Sunday, September 15, 2019

Comments by Catalyzt

Showing 40 of 40 comments.

  • Yes. Not only is the price ruinous, but my clients have also charges for services they not only didn’t need, but never even received.

    Some of these items, it seems, are just boilerplate crap that gets hammered into a bill– you’re automatically billed for certain ‘assessments,’ but if you dig down into it, uh… yeah, that doctor wasn’t even onsite that day.

  • Yeah, Steve– I found this out the hard way when one of my student clients was sent to a local facility for an assessment. Exactly the same pitch– “agree or else” is never voluntary. Very grateful to you, Vitas, for shining a light on this Orwellian practice.

    I complained. Loudly, and to several different individuals. And I have no idea what I’ll do if it happens again– probably get a release so parents, or some other decision maker– can help me advocate for the student in the event of a hostile commitment situation. I’m open to ideas if anyone’s got any.

    Informed Consent has become one of those quasi-religious rituals without substance that are used to absolve one of responsibility, like going through the rosary every morning after getting drunk the night before. (No disrespect to Catholics, I could have chosen any other religion or social institution to find examples.) When I asked about the necessity of drug testing so I could continue using the tiny dose (< 10 ME less than once a day) of opiates I need to function, my doctor said, "It's just like any other blood test to monitor your health." What a crock. Do I see those test results or know what method was used to get the results, as I could for any other test on my chart? Of course not.

    The same empty logic is what I am supposed to use to justify crackpot online questionnaires I am supposed to give to my clients every session. "It's just like any other test to make sure you are still healthy!" Uh, no. Byzantine, opaque, and incredibly crude AI that tries to take the humans out of decision making bears no resemblance to cholesterol or blood sugar tests.

    Instead, I tell the truth: I have problems with them because they don't use the same outcome measurements consistently and even if they did, they do not track "progress" longitudinally over a period longer than six months or a year.

    I also tell them that we will periodically assess whether we think they are being helped or harmed by the instrument, and if they are being harmed, we will stop using it.

    The larger point is that as clinicians, we are so used to these empty rituals that it's easy to stop questioning them, because it seems like if we did, that's all we would ever do. But of course, the reverse is closer to the truth– if none of us put up with this crap, it probably wouldn't continue.

  • I have, at various times, tried to trick my (old-school, psychodynamic, 80-year-old) shrink into telling me what my diagnosis is.

    But he never bites. I don’t think he really believes in diagnoses, either.

    Not to go galloping off on a tangent, but this raises another interesting point: Do therapists need to be free of the issues that they’re treating in others?

    My supervisor always said, “Absolutely.” However, in clinical training, it seemed like I could treat other people’s depression even if I was depressed, and their substance use even if I was using substances myself. I got rave reviews from my clients on the feedback questionnaires at my training site– and I kept asking my colleagues, “How is it possible that they are getting better while I keep getting worse?” No one had anything like a good answer. I occasionally run into people I treated during this period, and they still tell me how much I helped them. It was the stupidest damn thing I could imagine– at the rate I was going, by the time I had helped 50 people, I would be ready to be hospitalized myself. My depression, drinking, and road rage kept slowly getting worse.

    And then it all stopped– started doing 12 step, got my foot off the gas, I still get just as sad and anxious, but not for nearly as long.

    Now it’s more the way my supervisor said… I may actually have better coping skills than the people I work with, it kind of feels like that.

    But honestly, I have no idea why, and I feel like it could have gone the other way just as easily. I mean, my own shrink is very good, and that’s obviously part of it– I want to be a bad-ass, and he totally models that, just really calm, great sense of humor, nothing phases him, and impossible to intimidate. But I don’t know if that accounts for it. Sometimes I think I just lived long enough to see what was on the other side of what was standing in my way– and maybe my shrink and buddies in 12-step, as well as my friends and family, helped me get there in my mid-50s instead of having to wait until my 70s.

  • Nice post, Topher, and important article. As the late Mickey Nardo often pointed out on Boring Old Man we have completely forgotten what diagnoses were supposed to be used for– just a general shorthand so one clinician can describe symptoms and presenting issues to another.

    The only way I find diagnoses useful is during consultation, usually by saying which dx does not fit, like, “The delusions aren’t quite like schizophrenia, maybe more like complex trauma, the auditory hallucinations remind me of crystal meth, though not as pervasive, and the depressive symptoms are definitely not Major Depressive Disorder.”

    Medical professionals take diagnoses way too seriously, they are supposed to be shorthand, not an if-this-then-that guide to prescribing or treatment! It’s just as bad as using an assessment instrument as an outcome measurement in research when even the assessment instruments are extremely coarse, and require judgment and cooperation between clinician and the person they are treating. Topher mentions the GAD7 and the PHQ9– when these are most useful is when the person filling out the questionnaire writes their own comments in the margin!

  • Thanks so much for this– and yes, really, really well written.

    All I could add is that pill shaming is really insidious and tacitly seductive. My personal belief is that most of the “acceptable” ideas about psychiatric medication are pretty much backwards– benzos and even opiates are generally less harmful than newer drugs, like SSRIs and ‘atypical’ antipsychotics, which are supposed to be safer.

    But when I talk about this to friends and colleagues, I do get pretty worked up about it– and I have had friends and paraprofessionals who take SSRIs, and have found them helpful, warn me that the way I’m making my point sounds the hell of a lot like pill shaming, even though that’s not what I intend. This usually results in a fair amount of back-pedaling by yours truly… “I’m really sorry if I misspoke; I think I’ve said previously that I don’t see as many side effects with Lexapro and that you’re taking a very low dosage, and that I don’t have all the answers.”

    Shaming didn’t get me to stop smoking cigarettes and weed and drinking alcohol. Even if I did want to get my friends to stop taking SSRIs– and I generally don’t, because the few friends I have who have stayed on them do seem to take the ones that generally seem have fewer harms and take them in lower doses– shaming would be the WORST way to do that.

    Thanks again. Great stuff!

  • Great article, Michael. The approval of devices like these does an end run around an inconvenient truth of neurobiology: The entire idea of functional localization neutoanatomy is highly suspect to begin with, so it would seem impossible to even speculate reasonably about what the outcome would be of simply attaching an electrode to the front of someone’s head. This intervention would appear to be absolute crackpottery of the most brazen and malignant kind.

    This article was from 2002, but I do not think much has changed since then.

    https://www.ece.uvic.ca/~bctill/papers/learning/Brett_etal_2002.pdf

    “Current methods of matching different brains
    cannot eliminate differences in functional
    areas across individuals, because the positions
    of these areas are not well predicted by gross
    anatomical landmarks in many regions.”

    I admire your stats as a no-hitter for medication referrals. (I’ve only made one since I’ve been licensed, with a patient who absolutely insisted on it, though I’m hopeful the patient will not fill the prescription. They have not yet.) That is an incredible accomplishment you should be proud of.

  • Great stuff as always, Alex. What spoke to me in particular was the bit about keeping things simple. When I went through clinical training, we were just migrating to the Electronic Medical Record, and my first reaction was, “This is so byzantine and chaotic, how can this possibly be right? This is about opacity and privilege, creating some bizarre digital temple where the sacred knowledge can be stored– or used against clients or even clinicians– effectively weaponzing it.
    And how is it possible that supervisors I trust are acting like this is not a terrible and dangerous step in the wrong direction?”

  • I’m with Steve on this. “Free markets” worked extremely well for a heartbeat in the early days of the industrial revolution, but started becoming problematic around the middle of the last century, and are now a viral toxin strangling innovation and amplifying human suffering. I’m weary of Chicago-School-of-Economics blather that has changed economics from an amusing but occasionally useful mix of humanity and science into a fundamentalist religion. We are moving into an age of limits– limited water, limited oil, limited food– and free market economics are so obviously the worst possible solution that the entire idea of unfettered capitalism itself will provoke extreme cognitive dissonance in anyone who can look at the sky, the water, the gas pump, and the supermarket shelves and realize things have changed very drastically over the last half century. There is nothing pathological about considering the idea of blowing your brains out when your culture relentlessly shrieks at you to acquire more stuff even though we are obviously running out of stuff to make the stuff with. The notion of socialism or communism vs. capitalism is as obsolete as thinking about the human body in terms of four humors. The irony is that the people profiting from big pharma’s money do not lead lives most people would like to emulate. I briefly freelanced for a medical PR firm in the early ’80s, and the foks I worked for absolutely horrified me– soulless yuppies with empty lives no one would envy. It does not seem much different now.

  • Great summary of KOLs, Sleep, thanks. Stumbled across this article as well:

    https://thepeopleschemist.com/fraud-in-medical-journals/

    Fortunately, as an LMFT, the situation is not quite as bad. My local licensing board has a LOT of options for getting CEUs, though your point still holds– the cheaper ones seem to be sponsored by someone, or to be shilling some kind of “evidence-baste” (baste your intervention in ‘evidence’!) treatment model that I suspect was developed by folks on some kind of gravy train, whether public or private sector. If I REALLY want to spend a pile of dough– which, actually, I do in this situation– I can pay an outfit that will let me read a book of my own choosing and write an essay on it. (They vet the book and make sure it’s relevant to my scope of practice, and give me a pass/fail grade on it.) Of course, I suppose there are people who game the system by just skimming the book or something, but I figure that if I’m paying the money, I might as well learn the material. For required topics like ethics and the law, there are mainstream standardized courses that are quite dull, but that test facts and reasoning skills surprisingly well.

  • Yes, totally obvious. We now have a bizarro world where what (corporate-sponsored) literature tells us are safer drugs are often what clinical experience suggests are more dangerous drugs. It’s reached the point where any time I hear of some great new drug, my first thought is, “It probably sucks” — which can be a dangerous bias in and of itself. No matter how hard you try to keep your head screwed on straight about what is and is not good science, read enough crap test results and literature, and it will eventually warp your judgment.

  • That sounds outstanding, MH. I think skill-based groups sometimes can focus on ‘issues’ — like, “that guy cut me off, I want to block his car, get out of mine, and smash in his window with a tire iron. What do you guys do when you feel like that?” And someone else will disclose their own outside-the-box technique that’s helped them get a handle on their road rage– that can work, BUT…

    Yes, the real growth is the in-the-moment interactions between group members– working through an impasse, or difficult feelings towards other people, or the chills-down-your-spine experience of really being heard. Even in a tool-based group, the most enduring change happens in process with the other group members.

  • Great article and comments.

    What resonated with me: It does seem like peer groups have a generally better rep, but based on what I hear from the people I work with, and my own experience, some peer groups are far more effective than others.

    In the 12-step domain, I’ve rarely been to a bad AA meeting, I only rarely hear people complain about Alanon and ACA meetings. Feedback about SLA meetings is a bit more spotty, I hear more scattered complaints, but they generally get outstanding reviews as well. I will never stop going to AA.

    I’ve never heard someone say, however, that OA changed their life. I get indifferent feedback about OA a lot, like, “I went for a few months, didn’t do much for me.”

    Some other programs, however, just do not seem to fit the 12-step model, and I rarely hear good things about them. UA and DA get pretty bad reviews– often some decent CBT-type interventions are sprinkled in with the worst kind of free-market “The Secret”-type ‘wishing will make it so’ self-help blather. The homework assignments from “PRGs” often seems shaming and dangerous.

    My takeaway from Cody’s piece is: It’s easy for me to forget, as primarily a 1:1 therapist, how much mediocre or bad feedback I get about some groups, and probably what I’m hearing is only the tip of the iceberg. Therapists should probably NEVER refer people to just any group on a list provided by an insurance company or hospital, and ONLY refer to groups that have a well established track record.

    I have heard a lot of bad things about therapist-led groups recently, particularly in IOP, inpatient, or HMO settings– brain-dead, checklist-type interventions with faded handouts that have been copied many times. When therapist-led groups work well, the facilitators pre-interviewed group members very carefully to see if the group was for them, they had really clear boundaries (particularly for DV or anger management groups), and the groups had been running a long time, with members and facilitators who were deeply committed to making them work. At their best? They were, essentially, peer-led groups with the therapist just there for intake, to make sure no one felt pressured to speak or not to speak, to provide structure, to consolidate what had been done the previous week, or ask some questions to kick start the process if needed– or bear witness if people simply wanted to sit in silence with each other.

    Personally, I find facilitating groups exhausting– it requires razor sharp reflexes; for example, if someone is dominating, or being dominated, it’s critical to intervene quickly. I ran a six-week grief group, and got very good feedback, but it kicked the crap out of me. Part of the reason for this, I think, was because it COULD have been damaging if all of us hadn’t been on top of it. I think at the end, we all had a sense of, “That was great, but holy crap, it was scary, too.” If I ever lead or co-facilitate another group, it will only be at a time when my caseload is light.

  • Hey, guys, just a few quick thoughts. Since I’m a headshrinker myself, I’m trying to stay mostly out of the way, I just speed-read this entire thread, and a couple of things jumped out at me.

    I. Child Abuse

    Quick question for PacificDawn: How many times have you filed a child abuse report or called the police? If the answer is more than once or twice, mad respect to you.

    How many times have you had an abusive parent who you KNOW owns a handgun into your office and explained why you made the call that caused the police to drag them out of the house at 4:00 AM, and had nothing but your wits to protect yourself– and sometimes your client, if security at the school is not optimal?

    That’s not ideology, it’s direct action. Any other form of revolution is too lame and tame for my taste.

    II. Refusing Clients Unless They are in Psychiatry

    Agree w/ Steve, totally gross– haven’t run into this yet, hope I never will.

    The enforced-compliance issue– e.g., some crackpot policy that I can’t treat people unless they are taking drugs– fortunately doesn’t come up that much in private practice. But I am actually about two millimeters away from calling my liability insurance carrier and investigating the idea of refusing patients who ARE taking certain combinations of medications– e.g., no more than one SSRI, no high-dose SSRIs, no more than one mood stabilizer, no more than one benzodiazepene.

    But of course, that’s yet another crap, pie-in-the-sky that doesn’t work in the real world. It’s a serious ethical dilemma, because polypharmacy patients often make no or only very slow progress, and I don’t take money from people who I cannot help. On the other hand, polypharmacy patients often would benefit from education about the risks of side effects, and how to advocate for themselves with the doctors, insurance company, etc. so it doesn’t seem right to refuse treatment. My current system is simply praying that these clients do not get referred to me, and it’s not working out real well, so any constructive ideas are welcome.

    II. Freedom of Religious Expression

    Sam, that was an awesome post. I respect individuals who do not allow themselves to be intimidated. Glad your wife is doing better, and yeah, I bet it’s gotta be weird that you both have totally different ideas about psychiatric medication!

    III. Life Coaches

    Rachel, great explanation. What really chaps my ass is when one of these blowhards tries to monetize an AA meeting– shows up supposedly to share about their sobriety, but on the back end, they’re handing out their number and trolling for clients.

  • One of the most heartbreaking cases I ever worked on was a young man or woman receiving ECT because of a suicidal gesture– e.g., actions that fall short of a suicide attempt, such as putting an unloaded gun to your head, putting a strip of masking tape around your neck like a noose, or wrapping a cable around your neck and tightening it briefly– when one has suicidal thoughts.

    This individual reported extreme memory loss, headaches, and many other symptoms that suggested some form of brain damage– blank stare at times, though moments of humor and laughter seeped through. He/she never had a chance to process the trauma that brought this about, which was the loss of a pet for which the patient felt responsible.

    I contacted the psychiatrist in charge of the case, tried to get him or her to budge on anything– stopping ECT, fewer treatments, titrate down on one of the 4 psych meds he/she was on. Very pleasant psychiatrist, very concerned, but did not change treatment in any way.

    I was trying to figure out if there was some asymmetrical tactic I could use to get her to a more responsible provider when he/she had a car accident on the way to session– and it was a completely avoidable accident, a U or left turn where patient could have avoided injury just by looking both ways. I reported it to the psychiatrist, but patient had to leave town for economic reasons, and I couldn’t help thinking: Did they pick on this patient b/c he/she did not have resources to resist? What other reason could there be? They had this machine, I guess, and needed someone to use it on, or that was what I speculated, so they chose someone helpless.

    Of course, the patient was never well organized enough to make it to session after that, and moved back home with his/her relatives out of state.

    I am trying to put together a better tactical plan for dealing with something like this if it ever comes up in the future. I still feel terrible guilt about not being able to help him/her, or advocate effectively, even though the “treatment” was near completed by the time he/she was referred to me.

  • And another thank you for Dr. Coleman regarding the ethical piece. This circles back to madmom’s comment upthread that clinician’s should not prescribe any drug that they wouldn’t take themselves. (Or something to that effect.) There is a long tradition of self-experimentation in psychoactive drug development, some of it disastrous, some quite successful, some of it ethical, some not so much. (My own opinion is that Hofmann’s self experimentation and writing about psychedelics was far more principled than, say, Shulgin or Leary’s.)

    I remember clearly the first time I took Paxil, (prescribed for depression) and thinking, “This feels vaguely like the jittery, shivering feeling of the first 45 minutes of dirty LSD, but I can’t tell when it begins or ends, it never seems to go anywhere or lead to anything like insight or well being, and I have no idea what this feeling has to do with being depressed or not being depressed.” After taking it for about 12 days, I had an arousal disorder that lasted six or seven years. The terror that normal sexual function would never return (fortunately it did, I was one of the lucky ones) was nearly as bad as the side effects.

    As Rosalee notes, treatment without consent is a crime, and for good reason. It was really sobering for me to visit a patient in the hospital recently and discover that he/she was not even informed properly of what drugs he/she was taking in what dose, let alone how the drug was supposed to work or what the side effects were. The fact that this is routine practice for mild to moderate garden-variety suicidal ideation that might not have warranted treatment in the 1970s seems utterly depraved.

  • Quite possibly, good point. And it also would follow that as I get older, that tolerance might tend to decrease as organ function generally declines with age. It does make sense to slowly titrate down and either stop the drugs entirely, or maintain at a much lower level. Time for an in-vivo experiment! I may try dropping to 3/4 of a milligram over the summer.

  • Cole, I’m not anything like a neurologist, but I would have no reason to doubt that you have persistent symptoms of some kind of neurotoxicity, or equally debilitating neuroadaptive effect. I am very glad you did not end your own life, that we are able to learn from your experience, and that you shared that experience, and the study, with all of us. And I absolutely agree that it what you suspect is true– that no one followed up on the request for more research– that is a serious problem. Just googling about aimlessly, I do see one study from 1988 about midazolam in dogs, and there’s also a very interesting 2016 study in BMJ exploring the link between benzos and Alzheimer’s, though I think the sample size was small and the results were correlative rather than causative. Yes, I’d love to see more longitudinal studies that controlled for factors like cardiovascular disease, alcohol use, exercise, type of medication, etc.

  • Steve, I don’t quite follow that. Doesn’t it seem more likely that alcohol damages the brain through it’s overall toxicity– the fact that it poisons the body in so many different ways: stomach, liver, kidneys, blood vessels. I think the gross morphological changes in the brain caused by alcohol are more likely due to vascular damage, not anything having to do with the GABA system. (Certainly, GABA affects a wide variety of systems, and it’s possible there are harms associated with that, but they seem more likely to be subtler than the changes noted in Cole’s PDF.) Frank, I agree that anxiety is not a disease, but I do not feel there is any clinical utility or moral imperative to classify any behavior as a ‘vice,’ or any particular virtue to labeling one’s own behavior in that way.

  • Fantastic article! Really enjoyed this, and agree with most of the conclusions, though I would have reached them by a different process of reasoning. I do not think that opiates, benzos, antipsychotics, mood stabilizers, and SSRIs have enough in common with each other that we can say we should have expected withdrawal or other effects from one drug based on our experience with others.

    I will never forget the reaction of a friend of mine who is an organic chemist when I showed him a diagram of the chemical structure of Prozac. “These are matchsticks,” he snarled– meaning that just by looking at the molecule, his expectation would be that it would have crude and unpredictable effects. Certainly, one can credibly argue that all psychotropic drugs are crude and unpredictable to some extent, and my own background in chemistry and neurobiology is quite weak, but it does seem like there are some differences in the side effect profiles of different classes of drugs.

    Benzos and opiates have catastrophic dangers for many classes of people, but seem to produce no problems for many, many others. Xanaz and Klonopin seem to be the most problematic benzos. With the opiates, it’s more of a crap-shoot as to which are most dangerous, though Oxycodone has obviously been one of the worst offenders.

    I think the evidence for opiate-induced hyeralgesia is very weak. All the studies I read seemed really agenda-driven, and I’ve never met someone who actually experienced these issues, but I have not worked with many chronic pain patients, only a handful. If this exists, my bet would be it only shows up over 10 ME per day.

    The reports I’ve heard about the side effects of antipsychotics and SSRIs (both as a clinician and just from friends), and the side effects I have observed with my own eyes for these two classes of medication, have always been far more alarming than what I’ve seen, or what’s been reported to me, about the others.

    I really don’t want to be a cheerleader for the other drugs, either. It just seems like the relative risk of antipsychotics are the highest and they are only effective for a very small subset of patients, which I would consider to be a SMALL subset of those who actually hallucinated and heard voices before being exposed to medication of any kind, e.g., ONLY those who are a clear danger to themselves and others– who wander into traffic, attempt to steal airplanes, etc. (Depakote did help my father in the last stages of dementia, when he did become, briefly, quite dangerous– his cognitive functioning improved and so did his mood, and I have no rational explanation for this.) Abilify seems to be the only “mood stabilizer” I’ve ever heard anything positive about– I’ve heard maybe five or six friends or clients tell me it helped them significantly, one or two who say it saved their lives.

    SSRIs seem to have a ludicrously bad cost-benefit ratio. I do not have a single suicidal patient who was never exposed to SSRIs, and all of them present very differently from suicidal people I met in the ’70s and early ’80s. I do not know a single person who ever told me it helped them significantly. They seem marginally effective for a very small percentage of patients, and extremely damaging to most. I cannot imagine why these drugs were ever approved.

  • Cole, I very much respect the fact that you included a link to actual evidence– and by all means, keep it coming, as I believe in healthy debate and I want to keep an open mind!

    At the same time, I have to note that the scans noted in the .PDF only reflect what was seen after benzo treatment. We have no idea what their brains looked liked beforehand, and there was no mention of control for other variables that might explain the atrophy. I have always been very skeptical of claims that even long-term benzo usage causes brain damage for reasons that, I must admit, are even more anecdotal: I’ve taken one milligram of lorazepam daily for at least 20 years, and I have noticed no impairment in executive function whatsoever. On the contrary, I seem to have a better memory for where my keys and phone are than people half my age (I’m in my early 60s) and I work in an academic environment with scientists and students who routinely make positive comments about my memory and executive function.

    While it’s certainly true that my memory of what happens right before I fall asleep– and approximately 90 minutes after I take the drug– is not as sharp as the rest of the day, even those memories are accessible, though with more effort. What really destroys my memory seems to be fatigue and anxiety. It is an in-vivo experiment, to be sure, and I acknowledge that it’s quite possible that I’ll be posting here 5 or 10 years from now complaining that I have some serious neurological problem. But I tend to doubt it.

    I do find that I find it almost unbearably frustrating to have conversations with friends over 45 who drink more than two units of alcohol a night– and even some who only drink two. It seems like they absolutely cannot keep up their end of the conversation; their processing seems noticeably slower, and their short-term and long-term memory seems obviously, and grossly impaired. (This speaks to Moncrief’s thoughts about benzos vs. ETOH, which I thought were very brave. I second her opinion, and I know it’s not a popular one.) When I stopped drinking about five years ago, my memory and sense of direction, improved dramatically; I think there’s very robust evidence that ETOH causes cerebral atrophy, and I did drink very heavily for decades, so I am at a lost to explain why the function returned. Again, I don’t mention all this because I want to pick a fight about this, I’m genuinely puzzled.

  • I realize that correlation does not prove causality, but it is astounding to me that every single one of my hospitalized or suicidal younger clients is taking SSRIs (prescribed by someone previously, not during therapy with me.) There is not a single exception.

    I also think SSRI-induced suicidality has its own signature that is not that hard to recognize, and young people taking SSRIs are much harder to treat. We are definitely making things worse.

    SG, my experience is that a lot of the ‘trends’ we hear about ‘millenials’ from the media are entirely fictional. The young people I work with are generally tough as nails and have to face a future that is far more challenging and uncertain than anything my own generation (I was born in the late ’50s) had to deal with.

    I cannot wait until they are turned loose on the real world and start cleaning house in business and politics. Many of these kids are incredibly well versed in ethics as well as hard sciences and arts, they understand logical fallacies, and have proven themselves to be incredibly resilient in the face of oppression, violence, and institutionalized crime.

    Do not be surprised if they make the ‘greatest generation’ look like a bunch of punters. If you are a hide-bound 60-or-70-something vulture capitalist, a word of advice: Run.

  • Thanks, Alex. There’s so much in that message I’d like to talk about at some point– I did most of my training in the LGBTQ+ community, and I share your feelings about how supportive an environment that was, among many other things. But I also hear you about needing to stop talking so much, so this is a good place to sign off. I was particularly moved when you said this:

    <>

    I choked back a sob, took a deep breath, and had a moment of clarity: I realized that my own truth is that there’s some personal business I need to take care of– that I have to be more mindful of self-care particularly in early winter and late winter/early spring when my caseload is very high. I get isolated, I feel like I don’t need to spend time with family, friends and colleagues, and that is a yellow flag– I’m putting myself, my friends and family, and the people I work with, at risk.

    I slammed the laptop shut and called an old friend; we talked on the phone for hours. I’m packing my bag right now, and heading out to spend a night in the country with my wife and the dogs.

    Apparently, I came to this blog to find something, and for the moment, it very much seems like I found it.

    I bet you’re pretty damn good at what you do. We’ve never even met in person, but I feel a lot better after hearing what you had to say. I’ll be back in a week or so. Thank you, I am very grateful for your thoughts and feedback, and I hope I can repay the favor someday!

  • Yeah– the discrepancies between what the client heard and what the therapist heard– if that is not approached from a position of mutual respect and genuine open-ended inquiry, that could be extremely damaging. I have one or two clients where this does happen occasionally. The client will say, “Last week, you said X, and I felt like you were angry at me.” The natural, and (in my opinion) completely wrong thing a therapist could say in this situation would be, “No, actually, here, look in my notes, what I said was something different, obviously I wasn’t angry at all.” Or, even worse, to write in their notes, “Client is being manipulative, exhibiting borderline features,” etc. That sh*t makes me want to hurl.

    How about, “Gee, I didn’t feel like I was angry at you– but maybe you’re on to something. Maybe part of me was irritated, or frustrated, or maybe I really was angry and didn’t know it. I’m so sorry that happened, and for my part in it. Let’s try to figure out what was going on.” I think therapists sometimes are afraid they will be sued for admitting they might have made an error– or that they might have been human. And that makes absolutely no sense; the real liability– both emotional and legal– comes from dishonesty and inhumanity.

    As for the advice to ignore people, I never considered exactly why that bothered me– but you’re exactly right, it does reinforce the idea that someone must be terribly damaged to want to seek professional counseling. Fortunately, at the clinic where I trained, my supervisors kind of said, “Well, in our community, that’s sort of impossible, just don’t reveal your a therapist– if your patient reveals it, limit disclosures.” And on a college campus? It would be impossibly rude and bizarre to be in line with a student at the cafeteria and not even acknowledge they were there! It’s also incredibly patronizing to assume that the poor, helpless patient has no idea where the boundaries are, and they need me, the mighty dream warrior, to help define the limits of the exchange. Sure, if someone started talking about something too personal, I’d absolutely change the subject– but in the real world, this seems to almost never happen, and the cost of not acting like a human being is way higher.

    Your experience at the mental health clinic sounds… kind of surreal, and not in a good way, more of the bad-acid-trip Clockwork Orange variety. Maybe someone should write an article for Psychology Today listing things you never want to have in your mental health clinic:

    * Muzak in the waiting room.
    * Television tuned to station that blares propaganda
    * Comics to ‘warm up’ the audience

    Particularly to be avoided:

    * Mirrors– one way or of any kind, except in the bathroom
    * Guns

    Thanks again for this, Alex. You know, I think part of me likes to pretend that this doesn’t go on, that the only abuses of power are the more routine issues that I hear about more often from my colleagues. And I very much appreciate the spirit and tone of your posts.

  • Thanks so much for that, Alex. As I was reading your post and writing this response, I found myself circling back to Gnaulati’s article, and the other responses, too– it all started coming together for me just a bit more.

    I can understand why you wouldn’t want to go into the long list of built-in problems with the paradigm, though it would be a fascinating conversation to have.

    My short version of it is, the two biggest baked-in issues are the exchange of money, and the transferential and counter transferential problems you are alluding to. The other one you identify– the ‘professional service’ issue– can be framed as a boundary problem, and I think the licensing boards and training programs are doing a little better job with those than they did 10 or 20 years ago. But like the first two, it cannot be completely solved. One sort of has to make an uneasy truce with all three of these, and those agreements have to be constantly reexamined and renegotiated.

    Of course there are others– if I don’t mention them here, it’s not because I think they should be ignored. Rachel mentions sexual predator therapists, and historically, this has been a huge problem. There was a terrible cult that evolved from a splinter faction of primal scream therapy in Los Angeles; it took forever to prosecute the ‘clinicians’ involved, but the case law that evolved completely changed the licensing process in California. It’s still a real issue, and it does still happen– I heard of one really shocking case during my internship.

  • It is very helpful for me to learn about the terrible experiences many of you have had with your therapists, I’m very grateful for that, and I’m not just saying that, either. I mean it.

    I wonder if I am the only one who feels that some of these responses are getting to be a bit of an echo chamber. I feel like sometimes one of you– often it’s Alex– will start off with a great post that has some insights I’ve never heard before, or a different way of framing an issue or problem. Then someone else will add something equally incisive or thought-provoking… but somehow, after about 5 or 10 posts, the thread has degenerated into something more like a Yelp review. The targets of attacks are indiscriminate, the ideas become more vague and repetitive, the ideas harder to follow.

    I would ask a few questions:

    Do you imagine that practicing psychotherapists have never been on the receiving end of abusive prescribing, bullshit happy-talk interventions, and coercion and manipulation by health care providers?

    Do you think it’s possible that maybe that’s WHY some of us got into the profession in the first place?

    Sylvain– do you actually confront individual psychiatrists on the job and challenge their prescribing practices? Or… do you just prefer to express your thoughts on blogs like this, maybe go to a few demonstrations, organize some letter-writing campaigns? I do not mean to insult you, only to challenge your thinking a bit. Because ‘raising awareness’ on these issues has not gotten very far in the US, at least, and direct action is impossible unless you have direct access to the individuals and social institutions perpetuating the abuse, yes? I grow weary of the academic conceit that having anything to do with an oppressive institution makes it impossible to avoid becoming complicit in it. Yes, that is often true… but not always, I think.

    Do you imagine that every therapist who accepts reimbursement from insurance companies follows the protocols that they ask us to follow?

    Do you think that insurance companies are somehow allied with psychotherapists? From my perspective, this is just an incredibly strange idea. It seems to me more likely that insurance companies are working as hard as they can to abolish psychotherapy completely, and I think one of the reasons for this is that psychotherapy sometimes really does work– and that means less repeat visits to primary care, less dependence on medication, and less revenue for the corporation.

    Sure, people told me I should be a therapist most of my life, and I’d always thought about it. But it was only after a dozen doses of Paxil shredded my entire sense of identity, and robbed me of happiness for nearly 6 years that I decided I had to try to make sure it didn’t happen to someone else. Not the only reason I chose the career, just the final and catalytic one.

  • Thank you so much for your story, Melody– I cannot tell you how valuable this is, because while I have learned a lot about brain zaps with SSRIs, I had never heard of them with amitryptiline, and TCAs may become more popular again as people learn how dangerous SSRIs are.

    A few well-known SSRI critics — damn, I can’t remember which ones, it might have been Healy or Whittaker or maybe Mickey Nardo– actually said that imipramine, another TCA, did work pretty well for severe Major Depressive Disorder– what Mickey Nardo called “big D depression,” (depression as described in the DSM III or DISM IV) which is actually quite rare. (Most people are prescribed antidepressants for problems in everyday living or adjustment disorders, IMHO.) I did try Elavil once– when I was about 16, and very, very stupid, I saw it in someone’s medicine cabinet and just took one for the hell of it, and man, that sh*t was gross! Yecch! In the 70s and 80s, they gave Elavil to older patients who were depressed or who had had strokes, I think– at least I knew a few older people who had it prescribed, occasionally someone in middle age, but you’re the first young person I’ve ever heard of who was on it.

    And when I hear brain zaps, I think mostly of Effexor. I had one client when I was in clinical training who said he would get brain zaps if he was ONE HOUR late with a dose, and that scared the crap out of me. I’d never heard of a drug besides high-dose opiates that had withdrawal that bad.

    Really great article about a lesser-known drug, raises all kinds of disturbing questions about brain zaps I had never considered before.

  • I would definitely agree that counseling centers should be approached with great caution, and the school I work in– as well as a few others locally– may well be exceptions. After re-reading the lead to my post, it does sound like I’m saying things are changing everywhere, and I do not actually know if that is true. I tend to think that because a lot of the people I trained with are activists, and even at my group practice I don’t hear as much doctrinaire blather as I used to about people ‘needing to be on medication’ so they can participate in therapy. That part of Varun’s story really broke my heart, because I haven’t personally heard anyone peddling that twisted fantasy since about 2010. That is just the strangest idea I’ve every heard of– I’ve always felt that folks who were medicated are often harder to work with in psychotherapy, unless their symptoms are so intense l that they can barely make it to the consulting room. We don’t work with people who are stoned or drunk, so why is it better to work with people who are chemically altered in some other way?

    If I were a student, I would want to know exactly who I was meeting with, and be able to have a look at the clinician’s website, as well as checking for any actions taken against them by a licensing board– at a minimum. Better yet would be to have referrals from another student.

  • I can speak from firsthand experience that this is definitely changing.

    I am a therapist on a college campus for nearly 4 years, my caseload is roughly 25 students at peak, maybe 40 students in and out the door per semester, and have never had to make a single psychiatric referral EXCEPT on a few occasions when a student who was already on psych meds appeared to be having side effects. If I believe those side effects might include self harm, I absolutely inform them that this is a possibility. I tell them what Akathisia is, and how in my experience, intrusive images caused by SSRIs differ from images caused by trauma, (as one example), and that encourage students to do research on their own and discuss with their prescriber so they can make an informed choice.

    I cannot advise students to consider a taper– I could lose my license for that– but I can absolutely provide education about side effects, and encourage them to review literature on their own, and often direct them to the RIAT reanalysis of Paxil Study #329. I help them weigh the pros and cons, and encourage students to advocate for themselves.

    I do visit students in the hospital and check all doses of medications– because, of course, typically the only students who need to be hospitalized are those who were already taking medication before coming to see me. If I notice a student’s voice is trembling, and that the dose of a medication has been increased, again, I cannot tell the hospital what I think they should do. But I can say, ‘I noticed that you tripled the dosage of this medication, and my client cannot sit still.”

    The counseling center on campus probably does make more psych referrals, but they do not refer every student.

  • Point taken. I’m talking about psychiatrists who were licensed long before the SSRIs came on the scene. The methodological flaws in the research are not always so easy to see, and if only a small percentage of your caseload used SSRIs– say your caseload is only 15% SSRI, 15% MAOI or tricyclic, 10% mood stabilizer, 10% antipsychotic, and 50% unmedicated who do only talk therapy– it is harder to see the harms of SSRIs. Even if most of your SSRI patients had adverse effects, it could be well-hidden in your drop-outs and transfers. I can easily imagine that it would take a quarter century or so to start connecting the dots, particularly if you’re being bombarded with well-crafted propaganda from companies that you trusted, at least somewhat, in 1980.

    In my Master’s program, I was trained to hunt for logical fallacies and junk science. A few generations ago, I think clinicians were much more naive in this respect.

  • Alto– good to see you again. I remember you well from Boring Old Man, I miss Mickey, Bernard, and the rest of the crew badly, and remember y’all fondly. I like to think things have changed a little bit over the last three or four years, but so sloooowwwwllly. (BTW, I still enjoy visiting your site, though I don’t get over there as often as I should.)

    Recently, I had an appointment with my own neurologist for headaches– Ivy-league educated, very fast and thorough exam, classic 21st century doctor’s appointment. I came prepared with a list of symptoms and history, and she delivered as good an assessment as you could ask for given the time constraints.

    At one point, she asked me if I had tried SSRIs or serotonin agonists. I quickly used my toolkit of coping skills to keep my blood pressure from skyrocketing, and simply asked her, “Why on earth would you use a serotonergic agent? Yeah, the headaches are bad, but serotonin is the most common neurotransmitter, it can show up almost anywhere in the brain, you never know what the hell it will do.”

    I guess I was expecting some kind of an argument. Instead, she just nodded curtly and said something like, “Yeah, I get where you’re coming from. Let’s keep doing what you’re doing for now.”

    Six or seven years ago, I might have gotten some glib neurobabble or a power-point presentation with a graphic of little parachutes making the brave journey through the synaptic gap and huddling together at the receptors. Of course it’s impossible to extrapolate from one person’s experience, but I feel like it’s possible… possible… that at least some junk psych meds are finally becoming a little less popular. And in my own practice, I’ve recently had referrals for clients of all ages, but particularly young people, who were “depressed” (per DSM V) but hadn’t been started on SSRIs– a welcome change since the days of my internship. The patients who haven’t started on SSRIs do seem easier to work with, both in brief and long term modalities of talk therapy. Some of ’em turn on a dime, particularly the kids with no history of major trauma– work through some attachment issues, identify some resources, out the door and back on the road in 12-26 weeks.

    One reason I wish I’d started this career sooner (though it would have been impossible, I was too much of a hothead when I was younger) is that I’d love to see how some of these folks do as they get older. I expect some of them to come back now and then over the next quarter century or so, if I live that long and can keep practicing, but I just have a hunch that the unmedicated ones will only be coming in for a 5-to-26 week tune-up after a major life transition or crisis.

    To be fair, I do see good outcomes for some medicated clients, and a few very favorable long-term prognoses within that group as well… but not nearly as many, and all of them were doing regular weekly therapy well over a year, sometimes over two years.

  • Part of the disconnect between psychologists (or MFTs for that matter) and psychiatrists is that psychologists often see their patients with greater frequency over a longer period of time.

    I know older psychiatrists who actually practice psychotherapy, though they also have patients they see for medication. Generally, they are less aware of adverse effects of medication because many of those effects may manifest well after discharge. As an MFT, I see many patients who have been on SSRIs for many years, and so I see adverse outcomes such as suicidality and withdrawal far more commonly in my practice than my psychiatrist does in his or hers.

    Before I got my license, I think my psychiatrist found my views on SSRIs to be a little hysterical. Now? Not so much. I don’t know a damn thing about his caseload, obviously, but he knows what I have seen and he trusts me, it’s impossible to imagine that his prescribing habits have not changed, though of course he could not tell me if I asked him. Many psychiatrists are actually dedicated healers with a wealth of clinical experience who have been fed the same propaganda their patients have.