Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Thursday, December 31, 2015

Mourning and Falconry-A Book Review

I recently finished reading, H is for Hawk, by Helen Macdonald. I stumbled across it in a bookstore in Berkeley called, Books Inc. A real bookstore. The small kind that has a mini-review or commentary by the staff every few books on the shelf. It was refreshing to be there.  I didn't realize it was a NY Times Bestseller. It just drew my eye and looked interesting.

According to her page at The Marsh Agency, Ms. Macdonald is a, "writer, poet, illustrator, historian, and naturalist, and an affiliated research scholar at the Department of History and Philosophy of Science at the University of Cambridge. Over the years she's also worked as a Research Fellow at Jesus College, Cambridge, as a professional falconer, assisted with the management of raptor research and conservation projects across Eurasia, and bred hunting falcons for Arab royalty. She's also sold paintings, worked as an antiquarian bookseller, organised academic conferences, shepherded a flock of fifty ewes and once attended an arms fair by mistake."

H is for Hawk is moving and fascinating, but I'm also very happy to report that even if the subject didn't interest me, I would have enjoyed the book because the woman can write. Sometimes I'll read a book, particularly fiction, and while I may be enjoying the story, I find myself editing the writing- this passage was awkwardly phrased, that sentence would have been better at the end of the paragraph, etc. Not so for Macdonald's writing. It's both beautiful and accessible.

Here's a sample (p. 181):

But then the pheasant is flushed, a pale and burring chunk of muscle and feathers, and the hawk crashes from the hedge towards it. And all the lines that connect heart and head and future possibilities, those lines that also connect me with the hawk and the pheasant and with life and death, suddenly become safe, become tied together in a small muddle of feathers and gripping talons that stand in mud in the middle of a small field in the middle of a small county in a small country on the edge of winter.

Shortly after her father's sudden death,  Macdonald decided to train a goshawk. She'd been fascinated by hawks all her life, and had extensive experience training them. But this was her first attempt at training the notoriously challenging goshawk.

There are a number of reasons she made this decision. One early-Spring morning, she felt restless, got up at dawn, and for no discernible reason, drove to the Brecklands to see goshawks, which are rarely visible in the open except at that time of year. The experience reminded her of watching for sparrowhawks with her father, when she was a child. She brought home a piece of reindeer moss she'd been gripping while watching the goshawks that day, and three weeks later, she was staring at the moss when her mother called to tell her her father had died.

That's the first connection. One of the brilliant things about the book, and there are many, is that Macdonald clearly recognizes the complex interactions between her thoughts and feelings, and her behavior. But she does not dwell on them, as one would in a typical psychoanalytic case report. She simply describes them, and leaves the reader to draw conclusions, although she does, occasionally, mention Melanie Klein, Freud, and other analytic thinkers.

The next connection is closer to the heart of her mourning. She describes a summer experience she set up for herself when she was 12, and went to spend several weeks with some gentlemen who flew goshawks:

I was terrified. Not of the hawks: of the falconers. I'd never met men like these. They wore tweed and offered me snuff. They were clubbable men with battered Range Rovers and vowels that bespoke Eton and Oxford, and I was having the first uncomfortable inklings that while I wanted to be a falconer more than anything, it was possible I might not be entirely like these men...

On the first day of that trip, she watched a goshawk kill a pheasant, her first sight of death. She also watched as later that same day, the goshawks seemed to lose interest in their handlers and flew off into the trees. Some took hours before returning:

The disposition of their hawks was peculiar. But it wasn't unsociable. It was something much stranger. It seemed that the hawks couldn't see us at all, that they'd slipped out of our world entirely and moved into another, wilder world from which humans had been utterly erased.

After that summer, she chose to stay away from goshawks:

I never forgot those silent, wayward goshawks. But when I became a falconer I never wanted to fly one. They unnerved me. The were things of death and difficulty: spooky, pale-eyed psychopaths that lived and killed in woodland thickets. Falcons were the raptors I loved...

Yet another connection has to do with T. H. White, best known as the author of, The Once and Future King. He also wrote a book entitled, The Goshawk, his firsthand account of training his own goshawk, who he named, Gos. It was a disaster. It's like an instruction manual for how NOT to train a goshawk, or any other animal, for that matter. As a child, Macdonald reviled White for his inconsistent, and ultimately cruel treatment of Gos. But in H is for Hawk, she comes to view, The Goshawk, differently, as White's account of his conflicts surrounding sadism and love, and his struggle to become himself through his identification with Gos.

Macdonald is a much better trainer than White, although she doubts herself constantly. Is she feeding Mabel (her goshawk) too much, or too little, or the wrong kind of food? The feeding of a goshawk is not a trivial, Jewish mother issue. Goshawks weigh around two pounds, and a couple ounces either way can throw off their flying completely. But the level of Macdonald's worry is indicative of her mourning, which, by her own acknowledgement, is mixed with depression to a degree that would bewilder the most hardcore DSM-5 enthusiast.

Certainly, Mabel is a comfort to Macdonald. She turns out to be not that difficult to train, and is even playful-there's a lovely description of a game involving some rolled up paper, with Macdonald commenting that she hadn't realized goshawks DID play. She attributes at least some of their affinity to their shared gender, and notes that all the falconers and austringers (solitary goshawk trainers) who have described the bird as difficult and sulky have been men.

Incidentally, I attempted to contact Macdonald through her agent to get permission to use a photo of Mabel that I found online, in this post, but I never heard back from either of them-I suspect my message didn't get through-so I'm not comfortable using the picture here. But if you google "Mabel the goshawk" you will see that she was very beautiful.

Macdonald traces her bonding with Mabel, as well as her use of Mabel to isolate herself while she's mourning. We sense the appeal of the hawk's ability to "slip out of this world". By identifying with Mabel, she can distance herself from her pain, or access her father, who has "moved into another, wilder world from which humans had been utterly erased."

And we see the painful, drawn out process of letting go that Freud wrote about in Mourning and Melancholia (Freud, S. (1917). Mourning and Melancholia. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XIV, Pp. 244-5):

In what, now, does the work which mourning performs consist? I do not think there is anything far-fetched in presenting it in the following way. Reality-testing has shown that the loved object no longer exists, and it proceeds to demand that all libido shall be withdrawn from its attachments to that object. This demand arouses understandable opposition—it is a matter of general observation that people never willingly abandon a libidinal position, not even, indeed, when a substitute is already beckoning to them. This opposition can be so intense that a turning away from reality takes place and a clinging to the object through the medium of a hallucinatory wishful psychosis. Normally, respect for reality gains the day. Nevertheless its orders cannot be obeyed at once. They are carried out bit by bit, at great expense of time and cathectic energy, and in the meantime the existence of the lost object is psychically prolonged. Each single one of the memories and expectations in which the libido is bound to the object is brought up and hyper-cathected, and detachment of the libido is accomplished in respect of it.

At some point, Macdonald has to literally let go of Mabel's jesses and allow her to fly free, to have faith that she'll return.

I learned a lot of fun terminology from the book, too. Jesses are the leather straps that fit through the anklets on a hawk's legs. Bating is a, "Headlong dive of rage and terror, by which a leashed hawk leaps from the fist in a wild bid for freedom." That was me quoting Macdonald quoting White.

She describes making jesses as a child. Then she comments, " I have a suspicion that all those hours making jesses and leashes weren't just preparation games...It reminds me of a paper by the psychoanalyst D. W. Winnicott, the one about the child obsessed with string; a boy who tied together chairs and tables, tied cushions to the fireplace, even...Winnicott saw this behaviour as a way of dealing with fears of abandonment by the boy's mother, who'd suffered bouts of depression. For the boy, the string was a kind of wordless communication, a symbolic means of joining. It was a denial of separation. Holding tight. Perhaps those jesses might have been unspoken attempts to hold on to something that had already flown away."

Macdonald had a twin brother who died shortly after birth. She wasn't told about him until years later, but she wasn't that surprised by the news. She wonders if a detailed drawing of a kestrel's jesses, that she drew when she was six, was, "...a way of holding tight to something I didn't know I'd lost, but knew had gone..." And she imagines that the jesses she makes for Mabel are a way of similarly holding on to her father. But I wondered if her father's death hit her as hard as it did, in part, because of the unremembered but somehow perceived loss of her twin, now being re-experienced. And I wondered further what it means to her that she survived, and her brother didn't.

Because we also see the connection between death and aggression. Mabel is beautiful and playful, but she is a powerful killer. That's what she does. That's why Macdonald got her in the first place. So they could hunt together.

Mabel, as she kills her prey, becomes the actualization of Macdonald's rage against her father's death, and against her father, for dying. When she and the bird are one, she becomes the master of death, able to decide who lives and who dies. A powerful wish fulfilled, only too late for her father.

Ultimately, with Mabel's assistance, but also of her own accord, Macdonald gets through her mourning period and is able to resume her life with some joy. To begin again.

Happy New Year!


I really don't get twitter. I couldn't figure out how to send a private message to Helen Macdonald to ask permission to use a photo of Mabel, which is why I contacted her agent. But when I tweeted this post, I added her twitter handle, and she read the tweet, and apparently the post, and gave me permission to use a photo. So, this is Mabel. Wasn't she beautiful? (Disclosure: I grew up with parakeets, and I have a soft spot for birds):

Thursday, December 17, 2015

Thank You, Mickey! Part II

Picking up where I left off in Thank You, Mickey! Part I, I was about to describe how the article I'm examining, Effectiveness of influenza vaccine for preventing laboratory-confirmed influenza hospitalizations in adults, 2011-2012 influenza season, figured out that there is a 71% reduction in flu-related hospitalizations in patients who have been vaccinated against flu, vs. those who haven't.

One of the articles Mickey sent me was from the World Health Organization (WHO), Field Evaluation of Vaccine Efficacy, written in 1985 by Orenstein, et al, and published in the Bulletin of the WHO. This article was, in fact, listed in the bibliography, but I didn't notice it. Thanks again, Mickey.

In general, Vaccine Efficacy (VE) is the difference between the incidence or attack rate of disease among the unvaccinated (ARU) and vaccinated (ARV), divided by the ARU, and multiplied by 100.

VE=(ARU-ARV)/ARU x 100.

So, for a perfect vaccine, the ARV would be zero, and then

VE= (ARU-0)/ARU x 100
     = ARU/ARU x 100
     = 100%

For a vaccine that didn't work at all, the ARU would equal the ARV, and then

VE=(ARU-ARU)/ARU x 100
     = 0/ARU x 100
     = 0%

In the study, we have the following data:

The ARU is the number of those who were unvaccinated and flu positive divided by the total number of unvaccinated.

ARU= 11/65 = 0.169


ARV= 6/104 = 0.058

Therefore, the VE= (0.169-0.058)/0.169 x 100 = 0.111/0.169 x 100 = 66%

It's close, but it's not 71%, and the reason for this is that this is the general formula for VE. The study had a case-control design with unmatched pair analysis, in which case,

VE= (1-RR) x 100,

where RR = relative risk, which is roughly equal to the Odds Ratio (OR) in this case.

OR = (Flu+, Vaccinated)(Flu-, Unvaccinated)/(Flu-, Vaccinated)(Flu+, Unvaccinated)
      = 6x54/98x11
      = 324/1078
      = 0.301

So VE= (1-0.301) x 100
           = 0.700 x 100
           = 70%

The study got 71%, but I'm assuming they had a better calculation of the OR, so 70% is close enough.

Okay, now we know how they determined that the flu vaccine effectiveness was 71%. So I'm going to act like an analyst and ask, "What does this really MEAN?"

The article claims it means that there was a 71% reduction in flu-related hospitalizations in patients who have been vaccinated against flu, vs. those who haven't.

But I don't think that's correct, and it was one of the things I went back and forth about with Mickey.

They looked at patients' vaccination statuses, and at which patients tested positive for flu. The appropriate conclusion to draw from this data is that vaccination resulted in a 71% reduction in flu INFECTION, in this population.

They did NOT look at patients' vaccination status, which patients tested positive for flu, AND which patients ended up hospitalized. They couldn't possibly look at that, because the entire population was hospitalized. So they can't logically draw any conclusions about whether vaccination reduced hospitalization or not.

For example, let's say they looked at 3000 people in the community, 1000 of whom were vaccinated against flu, and 2000 of whom were unvaccinated. And let's say they checked to see who was hospitalized with an illness that looked like flu, and it turned out that 104 vaccinated patients and 65 unvaccinated patients were hospitalized. These are the same numbers as in the study.

Now let's say they checked to see which of the hospitalized patients were flu+, and it turned out that 6 of the vaccinated, and 11 of the unvaccinated patients were flu+.  Again, same numbers.

Then 6/1000 = 0.60% of the vaccinated patients were flu+ and hospitalized,

And 11/2000 = 0.55% of the unvaccinated patients were flu+ and hospitalized.

So how would the vaccination have reduced flu-related hospitalizations by 71%, when the rate of flu-related hospitalization is lower for the unvaccinated patients?

Obviously, I just made up the 1000 and 2000 figures, but my point is you can't know whether vaccination reduced flu-related hospitalizations without knowing how many were NOT hospitalized.

The thing is, I really know very little about statistics. So I suspect I'm missing something here. But I can't figure out what. And in case I'm not missing something, it's a pretty big deal that the CDC is using this result to support their recommendation for universal flu vaccination.

The truth is, a vaccine efficacy of 71% is not so great. By comparison, the inactivated polio vaccine has an efficacy of 90% after 2 doses, and 99% after 3 doses (link). This doesn't mean there isn't good reason to recommend universal flu vaccination. For one thing, older people, who stand to benefit greatly from not getting flu, don't have a good serologic response to the flu vaccine, simply by virtue of age. The best way to protect them, then, is herd immunity, which you can get from having younger adults vaccinated.

I would really appreciate comments on this post. In particular, comments from people who know some statistics and have taken a look at the article. I'd like to know what I'm not seeing correctly, or if perhaps I am seeing things correctly.

Thanks for your help, especially Mickey.

Wednesday, December 16, 2015

Thank You, Mickey! Part I

Where to begin? I got an email with a letter from the commissioner of the NY DOH that covered three topics:

1. Flu Season
2. Synthetic Cannabinoids
3. NY's Medical Marijuana Program

The bit about Synthetic Cannabinoids started with, "The surging popularity of these man-made drugs has created a serious and sustained public health problem in New York State..."

It went on to describe the problem, and ended the next paragraph with, "Be on the lookout for the use of these drugs by your patients. We need to work together to stop this scourge."

This was immediately followed by:

If you have patients with medical conditions that may benefit from the use of medical marijuana, I would also like to remind you that next month is the launch of New York’s Medical Marijuana Program. I encourage you to enroll in the online course to become a registered physician, so you can certify eligible patients to receive medical marijuana. For more information, please access at: https://www.health.ny.gov/regulations/medical_marijuana/practitioner/.

Granted, synthetic cannabinoids are not the same thing as medical marijuana, and the letter even remarks on this point. But you'd think someone would have noticed the irony in the juxtaposition, and the complete absence of any comment about the problems with medical marijuana.

However, this post is really about flu vaccination. I know I've written about this topic before, and it's not a psychiatric topic, but the interpretation of research findings is a psychiatric and clinically relevant topic, and this turned into an exercise in understanding the literature.

 The commissioner's comment on Flu includes the following:

It’s impossible to predict the severity and timing of any flu season. Every year, however, flu causes widespread illness. Last year’s flu sickened approximately 51,000 people in New York, causing more than 11,000 hospitalizations and six pediatric deaths. The Centers for Disease Control and Prevention recommends an annual vaccine for everyone over six months of age... One study showed that flu vaccination reduced flu-related hospitalizations among adults of all ages by 71 percent.

No reference was given for the "one study".

This topic holds personal relevance for me because I don't get the flu vaccination, and as a result, I have to agree that I will not be around patients in my affiliated hospital without wearing a mask.

The reason I don't get the flu vaccine is the Cochrane Review (the link goes to the summary of the review, from which you can access the article). Briefly, they looked at a total of 90 studies, 20% of which had a high risk of bias, and 10% of which had good quality methodology. The evidence is current through May of 2013.

They found that the Number Needed to Vaccinate (NNV) to prevent one case of influenza-like illness (ILI) was 40 (CI: 26-128), and 71 (CI: 64-80) to prevent one case of confirmed influenza, in the case of parenteral inactivated vaccine. For live aerosol vaccine the NNV for ILI was 46 (CI: 29-115).

In addition, "Vaccination had a modest effect on time off work and had no effect on hospital admissions or complication rates." I view time off work as a good measure of severity of illness, because if you're really sick, you don't go to work.

That's why I don't get the flu vaccine.

But I was curious about this statement from the DOH letter that, "One study showed that flu vaccination reduced flu-related hospitalizations among adults of all ages by 71 percent." I mean, according to Cochrane, vaccination has no effect on hospitalization. And according to this study, it reduces flu-related hospitalization by 71%.

The first thing I looked at were the CDC recommendations, and none of their references seemed relevant. Please note that I was only looking for information about adults. There may be some stuff there about kids.

So then I looked for the 71% study, and I found it through a link on NPR, of all places. The study is entitled,
Effectiveness of influenza vaccine for preventing laboratory-confirmed influenza
hospitalizations in adults, 2011-2012 influenza season, by Talbot et al. It was funded by the CDC,  and ultimately published in Clinical Infectious Diseases.

Talbot, et al did a case-positive control-negative analysis of 169 adult patients admitted to a hospital for something that looked like flu. That is, after eliminating patients who didn't meet eligibility criteria, they had 169 left. They were able to track down the vaccination status for these patients, and they tested them for flu.

It turned out that 11 of 65 (17%) non-vaccinated patients were positive for flu, and 6 of 104 patients (6%) were positive for flu. There were confounding factors, e.g. the vaccinated group was older, and the non-vaccinated group smoked more.

They concluded:

"Unadjusted vaccine effectiveness was 71.1% (95%CI: 17.3%, 89.9%) for all adults and 76.8% (24.1%, 92.9%) for adults ≥50 years. Adjusted vaccine effectiveness for preventing influenza associated hospitalizations was 71.4% (95%CI: 17.1%, 94.9%) for all adults and 76.8% (24.0%, 97.9%) for adults ≥50 years."

This is where I got stuck. There was a table at the end, but it didn't help all that much, except to give me the 11 and 6 numbers above. I didn't know how they got their 71%, and I didn't know how to reconcile their findings with Cochrane's conclusions.

So I asked for help. I emailed Mickey, who writes the 1boringoldman blog. It's a great psychiatry blog-you'll see a link listed on my blog roll, to the right. Please visit it early and often. An embarrassing fact is that when I first started reading it, I thought Mickey's last name must be, "Goldman". Or, "Oldman". It's not.

Three of Mickey's recent posts, In the Land of Sometimes 1, In the Land of Sometimes 2, and In the Land of Sometimes 3, are excellent statistics tutorials. Mickey is also one of the people responsible for republishing Paxil Study 329, which involved quite a bit of statistical knowledge. So I thought he'd probably be able to help.

That I thought he'd be interested in and willing to help is probably a testament to his decency, which comes through in his blog posts. We'd had a couple of email exchanges in the past, so I wasn't contacting him completely cold, but he really didn't need to help at all. And within a few hours of emailing him, he got back to me with an explanation, computation, and references, and I am close to tears over his generosity as I type this.

I'm going to stop here, and continue in the next post with how to compute Vaccine Efficacy, how the 71% statistic came to be, and my discussion with Mickey about the conclusions.

Thanks, Mickey!

Wednesday, December 2, 2015

Summing Up 2015

Here we are at the end of the year. A lot has happened in the world of psychiatry in 2015.

Collaborative Care is alive and scoring a 0 on the PHQ-9. The Clozaril REMS deadline was extended. Tom Insel left NIMH for Google. Mandatory E-prescribing was postponed until this coming March. EHRs continue to disappoint. Meds long past patent have had their prices jacked up 5000%. The FDA is looking to appoint a new head, and Robert Califf, a cardiologist with strong ties to the pharmaceutical industry has been nominated (See NY Times and David Healy).

On the upside, Dinah at Shrink Rap came up with a brilliant way for people to access psychiatric care in Maryland. I hope this approach is replicated more broadly.

I was perusing my posts from this past year, and I made a list of some of the major topics, and their respective posts, both general and personal:

Maintenance of Certification

I studied for:
The Montillation of MOC

And passed:
There and Back Again
Signed, Sealed, Delivered
Switching the Labels

my board recertification exam.

And I was certified by the NBPAS, as well:
Another Board

The ABPN refused to make any significant changes to MOC, especially Part IV:
I Really Should be Studying, But...
An MOC Step?
Follow the Money

Although the Part IV Feedback modules are now optional.

And I developed my own Psychoanalytic PIP Module:
Here Goes Nothin'
A Monkey's Uncle

The best part about all of this is that I've written enough MOC posts that I now misspell "Maintenance" only about 5% of the time.

Affordable Care Act (ACA)

The ACA has kicked in:
Out of Network Benefits in NY

And pushed me over the edge into the realm of blog ads:
Adding Ads and the ACA


I terminated my analysis:

And wrote some other posts about psychoanalytic evidence and topics:
Analytic Evidence
AA Brill
The Blank Screen
Narcissism, Part I
Narcissism, Part 2

Jeffrey Lieberman

His book, Shrinks was published:
"Shrinks" Review: Introduction
Shrinks: The Untold Story of Jeffrey Lieberman's Oedipal Victory over Papa Freud
Shrinks Links, Etc.

And a torrent of posts followed, culminating in the one about his fiasco of a presentation at the White Institute:
Lieberman Speaks


The FDA approved a drug that could hurt you but can't help you:
They Caved

That was immediately sold for $1Billion:

And then the FDA and Valeant pawned off responsibility onto the doctors who prescribe it, and the pharmacies that fill the prescriptions:
Addyi REMS-A Shanda

Paxil 329

Finally, and perhaps most importantly, the restored version of Paxil Study 329 was published, with disturbing conclusions:

Do I have a favorite post from the year? Not really. The Lieberman posts, especially the reviews and the one about his talk at White took the most out of me. But in terms of content, I think the Analytic Evidence and 329 posts are the most important.

On to pastures greener.

Friday, November 27, 2015

Adding Ads and the ACA

You may have noticed that I added an ad towards the bottom of the page, on the right. I've been toying with the idea of using Google's Adsense for a while but I was reluctant to do so for a couple reasons.

1. I wasn't sure I wanted to monetize the blog at all. It's not a comfortable idea for me, selling out.

2. I couldn't figure out from Google's description how much control I'd have over the ads that did show up.

Incidentally, for the most part, I'm a big fan of Google. I think some of the things they do are amazing, if creepily intrusive. But I find their help pages incomprehensible, and I invariably end up Googling another source of information for answers. Ironically.

But the bottom line is, well, the bottom line. The Affordable Care Act (ACA) has already significantly impacted my income. I'm down quite a bit from last year.

In New York, at least, none of the insurances you can get on the exchanges has any out-of-network coverage. There are some groups that are working on this problem, but for now, that's how it is. So I haven't gotten as many new patients as previously because people want to stay in-network. Several of my ongoing patients have lost coverage and need to cut back on frequency, and/or have reduced fees. Some patients have stopped treatment with me entirely. I try to be flexible, but sometimes there's nothing you can do.

That's why another income stream is looking pretty appealing. I don't see the Obamacare effect abating any time soon. And I devote quite a bit of time to the blog. So I decided to conduct a little Adsense experiment.

I put the ad down at the bottom on the right, not all the way, but almost. I feel like that's visible but not terribly intrusive. In the future, I may move it further up on the page, but I'll have to see how I feel about it.

I keep checking ads to see if I find anything offensive or inappropriate. Like this:

It turns out, there are categories of ads, and you have a limit of 50 categories that you can block across the board. I tried to get rid of egregious things like pharmaceutical ads. But you can't block everything. What you can do, is if you find a particular ad offensive, you can copy the URL and tell Adsense about it, although I've forgotten where I saw that and I'd have to look up how to do it.

There are also sensitive categories, like get-rich-quick and sexuality, and you can block as many of those as you like, in addition to the other 50.

What I haven't figured out how to do, and maybe it can't be done, is to tell Lord Google which ads I especially would like. I'll have to look into that further.

If you're really offended by my ads, please let me know, and I will take that under serious consideration. Thus far, it looks like I'm on a roll-I seem to have earned a total of 2 cents.

And part of the agreement with Google is that I can't click on any ads myself, nor can I encourage others to click on ads just to help me out. So if you're actually interested in the content of an ad, go ahead and click on it, but otherwise, don't.

Now I want to make a comment about comments.

I recently discovered, based on communications about a recent post, that I hadn't been getting my comments notifications for several months. I think I've fixed the technical problem, and I've gone back and published those comments that I missed that weren't offensive or spam. So if you wrote a comment and didn't see it published, I apologize. If you check back now, it's probably there.

Wednesday, November 25, 2015

Turkey Trivia

Fun Facts About Turkeys (most via Wikipedia)

* The domestic or wild turkey is native to North America

* A relative, the ocellated turkey, is native to the Yucatan Peninsula

* Turkeys are classed in the same family, Phasianadae, as partridges and pheasants

* Aside from "turkey", two other animals that end in K-E-Y are "donkey" and "monkey"

* Early Europeans in America incorrectly identified turkeys as a type of guineafowl, thought to originate in Turkey, and began calling them, "turkey fowl", later shortened to "turkey"

* The wild turkey was domesticated at least 2000 years ago

* Young domestic turkeys readily fly short distances

* Turkeys are very social animals, and will identify and attack a turkey alien to the group

* The eggs of some turkey breeds can develop without fertilization

* Hens of the dominant commercial breed must be artificially inseminated, as the mature males are too large to achieve natural fertilization without injuring them

* It is difficult not to overcook a turkey

Happy Thanksgiving!

Sunday, November 22, 2015


I notice that after I've written a post, or a series of posts, that required a large investment of time and emotion, I get blog burnout. It's not that I'm not interested in posting as much as I can't think of anything I want to write about.

So instead of just waiting around for several weeks, I thought I'd try doing something light.

The thing is, I hate my analytic couch. It's not the one I started with. That would be this one:

The Barcelona Daybed by Mies van der Rohe. Mine was a knockoff, but it basically looked the same. It's comfortable and it looks good, but a couple years ago, I had to make a last minute move to a new office because the people I was subletting from didn't realize they had a demolition clause in their lease. Long story.

I found a new office quickly. It's quite small, but otherwise, I love it. Great neighborhood, great building, great office setup, great office-mates. It would be perfect if it were a little larger.

But it isn't, and I had to get a new couch because the old one was too big for the space.

What I got was something I think of as a placeholder, even though I've had it for four years. It's a modern curved chaise with a chrome base in a whitish, tufted synthetic leather. I had very specific dimension requirements, and it was the best I could do at short notice, but I just don't like the thing.

Still, I haven't been able to find a suitable replacement, which hasn't stopped me from looking and virtual window-shopping. I've found a lot of beautiful couches, but thus far, nothing that will work in the space. Still, a girl can dream.

Here are some of my favorite couches, and I'll save the best for last:

The DWR Midcentury Modern Lounge

The Maxime Daybed from Jonathan Adler

The Danner Chaise, also from Jonathan Adler

This 1950's number by Paul McCobb

This very simple piece I found on Flickr

This Adrian Pearsall that sold on ebay

This one that sold on 1st Dibs

This beautiful William Haines Piece

This Ash Lounge Chair I found on Overstock. It's too red, but I still like it.

This lovely and conceptually simple piece.

And finally, the big reveal of my absolute favorite:

The stunning Ash Crescent Lounge from Vonnegut Kraft.

Tuesday, November 17, 2015

A Monkey's Uncle

I had a hard time naming this post. Everything I thought of had some kind of expletive in it.

Holy ____! 

____ me dead! 

l'll be ____!

I'm not averse to this kind of language in my speech, but I try to keep it out of my writing unless there's a good reason for it. Like if I'm quoting someone. Or if I'm writing about having witnessed a potted tulip fall from space and say, "Not again!"**

Suffice it to say, I'm surprised. I got a response today from the ABPN about my proposed PIP Clinical Module on the "Suitability for Psychoanalysis". Here it is:

Thank you for submitting an individual PIP for preapproval consideration.

Your PIP Clinical Module on the ‘Suitability for Psychoanalysis’ has been preapproved, provided you use your own patient charts/data for the initial and follow-up reassessment.  The patients that you use for the reassessment can be the same or different patients from the initial assessment.  This module will count for the PIP Unit that you need for your 2016-2018 CMOC block.

Please retain this preapproval in the event of an audit.

Let me know if you have any other questions.

I did have questions, so I responded:

Thank you for your prompt response. I will certainly use my own patient charts and data.

I have 2 questions:

1. Does "preapproved" mean it's approved, or is there something else that has to happen?

2. Are others allowed to use this module for their own patients?

Thank you for your attention to this matter.

I just sent off my response, so I don't know what will come of it. I'm a little worried that it's too good to be true, and I should have left well enough alone and not asked my questions because now they'll change their minds. But I'd like for other people to be able to use the module, and I wasn't sure if, "provided you use your own patient charts/data for the initial and follow-up reassessment," means that for some reason, they thought I would use someone else's patients' data, or if it's only approved for my use. Maybe that's what "preapproved" means.

So for now, Odds Bodikens!, Zounds! Holy Mackerel! I'll eat my hat!, and I'm a Mongoose! And remember, if I can make up a PIP Module that gets "preapproved", anyone can.


Wow! While I was previewing this post, a response from ABPN came in:

1.        Preapproval means that your PIP meets the criteria, although you are still subject to auditing.

2.       Preapprovals are done on an individual basis; but, yes, if you’d like to share your outline with colleagues, they could submit it for preapproval as well.

So I guess anyone can use it, provided he or she submits it for preapproval. Here's a link to it in pdf form. I hope it's helpful.

Addendum #2: If you happened to download the pdf before 11.17.15 4:55pm Eastern time, please disregard it and use the currently linked form, which includes the practice guideline source.

**“Curiously enough, the only thing that went through the mind of the bowl of petunias as it fell was Oh no, not again. Many people have speculated that if we knew exactly why the bowl of petunias had thought that we would know a lot more about the nature of the Universe than we do now.”― Douglas AdamsThe Hitchhiker's Guide to the Galaxy

Monday, November 16, 2015

Here Goes Nothin'

I did it. I just now submitted an application to the American Board of Psychiatry and Neurology (ABPN) for approval of an Improvement in Medical Practice Clinical Module. That's the notorious, MOC Part IV Performance in Practice (PIP) module.

I don't expect much to come of it, although I was inspired to make the attempt by Jim Amos at The Practical Psychosomaticist, who submitted his own CL module. Brave man.

Let's review. In order to maintain board certification by the ABPN, psychiatrists no longer need to submit the Part IV feedback modules, which asked for reviews from 5 peers, and from 5 patients. But, we still need to do those idiotic practice improvement modules, one every three years. You take 5 patient charts. You go through them to see if you're meeting "evidence-based" practice standards in a specific area, like depression, for example. And they HAVE to be based on some "evidence-based" guideline.

If you're not meeting the standards, you implement the suggested "evidence-based" changes, which mostly involve questionnaires like the PHQ-9, and then two years later, you do another chart review to see if you've gotten your act together by then and have been using PHQ-9's with all your patients. Then you've demonstrated improvement.

Of course, if you were doing things "right" to begin with, then two years later, you will have failed to improve because you haven't implemented any changes. It's my understanding that some people understate what they're doing in the initial review, or outright lie about it, so they can demonstrate improvement two years later. I didn't do that. I just documented that I made none of their recommended changes because they weren't clinically appropriate.

My version is a Psychoanalytic PIP. I considered starting it back in a post I wrote in July, Fascinating, but I had trouble finding a suitable Practice Guideline. Well, I subsequently found one, the American Psychoanalytic Association's (APSaA's) Practice Bulletin 7: Psychoanalytic Clinical Assessment. This is an interesting document, with a lot to say about the limitations of the DSM system, and the risks of diagnosing a patient:

The current DSM system does not include information derived from psychoanalytic
research methods and, with a few notable exceptions, ignores the accumulated
knowledge from a century of psychoanalytic clinical experience...For example, the DSM-IV system does not account for unconscious aspects of mental functioning that are at the heart of the psychoanalytic treatment process. The DSM-IV perspective aims to confine its data to experience and behavior at the level of phenomena that can also be observed outside a therapeutic context. In contrast, a psychoanalytic perspective recognizes unconscious processes and unconscious meanings of experience and behavior as these become observable over the course of treatment. Some examples are intra-psychic conflict, defenses and their associated internal object relations, ego functions, the cohesiveness of the sense of self, the patient's subjective inner life experience, etc....

Clinical use of "official" diagnostic labels tends to act as a suggestion that might become a new guiding aspect of the patient's sense of self and might serve to alter the treatment process. In some cases, this suggestive technique might help a patient who feels fragmented to organize his or her sense of self enough to participate more effectively in treatment. However, the experience of being labeled with "the diagnosis" may create new defensive barriers that can block free psychoanalytic exploration and obstruct the treatment process. 

It has a section about assessment of strengths, to determine a patient's suitability for analysis, and this is what I used for the PIP module. The relevant parts of the module application look like this:

I chose "Type of Treatment" as my category, and I listed the practice bulletin as the guideline to be used. As it turns out, the bulletin has exactly four clearly delineated categories in the assessment of strengths section, so that worked out well.

1. Motivation: How clearly and seriously does the patient see the presenting problem(s) and how does this relate to the patient's determination to pursue an analytic effort at self-exploration? How stable is the patient's current life situation and how strongly is the patient willing and able to invest the effort, time, and financial resources necessary for successful psychoanalytic treatment?

2. Potential for self-observation: How strong are the patient's capacities for introspective self-reflection, cognition, verbal communication, and expression of thoughts, feelings and fantasies?

3. Potential to withstand the tensions of analysis: How strong is the patient's capacity for impulse control and frustration tolerance? How effectively has the patient utilized prior treatment opportunities?

4. Potential to work analytically: To what degree does the patient show abilities for adaptive internal conflict resolution (e.g., via sublimation, grief and mourning, etc.), for maintaining a loving, caring investment in a human relationship in the face of some frustration (object constancy), for recognizing and experiencing others as both similar and different from oneself (e.g. self-object differentiation), and for reliable recognition of the difference between reality and fantasy (reality testing)? How strongly does the patient show the potential to analyze rather than avoid or mal-adaptively enact the anticipated powerful feelings, wishes, and urges that emerge toward the analyst?
I included only the headings in the application, and I attached a form I made up that delineates the specific details under each heading.

Then I included this description of procedure:

Chart review of 5 patients to determine suitability for psychoanalysis. Patients may be in psychoanalysis currently, or in another modality of treatment. See attached pdf of module questionnaire. If patients are suitable for psychoanalytic treatment, then either continue with psychoanalysis if already in progress, or switch them from their current modality to psychoanalysis. If patients are not suitable for psychoanalysis, then switch them from psychoanalysis to another suitable modality, if they are currently in psychoanalytic treatment, or continue with current treatment. Follow up in 2 years to determine if patients are being properly assessed for appropriate treatment.

And that was basically it, aside from attaching a pdf of my nice form, modeled after the PIP modules I've done already:

What this module addresses is the question: Is the patient suitable for analysis?

It doesn't address the question: Is analysis suitable for the patient? So you can't really jump directly from noting that a patient is suitable for analysis to starting an analysis.

I thought about including this question in another section, but I didn't for several reasons. First is that the practice bulletin doesn't directly treat this topic. It makes reference to it, but not as clearly as the four topics under "Strengths". And while determining whether a presenting problem is suitable for analysis is part of analytic training, I wanted something simple and boldly stated, so that whoever evaluates this doesn't have an excuse to reject it.

Also, the application asks for a minimum of 4 measures, so I gave it 4 measures. I'm not doing any extra work for this nonsense. I don't really expect the application to be approved, so I didn't try all that hard. I assume the ABPN won't think the practice guideline is "evidence-based" enough. Or perhaps my phrasing is not in line with what they think of as measures of quality. But who knows? If they approve it, I might actually do a PIP module and consider maintaining my certification status. I'll just have to wait and find out.

Thursday, November 12, 2015

Narcissism, Part 2

Picking up where I left off in, Narcissism, Part 1, we were about to discuss narcissism by way of self-psychology and the Kohutians.

Heinz Kohut (1913-1981) started his professional life as a traditional analyst, but gradually moved away from a focus on drives and conflict related to the oedipal period to earlier developmental stages, and the establishment of the self. Kohut characterized narcissism by a:

lack of genuine enthusiasm and joy
sense of deadness/boredom
frequency of perverse activities

He believed there is a developmental need for the infant to endow caretakers, particularly the mother, with idealized capacities for power and omniscience which the infant can then identify with and borrow from. There is also the primitive need to be noticed/admired/approved in ones grandiose aspirations.
These developmental aspects of the self precede the development of drive. In pathological narcissism, there is a deficiency, an arrested development of adequate psychic structure, due to the failure of the caretaker to meet these needs, so that a crucial developmental task is left uncompleted . Traditional psychoanalysis (PSA), according to Kohut, prevents the emergence of this deficit, with its focus on conflict and the oedipal period. Further, in more traditional PSA the analyst’s muted responses repeat experiences of early deprivation.

Kohut's approach to treatment was to allow the idealizing and mirror (i.e. need to be noticed/admired) transferences to emerge in the early phases of treatment. For example, when a patient would start to say something along the lines of, "Dr. Kohut, you are the best doctor in the world," instead of questioning the need for the patient to think of him that way, or pointing out the denial of aggression and envy in such a statement, he would just let it ride. In fact, for Kohut, the emergence of such a transference early in the treatment was diagnostic of narcissistic pathology.

He also employed reconstruction, in which the inevitable failures of empathy by the analyst could be used to reexamine the original failures of empathy in the patient's life.

In this way, he believed the developmental task that had been uncompleted in childhood, the establishment of a sense of self, could now be completed in adulthood, and the patient could then go on to address less narcissistic issues.

A contrasting view of narcissism is that of Otto Kernberg (1928-).

Kernberg characterizes pathologic narcissism by an incapacity to depend on internalized good objects. These patients look depressed when they're abandoned, but what they actually feel is anger, resentment, and vengeance rather than real sadness over loss. They lack true emotional ties to others, and there is an overall sense of emptiness, and absence of genuine feeling. They lack positive feelings about their own activities. They think of themselves as denigrated, hungry, weak, enraged, fearful, and self-hating. They lack the ability to sustain relationships except as sources of admiration, and they have a tenuous hold on their self-esteem, maintaining it by depreciating others and avoiding dependency. They also experience destructive rage and envy towards those they depend on.

Etiologically, Kernberg views the self as a vital aspect of the early ego, developing originally as a fused self/object internalization. That is, the very young infant views itself as undifferentiated from the primary object, in most cases mother. On the way to thinking of itself as a separate entity, the infant internalizes this idea of itself as fused with the mother, in order retain a sense of omniscience in the face of the helplessness of being a little child. Later, in normal development, the child is able to relinquish the fusion, and can ultimately perceive both itself and the object as separate entities, each with inherent strengths and limitations.

(I'm leaving out a lot of stuff about normal internalization of, as opposed to fusion with, the object and subsequent development of the superego, but suffice it to say that Kernberg sees superego distortions in narcissistic pathology, and feels that antisocial character disorders are a subgroup of narcissistic ones).

In Narcissistic Personality Disorder, stable ego boundaries have been established, (i.e. reality testing is intact, unlike in more primitive pathology), but there is a refusal to accept the differentiation between the idealized object and the self. It's like saying, “That ideal person and my ideal image of that person and my real self are all one and better than the ideal person whom I wanted to love me, so that I do not need anybody else anymore.” These patients are often raised by parents who are cold and aggressive.
Cooper, A. M. Narcissism (1986) in Essential Papers on Narcissism, Andrew P. Morrison Editor, pp. 112-143. New York University Press

For Kernberg, the goal of treatment is for the patient to give up his yearning for perfection, accept the terror of intimacy and the reality of the other person as genuine but flawed. This is where he fundamentally disagrees with Kohut. Where Kohut encourages the idealizing and mirroring transferences, Kernberg sees the goal as undoing pathological idealizations, not encouraging new ones with the analyst. Kernberg views these idealizations as defenses against rage, greed, and emptiness, which need to be interpreted.

It's basically that Kohut and Kernberg have different ideas about the developmental problem that causes narcissistic pathology. Visually, it's like this:

Where the dotted arrows represents normal development, and the solid arrows represent narcissistic pathology. For Kohut, development has been halted at the point of establishing the sense of self, and if it can just get past that barrier, normalcy will ensue. For Kernberg the self has been established, but in a distorted way, so treatment is very different.

Clinical examples are always helpful in elucidating theoretical concepts, and I use them in my class, but unfortunately, I can't do so here, so my apologies for that. But I hope there's at least some information that may be useful.

Friday, November 6, 2015

Lieberman Speaks

Last night, I went to hear Jeffrey Lieberman (JL) speak about his book, Shrinks, at the William Alanson White Institute. He spoke on a panel, along with Andrew Gerber (AG), Medical Director and CEO of Austen Riggs, and Jack Drescher (JD), a training and supervising analyst at White (among many other impressive credentials). Each gave a brief talk in reference to the book, then they commented on each other's presentations, and then there was a Q&A. The moderator was Sue Kolod (SK), another training and supervising analyst at White.

A little background. The White Institute was founded in 1943 as an alternative to "mainstream orthodox Freudian psychoanalysis". It's known for its interpersonal point of view, and for an interdisciplinary approach. It was only very recently (like, last year) admitted to the American Psychoanalytic Association. I don't get all the politics involved. Frankly, I don't care. But I think the delay had to do with the less traditional approach, including differences in required frequency of analysis (3 times per week vs. 4 or 5), and other stuff I also don't get. In any case, I'm not affiliated with White.

The institute I am affiliated with, NYPSI, is more traditional. At least, that's its reputation. It's a lot more relaxed than it's given credit for, but it's not great at broadcasting that fact. Now, when Shrinks was published, NYPSI invited JL to speak. He declined. Well, no, actually he never responded. Even after several attempts by the chair of the program committee.

I had given up on seeing him address an analytic audience when I learned he'd be speaking at White. So I went. Maybe it was a good idea for me to go, maybe it wasn't. I took notes. I didn't get everything down. Sometimes I got most of a part down but missed a few points and interpolated. I'll try to indicate when that was the case.  I'm sure I got some things wrong, too. Unless otherwise indicated, I am quoting or paraphrasing the speaker being described. Here's what happened:

It was an oversold event, so they moved it to a larger location, a synagogue near White, with a moderately sized auditorium-not the main prayer space. Early in the event, someone asked the audience how many had read the book. Very few raised their hands. There was a pile of copies of Shrinks on a table in the back. By the end of the night, the pile of Shrinks had not shrunk very much.

SK introduced everyone. She said she had the idea of setting up this talk after reading Shrinks. She agreed with most of it, especially the parts about psychoanalysis' history of homophobia, rigidity, rituals, and a non-scientific approach. She had two goals. 1. To recognize that in his book, JL helps us to see how the general public sees us; and 2. To introduce JL to modern psychoanalysis, as it's practiced today, and hope to change his point of view.

Jeffrey Lieberman

JL spoke first. He said that even though we were in a synagogue, we had dispensation not to wear "yarmulkas or tallits" (skullcaps or prayer shawls). He was pleased to have 2 of his favorite colleagues as co-panelists.  He announced, "My analysis failed!" and said no more about it. I like to think that validated the hunch I mentioned back in my review of Shrinks:

Lieberman, (or maybe it's Ogas) writes with particular vehemence about the period when most psychiatrists did analytic training. It made me wonder if he was rejected from a training program at one point, or if he was in an analysis that he quit because he found it intolerable. I have absolutely no basis for these thoughts- they're just conjecture.

JL said that his concern about the stigma of mental illness is what prompted him to write the book. It's like the sign of Cain. or the Scarlet Letter. Or the gold star Jews were forced to wear in the holocaust. Why should mental illness be stigmatized? He asked, "Would you prefer to say you were missing a (something) because you threw your back out, or because you were depressed?" That, he said, is stigma.

He reminded us that there is no anti-cardiology movement. That the stigma of mental illness is woven into popular culture. That it is vestigial, and in contrast to the scientific research of the last 50 years, which demonstrates that mental illness is in the brain. Stigma denies the array of available treatments. He said something about the brain being more complex than the heart, and that it's taken a long time to understand how the brain works and gives rise to mental illness, and that we're just starting.

He pointed out the stigma that existed with AIDS early on, but then came the ACT UP movement which made sure there was money for research, and then came AZT, and now we manage AIDS like diabetes or hypertension.

He said that in the past, there was little treatment available for mental illness, but now things are different. He spoke about an anxious patient he had seen that day, who is now treated for his anxiety, and can't believe how different he feels.

He had a patient, Sarah, who suffered from (I didn't hear this but he must have said, "agoraphobia"). He had to see her in her home. But after initial introductions, followed by appropriate medication, she is doing well.

He said there are failures. He recalled a borderline patient, L, who he had seen as a resident, before there was DBT. His goal was just to keep her alive. She dropped out of treatment, and he didn't know what happened to her.

He said there is an indisputable difference between now and before the mid-20th century. Back then, the barrier to care was lack of treatment. The new barriers to care are: stigma, lack of awareness, and lack of access. He emphasized the need for early detection of mental illness via screening in primary care settings, schools, and the workplace. Like for TB. Also the need for coordination of community care in advanced disease. He mentioned that there is a 7 year delay in treatment for depression, and that women should be routinely screened pre and post-partum, and children routinely for LDs and ADHD (I think he said ADHD).

He claimed all this would reduce homelessness, jail populations, and violent episodes. He mentioned, among others, Adam Lanza (the Newtown, CT shooter), who had clear signs of mental illness for years and could have been treated. (Please see my post, Behind the Violence, for a more nuanced discussion of the matter). They were all shunned, no one reached out to them. We need to trade "don't ask don't tell" for "I am my brother's keeper".  We shun people who look weird or menacing, but we need to be proactive.

JL spoke about a piece he wrote following Robin Williams' suicide (BTW, did anyone else see the thing about Williams having Lewy Body Dementia?). He got a letter following its publication from a psych-nurse who turned out to be the borderline patient, L, now doing well, and grateful to JL for genuinely caring about, and not judging her.

He ended with, "End Stigma!"

Andrew Gerber

(I'm going to skim through this one) AG thinks JL is a great guy and a great chairman. He broke the book down into 3 parts:

1. What analysts need to hear-JL just wrote things we say to each other anyway, that analysis has a history of intolerance, of who's in and who's out. We need to think about how to test our ideas. We have a history of being anti-meds, of excluding non-MD's, of ethical violations. He mentioned the Central Fact-Gathering Committee of the American Psychoanalytic association which, back in the '50's (?) suppressed data about the limited success of analysis.

2. What we can teach JL-analysis is not the same today. White and Columbia are responsible for vast changes, there are >100 trials showing the effect of psychodynamic psychotherapy.

3. What can we do together? Teach each other about the mechanism of action in therapy, exposure/response prevention, modeling relationships, interest in the patient's narrative, EEG's, biomarkers, case studies. We need to tackle healthcare funding together.

Jack Drescher

JD noted that he is not a cheerleader for PSA (psychoanalysis). He has written extensively about, for example, homosexuality in analytic history. He is not opposed to the DSM (he was a member of the DSM-5 workgroup on sexual and gender identity disorders), or to ECT or meds. But he felt the book was an anti-PSA polemic. That you can't lay the low status of psychiatry at the foot of PSA. He noted the links between psychiatrists and big pharma. He had 4 main points (I wasn't really clear on what they were trying to accomplish but here goes):

1. How to tell a story-addressing a popular audience. There was early approbation of thorazine for relaxation, nausea in pregnancy, and hiccups. TD is not mentioned in Shrinks.

2. The limits of rationality-he was taught as a resident that patients will take their meds if you simply explain to them that they need to. There is a need to empathize with irrationality.

3. Attributing motives-JL accused PSA of folding everyone into its net, with no clear demarcation between normal and abnormal, but JD noted that if it was done, it wasn't malicious.

4. Again, PSA not responsible for the low status of psychiatry, and most people don't know anything about PSA, certainly not in its contemporary form. We don't look to the Schreber case to treat psychosis today. The stigma of mental illness may be transferred to the profession that treats it. The book doesn't improve things by taking pot shots at PSA.

Now the mutual comments:

JL: The idea of writing the book was to gain credibility by fessing up to the history of psychiatry. When I included the quote (p.200) that, "Freud's ideas, which dominated the history of psychiatry for much of the past century, are now vanishing like the last snows of winter, " I just meant that Freud is not as influential. The therapeutic relationship is always important when you talk to people.

JD: We argue among ourselves about ideology.

There was quite a bit more, including comments by AG, but I was distracted thinking about JL's "fessing up".

Then came the questions.

The first to speak was Leon Hoffman, who disclosed immediately that he had written a review of Shrinks in JAPA. He reiterated some of the things he had noted in the review, like the way JL's lack of ability to establish a rapport with patients' families (the two he describes in the book) doomed the treatments to failure. Hoffman said he was pleasantly surprised to hear that JL did value the therapeutic relationship, because that wasn't clear from the book. To which JL replied, "I'm not sure you read my book." Hoffman asked if JL thought psychiatrists should be trained in therapy at all. JL responded, "If that didn't come through in the book, then I failed."

There was another interesting exchange with a brave man whose name I didn't catch, he's a psychiatrist and analyst who treats mainly schizophrenia. He uses therapy and meds. He says his patients are mostly people whose mothers never gave up on them. And he has helped them extensively. He pointed out that stigma is decreased by understanding the meaning and significance of the illness, not by making it the same as diabetes. JL said, "All illness has meaning." The man replied, "Not the primary meaning." Then JL, with an incredulous look, said something to the effect that this would imply there's something different or exceptional about mental illness, as compared to other types of illness. And most of the audience went, "Yeeees."

I think this was when JL started yelling. Truly, he was yelling. He said, "Your opinion doesn't matter! Cases don't tell you anything! You need evidence!" He sounded really mad. He also said something like, "I'm sure you mean well, but..."

The guy started mentioning some of the evidence that's out there, and JL just talked over him. I heard someone near me use the phrase, "Used car salesman".

Once JL was done, JD said something about how the meaning might reduce the stigma for the patient, but not for everyone else.

There were a few more questions, with audience members starting to file out. One resident asked about how he can make a decision about where to direct his career with all this sectarianism. This elicited long responses from all three panelists, a kind of, let's take this opportunity to educate the young'uns.

I missed a lot of the Q&A because I was so disturbed by the "fess up" comment. So I did something atypical for me, and I got in line to ask a question. The gentleman in front of me had more of a comment, to the effect that JL is not helping the profession by dissing analysts.

I'm a little confused about the sequence of events, but I think JL said something here about the complete lack of evidence for PSA, except for a few little studies (with a hand wave), and how you can't expect to be reimbursed for something that has no evidence.

Then it was my turn, and I was the last questioner, which suited me fine because the room had cleared out a lot by then. I'm a pretty comfortable public speaker, so I was surprised to note how much my voice was shaking, until I realized it was rage, not stage-fright.

I told him I had read his book, that there's a lot more evidence for PSA than he's allowing for, and I paraphrased the passage where he states that if Willem Reich's patient were alive today, she would be diagnosed with an anxiety disorder and treated with an SRI and CBT, which made it sound easy. I pointed out that he was concerned about gaining credibility by fessing up to psychiatry's history, but the fessing up was selective, and that nowhere does he mention the difficulties with treatment, including things like metabolic effects of antipsychotics, or Paxil Study 329, and how does he mean to engender trust in the public by omitting those kinds of facts?

I know I was far less eloquent in my phrasing, and what I just wrote is not so great to begin with. I think he cut me off towards the end, because I never said anything about the severe limits of what we actually know about mental illness. He rolled his eyes and said, "Medications have side effects. Am I supposed to list every side effect in the book?" I have the impression he was still yelling something, but I could be wrong.

Some poor soul got up then and tried to talk about research by Jonathan Shedler, but he got steamrolled. I think JL said something about adding that to the next edition.

I was going to do a lot of editorializing, but this post is already really long, and in any case the facts speak for themselves.

Tuesday, November 3, 2015

Narcissism, Part I

Long time no see!

I've been busy teaching. And it's been  a lot of work. I'm assistant-teaching an analytic class on Affects and Affect Pathology, and I just finished solo-teaching a psychotherapy class on Narcissism. This hasn't left a whole lot of time for blogging, or doing research for blogging, so I thought I'd attempt to combine the two by sharing some of the ideas from the Narcissism class.

If you think about it for a minute, you'll realize that "narcissism" is one of those words that has so many meanings, it's meaningless.

In the early analytic literature, narcissism was used in at least four different ways:

1. To denote a sexual perversion characterized by the treatment of ones own body as a sexual object

2. To denote a stage of development

3. To denote two different phenomena in the realm of object relations:
    a. a type of object choice in which the self plays a more important part than the real aspects of the object
    b. a mode of relating to the environment characterized by a relative lack of object relations

4. To denote various aspects of the complex ego state of self esteem
(Cooper, A. M. Narcissism (1986) in Essential Papers on Narcissism, Andrew P. Morrison Editor, pp. 112-143. New York University Press)

For those not familiar with the jargon, and ironically, in psychoanalytic-speak, people are referred to as, "objects".

Importantly, we can differentiate (Freud, 1914, "On Narcissism")  between primary narcissism, in which libido is invested in the now-differentiated ego, prior to the formation of object ties, and secondary narcissism, the withdrawal of libido back into itself, after object ties have been established. These are somewhat archaic descriptions, but the bottom line is that there is a normal, healthy type of narcissism that is part of development, and there is an abnormal, unhealthy type of narcissism that forms when something goes wrong developmentally.

Why is it important to know about narcissism? Because we see it all the time. There are the blatantly obvious cases, such as the super-entitled patient with zero empathy, or as a specific example, Richard III, about whom Freud writes in, "The Exceptions".

But there are also the more subtle cases: The patient who has been unemployed for years because he is unable to give up an unrealistic dream in favor of a potentially fulfilling and attainable but less grand goal; The perfectionist who can't differentiate between a minor mistake and a paralyzing, life-ruining humiliation; The patient who is unable to view others as anything but an extension of herself, who cannot understand why her friendships and romantic relationships never last; The highly somatic patient whose concerns with his body reflect his worries about the disintegration or annihilation of his sense of self.

And finally, there are the ones who do not have a primarily narcissistic pathology, but who suffer some sort of major narcissistic injury (e.g. loss of job, spouse, friend), who in response, regress to a more self-focused, withdrawn state, sometimes in the form of depression, and who need help re-establishing ties with the world.

Some of the qualities of Narcissistic Pathology:

sense of vague falseness
defensive self sufficiency

Fear of fragmentation can be displaced into preoccupation with physical health
Denial of remorse and gratitude
Guilt or dependency is shameful
(McWilliams, N. (1994) Psychoanalytic Diagnosis. New York: Guilford Press)

defensive self inflation
lack of integration of the self concept
inordinate dependence upon acclaim of others
poor object relations
vulnerability to feelings of rage, shame, depression
relentless pursuit of self perfection
impaired capacities for concern, empathy, love for others
self aggrandizement/omnipotence
(Auchincloss, E., and Samberg, E. (2012) Psychoanalytic Terms and Concepts. Yale University Press, pp. 162-6)

And here are DSM-IV (left) and DSM-5 (right) criteria for Narcissistic Personality Disorder:

Interestingly, DSM-IV is more focused on presenting symptomatology, while DSM-5 harkens back to a more etiologic conception, with emphasis on impairments in sense of identity and self.

There is a rich literature about the role of the "self" in narcissistic pathology. Sullivan writes about "self-dynamism" formed by notions of the "good me", the "bad me", and the "not-me". Rado writes about the "action self", a gauge of a person's emotional stature.

Horney describes the loss of the "real me" under conditions of parental coercion, resulting in unproductivity, excessive expectations, grievances and hostility.

Winnicott writes about the "true self" vs. the "false self":

A True Self begins to have life through the strength given to the infant's weak ego by the mother's implementation of the infant's omnipotent expressions. The mother who is not-good-enough is not able to implement the infant's omnipotence, and so she repeatedly fails to meet the infant gesture; instead she substitutes her own gesture which is to be given sense by the compliance of the infant. This compliance on the part of the infant is the earliest stage of the False Self, and belongs to the mother's inability to sense her infant's needs.
(Winnicott, D.W. The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development. New York: International University Press, 1965, p. 145.)

For narcissism, in its pathological form, development of the self is where it's at. Which brings us to self-psychology, or the Kohutians, my preferred term because it sounds science-fiction-y.

To Be Continued...

Thursday, October 1, 2015

Does Talk Therapy Work?

Take a look at the article in today's NY Times, Effectiveness of Talk Therapy Is Overstated, a Study Says.  

It's about a study published in PLOS one,

Does Publication Bias Inflate the Apparent Efficacy of Psychological Treatment for Major Depressive Disorder? A Systematic Review and Meta-Analysis of US National Institutes of Health-Funded Trials

Well, it's all very interesting. They were trying to look at publication bias in studies about talk therapy, and they found it. Of the 57 studies that met their inclusion criteria, 13 were never published-they learned about them by contacting the study authors.

And by their estimation, talk therapy is 25% less effective than previously believed.

The study looked at NIH grants between 1972 and 2008, and tried to match the grants to published studies. They were pretty thorough in their search terms:

(1) “depression” (depression, depressive, major depressive disorder, mood disorder, affective disorder, melancholic, melancholia) and (2) “psychological treatment” (cognitive therapy, behavior therapy, behavioral therapy, interpersonal therapy, psychodynamic therapy, dynamic therapy, humanistic therapy, therapy, supportive therapy, experiential therapy, [self-] control therapy, [problem-] solving therapy, [supportive-] expressive therapy, family therapy, group therapy, marital therapy, couples therapy, aversive therapy, exposure therapy, psychotherapy, psychotherapies, psychotherapeutic, counseling, disease management, psychoanalytic, behavioral activation, cognitive behavioral analysis system, desensitization, relaxation techniques, and progressive muscle relaxation). 

Of note to me is that they included "psychoanalytic", but not "psychoanalysis".

Inclusion criteria were:

(1) a randomized clinical trial examining (2) psychological treatment for (3) acute depression in (4) adults

This is a diagram of how they selected studies:

It bothers me a little that they started out with 4073 studies, and ended up with 57. But they seem to have been pretty thorough in how they went about it.

This is the table of the 57 varieties of studies they looked at:

Sorry,  I meant:

Of note again to me is that 5 of the studies are in Short Term Psychodynamic/Psychoanalytic Psychotherapy (STPP).

I'm not terribly surprised by their results. I don't put that much stock in the long-term effects of short term therapy. You may recall my post, Analytic Evidence, probably worth a shifty in this context. I've never been a big fan of CBT, except in very specific presentations, but admittedly, I think my CBT training was inadequate.

What I don't like about the study, and the Times article, is the overall message to the uninitiated. These were short-term treatments, and they were heterogeneous in type. These limitations are not addressed in the discussion section of the study. So the message is that all "Talk Therapy" doesn't work as well as we thought, with no differentiation between type or duration of therapy. And this is misleading and may keep people from seeking help.