You are currently browsing the monthly archive for May, 2008.
Nothing ventured, nothing gained.
I can do all things through Christ who strengthens me. Philippians 4:13
I was excited to find the book Do Hard Things by Alex and Brett Harris, two 18-year-old twins who encouraged teens to break from the low expectations of teenagers. Their approach, in some ways, echoes my own way of thinking. I started my first business at the age of 17, second at the age of 18, and third at the age of 21. I worked 40-60 hours a week in my own business while taking 19 hours of college courses, and then went to graduate school. I teach the teens I work with the importance of fully applying themselves, to break free of the expectations of others, and to challenge their internal limitations. The biggest limitations that people have, come from the inside. It’s in the form of thoughts, “I can’t do it. I’m stupid. I’d probably just fail anyway. I’m a kid, I’m just supposed to have fun.” The list is virtually endless and the causes are varied. As I teach people, God did not just roll the dice one day in order to determine the strengths and abilities that a person has. You were given these things for a reason. A lot of times, people don’t even know how much they are capable of doing. I have not met a single person who truly knows how much they could accomplish. I am even talking about people who have already accomplished a great deal. One of the ways you learn about your strengths and limitations is by applying yourself with intensity and putting a great deal of effort into things. You cannot learn this otherwise. By doing so, you risk failure. Failure is an important part of life, and provides an opportunity to learn something new. When you fail, it is time to reflect on what you might have been able to do better, and how to approach it differently next time. It is not a time for “beating up” on yourself. Use your failures constructively, and by all means risk failing.
Milton Erickson, who was the world’s foremost expert on hypnosis, told a story about failure. (I might get a few of the details wrong, but they are not important to the message). He told about two classmates. One was bragging about missing only one item on a spelling test. The other was bragging about missing only 2 items. Erickson had missed 8 items. He told his classmates, “I have the advantage because I will remember the 8 I missed forever, whereas you will remember only 1 and you will remember only 2.” He used this teaching story to explain how failure strengthens memory and can be an advantage in life.
Milton Erickson also, did hard things. He suffered from polio, which he barely managed to survive. After recovering enough movement to crawl, he purchased a canoe. He paddled this canoe 1200 miles down the Mississippi river. At times he crawled over sandbars, dragging the cannoe behind him. By the end of the journey, he was able to walk with the use of a cane. He got to this point from the point of only being able to move his eyes. Most of us have never had to do something so incredibly difficult. So, we don’t even know what the limits are to what we can do. I think there have been times when I have gotten close to my limits, but never fully reached them. When I think about Erickson’s story, I don’t think I was as close as I thought I was.
When I was a junior in undergraduate school I was thinking ahead in time. I realized that I had a tremendous amount to learn about the conscious and unconscious minds in order to be able to help people in an truly effective way. I realized that I had 7 more years of school and intership ahead of me. I had heard that graduate school can be an absolute nightmare. I became utterly despondent. It was before my first class of the semester. I said to God, “Lord, I don’t think I can do this. It’s too much for me. It’s like I’m sitting down at the bottom of Mount Everest and looking up, and I think it’s impossible for me.” I was thinking about abandoning the whole thing and going back to what I knew I could do. I had been successfully running my own computer and Internet business for several years. I had no doubt I could be extremely successful at that and make a lot of money. Yet, I felt God was pointing me toward being a psychologist….using my intelligence to help people overcome their emotional difficulties instead of troubleshooting problems with machines.
So, I went to my first class of the semester. I remember it distinctly. Psychology of Old Age. As they always do on the first day of class, the professor was discussing classroom policies, procedures, and whatnot. This was about 20 minutes after my anguished prayer. The professor says, “Now my office is all the way up on the 4th floor. You can come in to talk to me at any time. Now, don’t take the stairs, and come into my office all huffing and puffing and telling me stories about climbing Mount Everest. That’s why God made elevators.” At that point in time, I felt chills throughout my body and the hair stood up on the back of my neck. I said to God, “Message received.” God would provide an elevator for me where needed. And indeed, He did. At those times when I thought things were beyond me, I got the help I needed.
Thus, the quote at the beginning of the post, “I can do all things through Christ who strengthens me.” You might doubt the power and strength of yourself, but God’s power and strength is beyond your comprehension. Now, I know I’m not sounding much like a traditional Shrink here. The research shows that only 33% of psychologists believe in God. But, such is life. I can tell you unequivocally, that the best treatment outcomes I have had are with those who believe in, and rely upon, God. I have seen people overcome things that the textbooks say are BIOLOGICAL, unammenable to treatment with psychotherapy, and the best you can hope for is a slightly better management of symptoms. I have seen people overcome personality disorders, obsessive compulsive disorder, depression, and varieties of anxiety. Like I say, the most impressive results have been with believers. I’m not saying that you have to be a believer to overcome your difficulties, because I have seen non-believers make incredible progress as well. But the most impressive results have been with believers, who through faith, were willing to Do Hard Things.
Empirically supported treatments in psychology have many problems. There are politics and personal ideologies that influence the research, despite what the researchers would have you believe. The biases of academic researchers plays a definite role in treatment outcome, and the studies do not reflect real-world reality.
However, there is one area I would like to see empiricism applied, and that is to government programs. Government programs should be treated as the experiments they are. They should not be implimented without a timeline, and should not be continued without scientific data that they help solve the problem they were intended to solve. Federal government programs should be required to demonstrate efficacy through research studies and trials of the programs that have clearly defined outcome measures. Ostensibly, we don’t allow drugs or medical treatments to be approved without some demonstration of efficacy. Even though there are many problems with that process it does in the minimum provide some safeguards. We have no safeguards against public policy and programs that may “do harm” or not help in the slightest. There is no standards for efficacy of programs, and once implemented, they tend to go on for ever even if they don’t work. Take the headstart program for example. Studies have demonstrated no benefit to the program, but it keeps going and going. A government program is a hypothesized solution to a social ill. Government programs should be subjected to the same rigors and standards of evidence that medical treatments are subjected to.
It seems like a decent idea for a compassionate society…to provide a safeguard for people who are disabled. And in some cases it really is, and it other cases it’s like handcuffs. I worked with one patient who received state medicaid and had medical bills that would have totalled $60,000+ per year because of a specific medicine. Now, this individual probably could have worked at least part time, but if she did that, she would lose her medicaid. With taxes, routine living expenses, etc… she would have had to make over $100K just to make ends meet. Because she would lose her medicaid if she were to work. Many people would like to go off of disability, but there’s no good safeguards for them, and they tend towards safety (naturally, who wouldn’t?). So they are left with a sub-standard living that provides some security versus losing all security. People tend towards the more secure option, so it is rare that individuals are able to break out of this system. It’s really a shame the way the system works. Many people who I have thought should get disability do not, and many who do, I feel should not. And many who are on disability and make improvements are stuck with a catch 22 situation. I wish that good folk in the community would organize and provide an alternative system to the poorly managed and broken system provided by the government, but to my knowledge, nobody has stepped up to the plate.
When I worked at a mental health center, I often found myself scratching my head as to the diagnosis that was given to a patient by a psychiatrist. I had diagnosed one individual with an Adustment Disorder, which is anxiety and depressed mood related to a difficult situation in life. The psychiatrist diagnosed, schizoprenia, paranoid type. I was left utterly scratching my head as to why the psychiatrist had diagnosed schizophrenia, whereas I diagnosed an adjustment disorder. After looking at the medications that were prescribed, I found the reason, Abilify….an antipsychotic medication. Even though this patient did not meet the diagnostic criteria for Major Depression, let alone schizophrenia, the psychiatrist wanted to try Abilify; therefore diagnosed schizophrenia. That was the only conclusion I could come to. I saw this on numerous occasions. The diagnosis didn’t fit, and the medication was an antipsychotic. So, the diagnosis would be Bipolar Disorder, or a psychotic disorder.
As the Last Psychiatrist noted:
“You might argue the diagnosis leads us to the treatment, but in most cases, meds are used across all diagnoses, and more often than not a diagnosis is created to justify the medication.”
I had one patient, who for 14 years, was diagnosed with depressive disorder, NOS and personality disorder, NOS, until the psychiatrist wanted to try an antipsychotic. Suddenly, the diagnosis became schizoaffective disorder.
You may think that the diagnosis doesn’t have implications for treatment, but it does. If you are psychotic, you are not responsible for your behavior. The patient diagnosed as schizoaffective, was seen as psychotic by his wife and his psychiatrist. Therefore, he was not responsible for his Borderline, manipulative, aggressive and passive aggressive behaviors. This was the way the psychiatrist and his wife saw his behavior. I did not see the behavior this way because I was his psychologist. So, this puts me in a difficult position. I see him as responsible for the choices he makes, but the psychiatrist and wife see him as “mentally ill” when he engages in unsual behavior. I have to set limits and tell him that I would “find him a therapist who expects less” of him when the psychiatrist and husband justifies his behavior.
You see, I also do evaluations related to “sanity” and “fitness to stand trial.” This particular individual would likely be seen as incompetent and insane for his inappropriate behavior by the psychiatrist, but would be seen as perfectly sane by me who sees him as having a different diagnosis. You can say the diagnosis has no implications, but it really does in terms of personal responsibility and therapeutic issues with respect to psychotherapy.
So, this is one reason that I see diagnostic accuracy as being an important issue for treatment. My personality testing, interviews, and observations yield a diagnosis of a primary personality disorder, whereas, the psychiatrist’s desire to prescribe an antipsychotic yields a diagnosis of a psychotic disorder. So, it comes down to a situation where the patient has to decide to believe a professional who believes that they have control over their decisions versus a professional who believes they have no control or responsibility for their decisions. So far, when faced with this decision, my patients go with me, who believes that they have control and responsibility for their decisions. When they are legitimately psychotic, that’s one thing, when they are not, that is another. The diagnosis has real world implications in terms of personal responsibility and psychological treatment. Fortunately for most patients, when push comes to shove, they would rather believe that they are responsible for their behavior and have a desire to make efforts towards changing their maladaptive behavior. Unless they truly are psychotic….then the issue of personal responsibility has less meaning to them, because their reality contact is impaired.
So generally, when one of my patients is seeing a psychiatrist, the diagnosis has real world implications. And when they are not, the diagnosis has less meaning. Only the individual factors that contribute to the person’s difficulties are relevant. When the psychiatrist renders a diagnosis, then there are real world implications that affect the patient and their family.
I’m afraid to publish my blog using my real name when talking about controversial issues in psychology. I really wish this wasn’t the case, and maybe some day I’ll have the guts to do it. Frankly, it’s a big risk to state opinions against the mainstream in certain areas of psychology.
Take a look at what happened to Michael Campion, Ph.D., just for being a board member the Illinois Family Institute, a conservative Christian group that espouses conservative viewpoints. This is not just about the APA here, it’s about society and power associated with the political correctness movement.
Frank McNeil, who was a city council alderman reported that he told the mayor, “I went to Tim and said, ‘Hey, this guy’s gotta go.’ ”McNeil recalls. “He’s out of touch with the mainstream. He has an absolute right to his conservative views, and we have an absolute right to change reviewers.” This is absolute discrimination based on political viewpoints, and Dr. Campion was fired from his position of providing evaluations for firefighters who were seeking employment with the Minneapolis Fire Department. The Illinois Times has a story in which this quote appears.
The field of psychology is so rampant with liberal political beliefs that other psychologists feel completely free to espouse their liberal beliefs in the company of other psychologists, as-if, other psychologists will automatically agree with them. I remember one professional conference I attended, where all of the psychologists at the table were freely deriding president Bush and talking in glowing terms about liberal politicians. They seemed completely oblivious to the possibility that anyone sitting at the table might have a different point of view, which I did. I just kept my mouth shut and marveled at the lack of ‘diversity’ in the field, a field which acts like it champions diversity. There was rarely a day that passed in graduate school when I did not encounter similar talk from professors, and very often more extreme. Anyone with a conservative viewpoint was viewed as ‘uneducated’ and frankly stupid. Worse yet, were those who professed belief in God.
What has always eluded me is, why would anyone enter a helping profession if they do not believe in God? When you are a shrink, you encounter such great misery on the part of those you treat, and quite frankly, there are better ways to make money. Sometimes, I think it is just a comfortable outlet for liberal political agendas, and this can sometimes be a draw for folks going into the field. I view my job as promoting the American dream, the ability to live life, have liberty, and pursue happiness without undue distress. Does this make me biased? Probably. But somebody needs to provide a little balance to a completely unabalanced field.
And the studies just keep coming. This time with Paxil showing that it was no better than placebo in adolescents, plus a relative increase in adverse events compared to placebo.
John Grohol, PsyD has a writeup on PsychCentral.
It seems some psychologists are bored… They must be. Recently, a new movement towards treatment of worry about the future of the planet has emerged. Psychologists and therapists are having groups and treating individuals who are anxious about the future of the planet. There are plenty of legitimate difficulties out there for psychologists to treat, and I suppose this helps certain psychotherapists keep their practices simple, easy, and on the surface. In other words, “lets work with something that’s not too difficult and we’ll feel good about ourselves for addressing this major social concern.”
I suppose this appeals to the by-and-large liberal sentiment of psychologists in the field. Or it’s another fad for largely academic psychologists who magnify the importance of their personal interests. Although I must admit, there’s a certain appeal to adding “Simple Phobia, Ecological Type” to the DSM-V as a disorder that needs to be a focus of treatment. Then we’d have a label for people with ideology like Al Gore. Cogtive-behavioral psychologists could address the catastrophizing and psychoanalysts could examine the potty training conflicts of people worrying about “poluting the environment.”
For more on Ecopsychology and treatment, the New York Times, has an article.
And when he was gone forth into the way, there came one running, and kneeled to him, and asked him, Good Master, what shall I do that I may inherit eternal life? And Jesus said unto him, Why callest thou me good? There is none good but one, that is, God.
Mark 10:17
Ah yes, but we are separated right? Good people and bad people. In this case, the bad people are the mentally ill. I would not be incorrect in saying that there are only bad people. Only God is good. But is there a need to protect ourselves from people who would do us harm? Certainly. But look at the statistics. Are you more likely to die from a spree killer or a car accident. What about a heart attack? I suppose it wouldn’t make a good headline to say, “1000 people died yesterday from a heart attack.” Or…”150 people were killed yesterday on the nations roadways.” It’s only the things that are novel or unusual that make headlines. It’s only things that are unlikely to actually occur.
Sensationalist media reporting increases both suicidal and homicidal behavior (see The Copycat Effect). But it seems that law makers and the media want to talk about how we can stop these “mentally ill” people from acquiring guns. Having a mental illness does not necessarily make a person any more likely to commit violence than the general population. In fact the research shows that individuals discharged from psychiatric institutions are of roughly the same risk of being violent as others in their community. They are more likely to engage in violence than others in their communities if they are abusing substances. The same is true for others who abuse substances (they are more likely to be violent). If the media are truly concerned about these spree killers, they’ll change their reporting practices.
In rural America, a lot of people take their rights seriously. It scares them to seek help if they know they could lose their right to bear arms. The state of Illinois wants to extend state reporting on mental illness to include outpatient settings. So, if a patient has exhibited violent or suicidal behavior they must be reported. Furthermore, there are proposed links to the federal database so that people reported to the state, would automatically be entered into the federal database. It’s difficult to imagine how I, in good conscience, could comply with this requirement. I can see it now, I tell a patient if they have recently engaged in suicidal or violent behavior that I must report them. They won’t tell me, and the problem won’t be addressed. Result….dead bodies.
Also, I wonder how far this extends. Does it extend to thoughts??? “I’d like to stangle Bob. He really gets on my nerves!” Does this fall under the mandatory reporting rule? Who hasn’t had a thought like that. Wait….I never have!! Please don’t report me. No, the difference between violent and non-violent people is a history of violence. There’s already a reporting system in place for that…it’s called a criminal record. Would that have caught Kazmierczak before he was able to purchase guns and kill 5 students?? No, but neither would any of the reporting laws. We don’t know what caused this guy to unravel, but don’t blame the mental health system and don’t think we need more restrictive laws. People have free will, and there is no way to legislate against that. I do think the recent reportings of multiple spree killings could have played a role. I’m sure there are other newsworthy events out there in the world, like the spree killings of tornados in recent months. Maybe we should pass a law against high winds and thunderstorms….but that would be ridiculous right??? Just saying…
Since substance abuse seems to be an actually important variable, maybe there should be mandatory reporting for people undergoing treatment for substance abuse problems. I don’t actually think that, but at least it is risk factor that makes more sense. I’m saying that just to emphasize the point that these laws are not based on protecting people from violence, but that there is an incremental political agenda based stereotypes of the mentally ill with the ultimate goal of limiting the rights of all people.
Electroconvulsive therapy has a long controversial history in the treatment of psychiatric disorders. In its heyday, it was used much more comonly for a wide range of difficulties. One person told me about being given ECT as punishment for being “incorragable” as a child in a way that appeared to be punishment for unruly behavior. Now, ECT is typically used only in the most severe cases of depression.
I have no doubt that ECT has some efficacy in the treatment of emotional disorders; however, to me the bigger issue is should it be used? Not everything that works is humane. Consider the case of the Russian substance abuse treatment program. People involved in the program were given two hundred lashes with a whip if they relapsed. Amazingly, this program had a 80% recovery rate. Something that is unheard of in the treatment of substance abuse problems. I read about this probably 8 years ago, and could not find any information about it today. So, they may have stopped the program.
I feel pretty certain, that if you were hit with a whip every time you had a negative thought, you’d probably stop having negative thoughts that lead to depression. Would that be humane? No way!! So does ECT differ from a severe punishment? Lets see. The people that I have seen who underwent ECT completely lost 6 months of their lives. In other words, they could not remember the last 6 months and were perpetually in a daze for several months after the treatment. That does not seem to be humane to me, and I have difficulty differentiating ECT from any other type of severe punishment.
I remember thinking increduously about the patients I have known who received ECT. They were so very depressed and desperate. Yet they were unwilling or unable to follow through with suggestions that would help them to make progress with their depression (increasing activity, exercising, healthy diet, etc…). It would have made more sense to me to have a family member take them to a gym and encourage them to exercise, or to even hire a personal trainer. I was not in charge of their treatment at the time they received ECT, so I was powerless to influence the process.
You can address some of the physical aspects of depression with exercise and diet (low energy, low motivation, apathy, and poor sleep). Once you get the ball rolling, you can begin to address the psychological aspects. In my opinion, if you are going to do something extreme, make it extremely positive or extremely beneficial. Don’t fry someone’s brain because it has been labeled a “medical treatment.”
The idea of self-harm is not displeasing to some who are severely depressed…thus the higher suicide rates. When someone volunteers for ECT, I would speculate about the desire for self-harm. In other words, this harmful treatment becomes a more compelling option if you are willing to harm yourself in other ways. A patient with such an extreme desire for a radical procedure should be given the option of trying something radically positive that will not damage their brain.
I know there are some out there that credit ECT with saving their lives. I have never met one of these people. In my experience, I’ve only seen harm come from ECT.
I’m not a member of the APA (the American Psychological Association), because the APA is extremely active in the political arena promoting liberal causes and agendas. They attempt, through political activism, press releases, and even their code of ethics, to push their morality onto society and practicing psychologists.
On Homosexuality
See the following official Q&A portions taken from the APA’s website:
Is Sexual Orientation a Choice?
No, human beings can not choose to be either gay or straight. Sexual orientation emerges for most people in early adolescence without any prior sexual experience. Although we can choose whether to act on our feelings, psychologists do not consider sexual orientation to be a conscious choice that can be voluntarily changed.
Can Therapy Change Sexual Orientation?
No. Even though most homosexuals live successful, happy lives, some homosexual or bisexual people may seek to change their sexual orientation through therapy, sometimes pressured by the influence of family members or religious groups to try and do so. The reality is that homosexuality is not an illness. It does not require treatment and is not changeable.
However, not all gay, lesbian, and bisexual people who seek assistance from a mental health professional want to change their sexual orientation. Gay, lesbian, and bisexual people may seek psychological help with the coming out process or for strategies to deal with prejudice, but most go into therapy for the same reasons and life issues that bring straight people to mental health professionals.
What About So-Called “Conversion Therapies”?
Some therapists who undertake so-called conversion therapy report that they have been able to change their clients’ sexual orientation from homosexual to heterosexual. Close scrutiny of these reports however show several factors that cast doubt on their claims. For example, many of the claims come from organizations with an ideological perspective which condemns homosexuality. Furthermore, their claims are poorly documented. For example, treatment outcome is not followed and reported overtime as would be the standard to test the validity of any mental health intervention.
The American Psychological Association is concerned about such therapies and their potential harm to patients. In 1997, the Association’s Council of Representatives passed a resolution reaffirming psychology’s opposition to homophobia in treatment and spelling out a client’s right to unbiased treatment and self-determination. Any person who enters into therapy to deal with issues of sexual orientation has a right to expect that such therapy would take place in a professionally neutral environment absent of any social bias.
There are some incredible statements in here (people cannot choose their sexual orientation, homosexuals cannot change, and therapy should take place in the absence of any social bias). I’ve worked with a number of homosexuals who did in fact, choose their sexual orientation. I won’t make a blanket statement like the APA does, but there are homosexuals who do in fact choose this lifestyle. Sometimes after living many years as a heterosexual. Now take homosexuals cannot change. This is another remarkable statement from the organization that purports to be at the pinacle of knowledge on changing behavior. They reject studies showing that homosexuals can change by criticizing the research methodology. At the same time, almost anyone who would try to conduct rigorous studies in a university setting would be ostracized and likely labeled as unethical. I don’t mind them criticizing research, that’s fine. But to flatly answer NO to the question of whether people can change their sexual orientation is nothing less than pure politically biased ideology. That brings me to the third remarkable statement, “Any person who enters into therapy to deal with issues of sexual orientation has a right to expect that such therapy would take place in a professionally neutral environment absent of any social bias.” First of all, there does not exist a neutral environment, absent of any social bias. Second, if you took the approach advocated by the APA, you would be taking the approach of a liberal political bias. To translate, they are saying, you had better not believe that homosexuals can change, or have the right to seek change. To do so would be “social bias.”
On Abortion
The APA thinks it’s a good thing. Why, look at this study purporting to show that having an abortion has no effect on a person’s well-being, but being an unwed mother (i.e., not choosing to have an abortion) has the biggest negative effects on well-being. Having worked with women who have had abortions, I can tell you that at least sometimes, they carry a heavy burden of guilt and regret that may be expressed in complex psychological forms not necessarily tapped by asking a question about their emotional well-being (as an example psychosomatic symptoms).
The APA is against parental consent in the case of an adolescent seeking an abortion. More on the APA’s support for abortion here with the admission that the mental health effects of abortion are irrelevant because abortion is a “civil right.”
After I ended my last post, I got to thinking that maybe Irving Kirsch already had something to say on the matter of the effectiveness of antidepressants for children. Turns out, he did.
Basically, on the very limited number of studies that were available, he found the same thing for SSRIs that he found with adults–75% of the effects of SSRIs was duplicated by placebo. For tricyclic antidepressants, it was 98%. He concluded that SSRIs did not offer a clinically significant difference over placebo, and TCAs were completely ineffective.
So, my advice would be to first consider psychotherapy, unless the depression is very severe to the extent that the child or adolescent has a great deal of difficulty in functioning. Certainly, you want to have a thorough physical examination with a physician as the first step to rule out any physical causes.
Now, there are many (probably most) psychotherapists will recommend antidepressants anyway, because that is the way they’ve been trained. But there are those out there who will support your efforts to overcome your mild to moderate depression without medication. I would want to try that first with children for two reasons. The first is that we do not know what the long-term effects of these medications are on the brain. The second is a philosophical communication (or unconscious communication) that occurs when you take medication versus participate in psychotherapy. I think the communication with medication can often be that there’s something wrong with your brain. You needn’t bother changing anything in your life, just take this pill. At least with psychotherapy there can be the communication that something is wrong in your life, in your relationships, in the way you think, in internal conflicts that need to be resolved, or in your activity level that needs to change. It’s a matter of teaching people to be in control of their lives versus teaching them they are controlled by their biology.
That’s what the latest study published in the American Journal of Psychiatry says. In a nutshell, they initially selected their subjects based on whether they were depressed and were excluded based on a number of factors (one of which was previous failure to respond to prozac or adverse reactions to prozac). All of the participants were initially tried on prozac, with dosage increases in waranted. Those who didn’t respond to prozac were excluded from the continuation phase. Then they were randomly assigned to continue on prozac or placebo. So, the placebo group is abruptly taken off of prozac and put on sugar pill while prozac group experiences no such disruption. The authors thought this was okay because of prozac’s “long half-life.”
The study found that 42% of the prozac group relapsed within 6 months, whereas 69% of the placebo group relapsed. With an even stricter measure of relapse, only 22% of prozac group relapsed, whereas 48% of the placebo group relapsed.
This makes prozac sound pretty good for kids, does it not?? It does….
But there’s a catch. I’ll just focus on the “stricter” measure of relapse for now. This was based on scores on a scale that measures sympoms of depression the CDRS-R. Scores >= 40 over two sessions with a psychiatrist (separated by 2 weeks) were considered to be relapses, whereas scores under 40 were not considered to be relapses. How do we know whether 69% of the prozac group didn’t have scores of 39 (not relapsed), whereas 69% of the placebo group had scores of 41 (relapsed)?? We don’t know, because we don’t know any scores. We don’t know if the differences are truly clinically significant, because we don’t know what the differences in the actual scores were.
Also, the fact that the study was set up to only include people who respond to prozac, we know nothing about how this would work if applied to the general population of children who are depressed. In other words, the deck was stacked in prozac’s favor. The authors, in my opinion, just seemed to gloss over the possibility that the increased “relapse” in the placebo group could have been caused by the abrupt discontinuation of prozac.
I suppose we’ll have to wait another 10 years for Irving Kirsch to publish an analysis on whether antidepressants provide any clinically significant benefit over placebo. I, for one, am not convinced by this poorly designed and written study.
Be ye angry, and sin not (Ephisians 4:26).
If you do not wish to be prone to anger, do not feed the habit; give it nothing which may tend to its increase (Epictetus).
If you are patient in one moment of anger, you will escape a hundred days of sorrow (Chinese Proverb).
We have our emotions for a reason. They tell us things. They help us understand what we like and what we don’t like. They help motivate us to make changes in our lives and environments. They help us form and maintain relationships, and motivate us to address problems in those relationships.
Anger, like the rest of our emotions, is part of life. You can’t rid yourself of anger. You might think that you would like to, but without it you’d be missing out on an important signal and motivator. However, many people have problems with how they respond when angry, or have anger that is too intense to the point of rage. Anyway, your stuck with feelings of anger, but what you do when you are angry is a choice. This is difficult to understand for some people who have for so long thought that they have no control over their anger and what they do when they are angry. But it is the truth.
Some people view their anger as something they are born with. While there may be some support for a genetic component to the range or intensity of emotions that people feel, how you respond when angry is learned. For many men, they learned how to express their anger during childhood, from family members or other important people in their life. For men, if dad is angry and abusive, they sometimes learn that this is the way that men respond when angry. Others in the same circumstances learn to fear and suppress their anger, which can come out as anxiety or indirectly (such as the silent treatment). For many women, they learn not to express their anger, and again, this can come out in a variety of ways.
So there are two major problems with anger that people develop. They either can become violent, abusive, destroy things, yell and scream, or they can bury their anger and seethe on the inside or to the point that they are not consciously aware they are even angry. Both of these patterns are problematic.
The most important thing to know about anger and emotions in general is that they are temporary. They will subside on their own whether you do anything about them or not. So, if you have a problem with what you do when you are angry, you need to plan to isolate yourself when you have those intense feelings so that they have time to dissipate. One of the best descriptions of emotions that I have heard is that they are like waves breaking on a beach. The wave comes in to the shore, and then it goes back out again. This is true of anger. So, plan to remove yourself from the situation when you find your anger becoming overly intense. If you are in a relationship, you need to make it clear to your significant other ahead of time that you have a problem with anger and that there may be times when you need to be alone to “cool off.” Be sure to work this out ahead of time, because not doing so can lead to misunderstandings and further arguments.
Now, one of the most significant aspects of what determines how angry we get about something is what we think about something. It’s not true to say that someone else made you angry, such as “My boss made me angry.” The truth of the matter is that your boss may have done something, and you perceived it in a certain way. The way you perceived it determined how angry you became over it. For example, if you think, “My boss is such a jerk. All he ever does is put me down. I’d like to knock him in the head.” Now, if you think about it that way, you’re going to become very angry, and depending on your history, you may or may not do something you regret as a result of those thoughts. If you perceived things in a different way, such as, “My boss is disrespectful to me and I don’t appreciate that. I need to either discuss this with him or start looking for another job.” When you think about it this way, you may also feel some anger, but it will not be as intense as the first way of thinking. It also makes it more likely that your actions as a result of your anger will be constructive and beneficial.
So, one of the first tasks is becoming aware of the situations that trigger your anger, and then examining how you think about those situations. You need to work on changing how you think about those situations in order to experience less anger and to avoid negative consequences that would occur if you express your anger inappropriately. It can be difficult work to change the way you think, and you may need the help of a psychotherapist to help you in this process. The reason is that we often have blind spots, things that we are unaware of, and need another person to be able to help us discover those blind spots. In a nutshell, the type of thinking that leads to inappropriate anger has been called “distorted thinking.” It is thinking that ignores, magnifies, minimizes, or in some way filters information about the situation in a way that distorts the reality of the situation. You can do a Google search on distorted thinking if you would like to learn more about the various types of distorted thinking.
Another fallacy about anger is that doing something like hitting a punching bag, pillow, or breaking something of little importance will help to diminish your anger. The fact is, that these actions actually increase your anger, and are a form of ‘anger practice.’ In other words, you are practicing responding to your anger with aggression. The more you do this, the more it becomes automatic and begins to feel more comfortable. Also, many many people think that yelling and screaming is a good way to “release” their anger. The truth is, that the louder your voice becomes, the angrier you become. Most people think this is the other way around. “The angrier I am, the louder I yell.” But the truth is, that yelling and screaming increases anger. You want to pay attention to how loud your voice is becoming and lower the volume of your voice if you want to become less angry. It really does work! So, don’t hit pillows, and don’t yell and scream to release your anger. If you feel like you are losing control, immediately remove yourself from the situation (count to 10, go to another room, take a walk). Then you can return to the discussion when you are in a calmer state of mind.
And as you begin to become more aware of when you are becoming angry, you can use your thoughts to help yourself become less angry. One way I have heard this described is “using cool thoughts.” Some examples are to think to yourself, “This is not that big of a deal, I just need to calm down. I am blowing this out of proportion. I don’t need to get bent out of shape about this. I just need to chill out.” Now, you’ll probably have your own thoughts that may help you to reduce your anger, and what I provided is just an example. The example may not be the ideal thing to use for everyone.
Another aspect of anger are the physical and non-verbal aspects. You want to begin to pay attention to these things when you become angry. You might notice that your fists are clenched, your jaw is clenched and your muscles are tense. When you notice these things, you’ll want to unclench your jaw, open your fists, and focus on relaxing your muscles. Some people find progressive muscle relaxation techniques to be helpful here. You can also do a search on that to learn more. The point is, by changing this physical response in your body, you will become less angry. Pay attention to your non-verbal behavior such as intense angry stares, or your body posture. When you notice you are staring aggressively, breaking this stare will help you to become less angry. There are also aggressive body postures, which can be handled by changing your posture, or leaning up against a wall, putting your hand of a chair, etc…
It’s good to establish some ground rules for yourself.
Some that I would suggest are:
1. Never hit anyone, break anything, throw anything, or hit anything when angry.
2. Do nothing at all. The feeling will pass with time. One of my patients described this as “riding the wave.”
3. Do not yell or scream.
4. Do not curse when angry (this actually increases the intensity of your anger).
5. Immediately remove yourself from the situation when you feel your anger is too intense.
6. Do not make any big decisions when extremely angry.
7. Develop some strong personal beliefs about anger, “Whatever is happening, it’s never worth getting bent out of shape over.”
Above all, plan to practice responding appropriately to your anger. After something happens and you become angry, think back about what happened and try to figure out how you could have responded differently or thought about the situation differently. The most important thing to remember, is that you will require a great deal of practice in learning to respond more appropriately when you are angry. And don’t hesitate to seek professional help if you find yourself having a significant anger problem that you have struggled with for many years. If the psychotherapist tells you to hit a pillow, fire him or her, and find a psychotherapist with more experience and knowledge about anger.
I plan to post more in the future on the other side of this equation, anger that is suppressed or repressed, and finds it’s outlets in unconscious ways.
Well not actually duds. Just good placebos. I’ve posted on this before and the data keeps coming in (See this article). The previous studies were extended to include the newer generation of antidepressant medication (fluoxetine, venlafaxine, nefazodone, and paroxetine).
All studies are biased and have an agenda. The Last Psychiatrist thinks that reporting on this story in the press is a move to promote antipsychotics for depression. I’d say that’ll probably happen.
The fact is, there is a large proportion of people who are depressed, and don’t want to think about psychotherapy or go through the process. They would prefer to take a pill. So, don’t worry, the pills will still be there. Only now, they’ve got worse side effects….
I’m a psychologist, and so my bias is towards psychotherapy. Very few of my patients, want, or take, medications. That said, I believe a signfiicant portion of people who take antidepressant medication would prefer psychotherapy if they were given the option. The majority of antidepressants that are prescribed in the nation are prescribed by the family doctor. Even though I work in “the sticks,” I am not hurting for business. However, there are a lot of psychologists in the field who struggle to build a practice. This is good news if it leads to more people recieving psychotherapy instead of medication; however, I don’t think this is very likely to occur. What’s more likely is a new set of biased data promoting the next wonder drug…. And again, this is OLD news. Studies like this have been around for 10 years, and now with the antidepressant patents running out… Suddenly, everybody takes notice….
Back in graduate school, I began to speculate about the nature of the placebo effect and psychotropic medication. I did many literature searches and read as many articles as I could find on the subject. What I discovered was the placebo effect is a powerful demonstration of the interaction between mind and body, and that the effects of many medications can be largely explained by this effect despite attempts at experimental rigor with double-blind experiments.
The review article by Kirsch and Sapirstein (1998) comparing the efficacy of antidepressant medication to placebo. One of their findings was that 75% of the effects of antidepressant medications could be explained by the placebo effect. Indeed, it was further suggested that the remaining 25% of the effect could be due to an active placebo effect. Meaning that because of side effects, the participants figured out they were in the active drug group, which enhanced their beliefs that they would benefit. Because of my research on cognitive dissonance, I speculated an additional possibility for why side effects enhance the placebo effect. When people suffer as a result of something that they believe will be helpful, this sets up an inconsistency of beliefs that must be resolved (”I’m taking this antidepressant medication, but I have trouble with sexual functioning now….But you know it’s worth it, because this is really helping me!”) So, the medication comes to be more valued because of the side effects, not in spite of them.
My dissertation was on cognitive dissonance (how people react and change their beliefs unconsciously when they are inconsistent). Cognitive dissonance theory might predict that people might believe that they are being helped more by a medication that actually has a slightly negative effect as opposed to a true placebo (such as a sugar pill). Additionally, dissonance would be increased by paying for the medication. Therefore, I would expect that people who pay for medication out of their pockets might have a somewhat better effect with medication. Generally, enhanced placebo effects from medications would need to a nuisance and not extremely negative. In other words, it’s difficult to develop a positive attitude about a medication with a serious negative effect. However, the more serious the condition, the greater the negative side effects could be, and the person could still come to the conclusion “I have these horrible side effects, but you know, it’s worth it because I feel better.”
Beliefs are powerful in all emotional disorders. If you truly believe something is beneficial, it usually will be. This also applies to some extent to a lot of physical disorders. Kirsh and others recommend that experimental procedures for medication be revised to include an active placebo group (a group that takes medication that causes some similar side effects), so that the true effectiveness of medication can be determined. I support this idea wholeheartedly.
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