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.

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...