March 4, 2012 · 8:44 PM

Back to Work or Not?

After just a few quick hours of procrastination, I start looking for materials for a new post. The first promising topic I find is a new intervention that helps short-term disability recipients get back to work. Coincidence? I’ll tell myself that it is.

Suzanne Lagerveld, Roland W. B. Blonk, et al, of Utrecht University dub their cognitive-behavioral therapy (CBT)-based intervention, “W-CBT”.  Besides treating mental health symptoms generally, it provides a module that focuses on work-related cognitions and returning to work in gradual steps. For their research just published in the Journal of Occupational Health Psychology, the authors enlisted employees on short-term disability for mild anxiety and depressive issues. They ruled out those with major depression, post-traumatic stress disorder or physical disabilities. One half of their sample received the new modality and regular CBT was provided to the rest. Per their findings, (PDF here, at least for now), W-CBT got clients back on the job significantly faster. After three months, 15% more W-CBT clients were back to work than clients from the standard CBT group. After six months, that gap increased to 18%. As the authors point out, mental-health absenteeism means lost productivity and profits.  The study’s faster return-to-work (RTW) rate provided a euros-and-cents benefit to Dutch employers, the Netherlands’ economy and society as a whole.

So why doesn’t it feel right?

What if he doesn't want to focus on returning to work ASAP?

Part of informed consent is the client’s freedom in choices about their therapy, including their choice of goals. The article doesn’t address who the client is in W-CBT. Is it the employer, who pays part of the insurance cost?  Or is the employee, who might not want to prioritize RTW? You could argue employees are morally obligated get back to work as fast as possible – if you were their clergyperson. Psychotherapists have a duty not to impose their views on clients, even such widely-held values as a work ethic.

The article states clients were not required to address RTW issues, but that the therapists were encouraged to say things such as, “You won’t recover from your symptoms just by sitting at home. It would probably even get worse.” Per this study, that isn’t necessarily true. According to Lagerveld and Blonk’s  findings, W-CBT and regular CBT had about the same effect on mental health symptoms. If it was once OK to imply symptoms grow worse if one doesn’t race back to the job site, it doesn’t appear ethical anymore.

The researchers are to be congratulated on producing a fascinating conundrum – W-CBT may be simultaneously effective, good, and, at least in some situations, ethically wrong.

Citation:

Work-focused treatment of common mental disorders and return to work: A comparative outcome study. Lagerveld SE, Blonk RW, Brenninkmeijer V, Meij LW, Schaufeli WB. J Occup Health Psychol. 2012 Feb 6.

@ 2012 Jonathan Miller All Rights Reserved

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February 21, 2012 · 10:55 AM

Herodotus on Psychosomatic Symptoms

From the great historian’s account of the Battle of Marathon:

A strange prodigy likewise happened at this fight. Epizelus, the son of Cuphagoras, an Athenian, was in the thick of the fray, and behaving himself as a brave man should, when suddenly he was stricken with blindness, without blow of sword or dart; and this blindness continued thenceforth during the whole of his after life. The following is the account which he himself, as I have heard, gave of the matter: he said that a gigantic warrior, with a huge beard, which shaded all his shield, stood over against him; but the ghostly semblance passed him by, and slew the man at his side. Such, as I understand, was the tale which Epizelus told.

@2012 Jonathan Miller, all rights reserved

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February 18, 2012 · 2:34 PM

PTSD is Overdiagnosed Unless … Part 2

I’m reading “What Doesn’t Kill Us“, by Stephen Joseph, mentioned in this earlier post.  No mention of over-diagnosis yet. Reader Christy wrote in to say:

Same issue at one of my old jobs. Clinicians diagnosed all the kids with PTSD because they were abused. I remember sitting in group supervision explaining why experiencing trauma does not necessarily mean that one will develop PTSD.

Grieving? Clearly. Traumatized? Possibly. Post-Traumatic Stress Disorder? The odds are 2-to-1 against it.

Unfortunately, I’ve heard similar stories at my community mental-health job. Allen Frances, MD, psychiatrist and chair of the chair of the DSM-IV Task Force, suggests that PTSD is both the most over- and under-diagnosed disorder around.

The Other Side of Sadness is an excellent book on grief and resilience. In it, author George A. Bonanno describes New Yorkers’ surprisingly low rates of post-traumatic symptoms  after the 9-11-01 attacks. He writes of how he and the original researchers sifted the data [i] to focus on the people closest to the tragedy – those who witnessed the WTC towers fall with loved ones inside:

“The people who experienced this kind of bereavement had the greatest proportion of severe trauma reactions. Just under one-third met the criteria for PTSD. That is about the highest proportion of PTSD that any event will produce. And yet just as many people who had experienced this same horror — one in three — had no trauma reaction at all.”

Exposure to trauma is not the same as post-traumatic symptoms.  Post-traumatic symptoms are not the same as Post-Traumatic Stress Disorder.  These days, there’s a lot of heat on the American Psychiatric Association over the upcoming DSM-5.  Evolving criteria for diagnosing mental illness is a much less serious threat to accuracy than those who don’t or won’t take the time to use the DSM properly.

@ 2012 Jonathan Miller All Rights Reserved

[i] Bonanno, G.A., Sandro Galea, A. Bucciarelli, and D. Vlahov. 2006. “Psychological Resilience after Disaster – New York City in the Aftermath of the September 11th Terrorist Attack.” Psychological Science, 17(3): 181-186.

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February 12, 2012 · 1:57 PM

“Against Psychotherapy”

Photographer Brendan Bernhard catches an intriguing piece of advertising-turned-street-commentary here.

Three reactions:

  1. Solemn reminder of how difficult the therapy process can be for the client, especially when progress is slow.
  2. Aesthetic respect – both for the contrast between the torn paper and Helvetica font, and the harmony among the blues, yellows, greens and browns.
  3.  Suppressed giggle over, “The therapist gets rich either way.” Clients’ subjective perception of therapist motivation can’t always fit with our financial realities.

@ 2012 Jonathan Miller All Rights Reserved

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February 8, 2012 · 7:19 AM

“Ritalin Gone Wrong” Reviled

L Alan Sroufe, Professor Emeritus at the University of Wisconsin, Madison, and author of the controversial essay

L Alan Sroufe, Professor Emeritus at the University of Wisconsin, Madison, and author of the controversial essay. (cehd.umn.edu)

L. Alan Sroufe drew a hailstorm of comment  last week with his New York Times essay that criticized medication for Attention-Deficit/Hyperactivity Disorder. Plenty of bloggers focused on his claim that parents can cause AD/HD by putting a baby in the bath too fast. Others barraged his claim that meds are a waste of time, because they aren’t a cure.  Appropriate treatment of AD/HD is a critical issue.  Let’s ask some critical-thinking questions:

1. Is the author an expert in the field?
Prof. Sroufe is an eminent psychologist who has studied behaviorally-disturbed children for more than forty years. What he is not is a psychiatrist, neurologist, neuropsychologist or AD/HD researcher. Time Magazine columnist Judith Warner points out that Sroufe last studied medication’s effects on behavior in 1973. Over at PsychCentral, John M. Grohol, PsyD notes Sroufe cites only one other study completed since. You can dismiss Warner’s quasi-Freudian speculations on Sroufe’s motivations, and still suspect his assumptions are as dated as Ziggy Stardust’s leotard.

A refrigerator magnet endorsing Sroufe's views.

2. Does the author back up what they say?

He states: “… the large-scale medication of children feeds into a societal view that all of life’s problems can be solved with a pill.” Is this society’s view? Sroufe cites no evidence that it is. Patently offensive but zeitgeist-y cartoons suggest the reverse. A Google search on “drug free”+ADHD+treatment yields 5,840,000 hits as of this writing. Ned Hallowell, MD, a former Harvard Medical School faculty member who runs clinics in New York, NY and Sudbury, MA states,

“…19 out of 20 people who come to me for help for themselves or their child adamantly oppose the use of medication. Only when they fully understand the medical facts do many of them change their minds. Far being predisposed to the use of medication, the people who come to see me are predisposed in precisely the opposite direction.”

According to the Centers for Disease Control, 5.4 million American children aged 4 to 17 have been diagnosed with AD/HD. Per the same study, 2.7 million of those children are  prescribed medication. If we, as a nation, ram pills down innocent throats, we’re slacking on the job. We haven’t even inflicted meds on all the kids who meet AD/HD criteria yet.

An opposing view from a defunct humor site.

3. Do the examples fit the argument?

Sroufe says children’s behavior can worsen after they are taken off stimulants.  He states, “Adults may have similar reactions if they suddenly cut back on coffee, or stop smoking. ” Nicotine withdrawal lasts four weeks max, and caffeine withdrawal is over in a couple of days. Does that make it a mistake to perk yourself up with a daily cup of joe in the first place?  If there’s a reason someone with AD/HD needs to stop the meds, a week or two of adjustment seems a mild price to pay for the improvements stimulants bring. Sroufe also notes (correctly):

Behavior problems in children have many possible sources. Among them are family stresses like domestic violence, lack of social support from friends or relatives, chaotic living situations, including frequent moves, and, especially, patterns of parental intrusiveness that involve stimulation for which the baby is not prepared.

He’s gotten a lot of heat for the comments about parental intrusiveness. No one seems to have noticed the bait-and-switch from ’causes of AD/HD’ to ’causes of behavior problems in general’.  Airplanes and motorcycles are both motor vehicles. That doesn’t mean 747’s come from the Harley-Davidson factory.

4. Do important points get obscured in controversy?

Criticism of Sroufe’s column has slammed the parts where he seems to say that parents are to blame, or that effective medications are a bad idea because … well, because they’re medications. Much less attention has focused on propositions like this:

Putting children on drugs does nothing to change the conditions that derail their development in the first place. Yet those conditions are receiving scant attention. Policy makers are so convinced that children with attention deficits have an organic disease that they have all but called off the search for a comprehensive understanding of the condition. The National Institute of Mental Health finances research aimed largely at physiological and brain components of A.D.D. While there is some research on other treatment approaches, very little is studied regarding the role of experience. Scientists, aware of this orientation, tend to submit only grants aimed at elucidating the biochemistry.

You could knock Sroufe for a syllogistic fallacy here (“We need to spend more to research causes of AD/HD that haven’t been demonstrated to cause AD/HD”),  but you’d miss his larger point. We don’t know enough about how and when environment influences behavior. Research dollars are funneled to well-researched topics, instead of to open questions. If too many children are receiving meds without therapy or behavior management skills, that’s a failing to address immediately.

My criticism of Sroufe?  He blew it. He had national commentary’s version of a Super Bowl ad to advocate for more comprehensive treatments and research. He distracted everyone by arguing, “Let’s quit using the most effective individual tool we have.”

@ 2012 Jonathan Miller All Rights Reserved

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February 2, 2012 · 11:10 PM

What (exactly) is Anxiety?

If you were to see this, technically, you would feel anxiety.

There’s a terrific post here from Joseph LeDoux, professor of neural science and psychology at New York University, that defines anxiety, from the amygdala on up. LeDoux specifies anxiety as a flavor of fear. When you expect that you might face a threat, you feel anxiety. When you actually face that threat, you feel  fear.

The explanation is more necessary than it might seem. Twice in recent months, I’ve had male clients stare blank-faced and ask, “What exactly is anxiety?”  The first time, I had to stammer out an explanation of apprehension, physiological arousal and the fight-or-flight reaction, while hiding my surprise that  someone would need to ask. The second time, examples worked well: “Anxiety is what you feel when you walk in a room and everyone goes quiet.” “Anxiety is what you feel when the police car behind starts its’ siren.” For this client, “Anxiety is what you feel when your girlfriend says, ‘We need to talk’,” made the concept crystal-clear.

If you were to see this, technically, you would feel fear.

These conversations made me wonder why the question isn’t more common, and why only men have asked. In session, guys often seem more comfortable talking about ‘edginess’ or ‘agitation’ than with the A-word.  LeDoux’s explanation of anxiety hints at one possible reason why:

“… human anxiety is greatly amplified by our ability to imagine the future, and our place in it, even a future that is physically impossible.  With imagination we can ruminate over that yet to be experienced, possibly impossible scenario. We use this creative capacity to great advantage when we envision how to make our lives better, but we can just as easily put it to work in less productive ways — worrying excessively about the outcome of things.”

For some men, especially those with long memories of junior high school,  the best definition  might be, “Anxiety is what you feel when you think your buddies can see you’re nervous.”

 

@ 2012 Jonathan Miller All Rights Reserved

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January 26, 2012 · 7:26 AM

Pediatrics: Food isn’t medicine enough for AD/HD

Sugar, by the way, was ruled out as a cause of hyperactivity years ago.

If you google “Food is medicine”, you’ll get 242,000 hits. Parents of children with Attention-Deficit/Hyperactivity Disorder have long sought a menu-based answer to their kids’ trouble with distractability.   A new study published this month in Pediatrics runs a meta-analysis of multiple studies from recent years on the topic. Authors J. Gordon Millichap, MD, and Michelle M. Yee, CPNP, found changes in children’s meal plans may be helpful – in cases where medication has already failed.

A greater attention to the education of parents and children in a healthy dietary pattern, omitting items shown to predispose to ADHD, is perhaps the most promising and practical complementary or alternative treatment of ADHD.

I’ll bet the researchers wish APA style would let them underline the words “complementary or alternative”. They agree that Omega-3’s are worth further research and that iron and zinc supplements may enhance medication’s effects. Hyperactivity due to food-dye sensitivity isn’t AD/HD, by definition. Unfortunately for parents who are suspicious of the pharmaceutical industry or reluctant to medicate their kids, it doesn’t look as though diet changes will be a magic bullet for hyperactivity or inattention.

@ 2012 Jonathan Miller All Rights Reserved

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January 22, 2012 · 1:22 PM

Stress Management Blogging #1

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January 17, 2012 · 10:44 PM

Is Bipolar Disorder a Thing?

"So, am I depressed, or Bipolar, or what?

When you have to diagnose a client with lots of depressive symptoms and a few, brief manic symptoms, you can be faced with a zebra riddle: is this a mild case of bipolar disorder? Or just a depressed person who gets very, very energetic when their mood improves ?

James Phelps, MD posts to the Psychiatric Times to suggest the problem may lay in the categories themselves. In a review of studies done with different definitions of hypomania (symptoms lasting at least four days… or three… or possibly two…) Phelps found hypomanic symptoms occur at lower and lower frequencies until they vanish altogether. He suggests Bipolar Disorder isn’t a ‘thing’, like a broken arm. Rather, he proposes it is a range along a spectrum of symptom intensity, the way doctors diagnose hypertension when their patient’s blood pressure gets up around 140/90.

What to do?  Dump the existing diagnoses? Start over by rating symptoms and personality traits on empirically-based scales?  It’s true that a switch to research-based constructs would bring us all closer to the reality we can know and measure. The downside is that it would produce chaos during the conversion. To know one’s diagnosis is a fundamental client right – how long would it take to explain diagnoses like, “5-2-6-2-1-7-8”? How would we file and reference the research on extinct disorders? Where will Borderline Personality Disorder support groups meet  if we declare there’s no such thing? To overturn established systems, one has to counter massive inertia. American therapists of a certain age will remember how the U.S. didn’t convert to the metric system in the 1970s – and it had a 200-year track record.

Phelps suggests we contain the collateral damage by taking a cue from physicists. They’ve understood for years that light sometimes acts like a particle and sometimes like a wave. They’ve conducted useful research (and kept their heads from exploding) by using the most appropriate model for the problem they face.  This “complementarity” principle means we can be more empirical without bewildering clients. For research, we’d use the ‘wave’ model, where it’s understood that ‘major depression’ and ‘bipolar’ mark points on a curve measuring the length and intensity of manic symptoms. When talking to clients, we’d use the ‘particle’ model, where we’d speak as though those conditions were as different as asthma and a hangnail. Would we lose specificity? Not enough to leave our clients uninformed. After all, even if Bipolar Disorder isn’t a ‘thing’, it shouldn’t take a psychology degree to get treatment.

@ 2012 Jonathan Miller All Rights Reserved

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January 9, 2012 · 9:41 PM

Sylvia Plath on Electroconvulsive Therapy, Pt. 2

A description of ECT applied a little better in the mid-1950s, from The Bell Jar, pgs. 213-214: [i]

Through the slits of my eyes, which I didn’t dare open too far, lest the full view strike me dead, I saw the high bed with its white, drumtight sheet, and the machine behind the bed and the masked person  ̶  I couldn’t tell whether it was a man or a woman  ̶  behind the machine, and other masked people flanking the bed on both sides.

Miss Huey helped me climb up and lie down on my back.

“Talk to me,” I said.

Miss Huey began to talk in a low, soothing voice, smoothing salve on my temples and fitting the small electric buttons on either side of my head. “You’ll be perfectly all right, you won’t feel a thing, just bite down…” And she set something on my tongue and in panic I bit down, and darkness wiped me out like chalk on a blackboard.

[i] Harper Perennial Modern Classics edition, ASIN B004N8X6LK

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