See What You Want to See

Sandra Steingard, MD
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August, 1985.

My first academic article, entitled, “Dissociation and Psychotic Symptoms” is published in The American Journal of Psychiatry (1).   It was a case report of a young girl who experienced visions and voices. We thought that she had dissociative symptoms and we had taught her how to control these experiences through self hypnosis.

In the same month, an article was published in another academic journal (2).   This was entitled, “Treatment of Bulimia and Rapid-Cycling Bipolar Disorder with Sodium Valproate: A case Report .”

We were describing the same young girl.  Our treatments were concurrent.  How could this be?

Further review gives some clues as to how psychiatry evolved in those years.

The teen-ager was one of my first patients when I was started my psychiatry residency in 1982.  She had been transferred from another hospital. In those days many insurance policies covered 60 days in a psychiatric hospital. Patients who were not considered well enough to return home after 60 days were often transferred to a psychiatric unit located within a general hospital and this is where I was working at the time.

She had been diagnosed with Bipolar Disorder, rapid cycling type, a new diagnosis at that time.  She had been treated with valproic acid, an anticonvulsant which was just starting to be used in psychiatry.  I can no longer remember why she was transferred to us because when she arrived, she was mildly depressed but otherwise doing fairly well.

We learned was that she was a troubled young woman who came from a troubled family. She had already been hospitalized a number of times since the age of 13 for problems that included mood disturbance, auditory and visual hallucinations, and bulimia.  When we reviewed her record, we noticed that she often improved rapidly after being admitted to the hospital.

One of the senior psychiatrists in our department, Fred Frankel, had a long standing interest in hypnosis. For a number of reasons, we thought she was experiencing dissociative episodes.  We asked her if we could try to hypnotize her and we found that she easily entered into a hypnotic state during which she experienced her voices.  We explained to her,  her family, and her outpatient psychiatrist, that this capacity – to enter a trance like state – could be thought of as a gift but that it was one that she needed to learn to control.  We taught her how to induce and end a trance. We thought that she entered into these states at times of stress. We hoped that with psychotherapy she might learn more about why this happened and also how to be in better control of her tendency to dissociate.  We did not continue her on the valproic acid.

We thought this was an important observation – that sometimes psychosis could be a manifestation of a dissociative state – so we wrote our paper.

The doctors who referred her to us were in the midst of studying the effects of valproic acid on people who they had diagnosed with rapid cycling Bipolar Disorder.  We had been in contact and they knew of our observations but they viewed her response to treatment differently. They report that she responded extremely well to this drug and they reiterated this point when they included her in another paper published a few years later (3).

Reviewing all of this 30 years later, it is hard to know from a close reading of the papers that we were describing the same person.  Beyond our varied etiological explanations for her symptoms, our description of the outcome over the ensuing 18 months is not the same. I was in contact with her treating psychiatrist and recorded what he told me.  According to his report, she had experienced some ongoing challenges, but she was learning to control her dissociative experiences.  According to my colleagues, her symptoms waxed and waned in fairly close correlation to her level of valproic acid and our decision to stop it was ill advised.

I wrote a letter to the editor suggesting that given her high level of suggestibility, she was not a good person to include in a case report (4).  In their response, they chided me for having concerns about the potential risks of valproic acid and reiterated how much better she had done when she took the drug (5).

What is so interesting to me is how one’s perspective can influence what one observes.  Daniel Kahneman in his book, Thinking, fact and slow drives home the point that our view of reality is so easily distorted by our biases.  That seems to have been what happened here.

What I did not realize at the time was that this was something of a turning point in the field. This was the beginning of the franchise of Bipolar disorder – type II, rapid cycling, NOS – to encompass a broad array of people who experienced shifting mood states.  Valproic acid, marketed as Depakote, became one of the first blockbluster drugs in psychiatry and it continues to be widely prescribed.  The authors of that article became well-known and highly respected leaders of my field.

At the same time, the use of hypnosis in psychiatry and psychology had its own notoriety.  Dr. Frankel spoke often of the need to be cautious in the use of hypnosis.  He warned us that it was easy to “induce” symptoms.  A few years after these articles were published, the notion of recovered memories became a prominent and sensationalized topic.   This  did much to discredit and impede our understanding of dissociation and our use of therapies that might help individuals who are prone to this experience.  However, the notion of trauma has achieved a growing recognition as being an important factor in so much of the emotional distress people experience in their lives.

I wonder about this young girl who is now a grown woman. I suspect she continued to face serious challenges in her life.  The treatment we suggested was no panacea and if there was a drug that was truly effective I would have gladly suggested she take it.  I wonder if one day she realized that the notion of chemical imbalance was not as definitive as she may have been led to believe at that time.  I wonder if she remained on medications and if she went on to try any of the other drugs that were marketed in the next two decades.  I wonder if she ever was able to make sense of some of the difficulties she faced as a young teen.

1. Steingard, S and Frankel, F. Dissociation and Psychotic Symptoms. Am J Psychiatry 142:953-955, 1985.

2.  Herridge PLand Pope HG.  Treatment of Bulimia and Rapid-Cycling Bipolar Disorder with Sodium Valproate: A case Report.  J  Clin Psychopharmacol 5:229-228, 1985.

3. McElroy, SL,Keck,PE, and Pope, HG. Valproate in the Treatment of Rapid-Cycling Bipolar Disorder.  J Clin Psychopharmacol 8:275-279, 1988.

4. Steingard, S Valproate in the Treatment of Rapid-Cycling Bipolar Disorder, J Clin Psychopharmacol 9:382-383, 1989.

5. McElroy, SL,Keck,PE, and Pope, HG. Reply from Dr. McElroy and Associates.  J Clin Psychopharmacol 9:383-384, 1989.

 

34 COMMENTS

  1. Seems clear to me. If “she often improved rapidly after being admitted to the hospital”, it is probably because the hospital was a place of hope and escape from an unpleasant reality. It is also possible that engaging her in activity was the benefit, not necessarily the hypnosis itself.

  3. Sandy, when I read your articles I try to see what Whitaker sees. I believe in him and he believes in you. But I don’t see what he sees… I see, in my perception, someone who loves being a psychiatrist and doesn’t yet accept the limitations inherent in psychiatry and its conceptual understandings.

    There was no suitable pill for the particular pain of that teenaged girl then in the early eighties, just as there is none for a analogous American girl today. The big difference now is quantity.

    When a girl is hospitalized in the 21st century, she would be ashamed to only receive Depakote! A girl today can also expect a SSRI/SNRI, a benzo, and perhaps a special added touch of a 3rd generation antipsychotic of Abilify (it is a great add-on to depression!). I would know as I was never on fewer than a three psych drug regimen since my initial diagnosis in 1999 (though I’m now newly sober for the last 16 months). “Monotherapy” is for underachievers, both patients and clinicians alike! Why not get more creative?

    This is one of the fundamental improvements in mental health care that you have no doubt witnessed on your watch as a psychiatrist in the last 30 years. I can only wish my comment was mere hyperbole. Or maybe you don’t see that.

      • Hi Rossa! Interesting question. It seems straightforward enough, but really covers a bigger issue of where I have been, how I identify and encompass all of those experiences, and how I make sense of it to others.

        The easiest thing to say is that the only mental health community I run in is MIA. I don’t really know what is popular or what the cool kids are doing.

        When I think of the word ‘sober’, I think of not drunk, of alcoholics, of somber clothing or thinking. But I also think more broadly of coming to a new realization of oneself and liberation from a destructive way of living. It is this latter description that I seek to capitalize on to describe my situation of no longer identifying as mentally ill, no longer taking pills, and also feeling like I have recovered my dignity in the process.

        If you are further interested in this topic you might want to check out the Beyond ‘Anatomy’ forum thread “The Problem with Language” where I am the 13th entry to weigh in thoughts on words and wording. https://www.madinamerica.com/forums/topic/the-problem-with-language/ You might even want to add to the discussion.

    • I disagree. I see Sandy as one of those rare psychiatrists who is struggling to come to terms with the “limitations inherent in psychiatry and its conceptual understandings.” I believe that her main point here is how “blind” all of us can be to the reality of what is as opposed to what we think it is or want we want it to be. Unfortunately, because of the undue power that they hold, when psychiatrists are “blind” it has terrible and far reaching effects.

      Sandy doesn’t always end up at the point that I think she should be at, but it’s not for me to say where she should and needs to be. By the very fact that she is willing to question and struggle with the “messy” things is a huge point in her favor. I don’t like doctors of any kind and will not automatically trust my life to any of them until they show me that they are worthy of taking care of this very precious entity known as Stephen. I would work in partnership with Sandy because she doesn’t claim to be the “expert” on my life.

  4. Thank you for your comment.
    I do not think I was clear in the blog.
    I did not prescribe valproic acid and I agree that “There was no suitable pill for the particular pain of that teenaged girl.” That was what we wrote in our report.
    I was trying to describe a time in American psychiatry when the march towards the kind of polypharmacy we see today began; I was not trying to defend that change.
    Re your assessment that I do not “yet accept the limitations inherent in psychiatry and its conceptual understandings.”
    The reason why I blog here is that I am dismayed by psychiatry and its limitations. However, I understand that for some of the people who are interested in this site – and perhaps this includes you- it is impossible to conceive of continuing to work as a psychiatrist if one truly accepts the limitations of the field.
    But you are not alone in pointing out aspects of my belief system of which I may not be fully aware. I try to remain humble on this topic.

    • Thanks for the response, Sandy. There is much to muse about. I appreciate your interest in learning from others who are not colleagues and I appreciate your use of the word ‘humility’ (which definitely cannot be found anywhere in the DSM or most writing involving psychiatry). My experience of psychiatry has taught me much about transforming humiliations into humility! It is an ongoing lesson…

  5. Hi Sandy,

    I have had dissociative experiences since I was about six and have learned to control it (unmedicated), and even appreciate it. One of the biggest issues I faced with this was not feeling embarrassed about it or learning to see it as simply another facet if myself. Half of the difficulty, I think, is convincing the person that it isn’t weird or wrong. Sometimes I fear that the minute we start talking in diagnostic terms, the experience loses some of its meaning. I love dissociation because it saved my life, and it gives me a safe place to challenge my own identity. I think its important for others to feel as safe with their experiences as I do.

    Cheers!

    • Yes! I just read a great journal article about “healthy” subjects being able to easily dissociate staring at a mirror (I call this the abyss of the mirror). I think most people do have the capacity under certain conditions, as well as the ability to learn to stop the experience as it occurs (which I do sometimes) or purposefully dissociate to experience another creative state (which I also do on occasion).

  7. In order to truly help someone to stop dissociating to exteme levels one has to understand WHY they were dissociating to begin with. What you wanted to achieve was symptom reduction, just the same as one sedates someone with antipsychotics. It does nothing at all to help a person over the longer term.

    Most of the most respected people in the trauma field do not agree with hypnosis. It asks a person who has usually suffered profound trauma at the hands of another person to allow a person they barely know and have little reason to trust to control them. That is not healthy for anyone in that situation. They need to learn to trust people at there own time in there own way. Trust is something that cannot be forced onto someone. Hyponosis makes it much easier to rape or otherwise abuse someone. A person who is that vulnerable should not be placed in that situation.

    As for self hypnosis. A person who is truly in a dissociative would not be capable of such a thing. We do unerstand enough about the biology of trauma to know how people react to things. When they enter these states they are entering very primative states, which is much like a very young infant. They have no self control and no ability to calm themselves down. When a person is in an acute trauma they cannot do such a thing. The work of Bruce Perry at the Child Trauma Academy is the best example of that. If you have not read his work, you should. His first book the Boy who was raised as a dog is as much an essential reading for anyone in the menatal health field as is Whittakers work.

    Of course the most clear sign of anything should have been that she continued to get well in hosptial. Ie, remove her from the family and she recovers, put her back into the family and she falls apart again. but then again, psychiatry is not capable of considering those things.

    I do however agree that psychiatrists only ever see what they want to see. The fact that you can have 10 psychiatrists examine the same person and all come up with totally different diagnosises, says it all. If they do by pure chance diagnose the same, you can be 100% certain that they would treat it differently!!

    • Thank you, Belinda.
      I appreciate your comments and I do not disagree. The main point of the post was not really about treatment but more on what you state in your last paragraph.
      We did not think her treatment would only involve teaching her to use self hypnosis but her ability to experience voices and visions so easily seemed telling.
      This was 30 years ago and our understanding of trauma was different. Bruce Perry was only starting his work.
      This was meant as a bit of history. It may be of less interest to others but I sometimes wonder about my profession – how did we get here from there?
      Mad In America tracked one part of the history of American Psychiatry but there was more to it. This is just one tiny – and perhaps in some ways telling – piece of that story.

  9. “What is so interesting to me is how one’s perspective can influence what one observes.”

    It gets even more complicated when family members meet with the psychiatrist to discuss the patient in question. This is one reason why I have distanced myself as much as possible from meeting with my son’s psychiatrist. Can you imagine any one outside of a psychiatric patient being put under the microscope while others discuss the possible reasons for certain behaviors? This is indeed crazy-making behavior.

    • “Crazy-making” is right! When my son was briefly in the psych ward of a teaching hospital, he complained that they were always watching him and taking notes on his behavior and things he said. He felt like he was being constantly observed through a magnifying glass. Of course, the white coats interpreted his discomfort as “paranoia” and a symptom and therefore proof of how “ill” he was. Infuriating!

        • That’s wise. Teaching hospitals are the worst possible place to take somebody for mental health care. The psych departments of teaching hospitals have been the breeding ground and incubator for the mental illness industry – dispensaries of poisonous labels and “remedies.” Ptooey.

          • I work at a state hospital in the same city where the university hospital is located. They have a big, prestigious Psychiatric Institute. When they get patients that are not compliant or who are “more than they want to handle” we suddenly end up with said patients. I have absolutely no respect for the Institute at all!

            We have one unit in the hospital that is a teaching unit and when I was there as a patient the two med students that I had were absolutely wonderful. They were more helpful than my attending psychiatrist. I also had an intern psychiatrist who actually did talk therapy with me every weekday afternoon for a month. He was also wonderful and very helpful and not your typical quack psychiatrist. He was actually willing to share some of his own life experiences with me in order to show me that forming a real relationship with me was important to him. They don’t treat people on that unit like lab animals.

  10. Being aware of the historical shifts in psychiatry history should definitely make everybody humble. I like your perspective, and your narration of historical context.

    On a lighter note, is your post title one of those mind tricks where nobody is supposed to notice the duplication of the word “to to” (maybe “we want to see” only one “to”?)?

    To comment on the meaning of the title, I wonder if previous knowledge, and previous perceptions are not possibly more important than our will (or our conflict of interests) in having different people interpret the same reality differently. I will admit my perception bias: I think the metaphor of the elephant and the blindmen has more validity to explain those perception differences than explanations based on “emotional” or “want” biases (even if I am also a big fan of Kahneman).

    Thanks for posting.

  11. Sandra,

    Thanks for this eye-witness account of “the beginning of the franchise of Bipolar disorder – type II, rapid cycling, NOS.” LOL! That franchise has been quite the money-maker, hasn’t it? Ick.

    Sandra, you are one of the most clear-thinking individuals I have ever encountered. And I adore the way you fearlessly challenge your colleagues with that clear thinking. Keep it up!

  12. I thought it quite telling that you wrote, “According to my colleagues, her symptoms waxed and waned in fairly close correlation to her level of valproic acid and I our decision to stop it was ill advised.”

    This is often how current day UK psychiatrists talk. Far too often they have almost no interest in what is happening in someone’s life.

  13. My immediate thought was, maybe her symptoms reduced when she was in the hospital because she was able to escape from whatever abuse or oppression she was experiencing at home. Why this thought does not seem to occur to the mainstream psychiatrist is puzzling at best.

    I once talked to a psychiatrist to get some history about his patient. He told me she was an intractable case of depression, been seeing her 15 years, tried everything (listed a bunch of drugs they’d used), nothing seemed to work. I asked him what had brought her to his attention initially. He said, “Huh?” I asked, “What was she originally depressed about that brought her to your care?” His rely, “Gosh, I don’t know!” Stated in a mildly incredulous tone that suggested, “Why would THAT be relevant?” He’d tried everything except asking her why she felt bad. She would have been better off talking to an average 8-year-old, who would at least have had the sense to ask her, “Why are you crying?”

    Part of seeing what they want to see is seeing things from the perspective only of what benefits them, and yet being able to rationalize it as for the patient’s own good. We’re all susceptible to this, but a true professional knows s/he has this vulnerability and is constantly checking him/herself for losing focus on the client. Humility is, indeed, the word. Medical decisions shouldn’t be made for personal profit or ego enhancement; moreover, decisions about people’s emotional/spiritual life shouldn’t be considered medical decisions in the first place.

    Sandy, it sounds like you have been a bit of a radical all along, although it’s disturbing that the idea of taking the time to understand your patient is actually a radical one in psychiatry today. I don’t know that I could have tolerated working in those circles as long as you have, but I admire your courage AND your humility and am glad you’re there to help open they eyes of those that are willing to see beyond what makes them personally comfortable.

    —- Steve

  14. The idea of listening to one’s patients was not radical. At the time, the psychoanalysts and psychotherapists were the old guard.
    1boringold man has written recently about his experiences when psychiatry turned in its current direction: http://1boringoldman.com/index.php/2012/11/12/squishy/
    It is interesting because we are talking about the same era – the early 1980’s shortly after the introduction of the DSM III.
    To be clear and honest, I moved in the same dirction as the rest of my field because I was not impressed by the intellectual rigor of psychoanalysis. Given the shenanigans of the more empircally based members of my profession, that is ironic isn’t it?
    At the same time, these early experiences taught me to question the status quo.
    Thanks for reading and for your comments, Steve.