February 2010


“I think the best function of funerals is served if it brings relatives and friends into the best possible functional contact with the harsh fact of death and with each other in this time of high emotionality. I believe that funerals were probably more effective when people died at home with the family present, and when the family and friends made the coffin and did the burial themselves. Society no longer permits this, but there are ways to bring about a reasonable level of contact with the dead body and the survivors.”

Murray Bowen, in Walsh & McGoldrick’s Living Beyond Loss: Death in the Family

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The Diagnostic and Statistical Manual of Mental Disorders is revised every decade or so, and a revision is under way right now. Up until recently, there has been criticism that the proceedings were taking place in secret. This is not unusual, as I understand it, but it is significant for many people. Mental-health clinicians, for example, have to use the diagnostic categories in the DSM to label their clients, and if the categories and descriptions listed don’t coincide with their experiences or beliefs, this can be quite difficult. It is significant for mental-health clients, too, for complementary and even more personal reasons. What will happen to your diagnosis? In? Out? Changed? These decisions have a big impact on social issues, like stigma, and economic issues, like what insurance companies will pay for.

The DSM committee is proposing, for example, to subsume the diagnosis of Asperger’s Disorder into Autism Disorder. This seems to make a lot of sense, unless you or your child is benefiting from the existence of Asperger’s because of insurance company rules, state regulations, or other regulatory factors.

The content of the DSM is important to people for political reasons, too. For example, the third revision of the DSM eliminated homosexuality as a mental disorder. That was in 1973, for the DSM-III. (We’ve since had the DSM-III-R, DSM-IV, and DSM-IV-TR. They are currently working on the DSM-V.) It may be hard to believe that being gay was an official Mental Disorder, but it was. People were even lobotomized for it: Here, let me “help” you with that unnatural sexual attraction by forcing an icepick in over one of your eyes, through your skull, to twist it in your brain. The removal of homosexuality from the DSM was very controversial in its day, but no one credible is fighting for it to go back in.

That is to say, the DSM can reflect the changing mores of society, which in turn influences the way society sees mental health and illness. This process can effect the quality of a lot of our lives. And now the DSM committee has revealed the changes they are contemplating and is asking for feedback. This is from their website:

“Your input, whether you are a clinician, a researcher, an administrator, or a person/family member affected by a mental disorder, is important to us.  We thank you for taking part in this historic process and look forward to receiving your feedback.”

You almost certainly fall into one of those categories. Take part in this opportunity! Of course, our input being “important” to them does not mean they will pay attention to it, but it can’t hurt to try. The worst that can happen is that you will be better informed about your mental-health system. Here are the categories that they are considering changes in. Click on them to read the proposed changes. To submit feedback, you have to register with them, but it only takes a minute:

Structural, Cross-Cutting, and General Classification Issues for DSM-5
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
Delirium, Dementia, Amnestic, and Other Cognitive Disorders
Mental Disorders Due to a General Medical Condition Not Elsewhere Classified
Substance-Related Disorders
Schizophrenia and Other Psychotic Disorders
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Factitious Disorders
Dissociative Disorders
Sexual and Gender Identity Disorders
Eating Disorders
Sleep Disorders
Impulse-Control Disorders Not Elsewhere Classified
Adjustment Disorders
Personality Disorders
Other Conditions that May Be the Focus of Clinical Attention

Psychology hit the actual headlines last week, with Sharon Begley’s “The Depressing News About Antidepressants” in Newsweek. The story is that, if you look at all the evidence, not just the “successful” trials, SSRIs like Prozac and Paxil do not work better than a placebo for mild and moderate depression. Begley also tells the story as if she’s sorry to break the news and spoil the placebo effect. Here’s my version of the headlines from this story:

Pharmaceutical Companies Have Known For At Least Ten Years That SSRIs Work No Better Than Placebos: At least, anyone there who understood statistics and paid any attention to their research.

The Idea That SSRIs Are Better Than Placebos Was Propagated By Publishing Only the “Successful” Trials: This, obviously, was quite unethical.

The FDA Almost Certainly Knew That SSRIs Were No Better Than Placebos, Too: They had all of the research. Perhaps they did not read it.

People Who Read Psych Journals Knew SSRIs Were No Better Than Placebos Two Years Ago: The news caused a stir in my undergrad psych lab in 2008.

We Do Not Know What Causes Depression: The idea that depression has to do with the neurotransmitter serotonin was based largely on the (incomplete) evidence that SSRIs (selective serotonin re-uptake inhibitors) cured depression. In fact, we have pretty limited knowledge of what goes on inside a living brain. In fact, we have no ethical way to measure how much serotonin or any other neurotransmitter is where inside anyone’s living brain, so when a doctor tells you something like, “You are depressed because you have overactive serotonin re-uptake mechanisms,” they are passing on speculation, not science.

If You Recovered From Mild to Moderate Depression While On An SSRI, It Was Probably Your Own Hope That Lifted You Out: The thing about placebos is that they work pretty well. If you benefited from the placebo effect, it was your own strength, your own hope, that made the difference. You overcame that challenge. I think that’s pretty cool.

While SSRIs Do Not Treat Depression Better Than Placebos, They Do Have Side Effects: Here’s a list from wikipedia: Decreased or absent libido, Impotence or reduced vaginal lubrication, Difficulty initiating or maintaining an erection or becoming aroused, Persistent genital arousal disorder despite absence of desire, Muted, delayed or absent orgasm (anorgasmia), Reduced or no experience of pleasure during orgasm (ejaculatory anhedonia), Premature ejaculation, Weakened penile, vaginal or clitoral sensitivity, Genital anesthesia, Loss or decreased response to sexual stimuli, Reduced semen volume, Priapism (persistent erectile state of the penis or clitoris)anhedonia, apathy, nausea/vomiting, drowsiness or somnolence, headache, bruxism (involuntarily clenching or grinding the teeth), extremely vivid and strange dreams, dizziness, fatigue, mydriasis (pupil dilation), urinary retention, changes in appetite, changes in sleep, weight loss/gain (measured by a change in bodyweight of 7 pounds), may result in a double risk of bone fractures and injuries, changes in sexual behaviour,increased feelings of depression and anxiety (which may sometimes provoke panic attacks), tremors (and other symptoms of Parkinsonism in vulnerable elderly patients), autonomic dysfunction including orthostatic hypotension, increased or reduced sweating, akathisia, liver or renal impairment, suicidal ideation (thoughts of suicide), photosensitivity (increased risk of sunburn), Paresthesia, Mania, hypomania, sexual dysfunction such as anorgasmia, erectile dysfunction, and diminished libido, a severe and even debilitating withdrawal syndrome, a slight increase in the risk of self-harm, suicidal ideation, and suicidality in children, neonatal complications such as neonatal abstinence syndrome (NAS) and persistent pulmonary hypertension, and platelet dysfunction.

Until Your Medicated Kids Are Old, We Will Not Know What All of the Side Effects of Treatment by SSRIs Are: This is true for any new drug, and it’s worth considering. If your child is on Prozac or other new drug, they are essentially part of a massive experimental trial.

Pharmaceutical Companies Pay for Psychiatric Educations: Why would it surprise anyone that treatment equals drugs in this case?

Most Antidepressant Prescriptions Written by Health Care Providers With No Significant Psychiatric Training: GPs, OBGYNs, pediatricians, etc account for 80% of SSRI prescriptions.

Yesterday, I participated in my master’s program’s OSCEs–Objective Structured Clinical Exercises–for the students in the year ahead of me, who are about to graduate. My cohort played clients in specific, challenging scenarios for the second-year-cohort therapists. The activity was adapted from a medical school test of clinical ability.

My scenario was the most challenging of the day. The therapists came in expecting to be doing a goal setting exercise with a couple but found that only one of us (me) had showed up. I was to immediately disclose an affair and request that the therapist not tell my wife about it. I had ended the affair, felt very guilty about it, and was certain that revealing it would destroy our relationship. I was to try and get the therapist to help me with the “things that pushed me to do this.”

I am not a good actor, so it took all my attention just to get my part across in a semi-believable way. When I watched my cohort-mates play the same part, though, it was heart wrenching. They did such a good job showing remorse, almost crying, showing the fear of losing their husbands, and over “a stupid mistake.” (Well, three stupid mistakes with one person.) I really felt for them–and they were just pretending! I can see how much preparation I will need to do to handle this kind of situation effectively. I am certain to have clients who have affairs. I just looked up the statistics, and the lowest numbers I found are that about 15% of married women and 25% of married men have sexual affairs. That means that at least one out of four couples I see will have had or are heading towards an affair.

Our clinic has a “no secrets” policy for couples counseling. It’s something we bring up on the first day of therapy. If one member of a family has an individual session, what is said in that session is not going to be confidential to the rest of the family. The idea is that for this work, it is the relationship that is our primary client, not the individuals, and that secrets (differentiated from privacy) are toxic to relationships. Also, if the we are brought into one person’s secret and keep it, we can no longer serve the relationship without bias.

I think that the no-secrets policy is a good idea and I have been planning to use it in my work, but now, seeing it in practice, I see that it’s not just a matter of having a policy. I will need to thoroughly wrap my head around how it will apply in different scenarios. I will need to talk it through with a lot of people so I feel comfortable and confident in my thinking. I will also need to remember to remind clients about the no-secrets policy the moment I see that a couples client has come in alone. We introduce the policy during the first session, but that may not be what a client is thinking about when they disclose an affair. They may think that I have trapped or betrayed them if their disclosure is followed by, “Remember that no-secrets policy we talked about during our first session?”

Ideally, in this case, we would work together with the client on a palatable way to reveal their actions to their partner and then work with the couple to heal the rifts. We don’t automatically tell the partner about affairs, either. There are some things that we are required by law and ethics to report, like death threats or the abuse or neglect of a child, but affairs are not one of them. If the cheating partner refuses to allow revealing the secret, I would have to refer the couple, for suitably non-specific reasons, to another therapist who could be unbiased, if in the dark.

I think that I need to rid myself of some countertransference when it comes to affairs. That is, as it stands, I think I might favor cheat-ee over cheating clients, because it’s harder for me to relate to cheating. I walked out of our role plays thinking, “Wow, it’s so much simpler and less painful to avoid an affair than it is to deal with the aftermath!” Can anyone recommend a good book or movie that could help me empathize with someone having an affair–especially someone who feels like they are not in control of their actions, or just not thoughtful, in sexual infidelity?

This is interesting and sometimes painful work I am getting myself into!

Alexithymic describes someone who can’t talk about emotions. They also have trouble knowing when they or others are experiencing an emotion, and trouble distinguishing which emotion it is, if they do notice one. It is not a considered a clinical condition, but it can produce clinical conditions, like somatization, where people develop various body conditions instead of feeling emotions. It becomes a problem when somatizers insist on one medical test or procedure after another for a problem that will never yield to biological intervention. I read one estimate that 20% of money spent on medical services is for these kinds of concerns. (!)

There are social consequences, too, of course. If you can’t recognize that you’re in the grip of an emotion, you can be hard to understand and hard to deal with. It’s also hard for an alexithymic person to relate to others who are having emotions–it’s more difficult to take their perspectives and to have empathy.

It’s not a black-or-white condition, of course. Everyone is somewhere on the spectrum of emotional fluency. It’s not an intractable state, either. You can learn emotional fluency, and most people do, to some extent. It’s part self-awareness, part self-acceptance, and part vocabulary. It’s something you continue learning throughout life, given a supportive environment. Parents can stifle the learning curve in their children by how and when they give them attention. Somatizing children, for example, can come from parents who give them attention for physical pain but not emotional pain. Another problematic parenting technique, called “mystification” by psychologists, works to slow the emotional learning curve; when a child is angry, for example, a parent might say something like, “You’re not angry,” or “You shouldn’t be angry.” That kind of thing goes a long way to confuse people about emotions.

My friend Grace is flying to Ethiopia today to meet her adopted son, Yared, for the first time. What a journey to make! My thoughts are with her. Last Sunday I was at her baby shower, a moving ritual arranged by our friend, Kyla. There were lots of flowers and food, but instead of presents, we each brought a story–something we loved about how our parents were with us. We told them to Grace and wrote them down for a book for her to keep. It was lovely. I cried, off and on, hearing all of those beautiful, funny, endearing stories. Here’s what I wrote:

Hi Grace. Off the top of my head, I love how my parents sang a lot. My mom sang around the house, washing dishes or whatever, whatever song was in her head. I remember her singing the Oompaloompa song from the other room after we’d recently watched Charlie and the Chocolate Factory. I remember thinking that she sounded so good–just right. My dad sang to us every night at bedtime. He’d come up  to me and Ely’s room after we were tucked in and sing us a few songs with his guitar. I had no idea how special that was–it was just something that happened, but it’s such a warm memory now. They were usually the same songs but I never got tired of them. One of them was Gordon Lightfoot’s “The Pony Man.” That was my favorite. One was “I Been Working on the Railroad.” He also sang an odd little song I’ve never heard anywhere else that went “What do you do in a case like that?/What do you do but stamp on your hat?/And your nail file and your toothbrush/And anything else that’s helpless.” Hilarious!

But writing about my bedtime made me think of a larger story about how I was parented. My days and weeks–my life–as a kid were punctuated with so many fun, comforting rituals. Bedtime was the best. My dad’s singing was the last part of a great time. My mom read to us from a chapter book every night. I could count on it. I could anticipate it with total safety. I loved it. And yes, sometimes I cried when she was ready to stop, because I wasn’t ready for her to stop, but I also looked forward to it the next night. We brushed our teeth together in our tiny bathroom, and my dad would call out the checklist of things we might need to do before bed, “OK, pee, poop, throw up, brush your teeth, go to bed,” and then, while brushing, the dental geography, “Bottoms of the tops, tops of the bottoms….” My mom would tuck us in, and gave us our choice of a back or head scratch.

That was just bedtime. We ate all of our meals together as a family. Each kind of meal had its own ritual. My dad’s dishes all had names that he announced with triumph: “Lentissimo Magnifico!” was one of his lentil dishes. He could be counted on (and still can, now that I think of it) to remind us that broccoli were miniature trees and that beans were miniature potatoes. On Saturday mornings we baked bread and Saturday nights we ate pizza on the homemade pizza crusts. On Sunday mornings we had pancakes. Every two weeks we’d all go out to the local dairy and watch the cows get milked. My parents bought the milk before they pasteurized it. We’d sit around the living room, shaking quart jars of fresh, whole milk until it separated. We made butter from the cream and (usually chocolate, s0metimes tapioca) pudding from the whey. We had regular nights with foot rides or crazy eights or The Muppet Show. There were great wrestling matches, the brothers against my dad. We’d apparently pin him every once in a while and he’d say “Now any normal person wouldn’t be able to move right now…” and that meant we were about to get (gently) tossed around the room.

I think I was an extra-sensitive kid, so maybe I was a special case–I mean, I don’t know that this will apply to Yared–but I’m so grateful to my parents for all of the regular, predictable, fun, comforting moments. They created structure for my days, gave me things to look forward to, cushioned the blows when things didn’t go my way. They also created a culture for the family: This is what life is like for us. This is what it feels like to be a Lester. There were exciting times, too, of course.  Like ice cream once a year or so. Or Disneyland, or relatives visiting. Or the couple times that we moved. That kind of stuff made vivid memories, being so rare, but it is the predictable stuff that I feel so warmly about.

As I’m thinking about all that, too, I’m reminded of the communication theory I’ve been learning in my Couples and Family Therapy program. In it, human communication exists on two levels. One is the obvious, content level–what the words mean. The other is a higher level communication, a non-verbal assertion about the nature of the relationship. The non-verbal sets the context for all of the other communication, colors it. One thing about non-verbal communication is that there’s no negative term. You can’t say, for example, “I will not hurt you” with non-verbal behavior. All you can do is put yourself in a position where you could hurt someone, and then not do it. One book, Pragmatics of Human Communication uses the image of an animal communicating to another that it will not hurt them by taking their throat in its jaws and not biting down. It seems like being a parent (and maybe part of any relationship) is to be constantly in that position. It seems to me that love is like that. The words “I love you” do not convey love by themselves. I appreciate so much how my parents showed me their love–rather than telling me about it–in all of these little, regular, predictable ways, making me feel comfortable and cared for, giving me a safe physical and emotional space to explore myself and the world in.

Love,

Nathen