Monday, July 21, 2014

Dr. Allen Interview on VoiceAmerica Internet Talk Radio

Dr. Allen was interviewed by Kathryrn Zox, the "Social Worker with a Microphone," on Voiceamerica, a leading internet talk radio network. The date was Wednesday, July 23, 2014.  

The subject was issues in the mental health field, with an emphasis on borderline personality disorder.  

The interview has been posted on the internet at:

Tuesday, July 15, 2014

Book Review: David and Goliath by Malcolm Gladwell

In my blog post of May 12, Are Scientists More Objective and Rational than the Rest of Us?, I related the stories of some scientists who somehow were able to “think outside the box,” to use the annoyingly well-worn cliché. They broke through the conventional wisdom, academic politics, and scientist groupthink and made radical changes to accepted scientific concepts and explanations for various phenomenon. 

I discussed Clare Patterson, who successfully took on a respected scientist who had became an oil industry lackey and who had pushed the idea that lead in gasoline was not dangerously polluting the environment. 
Then there was Elizabeth Gould, who took on neuroscience guru Pasko Rakic, who had set the field of neurobiology back a full decade by refusing to believe a lot of data coming out that disproved the prevailing notion that sophisticated animals are born with essentially every brain cell they would ever have, and that no new neurons develop during adulthood.
Another good example was German meteorologist Alfred Wegener, who first proposed – way back in 1915 - that South America and Africa had one time been joined. He was almost laughed out of academia. He even had fossil evidence for his proposition, but the geologists of his day not only mocked him but counter-proposed that there are (now sunken) land bridges to account for the fossils - without any evidence that this was in fact the case. Now all geologists accept the theory of plate tectonics.
So what makes some people able to do this? This is actually two questions, not one: First, why can some people think in novel ways while others seem stuck with the groupthink no matter how preposterous it starts to become? Second, why do some of these people succeed in creating – again pardon the second annoyingly well worn cliché – a paradigm shift in the scientific community, while others fail?
I was discussing these questions with a friend, and in response he gave me an interesting book called David and Goliath, Underdogs, Misfits, and the Art of Battling Giants by New Yorker journalist Malcolm Gladwell.

Malcolm Gladwell

It’s mostly about the individual and group factors that lead some people to think apart from prevailing wisdom, rather than about which of these people succeed in making a mark and which do not, but I thought it was a very interesting read.
Now of course Mr. Gladwell is a journalist and not a neuroscientist or psychologist, and his work has garnered a lot of public criticism from professionals in those fields, particularly Steven Pinker and Chris Chabris. Gladwell is above all a storyteller, but he goes on to make some interesting hypotheses about the psychology – and to a lesser extent the sociology – of the people at the center of his stories. He then speculates further about what these hypotheses could mean more generally.
Chabris accused him of “telling just-so stories and cherry-picking science to back them up,” and “presenting as proven laws what are just intriguing possibilities and musings about human behaviour.”
Fair enough, although I'm not sure I would agree that Gladwell is saying his ideas are proven. On the other hand, the belief of some psychologists in the sanctity of statistics and so-called empirical studies in the social sciences is also grossly overestimated. There are some inherent limitations in our current ability to explain and predict things, particularly in psychology. In the words of the neurobiologist Steve Rose, "It is in the nature of living things to be radically indeterminate."
I discussed the issue of “anecdotal” evidence versus inductive conclusions in a prior post. But an even bigger problem is the obvious difficulty in precisely mapping out the interactions between genes and environment, when there are literally thousands of environmental variables and a trillion constantly changing synaptic connections between brain cells, all of which interact at constantly changing frequencies over decades. No one can even come close to controlling for all of these variables in a lab experiment. This is the definition of chaos.
Sometimes the best way to eventually understand a psychological question of this sort – and one can only talk about increased or decreased probabilities of certain results given certain pre-conditions, never about anything approaching absolute certainty – is by looking at all the details in the stories of a variety of individuals. With all of the variables at work, only individual stories can provide some of these necessary details. With psychology, details matter. 
And sometimes it is the exceptions to the conventional wisdom that prove or disprove a perceived “rule.”
So with this in mind, reading Gladwell’s stories does bring up some intriguing possibilities. His major premise is that the experience of certain types of adversities can make someone stronger and far more resolute than he or she might be otherwise. Gladwell brings up, for example, the strength of the population of London during the rocket and bombing attacks by the Germans in World War II. The fact that so many people experienced what he calls a “near miss” – surviving a bombing in which your neighbors did not - can strengthen people's resolve to carry on.
He also discusses how some people with dyslexia had to ingeniously develop alternate ways of accomplishing certain tasks in order to overcome their limitations, which later helped them to be wildly successful. Again, I do not think the author is arguing that dyslexia is a good thing, or that for most people it does not impair or even destroy their attempts at success. So other variables are obviously involved.  

But that doesn’t necessarily negate the premise that sometimes weaknesses can be turned into strengths – as David did in the story of David and Goliath. Goliath was only prepared to fight someone who fought just like him, which left him vulnerable to a projectile from a slingshot.
Then there was the story of Emil “Jay” Freireich, a doctor who was a major player in the vast improvement in the treatment of childhood leukemia. The good doctor lost his father when he was quite young to a probable suicide after the stock market crash of 1929. The family was left destitute, and the mother was frequently absent in order to work, leaving him to fend for himself.
To oversimplify just a bit, Freireich realized that children were dying because individual drugs, which were causing horrific side effects, did not work fast enough. The leukemia killed the children before the drugs really had time to work. The drugs were just not killing enough cancer cells quickly enough. He knew that this meant that the children needed more aggressive treatment, and that drug “cocktails” were probably called for. But this meant that the children would suffer even more horrible side effects as the cocktails were given to them, and the medical establishment recoiled in horror at such a thought.
But Freireich had learned to persist in the face of adversity, and would not be deterred. Of course, the places in which he worked could have easily fired him for his activities, so a lot of luck was also involved. He had to be surrounded by at least some people who recognized the possibility that he might just be right. Fortunately, that was the case. Today’s cure rate for the type of cancer he fought stands at about 90%.
As Gladwell points out, “Does this mean that Freireich should be glad he had the kind of childhood he had? The answer is plainly no. What he went through as a child was something no child should have to endure…the right question is whether we as a society need people who have emerged from some kind of trauma – and the answer is that we plainly do.”

As an aside, Gladwell also brings up sort of in passing something that I wanted to mention because it puts an additional, very interesting new spin on the problem of some African Americans internalizing the racist, negative attitudes of Whites toward Blacks, so that they end up treating each other just like Whites used to treat them. I discussed this in my post of 8/14/2010 called The N-word

In some cases, apparently African slaves actually pretended to act out White stereotypes - in order to passive-aggressively harm their slaveholders! Gladwell quotes historian Lawrence Lavine about the phenomenon of the "trickster hero": 

"...a significant number of slaves lied, cheated, stole, feigned illness, loafed, pretended to misunderstand the orders they were given, put rocks in the bottom of their cotton baskets in order to meet their quota, broke their tools, burned their master's property, mutilated themselves in order to escape work, took indifferent care of the crops they were cultivating, and mistreated the livestock placed in their care to the extent that masters often felt it necessary to use the less efficient mules rather than horses since the former could better withstand the brutal treatment of the slaves."

So, when African Americans makes themselves look like a parody of a White stereotype, are they doing this on purpose to be a trickster, or subconsciously out of fears - originally concerning retribution - passed down unknowingly from one generation to the next? Actually, any given case could be either one - or even both. That the behavior can be this ambiguous shows the power of what I call the actor's paradox.

Tuesday, July 8, 2014

Guest Post: Always the Mediator

Today’s guest post is by Ashley Hardway. She discusses her personal experiences being in the dysfunctional family role  of the mediator, the one in the family who always tries to help settle disputes among other feuding family members. It is an version of what Murray Bowen called triangulation, the process by which two people in an unstable relationship rope in a third member to contain the conflict without actually solving it. When one person in a family is the one who always volunteers to mediate disputes, and/or is the person who everyone else always turns to to fullfil this function, the role often may then spread to variety of other relationships, particularly with spouses and in-laws. It may also happen that the persons everyone turns to is criticized for the way they are carrying out the task as wells as frustrated in their attempts to accomplish it, and yet also criticized if they stop mediating.

As far back as I can remember I have been in the middle. I am the middle child and I began mediating between my two siblings when we were just wee children. This carried on into adulthood with me being the mediator between practically everyone. I really do not know why. Maybe it was all the practice I had growing up, or maybe I thought I was good at it. I was always trying to make peace but it never seemed to work out the way I planned.

When I got to be an adult I was still mediating between my siblings and between my dad and siblings. No one seemed to be able to communicate their feelings and I was constantly trying to enlighten everyone to what someone else was truly saying. Our family was not exactly a cohesive unit but we always did have the fundamental foundation of love which kept us trying.

When I got married I became the mediator between my husband and my family and between his family and mine. My family has very few boundaries and would drop in without announcement. I was used to that, but what made the boundaries fall even more by the wayside was the fact that our mother lived with us. So it was pretty much no longer considered my home - it was mom’s home and anyone was welcome at any time. This did not go over well with my husband or his family as you can imagine. I tried to make peace and I tried to set my family straight but life-long habits are hard to break.

My husband’s family was the type that scheduled days to see their parents and make arrangements with each other in advance for any visits as well. So you can easily see how our situation could cause resentment. Now, not only was I hearing about it from my husband but his family began to chime in as well. I was caught in between trying to talk to my family about the situation and at the same time smooth things over with my husband and in-laws. I was trying to do it all without totally breaking off ties with either side of the family and keeping my marriage together. Along with all the mediating, I was doing my best to not only hold down but also excel in a full time job and raising two children whom I adore.

One of my siblings eventually moved out of state, which alleviated some of our problems for a while. But it was not too long afterwards that my mom’s sister and her mother, my aunt and grandma, moved to get closer to mom because they were all alone too. They moved in about a half mile down the road, and thankfully mom went over there most of the time. The trouble started when my mom’s brother, a dear uncle, was diagnosed with brain cancer and could no longer work. He too moved in with my grandma and aunt, but before long he became quite ill.  He loved to drop in and play with my kids. And not too long after that my youngest sibling got a divorce and was also dropping by constantly and unannounced for visits and for meals.

Everyone had legitimate needs and I loved them all, but this once again made my position of mediator more difficult. I found myself constantly talking to my mom and siblings about the problems created by everyone gathering at our house and how it upset my husband and his family. I was also constantly explaining to my husband that the reasons for the frequent visits by my family was that everyone was either sick, lonely, or hurting. It upset my mom when I would talk to her about this situation because she is the type of person who has never been able to say no to anyone - and of course she loved them all. It upset my husband because he did not have the same feelings towards these people and did not understand them. I found myself drowning in a churning whirlpool of emotions that never seemed to stop.

Nothing I did seemed to solve these problems in my marriage or in my relationships with my or my husband’s family. Nothing I could say or do seemed to help and I eventually just gave up talking and let things happen as they happened. I thought that maybe if they duke it out on their own, then things would get better.

Being in the middle for so long and trying to make things perfect had completely exhausted me. The reason that I finally gave up was that my family began criticizing me as well as teasing me about being so high strung. When I had worked as hard as I could to make things work and no one cooperated I ended up angry or in tears. I remember one Christmas they were actually betting on how long it would take before I had my meltdown. My husband normally acted unhappy or somewhat indifferent, but when the betting took place he joined in on it! So I decided to give in and let everyone fend for themselves except for my kids. After that my relationship ties were mainly with my children.

Of course this did nothing to help the situation but it also seemed to make my marriage and my relationship with my in-laws even worse than before. Throughout the course of a full decade I had done my best to talk to my husband about what was going and let him know that I was trying to set boundaries. I was fighting a battle I could not win. After all, my family had been used to me trying to mediate all my life and they had the ability to just shut me out when I talked.

I tried to talk to my husband and see if he could help me find a solution. Perhaps if he could step up and let my family know how he felt in a controlled manner it would help. But he was not that type of guy; he felt like I should be handling it and if I loved him then I would make it work. He would basically sit in the background and complain to me or just disappear and/or complain to his family. Do not get me wrong - I do not blame him, but I sure could have used his help because I was purely and utterly overwhelmed.

I believe being a mediator is hardest when you are mediating between family members.  This is especially true when you dealing with a family with no boundaries in the first place. In pretty much any other arena you can lay down facts and work at getting people to see other people’s views.

I hate to say it, but the only way I got out of the role as mediator was to give up and let things fall where they might. My family then wondered why I was distant and sometimes indifferent. As time went on my husband and I became almost strangers living in the house together and my marriage ended in separation and eventually divorce. At that point it was somewhat of a relief even though of course it was still painful. It felt something like the death of a terminally ill patient whom you know is now no longer suffering.

When they all started making fun of me I really realized how little I could do to help anyone. I wasn’t helping myself, certainly, by putting on all this extra stress. I figured out something. “You can lead a horse to water, but you can’t make him drink.” No matter how hard I tried I could not make everyone happy. In fact I could not make anyone happy, not even myself.

When I finally gave up on trying to mediate with the adults I invested myself in my kids. Of course I went from one unhealthy situation to another. I made my kids the focus of my whole life and, rather than finding happiness within myself, tried to find happiness through their lives. One of them handled it badly, seeking to run away. The other one seemed to do great on the surface but after a long time finally admitted to me how hard the strain was of trying to be my happiness for me. I didn’t even realize I was doing it, of course, because I never wanted to hurt my children. It has taken me a long time, and is still a work in progress, but I have started to look for happiness inside myself instead of trying to make everyone else happy thinking that would make me happy.

I finally learned that I can’t please everyone and saying yes to everything does not make their lives or my life better or happier. By finally setting boundaries with myself, I could at last set boundaries with those around me. I had to give up my need for love and affection, at least as I wanted it, and learn to be happy within myself. It has been a struggle, but I am working towards a healthier way of living. It has certainly helped that many of the family members that perpetuated the chaos have passed away or moved away. A little peace can go a long way!"

My attempts to mediate failed pretty much my whole life, but I kept trying because I hated to see people unhappy and misunderstood. I put myself in a place that I was not really capable or qualified to handle. Now I know, without a shadow of a doubt, that it is not possible to make everyone happy all the time. I cannot be responsible for any one else’s happiness but my own. I still have no idea how I could have handled that situation any differently. But I do know when you put yourself in that position you are certain to fail.

Always curious, Ashley Hardway is constantly learning and passionate about sharing what she learns with others. Based in the Houston, Texas office of Morningside Nannies, she loves to help families grow stronger, help their environments and communities, and keep moving forward! Check out @NannyLady on Twitter to connect and find out more.

Tuesday, July 1, 2014

Electronic Medical Records and Symptom Rating Scales: "Solutions" Making Problems Even Worse

Sometimes an effort to solve a problem just creates different, and at times even more serious problems. Take the electronic medical record (EMR) for example. Please. (Apologies to Henny Youngman).

In a clinic I work at that uses an EMR, we are required to fill out a “treatment plan” on each patient. This is - for me at least - a waste of time since my initial psychiatric evaluation note contains all of the information contained in the treatment plan, as well as important contextual information about the patient that is not included in the plan.

The treatment plan is not only redundant, requiring me to enter information twice, but increases the number of notes in the medical record, making it more difficult for anyone reviewing the chart to find specific information they may need to as they attempt to properly care for a patient. 

Sometimes trying to find specific information in the record is like searching for the proverbial needle in a haystack. Since we aren’t given a lot of time to review charts before patients come into see us in the first place, this takes time away from the all-important face time with patients.

A narrative note is always better than a form with boxes, which often does not provide a “box” that adequately addresses an issue for a patient. But having reviewed the notes of other psychiatrists, I can see why some administrator felt that having a formal treatment plan in the EMR was a good idea. A lot of the information inherent in a good psychiatric evaluation was nowhere to be found in the notes from a good percentage of my fellow clinicians.

Not only that, but many of their follow-up progress notes did not mention what symptoms were being addressed by the doctor's treatment. Nor did they mention what symptoms, if any, had responded to any medications that were prescribed, let alone whether or not the symptoms had actually resolved.

The treatment plan template wisely asked for these target symptoms. Recently, however, the plan template was changed to include a question asking the clinician how symptom improvement was to be measured.

The answer should be, “by clinical evaluation.” And that is what I always write. However, I think the designers of the template are looking for some sort of psychological assessment device, as if that were more valid that a clinician’s evaluation. As I frequently rant about on this and other blogs, such measures are typically screening tests consisting of symptom checklists, and as such are NOT meant to be a measure of clinical progress, let alone of a definitive diagnosis.

The question a good psychopharmacologist asks, particularly with major mood disorders, is not only whether the symptoms the patient has have improved. It is whether the patients have returned to their “baseline,” the way their mood was before they developed an episode of, say, major depressive disorder.

The Hamilton Depression Scale (HAM-D) scale for rating depression is one of the most frequently used symptom checklists, both clinically and in research.

It was published fifty years ago Max Hamilton (1912–1988). Interestingly, Hamilton himself was forever pointing out that the HAM-D was not intended to be used to make the diagnosis of depression. It does not have either sensitivity or specificity—there is a great deal of overlap with symptoms of other diagnoses, particularly anxiety disorders. 

Yet somehow it became the gold standard for not only evaluating the efficacy of antidepressants, but for measuring symptom improvement clinically.

I would much rather the administrators of the clinic solved the problem of absurdly vague “progress notes” by spelling out the minimum information they need to contain, not by asking a stupid question on a treatment plan form.

Tuesday, June 24, 2014

Your Children Like to Give You What You Seem to Expect From Them

During the times when parents are making major parenting errors, they are often giving their children a double message in one way or another. The parents, usually because of their own ambivalence about rules they themselves learned in their own families of origin as they grew up, say one thing but seem to act in ways that contradict what is being said verbally.

In this situation, children make sense of their parents’ confusing expectations of them by taking into account the entire context of the family’s interactions. They use three rules to sort out and hierarchically rank double messages that are given on a consistent basis. These rules are described in detail in my post of March 8, 2011, How Children Respond to Double Messages From Parents, Part I.

The parents’ behavior may seem to indicate to children that the parents have certain expectations about how the children are supposed to turn out, and children will not want to disappoint the parents by defying their apparent expectations. This will happen in spite of the fact that the parents verbally instruct the children not to act in the way the parents seem to expect, and criticize and/or severely punish them when they do. Admonishments, especially verbal ones, will be disregarded. Actions speak louder than words (Principle #1 from the earlier post).

In this post, I am going to list several examples of frequently-seen problematic parenting practices, as well as the consequences that such practices frequently lead to. They may cause relatively mild problems, but often they cause major issues. These patterns have been described to me over and over again by my adult patients as they discuss their family’s behavior over time.

The problems I list all have a common theme: parents trying to micromanage their children's behavior in one way or another. Parents may protest: "I have to focus on my child's troublesome behavior because they won't stop it." They don't realize that it actually works the other way around: the child won't stop the behavior because the parent keeps focussing on it!

After one of these problems goes on for a while, the situation gets more complicated. The parents and children begin to feed into one another's anxiety and compulsive behavior simultaneously.

In order to solve such a problem, the parents have to be the ones who calm down about the issue first, or the children will be very unlikely to ever calm down and start behaving differently. When the parents do stop micromanaging, other difficult but solvable problems predictably ensue. These are discussed in the last paragraph of this post.

In discussing any problematic parenting issues, there is always a rather devilish and perplexing conundrum that makes any such conversation frought with peril. Many troublesome parenting behaviors are driven by a parent's guilt over their own thoughts and feelings concerning their role as parents, and if one discusses what they may be doing wrong, this adds to their sense of guilt. They therefore often become very defensive and, if anything, dig in their heels. Their problematic practices then get even worse than before!

On the other hand, if they do not really understand what they are doing wrong, they also continue doing it. 

A real lose-lose proposition this.

Parental guilt is often increased by negative comments about their parenting practices that come from their own parents, the children's grandparents. This in turn is caused by certain changes in western culture which have been rapidly evolving over the last few decades. I describe these cultural issues in more detail in my last book, in Chapter Two, Don't Blame Us.

Really, looking for someone to blame for family problems is a complete waste of time. The most important questions is, which would you rather do: find fault with people, or actually solve the problems? It is damn near impossible to do both. To naysayers I say, "Grow up!" 

The problems are created over several generations, so let's all just blame Adam and Eve, and be done with it.

And so I proceed.

Some additional points: Some psychologists and parenting experts intuitively understand the type of consequences that I list below, but IMO they miss the real reason why they occur. Most seem to think that the parents are somehow “gratifying” their children in a counterproductive way. However, in my experience, children who are in many of these situations are anything but gratified. 

They are almost always quite miserable, and behave in self-destructive ways to boot. Feeling good and being self destructive are for the most part mutually exclusive.

Rather than being gratified, I believe - as I have said many times in this blog - that the children are sacrificing themselves to give the parents what the parents seem, in the estimation of the child, to desperately need. 

Another frequent explanation, particularly by cognitive-behavioral therapists, is that the problematic parenting practices prevent children from acquiring certain social skills. While that explanation may at times have some truth, many of the "skills" such children are supposed to lack are not exactly rocket science. And these same children often demonstrate in other interpersonal and environmental contexts the very skills they are not supposed to have ever learned!

Critics of course will also point to examples in which the types of parental behavior described in the post do not or did not seem to be followed by the predicted negative consequences. As usual, I need to put in a disclaimer: The consequences of the parental behavior I mention do not always result in every situation in which the parenting problem is seen. They are not hard and fast. 

Kids have minds of their own. Other adults in the house or even in the community may provide a counterweight. Some parents behave more consistently, others much less so. Some are consistently inconsistent. Parents might get sick and tone down their rhetoric for extended periods. A zillion other things may come into play.

There is a chaos effect: small changes in initial conditions can lead to big changes down the line. However, if parents make the kind of errors I describe, the odds are very high that the predicted consequences will indeed occur. We’re talking probabilities here!

So, without further ado, here’s a list of common parenting errors created by parental ambivalence about their own behavior. By no means is it a complete one:

If you constantly try to fix a child, the child will find different ways to keep being broken so you can continue in your efforts.

If you continually bail children out of their own messes, they will continue to make messes for you to bail them out of.

If you give your kids money whenever they ask and almost never say no, they will continue to ask you for money, and may seem to develop problems supporting themselves when they grow up.

If you constantly try to mediate disputes between your children, they will continue to fight one another so you can continue to mediate.

If you blame yourself for your children’s failings, your children will blame you for their own woes. (In a perverse and ironic way, their problems are partly your doing. But it’s your guilt about your own behavior that creates the problem, not your basic character or intrinsic worth).

If you repeatedly tear apart your child’s room looking for drugs when there is no evidence that he or she is using, just to make sure he or she is not using, the child is more likely to use drugs so you can find what you are looking for.

If you continuously help children with their homework instead of telling then to figure it out for themselves, they will continuously need your help.

If you keep making a huge deal about something your children do or say, they will keep repeating whatever it was so you can continue to obsess about it.

If you instantly replace any items lost by your child, your child will continue to lose things.

If you do nothing when your children disrespect you, or if you just whine and scream at them about it, they won’t ever respect you.

If you look uncomfortable getting presents on holidays and birthdays, your children won’t give you any, or will give you thoughtless gifts. (If you then question them about it, they will get angry or passive aggressive, and may start giving you things, but looking as if they are only doing so because you asked, not because they care about you).

If you seem to get a kick out of a child’s misbehavior, they will continue to misbehave, no matter what else you say about it.

If you set a low bar in your expectations for your child (academically, for example), they may meet the bar, but they will not exceed it.

If you compulsively pay more attention to your children's needs than you do to those of your spouse, they will make gallant efforts to regulate the amount of intimacy you have in your marriage by inserting themselves between the two of you.

Last - and this is perhaps the most pernicious of all - if you constantly give in to your children's demands out of guilt, but then get angry at them because they are too demanding, then they will fear for your mental stability. In response, they will try to regulate your emotions like a thermostat: If you start to get too angry they will try to make you feel guilty, but if you start to feel too guilty, they will try to piss you off royally.

Whenever you try to stop doing any of these things after having done them for a long time, expect a negative reaction, because you will be confusing your children. They thought they had you all figured out, and suddenly you are not performing to their expectations. Therefore, their behavior will get even worse in order to see if you really mean what you say and are going to continue to be different. Their behavior will, however, eventually get better if you stay the course.

Tuesday, June 17, 2014

Is Your Psychiatrist Committing Malpractice Even if Doing What a Lot of Other Psychiatrists Are Doing?

My malpractice carrier, which is physician owned and operated, recommends taking one of their seminars or online courses on different aspects of medical malpractice every year, and gives those policy owners who do a 10% discount on their yearly premium. 

The course I took this year was on misdiagnosis.

The course was not really geared to psychiatrists at all, but it seemed to me that the general advice still applies to them. However,  in my experience the advice is not clearly being followed by a lot of my colleagues these days. If these recommendations are indeed valid, and I certainly agree that they are, a lot of psychiatrists are getting away with gross negligence. 

Statistics show, by the way, that doctors are actually far more likely to get sued for something they did not do wrong than they are to get sued for actual malpractice. Isn’t that bizarre?

Some of the advice in the malpractice course concerns two major criticisms of my colleagues that I have written about extensively on this blog and in my last book: relying on symptom checklists, and relying on a diagnoses made by a prior clinician. Truly frightening.

So, as a public service, here’s some information from the course that psychiatric patients might find useful if they are considering suing a psychiatrist for malpractice. From MedRisk (Medical Risk Management, Inc.).

Misdiagnoses were more likely to be considered negligent in malpractice suits. Misdiagnoses were more than three times more likely to result in serious patient injury than medication errors.

2.      Multiple case law decisions have consistently held that the patient has no duty to volunteer information the physician does not ask about, and the patient’s only duty is to answer the physician’s questions honestly. (A smoker actually has no duty to tell his cardiologist about the smoking if the cardiologist does not ask!)

3.      Review any written history questionnaires with the patient to make sure the information is accurate. Patients who are sick or in pain can’t be relied on to even read the questions carefully, let alone provide thoughtful answers. Many patients will simply respond with a “No” to all prior diseases without reading the list and some patients, as discussed below, may not even be able to read or understand the questions. For example, the patient with a known history of high blood pressure may answer “No” when asked if he has ever been diagnosed with hypertension simply because he doesn’t know that they are the same thing. So make sure that your questionnaires are worded as simply as possible. Even then, review the responses verbally with the patient and make sure that you really do have a useful medical history. 
      Most healthcare instructional materials provided to patients are written on a 10th grade reading level or higher. Yet the reading level of the average patient is 4.6 grade levels below the last year of school completed, which means that a typical high school graduate reads at around an 8th-grade level. Further, the average Medicaid recipient reads at less than a 6th grade level, with more than one-third reading below the 4th grade level.

4.      Hear the patient out while taking the history and do not interrupt. Physicians are often overworked, overbooked, and scrambling to stay on schedule. This can leave them anxious to get to the point of a patient visit. One study found that physicians on average interrupted patients only 18 seconds into the explanation of the reason for the visit. This is significant because patients typically have a list of several complaints or observations they would like to discuss, yet rarely get beyond the first or second before being interrupted. Cutting the patient off before you’ve heard him out is called “premature closure,” and the main problem with this approach is that it assumes that the presenting complaint carries the most medical significance.

This is often not the case because the patient experiencing multiple symptoms may not know which are the most important, nor which may be related to the same underlying cause. For example, the patient who reports transient blurriness in her right eye may not realize that the simultaneous tingling sensation she feels in her right arm and leg are related. Premature closure typically involves a patient with a serious but uncommon diagnosis who presents with symptoms suggestive of a less serious and more common diagnosis.  

Contributing to premature closure is a general human tendency to hear what we expect to hear, and mentally filter out as extraneous any details that we don’t expect. Fortunately, the main assumption underlying premature closure—that patients will talk endlessly if allowed—appears to be incorrect. Several studies have found that patients who are allowed to list all their concerns without interruption rarely speak for more than two minutes. Allowing the patient those two minutes not only prevents premature closure, but can actually save you time by allowing you to focus on the most important symptoms first. It also avoids those “Oh, by the way…” conversations in which the patient brings up a new problem just as you’re headed for the door.

And finally:

5.      Every doctor owes a duty of making an independent assessment of the patient, utilizing the full range of his or her clinical skills, regardless of whether you’re a primary care provider or a sub-specialty consultant. If you’re an FP [family practitioner] and receive a specialty ob-gyn report informing you that a 60-year-old woman who had a hysterectomy 15 years ago is pregnant, you’d obviously recognize that you’d received the wrong patient’s report or that some other mix-up had occurred. Yet far less blatant errors occur all the time in the exchange of patient information, and you should always be mindful of that possibility any time the specialist’s opinion doesn’t fit your clinical finding or the patient fails to respond to treatment as expected.

Clearly, the same can be said for not entirely relying on the diagnosis of some other practitioner even  in the same specialty, who may or may not have done a good diagnostic workup, but instead doing one’s own independent assessment. If a  psychiatrist prescribes something to you after initally talking to you for just fifteen or twenty minutes, find another doctor.

Tuesday, June 10, 2014

Guest Post: Are You Inadvertently Shaping Your Child's Future with Labels?

Today’s guest post is by Rachel Cherry. She discusses how parents may inadvertently induce their children to create what I call a false self or persona - a recurrent theme of this blog - by verbally pinning labels on them. These labels or pet names are sometimes just meant to be "cute," but, depending on other things that parents may say or do and the entire social environment of the familymay take on added meanings for the child and set up behavioral expectations for them. When this occurs, it forces them to try and hide their true nature, preventing what experiential therapists refer to as self-actualization

Labeling people is quite common in the world we live in. While many of the names that we call each other have respectful undertones or are shrouded in warmth and concern for  the other person, others are used as digs at a person and are clearly derogatory. When it comes to parents and children, such names can affect childhood development when the actions of the parent reinforce any behavior of the child that is consistent with the label. While most parents do not intentionally try to mentally scar a child in such a fashion, their behavior in a variety of contexts has the potential to solidify certain beliefs children begin to form about themselves and about how they are supposed to behave in various social situations.

There are two parts to any given individual's personality: outward demeanor and inner nature. Your demeanor is how you act around others, and this can be contradictory to how you are truly feeling inside. The demeanor aspect of your self-image is usually centered around how you want people to view you, and it can sometimes completely overwhelm your true, private personality. Inner nature is how you truly think and feel inside. For instance, someone's demeanor may outwardly be cold and calculating - as seen in some company CEOs for example - but his or her nature could secretly be nurturing and caring towards friends and family. Many people feel vulnerable whenever they show their true nature.

Labels and name calling whether good or bad can, when reinforced by certain actions by the parent, alter children’s perception of what sort of demeanor they believe they are supposed to present to the outside world. The child's outward behavior then assumes the qualities inherent in whatever the name signifies to them. Instead of being proud of their own true nature, the child may believe that the outward perception of others is the most important indicator of their validity as a person - especially if the actions of the parent strengthen that belief.

Reinforcing Demeanors:  When someone calls a child a "little princess" or "little prince," he or she could take it as a sign of affection. After all, what child doesn't want to be a part of royalty? However, when parents reinforce negative aspects of that label with actions such as providing various lavish gifts and succumbing to every whim and demand of the child, the child could begin to form a mental correlation between being thought of as royalty by the parents and demanding everything he or she wants. This may easily create a sense of entitlement that children can easily take with them as they develop into adults and interact with outsiders.

Family Sarcasm: Creating an altered persona of the child can be unintentional when the parents think of a label they apply to their child as mere humor. This could inadvertently provide a framework by which a child internalizes the label in a negative way. If jokes go too far, the parents may simply be unaware of how much damage they are truly doing. Taking a jocular stance concerning a child's shortcomings is quite common, but it could create for the child a like-minded negative demeanor as he or she begins to live up to the expectations implied by the comment. For example, jokingly pointing out the failures of a child while sarcastically calling him or her a "loser" could not only make the child feel worse, but it could also create the idea in the child that he or she will always be a failure.

Ignoring Aspects of a Child’s Behavior That May be Related to a Label:  Interestingly, not addressing certain behaviors while using labels can be just as deleterious to the child’s self-image as the labeling itself. If a parent ignores certain of the child’s related behaviors, the child may assume that those behaviors are justified as being part of what the label suggests. While it may be cute to watch a young child plot and scheme in order to get his or her own way in regards to minor situations, if the parents starts to call the child an “evil genius,” the behavior could easily develop into a demeanor for the child that is not so cute in other contexts.

Tone of voice is also important. If the parent uses a positive tone while labeling a child as a "little genius," the child could assume that this behavior is not only acceptable but expected. It could turn into something more elaborate as he or she develops into an adult. Instead of that cute little evil genius plotting to get a cookie, you could end up with a child who winds up spending a great deal of time behind bars.

Labels are Not Always Negative:  Not all labels have to produce negativity in a child. For example, when you call your child a "tough cookie" when he or she doesn't cry or otherwise expresses emotions when injured, it could help the child develop a sense of inner strength. As we all know, despite your best efforts to prevent your child from being injured, accidents frequently happen with the young. Children take their cues on how to react to those situations from the parents’ behavior. Most young children will wait to see the parents' response to an injury before reacting themselves. If you treat the situation light-heartedly, so will the child. This "tough cookie" demeanor could be beneficial throughout the child's life as he or she learns the value of inner toughness and self-reliance.

Labels in and of themselves do not usually create a child's entire demeanor. It is the actions of the parents and others that reinforce their concept of how to behave in interpersonal situations. If this behavior continues to be reinforced by the parents, the child's demeanor could overwhelm his or her true nature and reduce the child’s capacity to discover his or her true inner-self. If the child is constantly putting on a show for everyone by trying to be whatever he or she thinks others want, then there is less of a chance for the child to develop his or her potential. Your behavior as a parent is key to your child's development, and it is wise to monitor yourself closely when applying any label to your child.

Rachael Cherry is a wife, mother, and writer who is passionate about helping connect families in need with high quality caregivers. She has taken that passion and put it to work through NannyPro, a respected online nanny referral service. Learn more by visiting @NannyPro on Twitter.

Tuesday, June 3, 2014

Researchers Aren't Wasting Time Looking for Cures for Alzheimer's Disease or Schizophrenia

As I did on my posts of November 30, 2011,  October 2, 2012, and September 17, 2013, it’s once again time to look over the highlights of the latest issue of one of my two favorite medical journals, Duh! and No Sh*t, Sherlock. Let’s take a look at the unsurprising findings published in the latest issue of Duh! My comments in bronze.

As I pointed out in those earlier posts, research dollars are very limited and therefore precious. Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already known to be true but have yet to be "proven"? Such an approach increases the success rate of studies almost astronomically. And studies with positive results are far more likely to be published than those that come up negative.

9/13/13. Effects of Child Abuse Can Carry Over, Study Finds.
Researchers with the National Academy of Sciences reported Thursday that the damaging consequences of abuse can not only reshape a child’s brain, but can last a lifetime. Untreated, the effects of child abuse and neglect, the researchers found, can profoundly influence a child’s physical and mental health, their ability to control emotions and impulses, their achievement in school, and the relationships they form as children and as adults.
Cognitive behavioral therapists are all up in arms in reaction to this, thoroughly annoyed that the psychoanalysts were right about some things.

9/16/13.  Teens Who Text About Fighting, Drug Use More Likely To Engage In Those Behaviors.

HealthDay (9/14, Preidt) reported that research published in the Journal of Abnormal Child Psychology suggests that “teens who text about bad behaviors such as drug use or fighting are more likely to actually engage in those behaviors.” Researchers examined the text messages of more than 170 ninth-graders. Their behaviors were rated by their teachers, parents, and fellow students. The investigators “found a strong link between antisocial text messages and higher ratings of antisocial and aggressive behavior at the end of the school year.”

If they were real sociopaths, they wouldn’t have to brag about it.


9/27/13. Common Pain Relievers May Reduce Depression In Individuals With Osteoarthritis.

Reuters (9/27, Doyle) reports that research published in the American Journal of Medicine suggests that common pain relievers may reduce both pain and depression among individuals with osteoarthritis. Investigators came to this conclusion after looking at data from five trials that included approximately 1,500 patients.

Pain causes people unhappiness??  I always thought pain was something that causes unremitting happiness and celebration.

10/21/13. Stalking May Cause Psychological Distress.

HealthDay (10/19, Dallas) reported that, according to a study published online in the journal Social Science Quarterly, “women who are the victims of stalkers are up to three times more likely than their peers to experience psychological distress.” Researchers arrived at this conclusion after examining data “compiled on over 8,100 women from three major surveys.”

And here I thought stalkers were spreading joy wherever they went.

2/27/14.  Suicide Attempts Early in Life Signal Long-Term Social, Health Problems, Study Finds

Young people who attempt suicide are not only more likely to have persistent psychiatric problems as they approach midlife than non-attempters, but they are also more likely to have physical health problems, engage in violence, and need more social supports as they age. These are key findings from a study by led by Sidra Goldman-Mellor, Ph.D., and colleagues at Duke University and several other institutions and reported in JAMA Psychiatry.

The best predictor of future behavior is past behavior?  Who knew?

2/27/14. Study: Stigma Associated With Mental Illness May Prevent Many People From Seeking Care.

HealthDay (2/27) reports that research published in Psychological Medicine suggests that “the stigma often associated with mental illness prevents many people from getting the care they need.” Investigators looked at data from 144 studies that included a total of approximately 90,000 people. The researchers found that “stigma ranked as the fourth highest of 10 barriers to care.” The investigators also found that, “aside from the stigma of using mental health services or being treated for mental illness, the participants also reported feelings of shame and embarrassment as reasons for not seeking care.”

Caring about what other people think?  Worrying about your reputation?  Who does THAT?

3/17/14. Stress May Impact Kid's Health, Well- Being  

HealthDay (3/15, Preidt) reported that according to research presented at the American Psychosomatic Society’s annual meeting, “stressful events can have an almost immediate impact on children’s health and well-being.” After analyzing data on some 96,000 US children, researchers also found that youngsters “who experienced three or more stressful events were six times more likely to have physical or mental health problems or a learning disorder than those who had no stressful experiences.”

Nonsense.  Learning how to react to constant threats to your well being builds character!

4/8/14. Study: Physician appointment availability greater with private insurance than Medicaid.

Reuters (4/8, Seaman) reports on a new study, published in the current edition of JAMA Internal Medicine, which shows the availability of physicians varies depending on a patient’s insurance coverage. Researchers, from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, found they were able to book appointments 85% of the time when claiming private insurance, compared to just 58% when they claimed to be covered by Medicaid.

Oh come on. Doctors absolutely hate to make money.

4/14/14. Paternal Alcoholism Tied To Family Conflict.

Reuters (4/11, Bond) reported that according to a study published online March 15 in the journal Addictive Behaviors, families in which the father had a problem with alcohol appeared to experience increased levels of conflict. However, treating men for alcoholism may result in an improved home life for their children.

Gee, and I thought drug addiction was a symptom of family harmony.

4/22/14.  False-Positive Mammograms Linked To Increased, But Temporary, Anxiety.

The Los Angeles Times (4/22, Kaplan) “Science Now” blog reports that in a study published in JAMA Internal Medicine, investigators “examined data from a large clinical trial of digital mammography and concluded that false-positives produced a ‘significant increase in anxiety,’ though it was only temporary.”
People get nervous if they think they might die. Really?

5/1/14. Effects of Recurrent Violence on Post-traumatic Stress Disorder and Severe Distress in Conflict-affected Timor-Leste: a 6-year longitudinal study

Silove D, et al. – Recurrent violence resulted in a major increase in post–traumatic stress disorder and severe distress in a community previously exposed to mass conflict. Poverty, ongoing community tensions, and persisting feelings of injustice contributed to mental disorders. The findings underscore the importance of preventing recurrent violence, alleviating poverty, and addressing injustices in countries emerging from conflict.
So what does trauma have to do with PTSD anyway?