline personality disorder often extensively use the defenses of idealization, devaluation (often combined in "splitting"), grandiosity, and types of projection.  But use of these defenses often are not apparent to the casual observer, and, because defenses are unconscious, the borderline person remains unaware of their own use of these defenses.

Although I believe Kernberg's theories to be mostly correct and especially helpful in terms of formulating a prognosis, like many psychoanalytic theories, it doesn't really address the issue of later environmental factors (Kernberg believes that early environmental factors combined with genetics are at the root of personality disorders). Starting about 20 years ago, theorists began to notice that the typical symptoms of persons with borderline p.d. were quite similar to those of trauma survivors and suggested that some borderlines might actually have PTSD and had been misdiagnosed. But one could say that this is the very reason why Kernberg's perspective is  important, because it emphasizes the underlying defenses rather than the overt symptoms.

Earlier this year I went to a talk by Dr. Michael Stone, the forensic psychiatrist, in which he suggested clinicians decide whether the borderlines with whom they were working had primarily a trauma-based condition or primarily a genetic condition. I've begun to believe that there are different types of borderline p.d. Perhaps eventually diagnostic manuals will reflect what clinicians have been seeing for many years.

How is borderline personality disorder treated? Some would answer, not well. The general consensus is that the disorder is resistant to change. However, there are a multitude of treatments that may help. Traditionally the disorder has been treated with intensive psychotherapy to address the pathological defenses. The underlying premise of this treatment is that human personality is malleable, is developed in an early dyadic relationship, and can be altered by the patient/therapist dyadic relationship even in later life. I believe this to be somewhat true. In the 1990s, a psychologist named Marsha Linehan developed a treatment protocol called Dialectical Behavior Therapy to help borderlines learn to cope with their emotions and interpersonal relations. DBT is now used to help people with other disorders as well.  I occasionally use DBT techniques, as they help people learn assertiveness as well as distraction techniques, especially "mindfulness," to relieve overwhelming emotions. I have found people with anxiety disorders often benefit from DBT.  The DBT program does not really alter the underlying personality structure, however.

I've treated a number of people with borderline personality disorder, and have found them to be quite different from each other. A childhood marked by invalidating remarks by parents is common, but not everyone subjected to such an environment will develop BPD. Psychotherapy that combines validation with confrontation of unhelpful defenses seems to be useful for my personality-disordered patients. In a few cases, I've seen patients with borderline personality disorder benefit from a mood stabilizing medication called Lamictal, which moderates their unstable emotions.

Wednesday, September 30, 2015

"Trigger Warnings"

After writing my last post, on PTSD, I started thinking about the current controversy over "Trigger Warnings," labels that are being placed on some class materials by some college professors. This term misappropriates a concept from mental health treatment. A content warning label is not a "trigger warning."The so-called "trigger warnings" are not really trigger warnings at all, as I will explain:

The concept of a "trigger" that incites symptoms has been used for some time in the study of PTSD (post traumatic stress disorder). For example, it has been observed for many decades that some combat veterans are triggered by the sound of explosions to re-experience combat experiences in a dissociative state. People who have been raped and who have PTSD as a result may experience a triggering of symptoms by a wide variety of stimuli: Some may experience anxiety when alone with a man, during sex, or when exposed to something only tangentially related to the rape--this could be anything from a song that was playing while they were being raped to a particular smell. Clinicians who work with people with PTSD, and researchers who study PTSD, know that a traumatized individual may have very individual, specific, triggers. Thus, it's impossible to predict in advance what might trigger PTSD symptoms in a person with PTSD without knowing that person.

Content warning labels have been used for a long time for movies, and more recently, for record albums. All movies are given a rating for content, the purpose of which is to alert parents that some content might not be appropriate for children. Warning labels on music, which began in the 1980s, perform a similar function. Content warning labels were not designed to help people with PTSD, but to provide information for the general public, especially parents.  Are such warning labels appropriate for college reading materials? College students aren't children and college reading assignments aren't entertainment, but may in fact be designed to provoke or challenge.

A college professor doesn't know individual students at the start of the semester, and can't possibly know whether the class will include students with PTSD, and in any case, what their triggers would be. Many students with PTSD can often figure out, by looking at synopses of books, films or other material that they will have to view for class, whether the materials might contain triggering material. But depending on the individual's triggers, it might also be impossible to predict. What is absolutely certain, however, is that it would be impossible for the professor to predict what material might be triggering to any particular student. And even if it was possible for the professor to know in advance that particular material would be triggering to a particular student, is it the professor's responsibility to warn the student? This puts the professor in the role of mental health clinician, a role most college professors are not qualified or licensed to fulfill.

From a clinical perspective, this type of discussion might be beside the point. Therapists don't counsel PTSD patients to avoid triggers. We don't tell rape survivors to avoid men, or tell Iraq combat veterans to avoid driving so that they won't think about roadside bombs. We help people develop coping skills, tell them that their symptoms are likely to subside over time, and encourage them to NOT avoid triggers, because to do so can increase the fear and create a phobia. This is precisely why the area of PTSD triggers is best left to mental health clinicians and not college professors from unrelated fields. I read a comment from a philosophy professor, in The New York Times, that she gives "trigger warnings" so that students with PTSD can meditate or take medication before exposing themselves to difficult material. As a therapist, I encourage meditation for people who can benefit, but I would never counsel anyone to take an anti-anxiety medication prior to reading a book. This could set the stage for a bad habit. This is not the purpose for which anti-anxiety medication is prescribed.

If a college student had such severe PTSD that she or he was unable to read or view triggering material without experiencing disabling symptoms for hours or without having a suicidal, homicidal or psychotic episode, that person should not be in college at all. College is a stressful environment and persons who are severely psychiatrically ill do not belong in college. However, few PTSD sufferers fall into this category. For most students with PTSD, attending therapy to improve coping skills and process the trauma in a safe environment is enough to be able to attend classes and complete all assignments. There is also the fact that some people with PTSD may have to  acknowledge that for the rest of their lives, they are going to experience some discomfort from certain stimuli that would have no affect on most people. Many people learn to live with symptoms from medical or psychiatric problems, because treatment often doesn't mean a 100 percent cure.

As I thought about this topic, it occurred to me that perhaps what I'm saying here is obvious, and maybe I am missing the point: Maybe the point isn't to help PTSD sufferers at all. Maybe the point of these so-called "trigger warnings" is to alert students to the professor's opinion about the material. Maybe what these "trigger warnings" really do is alert students to the fact that the professor finds the material troubling, and to suggest that the students should also find it troubling. I hope this isn't what's really going on, because it would be a violation of the basic principle of a liberal arts education, which is to teach students independent critical thinking.

Wednesday, September 23, 2015

Taking a Closer Look at PTSD

I wrote a previous post about PTSD (post-traumatic stress disorder), but I decided the subject could use more elaboration. There seems to be  misinformation about PTSD floating around. In addition, there is some dispute in the mental health field about how to categorize PTSD patients who've had different experiences.

PTSD can result from a wide range of traumatic experiences. The Diagnostic and Statistical Manual of Mental Disorders states that PTSD can result from exposure to "actual or threatened death, serious injury, or sexual violence." This covers many types of situations.

It's normal for people exposed to one of the above situations to have symptoms including fears, flashbacks and intrusive memories, for up to one month following the incident. If symptoms last only one month or less, the syndrome is called "Acute Stress Disorder," but in my opinion it is not a disorder at all, but a normal reaction. Most people who have witnessed an accident or a crime that involved serious injury or death to another person will have some of these symptoms. For example, I counseled someone who, while working at a bank, witnessed the bank's armed robbery. In another case, the patient witnessed the sudden death of a co-worker from natural causes. These individuals had some symptoms, but they were not serious.  These types of patients might not need long term treatment and may only need support. If the incident happened at a workplace, sometimes it is helpful for employees to meet as a group for support. I have facilitated some groups for this purpose.

The PTSD cases I've treated have been diverse. At least two patients I've seen had PTSD from terrible accidents. One case resulted from a construction accident in which one person was killed and another seriously injured. Another patient was a driver in a car accident that killed several people--his friends. These individuals had severe PTSD that included hallucinations. In these hallucinations, they saw their dead friends sitting next to them on the sofa and in some cases were able to "touch" the dead friend. The presence of such symptoms does not indicate a chronic psychotic disorder. In fact, visual hallucinations are not uncommon in PTSD, whereas chronic psychotic disorders such as schizophrenia are more likely to involve auditory hallucinations ("hearing voices"). Both patients got somewhat better over time with treatment, but unfortunately one of them developed a drug addiction, which complicated matters.

I've also worked with combat veterans from conflicts including Vietnam, Lebanon, Kosovo,  Iraq and Afghanistan. It is normal for any combat veteran to have some stress disorder symptoms. In some cases, however, symptoms persist long after the person leaves the combat zone. Why does this happen with some individuals and not others? There can be many factors, including the severity of combat experienced, and, as I mentioned in my previous post, guilt feelings.  The guilt can be either irrational or rational. Irrational guilt feelings can be treated in psychotherapy through examining the irrational thoughts and how they developed. Helping someone who feels guilty about doing something that was actually wrong is a bit more complicated. In those cases the treatment might involve helping the person to make amends in some way or helping the person to put  actions in a context. In some cases, when a person has voiced religious views, I have suggested that he speak with clergy from his denomination. I can't answer the question "am I going to Hell?" 

 Exposure to wartime combat may change views on life and prompt philosophical questions. In my opinion dealing with such issues can be an important part of therapy, but unfortunately, there is a trend in the field to emphasize behavioral approaches to PTSD that may be helpful in symptom management but ultimately fail to address the roots of the disorder. Many people who have been exposed to trauma suffer a loss of a previous, idealized view of the world that is common but also inaccurate. I believe that trauma survivors, far from being merely damaged individuals, often have  wisdom that should be appreciated.

About 20 years ago, a psychiatrist named Judith Lewis Herman proposed a new diagnosis called "Complex PTSD" for people who have survived long-term captivity in an abusive situation. This category includes survivors of childhood abuse, as children have no power to leave their abusive situations. This diagnosis has never been formally accepted by the American Psychiatric Association, which is a puzzle to me, because PTSD from long-term childhood abuse is going to result in a different symptom profile than PTSD from a one-time incident or even PTSD from wartime combat.  Long-term exposure to trauma, especially if it starts during childhood, can cause personality changes.

In short, there are many factors to consider when evaluating stress disorder symptoms. These include whether the trauma was a one-time incident or a prolonged series of incidents, whether or not the patient feels guilt about the trauma, and if so, is the guilt  rational or irrational, at what age was the trauma experienced and for how long, and also the identity of the perpetrator if there was one (or more than one). There are probably more factors that I can't think of at the moment. Treatment for PTSD in my opinion should involve a combination of insight-oriented and cognitive or behavioral interventions and in some cases medication may be necessary. Group therapy can sometimes be helpful, perhaps especially for combat veterans and for survivors of childhood sexual abuse. 

Tuesday, September 1, 2015

Diagnosis and Prognosis in the Information Age

Recently I read a quote from a celebrity, I think on Facebook, saying that he has been "struggling" with anxiety and depression for at least 7 years. I was puzzled by this, because there's no reason for anyone to struggle with anxiety or depression for that length of time. There are numerous treatments for depression and for anxiety disorders. Most people with depressive or anxiety disorders are able to resolve their symptoms or at least tolerate them, if they get the appropriate treatment.

 I wondered whether the celebrity had really been diagnosed with bipolar disorder or borderline personality disorder, but was afraid to say so, because these conditions are far more serious and he thought it would be too stigmatizing to admit he had them. It's also possible that his treatment professionals told him that he had "anxiety and depression" when in reality they had diagnosed him with borderline personality disorder or possibly even with bipolar disorder, without telling him. In other words, it's possible his treatment professionals lied to him, to avoid upsetting him (and potentially losing a high-paying patient). It's also possible the celebrity was misdiagnosed or was receiving inappropriate or inadequate treatment, or that he has been noncompliant with treatment. All I know is that something was missing from the picture.

This scenario and its possible behind-the-scenes factors illustrate some of the pitfalls of our "Information Age" in which people are inundated with "information" from the internet and especially from social media. It also may illustrate the continuing stigma relating to mental health conditions, as well as the general difficulties people may encounter getting correct diagnoses, information and treatment for their conditions.

I have learned that it is important to tell people what their diagnoses are. When I was in graduate school, some of my professors minimized this educative component of treatment. Many colleagues I've had believe that patients can fixate on diagnosis, or that diagnoses are controversial or often inaccurate. Although I agree with those colleagues that there are many potential problems involved in telling patients that they have a condition such as borderline personality disorder, antisocial personality disorder, or another stigmatizing condition, I now believe patients have a right to know and I feel comfortable making such diagnoses when I have the required evidence. 

I saw numerous comments on the actor's Facebook page from fans stating they too had been struggling with depression or anxiety and depression for years. I didn't see any comments from people speaking about how they recovered from their conditions. No one seemed to be questioning whether they had been given the correct diagnosis or the right treatment. This is sad. With only a couple of exceptions that I can think of, every patient I've worked with who had a depressive disorder or an anxiety disorder as their primary diagnosis got much better, sometimes with therapy alone and sometimes with a combination of therapy and medication. In the two cases that spring to mind in which the person did not get better, I strongly suspected the patients were not compliant with their medication and in one case, the person was using drugs. I also had one patient who didn't recover from severe depression until she had  treatment with a brain stimulation method that at the time was only available in Canada ( I believe it is now approved in the US). The medications she'd previously tried had been ineffective. It may take some time to find the correct treatment regimen for someone's condition. But there is no question that depression and anxiety can usually be resolved. The treatment of a condition such as borderline personality disorder is far more difficult and perhaps I'll discuss this in a later post. Bipolar disorder is incurable but can be managed with medication.

I commend public figures for speaking about their personal problems in an attempt to destigmatize those problems, but this is only useful if what they are saying is the truth. It's sad that both patients and their treatment professionals are still sometimes victims of the fear of stigmatization. Perhaps one day our society will acknowledge that there's no such thing as perfect mental health and that we all have problems.

Sunday, July 26, 2015

What You Can Do To Improve Your Mental Health

There are many factors that influence mental health. Most emotional disorders are created by a combination of "nature" and "nurture"--genetics and environment. When clinicians do assessments, they evaluate the patient's family background and stressors and often make a decision as to whether symptoms have a mostly biological background or are mostly due to environment. Rarely, if ever,  is an emotional disorder created only by biology or only by environment. What's most important for the patient to remember, however, is that current environment, behaviors and choices have an impact on mental health. Although the past can't be changed and neither can one's genes, people make many choices in their lives that affect their mental health.

The worst decisions that people make affecting their mental health include decisions to avoid treatment for emotional problems, decisions to continue using drugs or alcohol despite problems with these substances, and decisions to stay in bad relationships. People can also make bad career and financial decisions that often have very negative effects on their mental health later in life (see my previous post http://notesonsanity.blogspot.com/2015/01/do-therapists-give-advice.html.)

But let's reframe this question in a more positive way: What are the good decisions people make that can enhance their mental health?

In addition to promptly seeking help for emotional and behavioral problems, limiting or eliminating substance abuse and other dangerous behaviors and leaving abusive relationships, smaller decisions can have a big impact. Here are some healthy habits:

1. Exercise regularly see my previous post  http://notesonsanity.blogspot.com/2014/08/run-for-your-life.html

2. Pursue your dreams while maintaining realism in your career choices (not so easy in practice, which is why it's good to get advice from others whom you trust).

3. Write in a journal. Writing down feelings and thoughts helps people gain a sense of control over their feelings and thoughts.

4. Pursue a hobby. Learning and gaining competence in a field unrelated to your job makes you less dependent on your career for your self esteem and means you can never be bored. Play a musical instrument, take up photography or painting, engage in creative writing, study foreign languages...etc. A hobby can also turn into a second career or at least something to add to your resume.

5. Develop a life philosophy and try to find a group of people who share it. There's a reason why religion continues to be popular despite the Scientific Revolution--people need a sense of meaning, purpose and belonging, in life.  But there are many philosophies that don't require belief in a deity or practices that are thousands of years old. These include political philosophies and movements, alternative religions, 12-step programs, and various modern philosophies.

6. Associate with different types of people. Perspectives can become narrow when one only associates with people from one's own socioeconomic class and nationality. Associating with different types of people can lead to insight about expectations and pressures from one's social circle that aren't necessarily helpful but are based on tradition or culture.

7. Become a fan. This may sound like strange advice, as the word "fan" comes from the word "fanatic." But there's been some research indicating sports fans have better overall mental health than people who aren't sports fans, and it stands to reason that other types of fandom may have a similar effect. There is a human need to look to icons, which is another reason why religion survived the Scientific Revolution. 

8. Neither ruminate on the past, remain stuck in the present, nor worry excessively about the future. Thinking about the past can be beneficial for two reason: One, to determine a chain of events that led to bad decisions, and two, to reflect on one's accomplishments, which is beneficial for increasing self-esteem. Dwelling on past traumas is not healthy, although  talking about them with a therapist might be. People who only exist in the present lose perspective. It's important to remember the past to know who you are, and it's important to visualize and to even fantasize about the future, because this helps you to set goals. Worrying about the future, on the other hand,  serves no purpose unless you have legitimate worries that require immediate action.

Saturday, June 20, 2015

Is Racism a Mental Illness?

Many clinicians have long believed that racism is a type of  Delusional Disorder. According to the Diagnostic and Statistical Manual of Mental Disorders, delusions are "fixed beliefs that are not amenable to change in light of conflicting evidence."(I find the DSM's definition of delusions somewhat humorous, since many people stick to beliefs that are cultural or religious despite overwhelming data indicating a lack of scientific evidence for these beliefs. Most of these beliefs are not dangerous, however; whereas some delusions can be dangerous).The DSM categorizes delusions by whether or not they are bizarre (not possible) and according to type, e.g. Erotomanic, Grandiose, Jealous, Persecutory or Somatic. Jealous, Persecutory and Erotomanic delusions can be dangerous. Some racist beliefs could be categorized as persecutory delusions.

After reading reports of the recent shooting in Charleston, South Carolina, I wondered if the perpetrator's thought content might qualify as delusional and persecutory. According to reports, the perpetrator, Dylann Roof, expressed thoughts that black people were "taking over" and were responsible for raping white women. There is no evidence in reality for these beliefs. Rapists tend to pick victims from their own racial group, and the percentage of black people in the US is not growing. Of course, people can have erroneous beliefs based on misinformation or ignorance rather than paranoia. I suppose it's possible Roof subscribed to websites or other sources of misinformation that promoted these erroneous beliefs. It's also possible they were simply inventions of his own mind, in which case they could be classified as persecutory delusions.

Some may find this discussion irrelevant in light of the fact that Roof apparently committed murder and his emotional problems aren't the point. Others might fear that examination of the perpetrator's mental state could lead to a conclusion of lesser responsibility. I disagree with these points of view. Before any incident, there is a chain of events. To prevent crimes and disasters, it's important to analyze the factors that led up to the event. Moreover, having a mental illness does not preclude responsibility for a crime. To be found Not Guilty By Reason of Insanity  (NGRI), a person has to be shown to be unaware of the difference between right and wrong at the time of the crime. A rationalization for the crime does not count as a lack of awareness of right and wrong.

What, if anything, could have prevented the murders in South Carolina? Sadly, psychotherapy does not have a good track record in treating delusional disorder. The delusional person doesn't necessarily think that anything is wrong with him or her. Sometimes feelings of paranoia respond to anti-psychotic medications, but this treatment is only possible if the patient agrees to take the medication. What we do know is that most mental conditions can be exacerbated by stress. Unemployment or financial problems, or lack of social support, could exacerbate paranoid and delusional beliefs. According to reports Roof was occasionally living in his car, prior to the incident.

Roof was also voicing violent thoughts to his friends and some were aware that he had a gun. Yet, no one took action to prevent what in hindsight seems like the inevitable. I believe that a gun license should require psychological testing, which almost certainly would have revealed pathological and dangerous thought content in the case of Roof. One of Roof's friends reportedly removed his gun, but then put it back after fearing he himself could get in trouble for owning a gun. It's easy to see that some creativity on the part of Roof's friends might have averted the incident, but we can't rely on lay people who may have their own problems to intervene in these circumstances. We need to screen out the paranoid and delusional from gun ownership.

Wednesday, May 27, 2015

Should "Research" Guide Psychotherapy?

A couple of  months ago,  a patient was telling me that a research study from some years ago that had concluded that there's no such thing as bisexuality was recently debunked. (She probably was intrigued by this because she's bisexual).  I told the patient that I was surprised anyone had believed the original study, because bisexuality has been documented in historical, religious and literary texts going back thousands of years.

We live in a society that often seems to worship science, or what is alleged to be science, and denigrates common sense and the accumulated wisdom of the human species. The media play a strong role in this disinformation, advertising the results of each recent research study on a popular topic with headlines that blare "Scientists Say...." "Studies Report..." Any scientist knows that one research study is almost meaningless. Research results have to be replicated to have any credibility.

Social science research is trickier than research in the natural sciences, because research into human behavior is often based on the self-reporting of the subjects. I was amused by a recent story in The New York Times that declared "Severe Mental Illness Found to Drop in Young, Defying Perceptions" http://www.nytimes.com/2015/05/21/health/reduction-is-found-in-severe-mental-illness-among-the-young.html?ref=health
Not only was the headline and much of the article based on one research study, but the study was based on parental perceptions. Surely one does not have to be a scientist or a psychotherapist to know that parents' perceptions of their children are distorted by the parents' wishes and fears. Although the study compared two sets of parental perceptions, from the past and the present, the changes in perceptions might have nothing to do with changes in  the children's symptoms. The study may in fact be more useful for how it is documenting that parents are increasingly underestimating their children's symptoms. That possibility would be in line with research (as well as anecdotal observations by therapists) that people are becoming more narcissistic and that parents are more psychologically invested in their children, than in the past.

I frequently get communications from health insurance companies exhorting clinicians to use "evidence-based" practices. I often wonder which evidence they have in mind. Over the course of my career and my life, I have seen different types of therapy first promoted and then debunked. When I decide what techniques to use with patients, I don't base my decisions on the latest research study. I base my decisions on what theories and techniques have stood the test of time, and what techniques I have found previously helpful in my own practice for particular types of patients. I use my professional experience, common sense, and the accumulated wisdom of previous generations of therapists.

Tuesday, May 12, 2015

Bad Therapy

I often see people who've seen previous therapists. Some of them report positive experiences, and some report negative experiences. In either case, I often find that people don't give me a lot of details about their previous therapy. This is a problem, because it's important for me to know what worked and what didn't work in someone's previous therapy.

I have pondered if some persons think that if they talk at length about a previous therapist's failings, I will side with the previous therapist. This is not true, as I am well aware that many therapists are not good. In fact,  I sometimes say to friends, "I wouldn't refer a cat to 80 percent of the people in my field." It's not a joke.

When I do hear complaints about previous therapists, the most common complaint is that the therapist talked about him/herself. Why does this happen? Probably for many reasons. One possibility is the decline in the popularity and influence of psychoanalysis and of psychoanalytic training. Although psychoanalysis has some limitations as a treatment, it does insist on the neutrality and relative anonymity of the therapist. Other schools of therapy don't necessarily encourage therapist self-disclosure, but they don't place as much of an emphasis on boundaries as psychoanalysis does.  Unfortunately some less-than-competent therapists may assume that if their training didn't emphasize boundaries, it means boundaries aren't important.

I usually limit information on my personal life to answers to direct questions asked by patients, in cases where the information might be relevant--for example, if someone asks me "are you going away on vacation?" I will answer, as this could relate to the issue of whether I can be contacted in an emergency. Another example would be when a patient discusses a movie they've seen and wants to know if I have seen it. I've found that discussions about movies are often quite meaningful, as which characters patients identify with, or which ones remind them of their family members, can lead to interesting discussions.

Therapists should not talk about events in their personal lives or personal problems.  I've heard two (!) stories about therapists who talked about their own upcoming weddings--I can't think of any way this could  be appropriate and it could be damaging to the patient.

I've developed a hypothesis that some therapists talk about themselves because they are bored by their patients and don't feel a connection with them, and are hoping that if they talk about something they have "in common" with a patient it will help them feel more connected and less bored. This boredom usually represents a type of narcissism. Unfortunately, some people become therapists for the wrong reasons. Some people believe that as a therapist they will be super-important to their patients and will wield great influence over their patients' lives. Although this can happen, it's not a good reason for someone to become a therapist. People with narcissistic problems are often attracted to the field of therapy.  These persons should not be therapists, but they are not screened out of graduate school programs.

Other personal problems of therapists that interfere with therapy include difficulties with the opposite gender or with cultural differences.  I've heard stories about  male clinicians who gave compliments to female patients on their clothing and make-up. It apparently didn't occur to these clinicians that this behavior might be seen as objectifying by their patients--the clinicians probably thought they were boosting the patient's self-esteem.  I've also come across female therapists who can't work with male patients due to projections of anger or disgust that come from their own experiences with men. In conversations with therapists from other parts of the country, I've discovered that religious bigotry is not uncommon. It's hard for a bigoted therapist to practice in New York, but once in awhile I've come across a homophobic therapist here, or other types of issues.

The worst failings of other therapists that I have come across, however, are inaccurate assessments. Sometimes the end result of these errors is tragic. In the worst cases, there may be a preventable suicide. Fortunately I haven't heard very many of those stories.

Errors in assessment and diagnosis often stem from  a belief that recognizing someone's severe pathology is tantamount to not liking them or not recognizing their strengths: Years ago, while working in a clinic,  I worked with a paranoid schizophrenic whose previous therapist encouraged him to attend college. The vast majority of people with schizophrenia cannot complete college. The patient dropped out and was left with student loans he could not repay as well as a blow to his self-esteem. In another case, a therapist treating a family member of one of my patients didn't notice the woman's severe personality disorder and the extent of her pathological behaviors, which were affecting my patient. Many therapists have bought into society's stigma against mental illness, and this makes them believe that diagnosing a patient with a disabling condition is equivalent to condemning them or not liking them. 

Being a therapist requires a sober view of humanity and its problems combined with a genuine interest in other people and their lives. Unfortunately, my field is filled with therapists who aren't really that interested in other people--especially those who are different from them--and others who confuse recognizing their patients' serious problems with not liking them. I keep a short list of other therapists to whom I can refer people when I can't treat them. I wish there were more people whose professional expertise and behavior I could trust.

Tuesday, April 14, 2015

Addiction: Truth and Myth

 I spent the first several years of my clinical career working in substance abuse treatment programs. On the front page of my website, I note this fact and state that I "frequently work with persons in recovery." If only this were actually true! What has happened over the years is that the people who've come to see me for my addictions treatment experience are mostly not in recovery. Most  have been people who are still abusing drugs and/or alcohol. But psychotherapy is not the best treatment for addictions, which is why I tried, in the language on my website, to suggest that I want to work with people who've already stopped using drugs/alcohol and are looking for relapse prevention and treatment for other emotional problems.

"Recovery" means that you have stopped abusing substances--you are now abstinent from the problematic substance and any other substance with a similar effect, and are engaged in a different lifestyle. What I have found consistently in the course of my career is that 90 percent of addicts/alcoholics need a 12-step program to remain in recovery. Sadly, most of the substance abusers who have come to my office, although they may verbally express an interest in going to a 12-step program, don't stick with it and thus they don't stop using drugs/alcohol.

Most abusers of alcohol and drugs who come to my office claim that they "know" they have a "problem." This may represent a change from the attitudes found before the 1970s. Before the 70s, most alcoholics and addicts lied about their problem and were frequently in denial about its severity.  Celebrities in the late 70s started to come out of the closet with their addiction problems. Now it's become socially acceptable to admit you have a problem with drugs or alcohol. But  most people who "admit" this fact still  don't really want to change.  This may not make sense to most people, not only because using drugs/alcohol in the face of death or other severe consequences doesn't seem logical, but also because the media promote the myth that people use drugs because they don't have access to treatment. Nothing could be further from the truth, as the 12-step program is free and available all over the country. In addition, most inpatient rehabs are desperately seeking patients and some have closed.

Why would someone continue to engage in addictive behaviors despite access to treatment? There are many possible reasons, some that are psychological and some that perhaps could be better described as philosophical or spiritual, depending on one's beliefs.

Some recovering addicts have told me that before they found the 12-step program, they simply thought that they were destined to be drug addicts--it was their identity and fate. When they heard, in 12-step meetings,  the stories of people like themselves who had completely changed their lives, they realized they were wrong.  They realized they could choose their fate. They also realized that they needed help from others to remain free of drugs and alcohol. This may seem paradoxical, but all humans need both a sense of autonomy and self-direction and also social support.

 People with intractable addictions--those who go to 12-step meetings but still don't arrest their addiction--may be people who are too narcissistic to accept their dependency on other people. This makes them unable to use the 12-step program. Others can be persons who just don't see a meaning in life. Ordinary activities that give others' lives meaning, such as the sense of pride in working for a living and doing a job well, mutual interpersonal relationships, and greater causes or beliefs, are meaningless to them. Without a sense of meaning in life, it's hard to see a reason to stop drinking or doing drugs.  All experienced substance abuse counselors know there is a percentage of the population who cannot be helped and who will not recover from addiction.

Initially in private practice, I thought I would screen out all active addicts, and instead insist that they first attend 12-step or an inpatient rehab, or both. I changed that position when I realized some of the addicts and alcoholics coming to my office had severe depression or anxiety that needed to be treated. I didn't think it was right to deny treatment to someone for one disorder because the person refused treatment for another. I can say that I did help some of these individuals, whose depression and anxiety did improve, even though they did not completely arrest their addiction(s). (The fact that these individuals did not stop using drugs or alcohol despite recovering from their anxiety and depression shows that a popular theory, the "self-medication theory," is wrong. The self-medication theory, believed by many psychotherapists, holds that drug and alcohol abusers are simply self-medicating depression and anxiety and will stop their behavior if they take medication and go to psychotherapy. If this were really true, addiction would not be the vast social problem that it is). Recently, I've come to realize that active alcoholics and addicts present liability concerns for my practice. Therefore, I've decided to go back to my original position of requiring that addicts/alcoholics be in recovery before I will agree to see them.

Thursday, April 2, 2015

Evaluating Risks Part 2

I decided my last post needed a follow-up. In the last post, I discussed how employers can conduct psychological screening that could help them identify potentially suicidal and homicidal employees. For jobs that give people the power to endanger the public, I believe such screening is necessary. I noted that I discovered, through reading recent media reports, that airlines don't usually conduct such screening on pilots, which is incredible considering that pilots have the lives of hundreds of people under their power. However, it has occurred to me, after reading additional media reports,  that some people may misinterpret employment-based psychological screening as something that keeps individuals from getting the mental health care that they need. The "argument" I've been reading is that people won't obtain mental health care if they think it will lead to loss of employment.

The Americans with Disabilities Act, passed in 1990, forbids discrimination based on disability, under most circumstances. Businesses have to show that employing a person with a disability would impose an unreasonable burden in order to be able to "discriminate" against such applicants or employees.This law means that you can't be fired for a mental health problem or even a substance abuse problem unless it makes you unable to do your job even with treatment and reasonable accommodation. Therefore, if you need to take a month off work to go to a treatment center, your job has to allow you to do so. If you need to leave early one day a week to see a therapist, your job has to allow you to do so.

If, on the other hand, despite your treatment you continue to do drugs and this impairs your work performance or causes disruption to other employees or clients, or creates a hazard, you can be fired. If you come to work late every day because you're too depressed to get out of bed, because you either refused treatment or treatment simply did not work, you can be fired. I believe the ADA is a fair law that has worked well. Someone who is too disabled to work qualifies for federal disability payments but most people with disabilities can work if they receive treatment.

Duty to Warn

Therapists in the US have to abide by something popularly known as "Duty to Warn." If we have a patient who threatens to harm someone else or whose illness puts the public at risk, we are required to break confidentiality to take action to prevent the loss of life or injury to another person. I had to do a "Duty to Warn" some years ago when a psychotic patient came to my office with a plan to kill a relative. In addition, he showed me a recipe for making bombs. I sent him to the emergency room and I also called the police in his relative's town. These are the requirements under "Duty to Warn." Even though I believed the patient was unlikely to act out his homicidal ideas, it didn't matter because it was possible that he would. The hospital re-evaluated him and, if I remember correctly, changed his medication. The patient didn't lose his job (he was a doorman) and no one was killed. (There was no evidence the patient had constructed a bomb or that he was actually planning on doing so). The hospital agreed to continue his treatment on an outpatient basis as it was too much for someone in private practice such as myself.

A colleague of mine years ago had a patient who was a motorman on the subway. The patient had severe panic attacks. My colleague did a Duty to Warn because panic attacks can occur without warning and can be disabling, and the patient was responsible for the lives of hundreds of people on the subway. I don't recall what the end result of this was, but I imagine it was something similar to what happened with my patient: The patient probably took a leave of absence, went on medication and then went back to work if his treatment was effective.  In my opinion he should have been monitored by the MTA afterward to make sure he was complying with his treatment. I don't know whether this happened, however.

There are some people who are too sick to be able to safely work at jobs in which they hold the lives of others under their power.  Most people who fall into this category are substance abusers, and only a small percentage are people with other clinical problems. Most people with mental health problems are effectively treated and can do most jobs. However, our societies do need ways to screen out people with intractable problems from jobs in which they can put the public at risk.

Friday, March 27, 2015

Evaluating Risks

Yet again, a suicidal/homicidal person causes a tragedy. In this case, the person flew a plane into a mountain. As usual, media reports are full of quotes that make no sense. Authorities quoted in The New York Times report that the pilot, Andreas Lubitz, was "100 percent flightworthy" (obviously he wasn't) and that they are pondering "whether" it was a suicide or homicide (don't the facts speak for themselves?). Many laypeople may assume it's impossible to determine whether or not someone is homicidal or suicidal, if the person decides to lie. This is only partly true.

Most people who truly want to commit suicide or a homicide will lie about it if asked directly, because they want to succeed in their plans. But that doesn't mean organizations can't screen out persons with serious pathology.

Psychological testing is a simple and accurate way to screen for serious pathology. I don't do psychological testing, but I have read many psychological test reports. Some were done on patients I was seeing and in a couple of cases, I participated in appeal evaluations for NYPD and Dept. of Corrections applicants, which allowed me to read the test results performed by the NYPD and Corrections psychologists. What I have found is that these tests are accurate. In the clinical cases, they weren't that helpful, because if you're someone's therapist and you're competent, the results of their standardized psychological tests should come as no surprise. In the cases of the appeal evaluations, although I felt sympathy for the rejected applicants, the results that I and the other professionals performing the appeal evaluations came up with were similar to the NYPD and Corrections evaluations' results (if you're wondering about how someone can pass the NYPD psychological tests and still murder someone by strangling them to death, I don't have a good answer. One possibility is an incompetent examiner).

One common psychological test, the MMPI (Minnesota Multiphasic Personality Inventory) has a built-in "lie scale" that determines the level of truthfulness of someone's responses. One would think that any applicant for a sensitive job with a high score on the "lie scale" would be rejected. One hopes that this is true, anyway.

Another well-known and occasionally ridiculed test is the Rorshach inkblot test. Although results from Rorschach tests don't diagnose particular illnesses, they give clues that could guide an examiner or clinician to ask further questions.

People don't become homicidal or suicidal overnight. There are many psychological problems that create risks for future homicidal or suicidal behavior. These include not only depression, but also impulsivity, sociopathy, and narcissism. I don't know how Lufthansa pilots are screened and can't comment on whether I think Lufthansa is doing the right tests. What I do know is that personality remains more or less consistent during adult life and that there are many types of psychological tests and interviews that can reveal the types of problems that indicate a risk for future suicidal or homicidal behavior.

UPDATE 3/29: I just found out, through reading The New York Tiimes, that most airlines don't conduct any psychological testing on pilots or prospective pilots. This is incredible. 

Sunday, March 15, 2015

Know Who You're Talking To

Recently, I was invited to join a few "Closed" or "Secret" Facebook groups. They looked like fun, so I accepted. Within a few days I had left all the groups. One reason was that they cluttered my Facebook feed with posts from people I don't know. But another reason was that I realized they were neither "Closed" nor "Secret." Anyone could easily take a screen shot of a conversation in the supposedly "Secret" group and post it anywhere and everywhere on the internet. I thought about an old adage, "if you wouldn't be comfortable seeing something on the front page of The New York Times, don't put it in writing."

Of course, today, many people put almost every communication in writing, via text messaging or email. This is a mistake. I find that many people don't know their friends as well as they think they do. Of course, voicemail is also recorded, but it isn't as easily transmissible.

The best way to communicate is in person. Not only is it confidential, but it allows for the nuances of tone and body language. People also feel more free to insult, abuse and harass people when they don't have to face them. The more you communicate virtually instead of in-person, the more you're likely to expose yourself to the type of cowardly and abusive people who like to harass people online, where they can usually hide behind anonymity or at least not have to face their victim.  The New York Times recently published a long feature on people whose lives were ruined by Twitter:

I've been a professional writer, which puts me at an advantage compared to most people in terms of writing for the public. One of the rules of writing is to know your audience. I think that one of the mistakes Justine Sacco--one of the individuals profiled by the Times--made was to assume that her Twitter followers were people like her. She made a joke that was a type of ironic self-parody. It apparently didn't occur to her that people who understand ironic self-parody are those who have higher-than-average intellectual capacity. There's a reason why most newspapers are written on a reading comprehension level of 10th grade or below.

Many of us live in bubble worlds, in which we associate with co-workers, friends and relatives who work in similar types of occupations, have similar educational/intellectual abilities and similar values. If you don't associate with a wide variety of people, it's easy to forget, or to never learn, that other people aren't like you. They may be stupid, they may lack a sense of humor, and they may be malicious. Today people are "friending" people on Facebook  and "following" people on Twitter whom they do not know. Facebook requires people to use their real names (although many find ways around this rule) which means anything you write is attached to you. Twitter has a special risk created by the fact it uses short sentences or sentence fragments as a form of communication. Not only are these easily misunderstood, but this type of communication attracts many followers who can't understand or don't have the interest in following a complex argument. They prefer reading tweets to newspaper op-eds or blog posts such as this one, because 145 character tweets don't strain the brain. Do you really want to be "followed" by such people?

I've read some comments (on the internet!) that people should "own" what they say, because, they said it. This point of view is naive. Anything that is said can be misunderstood, taken out of context, or otherwise twisted. There's a reason why the police "Miranda" warning states "ANYTHING you say can, and will, be held against you." The New York Times' profile is a perfect example--ironic self-parody was interpreted as racism.

I have a private Facebook profile, but more importantly, I limit what I say and post there and keep my "friends" list to less than 100 people. If you are using Facebook for business networking, you should  have a "page" rather than a "profile" for that purpose. Don't confuse the two. Business and friendship don't always mix. If you want a forum to talk to people you don't know and say whatever you think, join a message board where you can post under a pseudonym. And still be careful what you say.

Tuesday, February 17, 2015

Can Therapy Help You Find A Marital Partner?

Not infrequently, someone comes to my office complaining that they can't find a mate. Usually the person is a woman, but sometimes a man. Typically,  the person also complains of  anxiety or depression. What I have found is that when someone's anxiety and depression are alleviated,  barriers to dating and finding the "One" often go away. People who are depressed or riddled with anxiety aren't attractive to most people. They can be difficult to be around. Depression also saps energy and self-confidence, which are necessary to tough it out in the New York dating scene.

Several patients I've worked with found marital partners while they were in therapy. I am convinced that in most cases, it was the alleviation of the person's depression or anxiety that was the key to helping them find a mate. In some cases, looking at reasons why the person had chosen dysfunctional mates in the past also played a role in helping the patient find someone.

Coming to therapy for no other reason than wanting to find a mate may not work. I recall a patient, who I'll call Patient X, who came to my office with the complaint that her friends were getting married and she wasn't, and she felt left out.  She didn't mention any other complaints.  I had the sense in our first session that she might be depressed, and that there might be other issues she wasn't voicing. I decided that although I'm not a match-making service and can't find someone a husband, the patient would benefit from therapy. In retrospect, I never should have agreed to work with this person. I should have listened more closely to what she said in our first meeting. What I mean is that the patient never said that there was anything wrong with her.

Like most therapists, I want to help everybody. I am also trained to listen for what people aren't saying and to look for unconscious motivations. When I see someone in front of me who shows evidence of a clinical problem that I am trained to treat, I want to help that person. But every course of therapy is based on a "contract." This is the verbal agreement between patient and therapist about what they're going to work on. It isn't usually written out, but just discussed in the first session. Sometimes, patients only voice that they want to feel better, or that they feel "stuck" in their lives, which usually means that they are having difficulty with motivation or making decisions. Regardless, as long as the patient admits that there is something wrong with them and asks for help, they can usually be helped. But if the patient frames the problem as something in the outside world, I can't help them, because I can't change the world.

Patient X stayed for a few months and I thought we were working on some real issues. Then one day I received an email from her telling me she was dropping out of therapy with me. She implied in the email that I didn't agree with her quest for a high-status mate and therefore, we weren't on the same page. I am sure that I never stated such a thing, although it was true that I was somewhat puzzled by her criticisms about men she dated. The mistake I made, however, was in not telling her in the first session, "if you have no other issues you want to work on  besides lack of a husband, I can't help you."

It occurred to me that the patient's inability or unwillingness to talk in person with me about what she perceived as a conflict between us was probably related to her problem finding an intimate relationship. Relationships all involve conflict and require discussion and negotiation. If you can't do this with a therapist, it's unlikely you'll be able to manage a more demanding type of relationship. This illustrates a sad paradox of psychotherapy: Many people want help with relationships, but therapy itself involves a relationship with the therapist. Often people enact with the therapist the same behaviors and patterns they experience in their relationships with other people. This can be useful if the patient is willing to discuss and examine the behavior. These discussions can lead to insights.

In short, therapy can help you find a marital partner, it you admit that you might have a problem or two and if you are willing to engage in an honest discussion with the therapist about what these problems are.

Wednesday, January 28, 2015

Do Therapists Give Advice?

A couple of years ago, I and some other therapists were debating whether or not we should give advice to patients. Traditionally, advice-giving has been frowned upon in the field of psychotherapy. Psychotherapy is supposed to be a treatment process to help people to grow emotionally--to understand themselves, to become aware of unconscious thoughts or suppressed emotions, to build a sense of self and to increase mastery over both feelings and behaviors. The giving of advice was seen as potentially undermining the patient's autonomy and sense of self. The reason I and the other therapists were pondering this tradition was because many of us were working with young adult patients who did not seem to have anyone in their lives from whom to ask for advice. Ultimately we reached a consensus that we often had to give advice, because no one else was advising our patients, who often were in the position of having to make important life decisions. 

There are many pitfalls in giving advice, the most obvious one being that you could be wrong. When I give advice to patients I usually start by saying "in my experience." I also advise people to seek out advice from other professionals, such as attorneys or accountants, if they need legal or financial counseling that I'm not qualified to give.

Sometimes patients ask me bluntly what they should "do." In most circumstances, I don't tell people what to do. It's important to learn how to make decisions. Usually, I just help people evaluate their choices and offer what information and insight into their situations that I might have.

It's easier to be a therapist who never gives an opinion, because this means fewer opportunities for disagreement with a patient. Sometimes patients will drop out of therapy if the therapist doesn't nod in agreement with all of their decisions. In my opinion, it is better to risk losing some patients than to allow someone to leave my office on the verge of making a bad, perhaps life-altering decision, without hearing some information that might suggest they give the decision more thought. Here is an example of such a situation:

A young woman who was seeing me for problems with anxiety mentioned to me that she was planning on entering the same type of graduate program I had completed 20 years earlier. She told me she planned to take out $40,000 in loans for this program. I informed her that her starting salary would probably be $40,000 and since she already was paying loans for her undergraduate degree, the total would be quite a lot of money for someone making a fairly low salary. The patient looked at me quizzically and told me that the financial aid office had told her it was ok to take out loans up to one's expected annual salary. It hadn't occurred to the patient that the financial aid office had a vested interest in getting people to enroll in the university and pay however they could. (I find many patients, and people in general, do not evaluate the sources of the information they receive and their possible bias). The cost of the type of graduate program I attended is approximately four times what it was when I was a student, and entry level salaries haven't even doubled. I suggested to the patient she think about a different degree that would allow her to make more money in the short term but also allow her to pursue a career in the mental health field. The patient never came back for another session. Did she drop out of therapy because I suggested her plan wasn't the best idea? It really doesn't matter, because I could not in good conscience allow a young person to leave my office thinking a lifetime of debt for a degree that isn't worth what it used to be was a good idea.

When I work with patients who are a little bit older--in their 30s and 40s--I not uncommonly find that their lives have been severely disrupted by bad choices. I often wonder if they discussed their choices at the time with anyone and what that person or people said. Sometimes I ask this question. Here are a few of the disastrous situations I have encountered. I found myself thinking, in each of these cases, that I wished I had seen the person earlier in life and given them some advice:

1. A middle-aged woman came to me with  complaints of dissatisfaction and irritability. She had a job she didn't like and some family and marital conflict. When I explored her history, I discovered she had made a couple of fatal career decisions some years previously--decisions to turn down great job offers. She turned down the job offers for the sake of a relationship with a man. Then she discovered marriage isn't a  solution to life's problems. If I had been the woman's therapist earlier in her life, I would have advised her to think of the long-term consequences of giving up what might be one-time career opportunities.  I might have also asked her to ponder why her boyfriend would want his future wife to derail her career in order to be in closer proximity to him and what this might indicate for their future relationship.

2. A man who was seeing me lost his $300,000 a year job and was forced to live off of unemployment compensation and savings. He had acquired student loans in the sum of six figures. I discovered that he didn't really like his career and only entered it for the money. Unfortunately, most people who enter careers only for the money aren't very successful in those careers. If I had been his therapist years earlier, I would have encouraged him to do something he liked and to choose a university and/or graduate program he could afford.

3. A woman who worked in a prestigious field complained of constant anxiety. She was wracked with anxiety because her job involved making life-or-death decisions and she did not have a decisive personality. I found out she had accrued more than $100,000 in student loans and it wasn't feasible for her to switch careers because her job was one of the few that would allow her to pay off these loans. In addition, she was no longer young. If I had been her therapist years earlier, I would have helped her explore whether her personality and talents fit the career she thought she wanted. I strongly believed she chose her career  because it seemed prestigious, not because she really wanted to do it. Her family may have played a role in her decision to choose this ill-fitting career.

My experience with patients has taught me that helping patients explore life choices can be an important part of therapy. Sometimes it may be necessary to give advice, in one form or another.