Monday, May 29, 2006

Toxic Spirituality and Naive Spirituality

Here is central Pennsylvania, things are just a little conservative. It's the only part of the state, for example, where Senator Rick Santorum is still leading in the polls. (Don't get your hopes up. Santorum will probably lose, but Bob Casey is barely a Democrat.)

In a conservative area like this, fundamentalist spirituality is pervasive, and frequently, it can be toxic. Toxic spirituality encourages people to think of themselves in black and white terms. I am either good or bad. Usually, since we can't be perfect, we're bad. Bad things that happen to us are our fault. If we had been better people, nothing bad would happen to us.

I encounter it frequently, because toxic spirituality encourages guilt, and guilt is a path to depression. For my clients, it's not a hard thing to deal with. You start off by pointing out that people do good things and bad things. Then you ask, if you did 1,000 good things and 1 bad thing, would you be a good person or a bad person. Most of the time, people respond that they'd be a good person. Then I ask if they did 1,000 good things and 2 bad things, would they be a good person or a bad person?

By this time, they start to get the point. But then, my clients aren't the hard core fundamentalists, so they're not as locked into that kind of thinking. More of my clients manifest a more subtle problem, which I call naive spirituality.

People with naive spirituality embrace beliefs that are brittle and unrealistic. Frequently, their beliefs revolve around the idea that God intervenes in this world to protect them or to make things work out for them.

Then, of course, something awful happens and they feel abandoned by God. This leads them right into thinking, "I must be a terrible person, because God is punishing me." So, naive spirituality is the precursor of toxic spirituality.

Yet, it's often difficult to break into naive spirituality. People don't see the need to change it until it becomes toxic. After all, it's very comforting to believe that God will protect us. It's just not true. Check the paper. Check the history books. How many soldiers would die in wars if God was protecting us?

Evil happens because the world isn't perfect. A healthy spirituality recognizes that bad things will happen to innocent people. A healthy spirituality will also inspire people to correct the things that have hurt people.

Often, when I encounter naive spirituality, I encourage people to read two of Harold Kushner's books, When Bad Things Happen to Good People, and How Good Do We Have to Be? It's hard to get people to face these issues directly, so I often suggest that they read Kushner just to get a different perspective. Often, that's a good start.

The critical thing is this: You cannot challenge someone's spirituality without supplying an alternative. Similarly, when you provide the alternative, don't be surprised if the person walks away with something different from what you provide. Just work to make sure that what ideas they get help them develop a healthier spirituality.

Tuesday, May 16, 2006

Suicide by antidepressants? A clarification

In my previous post, I was talking about the role of SSRI's in stimulating manic episodes. I made an error where I commented,

It's possible, then, that SSRI's may cause a manic or hypomanic episode in bipolar clients who have been misdiagnosed with recurrent depression.
While that is true, I neglected to get where I was going. Some people do not have pure manic or hypomanic episodes. Instead, they have mixed episodes, where symptoms of mania mix with symptoms of depression. A person who is depressed, suicidal, agitated, and impulsive can be very high risk of suicide.

So, I was addressing concerns about SSRI's causing manias. I should have been addressing concerns about SSRI's precipitating a mixed episode.

By the way, one of the best books I've read about bipolar disorder is An Unquiet Mind, by Kay Redfield Jamison.

Sunday, May 14, 2006

Suicide by Antidepressant?

According to the New York Times ,

After analyzing data from clinical trials, GlaxoSmithKline has sent letters to doctors warning that its antidepressant drug Paxil appears to increase the risk of suicide attempts in some young adults.
We've known for a while that Selective Serotonin Reuptake Inhibitors (SSRI's) sometimes cause agitation and suicidal ideation in depressed adolescents, but this is the first time that SSRI's have been linked to the same behavior in young adults. It's important to note, however, that the study reports increased risk of suicidal ideation and suicide gestures. It did not identify an increased risk of completed suicide.

I can recall a few cases like this. Both the psychiatrists I worked with and myself were mystified. It was terrible to watch someone get good care and deteriorate so quickly. One client wound up in a state psychiatric hospital for about three months and was still quite agitated and bizarre after discharge. He was still on the same SSRI he was admitted on.

Nobody is too sure why these antidepressants, SSRI's such as Paxil, do this. The original thinking identified the psychology of depression. There are two different aspects to depression: the cognitive and the behavioral. Almost all depressed clients manifest cognitive changes, consisting of self criticism and pessimism. Behaviorally, many clients also manifest vegetative symptoms. They have little energy, they have difficulty getting out of bed, and they can't concentrate or organize their behavior.

These vegetative symptoms are actually protective. A depressed, suicidal, individual, who is also vegetative can't organize his or her behavior well enough to commit suicide. But with treatment, the vegetative symptoms may lift before the cognitive symptoms, leaving the client more capable of planning and carrying out a suicide. Every clinician, treating with drugs or psychotherapy, worries about this.

This is what we thought this was happening when clients on SSRI's became suicidal. Unfortunately, the data didn't support that. The agitation lasted too long and risk of suicide lasted even after the cognitive symptoms had improved.

I suspect that we are seeing something else. We've also known that SSRI's increase risk of mania in bipolar clients. Bipolar disorder , previously called manic-depression, consists of mood swings, from depressed (often with vegetative symptoms) to manic. The mania is marked by agitation, impulsiveness, irritability, grandiosity, and insomnia. Some forms of bipolar disorder manifest a milder form of mania, called hypomania. Hypomania, looks a lot like agitation with impulsivity. So there are three hypotheses:

First, some of these depressed clients, who react badly to SSRI's, may actually be bipolar. Bipolar disorder usually emerges in adolescence or young adulthood. It's not unusual for there to be a period where the client is diagnosed with recurrent depression. It's not until an unmistakable manic episode breaks through that we diagnose bipolar disorder. It's possible, then, that SSRI's may cause a manic or hypomanic episode in bipolar clients who who have been misdiagnosed with recurrent depression.

Second, most depression fluctuates. That is, a person who is clinically depressed may also have periods where he or she feels pretty good, or at least, not terrible. Then, there are other times when he or she feels suicidal and vegetative. I wonder if there is, at a biochemical level, some similarity between bipolar disorder and some recurrent depressions. To what extent does this similarity cause similar responses to SSRI's?

Finally, the adolescent brain still is developing the structures necessary for impulse control. I wonder, here, too, if the SSRI's differentially affect the adolescent brain. It is possible that these structures have not fully developed in the brain of the young adult, too.

In any case, until we can improve our understanding of this problem, we need to increase our monitoring of depressed patients. Physicians should never prescribe SSRI's or any other antidepressant to an unknown patient and send them away for 3 months.

Obviously, my preference would be referral for psychotherapy, but even that strategy is prone to problems. Most therapists I know today are overloaded. I often can't see someone for two or three weeks after the initial appointment. I have to schedule several appointments to keep seeing a client on a regular basis. This leaves the client unmonitored for a few weeks during the most critical period of starting medication. Fortunately, my employer has a crisis team, who, on my instructions, can call a client in crisis on a specified schedule to check on them. This study should encourage changes in practice for all practitioners.

Thursday, May 11, 2006


I just noticed a link to my blog from Science and Politics .

Thanks, Bora! I promise to post more on science in the future. The other stuff is much easier, and I've been overwhelmed with work lately.

Wednesday, May 10, 2006

Ethics and Clinical Psychology

Ethical issues are always a concern for most psychologists. As the profession has grown, the ethics code has grown from a brief statement to a whole field of study. Professional ethics create tremendous anxiety for clinicians. Let me scratch the surface by citing an article posted by Ken Pope on his web site.

Pope reports the results of a recent survey of American Psychological Association members on ethical dilemmas. The abstract notes:

A random sample of 1,319 members of the American Psychological Association (APA) were asked to describe incidents that they found ethically challenging or troubling. Responses from 679 psychologists described 703 incidents in 23 categories.

As always, the response rate (just under 50%) raises questions about how representative the results are for American clinical psychologists. But the data does show some interesting trends. First, of the 679 responses, 134 reported experiencing no direct experience of ethical dilemmas. Of the remaining responses, 49% fell into three categories: (a) confidentiality, (b) blurred, dual or conflictual relationships, or (c) payment sources, plans, settings, and methods. Let me give you an idea of what psychologists deal with on a regular basis by just touching on pieces of these three areas.

a. Confidentiality. A clinician cannot reveal any information about a client without the client's consent. There are only three exceptions. First, a judge may order a clinician to reveal information over the client's objects. This rarely happens. It may happen when the client is accused of criminal activity and might have disclosed it to the clinician.

Second, the clinician must reveal information to protect a client who is likely to harm the client or others. This happens more frequently. A depressed client calls a clinician and indicates he is suicidal. If the client refuses to go to the hospital voluntarily, the clinician can initiate involuntary commitment procedures.

Finally, clinicians are required to reveal ongoing or recent information to the authorities concerning sexual or physical abuse of minors (and in some cases, the elderly). There is always real concern about balancing the interests of an abusing client against protection of an abused child. While in some cases it's a no-brainer to report, there are other cases where the abuse is suspected or probable, and the clinician must make a judgment call as to whether or not to report. Remember, when you report your client to the authorities, you may be ending your relationship with the client. If you made the wrong call, and the client isn't abusing a child, all you've done is hurt the client. That client will never go back to another therapist after having the police show up at their door.

Confidentiality issues become more complicated when you are treating children from a divorced couple and there is a noncustodial parent, custodial stepparent, and a noncustodial stepparent. Who gets to hear what, and what do I do to protect my client from a parent who might use that information against the other parent? This is one reason why many clinicians have stopped seeing children. There's too much to sort out and too much extra-therapy time required to deal with all those relationships.
b. Dual relationships. If I am seeing a client for therapy, it is my obligation to avoid any other relationship with the client. So, for example, if my client fixes furnaces, I don't hire him to fix mine. Think of how therapy would go if the client does a bad job for me.

The worst example of dual relationships involves clinicians who have sexual relationships with their clients. It's a felony in Pennsylvania, yet it still happens remarkably often. Hollywood seems to think there's nothing wrong with it, which is really bizarre, given the amount of therapy taking place there. There were some recent jokes on TV about it, which really offended me.

Even dating a client years after you have terminated therapy is a terrible idea, although in some instances, it's considered ethical. Personally, I don't see how you can have a relationship with a former client that is truly egalitarian. There would always be some remnant of the old theraputic relationship there.

For those of us in small communities, simple decisions can raise problems with dual relationships. For example, say I want to buy an Accura. The only dealer in town is a client of mine. Do I go to the client's dealership (in which case, he can look at my credit history—another can of worms), or do I go out of town? How do I explain that to my friends, without revealing my relationship to the client, or implying there's something wrong with the dealer? Imagine if that gets back to the client.

c. Payment for services. When clients lose their health insurance or if their benefits run out, the clinician is left in a quandry. Referring long-term clients away to a county agency can be traumatic for the client, evoking old fears of abandonment. When I was in private practice, I might decide to see someone pro bono. That's a lot harder to do when you work for a large corporation with specific ideas about the bottom line.

The flip side of payment issues is productivity. Most employers today expect psychologists to produce a quota of charges for the week. The quota has been rising over the years. A long time ago, the American Psychological Association defined a full time caseload as 20 clients a week. As costs have risen and reimbursement has lagged, caseloads have risen.

Currently, it is expected that you see somewhere in the vicinity of 28 or 30 clients per week. That means that you are seeing at least 6 people per day in a 40 hour week. That is certainly doable, but it's very tiring. The last client of the day may not get the best services. At what point does the large caseload become an ethical issue?

Professional ethics are, by their very nature, a minefield. A middle aged psychologist once remarked to me that her only ambition was to make it through to retirement without getting sued. That's a pretty low level of ambition, particularly because the odds of being sued are pretty low, despite the minefield we have to negotiate every day.

When I started into private practice, malpractice insurance cost $150 a year. Today, it's 10 times that amount. Still, that's not a bad expense, compared to many other professions. Part of the reason, I believe, is that American psychologists have taken ethics seriously. While the APA doesn't have much teeth to it's ethics committee, the state boards of psychology do.

State boards are run by state governments. Most of them have written the APA ethics code into their professional licensure laws. The boards have teeth and they do bite on a regular basis. Most boards can issue reprimands, fine psychologists, limit or even revoke their licenses, depending on the severity of the infraction. I hear a lot of complaints about them from other psychologists, but the Boards keep us on our toes. They've made us more responsive to our clients' needs. Last year, in Pennsylvania, according to the Board of Psychology newsletter, only 11 people were disciplined, so in this state, that's not much of a risk.

State boards are only one kind of landmine. The other is the malpractice suit. This, fortunately, is very rare. I believe (I could be wrong here) that the probability of a clinical psychologist being sued in the course of a lifetime is about 2%. Those are pretty good odds. However, I hear from others who have been sued that it is a terrible experience, as it is when you're disciplined by the board.

Ultimately, ethics are about good practice. Keeping up with the latest literature, maintaining confidences, consulting other clinicians when in doubt, are all ways of providing good treatment and keeping yourself safe from malpractice. You can't be 100% certain of avoiding a suit, but you can keep yourself reasonably safe.