Canton School Board Abandons Abstinence Only Sex Education

This story is certainly not surprising:

An Ohio school board is expanding sex education following the revelation that 13 percent of one high school's female students were pregnant last year.

There were 490 female students at Timken High School in 2005, and 65 were pregnant, WEWS-TV in Cleveland reported.

We live in a very sexual society, but under the current conservative philosophy, we are not allowed to educate our children about sex. As a result, we have the worst of both worlds. All of the advertising and movies out there encourage children to have sex, but children have little knowledge of appropriate sexual behavior.

Telling children, "Just don't do it," isn't good enough, as Timken High School found out. Children need to be taught what responsible sexual behavior is. Once they understand that, it's easier to show them that having sex during childhood is always irresponsible.

That first sexual experience is always done for the wrong reasons: To find out what all the shouting is about; to prove you're a "Man" or a "Woman"; to keep your lover happy; or because you're supposed to have sex on your wedding night. So, the first sexual experience should come at a time when you have the maturity to deal with all the emotional and physical fallout from bad sex.

It's good to see that the adults running Timken High we willing to look at the data, cast ideology aside, and do what's good for their students.

A Slow Summer

This is a slow summer, and I've had little to blog about. That's not to say I haven't been busy. I've been running up my contact hours like crazy.

Normally, August is a slow month for clinicians. My take on the pattern is that people are taking vacations, and with good weather, people are out, doing enjoyable things, and lifting their moods. During the winter, in contrast, people stay inside, gradually going stir crazy. By February and March, they're calling for help.

This August, however, has been anything but slow. I wonder if it's because it's been so hot, people are staying inside, in the air conditioning, going stir crazy. I keep praying for a cancellation or no-show so I can catch up on my paperwork.

So what makes this summer slow? Mostly, it's the absence of news. The research presses have slowed down for the summer. They'll gear back up for the new academic year.

There have been only two interesting stories this month. A new research study on post-traumatic stress disorder (PTSD) challenges a previous estimate of the risk of PTSD. A previous study estimated that 30.9% of Viet Nam veterans experienced symptoms of PTSD. The new study, which is apparently much more rigorous, concluded that the number should be 18.7%.

I've heard no complaints about the methodology in the study, and from what I've seen, it does look pretty solid. Still, dropping the risk factors from just under 1 in 3 to just under 1 in 5 is nothing to write home about. War is still a pretty scarring business.

Despite this data, veterans returning from Iraq seem to be reporting symptoms at a 1 in 3 rate. Apparently, it's because a greater percentage of soldiers are serving in combat roles, compared to the Viet Nam war. Now, support jobs going to soldiers are going instead to civilian contractors. And, by the way, we don't have data on the contractor's risk of PTSD.

I really wish we would never again have to do research on the risks of PTSD in combat.

Another story, which just popped up today in the New York Times concerns pedophilia. Using conversations from chat rooms, the Times was able to draw a very convincing portrait of the rationalizations and defenses pedophiles use to explain away their own behavior.

Psychological defenses are amazing things. Drunks create chaos in the family, and everybody looks the other way, insisting their family is perfectly normal. The old substance abuse counseling line that "Denial is not just a river in Egypt," is equally applicable to pedophiles themselves.

Spirituality and Religion: A Personal Approach

A few weeks ago Mark Isaac, on The Panda's Thumb wrote a piece entitled, The Larger Issue of Bad Religion. It created quite a stir. I was tempted to comment, but I needed time to think about it. By the time I got my thoughts together, the comments had gone south. They devolved into insult, and the last comment on the blog just repeated the phrase, “religion sucks!” more times than I want to count.

It occurred to me that identifying “religion” as “good” or “bad” is useless, because “religion” is a very broad concept. There is no single set of “religious” practices or beliefs. If you don't believe me, just compare Catholicism to Pentecostalism to Orthodox Judaism to Reform Judaism to Unitarianism. It's all religion, but it sure ain't the same. To make decisions about what is good and bad about religion, we need to be more specific.

If “religion” is a brand (e. g., Christianity, Judaism, Protestantism, Islam, Buddhism), then “spirituality” refers to their component beliefs and practices. We can evaluate each individual component itself, and can then decide for ourselves what kinds of spiritual practices work for each of us individually. This is not a new thought for me. I'm an individualist, and refuse to let others make my spiritual decisions for me. But, it was a new and direct approach to doing it. I got really excited and started listing spiritual practices in bipolar form. Then, two problems jumped out at me.

First, on what scale do I evaluate these components: “Good vs. bad,” “healthy vs. unhealthy,” “toxic vs. nourishing,” or something else? Second, as I wrote out my list, I suddenly realized that I wasn't evaluating religion or spirituality. I was describing my own beliefs.

I've spent a lot of time thinking about my beliefs, and have been struggling with an ethical will. So, if I'm describing my beliefs, it's narcissistic for me to say, “These beliefs are good, and these beliefs are bad.” That was the solution to both problems.

Below, I've generated a list of spiritual beliefs and practices that I either embrace or reject. You may agree or disagree with me; I don't care. I do think there are some truly toxic beliefs; I've discussed them before. But, this list is more than just a discussion of toxic spirituality.

I embrace spirituality: That helps me find meaning in life.

I reject spirituality: That imposes meaning on me.

I embrace spirituality: That encourages me to find faith through reason.

I reject spirituality: That encourages me to "just believe."

I embrace spirituality: That inspires me to be more ethical.

I reject spirituality: That uses fear and shame to motivate me.

I embrace spirituality: That teaches respect for others.

I reject spirituality: That teaches God likes you better because you're one of us.

I embrace spirituality: Where nonmembers are taught about one's beliefs.

I reject spirituality: Where nonmembers are told, “Our beliefs are better than yours.”

I embrace spirituality: That encourages involvement with the larger community.

I reject spirituality: That encourages withdrawal from the larger community.

I embrace spirituality: That sees pleasure as a legitimate part of life.

I reject spirituality: That encourages self-denial and elevates suffering.

I embrace spirituality: That comforts people cope suffering from misfortune.

I reject spirituality: That blames people for their misfortunes.

I embrace spirituality: That accepts human fallibility.

I reject spirituality: That demands perfection from humanity.

I embrace spirituality: That encourages people to make the world a better place.

I reject spirituality: That encourages people to tolerate things as they are.

I embrace spirituality: That uses ritual to reinforce beliefs or connect with the past.

I reject spirituality: That uses ritual to please God.

This list is far from exhaustive. I'll probably spend the rest of my life populating and revising it. Generate your own list. It's a great experience.

New Psychology Advocacy Group is Formed

The National Psychologist reports that a new advocacy group, the National Alliance of Professional Psychology Providers, has just been formed. Their web site states,

The National Alliance of Professional Psychology Providers (NAPPP) is a new, nonprofit organization for professional psychologists to advance and secure the practice of psychology. The purpose of NAPPP is twofold. First, we will function as an advocacy organization to assertively protect and advance scope of practice issues through lobbying, legislative and litigation strategies. Second, we want to help educate and inform practitioners about the business of practicing psychology so that this much ignored aspect of the profession can grow and develop.

It sounds good. Although NAPPP doesn't describe itself as a replacement for the American Psychological Association (APA), it certainly could fill a gaping hole.

I dropped out of the APA for two reasons. First, because the APA seemed to be disinterested in protecting practitioners from the erosions of managed care. When managed care came in, they...well...managed care. Managed care wanted to see that their dollars were being well spent. They were at times intrusive, and always were a pain in the ass, and APA took a stand against managing care. Unfortunately, APA missed the bigger problem until it was too late.

The real problem was that managed care eroded our fees. As a result, caseloads skyrocketed. Twenty years ago, 20 clients a week was considered a full time load. It paid for the clinician's salary and the office overhead. Today, it takes 30 clients a week. The APA has done nothing about that. Managed care oversight is essentially gone, at least in Pennsylvania, because it was too expensive. But, the fees are still lousy. So, a word of advice: Never see a psychologist late on a Friday afternoon.

The second reason I resigned was the inability of APA to stand by it's belief that psychotherapy could be a practice based on scientific principles. Some forms of psychotherapy, such as cognitive therapy and interpersonal therapy, have some pretty good evidence for their effectiveness. Yet, when questionable therapies, such as rebirthing therapy, emerged, the APA has been silent. Eventually, rebirthing therapy killed a child. Organized psychology should be taking strong stands against pseudoscience, and it's not.

So, I hope that NAPPP does well. At $240 annually for membership, it's a little pricey, but it could be worth it. I'm considering joining.

A few days ago, the US Supreme Court ruled on another wrinkle in the insanity defense. An Arizona man, clearly schizophrenic, argued that his illness prevented him from forming the requisite intent to commit a crime. According to the New York Times:

The case was brought by an Arizona man who was a teenager suffering from paranoid schizophrenia when he shot and killed a police officer. He was convicted of violating a law that makes it a crime to kill a police officer intentionally, and he argued that the delusions caused by his illness had prevented him from forming that specific intent.

The key to the case involved the word, "intent." The defendant argued that because he was schizophrenic, he couldn't have formed any intent. The Supreme Court, keeping it's ideological purity intact, essentially dodged the issue with a narrow ruling. Writing for the court, Justice David Souter said that the states were so varied in their approaches to insanity, that there is no single, unambiguous standard for legal insanity. It's a sad state of affairs that this is true.

The court system is teetering between three models of criminal behavior: Moral, psychosocial, and medical. The moral model attributes criminal behavior to immorality. If you punish the immoral behavior, it will stop. The psychosocial model attributes criminal behavior to a complex interaction among family, community and economic causes. The medical model holds that criminal behavior is the result of genetic and biological causes.

All three models have their elements of truth, but the moral model holds sway, to the detriment of the other two. Criminal behavior does need to be punished, but, we should also attend to the social and economic framework in which criminal behavior occurs. Social inequity is the fertilizer in which criminal behavior grows.

We are becoming convinced that schizophrenia is primarily a medical problem. Why are we holding schizophrenics accountable for their behavior in the same ways that "normal" people are? It's a sad thing that we no longer see social services as a force for good. Even though crime rates drop during good economic times, even though education is a proven route to rehabilitation, we are still committed to the moral model to the exclusion of the others. It's a shame that compassion is passe.

Advice for Other Psychologists

If you're like me, you dread telling people what you do for a living. You tell them you're a psychologist, and somebody always says, "We better watch out what we're saying!" A real original comment. I finally came up with the perfect response:

"Don't worry. Your secrets are safe with me."

If I'm feeling particularly sadistic, I can add, "You know that sexual issue you have? Don't worry, I won't say a word."

Who was Freud?

Over at Frontal Cortex on the newly expanded ScienceBlogs, Jonah Lehrer compares Malcolm Gladwell (author of Blink, in which he discusses rapid, unconscious, "snap" decision-making) to Sigmund Freud:

Sigmund Freud was also a master prose stylist, wasn't particularly interested in the neurological foundations of his theories, and loved theorizing about the all powerful unconscious. (Like Gladwell, he also loomed large in mass culture and had a talent for giving his books pithy names, although I'm pretty sure Freud never made the rounds of the corporate lecture circuit...) Blink could have been a great book. It could have really explored the modern science of unconscious thinking.

I haven't read Blink yet, so this post isn't about the book. Instead, I am concerned about the trivialize of Freud. Freud was a brilliant man. (No, he wasn't obsessed with sex.) Much of psychoanalysis has been put aside, but it was Freud who recognized that there can be pathology in thought. He recognized that there is value in introspection. He created the idea of the therapeutic relationship, and these ideas have woven their way into the fabric of our lives.

Freud was a visionary. His power came, not from being a literary stylist (he didn't even write in English), but because he presented a compelling new vision of humanity. Today, that vision is dated. Popular conceptions of psychoanalysis inevitably simplify it, and those simplifications seem very trite.

Nevertheless, Freud's vision of the human psyche changed the way we think about ourselves so fundamentally, we take it for granted. For some people, no argument with our spouse is complete unless we have introspected about our motives. Did I really tell here what I was angry about? Is there another issue I'm not facing? The idea that our motives can be hidden from ourselves came from Freud.

As parents, we worry how our parenting will affect our children when they grow up. That came from Freud.

As I've said before, I'm not a psychoanalyst. But I have to respect Freud's vision, his creation of a whole new way to help people, and his contribution to our current culture.

Psychological Effects of Day Care

The New York Times has a summary of an extensive study on daycare, conducted in Quebec. In 1997, Quebec began subsidizing daycare for all 4 year olds, regardless of income. By 2000, the program was expanded to include all children not in kindergarten. The program was very popular, and resulted in significant economic expansion in Quebec. Three economists, Michael Baker, Kevin Milligan, and Jonathan Gruber collected data on the well-being of the children going through daycare.

They compared those results with children in the rest of Canada during that same period. Unfortunately, they found that the children in daycare did not fare so well. The Times reports:

Young children in Quebec are more anxious and aggressive than they were a decade ago, even though children elsewhere in Canada did not show big changes. Quebec children also learn to use a toilet, climb stairs and count to three at later ages, on average, than they once did. The effects weren't so great for parents, either. More of them reported being depressed, and they were less satisfied with their marriages — which also didn't happen in other provinces.

I can hear the pontificating now. Mothers should stop trying to work and just stay home with the children. Enough of this liberal working mother stuff and be good, pro-family conservatives!

Ecch.

David Leonhardt, the author of the Times article, makes the following comment:

The big lesson from Quebec is that parents really do need more support, but they need the kind of support that allows them to choose what is best for their family. Mothers and fathers should get paid time off after a baby is born, and the money should come from a government insurance program, as it does in Canada, England and other countries. Companies need to be given incentives to create more part-time jobs that don't derail careers — and then find some up-and-coming men who want those jobs. High-quality preschool programs should be available for every low-income child and perhaps universally.

Wouldn't that really be pro-family?

Intermittent Explosive Disorder: The New Rage?

Sorry, I couldn't resist the title.

Apparently, intermittent explosive disorder (IED) has hit the popular press. I've seen about 3 or 4 different references to it in the last week. The stories have been confusing it with road rage, but it's not. IED has been a diagnosis for years.

The whole thing follows a predictable arc:

1. An obscure diagnosis sits in the current Diagnostic and Statistical Manual.
2. Someone finds a way to use it to sell drugs. psychotherapy, or self-help books.
3. It catches the attention of the press.
3. It gets initials (e.g., IED) and becomes overdiagnosed and overtreated.
4. Warnings are issued about overdiagnosis.
5. Clinicians who benefit from the diagnosis argue that in the past it was underdiagnosed.
6. It continues to be overdiagnosed.
7. In some cases, associations get formed, and the diagnosis starts getting used as an excuse for underachievement or misbehavior.

We saw this with attention deficit disorder. Now Ritalin is rampant, and people with ADD get longer to take tests. A few years ago, oppositional defiant disorder followed the same arc, as did autism. Now, intermittent explosive disorder is hitting the same arc.

For the record, clinicians have been treating anger for many years. I recall diagnosing intermittent explosive disorder a few years ago, and having the insurance company kick the claim back saying they don't cover it. When this happens, clinicians always fall back on the same strategy. You avoid diagnoses that you don't get paid for.

That's not quite as dishonest as it sounds. A quick perusal of the Fourth Edition of the Diagnostic and Statistical Manual (DSM-IV) will show that multiple disorders manifest the same behavioral symptoms. For example, irritability and rage are the prime symptoms of intermittent explosive disorder, but, they are also associated with unipolar depression, bipolar disorder, attention deficit disorder, conduct disorder, and various personality disorders.

So, in the past, to assure payment, we treated anger as a symptom of another diagnosis. IED wasn't very common because no one was diagnosing it. I could be wrong here, but it's my recollection that when the Columbine School shootings occurred, more attention was brought to the problems associated with anger. We started to hear about "anger management," and I suspect this led to more diagnosis of intermittent explosive disorder.

So, two takeaways from this. First, diagnosis in mental health is not the same as in physical health. Despite all the huffing and puffing about biochemical imbalance, we have no clear understanding of the underlying mechanisms of depression or other mental illnesses. This means that ultimately "diagnosis" involves just summarizing what particular symptoms are being treated. It says nothing about etiology.

Second, diagnoses are influenced by social and economic factors. After Columbine, we stopped thinking that anger was just a matter of rudeness and immaturity. Now we think it's something serious that should be addressed, and our patterns of diagnosis have changed as a result. Let us not forget, however, that from spousal abuse to school shootings to office shootings to road rage, anger is a real problem.

I don't want to see it trivialized, either. I'm sure we'll soon hear, "I shouldn't be found guilty for running that man off the road because I have intermittent explosive disorder." That doesn't fly. IED is a serious problem and a treatable one, but it's not an excuse.

Early Infant-Mother Attachment

The latest issue of Current Directions in Psychological Science contains an interesting article on early infant-mother attachment, by Myron Hofer. His work is based on research with rats, but nevertheless, there is much interesting data that is relevant to humans.

The term, attachment, as Hofer uses it, refers to “the processes that maintain and regulate sustained social relationships” (p. 84). Attachment between mother and infant is the first bond that occurs. Much clinical and social experience over the last 50 years has shown that inhibiting this process has long and severe consequences for the infant. The current thinking is that both reactive attachment disorder and antisocial personality disorder stem from impaired attachments during infancy and childhood. There are also suggestions that borderline personality disorder is also related to disrupted attachment.

Hofer addresses three issues. First, he presents data suggesting the attachment bond is created through the interaction of mother and infant through a complex pairing of stimuli. Apparently, there is an early period, immediately after birth, when the infant rapidly learns to associate smells, sounds, taste, and touch with the mother. It happens quite rapidly, enabling the infant to discriminate the mother from other parents and probably from other objects in the infant's environment.

Interestingly, Hofer mentions some data that indicates that aversive stimulation may intensify the bonding. He links this finding with the intense bond between a child and an abusive parent, and why this occurs needs to be clarified. Rapid bonding between the infant and the mother makes good sense from an evolutionary point of view. The mother provides all of the infants needs for survival, so the sooner the infant can recognize the mother the better. But the reason for increased attachment in the face of pain makes no sense to me.

The second issue involves the question of why maternal separation is stressful. Hofer says that basic biological processes are initially regulated by the mother in subtle ways. In describing an experiment with rats, he commented, “We concluded from these surprising results that warmth provided by the mother normally maintained the pup's activity level and that her milk maintained her pup's heart rate. Maternal separation withdrew these regulatory influences that were hidden within the ordinary mother–infant interactions, resulting in slowed behavior and low heart rate.” (p. 86).

The final issue Hofer addresses is why disruption of the early maternal-infant relationship can have lasting effects. Hofer argues, “when all maternal regulators are withdrawn early, a number of physiological and behavioral systems are altered in their developmental paths and in their relation to each other, creating a complex, changing pattern of vulnerability over the life span.” (p. 86). Interestingly, not all those changes are negative, which is consistent with what humans will tell you.

People who have gone through arduous childhood experiences often comment that they take away some positives from it. For example, some of my clients have said that because of the abuse they suffered as child, they have learned to manage stress better than their friends. They do not minimize the experience or deny how bad it was. They simply recognize that they did manage to take something positive from it.

Finally, it's always a pleasure to read a basic science article that has implications for practice. There's an awful lot of stuff out there that will never be of any real use to anyone beyond a line on a vita.

Hofer, Myron A. (2006). Psychobiological Roots of Early Attachment. Current Directions in Psychological Science 15 (2), 84-88. doi: 10.1111/j.0963-7214.2006.00412.x

Available on-line $

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.

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.

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.

Thanks

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.

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.

Freud and Psychotherapy

A collection of Sigmund Freud's drawings is scheduled for exhibition at the New York Academy of Medicine, according to a story in the New York Times. The drawings reflect Freud's progression from a neuroanatomist to psychoanalyst. As is obligatory in articles about psychoanalysis, the comment is made, "Freud's methods have fallen from favor in recent decades, but science historians say that his investigation of the unconscious more than a century ago stands as a revolutionary achievement that still informs many therapists' understanding of memory, trauma and behavior."

When I was in graduate school, the conventional wisdom was that Freud's greatest contribution was his concept of transference. In traditional psychoanalytic thought, transference refers to a client's tendency to think of his or her analyst as a parent. The client's behavior toward the analyst was then used as evidence of early relationships and interpreted back to the client.

Today, the term, transference, is out of style. Nevertheless, a good clinician uses behavior in the office as the primary data for treatment. How a client responds to me tells me much about how the client behaves outside of therapy. For example, I usually teach angry clients relaxation exercises, so they can calm themselves when angry. If a client tells me that relaxation exercises seem silly to him, it tells me a lot about how he behaves outside of the session. He may behave judgmentally toward his bosses, coworkers, or family members. Then, I can show him how he angers himself, by saying, "This is silly. I shouldn't have to do this." From there, it's a simple step to restructuring the thoughts by substituting, "It can't hurt to try it and see if it helps."

I certainly don't think of myself as a psychoanalyst, although I respect Freud's genius in uncovering the healing nature of a relationship. Freud did something else, which therapists should never forget. He let his patients teach him about healing.

Psychotherapy for Compulsive Gambling

Slot machines are coming to Pennsylvania. Like most psychologists who don't work near a casino, I don't see many gamblers. When the slot machine law was initially enacted, I took some continuing education credits to brush up. It taught me how little we really know about gambling.

Mostly, psychologists see gamblers when their luck has run out and their lives are in a shambles. We'll be seeing more of those people as casinos become more common. I just reviewed an on-line book on gambling , [Sorry, this link is dead--F. O. 8/27/2009] dated 1999. It's a little old, but not much has changed since it's publication. It's also a little thin on treatment, but it does have some good data. For those that are into diagnostics, they have a copy of the diagnostic criteria for pathological gambling.

The current issue of the APA Monitor has an article entitled, Gamble at Your Own Risk , which discusses some research on controlling compulsive gambling. The article reports on two studies. In the first, they found that even people well-versed in the probabilities of gambling, will still do it. In one study, students in an introductory statistics class got intensive education in the probabilities of winning at gambling. They still gambled at the same rate as students in a control group.

In the second study, a casino was set up, using a computerized roulette game. Warnings, such as, "If you bet more to make up your losses, you're likely to lose more money" and "If you continue to gamble, you'll eventually lose money," were flashed on the screen. Not surprisingly, students receiving the warnings did gamble less money. But come on, do you think you'll ever see warnings in a casino?

Generally, treatment for pathological gambling follows the addictions model. The goal is not to "recover," but instead to stay in recovery for the rest of one's life. To assist in this process, the clinician must address at least four areas:

1. The negative effects of gambling on the client. The goal is to help the client see that gambling is the cause of all their major problems. Once they are convinced that not gambling will improve their life, they can be engaged in therapy. I always begin by taking a history from my clients. For problems like gambling, the client may find it very traumatic to recount their gambling behavior. Having the client write an autobiography, linking major events in their life to gambling may be a very emotional experience, too.

2. Education about pathological gambling. There are two issues here: First, gamblers need to understand gambling itself, and see that the odds are generally stacked against them. Their unrealistic beliefs about gambling, such as the belief that they can make up for their losses, need to be challenged.

Second, they need to understand their own addictive behavior. For me, the best explanation of gambling comes from basic learning theory. People do what they are reinforced (rewarded) for. There are two rewards for gambling. First, there is a "high" to gambling; a thrill that people report when they are about to pull the lever, lay their money on the table, or watch the outcome of a game or race. That high is very rewarding for the gambler. Second, the behavior is intermittently reinforced. That is, they are rewarded by winning just often enough to keep people playing in the face of their losses. Combining the immediate reinforcement of the high with the intermittent reinforcement of winning makes the gambling behavior very resistant to treatment.

3. Repairing the damage. Pathological gambling does tremendous damage to people's lives. The client needs a great deal of supportive therapy to deal with the financial or legal fallout from the gambling. It's not unusual for a person to have repeatedly run up tens of thousands of dollars in debts, leaving the family struggling to get by. Often, the gambler has embezzled money from their employer, also and may be up on charges as well. In addition to individual therapy, family or marital therapy is necessary to heal the anger that loved ones feel over the client's behavior. The clinician must be careful to support the client, help him or her over the difficulties, but not to minimize or excuse the behavior.
4. Support for abstinence. It might be possible for some gamblers to return to controlled gambling, but I think the risk is too great. The client needs to go to Gambler's Anonymous on a regular basis. Family members should go to Gam-Anon , too.

As the gambler abstains from gambling, they will experience cravings, just like an addict. These cravings are a vital part of recovery. In therapy, they can be used to help the client understand the role of gambling in their lives. Abstinence reveals how gambling filled the holes in the gambler's life. Filling those holes with healthy behavior is a vital part of recovery.
Working with addiction is always frustrating. In some ways, gambling is the worst of the addictions. Substance abusers can avoid their drug of choice fairly effectively. However, with the proliferation of lotteries, casinos, and Internet gambling, the recovering gambler is never far from the scene. Relapses are common with gambling, and are much more catastrophic than with substances. A drunk can go on a bender and then climb back on the wagon. A gambler can relapse and lose $10,000, in a weekend, literally erasing all the good work he had done.

In conclusion, therapy is a mix of educational, supportive, and confrontational treatments. Knowing when to implement them is challenging, to say the least. Gamblers often do enter and maintain their recoveries, although it can be a difficult road there.

Links Between Drug Companies and Psychiatry

Diagnosis in mental health is detailed in the fourth Diagnostic and Statistical Manual (DSM-IV), published by the American Psychiatric Association. The New York Times today published a report of a study claiming to show links between the authors of DSM-IV and pharmaceutical companies. The report stated,

The researchers found that 95 — or 56 percent — of 170 experts who worked on the
1994 edition of the manual, called the Diagnostic and Statistical Manual, or
D.S.M, had at least one monetary relationship with a drug maker in the years from 1989 to 2004. The most frequent tie involved money for research, according to the study, an analysis of financial records and conflict-of-interest statements.

Honestly, I'm not surprised or upset by the relationship. DSM-IV is published by psychiatrists for use by psychiatrists. It reflects a medical model of mental illness, and most of the experts who work on it are researchers in the biological side of treatment. Most of psychiatry is conducted drug treatment. Psychiatrists prescribe medication. Psychologists, social workers, psychotherapists and counselors conduct psychotherapy. A few psychiatrists still dabble in psychotherapy, but they are a dying breed.

Not surprisingly, then, DSM-IV works fine for medical management of mental illness. It stinks as a diagnostic tool for psychotherapy. Let me show you how it works. A person is diagnosed along five "axes:"

I. Clinical disorders
II. Personality disorders or mental retardation
III. General medical conditions
IV. Psychosocial stressors
V. Global Assessment of Functioning

Axis I disorders correspond to depression, anxiety, and other problems that we normally treat (and are advertised on TV). Axis II refers to personality problems that are long-standing. (Why personality disorders and mental retardation are linked is beyond me.) Axis III details medical status. It's important to know this, as many medical illnesses may manifest the same symptoms as depression or anxiety. Axis IV describes psychosocial stressors in very general terms. Axis V describes a person's level of functioning with a 0 to 100 scale.

So, for example, a person might have the following diagnoses:

I. Major depressive disorder, moderate, recurrent
II. Borderline personality disorder
III. No diagnosis
IV. Problems with the primary support group
V. Current GAF 57

There are myriad problems with this scheme. First, the use of the term "axis" implies that each axis is independent from the others. Nothing could be further from the truth. People with personality disorders, for example, are more likely to have anxiety and depressive disorders than others without personalty disorders.

Second, we don't really know what a "disorder" is. In most cases, there is evidence of both psychosocial and biological causes for a client's complaints. Both psychological and biological treatments are effective for the same "disorders." So, what are we really treating?

Third, this scheme doesn't describe the quality of the client's life very effectively, and that's what we really deal with in psychotherapy. Axis IV, where this should be placed, is very general, and poorly delineated. "Problems with the Primary Support Group," covers a lot of ground, from arguing with your wife to repeated sexual abuse of a child.

Fourth, assessment of these disorders remains rooted in the clinical interview. We've known since the 1950's, with a book by Paul Meehl that clinical interviewing is not very reliable. Unfortunately, psychologists, who are the true experts in assessment, have dropped the ball entirely. We have not generated the kind of data necessary to add psycosocial assessment to the diagnostic manual.

So, why do we need diagnosis at all? We need it to describe what we're treating. We need it to organized our research into better treatment methods. So as a result, we limp along with the diagnostic manuals as written. Hopefully, the next one will be better.

New Orleans Evacuees Suffering from Lack of Health Insurance

Today the New York Times published a story on the mental and physical health of New Orleans evacuees. According to the story:

The study, conducted by the Mailman School of Public Health at
Columbia University and the Children's Health Fund, is the first to
examine the health issues of those living in housing provided by the Federal
Emergency Management Agency. Based on face-to-face interviews with more than 650 families living in trailers or hotels, it provides a grim portrait of the
hurricane's effects on some of the poorest victims, showing gaps in the tattered
safety net pieced together from government and private efforts.

I haven't been able to find the source on line, so I can't comment on the specifics. However, the overall picture is not surprising. One observation they made caught my eye:

Forty-four percent (of adult evacuees) said they had no health insurance, many because they lost their jobs after the storm, and nearly half were managing at least one chronic condition like diabetes, high blood pressure or cancer.

Our reliance on employer-based insurance coverage continues to fail all of us, but especially the poor. It is infuriating to me that we continue to insist this is the only way, while Western Europe, Australia, and Japan have been able to provide universal coverage to their citizens. The only reason we can't is that we cater to large insurance corporations who like the current system. Remember how they reacted when Clinton proposed changing it?

The current system is completely anticompetitive. Employers negotiate with a few insurers, who are only interested if the employees are a good risk. The employers are interested in insurance that is the least expensive for them. The employees themselves, who will actually use the services are not consulted on what they want.

Once the insurance goes into effect, the only competition that goes on occurs between the provider offices and the insurance company. Basically, the system is this: the physician office employs at least one person to make sure all claims are paid. The insurance company employs people whose job it is to assure that as few claims as possible are paid. They fight it out with each other, raising costs, and slowing down service delivery. It's no wonder we have an incredibly expensive system that nobody likes.

I'm glad that Massachusetts is trying to provide insurance to all, but I'm pessimistic about the plan. State governments don't have the resources to manage a plan like this. Ultimately, as New Orleans is showing us, the solution has to be with the Federal Government.

Professional Ethics and the Clinical Psychologist

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.