Tuesday, October 22, 2019

Comments by Donald J. Bermont, Ph.D.

Showing 10 of 10 comments.

  • I want to congratulate Sera David for being persistent and continuing to state her case. Today (8/12) the Globe published an op-ed piece that she wrote. They put it on their editorial page. They included a list of resources that reflect the kind of treatment that MAD has been advocating for years. Sera stated the case for the need for not only more treatment, but different kinds of treatments; treatments that are humane and effective.

    They didn’t put her piece on the front page, but it was in a prominent place. I’m not sure how many minds it will change, but at least it will expose more people to the idea that sometimes the “problem” is the treatment.

  • It is reasonable to hypothesize that each of us has different genetic predispositions to act in certain ways. We are not blank slates or black boxes at birth. We all have different constitutions and different sensitivities. Some of us are more active, some are more observant.

    That said, the interactions between our genes and our environment is very, very complex, and no science is anywhere close to figuring it out. How and when a gene gets expressed is very dependent on what is going on around that person. We are very sensitive to the timing of what happens, and also to what kinds of experiences we had happened previously.

    Also, just in the last five years there are many studies that have shown that the process of translating our DNA into proteins is much more complex than anyone had expected. It is very possible that if someone does attempt to give a person a genetically targeted pill for a behavior they may somehow change that behavior, but there is a huge likelihood of wildly unanticipated side-effects, like a missing ear or a mushy brain.

    I expect we will have a better understanding of how this all works, perhaps in a hundred years.

  • From my forty years as a therapist here are my anecdotal views of the major causes of psychological distress:

    1. Loss
    of a loved one, of a job, of a house, of a lot of money, of your pet

    2 Loneliness
    see the article for which there is a link above. Also, loneliness leads to a lot of ruminations, self-incriminations, often a bit of paranoia

    3. Illness
    from a cold to cancer, if you don’t feel well, you don’t feel well. That’s also true if someone in the family is sick.

    4. Conflict
    in the family, in the neighborhood, in a war. Chronic fear and anger are never helpful

    5. Victimization
    Prejudice of any kind, racial, sexual, religious, gender, height, weight, being bullied for anything, for nothing,
    rape, molestation, abuse, any kind of trauma

    6. Stress
    It doesn’t have to be so dramatic, especially if it’s chronic. Having a bad boss, many deadlines, being late with the rent, your girlfriend is pregnant, your failing in school, you kid won’t go to sleep

    But it is also true that different people respond to these kinds of events differently. To a large extent that depends upon their previous experiences. Do they have successful coping skills? Do they have a solid support system? Have they recovered from these kinds of happenings before?

    Still, all people have different bodies, brains and minds, and some are just genetically stronger, both physically and psychologically. All of these factors interact, and the intensity of all of them varies from time to time.

    That’s what makes treatment so difficult. The underlying causes of the things we label as depression, anxiety, bipolar, etc. are all the result of complex interactions : What happens around you changes not only your behavior, but your brain, Those brain changes affect how you behave in different circumstances: fight or flight, go to work or go to bed, think fast or slow. Your behavior then alters the environment as others react to you, and so it continues.

    Will it be a problem if you stay our of work the day your dog dies? That depends upon your job, your boss, your mother, if you will get paid, or if you need the money. But if you go to work, and cry in front of customers, you will get fired. Then you will be unemployed, and stress about your bills, and soon you will be labelled as depressed.
    Someone may give you a therapist or a pill, but what would help most is someone who you can cry with, getting a better job, and a new dog.

  • I wonder how members of this community respond to the article in this week’s ( March 28, 2016) New Yorker Magazine by Siddhartha Mukherjee who describes how his brothers and uncles suffered with symptoms of what was diagnosed as bipolar disorder and schizophrenia. He goes on to discuss the work of two geneticists, Beth Stevens and Steve McCarroll, who have found a strong relationship between a gene labelled C4A and the behaviors described as “mental illness.”

    Mr. Mukherjee, who wrote “The Emperor of All Maladies” does I good job of showing that a group of genes is not the only cause of these behaviors, but that when these genes, C4A, are configured in a certain way, they create proteins that do more than the usual amount of pruning of the synapses in the parts of the brain that are associated with planning and cognition.

    He also talks about how difficult it is to separate the genetic differences in his brothers from who they are as people. He acknowledges that the current treatments for bipolar disorder are very unsuccessful, and that, even knowing that there is this genetic correlation, a better treatment is still very far off.

    What his article helps to show is that any “psychiatric” disorder, is really due to very complex causes. For years as a therapist, I have tried to show people that the causes of their distress comes from many factors. It may begin with a genetic vulnerability, such as being a more shy or more sensitive person, or it may even be the opposite, as being someone who is naturally more aggressive and less aware of other’s feelings. But these things all need the proper environment to shape different behaviors. That environment comes from the family and the community in which a person lives. Someone who may seem a bit different, but who was raised in a very accepting and supportive family may grow up to be very creative and happy, while a person with a very similar genetic profile, but in a more rigid, conforming family may suffer greatly and be burdened with several psychiatric labels.

    A family and community’s reaction to the genetic results of someone being gay, uncoordinated, dark skinned, shy or short may result in a life of suffering, or it may not turn out that way at all. All of our lives are shaped by the interaction of many forces. Our genetics is certainly one of them, but not the only one.

  • The problem isn’t Trump. He speaks for the people who are lost and don’t know what to do. The problem is what Nobel Prize winner Daniel Kahneman pointed out years ago — people are not rational.

    Yes, if you think about cause and effect it becomes clear that we are ruining our planet and we are also fighting needlessly with each other. The pity is, with our new technology and new ways of communicating, if we worked together we could vastly improve the lives of almost everyone.

    But people are easily frightened. Their natural tendency is to protect themselves, their family and then their community before they can think about the greater good and helping people they don’t know — especially people who are different from them.

    Once somebody begins to take more than their share, the race begins for everyone to grab as much as they can before its all gone. It becomes a race to the lowest common denominator. Trust disappears and fear takes over.

    If things are going to change we have to find ways to reassure a critical mass of people that they will be better off. We have to restore the trust that has been lost. The world has become so interactive that we have to show that no one can “go it alone” without tearing the fabric of our society.

    That’s why Bernie Sanders is calling for a “revolution,” and people are responding; more than expected. Perhaps the world is getting ready.

    Whether you vote for Sanders or not, we all have to continue to attempt to show that we understand that people come from different places, and that we all need to know that a change will be helpful. We need to understand the origins of the actions of the poor, the sick and the anxious, as well as the rich, the striving, the self-promoting and the power hungry. We have to understand and reassure the angry, the lost and the confused.

    Trust and understanding. It’s emotional, not rational.

  • Dr. Moncrieff has posted an excellent description of how psychological and emotional difficulties have such complex and interactive causes. If a person gets a physical illness, and misses work they will soon lose their job. This leads to the person becoming discouraged and frustrated.

    That kind of emotional upset will soon put them in a psychiatrist’s office where they will be offered medications, which may sedate them but won’t change the situation. If they seek therapy, they may learn to understand their difficulties from a different perspective. But even then, their therapist has very little power to help them find work.

    If they are out of work and have a family to support, the stress mounts and often the family relationships become strained due to financial pressure, loss of status and loss of a sense of competence..

    Added to this is the pressure that comes from many in our highly competitive, highly capitalistic society that labels the person not only as crazy, but lazy.

    To turn this around, to help a person begin to feel competent and human again takes many people. A good therapist can be a help, but there needs to be a support network of family and friends. It would also be most helpful if there is an understanding community that offers a path to a meaningful life.

  • “Blame” is not a helpful word when trying to find causes of social, emotional and behavioral problems. Almost all parents want to raise their children in the best way possible. Unfortunately, there is not agreement on what is “best.” There are many different philosophies about child raising ranging from “do anything to make the child happy,” to “It’s a tough world, and the sooner as the child learns to deal with that, the better he/she will cope.” Some parents demand respect and obedience, others seem to put the child in charge, even when the child has no concept of how to make a decision.

    Each parent has his/her own ideas about how to raise children. These ideas are based partially on what they liked or didn’t like about their own childhood. There are also cultural norms that change drastically from one generation to the next. Dr. Spock or no Dr. Spock?

    Added to this mix is that each child is born with their own genetic temperament. An active child in a quiet household will be treated differently than a quiet child. A fifth child is treated differently that a first born. An infant with a physical problem will totally change the family’s dynamics.

    Yes Mencken, who certainly had his own flaws, was correct on this one — there are no simple solutions.

  • I think it is pretty clear by now, and it is being recognized by many therapists and even a few psychiatrists, that the psychiatric diagnostic categories, especially since the publication of DSM V, are just descriptions of some behaviors. The label that is put on those behaviors is nothing more than a hypothetical construct; it is not something that exists. The terms such as schizophrenia, bipolar, depression, and even anxiety, refer to many different things. The terms have no relation to etiology.

    Still, questions such as Dr. Hickey poses, while they offer a necessary response to the medical/psychiatric community, also are oversimplifications of the problems.

    I have been a therapist for over forty years. The people who have come to me for help suffer with a combination of psychological, emotional and behavioral difficulties. Do they have a “brain disease?” No. I don’t think “disease” is accurate. Some clearly had brain injuries. Some have toxins, such as lead, that have damaged their brains. But also, some people are clearly wired differently, mostly due to slight variations in their unique genetic codes. They had different placements of a few amino acids along their double helix.

    But, that usually is not the sole cause of their problem. Genetic differences manifest themselves very differently depending upon the environment in which the person lives. This means that family dynamics play a huge role in shaping personalities, in shaping behavior and in forming belief systems.

    Families now come in many shapes and sizes, and they are all ;giving in very different communities. As Dr, Hickey points out, what is acceptable in one culture often seems very weird when that person moves into another culture.

    We can see that with some of the strangeness that goes on in the world today. Are all suicide bombers Crazy?

    My point is that the causes of “mental illness” are very complex, and they are very interactive. Some families are tolerant and accepting of a wide range of behaviors. Other families, or communities, may label those behaviors as “sick.” Once those labels are applied many different experiences begin to befall that person which usually make their lives more difficult.

    Still everyone starts their lives with slightly different brains. Some are more sensitive, some are more active, some are more distractible, some seek more stimulation, some are more active physically. Some people are naturally just happier, while others are just more uncomfortable. These are biological differences. When they interact with their environment, and other people interact with them, it can lead to support, peace, love and understanding, or it can lead to anger, depression or bipolar behaviors.
    It’s complex.

  • Dr. Sptizer was a medical doctor. He wanted to raise the image of psychiatry as a specialty that would fit into the medical model, so he devised diagnosis. He tried to describe the symptoms of “mental illness.” In the early twentieth century most medical diagnosis were based on descriptions, but by the end of the twentieth century other medical diagnoses were based on more objective, measurable, physical data. There are x-rays, blood counts, MRIs, blood pressure, temperatures, biopsies, and many other lab tests to help determine what causes the symptoms. That never happened for emotional, psychological or behavior problems.

    What are the causes of “mental health” difficulties? Here is a list from the top of my head:

    Loss, loneliness, illness, stress from work, stress from a relationship, financial problems, racial discrimination, poverty, as well as sexual abuse, domestic violence, living in a war zone, living in a family that seems like a war zone. Also, genetics play a part, and now we also see epigenetics have something to do with behavior, and the microbes in our digestive tracts, and brain injury, and the toxins from food, lead paint, air pollution, water pollution. And a dark, cold winter, and being bullied, being very fearful for no apparent reason, being very fearful for very apparent reasons, losing a job, going to war. having parents who are rigid and mean, having parents who spoil you, not conforming to the local culture, conforming too the local culture….

    The cause of psychological, behavioral and emotional problems are all of those things and much more. It comes from many of those thing happening at the same time and all of them interacting with each other. The causes are physical and environmental. They are personal, social and political. If only the biological is treated, then the environmental and social will make progress difficult. If you only treat the environmental, the biological and social will still cause difficulties.

    The trouble is that if our society is going to pay for treatment the problem needs to fit a medical model. Emotional and behavioral problems really don’t fit. Spitzer tried to make everyone think that it did. The more he succeeded, the more the treatments failed.

  • The difference between “can’t” and “”won’t” has always been a very difficult differentiation for anyone dealing with mental health issues. It certainly has been for me as a therapist.

    I have always felt that part of my role as a therapist is to help the people I see to feel more in control of their lives and their destinies. Yet, as a Psychologist and a scientist it is impossible not to realize that every behavior has an antecedent — that every effect has a cause — that humans really do not have “free will” at the moment that they are making decisions. Behavior is determined by who we are biologically, and how that has interacted with all of the experiences we have received from our environment. Our actions don’t just randomly appear, they come from our history and our motivations, most of which we are not consciously reappraising at the moment of action.

    As Dr. Hickey describes,recently there have been many attempts by defense lawyers to use a psychiatric diagnoses, such as bipolar disorder, or intermittent explosive disorder, to get their clients to be seen as being victims of the disorder and not responsible for their actions. Philosophically, in many ways this is true. It is true of all of us. We are limited by who were are and what we have experienced. I don’t have the “free will” to wake up tomorrow and play in the NBA, be a lawyer, a hedge-fund manager, or even be a good trash collector. (although, obviously I could run for President of the U.S., as the bar for that is very low).

    But we can’t live in a society that forgives people for the lives they have led. Laws and courts are there to judge people by their actions. There has to be a sense of responsibility, especially for anyone over eighteen years old. The question becomes one of how much “extenuating circumstances” are considered in the sentencing.. Sometimes, treatment is a much better solution than just throwing someone in jail. It could be a better option for the criminal, and for society. Sometimes it’s not. Michael S. Gazzianiga, the psychologist/neurologist at the University of California, Santa Barbara discusses this issue at length in his 2014 book “Whose in Charge Here.”

    Unfortunately, this is a very difficult and complex question to throw at a jury of untrained citizens. “Common sense” gets very confusing. Also, sadly, it plays into many prejudices, especially racial. The question of who is culpable often becomes one of who we are afraid of. In addition, what needs to be considered is how effective treatment would be for the criminal. If we believe that a crime was determined by a person’s genetic make-up, does that mean there is nothing we can do about it. If so, shouldn’t that person be put away forever, just to keep the rest of us safe? If I know someone has an uncontrolled warrior gene, shouldn’t I just shoot him before he shoots me, and then tell the judge I feared for my life?

    Laws are there to answer these questions, not psychiatry.

    As Dr. Hickey writes, people are responsible to learn from their parents, their community and from their own mistakes. Responsible people learn to alter their behavior in order to function better, as individuals and as citizens. We assume that people who “act-out” are making a choice, based on who they have allowed themselves to become. I feel it is the role of a therapist to help create a series of new experiences that help with that learning process, and perhaps have some input into who goes to jail.