Sunday, May 27, 2018

Is Marijuana Safe?

I've long been suspicious about claims that marijuana is harmless. I was interested in this article in the Washington Post, by a neuroscientist. Any drug changes the body's chemistry.

Tuesday, May 15, 2018

College Students and Suicide

Recently The New York Times published an article about a growing controversy: As more college students commit suicide, parents are frustrated by medical and academic confidentiality laws that seemingly have prevented the colleges from contacting them about their children who are having mental health problems. What should be done about these situations?

When new patients come to my practice, I have them fill out a form that includes space to list an emergency contact. So far, no one has refused to name an emergency contact. I've only called an emergency contact once or twice in 16 years, but it is necessary for me to have this information, because someone's life could be at stake.  Why don't colleges and universities do the same? I don't know. Perhaps their administrators believe psychiatric emergencies aren't their purview.

Of course, it's possible that a student would list someone other than his or her parents as emergency contacts, in a university setting. But that's not the point. The point is that there should be someone who can be called who can assist the student in accessing resources--that could include calling the parents, as laypeople aren't bound by confidentiality laws.

An emergency contact person is ideally someone who is willing to escort the person to an Emergency Room or stay with the person until the crisis is over.

In a genuine emergency, confidentiality laws don't apply. If someone in my practice tells me that he or she is planning on committing suicide, I ask to escort them to the Emergency Room, and if they refuse I would call 911. I do not need a confidentiality waiver to call 911, but, I have in fact never needed to call 911, because every time, the person has agreed to go to the hospital. A college counseling center should be staffed by licensed clinicians who are obligated to work with their patients the same way that I am.

What about situations in which a college student is deteriorating, but it's not clear if it's an emergency? The student should be asked to take a leave of absence for a semester and engage in mental health treatment. Then the treating clinician should be asked to sign off on a form stating that the patient is not at risk, before the student can resume classes. Of course, it's possible for someone to relapse--but at that point the parents could not reasonably claim they didn't know anything was wrong. If they are in contact with their child at all, in most cases they would at least  know that their  child was not attending school that semester.

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 include "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 term created by entities with ulterior motives. 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 been said that "the winners write history." They also write the laws, the rules, and the diagnostic criteria.

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. 

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?

 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.

Thursday, January 18, 2018

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

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

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

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

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

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

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

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

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

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

Thursday, January 4, 2018

Some Important Tips About Being in Psychotherapy

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

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

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

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

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

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

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

Your Privacy

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