January 29th, 2010
 Cross-posted from “Sacramento Street Psychiatry“
The New York Times blog called “Well” recently asked: “Will Olympic Athletes Dope if They Know It Might Kill Them?” The answer is surprisingly clear: Many would if they could. In bi-annual surveys conducted from 1982 to 1995, researcher Bob Goldman asked elite athletes whether they would take a drug that guaranteed them a gold medal but would also kill them within five years. Again and again about half the athletes said yes, they would accept such a trade-off. This question has come to be known as the Goldman dilemma, and for most of us the high rate of acceptance is shocking. In contrast, a 2009 study asked the same question of the Australian general public, and only two of 250 respondents reported they would accept this Faustian bargain.
Sports success obviously matters more to dedicated athletes than to the rest of us. But what about success in general? Or happiness? Would you give up years of life in exchange for more happiness, in whatever form that may take?
I imagine many of us would say no, especially if the choice were posed concretely (e.g., blissful happiness for five or ten years, then death). We live life “for better or worse”; it feels like our duty to accept what life deals out. Yet nearly all of us engage in activities that make us happier in the moment at the possible cost of a shortened lifespan. From tasty but unhealthy foods to exciting but dangerous extreme sports, from alcohol to tobacco, our actions seem to show that longevity is not our highest priority. Memorable experiences are a particularly cost-effective way to buy happiness, but many of these experiences carry risks.
One factor that colors our willingness to trade longevity for happiness is how we deal with probability. The Goldman dilemma is posed as a sure thing, whereas the risks we face in real life are likelihoods. Genuine satisfaction in the moment is weighed against potential risk later on. The latter does not feel quite real, even if its likelihood is very high. We rationalize our choices by imagining we will be lucky.
Even more important is that we choose without consciously choosing. No one decides, cigarette by cigarette, how many minutes of life to trade away for each puff. Motorcycling and skiing would lose their luster if sober calculations of risk were undertaken before each run. We maximize our happiness by means of selective inattention.
The most shocking thing about athletes’ acceptance of the Goldman dilemma is that they admit, out loud, a value that the rest of us share only silently, awkwardly, and ambivalently: We often do value quality over quantity in life. A life devoted exclusively to safety and longevity strikes many of us as unsatisfying. Perhaps we will make better — not necessarily safer — choices if we consider consciously the trade-offs we already make.
Would you trade years of life for happiness? Chances are excellent that you already do.
Illustration: Happiness and Longevity (Fu Shou). Calligraphy by Tao Gui, Ming dynasty (1547), China.
December 9th, 2009
 A reader named Kim wrote:
I do tend to be cerebral and look for stuff on the internet like this blog to try to get more insight into what my therapist is doing. I am curious, do you think this dilutes the “magic” of the therapy somewhat, or do you think it is helpful or both.
Good question. My short answer is that therapy isn’t magic. It doesn’t rely on distraction, illusion, or diverting your attention. It need not be surprising or even unexpected to effect change. You won’t ruin, hurt, or dilute anything by understanding how therapy, or therapists, operate. Moreover, knowledge is power: An informed consumer can better judge whether a given therapy is legitimate, and whether it is likely to be helpful. Feel free to read up on therapy, learn about it.
The longer answer is a little more interesting. A few years ago I wondered a similar thing myself: Does being a therapist, and thus knowing a lot about how therapy is done, help or hurt one’s own therapy? I re-read a paper I saw some years earlier, “Psychological Mindedness as a Defense,” by Gerald I. Fogel. It’s a very good paper, written in technical language aimed toward mental health professionals. Dr. Fogel’s basic point is that an intellectual understanding of one’s problems, or ease in placing one’s issues into conceptual categories, doesn’t move one’s own therapy forward. On the contrary, comfortable ways of knowing and understanding oneself must be shaken up and disorganized in therapy in order to re-form them in a healthier way. Facile use of therapy lingo (“psycho-babble”) can actively interfere with real experiencing in therapy, and therefore hinder true insight.
A more nuanced answer, then, is that learning about therapy online or elsewhere may help at a conscious level to produce a better mental health “consumer.” Conversely, it may hurt if it refines and strengthens the defensive use, conscious or unconscious, of psychological-mindedness.
In most instances, though, I suspect it neither helps nor hurts. Intellectual knowledge exists on a different plane than the interpersonal work done in dynamic psychotherapy. There is a big difference between knowing something intellectually and knowing it deeply.
November 16th, 2009
 Cross-posted from “Sacramento Street Psychiatry“
For more than a decade I’ve taught a seminar in dynamic psychotherapy to psychiatry residents. One tricky issue that arises every year is the apparent choice between conducting a “supportive” psychotherapy, versus an “analytic” or “insight-oriented” one. I developed a sailing analogy to clarify this issue, and to teach an important point about it.
Most patients appreciate emotionally comforting support. Many seek a therapist who will provide a listening ear, who won’t judge them negatively, who will encourage them and praise their successes, and who will offer solace and kind words in the face of setbacks. However, many critics charge that such support requires no special training — other than learning to listen, no small feat perhaps — and can be offered by teachers, relatives, clergy, counselors, and many others. Supportive therapy is sometimes derided as “buying a friend.” Indeed, friends often offer support of this type.
Dynamic psychotherapy, originally derived from Freudian psychoanalysis, strives for something else. Freudian analysts are stereotyped as cold, painstakingly “neutral,” and anything but supportive. While this caricature exaggerates reality, it nicely illustrates the contrast between “support” and “insight.” In this type of therapy the patient is left to grapple with his or her own thoughts and feelings. These are brought into the light of consciousness by the therapist, but not softened or eased by emotional support. The aim of such therapy is not to help the patient feel better in the moment, but to lead to deep self-knowledge and the ability to accept one’s own feelings as they are. Critics sometimes claim that such therapy doesn’t really help or that it’s unnecessarily harsh, but no one calls it “buying a friend.” It isn’t all that friendly.
Psychiatry trainees learning about psychotherapy are usually told to aim for as much “insight-oriented therapy” as the patient can tolerate, and as much “supportive therapy” as the patient needs. In other words, insight is really the goal, but if a patient can’t tolerate the process to get there, add support as needed. Even presented this way, trainees often cubbyhole patients into “support cases” and “insight cases,” as though these are permanent categories, like blood type.
My sailing analogy aims to break down this sharp (and artificial) categorization. The aims of insight and support are fluid, and change moment by moment within a given therapy.
If you’ve ever been sailing — or windsurfing, which was my original version of this comparison — you appreciate the trade-off between stability and forward motion. Let the sail billow loosely and the boat floats quietly in the water. It is very stable but it doesn’t go anywhere. Tighten the sail to catch the wind, and the boat starts to move. However, in doing so it also leans over. It feels less stable, and in extreme cases threatens to capsize. Although I’m not much of a sailor, and even less of a windsurfer, I was struck by the kinesthetic reality of this moment-to-moment trade-off. At every moment, one chooses how tightly to trim the sail, and thus how much stability to trade away for forward progress.
In dynamic therapy, the therapist chooses how much anxiety to allow (or invoke). Minimize anxiety by avoiding painful topics and providing ample emotional support, and the boat of therapy sits stable but motionless in the water. The therapy is comfortable but does not go anywhere. Introduce some anxiety by gently confronting the patient, or simply by not offering as much support, and the boat of therapy starts to move. However, it also becomes less stable, and in extreme cases may threaten to capsize. The job of the therapist, the sailor in this scenario, is to adjust the sail at every moment, such that anxiety and stability are in balance: Enough stability that the patient can trust the process, enough anxiety to propel the therapy forward.
The sailing analogy can be extended by noting that some boats are inherently more stable. They can withstand more sail pressure and go faster, while others are more easily capsized and need to be sailed more carefully. Likewise, some patients are more resilient, some more fragile. Also, external stressors in a patient’s life are like a strong gusty wind blowing over the water. In such conditions a boat will move ahead even if the sail is loose. Tightening the sail in such conditions is more apt to upset the boat. This parallels therapy in the face of severe external stressors or trauma, when a lighter, more supportive touch is needed. Conversely, in calm conditions a boat can be sailed more aggressively. Likewise, a person not dealing with severe current stressors can bear more anxiety imposed by the therapy itself, which may allow more fundamental change to occur.
The main point is that patients don’t come stamped with “support” or “insight” on their foreheads. Everyone is on a continuum between the two and benefits by both. Moreover, everyone moves along this continuum on a moment-by-moment basis, the result of a complex interplay of defenses, the topics being discussed, and the relationship between the two parties. A sensitive therapist recognizes this and tailors the therapy accordingly.
November 14th, 2009
I had planned to submit articles to Technorati on occasion, but they are seeking short, newsy pieces that are not a good fit for me. This led me to look for other places to write. I found that Psychology Today has an active group of mental health bloggers on its site. I joined up and created a new blog called “Sacramento Street Psychiatry.” (The name is explained in my first post there.) This weekend I re-posted “Anti-depressants are just a crutch” to this new blog, and seem to have attracted many readers.
In the future I’ll sometime post there first, sometimes here first. I may not post everything I write here to “Sacramento Street Psychiatry,” however I will cross-post everything I put there here too.
October 15th, 2009
 Cross-posted from Technorati with permission.
At a dinner meeting a couple of weeks ago I met two psychiatrists who work at Kaiser Permanente, the large HMO system that boasts a 24% health insurance market share in California. (This has nothing to do with my story really. I just think it’s amazing that a quarter of all insured Californians are Kaiser patients.) As we described our practices, I mentioned that I recently helped a patient stop his Adderall, the amphetamine combination drug given for Attention Deficit Hyperactivity Disorder or ADHD. The patient had come to me on a very high dose and was complaining of many side-effects: anxiety, muscle twitching, severe insomnia, weight loss. I gradually tapered and eventually discontinued the stimulant over several weeks, with resolution of most of these symptoms. He thanked me and said he felt much better. I related this story with some pride, and mentioned to my dinner companions that I’ve had more success stopping high-dose medication, especially for ADHD, than I’ve had starting ADHD medication. Moreover, I opined that ADHD is too readily diagnosed in adults, resulting in a lot of unnecessary amphetamine being prescribed.
I had not anticipated how odd these statements sounded coming from a psychiatrist. One of the Kaiser docs, a child psychiatrist, quickly noted how many kids she’d helped by identifying and treating their ADHD. It’s an under-recognized problem, she assured me. The other psychiatrist only saw adults, yet he too underscored how Adderall, Ritalin, and other stimulants helped his patients. Someone mercifully changed the subject, and we let the matter drop.
It got me thinking though. First, could we all be correct? I have no reason to doubt the experience of child psychiatrists who see their young patients perform better, achieve more, and get along better with others when treated for ADHD. I don’t see children myself, and am basically a bystander in the debates over medicating children for ADHD and behavioral problems. Moreover, even in adult psychiatry I believe that prescribed stimulants can sometimes help, not only for ADHD but also for depression in the severely medically ill, and in some other situations.
But my own experience has led me to be cautious. ”Adult ADHD” is a fad. Its rate of diagnosis and treatment have skyrocketed in recent years, for no good scientific reason. I get calls all the time from people who have diagnosed themselves using a simple online checklist and are seeking an MD to rubber-stamp an amphetamine prescription. Since amphetamines are performance-enhancing even in normals and have street value as drugs of abuse, these potential patients put me in the uncomfortable position of second-guessing their request. I’m not saying adult ADHD doesn’t exist — in fact, I’m sure it does — but this isn’t the kind of relationship I want with patients. So I tell callers I don’t do ADHD evaluations, leaving me with lingering regrets about thwarting the subset — I don’t know how big it is — who have a legitimate need for this treatment.
And frankly, I’ve seen these medications over- or mis-prescribed by my fellow psychiatrists on a number of occasions. In addition to the patient mentioned above, for nearly a decade I’ve seen a distinguished senior academic for medication treatment of anxiety and depression. He’s never had an ADHD diagnosis. Nonetheless, he asked his psychiatrist back in 1993 to add Ritalin because a relative with ADHD benefited by it. He’s been on it ever since, 16 years. I tapered the dose down by more than half, but my patient resists using less, even though it likely worsens his anxiety and he needs medication for sleep. At this point I expect he’s on it for life. Another patient of mine, a young woman without an ADHD diagnosis but with a history of anorexia, had been prescribed 40 mg of Ritalin daily by her prior psychiatrist. It helped her concentrate, but also suppressed her appetite, which was a major psychological issue for her. We tapered down the Ritalin and discontinued it over about a year and a half, at which point she was doing well and reconciling with her mother — who, my patient said, had abused Ritalin herself for a long time.
Well, you get the idea. I’m not opposed to psychostimulants, honest. And I do believe ADHD is a serious problem and that it responds well to medication, along with other treatment. However, I also believe that, in adults anyway, inattention and hyperactivity can mean lots of things. I believe stimulant medications that cause anxiety, insomnia, loss of appetite, teeth grinding, high blood pressure, and other side-effects ought to be used judiciously. (And I also believe that a patient needs to have had symptoms by age 7 to fulfill DSM-IV diagnostic criteria for ADHD.)
Some of the most contentious, polarized arguments in psychiatry revolve around ADHD and its treatment. Are we poisoning our children with stimulants? Or leaving thousands to suffer unnecessarily? So far, these arguments still generate more heat than light. The main thing I learned at the dinner meeting I attended is that, like politics and religion, ADHD and its treatment remains a touchy topic in polite conversation.
October 14th, 2009
Technorati.com, the popular blog portal, recently invited bloggers to contribute to their newly revamped site. I signed up and submitted an article there, on ADHD medication. I’m happy to say it appeared on their site this morning, as the leading post in their “lifestyle” section. (I’m sure it will rotate out of the leading position soon.)
We contributors agreed to submit content appearing first on Technorati. I’ll re-post the piece here once I learn how long they’d like me to wait. For now, head over to their site and take a look, and feel free to comment there, here, or both.
September 28th, 2009
 Two events prompt me to write about therapy endings. In the more abrupt and traumatic of the two, a local psychiatrist died last month in a tragic accident, leaving many patients suddenly without their doctor. The other event, far more commonplace, was the decision of one of my own patients to stop therapy. These events illustrate opposite ends of a continuum, as I hope to describe below.
I discussed typical features of open-ended dynamic psychotherapy in my last post. Timelessness, wide focus, relative freedom from protocol and direction, and promotion of transference all come into play when such a therapy eventually comes to an end. Since this type of therapy has no “built-in” ending, each ending is unique.
In the real world psychotherapy often does not feel timeless. External events like a job change, a move, or a change in insurance coverage may end therapy prematurely. Therapists retire or move their practices far away. These endings are not chosen by the patient. Any unchosen ending can feel like a loss, or even an abandonment. These events do come with advance warning, however, and can be discussed ahead of time. The emotional repercussions can be contained, reviewed, and comforted in what is termed the “termination phase” of treatment: the sessions between acknowledging that therapy is ending, and the actual last session.
However, sometimes there is no warning, for example when a psychiatrist or other therapist suddenly dies. Such events are emotionally traumatic. Patients feel the acute loss of a relationship they came to rely upon, and often there is a rocky transition to another doctor, facilitated by the colleagues, professional partners, or secretarial staff (if any) of the deceased therapist. This mini-community steps in, without advance preparation nor much knowledge of the patients affected, to make the best of a very difficult situation. I consider this one extreme of the continuum of therapy endings, the pole where it is not the patient’s idea or wish at all.
In my view, the ideal way to end psychotherapy is not the other pole of the continuum either, where the decision is entirely the patient’s. This was the case with my patient who recently decided to end treatment after making much progress over the past couple of years. Yet, in my opinion she had a long way to go. Obviously, it is the patient’s choice to spend time and money on therapy; I can’t keep anyone in therapy if they choose otherwise. And sometimes a patient’s unilateral choice to stop reflects progress: a newfound ability to assert oneself, or to make definitive life decisions. Nonetheless, it isn’t an ideal outcome because it isn’t collaborative.
Psychodynamic therapy relies, first and foremost, on a “working alliance” between patient and therapist. If the patient feels he or she must make a unilateral decision to end therapy, this alliance has been damaged somehow, or was never strong in the first place. In a therapy with relatively little protocol or explicit direction, and where transference is promoted as a therapeutic tool, the one bedrock that both parties can rely upon is their mutual aim to help the patient. Ideally, then, a time comes when the patient feels ready to stop, and the therapist feels likewise. This is the midpoint on the continuum of therapy endings, where it is neither the therapist’s abandonment of the patient, nor the patient’s defiant separation from the therapist. It is a shared understanding that the work is ending, the culmination of a shared exploration in therapy.
Yes, this does happen in real life, although not as often as anyone would hope. Yet even when it’s the patient who chooses to end therapy, and the two parties “agree to disagree,” it is still very beneficial to plan ahead and allow for a termination phase — the length being roughly proportional to the length of the therapy, from a couple of sessions to several weeks — to discuss the ending. Unexpected feelings can arise when time is short. By exploring these feelings, therapy can be therapeutic until the very end.
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